179
CRISIS CONSULTATION Preventive psychiatric work, mainly with bereaved families, at the Slough, England, Child Guidance Clinic
by HILDA BLANK
Psychiatric Social Worker Member ofthe British Association ofSocial Workers (This article received joint equal first prize in the Social Workers’ Essay Competition, 1972, from the Mental Health Trust & Research Fund) CRISIS CONSULTATION
AN attempt to describe preventive work done at the Slough Child Guidance Clinic mainly with bereaved families. It was started in 1960 by Dr. Mildred Pott, who was then the psychiatrist in charge, and has been continued since 1969 under the directorship of Dr. Vera Wilkinson.
(Bucks.),
INTRODUCTION
"During crisis a relatively minor force, acting for a relatively short time, can switch the whole balance to one side or the other—to the side of mental health or the side of mental ill-health." Gerald Caplan After encountering in her work a number of children whose emotional difficulties could be traced back to unresolved problems and feelings centring around the death of a near person, Dr. Pott felt that treatment could have been more effective and shorter, had she been able to see these children and their families at the time of the bereavement, and she initiated the Crisis Consultation service. The aim was to help bereaved families immediately for short periods, as a preventive measure, and to reach those who in the ordinary way would not have needed psychiatric help. Attitudes towards death In primitive societies the feelings of sorrow, fear, horror and mystery which accompany death are openly expressed by wailing, pacifying the spirits, purifying uncleanliness, bringing gifts and making sacrifices. Definite rules and rituals are also laid down for the behaviour towards bereaved people and for their own conduct within the community. The tribe rallies round the bereaved and encourages him to express his grief. Up to the turn of this century most societies in the world had certain customs laid down for mourners, according to their religion and social standing. With the advance of medicine, new drugs and vaccinations, death in a family has become rare compared, for instance, with the Victorian era, where hardly a family grew up without losing some of its members in infancy or childhood, and where parents often died young. With family gatherings around the deathbed, paying last respects to the dead laid out in their coffins, and elaborate funerals, the reality of death was forcefully brought home to adults and children. There was less secrecy surrounding death and people found support and guidance in their religious beliefs. Today, in Britain, only small communities of minorities have rules for the mourner and support him, or encourage the expression of emotions. The general Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
,
180 our society is denial and suppression of painful emotions connected with tendency to pretend that nothing has happened. The greatly admired person is one who keeps a stiff upper lip&dquo;, shows none of his hurt feelings, does not talk of the dead person and &dquo;carries on as usual&dquo;, thereby saving people around him from uncomfortable and disturbing emotions. Many bereaved people feel &dquo;shunned like lepers&dquo; or are deeply hurt by the seemingly callous behaviour of their neighbours
trend in
death,
.
a
who make no reference to the loss of the dead person. As sex loses its aura of secrecy and mystery, death seems to take its place as the &dquo;unmentionable&dquo; subject. Intelligent and otherwise reasonable people refuse to tell a child of his parent’s death, deceiving themselves that he will &dquo;forget&dquo;, disbelieving that emotional disturbance and insecurity are bound to follow the unexplained disappearance of a most loved and needed person. Fewer people today believe in an after-life in heaven and a personal god. Nevertheless, non-religious parents, unsure of themselves and unable to fill the void which the abandonment of religious beliefs has left, revert in bereavement to religious formulae which in their family setting and to their children have no substance and meaning, but are used to hide their own confusion and fear, whilst creating bewilderment in their children. The unfamiliarity with death, the adults’ unconvincing or withheld explanations, the reluctance to talk about the dead person, all combine to erect a barrier between the child and his understanding of death, so that mourning and working through his grief seem denied to him. Effects of parental loss on children Children under the age of five years are particularly vulnerable to the loss of parents because of their great emotional dependence on them and their undeveloped defences against emotional stress. Dr. Bowlby, in his article &dquo;Childhood mourning and its implications for psychiatry&dquo;, describes the three phases on being parted from the mother: protest, despair and detachment, says : &dquo;In childhood the processes leading to detachment are very apt to develop prematurely, inasmuch as they coincide with and mask strong residual yearning for and anger with the lost object, both of which persist ready for expression, at an unconscious level. Because of this premature onset of detachment, the mourning process of childhood habitually takes a course that in older children and adults is regarded as pathological.&dquo; He suggests that &dquo;in childhood (and in pathological mourning of later years) the development of defensive processes is accelerated. As a result, the urges to recover and to reproach the lost object have no chance to be exitinguished and instead persist,&dquo; and that repression or splitting of the ego with resulting fixation lead to faulty personality development and proneness to psychiatric illness. Freud, in Mourning and Melancholia, relates anxiety state, depressive illness or hysteria to bereavements, in which the mourning has taken a pathological course. Barry and Lindemann in 1960 found early maternal loss to be three times as common in psychiatric patients as in several control groups. Burlingham and Freud noted that among children separated from their parents severe grief reactions were common, especially among young children up to the age of three years. They also found that children who had experienced repeated or lengthy separations in infancy and early childhood tended to exhibit withdrawn, depressive, self-accusatory or hostile mood swings. ...
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181
Anthony points out that children between the ages of 8 and 12 tend to blame themselves for the death of a parent. Bowlby emphasises the importance of the child’s age at the time of separation and the severity of deprivation. Separation from the mother is likely to cause severe anxiety and excessive need for love. At the same time, the child’s resentment towards the parent who has abandoned him leads to guilt, withdrawal and depression and in certain circumstances an inability to form loving relationships later on. Severely deprived children seem also prone to delinquency and anti-social behaviour. Crisis consultation and the mourning process The first concepts of a &dquo;crisis theory&dquo; were developed by Erich Lindemann who thought that unhealthy reactions to bereavement could be prevented by helping people to mourn adequately, and who saw the obstacles to grief work in avoidance of the necessary emotions and distress. Parkes and other writers have explored the subject of morbid grief reaction, and Caplan has further extended the theories of crisis and the practice of prevention. In crisis people are confronted by serious and unavoidable problems which they seem unable to solve with existing coping and defence mechanisms. Unless they can mobilise additional forces within themselves, or be helped to do so, depression, anxiety, personality disorganisation and disintegration are threatening. When a loved person dies, the bereaved must not only accept his loss but also all the accompanying feelings of sorrow, anger, guilt, despair and frustration. He must &dquo;actively resign himself to the impossibility of ever again satisfying his needs through interaction with the deceased. He must psychologically ’bury the dead’; only after this has been done will he be free to seek gratification of these needs from alternative persons.&dquo; Gerald Caplan
But at the same time he must allow himself to think and feel about the dead person, and share his grief and mourning with other members of the family or with friends. Only in this way will he emerge from the crisis mentally healthy, perhaps enriched and extended in his capacities, and able to form new loving relationships. During mourning significant departures from normal behaviour and attitudes occur which would be regarded as pathological in other circumstances, as for instance visual and oral hallucinations, in which the mourner might see her dead husband digging in the garden, or hear her dead child calling, although she is quite aware of their death. These manifestations, which are unconscious attempts to soften the impact of the loss and to get the mourner more slowly accustomed to the new situation, can produce great anxiety in the bereaved who believes madness is ap-
proaching. People who try to avoid mourning, who suppress their feelings, carry on as if nothing had happened and throw themselves into work, in order &dquo;to forget&dquo;, will probably be overwhelmed by their unexpressed feelings at a later stage and develop symptoms of mental or physical ill-health. One of the defensive processes is &dquo;splitting of the ego&dquo; in which one secret part of the personality consciously denies that the dead person is lost whilst another part acknowledges the reality of the loss. A less secret device to avoid mourning has been called &dquo;mummification&dquo; in which the bereaved pretends that the dead person is still there and refuses to face up to the reality of his loss. His room and possessions are kept as they were before, a place might be laid for him at mealtimes, imaginary conversations being held and presents being given at anniversaries. If mourning proceeds normally, Lindemann states, there are three phases: a Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
182 short period of shock and numbness, a period of intense grief and a period of recovery. Crisis need not and should not be a wholly negative experience. It is a great challenge which can strengthen or weaken the ego, by integrating traumatic experiences into the adaptive capacities and so lead to greater maturity and strength in the end. The structure and functioning ofthe Crisis Consultation in Slough As the concept of helping families in their bereavement is new and alien to prevailing attitudes, it was important, as a first step, to contact professional people in the community who were likely to meet bereaved families, introduce them to the principles of Crisis Consultation, explain our service and ask for their co-operation. Doctors, clergymen, teachers and social workers were either seen in groups or got to know about the service by special letter (see &dquo;Appendix&dquo;). As a result they began to consult us about bereaved families or to refer them to the Clinic. We do not only rely on other agencies but also approach families directly, after reading about their bereavement in the local paper or hearing about it from other people. In these cases we write a letter of sympathy and offer our immediate help (see &dquo;Appendix&dquo;). Although some people do not respond at the time, a number of them keep the letter and contact us at a later date; one family after two years. We are also contacting such organisations as the Cruise Club for Widows, the Befrienders and the Samaritans and encourage them to send families to us for psychiatric help and we refer some of our families to these organisations for practical help and social contacts. Bereaved children would benefit from being seen very soon after a death occurs, but the adults, for the first two weeks, are usually shocked, numbed and overwhelmed with practical tasks, so that it is better to approach them after that time. A few children with dying parents were seen before death occurred so that a relationship could be established beforehand. Most children come with their own families but we have also seen foster- and houseparents who look after bereaved children. As our Educational Psychologists are in close touch with the schools, they may sometimes see bereaved children there, before the family comes to the Clinic. The first interview at the Clinic usually takes place between the adults in charge of the children and the PSW. This provides an opportunity for assessing the situation, for consultation on how and what to tell the children, and for emotional release of the adults’ feelings. Most parents weep at the Clinic and find relief in talking about the dead person. During the interview it is decided whether the psychiatrist should see the family, whether the adults want to come again without the children or work through the crisis with their children without further help from the Clinic. For subsequent interviews families are seen together or individually, according to their needs, sometimes once or twice only, although followed up by letter, phone calls or by our Educational Psychologists’ enquiries at schools and playgroups. Others are seen, with intervals, over several months. Since the service started about 130 families have been referred as Crisis cases. An additional 110 families were referred as ordinary Child Guidance cases with symptoms due to a crisis in the past. During the same period 142 families were approached but did not come. Crisis consultation, in contrast to general Child Guidance Work, limits treatment to the present situation and the feelings aroused by it, and aims at immediate help Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
183 short period. Inevitably, we meet in this service families whose psychological difficulties started long before the crisis and might be so severe that they need prolonged treatment through the general Child Guidance service. Although it has not been possible to conduct a systematic follow-up of families who have used the service, we have kept in touch with most of them over periods of several months or a year, and as long as they stay in the district our School Psychological Service are alerted in case of further difficulties. Our service aims at helping families to deal with a crisis from the outset in the least damaging way, to encourage the sharing of grief and the expression of anger, guilt, fear and anxiety, so that new forces in themselves can be freed which will carry them through adequate mourning to a new equilibrium. ----Discussion ofcases There has been a wide range of crisis cases, from children witnessing accidents of over a
~~
__
to three cases where the father murdered the mother. In one such case the father strangled the mother during a psychotic breakdown. The two children, aged 8 and 6, were frightened, withdrawn and confused,and tried to deny their feelings. A young couple who were related to the children had taken care of them and cooperated well with the Clinic. In their play-sessions with the psychiatrist the children acted out their fears and phantasies and gave up their position of denial. The fosterparents were sensitive to the children’s needs and after about six months’ treatment the children had become happy, affectionate and able to make friends. Anger, aggression and defiance are frequently reported by parents as the child’s reactions to a bereavement. Andrew, aged 7, was very attached to his older brother who died of encephalitis. After his death Andrew became extremely aggressive and defiant towards his mother, refused to attend school and suffered from sleep disturbances. His parents did not understand the source of Andrew’s anger and aggression and were at a loss how to deal with it. During several interviews at the Clinic the parents realised that Andrew was blaming them for his brother’s death and that he feared to die himself. They were able to help him through this period of anger and fear and he returned to school, found companionship with friends and later on
strangers
accepted a new baby. Guilt is experienced by almost every bereaved and if it is overwhelming and persistent it may lead to breakdown in communication with others, difficulties in functioning effectively, self-hatred and self-destruction. Excessive guilt was shown by Linda, aged 10, after her older brother had been killed on his bicycle. Because of her jealousy of him, she felt that her bad wishes had killed him, that she was possessed by &dquo;black magic&dquo; and that she would be punished in retaliation. Children who have witnessed fatal accidents experience guilt and remorse for their helplessness, especially if another child is involved, and worse, if the child was put in their charge. Alan and Terry, aged 9 and 7, were left with their little sister, aged 5, playing on the beach, whilst the parents went to a shop. They were loving and usually responsible parents who, for a short time, in holiday-mood forgot about dangers. The little girl was drowned in front of her brothers and the whole family was shattered by guilt and remorse. The two boys felt that they should have been able to save the child, became depressed and were unable to concentrate in school. The whole family needed support for about half a year and slowly recovered from their depression. Eventually their confidence and equilibrium were restored, the boys did well at school and the parents got over their guilt feelings sufficiently to want another baby. Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
184 Children who have experienced separations and prolonged insecurity in the past, prone to develop fears about the possible death of a parent. Christine had been separated from her mother as a baby for 4 months because the mother suffered from tuberculosis. When she was 8 years old, her grandfather and a baby of a neighbour died in quick succession. After that she became morbidly preoccupied with death and depressive thoughts and clung to her mother. She had no conscious knowledge of her mother’s previous illness, but the death of the grandfather and the baby had re-activated unresolved anxieties. She was helped by psychiatric treatment and lost her anxieties. It was noteworthy, when her father suddenly died five years later, that it was Christine, out of three sisters, who coped best with the bereavement. One would hope that the solving of a previous stressful situation had strengthened her ability to cope with a later one. Parents who lose a favourite child feel anxious and guilty about their resentment against the surviving children whom they might wish dead instead. In one family where the very much loved only boy died, the moster lost all interest in her remaining family, wanted to die herself and became almost completely silent with her two daughters and her husband who all suffered through her depression. She felt that the house was &dquo;like a morgue&dquo; without the boy and was aware of her death wishes against her daughters who felt worthless and rejected. The mother clung to her grief as a means of still feeling united with her son and seemed to dread the day when she would feel easier because that would threaten to break the link with him. At first she could only talk at the Clinic about her resentment, anger and destructive feelings but gradually she was able to share these with her husband, and after much work she came to understand his and the children’s sufferings and needs and was able to turn back to them. The younger child had become withdrawn and did not speak until she was over 3 years old, the older one became extremely shy, unable to work at school and claustrophobic, but with help from the Clinic and with the mother improving the children too got over their difficulties and presented no disturbances when seen during a follow-up two years later. Some parents invest all their emotions in a surviving child or expect a child to take the husband’s or wife’s place. Malcolm, aged 10, was left alone with his mother after the father’s death. The mother clung to her son and made demands on him, as if he were an adult. The boy became so overwhelmed with feelings of resentment against his mother and guilt towards his dead father that he was unable to function in any sphere. He refused to go to school and hardly ever went out of the house. He became withdrawn and paranoid about other people. Both mother and child had to be seen for frequent interviews before the situation improved. Boys in the oedipal position, competing with their fathers for the exclusive possession of the mother, might be terrified if this situation becomes reality, and girls experience the equivalent feelings on their mother’s death. Doreen lost her mother when she was 11years old and was torn by her conflicting feelings about her mother’s loss and the triumph of possessing her father. She was over-demanding and unhappy, became irritable with him on the slightest grounds and resented it when his work took him away from home. She became markedly jealous of her younger sister and wanted her father exclusively to herself. She tried to dominate him and their relationship became more and more involved and difficult. She was helped in sessions with the psychiatrist and the father was able to set limits to the unrealistic demands of his daughter. When the father married again, Doreen made an excellent relationship with her stepmother and seemed relieved that the reality situation restricted her sexual phantasies about her father. are more
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185
children become extremely anxious about a remaining parent, others show tensions like tics or nailbiting or they regress to infantile behaviour. Frequently they believe in the dead person’s power to come back and feel hurt by the apparent rejection, or they imagine their own &dquo;badness&dquo; has driven the dead parent away. During the last three years nearly four times as many families came to the Clinic
Many
nervous
where the father had died, compared with the death of a mother. This seems mainly due to the fact that more men than women die young. (Of all the cases that came to our knowledge during this period 39 fathers and 15 mothers had died.) But it also seems that widows feel more need for our service. (Of the 42 families who were approached but did not come 16 fathers and 9 mothers had died.) Apart from bereavement cases we have also seen children with marked grief reactions when a parent had gone to prison or hospital. Recently there have been several cases of newly divorced or separated parents where the children showed anxiety and grif for the absent parent and aggression or clinging behaviour towards the remaining one. A number of parents returned to the Clinic for consultation when they planned new marriages, either because they wanted to explore their own feelings or because they were unsure how the children would react to the new situation. In general, and other things being equal, it seems that families with good relationships are able to cope better with grief and mourning than those where marital or parent/child relationships were disturbed before the death and where the mourning process is hindered by excessive guilt and self-accusatory feelings. Our experiences with children who came many years after the crisis confirm that their treatment usually takes much longer than that of children brought early and that some of those are so defended or set in their behaviour pattern by the time they reach us that treatment is only partially successful. Conclusions on the methods ofthe service Since 1960 the Crisis Consultation service in Slough has tried to help bereaved and other families under stress by immediate psychiatric assistance for short periods. We are still not succeeding in seeing families as quickly after the crisis as seems necessary. This is largely due to the resistance in the community to exploring feelings concerning death and becoming involved in mourning. There is also reluctance to bring children to a psychological service when apparently there is nothing wrong with them, and many adults do not understand how deeply children are affected by death and separations. From experience it seems that although adults are often relieved to use our service and benefit from it, they are hesitant to bring their children into it. Perhaps a more adult-centred approach would meet with better response. It is possible that offering to visit people at home would bring us into contact with families who at present fail to respond, and in spite of the limited sessions available for the service, it may be useful to try this with some cases in the future. We have found that the correct timing of our approach is important and that it is often useful to have other agencies or professionals who can keep the contact until the family is ready to come and advise on the right moment for referral to the Clinic. Geoffrey Gorer, in Death, Griefand Mourning in Contemporary Britain, suggests the &dquo;desirability of making social inventions which will provide secular mourning rituals for the bereaved, their kin and their friends and neighbours.... Such rituals would have to take into account the need of the mourner for both
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186
companionship and privacy.&dquo; Such innovations might open up new channels for leading the bereaved to adequate mourning and better mental health which has been the object of the Crisis service. APPENDIX 1
Sample
of letter sent to
professional people
in the district
Health
Centre,
Burlington Road, Slough, Bucks. Child Guidance Clinic CRISIS CONSULTATION SERVICE FOR BEREAVED FAMILIES
As some of you alreay know, we have a special service at this Clinic for parents and children who have had a death in their family or among close friends and we would like to give you some more information about it. We believe that it is very important to offer help to children and parents at this time of crisis, as it is often difficult for them to deal with their feelings at the time and they may as a result have problems in later life. For instance, they may be unable to make good relationships, or have excessive fears, difficulties in learning and physical symptoms due to anxiety. One common reaction is that children fear that the remaining parent or they themselves will die or be sent away. During the time that our &dquo;Crisis Consultation&dquo; has been operating we have always very much relied on Health Visitors, doctors, teachers, social workers and clergymen to bring families in need of help to our notice and we would like to remind you that we would welcome your continued support in our work. Our help could consist in either discussing cases like these with you, so that you could support the family or in seeing the families at the Clinic if you would feel it appropriate and the families would like to come. We are keeping the hour 12-1 p.m. on Thursdays for discussion of these cases and one of us will be free to talk with you if you wish it. We would welcome the opportunity to meet you. ....................................
....................................
Psychiatrist Psychiatric Social Worker
Sample
APPENDIX 2 of letter sent to bereaved families
Dear ............................... It was with deep regret that we heard of your death. We did not want to intrude on you during the very difficult time you all must have had, but please accept at this late stage our sincere sympathy. At this clinic we have a special service for children and their parents who have lost relatives and friends and we like to see them so that we can talk to them and help them to adjust to their loss. Children are often bewildered by what has happened and this might lead to frightening imaginations and worries which may make life difficult at present or sometimes at a much later date. If you feel that we could help you, we would be very pleased to see you here. I could see you If this time is not suitable we would be glad to hear from you so that we could arrange a meeting for another time. Yours sincerely, Social Worker. ........................
.................................
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187 APPENDIX 3 Crisis Cases seen from 1969-1971
3f3 new families were seen during this period, in addition 24 other families were seen who were either follow-ups, re-referrals because of another crisis or re-marriage, or the crisis had occurred more than 2 years ago. The 38 new cases: 13 Referral: In response to the Clinic’s letter Doctors and hospitals 11I 6 Schools and Educational Psychologists Social Workers, Health Visitors 5 Parents 3 = 38 (Some referred from several sources, but only the initial one is given) How long ago did crisis occur before seen at the Clinic: 1 5 days 2 weeks 2 3 weeks 6 6 4 weeks 6 weeks 2 8 weeks 1 4 2 months 3 6 months 4 7-10 months 1 year 6 3 2 years 38 Nature ofcrisis: Father died 22 6 Mother died 5 Sibling died Father died and Mother 1 attempted suicide Uncle died 1 1 Neighbours died Parents separated 1 Father posted to Vietnam 1 38 How often seen: Once 4 Twice 12 5 Three times 7 Four times 7 Six times times 1 Eight 1 Ten times 1 Twelve times 38 -
-
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188
Follow-up :
Notmoved followed up because family followed other or
up
by
social workers over period of 3 months 5-6 months 8-10 months 1 year 2 years
4 5
9 4 111 5 -
Symptoms of the children: (Some showed more than 1 symptom) Parents reported no symptoms Anxiety and confusion Specific anxiety about remaining parent
Depression Aggression, tempers, defiance Lack of concentration, inability
,
to learn Infantile behaviour Withdrawal
Stealing Wandering
,
School refusal Suicidal Pains Excessive guilt Denial of death
38
9 14
12 10 9 6 6 5 3
2 2 2 1 1 1
BIBLIOGRAPHY
Anthony, S., The Child’s Discovery of Death. Kegan Paul, Trench & Trubner, London. Bowlby J., "Grief and Mourning in Infancy Early Childhood", The Psychoanalytic Study of the Vhild, Vol.
and
XV, 1960.
—, "Childhood Mourning and its Implications for Psychiatry". The American Journal of Psychiatry, Vol. 118, No.6, December 1961. The International Mourning", Journal of Psycho-Analysis, Parts IV-V, Vol. XLII, 1961. —, "Process ofand A., Infants without Families. London, Allen & Unwin, 1944. Burlingham, D.,
Freud,
Caplan, G., Principles of Preventive Psychiatry. Tavistock Publications. Freud, S., "Mourning and Melancholia", Complete Psychological Works of Sigmund Freud. London, Hogarth Press, 1958. Gorer, G., Death, Grief and Mourning in Contemporary Britain. London, The Crescent Press. Lindemann, E., "Symptomatology and management of acute grief", Amer. J. Psychiatry, 1944.
Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
189
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CRISIS CONSULTATION Preventive psychiatric work, mainly with bereaved families, at the Slough, England, Child Guidance Clinic
by HILDA BLANK
Psychiatric Social Worker Member ofthe British Association ofSocial Workers (This article received joint equal first prize in the Social Workers’ Essay Competition, 1972, from the Mental Health Trust & Research Fund) CRISIS CONSULTATION
AN attempt to describe preventive work done at the Slough Child Guidance Clinic mainly with bereaved families. It was started in 1960 by Dr. Mildred Pott, who was then the psychiatrist in charge, and has been continued since 1969 under the directorship of Dr. Vera Wilkinson.
(Bucks.),
INTRODUCTION
"During crisis a relatively minor force, acting for a relatively short time, can switch the whole balance to one side or the other—to the side of mental health or the side of mental ill-health." Gerald Caplan After encountering in her work a number of children whose emotional difficulties could be traced back to unresolved problems and feelings centring around the death of a near person, Dr. Pott felt that treatment could have been more effective and shorter, had she been able to see these children and their families at the time of the bereavement, and she initiated the Crisis Consultation service. The aim was to help bereaved families immediately for short periods, as a preventive measure, and to reach those who in the ordinary way would not have needed psychiatric help. Attitudes towards death In primitive societies the feelings of sorrow, fear, horror and mystery which accompany death are openly expressed by wailing, pacifying the spirits, purifying uncleanliness, bringing gifts and making sacrifices. Definite rules and rituals are also laid down for the behaviour towards bereaved people and for their own conduct within the community. The tribe rallies round the bereaved and encourages him to express his grief. Up to the turn of this century most societies in the world had certain customs laid down for mourners, according to their religion and social standing. With the advance of medicine, new drugs and vaccinations, death in a family has become rare compared, for instance, with the Victorian era, where hardly a family grew up without losing some of its members in infancy or childhood, and where parents often died young. With family gatherings around the deathbed, paying last respects to the dead laid out in their coffins, and elaborate funerals, the reality of death was forcefully brought home to adults and children. There was less secrecy surrounding death and people found support and guidance in their religious beliefs. Today, in Britain, only small communities of minorities have rules for the mourner and support him, or encourage the expression of emotions. The general Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
,
180 our society is denial and suppression of painful emotions connected with tendency to pretend that nothing has happened. The greatly admired person is one who keeps a stiff upper lip&dquo;, shows none of his hurt feelings, does not talk of the dead person and &dquo;carries on as usual&dquo;, thereby saving people around him from uncomfortable and disturbing emotions. Many bereaved people feel &dquo;shunned like lepers&dquo; or are deeply hurt by the seemingly callous behaviour of their neighbours
trend in
death,
.
a
who make no reference to the loss of the dead person. As sex loses its aura of secrecy and mystery, death seems to take its place as the &dquo;unmentionable&dquo; subject. Intelligent and otherwise reasonable people refuse to tell a child of his parent’s death, deceiving themselves that he will &dquo;forget&dquo;, disbelieving that emotional disturbance and insecurity are bound to follow the unexplained disappearance of a most loved and needed person. Fewer people today believe in an after-life in heaven and a personal god. Nevertheless, non-religious parents, unsure of themselves and unable to fill the void which the abandonment of religious beliefs has left, revert in bereavement to religious formulae which in their family setting and to their children have no substance and meaning, but are used to hide their own confusion and fear, whilst creating bewilderment in their children. The unfamiliarity with death, the adults’ unconvincing or withheld explanations, the reluctance to talk about the dead person, all combine to erect a barrier between the child and his understanding of death, so that mourning and working through his grief seem denied to him. Effects of parental loss on children Children under the age of five years are particularly vulnerable to the loss of parents because of their great emotional dependence on them and their undeveloped defences against emotional stress. Dr. Bowlby, in his article &dquo;Childhood mourning and its implications for psychiatry&dquo;, describes the three phases on being parted from the mother: protest, despair and detachment, says : &dquo;In childhood the processes leading to detachment are very apt to develop prematurely, inasmuch as they coincide with and mask strong residual yearning for and anger with the lost object, both of which persist ready for expression, at an unconscious level. Because of this premature onset of detachment, the mourning process of childhood habitually takes a course that in older children and adults is regarded as pathological.&dquo; He suggests that &dquo;in childhood (and in pathological mourning of later years) the development of defensive processes is accelerated. As a result, the urges to recover and to reproach the lost object have no chance to be exitinguished and instead persist,&dquo; and that repression or splitting of the ego with resulting fixation lead to faulty personality development and proneness to psychiatric illness. Freud, in Mourning and Melancholia, relates anxiety state, depressive illness or hysteria to bereavements, in which the mourning has taken a pathological course. Barry and Lindemann in 1960 found early maternal loss to be three times as common in psychiatric patients as in several control groups. Burlingham and Freud noted that among children separated from their parents severe grief reactions were common, especially among young children up to the age of three years. They also found that children who had experienced repeated or lengthy separations in infancy and early childhood tended to exhibit withdrawn, depressive, self-accusatory or hostile mood swings. ...
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181
Anthony points out that children between the ages of 8 and 12 tend to blame themselves for the death of a parent. Bowlby emphasises the importance of the child’s age at the time of separation and the severity of deprivation. Separation from the mother is likely to cause severe anxiety and excessive need for love. At the same time, the child’s resentment towards the parent who has abandoned him leads to guilt, withdrawal and depression and in certain circumstances an inability to form loving relationships later on. Severely deprived children seem also prone to delinquency and anti-social behaviour. Crisis consultation and the mourning process The first concepts of a &dquo;crisis theory&dquo; were developed by Erich Lindemann who thought that unhealthy reactions to bereavement could be prevented by helping people to mourn adequately, and who saw the obstacles to grief work in avoidance of the necessary emotions and distress. Parkes and other writers have explored the subject of morbid grief reaction, and Caplan has further extended the theories of crisis and the practice of prevention. In crisis people are confronted by serious and unavoidable problems which they seem unable to solve with existing coping and defence mechanisms. Unless they can mobilise additional forces within themselves, or be helped to do so, depression, anxiety, personality disorganisation and disintegration are threatening. When a loved person dies, the bereaved must not only accept his loss but also all the accompanying feelings of sorrow, anger, guilt, despair and frustration. He must &dquo;actively resign himself to the impossibility of ever again satisfying his needs through interaction with the deceased. He must psychologically ’bury the dead’; only after this has been done will he be free to seek gratification of these needs from alternative persons.&dquo; Gerald Caplan
But at the same time he must allow himself to think and feel about the dead person, and share his grief and mourning with other members of the family or with friends. Only in this way will he emerge from the crisis mentally healthy, perhaps enriched and extended in his capacities, and able to form new loving relationships. During mourning significant departures from normal behaviour and attitudes occur which would be regarded as pathological in other circumstances, as for instance visual and oral hallucinations, in which the mourner might see her dead husband digging in the garden, or hear her dead child calling, although she is quite aware of their death. These manifestations, which are unconscious attempts to soften the impact of the loss and to get the mourner more slowly accustomed to the new situation, can produce great anxiety in the bereaved who believes madness is ap-
proaching. People who try to avoid mourning, who suppress their feelings, carry on as if nothing had happened and throw themselves into work, in order &dquo;to forget&dquo;, will probably be overwhelmed by their unexpressed feelings at a later stage and develop symptoms of mental or physical ill-health. One of the defensive processes is &dquo;splitting of the ego&dquo; in which one secret part of the personality consciously denies that the dead person is lost whilst another part acknowledges the reality of the loss. A less secret device to avoid mourning has been called &dquo;mummification&dquo; in which the bereaved pretends that the dead person is still there and refuses to face up to the reality of his loss. His room and possessions are kept as they were before, a place might be laid for him at mealtimes, imaginary conversations being held and presents being given at anniversaries. If mourning proceeds normally, Lindemann states, there are three phases: a Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
182 short period of shock and numbness, a period of intense grief and a period of recovery. Crisis need not and should not be a wholly negative experience. It is a great challenge which can strengthen or weaken the ego, by integrating traumatic experiences into the adaptive capacities and so lead to greater maturity and strength in the end. The structure and functioning ofthe Crisis Consultation in Slough As the concept of helping families in their bereavement is new and alien to prevailing attitudes, it was important, as a first step, to contact professional people in the community who were likely to meet bereaved families, introduce them to the principles of Crisis Consultation, explain our service and ask for their co-operation. Doctors, clergymen, teachers and social workers were either seen in groups or got to know about the service by special letter (see &dquo;Appendix&dquo;). As a result they began to consult us about bereaved families or to refer them to the Clinic. We do not only rely on other agencies but also approach families directly, after reading about their bereavement in the local paper or hearing about it from other people. In these cases we write a letter of sympathy and offer our immediate help (see &dquo;Appendix&dquo;). Although some people do not respond at the time, a number of them keep the letter and contact us at a later date; one family after two years. We are also contacting such organisations as the Cruise Club for Widows, the Befrienders and the Samaritans and encourage them to send families to us for psychiatric help and we refer some of our families to these organisations for practical help and social contacts. Bereaved children would benefit from being seen very soon after a death occurs, but the adults, for the first two weeks, are usually shocked, numbed and overwhelmed with practical tasks, so that it is better to approach them after that time. A few children with dying parents were seen before death occurred so that a relationship could be established beforehand. Most children come with their own families but we have also seen foster- and houseparents who look after bereaved children. As our Educational Psychologists are in close touch with the schools, they may sometimes see bereaved children there, before the family comes to the Clinic. The first interview at the Clinic usually takes place between the adults in charge of the children and the PSW. This provides an opportunity for assessing the situation, for consultation on how and what to tell the children, and for emotional release of the adults’ feelings. Most parents weep at the Clinic and find relief in talking about the dead person. During the interview it is decided whether the psychiatrist should see the family, whether the adults want to come again without the children or work through the crisis with their children without further help from the Clinic. For subsequent interviews families are seen together or individually, according to their needs, sometimes once or twice only, although followed up by letter, phone calls or by our Educational Psychologists’ enquiries at schools and playgroups. Others are seen, with intervals, over several months. Since the service started about 130 families have been referred as Crisis cases. An additional 110 families were referred as ordinary Child Guidance cases with symptoms due to a crisis in the past. During the same period 142 families were approached but did not come. Crisis consultation, in contrast to general Child Guidance Work, limits treatment to the present situation and the feelings aroused by it, and aims at immediate help Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
183 short period. Inevitably, we meet in this service families whose psychological difficulties started long before the crisis and might be so severe that they need prolonged treatment through the general Child Guidance service. Although it has not been possible to conduct a systematic follow-up of families who have used the service, we have kept in touch with most of them over periods of several months or a year, and as long as they stay in the district our School Psychological Service are alerted in case of further difficulties. Our service aims at helping families to deal with a crisis from the outset in the least damaging way, to encourage the sharing of grief and the expression of anger, guilt, fear and anxiety, so that new forces in themselves can be freed which will carry them through adequate mourning to a new equilibrium. ----Discussion ofcases There has been a wide range of crisis cases, from children witnessing accidents of over a
~~
__
to three cases where the father murdered the mother. In one such case the father strangled the mother during a psychotic breakdown. The two children, aged 8 and 6, were frightened, withdrawn and confused,and tried to deny their feelings. A young couple who were related to the children had taken care of them and cooperated well with the Clinic. In their play-sessions with the psychiatrist the children acted out their fears and phantasies and gave up their position of denial. The fosterparents were sensitive to the children’s needs and after about six months’ treatment the children had become happy, affectionate and able to make friends. Anger, aggression and defiance are frequently reported by parents as the child’s reactions to a bereavement. Andrew, aged 7, was very attached to his older brother who died of encephalitis. After his death Andrew became extremely aggressive and defiant towards his mother, refused to attend school and suffered from sleep disturbances. His parents did not understand the source of Andrew’s anger and aggression and were at a loss how to deal with it. During several interviews at the Clinic the parents realised that Andrew was blaming them for his brother’s death and that he feared to die himself. They were able to help him through this period of anger and fear and he returned to school, found companionship with friends and later on
strangers
accepted a new baby. Guilt is experienced by almost every bereaved and if it is overwhelming and persistent it may lead to breakdown in communication with others, difficulties in functioning effectively, self-hatred and self-destruction. Excessive guilt was shown by Linda, aged 10, after her older brother had been killed on his bicycle. Because of her jealousy of him, she felt that her bad wishes had killed him, that she was possessed by &dquo;black magic&dquo; and that she would be punished in retaliation. Children who have witnessed fatal accidents experience guilt and remorse for their helplessness, especially if another child is involved, and worse, if the child was put in their charge. Alan and Terry, aged 9 and 7, were left with their little sister, aged 5, playing on the beach, whilst the parents went to a shop. They were loving and usually responsible parents who, for a short time, in holiday-mood forgot about dangers. The little girl was drowned in front of her brothers and the whole family was shattered by guilt and remorse. The two boys felt that they should have been able to save the child, became depressed and were unable to concentrate in school. The whole family needed support for about half a year and slowly recovered from their depression. Eventually their confidence and equilibrium were restored, the boys did well at school and the parents got over their guilt feelings sufficiently to want another baby. Downloaded from isp.sagepub.com at University of Manitoba Libraries on June 17, 2015
184 Children who have experienced separations and prolonged insecurity in the past, prone to develop fears about the possible death of a parent. Christine had been separated from her mother as a baby for 4 months because the mother suffered from tuberculosis. When she was 8 years old, her grandfather and a baby of a neighbour died in quick succession. After that she became morbidly preoccupied with death and depressive thoughts and clung to her mother. She had no conscious knowledge of her mother’s previous illness, but the death of the grandfather and the baby had re-activated unresolved anxieties. She was helped by psychiatric treatment and lost her anxieties. It was noteworthy, when her father suddenly died five years later, that it was Christine, out of three sisters, who coped best with the bereavement. One would hope that the solving of a previous stressful situation had strengthened her ability to cope with a later one. Parents who lose a favourite child feel anxious and guilty about their resentment against the surviving children whom they might wish dead instead. In one family where the very much loved only boy died, the moster lost all interest in her remaining family, wanted to die herself and became almost completely silent with her two daughters and her husband who all suffered through her depression. She felt that the house was &dquo;like a morgue&dquo; without the boy and was aware of her death wishes against her daughters who felt worthless and rejected. The mother clung to her grief as a means of still feeling united with her son and seemed to dread the day when she would feel easier because that would threaten to break the link with him. At first she could only talk at the Clinic about her resentment, anger and destructive feelings but gradually she was able to share these with her husband, and after much work she came to understand his and the children’s sufferings and needs and was able to turn back to them. The younger child had become withdrawn and did not speak until she was over 3 years old, the older one became extremely shy, unable to work at school and claustrophobic, but with help from the Clinic and with the mother improving the children too got over their difficulties and presented no disturbances when seen during a follow-up two years later. Some parents invest all their emotions in a surviving child or expect a child to take the husband’s or wife’s place. Malcolm, aged 10, was left alone with his mother after the father’s death. The mother clung to her son and made demands on him, as if he were an adult. The boy became so overwhelmed with feelings of resentment against his mother and guilt towards his dead father that he was unable to function in any sphere. He refused to go to school and hardly ever went out of the house. He became withdrawn and paranoid about other people. Both mother and child had to be seen for frequent interviews before the situation improved. Boys in the oedipal position, competing with their fathers for the exclusive possession of the mother, might be terrified if this situation becomes reality, and girls experience the equivalent feelings on their mother’s death. Doreen lost her mother when she was 11years old and was torn by her conflicting feelings about her mother’s loss and the triumph of possessing her father. She was over-demanding and unhappy, became irritable with him on the slightest grounds and resented it when his work took him away from home. She became markedly jealous of her younger sister and wanted her father exclusively to herself. She tried to dominate him and their relationship became more and more involved and difficult. She was helped in sessions with the psychiatrist and the father was able to set limits to the unrealistic demands of his daughter. When the father married again, Doreen made an excellent relationship with her stepmother and seemed relieved that the reality situation restricted her sexual phantasies about her father. are more
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185
children become extremely anxious about a remaining parent, others show tensions like tics or nailbiting or they regress to infantile behaviour. Frequently they believe in the dead person’s power to come back and feel hurt by the apparent rejection, or they imagine their own &dquo;badness&dquo; has driven the dead parent away. During the last three years nearly four times as many families came to the Clinic
Many
nervous
where the father had died, compared with the death of a mother. This seems mainly due to the fact that more men than women die young. (Of all the cases that came to our knowledge during this period 39 fathers and 15 mothers had died.) But it also seems that widows feel more need for our service. (Of the 42 families who were approached but did not come 16 fathers and 9 mothers had died.) Apart from bereavement cases we have also seen children with marked grief reactions when a parent had gone to prison or hospital. Recently there have been several cases of newly divorced or separated parents where the children showed anxiety and grif for the absent parent and aggression or clinging behaviour towards the remaining one. A number of parents returned to the Clinic for consultation when they planned new marriages, either because they wanted to explore their own feelings or because they were unsure how the children would react to the new situation. In general, and other things being equal, it seems that families with good relationships are able to cope better with grief and mourning than those where marital or parent/child relationships were disturbed before the death and where the mourning process is hindered by excessive guilt and self-accusatory feelings. Our experiences with children who came many years after the crisis confirm that their treatment usually takes much longer than that of children brought early and that some of those are so defended or set in their behaviour pattern by the time they reach us that treatment is only partially successful. Conclusions on the methods ofthe service Since 1960 the Crisis Consultation service in Slough has tried to help bereaved and other families under stress by immediate psychiatric assistance for short periods. We are still not succeeding in seeing families as quickly after the crisis as seems necessary. This is largely due to the resistance in the community to exploring feelings concerning death and becoming involved in mourning. There is also reluctance to bring children to a psychological service when apparently there is nothing wrong with them, and many adults do not understand how deeply children are affected by death and separations. From experience it seems that although adults are often relieved to use our service and benefit from it, they are hesitant to bring their children into it. Perhaps a more adult-centred approach would meet with better response. It is possible that offering to visit people at home would bring us into contact with families who at present fail to respond, and in spite of the limited sessions available for the service, it may be useful to try this with some cases in the future. We have found that the correct timing of our approach is important and that it is often useful to have other agencies or professionals who can keep the contact until the family is ready to come and advise on the right moment for referral to the Clinic. Geoffrey Gorer, in Death, Griefand Mourning in Contemporary Britain, suggests the &dquo;desirability of making social inventions which will provide secular mourning rituals for the bereaved, their kin and their friends and neighbours.... Such rituals would have to take into account the need of the mourner for both
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186
companionship and privacy.&dquo; Such innovations might open up new channels for leading the bereaved to adequate mourning and better mental health which has been the object of the Crisis service. APPENDIX 1
Sample
of letter sent to
professional people
in the district
Health
Centre,
Burlington Road, Slough, Bucks. Child Guidance Clinic CRISIS CONSULTATION SERVICE FOR BEREAVED FAMILIES
As some of you alreay know, we have a special service at this Clinic for parents and children who have had a death in their family or among close friends and we would like to give you some more information about it. We believe that it is very important to offer help to children and parents at this time of crisis, as it is often difficult for them to deal with their feelings at the time and they may as a result have problems in later life. For instance, they may be unable to make good relationships, or have excessive fears, difficulties in learning and physical symptoms due to anxiety. One common reaction is that children fear that the remaining parent or they themselves will die or be sent away. During the time that our &dquo;Crisis Consultation&dquo; has been operating we have always very much relied on Health Visitors, doctors, teachers, social workers and clergymen to bring families in need of help to our notice and we would like to remind you that we would welcome your continued support in our work. Our help could consist in either discussing cases like these with you, so that you could support the family or in seeing the families at the Clinic if you would feel it appropriate and the families would like to come. We are keeping the hour 12-1 p.m. on Thursdays for discussion of these cases and one of us will be free to talk with you if you wish it. We would welcome the opportunity to meet you. ....................................
....................................
Psychiatrist Psychiatric Social Worker
Sample
APPENDIX 2 of letter sent to bereaved families
Dear ............................... It was with deep regret that we heard of your death. We did not want to intrude on you during the very difficult time you all must have had, but please accept at this late stage our sincere sympathy. At this clinic we have a special service for children and their parents who have lost relatives and friends and we like to see them so that we can talk to them and help them to adjust to their loss. Children are often bewildered by what has happened and this might lead to frightening imaginations and worries which may make life difficult at present or sometimes at a much later date. If you feel that we could help you, we would be very pleased to see you here. I could see you If this time is not suitable we would be glad to hear from you so that we could arrange a meeting for another time. Yours sincerely, Social Worker. ........................
.................................
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187 APPENDIX 3 Crisis Cases seen from 1969-1971
3f3 new families were seen during this period, in addition 24 other families were seen who were either follow-ups, re-referrals because of another crisis or re-marriage, or the crisis had occurred more than 2 years ago. The 38 new cases: 13 Referral: In response to the Clinic’s letter Doctors and hospitals 11I 6 Schools and Educational Psychologists Social Workers, Health Visitors 5 Parents 3 = 38 (Some referred from several sources, but only the initial one is given) How long ago did crisis occur before seen at the Clinic: 1 5 days 2 weeks 2 3 weeks 6 6 4 weeks 6 weeks 2 8 weeks 1 4 2 months 3 6 months 4 7-10 months 1 year 6 3 2 years 38 Nature ofcrisis: Father died 22 6 Mother died 5 Sibling died Father died and Mother 1 attempted suicide Uncle died 1 1 Neighbours died Parents separated 1 Father posted to Vietnam 1 38 How often seen: Once 4 Twice 12 5 Three times 7 Four times 7 Six times times 1 Eight 1 Ten times 1 Twelve times 38 -
-
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188
Follow-up :
Notmoved followed up because family followed other or
up
by
social workers over period of 3 months 5-6 months 8-10 months 1 year 2 years
4 5
9 4 111 5 -
Symptoms of the children: (Some showed more than 1 symptom) Parents reported no symptoms Anxiety and confusion Specific anxiety about remaining parent
Depression Aggression, tempers, defiance Lack of concentration, inability
,
to learn Infantile behaviour Withdrawal
Stealing Wandering
,
School refusal Suicidal Pains Excessive guilt Denial of death
38
9 14
12 10 9 6 6 5 3
2 2 2 1 1 1
BIBLIOGRAPHY
Anthony, S., The Child’s Discovery of Death. Kegan Paul, Trench & Trubner, London. Bowlby J., "Grief and Mourning in Infancy Early Childhood", The Psychoanalytic Study of the Vhild, Vol.
and
XV, 1960.
—, "Childhood Mourning and its Implications for Psychiatry". The American Journal of Psychiatry, Vol. 118, No.6, December 1961. The International Mourning", Journal of Psycho-Analysis, Parts IV-V, Vol. XLII, 1961. —, "Process ofand A., Infants without Families. London, Allen & Unwin, 1944. Burlingham, D.,
Freud,
Caplan, G., Principles of Preventive Psychiatry. Tavistock Publications. Freud, S., "Mourning and Melancholia", Complete Psychological Works of Sigmund Freud. London, Hogarth Press, 1958. Gorer, G., Death, Grief and Mourning in Contemporary Britain. London, The Crescent Press. Lindemann, E., "Symptomatology and management of acute grief", Amer. J. Psychiatry, 1944.
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189
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