How to identify traumatic bereavement

Hello I’m David Trickey. I’m a consultant clinical psychologist specialising in working with traumatically bereaved children young people and their families and I’m co-director of the UK Trauma Council.

I’d like to say a little bit about how you can use measures within your work with traumatically bereaved children and young people. Now I want to say a few things first about measures: what they are and why we think they’re useful. Well one thing to say is that they’re predictable. So we know exactly which questions are going to come next but also the child or young person also knows what questions are going to come next and that predictability may be particularly important for children and young people who experience potentially traumatic events.

The measures are focused on pertinent areas and that’s really useful because it helps to keep us on track. It helps to keep us asking questions about the important things and not to stray off and to be curious about all sorts of other things. In fact that might be less overwhelming for the child or young person because they know what questions are coming next. They don’t think that we may ask them about anything and everything. They know because they can see the questions. They can see which questions are coming next and in fact that process can enhance collaboration.  Many people are worried that using a measure somehow gets in the way of the collaborative efforts of this session, but actually it can be very collaborative because the young person can see what questions are coming they can see how you score them up and you can then feedback in a way that they understand what meaning you’ve made of those measures.

Now sometimes using these measures can be very normalising for the child or young person because suddenly they realise that others have the same sorts of problems. So, they may be sat there thinking they’re the only ones that have these vivid intrusive images of what’s happened and then in one of the questions there may be a few questions about that and they suddenly realise that this might be a common phenomenon that they’re experiencing. They can actually be less intense than an actual conversation because if you’re sat with a young person and you’re looking them in the eye and you’re asking all these questions — that can be quite an intense and sometimes overwhelming experience. But with a questionnaire, you’ve both got a third thing to focus on and that just takes some of the pressure off.

Sometimes these measures can lead to really interesting and useful discussions. So you might ask them at the beginning of a session a question and they may not want to answer, but actually as they sort of warm up and as they ease into the session and they start to answer these third-party questions, if you like, that then triggers all sorts of things. All sorts of discussions and you can then follow up with additional questions.

Now there’s some very particular properties about standardized questionnaires that can be incredibly helpful. They are identical every time and as a result of that they can provide a numerical value or a score so you can score the measures up and you may have different sub scales and they end up with a number that represents where they feel where they are on that particular scale. Now that can be really helpful, but don’t get too preoccupied with where the number actually is and what the number actually means because these measures are not very precise. So, just take it as a rough ballpark idea of where their particular difficulties lie and because they’re the same and because you end up with a number this allows comparisons. It allows you to compare this young person’s score with other young people of the same age and that can give you a real added meaning to what that score means. You know how high is this score compared to other children young people of their age. But it also allows you to compare this score over time for the same young person. So you might see them at the beginning of your work with them and they score a particular score and then weeks later you can do the questionnaire again and they end up with a different score. Now I think it’s getting worse. This questionnaire can help us to identify when things are getting worse but they can also track change in a positive direction as well. Also this score can be really helpful when communicating with other professionals and other services. They immediately give an impression of how severe a young person’s difficulties are in a way that the other services can often understand.

Now how do you choose which questionnaire you’re going to use? Well you go back to your formulation. What does your formulation suggest might be the problem here or what does your formulation suggest you need to know more about? And then you’ll pick the questionnaire based on that and then of course the scores from the questionnaire and the answers to the questionnaire feedback into formulation so you end up with quite a circular process of formulation and questionnaire choice.

Now let me tell you about some questionnaires and these are questionnaires that we’ve recommended for this particular group of traumatically bereaved children and young people. There are other questions that you might use or you might be interested in but these are ones that we think you might find particularly interesting.

The first is the Revised Child Anxiety and Depression Scale (RCADS). Now this is quite a long questionnaire and it just looks at the young person’s difficulties related to anxiety and low mood and it really allows you to get more information about that anxiety. What exactly is it they’re anxious about? What type of anxiety do they have and how severe is it compared to other young people and children? There’s also a parent version of this questionnaire so it allows you to have two different sources of information.

Then we have the Children’s Revised Impact of Event Scale or the CRIES.

This looks at symptoms of post-traumatic stress disorder. One of the things that’s nice about this questionnaire is it’s very short. It’s just eight items and it really focuses in on those core elements of post-traumatic stress disorder. The intrusion – how often do they think about the event when they don’t really want to? How much does it intrude into their consciousness? And avoidance – how effortful are their attempts of pushing that image away or that thought away.

And then the Child Post-traumatic Cognitions Inventory or the CPTCI. Now this questionnaire is really interesting because it allows us to begin to look into the child’s world. How do they see themselves, the world and other people? Do they see themselves as vulnerable? Do they see the world as dangerous? Do they see themselves as damaged as a result of what’s happened? So this questionnaire is just one way to start opening up conversations about the way they see themselves, the world and others.

So in summary, measures should be chosen purposefully you don’t just do the measure because it’s there or because your service demands it. You do it for a particular purpose. You choose it carefully. You introduce it naturally. So I might be talking to a young person and I might start to talk to them about symptoms of PTSD and I might say: “Oh, whilst we’re talking about this, I just want to use this questionnaire because it will just make sure I don’t miss anything. It’ll just be interesting because then we can look at the scores over time. What do you think? Will that be okay?”

And then you bring out your questionnaire and you examine it together and you administer it collaboratively. So then work your way through together, working on this task and you give them some control. “Do you want to answer it or me to ask you the questions? Do you want to fill it in in silence? You choose.”

You score it carefully, so when you do the adding up to make the score make sure you don’t make mistakes. Once you’ve scored it carefully you interpret it cautiously so you don’t get too hung up on what the number is of the score. You don’t get too hung up on whether it’s below or above a particular threshold. It just gives us a general idea of how high or high low a particular score is. And then, really importantly, we check it tentatively with the child or young person so we say something like:

“The questionnaire thinks that you’re a bit worse or thinks that things are a bit worse than they were last week. What do you think? Does that fit with your experience?” And we feed it back sensitively so we might say: “So compared to other young people of your age, this is a high score.” You know we just check out with them how they feel about that.

So in summary we choose measures purposefully with a particular idea in mind. We introduce them naturally and we administer them collaboratively. Then we score them up carefully. We interpret them cautiously. We check them tentatively and we feedback sensitively.

Daniella:

So, David, I hear a lot about formulation and I’d really like to know in your own words how would you define formulation.

David:

Well, I think formulation is just a story that explains why a young person has got the particular problems they have at that moment. And then it sort of identifies a way forward and helps the therapist or clinician or practitioner to work out what’s likely to be helpful. So there’s nothing more fancy than that.

Daniella:

I think sometimes when we hear that word, I know as a practitioner, I can feel a bit like: “Oh gosh that feels a bit formal or what would that mean?” The clinical guide I think refers to 5 P’s and sometimes it can be a bit: “Oh what’s all that about?” How can we move forward from that kind of thinking and can you talk more a little bit about what those 5 P’s are?

David:

Well, the first thing to say is that lots of people are already doing formulations, they just don’t call it a formulation. Anyone that stops and thinks: “What’s going on for this young person and what can I do to help?” Well, that’s a formulation right there. You know it’s just that we don’t call it that. What I think we’re trying to encourage people to do in the guide is to just slow that process down and do it a bit better and give it a bit of time. So rather than just rushing in, going: “Oh what who which child is this? What’s going on with them and what am I going to do?” Thinking: “Okay, so for example from the animation, Wesley this is the problem, this is what’s going on and therefore this is what I’m likely to do that’s likely to be helpful. Because I think if we help people to do it in a structured and systematic way, they don’t miss things. They don’t just assume they know what they’re going to do. They’re actually able to tailor their intervention more specifically to that particular young person in front of them. Those of us working with children know that every child reacts in a very different way. So really formulation is a way of mapping out what’s going on for them and why. Therefore mapping our intervention on to those particular difficulties.

You mentioned those 5 P’s. That’s one way of doing it. It’s quite a nice simple way to just structure the information really, and to think about what’s going on. So the first P would be ‘Predisposing’. So what’s gone on for that person before their bereavement that actually might be playing a role in their current difficulties. Then we have ‘Precipitating.’ So what is it that’s triggered this particular reaction. Obviously in the cases we’re talking about, we’re talking about bereavement, but what was the bereavement and how did the person die? What is it about the way the person died that is triggering these particular difficulties? The next P is ‘Problem’ so as we know for young people who are bereaved they have a full range of difficulties. You know it’s very difficult to pin it down to just one thing. So this particular young person, what is their particular problem? What is it that they’re presenting with? What is it they want to change. The next P is ‘Perpetuating’ so what is it that’s keeping these problems going? When we think about traumatic bereavement we’re thinking about a grief reaction that isn’t naturally responding — isn’t doing what it would normally do and the young person isn’t adjusting to their loss over the time. Actually the difficulties are continuing so what is it that’s keeping those difficulties going? Then the last P is ‘Protective’ so what have they got going for them? What are their strengths that we can really build on? So that’s those 5 P’s. That’s not the only way to do a formulation, but it’s not a bad place to start. It’s a nice way to structure the information gathering and to think how do these different bits kind of interact with each other. Therefore what can I do to try and help this young person.

Daniella:

Yeah I think it’s so helpful to reiterate that message that we’re probably already doing it in in a less structured way. Of course we are. We’re already, before we go into that session even if it’s that quick kind of thinking, “What’s the purpose of this activity I’m going to do? What am I actually trying to accomplish with this young person?” So I think it’s really reassuring to not feel like it’s this real formal process necessarily, but there’s real value, which I know we’ll talk about in a moment about the value of actually taking some time to do a formulation.

David:

Another thing that’s worth saying is it’s not kind of set in stone. It’s not like you do a formulation the first time you meet the person and that’s it. You kind of stick to that rigidly — far from it. It’s just it’s a flexible process that should change over time as you get more information. As you get to know the young person more you can actually change it. You can add more information and we might get them wrong sometimes and that’s okay. Then we can redo it and put it back together and see what it is that’s going on.

Daniella:

I think I’m interested, I guess to talk about maybe a little bit about why it’s so important to do and we’ve already kind of touched on that a little bit. It is about maybe not missing that information potentially and revisiting, as more information, as more data comes to you. So why else, I wonder?

David:

I think, one of the reasons for doing a formulation is it’s a very collaborative process in fact. You know if you go to your GP and you tell them what the problem is, you don’t want them to just give you some medicine and send you away. You want them to explain what it is that’s going on and therefore how that medicine is going to help and it’s the same with our work. You know when a young person comes to us and they’ve got a problem that they want our help with, we don’t just tell them what to do and expect them to go off and do it. We explain what we think is going on, so we can say, “Well this is what’s going on. This is why we think it might be and therefore this is what might be useful.” And the great thing about that process is they can then tell you how accurate your formulation is. You know they might say, “Well actually, I’m not sure I agree with that and they can contribute to it. So it becomes very much a collaborative process. So i think that’s another really good reason for doing it.

Daniella:

I think I’ve heard you say before, David, that if that young person was to ask you at the end of a session or even as you’re about to do an activity: “Why are we doing this?” Would we be able to answer that and that’s exactly why there’s so much value in kind of coming in with some formulation and taking that time to have a bit more of a think a structured kind of approach.

David:

Absolutely. I think increasingly young people and families are quite rightly becoming more assertive in their rights and they are asking these questions. Gone are the days where you just trust the person and do what they say. You know quite rightly people say “Why? Why do we think this is a good idea? Why do I want to do a memory jar? You know I’m missing my maths lesson at the moment and I want to do well in my

GCSEs. Why do you think doing this memory jar is going to be helpful?” And I think we need to be able to answer that question and more than “I just feel it’s going to be helpful” or “It’s helped other people.” It’s got to be better than that. We’ve got to explain to that young person what it is that’s going on for them and therefore what role building a memory jar is going to play in us helping them to adjust to their loss.

Daniella:

Yeah and I think as you were talking there I thought you know there’s so much value as a practitioner to actually go through that process as well to hone your own skills and to actually have that rationale as to why you’re choosing and to be able to articulate that because sometimes it can feel quite instinctual to just feel like yes that feels like the right thing for this particular person at this particular time but why? So this formulation process can really break that down I think quite easily if you really stop and think about it.