How to support traumatically bereaved children and young people

Katherine:

So, in the clinical guide to support practitioners in working with children who have been traumatically bereaved, we talk quite a lot about relaxing the body and relaxing the mind and supporting children and young people to find ways to help manage their physical and emotional experiences. Can you say something about why that’s so central?

Beck:

I think it’s probably an important component in the work that we might do with a child or young person that’s been traumatically bereaved. Essentially, we’re wanting to create a sense of safety in the room and a sense of calm. So it can be helpful as we then embark on some more difficult conversations and potentially bring some memories that might feel quite difficult into the mind — that child or young person has got a way, a rehearsed strategy, of managing if their body starts to feel a little bit more tense. They’ve got something they might then be able to take out of the session into everyday life to help them if they’re struggling with ways of emotion and they want to kind of calm their body down, if they’re struggling with some of those trauma memories.

Katherine:

So it sounds like that could be really helpful both in the sessions and in the process with the practitioner and also outside for the child or young person. But do you feel like it’s always necessary when we’re doing this work to include this element?

Beck:

I think it’s really difficult to say always necessary because every young child and young person is going to be different. But I think it’s probably likely to be a very helpful part of that our work with most children and young people. But we’d have to kind of negotiate with the child a young person explaining why and how and seeing whether they’re comfortable with that.

Katherine:

Okay. So, it’s something that should always be that the practitioners should always have in mind and always try and introduce, as you say, work out with the child or young person how and whether that’s going to be possible.

Okay. And what exactly does that involve? So, when we’re thinking about relaxing the body and relaxing the mind, what do you actually do with children and young people?

Beck:

I guess typically we might start with a body scan. Can the child, can the young person, even identify where in their body they’re already holding some tension. So can they do a scan upwards, downwards to work out where in their body might already be feeling a little bit tense. Then that enables us to go into some form of muscle relaxation whether it’s tensing and relaxing, whether it’s using a story and to help particularly with the physical parts of the body.

<<CONSIDER INSERTING Figure 8.1 Mind travel questions.>>

And then we might also do something around calming our mind down and by doing something like mind travel, we talk about in the clinical guide. And then of course there’s lots of technology and apps and things that we can make use of for young people where they want to use one of those as a ways of doing some a way of doing some mindfulness and finding some other ways of regulating their breathing and calming down.

Katherine:

Okay, so it sounds like it might be very playful and might use stories and play or it might be something that’s a bit more that you can explain more in words and also use other kind of props and sometimes technology can be involved in that as well.

So, Wesley is one of the characters that appears in the animation and also in the clinical guide and Cara is another central character. I guess I’d be interested to hear a bit about how you might introduce these ideas, to Wesley first of all, and to help him to buy into it and really understand and believe that this might be helpful to him. What might you say to Wesley?

Beck:

Yeah, I think if I had a 15-year-old young man and who’s clearly struggling and having a very tough time, I’d want to be very mindful of asking anything that might feel uncomfortable and strange. But I think when we’ve got confidence in what we’re suggesting — the activity — that can help, and that can be conveyed to the young person and if we can give them a really clear rationale this is why we want to do, something that might feel a little bit weird and for a moment, but there’s a really good reason for it because actually we’ve been hearing about how hard it is for you to even think about your dad and how hard it is for you to even talk about him. So if we can get these, if we can have a go and find a way of you having a safety net — a way that you know that you can help your body relax again and feel a bit calmer, then maybe you’ll feel more confident in having some of those conversations with me in the sessions that go forward.

Katherine:

Okay so it’s sort of naming something about the awkwardness but also holding ourselves as practitioners you know us not being too awkward and actually being quite confident that this could be helpful if it’s given a go.

What about with a younger child like Cara?

Beck:

With Cara, it may be that she’s more at age six. Maybe she’s more readily

eager to do something particularly if we can dress it up through music through story. In the clinical guide in the appendix is a lovely story about a scarecrow and how he goes from rigid and tense to relaxed. We might even with Cara, who likes the pet cat, we might do about the tense cat and the relaxed cat. So, drawing in on her interests. Maybe she’s more used to sitting with her eyes closed when there’s a piece of music on at school. So, we might be able to find out things that she already enjoys to relax and then kind of harness those and use those as tools to facilitate her relaxation in the session.

Katherine:

So sometimes using something we know about the child or young person and sometimes also really applying what we understand about their age and developmental stage. Brilliant. Okay and is there anything else we can do in terms of creating an environment that helps a child feel safe and feel able to kind of try these relaxation techniques? Or even with our own bodies or with our own presence, how do we create that sense of safety?

Beck:

That’s such a good question isn’t it to think about not just the activity that might create a sense of safety, but all those things around it in terms of the environment. Is this a room? Are we in a place where this child feels relaxed and safe? Is there lots of traffic coming past? And obviously we can’t always create the perfect space, but can we allow the young person the child to work out where do they want to sit? Where should we put the table? How do you want to be? And then, absolutely as you said, about being mindful of our own bodies and if we’re sitting there tense then that might convey something that isn’t so helpful to a child. If we’re able to show the relaxation and actually take part in it with the child maybe that’s a way of us being aware of our own body and working out how we can help the child feel more relaxed.

Katherine:

Yeah, I think sometimes you can really model something you can kind of and that really helps the child or young person come through that awkwardness or that sense of kind of unease to something more comfortable.

Beck:

And then I wonder whether it can also be part of a really familiar routine in our sessions once we’ve got that going that we set up the room. We create a place that feels calm and safe and then maybe we’ll do a little bit of that relaxation to start the session and get us in a place where we’re ready to talk about and think about some of those things that have been really hard for them and with their traumatic bereavement.

Katherine:

So Beck, we’ve talked a bit about the real preparation that we need to do with children and young people to make sure they’ve got a kind of safety net, so they can return to a relaxed state when they’ve touched on something upsetting or difficult.

How would you choose which other elements to use with children and young people? I know in the guide we start with formulation and that’s the source of information about the child and the child or young person that we’re working with. How might that help us to make decisions about which activities to use or which kind of sections to move towards after we’ve done those relaxation techniques and after we’ve maybe helped the child or young person say something about their experience of the death?

Beck:

Thank you. I think that’s a really important thing for us to consider and probably going back in the guide to that section about how we identify traumatic bereavement is going to be key for us thinking about, okay, so what activities do we want to use? So, in the guide there’s that section about formulation where you’re drawing together, ideally with the child and young person, and gathering the information about the factors have made it hard, those predisposing.

The triggers of what happened around the death that precipitated and then they kind of lead into this middle part: the presenting need. So we started to draw up, with listening to the child and young person about the ways and their grief is impacting on them, we started to draw up what the difficulties are. For Wesley we were seeing very much that he was becoming disengaged, had withdrawn from his peers, was lacking motivation, even engaging with mum at home had been hard. So, we kind of got an idea of something around there. We might then have gone on to use some of the tools and measures. Maybe with Wesley we would have used the RCADS. Not so much for the anxiety side but it might have showed us that his low mood and depression score was a little bit higher and that might give us an indication actually that matches what Wes is telling me, what I’m hearing from mum, along with mum what we’ve got in the formulation. Then it’s about having a look. We’ve done some work on relaxation, we’ve had a really good think about what happened when your dad died and we’re beginning to understand what’s made it so hard for you – the meaning you’ve made from that death and you’ve done amazingly at doing that. I’m also hearing that actually it’s really hard for you to engage and there are lots of things you used to enjoy doing but actually you can kind of see them out there in the distance but they’re not things that you feel ready to take a step and that’s making me wonder whether we could do some work specifically about rebuilding your life. Start beginning to get you back to doing some of the things you used to enjoy and see how that feels for you. So kind of really leading on from that formulation, the information we’ve gathered and then asking the young person and checking we’ve got it right.

Katherine:

So, there’s that there’s that thinking through process for the adult and really trying to follow that thread, that logical thread of: these are the things I’ve noticed, these are the things that have come up in the questionnaires that I’ve used.

Selecting an activity

These are the things that other people say the school, or the parents have told me and that leads me to think that this might be the most important most useful kind of activity that we could do. But then checking it out with the young person and see if that makes sense to them as well and fits with their sense of what they need. That’s really helpful and I guess it it just reminds me that we’re not suggesting in the guide that every element is necessary. You don’t have to work your way through kind of using every activity and kind of covering everything.

Beck:

We would want to avoid some kind of scatter gun where you do this activity, this activity and this one in a kind of vague hope that something is helpful. That it is really tailored to the young person and the thing that they’re struggling with most — the aspects that are impacting on their life the most. By checking in that we’ve got it right, we also help the young person hopefully feel that we’ve listened to them and we’re validating what they’re feeling and thinking and experiencing. And then we can move into: “Should we have a go at this? Some young people have found this is helpful. The evidence suggests that when we’re feeling like that.” We can start to introduce those new activities and the right activity hopefully for that childhood young person.

Katherine:

It sounds like once you’re convinced that that might be helpful, it’s also about getting the young person on board and kind of working in partnership and help making sure that you’re sort of setting off into that process together

Beck:

Yeah. I think one of the reasons we also wanted to include some psychoeducation so that the practitioners got a really clear idea about why we’re suggesting that activity and then they can take that and explain to the child a young person: “This is why we think this one might be helpful, we wonder whether this is what’s happening for you.” And we know that within low mood that kind of cycle, that vicious circle that’s going around of feeling low, thinking low things: “My life’s rubbish,” and then not wanting to do things, kind of keeps that circle of thoughts, feelings and behaviours going. And we also know that if we wait for the mood to change — often a young person will say: “Well I’ll just wait until I feel better and then I’ll start doing things again.” Actually, you might not feel better because you’re still trapped in that cycle. So, it’s about saying should we try doing something different just to see how it works and let’s collaborate. Let’s give it a go and see what happens.

Katherine:

So there’s a process in a way of kind of deciding together. I think it’s really good idea to use those visuals to kind of show, for example if you were going to show Wesley, show him how his kind of thoughts and feelings are compounding his decisions which actually then lead to him feeling low even more so show him that cycle and how that kind of is evidence that goes against the idea that things will just get better on their own. That actually something different needs to happen.

Beck:

And that we should we just try something different and see how it goes.