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Growing up with Grief: Revisiting the Death of a Parent over the Life Course

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OMEGA, Vol. 63(3) 271-290, 2011

GROWING UP WITH GRIEF:

REVISITING THE DEATH OF A PARENT
OVER THE LIFE COURSE

NANCEE M. BIANK
ALLISON WERNER-LIN
New York University

ABSTRACT
In the era of managed care, evidence-based practice, and short term, solution
focused interventions, clinicians in agency based settings generally do not
have the luxury of long-term contact with bereaved children. Although a
substantial, yet controversial, literature argues that children cannot fully
resolve early loss until adulthood, limited attention is given to how children’s
understandings of early loss shift as their cognitive capacities mature. This
article argues the emotional experience of grief shifts: 1) as children grapple
with both normative life changes and the tasks of mourning, and 2) as their
cognitive and emotional development allow them to understand and question
aspects of their deceased parent’s life and death in new ways. This article
will present an overview of longitudinal and cross-sectional research on
the long-term impact of childhood grief. We then suggest the ways bereaved
children and adolescents revisit and reintegrate the loss of a parent as their
emotional, moral, and cognitive capacities mature and as normative ego-
centrism and magical thinking decline. To demonstrate these ideas, we
draw on the case of a parentally bereaved boy and his family presenting
across agency-based and private-practice work over the course of 14 years.
This case suggests the need for coordinated care for children who are
moving beyond the initial trauma of parental loss into various stages of grief
and reintegration.

271

Ó 2011, Baywood Publishing Co., Inc.

doi: 10.2190/OM.63.3.e
http://baywood.com
272 / BIANK AND WERNER-LIN

While the loss of a parent is permanent and unchanging, the process is not:
it is part of the child’s ongoing experience. (Worden, 1996, p. 16)

INTRODUCTION
A substantial literature explores the ways early parental loss and bereavement
map onto a child’s development and core competencies. This literature identifies
the challenges the parentally bereaved child faces in mastering both the normative
tasks of development and the primary tasks of mourning (Oltjenbruns, 2001).
As these processes unfold in tandem, the death of a parent and the grief that
follows are woven into the core fiber of the bereaved child. Development becomes
overshadowed with guilt-laden magical thinking, fantasies of reunion, and the
continued devastation and regret about the life that could have been had the
parent lived. The deceased parent’s absence suggests the child does not have the
familiar supports to accomplish normative or grief-related tasks. The potential
psychological loss of the surviving parent to their own grief means children
may be attempting to grow and grieve on their own. The child development
literature suggests children’s acquisition of cognitive, moral, and emotional skills
progresses somewhat sequentially and is cumulative; earlier tasks must be
mastered before more complex ones can be attempted (Davies, 2004). When a
child experiences disabling grief (Webb, 2003) s/he is overwhelmed with the
tasks of mourning and may become unable to stay on track developmentally.
Thus, the changes that ensue as a parent becomes ill and dies significantly
impact the child’s developmental trajectory. Yet limited empirical or clinical
attention is dedicated to tracking the long-term consequences of early parental
loss as children grow.
Models of grief and human development must attend to the unpredictable,
cyclical, and chronic nature of parental loss in childhood (Edelman, 2006).
Children do not have the moral or cognitive capacity to understand and process
the separation and its immediate or long-term consequences. Thus, children
cannot complete the mourning process. This notion is supported by a solid
literature (Christ, 2000; Christ, Siegel, &, Christ, 2002; Worden, 1996). Clark,
Pynoos, and Gobel (1994) posit a “shocks and aftershocks” or “cascade” model of
children’s grief, where children re-experience the death of a parent at successive
developmental stages. Bowlby (1980) suggests children retain a relationship with
the deceased parent. He suggested, and we have found evidence in our clinical
work to support the notion, that part of healthy mourning involves reconsidering
this relationship at the varied stages of development. As the bereaved child grows,
s/he reinterprets their parent’s life and death in light of more finely developed
cognitive and emotional tools. We suggest here that this reworking is a lifelong
process. Further, we suggest that as children reinterpret the death of their parent,
they must also address their own earlier understandings of their parent’s life and
death, and they must grieve the life they lost when their parent died.
 GROWING UP WITH GRIEF / 273

The case discussed in this article describes clinical work with a boy and his
family over the course of 14 years and across two different clinical settings. This
work began in the context of a non-profit, community based organization that
offers a host of psychosocial services at no cost to individuals, families, and
communities affected by cancer. Programs provide educational, psychosocial,
and supportive interventions in support group, family, and individual modalities
(Biank, 2002). Families transitioned in and out of groups, matching the ebb and
flow of cancer’s chronicity (Werner-Lin & Biank, 2009). As the needs of children
or parents became intermittent or too specific for the structured curriculum in
support groups, families had the option of transitioning into private practice with
the facilitating group social worker. This was common as the needs of these
families were no longer in line with the needs of families in the throes of the end
of life or the immediate family reconstitution following parental death.

TRAJECTORIES OF CHILDREN’S GRIEF

Evidence of the Long-Term Impact

of Early Parental Loss
Collectively, longitudinal studies addressing grief over the death of a parent
suggest confusing results. Some studies find that children tend to revert to
previous levels of functioning between 6-12 months following the death of a
parent (Raveis, Siegel, & Karus, 1999; Worden, 1996). Other studies find that
children experience increased risk of psychiatric disturbance in the first 2 years
following their parent’s death (Cerel, Fristad, Verducci, Weller, & Weller, 2006).
Discrepancies between these investigations may be explained in the longevity of
the study rather than differences in the circumstances surrounding the parent’s
death or in measurement strategies.
Worden (1996), in a 2-year prospective study, followed 70 bereaved families
with 125 children and 70 non-bereaved families with 70 matched controls.
Researchers conducted semi-structured interviews with both children and
surviving spouses at 4, 12, and 24 months following the parent’s death. The
research team found that within 6-12 months nearly 80% of his sample resumed
levels of functioning commensurate with those before the loss. However, 21%
of his sample showed more serious bereavement complications 2 years following
the loss. Common psychiatric and emotional symptoms in this group included
higher levels of anxiety, social withdrawal, social skills deficits, and lower
self-esteem and self-efficacy. Of particular concern here are social skills deficits
that inhibit help seeking and relationship development to support children
as they grieve. Further, the most pronounced differences in this sample were
not apparent until the 2-year anniversary of the loss (Worden, 1996). While in
the year immediately following the loss family and community supports tend
to bolster family resources and coping, this support is generally significantly
274 / BIANK AND WERNER-LIN

diminished in the second year, leaving families to feel greater emptiness and
isolation. This difference in community supports is not captured in “longi-
tudinal” studies of child bereavement lasting less than 1 year.
Cross-sectional investigations suggest the key to understanding the inter-
section between grief and child development lie in prolonged engagement. Hope
Edelman’s (2006) extraordinary work Motherless Daughters demonstrated how
chronic grief is woven into the fabric of emotional development throughout the
life span. In a retrospective study, Edelman interviewed 92 women and surveyed
another 154 by mail. Participant demographics represented a variety of geographic
and demographic variables, and nearly 75% of the participants’ mothers died
before their daughters turned 19. Her respondents discussed how their mother’s
death marked the end of childhood. They discussed having grieved to the
best of their ability as children, yet without the possibility of resolution, their
mother’s death shaped their very core identities and their movement through the
life course. At major developmental transitions, the longing for the deceased
parent reignited the grieving process as they wrestled with feelings of loss and
abandonment. The childlike desire for the parent never truly ended, so mourning
never completely ended. To support this, while her study population included
women aged 18-70, a full 84% of survey participants responded they had either
only partially completed grieving or had not completed grieving at all.
Cross-sectional studies also suggest permanent separation from primary attach-
ment figures early in life can lead to the development of poorly regulated neuro-
emotional response systems (Brotman, Gouley, Klein, Castellanos, & Pine,
2003). In adulthood, parentally bereaved children experience elevated cortisol
activity when faced with daily stressors compared to adults raised by two
married and cohabitating parents (Luecken, Kraft, Appelhans, & Enders, 2009).
The build up of daily stressors, or “allostatic load,” leading to chronically elevated
cortisol increases adult risk of developing a host of health complications (McEwen
& Seeman, 2006), including heart disease, chronic pain, hypertension, athero-
sclerosis, immune disorders, in addition to modifying brain structures that support
memory and cognitive functioning (Lupien, Ouellet-Morin, Hupbach, Tu, Buss,
Walker, et al., 2006; Vanitallie, 2002). Chronic stress shapes the way information
is translated and stored in the brain, influencing whether or not events are defined
as stressful (Lupien et al., 2006). Early parental loss is also linked with elevated
risk of adult psychopathology, specifically depression and lower self-confidence
(Mack, 2001; Mireault & Bond, 1992; Saler & Skolnick, 1992).
Parentally bereaved children are likely to face additional stressful losses,
including their homes, family income and health insurance, and other familiar
community supports that would have otherwise supported their grief and cele-
brated their achievements (Werner-Lin, Biank, & Rubenstein, 2010). Further,
the death of a parent involves pervasive disruptions in family life and in the
child’s representational models. The child’s confidence in the world, in the
parent’s omnipotence, and in their own agency are destroyed. These additional
 GROWING UP WITH GRIEF / 275

stressors may be experienced profoundly, as their parent’s death robbed them of

an important relationship within which they could build mastery over emotional
regulation. To cope, children fall back on defensive strategies that previously pro-
moted mastery (Samuels, 1988). In sum, not only do children experience the pos-
sibility of a greater number of life stressors following the death of a parent, but their
stress responses are likely to be more intense, chronic, and health-threatening.
Studies of adult cortisol disregulation of parentally bereaved children suggest
poor health and mental health outcomes are consistently mediated by warm,
responsive, and consistent caregiving in the aftermath of parental death (Luecken
et al., 2009; Luecken & Lemery, 2004). Yet, bereaved spouses and other sur-
viving loved ones are frequently consumed with grief and unable to provide such
consistent nurturing. As families progress through the stages of adaptation to
loss, the experience of grief may differ dramatically for partners and children.
The death of a wife or husband is qualitatively different than the death of a
parent. As grief trajectories fork, children may continue to experience intense
loss while adults, more cognitively and relationally savvy, are able to experience
acceptance and integration. Yet, the bereaved child may never fully separate
(decathect) from the deceased parent (Silverman, Nickman, & Worden, 1992).
Thus, successful grieving is not measured in the termination of grief, but rather
in the child’s functional adaptation to prolonged grief. The child’s successful
adaptation, then, is highly dependent on the surviving parent’s ability to manage
their own grief and to tolerate their child’s ongoing pain.
Research on child bereavement suggests early parental loss has significant
long-term implications for relational development (early attachment models
integrate expectations for abandonment or painful separation), social develop-
ment (teens struggles with anxiety and perceived lack of predictability in their
lives, for example, Worden & Silverman, 1996), emotional development (adult
psychopathology) and physical health (disregulated/overactive stress response).
Yet these responses are limited if the surviving caregiver (or other consistent
adult) can manage their own grief to provide consistent, responsive nurturing to
children. When such support is not available, the child may adapt coping skills
useful in the moment, but which elevate risk for future psychopathology.

Linking Events Surrounding the Death

to Long-Term Adaptation

Like Worden (1996), Cerel and colleagues (2006) also followed bereaved
children for 2 years. They separated their sample into children experiencing
“simple” versus “complex” bereavement. Complex bereavement was defined by
situational antecedents to the parent’s death, not events afterwards. This follows,
since children and adolescents frequently struggle more during the terminal
phase of an illness than after their parent’s death (Siegel, Karus, & Raveis, 1996).
During the terminal phase, children may witness the violent throes of a parent’s
276 / BIANK AND WERNER-LIN

death. Cerel and colleagues (2006) found that children experiencing anticipatory
loss displayed more symptoms of anxiety and depression and reported lower
self-esteem during the terminal phase of illness (when psychosocial support
may not be in place) than immediately after (when the community may recognize
more easily the need for formal support to children and families).
Problems with long-term adaptation also brew in the terminal phase of an illness
because children are given incorrect, incomplete, or abstract information about
illness, death, and mourning (Bowlby, 1980). Inconsistencies and abstractions
challenge a child’s already taxed emotional immunity by further confounding the
reasons for the parent’s impending death. Children create meaning from these
complex messages. Often self-deprecating or magical thinking are woven into
these meanings and become entrenched in long-term understandings of life, death,
self-worth, and agency. Saler and Skolnick (1992) found that the ability to speak
openly about the death served a protective role against adult depression. Yet,
surviving loved ones frequently struggle to answer children’s questions with the
same candid and direct manner in which children ask them.
The body of literature examining the long-term implications of early child-
hood parental death suffers from a number of methodological and theoretical
constraints. First and foremost, cultural understandings of the pacing of grief and
the realities of research funding and endurance necessarily limit the length of
longitudinal studies. In addition to Worden (1996), Christ (2000) followed 87
families with 157 children starting 6 months before the parent’s death to cancer
and for 14 months after their death. Cerel, Fristad, Verducci, Weller, and Weller
(2006) followed 360 bereaved children and their surviving parent, interviewing
each at 2, 6, 13, and 25 months following the parent’s death. Worden’s (1996)
findings in particular suggest a longer time frame is necessary to adequately
understand the ebb and flow of children’s grief. Studies of children’s grief,
whenever possible, should recruit children before the parent’s death to address the
pre-death family dynamics and communication that shapes children perceptions
and coping. Yet death, even when it is anticipated, is a much simpler point of entry
into the research endeavor.

GRIEF AS A FOUNDATION FOR CHILD DEVELOPMENT

Healing children’s grief included the construction of a legacy created by
continuously revising the image of their dead parent. As such, the legacies
represented complex reconstructions of children’s relationships with a parent
who was no longer present for day to day interactions but who nonetheless
remained a constant reality in their lives. (Christ, 2000, p. xvii)

A Developmental Frame:
Grief is Renegotiated, Not Resolved
Worden (1996) lays out the tasks that mourning children face after the death
of a parent, tasks that must be understood in the context of the child’s developing
 GROWING UP WITH GRIEF / 277

cognitive, emotional, and social life. The first task is to accept the reality of
the loss, a task challenging for young children who have not yet mastered the
concepts of permanence, irreversibility, and decentration (Davies, 2004). In place
of accepting death, bereaved children must accept the enduring separation from
the deceased parent. The second task of mourning calls for the child to experience
the pain of the loss. The third task involves adjustment to the environment without
the deceased parent, accomplished by filling the pragmatic and emotional gaps
left in their wake. This includes a dynamic shift in the child’s relationship with
the surviving parent (Christ, 2000; Worden, 1996). The final task involves placing
the deceased parent into the context of the child’s ongoing life and memorializing
them in a way that supports growth.
We suggest that children’s grief is never fully resolved. Successful mourning
is not accomplished within the bounds of any developmental stage. Children may
adaptively address each of the tasks of mourning at each stage. Yet, as they grow
and encounter nodal life transitions, they must begin these tasks again with
a more mature set of tools. Revisiting the tasks of mourning allows the child to
understand death more generally, their parent’s death more specifically, and their
own loss with new eyes. As children revisit the tasks of mourning at each
successive stage they rework not only the death. They also rework their own
formulations about the death from earlier developmental realms and their own
beliefs about the hypothetical life they would have led had their parent survived.
Models such as Worden’s (1996) provide significant contributions to devel-
oping interventions to support children in the immediate wake of parental loss.
These models must grow, however, to address the ways children confront these
tasks as their cognitive and emotional capacities mature. Before children acquire
concrete operations, they struggle to take the perspective of others and tend to
focus on the most salient aspect of an event or experience. When children are
entrenched in egocentric thinking they are the most salient aspect of their own
environment. Magical thinking leads the child to believe they are at fault for
their parent’s pain, illness, or death. Decentration, a core competency of concrete
operations (Davies, 2004), is of particular importance since it marks the decline
of egocentric thinking and allows elementary perspective-taking. Consequently,
as children develop concrete operations and later the ability to contemplate
abstractions (Davies, 2004), they are able to understand their parent’s death in
increasingly complex and less egocentric ways (Corr, 2010). This permits the
child to see the death and the events surrounding it differently from how they
experienced it.
We further suggest that the intensity of the child’s grief work is not diminished
until the child becomes an adult. Rather, grief becomes a primary context
within which the child’s development occurs. Loss becomes integrated into
the child’s core self at each stage of development, a platform for the child’s
understanding of him or herself as an actor in the world. Reworking the parent’s
life and death are not evidence of pathology, but rather demonstrate the creative
278 / BIANK AND WERNER-LIN

ways children dole out grief in manageable portions to digest as their development
allows more comprehensive and intense attention (Altschul, 1988).

Transitions

Developmental transitions are a time of normative structural flexibility to

accommodate change in family life (Carter & McGoldrick, 1999). For the
parentally bereaved child, this flexibility may be interpreted as instability.
Normative transitions such as entering high school, experiencing a first romantic
relationship, or applying to college may not be undergirded by the safety of
consistent caregiving that facilitates adaptive transformation. The absence of the
deceased parent is felt profoundly, sometimes surprisingly, especially if the
surviving parent is preoccupied with either their own grief or with pursuing a
life after their spouse’s death. Skills the child adapted to cope with their parent’s
death are no longer adequate as they face new possibilities. Since the deceased
parent would have supported these transitions, the child is likely to seek out a
new relationship with their deceased parent at these times to support forward
movement. Otherwise, the child would not have the confidence or the continuity
to make life changes. In addition, new cognitive and emotional skills require the
child to transform understandings of the parent’s life and death (Miller, 1995)
at a time when the child is feeling particularly unsteady.
By virtue of these being transitions along the spectrum on individual
development, the child is likely to be hitting them in isolation; for example, s/he
is the only child preparing to graduate from high school. The pacing of grief
across the family system varies tremendously based on the relationship to the
deceased. The death of a spouse is different than the death of a parent, and all
family members grieve at their own individual pace. While the surviving spouse
may experience some resolution and forward movement, the child remains
entrenched in the loss. Dis-synchronous expressions of grief may inhibit feelings
of connection in families (Tyson-Rawson, 1996), further isolating the bereaved
child. An actively grieving child may be marginalized, or worse, ridiculed, by
family members who are no longer actively grieving, pushing the child’s grief
into hiding. This child’s grief is then renegotiated without the support and
continuity of the surviving parent. In this case, the relationship with the deceased
parent becomes a critical link back to the child’s past that allows the child to
move forward.
Children who lose parents much earlier in childhood are likely to experience
isolated grief with fewer constitutional resources. These losses more significantly
and detrimentally impact the development of ego strength, a sense of agency, and
enduring memories of the deceased. The adolescent who experiences a parent’s
death is equally and profoundly bereaved and in crisis. Yet this teen has also
had additional time with their parent, increasing the extent of nurturing to build
ego strength and a core self. The adolescent who is grieving 10 years following a
 GROWING UP WITH GRIEF / 279

parent’s death not only had less time with their parent, but is experiencing chronic
mourning without the solid foundation of the other teen.
The following case will demonstrate the clinical issues faced by a parentally
bereaved child over 14 years beginning before his mother’s death and following
him for 10 years afterwards. The case of Matthew demonstrates the clinical
presentation of normative grief as it is revisited during developmental transitions
and transformed with new cognitive and emotional tools. The clinical team
worked with the entire family starting four years before his mother’s death.
Matthew’s family remained involved at the community organization for a year
after Paula’s death, at which time Matthew transitioned into private sessions with
the facilitating social worker. This case is intended to demonstrate the pervasive
impact of parental loss and the nonlinear pathways of grief for this growing
boy. Clinical work with Matthew and his family suggest a therapeutic relation-
ship with the deceased parent before their death facilitates clinical work with
surviving children.

THE CASE OF MATTHEW

“I’m Grieving in My Sleep”

Matthew was 4 years old when his mother was first diagnosed with breast
cancer. The nuclear unit, including Matthew’s parents (mother Paula and father
Javier) and brother Chris, older by 4 years, presented for treatment. Paula worked
before the boys were born, and she was home full-time raising the boys when she
was first diagnosed. She and Javier had a strong, jovial marriage and a relatively
traditional division of labor. Paula was the nurturing parent and mediated between
Matthew and Chris when conflicts arose, Javier was the disciplinarian and was
more emotionally restrained than Paula. The family loved baseball, the boys
played on local teams and the family frequently attended professional games
together. At the time of Paula’s diagnosis, the family began concurrent support
groups, one for children and one for parents. Matthew was precocious, able to
participate and asked appropriate questions. Paula’s cancer went into remission
and the family terminated.
Two years later when the cancer returned more aggressively than before,
Matthew asked his parents to restart the support groups. He participated appro-
priately during group meetings, helped other children with activities, and engaged
actively with group facilitators. At age six, Matthew was a happy and sociable
child, on track developmentally and academically. Paula and Matthew had a
strong and positive bond. Paula knew her prognosis was poor and she worried
about Matthew, who was a more sensitive soul than Chris, one Javier never
fully understood. While Matthew knew Paula was ill, during the course of her
illness he never thought she would die. He learned when he was four that cancer
made his mother sick, but then she got better and life returned to normal.
280 / BIANK AND WERNER-LIN

As Matthew approached his eighth birthday, Paula became critically ill and
entered home hospice. At this point the social workers met with Paula and Javier to
help them tell Matthew and Chris. They agreed to continue being open and respon-
sive with the boys. Both parents were concerned they might get too emotional
in front of the children and were reassured by the social worker that it was
appropriate to cry together. They told Matthew and Chris, “Mom’s doctors are
doing everything they can to help her fight, and mom is doing everything she can
to fight cancer. She is taking her medicine, resting, going to support group. But the
cancer is still growing and this means mom will most likely die.” Paula expressed
hope that the social worker would continue to be involved in Matthew’s life after
her death, to support his growth and help mediate between Matthew and Javier.
The agency staff was particularly involved in supporting this family when
Paula was at the end of her life. She was in and out of consciousness, barely
speaking, and no longer eating. The night before she died, Matthew sat with her
on her hospice bed and read her his favorite bedtime story. He believed she
heard him because she smiled at him when he finished reading. With the social
worker’s help, Javier explained death to Matthew and Chris, and he coached
the boys to say goodbye to her. When Matthew left for school the next morning,
Javier told him Paula might die that day. So when Matthew was called into the
principal’s office he was not surprised to learn his mother died.
Paula’s funeral service was filled to the brim. Matthew and Chris’ baseball
teams, which Javier coached, arrived in uniform and sat together in the back.
Javier delivered a eulogy, Matthew recited a short poem, and Chris made a short
speech. Matthew was pleased with the outpouring of support. To this day the
family remains very close with members of the community. The family transi-
tioned into the agency’s bereavement program. Matthew and Chris continued in
the program for the year following Paula’s death, and Javier participated in the
parallel bereavement group for parents, where he acknowledged his need to
learn more about his sons’ experience with grief.
Two years after terminating in the bereavement program, Javier contacted
the social worker that supported their family for consultation about Matthew.
His grief, dormant for several years, was reignited by a school project to write an
autobiography. The assignment required him to confront his grief and the reality
of his mother’s death. He was unable to complete the project and failed English.
Javier was furious. He believed Matthew’s continued grief to be manipulative
and brought Matthew reluctantly for individual treatment. Matthew returned to
treatment feeling isolated. He felt unable to approach Javier with his questions
and feelings about Paula since he had learned not to talk about her or her death.
He was also scared and questioned his feelings since Javier hammered into him
that his grief should be finished. Matthew, however, had lingering questions
about his mother’s death. Matthew was mad at God, and worried that God and
his mother would be angry with him for failing. He brought these questions and
concerns to the individual sessions with the same clinician who had known his
 GROWING UP WITH GRIEF / 281

mother. In their work together, Matthew reported a series of vivid dreams that
facilitated the clinical work that ensued.
Matthew dreamt he was watching a baseball team dressed in white uniforms.
His mother was playing shortstop, his maternal grandmother (deceased) was
playing first base, his paternal grandmother (deceased) was on the bench and
Freddie Mercury (deceased) was in left field. The coach was a God-like
image. The other team was dressed in red and black.

Matthew interpreted this as a sign his mother was in heaven with other deceased
loved ones (and apparently with famous dead singers). At this point in his
life, Matthew needed assurances that his mother was in a safe place he could
access. The clinician guided him to connect with his mother in his heart and his
memories. Listening for errors in Matthew’s 8-year-old perceptions, the clinician
was able to provide some basic facts about the time surrounding Paula’s death.
The clinician was familiar with Paula, participated in her funeral, and provided
support before and after her death. The clinician’s memories of Paula bolstered
Matthew’s beliefs in himself and his mother’s love and concern for him while
also validating his memories of his relationship with her. She told Matthew
of Paula’s concern that he was particularly sensitive, and different in this way
from Javier and Chris. These conversations provided Matthew with additional
memories of his mother for him to internalize. At this point, the clinical relation-
ship became a critical and powerful link back to his mother, increasing Matthew’s
alliance with both women and shaping the maternal transference between the
two. The social worker facilitated a conversation between Matthew and Javier
during which Matthew was able to tell his father that his father scared him. Javier
listened with mixed emotions; he expressed disappointment that Matthew did
not come to him directly with questions, but acknowledged his parenting style
was rejecting of Matthew’s experience.
At age 13, Matthew returned to treatment. His return was precipitated by
the convergence of several important events. He was approaching the 5-year
anniversary of Paula’s death, which coincided with Mother’s Day, and what
would have been her 48th birthday. He was also beginning high school. Javier
chastised him for needing further therapeutic guidance. At age 11 Matthew was
positive his mother was in heaven. At age 13 he was “pretty sure” that heaven
existed and that Paula was there. He shared this recurring dream:
Matthew dreamt he was riding along a black, bubbling river in a canoe
pulled by a man with a sickle. The boat approached a divide in the river and
the man steered towards the path with light, angelic music. He thought
the man might be taking him to his mother.

At this point in his grief, Matthew is entertaining abstract, existential thought

less defensively. The clinician allowed him to discuss these thoughts and to
question God without judgment.
282 / BIANK AND WERNER-LIN

Matthew also had new questions about his mother’s death. He had dreamt about
her death and was unsure of whether his dream was a real memory or a con-
struction of his brain. He came in wanting more detail about his mother’s illness
and her choices. He shared this dream:
Matthew was observing himself and his mother during the last 18 hours of
her life. She was in a coma and he was reading her a book while she lay next
to him listening. He felt happy to be with her. Then he flashed to the
next morning and he saw his father sitting with his mother, looking sad.
His father was holding his mother’s hand, which suddenly went limp which
he knew meant she had died.

Specifically, Matthew knew Paula ordered a DNR. At the time Javier discussed
this with the boys but Matthew did not understand what it meant. He remembered
her intermittent comas, and wondered whether Paula might have survived without
the DNR. At age 8 years, he believed the DNR meant she was too tired to stay,
that she had given up on him. This belief lingered for 5 years and severely
damaged his sense of self-worth. He shared this dream:
Matthew was walking through a hallway and on each side were people
he needed to apologize to. Some were alive and smiling and others were
dead with stone cold faces. The ones that were alive were a girlfriend he
had broken up with and a former friend with whom he had lost contact.
His mother was among the dead, and he apologized for his grades, his
behavior, and giving up on God.

Matthew’s lack of self-esteem was palpable as he discussed this dream. Inter-

ventions following this dream involved educating Matthew about why, when, and
how a DNR is ordered. He came to understand that the DNR did not cause her
death. Understanding the biology of the illness and her death allowed him to
move away from the magical thinking which connected his sense of self-worth to
her departure. Further, the ability to take his mother’s perspective permitted him to
see this as a viable choice that was intended to protect him. These experiences
reinforced the finality of her death and enabled him to separate and respect both his
own experience of her death and the medical circumstances of her death.
As Matthew came to understand the finality of Paula’s death in greater concrete
and abstract terms, he began to mourn the possibility of reunion. Once again,
he felt the emptiness of her absence and the impossibility of a family life lost.
He shared this dream:
Matthew awoke and went downstairs to have breakfast before school. As he
sat down at the kitchen table, the back door flung open. His mother stood
there, covered in dirt and bald like she was when she died. He was immedi-
ately happy to see her and she spoke with her regular, loving voice. Then he
looked closer and her face was demonizing and she shot him in the neck. He
felt pain shoot down his body and he fell to the floor. Then Paula growled,
“You’re coming with me!” while she dragged him out the door by his feet.
 GROWING UP WITH GRIEF / 283

In heaven, Matthew saw the possibility of reunion. While he was not suicidal, he
wanted to be with Paula. He worried Paula would have been angry about how
Javier was treating Matthew, specifically about Javier’s belief that Matthew’s
grief was manipulative.
Matthew continued to make sporadic visits to the therapist throughout high
school. He developed a passion for singing, participated in chorus and took
individual voice lessons. He came in for a session when he earned the lead in a
school play and wanted to share the exciting news with someone who would
understand his pride. He talked with the social worker about how his mom died
before he learned he was a good singer. They discussed how this was something
his mom did not know about him. He sang instead for the social worker. The
social worker interpreted this as a transference experience, and she applauded
his efforts as would his mother.
Matthew then presented for treatment with the same clinician as he began
to ferret out where he wanted to attend college and what he was interested in
studying. High school gave him the opportunity to explore other parts of himself
and he found that he has an interest in international business and finance. The
“international” piece was a remnant from Paula who dreamed of travel. He talked
with the social worker about her dreams, which he may want to fulfill in his
travels. Matthew called a few days before leaving for college. He had a dream he
wanted to share with (or store with) the social worker.
Matthew was in his room packing for college. Paula entered and sat on the
edge of his bed just as Matthew sat on her bed the night before she died. She
watched what he was putting in his suitcase and told him to enjoy school and
to take advantage of everything he could. Then she stood up and walked out.

He said the dream made him feel sad and relieved at the same time. He was glad
that she appeared and had good things to say, but he was sad it was only a dream.
We discussed that college was another part of his life he could not share with her.

Case Analysis
Understanding the Nature and Permanence of Death

At 6 years old, Matthew is given developmentally appropriate information

about his mother’s illness and her death. In support group, he learned the language
that he would need to navigate his life in relation to cancer and Paula’s death.
At age 8 years, he knew to anticipate the news of Paula’s death, which enabled
him to say goodbye. He participated actively in her funeral, which was very well
attended, and his family received an outpouring of support. These experiences
helped to feed his understanding of the finality of her death and feed his core
sense of self in relation to his mother.
Concrete operations allow children to begin understanding death conceptually,
and their parent’s death specifically. Yet children retain lingering strategies to
284 / BIANK AND WERNER-LIN

defend against separation they do not entirely understand. Two years after
Matthew terminated with the bereavement group and 3 years after Paula’s
death, he entered individual treatment with the therapist he saw at the agency.
This piece of the work was needed due to a school assignment—a request for an
autobiography. It was a year-long assignment that Matthew ignored. To him, it
felt like a year-long assault on his sense of himself. At 11 years old, he was
paralyzed by facing the truth of his mother’s death and needed to continue
processing the death. He also needed to be cared for and protected to support
his fledgling sense of self-worth.
In parallel to Matthew’s questions about himself and his mother’s love for
him, he had enduring questions about death that reflected his experiences sur-
rounding the loss. These questions were biological, existential, and emotional in
nature, and to facilitate mourning, they needed to be adequately respected and
addressed (Thompson & Payne, 2000). Matthew’s questions revealed his growing
understanding of the physiological process of death, advance directives, and
his mother’s end-of-life intentions and priorities.

Reconstructing the Deceased Parent

and Her Death

The relationship between a child and parent is complex and dynamic, changing
as the child grows older and begins to see the parent as a multifaceted person.
The process of reconstructing the deceased parent is founded on the assumption
that the child can construct a parent in the first place. When Paula died, Matthew’s
understanding of her was appropriately egocentric and simplistic. Without his
own data or memories, Matthew needed to gather information from other sources
to feed his understandings of her and his internalized sense of her.
As Matthew came to understand the biology of cancer and death, he was
gradually able to engage in reconstructing Paula and himself in relationship
to her. At age 8 years, he understood his own experience of her death. Yet, as he
grew, lingering doubts and questions emerged which shed light on Paula’s
choices. The answers to these questions, sought out in therapy, shed light on his
own interpretations of her motivations from the perspective of a younger child.
These questions emerge twice during treatment in powerful ways. The first
surrounded the DNR. The second emerged as Matthew dreamt of the scene at the
time of her death, a scene he did not witness first hand. Yet his desire to physically
locate himself at the moment of her death, to understand the events, enabled him
to create a cohesive story.
Here, the social worker’s relationship with Paula provided a critical link for
Matthew. Matthew entered treatment and spent time with a clinician who knew
Paula, participated in her memorial, and remembered things about her that she
was willing to share. This bolstered Matthew’s inklings about his mother and
forged a strong transference bond between Matthew and the clinician.
 GROWING UP WITH GRIEF / 285

Transitioning: Continuity and Change

For children, safety is experienced in consistency, and change precipitates

stress. During times of stress, children seek out consistent and responsive care-
givers to provide nurturing, assurance, and guidance. The death of a parent is
one of the most stressful experiences a child can endure and the presence
of a consistent attachment figure is critical to children’s short- and long-term
adaptation. The clinician working with Matthew and his family became this
attachment figure by providing both safety and consistency. The clinician func-
tioned as a transitional object for Matthew, one he revisited to shore him up during
his developmental leaps forward. These leaps involved both significant events
(graduations, achievements, life changes) and the development of new cognitive
and emotional lenses with which to view Paula’s life and death.
Matthew began treatment at the agency during a critical and life-altering
change: Paula’s cancer diagnosis. He asked to return to the agency when her
cancer recurred, and stayed through her illness, death, and family reconstitution.
His visits became more intermittent as he returned at several nodal points in
his childhood and adolescence. At age 11, he first entertained abstract thought
(Davies, 2004) and questioned his mother’s end-of-life choices. He separated
himself from her choice for the first time. This shift in understanding allowed
him to move forward with a replenished sense a self-worth. At age 13, he entered
high school and approached the 5-year anniversary of his mother’s death. He
came to treatment to share his successes and interests with the clinician in the
space that contained his relationship with his mother. He also returned as he
prepared to leave for college. As Matthew grows into adulthood we anticipate
he will return as he completes college, moves into his own residence and con-
templates marriage.

Roles for Surviving Parent

Surviving parents (and other close family and community members) provide
a number of significant roles for the bereaved child. When these roles are
performed optimally, they mitigate the risk of a bereaved child developing health
and mental health complications in adulthood. These roles include providing a
healthy mirror and model for the child’s grief, providing consistent and nur-
turing parenting, and responding to the child’s ongoing questions about the loss
and about himself/herself (Saldinger, Porterfield, & Cain, 2004). Finally, the
surviving parent contains a wealth of information about the interests, emotions,
regrets, and experiences of the deceased parent that facilitate reconstruction
for the bereaved child. In the year following Paula’s death, Javier provided a
sound mirror. He was actively grieving and attending to the needs of the boys.
Yet, 2 years following termination with the bereavement group, Javier found
Matthew’s grief manipulative. Not only did he fail to mirror Matthew’s experi-
ence or recognize his need for continued discussion about Paula, he actively
286 / BIANK AND WERNER-LIN

admonished Matthew for his feelings. This shut down Matthew’s emotional
expressions of grief, further damaged his sense of agency and self-worth, and
led him to feel increasingly isolated.
Javier’s receptivity to questions and emotional expression about Paula’s death
shaped Matthew’s outlets for his grief (Raveis et al., 1999). Javier needed to
be reminded that even though he experienced resolution and integration about
Paula’s death, Matthew did not. Matthew needed to continue a relationship with
Paula. Coaching Javier to respect the longevity, pacing, and dynamic shifts in
Matthew’s grief enabled him to support Matthew’s link back to her so that
Matthew could move forward developmentally.

DISCUSSION

Transference and Countertransference

Through his enduring relationship with this clinician, Matthew is able to
reach his mother. The clinician had her own relationship with Paula and can feed
Matthew’s sense of his mother while strengthening his bond and facilitating
reconstruction of her. When Matthew returns to treatment he comes back not
only to the clinician, but also to his mother and his evolving relationship with
her. Part of Paula’s peace of mind at the end of her life came from knowing the
clinician would continue to support Matthew, Chris, and Javier. This is a solemn
and heavy charge. Paula was able to teach the clinician about Matthew before
her death, and in doing so she supported Matthew’s grief and development.
Countertransference is powerful. In supervision the clinical team discussed
the challenges of working with the family while knowing the child’s grief will
be lifelong. How can we sit with a child and support them while knowing their
grief will never go away? It is with both heavy hand and heavy heart that we
present this case, only one of the 250 families that passed through the doors at
the community agency over 15 years. In some ways, knowing what is in store
for the child before s/he does parallels the experience in psycho-oncology of
seeing medical turning points before the patient; at times we know the patient/
parent will die before the family does. Clinicians must hold this knowledge
gently and introduce possibilities both slowly and preventively to support ongoing
coping and maintenance of resources.

Anticipation and Planning: The Holding

Environment in Long-Term Grief Work
The clinical environment, the physical space where the work happened and the
relationship between child/family and clinician was built, provided a holding
environment that contained the insurmountable feeling of loss to which this
child was exposed. The therapist held Matthew’s true self, his vulnerable self.
 GROWING UP WITH GRIEF / 287

Since the bereaved child must revisit the parent to move forward, as Matthew did,
s/he will need to revisit the parent metaphorically and emotionally for the strength
and permission to grow beyond the point of the parent’s death. For example,
Matthew’s love of music developed after Paula’s death. This passion marked the
first talent/experience his mother was missing out on. Matthew had dreams of
competing on an internationally televised singing competition, a fantasy designed
to shore up his fledgling self-worth with world wide acclaim.
The clinician, in preparation for the nodal points in Matthew’s life, worked
with Javier to prepare him for resurgences of grief. This will hopefully pre-
vent Javier from continuing to pathologize Matthew’s emotional needs and
allow Javier’s alliance with Matthew to grow. The bereaved child experiences
resurgences of grief at different nodal events, and we predict Matthew will return
as he prepares to graduate from college and when he begins to think about
marriage. His brother Chris, who is heavily allied with Javier, may not revisit
Paula’s death until he has children of his own or until Javier reaches old age.

Recommendations: Partnerships in
Practice and Community-Based Research

Community agencies can offer cost-effective and time-limited group and family
support programs. Agency-based programs should be structured and task-oriented
to deal with the specific and immediate needs of children and families from the
point of diagnosis through recovery or the initial 6-18 months following a parent’s
death. Programs should integrate psychoeducational models for both parent and
child groups. Parent support and education should focus on building language
and understandings of the trajectories of children’s grief to prepare them for the
lifelong process of mourning that children are embarking on. Children also need
language and education about illness, death, and mourning to support their still
growing capacities to understand and process separation and change.
Collaboration with hospice facilities and their multidisciplinary teams can
support families with intermittent support in the period immediately surrounding
the death and through the year following. Yet, the private clinician has the
flexibility and the opportunity to become a bridge between potent resurgences of
grief. Even if the clinician meets the child after the parent’s death, the therapeutic
relationship can contain the grief, help the child to locate the deceased parent,
and understand their loss. Clinicians can identify areas of abandonment and
helplessness, and reinterpret them in a manner that unlocks growth and creativity.
Agencies and clinicians in private practice can collaborate to establish support
groups to undergird children’s grief intermittently during this lifelong process
to normalize their experiences. Such endeavors would provide rich venues for
true longitudinal research. Such research could normalize (rather than pathol-
ogize) the ongoing nature of childhood grief to showcase the creative ways
children mourn and adapt.
288 / BIANK AND WERNER-LIN

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Direct reprint requests to:

Allison Werner-Lin, PhD, LCSW
NYU Silver School of Social Work
1 Washington Square North
New York, NY 10003
e-mail: [email protected]

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