Sibling grief: A case report

Sibling Grief=A Case Report Sue P. Heiney The intensity of sibling grief and the significance of sibling mourning are described in research studies. Yet, nurses caring for dying children may be unaware of these findings and may not offer adequate support to assist siblings in working through grief. Thii article detaii one child’s perceptions of the loss of a brother and provides rich clinical material for understanding typical sibting responses. The description of the therapy sessions provides a model for working with siblings and demonstrates the value of art as a therapeutic medium. These strategies are useful for nurses working with grieving siblings and may be applicable to other situations in which children experience a significant loss.

Copyright

0 1991 by W.B. Saunders

Humpty-Dumpty sat on a wall. Humpty-Dumpty had a great fall, All the King’s horses and all the King’s men, Couldn’t put Humpty together again.

T

HE NURSERY rhyme, Humpty-Dumpty, reflects both lay and professional beliefs about sibling grief. Caregivers and families alike have avoided discussing the death of a child’s sibling, fearing that the child would be devastated by the discussion and would fall apart and and be inconsolable. Harboring such misconceptions about children and grief has led to a poor understanding of sibling grief and to its being largely ignored by nurses and other practitioners (Demi, 1987). The purpose of this article is to describe the content of eight counseling sessions with a 9year-old boy whose baby brother had recently died of cancer. The sessions evolved from a support group project and was part of an overall program of bereavement support developed by the author, whose nursing practice focuses on providing psychosocial support to children with cancer and their families. Additionally, a framework for the sessions and specific therapeutic interventions used will be detailed. LITERATURE REVIEW AND THEORETICAL FRAMEWORK A review of the literature uncovers a wealth of information concerning healthy children’s understanding of death. Since the child in this case study was 9 years old, a summary of these findings is

Company

given. Additionally, specific research ecdotal reports related to sibling grief rized. This information was the basis retical framework that guided the interventions. Children’s

Understanding

data and anare summafor the theotherapeutic

of Death

Jean Piaget was the first to present a theory that described children’s cognitive development as occurring in stages from sensorimotor to formal operations (Piaget, 1960). Researchers since have applied Piaget’s theory to children’s understanding of death and have found that three of the stages that Piaget posited-preoperational, concrete-operational, and formal operational-parallel the child’s changing cognitions about death. For example, Nagy’s landmark study (1948) found that children younger than 5 years old (preoperational) perceive death as reversible; children between the ages of 5 and 9 years perceive death in terms of magical thinking; children older than the age of 9 years see death as the end of corporal activities. Additionally, the 9.year-old child recognizes that death is

From the Children j Hospital Center for Cancer and Blood Disorders at Richland Memorial, Columbia, South Carolina. Address reprint requests to Sue P. Heiney, M.N., R.N., C.S., Mental Health Clinical Nurse Specialist, Children’s Hospital Center for Cancer and Blood Disorders at Richland Memorial, Five Richland Medical Park, Columbia, SC 29203. Copyright 0 1991 by W.B. Saunders Company 0883-9417l91/0503-0002$3.00/0

Archives of Psychiatric Nursing, Vol. V, No. 3 (June), 1991: pp. 121-127

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universal, that it happens to all living creatures. Later researchers have substantiated healthy children’s conceptions of death as coinciding with their developmental stage. Three death-related concepts were studied: irreversibility, universality, and inevitability. Therefore, between birth and the age of 9 years children gradually come to understand that a dead person is gone forever and death eventually will happen to everyone (Childers & Wimmer, 1971; Gartley & Bemasconi, 1967; Koocher, 1973; Nagy, 1948). A partial understanding of sibling grief comes from children’s concept of death. Additional understanding is gained by reviewing the literature on children’s grief. Children’s

Grief

Mental health specialists, depending upon their theoretical orientation, have differing opinions about whether children grieve or mourn. Psychoanalysts contend that children are not emotionally capable of detaching from the inner representation of the person who died (Fox, 1988). In contrast, other theorists believe that grief is a process of reactions to loss, and includes the mental work that a child completes following the loss of a loved one (Fox, 1988; Furman, 1974; Rando, 1984). Elements that must be present for grief to occur are the understanding of death described above, an understanding of time (past, present, future), a concept of self, and some ego mastery (Furman, 1973). Normal grieving involves realizing and feeling the pain of the loss, adjusting to life without the missing person, and withdrawing emotional energy from the loved one and reinvesting it in another (Worden, 1982). Sibling Grief

The death of a brother or sister during childhood is a loss that may precipitate grief. Recently, researchers have begun to study sibling grief as a subset of childhood grief (Balk, 1983; Michael & Lansdown, 1986). As early as 1963, a review by Cain, Fast, and Erickson of children’s disturbed reactions to the death of a sibling found guilt and blame; distorted concepts of illness and death; disturbed attitudes toward doctors, hospitals, and religion; death phobias; comparisons and identifications and misidentification with the dead child; and disturbances in cognitive functioning. No effort was made to determine if these were healthy or

unhealthy indications of grief and mourning. Notable work also has been done by Rosen, who found that the most striking feature of sibling loss is a prohibition against mourning. The prohibitions came from parental, personal, and societal influences. The surviving child tries to protect the parents from further distress by avoiding discussions about the deceased. Additionally, the child’s support network lacks the understanding that the grief is valid (Fox, 1988; Rosen, 1984, 1986). Therefore, the child is encouraged not to reminisce or express feelings, but rather, to be strong and silent. Consequently, the child does not mourn the loss openly. Rosen’s and other researchers’ findings further suggest that sibling grief is similar to grief experienced by adults, may cause long-term distress, and has life-long significance to the survivors (Michael & Lansdown, 1986; Rosen, 1984, 1986). The literature documents a myriad of normal reactions that grieving adults experience: Children’s and siblings’ responses to loss encompass both the same reactions and different ones. Siblings may deny the event or experience sadness, anger, guilt, and fear. Also, the child may complain of bodily discomfort or act out by refusing to obey rules. On a more serious level, the sibling may become depressed, misbehave excessively, or withdraw and be indifferent. The child may have many questions about the death and may respond in an egocentric manner, e.g., ask if he can move into the dead child’s room (Fox, 1988; Scherago, 1987). Grieving parents may react severely to this behavior, leading to further suppression of the grief reaction. In addition to research findings and professional reports about sibling grief, the lay literature has recently addressed this problem. True accounts of sibling grief are described in Losing Someone You Love (Richter, 1986) and For Those Who Live (LaTour, 1983). These books relate personal experiences with loss of a sibling. They reinforce the research finding that sibling loss is a significant loss, attended by grief and mourning. A third source for a perspective on sibling loss is children’s books that give fictional accounts of sibling loss. Some of these accounts seem to be based on the author’s personal experience with loss. Notably, Nadia the Willful (Alexander, 1983), which is a story about a powerful sultan who will not allow his beloved deceased son’s name to be spo-

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GRIEF

ken, gives powerful credence to the against mourning. Several sources mented sibling grief and provided an bereavement issues that may emerge counseling sessions.

prohibition have docuinsight into during grief

CASE HISTORY

Johnny (all names used in describing the case study are fictionalized) is a 9-year-old boy whose younger brother had been dead less than 3 months when he participated in the sessions described below. Johnny is a bright student in a local elementary school who earns average grades. Other than the loss of his brother, his most recent stress was a move to a new neighborhood that necessitated a change in schools. He seemed to make friends easily and to have a good relationship with his parents. His parents seemed to be loving and caring, but were deeply grieving the death of their younger child. The parents seemed psychologically healthy: the mother is a school teacher and the father is a retail salesman. The parents had exhibited minimal denial of the impending death of their child, had encouraged Johnny to be in the hospital with them, and had supported him. The entire family seemed to have an extensive support network. Both parents completed the parent bereavement group sessions held concurrently with the sibling sessions. CONTENT DESCRIPTION OF EACH SESSION

Originally, the therapists planned to have a sibling support group that met concurrently with a parent bereavement group. However, due to a number of bereaved parents who dropped out of this group and the large number of families whose only child had died, Johnny was the only child who attended more than two sessions. Although no psychological testing was planned, informed consent was obtained from the parents for Johnny to participate in the sessions. At the conclusion of the sessions, written consent was obtained from the parents and from Johnny to make slides and blackand-white pictures of the drawings described in this paper. A detailed account of the session’s content, based on the process log kept by the author, is described below. The sessions were structured around topics critical to the resolution of grief and included positive and negative feelings, memories

about treatment, memories about the funeral, the meaning and causality of the death, and saying good-bye. The general format of each of the eight sessions was introduction of the topic for the session, asking the child to draw a picture about the topic, and encouraging the child talk about and explain the picture. Additionally, the sessions were structured around the child’s developmental stage (concrete-operational), which indicated that Johnny understood that death is irreversible and is the cessation of life. He seemed to understand that his brother was gone forever. Session I

This session began with the cotherapists description of the purpose of the sessions and the group’s contract. Confidentiality of the sessions was not a contract item because the therapists believed that the parents and children needed to be connected in their grief and that the parents should receive a summary of the sessions and of their child’s participation. The leaders then explained that the children needed to get to know each other. Each child was asked to list several things about themselves and then to tell the group about these items. For example, the children were asked to tell about their favorite color and class in school, a favorite time of the year, and a place they liked to go. Next, each child was asked to share a positive memory of their deceased sibling. Johnny remembered that his brother “laughed a lot. ” Next, the leaders discussed the purpose of the group, which was to be a special time for sharing thoughts and feelings about the brother or sister that had died. Only one child (Johnny) was able afterward to state the purpose of the group. Lastly, a brief overview of the next sessions was given. Session 2

In session 2, the idea of drawing pictures about the topics was introduced. The child was encouraged to draw during this and each subsequent session. Johnny was told that he could make a memory book about the sessions that he could take home when the sessions were over. The focus of this session was memories about diagnosis/ treatment. Johnny drew two pictures: one depicts an angry child hitting a figure wearing a nurse’s cap; the second shows a doctor helping another patient. The therapists acknowledged that he could have both good and bad memories about his broth-

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er’s treatment. When discussing the child hitting the nurse, Johnny made veiled references to the baby but would not directly admit that the drawing represented his brother. He certainly could not verbalize that it may have represented his own feelings of anger toward the doctors and nurses. Instead, he said, “They want to do good.”

fears and concerns that sharing his feelings would make his family, especially his mother, feel greater sadness and increase her episodes of crying. The therapists explained that being sad is normal and that parents may feel better after they cry. He was encouraged to talk with his parents and tell them his feelings.

Session 3

Session 5

The focus of this session was remembering the last few days before Johnny’s brother died. His baby brother was in the hospital and Johnny visited but only stayed in the room a short time. He would often go to the playroom and interact with the child life specialists. Johnny’s best memory of this time was going to a carnival and getting his face painted like a clown. He remembered making his brother laugh. His picture shows a child standing beside a crib with his arms raised and a baby in the crib smiling. He entitled this picture, “The clown that made Bobby laugh. ” As he talked about his picture he began to express intense feelings of sadness at his loss. He graphically described his plan to commit suicide, to swing out on a rope over a lake, jump in, and not come back up. The therapists gently asked Johnny whether he intended to follow through with his plan and whether he was feeling that he might hurt himself now. He responded that he was not as sad at this time as he had been and did not want to carry out the plan. The therapists supported him in feeling very sad and not knowing what to do to get rid of the pain. The therapists contracted with him to talk to them or another adult if he felt that bad again in the future.

Session 5 was structured to explore existential issues surrounding the death, the meaning of the loss, and explanations of the cause of the death. Johnny was asked to draw a picture about why his brother became sick and died. He drew a refrigerator and stove with a pot sitting on top holding an object. A child is standing to the side and a caption above his heads read, “Oh, no!!!” The title of Johnny’s picture was, “I’m afraid I made Bobby die.” Johnny explained that he thought his brother got sick from cancer because he had not boiled the bottle nipples long enough. After listening to his explanation, the therapists explained that no one knows why children get cancer, but that scientists do know that it’s not anyone’s fault. After further discussion, Johnny drew another picture to explain why bad things sometimes happen. He drew two children with bicycles, one riding and the second one falling down and bleeding. Across the top of the picture are two figures, separated from the rest of the picture by a wavy line, which may have represented heaven or clouds. He explained his drawing by stating that the guardian angel was not watching and consequently, the child fell down. The second figure was never explained but was smaller than the angel. Johnny entitled this picture, “Good days and bad days.”

Session 4

Especially because of the intense feelings of sadness expressed in the last session, the therapists felt strongly that they should continue to explore Johnny’s memories of his brother and significant information about the funeral. Therefore, Johnny was asked to draw his memories of the funeral. He drew a picture of a baby in a casket holding a toy and a pacifier. Two adults stand on one side of the casket, the mother has a tear falling from her eye; the father is expressionless. Johnny stands with tears falling from his eyes on the other side of the casket. He entitled this drawing, “The family is feeling sad.” During this session, Johnny was able to more openly discuss his feelings of sadness and how much he missed his brother. He expressed

Session 6

The purpose of this session was to assess Johnny’s current functioning and encourage him to interact with friends. He drew a picture of himself and his friend playing outside his house. His parents are watching through the windows. Session 7

This session focuses on further exploring Johnny’s feelings, especially his guilt and current functioning. The therapists asked him to draw a picture showing how things were now. He drew a picture of himself playing football with his father. He entitled this picture, “I feel better now because

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I talked and found out it wasn’t my fault. ” Toward the end of this session, Johnny stated, “I didn’t kill Bobby.” However, he did not yet feel comfortable talking with his parents about these feelings. The therapists did see Johnny tell a friend whom he saw after the sessions that he was attending a group for children who had lost a brother or sister. Session 8 Session 8 was a termination session and focused on the therapists’ telling Johnny good-bye as well as facilitating Johnny’s saying good-bye to his deceased brother. This was very hard for Johnny, who wanted the sessions to continue. The therapists shared their feelings of sadness and how much the sessions had meant to them. Johnny became teary and expressed much sadness. The therapists suggested that maybe Johnny did not get a chance to say good-bye to his brother as he may have wished. Johnny agreed. He was offered a chance to say good-bye in a drawing by showing what he might have wanted to do before his brother died. He drew two figures, one large and one small; the large figure appears to be holding the smaller figure in his arms. Johnny entitled this picture, “Good-bye, I will miss you for a long time and I love you. ’ ’ Parent Conference After the sessions were over, both parents were invited to discuss the results of the sessions. They were aware of some of Johnny’s sadness but were totally unaware of his intense guilt and suicidal thoughts. They were visibly disturbed by this information. This information was not shared earlier with the parents because the therapists’ assessment during the session in which the thoughts were revealed indicated that the suicidal ideation had passed and the child was not in danger of hurting himself. However, the therapists were able to help them see that Johnny’s concern for their feelings had motivated him to keep these thoughts to himself. They were encouraged to talk to Johnny and share their feelings while showing him that they could tolerate their sadness and distress. This approach provided an ongoing model for Johnny and further promoted sharing and supporting each other as a family to resolve their grief.

Current Status Three years have passed since Johnny participated in these sessions. In ongoing, informal contact with the family, they report that it was easier to talk with Johnny who was, in turn, more open with them. Although the loss was still painful, communication was improved. He is now in middle school and pursuing the usual activities of a preadolescent. He is outgoing and displays no apparent psychopathology. More importantly, he is enjoying his role as big brother to his new baby sister. His parents are active volunteers for some of the hospital’s fundraising events. The family seems to have weathered the grief and to have adjusted remarkably well. What could be done to promote similar positive outcomes in other siblings and families? DISCUSSION

This case history poignantly illustrates the reactions and feelings of a bereaved sibling. The sessions provide information that supports research studies on sibling grief and reinforce the reality that children do grieve. The sessions suggest goals and interventions for nurses to use in helping siblings resolve their grief. Goals for the sessions included facilitating the process of grief, promoting family communication and support, and preserving memories. The nursing interventions, such as expressive art, family therapy strategies, and therapeutic communication, emerged from these goals. Facilitating

Normal Grief in Children

Since the grief of children is similar to that of adults, children may benefit from similar therapeutic approaches (Rosen, 1984; 1986). Guidelines for working with bereaved children include the following: (1) adjust interventions to the developmental stage of the child; (2) determine the child’s thoughts and feelings about the loss; (3) help the child concretely understand the circumstances of the death; (4) give the child permission to grieve; (5) promote ventilation of feelings; (6) encourage play as a way of expressing the grief; and (7) identify magical thinking which might lead to inappropriate feelings of guilt (Fox, 1988; Rando, 1984; Rosen, 1984, 1986; Scherago, 1987). Art was the medium for the nursing intervention of facilitating the child’s normal grieving. Art was chosen as a medium that would enhance commu-

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nication and promote the expression of thoughts and feelings during the sessions. Additionally, art therapy is an ideal strategy for working with children Artwork may be seen as an extension of the inner world of the child, a projection of the child’s thoughts and feelings. Through drawings, the child is able to express emotions and beliefs in a selfprotective manner. Drawings may reveal conflicts and fears that the child is unable to put into words. Additionally, in the process of drawing, the child may work through conflicts, gain self-understanding, and experience personality reconstruction (Walker, 1989). In this case, Johnny’s drawings both elicited previously unexpressed feelings and facilitated the discussion of the session topics. More importantly, the art seemed to provide an outlet for Johnny to work through his grief and have a corrective emotional experience. By talking through his artwork, Johnny was able to let go of his overwhelming sadness and guilt, give up his suicidal ideation, and reconnect with his family. Promoting Family Communication and Support Families under intense stress may not communicate effectively and may be unable to support each other (Heiney, 1988). Loss of a child is probably the greatest stress a family will encounter. The searing pain that assaults the family creates a hole in the fabric of the family’s life. Each family member may be paralyzed by her or his own grief and be fearful of hurting other family members. Therefore, they withdraw from each other and avoid discussing their feelings (Johnson, 1987). A major task of therapists working with grieving families is to help the family to reweave the fabric of their life. The therapist must promote the maintenance of the family system by establishing supportive communication patterns and creating a climate in which a variety of emotions and coping strategies are tolerated. In such an atmosphere, family members can work out their very personal grief while permitting the same in other family members (Rosen, 1984; 1986). This case study highlighted the prohibition against mourning and the need for the family to be more open in expressing their feelings and allowing Johnny to express his sadness and guilt. Through both the individual and family session, the family realized that tears are a way of healing and do not need to be hidden. Before the sessions, Johnny would not talk about his brother because he was afraid of his mother’s

SUE P. HEINEY

tears. After the interventions, all three family members were more open to each other’s expressions of grief. Memory Preservation Ideally, when a family member is dying, a dialogue between the dying person and the remaining family members facilitates grief work. A discussion that focuses on the meaning of the person’s life and the future without them helps to preserve the identity of the person by actively remembering his or her life. These remembrances help to ascribe meaning to the purpose of the person’s life. Also, by confronting the changes in the family system that come about due to the loss, the family members begin to redefine their relationships and see a future without their loved one. This process helps promote grief resolution (Collison, 1987). When a child dies, his or her brothers and sisters may not be given the opportunity to talk about them. Siblings may be protected, excluded, or ignored by parents who are overcome with grief. Therefore, they may not have optimum grief resolution (Worden, 1982). By focusing on Johnny’s memories in the counseling sessions, the therapists opened the door for grief work to begin. As the sessions proceeded, feelings associated with Bobby were expressed in healthy ways; Johnny’s erroneous magical thinking concerning the cause of death and his guilt was decreased. Therefore, his mourning was facilitated rather than inhibited. Johnny’s memory book was an important tool in assisting Johnny to talk with the therapists and remember his brother because, symbolically, he was able to dialogue with his decreased brother. When the sessions were over, he indicated strongly that he wanted to keep the book. He seemed very proud and happy when he put each of the pages into a binder to complete the memory book. Implications This case report illustrates the intensity of sibling grief and the reactions that nurses may encounter. The description of the sessions gives powerful credence to siblings’ need for support and guidance as they navigate through the storm of bereavement. The experience of one sibling in grief counseling establishes a lighthouse whose beacon may guide nurses to help children deal with the loss of a brother or sister as well as other significant losses.

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The study has highlighted several areas needing further research. A formal evaluation of the outcomes of grief counseling both individual and group would provide empirical data to support the efficacy of these interventions described in this case report. Additionally, an assessment of family functioning following the intervention is needed to document improvement in communication and support. ACKNOWLEDGMENT The project staff wishes to acknowledge the memory Collison, Ph.D., and her consultation to the Bereavement Group Project. The author expresses thanks to Ronnie W. Neuberg, M.D., for his critique of Carol

and

recommendations

regarding

this

article,

and

ac-

for his assistance with the support group. A special appreciation is expressed to R.K. and his family who courageously faced their pain and taught us so much. knowledges

Ken Goolsby,

M.D.,

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