Art therapy is particularly useful with younger children. With children under the age of eight it can be difficult for them to grasp the concept of death, it can be equally as difficult for them to express the things they are feeling about the loss of a loved one (Shaw, 2000). Through the medium of drawing or painting a counselor may gain a better understanding of their patient's subjective experience of the loss as well as any unresolved emotions or unanswered questions remaining after the fact. Art therapy is also an effective means of determining the relative normality of a child's cognitive function following a traumatic event (Shaw, 2000).
Older children respond more effectively to client centered interviews (Shaw, 2000). A client centered interview is a psychoanalytic approach which encourages the patient to talk extensively guided minimally by questions or suggestions from the therapist. This approach might allow through the extensive vocalization of formally internalized feelings, thoughts, and questions the root of any unresolved issues associated with the loss which may have proven detrimental to the client's successful continued psychological functioning (Shaw, 2000).
Secondary intervention techniques are more intensive as the behavioral and psychological problems associated with bereavement are apparently persisting to a degree which is disruptive to the individual's daily functioning (Gwynne, Blick, & Duffy, 2009). These techniques include weekend retreats and even the referral to group therapy session or support groups. While it is at times useful to spend a significant period of time reliving a significant life event such as the loss of a loved one, in children it may ultimately prove more harmful than helpful (Larson, & Hoyt, 2007). Perpetually reliving a traumatic event may actually reverse the process of healing and acceptance especially with younger adolescents effectively trapping them in that stressful and difficult time. The participation in group therapies and support groups allows individuals particularly adolescents to gain a sense of camaraderie which can be important in times of grief, however, these groups may act to foster malingering or even a psychological dependence on the sympathy and attention garnered at such sessions (Larson, & Hoyt, 2007).
Tertiary intervention techniques are long-term therapeutic treatment plans including behavior modification, drug regimens, and standing appointments with therapists for the treatment of pronounced disorders resulting from bereavement. It is the function of primary and secondary intervention strategies to prevent the majority of individuals in need of some bereavement intervention from reaching this final and most severe treatment stage (Burnett et al. 1997). To qualify for a tertiary intervention treatment an individual must display a pervasive and fundamentally disruptive pattern of behaviors stemming from the loss event and preventing their successful reintegration with society (Tomita, & Kitamura, 2002). In the case of children, the need for a tertiary intervention is especially concerning in that it will inevitably impact the rest of their lives.
Given the generally pessimistic review of bereavement intervention techniques shared by the majority of researchers, it would be interesting and probative to determine whether the results of these trials are replicable in the field. Rather than including all data, it would be of use to screen participants prior to the inclusion of their treatment objectives and outcomes in the raw data collected. If treatment is provided efficiently and immediately only to those individuals actually in need of counseling, it is my contention that intervention techniques would produce statistically significant results in lessening the amount of time necessary for participants to return to normal functioning following a crucial loss.
This study will be cross sectional. A local hospital will be chosen based on proximity to the researcher as well as their willingness to participate in the study. The grief counseling department will agree to turn over redacted records of applicable participants. No personally identifying information will be included about the participants themselves, nor will the researcher have any interaction with them. The grief counseling center will provide the participants with a copy of the Inventory of Complicated Grief before and after the therapy as well as the Core Bereavement Items measure. The inventories as well as general nature of the therapeutic intervention including; who initiated the therapy, duration of therapy, and clinicians opinion of efficacy of therapy will be turned into the researcher upon conclusion of the study period. All participants will receive a briefing form prior to their completion of the inventory. Participation will be entirely voluntary and informed consent will be required for their inclusion.
Ideally the sample would include an ethnically, economically, and age diverse group of participants. However, as this study utilizes convenience sampling such normative distribution is unlikely to occur naturally. As such a number of local hospitals should be included in the study. Further, only participants who score greater that 25 on the ICG and greater than 17 on the CBI. This ensures that only individuals presenting with a genuine need for therapeutic intervention will be included in the data analysis. It is important to limit the sample to those individuals genuinely in need in order to ensure that the effects observed are actually a result of therapeutic intervention.
The two measures proposed for the study are the Core Bereavement Inventory (CBI) as well as the Inventory of Complicated Grief (ICG). The CBI is a 35 item self-assessment scale which measures the subjective experience of loss. Composed of three internal subscales which assess thoughts, separation, and grief this scale is easy to administer yet highly informative in terms of assessing a full picture of the individual's relative psychological functioning. The scale has a cronbach's alpha of .85 which is a reasonable level of internal reliability. Further, this scale is attractive because it can be used with children and adolescents.
The ICG is a 19 item scale which assesses the physical components of grief and the degree to which they are disrupting an individual's life. This scale specifically measures symptoms of grief distinct from unrelated depression or anxiety. A cluster of seven symptoms assessed by this measure were indicative of long-term dysfunction. The cronbach's alpha for this scale is .94 indicating an extremely high degree of internal reliability.
The final item used in data collection is the redacted case file of the participants. Specific information regarding the nature of the loss, and personally identifying information will be removed prior to review of the data. The relevant factors are age of participant, nature of loss (general descriptor ie: mother, father, uncle), who initiated treatment, length of treatment, techniques employed, reason for terminating treatment, success of treatment. These items are non-invasive yet in combination with the pre- post test design of the study will yield information regarding the techniques which are most successful for distinct age groups.
This study will employ a cross sectional pre- post test design. The relative success of each participant's intervention will be determined through the use of the two grief measures taken before and after treatment. These results will then be correlated with the various intervention techniques to determine which are on average most successful. The participants will be grouped by age and ethnicity when sufficient data is available.
The ultimate value of this study will be in the empirical evidence supporting the inclusion or exclusion of commonly used bereavement intervention techniques. The inclusion of only those individuals in actual need of therapeutic intervention will allow researchers to assess the specific therapeutic success of techniques without interference from data sets which are inconclusive because the intervention addressed an individual coping normally with the loss. This research may also effectively rejuvenate the somewhat pessimistic view of bereavement intervention.
The primary limitations of this study will be in the acquisition of a diverse sample population. Because the study is employing a convenience sampling technique, the sample may not be representative of the community as a whole; as such this study will need to be repeated on a larger scale including more grief counseling departments and offices. The ability to get conclusive data regarding children specifically those under the age of 12 will also be difficult given the sensitive nature of the treatment and many parents and guardian's desire to shield their child from any additional trauma or stress. It should be emphasized though that the collection of this data will ultimately be no more invasive or traumatic than their participation in therapy. The potential for long-term effects of this study, or harm as a result of this study to participants is extremely low.
In future such measures of exclusion should become more stringent addressing the problem of eliminating confounding variables such as individuals who have existing mental health problems, or who are coping normally with their grief. Until data samples are collected which control for such variables, the data will be largely inconclusive.
1. Tomita, T., & Kitamura, T. (2002). Clinical and research measures of grief: A reconstruction. Comprehensive psychiatry, 43, 95- 102.