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Clinical Issues in Providing Therapeutic Services: Clinical Issues in Providing Therapeutic Services:

Clinical Issues in Providing Therapeutic Services: - PowerPoint Presentation

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Clinical Issues in Providing Therapeutic Services: - PPT Presentation

Grief Loss and Separation 1 Good Morning 2 To Dr Hal Grotevant and Dr David Brodzinsky who contributed their expertise to the development of this session Special Thanks 3 What issues related to adoption arose for you since we last met ID: 742741

grief loss birth adoption loss grief adoption birth parents adopted children case children

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Slide1

Clinical Issues in Providing Therapeutic Services:

Grief, Loss, and Separation

1Slide2

Good Morning!

2Slide3

To Dr. Hal Grotevant and Dr. David Brodzinsky who contributed their expertise to the development of this session

Special Thanks

3Slide4

What issues related to adoption arose for you since we last met?

For Discussion

4Slide5

Our focus today . . .

Loss

Grief

Separation

From the perspective of the adopted person, adoptive families and birth families

5Slide6

Describe three ways that loss, grief, and separation impact adopted children, birth parents, and

adoptive families and kin and give examples of each.

Describe four different ways that children express grief.

List the four psychological tasks of the Good Grief Model.

Describe two ways that a therapist can provide a safe,

supportive and confidential environment for adopted

children and youth

Our Learning Objectives

6Slide7

Demonstrate two clinical interventions in working with adopted children and youth to help them process their grief and loss

Identify three types of losses that adoptive parents may experience after adoptionDescribe two clinical interventions in working with a birth parent to process the experience of relinquishment/termination of parental rights and adoption

7

Our Learning ObjectivesSlide8

Bringing Adoption into the Clinical Assessment

8Slide9

How comfortable are you in raising the subject of adoption with the individuals and families with whom you are working?

Can you give an example of a case where you asked about adoption early in the counseling process and were glad you did?

Can you give an example of a case where you did not ask about adoption early in the counseling process and later wished that you had done so?

 

Bringing Adoption into the Clinical Assessment

9Slide10

Why might clinicians have difficulty asking about adoption?

How might a question about whether a child is adopted be posed to parents?

Bringing Adoption into the Clinical Assessment

10Slide11

Our Own Experiences with

Loss, Grief and Separation

11Slide12

In your pre-session work, you completed two assignments related to your own experiences of loss, grief and separation. In the first assignment, we asked you to reflect on any personal connection you have with adoption and then to think about your own experiences of loss and how you have dealt with these losses in your life.

Would anyone like to share their reflections on these issues?

12Slide13

13

Break Time!Slide14

“Families linked in adoption come in as great variety as the range of human possibilities permit. Regardless of their particular link to adoption, they must deal with universal human needs for attachment,

generativity, and coping with loss. The only certain commonality among these families is that they have undergone fundamental loss experiences beyond those that any family can normally expect. No other common experiences can be assumed for all families linked in adoption.”

Reitz and Watson,

The Adoptive Family System

14

Loss Slide15

Unlocking the Heart of Adoption

By

Shiela

Ganz

15

Movie Time!Slide16

16

Lunch Time!Slide17

Unlocking the Heart of Adoption

What is your immediate impression of the concerns that the individuals featured on the video expressed about the adoption experience – specifically about loss? How did these stories expand or change your knowledge of adoption?

As a clinician, do these stories help you to understand adoption-related loss better?

17Slide18

Unlocking the Heart of Adoption

You may wish to learn more about the people featured on the documentary. More about their stories can be found at:

http://unlockingtheheart.com/www/index.htm

18Slide19

The Impact of Grief, Loss, and Separation

19Slide20

Loss is inherent in adoption. Grief is a normal response to loss; it’s not considered pathological. Unless loss is recognized, however, grieving cannot take place.

Recognizing the stages of grief can help adopted children and youth, adoptive parents and birth parents understand that they are experiencing appropriate feelings.

20

LossSlide21

21

Grief

Handout #4.1

Kubler

Ross Stages of GriefSlide22

At each of your tables, discuss how these stages of grief might apply in adoption. I will assign one stage to each of you. Discuss how the stage assigned to your table might be experienced by adopted persons, adoptive families and birth families.

22

Small Group WorkSlide23

Report Out

23Slide24

Ambiguous Loss

No doubt, some of you have encountered the concept of ambiguous loss in reading or in your own practice. What does ambiguous loss mean?

24

Loss and Grieving in AdoptionSlide25

Why is ambiguous loss so devastating?

25

Ambiguous LossSlide26

What might we see clinically when adopted children lack certainty in their lives?

26

Ambiguous LossSlide27

27

Handout #4.2

Adoption Glossary: Loss and GriefSlide28

What do you think it means to

“resolve a loss”?

Does “resolution” mean that one never thinks about the loss anymore? That it is completely understood and dealt with forever?

Resolving Loss

28Slide29

The metaphor of keeping losses in a box

The Impact of Grief and Loss on Adopted Children and Young People

29Slide30

30

Small Group Work

Handout # 4.3 Case Examples: Adopted Children’s Experiences with Loss

Look at

Handout #4.3: Case Examples: Adopted Children’s Experience of Loss

. Return to your small groups. I will assign one case to each table. Talk about the potential losses that your assessment might focus on in the assigned case and discuss the potential impact of these losses on the adopted child/young person. Slide31

Sam, Terry and Amanda

Sonita and Cassandra

31

Report Out Slide32

Betty and Brian

Lori, Tammy and Shonisha

Beth and Tamika

32

Report OutSlide33

Evelyn Burns Robinson: Adopted children “…suffer from the loss of their relationship with their

natural mothers, the loss of kinship, being separated from their extended family and community, and the loss of identity from not knowing exactly who they are” (

italics added)

[

Adoption and Loss

, , 2000].

What do you think about the use of the term, “

natural mothers

”?

Adoption and Loss

33Slide34

What are other losses that

adopted children and youth may experience

as a result of adoption?

Adoption and Loss

34Slide35

Grief as THE core issue that adopted children deal with

Adoptive parents’ concerns about their children’s grief and how to help them grieve

35

Adoption and LossSlide36

Let’s look at the right answers. Feel free to add to the discussion of each.

 

Children’s Grieving: Your Pre-Module Quiz

36Slide37

Adopted children DO bring multiple issues of loss with them into their adopted families, no matter what age they were adopted.

Children’s Grieving

37Slide38

Childhood grief is NOT based on many of the same issues that impact adults.

Children’s Grieving

38Slide39

It is NOT relatively easy to identify children’s grief reactions.

Children’s Grieving

39Slide40

The Bonnet family adopted 8 year old Stevie from foster care where he had lived with three different foster families before being adopted. When he arrived, he had a normal appetite but after a week or so, he stopped eating when the family sat down together for dinner. He now barely eats breakfast or lunch and refuses to eat anything at the dinner table. Mrs. B recently discovered that he was hoarding food, hiding it under his bed.

YES, these behaviors are possible signs of grief.

Children’s Grieving

40Slide41

Brad and Tim adopted three year old Amy who lived with her birth parents all of her life. Her birth parents placed her for adoption when they divorced and neither parent believed that they could raise her. Amy was toilet trained when she joined Brad and Tim’s family but now refuses to use the toilet, frequently soiling herself. When Brad gets ready to leave the house, she clings to his leg crying loudly until Tim pulls her off.

YES, Amy’s behaviors are possible signs of grief.

Children’s Grieving

41Slide42

Marlene adopted 15 year old Troy from foster care. Troy was in foster care for 10 years and few efforts were made to find an adoptive family for him. Marlene met him at his group home when she did volunteer tutoring. After the adoption, the initial few weeks went very smoothly, but now, Troy alternates between deep sadness and anger

.

YES, these are possible

indicators of grieving.

Children’s Grieving

42Slide43

TRUE: Children may cover their grief by being “perfect.”

Children’s Grieving

43Slide44

A therapist can use ALL of the following to help parents help their grieving children

: Help parents feel comfortable taking the initiative in talking with their child about loss and grief.

Help parents learn how to teach their children emotion words and expressions

Help parents recognize that

even if they acknowledge and

assist their children in the early

years with grief and loss, their

children’s grief will not be over.

Children’s Grieving

44Slide45

"Grieving over adoption issues doesn't happen easily or neatly. It has to be revisited over and over into adolescence and adulthood."

Ed Entmacher

, MD

Children’s Grieving

45Slide46

Continuum of Children’s Reactions to Loss

46Slide47

What are some factors that may influence how a child reacts to loss?

Children’s Reactions to Loss

47Slide48

48

Children’s Reactions to Grief

Handout #4.4

The Good Grief Program of Boston Medical Center: What Children NeedSlide49

What are the four psychological tasks

of grief work?

49

The Good Grief ModelSlide50

The Principles Guiding our Grief Work with Children

50Slide51

Life Books

Loss Box

CASE’s Teen Treatment Model

Individual Therapy

Group Therapy

Written Role Play

Interventions

51Slide52

Life Books

52Slide53

What it isHow a loss box is made

Your turn to make a loss box!

The Loss Box

53Slide54

What are your thoughts about the loss box as a way of helping young people identify and acknowledge their losses?

The Loss Box

54Slide55

55

Teen Treatment Model: Small Group Work

Handout # 4.5 Alicia

Divide into pairs and refer them to Handout #4.5, Alicia’s case. Read the case example and then to discuss each question before going to the next question. Slide56

Report Out

56Slide57

To complete Alicia’s story, here is what the therapist learned about Alicia’s background. She was placed with her adoptive family from the orphanage when she was 6 years old. Her younger sister had been sent to another orphanage. Alicia had not shared with her parents that she had a younger sister. She had been living in a state of denial, protecting herself from the painful truth of the loss of her sister.

57

Alicia’s StorySlide58

Benefits of Group Therapy

“I thought I was the only one who ever thought about what it would have been like to have been raised by my birth parents.”

Group Therapy

58Slide59

CASE Scripted Group Schedule: Group Therapy with Teens

 

59

Handout # 4.6

C.A.S.E. Scripted Group Schedule:

Group Therapy with TeensSlide60

A Summary of Your Responses to Amy’s Written Role Play

Written Role Play: Amy

60Slide61

Confidentiality and

Creating a Safe Environment

61Slide62

62

Break Time!Slide63

Grief and Loss: Adoptive Parents and Birth Parents

63Slide64

64

Small Group Work: Grief and Loss: Adoptive Parents

Handout #4.8

Adoptive Parent Losses: Case Examples

I will assign one case to each group. Discuss possible losses for the adoptive parent in the case and how you would assess the impact of these losses – what questions would you ask?

 Slide65

CASE #1:

Beth

CASE #2: Katie’s Son

Report Out

65Slide66

CASE #3: Mack, Mira and Evan

CASE #4: Donna and

Cami

Report Out

66Slide67

The extent to which they have physical contact with their child

The psychological presence or absence of the child in their lives

Disenfranchised grief

The Losses of Birth Parents and Extended Birth Family

67Slide68

68

Physical Contact

Handout #4.9

Obtaining Information from Birth Parents on Physical and Psychological Contact with their Child and

Disenfranchised Grief Slide69

69

Psychological Presence/Absence

Handout #4.9

Obtaining Information from Birth Parents on Physical and Psychological Contact with their Child and

Disenfranchised Grief Slide70

Disenfranchised Grief

What is meant by disenfranchised grief?

70Slide71

Evelyn Robinson writes that the grief of relinquishing mothers fits the definition of disenfranchised grief in several ways (see

http://library.adoption.com/articles/grief-and-disenfranchised-grief.html)

71

Disenfranchised GriefSlide72

72

Disenfranchised Grief

Handout #4.9

Obtaining Information from Birth Parents on Physical and Psychological Contact with their Child and

Disenfranchised Grief Slide73

Brief Symptom Inventory

http://www.masspartnership.com/provider/outcomesmanagement/Outcomesfiles/Tools/BSI.pdf

73Slide74

74

Handout #4.10

PACT: Stages of the Grief Process for Birth Parents and Extended Family Members

Numbness and Denial

Eruption of Feelings

Accepting the Adoption Decision

Accommodation to and Living with Uncertainty

Reevaluating and Rebuilding Slide75

Voluntary relinquishment or involuntary termination of parental rights and disenfranchised grief

Disenfranchised Grief

75Slide76

What losses might a birth mother or father whose parental rights are involuntarily terminated experience?

Luanne’s Case

Birth Parents’ Losses

76Slide77

LuAnn’s two children, Jake (age 4) and Jeremy (age 5), entered foster care two years after LuAnn left them alone in the apartment for three days. A neighbor heard the children crying and called child protective services. LuAnn has serious substance abuse issues. She had planned to return to the apartment but had gotten high then physically sick and stayed with a friend. She lost track of time.

Case Example: LuAnn

77Slide78

Since the children have been in foster care, she has not succeeded in completing a substance abuse treatment program and has continued to blame the neighbor for the fact that the children came into foster care. The agency files a petition to terminate parental rights. LuAnn attempts to fight the termination but the court terminates her rights as a parent.

Case Example: LuAnn

78Slide79

What losses might LuAnn experience?

Case Example

79Slide80

80

Birth Fathers’ Experience of Loss

Handout #4.11

My Birth Father’s Legitimate Grief Slide81

What types of loss did this birth father experience?

Are these the losses that you would expect a birth father to experience?

Discussion

81Slide82

Written role play

Therapeutic ritualsJournaling

Group work

Clinical Interventions with Birth Parents

82Slide83

Written Role Play

83

Clinical Interventions with Birth ParentsSlide84

Therapeutic Writing

84

Clinical Interventions with Birth ParentsSlide85

85

Clinical Interventions with Birth Parents

Handout #4.12 Elizabeth Slide86

Therapeutic Rituals

Clinical Interventions with Birth Parents

86Slide87

87

Clinical Interventions with Birth Parents

Handout #4.13 EmilySlide88

What do you see as the purpose of an entrustment ritual?

How does this type of ritual benefit both the birth parent and the adoptive parents? 

What are some of the ethical issues that must be considered in helping to facilitate such a ritual?

Therapeutic Rituals: For Discussion

88Slide89

Group Work

Clinical Interventions with Birth Parents

89Slide90

Summary and Closing

90Slide91

What We Have Learned:

Can You . . .

91

Describe three ways that loss, grief, and separation

impact adopted children, birth parents, and

adoptive families and kin and give examples of each.

Describe four different ways that children express grief.

List the four psychological tasks of the Good Grief Model.

Describe two ways that a therapist can provide a safe,

supportive and confidential environment for adopted

children and youthSlide92

92

What We Have Learned:

Can You . . .

Demonstrate two clinical interventions in working with adopted children and youth to help them process their grief and loss

Identify three types of losses that adoptive parents may experience after adoption

Describe two clinical interventions in working with a birth parent to process the experience of relinquishment/termination of parental rights and adoption Slide93

The Brief Online Survey

Next Steps

93Slide94

Trauma and Brain Neurobiology

Our Next Session

94Slide95

Until Our Next Session Together!

95