Grief and Loss in Adolescence: Principles, Responses and Challenges

Grief and loss are fundamental aspects of life; they are inevitabilities that stem from our mortality and our natural propensity to form deep emotional bonds with those closest to us—our family, friends and colleagues.
Perhaps C. S. Lewis captured the sensation of grief best when he said: “No one ever told me that grief felt so like fear. I am not afraid, but the sensation is like being afraid. The same fluttering in the stomach, the same restlessness, the yawning. I keep on swallowing. — C. S. Lewis, A Grief Observed How one physically manifests grief may vary between age groups and cultures but it is a universal occurrence in humans who are of normal cognitive development.
In this paper, grief and loss will be reviewed in the context of Worden’s principles and theories; specifically, what these principles say about grief and loss, how they might apply to the adolescence demographic, what challenges the health care provider might expect to encounter when working with a grieving adolescent, and how a health care provider can best respond to a grieving teenager. A series of hypothetical acute care settings will be presented to illustrate how a nurse might best proceed in responding to a grieving adolescent.

Death during Adolescence
Adolescence is a transitionary stage of life that poses unique challenges for the individual. Change is the hallmark of this developmental period as teenagers struggle with hormonal changes, newfound desires for independence, confidence issues, and concerns about body image. Grief and loss during this stage of life, whether it be the loss of a parent, relative, or close friend, often greatly exacerbates the emotional state of a teen who is already experiencing the stresses associated with the transition from child to adult.
According to Metzgar, typical grief responses of teenagers include anger, depression, withdrawal, frustration, confusion, acting out, and noncompliance (Metzgar, 2002). Unlike young children, who often do not fully contemplate the finality of death, adolescents are usually aware that death is final (Freeman, 2005). According to Freeman, adolescents have the mature intellectual development necessary to understand the core concepts of death—universality, non-functionality, irreversibility, and causality—and can elucidate fully the details (Freeman, 2005).
This greater understanding of death places adolescents closer to adults on the level of death awareness; however, teens may wonder if a dead person will return; this thinking may include supernatural elements as teens often associate an unexpected death or serious illness with a supernatural event or cause (Brewster, 1982). An adolescents’ grief experience is highly personal in nature, and unlike adults, teens tend to grieve more intensely.
Often their grief response is not expressed smoothly or continuously but takes the form of a series of punctuated outbursts; in some cases an adolescent may make a concerted effort to control his or her emotions (Worden, 1996). In attempting to control their emotions, a teen may retreat inwardly by immersing themselves in highly personal activities such as reading, writing, listening to music, or exercising; in other cases, a teen may want to release the anger and sadness associated with their grief; in this case, he or she may act out angry or antisocial behavior (Worden, 1996).
Of particular importance from a health care perspective is the recognition that teens often perceive death as something that happens to others even though they recognize that death is a phenomenon that can and will happen to everyone. When a teen is confronted with the death of a close friend or relative, their perception of death as being a phenomenon that is distant from them, is abruptly challenged. In the case of the death of a peer, death is often sudden—in an American study, the three leading causes of death in the 15 to 24 year-old age group are accidents, homicide, and suicide (Minino and Smith, 2001).
In such cases, a teen’s sense of pseudo-immortality is often shattered (Freeman, 2005). The trauma associated with this may cause a teen to experience an overwhelming sense of helplessness or powerlessness (Aronson, 2005). In the case of the loss of one or both parents, a teen may experience a grief reaction that is unique for their age demographic—an irrational guilt associated with the normal desire to detach from their parents (Freeman, 2005). For the health care worker, it is crucial that this particular grief reaction is considered when helping a teen deal with the loss of one or both parents.
Theoretical Principles: Grief and Loss according to Worden.
In Grief Counseling and Grief Therapy, Worden conceptualizes the process of grief into a framework of four tasks that he suggests need to be addressed and completed before the process of mourning can be concluded (Worden, 1991). Worden’s four task paradigm consists of:
Task 1. To accept the reality of the loss
Task 2. To work through the pain of grief
Task 3. To adjust to an environment in which the deceased is missing
Task 4. To emotionally relocate the deceased and move on with life
According to Worden, children and teens, like adults, must acknowledge and accept the reality and finality of death before they can begin to deal with the emotional impact of this loss (Worden, 1991). Generally this is easier for teens than children because their concept of death is more developed and in tune with that of an adult’s. In order to help facilitate acknowledgement of loss, a health care worker needs to explain the circumstances of the loss in a language that is both accurate and age appropriate.
Since maturity levels vary within the teen demographic, one must not assume a given maturity level based on age; in this case the carer should make a concerted effort to determine the maturity level of a teen through dialogue and observation (Smead, 1994). In task two, Worden suggests that the painful emotions associated with grief need to be worked through. By working through, Worden suggests that emotions need to be released in a healthy manner such that a teen is able to cope with the nature of their loss.
In this case, the carer needs to assist the teen with opening up—helping the teen discuss their fears and anxieties in a non-judgmental way. Encouraging teens to express their grief through creative arts and by engaging in rituals can be therapeutic in this regard. (Silverman and Nickman, 1999) In Worden’s third task, adjusting to the loss of a deceased peer, sibling or parent requires that the adolescent develop an adaptation to this loss.
Adaptation will be heavily influenced by what role the deceased played in the teen’s life; often this adaptation requires an extended period of adjustment (Worden, 1991). In this case, the health care worker’s role is to help the teen adapt to the loss of old roles (roles associated with the deceased) and adjust to the emergence of new roles (roles previously associated with the deceased now taken up by other individuals). In Worden’s final task, the deceased are relocated—they are placed in an appropriate emotional place such that the bereaved can move on with their lives.
For many bereaved individuals, relocation may involve the pondering of existential questions: Where did the deceased go? Why did they die? Is there a Heaven? Children and teens are often more open to supernatural explanations, and in this case, belief in an afterlife can be therapeutic as it helps the individual maintain a healthy and tangible link to the deceased—it may give the bereaved a sense that the deceased is watching over me from Heaven (Silverman, Nickman and Worden, 1992).
Grief and Loss in the Acute Care Setting: A Nurse’s Role
When a nurse is expected to provide emotional care to a bereaved teen, he or she must consider a number of factors that may influence the grieving process. These may include: age, level of maturity, psychological state, physical state, and circumstances of the loss. In the following hypothetical case studies, a nurse will offer emotional support directed specifically at teens whom are experiencing different stages of grief as outlined by Worden. The question to be answered in each case is this: What would be the most appropriate nursing response? In each case, as the attending nurse, you will note the individual’s age, statements, stress level, and physical demeanor.
Case Study One – The immediate loss of a best friend
Tom is an 18 year old who has been admitted to a hospital emergency room after a traumatic car accident. His best friend Bret was a passenger and has been killed in the accident. Tom has minor physical injuries that you are tending to. He has just been informed that his best friend died at the scene. Emotional and in disbelief, he yells: “You’re all lying! Bret is not dead! He can’t be dead! He can’t be! It’s my fault!” Bret is shaking.
Response:
Using compassionate but clear and direct language you reaffirm that Bret has died. You show empathy to Tom but avoid making value judgments for him that offer explanations for the death or attribute blame. When interfacing with Tom’s parents you explain to them the stage of grief their son is going through and how best to assist him through it.
Case Study Two – Working through the loss of a parent
Sarah is a somewhat rebellious 17 year-old with a strong sense of independence. She doesn’t always see eye to eye with her mother, Jenifer. Six months previous, Jenifer died suddenly in car accident. Since the accident, Sarah has suffered major anxiety attacks and has been plagued by guilt. At school she has been involved in arguments and fights with other girls; on this occasion she is in the school infirmary after fighting with another girl. After initially appearing angry, Sarah breaks down in tears and says: “Why did my Mom have to die! I didn’t really want her out of my life!”
Response:
You consol Sarah, and listen to her—you let her release her emotions without restraining or judging her. You reassure Sarah that it is ok and normal to feel fear, guilt and doubt, and that is ok to express her feelings. You tell Sarah that she can come and share her feelings with you whenever she feels the need. If interfacing with Sarah’s father, explain to him what Sarah is experiencing, and offer helpful suggestions that are in line with Worden’s model for task two grief.
Case Study Three – Adapting to the loss of a sibling
Janet and Karen are sisters close in age, 15 and 17 respectively. They were inseparable and enjoyed doing things together such as sports, shopping and talking about boys. Janet looked up to Karen who she thought of as being her pillar of strength and confidant. Last year Karen died suddenly from a rare form of meningitis. Janet has accepted the loss but has had a hard time readjusting to life without her sister. She is in the hospital being attended to for self inflicted cuts on her arms. Janet states that life is unexciting now because her sister is gone.
Response:
With empathy you help Janet recognize and reassign the emotional roles filled by her sister. You may suggest ways to help Janet remember Karen in a desensationalized way such that the memory of Karen is retained and respected but that recognizes that life must go on. The suggestion of doing activities (previously done with Karen) with friends or classmates might be helpful. This information should be relayed to Janet’s parents to help them understand how they might be able to assist Janet adjust to life without Karen.
Case Study Four – Relocating a deceased grandparent
Fourteen year old Ben loved fishing with his grandfather. Granddad was Ben’s best friend. Earlier this year Ben’s granddad died suddenly from a heart attack. Ben accepted that granddad was gone, and he knew that there would be no more fishing. Ben was admitted to the hospital to receive stitches for a fall; Ben asks you: “Miss, where do dead people go? My Granddad died this year you know.” In a melancholy tone he continues, “I’ll never have a friend like him again.”
Response:
In a compassionate tone reply that you are not sure where people go when they die and that it is one of life’s great mysteries. You may suggest that many people have different ideas as to where people go after death. Suggest to Ben that life is about continuing to develop special moments with people we associate with in life. Keep in mind that grief resolution involves reflecting on the meaning of a deceased person’s life, and keeping this as a pleasant memory. It is not meant to focus on the death itself.
Conclusions
Grief is a fundamental aspect of life. Adolescence, being a major transitional stage in human growth and development brings with it unique emotional challenges. These challenges need to be addressed by the health care worker if he or she is to effectively assist a teen who is grieving for a deceased peer, sibling or parent. Worden suggests a four step paradigm for the grieving process that can serve as a guide for elucidating the stage of grief an individual may be experiencing.
Knowledge of this model can assist the health care worker in grief stage recognition, and in making informed decisions that will ultimately help a teen deal with challenges involved in the of grieving process. With the support and encouragement of health care workers, peers, and relatives, adolescents can learn to successfully manage grief and loss, and move forward with their lives.