Clinical Issues in Providing Therapeutic Services:

1. Clinical Issues in Providing Therapeutic Services: Grief, Loss, and Separation

2. Good Morning!

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

4. For Discussion What issues related to adoption arose for you since we last met?

5. Our focus today . . . • Loss • Grief • Separation From the perspective of the adopted person, adoptive families and birth families

6. Our Learning Objectives 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

7. Our Learning Objectives 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

8. Bringing Adoption into the Clinical Assessment

9. Bringing Adoption into the Clinical Assessment 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?

10. Bringing Adoption into the Clinical Assessment Why might clinicians have difficulty asking about adoption? How might a question about whether a child is adopted be posed to parents?

11. Our Own Experiences with Loss, Grief and Separation

12. 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?

13. Break Time!

14. Loss “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

15. Movie Time! Unlocking the Heart of Adoption By ShielaGanz

16. Lunch Time!

17. 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?

18. 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

19. The Impact of Grief, Loss, and Separation

20. Loss • 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.

21. Grief Handout #4.1 Kubler Ross Stages of Grief

22. Small Group Work 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.

23. Report Out

24. Loss and Grieving in Adoption 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?

25. Ambiguous Loss Why is ambiguous loss so devastating?

26. Ambiguous Loss What might we see clinically when adopted children lack certainty in their lives?

27. Handout #4.2 Adoption Glossary: Loss and Grief

28. Resolving Loss 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?

29. The Impact of Grief and Loss on Adopted Children and Young People The metaphor of keeping losses in a box

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.

31. Report Out • Sam, Terry and Amanda • Sonita and Cassandra

32. Report Out • Betty and Brian • Lori, Tammy and Shonisha • Beth and Tamika

33. Adoption and Loss 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”?

34. Adoption and Loss What are other losses that adopted children and youth may experience as a result of adoption?

35. Adoption and Loss • Grief as THE core issue that adopted children deal with • Adoptive parents’ concerns about their children’s grief and how to help them grieve

36. Children’s Grieving: Your Pre-Module Quiz Let’s look at the right answers. Feel free to add to the discussion of each.

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

38. Children’s Grieving Childhood grief is NOT based on many of the same issues that impact adults.

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

40. Children’s Grieving 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.

41. Children’s Grieving 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.

42. Children’s Grieving 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.

43. Children’s Grieving TRUE: Children may cover their grief by being “perfect.”

44. Children’s Grieving 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.

45. Children’s Grieving "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

46. Continuum of Children’s Reactions to Loss

47. Children’s Reactions to Loss What are some factors that may influence how a child reacts to loss?

48. Children’s Reactions to Grief Handout #4.4 The Good Grief Program of Boston Medical Center: What Children Need

49. The Good Grief Model What are the four psychological tasks of grief work?

50. The Principles Guiding our Grief Work with Children