Anticipatory Bereavement

The death of a child disrupts the natural family life cycle. Children are supposed to outlive their parents, not the other way around. Decisions related to treatment during the terminal phase of an illness can be excruciating for parents who on one hand do not wish for their child to suffer but on the other hand cannot tolerate thoughts of ending treatment.

Psychotherapy with the dying child is differentiated from more routine psychotherapy by the simple fact that the patient is confronting the concrete reality of death and loss rather than unrealistic fears and fantasies. Patients are generally aware that death is approaching, with the unknown being its time of occurrence. Nevertheless, awareness of death is a fluid rather than static state (Sourkes

1998). Children tend to "dose themselves" regarding the degree to which they can discuss their illness (i.e., one minute crying and the next found playing a game). The level of awareness may fluctuate depending on their medical status. Therapy provides the opportunity for the expression of grief and integration of their life experiences. It provides an opportunity for discussing quality-of-life issues as well as facilitating the child's expression of their own wishes for what is left of their life. As the risk of mortality increases in different pediatric illness populations, there are three common fears: fear of pain, fear of being alone, and fear for the well-being of others (parents/friends) after the child's death.

Children and adolescents can derive great comfort from the safety of a therapeutic relationship in which there is the opportunity to discuss their awareness of impending death. The therapist "bears witness" to the child's extraordinary situation and responds within the context of that reality (Coles 1990). A shared "knowledge" of the fine line that separates living from dying, whether implicit or ex plicit, becomes the containment of the psychotherapy (Sourkes 1992).

The development of anticipatory bereavement suggests a patient's greater recognition of his or her poor prognosis. The grief related to the impending loss of important relationships becomes manifest in an increased sensitivity to separation without specific references to death or in the form of direct and explicit discussion about death (Sourkes 1992). There may be themes of presence and absence or disappearance and return. Patients can project their concerns onto significant adults as well as show concern about the emotional well-being of their parents or loved ones after their death. There may be fears about being replaced and resentment of healthy siblings. As death approaches, children often turn inward and withdraw from the external world. Normal responses at this time can include retreat from physical contact, quietness, and irritability. It is common for the patient to withdraw from the therapeutic relationship. In the terminal phase, the consultant may only get to see the child in the presence of the parents. This may, however, be a time where important disclosures are made by the child.

In work with physically ill patients, the therapist must possess a high threshold for witnessing and tolerating pain, particularly pain involving separation and loss (Sourkes 1992).

The therapist may have feelings of guilt about his or her own health or that of his or her loved ones in relation to the patient's illness or the therapist's own ability to move on quickly after watching a child die. This guilt may intrude on the therapeutic process, causing the consultant to withdraw instead of focusing on the patient's feelings of anger and isolation (Shaw and DeMaso 2006).

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