Grief Processing: Healing Traumatic Wounds
Nuraida (not her real name) still remembers her slippers, umbrella, and flower pot she left behind when they hurriedly left their house in Barira, Maguindanao. She was not able to bring any of them when her family escaped from the military assault when the war between government forces and Muslim rebels erupted in March last year. Tears swell at her black eyes when little details of that tragic episode come back to her. She recalls that she was playing with her friends when the first bomb exploded in the middle of their village. But that was all what Nuraida's remembers. Her mind seems to have formed an impregnable wall that shuts off the other images about the terror that shattered their lives. She said that she is only 9 years old, but her frail body betrays her real age.
But that was at the time when Balay counselors have first talked to her and other traumatized child-survivors. It took several psychosocial session with her and her parents until she learned to trust her counselor and got past the denial stage of her grief. Then the full story unfurled. With some of the details supplied by her parents, Nuraida recounted how the soldiers swooped down on their village populated by Maguindanaoan Muslims, prompting them to flee. Like chickens trying to avoid slaughter, they ran together with other villagers wherever their feet would lead them. In their haste, the family forgot the youngest child in their house. Her father ran back to get her, but before he reached their hut, a bomb exploded and burned their house, the 6-year old girl inside it. Because of the intense fighting, Nuraida's family never recovered the body of her sister. They were able to saved their lives but their anguish and grief started a fire in their hearts and mind, consuming them.
After eight months of psychosocial intervention, Nuraida has showed signs of being able to come to terms with her loss. She still expresses feeling of sadness whenever she remembers her younger sister, and wished that her remains will be recovered someday so that they can bury it in accordance to their Islamic practice. While she has learned to play again and get along with new friends, she is unsure whether she still likes to go back to their place or not. She is sure about not wanting to see a soldier in their place though. She liked to go back to school to study Arabic, so she can also teach her parents how to read and write.
Child-Survivors and Trauma
For the more than 30,000 displaced children affected by the armed conflict in Mindanao last year, the story of Nuraida captures one of the most harrowing tale about the cruelty of war. The psychosocial distress suffered by the child-survivors start with the breakdown of their community, destruction of schools and the disruption of the delivery of usual social services, death, fear, separation of families, hunger and displacement. The United Nations Children Fund (UNICEF) has estimated that 4.5 million Filipino kids have been affected or exposed to armed violence over the last 20 years.
To many of these children, the trauma they suffered made them lost trust in people causing them to withdraw from contact. Many of them stopped laughing and playing. Others become obsessed with war games or dwell on feelings of guilt and wallow in depression. The long-term effects of this condition is the loss of the child's close emotional relationship and the perpetuation of a culture of hostility and aggression.
In most cases, humanitarian organizations and government social workers focus mostly in providing relief and medical assistance in aid of people caught in an emergency situation. Too often, the equal importance of extending psychosocial service to survivors of war is overlooked. It is imperative for social workers and other agencies that respond to disasters to have an understanding of trauma and how it affects people confronted with life-threatening situations or related tragedies. This way, a more comprehensive view of relief and rehabilitation services may be appreciated.
The harrowing experience of Nuraida is an extraordinary episode that can cause debilitating effects on child-survivors like her, unless facilitated by a process that helps the affected child gets through the stages of grief and trauma. Trauma is different from stress in the sense that the later is a condition that is commonly experienced as a person goes about his usual daily routine in life. Trauma occurs when a person has experienced an event that is outside the range of usual human experiences and that would be markedly distressing to almost anyone. Examples of traumatic event are seeing another person who has been killed or seriously injured by physical violence or accident; serious threat to one's life or physical integrity, to one's children, spouse, other close relatives or friends; and sudden destruction of one's home and community.
Post traumatic stress disorder or PTSD develops when trauma is not overcome after a few months. In the case of Nuraida, it is manifested in at least the following signs:
Efforts to avoid thoughts or feelings associated with the trauma;
Efforts to avoid activities or situations that arouse recollections of the trauma;
Inability to recall an important aspect of the trauma;
Markedly diminished interest in significant activities;
Feelings of detachment or estrangement from others;
Restricted range of affect (e.g., unable to have loving feelings);
Sense of foreshortened future
In very young children, PTSD may be observed through repetitive play in which themes or aspects of the trauma are expected. In some instances, traumatized boy-children develop a liking or fascination with toy guns or helicopters. Others hide in fear upon the sight of soldiers or anything they associate with the military, such as an army vehicle or sound of hovering helicopters.
Psychosocial intervention among children is difficult and requires a lot of patience and a one-on-one approach. Children, especially very young kids are not articulate, and tend to express themselves more through their play and action. Nevertheless, they display many symptoms that are similar to adults. These are manifested in the cognitive, emotional and behavioral aspects of their being. If the stress or trauma is intense, critical incident stress debriefing or CISD should be conducted right away. Prompt intervention is crucial in giving the survivor of a tragedy a chance to let out his or her feelings, thoughts and actions to overcome the traumatic experience and move on with life.
The goal of critical incident stress debriefing (CISD) is to help a person to move towards acceptance and get on with life. Debriefing is a process that may require a series of intervention or sessions to complete. Caregivers should know what is the level or stage of grief a person is going through in order to come up with the right approach. Grief or trauma processing may address one emotional problem at a time. If sadness is the main problem at the moment, address the situation until it gets better before moving on to another problem manifestations of grief. It is possible that a child may achieve only partial acceptance, especially if he is too young to have a full sense of the tragic event. Complete healing may be achieved as he gets older.
Stages of emotional grief may be demonstrated not in a serial manner but rather in a "circular" manner, depending on personality of the child and the context in which the tragedy took place. Not all symptoms of grieving may appear at once and must be addressed accordingly. It is possible that a child may easily cope up with sadness but nurture his anger.
Debriefing of children works best in a one on one basis. For kids with ages from 9-12 years old, a group processing may be held, as long as each child-survivor is prepared individually before the group session. The number of participant per group should not be more than 3 kids.
Debriefing for Death Trauma of Children
Before going into CISD, consider where the child is in the mourning cycle and how much the child can understand. For young children, part or all of the debriefing steps will have to be repeated several times during their developmental years until they reach a more mature understanding of death and have finally come to terms with the impact of loss of a loved one. For kids who have not fully recovered from trauma, memories or feelings associated with the distressful event in the past will haunt them as they grow up and reach certain milestones in their lives. For example, a young girl who is about to graduate with honors from high school may suddenly feel intense remorse or extreme sadness upon remembering the loss of her parents who will never see her receive her awards for academic excellence. In this instance, CISD may be repeated to the grieving person until she is comforted and gain a mature understanding and acceptance of the loss.
There is no ideal time or circumstances to begin talking to young children about their death trauma. It is generally better to be quick and truthful when telling children rather than wait for a perfect moment to bring it up. Gather as much data as possible before talking to a child-survivor. This may be done through direct observation, asking questions to the close relatives, knowing the age level and the characteristics of the child.
When doing CISD, make sure that the child is in a "comfortable" or secured and non-threatening environment. The important thing is to begin as soon as possible. Just make sure that the child is ready to cooperate and trusting to the counselor. If not, learn ways to gain the trust of the child.
As a facilitator or a debriefer should prepare and attune her heart and mind to the issues of grief of the child-survivor. When the child is ready, explain to the child the reason behind the death of a loved one (be ready to present medical facts in a manner that is comprehensible to the child.) Avoid agitating the grieving child and don't stoke her emotions further by describing gory details over the death of a loved one. Don't fuel hatred or thoughts of vengeance either.
Culture and Healing
Religion provides strength, but a child has a little understanding of divine providence at his age. Avoid telling the child that god is responsible for the death of his relative because the child may develop resentment to god for taking away his loved one. Talking about the funeral or the wake helps in underscoring the reality and finality of death.
In Muslim culture, they regard the death of a mujaheedin as a noble sacrifice that is pleasing to Allah. A debriefer, or any culturally-sensitive person for that matter, should respect this belief. However, this does not offer a guarantee that grief of those close to the departed will be easily surmounted, especially for child-survivors.. While the mind (due to religious belief) may say that the death of a loved one is okay in the eyes of god, inside the orphaned or widowed person is in the grip of intense sadness and remorse. The role of CISD in this case is to facilitate the convergence of the mind and heart (thoughts and feelings) into coming to terms with the reality of the loss towards its acceptance and healing. This process takes a while and requires "surfacing" and letting go of the traumatic event.
In handling child-survivors, a debriefer should possess child-like qualities, such as being playful, understanding, patient, and creative. The caregiver should also establish a close association and partnership with parents of the child-survivors. Parents should know and approve of the healing activities for their children.
Sharing the child's reaction to the tragedy entails assuring the child that his reactions (i.e. anger, sadness, guilt, etc) are "normal" reactions to a tragic or traumatic event. The child should be allowed to pour out his heart and mind in order not to sweep under the rug his thoughts and feelings over a tragedy. Help the child gain a sense of the situation, but keep the explanation short and the language simple enough for the kid to understand.
When attending a wake or funeral, it pays to explain to the child factually the significance of the event. In situations where the body of a love one is unrecovered, it is important for the family or relative to have a certain level of certainty that their kin is already dead or killed. When this is realized the ritual of parting should be done.
Among Muslims, the ritual of burial and offering is a significant element in the acceptance and overcoming grief and mourning. The holding of a kanduli or an offering (prayer or food) is helpful in the healing process. But sometimes it is not enough, especially for children. In some instance, a child-survivors may be asked to write or draw something for the departed and express his positive thoughts on the dead relative. Placing the letters in the grave or sending them floating down creeks or rivers can be a liberating ritual to some.