Children in Families Affected by Illness and Death

All children, in the normal course of their development, learn about being sick, and most, by the time they enter school, have at least rudimentary understanding of the word “dead” through the experience of seeing dead insects and animals. However, when a young child lives in a family in which a parent has a recurring illness such as cancer and/or in which an older sibling dies suddenly of a drug overdose, the child’s confusion and anxiety about his or her own personal survival and that of the well parent are entirely understandable. In the case outlined here and described throughout this chapter, we see that this was the family context of illness and death in which young Sabrina completed kindergarten and entered first grade. Mrs. Rossi had been married previously; her first husband had died of a heart attack at the age of 45, when John was 14. She stated that her husband had a history of depression and alcoholism and that they had been separated since John was 2½. Neither she nor John had contact with any of her first husband’s relatives. In fact, she stated that she did not know their whereabouts. Mr. and Mrs. Rossi have been married 8 years. They are of different religious backgrounds: The father and his relatives are Catholic and Italian, whereas the mother is Protestant and of northern European descent. However, neither Mr. nor Mrs. Rossi attends church services, and both have been interested in Eastern religions; they have a large statue of the Buddha in their living room. Mrs. Rossi telephoned to request help for her family because she was facing major surgery, and she was concerned about how they would cope with her projected long postoperative period. Lida had a large tumor that required removal, necessitating both a colostomy and a vaginectomy. She stated that there was a lot of tension and conflict between her husband and her son and that she was quite worried about how they would manage without her presence as a buffer. Although the operation was not considered life threatening, Mrs. Rossi said that she wanted to work with a therapist who was experienced with both family and bereavement issues. Assessment and Plan for Intervention Because the operation was to occur in 10 days, time was limited. Mrs. Rossi had indicated on the phone her reluctance to include Sabrina in the initial family meeting, so I began by seeing the parents and John to address Mrs. Rossi’s specific concerns. It was very evident that Mr. Rossi was angry about John’s lack of employment or plans for his future. The boy, who looked more like a 14-year-old than an 18-year-old, had overdosed on cocaine 6 months earlier and since then had dropped out of college. He spent most of his days sleeping and his evenings out with friends, drinking beer and drawing graffiti. There was a great deal of tension between Mr. Rossi and John; nonetheless, Mr. Rossi gave John money every week so he could buy gas to go job hunting. Recently Mrs. Rossi had insisted that John enter therapy, and he had gone for two or three sessions at the time of the first family meeting with me. Mrs. Rossi herself had been engaged in individual therapy for several years. I sensed that Mrs. Rossi seemed to be trying very hard to “put her house in order” before going into the hospital. She wanted John and her husband to promise to help her when she came home, when she herself would be too weak to go shopping or perform routine housekeeping tasks. During the session, we listed the chores and obtained agreements about who would do what. It was evident that everything related to John was a struggle; he resisted the idea of doing his laundry regularly rather than leaving it piled up, and he seemed equally reluctant to promise to feed his own cats or to meet Sabrina’s school bus, because he “might be sleeping.” He did agree to do the shopping, and Mr. Rossi agreed to vacuum and cook. I made an appointment to see Mr. Rossi and John together the day after Lida’s operation. I also expressed concern about Sabrina’s reaction to the impending separation from her mother, especially after Mrs. Rossi told me that the child’s kindergarten teacher had commented recently about Sabrina’s “spaciness” and inability to concentrate. I encouraged Mrs. Rossi to bring her for one session to prepare her for her mother’s absence. We agreed that couple, family, and/or parent–child sessions would be planned later, depending on Mrs. Rossi’s stamina and the family’s needs after her operation. Mother–Child Session Sabrina brought a stuffed white toy cat named “Sassy” with her. At the beginning of the session she seemed quite anxious, as expressed in silly, teasing behavior in which she had Sassy crawl all over and tickle her mother. I explained to Sabrina who I was. I then said that I knew her mother was going into the hospital next week and that I wondered what it would be like for her without her mom at home. Sabrina said that she was “mad” because she had to stay at her grandmother’s. She had her own room there, but it was dark at night, and she didn’t like it. Mrs. Rossi immediately said that they would get a nightlight for that room, just like the one she had at home. Sabrina seemed somewhat placated by this idea. I asked Sabrina to draw a person. The drawing (see Figure 12.1) appeared to be very primitive and almost frightening. The core body was in black, with parts of the hands, legs, and feet outlined in red. Sabrina also outlined the body and arms in purple. The features of the face were minimal, and the figure had no hair. Sabrina declined my invitation to tell me about this person. I considered that it might reflect the child’s fantasy about surgery (the distinctive red color could signify blood). I decided to prepare Sabrina for the experience of seeing her mother hooked up to intravenous (IV) lines. I knew that Mr. Rossi planned to take her to the hospital to visit soon after the operation. Therefore, I made a crude drawing of a person in a hospital bed with the IV stand next to it, with connections to the patient (see Figure 12.2). I explained to Sabrina that after an operation people cannot eat as usual and that their food and medicines are given to them in tubes that go into the veins in their hands and noses. Sabrina expressed disgust about the nose tube, but her mother reassured her that it was only for a short time and that it didn’t hurt.I then brought out a doll family and bedroom furniture and suggested that we play out what it would be like to go to visit Mom in the hospital. We set up Sabrina’s home in one location, with a toy telephone, and Mom’s hospital bed in another, also with a phone. I invited Mrs. Rossi to role-play what it would be like after her operation, suggesting that she tell Sabrina she felt very tired and weak but that she would get stronger later. Mrs. Rossi played this scene with Sabrina very effectively, and at the end Sabrina hugged her mother and said, “I’m glad it’s not today!” Summary of the Next 8 Months The first several months after Mrs. Rossi’s surgery were a period of hope and optimism. Mrs. Rossi had a good recovery from the operation, despite the considerable adjustment in adapting to using the colostomy and urinary bags. No chemotherapy or radiation was prescribed, as Lida had previously undergone a course of radiation in an earlier attempt to shrink the tumor. Mr. Rossi was very supportive of his wife and hopeful that they could resume some form of sexual activity, adapted to his wife’s limitations. Mr. and Mrs. Rossi and Sabrina went on a vacation together, and Lida was making plans to resume her professional career. John had obtained employment, with the intention of getting his own apartment and returning to school the next semester. Sabrina was doing well in her first-grade class; she drew a picture of a “princess” (see Figure 12.3) 2 months after she had drawn the primitive, insect-like drawing prior to her mother’s hospitalization. Comparing the two drawings now, I believe that the earlier figure reflected the child’s fears and regression caused by her anxiety about her mother’s upcoming operation and the anticipated separation.
During this period I saw various members of the family at 2-week intervals in different combinations, including the parents together, Sabrina alone, Mr. Rossi and John together, and Mr. Rossi alone. John was continuing sporadically in individual therapy with another therapist. The family mood was positive, despite the ongoing concern about John. Because Sabrina was doing so well in school and at home, it was not necessary to see her weekly. Eight months after Mrs. Rossi’s operation, this period of optimism and hope for the future came to an abrupt and tragic end when John was found dead of a heroin overdose in a friend’s apartment. My initial thought upon hearing the news was that it was a suicide, but both Mr. and Mrs. Rossi stressed that John had recently found a job and was in good spirits, talking about getting his own apartment and returning to school. They regarded the death as an accident and believed that John had not used heroin previously. They also criticized the friend who had given it to him because he ignored John when he passed out in a drugged state. Members of both Mr. and Mrs. Rossi’s extended families attended the funeral, as did many of John’s friends; Sabrina sat in the front row between her parents. I refer to the Rossi family at the time of John’s death to illustrate some typical bereavement reactions throughout the chapter.