Pathfinders: Promoting healthy adjustment in bereaved children and families

ABSTRACT

Pathfinders is a 10-session program developed in a community setting to creatively address the diverse needs of bereaved children and families, prevent complications of grief and trauma, and promote healthy adaptation. It is an accessible, grief-focused and trauma-informed family systems model that is theory-driven, research-informed, and grounded in practice-based evidence. Pathfinders incorporates principles central to narrative approaches, with a focus on restorative processes for helping children and families stay on track developmentally. This article outlines the structure, process, and content of Pathfinders, including examples of creative interventions used within the program.

Although death is a natural part of life, the death of a parent, sibling, or other attachment figure during childhood is not normative or expected. Indeed, it is considered by many to be one of the most stressful and potentially traumatic experiences a child can endure (Keyes et al., 2014; Yamamoto et al., 1996). Without appropriate support, the death can significantly alter a child’s worldview, sense of security, and developmental trajectory (e.g., Sandler et al., 2003; Webb, 2010).

Reactions following a death can be complicated by a number of factors, including a child’s relationship to the deceased or their surviving caregivers, their developmental understanding of death and its permanence, or the circumstances of the death (Kaplow, Layne, Pynoos, Cohen, & Lieberman, 2012). For instance, while sudden, unexpected deaths caused by accidents, suicide, homicide, or other forms of violence are more widely recognized as traumatogenic (e.g., Cohen, Mannarino, & Deblinger, 2006; Melhem, Porta, Shamseddeen, Walker Payne, & Brent, 2011; Rynearson, 2001), there is growing evidence that sudden medical deaths (Melhem et al., 2011), and even anticipated deaths caused by long-term illness (Kaplow, Howell, & Layne, 2014), can also lead to trauma reactions, particularly for children. Exposure to death and associated circumstances, including observation of physical deterioration, invasive medical procedures, or prolonged suffering, as well as the permanent separation from an important attachment figure, can lead to significant difficulties for children (Kaplow et al., 2014).

When left unaddressed, grief and trauma reactions can result in problems such as enduring symptoms of anxiety, depression, and posttraumatic stress, and difficulties including aggression, absenteeism, academic or work struggles, and relationship issues (e.g., Brent, Melhem, Donohoe, & Walker, 2009; Brown & Goodman, 2005; Cohen et al., 2006; Dillen, Fontaine, Verhofstadt-Denere, 2009; Haine, Ayers, Sandler, & Wolchik, 2008; Kaplow, Saunders, Angold, & Costello, 2010; Kaplow et al., 2012; Melhem et al., 2011; National Child Traumatic Stress Network (NCTSN), 2015; Worden & Silverman, 1996). Many youth exhibit difficulty coping with even normal stressors or trusting interpersonal relationships after a death (Sandler et al., 2003).

Children who experience the death of an important attachment figure as destabilizing or traumatic are at increased risk for psychological and behavioral vulnerability. As such, access to grief-focused, trauma-informed care is necessary to mitigate potential disruption of healthy developmental trajectories. The purpose of this article is to describe the Pathfinders program (Judi’s House, 2012b), a preventive intervention that creatively addresses the diverse range of grief and trauma reactions of youth and families seeking support after a death.

Judi’s House and the Pathfinders program

Pathfinders is a core component of the Comprehensive Grief Care (CGC) approach developed and evaluated at Judi’s House (JH), a nonprofit, community-based family bereavement center providing services free of charge since 2002 (Griese, Giusto, & Silvern, 2012). The CGC continuum of preventive services supports grief-focused, trauma-informed care for the whole child, family, and community (Griese, Burns, Farro, Silvern, & Talmi, 2017). CGC utilizes a systems approach to provide individualized assessment and interventions to a demographically diverse population of bereaved youth ages 3–25 years and their parents or caregivers. CGC services include Pathfinders, typically provided to the whole family in parallel, age-appropriate groups; Connections groups for ongoing support; and individual and family therapy for more intensive intervention. Services are individualized to meet the complex needs of children and families, with the overarching goals of preventing complications of unaddressed grief and trauma and promoting healthy adaptation following a death.

In 2006, JH established a formal evaluation and research initiative, in partnership with the University of Colorado, to ensure rigorous evaluation and continuous data-informed quality improvement of all of its programs. The initiative included the development and implementation of a bereavement-specific, multi-method, and multi-informant assessment protocol that incorporates standardized measures of general adjustment, depression, and trauma, as well as grief-specific measures, including the Adjustment to Trauma, Loss, and Adversity Scale (ATLAS, Judi’s House, 2012). The protocol also employs four separate developmentally tailored, semi-structured interviews (adult, young adult, adolescent, school-age, and preschool) to gather additional qualitative and clinical information. Integrating academic research into a community-based setting, while providing services to over 1,000 individuals annually, has allowed JH to amass one of the largest known research datasets focused on understanding the needs of grieving children and families. The evaluation and research initiative is now housed in the organization’s Judith Ann Griese (JAG) Institute, established in 2014 to expand research and training efforts both locally and nationally. This integration of practice-, research-, and community-based knowledge has continuously informed the development of Pathfinders and the larger CGC system of care provided at JH (Griese et al., 2012, 2017).

Theoretical influences, philosophies, and goals of Pathfinders

Developing an effective, trauma-informed model of care for a community-based family bereavement center was a creative challenge because of the participants’ diverse ages, demographics, and types of deaths experienced, as well as the broad range of severity and complexity in their grief and trauma reactions (Griese et al., 2017). Program participants at JH range from preschoolers to caregiving grandparents, with nearly half identifying racially as non-White and the full spectrum of socioeconomic status reported. Whereas adult caregiver participants are predominantly female, gender tends to be evenly split among child participants. In a typical year, around 70% of participating youth are grieving a parent’s death and just over 10% are grieving a sibling loss, with all types of relationships and causes of death represented, including long-term illnesses, accidents, violence, and suicide. While many participants have clinical elevations on standardized measures of adjustment, others do not meet established cutoffs. The goal was to develop a systemic approach that honored these varied backgrounds and needs, allowing the entire family to receive parallel services simultaneously while still having safe, developmentally appropriate opportunities for peer connection and sharing.

Contemporary grief and trauma models

The development of Pathfinders was influenced by the psychological and developmental theories and empirically supported grief and trauma interventions described below, but even more so by the voices and experiences of the children and caregivers seeking care at JH. Early research findings, clinical observations at JH of the severity of child- and caregiver-reported adjustment difficulties, and direct feedback from caregivers about the program provided the impetus for JH to develop a more structured and trauma-informed model to better address the full range of families’ presenting needs (Griese et al., 2012, 2017). Pathfinders, therefore, integrated elements from existing models that targeted some of the specific subpopulations and issues seen at JH. This included the Family Bereavement Program, a preventive intervention for parentally bereaved youth focused on psychoeducation, coping, and caregiving skills (Sandler et al., 2003), and Trauma-Focused Cognitive Behavioral Therapy (CBT) targeting posttraumatic stress reactions that interfere with grieving (Cohen et al., 2006; Goodman et al., 2005). Pathfinders also shares similarities with cognitive behavioral treatments developed for traumatic events including but not limited to bereavement (e.g., Layne et al., 2001), such as Salloum’s (2015) Grief and Trauma Intervention (GTI) developed for 7–12 year olds. Like GTI, Pathfinders has commonalities with Rynearson’s (2001) restorative retelling approach used with violently bereaved adults and older adolescents. Pathfinders incorporates elements of these empirically evaluated models with peer grief support group approaches long used to foster normalization, validation, and decreased isolation, including experiential and expressive arts activities and group sharing in a comfortable setting (Schuurman & DeCristofaro, 2010).

While Pathfinders shares commonalities with these approaches, it is distinct in several ways. As noted, Pathfinders was conceptualized and designed to be an accessible program that reduces stigma and barriers to care by serving a broader range of ages and bereavement reactions. Contrary to a “one size fits all” approach, a fundamental goal of Pathfinders was to create an environment of acceptance and inclusiveness that recognized that the intensity, complexity, and duration of grief and trauma responses are unique to each person. Historically, children’s bereavement programs have either provided peer support for “normative” grief or targeted therapies for complicated or problematic grief and trauma manifestations. In contrast, Pathfinders was intentionally designed to serve both as a specific preventive intervention for some and a time-limited therapeutic intervention for others—sometimes within the same family (Weisz, Sandler, Durlak, & Anton, 2005).

Pathfinders avoids minimizing or pathologizing grief and trauma reactions, focusing on addressing each individual’s distinct needs. The program is highly customizable in that it allows for combinations of group, individual, and family therapy modalities. The initial assessment protocol allows providers to make recommendations about the client’s cognitive, emotional, and social development, program readiness, potential group placement, and additional supports. Clinical evaluation informs the recommended therapeutic modality for clients presenting with more significant grief or trauma. This flexibility allows for family systems level work that simultaneously can coincide with individualized, developmentally tailored services for each family member. For example, at JH if one child in a family struggles to regulate, comprehend, or process in a group context, they can receive Pathfinders individually while other members of the family participate in groups.

Developmental models

Pathfinders is based in a developmental framework with the overarching goal of promoting healthy developmental trajectories by mitigating risk factors and strengthening protective factors for bereaved youth and families (Sandler et al., 2003). Taking a strengths-based perspective, grief is understood as a universal and natural reaction to loss, and each individual is believed to have the ability to heal with appropriate support and care (e.g., Schuurman & DeCristofaro, 2010). Throughout Pathfinders, congruence, empathy, and unconditional positive regard are essential to meeting clients where they are emotionally and encouraging them to share their own wisdom with others (Rogers, 1957). Clinicians and families work together to identify manifestations of grief and trauma that are interfering with healthy development to prevent further disruption (Webb, 2010).

Pathfinders specifically focuses on decreasing disruptive grief reactions commonly observed at JH as interfering with grieving and adapting, while increasing restorative grief experiences thought to promote healing and adjustment to loss (see Table 1). While grief itself is not something to be prevented, complications resulting from grief and trauma can significantly disrupt an individual’s life if not appropriately addressed and supported (e.g., Keyes et al., 2014). This is particularly true for children and adolescents (Cohen et al., 2006; Kaplow et al., 2014). Common techniques employed by youth to understand and cope with the death (e.g., isolation, drugs, alcohol, truancy, acting out, self-harm) often lead to negative present and future outcomes. By targeting disruptive grief reactions with evidence-informed interventions, and encouraging restorative grief experiences, youth participating in Pathfinders are supported in staying on track developmentally and strengthening their connections to supportive peers and adults.

Table 1. Reactions and experiences targeted in Pathfinders.

Disruptive grief reactions	Restorative grief experiences
Denial about the death	Expressing grief and distress
Confusion about cause of death	Developing healthy coping skills
Overwhelming separation distress	Connecting with supportive peers
Debilitating depressive symptoms	Building supportive relationships with caring adults
Suicidal ideation or self-harm	Seeking support from professionals when needed
Explosive anger	Forming and sharing a coherent narrative
Excessive fears, worries, anxiety	Remembering, memorializing
Guilt and self-blame	Maintaining an enduring emotional connection with deceased
Isolation, withdrawal, mistrust	Meaning making
Posttraumatic stress symptoms	Engaging in enjoyed activities
	Reflecting on personal or posttraumatic growth

Trauma-informed care

At its foundation, Pathfinders applies principles of trauma-informed care, including a strong emphasis on safety, transparency, trustworthiness, collaboration, choice, empowerment, peer support, mutuality, and inclusiveness (Substance Abuse and Mental Health Services Administration (SAMHSA), 2015). Given the diversity of the population served, safety is prioritized. In the initial session, participants review and agree to establish a “safe zone” defined as mutual respect for all people regardless of race, ethnicity, gender expression/identity, sexual orientation, income, age, religion, body shape, size, and ability. This sentiment is reinforced throughout the curriculum when discussions or activities may highlight differences in world view (e.g., existence of afterlife). Using ongoing assessment throughout services, clinicians continuously identify and address cumulative and bereavement-related trauma symptoms which may complicate the grieving process or warrant specific interventions, thereby creating experiences of grounding. At every point of contact prior to engaging in grief and trauma exploration, individual and family needs (e.g., physical and emotional safety; Maslow, 1943) are assessed to inform session by session progress and overall treatment planning, recommendations, and coordination of care.

Cognitive behavioral theory

Given the evidence for CBT effectiveness in reducing many disruptive reactions to trauma (Cohen et al., 2006; Salloum, 2015), elements and techniques of CBT are prominent in Pathfinders. One core component, the Coping Companion (Judi’s House, 2012b; see Figure 1), provides a concrete and interactive tool to help caregivers and children across developmental levels gain awareness of their cognitions, emotions, physiological responses, and behaviors and the connections among each in relation to the death and their grief. This creative approach moves clients toward healthy adjustment by providing a platform for developing an internal locus of control and positive coping skills for regulating and managing the difficulties resulting from grief, trauma, and other secondary stressors. Participants give the Coping Companion a persona, including a name, age, and specific type of death loss, and then use this personified schematic to explore specific imaginary and real-life scenarios in which healthy coping skills could improve internal or external reactions to the situation. Recognizing the importance of coping flexibility in fostering healthy adaptation to grief and trauma, Pathfinders introduces and teaches participants a variety of established coping skills (e.g., relaxation, mindfulness, physical release, and cognitive strategies) and encourages the entire family to practice and model the skills for one another.

Figure 1. Coping Companion tool.

Narrative theory

As with other approaches in this special issue, narrative components are central to Pathfinders. Clinicians create a supportive environment for developing and sharing a coherent and accurate narrative of the death to integrate the experience into a larger life story (e.g., Rynearson, 2001; White & Epston, 1990). Given individualized support for narrative reconstruction during or outside of Pathfinders, participants are empowered to choose what they feel comfortable disclosing with others. Pathfinders offers creative approaches (e.g., interviews, drawings, comic book or storyboard layouts, sand trays, music lyrics, and poetry) to scaffold story sharing to decrease inhibition. Throughout the retelling, clinicians assess for and address signs of posttraumatic reactions or vicarious trauma. As each individual family member creates their narrative, a meta-family narrative that allows for differences in experience begins to emerge. Emphasis is also placed on the unfolding story of the families’ collective and individual grief story.

Dual process theory

Recognizing that grief is not experienced in predictable, orderly stages, Pathfinders respects that grief is experienced in waves over time and—particularly for children—is best tolerated in small doses (Neimeyer, 2001; Wolfelt, 1996; Worden & Silverman, 1996). Applying dual process theory (Stroebe & Schut, 1999), Pathfinders honors the need to go toward difficult aspects of grief through safe activities and discussions, while encouraging conscious and intentional breaks from these emotionally heavy aspects. This oscillation between loss-oriented and restoration-oriented coping is evident throughout Pathfinders (e.g., curriculum structure and time designated for snacks, free time, and play). Moreover, this dual process is reinforced by opportunities for families to return to JH for services following completion of Pathfinders, recognizing that children mature developmentally and experience their grief differently or find that significant life events trigger grief waves.

Systems theory

Pathfinders’ systemic approach considers multiple attachments and communication patterns that impact the family by involving caregivers, siblings, other family members, and friends. By involving subsystems of each participant’s context (e.g., caregivers, school professionals, healthcare providers, community supports; Bronfenbrenner, 1979), Pathfinders creates opportunities for immediate growth while also supporting long-term adjustment for the entire family. For example, while caregivers are provided support for their own grief at JH, they are also encouraged to continue conversations about Pathfinders activities and concepts at home to promote system-wide understanding and healing. Although the program can be provided without the involvement of multiple family members (e.g., in school-based settings), the systems orientation is fundamental to the intervention and suggestions are offered for incorporating caregivers, teachers, and other healthcare professionals.

Attachment theory

Pathfinders reinforces contemporary, bereavement-specific attachment theories by emphasizing continuing bonds—creating an enduring emotional connection to the deceased despite physical absence (e.g., Klass, Silverman, & Nickman, 1996). For instance, youth engage in activities related to the children’s book “The Invisible String,” that explains how bonds to loved ones are ever-present, even in death (Karst & Stevenson, 2000). Process activities allow participants to identify ways they can maintain connection to the deceased and engage in meaning reconstruction to assist in integrating the loss into life and encouraging healthy adjustment (Goodman et al., 2005; Neimeyer, 2001).

Strengths-based practice

In addressing disruptive grief reactions and promoting restorative grief experiences, Pathfinders offers a growth-oriented perspective of adjusting to death loss. For instance, in children and families exhibiting trauma reactions, Pathfinders facilitates opportunities to explore possibilities of posttraumatic growth (PTG). PTG is defined as positive change resulting from wrestling with the reactions one has in response to a traumatic life event (Tedeschi & Calhoun, 2004). Examples of PTG include increased empathy for others, greater appreciation for life and relationships, engaging in altruistic acts, and increased strength, coping, and competence. The PTG construct has gained prominence and recognition in adult populations, and there is emerging evidence of its generalizability to youth (Meyerson, Grant, Carter, & Kilmer, 2011). Kilmer et al. (2014) highlight the Pathfinders program as a promising intervention that actively engages participants in cultivating a growth experience in relation to a potentially traumatic experience. For instance, the Helping Hand activity in Pathfinders encourages clients to trace their hand and leave a message of hope, encouragement, or shared wisdom with grieving individuals who will come after them—promoting the concept of reflecting on personal growth and channeling one’s loss to help others.

Structure, process, and content of Pathfinders

Pathfinders is provided over 10 sessions, and three distinct phases within the intervention provide a guiding structure for individual session themes (see Table 2). The length of the session may vary based on setting and modality, but ranges from 50 to 90 minutes. Utilizing a journey metaphor, participants are given a Pathfinders map, marking theory- and practice-based themes with a symbolic cairn. Participants learn that cairns, piles of stones gathered by many hands, have been used historically for two purposes: to mark unclear paths and to memorialize the deceased. In this way, children and caregivers are continuously reminded they are not alone on their grief journey. In Pathfinders, the collective wisdom of previous participants is used to inform and shape the program. Current clients are encouraged to contribute their experience to the knowledge base to assist others. Participants also create their own memorial cairn, adding a stone at the end of each session.

Table 2. Pathfinders program by session.

Cairn themes	Milestones of Healing	Influences	Sample references
Phase I: Getting started—Grief education and skill building
1. Beginning	Understanding and accepting the reality of the death and its impact	Psychoeducation, group process	Worden (1991)
2. Grieving	Recognizing connections among diverse grief reactions	Trauma, cognitive behavioral	Cohen et al. (2006)
3. Coping	Building skills for coping that promote healing and well-being	Coping, dual process	Stroebe and Schut (1999)
Phase II: Telling our stories—Honoring the narrative
4. Sharing	Developing a narrative of the death and integrating it into a larger life story	Narrative	White and Epston (1990)
5. Changing	Acknowledging and adapting to changes in life and self after the death	Existential	Yalom (1980)
6. Exploring	Addressing difficult aspects of the relationship, the death, or the grieving process	Gestalt	Greenberg and Foerster (1996)
7. Remembering	Maintaining memories and enduring connection to the person who died	Attachment, continuing bonds	Klass et al. (1996)
Phase III: Moving forward—Integrating loss into life
8. Connecting	Engaging in supportive relationships and enjoyed activities	Ecological systems	Bronfenbrenner (1979)
9. Preparing	Reflecting on growth and planning for the future	Strengths-based, posttraumatic growth	Tedeschi and Calhoun (2004)
10. Continuing	Progressing on a path of health and wellness	Family systems	Sandler et al. (2003)

Overarching needs or “tasks” commonly identified of grieving children include accepting the reality of the death and its permanence, allowing for the experience of diverse reactions to the loss, and adjusting to life without the deceased in a manner that allows for normal development and meaningful connection (e.g., Worden, 1991; Worden & Silverman, 1996; Wolfelt, 1996). In Pathfinders, these needs are captured by the Milestones of Healing that correspond with the cairn themes. Participants learn that the milestones are not finite or sequential and revisiting them over time may be necessary as they experience different developmental stages and life events. Returning to these themes in the future is characterized as adaptive integration of the loss experience rather than regression.

Table 2 outlines the three Pathfinders phases with the corresponding cairn themes, the Milestones of Healing, and theoretical influences. In session, clinicians emphasize the general principles of each cairn, providing tools to aid with present and future growth and development. The first phase fosters comfort, safety, coping competence, and stabilization while laying a foundation for the work ahead. The narrative retelling activities of the second phase allow for exploration of the existing story with opportunities for the co-creation of a coherent individual and family systems level narrative. Distortions and fixations are identified that may require revision for successful integration. Finally, the third phase of Pathfinders supports continued or improved engagement in relationships and activities that promote full enjoyment of life after a loss.

Upon arrival for Pathfinders, families are offered dinner or snack, setting the stage for meeting basic physiological needs that could distract from the session if unaddressed (Maslow, 1943). Each session begins with consistent and predictable routines, rules, and rituals, promoting comfort and healing (Cohen et al., 2006; Freedman & Combs, 1996). This allows clinicians to assess safety, belonging, and cohesion throughout successive sessions. For example, JH clinicians instruct and practice a new coping skill in a manner suited to the clients’ developmental needs. Emphasis is placed on identifying and replacing negative coping with new knowledge and skills that support healthy adaptation. Subsequent activities are designed to elicit meaningful experiences and discussions focused on the specific cairn theme. Each Pathfinders session ends with a distinct ritual that marks a transition from grief-focused processing to restorative experiencing. At JH, younger children may play or create art, and older youth may engage in casual discussions or listen to music. Clinicians assess each participant’s ability to shift back into their daily lives. The session ends with a snack and reunification with other family members, providing clinicians opportunities to follow-up with concerns that may have surfaced in session.

Three distinct but parallel Pathfinders curricula are designed for children (3–11 years), adolescents (12–to 18 years), and adult caregivers. When available, developmentally tailored groups normalize grief experiences and decrease isolation through supportive connections with same-age peers (Yalom & Leszcz, 2005). The child Pathfinders curriculum emphasizes flexibility and spontaneity through brief, creative, and playful activities that promote fun while directly targeting bereavement experiences. The Adolescent Pathfinders curriculum focuses on peer relationships, autonomy, and independence by encouraging participants’ collaborative ownership over content and process thus creating a space for self-exploration. The caregiver Pathfinders curriculum is the foundation for a systemic approach to care and follows the same structure and content reflected in Table 2. Caregiver participants have a range of grief experiences from deeply grieving the death to not personally knowing the deceased. Caregivers discuss constructs and complete activities that align with the children’s groups. Balance is provided by focusing equally on processing adult clients’ grief and on caretaking/parenting a grieving child, including introducing a caregiving skill in each session. Family-based activities are encouraged, contributing to the system joining together outside of Pathfinders to reinforce communication and adaptive coping.

Pathfinders curricula also provide further guidance for adaptation to specific ages (e.g., preschool, young adults), causes of deaths (e.g., suicide deaths, child deaths), treatment modalities (e.g., individual and family therapy), and settings (e.g., school and community organizations). The content is sensitive to diverse demographics, cultures, and religious beliefs and is currently being translated for use in Spanish. Pathfinders’ semi-structured content also allows clinicians flexibility to address pressing concerns or to account for unpredictable events affecting families and communities. By meeting bereaved families where they are, and encouraging reinvestment in life and a hopeful, productive future, participants of all ages and backgrounds are supported in moving toward healthy adaptation and personal growth.

Future directions: Expanding access to grief-focused, trauma-informed care

Given the growing demand for grief-focused care for youth, in its surrounding community and beyond, JH established JAG Institute to expand the network of professionals trained in providing Pathfinders in other settings. This includes an expanded evaluation and research initiative to closely track fidelity and effectiveness with rigorous data collection and analyses. Multi-site training and research will allow for greater learning about the individual differences related to adjustment to bereavement and differential response to services, including variations related to geography, types of deaths, culture, ethnicity, religion, and other demographics. Learning which interventions work for whom is an ongoing research question that will continue to drive program evaluation and development for many years to come at JH and JAG Institute, and this should be a priority for others conducting research in this area, as well. To meet the complex needs of the children and families seeking services after a death, we need a much larger knowledge base about which interventions are effective, accessible, feasible, and sustainable in the community. The childhood bereavement field still has large gaps in its understanding of the best ways to support children and families with diverse grief and trauma reactions, and evaluation of programs that have been successfully provided in community-based settings is an important element of growing this knowledge base. It is our responsibility to the grieving children and families we serve to continue to learn from them, disseminating the wisdom they share through research and training to help increase access to effective care and support.

Acknowledgements

The authors acknowledge the children and families who courageously share their experiences at Judi’s House, and the devoted staff, volunteers, and donors who lend their support.