Let’s consider a teenager, accompanied to the hospital by their parents or guardian, with signs of depression, anxiety, or self-harm. They are admitted for observation. The intake describes a pre-pandemic adolescent as being social, doing well at school, involved in activities such as sports or theater, and following a normal developmental process for their age. But everything changed after the pandemic began.

This teenager is living in a metaphorical straight-jacket. They are trying to burst out – but can’t. They are literally growing out of their surroundings with nowhere for their growing body or mind to go. You, as the social worker or in-take clinician, are working the shift. Now what?

Most likely, you’ve seen lots of these 13- to 18-year-olds walk through the doors of your hospital or clinic lately. They appear despondent, listless, afraid, and silent. Some of them are coping through self-harming behaviors, some are using drugs or alcohol, while others are not sleeping or have become paranoid. Remember, prior to the COVID pandemic, these behaviors were not apparent. Why now?

Teenagers Are Experiencing Undefinable Grief and Loss

The language of “grief speak” is different for adults than it is for teens. There is nothing neat or orderly about the ways adults feel or respond to grief, mourning, and loss. With adolescents, it is even messier. Trying to define or describe how grief is exhibited in teenagers, especially in those precious years between age 13 and 18, as the hormones are pulsing, can be precarious. They are experiencing an intense cycle of changing hormones and new grief resembling an overwhelming emotional roller-coaster ride. Yet, it is important to assess the differences between the grief inherent in a teen’s developmental process, grief in response to the death of a loved one, and grief related to other factors, like isolation, lack of socialization, and an interrupted life (including interrupted development).

When it comes to pandemic-related factors (ie, isolation, social distancing), the adolescent brain does not have a chance to fully engage in its yearning to grow and develop, where this type of grief typically evolves and exists. Understanding the intricacies of growth spurts experienced by this age group offers insights as to how to best treat and address their responses to grief.

How to Respond to Teenagers and Disenfranchised Grief

For so many teens today, they are feeling grief as they face a world dominated by a virus that seems to have no end, is oppressive, and feeds the pain of what is aptly called: disenfranchised grief. Kenneth J. Doka, PhD, defines disenfranchised grief as a grief response that is unrelated to the loss and death of a loved one, albeit parent, sibling, grandparent, aunt or uncle.

This type of grief is not to be dismissed. It does not fit into the Elisabeth Kubler-Ross form of stage theory, which she wrote for the dying, not for the living going through grief. In my years of writing about grief and counseling patients through grief, I have learned that grief is fluid. It flows and is non-linear. Grief changes, moves around, and forms alliances with anxiety and anger before often moving into role confusion, numbness, and denial. For a teenager, when disenfranchised grief meets denial, it can sound like, “I’m fine,” “Nothing’s wrong,” or “I would rather not be here.”

Build Trust

By the time you meet this teen, their daily routines have already become fractured. The adults in their lives may have relayed messages of “Get over it” or been lost in their own turmoil, leaving the teen without support. If the teen has learned not to trust their environment when it comes to getting help to grip with the unreality of what they are experiencing, anxiety sets in. When this occurs, the “all or nothing” mindset – a hallmark of anxiety – is likely at its peak and anger is around the corner.

At this point, it is crucial to build trust with the teenager. Below are innovative ways to achieve this trust:

  1. Explain the Human’s Natural Instinct to Self-Protect: Tell them you’re not ready to hear the story of how they got to the hospital or into therapy. Instead, let them hear that you have their best interest at heart. Let them in on the self-care secret – that is, one’s need for self-protection. This concept is important meta-communication to their inner brains, especially before they consider becoming vulnerable to someone they don’t know. This approach may sound out of the ordinary, yet it works. There’s a high probability that no one has given them a chance to slow down and process what is happening within their minds, their bodies, and their psyches.
  2. Label their Grief: Give them a language to use, including a name for what you believe is going on with them: grief. Say to them, “I imagine you’ve lost a lot recently. These losses are strange because we’ve never been in a situation like this. I believe you are grieving.” Label grief. Label anger. Label anxiety. Give them a platform that sounds reasonable. Enforce that “You are not your grief, you are not your anger, you are not your anxiety. They are part of you, but they are not you.”
  3. Illustrate the Loss. Help them provide you with a metaphorical picture of what they feel they have lost. I have found success by using core concepts for regulating a nervous system within the work of Dr. Stephen Porges whose book, Polyvagal Theory informs my process as a grief therapist. Utilizing his theories in combination with the Polyvagal Ladder created by Deb Dana offers creative and innovative pathways to help the brain move from a stuck place of being into a growth and metamorphosis state of being. This means you can help the brain move from a dysregulated place to greater regulation. A patient can point to where they are on the ladder (see Figure 1). Ask them if they have ever been in the green zone. What did life look like then? If they’ve had a sense of what it is to feel safe, connected, calm, and calibrated, ask them for their stories in the context of those experiences.

The third part of the conversation provides an opportunity to help them see beyond being a victim of the pain they are in. You want to elicit the picture they hold of themselves before grief enters the picture. This is a time when the memory of who they were is often not accessible, and if it is, they yearn for it, because they can’t get back to it or recreate it. They may have forgotten who they were. You want to identify the amnesia, so to speak, and help to create new visions and dreams. Whether they are in either fight-or-flight mode or numb and disconnected, identify where they are.

Polyvagal Ladder

Figure 1. The Polyvagal Ladder

 

Grief can be filled with depths of isolation and confusion. Help the teenager move into past memories, a time in their life when they connected to feeling safe, calm, and happy. The goal is to help them get in contact with a dormant part of the self, the ventral vagal network. This is also known as the social engagement system. The ventral vagal network is often dormant in the face of grief – especially, during the intensity of the pandemic. Essentially, you are asking for awakening to occur within them. Out of dormancy, out of fear, and into a greater sense of attachment to the self.

Humanize Yourself as a Clinician

After building trust, it’s important to humanize yourself. As most therapists and social workers know, you will get further with a patient or client when you play the role of human, not clinician. You are facing the same pandemic – the same grief and loss – they are. By sharing your own vulnerability (as much as you are comfortable as a professional), you can implement an opening you might not otherwise get.

It may help you to envision their pain as an aspect of burnout, of intense grief. The greatest gift of healing you can give to them is to listen, hear their stories, and find creative ways to get them to talk about their grief. Rather than diagnosing them, allow for their stories, creativity, and losses to have a place to be expressed. Dedicate your time with them to understanding how their symptoms are a cry for normalcy, and work toward making a concrete plan.

A concrete plan may include:

  • daily mood self-check-ins so that you and the patient can track mood elevation or remission
  • breathing exercises taught for the purpose of self-regulation
  • cognitive interruption, which can be as simple as using the rubber band technique, described below.

The rubber band technique is great for working with teens because no one will know they are using it. It is as easy as putting a rubber band on the wrist and when a negative thought comes in, snap the rubber band, say “Stop It,” and change the thought. Take in a breath and let it go. You can practice this with them. Create thoughts that are easy to go to for them. A list can be developed within a session, so they have a sense of collaborating with you.

Become an Interrupter

Disenfranchised grief is complicated, so a multi-leveled approach is needed to help treat the grief. This approach helps to interrupt the teen’s internal cognitive messaging about loss. They may have learned this messaging through social media, news heard at home, in school, etc. Remember, a teenage brain is still in development mode and easily overloaded by any stimulation (messaging) they may be experiencing from the pandemic, but you can help them break down these internal messages and help them define what was lost.

As a social worker or clinician, you need to intervene but not in the way you may have done so in the past. The crisis of today’s pandemic calls for “out-of-the-box” thinking. I call it “intervention with a capital I.” Do so carefully because you are facing someone whose ability to trust is fragile. They are trying to cope with new parts of the self they never knew existed and these parts are filled with desperation, fear, and grief.

Ask them questions they don’t expect. For example, how do you breathe? Or, what used to make you laugh? Or, what was the worst movie you ever saw? They are questions not usually asked, they add a bit of casualness to the session, and it may be more of a way in than you realize. Ask for the story they are telling themselves about the future. Kids are storytellers – they thrive when able to share a story of success, of how they got the goal at the last minute, or how they prepared for a production. To be a good interrupter, you need to keep in mind what’s happening in their brains right now.

Teenagers likely feel trapped and unable to unleash creative, analytical, or critical thinking. They want to return to their normal state where their brains are able to focus on conquering challenges, learning what works (and what doesn’t), and where they fit into the world schema.

Reinstall the Teen Dream State

Remember also, that just like adults, teenagers likely had dreams or plans that were thwarted by the pandemic. They, too, rely on patterns and rituals.

Without these rituals, internal chaos erupts. What normally keeps the chaos in check within the mind and heart of a teenager, is being a dreamer, living in self-discovery, and tapping into their sexual selves. Most of these necessary developmental components have been unavailable to the teen during the pandemic.

Remind them that a dream does not have to end if it can’t be immediately implemented. There are deep learning curves here. This is where you have a chance to help them define their collaborative alliances. What can they collaborate on, with whom, and how? As a start, you can be their first alliance. Your relationship with them, including acknowledging and caring about the little steps they take to get out of the web of grief, can point them in the right direction.

Moreover, by instilling this type of mindset,  you can break the fusion to the pandemic response of grief and bring in a thought change. Little by little, what may have seemed impossible to the teenager entering your hospital or clinic, may now be viewed with hope.

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Last Updated: Apr 12, 2021