The impact of loss, grief and relational connection for youth in foster care
Over the past 20 years, through youth-centered research, practice and mentorship, I’ve listened to and learned from thousands of youth in foster care as they’ve shared what it is like to experience foster care transitions. My heart has weighed heavy as youth discuss what it is like to be removed and disconnected from their families, placed into foster care, how they cope with loss and grief while navigating the foster care system, what it has been like to return or not return to their family, and all the ambiguities that further complicate their reality.
In the following piece, I draw upon the stories and quotes from children, teens, and young adults that I have been privileged to know as a listener, the research that I and others have conducted, and the lived experience of removal and disconnection for youth in the foster care system. Their stories highlight current challenges within the child welfare system related to becoming and being grief-informed.
The harm of disconnection
When a youth experiences removal, they are inundated with loss from this first transaction. Most youth whom I have worked or spoken with equate this experience to “being kidnapped,” “being tooken,” or “ripped away.” One youth asserts: “It was a horrible, traumatizing experience for all of us – to be ripped away from your family.”
Unfortunately, the primary loss of removal can also lead to secondary losses. These losses include, but are not limited to losses of identity, losses of community, losses of routines and losses of self-worth. As one youth advised, “My loss was more lack of self-preservation and self-worth. I feel as if this could happen to someone no one cares about.” As illustrated by this youth’s experience, placement into foster care can also lead to a loss of hope, self-worth and belonging. While it can sometimes be a challenge to admit this, the system, which is designed to help youth, has also harmed them and the elephant in the room needs to be addressed.
Unaddressed grief in foster care
Grief is an inevitable result of loss and is commonly reduced to being “an emotion.” While grief can be expressed as emotion, it is so much more than that. Grief can be felt and manifested in our bodies, in our minds, in our spirits and in our interpersonal relationships. Sadly, grief is often overlooked and misunderstood in the child welfare system and is not adequately addressed.
While each relationship is unique, for youth who have been separated from siblings, this relational disconnection can be exceptionally challenging. Youth reports include: “A major loss that I had was not being able to see my sisters and being around my sisters and my family as much as I wanted to. And, having somebody that, you know, understands you that doesn’t necessarily just judge you and just stare at you like a foster child,” and “I got taken away from my sisters, who I promised I would never let them get hurt. I was pissed and I was what most people called a troubled child or hellion.”
The youth are telling us to listen, to really listen, to what the heart of their stories are telling us. Removal and separation from their families is painful; the subsequent grief resulting from separation from family, friends, homes and communities needs to be attended to; opportunities to discuss and explore their grief are not at the forefront of service delivery; and, in the absence of these supports, youth are feeling “betrayed,” “hurt,” “alone” and “unloved.”
Grief-informed best practices
Being grief-informed involves understanding the ten core principles of grief-informed practice and how understanding and applying these principles can better assist professionals in providing person-centered support to people who are grieving. These best practices include understanding that grief is natural, complex and nonpathological, contextual, disruptive, person-centered, dynamic, nonfinite and that people who are grieving require relational connection, perceived support, safety and personal empowerment and agency.
Ultimately, it is essential for child welfare professionals to understand the dynamic nature of grief and how to tailor their support in a way that respects the dignity and worth of each youth they are serving. While unpacking the core principles of grief-informed practice and their application to child welfare is beyond the scope of this article, there are resources available for child welfare professionals interested in providing grief-informed support to youth who are grieving. For example, The Bill of Rights for Youth in Foster Care Who are Grieving, developed by youth, outlines the ways that adult caregivers, teachers, friends and other people in a youth’s life can support them as they navigate their grief while in and after foster care. Additionally, Tips for Supporting Youth in Foster Care Who are Grieving provides grief-informed tips to support youth in foster care who are grieving due to separation and disconnection, and Now What? Tips for Teens Who are Grieving in Foster Care provides tips for teens who are grieving in the foster care system.
Some states have started to consider how to integrate grief-informed best practices into their core principles of child welfare practice. In Utah, for example, a cross-system statewide child welfare collaborative consisting of child welfare professionals — judges, guardians ad litem human services staff, etc.) — developed core principles and guiding practices for a fully integrated child-welfare system. In their guidance to child welfare professionals throughout the state, they identify the need for the child welfare system to be grief-informed and their commitment to ensuring that youth in foster care receive grief-informed services. Utah has provided an excellent example for other states interested in learning how to incorporate grief-informed best practices into state policy and service delivery.
Psychotropics: the dominant intervention of child welfare
According to the American Academy of Pediatrics, “one in every three children in foster care are on psychotropic medications designed to alter their mental status or mood.” Furthermore, research has found that children in foster care who are on Medicaid are prescribed psychotropic medications four times more than children on Medicaid who are not in foster care.
In March 2022, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) included a new mental health diagnosis, “prolonged grief disorder.” The addition of this new pathology creates serious concerns for the well-being of youth in foster care. Aside from the concern that grief is being labeled as a pathological response to a normal human experience and life condition, this new diagnosis opens the door to more drug development and treatment for this “disorder.” In 2020, a clinical trial for a drug to treat prolonged grief disorder was underway.
Here is one of my primary concerns: The drug being used to “treat” grief, naltrexone, is one that is currently approved by the Federal Drug Administration for alcohol use disorder and opioid use disorder. The researchers who conducted the clinical trial conceptualize Prolonged Grief Disorder as a disorder of addiction, with persistent yearning and longing for a deceased loved one as the primary symptoms.
They hypothesize that the positive reinforcement provided by memories of the person who has died enables a craving or addiction. As such, they purport that a drug that helps to resolve the addiction is needed. Naltrexone, their theory asserts, may reduce the craving for the person they are grieving and thereby addresses the severity of the person’s prolonged grief disorder. In other words, the goal of naltrexone is to disrupt the social bonding between the person who is grieving and the person they are grieving. As a thanatologist, youth advocate and child welfare researcher, I am deeply concerned about the short- and long-term consequences of “treating” grief as a mental disorder and inadequately addressing grief for youth in foster care. Grief is not something to be “treated” or “fixed.” It is a normal and natural response to loss that requires relational connection, not social disruption.
As one youth reported:
“A lot of the so-called treatments that I was supposed to be receiving there consisted of a lot of suppressing what comes natural. I think that it’s had more of a negative effect than it’s had a positive effect, due to the fact that, you know, if you suppress something for so long, it’s not going to just go away. It’s going to wait and it’s gonna come back with a vengeance later when you finally get a chance to express yourself.”
Medication will not get to the heart of grief; human connection does.
The power of relational connection and perceived support
In addition to recognizing and acknowledging that grief is a normal and not pathological response to loss, it is critical that relationally based grief-informed interventions be available to youth in foster care to address death and non-death losses. Having an interpersonal relationship, also known as a relational home, for expressions of grief to be received and held is essential to well-being. As one youth in foster care reported, “Without being able to talk to anybody, I was walking around angry all the time and getting into trouble.”
Listening and Led by Youth in Foster Care: Grief, Hope, & Transitions (L.Y.G.H.T.) is one example of a relationally based grief-informed intervention. L.Y.G.H.T., an evidence-based and trauma-informed peer grief support program for youth in foster care, was created in response to youth reports indicating their need to express their grief with others who would understand and support them. From their expressed need, the L.Y.G.H.T. program was developed as a grief-informed, youth-centered relational intervention.
Because peer support and personal empowerment are protective factors for youth who are grieving, an intervention, other than medication, is needed. Through the L.Y.G.H.T. program, hundreds of youth in foster care have benefited from the relational support they offer to one another to cope with their death and non-death losses. L.Y.G.H.T. program participants have experienced increased social support, hopefulness and self-worth as well as a reduction in perceived problems. The power of a peer grief support program for youth in foster care is that it provides a sense of belonging through a relational home that is youth-centered and youth-led.
Not just trauma-informed, but grief-informed
While recognizing there are situations when the health and safety of a youth warrants removal, disconnection from family, friends, and other significant relationships is harmful. As a result of being removed from their families, youth are inundated with loss, grief, and ambiguity from these disconnections, which frequently go unacknowledged and unaddressed, leading to long-term negative outcomes.
It is critical for child welfare professionals to not only be trauma-informed but also grief-informed. A lack of grief-informed education can lead to inappropriate and harmful pharmaceutical responses to “treat” grief instead of utilizing grief-informed interventions that promote relational connection and youth well-being.
Note: This op-ed is an abridged version of Dr. Mitchell’s essay for the first edition of the Family Justice Journal.