Therapeutic Dialogue Through Play As Children Approach Death
By Cynthia J. Weaver, DMin, MDiv, ACSW, LSW
Social Work Today
Vol. 5 No. 4 P. 22

Dying children reveal fears, thoughts, and beliefs about death through play.

Children’s play is their work and children work diligently at their play. Children at play provide those observing with a window to their inner feelings, beliefs, thoughts, and fears. Children at play communicate to the observer how their life apart from play has been and how they desire their life to be in the future. Over time, children at play develop a theme to their play, demonstrate rules and boundaries, provide specific responses to good and evil, and model behaviors they have themselves experienced (Timberlake & Cutler, 2001).

Within the therapeutic relationship of child and therapist, play is interactive and at best, nondirective. The professional begins where the child is and follows the child’s lead. Early in the therapeutic play relationship, the shared space of the child and therapist provides a safe environment for developing attachment and bonding.

What about the child who does not have the physical capacity to play? How does a child whose body is limited from a birth defect or deteriorating from disease play? What is the play of a child confined to a wheelchair? What is the play of a child restricted to a hospital bed because of severe burns? What is the play of a child who is paralyzed? What is the play of a child approaching his or her death?

For children aware of their impending death, play becomes the medium to seek answers to the difficult questions many of us ask regarding death, such as: “Why do bad things happen to good people? Is there an afterlife? Am I worthy enough to be accepted into a better life? How will I be remembered when I’m gone?” The approaching death of a child is a difficult area of work for professionals in any discipline. Nondirective play therapy, including the creativity and imagination of the child, is an effective tool in assisting children in expressing their fears, feelings, and beliefs as they approach death (Timberlake & Cutler, 2001). Themes of play are expressed through repetitive play, enabling the professional to determine areas of question and confusion the child has surrounding his or her impending death. Over time, the therapist can piece together children’s fears and questions, as demonstrated in their play. The therapist’s role is to provide a “safe place” for the child to explore such uncertainties and, in turn, the therapist becomes an interpreter of the child’s play.

Melinda’s World
The referral would be a stretching of my own professional skills, yet I respond because of the nature of the request. Those caring for Melinda have questions that need answers, such as, “Why must young children suffer and die?” Melinda’s questions, however, are not about suffering or death, but rather, “How do I get from this life to the next life and what will that place look like?”

Diagnosed with a degenerative disease since birth, Melinda is aware of her impending death. Although her physical body is deteriorating rapidly, her intellect is sharp and her emotions support an engaging personality. She does not question the reason for dying or the timeframe for this event. Melinda’s parents placed her in care as an infant, unable to provide financially, medically, and emotionally for a child they were told would die as an infant. At age 7, however, Melinda has already lived well past the initial prognosis and every day she gives more thought to life after death. With years invested in Melinda’s care, her caregivers struggle with her questions surrounding her impending death.

Melinda’s physical limitations are severe. She is unable to independently move any part of her body, confined to a wheelchair or hospital bed, and dependent on oxygen. Her speech is slow and labored from a tracheotomy. Her days consist of tube feedings, repositioning to avoid pressure sores, suctioning, physical therapy, occupational therapy, medical appointments, and television watching. She attends special education classes at the nearby public school, traveling in a van equipped with a hydraulic lift and with a nurse accompanying her in support of the various medical interventions needed throughout the school day.

I meet Melinda at her school, in a classroom with other medically involved children, a teacher, two instructional aides, and Melinda’s nurse. The classroom is filled with medical equipment and educational materials and is a pleasant environment, yet the only movement in the room is from the four adults. Melinda, her nurse, and I move from the classroom to a smaller room for quiet and confidentiality. As we travel down the long hallway, Melinda’s nurse speaks quietly to me about her own grief surrounding the impending death of a child for whom she has provided daily care for more than three years. I realize my work with Melinda will parallel some work with the nurse, the surrogate mother. I will need to form a strong alliance with the nurse, aware of her expertise in Melinda’s care. I will need the nurse to supervise the involved medical equipment and interpret Melinda’s words to me when I am unable to clearly understand them because of Melinda’s dependence on the tracheotomy. Melinda leads the way, moving her head ever so slightly to power and steer her new battery-operated and computerized wheelchair.

Therapeutic Play With Melinda
Melinda is well aware of the role of a social worker—a child institutionalized with multiple medical needs often interfaces with a variety of social workers. Melinda appears pleased that someone is assigned to speak with her about her dying process. When I use the term anticipatory grief, she makes clear that she is not grieving but attempting to determine what her new home will be like after she dies. Having moved from one facility to another, Melinda appears to treat the onset of death as literally a move from her present facility (group home) to another facility (heaven), not exactly clear how the new facility will look or whether it is equipped to meet her needs. Observing the nurse with tears in her eyes sitting quietly behind Melinda, I realize the nurse is the one with anticipatory grief. Melinda is ready to leave the group home and ready for her new home, hopeful for a better life there.

Our play during the first few sessions is an exploration of the things I bring along in my bag, adding new items each week to determine whether they are helpful. I have dolls, puppets, paper, crayons, books, and other mediums familiar to those who play with children in a therapeutic environment. Melinda eventually settles on three small hand puppets that she has me position on her wheelchair. She names the puppets Sally, Bobby, and Melinda and makes vivid use of her imagination in the activities they do together. The setting of her play is the playground: the sliding board, the swings, the seesaw—all pieces of equipment that require physical activity. Melinda teaches me that she does not need to be physical to play. Melinda squeals with delight in pretend play as Sally, Bobby, and Melinda whiz down a sliding board together; grunts for Bobby as he pushes Sally on the swing; and laughs loudly when Melinda bumps Bobby off the seesaw.

Melinda’s imaginary play communicates the quality of care she is receiving at the group home. Her level of comfort in having the puppets interact within her environment parallels her own experience of multiple encounters outside her group home. In her imaginary play, she is creative, resourceful, social, and caring, modeling the care others provide to her on a daily basis. When some puppets disagree, Melinda has the group process the problem, compromise, and continues in play. Melinda demonstrates her great desire to be in relationships with others.

I realize during the middle, or work phase, of our sessions together that in Melinda’s play no one is ever seriously injured or dies. As I nudge Melinda to talk about death, even the death of a puppet, death never happens in her play. In our imaginary play when the puppet is injured on the playground, has a serious disease, or when the grandfather puppet is old and about to die, death never comes. There is always someone to intervene with CPR, an extra oxygen tank available when the first one runs out, the ambulance arrives on time, and there is always a new cure for a deadly disease. Melinda’s security in her own care and positive outlook of life is clear through her imaginary play.

Letting Go
Before Melinda can let go, she needs to know of the next place. This is why she insists that the pet frog, which died last month, is kept frozen in the refrigerator at the group home. Staff attempted to have the frog buried, but Melinda would not hear of such a thing. Because of the staff’s concerns and Melinda’s inability to process the frog’s death, I was consulted.

At the beginning of a session with Melinda, and using my own imagination, I suggest a new game. Although I wince inwardly over the suggestion of such a game to a child who is terminally ill, Melinda anxiously enters into the new game. I explain that this new game is called “Let’s Play Dead” and that one puppet will die, go to heaven, and come back and tell us what such a place is like. I am clear to differentiate that in real life when people die, they do not come back to life on earth again, but in our game we will pretend they can come back and tell us about their journey. Melinda earlier identified heaven as a place, yet wasn’t clear what this place looked like, who was there, or how one arrives at such a place.

Eager to play the game, Melinda communicates to me that one must grow wings upon death to fly from earth to heaven, similar to how a caterpillar becomes a butterfly. Melinda’s need to have an answer to the transition and transportation of a person from this life to the next is necessary for a child who always faces transition and transportation needs in her present life. She is dependent on nurses to move her from her wheelchair to her bed, position her, reposition her, turn her during the night hours, and then transition her back to the wheelchair each morning. She is familiar with the schedule of the group home, where moving many physically dependent children requires numerous staff and hydraulic devices for lifting. Melinda clearly understands the need to have her own nurse accompany her to school, to assist her in the many tasks and life skills other children are physically independent in doing. Melinda values the newest technologies, providing her with a wheelchair taking her wherever she desires, simply by the slightest movement of her head. Transitioning from one place to another takes up most of Melinda’s life, therefore the problem of relocating from earth to heaven needs solving first. In Melinda’s resilience, wings solve the transitional problem.

Ideas of Heaven
With transportation needs resolved, Melinda is ready to use her imagination to explore the possibilities of heaven. This time in our imaginary play, Melinda quickly sets up a play scenario in which my puppet, Sally, becomes seriously injured and dies. When the puppet, Sally, falls from the sliding board, there is no one trained in CPR, the ambulance has a flat tire on the way, and Sally dies. Melinda becomes quiet, waiting for me to take my imaginary trip to heaven and return. After a short period of time, she excitedly says, “Tell me all about what you saw in heaven.”

I have my own theological and religious understandings about heaven, but I need to work with Melinda’s understandings, not mine. Melinda never attended church, synagogue, or mosque, and her parents did not provide her with a religious identification when they placed her in the group home. In the community of the group home, there is not a physically accessible worship setting available for children like Melinda. Melinda does not view heaven through religious or theological perspectives, but through transitional living. She is clear that she will go to heaven but unclear about how she will be transported to heaven and what heaven will be like. I share with her that my imaginary trip to heaven was safe and fast. I share that when I arrived at heaven, I was greeted by many children who showed me a beautiful playground with lots of equipment. Melinda’s eyes open wide and her smile is broad. She tells me that it is now her turn.

We again use the puppets to play on the earthly playground and again resources are not timely and her puppet dies. Melinda closes her eyes and pretends to be in heaven. I sit quietly, wondering where her imagination will take her. After what seems to me to be an eternity, Melinda opens her eyes and shares with me that she, too, found a playground in heaven and that the place was beautiful. She then proceeds to tell me of another child in heaven with the same name as hers, who instructs her that when she comes back to heaven for her final stay she should not bring her wheelchair. The child tells Melinda there is no need for a wheelchair in heaven since Melinda will be able to physically ride all the playground equipment, much different than her life here on earth.

Later that week while speaking to the staff at the group home, I learn that Melinda asked to bury the frozen frog. Melinda directed her staff to decorate an empty shoebox and together they bury the frog in the garden behind the group home. During our next session, Melinda shares that near the playground in heaven there is also a pond in which frogs live and play.

Brett Webb-Mitchell (1993) reflects on characteristics revealed through Robert Coles’ work (1990) where “…the adult becomes a student in relationship with the child, who becomes the master of life … the children become the teachers instructing the adult learners, giving flesh to the adults’ abstract concepts and theories” (p. 10).

Although I provided a service and intervention to Melinda and the staff of her group home, Melinda provided me with “flesh” to my concepts, theories, and theology. Melinda not only gave me insight in working with children with severe physical limitations around their impending death; she also led me to an extended spiritual view of life after death—a playground where children will have access to a variety of playground equipment, listening to a chorus of frogs from a nearby pond.

— Cynthia J. Weaver, DMin, MDiv, ACSW, LSW, is an assistant professor of social work at Marywood University. She has more than 25 years of practice experience in child welfare (public and private), early intervention, mental retardation, and religious systems.

References
Coles, R. (1990). The Spiritual Life of Children. Boston: Houghton Mifflin Company.

Timberlake, E. M., & Cutler, M. M. (2001). Developmental Play Therapy in Clinical Social Work. Boston: Allyn & Bacon Publishing House.

Webb-Mitchell, B. (1993). God Plays Piano, Too: The Spiritual Lives of Disabled Children. New York: Crossroad Publishing Company.