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Teaching Thanatology

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National Students of AMF: Peer Support and Service as Therapeutic Supports Among Grieving College Students

By David Fajgenbaum, MSc

About one in four college students has expe-rienced the death of a family member or close friend within the past year (Balk, Walker, & Baker, 2010). Several factors unique to the college age and environment can make grief during college particularly difficult to encounter with resilience. These factors include geographic distance from

home and usual support systems, academic pressures, inadequate peer support and empathy, and limited resources for grief support on many college campuses. Thus, grieving college students are at greater risk than their peers for a host of physical, academic, social, developmental and emotional issues (Balk, 2008; Servaty-Seib, 2006). Moreover, grieving students commonly report feeling alone, help-less, unsupported, and like no one “gets it” (Fajgenbaum, Chesson, & Lanzi, 2012). Despite the need and calls in the literature for improved university support efforts (Balk, 2001; Wrenn, 1999), few targeted, sup-portive interventions existed on college campuses before 2005.

National Students of AMFFollowing my mother’s illness with cancer and death in 2004, I

worked with other grieving college students and administrators to found the Students of AMF Support Network at Georgetown Univer-sity. The acronym “AMF” stands for “Ailing Mothers & Fathers,” but the student organization is open to all college students grieving the illness or death of a family member or friend. “AMF” are also the ini-tials of my mother, Anne Marie Fajgenbaum. AMF made an immediate impact on Georgetown’s campus, and students from other campuses requested information about starting up groups using our blueprint. In 2006, Ben Chesson (the founder of the University of North Carolina chapter) and I, both juniors in college, created the National Stu-dents of AMF Support Network (NSAMF). Today, NSAMF connects, empowers, and supports hundreds of grieving college students nation-wide through NSAMF Campus Chapters.

Targeted grief supportNSAMF Campus Chapters are student-led, faculty/staff advised, and

university-sponsored student organizations. Each chapter includes a peer-led, open-discussion grief support group, service group, and fac-ulty mentoring programs. The Support Group provides a safe and uplifting environment for bereaved students to share their feelings and experiences. Several goals are typically achieved during meetings: students feel less alone; they support one another and in doing so help themselves; and a rare opportunity for discussion about grief is of-fered (Fajgenbaum, et. al., 2012).

I was 16 years old when my mother died. I was incredibly fortunate to have the unwavering support of my wonderful friends and fam-ily. But, when I went from a small high school where everyone knew about my Mom’s death, to a huge university where nobody knew, I felt completely alone. I remember the feelings on move-in day as all the other moms helped their kids move into the dorms. I remember the

questions: What do your parents do? Where’s your mom? But above all those, I remember the day that Students of AMF became a reality.

Through the AMF Support Group, I have formed lifelong friend-ships with the most incredible people. It is so powerful to have a group of other students that understand what I’m going through. They un-derstand those days where everything you see reminds you of your loved one, they understand how hard holidays can be, and they under-stand those times when you really just need a hug. Students of AMF has been there for all those moments, and for that, I am so grateful. – Kristen graduated from the University of North Carolina in 2011 and is currently a first-year MSW student.

Service as a mode of supportCampus Chapter Service Groups encourage chapter members to

channel their grief towards championing causes that have impacted their own or their peers’ lives. The Service Group provides a tangi-ble and therapeutic benefit for the bereaved, a positive impact on the community at large, and an opportunity for friends of the bereaved to show their support. Abundant anecdotal evidence suggest that stu-dents, especially males, who may shy away from support groups and professional counseling, have found participation in NSAMF service activities to be a significantly therapeutic and often preferable outlet (Fajgenbaum, et al., 2012).

Kelly Hudson, a sophomore at Central Michigan Uni-versity, was overwhelmed with distress when her best friend died and her mother was diagnosed with brain cancer two weeks afterwards. Six months later, Kelly started a chapter of Students of AMF at Central Michi-gan. Wanting to do her part to fight back against cancer, she decided to make their first project a “Give a Spit about Cancer” drive. She enlisted fellow grieving and non-griev-ing students to register students for the bone marrow registry by swabbing their mouths. Kelly shared, “it is so rewarding and feels so good to be able to channel my grief towards something that is helping my peers on campus and a service project that may save someone else’s life.” The University of Pennsylvania chapter also organized a “Give a Spit about Cancer” in Fall 2011 and the two chap-ters combined to register over 400 college students.

Interactions among chapters, staff, and the counseling centerLastly, Campus Chapters offer opportunities for faculty mentoring,

work extensively with campus resources, and promote campus re-sources with the “student voice.” Chapters refer students reciprocally to counseling services, campus ministry, residential life, and faculty/staff. The most successful chapters are closely linked with the coun-seling center, campus faculty/staff, and a dedicated faculty advisor. Likewise, campus grief support resources, such as campus ministry and local bereavement resources, have seen an increase in student participation on campuses with Students of AMF chapters.

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Dr. Illene Cupit, a professor of human development at the University of Wisconsin at Green Bay (UWGB) and First Vice President of ADEC, decided in 2008 that she wanted to help to bring a chapter of Students of AMF to UWGB. Illene encouraged one of her students, Kiri Thompson (now a National Students of AMF volunteer National Chapter Coordinator), to start a chapter at UWGB. Dr. Cupit has served as the faculty advisor for the last three years. Under her leadership, chapter members have participated in meaningful support-group meet-ings, volunteered at Camp Lloyd (a summer camp she founded for bereaved children), participated in various disease research fundraisers, and created the universi-ty’s Campus Memorial Garden in honor of deceased loved ones of students, faculty and staff at UWGB.

National ProgrammingNSAMF provides an array of resources to facilitate the creation

of Campus Chapters that empower students and faculty, like Kris-ten, Kelly, Kiri and Dr. Cupit. The online Chapter Toolkit and Support Group Leader guide offer best practices regarding how to receive offi-cial university recognition, lead Support Group meetings and Service events, and promote the chapter. Volunteer Chapter Coordinators and monthly conference calls guide Chapter Leaders through the pro-cess of growing their chapter. NSAMF offers financial assistance for chapter costs, such as T-shirts/promotional items, refreshments at meetings and events, printing/copying costs, and expenses for chapter leaders to attend the annual National Conference on College Student Grief. Periodically, the Board of Mental Health Professionals, which is composed of college mental health and bereavement experts, is con-sulted for advice related to a specific chapter or member.

NSAMF also raises awareness through National College Stu-dent Grief Awareness Week, provides grief support and information through www.studentsofamf.org, and hosts the annual National Con-ference on College Student Grief. The Conference, held inaugurally in 2008, provides a national forum for student leaders, grieving col-lege students, university faculty and college mental health leaders to discuss issues and future directions for college student grief support.

AchievementsOver the last six years, NSAMF has worked with students from

over 160 colleges and universities to start up Campus Chapters, de-veloped 42 officially recognized Campus Chapters, supported over 1,500 grieving college students, and received hundreds of testimonials of improved well-being, retention in school, and sense of community from its members. Our accomplishments have been featured in USA Today, Reader’s Digest, and the Today Show. Recently, Eli Lilly se-lected NSAMF as the recipient of the 2012 Welcome Back Award in Community Service for our work to improve the lives of those suffer-ing from depression.

Innovative approach to college student grief supportNSAMF is the first initiative of its kind: created by grieving college

students for grieving college students. NSAMF has also benefited from the expertise of nonprofit leaders, professional staff, college mental health professionals, and bereavement experts, like Dr. Cupit. Unlike generalized counseling services, NSAMF outlets are targeted to the specific population in need. Furthermore, NSAMF provides an array of supportive opportunities, since many college students may be re-luctant to participate in support groups or counseling and still others may benefit from more than one resource. Furthermore, chapter lead-ers make meaning and find benefits through channeling their grief towards helping other students. While researchers in other fields have studied the direct personal benefit of helping others through service (Piliavin, 2003), this has not been extensively investigated in thanatol-ogy and serves as an exciting new avenue within the field.

Current activities and future directionsCurrent NSAMF activities include growing existing Campus Chap-

ters, marketing to new campuses, developing partnerships with national advocacy organizations and potential funding sources, host-ing the annual National Conference on College Student Grief in August 2012, creating an Alumni Network, and leading National College Stu-dent Grief Awareness week in April 2012. Future activities include hiring additional staff to lead chapter development, expanding cam-pus grief workshops for students and faculty members, developing innovative methods to use social media and technology to connect and support grieving college students, and disbursing student tuition scholarships and research grants to evaluate program effectiveness.

I encourage you, as thanatologists and/or university members, to champion the needs of grieving college students. Please consider the following suggestions and visit www.studentsofamf.org for more in-formation.

Student-level• Educate bereaved students about the unique challenges that

they may face and the grief resources that are available (e.g., Campus Ministry, Residential Life);

• Encourage grieving college students, particularly males, to vol-unteer for service activities, such as a local cancer walk, in memory or honor of a loved one;

• Share information about NSAMF with students and encourage them to consider starting a Campus Chapter;

Campus-level• Determine if there is an identified contact or location on cam-

pus where bereaved students already can go to seek support, such as the counseling center, Dean of Students’ office, campus ministry, or NSAMF chapter;

• Facilitate the creation or growth of a NSAMF Campus Chapter at your university as a faculty advisor or informal advisor (con-tact us, and we will guide you step by step);

• Consider developing an annual memorial service or memorial garden on your campus;

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April 2012 Clinical Issues in Thanatology

Treatment for Adolescents After the Violent Death of Someone Close

By Alison Salloum, PhD

After the violent death of someone close, many youth are left with horrific violent dying imagery that replays constantly in their mind. They may struggle to shut out any person, place or thing that reminds them of the violent death. Even if the youth did not witness the event, violent death narratives are often

filled with gruesome images of the dying that keep the youth’s mind and body highly distressed. Practitioners need to use assessment tools to iden-tify highly distressed youth, be informed about ways to help youth with their questions of why and justice, actively work to help increase cop-ing capacity, and, when needed, provide empirically supported grief and trauma treatment.

Assessment Measures Community practitioners working with adolescents after violent death

are encouraged to use assessment measures to plan and monitor treat-ment. Some practitioners may argue that when working with bereaved youth, assessment measures are not necessary. However, research sug-gests that, after violent death, some youth may experience posttraumatic stress (Nader, Pynoos, Fairbanks, & Frederick, 1990; Zinzow, Rheingold, Byczkiewicz, Saunders, & Kilpatrick, 2011), depression, and functional impairment (Melhem, Porta, Shamseddeen, Payne, & Brent, 2011). It is imperative to be aware of comorbidity as these conditions can further complicate the bereavement process. It is also important to assess for other losses and traumatic events. Many standardized measures include a list of potentially traumatic events, and having the youth review the list will help the practitioner be better informed about past and current losses and traumatic events that may complicate the bereavement process.

When administering assessment measures, inform the youth that there is a range of symptoms and that other youth who have had someone close die have experienced these reactions. Assessment instruments can be used to normalize and educate the youth about possible reactions after a violent death. Also, sometimes it is easier for youth to identify what they are experiencing via the instrument than to talk directly to the practitioner, especially when first meeting. Assessment tools can also provide information about the youth’s strengths and competencies and provide an assessment of whether the youth is on track or has been derailed developmentally as a result of the violent death. Traumatic grief assessment measures have recently been developed and are undergoing further development. These measures include the Extended Grief Inventory (Layne, Savjak, Saltzman, & Pynoos, 2001), Complicated Grief Assessment for Children and Adolescents—long form (Nader & Prigerson, 2009) and Inventory of Complicated Grief, Revised (Melhem et al., 2007). Other measures that may be useful and are easy to administer are the UCLA Posttraumatic Stress Disorder Index for DSM-IV (UCLA-PTSD-Index; Pynoos et al., 1998), The Mood and Feelings Questionnaire–Child Version (Angold & Costello, 1987) and the Child Behavior Checklist (Achenbach & Rescorla, 2001).

“Why Did It Happen” and “Someone Has To Pay” Adolescents have the cognitive capacity to explore multiple perspectives

about their perceived role in the violent death as well as the roles of oth-ers. Questions of “why did it happen” may begin to shatter worldviews of safety and personal views of positive visions for the future. When work-ing with youth bereaved by a violent death, assess the youth’s perspective about their current life and future. Some questions to ask include:

• Who does the youth feel most connected to? • What does the youth enjoy doing, and do they have the opportunity

to engage in these healthy activities? • What is important to the youth (i.e. what has meaning and pur-

pose)? • What do they see themselves doing in the future? • Youth who have positive connections to others, are engaged in

meaningful activities, and have a positive vision for the future will be better able to cope with violent death than youth who are dis-connected from others, view everything as meaningless, and do not have a positive vision for the future. For those disconnected youth, enroll the help of others.

• Are there cousins, uncles, aunts, friends who could spend more time with the youth?

• Are there activities that the youth once enjoyed doing that he or she could engage in again or other activities that may be of inter-est?

• Are there mentors or experiences that could help the youth envi-sion themselves as having a more positive future?

• What would the person who died say to the youth about what their hopes and dreams would be?

Young people need to be provided with information that offers a fuller understanding of related facts about the death, although the reality is that for some deaths, the “why” cannot be fully known. Nonetheless, many youth will begin to create a story about why the death occurred and may need more information as they struggle with difficult questions. If the death was by suicide, it may be helpful to have a discussion aided by a fact sheet about suicide, then discuss perceptions or conclusions that the youth may have about why the person killed themself. Similarly, if the death was ac-cidental, youth may want to know related information, like how common that type of accident is, and circumstances unique to the accidental death. When young people are grieving due to a murder, assess for retaliatory thoughts and actions. Given the nature of the crime, having thoughts of wanting justice is normal and in some cases, justice may mean wanting to have the perpetrator killed. It is often helpful to explain the criminal justice process to adolescents so they are informed of the procedures that may take place in terms of investigations, hearings and a trial. After a violent death, practitioners and bereaved youth should explore any thoughts of re-taliation, involving other family members in the discussion who can offer strong messages that retaliation will not bring back the deceased or bring honor to the family and could potentially result in harm.

Coping Strategies Promoting and teaching coping strategies is one of the core compo-

nents of trauma counseling (Amaya-Jackson & DeRosa, 2007). Coping skills have been associated with decreased distress (Deblinger, Manna-rino, Cohen, Runyon, & Steer, 2010). Exploring positive coping skills (i.e.


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active and adaptive coping rather than avoidant coping) to lessen distress can help the youth with the grieving process. Decreasing traumatic stress may allow the typical grieving process to proceed without complications of trauma (Cohen, Mannarino, Greenberg, Padlo, & Shipley, 2002). Other important coping strategies to promote include family, peer and other so-cial support, relaxation management, anger management, if needed, and use of spirituality, if relevant.

Family, Peer Support, and Other Social SupportIdentifying and seeking social support is crucial to assisting the bereaved

adolescent after violent death. Social support is an important factor to help buffer against posttraumatic stress. Many times after a violent death, the youth and other family members may be hesitant to talk with each other due to fear of intense emotions and not wanting to add additional burden to others. Thus, the youth may feel family supports that may have been available prior to the death are not available anymore. If possible, it is often helpful to facilitate a family meeting so that members can talk with each other about their grief, discuss how different family members grieve, and what might be helpful to the whole family in coping with the death.

Spending time with peers is important during adolescence, but some peers may not know how to provide support or talk about what has hap-pened. Practitioners can role-play with youth about how they may talk with their friends about what they are experiencing or what would be helpful for them. Peer relations may help adolescents cope by providing distrac-tions such as going to movies, playing sports or “just hanging out.” Other ways that peers can help bereaved youth cope include allowing emotional expression, providing understanding of their experience, and helping the youth to stay connected rather than withdrawn and isolated. However, peers may be a source of conflict if the youth experiences perceived or ac-tual taunting about how the person died. For example, a 14-year-old youth lied to his peers and told them that his father was murdered, when in fact his father killed himself. He did not want his peers to know this for fear of being teased about his father being “messed up.” Adolescents who are in-volved in an intimate peer relationship may find it very helpful. However, in some instances, the youth may become more distant, having difficulty remaining in the relationship which may lead to a breakup—another loss that could further complicate the grief. Others such as teachers, neighbors, co-workers, mentors, religious leaders, extended relatives, other bereaved youth, and social network friends may provide support as well.

RelaxationTeaching adolescents various deep breathing, muscle relaxation and

guided imagery techniques can be very helpful to counter overwhelming feelings of distress. These techniques can often be used when other cop-ing skills, such as distraction by playing video games, are not appropriate (i.e. at school).

Anger ManagementAfter a violent death, what would normally be anger may become rage,

especially if someone was killed at the hands of another and “justice has not been served.” In these cases, helping the youth to manage his or her in-tensive angry feelings often becomes a priority for keeping the adolescent and others safe.

Spirituality and ReligionExploring how the youth’s spirituality or religion may be providing com-

fort or confusion is also important after violent death. Ask questions such as: what beliefs or practices, including cultural practices, provide comfort? What beliefs have changed? Has the youth belonged to a religious group in the past or presently and if so, how has this group and/or the beliefs been of help? Have feelings about the religious group, God or a higher being changed since the death? For example, a 17-year-old boy whose mother was killed by her boyfriend reported that he used to pray to God, but since his mother’s murder, he did not want to pray or go to church. After the ther-apist helped him to explore his feelings toward God and his confusion and anger about “why God would let his happen,” he was able to start talking with other family members about it and eventually started praying, ask-ing God and his mother to help him “do right” so that his mother would be proud of him.

Grief and Trauma Intervention After violent death, distressed bereaved youth need interventions that

can help lessen the distress that is often exacerbated by intrusive imag-ery of the violent way the person died, high avoidance of people, places, things and conversations related to the violent death, and increased hyper-arousal often leading to irritability, angry outbursts and difficulty in school. Youth who are experiencing grief and posttraumatic stress symptoms due to the violent death of someone close may benefit from a structured, em-pirically informed grief and trauma intervention. The intervention also needs to be developmentally, ecologically and culturally relevant so that the youth remains engaged in the treatment, and practical and applicable in “real world settings” so that practitioners can implement the interven-tion.

Salloum and colleagues have been involved in a program of research and practice that uses practice to inform research and research to inform practice that has been tested in a “real world setting” to develop an evi-dence-based grief and trauma intervention for children and adolescents. The Grief and Trauma Intervention (GTI), which has undergone several studies (e.g. Salloum, Avery, & McClain, 2001; Salloum, & Overstreet, S. 2008; Salloum, 2008; Salloum & Overstreet, in press) employs cognitive be-havioral and narrative therapy strategies to significantly reduce symptoms of posttraumatic stress, depression, and traumatic grief in children and ad-olescents. The GTI treatment manual for adolescents has been published (Salloum, 2004) and the GTI treatment manual for children is available at www.childrens-bureau.com. GTI for children has recently been selected for review for the SAMHSA’s National Registry of Evidence-based Pro-grams and Practices. While next steps involve additional research using GTI in different settings with different populations, we are also working on ways to disseminate the intervention that makes it more accessible to practitioners. For more information about GTI visit www.childrens-bu-reau.com or e-mail the author.

References Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-

age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth & Families.

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Amaya-Jackson, L., & DeRosa, R.R. (2007). Treatment considerations for therapists in applying evidence-based practice to complex presentations in child trauma. Journal of Traumatic Stress, 20, 379–390.

Angold, A., & Costello, E.J. (1987). Mood and feelings questionnaire. Developmental Epidemiology Program, Duke University. Retrieved from http://devepi.duke.edu/mfq.html.

Cohen, J.A., Mannarino, A.P., Greenberg, T., Padlo, S., & Shipley, C. (2002). Childhood traumatic grief: Concepts and controversies. Trauma, Violence, & Abuse, 3, 307-327.

Deblinger, E., Mannarino, A.P., Cohen, J.A., Runyon, M.K., Steer, R.A. (2010). Trauma focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 0 (on line),1–9. DOI 10.1002/da.20744

Layne, C. M., Savjak, N., Saltzman, W. R., & Pynoos, R. S. (2001). UCLA extended grief inventory. Unpublished psychological test, University of California, Los Angeles.

Melhem, M.D., Porta,G., Shamseddeen, W., Payne, M.W., & Brent, D.A. (2011). Grief in children and adolescents bereaved by sudden parental death. Arch Gen Psychiatry, 68, 911-91.

Melhem, N., Moritz, G., Walker, M., & Shear, K. (2007). Phenomenology and correlates of Complicated Grief in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 46(4), 493-499.

Nader, K., Pynoos, R., Fairbanks, L., & Frederick, C. (1990). Children’s PTSD reactions one year after a sniper attack at their school. American Journal of Psychiatry, 147, 1526-1530.

Nader, K. & Prigerson, H. (2009). Complicated grief assessment—Child and adolescent scales, long-form. Austin, TX: Two Suns.

Pynoos, R. S., Rodriquez, N., Stienberg, A., Stuber, M., & Frederick, C. (1998). The UCLA posttraumatic stress reaction index for DSM-IV. Los

Angeles: UCLA Trauma Psychiatric Program.Salloum, A. (2004). Group work with adolescents after violent death: A

manual for practitioners. Philadelphia, PA: Brunner-Routledge.Salloum, A. (2008). Group therapy for children experiencing grief and

trauma due to homicide and violence: A pilot study. Research on Social Work Practice, 18(3), 198-211.

Salloum, A., Avery, L., & McClain, R.P. (2001). Group psychotherapy for adolescent survivors of homicide victims: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1261-1267.

Salloum, A. & Overstreet, S. (2008). Evaluation of individual and group grief and trauma interventions for children post disaster. Journal of Clinical Child and Adolescent Psychology, 37, 495- 507.

Salloum, A. & Overstreet, S. (in press). Grief and trauma intervention for children after disaster: Exploring coping skills versus trauma narration. Behavioral Research and Therapy.

Zinzow, H. M., Rheingold, A. A., Byczkiewicz, M. Saunders, B.E., & Kilpatrick, D.G. (2011). Examining posttraumatic stress symptoms in a national sample of homicide survivors: Prevalence and comparison to other violence victims. Journal of Traumatic Stress, 24, 743–746.

About the AuthorAlison Salloum, PhD, is an assistant professor at the University of South Florida, School of Social Work. She has developed and tested the Grief and Trauma Intervention (GTI) for children. Dr. Salloum is the author of Group Work with Adolescents after Violent Death: A Manual for Practitioners (Brunner-Routledge, 2004) and Reactions: A Workbook for Children Experiencing Grief and Trauma (Centering Corporation, 1998). E-mail: [email protected].

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National-level• Attend the annual NSAMF National Conference on College Stu-

dent Grief in August 2012;• Serve as an Awareness Week Leader during National College

Student Grief Awareness Week in April 2012;• Share information about NSAMF with colleagues;

Consider offering your supportive guidance through volunteering for NSAMF, serving on an advisory board, or conducting quantitative research into the effectiveness of our programs.

ReferencesBalk, D. E. (2001). College student bereavement, scholarship, and the

university: A call for university engagement. Death Studies, 25(1), 67-84.

Balk, D. E. (2008). Grieving: 22 to 30 percent of all college students. New Directions for Student Services 121: 5-14.

Balk, D. E., Walker, A. C., & Baker, A. (2010). Prevalence and severity of college student bereavement examined in a randomly selected sample. Death Studies, 34(5), 459-468.

Fajgenbaum, D., Chesson, B., & Lanzi, R. (in press 2012). Building a network of grief support on college campuses: A national grassroots initiative. Journal of College Student Psychotherapy.

Piliavin, J. A. (2003). Doing well by doing good: Benefits for the benefactor. In C. L. M. H. Keyes, Jonathan (Ed.), Flourishing: Positive psychology and the life well-lived. (pp. 227-247). Washington, DC: American Psychological Association.

Servaty-Seib, H. L. (2006). Educational performance and persistence of bereaved college students. Journal of College Student Development, 42, 225-234.

Wrenn, R. L. (1999). The grieving college student. In J. D. Davidson & K. J. Doka (Eds.), Living with grief: At work, at school, at worship (pp. 131-141). Levittown, PA: Brunner/Mazel.

About the AuthorDavid Fajgenbaum, MSc (Public Health), is a third-year MD/MBA student at the University of Pennsylvania and the co-founder & Board Chair of National Students of AMF. David is the president and support group leader of the University of Pennsylvania chapter of Students of AMF and remains involved with the daily operations of the nonprofit. E-mail: [email protected].

National Students of AMF: Peer Support and Service as Therapeutic Supports Among Grieving College Students