Mapping Grief

Linda Machin PhD

2011

Exploring the Landscape of Loss

1. A model for recognising diversity in response to loss.

2. A mapping tool for exploring individual grief dynamics.

1. A model for recognising diversity in response to loss

The Range of Response to Loss model (Machin 2001; 2009)

Overwhelmed - a state dominated by distress

Controlled - a state dominated avoidance of distress

Resilience - a capacity to balance the emotional, social and practical consequences of loss (accept the loss, make sense of its consequences, an optimistic life perspective and an ability to make use of social support)

Conceptual links with other theories

Range ofResponse toLoss

Overwhelmedby loss

Resilientresponse toloss

Controlledresponse toloss

AttachmentStyleAinsworth etal (1978)

Anxious/ambivalentattachment

Secureattachment

Avoidantattachment

Dual ProcessModelStroebe +Schut (1999)

Lossorientation oscillation

Restorationorientation

An emerging picture of grief

overwhelmed controlled

balanced (resilient)

The nature of grief

Primary reactions - disbelief, sadness,anger, guilt, despair etc

learned/acquired reflexive responses to loss

Secondary responses - engagement with the consequences of loss by -

regulating emotion

adjusting to changed relationships

adjusting to changed social realities

making sense of the loss etc.

Exploring primary grief reactions

Immediate, passive reactions to grief:

overwhelmed controlled

Dominance of feelings- sadness,

anger, guilt, despair,desolation etc

bringing a sense of powerlessness

Dominance of emotional avoidance, giving an illusion of

powerfulness

Images as grief stories – Overwhelmed

Images as grief stories - Controlled

Exploring secondary grief responses

Active engagement with the consequences of loss - coping

Resilience Vulnerability ( a new, fourth dimension in the RRL model)

Acceptance of the loss and the feelings

associated with it, effective management of day

to day life, finding a sense of meaning,

making good use of support etc

Difficulty in facing the loss and the feelings

associated with it, problems in managing day to day life, lack of a sense of meaning,

makes poor use of support etc

Coping as a mediating factor in grief (Stroebe et al 2006)

Acquired coping stylesAttitudes to difficult life eventsThe extent to which stress factors exceed

the capacity of an individual to manage the consequences of the loss

The role of perception in shaping resilience and vulnerability

Seligman - Learned Helplessness Resilience (1975/92) (1999)

Permanence bad events seen as bad events seen as

permanently effecting life temporary

Pervasiveness a failure in one area of life bad events seen as

produces helplessness in specific not

others universal

Personalisation poor self esteem results bad events

from self blame when attributed

things go wrong to external factors

Factors which contribute to resilience in bereavement

Personal resourcefulness- flexibility, courage, perseverance, sense of self worth

A positive life perspective- optimism, a capacity to make sense of experience

Social embeddedness- availability of support, capacity to access support

Resilience

Overwhelmedfocus on feelings

A capacity to balance and accept the competing

forces of grief

Controlledfocus on thinking

and action

Images as grief stories - Resilient

Disorganised/disorientated attachment

Main (1991) described this as a fourth attachment style where there might be evidence of -

a mix of anxious and avoidant responses

Stress factors which contribute to vulnerability in bereavement

Circumstantial risk factors - unexpected death, untimely death, horrific death, multiple losses, stigmatised death etc and concurrent stresses e.g. caring for others, financial problems etc

Personal risk factors - insecure attachment with with the deceased, young children, adolescents etc and physical, psychological problems, past history of difficulty in coping with stressful situations etc

Interpersonal risk factors -lack of social support, and /or makes poor use of support, loss of a child etc

Vulnerability

An inability to balance the competing forces of grief - tension between feeling, thinking and acting

Overwhelmedfocus on feelings

Controlled focus on thinking

and action

Images as grief stories - vulnerability

The RRL model showing the interaction between grief and coping

vulnerable

overwhelmed controlled

resilientCore grief impact responses Coping mechanism

A template for exploring grief in practice

vulnerable

Debilitating

personal and / or circumstantial factors socially - isolated and / or disconnected

Overwhelmed Controlled Enabling

personal and / or circumstantial factors

socially integrated and / or support felt to be adequate to needs

Resilient

Feelings ofgrief dominate + make day to

day life difficult

Denial of orstruggle with, the

reality of loss

Comfortableengagement with

the reality ofloss

Strong emotions are accepted as part of the consequences

of loss

A practice Matrix based on the RRL model (Relf, Machin & Archer 2010) (using scales of always, most of the time, sometimes , never, NK)

Factors (personal, circumstantial and social) contributing to vulnerability

Overwhelmed +vulnerable Vulnerability Controlled + vulnerable

struggle to manage

Strong emotions competing forces loss of control undermines

dominate + disable Inability to make capacity to deal with

day to day functioning sense of experience life demands

Comments Comments

Overwhelmed + resilient Resilience Controlled + resilientAble to face and accept Reconciliation between Able to think + act clearly

emotions of grief feelings and functioning + manage life demands

effectively

Factors (personal, circumstantial and social) contributing to resilience

2. A mapping tool for exploring individual grief dynamics.

A nine-item self report questionnaire5 point scale from strongly agree to strongly

disagreecurrent research - exploring use of the scale

to identify vulnerability

The Adult Attitude to Grief Scale

‘Overwhelmed’ items

2. For me, it is difficult to switch off thoughts about the person I have lost

5. I feel that I will always carry the pain of grief with me

7. Life has less meaning for me after this loss

Notions of grief contained in the overwhelmed items on the scale

Stressful

irreversible

uncontrollable (Mikulincer and Florian 1998)

The Adult Attitude to Grief Scale

‘Controlled’ items

4. I believe that I must be brave in the face of loss

6. For me, it is important to keep my grief under control

8. I think its best just to get on with life after a loss

Notions of grief contained in the controlled items on the scale

Restricted acknowledgement of distress

A need to be self reliant

Avoidance of grief through choosing a dominant focus on day to day life

(Mikulincer and Florian 1998)

The Adult Attitude to Grief Scale

‘Resilient’ items

1. I feel able to face the pain which comes with loss

3. I feel very aware of my inner strength when faced with grief

9. It may not always feel like it but I do believe that I will come through this experience of grief

Notions of grief contained in the resilient items on the scale

The capacity to face grief with:

courageresourcefulnessoptimism

(Greene 2002; Seligman 1998)

The Machin 2001 study demonstrated that:

The AAG scale was able to validate the DIFFERENT CATEGORICAL THEMES conceptualised within the RRL model when tested with other measures e.g. the Beck Depression Inventory, the Impact of Events scale and the Leiden Detachment scale.

BUT more importantly, It revealed the COMPLEX BIASES AND BLENDS

of overwhelmed, resilient and controlled reactions taking place within INDIVIDUALS

The biases and blends revealed by the AAG scale

overwhelmed controlled

resilient

O+C

O+RC+R

O+C+R

Two studies (2004, 2007) exploring the clinical usefulness of the AAG scale

The scale worked well for clients i.e. face validity It was an effective tool for the initial appraisal of client’s

grief It provided a structure for telling the grief story It provided a way of exploring (mapping) the complex and

sometimes contradictory aspects of grief It showed changes in grief response taking place over time It indicating the therapeutic focus necessary for nurturing

resilience

The AAG scale - a structure for qualitative responses (with some client responses)

Overwhelmed responses:2. For me, its difficult to switch off thoughts about the person

I have lost.

‘She’s there every minute of the day’

5. I feel that I will always carry the pain of grief with me.

‘I don’t think I will ever get over it’

7. Life has less meaning for me after this loss.

‘This loss has turned my life upside down’

The AAG scale - a structure for qualitative responses (with some client responses)

Controlled responses:4. I believe that I must be brave in the face of loss.

‘I do believe that I must be brave for my family’

6. For me it is important to keep my grief under control.

‘I’ve always thought that showing emotions is weak’

8. I think its best to get on with life after a loss.

‘Seems very hard to pick up the pieces for me’

The AAG scale - a structure for qualitative responses (with some client responses)

Resilient responses(an absence of agreement with these items demonstrates vulnerability):

1. I feel able to face the pain which comes with loss.

‘I just feel like the world has fallen in’

3. I feel very aware of my inner strengths when faced with grief.

‘I thought I was a strong person but this has floored me’

9. It may not always feel like it but I do believe that I will come through this experience of grief.

‘Can’t see me coming through this’

Client comments about their experience of the AAG scale (2007)

‘The feed back was very shocking. I didn’t realise how low I was’.

‘I feel freed by gaining confidence and thinking things through’.

‘I feel happier and can understand my own feeling more’.

‘Going through the questions again helped me see how much I’d grown in strength’.

Counsellor comments about their experience of using the AAG scale (2007)

‘AAG statements helped clients identify what they were feeling and talk more openly’.

‘The overwhelmed items help people get their story of loss out’.

‘Clients all agreed it was an accurate reflection of their grief’.

‘Identification and affirmation of areas for most need of therapy’.

The AAG scale - introducing a fourth dimension

vulnerability

(tension)

overwhelmed controlled

(balance)

resilience

Vulnerability and attachment theory

Main (1991) defined the most problematic attachment style as:

Disorganised/disorientated attachment where there is a mix of anxious and avoidant responses to separation and loss

A new research development using the

AAG scale (exploring the fourth dimension)

Calculating a vulnerability scoreThe method (proposed formula currently being researched):

The core grief responses (i.e. overwhelmed and controlled scores) combined, and the positive coping responses (i.e. resilient scores) deducted

= vulnerability score

O + C - R = V

Calculating vulnerability - it is proposed that by reversing the scores for the resilient items and adding together all nine

AAG responses gives an indication of vulnerability on a scale 0 - 36

strongly agree neither disagree strongly

agree agree nor disagree

disagree

2 4 3 2 1 0

5 Overwhelmed 4 3 2 1 0

7 4 3 2 1 0

4 4 3 2 1 0

6 Controlled 4 3 2 1 0

8 4 3 2 1 0

1 0 1 2 3 4

3 Resilient 0 1 2 3 4

9 0 1 2 3 4

Working with loss in practice

A

anticipated loss B C D breaking bad news/ working

discussing life- alongside loss retrospective

changing events reflection on

loss

Goals for practice

Confront appraise the

the pain possibilities

personal resourcefulness

positive life perspective

social embeddedness

Access and use of support