Supporting Students Coping With Ambiguous Loss

Presenter APresenter B

Workshop OutlinePart 1- Ambiguous Loss

Loss and Trauma in Schools

Defining Ambiguous Loss

• Type I

• Type II

Rise in Occurrence

Factors Influencing the Risk of Trauma

Typical Response to Ambiguous Loss

Workshop Outline Part 1- Continued

Developmental Variations

• Infant and Preschool

• School Age

• Adolescent

Cultural Variations

Recovery as the Norm

Therapeutic Goals

10 minute Break

Workshop Outline Part 2 - Supports Appropriate for School

Psychological Education

Social-Emotional Learning Curriculums

• Benefits of Small Group Counseling

Cognitive Therapy

• Sample Tools

Mindfulness

• Sample Activities

Workshop Outline Part 2- Continued

Bibliotherapy

• Sample Lesson Plans

Individual Crisis Counseling

• Sample Script

Referrals for Outside Therapy

• Suicide Risk Assessment

Q & A session

Loss and Trauma Loss is not an uncommon experience for children Loss can be as traumatizing as witnessing abuse or

violence Loss can lead to PTSD, associated with:

• Low academic achievement• Depression• Social maladjustment

(Bowlby, 1982; Nickerson, Reeves, Brock & Jimerson, 2009)

Defining Ambiguous Loss Concrete Loss: when loss is absolute

• Death Ambiguous Loss: mixture of absence and presence,

• Alzheimer’s Disease Associated with lack of certainty, relationship

boundaries are ambiguous

(Bockneck, Sanderson & Brittner, 2009; Boss, 1999)

Type I Ambiguous Loss Physically absent,

psychologically present Psychological presence: a

person still has influence on thoughts, emotions, behaviors, identity and unity of family• Divorce/Separation• Incarceration• Deportation• Deployment• Foster Care/Adoption

(Boss, 2010; Fravel, Grotevant, & McRoy, 2000)

Type II Ambiguous Loss Psychological absence

combined with physical presence

Psychological absence: Cessation or alteration of previously reciprocal relationships• Mental or physical illness• Including exhaustion,

substance abuse problems Can be tied to Type I

Ambiguous loss of the other parent

(Boss, 2006; Boss, 2010; Lee & Whiting, 2007)

Rise in Occurrence of Ambiguous Loss Political and economic changes

• Deployment• Unemployment• Incarceration rates increase• Financial factors contributing to mental illness

Overall, students are more likely to be experiencing ambiguous loss.

(Bockneck et al., 2009; Bruckner, Snowden, Subbaraman & Brown, 2010; Harper, Jones, McKay & Espey, 2009; Rossen & Carter, 2011; United States Census Bureau, 2010)

Factors Influencing Risk of Trauma Duration Predictability Internal factors

• Developmental stage• Previous trauma• Mental illness

External factors• Availability of social support

(Boss, 2006; Brock et al., 2009; Nickerson, et al., 2009)

Responses to Ambiguous Loss Immobilization and

hopelessness Blocked coping due to

uncertainty Difficulty with transitions

and changes Symptoms of anxiety

and depression Great overlap with PTSD Want clarity but also

resist information

(Ashbourne, Baker & Male, 2002; Bockneck et al., 2009; Boss, 2010; Lee & Whiting, 2007; Minnesota Department of Human Services, 2010)

Developmental Variation: Infant and Preschool

Normal reactions• Separation anxiety• Will gauge their

behavior based on adult reaction

• Benefit from daily routines

Warning signs• Regression• Confusion• Night terrors

(Brock et al., 2009; Dowdney, 2000; Himebauch et al., 2008)

Developmental Variation: School-Age

Normal reactions• Difficulty identifying and

expressing emotions• Somatic complaints• Increased irritability

Warning signs• Regression• Night terrors• Obsessive retelling• Acting-out behaviors• Loss of interest in school• Poor concentration(Dowdney, 2000; Himebauch et al., 2008)

Developmental Variation: Adolescents

Normal reactions• Very similar to adults• More frequently

experience feelings of guilt

• Look to peers for support Warning signs

• Changes in energy level• Poor concentration• Loss of interest in school• Emotional numbing and

withdrawal

(Ashbourne et al., 2002; Himebauch et al., 2008; Nickerson & Nagle, 2004)

Cultural Variations Dominant culture may have different norms for

behavior Sharing of emotion varies across cultures Others may view self-expression as being self-indulgent

or disrespectful Cultural variations should be considered when

evaluating warning signs

(Brock et al., 2009; Nickerson et al., 2009)

Recovery as the Norm Most students will recover from loss Independent coping skills develop Self-reliance and resilience Consider warning signs carefully to offer appropriate

level of support Offering too much help can signal the wrong response

(Brock et al., 2009; Moos & Shaefer, 1986; NIMH, 2002)

Therapeutic Goals Supports for concrete loss may not be appropriate for

ambiguous loss Reconstructing identity

• Define family boundaries• Normalize overlapping boundaries• Identify positive family attributes

Normalizing ambivalence• Acknowledging existence• Coping with ambiguous related stress

(Boss, 2006; Boss, 2010)

Therapeutic Goals Continued Revising attachment

Thinking dialectically (learn to balance opposing ideas) Cling to hope while accepting change

Organize memorial ceremonies and farewell rituals Build community connections

(Boss, 2006; Boss, 2010)

Supports Appropriate for School Tier 1

Tier 2

Tier 3

(Merrell, 2008)

Psychological Education Provide informational documents and training to staff,

caregivers and students• Inform about ambiguous loss• Explain behavioral manifestations of grief and loss• Make suggestions about when to refer• Explore caregivers own strategies for coping

(Brock et al., 2009; Litz, Gray, Bryant & Adler, 2002)

Social Emotional Learning

Designed to teach emotional and social skills Promote resilience Strengthening assets Increase coping skills

(Dodge, Rice & Grimm, 2010; Committee for Children, 2012; Merrell, 2008; Webster-Stratton, 1990)

Kimochis: Toys With Feelings InsideSecond Step: Skills for Social and Academic SuccessStrong Kids: A Social and Emotional Learning CurriculumThe Incredible Years: Dina Dinosaur’s Social Skills and

Problem Solving Curriculum

Benefits of Small Group Counseling Solution-focused Learning to construct solutions rather than dwell on

problems Important for ambiguous loss since there is not

closure Normalize reactions Help each other identify positive coping skills

(Brock et al., 2009)

Cognitive Therapy Interventions1. Develop awareness of emotions

2. Awareness of how emotions vary

3. Detecting automatic thoughts and beliefs

4. Evaluating automatic thoughts and beliefs

5. Replace negative thought with neutral/realistic thought

(Boss, 2006; Merrell, 2008)

Emotional Awareness

(Adapted from Gimpel & Holland, 2003)

Emotional Variance

(Adapted from Gimpel & Holland, 2003)

Detecting Automatic Thoughts

What Happened?

How did you feel?

What were you thinking?

(Adapted from Merrell, 2008)

Evaluating ThoughtsMagnifying Glass

Making small things and events seem bigger than they really are.

All or Nothing Thinking

Looking at things in only extreme or opposite ways (for example, thinking of things as being never or always, black and white)

Tunnel VisionFocusing on only the negative parts of things.

PredictingMaking guesses about what will happen in the future without knowing for certain.

Blaming MyselfBlaming yourself for things that are not in your power to control.

Pointing the FingerBlaming others for actions or events that you should take responsibility for

(Adapted from Merrell, Carrizales,& Feuerborn, 2007)

Replacing ThoughtsWhat is the thought?

What is the error in the thought?

How can you think about it differently?

Mercedes just found out her parents are getting a divorce, she thinks their divorce is her fault since she is having trouble at school.

Blaming Myself Mercedes parents are getting divorced because they have difficulties in their relationship. It is not Mercedes fault.

Olivia’s dad just left for a tour in Iraq and she tells her mom that he is never coming back.

(Adapted from Merrell, 2008)

Worry Monster Sometimes students worry about things they feel

nervous about. When you worry it just makes your stress level worse, and all the energy that you focus on that worrying is misspent.

Sample Activity Have student rate his/her level of anxiety on a scale of 1 to 5 Set a timer for two minutes and tell them to worry Have student rate his/her level of anxiety after the

activity Ask follow-up questions

(Adapted from Schwab, 2008)

Freeze Frame Your ThoughtsSample Activity: 4 Steps for Freezing your Thoughts Recognize your stressful thought Tell yourself to freeze that thought. You can do this in

whatever manner reminds you best, saying “Freeze” out loud or imagining a freeze button on your personal remote.

Replace your frozen thought with a warm and calming thought.

Repeat this warm thought to yourself out loud or in your mind to melt the frozen thought away.

(Adapted from Schwab, 2008)

Mindfulness Recognize and accept undesired

feelings as part of life Focus on what can be done in the

present moment Meditation and breathing

techniques can be used

Breathing Exercises Effective in reducing generalized anxiety disorders, panic

attacks and agoraphobia, depression, irritability, muscle tension, headaches, and fatigue Sample Activity: 4 X 4 Breathing

1. Model how to do the 4X4 breathing (inhale for 4 counts, exhale for 4 counts, and repeat)

2. Practice taking multiple 4X4 breaths together3. Follow up questions• How did your body feel when you were doing the

breathing?• What about after you had practiced a few times?

(Geneva Center for Autism, 2008)

Progressive Muscle Relaxation Excellent results have been found in the treatment of

muscular tension, anxiety, insomnia, depression, fatigue, irritable bowel, muscle spasms, neck and back pain, high blood pressure, mild phobias and stuttering.

Sample Activity: Muscle Squeeze Relaxation Has students use their imagination Example includes squeezing a lemon or playdough, biting on a

jawbreaker or ice cube, squishing sand between your toes Helpful for younger students

(Koeppen, 1974)

Visualization Visualization is effective in treating many stress-related

and physical illnesses, including headaches, muscle spasms, chronic pain, and general or situation-specific anxiety

Activities: Metaphorical Images Favorite Place Visualization

(Davis, Robbins-Eshelman & McKay, 2000)

Bibliotherapy Gives children comfort and

insight Can normalize the

ambiguous loss experience Books available about a

variety of topics, including: deployment, separation, etc.

Check out the UNLV Bibliotherapy Project website for book recommendations

(Haeseler, 2009; Jack & Ronan, 2008)

Bibliotherapy Lesson Plan Steps Pre-reading Activity

• Flip through picture book and guess theme

• Read back of book

Guided Reading

• Ask questions while reading

Post Reading Discussions

Reinforcement Activities

Bibliotherapy Lesson Plan Appropriate for age: 12 and up Book Summary: The book follows the

story of Katniss Everdeen, a sixteen-year-old who lives in a post-apocalyptic world in the country of Panem. Katniss has fended for her family after the death of her father and the mental illness of her mother. A new challenge arises as she is chosen in the Hunger Games, an annual event in which one boy and one girl from each district of Panem is selected to participate in a televised battle with only one survivor.

Sample Post-Reading Questions:• Why is Katniss so angry with her mother and what

does she fear her mother will do in the future? • Why do you think it is so hard for Katniss to trust

others?

Bibliotherapy Lesson Plan Reinforcement Activities

• Katniss has a hard time accepting help, but there are many people who are there to support her during the difficult situations she experiences. Draw a web of people who support you.

• While Katniss fights through the Games various memories and experiences help to relieve her of the stress surrounding the Games. Make a list of things you do to relieve stress or identify positive memories you can think of when times are difficult.

Individual Crisis Counseling1. Establish psychological

contact

2. Verify emotional readiness to address problems

3. Identify and prioritize problems

4. Address crisis generated problems

5. Conclude and evaluate attainment of ICI goals

(Brock et al., 2009; Brock, 2011)

Referrals for Outside Therapy When students do not appear to be responding to the

mental health interventions offered at school referrals to outside agencies may be necessary

Ensure that past interventions and how the student responded are documented

Get family members to sign an exchange of information form in order to pass information on to the student’s outside service provider

Keep updated contact information for outside agencies to provide to family members as necessary

(Merrell, 2008)

Suicide Risk Assessment Some students coping with ambiguous loss may be

so distressed that they consider suicide

To assess suicide risk trained school personnel

should

• Explore the plan

• Find out if they have made preparations

• Create an immediate protective action plan

• Develop a suicide contract and/or follow-up planning

(Brock, 2011)

Questions and AnswersWhat questions about Ambiguous Loss do you have?

Ashbourne, L., Baker, L., & Male, C. (2002). Ambiguous loss in adolescents: Increasing understanding to enhance intervention. London, England: Center for Children and Families in the Justice System. Retrieved from http://www.lfcc.on.ca/ambiguous_loss.pdf.

Bocknek, E. Sanderson, J., & Britner, P. (2009). Ambiguous loss and posttraumatic stress in school-age children of prisoners. Journal of Child & Family Studies, 18, 323-333.

Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press.

Boss, P. (2006). Loss, trauma and resilience: Therapeutic work with ambiguous loss. New York, NY: Norton.Boss, P. (2007). Ambiguous loss theory: Challenges for scholars and practitioners. Family Relations, 56(2),

105-111.Boss, P. (2010). The trauma and complicated grief of ambiguous loss. Pastoral Psychology, 59(2), 137-145.Bowlby, J. (1982). Attachment and loss (2nd ed.). New York, NY: Basic Books.Brock, S.E. (2011). Specific crisis interventions [PowerPoint Slides]. Retrieved from http://www.csus.edu/indiv/b/brocks/Courses/EDS%20246b/g)%20Crisis%20Intervention%203/Specific%20Interventions.pdfBrock, S.E. (2011). School suicide intervention [PowerPoint Slides]. Retrieved from http://www.csus.edu/

indiv/b/brocks/Courses/EDS%20246b/j)%20Suicide%20Intervention/Suicide%20Intervention.pdfBrock, S. E., Nickerson, A. B., Reeves, M.A., Jimerson, S. R., Lieberman, R. & Feinberg, T. (2009). School crisis prevention and intervention: The PREPaRE Model. Bethesda, MD: National Association of

School Psychologists.Bruckner, T., Snowden, L., Subbaraman, M., & Brown, T. (2010). Economic antecedents of medicaid-financed mental health services among youths in california. International Journal of Mental Health, 39(2), 74-90.Collins, S. (2008). The hunger games. New York, NY : Scholastic Inc.

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