Why assessment tools?
Services and their staff offering bereavement care need to demonstrate ‘best practice’ by:
- Working towards agreed practice standards set out in ‘Bereavement Care Service Standards’ 2014;
- Recognising the need to provide appropriately varied provision for the varied needs of bereaved clients. Increasing use is being made of the NICE guidance on appropriate levels of intervention;
- Ensuring that intervention standards are being reached through monitoring processes and recording outcomes;
- Addressing the requirement of commissioning bodies for evidence of appropriate and effective interventions.
Practice use of the AAG
Within bereavement and palliative care settings interest and enthusiasm for using the Adult Attitude to Grief scale (AAG) has grown considerably and with it the need for clear guidance about its use in practice. This website is designed to help managers make informed strategic choices about assessment determined interventions within services and practitioners make appropriate and effective use of the AAG, and/or any of the authorised but yet to be validated modified versions (AHC, CAG, ALL) in their support of grieving people.
A step by step approach sets out the process of working with the AAG. Whilst it is meant to provide simplicity and clarity, the application of the scale should always be undertaken within the frame of wider professional judgement and expertise if it is to be a flexible and sensitive tool for practice.
The AAG is free to download from the resource page of this site but users are required to agree to use it without modification and in the way set out (see protocol below) by the copyright holder, Linda Machin. (See contact page)
To Download the AAG Practice Record Sheet go to the Resource page.
The Adult Attitude to Grief scale (AAG) is a 9-item validated measure derived from concepts in the Range of Response to Loss model (RRL) (Machin 2014; Sim, Machin and Bartlam 2014). The AAG provides practitioners with a structure to explore the expressions of grief and perspectives on loss experienced by bereaved people.
The AAG scale might be used by a service, in a health care context or in the charity sector of care, offering psychosocial support to people who are bereaved. A bereaved person my seek help themselves or a referral may be made when a relative or friend or other support agency feels there might be a need for or benefit from some form of psychosocial care. The AAG is a measure to appraise the relative vulnerability and resilience of a bereaved person and the consequent implication this has for their care needs.
For services who have adopted or intend to adopt the AAG as an integral part of their assessment of a bereaved person’s need for support, practice procedures will need to be put in place to identify when and how it will be used e.g. for systematic use of the AAG scale at an initial meeting either as a triage process or as part of the preliminary engagement with care provision, repeat use where ongoing support is given, and where possible at the end of support, as an outcome measure.
Guidance for using the Adult Attitude to Grief scale (AAG) in practice
How do organisations need to prepare to implement the AAG?
It is important for service managers and team leaders:
a) to understand the rationale for the scale’s use,
b) to appreciate its pertinence for the work of the service,
c) to ensure it is used competently.
- The provision of induction and ongoing training: to ensure knowledge of the theoretical underpinning of the AAG scales, understanding the link between theory and practice, and skills in the sensitive use of the scale. See Practice Competency document (Appendix 1).
- Addressing practitioner personal / professional perspectives on the AAG scale (positive and negative) to ensure that implementation can take place smoothly.
- Ensuring practitioners adhere to the Protocol for use of the AAG scale – set out in these guidelines.
- Understanding the place of clinical judgement in gauging the timing and appropriateness of using the AAG within a flexible policy for procedures and practice.
- Consider the resource implications: administrative time, training costs, IT systems etc.
How do practitioners need to prepare to use the AAG?
It is important for practitioners:
a) to understand the rationale for the scale’s use,
b) to appreciate its pertinence for their own work,
c) to employ it competently.
- Induction and ongoing training: knowledge of the theoretical underpinning of the AAG scale, understanding the link between theory and practice, skills in the sensitive use of the scales etc. See Practice Competency document (Appendix 1).
- Exploration of personal / professional perspectives on the AAG scale (positive and negative) by the practitioner and honesty in addressing how this might impact on practice use of the AAG. This needs to be addressed in training.
- Understanding of and adherence to the Protocol for use of the AAG scale – set out in these guidelines.
- Understanding the place of clinical judgement in gauging the timing and appropriateness of the AAG scale.
When to use the AAG? – exercising clinical judgement
Where a service/care team has decided to use the AAG as a systematic tool of assessment clinical judgement is still necessary to determine whether its use is appropriate with ‘this bereaved person’ at ‘this point in time’. Clinical judgement is crucial to the appropriate, effective and flexible use of the AAG.
|Factors requiring clinical judgement when using the AAG|
| Likely contraindications for use of the scale, where there is: |
a) Intense emotional distress
b) Immediate and pressing matters of concern for the bereaved person e.g. practical issues, social problems
| If the introduction of the scale is met with resistance, the practitioner might |
a) accept that as a reason not to use the scale;
b) gently explore and/or challenge the reasons for resistance;
c) introduce the scale at a later date.
| Looking at any inconsistency between the Vulnerability Indicator score and the narrative accounts of loss/grief/bereavement. |
Supervision is the context in which inconsistencies in the AAG quantitative and qualitative responses can also be explored.
|In all the above factors a crucial aspect is judging the appropriate timing for using the AAG including the readiness of the bereaved person to engage with it. This should not simply be a practitioner perspective but clients/service users, after discussion about the purposes and processes of using the AAG (See A1 below), should be asked about their readiness to engage with the scale.|
N.B. Throughout the rest of this document the term ‘client’ will be used to cover all service users seeking and receiving bereavement support.
A. Working with the AAG scale
1. Introducing the AAG scale and explaining the processes involved:
i) Describe the purpose of the scale…… as a way to help a client and practitioner have a clear picture of how the bereavement is being experienced.
ii) Explain how the AAG is used by the practitioner…… to decide what might be the most appropriate form of support for the client.
iii) Give a copy of the scale to the client…… and explain the 5 choices for each item on the scale (from strong agreement to strong disagreement).
iv) Assure…… the client that there are no right or wrong answers.
2. Gaining client agreement to use the AAG:
i) Provide information…… on record keeping and confidentiality.
ii) The right to withdraw…… at any point in the process of the scale’s use.
iii) It is good practice…… to check at points during the use of the scale that the client is comfortable with the process and happy to continue.
3. How to use the AAG scale:
i) Decide…… the practical process for using the AAG e.g. whether the client or practitioner will read out each item. Agree that the practitioner may note down qualitative comments. (Factors such as literacy and visual capacity need to be taken into account.)
ii) Clarify…… any specific words in the AAG scale or the meanings they are meant to convey which are unclear to the client making sure they reflect the concepts in the Range of Response to Loss model. (See Appendix 2.)
iii) Encourage…… the client to say more about the thoughts and feelings which each of the 9 statements brings up for them. When exploring qualitative comments, even for preliminary assessment purposes, if the client chooses to engage, a significant/ therapeutic conversation may develop. (See therapeutic use of the AAG in sections B, C4, D 1 and E below.)
iv) Explore wider issues…… within the qualitative discussion to increase an understanding of client circumstances, and factors influencing availability of support, cultural influences etc. Wider issues can be explored alongside use of the AAG but some services may use additional questionnaires to capture this information.
B. On completion of the AAG, discuss the experience of using the scale with the client:
i) Ask…… the client how it felt using the scale
ii) Did any one item…… stand out for the client as significant or especially difficult to answer?
iii) Reflect (with the client from your perspective as practitioner) …… on what you thought were the main issues or themes made by the client during this session. Anything else that struck you as salient, interesting, illuminating or important in this session. What you see as needing to be taken forward or followed up?
With practice it becomes easier to recognise the relative emphasis on overwhelmed feelings, the desire for control, or evidence of resilience, as the scale is being completed.
C. AAG – Assessment
Interpreting and exploring the AAG responses:
There are three steps to interpreting the AAG scores and additional guidance for exploring the client’s qualitative responses.
- The vulnerability Indicator score
The Vulnerability Indicator score provides an overview of the level of the client’s vulnerability. This will signal the likely level of support that is needed. The score will be supplemented by other clinical observations about the client’s vulnerability and needs.
It is important NOT to use a score sheet with clients or disclose the score as this can convey a sense of being tested and may prevent honest responses.
The scoring system for identifying vulnerability has been validated (Sim, J., Machin, L and Bartlam, B 2014).
> 24 severe vulnerability
21-23 high vulnerability
< 20 low vulnerability
2. Look for evidence of a bias in the AAG responses
Does the client have a tendency towards being overwhelmed by feelings (items 2, 5, 7), controlling of feelings (items 4, 6, 8) or resilient in their coping with grief / bereavement (items 1, 3, 9)? Use the grid (Table 1.) below to help you look at these tendencies. Also consider what the client’s additional comments tell you about their way of reacting and coping with their bereavement.
Always remember that if you are using the scores to look at individual categories, the ‘resilient’ item scores are reversed in order to show vulnerability.
Table 1. Looking at the AAG scores in the individual categories – overwhelmed, controlled, resilient
3. Look at the relationship between the Overwhelmed, Controlled and Resilient items.
Although there may be a tendency towards being overwhelmed, controlled or resilient, there is likely to be a mix of agreement across the categories requiring more careful interpretation.
i) Clients who agree strongly with both the overwhelmed and controlled items in the AAG show a tension between wanting to be in control while finding it difficult in manage the strong emotions which their grief prompts. This state of vulnerability is increased when a client also strongly disagrees with the resilient items.
ii) Clients who disagree with the resilient items and have some level of agreement with the overwhelmed and controlled items are also vulnerable.
Lower level of vulnerability:
iii) Clients who agree with the resilient items are likely to be able to moderate the impact of their overwhelmed and controlled reactions
iv) It is important to remember that while a ‘controlled’ reaction to grief might indicate vulnerability, control can also be an effective coping mechanism especially when it is combined with agreement with the resilient items.
4. Exploring the qualitative comments.
Qualitative comments made in responses to each of the items in the AAG scale add to the quantitative scores* providing a fuller perspective on the client’s grief reactions and coping responses.
This dimension is especially important as it can help promote a dialogue between practitioner and client as the themes within the AAG are explored. A meaningful conversation, which needs to be conducted sensitively at a pace led by client, can reveal the underlying attitudes which are shaping the client’s bereavement experience.
| AAG scale: |
Themes and associated issues to explore
1. I feel able to face the pain which comes with loss.
‘Facing feelings’: The ability to identify/name feelings prompted by the loss/bereavement; to acknowledge those feelings; to recognise the impact of the feelings; to be able to talk about them.
2. For me, it is difficult to switch off thoughts about the person I have lost.
‘Disturbingly intrusive thoughts’: What is the nature of these thoughts? How far are they unbidden thoughts and how far is the bereaved person choosing to dwell on them?
3. I feel very aware of my inner strength when faced with grief.
‘A sense of personal resourcefulness’: A sense of confidence about being able to cope. An identification of where inner strength comes from e.g. previous experience, religious belief etc.
4. I believe that I must be brave in the face of loss.
‘Belief in stoicism’: How far perspectives learned from family and culture have taught the importance of stoicism / being brave; how far being brave has become an instinctive reaction shaping how one ‘should’ react to testing life experiences such as bereavement.
5. I feel that I will always carry the pain of grief with me.
‘Persistently painful emotions’: Identify the nature of the pain of grief i.e. other words they might use to describe their feelings. This might be an important dimension in which to give space and safety to talk about how overwhelming grief is and fear that it will never get better.
6. For me, it is important to keep my grief under control.
‘Avoidance of expression of distress’: This may also be a belief learned within the family or culture – the importance of ‘the stiff upper lip’. It may be gender driven – ‘big boys don’t cry’. It may be driven by wanting to ‘keep going’ for other people. Explore how far this belief may not fit with the experience of the bereaved person who may be struggling to manage their grief.
7. Life has less meaning for me after this loss.
‘Life losing meaning’: This may prompt an exploration of existential concerns (life, death, belief etc). What has made life meaningful for the bereaved person in the past? How has that changed? Issues of suicidal ideation may also be raised (these need separate assessment)
8. I think it’s best just to get on with life in spite of this loss.
‘Diverting attention’: How far does this work as a coping strategy? How far is it avoidance of important issues relating to coping with the grief? Can avoidance and confrontation be balanced by the bereaved person?
9. It may not always feel like it but I do believe that I will come through this experience of grief.
‘Hopefulness / positivity’: How far has the bereaved person been able to confront the reality of the loss and feel hopeful about the long -term outcome. What other loss/grief experiences have they had which might shape either their optimism / pessimism?
© Linda Machin
* Sometimes there is an apparent mismatch between the Vulnerability Indicator score and the qualitative comments. It is then necessary to use clinical judgement in reaching a view on the nature of the patient’s / carer’s vulnerability. In this situation discussion in clinical supervision is also necessary.
D. AAG – Intervention
When the AAG is used to assess the need for support, the level of vulnerability will indicate the appropriate level of intervention. A hierarchy of support needs is based on four levels of psychological distress identified within NICE guidance for ‘Improving Supportive Care for Adults with Cancer’ (2004) and are used here as the basis for classifying different levels bereavement of intervention.
Figure 1. Components derived from the NICE guidance (2004) showing levels of need and matched interventions
1. Conversation generated by the AAG as an intervention:
a) Members of the psychosocial care team may use the AAG for assessment purposes and find within that function it naturally prompts a broader conversation on issues of importance to the client.
b) In order to be effective all levels of intervention, set out in the Figure above, are dependent upon sensitively conducted conversations. With more focused therapeutic work (at levels 3 and 4) those conversations will need to be structured and the AAG used to explore barriers to resilience in the face of bereavement (See Appendix 3).
2. When assessment indicates the need for an intervention, the AAG may be used as a framework for the practitioner and client to jointly set goals for achieving mutually agreed objectives. For example, to use therapeutic support to safely discus: feelings; practical issues arising from the bereavement; making sense of life in the face of loss etc.
3. When the grief responses are more complicated and counselling as a third or fourth level of intervention is indicated, a pluralistic therapeutic approach is recommended and set out in Chapter 7 of ‘Working with Loss and Grief’ (Machin 2014).
(See – ‘An approach to intervention’ for more detailed information)
4. When the AAG is applied as a framework for practice at levels 3 and 4 it is important to explore the quantitative and qualitative client responses within clinical supervision in order to determine appropriate and effective therapeutic approaches and strategies.This will assume the supervisor has knowledge and understanding of the AAG and is conversant with the skills necessary to apply it in practice.
E. AAG – Review / outcome
1. Re-use the AAG scale as part of a monitoring process, to review the client’s changing reactions and coping responses. This will provide useful insights for the client and practitioner.
2. At the end of the support process the AAG scale is used to evaluate the outcome of the client’s capacity to cope with bereavement and its consequences. It is important to recognise that grief is not finished at the end of professional intervention but that with support to help increase resilience and address some of the circumstantial factors contributing to vulnerability, a client’s capacity to move forward with on-going support from their own social network, will be strengthened.
Bereavement Care Standards (2014) – developed by Bereavement Services Association and Cruse Bereavement Care.
National Institute of Clinical Excellence (NICE) (2004). Improving Supportive and Palliative Care for Adults with Cancer. London.
Machin, L. (2014) Working with Loss and Grief. London: Sage (2nd edition)
Appendix 1. AAG practice competencies
Appendix 2. Conceptual links between the Range of Response to Loss model and the Adult Attitude to Grief scale
Concepts in the RRL model represented in the AAG
Overwhelmed reactions – feelings of grief for the deceased person and the losses of bereavement are experienced as ……..
| 2. …. disturbingly intrusive thoughts 2. For me, it is difficult to switch of thoughts |
about the person I have lost.
| 5. ….persistently painful emotions 5. I feel that I will always carry the pain of grief |
|7. … life losing meaning 7. Life has less meaning for me after this loss.|
Controlled reactions – a focus on functioning and avoiding or denying feelings of grief through ……..
|4. ….a belief in stoicism 4. I believe I must be brave in the face of loss.|
| 6. ….avoidance of expressions of distress 6. For me, it is important for me to keep my |
grief under control.
| 8. ….diverting attention 8. I think it best just to get on with life in |
spite of this loss.
Resilient coping – balances a capacity to deal with feelings and an ability to manage the consequences of grief through……..
| 1…..facing feelings 1. I feel able to face the pain which comes with|
| 3…..a sense of personal resourcefulness 3. I feel very aware of my inner strength when|
faced with grief.
| 9. ….hopefulness / positivity 9. It may not always feel like it but I do |
believe that I will come through this
experience of grief.
Appendix 3.Exploring the AAG scores