Introducing the AAG

Introducing the AAG so that the client clearly understands its purpose is essential to the appropriate and effective use of the scale.

  1. Explain how the AAG is used to help client and practitioner gain a clear picture of the client’s grief and their support needs.
  2. Give a copy of the scale to the client (or if using online/telephone provide a description of the format of the scale) and explain how it is used i.e. each item will be read out and choices made by the client about their level of agreement/disagreement with each statement based on what they are feeling and thinking ‘today’.
  3. Assure the client that there are no right or wrong answers.
  4. Encourage the client to say more about the thoughts and feelings which each statement brings up for them.
  5. Check that the client understands the information you have given and is willing to use the AAG as part of the support you are offering.

On completion of the AAG

  1. Ask the client how it felt for them, using the scale.
  2. Ask if any item(s) stood out for them as significant or troubling. 
  3. Reflect (with the client from your perspective as practitioner):
    • what you thought were the main issues which arose from their responses to the AAG.
    • Which issues might be the focus for on-going support.
    • What you see as the likely level of support.

With practice it becomes easier to recognise, as the scale is being completed, the relative emphasis on overwhelmed feelings, the desire for control, or evidence of resilience.
See the RRL and AAG as a guide to intervention pages.

N.B. The concepts and the processes described here apply also to the Attitude to Health Change scales (AHC -one for patients and one for carers) and to the Children’s Attitude to Grief scale (CAG). More information on these scales is described separately and access to those scales is on the Other scales and Resources pages.

What can the AAG tell us about a client’s grief?

Calculating vulnerabillity
AAG scale Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree
2 Overwhelmed 4 3 2 1 0
5 4 3 2 1 0
7 4 3 2 1 0
4 Controlled 4 3 2 1 0
6 4 3 2 1 0
8 4 3 2 1 0
1 Resilient 0 1 2 3 4
3 0 1 2 3 4
9 0 1 2 3 4

This is the scoring grid for calculating an indication of vulnerability. The direction of the resilient scores is reversed to allow for a simple addition of the nine AAG responses.

A worksheet for practitioners incorporating the scores is found in the Resources page.

Severe vulnerability> 24
High vulnerability21 – 23
Low vulnerability < 20
Scores run from 0 – 36

The levels of vulnerability were statistically derived from the data in the 2014 research (Sim, J., Machin, L. and Bartlam, B. (2014) (1).

The grid below helps look at the scores in the separate categories where the total for each is out of 12.

Remember that the resilient items have had their scores reversed to indicate lack of resilience i.e. vulnerability. The resilience score is derived by deducting the vulnerability score (as seen on the grid) from 12 – e.g. where the vulnerability score = 8, the resilient score = 4

This grid can provide a helpful way of exploring the AAG responses in supervision.

Exploring the AAG scores
AAG scale Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree
2. For me, it is difficult to switch off thoughts about the person I have lost. 4 3 2 1 0
5. I feel that I will always carry the pain of grief with me. 4 3 2 1 0
7. Life has less meaning for me after this loss. 4 3 2 1 0
Total for overwhelmed items (2, 5, 7) scores =
 
4. I believe that I must be brave in the face of loss. 4 3 2 1 0
6. For me, it is important to keep my grief under control. 4 3 2 1 0
8. I think its best just to get on with life in spite of this loss. 4 3 2 1 0
Total for controlled items (4, 6, 8) scores =
 
1. I feel able to face the pain which comes with loss. 0 1 2 3 4
3. I feel very aware of my inner strength when faced with grief. 0 1 2 3 4
9. It may not always feel like it but I do believe that I will come through this experience of grief. 0 1 2 3 4
Total for resilient items (1, 3, 9) scores =
 

Overall indication of Vulnerability

Combined overwhelmed + controlled + reversed resilient scores = Indication of Vulnerability
 

Encouraging and exploring the qualitative responses to the AAG

With encouragement each of the AAG statements are likely to trigger spontaneous additional comments from the client. The themes outlined below provide practitioners with issues which flow from each item in the scale and which they might use

  1. to clarify for a client any meaning of a word or statement which is unclear to them
  2. to facilitate a fuller exploration of the client’s grief.

As part of learning how to use the AAG, practitioners should spend time acquainting themselves with these themes in order to understand and develop skill in using the scale as part of a supportive conversation. This is a particularly important function of the scale.

Qualitative use of the AAG
AAG scale Themes to explore in conversation with the client
1. I am able to face the pain which comes with loss How far can feelings of grief be identified and acknowledged?
Is the impact of the feelings understood and accepted as a normal part of grief?
2. For me, it is difficult to switch off thoughts about the person I haves lost. What is the nature of these thoughts e.g. the relationship with the deceased / their death / regrets / happy memories / stolen futures etc? How far are thoughts unbidden and intrusive, and how far is it a choice to dwell on them?
3. I feel very aware of my inner strength when faced with grief. What is the nature of that inner strength? Where does the inner strength come from e.g. believing in the ability to face up to difficult things / previous experience of coping well / religious belief etc?
4. I believe that I must be brave in the face of loss. How far have family and / or cultural perspectives taught the importance of stoicism / being brave?
Is being brave how people ‘should’ react to difficult life experiences like bereavement? Has being brave become an instinctive reaction?
5. I feel that I will always carry the pain of grief with me. What words describe the pain?
What makes it feel like the pain will never go away e.g. the pain is so intense / there are feelings never experienced before / can’t imagine life without the person who has died / other?
6. For me, it is important to keep my grief under control. Is not showing grief encouraged within the family or culture e.g. the importance of ‘the stiff upper lip’ / gender driven – ‘big boys don’t cry’ / the need to ‘keep going’ for other people etc? Is it easy or a struggle to keep grief under control? Where managing feelings is difficult, is it because they are so intense / because there is no safe place to express them?
7. Life has less meaning for me after this loss. What has made life meaningful in the past?
How has that changed?
This may prompt an exploration of existential concerns (life, death, belief etc). Issues of suicidal ideation may also be raised and need to be followed up with a separate assessment.
8. I think its best just to get on with life in spite of this loss. Is this a way of avoiding the impact of the death and its consequences?
Is this a helpful way of coping with the death?
9. It may not always feel like it but I do believe that I will come through this experience of grief. How far has the reality of the death been accepted? Are the emotional, social and spiritual consequences of the death being faced? Is there a sense of hopefulness?

Downloads of the AAG Scales and Worksheets are available on the Resources page.

Frequently Asked Questions

When should I do the scores?

Complete the scores after the session. The scores will help you reflect (and consider in supervision) which aspects of grief might most helpfully be the focus of support. It is important NOT to present the client with their scores or the scoring system as numbers will not be meaningful to them but might convey a sense of being tested.

Are the scores more important than the conversation generated by the AAG?

Both are important. The scores give an overall shape to an understanding of the client’s vulnerability / resilience and the areas in which support most needs to be focused. But the conversation generated by the AAG becomes a very important component for the insights the practitioner and the client will gain from exploring the themes the scale prompts. Qualitative use of the AAG scale can itself be therapeutic.

References

  1. Sim, J., Machin, L. and Bartlam, B. (2014) Identifying Vulnerability in Grief: Psychometric properties of the Adult Attitude to Grief scale. Quality of Life Research. 2014;23(4):1211-20.