The Adult Attitude to Grief scale (AAG)

The Adult Attitude to Grief scale (AAG) was originally devised to test the validity of the concepts in the Range of Response to Loss model (RRL). While confirming the categorical distinctions – overwhelmed, controlled, resilience – it also demonstrated the potential for profiling individual grief responses (Machin, L. 2001) ^[1]Machin, L. (2001) Exploring a framework for understanding the range of response to loss; a study of clients receiving bereavement counselling. Unpublished PhD thesis: Keele University, UK..

The AAG scale has now been adopted by many bereavement services and is used to appraise the relative overwhelmed, controlled and resilient characteristics shown by bereaved clients and to use these characteristics collectively to provide an overall indication of vulnerability. The AAG is a 9-item Likert scale inviting responses from strongly agree to strongly disagree. Additionally, the items in the scale are used to prompt comments and conversation.    

The AAG was psychometrically validated as was its use to identify vulnerability (Sim, J., Machin, L. and Bartlam, B. (2014)) ^[2]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..

The AAG a tool for practice and research

The scale is set out below and shows the 9 items in the AAG scale clustered into the overwhelmed, controlled and resilient categories. 

The numbers show their actual position in the scale – they are randomly mixed to ensure the response a client makes to each item is not affected by their responses to the other items in the cluster.    

The concept of vulnerability is incorporated through the scoring system which adds together the overwhelmed, controlled and reverse order resilient scores to provide an indication of vulnerability. 

The AAG scale

The AAG shown in categorical clusters

The scoring system is described in more detail on the AAG in Practice, page.  

Two studies were undertaken to explore the clinical usefulness of the AAG scale (Machin, L. and Spall, R. (2004)) ^[3]Machin, L. and Spall, R. (2004) Mapping grief: a study in practice using a quantitative and qualitative approach to exploring and addressing the range of response to loss. Counselling and … Continue reading and (Machin, L. (2007)) ^[4]Machin, L. (2007) The Adult Attitude to Grief Scale as a tool of practice for counsellors working with bereaved people. A study report sponsored by Age Concern, Tameside and Keele University.

Examples of experiences fr​om practice

Practitioner comments:

• ‘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 support’.

Client comments:

• ‘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’.

An example of experience from research

The Adult Attitude to Grief (AAG) questionnaire was used by us as the primary outcome in our recent investigation of bereavement experiences during the COVID-19 pandemic (BeCovid study). The AAG scale consists of nine questions, and it contains three subscales (each of three items), namely: feeling of being overwhelmed; loss of control; and resilience. Each subscale score is formed by taking the sum over the three items in the given subscale and an overall index of vulnerability (IOV) may be formed by adding the overwhelmed, control, and “reversed” resilience scores together. A score for the IOV of 20 or below indicates low levels of vulnerability (and thus grief), a score of 21 to 23 indicates high levels of vulnerability, and 24 and above indicates severe levels of vulnerability. IOV was a very useful measure in our study, where we found a mean value for IOV of 20.41 (95% CI = 20.06 to 20.77; median = 21.00), which indicates broadly that a high level of vulnerability occurred in those people bereaved during the pandemic. 38.4% of the bereaved who did not experience feelings of social isolation and loneliness after the death of their loved one did however report high or severe levels of vulnerability via the IOV, although this percentage increased strongly to 58.0% for those who did experience feelings of social isolation and loneliness. Similarly, restricted funeral arrangements had a strong negative effect on vulnerability measured by IOV also. By contrast, problems with contact and communication with their loved one prior to their death and reduced contact with other close relatives or friends had less of an effect. The AAG scale was therefore very useful in determining which pandemic-specific problems had the strongest impact on grief experienced by the bereaved, which was important information in planning targeted bereavement support provision. Finally, the questionnaire was easy to use and (importantly) it has been validated / psychometrically tested. Indeed, we confirmed that high levels of reliability for the three subscales measured via Cronbach’s alpha coefficient for our data. (Dr Damian JJ Farnell FHEA MInstP MIPEM – a senior lecturer of applied mathematics in dentistry at the School of Dentistry at Cardiff University, UK,) ^[5]Harrop, e., Goss, S., Farnell, D., Longo, M., Byrne, A., Barawi, K., Torrens-Burton,  A., Nelson, A., Seddon, K., Machin, L., Sutton, E., Roulston, A., Penny, A., Smith,  K., Sivell, S., … Continue reading