The RRL and AAG as a guide to intervention
The RRL model and the AAG responses together provide a framework for considering appropriately focused intervention. Each of the six elements (see diagram) will be considered in turn:
- Personal and circumstantial factors which effect/add to vulnerability need to be recognised as influential in shaping a person’s capacity to cope with loss and grief. These factors may need to be addressed before the grief work can begin.
- Intervention aims to counter the disabling effect of heightened distress with strategies for thinking and behaving.
- Intervention aims to counter the inhibiting inclination to avoid emotions by providing a safe opportunity to explore them.
- Intervention aims to explore the barriers to accepting and accommodating the feelings of grief.
- Intervention aims to explore the barriers to effective management of loss and its consequences.
- Intervention focuses on reinforcing the capacity for resilience
1. Focus on vulnerability
The death of someone close inevitably produces some degree of vulnerability. People referred, or self-referring, for help will be seeking support because they feel vulnerable.
That sense of vulnerability may come from a lack of understanding about the nature of grief and the normality of many of its (distressing) symptoms. Reassurance rather than more focused support may be what is necessary.
However, an important starting point as a preliminary to more active interventions is to address the underlying factors which are adding to the complexity of grief in bereavement.
Explore the factors which are likely to produce underlying vulnerability:
- Circumstantial factors e.g. nature of death, relationship to person who has died, social situation of the bereaved etc.
- Personal factors e.g. present and historical physical/mental health issues, previous experience of loss etc.
- Consider how these factors are impacting on grief reactions and coping with loss.
2. Focus on overwhelmed grief reactions
The approach to working with overwhelmed grief reactions is to acknowledge the reality of the pain and then explore ways of restoring control through cognitive and behavioural strategies.
The areas in which grief is overwhelming will emerge from responses to items 2,5, 7 in the AAG
- Empathise with the painful nature of grief
- Give permission to take time to ‘rest’ from grief
- Counter the dominance of emotions with strategies for gaining some control
3. Focus on controlled grief reactions
The approach to working with controlled grief reactions is to create a safe space to explore the feelings which can seem threatening or the circumstances of loss which can feel disempowering.
The ways in which reactions to grief are being controlled will emerge from responses to items 4,6,8 in the AAG. The scale can provide a safe and structured way to explore these issues.
- Create safety to explore how maintaining control makes it difficult to face up to the impact of loss and its consequences.
- Explore how past experiences have influenced the suppression/ /avoidance of feelings and the challenges of dealing with loss
- Explore how control can be part of an effective coping strategy without avoiding the feelings of loss and confronting its consequences
4. and 5. Focus on overwhelmed and controlled barriers to resilience
What can we learn about barriers to resilience from the AAG responses? Look for areas of strong agreement and strong disagreement as clues to significant areas on which to focus.
Using the case study (Jane – see scores and qualitative comments) we can note:
Jane’s strong agreement with item 2 and 6 and strong disagreement with item 3. They show that her sense of not having inner strength makes dealing with the tension between not ‘switching off thoughts’ about her mother and ‘keeping her grief under control’ is central to her grief.
Jane’s coping is characterised by a sense that she will come through her bereavement experience by ‘getting on with life’. Perhaps this goal can be achieved by finding the direction she seeks, by addressing the tension between 2 and 6 and by looking to strengthen her inner strength /self-esteem.
diagram – table. exploring barriers to resilience
Exploring barriers to resilience (Jane Case Study)
|AAG scale||Strongly agree||Agree||Neither agree nor disagree||Disagree||Strongly disagree|
|1. I am able to face the pain which comes with loss.||x|
|2. For me, it is difficult to switch off thoughts about the person I haves lost.||x|
|3. I feel very aware of my inner strength when faced with grief.||x|
|4. I believe that I must be brave in the face of loss.||x|
|5. I feel that I will always carry the pain of grief with me.||x|
|6. For me, it is important to keep my grief under control.||x|
|7. Life has less meaning for me after this loss.||x|
|8. I think its best just to get on with life in spite of this loss.||x|
|9. It may not always feel like it but I do believe that I will come through this experience of grief.||x|
6. Focus on resilience
Resilience can be neglected when vulnerability is often most central to the bereavement care support agenda. Items 1,3,9 in the AAG bring resilience into focus.
Resilience here is contextualised in the wider frame of existential perspectives (Frankl, V. (1959)* Frankl, V. (1959) Man’s Search for Meaning. Boston, MSA: Beacon Press., (Seligman 1998)** Seligman, M.E.P. (1998) Building Human Strength: Psychology’s Forgotten Mission. American Psychological Association Monitor. 29 (1).
- Ability to face the reality of loss – the emotions and the consequences – confronting and accepting what cannot be changed.
- Capacity to cope with the consequences of loss – being able to feel, think and act with courage and confidence in dealing with the challenges of new life circumstances.
- *Achieve a sense of meaning through –
- creativity (a goal or a cause to follow)
- experiential (truth, beauty, love)
- attitudinal (a capacity to turn tragedy into triumph)
- **Reinforcement of natural strengths – through optimism and access to adequate support.
Focusing on resilience prompts reflection on the pain of grief and the possibilities for adjusting to loss.
A more detailed consideration of a pluralistic approach to working with grief can be found in Linda Machin’s book.
Frequently Asked Questions
Is using the AAG as a guide to working with clients, person-centred?
While the AAG is a framework for exploring the dynamics of grief, it is one which opens the way for the client’s own voice to be heard in the ‘story’ of their bereavement and how it is being experienced and expressed (person-centred). The practice guidelines emphasise the need to introduce the scale sensitively (person- centred) and are very clear about its use as a collaborative partnership between practitioner and client in gaining insight into the nature of grief and in setting goals jointly for the focus of the support being offered (person-centred).
Can I integrate this approach with other ways I have learned to work with bereaved clients?
People bring the riches of personal experience, and theoretical and practice learning to their work in bereavement care. Using the AAG is meant to complement that experience and knowledge through this grief-focused tool. As you begin to use it with clients and reflect on it in supervision, you will be able to consider how to blend all those strands of previous practice with an AAG approach.