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The Sudden Blog

News and views on all the latest developments in sudden bereavement care and support, with updates from researchers, support professionals and Brake staff and volunteers. All views expressed are those of the contributor and do not necessarily represent those of Brake or its employees.

An overview of the Adult Attitude to Grief Scale and Range of Response to Loss Model

An overview of the Adult Attitude to Grief Scale and Range of Response to Loss Model

In this blog, bereavement expert Dr Linda Machin shares insights into her pioneering models of bereavement and grief, the Range of Response to Loss (RRL) model and Adult Attitude to Grief (AAG) scale, and provides an overview of how these approaches can be practically applied.

Range of Response to Loss (RRL)

In my research and practice into bereavement, I have observed a wide range of experiences and expressions of grief [1].

As I began to develop a conceptual framework to capture this diversity, what became clear from my own work and that of other theorists was that grief can be seen as being made up of two dimensions.

The first is the instinctive, reflexive reactions to loss, which represent the ways in which we have learned to react to distressing circumstances, and are expressed in a range of feelings and functioning modes [2].

The second is the conscious way in which we cope with the loss that has occurred [3]. When feelings and functioning can be balanced, there is resilience; but where these cannot be managed, for a variety of reasons, vulnerability will result.

These two dimensions can be represented as intersecting elements of grief, as shown in the model below.

The Range of Response to Loss Model

RRL in practice

Underpinning this concept of grief are the social and cultural factors that shape reactions and responses to loss. These can include:

Ethnic identity and belief systems

The source of identity and beliefs can vary – they may be shaped by the family, grow from social influence or be conveyed and influenced by political organisations. The media, including social media, can also have a major impact on identity.

Specific social and circumstantial factors

Alongside influence from ethnic, social and religious identity, a range of additional factors can contribute to emotional vulnerability, and may impact response to loss. Difficult relationships, or problems relating to mental or physical health, can cause emotional vulnerability. Further challenges can be caused by economic difficulties or unemployment, which may lead to increased stress and strain. If an individual has suffered multiple life losses, this can also contribute to emotional vulnerability.

Cause of the death

Factors surrounding the cause of the death can also impact on the bereaved. A bereavement caused by a sudden, traumatic death is likely to contribute significantly to psychological vulnerability.

In practice, we might see the following characteristics in the four quarters of the RRL model: 

RRL Model

Adult Attitude to Grief (AAG) scale

The AAG scale was devised as a tool to test both the validity of the grief reactions – overwhelmed feelings and controlled functioning – and also the resilient capacity to balance these elements. The AAG consists of nine items on a five-point Likert scale, from strongly agree (score 4), to strongly disagree (score 0). The AAG is now used extensively as an assessment or evaluation tool, and to enhance therapeutic conversation.

The AAG scale incorporates nine concepts, under the three headings of ‘Overwhelmed’, ‘Controlled’ and 'Balanced/resilient’.                                

                                 

          The 9 concepts represented in the AAG scale

Overwhelmed Controlled Balanced/resilient

 
Disturbingly intrusive

Unremittingly painful

Robbing life of meaning

 
Valuing stoicism

Denial of, or covering distress

Focus on day-to-day living

 
Courage in facing the loss

Sense of personal resourcefulness

Hopefulness

Validating the use of the scale to calculate vulnerability was based on the following formula, where O represents Overwhelmed, C is Controlled and R is Balanced/resilient:

Adding O + C scores and adding reversed R scores = an Indication of Vulnerability             

The research confirmed the psychometric properties of the scale and its use to classify different levels of vulnerability. Where the highest level of vulnerability is 36 and the lowest 0, the following classifications are made [4]:

Severe              >24

High                 21-23

Low                  <20

Practice issues

When applying these ideas and this assessment scale to practice, a primary goal is to address the issues that contribute to vulnerability, and focus on enhancing resilience. Vulnerability may result from practical circumstances or personal factors that need to be recognised, understood and dealt with supportively. Effective practical help and empathy with emotional vulnerability will begin to lead to increased resilience. Helping people recognise the strengths they have and encouraging them to discover hopefulness and meaning can be difficult, especially after an unexpected and traumatic loss.

We know from others who have travelled that journey that new meaning can be found through having a goal or a cause to follow. For example, meaning can be found through memorialising the lost person in some way, through experiences that reconnect with love and beauty, and through beginning to adjust perspectives from tragedy – to the capacity to triumph. None of this may seem easy at the beginning of a loss, but many survivors of the worst of human experience, such as the Holocaust, testify to the possibilities.

Future plans

Research and practice developments continue with the RRL model and the AAG scale, including exploring whether the RRL model and the AAG scale are ‘culturally transferable’ and can be used by services offering bereavement care to diverse ethnic groups. Work is also progressing in validating other versions of the AAG, including adapting it for use in pre-bereavement with patients and carers, and also with children and young people.

For more information, see www.keele.ac.uk/mappinggrief

For copies of the AAG scale, contact Linda Machin: This email address is being protected from spambots. You need JavaScript enabled to view it.

About the author:

Linda began her career as a medical social worker, and from this experience developed an interest in bereavement. Following this, she began to conduct pioneering research into bereavement for the Anglican diocese of Lichfield. These findings led to the development of published material on grief, and the setting up of a service for the bereaved, Bereavement Care (now the Dove Service) in North Staffordshire.

An academic career followed at Keele University, with Linda teaching on both social work and counselling courses. She has an MA and PhD for her research into bereavement and is now an Honorary Research Fellow at Keele University. Throughout her career, Linda has conducted a range of research into bereavement care and grief, and continues to do so. Her book Working with Loss and Grief [5]  is used extensively in health and social care settings.

In this blog, Linda discusses how she developed the RRL model and AAG scale, and provides an overview of how these approaches can be practically applied.


References:

[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.
[2] Attig, T. (2011) How We Grieve: Relearning the World (revised edition). New York: Oxford University Press.
[3] Stroebe, M.S., Folkman, S., Hansson, R.O. and Schut, H. (2006) The Prediction of Bereavement Outcome: Development of an Integrative Risk Factor Framework. Social Science and Medicine 63: 2440–2451.
[4] Sim, J., Machin, L. and Bartlam, B. (2013) ‘Identifying Vulnerability in Grief: Psychometric Properties of the Adult Attitude to Grief Scale’, Quality of Life Research.
[5] Machin, L. (2009; 2014). Working with Loss and Grief. London: Sage.

Further reading:

Ainsworth, M.D.S., Blehar, M.C., Waters, E. and Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum. 
Cooper, M. and Mcleod, J. (2011). Pluralistic Counselling and Psychotherapy. London: Sage.
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 Psychotherapy Research,4(1), 9–17.
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.

Neimeyer, R.A. and Harris, D.L. (2011). Building Bridges in Bereavement Research and Practice. In R.A. Neimeyer, D.L. Harris, H.R. Winokuer and G.F. Thornton (eds), Grief and Bereavement in Contemporary Society. New York: Routledge. pp. 403–418. 

Relf, M., Machin, L. and Archer, N. (2010). Guidance for Bereavement Needs Assessment in Palliative Care (2nd edition). London: Help the Hospices.
Stroebe, M. and Schut, H. (1999). The Dual Process Model of Coping with Bereavement: Rationale and Description. Death Studies 23, 197–224.
Worden, W. (1983/1991/ 2003). Grief Counselling and Grief Therapy. London: Tavistock/Routledge.

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Thursday, 22 June 2017