Running head: BEREAVEMENT COUSELING 1

Running head: BEREAVEMENT COUSELING 1 Small-Group Bereavement Counseling with Middle School Students Jeannine O Brian UNC-Chapel Hill

BEREAVEMENT COUNSELING 2 Abstract This article addresses the treatment of grief in a middle school setting. It starts with a review of 1) prominent grief theories, 2) studies on the effects of grief on students experiences at school, and 3) previous attempts to address grief in school settings. It proposes a plan to address grief in middle schools through small-group counseling. Bereaved students would participate in six weekly group-counseling sessions. The proposed group activities are based on the continuing bonds theory and successes described in the literature. Changes in students feelings and experiences resulting from group would be measured using the Hogan Grief Reaction Checklist, several open-ended questions, and students GPAs. Expected results are presented. Keywords: student grief, middle school, grief intervention, academics

BEREAVEMENT COUNSELING 3 Small-Group Bereavement Counseling with Middle School Students Introduction Death and grief can be difficult, life-changing experiences. Middle school students, like anyone else, react in a wide variety of ways to the death of someone significant in their lives. Some of these reactions are outside a school counselor s realm of expertise; in these cases students should be referred to appropriate resources (Cohen & Mannarino, 2011; Granello, Ober, & Wheaton, 2012). That said, even what is considered typical grief can be disruptive to students emotional, social, and academic well-being (Abdelnoor &Hollins, 2004; Mallon, 2011; Monroe & Kraus, 2010; Silverman & Worden, 1992). Grief has been successfully addressed in schools, and school counselors are positioned to lead bereavement support groups (Glass, 1991; Granados, Winslade, DeWitt, & Hedke, 2009; Ross & Hayes, 2004). Literature Review Bereaved children and adolescents often report having difficulty focusing on school work, acting out in ways they know could be detrimental to themselves or others, and feeling sadness, anger, worry, and loneliness (National Alliance for Grieving Children, 2012). These themes are common, yet the experience of grieving is highly personal. Theories on grief vary widely, as do approaches to bereavement counseling and the results of empirical studies. In short, the study of grief is complicated. For decades following the publication of On Death and Dying, Kübler-Ross five stages of grief were the foundation of writings and studies on death, bereavement, and mourning (Mallon, 2011). Kübler-Ross identified the five stages during her extensive work with terminally ill people. The stages are denial, anger, bargaining, depression, and acceptance (Kübler-Ross,

BEREAVEMENT COUNSELING 4 1969). These stages became a widely accepted explanation of grief, and were used to help terminally ill and bereaved even though there was and is little empirical evidence supporting this model (Mallon, 2011). During the 1980s and 1990s, several new theories on grief emerged (Klass, Silverman, & Nickman, 1996; Stroebe & Schut, 1999; Worden, 1991). Worden posited that there are four tasks of grief to be worked through in a linear fashion. The tasks are: 1) accepting the reality of the loss, 2) working through the pain of grief, 3) adjusting to a changed environment in which the deceased is missing, and 4) emotionally relocating the deceased and moving on with life (Worden, 1991). Worden s later work with Silverman on what is known as the Harvard Bereavement Study found that children do not move through those tasks following the loss of a parent (1996). Worden has updated his task model as his research has progressed (Worden, 2009). The Harvard Bereavement Study remains one of the most often cited studies on bereaved children. The sample included 125 children, ages six to 17, from 70 families the greater Boston area, and 43 children of the same age group from 23 families in Israel (Silverman & Worden, 1992). The researchers first collected data from participants four months following the parent s death, and then again one and two years following the death. Data was both quantitative and qualitative. The findings most relevant to the purposes of this review involved school performance, peer support, and the desire to maintain a relationship with the deceased (Silverman & Worden, 1992). Most children had learning difficulties following the death. Children who reported having more peer support demonstrated fewer behavioral issues (e.g. insomnia) than those with less support. Silverman and Worden found that children invested considerable time and energy in staying connected with their deceased parent (1992).

BEREAVEMENT COUNSELING 5 Abdelnoor and Hollins (2004) studied more thoroughly the effect bereavement has on students school work. They found that bereaved students experience more anxiety than their peers, and also that bereaved students score lower on standardized tests than their peers. Out of the Harvard Bereavement Study emerged the theory of continuing bonds, which challenged the linear stage models of grief (Klass, Silverman, & Nickman, 1996). Through the semi-structured interviews with bereaved children and their surviving parents, the researchers found that children tend to seek out a continued connection with their deceased parent. Five common ways children strive to stay connected are locating the deceased, experiencing the deceased, reaching out to the deceased to initiate a connection, waking memories, and linking objects (Klass et al., 1996). Furthermore, the authors found that the connections changed over the period of two years that this sample was studied. While negative feelings and behaviors (e.g. sadness, crying, insomnia) diminished as time went on, the children continued their relationship with the deceased parent (Silverman & Worden, 1992; Klass et al., 1996). Klass et al. suggested that bereavement is not a condition to be resolved through letting go, but a process that involves coming to terms with the new role the deceased plays in the child s life. Stroebe and Schut proposed another non-linear model of grieving in which the bereaved go back and forth between concentrating on what they have lost ( loss orientation ) and concentrating on what they need to do to move forward in their lives ( restoration orientation ) (1999). This is called the dual process model. As time goes on, the bereaved spends more time and energy on restorative side of existence, and less on the loss side, but there is no definite point of resolution or recovery. In light of these and other models that de-emphasize moving through stages to let go of the deceased, the treatment of grief by mental health practitioners has evolved. Neimeyer

BEREAVEMENT COUNSELING 6 developed some strategies for grief therapy grounded in the notion that the grieving process is not universal or objective, but takes on whatever shape and meaning the individual gives it (1999). Neimeyer draws on narrative therapy and calls his approach constructivist. He used these strategies with individual clients, but some of them can and have been incorporated into group counseling (Granados et al., 2009; Hedke, 2012; Neimeyer 1999; Ross & Hayes, 2004). Neimeyer sees writing prompts, such as epitaphs and guided journal prompts as a key strategy in constructivist-style grief therapy. He argues that the client does not have to be good at writing to benefit from this kind of activity. In their school-based study of grief group counseling, Ross and Hayes adapted writing prompts for students in grades three through 11 (2004). Ross and Hayes found that students felt more confident and enthusiastic about school and school work following group counseling that included these writing prompts and other activities. Hedke wrote a book detailing her successes with group grief counseling at hospitals and Hospice facilities (2012). She uses elements of continuing bonds theory, the dual process model, and narrative therapy to create group activities, and has generated qualitative evidence supporting the notion that group therapy helps bereaved individuals move away from the negative emotions and behaviors associated with grief and towards more positive ones. Granados, Winslade, DeWitt, and Hedke implemented a modified version of Hedke s bereavement group program in middle and high schools (2009). According to qualitative feedback, this too was helpful to participants. One theme that emerged from the qualitative feedback in Granados et al., Hedke, Ross and Hays groups is that children benefited from sharing their experiences with other students who could relate to them. Neimeyer and others question whether or not grief counseling is effective at all, or necessary for adults and children experiencing non-pathological grief (Currier, Holland, &

BEREAVEMENT COUNSELING 7 Neimeyer, 2007; Jordan & Neimeyer, 2003; Wilson, 1994). Reviews of bereavement counseling studies call for additional research on grief interventions, especially with children. Given the evidence that bereavement affects children and their ability to function at school (Abdelnoor and Hollins 2004; National Alliance for Grieving Children 2012; Silverman & Worden, 1992), there is a definite need for a response to students struggling with grief. Based on Granados et al., Hedke, Ross, and Hays success with group counseling approaches that do not ask students to let go or move on, the present study aims to add to this line of findings. Research Question and Hypothesis The research question is, can small-group bereavement counseling help middle school students feel less sadness and hopelessness, and perform better in school? The hypothesis is that small-group counseling for bereaved middle school students can lessen these negative experiences, and help increase students academic performance in school. Methods and Procedures Variables and constructs. The independent variable is manipulated. It is participation in the bereavement group. The dependent variables are academic performance (as measured by GPA), and students selfreported feelings of sadness and hopelessness (as measured using the Hogan Grief Reaction Checklist). In this paper, the words grief and grieving are used to mean sadness in response to death. Bereavement is the state of having lost someone to death. Sampling process.

BEREAVEMENT COUNSELING 8 The population of interest in this study is middle school students who have lived through the death of significant person in their lives. Convenience sampling will be used; the sample will be drawn from students at the school where the researcher works. Bereaved students will be identified using data from the annual school-wide needs assessment. The study will also be advertised using flyers posted around the school, allowing others and more recently bereaved students to volunteer for the study. Students identified through the needs assessment will be asked if they would like to participate in group. Written permission to participate in group counseling will be obtained from all students parents or guardians. A group will be made up of four to eight students. In the case that there are enough participants to fill two or more groups, students will be randomly assigned to each group. Treatment process. Students with parental permission to participate will be asked to provide demographic information, and to complete a pretest that consists of the Hogan Grief Reaction Checklist and several open-ended questions about their grief experience (see Appendices A and B for instruments). The Hogan Grief Reaction Checklist stood up to testing for reliability and validity (Hogan et al., 2001). The checklist includes sixty-one items that address six factors: despair, panic behavior, personal growth, blame and anger, detachment, and disorganization. The checklist was developed with adults in mind, but it straight-forward and uses simple language. Students will read each item, decide to what extent the statement applies to them, and circle a number from one to five. One indicates that the item does not align with the student s experience, and five indicates that the item describes the student s experience well (Hogan et al., 2001).

BEREAVEMENT COUNSELING 9 The psychometric properties of the open-ended questions are unknown, but these questions will invite students to share parts of their personal experiences that may not be captured in the checklist. While useful, the checklist limits students in the experiences they share. Useful data collected in previous studies has come from open-ended questions and interviews (Hedke, 2012; Silverman & Worden, 1992; Wilson, 1994). Students GPAs will be recorded the day the pretest is taken. Students will take the pretest the day before the first group counseling session. Students will participate in six one-hour sessions, each scheduled one week apart. The sessions will be structured using Hedke s bereavement support group as an outline (2012). Some activities will be replaced by more developmentally appropriate ones from Neimeyer (1999), Ross and Hayes (2004), and Granados et al. (2009). Session one. After a general introduction to group, students will create group rules. Then they will introduce themselves and the person they lost. Students will work in pairs to answer more detailed questions about the deceased. Back in the larger group, everyone will share what he or she learned about their partner s loved one. Students will receive journals, and a journal prompt to complete individually (see Appendix E for journal prompts). Session two. Students will reflect on the previous week s journal prompt. Then they will work in pairs to answer this question: What kinds of things did people say to you before your loved one died or since his or her death about how you were supposed to feel, think, or act? With the whole group, students will share what they came up with and the leader will record the answers on chart paper. When everyone has shared, the group will go back through and talk about how hearing certain things affected them. Students receive a second journal prompt.

BEREAVEMENT COUNSELING 10 Session three. Students will reflect on the previous week s journal prompt. Students will have brought a photo or an object to group that reminds them of the person they lost. Students will take turns sharing their item with the whole group. Students will be asked to share a challenge that their loved one overcame. Students receive a third journal prompt. Session four. Students will reflect on the previous week s journal prompt. Then, they will an activity called the story wheel, where students sit with their backs to each other in a circle and each contribute a sentence to an improvised story in turn. The leader helps the group process the story. Students will be asked what their loved one would say their strengths are. Students receive a fourth journal prompt. Session five. Students will reflect on the previous week s journal prompt. Students will bring in photos or other material that can be turned into a collage-like creation. They will write words and phrases related to the person they have lost. After group, the leader will use the copier to shrink the collages down to the size of a credit card and laminate them. Students will receive a fifth journal prompt. Session six. Students will share their collages with the group. They will reflect on the final journal prompt, and on the group experience as a whole. They will discuss how they can support each other once group is over. The last 10 minutes of each session will be spent completing the checklist and answering one open-ended question about the group experience (see Appendix C). Two weeks after the completion of group, students will be asked to complete the checklist and answer a set of openended questions (See Appendix D). This process will be repeated one month and three months completing group. Each time the checklist is given, students GPAs will be recorded. In the case that there are enough students to fill multiple groups, these groups will happen during the same

BEREAVEMENT COUNSELING 11 six-week period, but on different days of the week. If at any time a student circles anything higher than one on item 17, indicating that he or she wants to die, the student will be assessed for suicidal ideation using the school s procedures. Validity. The extent to which group is the factor resulting in differences in responses to the grief reaction checklist and open-ended questions will be muddled by individual experiences of participants outside of group. The passage of time alone can result in lessened sadness and anxiety surrounding a death (Silverman & Worden, 1992). Going to religious centers, talking with friends and family, and other informally therapeutic activities outside of group may also result in more positive feelings and hopeful outlooks. Students may also engage in activities such as tutoring that have nothing to do with group but affect students academic performance. The extent to which this study can be generalized to the population of interest is limited. Given the school demographics, the participants will be predominantly African-American, with a smaller portion of Latino students. The majority will come from culturally Christian backgrounds. The participants may vary greatly in socioeconomic status, and greatly in terms of who they have lost. It will be necessary to bear in mind the racial and religious homogeny of the group when generalizing to other bereaved middle school students. Timeline for completion. Participants for the study can be identified during the first month of the school year using the needs assessment and volunteer recruitment. Three weeks should be allowed for the screening process and obtaining parental permission. The group process should be started in order that the six group sessions can be completed in six weeks, that is, before the week of Thanksgiving, and with enough time that the one-month follow up can be completed before

Score BEREAVEMENT COUNSELING 12 winter break. Starting the study during the fall semester will allow for a longer follow-up window. Projected Results Data collected from the Hogan Grief Reaction Checklist at each point in time will be averaged. It is expected that the average ratings will decrease for items that fall under five of the six factors: despair, panic behavior, blame and anger, detachment, and disorganization. Average scores on the sixth factor, personal growth, are expected to increase from the first measurement. The results for each of the sixty-one items will be examined individually but a summary of the results may look something like the graph in Figure 1. It is expected that students GPAs will increase, if only slightly. The change may look something like Figure 2. Open-ended questions will be read and common themes will be reported. Students' Average Scores on Hogan Grief Reaction Checklist 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Pre-group Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 2 Weeks 4 Weeks 12 Weeks post-group post-group post-group Time despair panic behavior personal growth blame and anger disorganization detachment

GPA (0-4.0) BEREAVEMENT COUNSELING 13 Figure 1. The group s average scores on the Hogan Grief Reaction Checklist over time. Pre-group data was measured the day before the first group session. Students completed the checklist at the end of every session, and then again two, four, and 12 weeks following the completion of group. 3 Students' Average GPA 2.5 2 1.5 1 0.5 0 Time Figure 2. The group participants average GPAs over time. Pre-group data was measured the day before the first group session. Students GPAs were checked after each group session, and again two, four, and 12 weeks following the completion of group.

BEREAVEMENT COUNSELING 14 References Abdelnoor, A., & Hollins, S. (2004). The effect of childhood bereavement on secondary school performance. Educational Psychology in Practice, 20(1), 43-54. Cohen, J.A. & Mannarino, A.P. (2011). Supporting children with traumatic grief: What educators need to know. School Psychology International, 32(2) 117 131. Currier, J.M., Holland, J.M., & Neimeyer, R.A. (2007). The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research. Journal of clinical child and adolescent psychology, 36(2), 253-259. Glass Jr., J. (1991). Death, loss, and grief among middle school children. Elementary School Guidance & Counseling, 26(2), 139-149. Granados, S., Winslade, J., DeWitt, M., & Hedke, L. (2009). Grief counseling groups for adolescents based on re-membering practices. Journal of School Counseling, 7 (34). Granello, D. H., Ober, A. M., & Wheaton, J. E. (2012). Grief counseling an investigation of counselors' training, experience, and competencies. Journal of Counseling and Development, 90(2), 150-159. Hedke, Lorraine (2012). Bereavement support groups: breathing life into stories of the dead. Chagrin Falls, Ohio: Taos Institute Publications. Hogan, N.S., Greenfield, D.B., & Schmidt, L.A. (2001). Development and validation of the Hogan grief reaction checklist. Death Studies, 25(1), 1-32. Klass, P.R. Silverman, & S.L. Nickman (Eds.). (1996). Continuing bonds: New understandings of grief. Washington, D.C.: Taylor & Francis. Kübler-Ross, E. (1969). On death and dying. New York: Macmillan. Jordan, J., & Neimeyer, R. (2003). Does grief counseling work? Death Studies, 27(9), 765-786.

BEREAVEMENT COUNSELING 15 Mallon, B. (2011). Working with bereaved children and young people. London: Sage Publications. Monroe, B. & Kraus, F. (2010). Brief interventions with bereaved children. Oxford: Oxford University Press. National Alliance for Grieving Children (2012). National poll of bereaved children and teenagers. Retrieved from: http://www.childrengrieve.org/national-poll-bereavedchildren-teenagers Neimeyer, R. (1999). Narrative strategies in grief therapy. Journal of Constructivist Psychology, 12(1), 65-85. Ross, D. & Hayes, B. (2004). Interventions with groups of bereaved pupils. Educational and Child Psychology, 21(3), 95-108. Silverman, P.R., & Nickman, S.L. (1996). Children s construction of their dead parents. In D. Klass, P.R. Silverman, & S.L. Nickman (Eds.), Continuing bonds: New understandings of grief (pp. 73-86). Washington, D.C.: Taylor & Francis. Silverman, P.R. & Worden, W.J. (1992). Children s reactions in the early months after the death of a parent. American Journal of Orthopsychiatry, 62(1), 93-104. Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197-224. Wilson, D. L. (1994). An outcome study of a time-limited group intervention program for bereaved children (Doctoral dissertation, Washington State University). Retrieved from http://search.proquest.com/docview/304138287?accountid=14244 Worden, J.W. (1991). Grief counseling and grief therapy: A handbook for the mental health practitioner. London: Routledge.

BEREAVEMENT COUNSELING 16 Worden, J.W. (2009). Grief counseling and grief therapy: A handbook for the mental health practitioner, fourth edition. New York: Springer Publishing Company.

BEREAVEMENT COUNSELING 17 Appendix A Hogan Grief Reaction Checklist This questionnaire consists of a list of thoughts and feelings that you may have had since your loved one died. Please read each statement carefully, and choose the number that best describes the way you have been feeling during the two week, including today. Circle the number beside the statement that best describes you. 1 = Does not describe me at all 2 = Does not quite describe me 3 = Describes me fairly well 4 = Describes me well 5 = Describes me very well 1. My hopes are shattered 1 2 3 4 5 2. I have learned to cope better with life 1 2 3 4 5 3. I have little control over my sadness 1 2 3 4 5 4. I worry excessively 1 2 3 4 5 5. I frequently feel bitter 1 2 3 4 5 6. I feel like I am in shock 1 2 3 4 5 7. Sometimes my heart beats faster than it 1 2 3 4 5 normally does for no reason 8. I am resentful 1 2 3 4 5 9. I am preoccupied with feeling worthless 1 2 3 4 5 10. I feel as though I am a better person 1 2 3 4 5 11. I believe I should have died and he or she 1 2 3 4 5 should have lived 12. I have a better outlook on life 1 2 3 4 5 13. I often have headaches 1 2 3 4 5 14. I feel a heaviness in my heart 1 2 3 4 5 15. I feel revengeful 1 2 3 4 5 16. I have burning in my stomach 1 2 3 4 5 17. I want to die to be with him or her 1 2 3 4 5 18. I frequently have muscle tension 1 2 3 4 5 19. I have more compassion for others 1 2 3 4 5 20. I forget things easily, e.g. names, 1 2 3 4 5 telephone numbers 21. I feel shaky 1 2 3 4 5 22. I am confused about who I am 1 2 3 4 5 23. I have lost my confidence 1 2 3 4 5

BEREAVEMENT COUNSELING 18 24. I am stronger because of the grief I have 1 2 3 4 5 experienced 25. I don t believe I will ever be happy again 1 2 3 4 5 26. I have difficulty remembering things from 1 2 3 4 5 the past 27. I frequently feel frightened 1 2 3 4 5 28. I feel unable to cope 1 2 3 4 5 29. I agonize over his or her death 1 2 3 4 5 30. I am a more forgiving person 1 2 3 4 5 31. I have panic attacks over nothing 1 2 3 4 5 32. I have difficulty concentrating 1 2 3 4 5 33. I feel like I am walking in my sleep 1 2 3 4 5 34. I have shortness of breath 1 2 3 4 5 35. I avoid tenderness 1 2 3 4 5 36. I am more tolerant of myself 1 2 3 4 5 37. I have hostile feelings 1 2 3 4 5 38. I am experiencing periods of dizziness 1 2 3 4 5 39. I have difficulty learning new things 1 2 3 4 5 40. I have difficulty accepting the 1 2 3 4 5 permanence of the death 41. I am more tolerant of others 1 2 3 4 5 42. I blame others 1 2 3 4 5 43. I feel like I don t know myself 1 2 3 4 5 44. I am frequently fatigued 1 2 3 4 5 45. I have hope for the future 1 2 3 4 5 46. I have difficulty with abstract thinking 1 2 3 4 5 47. I feel hopeless 1 2 3 4 5 48. I want to harm others 1 2 3 4 5 49. I have difficulty remembering new 1 2 3 4 5 information 50. I feel sick more often 1 2 3 4 5 51. I reached a turning point where I began to 1 2 3 4 5 let go of some of my grief 52. I often have back pain 1 2 3 4 5 53. I am afraid that I will lose control 1 2 3 4 5 54. I feel detached from others 1 2 3 4 5 55. I frequently cry 1 2 3 4 5 56. I startle easily 1 2 3 4 5

BEREAVEMENT COUNSELING 19 57. Tasks seem insurmountable 1 2 3 4 5 58. I get angry often 1 2 3 4 5 59. I ache with loneliness 1 2 3 4 5 60. I am having more good days than bad 1 2 3 4 5 61. I care more deeply for others 1 2 3 4 5

BEREAVEMENT COUNSELING 20 Appendix B Pre-Group Survey 1) Who was the loved one you lost, and what was their relationship to you? 2) When did you lose this person? 3) On a scale from 1-10, how much grief and sadness do you have when thinking about your loved one? 1 2 3 4 5 6 7 8 9 10 4) In addition to grief and sadness, what other feelings have you experienced in connection to the loss of your loved one? 5) What are some things that have been helpful to you when grieving? (what has made you feel better?) 6) What is your hope for your time in group with us (how could group be most helpful for you)? 7) Is there anything else that we should know before starting group?

BEREAVEMENT COUNSELING 21 Appendix C Weekly Question How has group been for you so far?

BEREAVEMENT COUNSELING 22 Appendix D Post-Group Survey 1) On a scale from 1-10, how much grief and sadness do you have when thinking about your loved one? 1 2 3 4 5 6 7 8 9 10 2) In addition to grief and sadness, what other feelings have you experienced in connection to the loss of your loved one? 3) What part(s) of group did you find helpful? 4) What did you DISLIKE about group? 5) What else should we know about your group experience?

BEREAVEMENT COUNSELING 23 Appendix E Journal Prompts (Hedke, 2009) 1. Besides group this week, when are the times that you notice a connection with your loved one who as died? 2. If you were to give advice to a person facing a similar experience, knowing what you know now about what is helpful and what is not, what might you tell them? 3. What were your loved one s moments of greatness in life? What would he or she say are your own moments of greatness? 4. Write a letter from your loved one to yourself. In it, please talk about the things you mentioned in the group. What does your loved one value and appreciate about you? 5. Who else shares your stories, love, and memories for your loved one?