Presenter A
Presenter B
Supporting
Students
Coping With
Ambiguous
Loss
Workshop Outline
Part 1- Ambiguous Loss

Loss and Trauma in Schools

Defining Ambiguous Loss
•
Type I
•
Type II

Rise in Occurrence

Factors Influencing the Risk of Trauma

Typical Response to Ambiguous Loss
Workshop Outline

Part 1- Continued


Developmental Variations
•
Infant and Preschool
•
School Age
•
Adolescent

Cultural Variations

Recovery as the Norm

Therapeutic Goals
10 minute Break
Workshop Outline

Part 2 - Supports Appropriate for School

Psychological Education

Social-Emotional Learning Curriculums
•

Cognitive Therapy
•

Benefits of Small Group Counseling
Sample Tools
Mindfulness
•
Sample Activities
Workshop Outline

Part 2- Continued

Bibliotherapy
•

Individual Crisis Counseling
•

Sample Script
Referrals for Outside Therapy
•

Sample Lesson Plans
Suicide Risk Assessment
Q & A session
Loss and Trauma



Loss is not an uncommon experience for children
Loss can be as traumatizing as witnessing abuse or
violence
Loss can lead to PTSD, associated with:
• Low academic achievement
• Depression
• Social maladjustment
(Bowlby, 1982; Nickerson, Reeves, Brock & Jimerson, 2009)
Defining Ambiguous Loss



Concrete Loss: when loss is absolute
• Death
Ambiguous Loss: mixture of absence and presence,
• Alzheimer’s Disease
Associated with lack of certainty, relationship
boundaries are ambiguous
(Bockneck, Sanderson & Brittner, 2009; Boss, 1999)
Type I Ambiguous Loss


Physically absent,
psychologically present
Psychological presence:
a person still has influence
on thoughts, emotions,
behaviors, identity and
unity of family
• Divorce/Separation
• Incarceration
• Deportation
• Deployment
• Foster Care/Adoption
(Boss, 2010; Fravel, Grotevant, &
McRoy, 2000)
Type II Ambiguous Loss



Psychological absence
combined with physical
presence
Psychological absence:
Cessation or alteration of
previously reciprocal
relationships
• Mental or physical illness
• Including exhaustion,
substance abuse
problems
Can be tied to Type I
Ambiguous loss of the
other parent
(Boss, 2006; Boss, 2010; Lee & Whiting,
2007)
Rise in Occurrence of
Ambiguous Loss


Political and economic changes
• Deployment
• Unemployment
• Incarceration rates increase
• Financial factors contributing to mental illness
Overall, students are more likely to be experiencing
ambiguous loss.
(Bockneck et al., 2009; Bruckner, Snowden, Subbaraman & Brown, 2010;
Harper, Jones, McKay & Espey, 2009; Rossen & Carter, 2011; United
States Census Bureau, 2010)
Factors Influencing Risk of
Trauma




Duration
Predictability
Internal factors
• Developmental stage
• Previous trauma
• Mental illness
External factors
• Availability of social support
(Boss, 2006; Brock et al., 2009; Nickerson, et al., 2009)
Responses to Ambiguous
Loss






Immobilization and
hopelessness
Blocked coping due to
uncertainty
Difficulty with transitions
and changes
Symptoms of anxiety and
depression
Great overlap with PTSD
Want clarity but also resist
information
(Ashbourne, Baker & Male, 2002;
Bockneck et al., 2009; Boss, 2010;
Lee & Whiting, 2007; Minnesota
Department of Human Services,
2010)
Developmental Variation:
Infant and Preschool


Normal reactions
• Separation anxiety
• Will gauge their
behavior based on
adult reaction
• Benefit from daily
routines
Warning signs
• Regression
• Confusion
• Night terrors
(Brock et al., 2009; Dowdney,
2000; Himebauch et al.,
2008)
Developmental Variation:
School-Age


Normal reactions
• Difficulty identifying and
expressing emotions
• Somatic complaints
• Increased irritability
Warning signs
• Regression
• Night terrors
• Obsessive retelling
• Acting-out behaviors
• Loss of interest in school
• Poor concentration
(Dowdney, 2000; Himebauch et al.,
2008)
Developmental Variation:
Adolescents


Normal reactions
• Very similar to adults
• More frequently
experience feelings of
guilt
• Look to peers for support
Warning signs
• Changes in energy level
• Poor concentration
• Loss of interest in school
• Emotional numbing and
withdrawal
(Ashbourne et al., 2002; Himebauch et
al., 2008; Nickerson & Nagle, 2004)
Cultural Variations




Dominant culture may have different norms for behavior
Sharing of emotion varies across cultures
Others may view self-expression as being self-indulgent
or disrespectful
Cultural variations should be considered when
evaluating warning signs
(Brock et al., 2009; Nickerson et al., 2009)
Recovery as the Norm





Most students will recover from loss
Independent coping skills develop
Self-reliance and resilience
Consider warning signs carefully to offer appropriate
level of support
Offering too much help can signal the wrong response
(Brock et al., 2009; Moos & Shaefer, 1986; NIMH, 2002)
Therapeutic Goals



Supports for concrete loss may not be appropriate for
ambiguous loss
Reconstructing identity
• Define family boundaries
• Normalize overlapping boundaries
• Identify positive family attributes
Normalizing ambivalence
• Acknowledging existence
• Coping with ambiguous related stress
(Boss, 2006; Boss, 2010)
Therapeutic Goals
Continued

Revising attachment
 Thinking dialectically (learn to balance opposing
ideas)
 Cling to hope while accepting change
 Organize memorial ceremonies and farewell rituals
 Build community connections
(Boss, 2006; Boss, 2010)
Supports Appropriate for
School

Tier 1

Tier 2

Tier 3
(Merrell, 2008)
Psychological Education

Provide informational documents and training to staff,
caregivers and students
• Inform about ambiguous loss
• Explain behavioral manifestations of grief and loss
• Make suggestions about when to refer
• Explore caregivers own strategies for coping
(Brock et al., 2009; Litz, Gray, Bryant & Adler, 2002)
Social Emotional Learning
Kimochis: Toys With Feelings Inside
Second Step: Skills for Social and Academic Success
Strong Kids: A Social and Emotional Learning Curriculum
The Incredible Years: Dina Dinosaur’s Social Skills and
Problem Solving Curriculum




Designed to teach emotional and social skills
Promote resilience
Strengthening assets
Increase coping skills
(Dodge, Rice & Grimm, 2010; Committee for Children, 2012; Merrell, 2008;
Webster-Stratton, 1990)
Benefits of Small Group
Counseling





Solution-focused
Learning to construct solutions rather than dwell on
problems
Important for ambiguous loss since there is not closure
Normalize reactions
Help each other identify positive coping skills
(Brock et al., 2009)
Cognitive Therapy
Interventions
1.
Develop awareness of emotions
2.
Awareness of how emotions vary
3.
Detecting automatic thoughts and beliefs
4.
Evaluating automatic thoughts and beliefs
5.
Replace negative thought with neutral/realistic thought
(Boss, 2006; Merrell, 2008)
Emotional Awareness
(Adapted from Gimpel & Holland, 2003)
Emotional Variance
(Adapted from Gimpel & Holland, 2003)
Detecting Automatic
Thoughts
What Happened?
How did you feel?
What were you
thinking?
(Adapted from Merrell, 2008)
Evaluating Thoughts
Magnifying Glass
Making small things and events seem bigger
than they really are.
All or Nothing Thinking
Looking at things in only extreme or opposite
ways (for example, thinking of things as being
never or always, black and white)
Tunnel Vision
Focusing on only the negative parts of things.
Predicting
Making guesses about what will happen in the
future without knowing for certain.
Blaming Myself
Blaming yourself for things that are not in your
power to control.
Pointing the Finger
Blaming others for actions or events that you
should take responsibility for
(Adapted from Merrell, Carrizales,& Feuerborn, 2007)
Replacing Thoughts
What is the
thought?
Mercedes just found
out her parents are
getting a divorce, she
thinks their divorce is her
fault since she is having
trouble at school.
What is the error in How can you think
the thought?
about it
differently?
Blaming Myself
Mercedes parents are
getting divorced
because they have
difficulties in their
relationship. It is not
Mercedes fault.
Olivia’s dad just left for
a tour in Iraq and she
tells her mom that he is
never coming back.
(Adapted from Merrell, 2008)
Worry Monster


Sometimes students worry about things they feel
nervous about. When you worry it just makes your stress
level worse, and all the energy that you focus on that
worrying is misspent.
Sample Activity




Have student rate his/her level of anxiety on a scale of 1 to 5
Set a timer for two minutes and tell them to worry
Have student rate his/her level of anxiety after the activity
Ask follow-up questions
(Adapted from Schwab, 2008)
Freeze Frame
Your Thoughts
Sample Activity: 4 Steps for Freezing your Thoughts
 Recognize your stressful thought
 Tell yourself to freeze that thought. You can do this in
whatever manner reminds you best, saying “Freeze” out
loud or imagining a freeze button on your personal remote.
 Replace your frozen thought with a warm and calming
thought.
 Repeat this warm thought to yourself out loud or in your
mind to melt the frozen thought away.
(Adapted from Schwab, 2008)
Mindfulness



Recognize and accept undesired
feelings as part of life
Focus on what can be done in the
present moment
Meditation and breathing
techniques can be used
Breathing Exercises

Effective in reducing generalized anxiety disorders, panic attacks
and agoraphobia, depression, irritability, muscle tension,
headaches, and fatigue
 Sample Activity: 4 X 4 Breathing
1. Model how to do the 4X4 breathing (inhale for 4 counts,
exhale for 4 counts, and repeat)
2. Practice taking multiple 4X4 breaths together
3. Follow up questions
• How did your body feel when you were doing the
breathing?
• What about after you had practiced a few times?
(Geneva Center for Autism, 2008)
Progressive Muscle
Relaxation


Excellent results have been found in the treatment of
muscular tension, anxiety, insomnia, depression, fatigue,
irritable bowel, muscle spasms, neck and back pain,
high blood pressure, mild phobias and stuttering.
Sample Activity: Muscle Squeeze Relaxation



Has students use their imagination
Example includes squeezing a lemon or playdough, biting
on a jawbreaker or ice cube, squishing sand between your
toes
Helpful for younger students
(Koeppen, 1974)
Visualization


Visualization is effective in treating many stress-related
and physical illnesses, including headaches, muscle
spasms, chronic pain, and general or situation-specific
anxiety
Activities:
 Metaphorical Images
 Favorite Place Visualization
(Davis, Robbins-Eshelman & McKay, 2000)
Bibliotherapy




Gives children comfort and
insight
Can normalize the ambiguous
loss experience
Books available about a
variety of topics, including:
deployment, separation, etc.
Check out the UNLV
Bibliotherapy Project website
for book recommendations
(Haeseler, 2009; Jack & Ronan, 2008)
Bibliotherapy Lesson Plan
Steps


Pre-reading Activity
•
Flip through picture book and guess theme
•
Read back of book
Guided Reading
•
Ask questions while reading

Post Reading Discussions

Reinforcement Activities
Bibliotherapy Lesson Plan


Appropriate for age: 12 and up
Book Summary: The book follows the story of
Katniss Everdeen, a sixteen-year-old who lives in
a post-apocalyptic world in the country of
Panem. Katniss has fended for her family after
the death of her father and the mental illness of
her mother. A new challenge arises as she is
chosen in the Hunger Games, an annual event
in which one boy and one girl from each district
of Panem is selected to participate in a
televised battle with only one survivor.

Sample Post-Reading Questions:
•
•
Why is Katniss so angry with her mother and what
does she fear her mother will do in the future?
Why do you think it is so hard for Katniss to trust
others?
Bibliotherapy Lesson Plan

Reinforcement Activities
• Katniss has a hard time accepting help,
but there are many people who are
there to support her during the difficult
situations she experiences. Draw a
web of people who support you.
• While Katniss fights through the Games
various memories and experiences help
to relieve her of the stress surrounding
the Games. Make a list of things you
do to relieve stress or identify positive
memories you can think of when times
are difficult.
Individual Crisis Counseling
1.
Establish psychological
contact
2.
Verify emotional
readiness to address
problems
3.
Identify and prioritize
problems
4.
Address crisis generated
problems
5.
Conclude and evaluate
attainment of ICI goals
(Brock et al., 2009; Brock, 2011)
Referrals for Outside
Therapy




When students do not appear to be responding to the
mental health interventions offered at school referrals to
outside agencies may be necessary
Ensure that past interventions and how the student
responded are documented
Get family members to sign an exchange of information
form in order to pass information on to the student’s
outside service provider
Keep updated contact information for outside agencies
to provide to family members as necessary
(Merrell, 2008)
Suicide Risk Assessment

Some students coping with ambiguous loss may be so
distressed that they consider suicide

To assess suicide risk trained school personnel should
•
Explore the plan
•
Find out if they have made preparations
•
Create an immediate protective action plan
•
Develop a suicide contract and/or follow-up planning
(Brock, 2011)
Questions and Answers
What questions about Ambiguous Loss do you have?
References
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Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University
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