Community College Grief Counseling Services: A National Survey of Grief Counseling Services for Counselors at. Community Colleges in the United States

Community College Grief Counseling Services: A National Survey of Grief Counseling Services for Counselors at Community Colleges in the United States by Gregory P. Bocchino Submitted in Partial Fulfillment of the Requirements for the Degree Doctor of Education, Counseling and Human Development Supervised by Professor Andre Marquis Margaret Warner Graduate School of Education and Human Development University of Rochester Rochester, New York 2008

ii Dedication I would like to dedicate my research in grief and loss in honor of my late grandfather, Salvatore Bocchino and my late grandmother Mildred Vera Ruberg. Their stories and life experiences provided me with a sense of purpose and meaning for which I will remain forever grateful for.

iii Curriculum Vitae Gregory Philip Bocchino was born in Staten Island, New York on July 10, 1971. He earned a Bachelor of Science degree in psychology from the State University of New York College at Oneonta in 1993. Gregory then received a Master of Science in Education with an emphasis in School Counseling also from the State University of New York College at Oneonta in 1995. He then went on to pursue post graduate coursework at St. Johns University, Queens, NY to fulfill the state certification requirements in school counseling. In 1997, Gregory was the recipient of New York State K-12 School Counselor Permanent Certification. In 2008, Dr. Gregory Bocchino passed and completed all the requirements for his Doctor of Education in Counseling and Human Development degree at the University of Rochester. Gregory worked as both a Substance Abuse Prevention and Intervention Counselor, in addition to being a Project Future Counselor for the New York City Board of Education from 1995-1998. He then worked for the State University of New York as a Career Development Counselor at Corning Community College and Monroe Community College from 1998-2007. Gregory currently coordinates the career development services for the College of Arts and Sciences at the University of Louisville, KY.

iv Acknowledgements I appreciate the opportunity to acknowledge some of the many people who have encouraged me and supported my professional endeavors throughout my academic career at the University of Rochester. I would first like to thank my advisor Dr. Andre Marquis for his instruction and guidance throughout my doctoral research. Thank you also to Dr. Doug Guiffrida and Dr. Judith Fonzi for their support and contributions to my personal and professional development as an academician. I would also like to extend a personal thank you to Dr. Howie Kirschenbaum for his advisement and feedback in my doctoral education and development of my research proposal. A personal thank you to both Dr. Fred Jefferson and Dr. Jerry Rubenstein at the University of Rochester as they had a significant impact on me and helped me grow and stretch as a human being and as a professional counselor. I would also personally like to thank Brenda Grosswirth, for her kindness and her willingness to always provide assistance, as she was instrumental in making my experience at the Warner School a very positive and rewarding one. Second, I would like to extend a general thank you to the many colleagues that have provided me with support and encouragement along the way, including, Nancy L.E. Andrews, Christopher Belle Isle, Sherry, Sweet, Michelle Mayo, Holly Wynn-Preische, Elaine Goldstein, and Anne White. Lastly and most importantly I would like to thank my family. Thank you to my parents, Vincent and Corene, for their constant support and love. It was solely because of them that I was able to attend two summer research institutes at the National Center for Death Education in MA to further my expertise and research in grief and loss. Thank you also to my brothers Dr. Christopher and Dr. Thomas, as your words, knowledge and insight has helped me persevere and persist in my doctoral studies.

v Abstract Empirical research on the grief experience of undergraduates in the United States has not traditionally focused on the experiences of students and counselors providing services at community colleges. Six hundred and ten counselors were surveyed to gain a better understanding of the training and education in grief of the professional counseling staff at national community colleges. The type and frequency of counseling services and resources (individual counseling, group counseling, workshops, seminars, techniques and strategies used, assessments, printed materials, etc.) that are provided to community college students experiencing issues of grief and loss, and representative descriptive data from a sample of counselors about the nature and scope of these services were examined. Counselors at community colleges reported the most frequent grief and loss situations that they have counseled students for in the past 5 years were the following: loss of relationship (84.5%), dropping out/withdrawing from school (83.7%), financial/money problems, loss of income (79%), loss of job/employment (76.9%), divorce (77.5%), and accidental deaths (motor vehicle, drowning, fire, etc.) (73.1%). However, findings suggested that very little grief counseling was provided at national community colleges; 44% of counselors indicated that they provided grief counseling only a few times a year. In addition, most respondents had very little graduate education in grief courses (equivalent to that of less than a 3 credit course) and a limited knowledge base of grief, grief counseling, and theories and models of grief deriving from formal graduate education. Fifty seven percent received less than 4 hours of professional development and training in grief counseling over the past 5 years. Additional research is needed to examine the state of personal counseling services at national community colleges and the training and education of the counselors in order to better address the needs of bereaved students.

vi Table of Contents Chapter Page I THE PROBLEM/INTRODUCTION 1 Definition of Terms 2 Statement of the Problem 3 Purpose of the Proposal and Research Questions 9 II REVIEW OF THE RELATED LITERATURE 12 Introduction 12 Literature Review 12 Characteristics of Grief 13 Factors that Influence Grief 14 Grief in Adolescence and Later Adolescence 15 Models of Grief Theory 18 Attachment Phase Model of Grief 19 Stage Model of Grief 21 Task Model of Grief 23 Criticism of Traditional Grief Theories & Contemporary Theoretical Approaches 25 Discussion of Significant Empirical Research 28 Disenfranchised Grief 31 Grief Work 33 Theoretical Framework of Grief Counseling 34 Philosophical Perspective 35

vii Spiritual Perspective 35 Psychological Perspective & Coping 37 Sociological Perspective, Grieving Styles & Rituals 39 Physical Perspective 42 Clinical Tools for Assessment of Grief 43 Qualitative Grief Assessment 45 Counselor Aspects and Training/Education 46 Grief Counseling & Grief Therapy 48 Group Counseling 52 Summary 53 III METHODOLOGY AND PROCEDURES 54 Research Objective & Research Design 54 Sample 55 Sampling Plan 55 Research Instrument 56 Data Collection Procedures 59 Data Analysis & Monitoring 59 Data Storage & Confidentiality 60 Summary 60 IV RESULTS 61 V CONCLUSION 95 References 116 Appendix 128

viii Table # List of Tables Page 1 Survey response rate 63 2 Community college counselor demographics 67 3 Student enrollment at national community colleges 69 4 Survey response count by state 70 5 Community college counselor job responsibilities 72 6 Importance of grief services at your community colleges 73 7 Community college counselor training or graduate education in grief counseling 77 8 Familiarity with grief theorists/researchers 79 9 Counselor awareness of models of grief 80 10 Counselor usage of models of grief 81 11 Services for grieving students at national community colleges 83 12 Informational grief resources for students at national community colleges 86 13 Situations where students seek grief counseling at national community colleges 84 14 Frequency of counseling services provided at national community colleges 85 15 Frequency of grief counseling regarding the death of a loved one 86 16 Counseling strategies and techniques used with grieving students 88 17 Grief education services performed by counselors at national community colleges 89 18 Counselor perception of importance of grief services at national

ix community colleges 90 19 Marketing and outreach for grief services 91 20 Themes of counselors final comments 94

x Appendix Appendices Page A Education 128 B Main Services Provided as Part of Community Counselor Job C D Responsibilities Training or Coursework in Grief Counseling Grief Researcher or Theorist Community College Counselors are Most 130 139 Familiar With 143 E Awareness/Usage of Models of Grief 144 F Services for Students Who Experience Issues of Grief 146 G Informational Resources for Students Regarding Grief 150 H Grief Counseling Related Situations at National Community Colleges 152 I Counseling Situations Regarding the Death of a Significant Person or Loved One 155 J Strategies, Techniques and Materials Utilized in Grief Counseling 156 K Outreach and Marketing Strategies for Grief Services 157 L Additional Comments on Grief by Counselors at Community Colleges 162 M Information Letter/Email 190 N Follow-up Letter/Email 191 O A National Survey of Grief Counseling Services for Community College Counselors 192

1 Chapter I Introduction There has been an increase in attention and focus on grief in research over the past 25 years, including its effects and characteristics and the range of intervention strategies used in grief counseling (Stroebe, Hansson, Stroebe, & Schut, 2001). Grief is the process by which we adjust to loss. Loss experiences such as death, divorce, separation, illness, relocation, and aging are present at some point in the lives of all human beings. How we handle and manage these loss experiences provide implications for counseling professionals in the practice of grief counseling and therapy. Experiencing a significant loss, such as the death of a loved one, may be one of the most overwhelming and consuming life events. Research has primarily focused on the grief of those experiencing the loss of a parent, grandparent, or sibling in a K-12 context. Current research also explores death experiences in the lives of undergraduate students mostly at large four year universities in the United States. Many adolescents experience grief for the first time during later adolescence as an undergraduate student in college. The college experience itself may cause difficulty in the lives of students, stirring feelings of anxiety, depression, and self doubt. As undergraduate students continue to develop their identity and a clearer sense of direction, they are also struggling with becoming more autonomous and independent. College students are confronted with postsecondary transitional issues including a variety of academic concerns (study skills, time management, career planning) and personal concerns (substance abuse, relationship issues, dealing with grief and loss). Undergraduates may not understand their grief or have appropriate coping mechanisms to manage their grief, and therefore seek counseling. According to Aubrey (1988) grief issues are often not the presenting problem when college students begin the

2 counseling process. However, grief issues will typically surface when background information is obtained in later counseling sessions. Definition of Terms Multiple definitions occur throughout the literature and research for the terms grief, loss, bereavement and mourning. According to Bailey, Dunham, and Kral (2000), there is considerable vagueness and ambiguity in the literature as to what exactly is meant by the term grief. For most of the 20 th century, grief and bereavement were defined as a process of letting go of one s attachment to the deceased person, moving on with one s life, and gradually recovering from sadness and depression as to return to normal behavior. The term bereavement is understood as referring to the objective situation of having lost someone significant (Stroebe, et al., 2001), the reality of loss. Bereavement is typically associated with an intense response or reaction of distress. This usual response or reaction to bereavement is termed grief, and is defined as a primarily emotional (affective) reaction to the loss of a loved one through death (Stroebe, et al., 2001). In addition to the affective quality, grief may also include physical, cognitive, and spiritual domains. Loss refers to being deprived of someone or something to which one was attached or previously possessed. Secondary loss may follow as a consequence of the primary loss (e.g., loss of income, loss of hopes, loss of faith). Grief can also be the result of incidents of loss not involving death such as loss of job, loss of a limb, loss of status, loss of marriage/relationship etc. Relationship difficulties and breaking-up are among the most common reasons that college students seek counseling services for (McCarthy, Lambert, & Brack, 1997). In grief, we are responding to the loss. Many people experiencing issues of loss and grief have no pathological indicators and experience a normal grief without the assistance of professional counselors or therapists

3 (Stroebe, et al., 2001). However, bereavement has been identified as a risk factor for the development of mental-health related disorders including anxiety and depression (Kendrick, 1999) causing some to seek therapy and grief counseling. Mourning refers to the ways our societies and cultures tell us how to behave in response to loss through death, including prescribed practices during the funeral period and, in some cultures, for a year or more thereafter (Attig, 1996). In Western societies, there is a traditional basic way to grieve, that is by a means of an emotional response. Societies and cultures socialize us regarding how to behave in response to loss, especially through death when there is a prescribed set of practices and cultural norms (Attig, 1996). But what role does grief counseling have in this? According to Attig (2003), grief is about the reality of taking in the loss, adjusting one s emotions, modifying behaviors, and making efforts in response to the grief. Many grievers seek out counseling because they are not prepared to deal with the intensity of their emotions or do not understand the importance of accepting and expressing them (Rando, 1984). Statement of the Problem Empirical research on the grief experience of undergraduates in the United States has focused primarily on those at 4 year institutions, typically large universities with enrollments of more than 20,000 students, even though according to the US Department of Education (Adelman, 2005), nearly half of all undergraduate students are enrolled in community colleges. Among them are millions of full-time students, many from low-income families, and most of traditional college age (18-24). According to Balk (1997) grief is more prevalent in the lives of college students than many realize and is an important issue on college campuses. Balk conducted surveys with undergraduate students at Kansas State University regarding such topics as the meaning of death, personal thoughts about one s own death, and personal experiences with

4 the death of family members and friends. The purpose of his survey was to identify the prevalence of death and bereavement in the lives of KSU students. His findings demonstrated that at any given point in time, 25-30% of students at KSU are within the first 12 months of the death of a family member or of a friend. According to Balk (2001) research with students conducted at the University of Arizona, Oklahoma State University, and the University of Memphis have also indicated that 22-30% of those college undergraduates are in the first 12 months of grieving the death of a family member or of a friend, and 35-48% are in the first 24 months. This research suggests a significant percentage and numbers of students are experiencing issues of grief and loss at large 4-year university campuses and are substantial enough to be an area of concern for counselors at community colleges. College campuses may not be the most sympathetic environment for grieving students and they may even be disenfranchising them, where issues of student grief often go unrecognized by the college community. Cohen (1996) focused her research at Syracuse University on the study of college students grief responses regarding death and non-death losses. Participants reported that non-death losses were just as emotionally distressing as death losses and that nondeath losses received less recognition on-campus and a lower incidence of help seeking behavior on behalf student grievers. Whatever the nature of the student s loss, the college atmosphere is rarely conducive to grieving, or even tolerant of the resolution of grief (Janowiak, Mei-Tal, & Drapkin, 1995). Thus, college counselors can potentially play a critical role in assisting students with managing and processing their grief experiences. A common notion is that talking about one s grief is both constructive and helpful. Balk s (2001) survey revealed that talking was utilized as a coping strategy for students. However, he also noted that students indicated that most persons around them seemed

5 uninterested and or uncomfortable when the death was mentioned. According to Balk, bereaved students found few, if any, persons in the university willing to discuss the death, to acknowledge the importance of the event in the student s life, or to recognize the significance for the griever of the person who died. Balk claims that there is a disparity between non-bereaved students understanding of what grief entails and their actions when with grieving students. Similarly, Tyson-Rawson (1996), who studied college females bereaved over a father s death, reported that none of the women in the study felt that they could share their bereavement with all of their peers. A limitation cited in this study was that the information found may not be applicable to all colleges and universities; hence further exploration is warranted in different types of college settings, including community colleges. A gap in the literature clearly exists about these issues at community colleges and there needs to be empirical exploration regarding grief support for bereaved students here. Wrenn (1999) pioneered institutional preparedness for universities to deal with student deaths, estimating that deaths on US campuses annually range from 5,000 to 18,750. In a second research study related to the grief of undergraduate students, he noted that they seldom consider the counseling center on campus as a place to go to for counseling services related to their grief over a death. Wrenn (1999) examined the needs and wants of bereaved college students in his research and identified the following needs of grieving students: they need to know where to go on campus for support and information when a death occurs; they need assistance with adjusting to a college environment that seems unchanged by their grief experience as they may feel alienated and that no one understands their situation; they need to know how to respond to people who ignore their grief, or who tell them they need to get on with life, and that it is not good for them to continue to grieve; students need to know that they are dealing with a death

6 normally; and they need to know how to address faculty members who may be skeptical in allowing grieving students extra time to make up late work, a missed exam, or to complete an incomplete class. Wrenn (1999) concluded that institutions of all sizes to be prepared in dealing with student grief issues and no such study exists regarding grief counseling services and resources provided to students at community college. The Association for University and College Counseling Center Directors surveys its member institutions annually, which is limited to only bachelor and graduate degree granting institutions. The AUCCCD in coordination with the International Association of Counseling Services, the accreditation association for university and college counseling services, have been involved in an empirical investigation of counseling services and related issues on campus on an annual basis since 1981. The purpose of this survey is to stay abreast of current counseling trends with ready access to the opinions and solutions of colleagues to problems and challenges in the field (administrative, ethical, clinical, etc.) (Gallagher, 2006). Most recent studies indicate an increase in the prevalence of disruptive, life threatening problems which has prompted counseling centers to provide additional psychotherapeutic service to the campus community. There is no such survey that represents data from counseling centers at national community colleges. The studies by Balk and Wrenn demonstrate the prevalence of grief on college campuses. However, research suggests that professionals voice a great deal of discomfort in working with the bereaved, proclaiming that they are unsure of how to respond (Kirchberg & Neimeyer, 1991). Many graduate programs in the counseling psychology and medical professions include death and grief education by integrating relevant content within required courses rather than offering separate death and dying courses. Elective death education course were more common in

7 medical and nursing programs in the United States, Canada, and the United Kingdom. According to Dickinson, Sumner & Frederick (1992), required death education courses were rarely reported. Kirchberg, Neimeyer and James (1998) investigated beginning counselors levels of discomfort and ability to respond empathically with clients presenting issues of death or loss. Their research found that neophyte counselors were more distressed by such presenting problems of loss and death than they are by other serious issues. They suggested further research in studying the impact of grief and loss counseling on both grief counselors and those they serve. Information about the grief education and training of counselors working at community colleges in the United States is not known due to a lack of descriptive data related to their job responsibilities. Even if campus counseling centers offer specific grief services, they may not have counselors who are properly trained in grief theory, assessment, and counseling strategies or understand the special issues that pertain to grief. Current CACREP and CSWE educational policies limit the scope and amount of grief counseling content that is covered in accredited counselor and therapist graduate degree programs. CACREP is an independent agency recognized by the Council for Higher Education Accreditation to accredit master's and doctoral degree programs in: career counseling, college counseling, community counseling, gerontological counseling, marital, couple, and family counseling/therapy, mental health counseling, school counseling, student affairs, and counselor education and supervision. CACREP develops standards and procedures for professional education in counseling and related graduate education programs. Standards are written to ensure that students develop a professional counselor identity and also master the knowledge and skills to practice effectively. The proposed revisions to the 2008 CACREP Standards make no mention of grief counseling as

8 a knowledge or skills/practice requirement. The Council on Social Work Education is (CSWE) is a nonprofit national association representing more than 3,000 individual members as well as graduate and undergraduate programs of professional social work education. Founded in 1952, this partnership of educational and professional institutions, social welfare agencies, and private citizens is recognized by the Council for Higher Education Accreditation as the sole accrediting agency for social work education in this country. After a review of the Council on Social Work Education s educational policies and accreditation standards, there is no specific indication of issues of grief, loss, bereavement, or death and dying as requirements; at best their educational requirements are vague. No survey data has been found that describes community college counselor training in the area of grief and loss counseling. According to Durodoye, Harris, & Bolden (2000), community college counselors will continue to be confronted with shrinking budgets, rising enrollments, and increasing demands for personal counseling services. Keim (1988) surveyed 458 counselors working at American 2- year colleges to understand more about their roles, functions, and job responsibilities, in addition to demographic information on community college counseling center data, counselor-student ratios, professional activities, time spent on college functions, and two-year college counseling trends. She found that counselors are highly educated, with 77% possessing master s degrees and 15% with doctorates in counseling, guidance, and or counseling psychology. However, Keim (1998) also reported that two-year college counselors spent more than half of their time on academic and educational counseling (45%) and only 11% of their time doing personal counseling; counselors expressed a preference to do more personal counseling. Personal counseling is an important function and service of the 2-year college and must be supported in a reasonable manner.

9 Similar studies also examined actual and ideal counselor time spent on various job duties at New Jersey community colleges (Drakulich, 1992); California community colleges (ASCC, 1997); and at Virginia community colleges (Short, 1998), all of which suggested a need for more time for personal counseling services and research opportunities at community colleges, and less time on academic advising. As a result, we may not know much about the grief and bereavement phenomena experienced by students at community colleges or the prevalence and type of counseling services available to students on these campuses, but we do know that personal counseling is an expressed need. Counseling services at community colleges have historically been marginalized, under-funded, and under-researched, and so there is so much to learn about guidance and counseling in community colleges (Grubb, 2001). A review of the literature suggests that current undergraduate students are experiencing more grief related issues and have been seeking out counselors on campus more often for support. The events of September 11 th, student tragedies, and an influx of students seeking psychological assistance, along with the increasing prevalence of disruptive, life threatening problems is prompting colleges to provide increased counseling services. Greater effort to collect data on community college campuses and those counselors that participate in research can play a significant role in promoting and initiating research within community college settings. Purpose of the Proposal and Research Questions The purpose of this research is to gain a better understanding of the grief counseling services that are provided at national community colleges and to gain representative survey data from a sample of counselors about the nature and scope of these services. In addition, it also serves to add to the limited survey data already in existence regarding community college counseling centers.

10 Community colleges typically have open admissions policies allowing higher education access to potentially any student (high school graduates, high school dropouts, returning adult students, GED recipients, etc.). As a result, many community colleges have increasingly diverse student populations (minorities, international students, students with disabilities, nontraditional students over the age of 25, married students with families, single parents, academically and economically disadvantaged students, first generation college students, etc.). There is need for further purposeful specification of developmental influences on the nature and implications of services for a grieving diverse student-body at community colleges. A national survey of 200 colleges and universities assessed how 4-year institutions of higher education responded to the needs of students that lost a parent by death (Erickson, 1991); she cited that additional research was needed specifically at community colleges, as her study failed to address two year institutions. This survey is being conducted to observe the extent to which grief support services are offered and provide needed knowledge in the field of grief counseling at national community colleges. While the review of literature provided very little information specifically on grief related services at community college counseling centers, it did provide some information about counselor roles and educational backgrounds. This study will address the following issues in the survey research questions as follows: (1) What grief counseling services are being offered to students at community colleges across the United States (individual counseling, group counseling, workshops, seminars, techniques and strategies used, assessments, resources, etc.); (2) To what extent are these grief counseling services being offered?; (3) What are the frequencies and the types of grief related issues that students are being seen for by community college counselors (death of a loved one, parental divorce, loss of relationship, etc.)?; and (4)

11 What is the educational background and training in grief of the counselor providing services? This research seeks to report information about the current job functions of community college counselors and statistically represent their experience in working with grieving students. It also seeks to provide more knowledge about the counseling services they may be providing (individual or group counseling, specific interventions, strategies and techniques) and data about the type of grief and frequency of occurrences with the undergraduate community college student population (parental death, loss of relationship, divorce, etc.). The purpose of the study is to examine trends in counseling centers at national community colleges regarding grief related services and resources as reported by the counselors. Far less is known about what is being done with grieving students at community colleges and the counselors providing the services. Survey information will be gathered, studied, and published to further create dialogue, and to explore current practices and community college counseling services, and to add to the professional grief literature. In addressing the above questions, this survey also intends to help inform community college administrators and policy makers on these issues so they can make better informed policy and staffing decisions.

12 Chapter II Introduction A review of the literature focuses on the following areas: the multiple theories and models of grief, theoretical frameworks of grief counseling and intervention strategies that are utilized with individuals experiencing grief, a delineation of the characteristics and the types of grief, and information on late adolescence, and research with undergraduate students in relation to grief and counseling. Understanding the theories and counseling intervention strategies associated with grief will provide a framework for understanding the basis of the information revealed by the survey participants. Literature Review Grief is typically referred to as the reaction or emotional response to loss, and is an experience that is common to all. According to the National Vital Statistics Report (2008) a total of 2.4 million deaths occur in the United States annually and it is clear that many in our society find themselves in a state of grief. The death of a loved one is a profoundly disruptive event that invariably initiates the process of grief in an individual (Bailey, et al., 2000). Throughout the past century, grief work has been the major theoretical construct to explain how people cope with bereavement (Stroebe, 2001). Psychologists, researchers, physicians and counselors have studied grief and its effects for more than a century. According to Sieber (1990), because loss and grief reactions are multi-dimensional and highly individualized, there have been divergent approaches to examining the experiences and response to loss. Therefore, an accurate understanding of each individual s grief is important for assessment and treatment purposes. A brief overview of characteristics of grief, the research in the field of grief, models of grief theory and grief counseling strategies and interventions is presented in Chapter II.

13 Characteristics of grief. Typical manifestations of grief are known due to an extensive research base and observations of the consequences on a persons mental and physical health due to loss and grief. According to Ringler & Hayden (2000), short term results of bereavement include: shock, numbness, sadness, anger, insomnia, loneliness, fright, survivor guilt, nightmares, suicide ideation, fears of own death, drug abuse, and problems at school or work. The term normal grief is typically used when referring to the behaviors and feelings that are common after a loss (Worden, 1991). Review of the literature shows consensus among descriptions of the so-called normal grief reaction (Shucter & Zisook, 1993; Stroebe, Stroebe, Schut, & van den Bout, 1998). The list of possible behaviors following grief is both extensive and varied. The most common categories that are utilized to characterize grief reactions include feelings, physical sensations, cognitions, and behaviors. The following dimensions and characteristics can describe, identify, and be applied to grief (Stroebe et al., 2001): (a) affective manifestations of grief include depression, despair and dejection, anxiety, guilt, anger, sadness, jealousy, fear, shame, relief, powerlessness, hostility, anhedonia (the loss of interest or pleasure in daily activities) (Morreau, 1997), and loneliness; (b) behavioral manifestations of grief include agitation, fatigue, crying, outward expression of emotion, physical activities, increase in alcohol/smoking, and social withdrawal; (c) cognitive manifestations of grief include preoccupation with thoughts of the deceased, lowered self-esteem, self reproach (remorse), helplessness, hopelessness, a sense of unreality, fantasizing, apathy, dreams, confusion, problems with memory/concentration, and attempts to understand the loss; (d) physiological and somatic manifestations of grief include low appetite, sleep disturbances, headaches, muscular aches, nausea, tenseness, energy loss and exhaustion, somatic complaints, physical complaints similar

14 to those the deceased endured, and susceptibility to illness and disease; and (e) spiritual manifestations of grief include searching for meaning or making sense of the situation and a change in spiritual behaviors, feelings, or beliefs. Further, contemporary grief is not to be understood as a specific state, but rather as a grieving process (e.g. involving ever changing reactions) that evolves over a period of time (Bailey, et al., 2000). Past theorists purported a specific timeframe of grief, some of which will be subsequently explored in the models of grief in this chapter. Factors that Influence Grief Many factors influence the nature of a grieving. Rando (1984) identified three categories or factors that influence the grief process of all individuals; these include physiological, social, and psychological factors. Physiological factors influence functions such as sleep patterns, physical health and diet. Individuals with debilitated physical functioning will have a more difficult time meeting the demands of grieving. Social factors greatly influence the grief process, including educational background, support system, as well as an individual s religious, cultural and ethnic background. Rituals generate social support and offer opportunities to find meaning (spiritually/philosophically) as it is applied to an individual s loss (Doka, 2000). Psychological factors also play an important role in the grief process. Various dimensions of one s psychological development, gender, past experience with death, personality, idiosyncratic meanings of the loss to the individual and mental health status all impact the grief process. Bereaved individuals who had a more positive relationship with the deceased individual reported more intense grief than those with a less positive one (Moss, Rubinstein, & Moss, 1997). Additional factors that may influence an individual s grief include (Muller & Thompson, 2003): (a) the bereaved person s unique relationship with the deceased; the quality of the relationship,

15 (b) the circumstances surrounding the death, the type of death, (c) reactions to previous loss, (d) historical approaches to grief and bereavement, (e) the personality traits and coping behaviors of the griever; personal vulnerability, (f) social support and nature of the family system, (g) cultural norms and religious beliefs and practices, (h) the ability to express emotions and seek/receive help, and (i) age, general health, and lifestyle practices. These variables account for some of the variability in the duration and experience of grief (Muller & Thompson, 2003); however the relationship to the deceased is the greatest influence on an individual s emotional response to the loss (Meshot & Leitner, 1993; Rubin, 1992). Research in this field has uncovered many factors that influence an individual s reaction to loss. Murray (2001) described factors associated with the loss, similar to Rando s proposed factors that influence grief. According to Murray (2001), internal factors that influence grieving include: age, gender, previous mental health effects, mental capacity, individual coping behaviors, attributional style (self-blame or dealing with guilt), resilience, spirituality, and physical health. Grief in Adolescence and Later Adolescence The period of later adolescence traditionally extends from the ages of 18 to around 22 years of age (the age group of traditional college students). Of significance at this age is the separation from home and financial independence, the typical markers that indicate the passage from later adolescence to young adulthood (Balk, 1995). The transition into adulthood may be viewed as a loss of childhood. According to Fleming and Adolph (1986), the phases of adolescent development can be linked with that of grief related issues and have implications based on individual cultural ethnicity, religious or non-religious affiliations, gender, and class. Research surveys in the late 1990 s, with representative samples of undergraduate

16 students at large universities (Kansas State University, the University of Arizona, Oklahoma State University, and the University of Memphis) revealed that 22-30% of undergraduates were in the first 12 months of grieving the death of a family member or a friend. When the time-frame was expanded to 24 months the percentages increased to 35-48% of students who were grieving (Balk, 2001). Bereavement requires adolescents to utilize coping skills (behaviorally, cognitively, and affectively) with issues that vary according to the maturational phase of adolescence. Fleming and Adolph (1986) identified five core issues to assist college students with coping, these included: (a) trusting in the predictability of the event; (b) gaining a sense of mastery and control; (c) forging relationships marked by belonging; (d) believing the world is fair and just; and (e) developing a positive self image (Fleming & Adolph, 1986). Addressing these core issues would allow for a multidimensional counseling approach to grief. Fleming and Balmer (1986) suggested that later adolescents would be more likely to share and talk with friends about grief because they are not as self-conscious or worried about self image as their younger counterparts. Fleming and Balmer (1986) observed that younger adolescents, reticent to speak about grief, are vulnerable to psychosomatic symptoms such as headaches and stomach pain, and indicate problems associated with forging relationships and achieving a sense of belonging. Developmental maturity, in both thinking and identity formation, enables older bereaved adolescents to discuss their grief with peers (Balk, Tyson-Rawson, & Colletti-Wetzel, 1993). Fleming and Balmer (1986) implied that maturity reduces denial as an ongoing coping strategy for these later adolescents, which in turn may produce more conscious psychological distress. Tyson-Rawson (1996) engaged in a grounded theory analysis of the responses of female college students whose fathers had died. More than half of her small sample indicated a

17 continuing presence of their father in their lives. Adolescent grief was examined within the contexts of both family and peer relations and it was found that few peers were willing to talk with those grieving female college students about bereavement or about their fathers. Balk (2001) also observed that few bereaved students found peers willing to listen or be present when stories of grief surfaced. In a study of non-bereaved students at Bowling Green State University (Vickio, Cavanaugh, & Attig, 1990) students identified attentive listening and personal presence as being the most helpful actions others can provide for grievers. Other research studies indicated, however, that students are being cut-off from both peer support and university support. Bereaved students found few if any persons on the university campus willing to mention a death to, acknowledge the importance of this event, or to recognize the significance of their grief experience (Balk, 2001). Wrenn (1999) noted that one of the central issues for grieving college students is learning how to respond to people who ignore their grief, or how to respond to people who tell them that they need to get on with life and that it is not good for them to continue to grieve. In addition, Wrenn (1999) stated that one of the primary concerns of bereaved students is where to go on a university campus for support and information/resources when a death occurs. Survey research provides sufficient evidence of undergraduate students having grief and loss experiences at this stage in their lives at four year universities. A gap in the research exists and indicates a need for further knowledge and information on grief with an overlooked sample of the higher education population, those at community colleges. Assessing the prevalence of bereavement experiences with a general college student populations has provided initial information necessary to develop intervention programs and outcome studies (Stroebe et al., 2001). Wrenn (1999) was instrumental in identifying several needs of grieving students to help address further needs on campus; they include the following: (a) a specific place on campus

18 readily recognized as a place to go for (grief) support and information; (b) a campus where students are able to adjust to a college environment that seems unchanged by death; (c) grief education and information (students need to know how to respond to people who ignore their grief, and what normal grieving entails); and (d) faculty need to allow for late work, make-up exams, or an incomplete for a class. Erickson (1991) conducted a national survey of 200 colleges and universities in order to assess how institutions of higher education responded to the needs of students that lost a parent by death. She stated that additional research was needed, specifically at community colleges, as her study focused on four-year colleges and universities and failed to address any two year institutions. David Balk has done a substantial amount of research on grief and bereavement issues among college students at very large Midwestern universities throughout the 1990 s. His findings suggested that bereaved students found few if any persons at a university willing to mention the death to, or acknowledge the event, or to even recognize the significance of their grief (Balk & Vesta, 1998). His research neglected to include or consider community colleges and issues of grief, and the implications on its students. Several studies also focused on shortterm grief and loss therapy groups at four-year institutions (Berson, 1988; Janowiak, et al., 1995; Toth, 1997) but not at community colleges. Models of Grief Theory Many theories exist that explain the characteristics, processes, and behaviors of grief. Initially, part of the difficulty of fitting grief into a theoretical framework is that it originated from a descriptive disease model, whereas grief is a process, not a state (Parkes, 1998). Most theories of grief attempt to address several core issues that seem to be characteristic of grievers, and whether the behaviors associated with grief are universally observed, or tempered by a

19 multitude of individual and cultural differences. According to Parkes (1998), grief is not a set of symptoms that start after a loss and then gradually fade away. Therefore, an accurate theoretical understanding of grief is highly important for assessment and treatment purposes. Theories of grief emerged from the notion that grief could be best understood as occurring in stages, phases, a series of tasks to be completed, a relinquishment of the attachments to the deceased, and psychodynamic grief work (Noppe, 2000). Each theoretical model has specific characteristics and features which have laid the foundation of grief theory. This allows for a common pattern to be observed without difficulty, justifying that grief is a distinct psychological process (Parkes, 1998). Attachment phase model of grief. Freud was the first to articulate a perspective on grief (or mourning, as it was termed by psychoanalysts at that point in time) in the early 1900 s. Based on his clinical observations, he described mourning as being a private intra-psychic process and it was believed to restore psychic equilibrium and return the individual to pre-death conditions. Freud focused on the pain of those experiencing mourning and described the work of mourning as a decathexis, or a letting go of attachments to the deceased (Murray, 2001). He believed that the bereaved person underwent a sorting through of mental representations, a type of mental reorganization, to reclaim libidinal energy in order to pursue future relationships and attachments. Building on the original work of Freud, Bowlby researched how mourning influenced interpersonal relationships through attachments rather than psychodynamic individual adaptation to loss. He maintained that working through mourning was important for the purpose of rearranging representations of the lost person and of the self (Bowlby, 1969). Bowlby s interest in attachment theory arose while he was observing the effects of maternal loss on children s later

20 psychopathology and delinquency. According to Bowlby (1969), human beings are born with an innate attachment behavioral system. Infants become emotionally attached to their primary caregivers and clearly exhibit a preference for them. Bowlby s work as a whole was a major contribution to academic thinking about the development of attachment and affectional bonds, along with the consequences of their disruption. Bowlby demonstrated that the attachment of the infant to the mother was significant in determining the individual s later security and success in forming relations with others. Separation from this, or loss of the mother, as he observed, resulted in a devastating effect. Attachment theorists argued that grief work was a normal response to the breaking of affectional bonds (Murray, 2001). Bowlby argued that the expression of grief was not simply a private response to loss, but an effort on the part of the bereaved to reestablish connection with the lost individual/object and/or to obtain comfort from other survivors (Bowlby, 1980). Bowlby stated that his attachment theory facilitated an understanding that the distress, emotional disturbance, and long-term problems experienced by grieving individuals are likely to be related to the previous relationships they had with the deceased (Humphrey & Zimpfer, 1996; Murray, 2001). Bowlby provided an explanation for the common human tendency to develop strong affectional bonds and that grief is an instinctive, universal response to the loss of such bonds. Bowlby was the first to describe grief as a process in the context of phases that were typically set in motion by the loss of a loved one. He suggested that mourning involved movement through a number of phases, beginning with disorganization and progressing toward a phase in which a person was able to make new attachments or accept a new reality (Murray, 2001). These phasal classifications included the following (Archer, 1999; Bowlby, 1980): numbness and disbelief, yearning and searching, disorganization and despair, and reorganization.

21 Bowlby believed that the mistakes of previous theorists would help fuel his research efforts toward the development of the term healthy mourning. However, by 1979, Bowlby attempted to create some distance from the specific analytic understanding, popularity, and confusion of the term mourning by replacing it with grieving (Hockey, Katz, & Small, 2001). In part, the shift in terminology was also designed to emphasize the internal world of grief, as opposed to the social manifestations of mourning which were seen primarily as a cultural ritual strictly following death (Hockey et al., 2001). Stage Model of Grief The 1960 s death awareness movement provided a cultural shift toward greater acknowledgement of the place of death in human life as it emerged into popular consciousness (Neimeyer, 2000). Kubler-Ross s (1969) stage theory of grief emerged from her research, interviews, and observations of over 200 dying patients. Preparatory grief, as introduced by Kubler-Ross, is the grief that terminally ill patients underwent in order to prepare for the final separation from the world and is described as the normal grief reaction to perceived losses (experienced by persons who are dying) (Kubler-Ross, 1969). Kubler-Ross observed and reported patient actions and emotions, and proposed that these dying patients progressed through stages of denial, anger, bargaining, depression, and acceptance of the dying process. Her analysis related not to the grief that occurred after a death but to the adjustment of people as they contemplated their own death and the process of dying (Hockey et al., 2001). Because of the simplicity of her stages, the ability to easily comprehend them, and the lack of visibility of other grief theories, Kubler-Ross quickly became the most widely referenced and recognized researcher in contemporary research and education on grief (Humphrey & Zimpfer, 1996). These distinct stages have been applied to bereavement and adapted by others to the grief