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ELIZABETH MOLLA

CLINICAL CONCEPTUALIZATIONS OF GRIEF AND LOSS EXPERIENCED

BY CLIENTS IN FOSTER CARE

A Dissertation

Presented to

The Graduate Faculty of The University of Akron

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Elizabeth Molla

August, 2020

CLINICAL CONCEPTUALIZATIONS OF GRIEF AND LOSS EXPERIENCED

BY CLIENTS IN FOSTER CARE

Elizabeth Molla

Dissertation

Approved: Accepted:

______Dissertation Chair School Director Dr. Rikki Patton Dr. Varunee Faii Sangganjanavanich

______Committee Member Acting Dean of the College Dr. Heather Katafiasz Dr. Timothy McCarragher

______Committee Member Executive Dean of the Graduate School Dr. David Tefteller Dr. Marnie Saunders

______Committee Member Date Dr. Christine Graor

______Committee Member Dr. Bernard Jesiolowski

ABSTRACT

The purpose of this dissertation is to answer the research question: how do clinicians conceptualize grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care. The comprehensive literature review details literature related to the research on the types of loss, grief, attachment and trauma. The method used by the current qualitative study was Narrative Inquiry, modeled by Clandinin and Connelly. For this qualitative study three marriage and family therapists were interviewed. Three themes and five subthemes emerged: clinical conceptualizations, barriers, and self of therapist. The subthemes were: understand and perceive, treatment approach, efficacy/competency, lived experiences, and clinical values. The results of this study reflected clinicians conceptualizations of grief stemming from the ambiguous loss of attachment figures experienced by foster care youths as grief, loss, trauma, and attachment. The results of this study aligned with the current research related to the topic.

The findings spoke to the lack of understanding, education, training, and resources regarding grief stemming from ambiguous loss of attachment figures experienced by clients in foster care. The appearance of the same four components: grief, loss, attachment, and trauma could verify clinical needs of clients in foster care to contain all four of those components.

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TABLE OF CONTENTS Page

LIST OF TABLES…………………………………………………………………...…..vii

LIST OF FIGURES…………………………………………………………………...... viii

CHAPTER

I. INTRODUCTION TO CLINICAL CONCEPTUALIZATIONS OF GRIEF AND LOSS…………………………………………………………………………………...….1

Clinical Conceptualizations……………………………………………………….2

Conceptualizing Grief and Ambiguous Loss Through Attachment Theory……....9

Significance for Marriage and Family Therapy……………………………….....10

Bridging Research and Practice as an Ethical Imperative……………………… 12

Purpose of the Study...…………………………………………………………...13

Operational Definitions……………………………………………………...... 14

II. LITERATURE REVIEW……………………………………………………...... 17

Grief …………….……………………………………………………………….17

Ambiguous Loss… ……………………………………………………………...47

Clinical Conceptualizations of the Intersection of Grief and Ambiguous Loss…63

Conceptualizations of Foster Care Youth’s Experiences with the Intersection of Grief and Ambiguous Loss……………………………………………………67

Theoretical Framework….……………………………………………………….72

The Current Study.……………………………………………………………….80

III. RESEARCH METHODS …………………………………………………………...82

Research Goal. …………………………………………………………………..82

Research Design………………………………………………………………….83

Methodology of the Current Study…..……...………………………………..….90

Trustworthiness of the Current Study……………………………………...…...108

Researcher Subjectivity Statement.……... ………………………………….…111

IV. RESULTS………………………………………………………………...... 113

Participant A …………………………………………………………………...113

Participant B ……………………………………………………………………134

Participant C ……………………………………………………………………148

Amalgamation of Three-Dimensional Framework .……………………... ……164

Amalgamation of Emergent Themes……………. .……………………………167

V. DISCUSSION……………………………………………………………………….171

Final Narrative……………………………………………………………….…171

Discussion of Major Findings…………………………………………………..177

Major Implications for the Field………………………………………………..190

Directions for Future Research………………………………………...……….195

Strengths and Limitations of the Study…………………………………………196

Final Thoughts……………….………………………………………………....197

REFERENCES...………...……………………………………………………………..199

APPENDICES………………………………………………………………………….209

APPENDIX A. INFORMED CONSENT...…………………...…………...... 210

APPENDIX B. DEMOGRAPHIC QUESTIONNAIRE……….……...... 212

APPENDIX C. INTERVIEW PROTOCOL……………….………...…………213

APPENDIX D. INSTITUTIONAL REVIEW BOARD APPROVAL…….....…215

LIST OF TABLES

Table Page

1 Participant Characteristics...... 97

2 Amalgamation of Three-Dimensional Framework by Participant...... 165

vii

LIST OF FIGURES

Figure Page

1 Methodology of Current Study ...... 91

2 Emergent Themes and Sub-Themes of Participant A...... 123

3 Emergent Themes and Sub-Themes of Participant B...... 140

4 Emergent Themes and Sub-Themes of Participant C...... 154

5 Amalgamation of Emergent Themes and Sub-themes of all Participants……...168

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CHAPTER I

INTRODUCTION TO CLINICAL CONCEPTUALIZATIONS OF GRIEF AND

LOSS

The purpose and motivation for the current study was founded by the personal clinical experiences of the researcher. Through her clinical work as an in-home marriage and family therapist (MFT), the researcher experienced first-hand challenges related to working with clients in foster care. Foster care is an out of home placement for children whose family of origin is unable to provide appropriate care, safety, and nurturance

(Child Welfare Information Gateway, 2019). The researcher began to notice that grief was an additional unacknowledged issue which impacted the ability of the client to progress in treatment. For the purpose of this study, grief is defined as a universal human experience in which individuals have emotional reactions to the loss of someone in their lives (Friedman, 2012).

The researcher sought out resources to assist her work with the complex concerns of foster care youths and found very little relating foster care and grief. The challenges the researcher faced made her aware of the ethical imperative of ensuring sufficient research regarding clinical conceptualizations of grief when working with foster care youths. Clinical conceptualizations are the manner in which clinicians understand and formulate experiences, disorders, and manifestations from a clinical standpoint. Clinical conceptualizations also include clinical experiences, diagnoses, assessments, and 1

treatment approaches. The researcher struggled to obtain resources to guide her clinical work, which hindered her ability to meet the unique needs of her clients in foster care.

There was a gap in literature related to how clinicians conceptualized the grief stemming from ambiguous loss experienced by clients in foster care. Ambiguous losses are the experiences of an uncertain loss that have been substantiated. Uncertain losses of a significant individual or loved one can result from a physical absence or psychological absence of an individual (Boss, 1999).

This chapter focuses on the introduction of clinical conceptualizations of clients in foster care, grief, ambiguous loss, and intersections with attachment theory. In addition, this chapter discusses the significance for MFTs and the ethical imperative of bridging research and practice. This chapter concludes with the purpose of the study and a discussion of the research question “How do clinicians conceptualize grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care.”

Clinical Conceptualizations

Special Considerations for Clients in Foster Care

In 2018, there were over 400,000 children in foster care (Adoption and Foster

Care Analysis and Reporting System, 2019). Children in foster care experience the ambiguous loss of an attachment figure when removed from their families of origin and placed into foster care (Boss, 1999, 2010; Mitchell, 2016). Attachment figures are the primary caregivers in a person’s life to which they form attachments (Bowlby, 1969).

Attachments are the bonds between child and caregiver that form the basis for long-term relationships or bonds with other persons (American Academy of Pediatrics, 2000).

The lack of understanding, stability, and predictability for children regarding reunification with their family and their journey in foster care create ambiguity (Mitchell,

2016). The ambiguity of a family member’s physical presence resulted in ambiguous loss and manifested clinically as grief (Boss, 1999; Meichsner et al., 2016; Shalev & Ben-

Asher, 2011). The number of children in foster care have steadily increased each year since 2014 (Adoption and Foster Care Analysis and Reporting System, 2019). The average age of a child in foster care was 8.3 years old in 2018 (Adoption and Foster Care

Analysis and Reporting System, 2019). The average amount of time in foster care was

19.7 months (Adoption and Foster Care Analysis and Reporting System, 2019).

There are several circumstances which could lead to the removal of children from their parent or guardian: in 2018 62% of removals were due to neglect, 36% were due to drug abuse of caretaker, 13% were due to physical abuse, 5% were due to abandonment, and 4% were due to sexual abuse (Adoption and Foster Care Analysis and Reporting

System, 2019). The National Survey of Child and Adolescent Well-Being found that over half of the surveyed children who entered foster care had an Adverse Childhood Events

Score (ACES) of 4 or more (Stambaugh, Ringeisen, Casanueva, Tueller, Smith & Dolan,

2013). The researchers noted that an ACES score of four or more for children ranging from 0 to 17 years old was considered “extremely high”. The original ACES findings reported two-thirds of the adult participants had reported an average ACES of one

(Stambaugh et al., 2013). It was evident that the foster care population was in need of a special emphasis placed on improving mental health treatment options. The special emphasis was supported by the abundance of research related to the negative long-term physical and mental health impacts of experiencing four or more ACES, as well as

research indicating the majority of children in foster care experienced a multitude of adverse childhood events (Stambaugh et al., 2013).

Children that experienced the loss of a primary attachment figure were more likely to develop an insecure attachment style or experience an attachment injury

(Thomson, 2010). Attachment injuries are negative experiences that can impact an individual’s ability to securely attach to a primary attachment figure (Bowlby, 1958).

When a child is removed from the care of their primary caregiver, the caregiver was no longer able to attend to their needs and thus create an injury to their relationship

(Leathers et al., 2012; Mitchell, 2016). Insecure attachment styles are unhealthy or unsecure attachments and can include negative views of self and others (Bowlby, 1969).

The research indicated individuals with insecure attachment styles struggled to cope with grief, reported mental health symptoms and a negative impact on daily functioning

(Mitchell, 2016). The research also signified foster care youths’ difficulty gaining closure while experiencing ambiguous loss could manifest into grief. Children in foster care might experience multiple ambiguous losses or attachment injuries as they build relationships with foster parents (Boss, 1999, 2010).

It was essential to explore how clinicians working with foster care youths were conceptualizing grief and ambiguous loss to determine if foster care youths were receiving appropriate clinical care. Foster care youths experienced the ambiguous loss of primary attachment figures when placed into foster care and may have struggled to cope with the resulting grief (Mitchell, 2016). It was common practice for foster care youths to receive mental health services at some point throughout or after their foster care experience to assist in coping with and adjusting to the separation from their families

(Quiroga & Hamilton-Giachritsis, 2016). However, there was limited research guiding clinical treatment for grief stemming from ambiguous loss experienced by clients in foster care. MFTs specifically might benefit from research informed treatment modalities when working with the family systems of clients in foster care.

Grief

Grief has been noted as one of the most difficult experiences an individual could endure in their lifetime and could be difficult to process (Burns et al., 2018; Glickman,

Shear, & Wall, 2017). Individuals might experience deep sadness, emotional pain, anger, preoccupation with the deceased, guilt, blame, denial, shock, depressed mood, withdrawal from others, change in appetite and sleep, increased fatigue, anxiety, loneliness, difficulty concentrating, and regret following the death of a significant individual (Charney et al., 2018; Dominguiez, 2018; Enez, 2017; Friedman, 2012;

Kubler-Ross & Kessler, 2005).

It has been well documented that mental health treatment for grief has been shown to have overall positive effect for clients experiencing grief. For instance, evidenced-based grief assessments and treatments utilized in clinical practice were found to assist in the identification and conceptualization of grief as well as distinguished grief from common comorbid disorders such as depression (Jordan & Litz, 2014). Further, proper assessment and diagnosis of grief and other comorbid mental health disorders could aid in providing accurate and effective treatment modalities and ensured clinical needs were being met (Enez, 2018; Jordan & Litz, 2014). Better understanding of how clinicians conceptualized grief and what resources were used to inform their clinical

practice regarding grief could also reduce negative long-term impacts of unresolved grief

(Breen, 2011).

However, there were several factors impeding clinicians’ practice in working with clients experiencing grief. For instance, there was a clear discrepancy in the literature regarding diagnostic criteria for grief, which impacted clinicians ability to find resources when working with clients experiencing grief. The discrepancy in the research regarding diagnostic criteria was further exacerbated by the lack of an official independent grief diagnosis (Jordan & Linz, 2014). The Diagnostic and Statistical Manual of Mental

Disorders was a commonly used manual to diagnose and conceptualize mental health disorders (5th ed.; DSM–5; American Psychiatric Association [APA], 2013). The DSM-5 did not classify grief as an individual mental health disorder, but as a V or Z code under

“Other Conditions That May be a Focus of Clinical Attention” section of the manual

(APA, 2013). Even though research has indicated the negative clinical impacts individuals could experience due to grief; formal diagnostic criteria for grief was not available for clinicians.

The lack of a unified definition and diagnostic criteria for clinically significant forms of grief could encumber a clinician’s ability to provide proper clinical care (Breen,

2011; Enez, 2018), and an inaccurate grief diagnosis could negatively impact the counseling process and not address the underlying grief (Jordan & Litz, 2014).

Additionally, clinicians working with clinical and maladaptive functioning in clients experiencing grief have limited empirically based clinical resources available (Breen,

2011). The few manualized treatment options were not openly accessible to clinicians

(Enez, 2018). Regardless, clinicians continued to treat manifestations of grief without

formal research-informed diagnostic guidance (Enez, 2018; Jordan & Litz, 2014). The current study aimed to better understand how to utilize assessments and diagnostic criteria in working with grief, as well as the effectiveness of those resources to help address this gap in the field.

Ambiguous Loss

Clinicians have conceptualized ambiguous loss as one of the most stressful losses an individual could endure due to the lack of resolution and uncertainty involved (Boss,

2016). The prolonged uncertainty and ambiguity surrounding ambiguous loss could have negative and pervasive impacts on clients. Those impacts included: denial, shock, enduring grief, guilt, stigma, isolation, anguish, hopelessness, helplessness, depressed mood, anxiety, confusion, worry, prolonged stress, fear of abandonment, anger, and rumination regarding the return or well-being of the absent individual (Coolhart, Ritenour

& Grodzinski, 2018; Shalev & Ben-Asher, 2011; Solheim & Ballard, 2016). Symptoms might have persisted until closure was achieved or the loss was resolved. Achieving closure was indicated as the most effective manner in reducing or eliminating negative impacts of ambiguous loss (Jackson, 2018). However, many individuals were limited in their abilities to resolve an ambiguous loss due to the circumstances surrounding the loss.

In such circumstances, a clinical focus of processing, coping with, and understanding the loss was shown to be more effective (Jackson, 2018).

Clients experiencing an ambiguous loss were also at risk for developing mental health disorders and pervasive symptoms that might impact their quality of life (Boss,

2016; Jackson, 2016) including symptoms similar to grief, depression, anxiety and other mental health disorders (Boss, 1999, 2016; Coolhart et al., 2018; Jackson, 2016; Solheim

& Ballard, 2016). However, formal research based diagnostic criteria for ambiguous loss was lacking (Robins, 2016). Inaccurate clinical conceptualizations could have hindered a clinician’s ability to utilize appropriate treatment modalities (Breen, 2011). Thus, clinicians may have struggled to effectively address the underlying clinical concern of ambiguous loss due to a lack of research-informed assessments and treatment modalities.

Robins (2016) noted clinical practices regarding ambiguous loss have been guided by clinical understandings of relationships due to lack of research. It was important to understand how clinicians conceptualized ambiguous loss due to the potential harm of not incorporating appropriate treatment practices and addressing the unique clinical needs of ambiguous loss (Jackson, 2018; Robins, 2016; Sampson et al., 2012). Clinicians have an ethical responsibility towards providing competent clinical care (AAMFT, 2015). The current study aimed to address the gap in clinical perspectives incorporated into research guiding clinical practice by exploring how clinicians conceptualized ambiguous loss.

Grief Stemming from the Ambiguous Loss

Ambiguous loss was conceptualized as an unavoidable life experience that could manifest into grief if closure did not occur (Boss, 2010). Individuals experiencing an ambiguous loss were vulnerable to developing grief due to the uncertainty and prolonged nature of the loss. Grief due to the death of a significant individual and grief manifesting from an unresolved ambiguous loss clinically differed from one another (Boss, 2010). It was imperative for clinicians to accurately conceptualize grief stemming from an ambiguous loss to ensure appropriate and effective client care and clinical treatment

(Boss, 2010; Meichsner, Psych, Schinkothe, & Gabriele, 2016). However, the literature lacked comprehensive diagnostic criteria, assessments, and treatments for grief stemming

from ambiguous loss. Better understanding of how clinicians conceptualized grief stemming from ambiguous loss and what resources were utilized could address the gap in the literature (Boss, 2010; Breen, 2011; Meichsner et al., 2016). In addition, the literature also lacked grief modalities that addressed nonfinite losses. Traditional grief modalities viewed loss in terms of finality which was applicable when addressing loss due to death.

However, ambiguous losses lacked finality and traditional grief modalities may not be appropriate (Boss, 2010). Future research regarding the development of effective and applicable diagnostic, assessment, and treatment modalities could benefit from incorporating clinical perspectives in the treatment of grief stemming from ambiguous loss.

Conceptualizing Grief and Ambiguous Loss Through Attachment Theory

The theoretical framework guiding the current study was attachment theory. John

Bowlby (1958) developed attachment theory, which posits individuals develop attachment styles based on communication and caring behaviors of primary attachment figures during their formative years. Individuals that experience the loss or separation from a primary attachment figure might experience an attachment injury. An attachment injury is an incident in the relationship that could be perceived as a betrayal, abandonment, or breach of trust by the attachment figure during a critical time of need

(Bowlby, 1958, 1959, 1960, 1969). Individuals that experience attachment injuries might continue to long for their attachment figure and experience grief symptoms. Individuals suffering the loss of an attachment figure reported sadness, anger, withdrawing from others, irritability, and other grief symptoms (Maccallum, & Bryant, 2018; Thomson,

2010).

Awareness of attachment injuries could assist clinicians in their clinical conceptualizations and aid clinical treatment (Maccallum & Bryant, 2018; Thomson,

2010). Attachment theory suggests the relationship between primary attachment figures and individuals creates the foundation of how the individual viewed themselves, others, and the world. The loss of a primary attachment figure, especially in childhood could greatly impact an individual’s view of themselves, others, and the world. Addressing the loss of primary attachment figures and attachment injuries on the individual could greatly benefit client care (Bowlby, 1969; Bretherton, 1992; Ponizovsky, Vitenberg,

Baumgarten-Katz & Grinshpoon, 2013; Sutton, 2018). Developmentally, children struggled to cope with grief and the ambiguous loss of primary attachment figures due to their dependence for support and comfort. Foster care youths specifically might benefit from addressing the loss of their primary attachment figures and the resulting attachment injury to aid in their ability to accept support from others (Mitchell, 2016).

Significance for Marriage and Family Therapy

The field of MFT emphasized a clinical focus on the individual client as well as the interpersonal connections in their life (Bertalanffy, 1968; Gehart, 2010). MFTs working with clients in foster care consider the impact of the client’s family of origin as well as their foster family over the course of therapy. The literature indicated clients in foster care benefited from the acknowledgment of their ambiguous loss and normalizing their experiences of grief (Mitchell, 2018). Foster care youths that were unable to express and process ambiguous losses were less likely to seek support from their foster parents.

Foster care youths might exhibit externalizing behaviors and struggle to attach to foster parents while grieving the loss of their primary attachment figures (Mitchell, 2016).

Engaging in externalizing behaviors, difficulty attaching to foster parents, or accepting support from others often may lead to foster parents requesting removal of foster care youth from their foster home (Leathers et al, 2012).

Removal from a foster home could reinforce insecure attachment styles (Leathers et al, 2012; Mitchell, 2016; Quiroga & Hamilton-Giachritsis, 2016). Foster care youths grieving the ambiguous loss of primary attachment figures also have an increased risk of developing an insecure attachment style (Schade & Sandberg, 2012). Insecure attachment styles could have long term impacts on current and future relational functioning (Bowlby,

1969). Individuals with insecure attachment styles might struggle to trust others, lack a sense of safety, and view the world as unstable (Bowlby, 1969). MFTs working with clients in foster care could attend to the impact of insecure attachment styles on client’s ability to engage in healthy relationships (Mitchell, 2018). MFTs specialize in enhancing interpersonal relationships. Including foster parents in counseling sessions could reduce conflict in the foster home, decrease the risk of removal from the foster home, and increase positive coping (Mitchell, 2016, 2018).

Clients in foster care struggle to trust others and long for reunification with their primary attachment figures. MFTs have the ability to address the multiple family systems to which clients in foster care belong (Maccallum & Bryant, 2018; Mitchell, 2016).

Acknowledging membership in multiple family systems was reported to reduce the stigma associated with foster care and assisted in client’s abilities to cope with the ambiguity of their foster care experience (Boss, 2010; Mitchell, 2016, 2018; Tucker &

MacKenzie, 2012).

Bridging Research and Practice as an Ethical Imperative

This study explored clinical conceptualizations of grief and ambiguous loss of clients placed into the foster care system. Historically clinicians have relied on research to guide clinical practice and ensure ethical client care (Breen, 2011). MFTs have an ethical responsibility to use research to inform their clinical practice (American

Association for Marriage and Family Therapy [AAMFT], 2015). Ethical guidelines emphasize the need for clinicians to provide competent clinical treatment and continuously enhance their knowledge and clinical practice in regard to specialty areas

(AAMFT, 2015). Two such specialty areas are grief and ambiguous loss, and include the intersection of both. However, literature and evidenced-based research regarding grief stemming from ambiguous loss had not been thoroughly researched (Boss, 1999;

Coolhart et al., 2018; Enez, 2018; Jordan & Litz, 2018; Mechling, Ahern, & Palumbo,

2018; Shalev & Ben-Asher, 2011; Shear & Bloom, 2017; Solheim & Ballard, 2016), which resulted in a lack of research-based conceptualizations and treatment modalities for clinical practice. This was particularly salient for special populations that are at a greater risk for experiencing grief stemming from ambiguous loss, such as foster care youth (Fineran, 2012; Mitchell, 2016).

Clients in foster care have higher needs for effective mental health services due to higher rates of experiencing abuse, neglect, trauma, unstable home environments, and inconsistent nurturing prior to entering foster care (American Academy of Pediatrics,

2000; Mitchell, 2016). Compared to the general population, foster care youths have been two and a half times more likely to develop mental health disorders (Bellamy et al.,

2010). Foster care youths were also more likely to develop grief manifested from the

ambiguous loss of primary attachment figures when placed into foster care (Fineran,

2012; Mitchell, 2016; Mitchell & Kuczynski, 2010). Despite the lack of research on grief stemming from ambiguous loss, clinicians continued to provide clinical treatment to clients and to foster care youths (Breen, 2011). Research-informed clinical practice incorporating current literature and evidence-based treatment modalities have been shown to be an effective approach to ensure competent and ethical clinical practice

(Johnson, Miller, Bradford, & Anderson, 2017).

However, research was not guaranteed to be completely effective or applicable in clinical practice. Generally, research has been structured and guided from a researcher perspective and lacked influence from a clinician’s perspective (Johnson et al., 2017). It is critical to understand how clinicians utilized research, incorporated research, and the overall effectiveness of the research to ensure clinical care. In doing so, clinicians’ conceptualizations could influence and enhance future research, which then could further the MFT field (Breen, 2011; Johnson et al., 2017). Connections bridging research with clinical practice has been needed and MFTs must take steps to ensure clinical competence in working with specialty areas and populations (AAMFT, 2015; Breen,

2011; Johnson et al., 2017; Mitchell, 2016). A brief overview of the research regarding clinical conceptualizations, grief, and ambiguous loss are reviewed as well as the theoretical framework for the current study and special considerations of grief and loss on clients in foster care.

Purpose of the Study

The literature lacked information related to how clinicians conceptualized the grief stemming from ambiguous loss experienced by clients in foster care. The current

study aimed to contribute to the limited literature to enhance future research. It is ethically imperative to explore how clinicians conceptualized grief stemming from ambiguous loss to better understand if current conceptualizations were aligned with ethical and effective clinical practice. As such, the current study addressed the following research question:

Research Question: How do clinicians conceptualize grief stemming from the

ambiguous loss of attachment figures experienced by clients in foster care?

Operational Definitions

Ambiguous Loss: The experience of an uncertain loss that might not be substantiated.

Uncertain losses of a significant individual or loved one could result from a physical absence or psychological absence of an individual (Boss, 1999).

Ambiguous Physical Loss: Uncertainty of significant individual’s whereabouts, well- being, or if they are alive or deceased (Boss, 1999, 2016).

Ambiguous Psychological Loss: An emotional, relational, or cognitive loss with the physical presence of an individual. (Boss, 2016; Mechling et al., 2018; Shalev & Ben-

Asher, 2011).

Attachment: A bond between a child and caregiver that forms the basis for long-term relationships or bonds with other persons (American Academy of Pediatrics, 2000).

Attachment Figures: Primary caregivers in a person’s life to whom they formed attachments (Bowlby, 1969).

Attachment Injury: Negative experiences that impact an individual’s ability to securely attach to a primary attachment figure (Bowlby, 1958).

Clinical Conceptualization: The manner in which clinicians understand and formulate experiences, disorders, and manifestations from a clinical standpoint. Clinical conceptualizations also include clinical experiences, diagnoses, assessments, and treatment approaches.

Complicated Grief: Complicated grief occurs when the grieving process has been interrupted or hindered due to difficulty regulating emotions, maladaptive behaviors, negative cognitions, or other external factors which could prolong the grieving process

(Burns et al., 2018; Glickman, et al., 2017).

Disenfranchised Grief: A loss that is not socially supported and cannot be openly expressed, supported, or accepted publicly (Doka, 1989).

Foster Care: Out of home placement for children whose family of origin was unable to provide appropriate care, safety, and nurturance (Child Welfare Information Gateway,

2019).

Grief: A universal human experience in which individuals have emotional reactions to the loss of someone in their lives (Friedman, 2012).

Insecure Attachment: Any unhealthy or unsecure attachment and could include a negative view of self and others. Lack of trust, safety, and stability in others may develop

(Bowlby, 1969).

Reunification: Foster care youths return to their parents’ custody and home (Campbell,

Silverman, & Patti, 1991).

Secure Attachment: A positive view of self and others as well as a sense of stability and security (Bowlby, 1969).

Traumatic Grief: Traumatic grief manifests when a significant loss results from a sudden or violent death (De Heus et al., 2017; Kristensen et al., 2012).

Uncomplicated Grief: A common response to tremendous loss and might not require clinical intervention if not complicated by other factors (Friedman, 2012; Ringdal,

Jordhoy, Ringdal, & Kaasa, 2001).

CHAPTER II

LITERATURE REVIEW

The current study explored clinical conceptualizations of grief and ambiguous loss of clients placed into the foster care system. This chapter provides a synthesis of the relevant literature pertaining to the grief, ambiguous loss, clinical conceptualizations, and experiences of foster care youths with grief and loss. This chapter also reviews the literature on attachment theory as the theoretical framework on which this study was based.

Grief

Grief is a universal human experience in which individuals had emotional reactions to the loss of someone in their lives (Friedman, 2012). When an individual experienced a loss, their belief system, thought process, and behaviors adjusted in response to the adverse experience of the loss (Enez, 2017). Individual manifestations of grief could be influenced by the individual’s cultural and religious backgrounds, availability and support of social network, personality, age, gender, how the loss was experienced, circumstances surrounding the loss, and the relationship with the deceased

(Burns et al., 2018; Ringdal et al., 2001). Due to varying reactions and responses to death and loss, a unified definition of grief was difficult to establish (Burns et al., 2018). A search of literature using PsycInfo displayed 3,400 articles were published in the past ten

years that included grief as a key term. The search of the literature reflected the lack of a cohesive and unified theory regarding the experience, manifestation, or process of grief.

Variations of Grief

The literature review also highlighted multiple variations of grief which were uncomplicated, complicated, traumatic, and disenfranchised. In general, uncomplicated grief has encompassed an experience that included deep sadness, but did not negatively impact an individual in multiple aspects of life and did not persist for a period of more than six months (Burns et al., 2018; Currier et al., 2008; Friedman, 2012; Kristjanson,

Monterosso, Lobb, & Aoun, 2006). Complicated, traumatic, and disenfranchised grief have been identified in the literature as experiences that indicated maladaptive functioning (Enez, 2017). Maladaptive functioning occurred when grief persisted longer than six months, created impairment in daily living, negatively impacted functioning, or if thoughts regarding self-harm and suicidal ideation emerged (Enez, 2017; Friedman,

2012). A critical review of uncomplicated grief, complicated grief, traumatic grief, and disenfranchised grief was completed to provide a deeper understanding of the experiences and manifestations of the various forms of grief. Awareness and understanding of the current literature’s view and operationalization of grief informed the interview protocol for the current study.

Uncomplicated Grief. In general, uncomplicated grief was a common response to tremendous loss and might not require clinical intervention if not complicated by other factors (Friedman, 2012; Ringdal et al., 2001). This experience has been described as a sense of deep sadness stemming from the death of a family member or significant individual that could be associated with somatic complaints and mental health concerns.

Uncomplicated grief could be experienced for a time span of a few weeks and up to six months (Burns et al., 2018; Currier et al., 2008; Kristjanson et al., 2006). The grieving period for uncomplicated grief could consist of emotional and behavioral symptoms which might occur in nonlinear stages (Hashim, Mei-Li, & Guan, 2013; Ringdal et al.,

2001; Stroebe, Schut, & Boerner, 2017). A prominent model incorporating stages to conceptualize uncomplicated grief was created by Kubler-Ross and Kessler, which provided a framework to better understand individual experiences (Bolden, 2007; Kubler-

Ross & Kessler, 2005).

Stages of Uncomplicated Grief. The stages of denial, anger, bargaining, depression, and acceptance may occur in any order (Kubler-Ross & Kessler, 2005).

However, the literature indicated the stage of denial often occurred in the beginning of the uncomplicated grief process. Denial often has presented first as a means of coping with the initial overwhelming sense of loss and sadness (Kubler-Ross & Kessler, 2005).

The stage of denial included difficulty accepting the deceased would no longer participate in their life and not necessarily denial of the actual death. Kubler-Ross and Kessler

(2005) noted denial might manifest in the disbelief they may never speak to or have further interactions with the deceased again. Along with a sense of denial, individuals could experience numbness and shock (Kubler-Ross & Kessler, 2005). Anger might appear as the initial numbness and shock dissipated.

Kubler-Ross and Kessler (2005) noted the stage of anger was necessary to heal from the uncomplicated grief. Anger as an initial emotion, allowed other underlying emotions to come to the surface. The anger may be directed at the deceased, themselves, or others for not preventing the loss or for causing the loss (Bolden, 2007; Kubler-Ross &

Kessler, 2005). As individuals focused on the causes of the loss or preventing the death, they might transition to the bargaining stage.

Bargaining was described as an effort to form a truce or agreement to alleviate the pain. This stage might also include preoccupation with actions that could have prevented the deceased from dying (Kubler-Ross & Kessler, 2005). A false sense of control could emerge as they focused on actions that could have prevented the loss or attempts to form a bargain to alleviate the pain (Bolden, 2007; Kubler-Ross & Kessler, 2005).

The depression stage often followed the bargaining stage due to moving into the present and acknowledgment of the loss (Kubler-Ross & Kessler, 2005). Depressed mood during the depression stage was noted as an appropriate reaction to a significant loss

(Bolden, 2007). Symptoms of this stage have included withdrawing from friends and hobbies, sadness, difficulty concentrating, sense of loneliness, and depressed mood.

However, the stage of depression has not been necessarily indicative of clinical depression (Kubler-Ross & Kessler, 2005). Transitioning out of the depression stage might include decreased depressed mood and increased interest in socializing with peers and hobbies (Kubler-Ross & Kessler, 2005). Motivation and desire to resume hobbies and daily tasks have been indicative of moving towards acceptance (Kubler-Ross &

Kessler, 2005).

The typical final stage of uncomplicated grief was the acceptance stage and included accepting the physical loss of an individual as well as the relational and emotional loss. The reality of life moving forward without the deceased formed during this stage (Kubler-Ross & Kessler, 2005). The acceptance stage could occur more than once and might not be the final stage for some individuals. Individuals might also

experience multiple stages at once or revisit certain stages (Kubler-Ross & Kessler,

2005). Individual cultural beliefs, circumstances surrounding the loss, availability and use of social supports, personality, age and development impacted how individuals experienced and moved through the various stages outlined by Kubler-Ross and Kessler

(Burns et al., 2018; Kubler-Ross & Kessler, 2005; Ringdal et al., 2001).

In general, uncomplicated grief emphasized the ability of individuals to move through the stages and grieving process with limited impact on overall functioning

(Hashim et al., 2013). A review of the literature consisted of varying perspectives on how uncomplicated grief could be processed or experienced (Hashim et al., 2013; Ringdal et al., 2001). The stages of uncomplicated grief outlined by Kubler-Ross & Kessler (2005) provided one model of how uncomplicated grief could be experienced. Overall, difficulty processing through the stages of uncomplicated grief may result in a maladaptive form of grief (Stroebe et al., 2017).

Complicated Grief. One variation of grief that was considered maladaptive was complicated grief. Complicated grief occurred when the grieving process was interrupted or hindered due to difficulty regulating emotions, maladaptive behaviors, negative cognitions, or other external factors which could prolong the grieving process (Burns et al., 2018; Glickman et al., 2017). Ten to twenty percent of individuals that have experienced a loss developed complicated grief and could experience symptoms daily, for a minimum of twelve months (Charney et al., 2018; Enez, 2017; Friedman, 2012).

Symptoms associated with complicated grief included chronic yearning for the deceased, preoccupation with the deceased, anger, difficulty moving towards acceptance, sadness, denial, withdrawal from peers, change in sleep and appetite, negative cognitions, shock,

fatigue, loneliness and anxiety (Charney et al., 2018; Enez, 2017; Friedman, 2012).

Individuals that have experienced complicated grief could be at a higher risk for lower quality of life and increased suicidal ideation (Charney et al., 2018).

A 2018 study focused on the experiences of complicated grief, symptoms, and quality of life among military service members and veterans. Participants included service members and veterans that served after September 11, 2001 and were actively seeking outpatient mental health treatment during the recruitment phase of the study

(Charney et al., 2018). Six hundred and twenty-two participants were evaluated between

2012 and 2015 and assessed for complicated grief, post-traumatic stress disorder (PTSD), depression, anxiety, and quality of life. The participants completed the Complicated Grief

19 item self-report inventory, PTSD Checklist-Specific self-report measure, 21 Item

Depression Anxiety Stress Scales, and Quality of Life Satisfaction, and Enjoyment

Questionnaire-Short form (Charney et al., 2018). Approximately 80% of the participants reported a experiencing a significant loss and 30% of the participants met the criteria for complicated grief as outlined by the Inventory of Complicated Grief. Participants that meet the criteria for complicated grief reported higher levels of PTSD, depression, anxiety, and stress. Charney et al. (2018) noted the manifestation of complicated grief due to a significant loss could have negative impacts on an individual’s quality of life and overall mental health.

Bellini et al. (2018) reported similar findings, indicating complicated grief was associated with depression and lower quality of life. Thirty-five participants recruited from a support group for individuals that have lost a family member or friend due to suicide completed a battery of assessments. The assessments utilized were the Beck

Depression Inventory II, Beck Hopelessness Scale, the Inventory of Complicated Grief, the Impact of Event Scale, the Subjective Happiness Scale, and the Satisfaction with Life

Scale (Bellini et al., 2018). The results indicated 63% of the participants experienced complicated grief. The results also indicated moderate correlations between complicated grief with higher rates of depression and hopelessness as well as lower rates of happiness and life satisfaction (Bellini et al., 2018). The researchers noted the higher levels of hopelessness reported by the participants experiencing complicated grief could indicate higher risk of experiencing suicidal thoughts (Bellini et al, 2018).

The literature suggested complicated grief could negatively impact an individual’s quality of life, mental health, and ability to process and accept a significant loss (Bellini et al, 2018; Charney et al, 2018; Enez, 2017; Friedman, 2012). Experiencing a trauma might complicate the grieving process and contribute to complicated grief (Charney et al.,

2018). However, a trauma resulting in the loss of a significant relationship might not develop as complicated grief and might manifest as traumatic grief (Charney et al., 2018;

Heus et al., 2017; Kristensen, Weisaeth, & Heir, 2012).

Traumatic Grief. Traumatic grief manifested when a significant loss resulted from a sudden or violent death (De Heus et al., 2017; Kristensen et al., 2012). Sudden and violent deaths could result from natural disasters, suicide, homicide, war related death, or accidents. Symptoms associated with grief and trauma were noted to both occur simultaneously for traumatic grief (Barle et al., 2017; De Heus et al, 2017; Kristensen et al., 2012). Those symptoms included deep sadness, longing for the deceased, preoccupation with the deceased, change in sleep patterns, difficulty concentrating, flashbacks of the traumatic loss, depression, and lower quality of life. The trauma might

induce guilt and blame, worry of losing another family member or friend, worry for their own well-being, questioning religious beliefs, and preoccupation with potential suffering the deceased could have experienced (Barle et al., 2017; De Heus et al, 2017). Symptoms could persist for several years due to difficulty coping with the trauma. Individual’s lives were forever changed and impacted when a significant loss was experienced in a traumatic manner (Barle et al., 2017).

Trauma itself had the potential to leave lasting effects and created devastating changes in one’s life. The combination of grief and trauma could become overwhelming to process and accept (Barle et al., 2017). Basic life assumptions such as safety, predictability, and security were challenged, which created barriers to accepting and processing significant losses. The sudden and potentially violent nature of the death could lead to PTSD, major depressive disorder, or development of other mental health concerns

(Barle et al., 2017; Kristense et al., 2012). Traumatic grief could persist longer than other forms of grief due to the unusual nature of the death and loss (Barle, Wortman, & Latack,

2017). The circumstances surrounding the death could also become a barrier to the grieving process and a sense of helplessness might develop especially if individuals witnessed the sudden and violent death (Barle et al., 2017).

De Heus et al. (2017) noted refugees were at higher risk for developing traumatic grief and PTSD due the multiple traumas and traumatic losses they experienced. Sixteen participants diagnosed with PTSD and Persistent Complex Bereavement Disorder were interviewed and completed the Traumatic Grief Inventory- Self Report between the years

2013 and 2014. All the participants identified as refugees and were engaged in mental health day treatment for traumatic grief. Results of the study indicated the participants

initially experienced high rates of PTSD and grief symptoms which negatively impacted their daily functioning (De Heus et al., 2017). At the conclusion of the study, participants reported reduced rates of PTSD, Persistent Complex Bereavement Disorder symptoms and increased daily functioning. The day treatment incorporated trauma and grief interventions as well as a focus on social supports. The researchers noted the comorbid diagnosis of PTSD and Persistent Complex Bereavement Disorder was often lacking in clinical treatment. More research and clinical treatments were needed to address grief coupled with trauma (De Heus et al., 2017).

Literature surrounding traumatic grief noted it was an overwhelming and difficult experience to process (Barle et al., 2017; Kristensen et al., 2012). Individuals that witnessed the traumatic loss or experienced the trauma firsthand were faced with the challenge of processing the loss, the unexpected and traumatic nature of the loss, and the trauma itself (Barle et al., 2017; De Heus et al, 2017; Kristensen et al., 2012). Clinical treatment and intervention were helpful in addressing the multiple components of traumatic grief. However, the literature noted a lack of research and clinical treatments specific to traumatic grief (De Heus et al, 2017). Another potential barrier to engaging in clinical treatment for individuals struggling with traumatic grief was the stigma and lack of support surrounding the traumatic loss. A lack of support or stigma surrounding a loss could inhibit individuals from expressing and processing the traumatic grief which resembled components of disenfranchised grief (Barle et al., 2017; De Heus et al, 2017;

Doka, 1989; Dominguez, 2018; Kristensen et al., 2012).

Disenfranchised Grief. Disenfranchised grief, defined by Doka (1989), is a loss that has not been socially supported and could not be openly expressed, supported, or

accepted publicly. The lack of support and inability to openly express grief complicated and negatively impacted the grieving process (Doka, 1989; Dominguez, 2018).

Symptoms of shock, anger, depression, loneliness, distress, feeling overwhelmed, guilt, regret, blame, withdrawal from peers, and sadness could manifest. Dominguez (2018) noted disenfranchised grief could be overwhelming, unacknowledged by peers and social supports, pervasive, and could lead to feeling disconnected from others.

The concept of disenfranchised grief originally stemmed from the lack of social acceptance and support individuals in same sex relationships faced when grieving the loss of their partner (Doka, 1989; Dominguez, 2018). Same sex relationships were not universally recognized and accepted in society and in turn, grieving the loss of partners and relationships were also not recognized or accepted. The inability to engage openly in the mourning process and receive support could hinder the grieving process, exacerbate symptoms, and could potentially have manifested as complicated grief (Doka, 1989;

Dominguez, 2018). Less conventional losses were more susceptible to being viewed as unworthy of sympathy due to potential stigma and stereotypes surrounding the loss

(Burns et al., 2018).

A study exploring fifteen adults aged fifty and older experiencing homelessness in

Montreal for the first time reported the perception of others negatively impacted the participants ability to grieve (Burns et al., 2018). Burns et al. (2018) noted when interviewing older adults struggling with homelessness, they experienced disenfranchised grief due to the stigma of homelessness and the lack of support. The participants expressed feelings of disbelief, anger, and despair which the researchers noted were much like the initial phases of grief outlined by Kubler-Ross (Burns et al., 2018). The

participants internalized the stigma and disenfranchised grief. Assisting this population included challenging the stigma of homelessness, normalizing their experiences with homelessness, validating their experiences of grief, and providing support. Creating positive relationships with mental health providers and professional supports assisted the participants to process and heal from their grief as well as move towards acceptance. The participants reported gaining a sense of family and friends with the supportive workers, providers, and professionals (Burns et al., 2018).

Stigma surrounding a loss or lack of supports could lead to disenfranchised grief.

Disenfranchised grief could encumber the grieving process and created symptoms in addition to the initial grief. The ability to grieve a loss openly and receiving support from others during the grieving process reduced the risk of disenfranchised grief from developing and aided in an adaptive grieving process (Burns et al., 2018; Doka, 1989).

Special Considerations for Grief in Children

A review of the literature within the past ten years utilizing the keywords of grief and children in PsycInfo displayed empirical and conceptual articles. The literature regarding grief in children included articles regarding children’s experiences of grief, treatment modalities, manifestations of grief, impact of grief, and grief in related to other specific topics (Dickens, 2014; Ener & Ray, 2017; Himebauch, Arnold, & May, 2008;

Sandler, et al., 2010). Literature regarding the experiences, manifestations, and impact of grief in children was reviewed and assisted in informing the interview protocols for the current study. Grief, in regard to the special topic of foster care youths, is reviewed following this section.

Ener and Ray (2017) explored the relationship between characteristics of children engaging in counseling for grief and loss. The study recruited ninety-eight participants between the ages of three and eleven from two university-based community counseling clinics. Ninety-seven of the participants reported grieving the loss of a family member and one participant reported grieving the loss of a friend. The characteristics analyzed were age, gender, ethnicity, type of loss, life stress, behavioral manifestations, and parent child relational stress (Ener & Ray, 2017). Caretakers of the child completed the Child

Behavior Checklist (CBCL) and Parenting Stress Index (PSI). The CBCL is a parent report measure that was utilized to gather data regarding behavioral manifestations of children’s grief. The CBCL included questions exploring problem behaviors, anxiety symptoms, withdrawn behaviors, somatic complaints, problems related to attention, and aggressive behaviors exhibited by the child.

The PSI was also a parent report measure investigating characteristics that negatively impacted the parent child relationship (Ener & Ray, 2017). A canonical correlation analysis (CCA) method was used to analyze the relationship between characteristics of grieving children and manifestations of behaviors. CCA was also used to analyze the relationship between characteristics of grieving children and levels of parent child relational stress (Ener & Ray, 2017). The characteristics of age, life stress, behavioral manifestations, and parent child relational stress yielded statistically significant results as compared to the other characteristics. The results of the study suggested a correlation between the age of the grieving child and manifestations of behaviors. Older participants were more likely to manifest behaviors indicative of anxious/depressed, withdrawn/depressed, and attention related problems (Ener & Ray,

2017). The study noted younger participants were more likely to manifest externalizing behaviors such as aggression, disruptive behaviors, and somatic complaints.

Another significant correlation was between age and parent-child relational stress.

Parents of younger children experiencing grief reported less stress in the parent child relationship as compared to parent reports of the older participants (Ener & Ray, 2017).

The younger participants sought support and comfort from their parents to cope with the grief and manifested behaviors, which potentially reduced the impact of stress on the relationship. Older participants were less likely to seek support from parents and more likely to seek autonomy during their grieving process. Seeking autonomy, withdrawal from others, depressed mood, and anxious behaviors negatively impacted the parent children relationship, and demonstrated an increased need of support from parents (Ener

& Ray, 2017). The researchers noted seeking support from caregivers by younger children and autonomy for older children as developmentally appropriate regardless of experiencing grief. A third statistically significant correlation was between life stressors and parent child relational stress. Higher rates of reported life stressors, in addition to grief, correlated with higher rates of parent child relational stress. The study noted children struggled to cope with multiple stressors while grieving, which contributed to higher levels of parent child relational stress. Children with lower reported life stressors were reported to potentially have increased support from parents and greater overall stability as well (Ener & Ray, 2017).

A literature review exploring the prevalence of complicated and traumatic grief in children following a sibling death was completed by Dickens (2014). The literature review reported prevalence and higher risks of children developing complicated and

traumatic grief following the loss of a sibling. Children rarely experienced the loss of a sibling and struggled to process and cope with such a loss. Factors such as the abruptness and cause of the death, level of family cohesion, age, and relationship with the sibling prior to their death, impacted the grieving process and increased the prevalence of complicated and traumatic grief. Children experiencing complicated grief might struggle to understand or accept the grief for a prolonged time interval. Children might also avoid memories of their deceased sibling, experience persistent or intrusive thoughts regarding the deceased, and manifested an irrational desire to be with their deceased sibling

(Dickens, 2014).

Symptoms reported by children experiencing complicated grief included blame, guilt, and anger towards themselves and other family members. Disrupted sleep patterns, decrease in academic performance, avoidance of discussing the deceased sibling, and fear for remaining siblings’ well-being may have also developed in children experiencing complicated grief. Older children and adolescents might withdraw from others, internalize emotions, display acting out behaviors, experience emotional pain and depressed mood, and struggle to find meaning in their life and meaning of the loss

(Dickens, 2014). Children experiencing traumatic grief had high prevalence of PTSD diagnosis as well. Assisting grieving children to express and identify emotions, share memories, and incorporate the deceased sibling into special occasions and holidays were reported as helpful in aiding children to process traumatic grief (Dickens, 2014).

Developmental Stages of Grief in Children. Special considerations for grief in children is needed since children conceptualize, process, and cope with grief differently than adults could due to developmental variances (Himebauch et al., 2008). Children that

experienced grief are at an increased risk of developing mental health concerns due to difficulty conceptualizing and processing death and grief (Himebauch et al., 2008;

Sandler, et al., 2010). They may blame themselves and others for not preventing the death and experience guilt and shame while grieving (Himebauch et al., 2008). Children might become worried for their own wellbeing as well as the wellbeing of others. They might feel alone, worried, fearful, anxious, depressed, exhibit acting out and risk-taking behaviors, and experience somatic complaints during their grieving process (Himebauch et al., 2008; Sandler, et al., 2010).

Symptoms and experiences of grief in children are impacted by their developmental stage. Himebauch et al. (2008) reviewed children’s experiences of grief and concepts of death based on developmental ages. The researchers noted children often processed grief in small spans of time and reprocessed their grief as they moved through developmental stages. As children grew and entered developmental stages, their grief was impacted with their growing understanding and perception of the world (Himebauch et al., 2008). Depending on development, children could struggle to understand the permanency of death, particularly for children younger than six years of age. Children younger than six are more likely to view the world in a concrete manner. They might become distressed when separated from attachment figures or significant others. They could also struggle to communicate their grief and regress behaviorally (Himebauch et al., 2008).

Around age six to eight, children may begin to conceptualize death as permanent.

Concerns of family members or other significant individuals dying may arise as well

(Himebauch et al., 2008). Children might blame themselves for the death and experience

guilt and shame as they attempt to process their grief. Anger towards the deceased for leaving them or anger towards themselves for not preventing the death was reported as part of the grieving process for children (Himebauch et al., 2008).

Beginning around age eight through age twelve, children may begin to conceptualize death and grief in a logical manner. They start to understand the biological aspects of death and might become interested in religious and cultural traditions regarding death and grief. Children also begin to understand causal relationships during this developmental stage but might not yet have mastered emotional expression and processing. Children ages eight to twelve potentially could understand the circumstances leading to the death of a significant individual but might struggle to process their emotions. Difficulty processing emotions regarding death and grief might lead to feelings of guilt or difficulty expressing emotions (Himebauch et al., 2008). Children about ages twelve and older may develop abstract thinking and become curious regarding the existential significance of death. Children in this developmental stage might exhibit strong emotional reactions while grieving but could struggle to express and process their emotions in an appropriate manner (Himebauch et al., 2008). Children could potentially feel alone, not understood, engaged in high risk behaviors, and challenge their own sense of mortality and limits.

Children generally experience difficulties processing, understanding, adjusting, and coping with grief (Himebauch et al., 2008). Reactions and experiences of grief could be impacted by the child’s development and ability to comprehend the finality of death and grief (Dickens, 2014; Ener & Ray, 2017). Special considerations for children’s grief

experiences is needed to address the unique differences in experiences, challenges, and manifestations that were distinctive from adults.

Grief and Foster Care Youth

Specific experiences of foster care youths with grief were reviewed due to the nature of the current study, which included experiences of this special population from a clinical perspective. A review of the literature via PsycInfo yielded fifteen articles that have been published in the past ten years regarding grief and foster care. Of those fifteen articles, one was applicable for review for the purpose of this study. The literature noted grief manifested when children were removed from their families of origin and placed into the foster care system (Boss, 1999; Mitchell, 2018). As children have been placed into the foster care system, relationships may become severed, strained, or distant which has resulted in experiences of grief. Foster care youths may grieve non-death losses of parents, family members, siblings, and loved ones (Mitchell, 2018).

Children are removed from homes that have been deemed by state child welfare agencies to be unsafe or harmful for the child (Mitchell, 2016, 2018). Foster care youths might not perceive their removal from loved ones and families as beneficial, but as negative or traumatic experiences due to the sudden change of familial relationships and placement into a strange and unfamiliar home (Mitchell, 2016; Mitchell & Kuczynski,

2010). The lack of understanding, stability, and predictability for children regarding reunification with their family and their journey in foster care has contributed to grief manifestations (Mitchell, 2016, 2018). Grief symptoms have included acting out behaviors, disruption in sleep and eating habits, aggressive behaviors, change in academic performance, and tearfulness. Foster care youths have also experienced

sadness, anger, confusion, fear, guilt, worry, anxiety, feeling unloved, loneliness, hopelessness, and helplessness (Fineran, 2012; Mitchell, 2016; Mitchell & Kuczynski,

2010).

Lived experiences and manifestations of grief for foster care youths were analyzed by Mitchell (2018) by conducting an applied theoretical study. The study explored the lived experiences of foster care youths from an ambiguous loss and grief framework that utilized secondary data. Results regarding ambiguous loss were reviewed in the ambiguous loss and foster care section. Mitchell (2018) drew upon findings from a qualitative longitudinal study exploring outcomes of over two hundred foster care youths transitioning out of the foster care system. The longitudinal study was conducted between

2010 and 2015. Data collection was conducted in three waves at ages seventeen, nineteen, and twenty-one. The applied theoretical study conducted by Mitchell (2018) utilized findings from the final wave of data collection at age twenty-one and included questions exploring lived experiences of loss and transitions while entering foster care, experiences during foster care placement, separation from important individuals and family members, and memories of others acknowledging their loss. The study’s analysis of the third wave’s data through a grief lens yielded results indicating foster care youths experienced grief due to non-death losses (Mitchell, 2018).

The study also indicated participants experienced symptoms of fear, depressed mood, loneliness, helplessness, confusion, anger, acting out behaviors, aggressive behaviors, hopelessness, sadness, and shame during their time in the foster care system

(Mitchell, 2018). Participants recounted experiences of loss and grief when they entered foster care and during foster care. One participant noted difficulty coping with the initial

separation from his birthparents and siblings and described the accompanying emotional pain he experienced during that time. This participant reflected on the “emotional death” he experienced after removal from his birth parents (Mitchell, 2018). The loss of relationship from his birth parents was reported as very sudden and emotionally painful and the resulting grief was overwhelming. The participant reported the experience of grief from being removed from his birth parents as being much like the grief he experienced following the death of a loved one. The overwhelming grief impacted the participant’s ability to adjust to new foster home placements. Difficulty adjusting to foster home placements could have increased risks of placement disruptions (Mitchell,

2018).

Another participant recounted experiences of multiple placements due to acting out behaviors fueled by difficulty processing and grieving the loss of her birthparents.

The participant noted struggling to accept support and comfort from foster parents due to longing for her birth parents. The participant reported consistent anger and frustration due to experiencing multiple placement disruptions, numerous new foster homes, and adjusting to several new foster families during her experience in foster care. Some participants noted grieving the loss of relationships with former foster parents when foster placements were disrupted. Increased foster care placements could lead to increased experiences of grief as foster care youths are separated from their families of origin, to then have multiple foster parents and foster siblings (Mitchell, 2018).

Mitchell (2018) reported participants’ lived experiences of loss while entering foster care and during foster care indicated overall difficulty coping with grief symptoms due to lack of support, lack of acknowledgment of grief, and lack of acceptance of their

grieving process. The overall theme of the study noted foster care youth experienced disenfranchised grief due to their experiences of grief not being addressed or acknowledged by individuals in their lives during their foster care experiences (Mitchell,

2018). Participants reported feeling unheard and unable to express their grief. Most participants reported their foster parents, caseworkers, and other professionals did not acknowledge their loss and hurt. The lack of acknowledgment negatively impacted their grieving experiences (Mitchell, 2018). Participants recounted being told their removal from their parents should be considered a positive experience and not viewed as a loss.

Minimal research examining the experiences of grief of foster care youths have been completed. The current literature indicated foster care youths experienced non-death grief when removed from their families of origin and placed into the foster care system.

The non-death grief experienced was comparable to grief due to the death of a significant individual. Reviewing the literature related to foster care youths’ experiences of grief assisted in providing relevant information addressing the purpose of the current study.

Clinical Conceptualizations of Grief

Clinical conceptualizations of grief for the current study has been defined as the manner in which clinicians understand and perceive grief experiences, disorders, and manifestations from a clinical standpoint. Clinical conceptualizations could also include clinical experiences, diagnoses, assessments, and treatment approaches. A search of the literature pertaining to clinical conceptualizes of grief conducted via PsycInfo highlighted an emphasis on diagnosing, assessment instruments, and clinical treatments of grief. The literature review reflected similar findings with minimal variations in information and

results specific to clinical conceptualizations. Relevant literature regarding the manner which clinicians conceptualized grief was reviewed.

DSM-5 Diagnoses. The majority of journal articles included in the literature review noted reference to the DSM-5 as a source of diagnostic information. The relevant diagnostic codes for grief disorders in the DSM-5 were included for review due to the common practice of clinicians utilizing the manual for diagnostic information, criteria, and aiding in the diagnostic process (APA, 2013; Jordan & Linz, 2014). In the DSM-5, grief was referred to as bereavement and defined as “the state of having lost through death someone with whom one has had a close relationship. This state includes a range of grief and mourning responses” (APA, 2013, p. 818).

Uncomplicated Bereavement. Bereavement was categorized in two sections of the manual. The initial entry of grief was listed as Uncomplicated Bereavement and classified as a Z Code (Z63.4) in the “Other Conditions That May be a Focus of Clinical

Attention” section of the manual (APA, 2013). Uncomplicated Bereavement and other conditions listed in this section were not considered mental disorders. The APA (2013) indicated the uncomplicated bereavement code could be utilized when the clinical focus was a reaction to the death of a loved one and not an official mental disorder. The symptoms and duration may vary and could be impacted by cultural values. Some symptoms associated with uncomplicated grief were insomnia, weight loss, depressed mood, and poor appetite according to the DSM-5 (APA, 2013). Symptoms manifested with uncomplicated bereavement might reflect symptoms similar to a major depressive episode or major depressive disorder (MDD) but do not meet the full criteria (APA,

2013).

Persistent Complex Bereavement Diagnosis. The second classification of grief was persistent complex bereavement disorder (PCBD), which was categorized in the

“Other Specified Trauma-and Stressor-Related Disorder” section of the manual. The corresponding code for this category was 309.89 (APA, 2013). This category referred to the categorization of symptoms that did not meet the full criteria of trauma and stress related disorders but might have caused clinically significant distress or impairment for the individual. The APA recommended use of this category to indicate concerns related to trauma and stress disorders followed by the specific reason, such as PCBD (APA,

2013). PCBD was described as “severe and persistent grief and mourning reactions”

(APA, 2013, p. 289). Further information and proposed criteria for PCBD was located in the “Conditions for Further Study” section.

Proposed criteria for section A of the PCBD diagnosis included experiencing the death of an individual with whom they had a close relationship (APA, 2013). Proposed symptoms from sections A, B and C must be experienced for a majority of the days for a minimum of twelve months for adults and six months for children following the death of a close individual. One of the following proposed symptoms for section B must have occurred, such as pervasive longing for the deceased, severe sorrow, recurrent crying, emotional pain, preoccupation with the deceased and preoccupation with circumstances resulting in the death.

A minimum of six of the following symptoms in section C must have been experienced as well. Criteria for section C included the following: difficulty accepting the death of a close individual, difficulty reflecting on positive memories regarding the deceased, anger, blame, avoidance of reminders of the deceased, longing to die to be

reunited with the deceased, reduced ability to trust others, withdrawing or sense of loneliness, loss of purpose and meaning in life without the deceased, identity or role confusion following the death of a close individual, reduced interest in hobbies or socializing, and significant impairment in social, educational, or occupational settings.

Grief experiences and reactions varied across social and cultural groups (APA, 2013).

Concerns of the DSM-5. Concerns regarding proposed criteria for grief disorders in the DSM-5 were indicated by Jordan and Litz (2014) in their article exploring and analyzing diagnostic assessment and treatment considerations for complicated grief.

Concerns regarding the validity of the proposed criteria were evident in the literature.

One concern was the lack of evidence supporting the proposed time frame of experiencing symptoms consistently for minimally twelve months for a complicated grief diagnosis. There has been more research and evidence supporting a time frame of experiencing symptoms consistently for minimally six months to indicate a clinical grief disorder (Jordan and Litz, 2014). The DSM-5 also lacked a comprehensive mental diagnosis and criteria for diagnosing complicated grief. Until future revisions of the

DSM-5 are published and incorporate proposed criteria for complicated grief, clinicians have the option to assess for and diagnose related disorders.

Related disorders clinicians could assess and diagnose for are Uncomplicated

Bereavement, Unspecified Trauma-and-Stressor Related Disorder, or Other Specified

Trauma-and Stressor-Related Disorder specifying Persistent Complex Bereavement

Disorder (Jordan & Litz, 2014). Empirically based diagnostic procedures for working with grief was lacking in the literature. Most grief assessments were self-report measures, questionnaires, and less empirically based measures. Researchers have noted very few

manualized treatment options have been developed and have not been widely accessible

(Jordan & Litz, 2014). Clinical experiences treating clinically significant grief disorders began prior to the accumulation of formal and empirically based research and literature.

Thorough research regarding the clinical conceptualizations of grief disorders was relatively underdeveloped compared to the extensive history of clinical grief work

(Jordan & Litz, 2014).

Grief Assessments. A search of the literature for grief assessments through

PsycInfo reflected two self-report instruments. Those instruments were identified as appropriate and effective assessments for complicated grief and could be incorporated into clinical treatment. The Inventory of Complicated Grief was a commonly used assessment to assess for and identify the presence of clinically significant grief symptoms

(Jordan & Litz, 2014). The assessment was reported as a valid and reliable measure, which also accounted for general mood and anxiety symptoms. The Inventory of

Complicated Grief consisted of nineteen grief related statements exploring thoughts and behaviors following the death of an individual. A Lykert scale with five options has been available to indicate severity of symptoms (Jordan & Litz, 2014).

The recommended time frame for administering The Inventory of Complicated

Grief was minimally six months following the death of a loved one. The second assessment reported by Jordan and Litz (2014) was the Brief Grief Questionnaire. The questionnaire consisted of five questions focused on grief symptoms. A three-point scale was available following each question. The Brief Grief Questionnaire did not take long to administer and could be utilized with various cultures. Assessing for suicidality might be necessary when complicated grief has been identified due to common comorbidity with

MDD. Assessments such as the Beck Scale for Suicidal Ideation and the Yale Evaluation of Suicidality Scale were indicated as helpful in assessing for suicide risks (Jordan &

Litz, 2014).

Jordan and Litz (2014) noted the importance of assessing for common comorbid disorders when assessing for complicated grief. MDD and PTSD were noted as common comorbid disorders to assess for in addition to assessing for complicated grief. However, complicated grief could trigger underlying mental health disorders for individuals that struggled with MDD and PTSD prior to experiencing the death of a close individual

(Jordan & Litz, 2014). A notable distinction between complicated grief and MDD was the pervasive nature and generalized depressed mood associated with MDD, whereas symptoms of complicated grief stemmed from and surrounded the loss of a loved one.

PTSD symptoms following the death of a close individual could also occur. Grief symptoms similar to PTSD symptoms included intrusive thoughts fixated on the deceased, preoccupation on the events surrounding the death, and avoidance of reminders of the deceased or death. The following symptoms were specific to a PTSD diagnosis and could be utilized to distinguish from a complicated grief diagnosis: nightmares, aggression, flashbacks of the events surrounding the death, and a sense of threat or worry.

Enez (2018) reported similar findings as Jordan and Litz (2014) regarding the diagnosis and assessment of grief. Differential diagnosis and comparison of complicated grief with MDD and PTSD were also analyzed and yielded similar findings. The limitations of the DSM-5’s diagnostic guidance on complicated grief and clinically significant grief was highlighted. Grief could manifest in a variety of unique manners depending on individual and cultural values and beliefs. Reports and observations of grief

symptoms derived from clinical experiences and conceptualizations included persistent longing for the deceased, suicidal ideation, self-harm behaviors, and preoccupation with circumstances surrounding the death for minimally six months (Enez, 2018).

The Inventory of Complicated Grief and Texas Revised Inventory of Grief were analyzed along with several other grief assessments utilizing a meta-analysis to analyze their reliability, validity, and availability (Enez, 2018). The Inventory of Complicated

Grief was reviewed in the previous article. The Texas Revised Inventory of Grief is a twenty-one-item scale assessing for unresolved or clinically significant grief. The first subscale included eight items assessing feelings and actions at the time of the death of a loved one. The second subscale included thirteen items assessing current feelings. A five- point scale indicating frequency was included following each item. Additional informal assessments exploring the impact of grief and loss of a loved one on domestic roles, financial concerns, daily functioning, sense of purpose in life, and withdrawal from social supports may have assisted in identifying risk factors and difficulty coping with grief.

Grief Treatment Approaches. Jordan and Litz (2014) reported the lack of a comprehensive and unified diagnostic criteria for complicated grief hindered the advancements of empirically based grief treatments. Pilot studies have suggested grief specific individual therapy were a beneficial treatment modality for grief. Grief specific individual therapy has incorporated psychoeducation regarding grief and the grieving process, importance and benefits of processing the grief and death of a loved one, returning to and engaging in life functions that may have stopped, exploring history of relationship with the deceased, and determining clinical goals (Jordan & Litz, 2014).

Clinical exercises and interventions included progressively increasing exposure of images

and recordings of the deceased, role-playing conversations with the deceased, processing positive and negative memories, developing plans toward life goals, brainstorming strategies to reduce avoidance of situations that trigger grief symptoms or reminders of the deceased, and challenging grief related cognitive distortions and self-blame.

Grief specific individual therapy was found to be an effective treatment modality to reduce grief symptoms (Jordan & Litz, 2014). Group therapy that incorporated or focused on grief counseling may also have been an effective treatment modality for clinically significant levels of grief. Group therapy included similar components and interventions as individual grief specific therapy modalities. Group therapy treatments allowed for increased support and praise from other clients in the group over the course of therapy. The grief focus, interventions, and group modality were found to be effective in treating clinically significant grief and complicated grief as indicated by Jordan and

Litz (2014).

The impact and symptoms of grief were also explored by Crunk, Burke, and

Robinson (2017) in a conceptual article. The article clinically conceptualized complicated grief and clinically significant grief symptoms. Information regarding the diagnosis, assessment, symptoms, and differential diagnosis of grief disorders was similar to previously mentioned articles and was not reviewed. However, identified treatment approaches were reviewed. Clinical intervention and treatment were found to be effective in the reduction of grief symptoms. Informal treatments and processing with time provided enough relief for uncomplicated grief manifestations (Crunk et al., 2017).

Clinically significant grief or complicated grief required clinical intervention and

treatment to assist in accepting and processing the loss and reduced risk of suicidal ideation.

Treatments incorporating monitoring of severity, frequency, and impact of grief symptoms assisted in reducing risk of harm. Techniques emphasizing positive memories, negative memories, and future planning were also indicated as beneficial and effective treatment approaches (Crunk et al., 2017). Cognitive Behavioral Therapy was noted as an effective treatment modality due to challenging negative cognitions stemming from the grief, replacing avoidance behaviors with coping skills, emphasizing positive and healthy thoughts, reducing guilt and blame, increasing social supports and prosocial behaviors, increasing acceptance of the deceased, and cognitively conceptualizing life without the deceased (Crunk et al., 2017). Restorative retelling was a ten-week group therapy treatment model with the purpose of addressing trauma and grief symptoms. Stabilization was the first step of the treatment prior to reducing distress, increasing resiliency, and celebrating the deceased. Results of the restorative retelling group therapy treatment indicated increased processing and coping with the death of a loved one, reduced trauma and grief symptoms, increased resiliency, reduced depression symptoms, and reduced avoidance of negative stimuli associated with the death (Crunk et al., 2017).

Shear and Bloom (2017) analyzed the effectiveness of another grief treatment modality, Complicated Grief Treatment (CGT). CGT is an empirically based treatment modality for complicated grief and includes structured treatment intervention that occurs over the span of sixteen weeks and four phases (Shear & Bloom, 2017). The clinician serves as a guide assisting the client to process, cope with, and honor the loss of a relationship and loved one. The goal of the treatment has been to accept the loss and

impact on life, establish new meaning and purpose, and gain knowledge. Core components of the treatment consists of sharing information, increasing self-awareness, self-regulation, rebuilding connections, working towards goals, processing the death of a loved one, processing life without the deceased, and enhancing bonds (Shear & Bloom,

2017). Empathy, hope, understanding, and adjusting to the loss are emphasized during the counseling process in addition to the structure to ensure the client’s needs were met.

Objectives of the first phase are to establish rapport, view client’s loss from their perspective, provide psychoeducation, begin monitory grief manifestations, and develop goals. The second phase focuses on processing the death, accepting the loss, coping with the grief, reestablishing connections, and conceptualizing a life without the deceased

(Shear & Bloom, 2017). The third phase continues the objectives of the second phase and incorporates reflecting on memories of the deceased. The fourth phase reviews progress towards goals and strategies to maintain progress, reviews and processes positive and negative memories, and prepares the client for treatment termination. The complicated grief treatment modality has been utilized in multiple clinical trials and the effectiveness of the model has been consistent. The treatment model has reduced distress and grief symptoms (Shear & Bloom, 2017).

The review of the literature for clinical conceptualizations of grief provided information regarding diagnosing, assessment instruments, and clinical treatments of grief. The literature review reflected a lack of diagnostic information, as well as criticisms of the DSM-5’s current proposed criteria. The literature also lacked empirically based assessments and treatment modalities. More empirically based research and

diagnostic information will be needed to better conceptualize, assess, and clinically treat grief experiences.

Gaps within Grief Literature

A unified and concise definition of grief was lacking within the literature (Enez,

2017). Various facets of grief have emerged in an attempt to account for the spectrum of grief. Concise and effective treatment modalities have also been lacking in the literature specifically regarding traumatic and disenfranchised grief (Barle, 2017; Burns et al.,

2018; Enez, 2017; Friedman, 2012). Barle et al., (2017) reported a lack of clinical focus and research in the comorbidity of PTSD and Persistent Complex Bereavement Disorder.

Trauma-focused treatment was present in the literature, but treatment for the grief resulting from a traumatic experience was lacking. The impact of the trauma on the grieving process was shown to significantly alter the grief from uncomplicated to a maladaptive form of grief (Barle et al., 2017; De Heus et al, 2017; Kristensen et al.,

2012). Accurate and concise diagnostic criteria for grief, empirically based treatments, and assessments were also lacking in the literature. The DSM-5, a widely utilized manual for the diagnosis of mental disorders, lacked appropriate information and diagnostic criteria for clinically significant grief disorders and symptoms (APA, 2013; Jordan &

Litz, 2014). A lack of comprehensive and unified diagnostic criteria for complicated grief hindered the advancements of empirically based grief treatments. It was unclear which components of clinical treatment modalities were effective and necessary for treating grief. There was also limited research indicating which components of grief were associated with developing a clinically significant grief disorder. Empirically based treatment modalities, assessments, and diagnostic resources were also lacking.

Research indicated grief was defined and recognized as a distinctive mental disorder, however, the DSM-5 did not reflect this (Jordan & Litz, 2014). Increased recognition of the potential for grief to develop into a mental disorder and corresponding diagnostic criteria was limited in the literature. Research regarding diagnosing, assessing, and treating grief were gaps in the literature that this study aimed to assist in addressing.

The literature contained differing criteria distinguishing uncomplicated grief from clinically significant grief and from common comorbid disorders. Some of the literature reported suicidal ideation as an indicator of MDD and not clinically significant grief, however, Enez (2018) reported literature included suicidal ideation as a symptom of grief. The literature and DSM-5 also differed on appropriate time frames of experiencing symptoms following the death of a loved one to indicate a grief disorder.

Another gap in the literature was the lack of research regarding non-death losses.

The majority of the literature centered on grief resulting from the death of a significant individual (Burns et al., 2018). The studies that acknowledged grief experiences due to non-death losses were present in studies regarding disenfranchised grief. More research was needed to explore the intersections of trauma and stigma on loss and grief, to better serve clients grieving the death of a significant individual. The current study also aimed to address this gap in the literature by exploring the experiences of grief stemming from non-death losses for foster care youth and the manner in which clinicians conceptualized the resulting grief.

Ambiguous Loss

Non-death losses could also be considered ambiguous losses. Ambiguous loss was created by Pauline Boss in the 1970’s (Boss, 1999). The following literature review

provided review of the limited literature regarding ambiguous loss. The literature review of ambiguous loss conducted with PsycInfo included operationalizations of ambiguous loss, a review of physical and psychological loss, special considerations of ambiguous loss in children, clinical conceptualizations of ambiguous loss, and gaps in the literature pertaining to the topic. Most of the literature stemmed from the seminal works of ambiguous loss by Pauline Boss and reported similar findings. This literature review informed the current study by offering a better understanding of the experiences, manifestations, and conceptualizations of ambiguous loss. Interview protocols of the current study benefited from the information gathered in the literature review of ambiguous loss.

Defining Ambiguous Loss

The literature defined ambiguous loss as the experience of an uncertain loss that may not be substantiated. Uncertain losses of a significant individual or loved one included a physical absence, psychological absence, or not knowing if the individual was alive or deceased (Robins, 2016). Ambiguous loss was noted in the literature as one of the most stressful losses due to the uncertainty and lack of resolution (Boss, 2016).

Ambiguous loss led to a sense of enduring grief, anguish, isolation, loneliness, hopelessness, helplessness, guilt, and stigma regarding the inability to find closure and cope with the loss (Boss, 1999, 2006, 2007, 2016). The uncertain and unsubstantiated nature of the loss hindered closure and acceptance regarding the loss (Boss, 1999, 2007,

2016). Living in a state of uncertainty and ambiguity regarding a loved one’s whereabouts, well-being and safety manifested as stress, depression, anxiety, or family conflict (Boss, 2016). The lack of uncertainty and resolution defining the loss could have

led to a lack of validation and support from social supports and others. The finality of the death of a significant individual or loved one is often proceeded by rituals to process and honor the loss, could provide a sense of finality and opportunities to receive support from others (Solheim & Ballard, 2016).

The literature also indicated experiences of uncertainty regarding family roles, membership, and structure developed following an ambiguous physical loss of a family member. Experiences specific to family structure was termed boundary ambiguity and focused on the impact families experienced following uncertain losses (Boss, 1999, 2006,

2016). The impact on family structure after loved ones were physically absent for undetermined periods of time dominated the initial literature as the concept of ambiguous loss was formed (Boss, 2016). As the literature grew and evolved, the term ambiguous loss was utilized to capture broader experiences of loss that were more applicable to the wider range of topics and populations covered in the research. The literature regarding ambiguous loss expanded beyond family structure and included uncertain loss due to addiction, cognitive impairment, health complications, mental health concerns, violence, war, acts of terrorism, and natural disasters (Boss, 1999, 2006, 2016; Mechling et al.,

2018; Solheim & Ballard, 2016).

The majority of the articles published within the past ten years have centered around the two main constructs of ambiguous loss: physical loss and psychological loss

(Boss, 2016; Mechling et al., 2018). Ambiguous loss due to a physical absence could occur when there was uncertainty regarding the duration of the absence, uncertainty regarding the individual’s whereabouts, circumstances surrounding the absence were unclear, or the well-being of the individual was uncertain (Boss, 2016). Ambiguous loss

due to a psychological absence could occur when the individual was physically present but psychologically absent. The literature noted cause for psychological absences could be due to cognitive impairment, addiction, medical concerns, mental health concerns, or difficulty with memory while remaining physically present (Boss, 2016). The literature regarding physical loss, psychological loss, as well as special considerations for children experiencing ambiguous losses were reviewed.

Physical Ambiguous Loss

The literature defined physical ambiguous loss as uncertainty of a significant individual’s whereabouts, well-being, or if they were alive or deceased (Boss, 1999,

2016). Ambiguous physical losses were due to an array of circumstances and events including war, acts of terrorism, kidnapping, genocide, natural disasters, emigration, incarceration, divorce, or adoption (Boss, 2016; Shalev & Ben-Asher, 2011). Ambiguous loss also occurred when a significant individual was absent from one’s life permanently or for a substantial period of time (Mechling et al., 2018). The lack of certainty and evidence of an individual’s death or permanent loss maintained the presence of the individual psychologically for their families and other significant relationships (Boss,

2016). The inability to confirm if an individual was alive or deceased hindered the grieving process. Individuals were prone to experiencing despair, depression, doubt, guilt, denial, and anxiety when the physical absence of a significant individual was uncertain (Shalev & Ben-Asher, 2011). Literature regarding symptoms of ambiguous loss experienced by children included prolonged stress, fear of abandonment, confusion, worry regarding the well-being of the absent family member, general fear, anger, sadness,

increased acting out behaviors at home and school, sadness, and rumination regarding the return of the absent family member (Shalev & Ben-Asher, 2011).

Solheim and Ballard (2016) reviewed relevant literature regarding the experience of ambiguous loss of families that voluntarily emigrated. Families that emigrated were at higher risk of experiencing ambiguous loss due to physical distance from family members remaining in their country of origin (Solheim & Ballard, 2016). The emigrated family as well as the family members that remained in the country of origin reported experiencing emotional pain, worry, depression, loneliness, distress, isolation, loss, and disconnection from physically absent family members (Solheim & Ballard, 2016).

Children specifically reported loneliness, anxiety, isolation, distress, deep sadness, worry, stress, attachment injuries and confusion regarding relationships with absent family members. Families that emigrated noted loss of connection to absent family members as well as to their countries of origin. Uncertainty regarding reunification or visits with absent family members contributed to the sense of loss (Solheim & Ballard,

2016). The distance from absent family members created a sense of disconnect and uncertainty regarding the continuation of the relationships. The physical absence of family members resulted in the renegotiation of family roles and responsibilities among the present family members. The process of establishing new roles and responsibilities resulted in confusion, delayed decisions, and unfulfilled tasks due to uncertainty of how to restructure the family to accommodate for absent members (Solheim & Ballard, 2016).

The physical restructuring of the family system did not obstruct the psychological presence of absent family members. Consistent communication with absent family members reduced worry, sadness and created a sense of separation. Limited or no

communication increased worries, sadness and disconnect from absent family members.

Solheim and Ballard (2016) reported families of undocumented workers worried about the worker’s safety, immigration status, living conditions, health care, financial stability, and access to consistent food and shelter. Emigrated individuals reported a longing for reunification and enduring homesickness (Solheim & Ballard, 2016).

Shalev and Ben-Asher (2011) completed a pilot study analyzing the impacts of physical ambiguous loss and noted the difficulty of coping with such a loss. The pilot study completed four in depth interviews of adult children that have experienced physical ambiguous loss due to their fathers becoming prisoners of war. The study emphasized the impact of the physical loss as well as the uncertainty regarding the well-being and return of their fathers. Participants reported struggling to cope with the physical absence and psychological presence of their fathers. Family roles, responsibilities, and routines became uncertain and difficult to navigate due to uncertainty if their fathers would return.

The passing of holidays, birthdays, celebrations, and family traditions were indicators of how long their fathers had been absent and exacerbated the experiences of loss.

Participants reported experiencing worry, confusion, a sense of abandonment, despair, withdrawing from others, fear of abandonment, prolonged stress, pressure to cope and persevere, denial of loss, depressed mood, helplessness, anger, and rumination regarding the absent individual and their well-being (Shalev & Ben-Asher, 2011).

Symptoms were persistent during their fathers absences and relief was reported after the ambiguity of the loss was clarified. Clarification of the ambiguity occurred when the individual returned or when information confirming the death or permanent loss of an individual was verified. The return of a physically absent individual did not necessarily

resolve the symptoms stemming from the ambiguous loss. The length of time the individual was absent, the circumstance leading to the absence, and other factors impacted the ability to process and heal from the loss. Physical ambiguous loss due to violence may have included persistent worry and fear of future physical losses of loved ones (Shalev & Ben-Asher, 2011). The family structure adapted to the physical absence of a family member and the return of the absent family member increased stress, tension, and role confusion. The adult children reported difficulty reintegrating their fathers into the family structure upon their returns. The families had adjusted to the fathers’ absence and were uncertain how to redistribute roles and responsibilities to include their fathers.

Individuals experiencing an ambiguous loss due to physical absence of a significant individual also reported difficulty feeling understood by social supports and the community due to the unique nature of their loss. Individuals noted pressure to reduce manifested symptoms following the physical ambiguous loss (Shalev & Ben-Asher,

2011). Similar symptoms were reported by individuals experiencing ambiguous loss due to the psychological absence of significant individuals (Boss, 2016; Shalev & Ben-Asher,

2011).

Psychological Ambiguous Loss

Psychological ambiguous loss occurred when the loss was emotional, relational, or cognitive (Boss, 2016; Shalev & Ben-Asher, 2011). The individual was physically present, but their mental capacity and personality was not (Mechling et al., 2018). A physical presence with psychological absence occurred when individuals struggled with cognitive impairment or memory loss. Medical and mental health concerns such as

Alzheimer’s Disease, chronic mental illness, traumatic brain injury, addiction, dementia,

or other conditions impeded an individual’s ability to be psychologically present (Boss,

1999, 2006, 2016; Mechling et al., 2018). Individuals experiencing psychological losses were faced with the challenge of coping with the duality of the absence and the presence of a significant individual (Boss, 2006).

Psychological ambiguous loss could elicit symptoms of anger, shock, denial, loneliness, confusion, sense of loss, sadness, grief, and confusion (Coolhart et al., 2018).

The complexity and contradiction of the loss can be difficult to cope with and understood by the individuals experiencing the loss, as well as the community surrounding them

(Boss, 206). The loss may not be recognized by others due to the physical presence of the significant individual, resulting in a lack of support and understanding. The physical presence and lack of support hindered the process of adjusting to and accepting the loss

(Coolhart et al, 2018).

Special Considerations of Ambiguous Loss in Children

Developmentally, children struggled to comprehend the paradox of a physically present but psychologically absent parent (Boss, 2006). Current literature regarding experiences of ambiguous loss of children and foster care youths was relevant to the current study and assisted in addressing the aims of the study. The current study aimed to explore the impact of ambiguous losses experienced specifically by foster care youths and to better understand the current literature to aid the development of the interview protocols.

Bocknek, Sanderson, and Britner (2009) also aimed to better understand the experiences of ambiguous loss by children. School aged children experiencing the physical ambiguous loss of a parent due to incarceration were analyzed. A mixed

methods approach was utilized and incorporated semi-structured interviews and standardized assessments measuring social support, trauma symptoms, behaviors, and interpersonal strengths. The study included thirty-five school aged participants recruited from a mentoring program. The results of the study indicated children experiencing the physical ambiguous loss of an incarcerated parent experienced high rates of internalizing and externalizing behaviors, stress, trauma symptoms, decreased mental health functioning, anxiety, anger, aggression, depressed mood, somatic symptoms, fear, worry, and guilt (Bockneck et al., 2009).

Uncertainty regarding visits with their incarcerated parent, their parent’s well- being, and when their parent would be able to return home maintained the symptoms. The ambiguity led to a loss of hope, denial, confusion, and difficulty coping with the physical absence for some of the participants. Increased ambiguity surrounding the loss led to an increase in seeking clarity and information. Participants reported difficulty obtaining information due to lack of resources or other individuals refusing to inform participants with accurate information. Difficulty obtaining information was reported to increase frustration, ambivalence, worry, and stress (Bocknek et al., 2009). The majority of the participants struggled to cope with the loss, adjust to life without the physical presence of their incarcerated parent, and lacked social support.

Children of incarcerated parents struggled to cope with the physical absence and psychological presence of the loss. Children reported worrying about and thinking about their incarcerated parent frequently and struggled to accept and adjust to their loss

(Bocknek et al., 2009). Uncertainty regarding when the loss would end hindered their

ability to cope during the process. Children coping with the psychological loss of a parent due to opioid use reported similar symptoms.

Mechling et al. (2018) examined experiences of children with parents struggling with opioid use through an ambiguous loss lens. The examination reported children were at higher risk of not receiving appropriate support and resources to develop healthy psychosocial skills and resiliency when a parent was psychologically absent (Mechling et al., 2018). Children may have perceived their parent as emotionally unavailable or changed from how they once recognized and understood them (Mechling et al., 2018).

The parent child relationship became at risk of being negatively impacted by the loss and the child may have struggled to receive support and nurturance. In turn, children struggled to express thoughts and emotions in a healthy manner and reduced help seeking behaviors.

Children reported losses of the relationship with their parent, of having parent child experiences, of a sense of control, and of receiving consistent attention (Mechling, et al., 2018). The experienced losses resulted in confusion, increased worries and uncertainty, difficulty adapting and coping with life stress, parentification of one child to care for their siblings, guilt, and fear of blame (Mechling et al., 2018). Uncertainty regarding the parent’s role in the family and division of responsibility arose as well due to the ambiguous loss of a psychologically absent parent. Tension, stress, and conflict became present in the home as present family members struggled to adjust to a psychologically absent parent. Children exhibited increased anger and acting out behaviors at home and school in response to the chaos in family structure and psychological loss of a parent (Mechling et al., 2018).

Mechling et al. (2018) noted children experiencing the ambiguous loss of a parent struggling with opioid use benefited from receiving support and nurturance from other caregivers. The support and nurturance from other caregivers provided a sense of value, understanding, and opportunities for healthy psychosocial development. Individuals struggling with psychological ambiguous loss benefited from supports that validated and acknowledged their loss (Boss, 2006; Mechling et al., 2018). The validation and support assisted in reducing guilt, anger, blame, loneliness, confusion, and sadness. The support and validation also increased understanding, meaning, value and purpose of the individual experiencing the psychological ambiguous loss (Boss, 2006; Mechling et al,

2018).

The literature review of ambiguous loss and children reported children struggled to cope with ambiguous loss. Participants reported a plethora of symptoms that were exacerbated by the lack of information and ambiguity surrounding the loss. Foster care youths often experience the ambiguous loss of their parents, and at times, their siblings and extended family members as well.

Ambiguous Loss and Foster Care Youth

Foster care youths are at an increased risk for experiencing multiple ambiguous losses while in foster care (Mitchell, 2016; Samuels, 2009). A review of the literature using keywords of ambiguous loss and foster care youth in PsycInfo provided one article of relevance to the current study. The article noted the loss of a loved one was one of the most stressful events an individual could experience. Children in foster care experienced this stressful event when removed from their parents (Mitchell, 2016). Children were powerless regarding their ability to reunite with their families of origin as well as their

ability to alter the circumstances which created their emotional pain. The ambiguous loss stemming from foster care placement and uncertainty regarding family relationships induced confusion, distress, pain, and shock. The impact of the ambiguous loss may have lasted for a prolonged period and became chronic due to the lack of closure and uncertainty surrounding the loss (Mitchell, 2016).

A conceptual article exploring the experiences of ambiguous loss for children placed into foster care was published by Mitchell (2016). The initial removal of children from their parents and home resulted in shock and emotional pain. Uncertainty regarding reunification, visits, and communication with parents and other family members caused distress (Mitchell, 2016). Attempts to negotiate the roles, rules, expectations, and relationships in the new foster home were confusing and overwhelming. The physical loss of the child’s home, parents, and family relationships mirrored grief reactions. Foster care youths experienced deep sadness and pain, a longing for their home and family, as well as desire to understand the circumstances resulting in their removal (Mitchell, 2016).

In attempts for closure or understanding, the foster child may have questioned reasons for removal, internalized blame and guilt, attempted to exert control, questioned world beliefs and values, and reevaluated motivations and expectations. Previous social supports had been removed, which left foster children without any safe and trusting supports to explore these questions, alleviate the distress, and challenge potential self- blame (Mitchell, 2016).

Attempting to acclimate to new environments, families, norms, values, and customs inhibited the child’s ability to gain understanding and healthy coping skills

(Mitchell, 2016). The foster care children’s familiar family structures were completely

interrupted when removed from their homes. Individuals struggled to conceptualize and understand family roles, membership, and structure. Children questioned if they were considered part of the family structure since they were no longer physically present in the home. Children placed out of the home experienced the loss of their home, loss of sibling relationships, school, peer relationships, and parental relationships (Mitchell, 2016). The ambiguity and uncertainty of the loss experienced in foster care was irresolvable during their time in foster care leading to difficulty adjusting to the loss. The uncertainty of foster care directly increased mental health symptoms as well as a reduced sense of safety and stability. The experiences and ambiguous losses due to foster care placement had traumatic impacts on foster care youths. Symptoms stemming from the losses and experiences had the potential to persist into adulthood (Mitchell, 2016).

A review of the literature indicated foster care youths are at an increased risk of experiencing multiple ambiguous losses. Due to the common practice of foster care youths experiencing multiple placements and the clear connection that placement change has to grief, it was necessary to add to the minimal pool of research connecting ambiguous loss and foster care experiences. The current study aimed to address the gap in the literature and explored clinical conceptualizations of foster care youths’ experiences with ambiguous loss. A better understanding of foster care youths’ experiences of ambiguous loss and the clinical conceptualizations of the loss could better guide treatment modalities to better serve this special population.

Clinical Conceptualization of Ambiguous Loss

For the purpose of this study, clinical conceptualization of ambiguous loss was defined as the manner in which clinicians understood and formulated experiences,

disorders, and manifestations of ambiguous loss. The literature review conducted via

PsycInfo regarding clinical conceptualizations of ambiguous loss did not include conceptualizations of diagnostic criteria but included conceptualizations of assessing and treating ambiguous loss. An in-depth review of ambiguous loss provided a deeper understanding of the clinical conceptualizations, assessments, and treatment modalities of ambiguous loss. An informed understanding of current literature regarding clinical conceptualizations of ambiguous loss informed the development of the interview protocol for the current study.

Jackson (2018) conceptualized ambiguous loss as the experience of ambivalence and ambiguity due to a lack of clear and concise information regarding a loss. Responses to ambiguous loss varied due to individual personality, cultural and religious beliefs, circumstances surrounding the loss and the ability to cope with distress. The absence of closure was noted as a key indicator of ambiguous loss which resulted in sadness, grief, loneliness, and pain. The symptoms may have persisted until closure was achieved or acceptance of the loss occurred (Jackson, 2018). Counselors could normalize the experience of the loss and provide an accepting and supportive environment to process their experiences, symptoms, emotions, and cognitions stemming from the loss. Reduced hope and movement towards acceptance of a loss could be a distressing process for the client. Jackson (2018) noted clinical treatment of ambiguous loss incorporated increasing resiliency, discovering meaning in life, providing sympathy, attempting not to minimize clients’ experiences, challenging negative cognitions, and reducing inappropriate blame.

Jackson (2018) cautioned utilizing traditional grief therapy interventions and treatment modalities as they did not address the ambiguity associated with ambiguous

loss and inhibited the client’s ability to work towards closure. Treatments specific to ambiguous loss included allowing the client to act as the expert on their life history and experiences of ambiguous loss, exploration of client narratives, and use of reflective questioning to explore the duality of absence and presence associated with ambiguous loss.

Sampson, Yeats, and Harris (2012) also spoke to the importance of addressing the duality of the absence and presence surrounding an ambiguous loss. A pilot study with eight participants engaged in a six-week psychoeducation support group sought to explore and analyze participants’ experiences with the physical presence and psychological absence of family members struggling with hoarding. The ambiguous loss framework guiding the treatment of the counseling group included psychoeducation regarding ambiguous loss, supporting and normalizing other group members’ experiences, explored and processed impact of ambiguous loss on family relationships, challenged negative cognitions and actions stemming from loss, reduced ambiguous loss symptoms, increased understanding of individual experiences of loss, and explore other losses such as loss of family traditions (Sampson et al., 2012).

Robins (2016) similarly aimed to conceptualize ambiguous loss and clinical practice applied towards community-based therapy. Ambiguous loss was conceptualized as a relational traumatic loss that was unresolved and negatively impacted an individual.

Clinical approaches and assessment practices have not been driven by a DSM diagnosis as noted by Robins (2016) but by familial and social understandings of relationships. A physical or psychological absence of a family member or loved one could greatly impact an individual. Taking into considerations the community perceptions of the loss benefited

the counseling process. Community based therapy practices included exploring the perceptions of community members regarding the ambiguity of the loss, beliefs surrounding the loss, potential assumptions, and emotions (Robins, 2016). Providing psychoeducation regarding ambiguous loss, reducing stigma, and normalizing reactions to the loss reduced symptoms.

Empowerment was another approach that was found to be beneficial.

Empowering clients to create physical or social spaces to remember and share memories, vocalize their experiences and needs, challenge negative outside perceptions, and actively engage in coping activities was helpful for community-based practices (Robins, 2016).

Reauthoring stories and identities were noted as powerful and effective in coping with ambiguous loss. Exploring how the ambiguous loss impacted clients’ identity, roles, and stories; processing the impact; and then reauthoring their stories was noted as beneficial for clients. Family therapy or group counseling could be beneficial to assist multiple clients in processing their losses (Robins, 2016).

Ambiguous loss could become a persistent and difficult experience to endure due to the lack of certainty and resolution. Clinical conceptualizations of ambiguous loss indicated clients benefited from supports that validated and acknowledged their loss

(Robins, 2016; Jackson, 2018). Clients struggled to obtain closure due to the ambiguity of the loss. Clinical treatment could focus on processing and coping with the loss as opposed to receiving closure (Robins, 2016).

Gaps within Ambiguous Loss Literature

Ambiguous loss literature lacked complexity and variety as evidenced by the majority of the articles centering on the two main constructs of physical and

psychological loss. Many articles focused on the experience of ambiguous loss regarding various special topics. However, those articles also focused on the two main constructs.

The majority of the literature reported similar findings (Jackson, 2018; Robins, 2016;

Sampson, 2012). The literature also lacked evidenced based clinical interventions and treatments to assist individuals struggling with ambiguous loss. More research was needed to appropriately diagnose, assess, and clinically treat ambiguous loss. The literature review indicated experiencing an ambiguous loss negatively impacted individuals and led to grief symptoms, however, diagnoses and evidenced based treatment modalities were limited in the research (Jackson, 2018; Robins, 2016;

Sampson, 2012). The current study sought to contribute to the gap in the literature by exploring how clinicians conceptualized, assessed, and treated ambiguous loss.

Clinical Conceptualizations of The Intersection of Grief and Ambiguous Loss

Clinical conceptualizations of the intersection of grief and ambiguous loss is defined as the manner by which clinicians understood experiences and manifestations of grief resulting from an ambiguous loss. Of the articles found during the literature review conducted by PsycInfo, two articles were relevant to the purpose of this study. The literature review provided information regarding how clinicians conceptualized the similar experiences of grief and ambiguous loss and treatment approaches. Ambiguous loss was conceptualized as an unavoidable life experience that potentially manifested into grief if closure did not occur (Boss, 2010). Appropriately conceptualizing grief and ambiguous loss enhanced client care and treatment modalities.

Clinical conceptualizations of grief stemming from ambiguous loss and effective treatment modalities were presented by Boss (2010). The manifestation of grief following

an ambiguous loss was due to the lack of closure and ambiguity surrounding the loss. The ambiguity prevented individuals from finding closure resulting in maintaining the grief which could become pervasive. Boss (2010) noted the importance for professionals to accurately understand and conceptualize the grief stemming from an ambiguous loss to ensure effective treatment. Grief stemming from ambiguous loss was distinguishably different from grief due to the death of an individual.

Professionals should carefully explore and assess the loss to determine if the loss was finite or ambiguous. If the loss was ambiguous, determining if the loss was psychological or physical influenced clinical treatment. When a loved one was physically or psychologically absent a part of them remained. The grieving individuals were faced with the remaining part of their loved ones, which prevented closure and maintained grief

(Boss, 2010). The remaining part was a reminder of the loss and prevented individuals from adjusting to the loss. Processing the grief due to the death of a significant individual could have included adjusting to life without the individual present. Grief due to an ambiguous loss might not have allowed grieving individuals to adjust to life without the significant individual due to uncertainty of if or when the individual would return. Boss

(2010) noted grieving individuals were immobilized in the grieving process.

Normalizing and addressing the immobilization of the grieving process has been an important component of treating grief due to ambiguous loss (Boss, 2010). Clients could report conflicted thoughts and emotions regarding the loss. Normalizing their experience provided a safe environment to process the conflicting thoughts and emotions and reduced the negative impact of the ambiguity. Challenging negative cognitions, guilt, and shame benefited the client as well as increased resiliency. Finding meaning and

gaining a better understanding of the loss assisted in adjusting to the loss. However, individuals struggled to find meaning or to understand the loss due to a lack of clarity in some situations. Better understanding of the impact of the loss on the individuals and their families could become another beneficial therapeutic option. Finding meaning included exploring cultural, religious, or spiritual values and beliefs. Incorporating personal beliefs and encouraging flexibility assisted clients in processing and adjusting to the ambiguous loss of a significant individual (Boss, 2010.)

Boss (2010) reported instances in which grieving family members avoided engaging in holiday celebrations and rituals due to the absence of a family members.

Exploring options for continuing to celebrate and engage in rituals and holidays while acknowledging their loss was found to be beneficial. The ambiguity and uncertainty led to a sense of helplessness and lack of control. Assisting clients’ ability to increase coping, functioning, and emotional regulation reduced helplessness and a sense of having a lack of control (Boss, 2010). The grieving process for an ambiguous loss was not a linear process and varied for each individual. Working towards closure was not necessarily an effective treatment goal. Goals focused on assisting clients in processing and adjusting to the ambiguous loss was more appropriate.

Meichsner et al., (2016) also emphasized clinical benefits of focusing on adjusting to and coping with ambiguous loss. They completed a randomized-controlled study analyzing grief intervention strategies for caregivers of family members diagnosed with

Dementia. Two hundred and fifty-three caregivers participated in the study and reported grief symptoms. A variety of interventions were utilized to determine which interventions better addressed the unique experiences of grief stemming from ambiguous loss

(Meichsner et al., 2016). Participants reported experiences of uncertainty regarding the psychological presence of family members. The dementia impacted the family members’ ability to remain psychologically present. This led to their caretakers grieving the psychological absence while dealing with the physical presence. The severity of the dementia impacted the family members’ ability to become psychologically present which contributed to their grief (Meichsner et al., 2016).

Transcripts of the therapy sessions were analyzed to determine the impact and effectiveness of the utilized interventions. Participants were divided into an intervention group, treated control group, and untreated group. Seven individual counseling sessions over the period of three months were conducted. The results of the analysis found four interventions effectively treated grief stemming from an ambiguous loss. The intervention strategies were identifying and accepting the loss, exploring future losses, reexamining the relationship, and normalizing the grieving experience. Utilizing the four interventions assisted participants with coping, an increased acceptance of the loss, having processed and reduced painful emotions, an increase in adjusting to the loss, and having reduced grief symptoms (Meichsner et al., 2016).

The articles covered in the literature review noted individuals experiencing ambiguous loss and grief reported a sense of shock, denial, and bargaining (Boss, 2010).

The literature also indicated grief manifested from experiences of ambiguous loss.

However, the literature lacked thorough diagnostic criteria, empirically based assessments, and evidenced based treatments for ambiguous loss or the resulting specific grief experiences (Boss, 2010; Meichsner et al., 2016).

Conceptualizations of Foster Care Youth’s Experiences with the Intersection of

Grief and Ambiguous Loss

Entering the foster care system involved the removal of a child from their home and caregivers. The removal and uncertainty regarding reunification created an ambiguous loss (Mitchell, 2016). Clinical conceptualizations of foster care youths’ experiences of grief stemming from ambiguous loss were explored. Clinical conceptualizations included the manner in which clinicians understood and treated grief stemming from ambiguous loss. A literature review regarding clinical conceptualizations of foster care youths’ grief stemming from ambiguous loss provided two relevant articles.

The articles reported foster care youths experienced ambiguous loss when removed from their homes and caregivers and placed into the foster care system. Foster care youths experienced the physical loss of family members but maintained the psychological presence of their home and caregivers. Uncertainty of when foster care youths would be reunited with or visited by their caregivers and families contributed to the resulting grief

(Fineran, 2012; Mitchell, 2016). The manner in which clinicians conceptualized foster care youths’ experiences of grief stemming from the loss of their homes and caregivers were reviewed.

Mitchell (2016) completed a longitudinal research study which analyzed the experiences of foster care youths transitioning out of the foster care system. The study was conducted between 2010 and 2015 and included over two hundred foster care youths.

All the participants identified experiencing an ambiguous loss of a family member due to entering the foster care system. The foster care youth participants reported struggling to cope with the duality of their grief and loss. Participants experienced the psychological

presence of their homes and family members by remembering them and yearning to return home. However, the lack of contact and ability to return home to family members created a physical loss. Mitchell (2016) conceptualized the grief stemming from the ambiguous losses as mourning of the physical absence of family members, loss of stability, loss of their home, and loss of self-identity. Uncertainty regarding returning home, reuniting with family members, and their role in their biological family while in the foster care system was noted in contributing to the grief. The inability to express or process their grief, lack of acknowledgment of losses by others, and stigma associated with expressing grief symptoms were also noted as contributing to the grief. The results of the study indicated foster care youths were more likely to develop disenfranchised grief due to the lack of acknowledgment of their losses (Mitchell, 2016).

It was suggested that professionals working with foster care youths provide opportunities to explore and process the youths’ sense of loss, grief, and uncertainty stemming from foster care placement (Mitchell, 2016). The uncertainty of foster care directly increased mental health symptoms. Foster care youth participants reported symptoms of externalizing behaviors, depressed mood, anger, negative cognitions, and anxiety. Assisting with clients’ ability to cope with their ambiguous losses could assist in the grieving process. Mitchell (2016) recommended acknowledging the loss, normalizing the grief, and identifying consistent supports as beneficial in treating grief stemming from ambiguous loss for foster care youths. Awareness of the potential for lack of closure and the sense of loss may have become chronic during the period of the child’s life away from their home. The chronic sense of loss also impacted the child later in life and did not often allow for closure. The lack of closure inhibited healing and processing the

experiences of foster care (Mitchell, 2016). Closure was difficult for foster care youths to obtain due to the uncertainty and lack of control surrounding reunification with family.

Application of Grief with Foster Care Youths. The second article explored the experiences of grief of an eight-year-old foster care youth utilizing the stages of grief outlined by Kubler-Ross. The foster care youth, named Mark for the purpose of the case study, was in the foster care system for six months. This was his third foster care placement. Fineran (2012) noted Mark experienced a physical ambiguous loss. He was physically removed from his mother and placed into three different foster homes. Mark reportedly thought of his mother often and desired to be reunited with her. She maintained as a psychological presence due to his continued thinking of her and the desire to return to living with her even though physically she was absent. The case study of Mark indicated he struggled to cope with the physical absence and psychological presence of his biological mother. Mark had consistent visits with his biological mother for several weeks and believed they would be reunified after she completed her treatment.

Towards the end of her treatment Mark’s mother stopped attending their visits and

Mark became worried. He was informed his mother had ended her treatment prematurely and left the facility against medical advice. Mark reported to his caseworker he believed his mother was working towards finding stable employment and housing for them and would return soon. Mark’s mother enrolled in another rehabilitation program when the court system began the process towards termination of her parental rights. Mark was able to visit his mother again at the new rehabilitation facility. She attempted to reassure him that she was working hard towards finding a home and towards reunification. The

ambiguity surrounding when and if Mark would be reunited with his mother prolonged the grief.

Fineran’s (2012) conceptualization of treatment for foster care youths grieving the ambiguous loss of their caregivers followed the Kubler Ross model of grief stages. The treatment consisted of four tasks addressing the different stages of grief. The first task focused on assisting the foster care youth to accept the reality of their loss. This task varied depending on the status of parental rights. Foster care youths whose parents were working towards reunification and regaining parental rights may work towards accepting the temporary loss or coping with the ambiguity of the loss. The case study highlighted the difficulty foster care youths had with accepting the reality of the loss when uncertainty regarding reunification emerged. Mark believed he would be reunited with his mother but was never provided clear information when the reunification would occur.

In turn, Mark was unable to determine or accept the possibility of a permanent loss of his mother. Fineran (2012) reported foster care youths experienced increased grief symptoms and emotional pain when they have been unable to accept the reality of their loss.

Clinicians could aid clients in this process by providing as much accurate information as appropriate to reduce the ambiguity.

The second task involved processing and coping with the grief. This task involved clinicians assisting foster care youths in identifying and expressing the emotional pain resulting from the grief and loss. Foster care youths struggled in doing so due to the duality of their loss. Normalizing the grieving of a physical absence and psychological presence was beneficial. Assessing for guilt and shame was also important since foster care youths commonly experience guilt and shame regarding reasons for removal from

their caregivers. Guilt and shame potentially manifested as negative emotions and actions towards their foster caregivers (Fineran, 2012).

The third task focused on adjusting to environments without their caregivers.

Foster care youths may have been placed in multiple foster homes and were faced with the challenge of adjusting to new environments. Foster care youths often struggled to adjust to new environments due to grieving the loss of their home and families. Assisting foster care youths to identify their role within the new environments, supports, and strengths assisted in their ability to adjust. Providing psychoeducation to foster parents regarding normalizing foster care youths’ behaviors and experiences reduced the sense of helplessness and loneliness (Fineran, 2012).

The fourth and final task involved foster care youths emotionally relocating the physically absent parent and moving forward with life. Foster care youths must accept the loss of their home and parents and adjust to life without them. In doing so foster care youths released the hope of reunification and visualized their life without their parents

(Fineran, 2012). They may continue to remember, value, and care for their parents but have accepted the loss and no longer long for reunification. This occurred if parental rights were terminated or if clarity regarding the loss had been gained.

It was essential to understand the unique grief experiences foster care youths encounter. Ambiguous loss was an innate component of the foster care process and the ambiguity surrounding the loss increased foster care youths’ risk of experiencing grief

(Fineran, 2012; Mitchell, 2016). Appropriate clinical conceptualizations and treatments of the grief stemming from the physical losses of their homes and families were necessary in providing effective clinical treatment. The literature and research were

limited in the conceptualizations, treatment protocols, and assessments of foster care youths’ grief manifested from ambiguous loss. There was also a lack of diagnostic criteria for the unique grief experienced. More research was needed to better understand the intersections of grief and ambiguous loss for foster care youths as well as clinical conceptualizations (Fineran, 2012; Mitchell, 2016).

Theoretical Framework

Attachment theory has been identified as the theoretical framework which guided the current study. Attachment theory consists of many attachment styles and the literature has consisted of a variety of studies utilizing the theory regarding many special topics.

For the purpose of this study a literature review of the theory’s main components, secure and insecure attachment styles, as well as the theory applied to grief and ambiguous loss were reviewed.

Attachment Theory

John Bowlby (1958) developed attachment theory which posited individuals developed attachment styles based on communication and caring behaviors of primary attachment figures during early developmental years, especially infancy. Bowlby worked as a psychiatrist in a clinic in London and treated emotionally disturbed children.

Bowlby’s observations and interactions with the children led to the hypothesis regarding the impact of the parent child relationship (Bowlby, 1959, 1969; Bretherton, 1992;

Ponizovsky et al., 2013; Sutton, 2018). Children and infants separated from their mothers experienced severe distress and anxiety. Children sought out physical closeness and nurturance from their mothers when upset or under duress. During the attachment style formation infants and children who have responsive, nurturing, and consistent attachment

figures tended to develop secure attachment and internalized positive feelings for their core self and for others (Bowlby, 1958, 1969; Bretherton, 1992). Secure attachment style is created by warm, nurturing, consistent, and attentive responses from a primary attachment figure. Consistent and nurturing responses create a sense of safety, stability, and comfort for the child. Individuals with a secure attachment style typically hold a positive view of self and others as well (Bowlby, 1969).

Bowlby posited the ability for an individual to grow and then develop a physical and emotional bond to another they must have been provided with stability and security

(Bowlby 1969; Ponizovsky et al., 2013; Prather & Golden, 2009). A positive and strong attachment to a caregiver creates a secure foundation for the child to grow upon. Healthy childhood development required the child to form a strong and positive relationship with minimally one primary caregiver. A securely attached child would have been comforted by their attachment figure and would have become distressed when separated (Bowlby

1969; Ponizovsky et al., 2013; Prather & Golden, 2009).

Children sought attachment figures when feeling unsafe in times of need.

Unresponsive, unavailable, inconsistent nurturing, or inconsistent parental responses from attachment figures leads to the development of insecure attachment styles (Sutton,

2018). The insecure attachment style develops out of cold, neglectful, abusive, and inconsistent parental responding, which are defined as attachment injuries (Bretherton,

1992). An insecure attachment style refers to any unhealthy or unsecure attachment and includes a negative view of self and others. Lack of trust, safety, and stability in others contributes to developing an insecure attachment style (Bowlby, 1969). These attachment styles are likely to remain with the child throughout their lives, creating a map for how

future relationships and relational functioning could be. Disruption to the relationship with a primary attachment figure negatively could likely impact a developing child and create severe distress (Bowlby, 1958; Sutton, 2018).

Attachment Theory and Grief

Literature regarding attachment theory and grief explored the impact of individuals grieving the loss of a significant attachment figure. PsycInfo was utilized in reviewing the literature for attachment theory and grief. The literature review provided thirty-eight articles with two articles relevant to the current study. The two articles exploring the connection between grief and attachment theory noted the loss of an attachment figure was a difficult experience to process (Maccallum, & Bryant, 2018;

Thomson, 2010). Individuals with an insecure attachment style were more likely to struggle during the grieving process and developed clinically significant forms of grief such as complicated grief (Maccallum, & Bryant, 2018; Thomson, 2010).

The impact of attachment styles on the grieving process was explored by

Thomson (2010). The death of an attachment figure created feelings of emptiness, lack of meaning, detachment from self and others, irritability, anger, and sadness. Grieving individuals experienced grief symptoms regardless of attachment style. The loss of an attachment figure impacted the individual’s sense of self, security, and stability.

Individuals with a secure attachment style were able to grieve the loss of their attachment figure and regained a sense of stability and security in their world. They were able to adjust and process life without their attachment figure and continued relationships with others (Thomson, 2010).

Securely attached individuals were able to reevaluate their identity and role in life due to a secure sense of self and trust in others. They were also able to seek comfort from other attachment figures or sources of support and utilized coping skills (Thomson,

2010). Individuals with insecure attachment styles grieving the loss of an attachment figure may not have had a foundation of security and stability prior to their loss and may have worried about their personal safety and stability while grieving. Individuals with insecure attachment styles may have struggled to adjust to life without their attachment figure and continued to view the world as unstable and unsafe (Thomson, 2010).

Insecurely attached individuals withdrew from social supports and struggled to seek comfort and safety. They may also have continued to seek comfort from the deceased attachment figure, struggled to accept the reality of their loss, or focused on the unmet needs from the deceased attachment figure (Thomson, 2010). The loss of an attachment figure was often a difficult and devastating experience. Having a secure attachment style assisted grieving individuals with processing and coping with the death of a loved one, whereas having an insecure attachment style hindered the grieving process (Thomson,

2010).

Maccallum and Bryant (2018) also theorized insecure attachment styles hindered individuals’ ability to grieve in a clinically healthy manner. Individuals with an insecure attachment style were theorized to be at an increased risk for developing complicated grief (Maccallum & Bryant, 2018). They may have struggled to trust others and not utilize social supports, become withdrawn, and minimized their grief symptoms.

Maccallum and Bryant (2018) aimed to study the relationship between attachment styles and grief outcomes. Over two hundred participants completed self-report measures and

clinical assessments assessing for attachment style and grief symptoms. The results of the study indicated higher rates of complicated grief and grief symptoms among participants with insecure attachment styles. Individuals with an insecure attachment style struggled to cope with the loss of attachment figures, continued to long for comfort from the deceased, struggled to cope with the loss, and experienced difficulty accepting comfort from others (Maccallum & Bryant, 2018). Insecurely attached participants also reported increased rates of emotional pain, role confusion, decrease in trust of others, anger, sadness, and avoidance. Acknowledgment or awareness of grieving individuals’ attachment style aided in the grieving process and reduced risk of developing complicated grief (Maccallum & Bryant, 2018).

The literature exploring the connection between attachment theory and grief reported individual attachment styles impacted grieving processes. A secure attachment’s positive sense of self, stability, and safety were noted as protective factors against developing complicated grief. Securely attached individuals were able to regain a sense of security and stability following the death of an attachment figure. However, insecurely attached individuals struggled to do the same. The lack of trust in self and others, stability, and security was shown to hinder the grieving process (Maccallum & Bryant,

2018; Thomson, 2010).

Attachment Theory and Ambiguous Loss

Insecure attachments also hindered an individual’s ability to cope with the physical separation and ambiguous loss of an attachment figure. A review of the literature regarding attachment theory and ambiguous loss provided one article for review. The loss of an actual or an idealized stable, nurturing primary attachment figure created distress

and was negatively impactful (Howard et al., 2011). A secure attachment was formed by consistent, stable, and nurturing responses from primary attachment figures. Lack of access and nurturance from an attachment figure due to separation or loss impacted a child or infant’s attachment style. Children required consistent physical access and communication with their primary attachment figures to ensure the development of a secure attachment style. Securely attached individuals were better able to cope with and tolerate separation from and losses of attachment figures. Insecurely attached individuals typically struggled to tolerate and cope with separation and loss from attachment figures

(Howard et al., 2011).

Separation and loss of an attachment figure during the first two years of a child’s life greatly impacted attachment style development. Separation and loss of an attachment figure during childhood led to an insecure attachment style, difficulty coping with future losses, increased anger and aggression. Howard et al. (2011) reported that uncertainty regarding the return of an attachment figure created distress for the child. Children and infants with a secure attachment were able to be comforted by other attachment figures during the physical absence of their primary caregiver and were receptive to their return.

Children and infants with insecure attachment styles may not have accepted comfort from primary attachment figures after they returned. If primary attachment figures did not return, insecurely attached children and infants often struggled to accept comfort from others. Increased physical separations and losses of attachment figures increased rates of acting out behaviors, anger, aggression, hostility, sadness, and poor coping skills

(Howard et al., 2011).

Attachment Theory and Foster Care Youths

A literature review regarding attachment theory and foster care youths was performed due to the purpose of the study having included conceptualizations of foster care youths’ experiences. The literature review via PsycInfo yielded thirty-two articles, one article was relevant to the purpose of the study. The literature noted children who were placed in foster care likely have experienced at least one form of an attachment injury prior to being placed in care (Schade & Sandberg, 2012; Schofield & Beek, 2009).

An attachment injury is an incident in the relationship that could be perceived as a betrayal, abandonment, or breach of trust by the attachment figure during a critical time of need (Schade & Sandberg, 2012). When a primary caregiver failed to respond to a child during a critical time of need that created an attachment injury for the child. If a child was removed from the care of their primary caregiver the caregiver was no longer able to attend to their needs, resulting in an injury to their relationship (Schade &

Sandberg, 2012; Schofield & Beek, 2009).

Foster care youth likely experience attachment injuries throughout their time in foster care. These injuries included the disruption in placement from primary caregiver to foster caregiver and then to a permanent caregiver, whether that was reunification with their primary caregiver or an adoptive placement. Foster care youths regularly experience multiple foster placements during their time in foster care. This foundation of instability and inconsistency could create a significant barrier to the likelihood of foster care youths healing from primary attachment injuries (Schade & Sandberg, 2012; Schofield & Beek,

2009).

Schofield and Beek (2009) explored the impact of secure attachment parenting interventions on foster care youths. The study hoped to reduce negative impacts of the foster care process on attachment styles and address attachment injuries. A longitudinal study conducted in three phases from 1997-1998, 2001-2003, and 2005-2006 included fifty-three foster care youths. The participants were between the ages of three and twelve during the initial phase of the study. The participants’ social workers and foster care parents were also interviewed to gather information regarding the participants’ behaviors and attachment style during the study (Schofield & Beek, 2009). Social workers and foster care parents were encouraged to utilize secure base model interventions to increase secure attachment styles of the participants. The secure base model included interventions centered on availability, sensitivity, acceptance, cooperation, and family members.

Increasing emotional and physical availability to foster care youths assisted in increasing self-worth, trust in themselves, and trust in others. Increasing sensitivity towards foster care youths’ experiences and behaviors aided in participants’ coping and emotional regulation (Schofield & Beek, 2009).

Acceptance interventions repaired or established foster care youths’ self-esteem.

The cooperation intervention involved working with foster care youths to increase a sense of control, to effectively seek comfort, to meet their needs, to form an attachment between foster care youths and foster parents, and to increase resiliency. Family membership interventions assisted in creating stability, security, and a sense of belonging. The results of the study reported foster care youths thrived in stable foster homes with consistent foster parents who had been utilizing secure base interventions

(Schofield & Beek, 2009). The secure base interventions utilized by foster parents

assisted participants to overcome negative impacts of insecure attachment styles, attachment injuries, and negative experiences of foster care (Schofield & Beek, 2009).

Literature regarding attachment theory reported the impact that caregiver responses and actions towards infants and children can have on the development of their attachment styles (Bowlby, 1958). Securely attached individuals overcome adversity, grief and loss more successfully than compared to individuals with insecure attachment styles. The lack of stability, trust and security for insecurely attached individuals negatively hindered their ability to cope and process grief and loss. Addressing and incorporating attachment styles into clinical treatment assisted clients in processing grief and loss.

Attachment theory has emphasized the importance of the parent child relationship on individual development. The loss or separation of an attachment figure or attachment injury has negative impacts on the individual, especially if that occurred during infancy or childhood (Maccallum & Bryant, 2018; Thomson, 2010). Individuals with secure attachment styles may have coped with grief and loss in a clinically healthy manner; whereas individuals with an insecure attachment style may have struggled and develop a clinically significant form of grief (Thomson, 2010). Clients in foster care have benefited from clinical approaches incorporating attachment styles and attachment injuries into treatment to assist with processing the ambiguous loss and grief of an attachment figure.

The Current Study

The purpose of this literature review was to describe the state of the current literature related to grief, ambiguous loss, and the clinical conceptualizations of those concepts. Special considerations for children’s and foster care youths’ experiences were

addressed due to the study’s inclusion of exploring clinical conceptualizations of this special population. In reviewing the literature gaps and limitations were uncovered. An overall lack of empirical literature regarding experiences, diagnoses, and assessments of ambiguous loss was evident. Another gap in the literature was a lack of clear understanding of how clinicians conceptualized grief and ambiguous loss when working with foster care youth. The current study addressed this specific gap in the literature by addressing the following research question: How do clinicians conceptualize grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care?

CHAPTER III

RESEARCH METHODS

This chapter provides the methodological framework for addressing the aims of the current study. The research goal is summarized and the background of Narrative

Inquiry and methodology for the current study are discussed. The research question is addressed and followed by the methods of data collection. Methods of data analysis and trustworthiness of the methodology are presented as well.

Research Goal

The goal of the current research was to gain a deeper understanding of mental health clinicians’ perceptions, understandings, and conceptualizations of grief stemming from losses experienced by clients in the foster care system, using Clandinin and

Connelly’s model of Narrative Inquiry as a methodological guide (Clandinin & Connelly,

2000; Creswell & Poth, 2018; Merriam, 2009). The literature review indicated limited clinical resources and research to accurately assess for and diagnose grief and loss, as well as guide treatment (Boss, 1999, 2010; Meichsner et al., 2016; Mitchell, 2016). The literature also reported potential negative impacts of unresolved grief (Barle, 2017; Burns et al., 2018; Enez, 2017). The purpose of the current study was to gain insight into how clinicians conceptualized the manifestations of grief foster care youths experienced. In doing so, greater understanding in how to serve this special population was gained.

Research Design

Narrative Inquiry

The current study utilized Narrative Inquiry as the research methodology.

Narrative Inquiry is a research methodology that has been derived from history, anthropology, sociology, literature, and education (Creswell & Poth, 2018). Many forms and techniques have been developed and utilized in many disciplines (Lal et al., 2012;

Merriam, 2009). Narrative Inquiry as a methodology is the analysis of stories and experiences derived from interactions with participants to gather data and information

(Sprenkle & Piercy, 2005). The data gathered captures knowledge regarding a topic, personal perspectives, thoughts, and motivations during an experience. In addition,

Narrative Inquiry explores the process in which participants created meaning from their stories (Merriam, 2009). Data and stories are gathered through first-person accounts and are collected throughout the study. Data sources could include interpretation of written texts, in-depth interviews, transcripts of interviews, life history narratives, autobiographies, historical memoirs, photos, among other sources of qualitative data

(Creswell & Poth, 2018). The data is then interpreted and analyzed in order to understand and gather perspectives of the meaning of narrative stories (Clandinin & Connelly, 2000;

Merriam, 2009).

The first-person accounts of experiences are utilized to present participants’ life stories through storytelling. The participants’ reflections of their narrative stories along with the researcher’s restorying of the data are also included in Narrative Inquiry’s methodology (Sprenkle & Piercy, 2005). First-person accounts are considered units of analysis to understand how individuals created meaning (Clandinin & Connelly, 2000).

The analysis of the stories provided better understanding and perspective into how and why participants understood and constructed personal stories. Special attention is paid towards the use of words and language during the narratives (Clandinin & Connelly,

2000; Merriam, 2009). Understanding an individual’s narrative and language can provide insight into their experiences and conceptualizations.

Narrative Inquiry allows the researcher to gather information beyond the context of an event or of experiences. Qualitative research emphasizes the participants’ experiences, memories, stories, and their process of constructing meaning (Salter &

Rhodes, 2018), and enables the researcher to explore and expand upon the detailed and rich data during the interviews. The objective of the qualitative researcher is to uncover and interpret the meanings and data provided by the participants (Merriam, 2009; Salter

& Rhodes, 2018). The individual voices and narratives are highlighted as well as major themes of the individual participants. Semi-structured interviews with open ended questions based on the research goal are utilized to gather data (Merriam, 2009).

The researcher is able to explore the emotions, emphasis, understanding, and meaning of experiences as well (Lal et al., 2012; Merriam, 2009). Capturing and retelling the emotional experiences and conceptualizations of first-person narratives provides thick and detailed descriptive data. Thick and detailed descriptive data provides information regarding themes, patterns, and meaning which emphasized societal and cultural influences of stories (Anderson, 2010; Leung, 2015). Narrative researchers capture data through a variety of narrative strategies such as life history, biographical study, autoethnography, or oral history methods (Creswell & Poth, 2018). For the purpose of this study, oral history methods were presented.

Oral history is the gathering of participant’s reflections of events and experiences.

Oral histories could be gathered from one or multiple participants and explore the causes and impacts of the events and experiences (Creswell & Poth, 2018). Oral history narratives also incorporate a specific focus surrounding specific events or experiences.

The focus could be specific to experiences of specific populations as well. Marginalized populations have been the focus of past oral histories as well as experiences of teachers in classroom settings. Oral histories are utilized in a multitude of frameworks to meet the needs of the researcher in capturing personal reflections (Creswell & Poth, 2018).

The role of the researcher is integral in the process of obtaining rich and descriptive data as well as in the Narrative Inquiry methodology process (Lal et al., 2012;

Merriam, 2009). The researcher provides a supportive environment for the participant to share their stories while remaining diligent in their efforts to join with the participants.

The researcher attends to language to clearly understand participant’s emotions, understanding, perspectives, knowledge base, and meaning of stories. Narrative stories contain epiphanies or turning points in which the researcher attempts to interpret and highlight in the narratives. The epiphanies could lead to positive or negative consequences in the stories that created meaning (Creswell & Poth, 2018). The researcher then analyzes the data, interprets the data, and uncovers themes presented in the narratives (Lal et al., 2012; Merriam, 2009).

Clandinin and Connelly (1990) and Narrative Inquiry

The current study utilized the model of Narrative Inquiry, introduced by

Clandinin and Connelly in 1990 through their work exploring teachers’ narratives regarding educational experiences (Clandinin & Connelly, 2000; Lapan et al., 2012). This

specific model of Narrative Inquiry notes the aim of the methodology is to capture detailed narrative stories and life experiences of one or more participant(s).

In order to capture detailed narratives, the methodology reflected a fluid approach to collect and analyze the data (Creswell & Poth, 2018). The nature of Narrative Inquiry incorporates components of data collection and analysis, which at times have occurred simultaneously and not in a stepwise manner (Butina, 2015). The researcher and participant dedicate significant amounts of time gathering and analyzing narrative stories through multiple data sources, also known as field texts (Creswell & Poth, 2018). Field texts consist of journals, diaries, researcher observations, interview transcripts, researcher field notes, researcher journal, letters, documents, or personal artifacts. Artifacts include historical documents, photos, or first-hand narratives from outside perspectives from individuals informed about the participant’s life experiences (Clandinin & Connelly,

2000; Creswell & Poth, 2018; Lapan et al., 2012). Field texts also provide the context of the narrative stories. The context includes personal experiences of work and home, cultural stories of race and ethnicity, and historical context of time and place of events and experiences. Context is essential to Narrative Inquiry and necessary to incorporate into the data collection, analysis, and restorying process (Creswell & Poth, 2018).

Narrative Inquiry modeled by Connelly and Clandinin (2000) constructs context into a Three-Dimensional Framework emphasizing temporality, sociality, and place of participant stories. Temporality is the past, present, and future of the participant’s narrative story. The beginning, middle, and end of the personal narratives are recorded and analyzed. An emphasis on the chronological or sequence of events of the personal narrative is unique to Narrative Inquiry. Sociality is the interaction of the individual and

society. The societal values, norms, and meaning that have impacted the participant are also emphasized along with individual culture. The place refers to the setting of the participant’s experiences. The contexts of temporality, sociality, and place highlight the plot, provide insight into the conflict, and identify the protagonists and antagonist of the narrative story (Clandinin & Connelly, 2000; Creswell & Poth, 2018; Lapan et al., 2012).

The researcher analyzes the field texts for data and information surrounding the

Three-Dimensional Framework during the restorying process (Creswell & Poth, 2018).

Restorying is the process of reorganizing the narrative stories into one chronological and cohesive narrative. The researcher is an integral component of Narrative Inquiry through their active role of restorying the participant’s narrative stories (Clandinin & Connelly,

2000; Creswell & Poth, 2018). Themes and meaning arise from the narrative stories through the analysis process. The researcher also pays attention to contradictions, wording, phrases, emotions expressed, and messages conveyed in the narrative stories

(Clandinin & Connelly, 2000; Creswell & Poth, 2018; Lapan et al., 2012). The field texts, themes and meanings conveyed, participants’ insights and contributions, as well as the researcher’s insights are organized into one cohesive narrative of the participants’ experiences. After the restorying process, the participant and researcher engage in the collaboration process (Clandinin & Connelly, 2000; Creswell & Poth, 2018).

The researcher and participant both contribute to the construction of narrative stories of the participant’s experiences (Creswell & Poth, 2018). Clandinin and Connelly described active involvement from the participant and researcher in their model of

Narrative Inquiry (Clandinin & Connelly, 2000; Creswell & Poth, 2018). The collaboration between participant and researcher assists in the understanding of the

participant’s experiences. The researcher collects data from the field texts and the participant reviews the data for accuracy. The researcher co-constructs the narrative stories with the participant and determins the themes and meaning conveyed from the narratives collaboratively (Creswell & Poth, 2018). The researcher is mindful of the participant-researcher relationship during the research process. Both potentially gain new insights during the narrative co-construction and restorying process (Clandinin &

Connelly, 2000; Creswell & Poth, 2018).

Finally, the narrative is presented in written form. Narrative Inquiry suggests a general structure for presenting the written narrative (Creswell & Poth, 2018). The structure includes a general introduction of the participant, purpose of the narrative, research procedures, information regarding the data collection and analysis process, as well as rational for the use of Narrative Inquiry. The presentation of the narrative also includes the telling of the participant’s story, patterns of meaning and themes, epiphanies, and final interpretations of the meaning of the narrative story (Clandinin & Connelly,

2000; Creswell & Poth, 2018).

Strengths and Limitations of Narrative Inquiry

Like other research methods, the literature has noted strengths and limitations of

Narrative Inquiry. Narrative Inquiry methodology shares similar strengths and limitations as other qualitative research methodologies have contained (Creswell & Poth, 2018). A strength of Narrative Inquiry is the ability to explore ambiguous and complex dynamics of individual, cultural, societal, and organizational experiences (Clandinin & Connelly,

2000). Storytelling as a form of methodology provides insight into experiences, emotions, and images of historical, societal, and cultural events. The constructed stories provide a

holistic context of emotions and images that provided reflection and reconstruction of experiences (Clandinin & Connelly, 2000). The emotions and experiences of the participants are then presented directly from field texts. At times, the stories and narratives are more compelling, powerful, and better spoke to the individual experiences.

The storytelling aspect of Narrative Inquiry also allows for flexibility in gathering data, as research is guided and influenced in real time by the data gathered during the interview process (Anderson, 2010). Follow up questions are utilized during the interview process to explore and gather data as new information emerged. Another strength of Narrative

Inquiry is the ability to suggest cause and effect, connections, relationships, and vibrant processes of phenomenon reported in narratives (Denscombe, 2010).

Limitations of Narrative Inquiry are the small sample size of participants due to the time required to gather, process, analyze, and interpret the data of each participant

(Anderson, 2010; Denscombe, 2010). The limited number of participants could result in a lack of sufficient data to describe a desired phenomenon. To address this limitation, researchers should aim for a sample size large enough to gather sufficient information without reaching saturation. Saturation occurs when the addition of participants does not add value or information to the desired phenomenon. (Clandinin & Connelly, 2000;

Creswell & Maietta, 2002). Difficulty replicating data is also noted as a limitation of

Narrative Inquiry. Replication of the data may not be possible due to the unique collaboration process between the participant and researcher (Anderson, 2010; Leung,

2015). Ensuring the validity of the narrative stories involves substantial time gathering and analyzing field texts, a collaborative and close relationship between the researcher and participant, and obtaining thick descriptions (Creswell & Poth, 2018). Thick

descriptions provide explanations of patterns and themes, meanings derived from stories, societal and cultural context, and detailed accounts of individual narrative stories. Thick descriptions provide context and information and allow others outside of the phenomenon to understand the narratives presented (Anderson, 2010; Leung, 2015).

A final critique of Narrative Inquiry is the difficulty of applying common standards of reliability and validity due to the subjective nature of the qualitative data.

The literature noted viewing validity and reliability in terms of trustworthiness is more appropriate than common standards (Anderson, 2010; Creswell & Poth, 2018).

Trustworthiness consists of credibility, confirmability, transferability, and reflexivity components. These components speak to the validity and reliability of Narrative Inquiry and are reviewed later in the chapter (Korstjens & Moser, 2018).

Methodology of the Current Study

The methodology of the current study was informed by Clandinin and Connelly’s model of Narrative Inquiry (Clandinin & Connelly, 2000). Utilizing a Narrative Inquiry methodology allowed the researcher to explore how clinicians conceptualized experiences of grief and ambiguous loss exhibited by clients in foster care. Insight into clinical conceptualizations provided information regarding diagnoses, assessments, and treatment modalities that were utilized in the course of clinical treatment (Merriam,

2009). The broad and fluid methodological approach of Narrative Inquiry organized the procedures into two parts. Data collection occurred during the first part and data analysis largely occurred during the second part (Butina, 2015; Creswell & Poth, 2018). The integration of data collection during the data analysis portion occurred during the collaborative analysis procedure as show in Figure 1.

• Applicability of Narrative Inquiry • Selection of Participants and Sampling • Determination of Data Collection Methods Data Collection • Data Collection Through Stories (Interview 1)

• Restory • Analysis of Interview 1 • Restorying • Collaborative Analysis (Interview 2) • Follow Up Questions from Interview 1 (Data Collection) Data Analysis • Collaborative Analysis with Participant • Presentation of Final Narrative

Figure 1: Methodology of current study

The outlined procedures of data collection and analysis were applied to participants individually. The procedures were replicated and utilized with each participant. The replication of procedures for all three participants ensured consistency and validity across the study. Regular meetings between the researcher and her advisor occurred throughout the study. The researcher and advisor reviewed procedures to ensure they were replicated properly and to safeguard against contamination of the data.

Participants were spaced an average of one and a half months between each other. The time in between participants allowed the researcher to debrief with her advisor, review the research procedures, and prepare for the next interviews. The time between participants was purposeful to allow the researcher to switch into the mindset of each new participant’s story. Completion of data collection and analysis for one participant occurred prior to beginning the next participant’s data collection. The stories and data of individual participants were not utilized in the procedures of the other participants.

The final step of the current study was to combine and analyze the participants’ stories together to represent the population of mental health clinicians and address the researcher question. The process of amalgamating and analyzing the participants’ stories occurred after completion of the last participant’s final narrative. Details of the study’s data collection and analysis procedures were described below.

Data Collection Procedures

The current study’s procedures of data collection began with determining the applicability of Narrative Inquiry in exploring the study’s research question. The next step of data collection was the selection of participants through sampling, followed by determining data collection methods. The final step of the data collection process was to collect data through the stories of participants. In Narrative Inquiry, the raw data is the stories of the participants, thus collecting their stories was a collection of raw data

(Butina, 2015). Narrative Inquiry, modeled by Clandinin and Connelly (2000), emphasizes embedding the context of stories into the methodological process and was incorporated into data collection and analysis. Embedding the context of stories was done by embedding the Three-Dimensional Framework to guide the interview questions, restory process, and final narrative (Creswell & Poth, 2018). The application of the current study’s data collection procedures guided by Narrative Inquiry were outlined below. The Narrative Inquiry data analysis procedures for the current study were described following the data collection section.

Applicability of Narrative Inquiry. The initial step of the current study’s procedure informed by Clandinin and Connelly’s model of Narrative Inquiry was the determination of applicability of Narrative Inquiry in the exploration of the research

question (Clandinin & Connelly, 2000). Narrative Inquiry was determined to be an applicable methodology in exploring the research question due to the emphasis of firsthand stories, collaboration with participants, and application of the Three-Dimensional

Framework. First-hand narratives provided insight into the chronology of events with temporality, societal and cultural influences, and places of experiences that contributed to the manner in which clinicians conceptualized grief stemming from ambiguous loss

(Clandinin & Connelly, 2000). Collaboration with participants ensured accurate stories were captured. The current study aimed to address the limited insight into clinical conceptualizations of grief and loss for foster care youths by proposing the following research question:

Research Question: How do clinicians conceptualize grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care?

To support the research question, the researcher inquired about participants’ conceptualizations of grief and ambiguous loss as individual constructs. The participants’ personal experiences, clinical education and training regarding grief and loss, as well as their understandings of effective clinical practices were also explored. The research question was informed by the review of the literature and recognized the gap in the literature regarding clinical conceptualizations (Boss, 1999, 2010; Meichsner et al., 2016;

Mitchell, 2016).

The gap in the literature highlighted a need to better understand how clinicians conceptualized grief manifesting from ambiguous loss due to a lack of empirical studies and diagnostic criteria. The research question was developed with the aim to understand how clinicians conceptualized grief manifested by ambiguous loss in order to understand

how and what clinicians utilized in their conceptualization process. Previous studies exploring clinical conceptualizations of grief indicated clinicians used information from educational and clinical trainings, clinical and personal experiences, and components of best clinical practice in treating grief in their conceptualizations of grief (Breen, 2011).

The literature review and relevant studies assisted in the development of the research question as well as interview questions.

Selection of Participants and Sampling. The next step of the data collection procedure was to select participants with stories in line with the aim of the current study

(Clandinin & Connelly, 2000). A combination of convenience and snowball sampling and designs were utilized to select participants from the overall population of licensed marriage and family therapists in Northeast Ohio. The researcher recruited from her own profession of marriage and family therapists and insured not recruit any direct colleagues as participants. The Marriage and Family Therapy community in Northeast Ohio was limited, which allowed the researcher to establish professional relationships with referral sources. Marriage and family therapists that the researcher established professional relationships with were contacted to request referrals for potential participants. Prior to contacting participants, the researcher obtained clearance for conducting research with human subjects from the Institutional Review Board and developed an informed consent.

The informed consent provided information regarding the proposed research study, methodology, possible implications for participating in the study, and potential psychological risks and benefits (Anderson, 2010).

Six potential participants were contacted via telephone to inquire about interest in participating in a Narrative Inquiry research study. Participants that expressed interest

were provided an overview of the aim, process, procedures, and participant requirements of the current study. The overview of the Narrative Inquiry methodology was provided and included information regarding audio or video recordings of in person interviews and transcriptions of the interviews. Participants were also informed of the need to dedicate significant amounts of time as well as the collaborative relationship between researcher and participant that the methodology required (Clandinin & Connelly, 2000). Of the six potential participants, three met the inclusion criteria and were willing to participate in the study.

The three final participants were provided the informed consent electronically per their request. The researcher reviewed the informed consent over the phone with the participants. They were informed their personal experiences and stories would be presented, which could reduce their anonymity as participants (Anderson, 2010). Efforts such as altering identifying information and storing field texts on password protected memory cards to ensure confidentiality of participant information were reviewed as well.

Participants were provided opportunities to ask questions regarding participant responsibilities and the informed consent. After questions were answered, the participants were asked verbally if they agreed to participate in the study. All three participants verbally agreed to participate in the study and electronically signed the informed consent to indicate consent of participation, understanding of expectations, and of the risks and benefits of participation in the proposed study (Anderson, 2010).

Inclusion and Exclusion Criteria. The main criteria for inclusion in the current study was obtaining a story to tell regarding the aim of the research (Clandinin &

Connelly, 2000). Participants with stories to share regarding their experiences of clinical

conceptualizations of grief stemming from ambiguous loss by clients in foster care were considered for inclusion. Other inclusion criteria for participation in the study included an active marriage and family therapy license, past and current clinical work with clients in foster care, willingness and ability to co-construct narrative stories, and ability and commitment to dedicate sufficient time to participate in the study. Exclusion criteria for participation in the study included no experience working with clients in foster care, lack of a marriage and family therapy license, and no clinical experience with grief.

Participant inclusion and exclusion criteria was informed by the literature regarding

Narrative Inquiry methodology procedures and previous studies regarding clinical conceptualizations (Clandinin & Connelly, 2000; Lal et al., 2012; Merriam, 2009; Wells,

2011). Of the six original potential participants, three meet the criteria and were willing to dedicate a significant amount of time. The three other participants either did not have current clinical experience with foster care youths or were unable to dedicate significant amounts of time.

Sample Size. The literature regarding qualitative research methodology indicated a sample size of five to nine participants was appropriate in providing ample data to address a qualitative research study’s goals (Lal et al., 2012; Wells, 2011). However, the literature regarding Narrative Inquiry methodology specifically noted one or more participants as an ideal sample size (Creswell & Maietta, 2002; Creswell & Poth, 2018).

The emphasis on smaller sample sizes for Narrative Inquiry methodology was rationalized due to the substantial amount of time required to gather participant stories, participant reflections of the stories, the restorying process, co-constructing the individual stories, and presentation of written narrative per individual participant (Creswell & Poth,

2018). The current study aimed to include three to six participants based on the literature regarding qualitative research guidelines and Narrative Inquiry guidelines. The final sample size of three participants met the minimum criteria for the study. The demographics of the three participants are reflected in Table 1.

Table 1. Participant Characteristics Participant A Participant B Participant C

Gender Female Female Female

Race Caucasian Caucasian Caucasian

Age 30’s 30’s 20’s

Highest degree obtained Master of Arts in Master of Arts in Master of Arts in Marriage and Family Marriage and Family Marriage and Family Therapy Therapy Therapy

# years clinical 10 6 4 experience

Credentials IMFT-S IMFT MFT

LPCC-S LPCC-S LPCC

Work Setting Mental Health Agency Mental Health Agency Mental Health Agency

Private Practice Private Practice

# years experience 8 6 4 working with foster care youth

Determination of Data Collection Methods. The third step of the study was to determine data collection methods. This step required the researcher to determine the methodology of collecting data as well as the field texts that would be utilized to gather and collect data (Clandinin & Connelly, 2000; Creswell & Poth, 2018). The current study collected data through semi-structured topical oral history interviews guided by the

Three-Dimensional Framework. The fields texts included the researcher journal, recordings of interviews, interview transcripts, and the demographics questionnaire.

Interviews. Semi-structured topical oral history interviews were utilized to gather data for the current research study. Semi-structured interviews were an effective and common Narrative Inquiry data collection method due to the ability of the researcher to actively engage in each of the participant’s processes of telling their stories (Merriam,

2009). Each participant partook in two interviews which were on average one to two weeks apart for all of the participants. Interviews took place at the researcher’s office, with the exception of the third participant. The third participant’s interviews were done electronically over a secure video platform. Two interviews were determined to be sufficient due to providing data addressing the research question. Further interviews would have been conducted if the data gathered failed to answer the research question.

The first interview was a semi-structured topical oral history interview using questions from the interview protocol (see Appendix C). The second interview allowed for follow up questions and a collaborative analysis.

The researcher expanded upon statements, asked in-depth questions, inquired about internal processes, and explored emotions as new information emerged during the interview (Lal et al., 2012). The researcher implemented topical oral history interviewing techniques which included a specific contextual focus (Merriam, 2009). For the purpose of the current study, the topical contextual focus was the experience of clinical conceptualizations. Personal reflections of experiences, events, as well as clinical and personal influences that have impacted clinicians’ conceptualizations of grief stemming from ambiguous loss were explored during the interviews. Interviews were recorded and

transcribed to ensure themes, emotions, and narratives were accurately obtained and analyzed (Lal et al., 2012; Merriam, 2009). The goal of utilizing topical oral history interviews and Narrative Inquiry were to address the gap in the literature regarding how clinicians were conceptualizing, diagnosis, assessing, and treating grief manifested by ambiguous loss (Breen, 2011; Clandinin & Connelly, 2000; Creswell & Poth, 2018;

Merriam, 2009). A total of six interview items were included in the interview protocol

(see Appendix C).

Embed Three-Dimensional Framework. Semi-structured interview questions integrated Narrative Inquiry’s Three-Dimensional Framework. The dimensions of temporality, sociality, and place were employed to guide the topical oral history interviews (Clandinin & Connelly, 2000). Semi-structured interview questions regarding temporality focused on the beginning, middle, and end of participants’ stories and reflected experiences that contributed to clinical conceptualizations (Clandinin &

Connelly, 2000). The beginning, middle, and end timepoints of the participants’ stories were prior to graduate school, during graduate school, and post graduate school. The temporality dimension captured experiences and stories salient to the identified timepoints.

The sociality dimension incorporated interview questions exploring interactions of the participants with society and culture (Clandinin & Connelly, 2000). Questions regarding the influence of societal norms and values, family values, cultural values, and employer values on clinical conceptualizations of grief stemming from ambiguous loss were incorporated. Messages, values, and experiences regarding grief and loss from participants’ graduate training, education, and clinical experiences were also explored.

The place dimension referred to the setting of the participants’ experiences (Clandinin &

Connelly, 2000). The place dimension contributed questions exploring settings prior to graduate school, during graduate school, and post graduate school.

Researcher Journal. The researcher journal included notes, observations, questions, decisions and reflections throughout the course of the study (Clandinin &

Connelly, 2000). The researcher journal was utilized before and after interviews, during the transcribing process, review of interview recordings, while determining research decisions, and during data analysis procedures (Clandinin & Connelly, 2000). The researcher journal was utilized for all of the participants and in meetings with the researcher’s advisor. The researcher journal assisted in reducing contamination of data across participants and accurately capturing the meaning of stories.

Recordings of Interviews. Audio recordings of interviews were recorded with a hand-held audio recorder, due to participants stating discomfort with video recordings.

Interview recordings were stored on a password protected memory card and placed in a locked cabinet in the researcher’s office to ensure ethical storage of confidential data.

Recordings provided auditory observations, tone, and expression of emotions during the storytelling process. Notes of visual observations were recorded in the researcher journal.

Visual and auditory observations enhanced the analysis of participant stories and experiences (Clandinin & Connelly, 2000).

Transcripts. Interviews were transcribed manually by the researcher soon after the interview ended. The researcher transcribed interview recordings verbatim into a word document. Manual and verbatim transcription methods ensured the accuracy of transcripts. Transcripts of interviews were reviewed and analyzed by the researcher and

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her advisor. Major themes and the meaning of experiences regarding clinical conceptualizations of grief stemming from ambiguous loss were also highlighted by the researcher and her advisor. The participants reviewed the transcripts, major themes, and meaning to confirm accurateness (Clandinin & Connelly, 2000; Creswell & Poth, 2018).

Transcripts were stored on a password protected memory card and placed in a locked cabinet in the researcher’s office as a means of ethical storage to safeguard confidential information.

Demographics Questionnaire. A demographic questionnaire was utilized to gather demographic information of the participants. Participants were provided the demographic questionnaire electronically. The demographic questionnaire was completed by the participants and reviewed by the researcher prior to the first interview. Information provided by the demographic questionnaire was expanded upon during the interview

(Creswell & Poth, 2018). A total of six demographic questionnaire items were included in the demographic questionnaire (see Appendix B).

Data Collection Through Stories. The fourth step of the current study and last step of data collection was to collect data through participant interviews. The current study’s data was collected through two interviews with each participant. The two interviews were approximately one to two weeks apart. Participants were interviewed one at a time with an average of one and a half months between participants. Interviews took place in person at the researcher’s clinical office. One participant was interviewed virtually through a secure video platform. Participants requested they only be audio recorded due to comfort and preference. The first interview was the primary data

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collection method and occurred during this step of study. The second interview occurred during the collaborative analysis and is described below.

The first interview consisted of semi-structured topical oral history interviews with a topical contextual focus. The topical contextual focus explored clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care (Clandinin & Connelly, 2000). Interview questions regarding the conceptualizations, diagnoses, assessments, and treatment approaches of grief stemming from ambiguous loss of clients in foster care were gathered. Narrative

Inquiry’s Three-Dimensional Framework also guided the interview questions (Clandinin

& Connelly, 2000). The temporality dimension included questions exploring three timepoints throughout the participants’ experiences with conceptualizations. The three timepoints were prior to graduate school, during graduate school, and post graduate school. Prior to graduate school accounted for stories and experiences informing clinical conceptualizations occurring during this time period (Clandinin & Connelly, 2000).

Experiences and stories in the participants’ personal lives, during graduate training, and while working as licensed clinicians were explored.

The place dimension incorporated questions regarding settings in which experiences occurred during the stories. Those settings included home, graduate school, and employment settings. The sociality dimension explored societal and cultural influences within the participants’ stories (Clandinin & Connelly, 2000). Some of the societal and cultural influences were participants’ values, their families, graduate school, and supervisors. The interviews had a topical contextual focus exploring clinical

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conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care (Clandinin & Connelly, 2000).

A total of six interview items guided by the Three-Dimensional Framework of

Narrative Inquiry were included in the interview protocol (see Appendix C). Questions were phrased in a manner in order to elicit detailed accounts of experiences, emotions, vivid imagery, and memories per Narrative Inquiry methodology guidelines (Merriam,

2009). Active listening during the interview process aided the researcher in guiding the participants to deepen and expand upon their stories (Merriam, 2009). The interactions between the participant and researcher were emphasized during the interview process.

Follow-up and probing questions were also utilized during the interview process to expand upon stories and information as they emerged. The interactions between the researcher and participants were also reflected in the interview recordings and transcripts

(Clandinin & Connelly, 2000; Creswell & Poth, 2018).

Data Analysis Procedures

The data analysis procedures of the current study were informed by Clandinin and

Connelly’s model of Narrative Inquiry (Clandinin & Connelly, 2000). The fluidity of

Narrative Inquiry influenced components of data collection among data analysis procedures (Butina, 2015; Creswell & Poth, 2018). The majority of data analysis for the current study occurred after most of the data collection was completed. The current study’s main data analysis procedures began with the restorying process, followed by the collaborative analysis and ended with the presentation of the narrative in written form

(Clandinin & Connelly, 2000; Creswell & Poth, 2018). The context of the stories was embedded into the restory and final narratives by utilizing the Three-Dimensional

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Framework (Creswell & Poth, 2018). Specifics regarding the study’s data analysis procedures and integration of data collection are described below.

Restorying. The fifth step of the study and first step of the data analysis process was restorying. Restorying occurred in between the first and second interviews. The restorying process organized the participants’ stories and field texts into a cohesive chronological sequence of the core ideas of the story (Clandinin & Connelly, 2000). In accordance with Narrative Inquiry methodology protocol, an analysis of Interview 1 was required prior to restorying. The audio recording of Interview 1 was reviewed several times to capture the meaning of the story. The recording was then transcribed and reviewed multiple times to ensure accuracy (Clandinin & Connelly, 2000; Merriam,

2009). Narrative Inquiry protocol indicated transcripts were organized into different chronological order of major events and experiences to assist in the construction the participants’ narratives. A thorough analysis of each transcript was conducted to determine salient themes and major events of individual interviews. A cross analysis of similar themes derived from field texts was also conducted (Merriam, 2009). The researcher’s advisor also reviewed the transcripts and determined salient themes. The themes determined by the researcher and advisor were similar and combined together.

Restorying occurred after the interview and transcriptions were completed. The researcher independently engaged in the restorying process without involvement from the participants (Salter & Rhodes, 2018). Direct quotes were incorporated to emphasize the first-person accounts of the narratives and to aid in providing rich and in-depth data regarding perspectives and experiences of clinical conceptualizations of grief (Salter &

Rhodes, 2018). Participants’ personal reflections of experiences, wording during

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Interview 1, phrases utilized, emotions expressed, clinical motivation and purpose, and messages conveyed during interviews were incorporated into the participants’ narratives

(Clandinin & Connelly, 2000). The researcher’s advisor reviewed the restory for accuracy. The restory was then shared with the participant during the collaborative analysis step to gain their validation of accuracy.

The restory was guided by Narrative Inquiry’s Three-Dimensional Framework.

The temporality dimension assisted in developing the restory in a chronological manner with a beginning, middle, and end. The place dimension highlighted significant settings within participants’ stories. Sociality uncovered the impact of culture and society on the participant and their stories. The purpose of the restorying process was not to simply recount experiences and narrative stories of participants (Clandinin & Connelly, 2000).

Restorying encompassed the rich data provided by the demographic questionnaire, interview transcripts, researcher journal, and participants’ narratives. Major themes and meanings were conveyed and incorporated into the researcher’s restory of the participant’s story (Clandinin & Connelly, 2000). The data analysis of restorying examined the data and gathered information beyond the context of an event or experience. As well as explored the emotions, emphasis, understanding, and meaning of an experience (Clandinin & Connelly, 2000; Lal et al., 2012; Merriam, 2009; Salter &

Rhodes, 2018; Wells, 2011). Restorying was followed by the collaborative analysis of the cohesive chronological presentation of the participants’ stories to ensure the researcher captured experiences regarding clinical conceptualizations accurately.

Collaborative Analysis. The sixth step of the study and second step of the data analysis procedure was a collaborative analysis. The collaborative analysis procedure

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involved a second interview with the participant which was scheduled one to two weeks after the first interview and completion of the restory. The collaboration process was lengthy and occurred for a significant amount of time. The second interview was divided into two sections. The first section was a data collection of open-ended follow up questions from Interview 1. The researcher asked follow-up and probing questions based on the analysis of field texts and interview to expand upon the stories presented

(Clandinin & Connelly, 2000; Creswell & Poth, 2018).

The second portion of the interview was a collaboration with the participants and researcher to co-construct narratives. Collaborative analysis is unique to the Narrative

Inquiry data analysis process (Clandinin & Connelly, 2000; Creswell & Poth, 2018). The participants reviewed the field texts, transcript from Interview 1, and the restory. The participants provided feedback regarding the accuracy of the data gathered and analysis to the researcher. Reflections and insights gained from analyzing and reviewing the field texts, transcript, and restory were also shared by the researcher and participant.

Inaccurate analysis of field texts, participants’ stories, themes, meaning, and other data were addressed (Clandinin & Connelly, 2000; Creswell & Poth, 2018). The participants reported few minor inaccuracies.

The participants and researcher collaboratively negotiated the meanings of stories and themes influencing the process in which they clinically conceptualized grief stemming from the ambiguous loss experienced by clients in foster care. Epiphanies to the story lines were also explored and co-constructed by the participants and researcher

(Clandinin & Connelly, 2000; Creswell & Poth, 2018). Two of the participants reported minor epiphanies. The participants and researcher collaboratively analyzed the impact of

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epiphanies on the narrative stories of clinically conceptualizing grief stemming from the ambiguous loss experienced by clients in foster care. The collaboration assisted in the development of the final written narrative of the participants’ stories (Clandinin &

Connelly, 2000; Creswell & Poth, 2018).

Presentation of Narrative in Written Form. Narrative Inquiry suggested a general structure for presenting the written narrative (Clandinin & Connelly, 2000). The presentation of the narrative in written form occurred after the collaborative analysis and did not involve the participants (Clandinin & Connelly, 2000). The researcher provided a general introduction of the participants’ demographic and clinical information, research procedures, information regarding the data collection and analysis process, as well as rationale for the use of Narrative Inquiry. The purpose and effectiveness of the Narrative

Inquiry research exploring clinical conceptualizations of grief stemming from the ambiguous loss experienced by clients in foster care were also provided (Clandinin &

Connelly, 2000). The presentation of the written narrative included the telling of participants’ story, patterns of meaning and themes, epiphanies, and final interpretations of the meaning of the narrative story. The researcher reviewed and analyzed the field texts, restory, and co-constructed narratives gathered during the collaborative analysis to construct the final written narrative. The final written narrative incorporated the participants’ and researcher’s insights. The participants reviewed the final written narrative for accuracy and enhanced trustworthiness (Clandinin & Connelly, 2000). For the purposes of this study and dissertation requirements, the final narrative was not presented as a whole. The presentation of the final narratives has been integrated into this chapter, Chapter 4, and Chapter 5 of this document.

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Amalgamation and Analysis of Data. The amalgamation and analysis of the data for all the participants was the final procedure of the study. The methodology of the current study was informed by Clandinin and Connelly’s model of Narrative Inquiry

(Clandinin & Connelly, 2000). This methodology did not present clear guidelines for data analysis of multiple participants but noted applicability towards multiple participants

(Creswell & Poth, 2018). The researcher applied similar data analysis procedures to the stories of all three participants. The data from the Three-Dimensional Framework, restory, and final narratives were analyzed together as a whole to look for meaning, patterns, and themes (Butina, 2015; Clandinin & Connelly, 2000; Lal et al., 2012;

Merriam, 2009; Salter & Rhodes, 2018; Wells, 2011). The results of the individual stories were combined together to create a broader story representing mental health clinicians as a whole. Differences and similarities of participants’ findings were reported to honor the meaning of individual stories. Findings from the Three-Dimensional Framework and themes were also analyzed to determine meaning and application to the general population of mental health clinicians (Butina, 2015; Clandinin & Connelly, 2000;

Merriam, 2009; Salter & Rhodes, 2018; Wells, 2011).

Trustworthiness of the Current Study

Narrative Inquiry methodology places emphasis on enhancing the trustworthiness for research studies (Nowell, Norris, & White, 2017; Salter & Rhodes, 2018). In order to ensure the trustworthiness of the current research study, issues related to credibility, confirmability, transferability, and reflexivity were addressed (Korstjens & Moser, 2018).

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Credibility

Credibility of Narrative Inquiry research is equivalent to internal validity in quantitative research (Korstjens & Moser, 2018). Credibility speaks to the truth and honesty of the research findings. Research credibility of the current study ensured information and analysis drawn from the semi-structured topical oral history interviews and the field texts had accurately interpreted the participants’ experiences. Strategies used to ensure credibility of the current research were prolonged engagement with the participants, triangulation of data, and member checking (Korstjens & Moser, 2018).

Prolonged engagement consisted of significant amounts of time with the participants gathering and analyzing field texts, the closeness of the researcher and participants, and of obtaining thick descriptions (Creswell & Poth, 2018; Korstjens & Moser, 2018).

Triangulation of data involved utilizing various data collection methods

(Korstjens & Moser, 2018). The triangulation of data of the current study included the demographic questionnaire data, in-depth semi-structured interviews, field texts, and data derived from the collaborative analysis of narratives. The researcher and her advisor individually analyzed the data for themes and collaborated findings. The participants, researcher, and researcher’s advisor also reviewed the transcripts, restory, and final narratives to ensure accuracy and credibility of the data. The researcher’s advisor reviewed and analyzed the data and field texts separately and shared findings with the researcher.

The same format, procedures, and questions were utilized for each participant to maintain consistency and insure a greater level of trustworthiness and rigor (Nowell, et al., 2017; Salter & Rhodes, 2018). The researcher and her advisor reviewed the

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procedures of every participant to ensure consistency. Lastly, member checking included the process of the researcher and participants individually and collaboratively reviewing the demographic questionnaire data, transcripts, analysis of transcripts, and constructed narratives to ensure accurate interpretations and findings (Korstjens & Moser, 2018).

Confirmability

Confirmability is the degree to which the research findings of the current study were confirmed by other researchers. Confirmability was addressed by transparently describing the procedures and processes implemented in the current study (Korstjens &

Moser, 2018). A complete set of notes regarding research decisions, analysis of transcripts, reflective thoughts, sampling process, experiences of the collaborative analysis process, and emergence of themes and findings were recorded in the researcher’s journal. The recorded accounts of the research process could assist other researchers in confirming the findings of the study (Korstjens & Moser, 2018).

Transferability

Transferability of data allows the reader to determine if the findings from the current study could be transferable or applicable to their setting (Korstjens & Moser,

2018). The researcher assisted in the transferability by providing detailed and thick data descriptions of the participants’ narrative stories. The context, individual experiences, themes, and meaning of the narrative stories regarding clinical conceptualizations of grief stemming from ambiguous loss of clients in foster care were also presented to assist the reader in transferring the data to their setting.

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Reflexivity

Examining the influence of the researcher’s conceptual lens and values in research decisions is the process of reflexivity in Narrative Inquiry research (Korstjens &

Moser, 2018). The researcher ensured reflexivity by critically examining and recording her own biases, values, conceptual lens, and assumptions in the researcher journal. The influence of the researcher’s individual values, biases, beliefs, assumptions, and conceptual lens of the participant interview were also recorded. Maintaining a researcher journal ensured continued examination and reflection of the researcher’s views and impact on the participants’ responses to the semi-structured interview questions and research decisions. Regular meetings with the researcher’s advisor also assisted in addressing reflexivity.

Researcher Subjectivity Statement

The researcher’s subjectivity statement was provided to aid in the trustworthiness of the current study. The research involved examining clinical work and experiences of colleagues working with clients in foster care. In order to ensure the research was presented and conducted without bias, aiding in the validity of the researcher, a subjectivity statement has been provided. The subjectivity statement allowed the reader to critically examine the researcher. The subjectivity statement was also provided to ensure related clinical experiences of the researcher was presented transparently.

The researcher shared similar theoretical perspectives as many of her colleagues, viewing relationships from a structural and systemic viewpoint. A bias while conducting the research was the assumption of what experiences and stories the participants were going to share during their interviews. The researcher attempted to avoid reflecting

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assumptions in the wording of interview questions and focused on systemic conceptualizations. In order to address the potential bias, the process of determining methods and instruments used was reflected upon and recorded in a researcher journal.

The data was also reviewed by the participants to ensure accurate analysis and interpretations were captured and not influenced by personal biases of the researcher.

The researcher gained insight into clinical barriers regarding treatment approaches to process the loss of primary attachment figures and completing treatment goals. Further inquiry into the impact of the loss of attachment figures during the doctoral marriage and family therapy program highlighted the potential of grief manifestations to occur following the ambiguous loss of attachment figures. The researcher determined the manner in which clinicians conceptualized grief stemming from ambiguous loss provided insight into the treatment approaches and perspectives utilized with foster care youths.

The researcher’s goal was to better understand how clinicians conceptualized grief stemming from ambiguous loss of attachment figures of clients in foster care.

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CHAPTER IV

RESULTS

This chapter provides an overview of the results of the current study presented in narrative form of participants’ experiences that influenced their clinical conceptualizations of grief stemming from ambiguous losses of attachment figures experienced by clients in foster care. Narrative Inquiry’s Three-Dimensional Framework of temporality, sociality, and place were utilized to report the results of the participants’ narratives (Clandinin & Connelly, 2000). The results have been organized by temporality to construct a beginning, middle, and end to their narratives. Specifically, the beginning, middle, and end time points were prior to graduate school, during graduate school, and after graduate school. The results of place and sociality dimensions were organized and reported within the temporality points in which they occurred. Additionally, results of the emergent themes of the individual participants have been reported in the participants’ final narratives of the three individual participants.

Participant A

Participant Background Information

Participant A was a Caucasian female in her late thirties with ten years of clinical experience. She obtained a Master of Arts in Marriage and Family Therapy and holds two professional licenses, IMFT-S and LPCC-S. Participant A had clinical experiences working with clients in foster care while working at a mental health agency and in private 113

practice. She worked at a mental health agency for four years as a clinician and then two years as a clinical supervisor. Participant A also worked at a private practice for four years with the two most recent involving work with clients in foster care. She also supervised clinicians working with clients in foster care for five years. Participant A attended one training on ambiguous loss and several trainings regarding working with clients in foster care.

Participant A’s Story

Participant A’s story was constructed using Narrative Inquiry’s Three-

Dimensional Framework. The participant’s experiences informing clinical conceptualizations of grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care was categorized by three time points throughout the participant’s life. Initial experiences with foster care youths occurred prior to graduate school in her personal life growing up. Clinical experiences with foster care youths first occurred during graduate school as a clinical intern in her graduate internship. The majority of experiences and stories influencing Participant A’s clinical conceptualizations occurred post graduate school working as a licensed clinician.

Prior to Graduate School. Prior to graduate school Participant A’s experiences contributed to her understanding and perception of grief, loss, and foster care. The participant’s career goals and undergraduate focus included trauma. The participant’s family experienced grief and loss due to different “lifecycle changes.” The story reflected lifecycle changes as impactful experiences for the participant. She stated, “I guess it was just having, uh change and different changes overall like lifecycle changes, seeing how that can lead to grieving.”

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The participant reported defining grief as “death, as the, ya know, dying and then hurting.” Her understanding of loss was “the basic idea of losing something and hurting from that.” When reflecting on personal and family experiences, understanding and perceptions incorporated grief and loss:

Um, that process in my family, I guess is where it helped build that conceptualization that grief is not just that death loss, it’s any loss. That loss of even something that seems minor, like I said if it’s a role, or, an idea or an ideal about somebody in your family, or a loved one um, that that can be just as impactful as a death on the grieving process.

Family experiences in Participant A’s story prior to graduate school also reflected experience with foster care. Extended family members had been foster parents and had adopted two children. The participant noted remembering that the family members

“fostered kids” but did not have close interactions or relationships with them. Her perception of foster care was:

I did have some family members who used to do foster and adoption. So, I guess my initial assumption prior to grad school was a lot of the people who are foster parents are overall good and they end up adopting the children. I didn’t really think about the children going home before.

The setting of Participant A’s story prior to graduate school was her home and undergraduate college. The participant’s home included experiences of “lifecycle changes” during this time period. The participant’s understanding of attachment was introduced during her undergraduate education. She stated, “I remember seeing some of the aspects of attachments, like the monkey and Bowlby and everything, so I guess I had that from the basic psych courses because my undergrad was in psychology.” The participant’s clinical interest in trauma and the impact of trauma on individuals was also present during this time period and undergraduate setting. The participant reported

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undergraduate research papers focused on the curiosity of variances of the impact of trauma.

Participant A noted:

I guess since at least undergrad I remember having the desire to work with traumatized youth, kids and their families early on to prevent possible negative outcomes, and I think I’ve always been someone to want to understand the underlying why, so in order to really effectively make a change.

The sociality dimension did not reflect any experiences or stories for the participant prior to graduate school. The participant did not mention personal, family, or societal values or beliefs that impacted her clinical conceptualizations.

During Graduate School. The participant’s story during graduate school reflected trauma focused coursework in one specific class, clinical experiences during internship, and self-directed research. The participant’s understanding of foster care and trauma “expanded some” through coursework and internship. The connection of trauma and abuse was present in one of the participant’s graduate courses. The professor of the course incorporated a clinical focus on clients in foster care, abuse, and trauma. The participant mentioned, “That class and then some other here and there papers that I had to do, expanded my overall knowledge of different aspects of foster care and the reunification piece of it.”

Participant A’s conceptualizations of grief and loss did not change during graduate school. Her understanding of attachment and trauma continued to develop. The participant’s story highlighted: “aligning more with the Rogerian positive regard and that people are basically good.” Her story also reflected her understanding of attachment to connect with Rogerian Theory. Participant A mentioned, “Positive internal model of self and negative self, that connects with attachment.” 116

The settings present during Participant A’s story during this time period were the graduate program and internship site. The graduate program offered opportunities to expand her knowledge and engage in self-directed research when completing assignments for courses. Participant A noted,

So, my papers and different kinds of research areas tended to lead me to learn more about the overall idea of the styles of attachment and that helped with my conceptualization overall with just how attachment is underlying in itself.

The participant’s internship site provided her first clinical experiences which contributed to her understanding of foster care. She discussed learning the logistics of the foster care system, “The difference between foster and foster to adopt. That yes, there is reunification, so I learned more about that.” Her story also reflected learning the foster care system was not as positive as she believed it to be prior to graduate school. Her experiences during graduate school altered her positive perception of the foster care system. She noted experiencing “the ugly side” of the foster care system. Experiences with some foster parents revealed their intent was: “not to be good people giving a home to these kids.” In addition to learning logistics of the foster care system the participant stated learning, “not all foster parents are great people.”

The sociality dimension reflected an emphasis on MFT in the graduate program.

The focus of the program was: “It was very structural family therapy theory focused. A lot of value on conceptualizing cases based on the theory.” Sociality of the participant’s internship site focused on: “administrative items more so, like documentation. A lot of more focused on that end and not just the clinical focus of things.”

Post Graduate School. The participant’s story during the temporality time point of post graduate school showed the impact of clinical experiences and trainings on

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clinical conceptualizations. The participant’s conceptualizations increased after graduate school while working with clients at two employment settings. She worked at a mental health agency for six years and private practice for four years. She worked directly with foster care youths in private practice for two years. The sociality dimensions of the mental health agency and foster care system were meaningful in the participant’s story.

The participant’s first work experience as a licensed clinician was with a mental health agency. The majority of her clinical work included foster care youths. The participant “got to kind of see the impact of that instability, um of the unknowing and how difficult it is.” She reflected on difficulty working with biological parents due to their own trauma experiences. Participant A reported, “These are parents who came out of trauma not able to do anything different other than to continue that generational slide of trauma so there’s more compassion I guess overall.” Clinical experiences with foster care youths focused on addressing traumas before and during foster care:

The initial life of the family of origin may have been very abusive, traumatic, and neglectful, but that is still what clients in foster care knew. They [foster children] have to adjust to a new life and that leads to any number of symptoms.

The participant also reported a focus on addressing the trauma and negative impact the experience of foster care had on clients. The participant reflected, “So I got to see just how unstable and on the mental health end how that instability lends to so much, just the attachment difficulties.” Participant A noted she did not feel she had all the resources, tools, or competencies she wished she had in order to work with children experiencing grief and trauma. She sought out additional trainings to address “gaps in even my abilities”. The participant attended Eye Movement Desensitization Reprocessing

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(EMDR), ambiguous loss, and trauma trainings. The participant’s story highlighted an increase in confidence working with trauma, grief, and loss after attending trainings.

Participant A reported a clearer connection between grief and loss after attending a training on ambiguous loss. The participant stated her conceptualization of grief was,

“The pain and emotional process associated with any loss.” The participant stated, “Just gaining more understanding of all of the different ways loss can impact people. The more experience I got the more I realize how prevalent losses are in clinical work.”

The participant also learned more about attachment injuries after her EMDR training:

I probably learned more about the connection between attachment and trauma and diagnoses. And then after doing EMDR and learning more about that and the connection with, again, yeah just doing more research myself, I expanded my just understanding of personality disorders into the attachment categories. So, I would say I have a pretty solid understanding of attachment at this point in my life.

The clinical experiences and trainings assisted in the participant’s clinical conceptualizations. Her clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by foster care youths was from a grief, loss, trauma, and attachment perspective.

Two settings were present in the participant’s story during this time period. The setting of mental health agency lacked trainings addressing grief, loss, and attachment injuries. The agency focused on meeting the needs of “collaterals” and not clinical preparation:

It was much more of a learn how to fly by the seat of your pants and do what is necessary to be effective and yet meet goals of collateral people such as caseworkers and also meet your productivity. So, a lot of navigating how to be a therapist and stay sane and balance all of the pressures.

The agency did provide trainings on trauma to address the needs of foster care youths. However, the participant mentioned the trainings and trauma focused 119

interventions and was not applicable to foster care youths. Her experience utilizing the specific trauma intervention required foster care youths to process and create their trauma narratives with their foster parents. The participant reported the training and intervention was not an appropriate framework to follow when working with children in foster care due to instability and lack of permanency in their lives:

We were trained in TF-CBT [Trauma-Focused Cognitive Behavioral Therapy] and a big issue with that for instance that one of the steps involved with that is to get the child’s trauma narrative, the idea is that you are working with their parents and that they are able to hold the space for them and that when you’re working at that time. Um, there’s not a sense of permanency. Um so it never like really made sense.

The setting also provided specific assessments to use with clients. She reflected on experiences using the Achenbach assessment: “The Achenbach created a cluster of symptoms and associated them with diagnoses. It really helped informing treatment, diagnosing and creating a framework.” The participant used the assessment to screen for symptoms and possible diagnoses. She reported being cautious with diagnosing foster care youths: “because at the core it is anxiety, pain, trauma, or adverse event.”

The private practice setting did not provide trainings or assessments but focused on “peer-type supervision”. Private practice offered supervision to focus on processing and developing clinical skills. Private practice provided more experiences working with clients in foster care. The participant reported the ability to focus on clinical work with clients in foster care without the restraints and “red tape” of mental health agencies.

The sociality of the mental health agency focused on administrative concerns and a trauma approach. The participant’s story highlighted experiences at the mental health agency focused on administrative concerns of meeting productivity and insurance billing.

Supervision did not focus on “theoretical conceptualization of clients and cases” or 120

“growing clinically”. The agency’s focus was described as, “A big value, although it’s definitely not ideal or what we want to think about our roles, but a big focus and value was on meeting productivity. Just so much more on the administrative, billing, political red tape end.”

The participant reported the mental health agency and supervisors focused on using trauma approaches with foster care youths. She mentioned, “The agency’s conceptualization of what trauma is and how to deal with it isn’t always right.” The participant’s supervisor focused on behaviors exhibited by foster care youths and not core issues:

Like it was the behavioral issues, help them cope with their behavior issues. Well, that’s not the core of the issue. Treating the rash and not figuring out what’s causing the rash.

The participant reported seeking out additional training to address the grief, loss, trauma, and attachment injuries of clients in foster care.

The sociality dimension also highlighted the impact of the foster care system. The participant reported case workers within the foster care system had their own goals and approaches to working with foster care youths. Some of the case workers the participant worked with focused on reunification, addressing behavioral issues, or maintaining foster care placement. The participant viewed case workers goals as: “They want to appease some of these issues, so they don’t have to move the child different places because that’s hard to find placement.” The therapist’s goal was addressing traumas, grief, loss, and attachment injuries, and providing a “stable and positive reflection for her clients”. The participant also reported balancing goals between foster care youths and parental figures.

Biological and foster parents’ goals “usually related to behavioral concerns”. Case plans

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were also a focus of biological parents and case workers: “Bio parents goals might also be related to their case plan”

The Three-Dimensional Framework of Participant A’s story reflected early experiences and understanding of grief, loss, foster care, trauma, and attachment. The temporality dimension highlighted that clinical conceptualizations were greatly impacted due to clinical experiences during graduate school internship and post graduate school.

The place dimension reflected a lack of overall focus on grief, loss, and attachment in the graduate school and mental health agency. The sociality dimension reflected the freedom of private practice and a focus on theoretical conceptualizations at a “deeper level”. The participant mentioned, “I guess too, my post agency experience, the values and focus there, definitely allowed for more freedom, more personalized treatment modalities.”

Graduate school and the mental health agency provided further information regarding trauma in one specific course and opportunities to engage in self-directed research. Graduate school internship and the mental health agency offered the participant clinical experiences with foster care youths. The agency also provided a trauma training and assessments to utilize.

Themes

Participant A’s story highlighted three main themes and five sub-themes. Themes were clinical conceptualizations, barriers, and self of therapist. Figure 2 displays the themes that emerged in Participant A’s story.

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Themes and Subthemes

Clinical Barriers Self of Therapist Conceptualization

Understand Treatment Lived Efficacy Clinical Values and Approach Experience Perceive

Figure 2: Emergent themes and sub-themes of Participant A

Clinical Conceptualization. Clinical conceptualization was a key theme in

Participant A’s story. The stories regarding clinical conceptualizations emerged as two subthemes. The first subtheme, understand and perceive, reflected the manner in which the participant understood grief stemming from ambiguous loss of attachment figures experienced by foster care youths. The second subtheme focused on treatment approaches addressing grief stemming from ambiguous loss of attachment figures experienced by foster care youths.

Understand and Perceive. The first subtheme indicated the participant perceived grief stemming from the ambiguous loss of attachment figures from a grief, loss, attachment, and trauma perspective. Grief, loss, attachment, and trauma were perceived as “interconnected” and a “big messy weave”. The participant perceived clients in foster care to have experienced traumas and loss:

The way that I view clients in foster care, um, I view them as having experienced a trauma of some sort and minimally if there’s not been a, as they say a big T trauma, there must have been. There’s some sort of severage between their birth parents or birth parent which is a huge loss.

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Foster care youths experienced attachment injuries when “entering foster care itself.” Attachment injuries from the loss of attachment figures were perceived as traumatic losses, “leaving a core injury or wound.” The participant conceptualized loss as, “the removal whether purposeful, or expected or nonpurposeful, of the something that someone is attached to, in one form or another.” The participant’s conceptualization also distinguished between loss and ambiguous loss. Participant A reflected, “Ambiguous loss, that that is one of the most difficult things for people to process and navigate through because there is no solution.” The manifestation of grief from loss, reflected the process of healing wounds and trauma:

I think it could really be, it’s the process of, that it’s the wound, it’s the wound after a loss. So, it’s very, it’s like a trauma, it’s a process of and navigating through pain and trying to, however effective or ineffective, cope with a loss.

The participant’s story indicated a clinical conceptualization of grief, loss, attachment, and trauma perspective when working with clients in foster care. Grief was the manifestation of losses. Attachment injuries experienced by foster care youths were perceived as the traumatic loss of their attachment figures. Grief could stem from “Death, ambiguous grief, or ambiguous loss”. The participant reported understanding and perceiving grief and loss as “interchangeable.” She focused on the “mental, emotional, physical aftermath of the actual loss.”

Treatment Approach. Participant A’s story showed a trauma, grief, loss, and attachment treatment approach when working with clients in foster care experiencing grief stemming from the ambiguous loss of attachment figures. The participant’s treatment approach began with assessing for attachment styles and injuries, experiences of loss, symptoms of grief, and traumas throughout the clinical process. Participant A

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mentioned, “I do have the focus more so on trying to understand, learn and attend to what the clients’ emotional needs are and with the idea of how interconnected all of those items are.” Participant A reported using informal assessments and clinical interviews to assess for loss, trauma, grief and attachment style. Her assessment process was described as:

Really just assessing through observation or exploration. Or of from the child perspective, from the caretakers perspective. If a caseworker was involved then taking from their perspective. Just kind of getting the background as much as possible and um, just overall just knowing what different things can, what different impacts certain backgrounds have.

The participant mentioned an emphasis on assessing for the ambiguity of the loss as well: “The biggest thing that impacts the way I conceptualize grief is if the loss is ambiguous or not. If there is closure with the loss that is creating the grief, that can play a part in the healing process.” Participant A also assessed for symptoms of grief, loss, trauma, and attachment injuries. She reported more observations of trauma due to foster care youths’ experiences of abuse and neglect prior to entering foster care:

The initial life of the family of origin may have been very abusive, traumatic, and neglectful, but that is still what clients in foster care knew. They have to adjust to a new life and that leads to any number of symptoms.

When assessing for grief stemming from the ambiguous loss of attachment figures for foster care youths, the participant noted observing and assessing for behavioral and emotional symptoms. The participant reported some of those symptoms were acting out behaviors, attention seeking behaviors, rejecting behaviors, negative self-beliefs, emotional pain, and a “large span of behaviors.”

Interventions and techniques used to treat grief stemming from the ambiguous loss of attachment injuries experienced by foster care youths were mentioned in

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Participant A’s story. She mentioned using informal approaches, trauma focused interventions, coping skills, and EMDR. The participant’s story highlighted the use of play-based techniques, “meeting the child where they are,” “a lot of unconditional positive regard,” “holding space,” and “validates their experience and perceptions.” The participant also used psychoeducation to increase “self-compassion” and understanding.

Participant A mentioned,

I think it’s very much, first and foremost, validating their experience and their perceptions, and their feelings around a lot of it, and acknowledging the emotions and the pain that is connected. Helping them to even see things through a grief lens, even when It’s not what you typically associated with a grief lens, so that they can have the self-compassion of whatever their emotional process may be.

EMDR was also utilized to address grief stemming from the loss of attachment figures for clients in foster care: “I do EMDR, which I think is a very good way to treat grief and loss because that, again, is a trauma […] I connect loss with a lot of adverse events like identity, like a loss in belief of others.”

Participant A’s story mentioned the use of diagnoses to reflect underlying trauma, loss or grief:

I don’t know if I ‘DSM’ diagnose grief. It’s trauma, or Other Stressor related, PTSD, or anxiety, or depression, due to experiencing a complete just loss. Especially if they are, depending how long they […] are in permanent custody of children’s’ services then. They have to navigate through that initial loss of their parent.

The participant also reported diagnosing Reactive Attachment Disorder (RAD).

The participant reported not diagnosing behavioral diagnosis such as Oppositional

Defiant Disorder (ODD).

Barriers. Barriers were present in the participant’s story and emerged as a major theme. The foster care system and lack of trainings were barriers in the participant’s

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experiences of clinically conceptualizing grief stemming from the ambiguous loss of attachment figures experienced by foster care youths. The subtheme of efficacy was directly impacted by the participant’s experiences of barriers.

Participant A’s story reflected barriers when working with the foster care system.

The participant stated, “So I um, there were several barriers.” Clients experienced instability when placed into the foster care system. Some of the challenges of working with the foster care system were instability and working with the collaterals involved in the foster care youths’ lives. The participant shared experiences of foster care youths struggling to cope and adjust to the instability of the foster care system. Clients in foster care did not have any control of their foster care placement, how long they would be there, or if they would see their biological family. The participant shared the memory of working with a client in foster care: “He has no control and there’s no, it doesn’t matter what he does because he knows he’s not gonna be here anyway so why feel comfortable, when he starts feeling comfortable he’s going to rejected.”

Participant A’s story highlighted foster care as a barrier that negatively impacted a client’s ability to heal from attachment injuries, trauma, and grief. She reflected, “Foster care placement can be a crazy huge barrier to work on healing attachment injuries and core attachment styles.” Foster care youths’ lack of a secure base and the instability of the foster care system contributed to the difficulties of meeting foster care youths’ clinical needs:

It is due to experiencing a complete loss or sometimes multiple losses depending on their situation. They have to navigate through the initial loss of their parents also. Some clients are in permanent custody of children’s services and their parent does not try to work on the case plan.

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The participant reported her clinical experiences included working with biological parents that experienced their own traumas. Biological parents’ mental health concerns impacted their ability to care for their children. Foster care youths often experienced their own traumas as well and incorporating biological parents to assist in meeting the client’s needs was challenging:

You are working with a child who has been traumatized in some fashion and you also are working with their guardians, parents, whatever. Who, the assumption is that they are able and stable enough to provide a safe and stable environment for the client and a lot of times that just wasn’t the case. Whether it was the parents were unstable emotionally, mentally had their own stuff that needed worked through, the client was in temporary kinship or foster care. Um just really didn’t fit.

Collaterals in foster care youths’ lives were biological parents, foster parents and case workers. The participant reported differences in treatment goals with biological parents, foster parents, foster care youths, and case workers:

Whereas with foster kids, you have maybe the goal of the child you have. If you’re working at all with or collaborating with the bio parents, a bio parent goal which is usually related to their case plan or what they want for themselves, and um well then the foster parent which a lot of times is related to ‘well I don’t want these behavioral concerns.”

Participant A stated her goals included, “ My goal was to be at least a stable and positive and reflection of positivity. Not like ‘oh rainbows’ positivity, but unconditional positive regard for the child.” Case workers at times had different goals determined by the foster care system, such as reunification. The mental health agency also had different goals and treatment approaches for working with foster care youths that differed with

Participant A’s conceptualizations. Her story reflected the mental health agency conceptualized clinical issues of foster care youths from a trauma perspective. The

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trauma focus was a barrier to addressing what the participant believed to be the core issues, which were grief, loss, attachment injuries, and trauma:

There were so many different conceptualizations, so like there was the agency’s conceptualization of what trauma and how to deal with trauma and then or like foster care, it wasn’t always even like trauma, wasn’t always like even discussed. Like when it’s a given? They didn’t, that wasn’t like a piece, like it was the behavioral issues, help them cope with their behavior issues. Well, that’s not the core of the issue.

The barriers theme indicated Participant A did not feel prepared to work with foster care youths. She mentioned, “I guess that I didn’t have all the resources, the tools”.

She reported the mental health agency did not provide helpful or applicable trainings to address grief, trauma, and loss experienced by clients in foster care:

They would offer trainings, um one of, so they I think had good intentions but too much red tape to really hold an overall goal of sticking to meeting needs of clients. They um for instance offered a TF-CBT training and really seemed to want to expand our skills in that, in CPP, in those very client focused areas, evidence-based treatment areas, however, a lot of those values, underlying theoretical pinnings were not applicable to the clients we worked with.

The mental health agency conceptualized mental health issues of clients in foster care from a trauma perspective. The trauma focus was a barrier to addressing what the participant believed to be the core issues, which were grief, loss, attachment injuries, and trauma:

Participant A’s story also reflected her graduate school experience did not prepare her to work with grief, loss, trauma, and foster care youths. One course included clinical conceptualizations of abuse and trauma for clients in foster care. The professor of the 129

course shared her clinical experiences and conceptualizations of working with foster care youths. The rest of the graduate program focused on MFT concepts and had a family systems focus. The participant developed her conceptualizations of attachment, trauma, and loss by engaging in self-research. The participant stated her interests assisted with her conceptualizations:

I think I attended more and did things when I had a choice of writing a paper about whatever or trauma. I would do that, so I learned more about attachment, but I wouldn’t say that’s the general experience of grad school.

The lack of trainings, preparation, and foster care system were perceived as barriers in Participant A’s story. The barriers impacted her ability to use clinical conceptualizations of grief, loss, trauma, and attachment with working with clients in foster care. The participant reported not feeling prepared and lacked appropriate training.

She had to “fly by the seat of my pants” and learned as she gained experience working with clients in foster care.

Efficacy. The story reflected a subtheme of efficacy. Efficacy emerged in the barrier theme due to the impact of barriers on the participant’s efficacy and confidence working with clients in foster care. Participant A stated she did not have “the competencies that I wish I would have had.” She reported the lack of trainings contributed to “a lot of the walls that I hit.” The participant’s story showed she believed she did not have enough expertise to work with caseworkers or parents of foster care youths: “I didn’t have enough of an expertise you know.” Participant A’s lower efficacy was a barrier in her ability to advocate for clients’ clinical needs, especially when case workers, foster parents or biological parents had differing goals. “Just my own like confidence or efficacy when there were those different types of goals.” The participant’s

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story showed the positive impact of grief, loss, and trauma trainings on her clinical efficacy. The participant reported later in her clinical career having more, “just overall confidence in myself” when working with foster care youths and addressing their clinical needs.”

Self of Therapist. The final and third theme of Participant A’s story was self of therapist. Self of therapist consisted of two subthemes, lived experiences and clinical values. Lived experiences and clinical values impacted the participant’s clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by foster care youths.

Lived Experiences. Lived experiences in the participant’s story showed the impact of personal clinical and clinical work experiences. The participant’s story reflected lived experiences contributed to her clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care. The participant’s first experiences and perceptions of foster care youths occurred prior to graduate school. The experiences of having foster care youths in her family and then some later being adopted, shaped her beginning conceptualizations of foster care.

Her story showed a perception of foster care youths transitioning to being adopted by their foster parents. She did not have an awareness of youths “going home” to biological parents. Other lived experiences occurring within Participant A’s family were experiences of grief and loss. Grief and loss were introduced into her conceptualizations through family “lifecycle changes.” Experiences of change in family member’s roles, family dynamics, and “lifecycle changes” shaped her perception of changes as “a sense of grieving.”

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The participant’s story included lived experiences that contributed to clinical conceptualizations occurred during graduate school as well. One graduate course provided clinical connections of trauma and abuse for foster care youths. The learning experiences in the graduate course increased her understanding of trauma and the impact of “bad things.” The graduate course specifically introduced trauma as a component into her clinical conceptualizations of clients in foster care. Participant A mentioned, “my understanding of foster care in grad school, um expanded some just based on some of the coursework.” The participant continued clinical conceptualizations through self-research in graduate courses to increase her understanding and perception of loss, attachment, and trauma.

Lived experiences as a licensed clinician at a mental health agency and private practice, were salient experiences in her story. Clinical experiences in the participant’s story reflected lived experiences as a clinical intern during graduate school and after graduate school as a licensed clinician. The participant’s clinical internship and first few years working as a licensed clinician occurred at a mental health agency. Participant A’s knowledge and clinical conceptualizations “greatly expanded” when working with clients in foster care. The experiences broadened her understanding and perception of the foster care system and foster care youths. She noted the clinical experiences taught her “a lot more about logistics” of foster care. Participant A had negative and positive experiences working with foster care parents, biological parents, and case workers. She noted the experiences of using “psychoeducation and collaborating maybe the caseworker and whatnot to assist with working towards reunification with the client.”

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Lived experiences at the mental health agency provided initial experiences using treatment approaches, diagnoses, assessments, and observing symptoms exhibited by clients in foster care. The trainings, diagnoses, and assessments used by the mental health agency were trauma and behavioral focused. They did not address the grief and loss experienced by foster care youths; “they are going through what seems like a grieving process.” The participant reported experiences of attending trainings that increased her clinical conceptualizations to include treatment approaches focused on grief, loss, trauma, and attachment.

Most recent lived experiences occurred at a private practice. Private practice allowed for “less crisis management type restructuring counseling um and more ability to conceptualize cases for deeper more secondary changes.” Experiences in private practiced assisted the participant to “grow further as a clinician, conceptualizing client cases in a more theoretical manner at a deeper level.” Participant A reflected on the overall impact of clinical experiences; “I think both of them, because I think with every client I see that adds information overall of my repertoire of how I conceptualize things or navigate the therapeutic process.”

Clinical Values. The subtheme of clinical values was evident in Participant A’s story due to several stories that included factors contributing to her clinical values. The participant mentioned clinical values and focus on unconditional positive regard and attachment. Participant A’s story indicated a use of “unconditional positive regard for the child” to assist in creating a stable environment during counseling sessions. She stated,

“use a lot of unconditional positive regard overall, and just holding the space for them.”

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The Rogerian concept of unconditional positive regard connected with attachment for the participant: “Rogerian is very, in terms of like, ‘ok good me good you,’ positive internal model of self, that connects with attachment.”

The participant reported an interest in attachment and attachment injuries which

“led me to go down that rabbit hole of attachment.” Participant A stated perceiving attachment as “the core of so many things.” The participant’s story indicated assessing for attachment injures and losses, “It’s something that’s already there or something I’m already looking at.” Attachment injuries were incorporated into her treatment approaches as well:

So, um because I think that is such a core so I um, mmm, like a lot of, I use a lot of psychoed with the clients for instance to help with compassion building um. And then I bring a lot of attachment stuff in. So, I let them know what attachment is and how big of a role in the crux that is attachment is with anything.

Participant B

Participant Background Information

Participant B is a Caucasian female in her thirties with six years of clinical experience. She has a Master of Arts in Marriage and Family Therapy and holds two professional licenses, IMFT and LPCC-S. Participant B has five years of clinical experience working with clients in foster care at mental health agencies. She has also supervised clinicians working with clients in foster care for one year.

Participant B’s Story

The participant’s story was constructed in the framework of Narrative Inquiry’s three dimensions. Participant B’s narrative of experiences informing clinical conceptualizations of grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care was categorized by three time points throughout the 134

participant’s life. Experiences and stories within those time periods, as well as the place and sociality dimensions, have been presented. Settings of home, graduate school, and mental health agencies were identified. Societal influences of her own personal and clinical values, graduate school values, and supervisors’ values were explored as well.

Prior to Graduate School. The temporality dimension, prior to graduate school, included an exploration of the participant’s personal life experiences, settings of experiences, societal values and family culture. Participant B had limited understanding, perceptions, and experiences related to grief, loss, and foster care youths. The participant reported “surface level” knowledge and awareness regarding foster care, attachment, grief and loss. The participant reported having a “narrow understanding” of grief and loss prior to graduate school. She noted, “My previous understanding of it was surface level.”

Participant B also stated, “I don’t know that I had really given it much more thought than that. That it was a big thing, but I didn’t know how.”

The participant reported no personal or family experiences with grief, loss, attachment injuries, or the foster care system in her story. Participant B reflected on the fortune of not personally experiencing grief or loss, “And I have been lucky in my personal life to not have to face that head on.” As such, her home setting did not include any experiences or perceptions to explore. Her story during this time point did include an awareness of the larger societal perceptions of grief and loss. The perceived societal view was, “Um I do feel like there is a certain level of ‘get over’ that still exists.” Her personal view of grief was stated as, “I have a difficult time in processing grief for myself, so I feel like that makes me extra sensitive or aware when I am working with someone who is experiencing grief.” The three dimensions of temporality, place, and sociality prior to

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graduate school reflected limited experiences and perceptions of grief, loss, and foster care youths.

During Graduate School. Participant B’s story during graduate school included an exploration of the participant’s educational experiences and sociality of her graduate program. Her story indicated her clinical understanding of grief and loss began during this time period and in the graduate school setting. Her connection between grief and loss also began during her graduate school experience. Participant B noted the topics were

“paired” together when discussed in class. However, grief and loss were not a focus of the program. The participant reflected, “Umm [grief and loss] may have been a topic of conversation but not necessarily a major focus. ” Her story indicated the societal values and focus of the graduate school was on marriage and family therapy and systemic perspectives.

Um, I feel like the program really focused on obviously the marriage and family aspects, but from a solely relational standpoint of things, so it touched on grief and loss it touched on development, all those kind of core things, but it was very family related like how it impacts the family side of things. There wasn’t necessarily a focus on how it impacts the individual or the actual topic itself.

The participant’s awareness of the depth of grief and loss began formulating while in the graduate program. She recalled, “We are introduced to the fact that there is an iceberg, but we don’t get training on said iceberg.” The participant’s story during this time period and setting of graduate school did not mention any experiences that contributed to her perspective of attachment or foster care youths. The majority of the participant’s experiences occurred after she completed her graduate program and began working as a licensed clinician.

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Post Graduate School. Chronologically, the majority of the participant’s experiences and stories regarding clinical conceptualizations occurred post-graduate school when working directly with clients as a licensed clinician. The participant reported working at three mental health agencies over the span of six years as a clinician. The participant’s employment settings of the three agencies emerged as one overall setting in the place dimension. The participant reported working with multiple supervisors as a clinician. The sociality dimension of the different supervisors’ values, perceptions, and priorities had positive and negative impacts on the participant during this time period.

The impact of working directly with clients, the mental health agency setting, and sociality of supervisors was evident in the participant’s story.

The temporality dimension, after graduate school, reflected the growth of the participant’s understanding and awareness of grief and loss due to direct clinical experiences. The participant’s story reflected significant increases in her perceptions, knowledge, and clinical skills while working at mental health agencies:

Since being in the field as a licensed clinician, my view of working with loss has expanded greatly. My previous understanding of it was surface level. And I feel at this point I probably have only just scratched a little deeper. I think when dealing with loss, there’s so much under that iceberg. And every client that I work with shows me that there’s more that I haven’t learned yet.

The direct clinical work provided experiences utilizing various techniques, diagnoses, and clinical approaches in her clinical work. Her understanding of loss began to enhance, and she started to realize the intricate clinical impact of loss. She noted,

“In relation to foster care and grief and loss that it’s an incredibly challenging nuance framework to work in.” Participant B emphasized a clinical value of assessing and gathering information throughout the clinical process and not just during the intake

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session. Her story showed a value of going at the client’s pace of clinical readiness, continued assessing and “digging” for symptoms, and enhancing her clinical skills.

The participant also noted a clinical approach that was emphasized, “So from a clinical standpoint, when that [loss] comes up, it’s information gathering and assessing just how someone has been impacted by grief.”

Mental health settings provided trauma focused trainings and specific assessments to utilize. The assessments centered around behavioral concerns, anxiety, and depression.

However, Participant B reported a lack of sufficient support and trainings in mental health agency settings to entirely meet the needs of her clients: “Um so I didn’t, I really didn’t feel like I got a lot of guidance in my first year.” She experienced challenging clinical cases that exhibited grief and loss. She reported,

That I have needed to expand my understanding and work with it. There have been a few clients in particular who their situation really stuck and really challenged me to go find more training to feel better equipped to help then what I was.

To better meet the needs of her clients and enhance her clinical skills, the participant reported seeking out grief and loss trainings. Participant B reflected on the experiences of limited preparation and training from the mental health agencies: “So, I subsequently ended up taking twenty CEUs worth of grief and loss trainings to try to combat how unprepared I felt.” The participant’s story indicated her first agency supervisor also did not assist in preparing or training her to work with grief and loss. The participant highlighted an experience with her supervisor that influenced her decision to seek out additional trainings:

And, um, I I sought out the 20 CEUs because um I was working and the client that I was referring to I actually inherited from my supervisor at the time and my supervisor did not agree, I suppose, with how I was assessing the situation and 138

very much made it clear that she didn’t agree. I asked for trainings when I, you know, I tried to get them to point me in the right direction, but um I wasn’t given anything and so I worked on finding trainings myself. I found those CEUs and took the material back to her to present and say ‘listen, We need to figure this out.’

The training provided foundational information and did not assist in her clinical preparation, per Participant B’s report. The sociality dimension highlighted the impact of differences in values, perceptions and priorities between the participant and agency supervisor. Participant B emphasized a clinical value of assessing and gathering information throughout the clinical process and not just during the intake session. Her story showed a value of going at the client’s pace of clinical readiness, ongoing assessing and “digging” for symptoms, and continued enhancement of her clinical skills. The participant believed her supervisor focused on administrative concerns and agency protocol, “We would talk about cases briefly, but it was very much um, kind of your day to day operations and billing and notes and logistics.” The participant reported more positive experiences with supervisors after moving on to another mental health agency:

Oh yeah. Well I had a different supervisor to fall back on and it linked heavily into our supervision sessions and that’s where I got the emphasis on trauma, and you know I actually got a lot of cases and they were fosters and had grief and loss wrapped up into it and we talked about that stuff.

The participant’s story showed positive clinical growth working with supervisors with similar clinical values. When working with supervisors with different values and who did not provide adequate clinical support she sought out other supervision and trainings.

The majority of experiences and stories influencing Participant B’s conceptualizations occurred post graduate school as a licensed clinician. The place dimension highlighted the salience of her employment setting in her story. Settings of 139

home and graduate school also appeared in her story. The setting of mental health agency was found to have an influence in her clinical conceptualizations regarding grief stemming from ambiguous loss of attachment figures experienced by foster care youths.

Home and graduate school settings were not found to provide prominent experiences or influences in the participant’s narrative. The most salient experiences and data was presented through the sociality dimension. The main societal influences in her story were her clinical values, graduate school values, and supervisors’ values. Stories through the sociality dimension highlighted conflict with Participant B’s clinical values with agency supervisors’ values.

Themes

The results of coding and thorough reviews of Participant B’s transcripts and restory revealed three themes and three subthemes. The themes were clinical conceptualizations, barriers, and lived experiences. See figure 3 for themes and subthemes.

Themes and Subthemes

Clinical Barriers Lived Experience Conceptualization

Understand and Treatment Competence Perceieve Approach

Figure 3: Emergent themes and sub-themes of Participant B

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Clinical Conceptualization. Participant B’s story included several components dedicated to the manner in which she perceived, understood, and clinically approached grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care. The components were consolidated into one all-encompassing theme. The theme of clinical conceptualizations encompassed the manner in which she understood and perceived grief, loss, and attachment injuries for clients in foster care. The conceptualizations also included diagnosis, symptoms, and treatment approaches of clients in foster care.

Understand and Perceive. Her understanding and perception of grief that stemmed from ambiguous losses of attachment figures for clients in foster care included components of trauma, attachment injuries, loss, and grief. The participant reported more developed conceptualizations of trauma and attachment injuries than loss and grief. She conceptualized grief as “persistent and heavy and lasting.” Her perception and understanding of grief were reported to be “similarly to loss.”

She conceptualized loss as experiences that “have multiple offshoots.” Foster care youths were faced with challenges of processing losses as well as the trauma from the loss. The relation and closeness of the individual that was lost determined the severity of the impact of the loss. She reported “we don’t always heal from that loss.” Her story indicated the loss of an attachment figure occurred when foster care youths are removed from their home and the placement into foster care, which negatively impacts foster care youths. The loss of an attachment figure was described as “not a thing that heals and is forgotten. It is a thing that leaves a scar and a soft spot behind it.” Attachment injuries

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and losses were described as “baseline” experiences that all foster care youths experienced.

Treatment Approach. The treatment approach did not focus on the components of trauma, attachment injuries, loss, and grief evenly. The treatment approach emphasized an overall trauma method and “weaving in” grief and loss. Attachment injuries were predominantly approached from a trauma perspective as well with a focus on the traumatic impact of the injuries. The resulting loss of attachment figures and manifestations of grief were secondary in the treatment approach. The trauma approach rationale was:

Um, trauma training and an awareness of, an awareness of meeting the kiddo where they are is incredibly key. Not pushing beyond what they are ready or capable for. And that comes into play when you are looking at reunification.

The participant emphasized utilizing a Person-Centered approach to “meet them where they’re at” and reduce possible harm. The therapist also indicated the treatment approach involved working with the foster care placement to ensure they were able to handle and navigate presenting concerns. Other presenting concerns unique to foster care youths were prioritized along with trauma. Clients in foster care presented with

“additional needs” that the therapist integrated into the clinical conceptualizations. The approach of addressing clinical needs unique to foster care youths was done to best meet client’s clinical needs. She also reported a clinical focus of “ensuring that they are processing and reviewing, um, either trauma or whatever set of circumstances led to their placement.” The “additional needs” of clients in foster care was noted as,

For clients in foster care. They have additional needs that have to be considered and taken into account for their clinical care…Conceptually, I feel like when working with kids in foster care, seeing them from the standpoint of needing to grow, not only in the need that other kids may need to as well, but how to work 142

through and grow from their particular set of circumstances. Everyone has different things in their life that need to be processed and addressed but a foster placement carries a different weight, a different view um for those kids.

Diagnoses related to foster care placement experiences, traumas prior to placement, and presenting concerns emerged as main diagnoses utilized. The high prevalence of trauma with this population coincided with the use of trauma related diagnoses. Trauma diagnoses, ODD, RAD, Attention Deficit Hyperactive Disorder

(ADHD), Generalized Anxiety Disorder (GAD), and MDD were mentioned. Grief was not directly diagnosed, but the manifestations of other mental health disorders stemming from grief manifestations were diagnosed. Her process of diagnosing grief was described as diagnosing the “byproduct” of grief. She mentioned, “So with kiddos you may be seeing behavioral outburst when the root cause may be grief. So, your initial diagnosis may not reflect the grief.”

The participant did not use particular assessments in her treatment approach.

However, she mentioned the Child Behavior Checklist was “a good um assessment to gauge a variety of different types of symptoms. So that is a helpful tool as far as techniques go.” She reported techniques implemented were in relation to the diagnosis:

“Um depending on the diagnosis it could range from CBT techniques or DBT

(Dialectical Behavioral Therapy) can be very helpful. Um but, very very Person-Centered and very Emotion-Focused, if they are ready for that.”

The treatment plan utilized informal techniques to address grief stemming from ambiguous loss of attachment figures. The techniques consisted of informal ongoing assessments, consistent “digging,” and information gathering. The impacts, severity, and client’s definition of grief and loss were presented as critical components in Participant

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B’s clinical conceptualizations. Participant B reported utilizing this information to “plant seeds” of grief and loss throughout the client’s treatment process. The participant reported low competency and barriers to treating grief and loss effectively.

Barriers. The theme of barriers/competency contained experiences of barriers to enhancing competence of clinical conceptualizations of grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care. The barriers were reported as the lack of adequate trainings, supervision, and education specific to grief and loss. The barriers impacted the participant’s competency regarding clinical preparedness and treatment approaches.

Barriers that impacted Participant B’s treatment approaches were administrative barriers and the foster care system. The participant reported administrative and insurance policies requiring a clinical diagnosis after the first intake session:

So, the information that, the information that you’re given on the first intake and the fact that in general you have an hour to come up with a diagnosis is more following a bouncing ball then it is fully digging through an iceberg to find out what level you are in. You might not find out for weeks.

The participant’s initial diagnosis and clinical focus was centered on presenting concerns and not core underlying concerns. Underlying clinical concerns may not manifest for several weeks after the initial intake session.

The foster care system was identified as a barrier that constrained treatment approaches. The participant reported a clinical need to address the unique challenges of the foster care experiences for clients prior to addressing underlying concerns:

They’ve been removed from their home or their parent and depending on their age they may or may not know or understand the reason why, and even if they know, they may not agree with the reason. But they are in a very difficult position, because like most other kids they have very little control over their situation and things can feel harder when you’re not with your parents and you want to be with 144

[them] and you are placed somewhere and that’s irrelevant of how good or nice the foster placement is. It is still very challenging for these kids, they’re all in that position.

The “additional needs” and unique challenges experienced by clients in foster care was indicated to impede their clinical readiness to address underlying core issues.

“Some aren’t ready to process it and that’s, that’s a challenge in and of itself…they can’t be forced.” The participant noted experiences in which the “adults” in the foster care youth’s world pressured clinical treatment to address underlying core issues before it was clinically appropriate. Instances of caseworkers, other adults in foster care youth’s world, were reported to also have their own perceptions of when clients in foster care should engage in “emotional healing or processing.” Clinical work with the foster care system involved working with different individuals and adults in the foster care youth’s world.

The focus on incorporating adults and resources added challenges to clinical treatment:

Um there have been cases where I have worked where I did feel very connected with all the parties in the system and there have been cases where there’s usually one person who isn’t really as involved as I would prefer. It’s very case by case. But most times there is someone who is more out of the loop than preferred. Now that may vary between the biological parent, that could be the caseworker, or it could be the placement parents or parent, uh depending on a situation. But from a resource standpoint that is also challenging because getting all the players to be a part of it and using all the resources in place is its own set of challenges. And making sure that you are trying to utilize techniques and resources that are appropriate for the situation can be hard to find or produce especially if the placement has tried counseling before or had experience with things not working.

Difficulty finding resources in general, was a major theme of the Participant B’s story. Her story included experiences of difficulty locating trainings “specifically designed to look at each layer and type of grief and loss.” The trainings she was able to locate failed to meet the participant’s needs: “It was very general, very overviewed, um I didn’t really feel that any of them were the level of in depth that I needed to feel

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prepared.” She reflected on the 20-hour CEU training previously mentioned in the chapter. “I even went to that hoping like please give me the answer key to this this issue.

But no luck, I felt vaguely more prepared but not in the grand scheme of things.”

The participant reported instances of receiving limited guidance and support from her initial supervisor at a mental health agency. She looked for suggestions and strategies of how to address grief and loss. Her graduate school experiences also failed to provide treatment directions and advance her conceptualizations. She noted “it’s hard to teach that kind of impact”. Her graduate education began the development of her clinical conceptualizations. Her awareness of “an iceberg” in regard to perceptions of grief and loss began.

Competence. The participant’s story reflected a limited competence in clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care. The need to increase her competence appeared in her story during accounts of working as a licensed clinician. She reported feeling

“unprepared” several times throughout her story. She reported an awareness of the

“iceberg” of grief and loss but a difficulty implementing effective treatment approaches.

A need for training and preparation was evident due to the potential of causing harm to clients in foster care. The participant stated,

Loss is very tricky. Some people, some kiddos need to process through loss. But it is a very precarious thing to guide someone through and again being keen to their level and their understand and their willingness can be the difference between being helpful or being hurtful. When you’re guiding someone through loss and you’re not paying attention to their perceptions and their reactions you’re not, you can reinjure them and make it worse.

Participant B reported the barriers, lack of trainings, and limited competence did not prepare her for the inevitable presence of grief and loss with clients in foster care: 146

“It’s a matter of when and how bad [...] As a clinician you are going to run into this especially when you are working with this population so there needs to be better preparedness for it.” Lastly, emphasized the need for adequate trainings, education, and supervision to prepare clinicians for the “onslaught that they’re about to walk into” when working with foster care youths.

Lived Experience. The theme of Lived Experience was apparent when reviewing the Three-Dimensional Framework of Participant B’s story. Her conceptualization of grief has evolved over time with experiences. “Yeah, I think my understanding of grief, as I’ve gone through this world, has changed over time.” The majority of her clinical experiences occurred while working as a licensed clinician. Participant B reported feeling clinically unprepared after her graduate training to work with grief and loss. She reported,

“Because I recall dealing with it [grief and loss] not too long after graduating and feeling like I didn’t really have a very firm grasp on how to work in that realm.” Clinical experiences with foster care youths increased her awareness and perceptions of grief and loss:

It was after I was um graduated and licensed I did work with um, coincidentally a foster family that [was] dealing with grief and loss and they were a real challenge for me [...] I had one client in particular who was very challenging from a multitude of angles and grief and loss was a huge factor for that.

Supervision experiences prior to becoming an independently licensed clinician were reported to impact clinical growth. The participant reported limited clinical growth with supervisors that displayed differing clinical approaches and focused on administrative concerns. Positive increases in clinical growth were noted during supervision with supervisors that addressed clinical concerns of grief and loss for clients in foster care. An off-site supervisor, especially, was reported as helpful in increasing clinical growth and 147

conceptualizations. She reported appreciation and enjoyment of that supervisor’s perspective and dedication to increasing her clinical understandings of loss, trauma, and clients in foster care.

Participant C

Participant Background Information

Participant C was a Caucasian female in her late twenties with four years of clinical experience. She had a Master of Arts in Marriage and Family Therapy and held two professional licenses, MFT and LPCC. Participant C had clinical experience working with clients in foster care while working at a mental health agency for three years. The participant transitioned to working at a private practice and worked there for one year.

Participant C’s Story

Narrative Inquiry’s Three-Dimensional Framework was used to present

Participant C’s story. Her story focused on the manner she clinically conceptualized grief stemming from the ambiguous loss of attachment figures experiences by clients in foster care. The participant’s story was organized by the temporality dimension to present a beginning, middle and end. The sequence of experiences was presented chronologically with three timepoints: prior to graduate school, during graduate school, and post graduate school. Place and sociality dimensions have been organized by temporality as well, and presented in the corresponding timepoints. Participant C’s story highlighted the impact of personal and family experiences of grief, loss, and trauma. The majority of experiences and stories formulating the participant’s clinical perspective occurred prior to graduate school and post graduate school in her personal life. Experiences contributing to her treatment approach and clinical understanding occurred post graduate school while

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working as a licensed clinician. Personal and family values also contributed to the participant’s clinical conceptualizations.

Prior to Graduate School. The temporality dimension, prior to graduate school, included an exploration of the participant’s personal life experiences, home setting experiences, personal values and family culture. Participant C’s story included multiple family experiences of trauma, grief, and loss. Her family grieved the deaths of multiple family members. The participant’s grandmother, grandfather, step-grandfather, and uncle passed away during this time period. Her grandmother and uncle both died in unexpectedly and traumatic manners. The deaths were unrelated and occurred years apart. Her parents also grieved the losses of multiple miscarriages. The participant’s story also reflected the grief and loss her grandparents experienced:

My grandpa was a poor immigrant […], so they experienced a lot of grief culturally. Um coming to the US and you know loss of their home, the loss there, um and then both of my dad’s parents lived through the Great Depression and they were broke from it. So, loss there.

The participant’s family experiences of grief and loss motivated her to research and educate herself:

I guess before grad school I looked at it um from a more spiritual perspective um and just like how to incorporate grief and loss spiritually within my own faith. Um and you know a lot I think some of the material I used to educate myself it went over the 5 stages of grief and uh incorporated that into it as well.

Participant C stated her research provided information regarding the impact of grief and loss on individuals and families. She also explored information to assist with incorporating grief and loss spiritually within her own faith. Her self-research and family’s experiences of grief and loss shaped her conceptualizations. She viewed grief as:

“the process of dealing with a loss that is significant to ones’ self. The journey or the

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process.” Participant C’s perspective of loss encompassed any loss that was experienced as “significant” to an individual. She stated examples of financial loss, cultural losses, loss of relationships, loss of loved ones, as well as loss through death. Overall, the participant conceptualized grief stemming from ambiguous losses from a more spiritual perspective that incorporated grief and loss. She described it as “I understood it from a spiritual perspective with some psychology added in.” Components of attachment injuries and foster care youths were not present during this time period and were not directly present in her conceptualizations.

The setting that emerged in Participant C’s story during the time period prior to graduate school was her home. The family experiences of grief and loss were a “big theme of what was discussed” in the home. Discussion in the home often included stories of loss, grieving family members, loss of dreams, and loss of culture. The losses her grandfather experienced during the Great Depression and cultural losses experienced when immigrating to the United States were openly discussed in the home. She noted memories of the impact of grief and loss on her family: “So I guess I was also exposed to how grief and loss can affect people.”

The home setting also noted stories of family traditions honoring loved ones. The role of family traditions, values, and spiritual beliefs were evident in the sociality dimension. Participant C’s family’s Catholic values and spiritual beliefs shaped her clinical conceptualizations of grief and loss. Her family traditions reflected their beliefs and values of honoring the lives of deceased family members. Her story highlighted memories of her family “visiting gravesites” regularly. She mentioned, “Grief and loss

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has always been a normal part of life and for the most part been honored, and the process has been respected.”

During Graduate School. Participant C’s storying during the temporality timepoint, during graduate school, introduced clinical and trauma perspectives. The participant noted the influence of her graduate training: “I mean I would say that I was looking for more research based, or maybe I started viewing loss from a more clinical perspective but incorporated personally my spiritual beliefs in that.” The participant’s story indicated her graduate school setting did not include experiences or courses concerning grief, loss, attachment, or foster care youths. She reported, “I don’t really remember discussing it (grief and loss), um at all.” The sociality dimension indicated the participant’s graduate school program focused on trauma as well as “family systems.”

Post Graduate School. The participant’s story during the post graduate school temporality dimension, highlighted the participant’s continued development of her clinical conceptualizations. Direct clinical experiences, supervision, trainings, and personal traumas influenced the participant’s conceptualizations. Her story reflected components of trauma and attachment had become more prominent but continued to include spirituality. The participant’s story also mentioned the settings of mental health agency and private practice. The sociality dimension showed that her personal values, supervisor values, and the foster care system were also influential in her conceptualizations.

The therapist reported most of her clinical skills were learned and developed post graduate school while working as a licensed clinician. She mentioned “So, I had a lot more education after grad school on trauma and along with that, the role that, I mean how

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loss plays a huge part in trauma.” Participant C completed EMDR training, DBT training, and other trauma focused trainings after graduate school. The trainings and certifications provided information regarding trauma, the role of grief in and individuals life, and specific treatment approaches. The EMDR training incorporated research and connections between trauma and attachment, per participant report.

The participant’s personal trauma experiences also contributed to her clinical connections between grief and trauma. Participant C’s medical experiences during this time period was perceived as a trauma, and resulted in grief and loss. Her medical trauma, grief, and loss influenced her clinical conceptualizations. She reported,

So, Um, so having really been traumatized myself, uh, […] grief and loss has been real, and it affects my family and my husband and myself, and having to go through those, […] and I probably to also look for that kind of loss more because I experienced traumatic loss, if you will.

The participant’s story indicated her personal experiences and trainings assisted her in recognizing and differentiating between trauma, grief, and loss clinically.

However, the participant stated feeling prepared to work with clients in foster care.

The participant’s personal experiences, graduate education, and trainings did not prepare her to work with clients in foster care. Experience working with clients in foster care first occurred in the mental health agency setting. The mental health agency did not adequately prepare or train the clinician prior to working with foster care youths. She stated, “I’ve had no training in working with [clients in foster care] but when you’re in an agency and forced to see foster kids, practically you just have to do the best you can and learn as you go.” The participant’s story indicated increased competence working with clients in foster care as she gained experience and attended trainings.

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EMDR and DBT trainings were provided by the mental health agency. The participant reported her clinical experiences at the mental health agency, EMDR training, and DBT training significantly enhanced her conceptualizations and knowledge of trauma. The private practice setting was not reported to have provided experiences that enhanced her clinical conceptualizations. The supervision received during the time period of working at a private practice was noted to be beneficial. The participant stated,

“She [supervisor] definitely has talked about grief and loss and trauma and attachment and all of that affected or both together.”

The sociality dimension highlighted differences in the participant’s supervisors.

The supervisor associated with the mental health agency focused on administrative concerns, behavioral approaches, and CBT. The supervision experience was described as,

“My supervisor […] really loved CBT, she didn’t talk about grief or loss at all. Also, it was more about ‘change your behavior and be a good kid’ was what she focused on, versus the deeper issues.” The participant’s most recent supervisor incorporated grief, loss, trauma, and attachment into their supervision. The sociality dimension reflected the participant’s supervisor valued client care and focused on “deeper issues.” The participant’s personal values and beliefs continued as a prominent component in her clinical work and conceptualizations. The participant stated, “If clients value or bring up spiritualty, she helps then incorporate spirituality into their grief work.”

Participant C’s clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care were significantly influenced by personal experiences, family experiences and values, and spiritual beliefs. Clinical experiences, trainings, and supervision directly formulated her treatment approach to

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working with foster care youths. Personal experiences coupled with clinical training aided in her ability to assess for and distinguish between grief, loss, and trauma.

Themes

Three main themes and five sub-themes emerged in Participant C’s story. Themes were clinical conceptualizations, barriers, and self of therapist. Themes and subthemes displayed in Figure 4.

Themes and Subthemes

Clinical Barriers Self of Therapist Conceptualization

Understand Lived Treatment Clinical Values and Approach Efficacy Experience Perceive

Figure 4: Emergent themes and sub-themes of Participant C

Clinical Conceptualization. Participant C’s clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care was mentioned throughout her story. The theme of clinical conceptualizations included the manner in which the participant understood, perceived, and treated grief stemming from ambiguous loss experienced by clients in foster care.

Understand and Perceive. The participant’s clinical conceptualization was from a grief, loss, and trauma focus. The participant reported incorporating attachment injuries into her conceptualizations as well. Participant C’s family and personal experiences of grief, loss, and trauma shaped the manner in which she understood and perceived experiences of loss or trauma: 154

I didn’t realize how much grief and loss was in my life growing up, uh until we discussed it. And I wonder if that is what led me to uh be the therapist that I am clinically, like I’m focused on attachments and trauma, EMDR.

Her personal experiences also assisted in her ability to recognize and assess for grief, loss, and trauma. She stated, “I mean you know going through the process and understanding what my clients are going through and you know what to look for.”

Clinical experiences strengthened her understanding, awareness, and treatment approaches of trauma and attachment injuries.

I became better able to recognize when clients are grieving versus or experienced a loss […] Because like trauma, grief and trauma present differently than just like grief and loss present, not always like people think it does. And then sometimes people get stuck with diagnosis and they’re stigmatized when the root of the problem is grief and loss versus they’re just defiant or they’re angry or just depressed. Uh, so I guess I’m also looking for the root of what’s going on.

Participant C’s clinical experiences working with foster care youths aided in her clinical conceptualization of foster care. Her clinical experiences revealed a pattern of trauma presenting consistently when working with clients in foster care. The participant reflected:

Clients in foster care experienced sexual, physical, mental, poverty, neglect, and other forms of abuses and trauma to attachment bonds. Changing environments can also be really hard on clients. Kids miss their parents and are sad or angry, and it’s grief.

She reported, “trauma is one of the root causes.” The participant’s story highlighted a focus of exploring and understanding the “root cause” of foster care youths’ behaviors. Ongoing assessment throughout the clinical process assisted in appropriately identifying, diagnosing, and treating “root causes” of clients in foster care. The participant’s assessment and understanding of symptoms of grief, loss, and trauma for clients in foster care were:

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I think grief presents other ways than just the five stages. So, I just see a lot of clients, bargaining, angry, sad, you know a lot of kinds of those things I think I, I mean also, when I evaluate for loss, um you now depending on what they’re coming in for. […] And then looking to see how they’re dealing with the loss and the grieving process. Being aware of signs and symptoms of grief and loss and um trying not to get them, um […] not confusing them with other diagnoses I guess.

Treatment Approach. The participant reported using diagnoses such as

Adjustment Disorder, trauma diagnoses, and PTSD. She reported treatment approaches and techniques of EMDR, DBT, CBT, psychoeducation, and bibliotherapy. She reported the use of “informal” approaches also clinical interview, honoring and respecting client’s grieving process, and incorporating spirituality. Clinical interviews were described as conversations and questions exploring experiences, impacts, and perceptions. Clinical interviews were also utilized to process grief, loss, trauma, and attachment injuries.

Participant C’s story indicated an emphasis on psychoeducation, bibliotherapy, respecting the client’s grieving process, and EMDR. Her story highlighted a blend of informal assessments, exploring family dynamics of foster care youths, inquiring about experiences of loss, and normalizing the client’s experience:

The clinical interview, trying to assess for loss, um, also to create a safe space for clients to express their losses. I do a lot of normalizing, of you know, ‘it doesn’t sound silly’, ‘this is a real thing that effects people,’ ‘you’re not alone.’ Um yeah, so normalizing, the psychoeducation on loss. We do a lot of talk about grieving and bereavements.

Participant C’s incorporation of attachment injuries into her clinical conceptualizations was evident in her story. The participant reported, “I think I was able to work on the grieving and the attachment parts with my clients, like I personally clinically focused on that more than the behavioral um side of things.”

Barriers. The theme of Barriers spoke to the participant’s experiences of barriers to clinical conceptualizations of grief stemming from the ambiguous loss of attachment 156

figures experienced by clients in foster care. The main barriers were the foster care system and lack of trainings. The barriers directly impacted the participant’s efficacy regarding clinical work.

The participant’s story indicated navigating the various dynamics and impacts of the foster care system was a barrier to her clinical work. Foster care youths’ family dynamics prior to foster care placement and dynamics of the foster care home were explored by the participant. Her story emphasized the need to understand and assess the various systems in the foster care youths’ lives to best attend to their clinical concerns:

I mean definitely how to work in their system, like the foster care system like the rules and […] learning the boundaries and the ins and outs of the foster care system is important and then it’s really acknowledging attachment issues in the children.

Participant C noted a barrier of the foster care system was differences in approaches to meeting the needs of foster care youths. The participant reported experiences in which case workers focused on completing case plans and behaviors. She stated, “It was more so ‘just complete your case plan,’ like act like, ‘act good and you’ll get your kids back.” A portion of the participant’s work was directed to addressing the demands of the foster care system, attending to boundaries of the system, and the “ins and outs of the foster care system.” She mentioned the requirements and dynamics of the foster care system were barriers to addressing what she believed was the appropriate focus of clinical treatment. She stated, “ acknowledging attachment issues in children” as an important clinical priority.

Balancing the perspectives and needs of biological parents, foster parents, and case workers was noted as a barrier to clinical treatment. Participant C’s experiences of

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determining appropriate clinical care for clients in foster care with the other systems involved in the youths’ lives:

It’s hard trying to […] coordinate care for the kids and getting approval from from the system like to work with them and then having them be, like some of them direct or try to direct the goals of therapy so strongly that I get, it oversteps my boundaries as a therapist.

The participant’s story indicated clients in foster care presented with multiple clinical concerns. Foster care youths often experienced attachment injuries due to trauma prior to entering foster care or due to foster care experiences. The participant faced challenges of addressing symptoms and manifestations of the traumas and attachment injuries and not the core issues themselves. The participant reported pressure to direct treatment approaches to focus on behavioral concerns in the foster home.

The therapist noted foster parents say the clients are disrespectful. Specifically, disrespectful to the foster parents, to the foster home, property in general, other children, and pets. Other behaviors clients have shown are not listening, refusing to do chores, and physical and verbal violence.

The participant indicated that the boundaries, rules and needs of the foster care system were barriers to addressing “root causes” of foster care youths’ clinical concerns.

The participant mentioned balancing her treatment approach and focus on grief, loss, and attachment with the needs of foster parents, case workers, and impact of foster care placement on clients. The participant addressed traumas related to foster care experiences, assisting foster care youths with adjusting to foster homes, addressing foster parents’ concerns regarding the foster youth’s behaviors, as well as case worker’s professional goals for the foster care youth.

Another barrier Participant C experienced in her clinical conceptualizations of grief stemming from ambiguous loss experienced by clients in foster care was the lack of

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trainings. The participant’s story mentioned multiple experiences of lacking appropriate trainings to work with foster care youths, trauma, and treatment approaches. The participant reported no personal experiences regarding foster care youths and need for professional and educational training.

So, growing up I didn’t really know many people in the foster care system, that wasn’t a thing in my family, so I didn’t have any firsthand experience with the foster care system. Um, so then having to learn it really quickly from foster parents and foster children the ground rules.

The participant’s graduate school failed to incorporate and focus on grief, loss, and trauma during her educational experience. “I mean honestly I’m feeling like my program did not do enough assessing or more in depth,” as reported by the participant.

The mental health agency Participant C worked at as a newly licensed clinician did not provide trainings or preparations to working with clients in foster care. The participant noted, “I’ve had no training in working with these kids but when you’re in an agency and forced to see foster kids practically, you just have to do the best you can and learn as you go.” The participant’s agency supervisor also did not assist in guiding treatment approaches or conceptualizations addressing core issues. Her supervision was described as, “Also it was more about change your behavior and be a good kid was what she focused on versus the deeper issues.”

The participant reported experiencing a “lack of training throughout my clinical experiences and schooling in regard to grief and loss and the foster care system, um and trauma.” Participant C’s story indicated the need for education and trainings addressing grief, loss, and trauma to meet the needs of her clients: “It’s just so, it’s important and I think, you know getting to the root of the issues is just so so so important.”

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Efficacy. The barriers and lack of training impacted the participant’s clinical efficacy. Participant C’s story indicated the barrier and lack of training she experienced impacted her efficacy in working with foster care youths and trauma. Lack of trainings during her graduate program and as a licensed clinician were both impactful. She reported insufficient educational preparation, trainings, and courses during her graduate program. The participant’s educational training during her graduate program lacked a focus on grief, loss and trauma. “I don’t think we were really taught that in our program or it wasn’t emphasized.”

When entering the counseling profession as a licensed clinician, the participant felt unprepared to work with clients in foster care, grief, loss, and trauma. She reflected “I don’t know as much as I thought I did.” She also reported a lack of clinical training from her employer, which contributed to her lower efficacy. Participant C had to “learn quickly” how to address the clinical needs of foster care youths. She did not feel confident in her ability to work with clients in foster care and wished she was prepared prior to beginning clinical work with foster care youths. Participant C reflected, “I just feel like this is such a big part of our job, that I wish we were trained on this.”

Participant C’s lower efficicacy was evident in her story when discussing the use of evidenced based assessments. Her story also indicated lack of resources and guidance in obtaining appropriate assessments. She noted uncertainty of what assessments to utilize that would address grief, loss, and trauma experienced by foster care youths:

Yeah I don’t really use a lot of assessments, which is probably not good, but I don’t. I need to be better personally at getting more. I mean um cuz, I feel like it’s good to have or use an assessment that’s umm clinically valid to have on file. I don’t know, I think assessments can work. I mean it’s not necessary but, I I think it would be helpful.

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As a licensed clinician she engaged in trainings, supervision, and self-education to increase her efficacy and confidence in her ability to meet the needs of her clients.

Participant C attended EMDR trainings to increase her efficacy and preparedness to address trauma when working with clients. “I didn’t know a lot about it before I did that.

Um and I think that that really spurred me um on to then I signed up for a DBT training.”

Supervision with an off-site supervisor increased her efficacy as well. Supervision enhanced her knowledge, understanding, and applicable treatment approaches regarding the interactions of grief, trauma, and EMDR. The participant reported, “Having the one to one learning more about trauma and EMDR, and the role that grief plays in a client’s life.

I had some more training on that but not extensive training. […] and a lot of self-read books.”

The theme of barriers and sub-theme of efficacy highlighted needs for trainings, education, and preparation for clinicians working with the foster care system and foster care youths. The participant reflected feeling unprepared and uncertain of treatment approaches and assessments to address grief, loss, and trauma as a newly licensed clinician. Her graduate program and mental health agency did not prepare the participant or provide her with adequate resources. The story reflected efforts to overcome barriers and increase her efficacy. She attended trainings, obtained an off-site supervisor, and engaged in self-education. The participant’s story indicated an increase in efficacy but need to continue learning and self-educating.

Self of Therapist. The third and final theme present in Participant C’s story was self of therapist. The self of therapist theme consisted of two subthemes, lived experiences and clinical values. The participant’s clinical conceptualizations of grief

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stemming from ambiguous loss of attachment figures experiences by foster care youths were impacted by lived experiences and clinical values. The participant’s personal experiences and clinical values shaped her conceptualizations and clinical work.

Participant C’s clinical value emphasized meeting the needs of her clients and appropriately attending to grief, loss and trauma.

Lived Experience. The subtheme, lived experience, captured the impact of the participant’s personal experiences on her clinical conceptualizations. The participant’s family experienced and grieved several losses: family members, culture, home, financial, and dreams. Some of those losses were traumatic; “My mom’s dad died tragically, so that was always a big piece.” She observed the impact of grief and loss on her family and openly discussed their experiences. “I heard about like my parents’ loss of their dreams, their finances as well. There was a lot of grief growing up.”

The participant personally experienced a medical trauma resulting in loss and grief. Her story reflected on personal experiences of grief, trauma and loss as a client as well:

I’ve gotten a lot of therapy for myself and marriage therapy for the trauma which has really been a game changer to A: stay in the field personally and B: continue to gain skills that I’ve seen work and continue to help my clients.

The participant’s awareness of grief, loss, and trauma was greatly due to lived experiences. The participant was motivated to learn about grief and loss. “Um, so I definitely did a lot of self-research on loss because I had a lot of loss in my life of loved ones.” Her awareness and lived experiences have “really helped me to be more compassionate on my clients.” She emphasized exploring and using the client’s definitions and perceptions of trauma, grief, and loss as well. “I personally clinically

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focused on that more than the behavioral um side of things. Uh but that’s just kinda my style.”

Clinical Values. The subtheme clinical values surfaced in Participant C’s story.

The participant spoke to a value and focus of addressing the “root of issues.” The story showed a value of helping clients heal. She mentioned, “You know getting to the root of issues is just so so so important and, you know, helping clients to heal. You know the dandelion is going to keep growing if you don’t pull the roots out.” In order to get to the

“root of the issue,” she indicated that she assesses for loss throughout the clinical process.

She reported that she tries to get a “clinical feel for a client’s grieving […] what it looks like. It’s not black or white, it’s a process you have to go through.” Participant C mentioned a clinical value of “honoring” the client’s grieving process. Her method of doing so was described as:

Trying to asses, you know, stay out of the way as much as possible but also to help the best that I can. And honor, just honor the client’s process, the process whatever it is, it doesn’t have to look like how I think it should, I’m here to help them with what they’re going through.

Participant’ C’s story spoke to the importance of helping clients. A consideration of ethics when helping and working with clients was another clinical value. The participant believed a lack of understanding and training of grief and loss was unethical.

She stated, “And I think we do an ethical disservice to our clients if we don’t have an understanding of grief and loss and that process.” Her story also stated it was unethical to work with clients in foster care without training. The participant reported, “I mean I don’t necessarily think its ethical to encourage a clinician to work with clients when they have no training. But they do it all the time, especially early clinical settings so that’s concerning to me.” The participant’s story mentioned observations of mental health 163

agencies encouraging newly licensed clinicians to work with foster care youths without training or preparation.

Participant C’s story included three overarching themes of clinical conceptualizations, barriers, and self of therapist; and five subthemes. The themes reflected the impact of experiences and beliefs in her clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by foster care youths.

It reflected personal and family experiences of grief and loss. The themes also highlighted the barriers impacting her clinical conceptualizations and ability to address

“root issues” of clients in foster care. The barriers lowered the participant’s efficacy when working with foster care youths. The participant’s self of therapist and clinical values showed an emphasis of meeting the needs of foster care youths and providing ethical care.

Amalgamation of Three-Dimensional Framework

The amalgamation of Narrative Inquiry’s Three-Dimensional Framework of all three participant showed commonalities and differences. Table 2 displays the amalgamation of temporality, place, and sociality among the three participants’ stories.

Temporality

The temporality dimension reflected the timepoints of prior to graduate school and post graduate school as meaningful for all participants. Prior to graduate school

Participants A’s and C’s stories included family experiences of grief and loss. However,

Participant A also had experiences with foster care youths and Participant C’s family experienced traumas. Participants A and C also engaged in self-education to better

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understand family experiences and pursue interests. Participant A’s story showed an interest in trauma prior to graduate school, while Participant C explored spirituality.

Table 2. Amalgamation of Three-Dimensional Framework by Participant Participant A Participant B Participant C

Temporality: • Lifecycle changes • No significant • Spirituality/family Prior to • Conceptualization experiences value graduate of grief, loss, foster • Grief/loss experiences school care, trauma began • Self-education

Temporality: • Conceptualization • Conceptualization • No salient experiences Graduate expanded of grief and loss • Lack of school • Attachment began training/preparation introduced • Lack of training • Clinical experience and courses began • Lack of trainings and courses

Temporality: • Majority of clinical • Direct work with • Clinical Post experiences clients informed experiences/trainings graduate • Trainings knowledge • Clinical understanding school • Interweave of • Sought out and treatment approach trauma, grief, loss, trainings • Trauma/attachment and attachment • Lack of trainings incorporated

Place • Home • Mental Health • Home • Mental Health Agency • Mental Health Agency Agency • Private Practice • Private Practice

Sociality • Mental Health • Supervisor values • Supervisors Agency • Foster care system • Private Practice • Personal values/Spirituality

Participant B reported no significant experiences during this time period. Clinical conceptualizations of grief stemming from ambiguous loss of attachment figures

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experienced by clients in foster care began during this time period for Participants A and

Each participant reflected a lack of training, courses, and preparation to working with grief, loss, trauma, attachment, and foster care youths during graduate school.

Participant B’s clinical conceptualizations began during graduate school when grief and loss were mentioned. Participant A’s clinical conceptualizations greatly expanded due to self-research and one graduate course that had incorporated information regarding trauma and clients in foster care. Participant A’s conceptualization incorporated attachment into her loss and trauma perspective. Participant C reported no salient experiences.

The third temporality time point of post graduate school emphasized the impact of clinical experiences. All three participants’ stories reflected an increase in ability to understand, perceive, and treat grief, loss, and trauma. All three participants also mentioned having experienced of lack of trainings and engagement in trainings. All of the participants’ stories included experiences of feeling unprepared to work with clients in foster care. The participants engaged in trainings to enhance their clinical conceptualizations. Participants A and C engaged in trauma focused trainings.

Participants A and B attended grief and loss trainings. Participant A attended an ambiguous loss training connecting grief and loss more clearly. Participant B attended several trainings focused on grief and noted a continued desire to increase her conceptualization of grief and loss. Participant B’s story highlighted difficulty finding appropriate grief and loss trainings.

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Place

Employment settings were salient across all three participant’s stories.

Employment settings all included mental health agencies for the participants, with private practice settings for Participants A and C. The places of employment provided clinical experiences for the participants. Experiences in the home settings contributed to clinical conceptualizations for Participants A and C. Family experiences of grief and loss occurred at home for both participants. A focus on spirituality and trauma experiences occurred at home for Participant C.

Sociality

The sociality dimension focused on the values, focus, and culture in the participants’ stories. Supervisors’ focus and values were significant in Participant B’s and

C’s stories. Participants B’s and C’s stories showed a mix of negative and positive experiences with supervisors. Some supervisors focused on behaviors and administrative concerns. While other supervisors focused on clinical concerns of clients in foster care.

The sociality of employment settings and not supervisors were mentioned in Participant

A’s story. The mental health agency focused on trauma, behavioral concerns, and had an administrative focus. The sociality of Participant A’s mental health agency was similar to some of the supervisor socialites of the other participants. The private practice agency in

Participant A’s story focused on theoretical conceptualizations and clinical needs of foster care youths.

Amalgamation of Emergent Themes

The amalgamation of emergent themes for the three participants consisted of the three major themes and five subthemes. Participants A and C’s stories reflected the same

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themes and subthemes. Participant B’s themes and subthemes of clinical conceptualizations and barriers were similar with one difference, Participant B’s subtheme under barriers was competency and not efficacy. Participant B’s third theme was lived experiences without a subtheme. Figure 5 below displays an amalgamation of themes and subthemes across the three participants’ stories.

Themes and Subthemes

Clinical Barriers Self of Therapist Conceptualization

Understand Treatment Efficacy/ and Lived Clinical Values Approach Competancy Experience Perceieve

Figure 5: Amalgamation of emergent themes and sub-themes of all Participants

Clinical Conceptualization

The theme of clinical conceptualizations for all three participants included the subthemes of understand and perceive and treatment approach. Participant A and B both conceptualized grief stemming from ambiguous loss of attachment figures experienced by foster care youths as trauma, grief, loss and attachment. Participant C’s clinical conceptualization included a focus on grief, loss, and trauma while incorporating attachment injuries. Participant A’s and C’s treatment approach reflected their understanding and perceptions of grief stemming from ambiguous loss of attachment figures. Participant B’s story reflected a trauma focused treatment approach and incorporated grief, loss, and attachment injuries. Participant B mentioned a “shallow” understanding of grief and loss reflecting the focus and emphasis on trauma-based

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treatment approaches. Participant C’s clinical conceptualizations included spirituality while the other two participants’ stories did not.

All of the participants reported using trauma diagnoses and PTSD. None of the stories indicated diagnosis grief specifically or using a grief diagnosis when working with clients in foster care. Participants A and B also diagnosed RAD, MDD, and GAD. All three participants’ stories indicated using a combination of informal and evidenced-based treatment approaches. The participants utilized psychoeducation, clinical focus on core underlying issues, and emphasized clinical treatment determined by client’s readiness.

Barriers

Commonalities of the theme of barriers reflected the impact of the lack of trainings, resources, and the foster care system on their clinical conceptualizations.

Participant B’s story included the barrier of administrative and insurance policies in her clinical experiences. The subtheme differed for the participants. The subtheme of efficacy emerged in the stories of Participants A and C. The lack of trainings, resources, and preparation impacted their efficacy and confidence in working with grief, loss, attachment injuries, trauma, and clients in foster care. Participant B’s story reflected competence as a subtheme which included efficacy and confidence. Participant B reported lower efficacy and not feeling confident in her ability to incorporate grief and loss into her treatment approach. Her treatment approach was trauma focused with an awareness of grief, loss, and attachment injuries. Her story showed continued desire to attend trainings to increase her clinical conceptualizations and learn treatment approaches to effectively address grief, loss, trauma, and attachment injuries of clients in foster care.

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Self of Therapist

The theme, self of therapist, included subthemes of lived experiences and clinical values of the participants. However, the subtheme of clinical values did not emerge in

Participant B’s story, allowing the theme of lived experiences to emerge as a major theme. The participants’ clinical conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care were influenced by their lived experiences. Participant B’s lived experiences of clinical work with foster care youths and supervision increased her clinical conceptualizations significantly.

Participants A and C also had lived experiences of clinical work with foster care youths.

However, their stories reflected personal experiences of grief and loss that contributed to their clinical conceptualizations. Participant C’s story mentioned the personal experience of a medical trauma and clinical experiences with survivors.

The subtheme, clinical values, reflected different stories and experiences for

Participants A and C. Participant A’s clinical value subtheme highlighted her emphasis on unconditional positive regard and an attachment focus. Participant C’s story focused on the “root of issues” and ethics when working with clients in foster care. Participant

B’s story reflected a sub-theme of “digging deep” but did not emerge as strongly in her story as it did for the other two participants.

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CHAPTER V

DISCUSSION

This chapter discusses the overall findings of the current study, formulated from

Narrative Inquiry. A discussion of the participants’ findings is reported from the

Narrative Inquiry’s Three-Dimensional Framework. First, the final narrative is presented, focusing on the clinicians’ clinical conceptualizations and factors contributing to those conceptualizations via the Three-Dimensional Framework and including emergent themes. Next, the major findings are reviewed and major implications for the field are discussed, followed by a summary of future directions, strengths and limitations, and final thoughts from the current study.

Final Narrative

The overall findings of the study provided insight into the following research question: How do clinicians conceptualize grief stemming from ambiguous loss of attachment figures experienced by clients in foster care? Specifically exploring clinicians’ understandings, perceptions and treatment approaches. Findings indicated clinicians clinically conceptualized grief stemming from ambiguous loss of attachment figures experienced by clients in foster care in individual and distinctive ways. The findings indicated there was not a collective or unified conceptualization among clinicians in the field of counseling. There were some common components of grief, loss, trauma, and attachment in participants’ conceptualizations of grief stemming from 171

ambiguous loss of attachment figures experienced by clients in foster care. The emergent themes were perceiving and understanding, treatment approaches, and self of therapist.

Narrative Inquiry’s Three-Dimensional Framework was used to construct and organize the participants’ narratives, and included temporality, place, and sociality as an organizational scheme for this final narrative.

Understand and Perceive

Individual conceptualizations of the participants were distinctive with some overlapping perspectives. Results of the findings indicated participants each understood and perceived the loss of attachment figures as an experience of loss. The loss of attachment figures in the framework of foster care youths were perceived as an experience of loss, trauma, and an attachment injury. The experience of loss and attachment injury manifested into grief and trauma. The clinical conceptualizations among all the participants acknowledged grief, loss, attachment injury, and trauma.

The degrees of understanding and incorporating the experiences of loss, grief, attachment injuries, and trauma into their clinical conceptualizations varied among the participants.

All of the participants’ conceptualizations incorporated the same components but the manner in which the components were understood and utilized differed. All of the participants’ conceptualizations included a focus of trauma and attachment with incorporations of grief and loss on some level. Participants B’s conceptualizations were trauma and attachment injuries with an awareness of grief and loss. Her conceptualizations did not directly incorporate grief and loss. The findings of Participant

B’s story indicated more developed understandings and competence with trauma and attachment. She reported uncertainty in how to incorporate grief and loss into her clinical

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work. Participants B and C reported greater understandings and personal experiences of grief and loss, which were reflected in their conceptualizations.

Participant C’s conceptualizations consisted of a focus on trauma, grief and loss with an incorporation of attachment into those components. The participant’s conceptualizations reflected her personal experiences of trauma, grief, and loss prior to clinical experience. Participant A’s conceptualizations were an interweave of grief, trauma, loss and attachment. Her conceptualizations reflected her personal experiences of grief and loss blended with interests of trauma and attachment. Participant C’s conceptualizations also included ambiguous loss which was unique to her story.

Participant C spoke to the ambiguity of the losses clients in foster care have experienced.

The varying degrees with which grief, loss, trauma, and attachment were understood and focused on impacted the participants’ treatment approaches.

Treatment Approach

The participants’ treatment approaches were mostly in line with their understandings and perceptions of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care. The findings reflected each story included a trauma approach in clinical treatments of grief stemming from ambiguous loss of attachment figures. Participant B’s treatment approach was trauma focused with an incorporation of attachment. Attachment injuries were addressed from a trauma perspective. Participant B’s story mentioned a desire to gain more skills and knowledge to include grief and loss into her treatment approach. The participant had more training and competence with utilizing trauma treatment approaches.

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Participant C’s treatment approach was a blend of trauma, grief, and loss, with considerations of attachment injuries woven into those three components. Her story was unique with the incorporation of spirituality. Participant A’s treatment approach was an interweave of grief, loss, trauma, and attachment. Participant A’s treatment of attachment included addressing attachment styles and attachment injuries of clients. The other participants’ stories did not include attachment styles in their conceptualizations. The findings of the study concluded clinicians’ treatment approaches of grief stemming from ambiguous loss of attachment figures experienced by clients in foster care have included a trauma component. However, the findings emphasized that a trauma focus alone was not the only treatment approach. The participants’ stories spoke to the importance of including components of grief, loss, and attachment into treatment approaches when working with clients in foster care. Specifics of treatment approaches are discussed in subsequent sections of this chapter.

Self of Therapist

The participants’ self of therapist was a major component of their final narratives.

Narrative Inquiry focuses on the stories and experiences of participants to gather data and create meaning (Sprenkle & Piercy, 2005). The participants’ stories appropriately reflected many personal and clinical experiences that shaped their conceptualizations. All of the participants’ findings reflected the impact of personal and clinical experiences on creating and influencing clinical conceptualizations. Participant C’s story included the most personal lived experiences of grief and loss and showed more developed conceptualizations prior to attending graduate school. Participant B’s story reflected significant conceptualizations following clinical experiences when working as a licensed

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clinician. Participant A’s story highlighted the impact of clinical experiences and clinical values on incorporating all four components into clinical conceptualizations. Clinicians experiences and values greatly contributed to their understandings, perceptions, and treatment approaches regarding grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care.

Discussion of Final Narrative from Three-Directional Framework

The current study was conducted using Narrative Inquiry as the methodology.

Temporality and sociality dimensions yielded the most findings. A discussion of the major findings of temporality, place and sociality is found below.

Temporality. The dimension of temporality was the beginning, middle and end of the participants’ stories. The current study focused on three time points: prior to graduate school, during graduate school, and post graduate school. The findings of those timepoints reflected salient experiences and stories. Major findings reflected the majority of experiences for participants occurred prior to graduate school and post graduate school. The timepoint prior to graduate school consisted of impactful family experiences which contributed to the beginnings of Participants A’s and C’s clinical conceptualizations. Post graduate school time period for the participants included the most stories and salient experiences informing their clinical conceptualizations.

The participants’ stories during graduate school reflected a lack of training, courses, and preparation in working with grief, loss, trauma, attachment, and foster care youths. This timepoint did show an increase in clinical conceptualizations, especially for

Participants A and B. Participant A’s expansion of clinical conceptualizations was due to

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her own self-research and one graduate course. Participant B’s clinical conceptualizations began during this time period but did not significantly develop until post graduate school.

The findings of the temporality dimension reported that the majority of clinical conceptualizations occurred prior to and after graduate school. The participants’ stories during graduate school reflected the least amount of experiences contributing to their clinical conceptualizations.

Place. The place dimension of Narrative Inquiry’s Three-Dimensional

Framework was the setting of the participants’ stories. Major findings of this dimension reported important settings of the home and settings in which clinical experiences occurred. Experiences and stories contributing to participants’ clinical experiences were personal and clinical. Those experiences occurred at home, mental health agencies, and private practice. Graduate school was not indicated as an important or salient setting due to lack of trainings, courses, and education.

Sociality. The values, focus, and culture were explored through the sociality dimension. Major findings of this dimension showed graduate programs focused on MFT course work and family systems. The education and training of graduate programs did not incorporate grief and loss in a manner that prepared their students for clinical work. The participants reported not feeling prepared to work with grief and loss after graduating from their programs. The findings also reported mental health agencies also did not prepare or adequately train clinicians to work with grief, loss, trauma, attachment, and foster care youths. The findings suggested a focus on administrative concerns, trauma, or addressing behavioral issues for clients in foster care. The sociality of the mental health

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agencies helped inform trauma perspectives but failed to adequately address grief, loss, and attachment concerns for clients in foster care.

Major findings of supervisors’ sociality signified the influence they have on clinician’s conceptualizations. Supervisors with a focus on administrative concerns were not found to be helpful in clinicians’ conceptual growth. The participants’ stories also mentioned lack of assistance and effective guidance from supervisors with a focus on trauma, behaviors of clients, and administrative concerns. Supervisors that addressed trauma, grief, loss, and attachment were found to be helpful and to positively impact participants’ conceptualizations. The sociality of individual participants and their families was relevant in one participant’s story. It was not an overarching factor in all of the stories.

The major findings of Narrative Inquiry’s Three-Dimensional Framework highlighted the influence of experiences occurring prior to and post graduate school. As well as the influence of home and clinical employment settings. The sociality of graduate schools, mental health agencies, and administrative supervisors hindered conceptualizations of grief stemming from ambiguous loss of attachment figures experienced by foster care youths.

Discussion of Major Findings

Findings of the study had three major themes and five subthemes across participants with some variation in themes among the participants. There were substantial similarities to form a cohesive presentation of themes of all of the participants. This section will provide a summary of the findings, implications of the findings and how the findings align with the current literature.

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Clinical Conceptualizations

The clinical conceptualizations of grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care was a core component of the participants’ stories. Major findings of this theme reflected factors contributing to conceptualizations and connections to the literature.

Understand and Perceive. As stated previously, the findings of the study reported three similar but distinct clinical conceptualizations of the participants. The stories reflected differing understandings and incorporations of grief, loss, trauma, and attachment for clients in foster care grieving the ambiguous loss of attachment figures.

Major findings of the theme reflected that personal experiences, trainings, supervision, clinical experiences, education, and self-research were factors contributing to clinical conceptualizations. Factors contributing to Participants A’s and C’s conceptualizations incorporated trauma, grief, loss and attachment. The results of the literature review also indicated grief, loss, attachment, and trauma were primary perspectives of foster care youths’ experiences (Boss, 2010; Fineran, 2012; Mitchell, 2016; Schade & Sandberg,

2012; Schofield & Beek, 2009). Participant A’s conceptualizations included an interweave of all four components, whereas Participant C did not emphasize attachment on the same level as the other three components. Participant C’s story reflected more experiences and trainings in grief, loss, and trauma than attachment. Her awareness and understanding of the impact of attachment for foster care youths contributed to the incorporation of attachment into her grief, loss, and trauma perspective.

Participant B’s disjointed conceptualizations paralleled the disjointed current research. Factors contributing to her conceptualizations were clinical experiences,

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supervision, trainings, and education. The participant’s story included efforts to gain more knowledge, understanding, and broaden perspectives of grief and loss, but experienced difficulties doing so. The lack of cohesive research addressing the grief, loss, trauma, and attachment style of clients in foster care could have impacted her ability to strengthen overall conceptualizations.

The current study’s finding of connecting the four components of grief, loss, attachment and trauma into clinical conceptualization of grief was unique from the reviewed literature, which only connected two or three components. The grief literature connected grief with loss and grief with trauma (de Heus et al., 2017; Ener & Ray, 2017).

The various facets of grief literature included connections of significant losses with manifestations of grief (Burns et al., 2018; Currier et al., 2008; Friedman, 2012;

Kristjanson et al., 2006). Uncomplicated grief literature reported a definition of grief as a common reaction to the loss of an individual (Friedman, 2012). The participants’ stories included similar definitions and perceptions of grief. Kubler-Ross and Kessler (2005) outlined five stages of uncomplicated grief stemming from the loss of a significant individual. Literature regarding disenfranchised grief and complicated grief both included findings connecting the maladaptive forms of grief stemming from significant losses as well (Burns et al., 2018; Charney et al., 2018; Doka, 1989; Dominguez, 2018).

Disenfranchised grief literature, in particular, connected components of grief and loss. The literature included stigmatized and socially unsupported losses in addition to losses due to death (Burns et al., 2018; Doka, 1989; Dominguez, 2018). The majority of traumatic grief literature focused on grief stemming from death with some incorporation of nondeath losses (Barle et al., 2017; De Heus et al, 2017; Kristensen et al., 2012). The

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traumatic grief literature connected components of trauma and grief by researching the impact of a trauma surrounding a loss on grief experiences (Barle et al., 2017; De Heus et al., 2017). Participant C’s story also included traumatic grief and traumatic losses in her conceptualizations. The components of trauma, grief, and loss were influenced by attachment injuries for Participant C, which was not similar to the literature. The overall understanding and perception of grief from the literature included viewing grief as a manifestation from a death, significant loss, traumatic loss, traumatic death, or stigmatized loss. Clinical understandings included components of grief and loss, and trauma, grief, and loss (Burns et al., 2018; Currier et al., 2008; Enez, 2017; Friedman,

2012; Hashim & Guan, 2013; Kristjanson et al., 2006; Ringdal et al., 2001).

The literature defined ambiguous loss as an unresolved physical or psychological loss (Boss, 1999). Participant A’s conceptualization included ambiguity and unresolved losses experienced by clients in foster care. The majority of ambiguous loss literature connected and perceived ambiguous loss and grief together (Boss, 2010; Coolhart et a.,

2018; Jackson, 2018; Meichsner et al., 2016). Two articles included trauma and ambiguous loss into conceptualizations (Bocknek et al., 2019; Robins, 2016). Bocknek et al. (2019) reported trauma symptoms experienced by children that have experienced an ambiguous loss. Whereas Robins (2016) reported that trauma was directly incorporated into the definition of ambiguous loss as an unresolved traumatic relational loss.

Ambiguous loss literature has understood and perceived ambiguous loss and grief together, as well as ambiguous loss, trauma, and grief together.

Literature regarding attachment theory and attachment injuries has included conceptualizations connecting attachment, loss, and grief. The literature included three

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articles conceptualizing the loss of an attachment figure as a loss with potential to manifest into grief (Howard et al., 2011; Maccallum, & Bryant, 2018; Schofield & Beek,

2009; Thomson, 2010). The literature included very few studies including ambiguous loss, which could have contributed to the lack of ambiguous loss in Participant B’s and

C’s stories and conceptualizations (Boss, 1999, 2010; Jackson, 2018; Robins, 2016;

Sampson, 2012).

Literature regarding foster care youths also reflected few connections to grief, loss, trauma, and attachment. The literature review included one article in the past ten years that was relevant to the current study (Mitchell, 2018). The article noted the removal from birth parents was experienced as a loss, trauma, and grief by foster care youths (Mitchell, 2018). Participants B’s and C’s stories reflected perceptions of loss, trauma, and grief when foster care youths were removed from their families of origin.

However, they also considered the impact of attachment injuries into their conceptualization, unlike the literature.

Literature regarding foster care youths and ambiguous loss included perceptions of foster care youths’ experiencing loss, ambiguous loss, and grief (Fineran, 2012;

Mitchell, 2016). Participant A’s story was more in line with ambiguous loss literature by accounting for the impact of ambiguity and physical losses experienced by clients in foster care (Mitchell, 2016; Samuels, 2009). However, she also included attachment theory and attachment injuries into her conceptualizations. The literature also reflected the loss of attachment figures experienced by foster care youths was perceived as a loss

(Schade & Sandberg, 2012; Schofield & Beek, 2009). Foster care literature included conceptualizations connecting grief, loss, and trauma; loss, ambiguous loss, and grief;

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and loss with attachment injuries (Bocknek et al., 2009’ Boss, 1999, 2006; 2010;

Coolhart et al., 2018; Mechling et al., 2018; Mitchell, 2016, 2018; Samuels, 2009; Shalev

& Ben-Asher, 2011).

The literature reflected connections between grief, loss, attachment, and trauma

(Altmaier, 2011; Barle & Latack, 2017; Bellamy et al., 2010; Boss, 1999, 2006; 2010;

Bowlby, 1969; Charney et al., 2018; Dickens, 2014; Fineran, 2012; Leathers et al., 2012;

Mechling et al., 2018; Mitchell, 2016, 2018; Prather & Golden, 2009; Robins, 2016;

Samuels, 2009; Shalev & Ben-Asher, 2011). However, the connections did not include all four components together. The findings of the current study contributed to the literature by bridging the research together and filling in the gaps between the components. The findings of the current study reflected the impact and intertwined manifestations of the four components when working with clients in foster care.

Treatment Approaches. Major findings of the current study highlighted commonalities among each participant’s reports of using informal assessments, combination of informal and evidenced based treatments, and the emphasis of assessing throughout the treatment process. Findings also reported similar use of diagnoses and observations of symptoms. Common diagnoses in the participants’ stories were PTSD,

GAD, MDD and trauma diagnoses. Participants A and B also diagnosed clients in foster care with RAD, which reflected their inclusion of attachment into conceptualizations.

The participants’ treatment approaches did not include the DSM 5 diagnosis for

Bereavement. Robins (2016) noted clinical and diagnostic approaches for ambiguous loss have not been driven by the DSM. Jordan and Litz (2014) noted the common occurrence of MDD and PTSD presenting with grief. This was reflected in the traumatic grief

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literature which included PTSD and MDD diagnoses (Barle et al., 2017; Kristense et al.,

2012).

Observed symptoms among the participants’ stories were acting out behaviors, trauma symptoms, anxiety, anger, and sadness. Participants B’s story mentioned more behavioral symptoms than the other two participants. The symptoms reported by the participants were in line with how current literature has described grief and loss symptoms experienced by children and foster care youths (Mitchell, 2016, 2018). The ambiguous loss literature also reflected similar symptoms, including anxiety, depression, acting out behaviors, and trauma symptoms (Boss, 2010; Dickens, 2014; Himebauch et al., 2008; Mitchell, 2018; Sandler, et al., 2010). Symptoms of clinically significant grief were noted in the literature, some of which differed from the participants’ stories. Those differing symptoms included guilt, shock, loneliness, disruption in sleep and eating patterns, self-harm behaviors, suicidal ideation and withdrawal from peers (Enez, 2018;

Fineran, 2012; Himebauch et al., 2008; Mitchell, 2016; Mitchell & Kucynski, 2010;

Sandler, et al., 2010).

The participants reported using mostly informal assessments and few formal assessments. Participant B noted using the CBCL, which was also mentioned by Ener and

Ray (2017) when exploring experiences of grief in children. Participant A reported using the Achenbach assessment which was not present in the literature as an assessment for grief stemming from an ambiguous loss of attachment figures. The literature noted few grief assessments which were not present in the participants’ stories. This could be due to the lack of assessments and limited resources to diagnose and assess grief (Enez, 2018;

Jordan & Litz, 2014). The participants mostly utilized informal assessments which was in

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line with assessments utilized in the literature. The ambiguous loss literature noted informal assessments exploring for losses and unresolved losses (Jackson, 2018).

Interventions reported by participants were trauma focused, CBT, attending to the readiness of the client, psychoeducation, family work with foster parents or biological parents, coping skills, and stabilizing symptoms. Participants A and C highlighted the use of EMDR to address trauma, grief, loss, and attachment. Participant C’s story showed a reflection of her personal experiences in her treatment approaches. Factors contributing to treatment approaches were influenced by employment settings, supervisors, trainings, personal experiences, and clinical values.

The literature also reflected similar formal and informal interventions focused on trauma, stabilization, coping skills, exploring experiences, emotional regulation, addressing acting out behaviors, use of sympathy, incorporating foster parents into treatment, normalizing experiences, challenging negative cognitions, and the use of CBT

(Crunk, et al., 2017; Fineran, 2012; Jackson, 2018; Jordan & Litz, 2014; Mitchell, 2016,

2018; Sampson et al., 2012). However, the interventions utilized by the participants were not found in all of the literature consistently. There were some variations in the literature.

Grief literature included treatment approaches of CBT, grief interventions, addressing suicidal ideation, and trauma interventions (Crunk et al., 2017; Jordan & Litz, 2014).

Ambiguous loss literature focused on increasing resiliency, sympathy, and challenging negative cognitions. Foster care youth literature was similar to the participants’ treatment approaches which focused on addressing externalizing behaviors, incorporating foster parents into treatment, and psychoeducation (Fineran, 2012; Mitchell, 2016, 2018).

Ambiguous loss and foster care literature both noted normalizing experiences, providing

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opportunities to explore and process experiences, and using sympathy in clinical treatment (Fineran, 2012; Jackson, 2018; Mitchell, 2018; Sampson et al., 2012).

The symptoms, diagnoses, assessments and treatment approaches mentioned in the participants’ stories, mostly connected with the current literature. The literature included broader ranges of symptoms, specific forms of grief, physical and psychological ambiguous loss, and specific grief interventions (Barle et al., 2017; Bocknek et al., 2009;

Boss 1999, 2006, 2010; Breen, 2010). Findings of the current study and the literature both reflected a lack of applicable grief diagnoses for clients in foster care. The literature consisted of few evidenced based treatments and spoke to the use of informal treatment approaches (Enez, 2018; Jordan & Litz, 2014). However, Crunk et al., (2017) indicated informal treatment approaches alone may not address all of the clinical needs or provide enough relief for more complicated or clinically significant manifestations of grief. The literature also noted traditional grief approaches may not address the ambiguity associated with unresolved losses (Jackson, 2018; Sampson et al., 2012). The literature included disjointed components of grief, loss, trauma, and attachment. The findings of the current study filled the gap in the literature regarding treatment approaches for foster care youths experiencing grief stemming from the ambiguous loss of attachment figures. The current study reflected treatment approaches connecting grief, loss, trauma, and attachment for clients in foster care.

The major findings of the clinical conceptualizations theme indicated clinical experiences, personal experiences, supervision, training, self-research, and education contributed to conceptualizations. The awareness and incorporations of grief, loss, attachment, and trauma in their conceptualizations reflected findings of the literature

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(Bowlby, 1969; Crunk et al., 2017; de Heus et al., 2017; Enez, 2018; Jordan & Litz,

2014; Mitchell, 2018). The inconsistencies among the participants’ utilization and emphasis of those components also matched the literature (Crunk et al., 2017; Enez,

2018; Jordan & Litz, 2014). The findings of the literature review as a whole regarding grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care indicated connections among the four components. However, the specific literature regarding the components individually do not clearly connect and bridge to the other components (Boss, 1999, 2006, 2010; Bowlby, 1969; Crunk et al., 2017; de Heus et al., 2017; Enez, 2018; Jordan & Litz, 2014; Mitchell, 2016, 2018; Ringdal et al., 2001;

Robins, 2016). Participants A and C had greater awareness and conceptualizations of interactions and connections of grief, loss, trauma, and attachment. Participant B’s story reflected more of a focus on trauma and attachment with awareness to grief and loss.

Participants with conceptualizations connecting and incorporating the four components experienced less barriers in obtaining resources and were more cohesive in their treatment approaches. As with the literature informing understandings and perceptions, there was a lack of cohesive research connecting treatment approaches to address trauma, grief, loss, and attachment together.

Barriers

Barriers emerged as a major theme in the current study. The subthemes of competence and efficacy were not present in all of the participants’ stories. Barriers to participants’ clinical conceptualizations was a major theme of the current study. The major barriers were the foster care system and lack of trainings and preparation.

Experiences with navigating and addressing the dynamics and needs of the foster care

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system were salient in each of the participants’ stories. A major finding of the study was the lack of preparation to work with the foster care system and the impact on clinical conceptualizations. The participants had to learn the logistics, needs, and goals of the foster care system while learning how to work with clients in foster care. As well as a focus on stabilizing symptoms, addressing traumas, addressing acting out behaviors, and allowing clients to process grief and loss when clinically ready.

The literature and participants both reflected that the foster care system created barriers to addressing grief, loss, trauma, and attachment injuries (Fineran, 2012,

Mitchell, 2016). The literature and findings of the current study both reflected the importance of including foster parents and biological parents into clinical treatment

(Mitchell, 2018). The literature noted similar barriers when working with foster care youths (Mitchell, 2016, 2018). Foster care youths often experience multiple placements, are faced with the challenge of adjusting to several new foster homes while grieving the loss of past homes, experience uncertainty and ambiguity regarding their relationship with biological parents, and experience difficulty expressing their grief and loss openly

(Fineran, 2012, Mitchell, 2016). The literature and participants’ stories noted foster care youths feared judgment by foster parents and caregivers, which negatively impacted their ability to process grief and loss (Mitchell, 2018).

Findings from Participant C’s story connected more with the literature in regard to barriers created by the foster care system. Participant C had more clinical experience and a course in graduate school incorporating foster care and trauma than the other participants. Participants’ stories reflected a lack of preparation and applicable trainings to address the grief, loss, trauma, and attachment concerns of clients in foster care. The

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literature reported lack of treatment approaches and literature regarding grief, loss, ambiguous loss, and treatment approaches for foster care youths (Enez, 2018; Fineran,

2012; Jordan & Litz, 2014; Mitchell, 2018; Sampson et al., 2012).

The participants’ stories reflected an awareness of insufficient knowledge and skills that were due to the lack of comprehensive trainings provided from their graduate schools or employers. Participants A and C relied on their personal experiences and self- education to fill in the gaps not addressed by their trainings. Participant B’s story reflected the impact of a lack of experiences and trainings to inform clinical conceptualizations. She placed an emphasis of trauma and attachment conceptualizations due to less competence in grief and loss. Her story showed an awareness of the need to address grief, loss, trauma and attachment, but experienced barriers in finding trainings and resources.

Competence/Efficacy. The subtheme of competence and efficacy did not emerge for all of the participants. The findings of the study suggested the lack of trainings were more impactful for Participant B’s formation of clinical conceptualizations. Participant B did not have understandings and perceptions of grief from personal experiences or self- education to address the gaps in her training. Participants A and C mentioned using their personal experiences and knowledge gained from self-education to inform their understandings, perceptions, and emphasis of the four components. Participant B’s uncertainty of how to incorporate grief and loss as well as limited treatment resources created a sense of lower competence. Her lower competence included a lack of efficacy and confidence addressing grief and loss to the degree that she focused solely on trauma.

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Participants A and C also noted the benefit of EMDR trainings in their treatment approaches to address grief, loss, trauma, and attachment. Participants A and C did not have subthemes of competence due to their stories reflecting incorporations of grief and loss into conceptualizations. The subtheme of efficacy emerged due to the mention of doubt and lowered confidence in grief and loss treatment approaches in the participants’ stories. The lack of trainings and evidence-based approaches resulted in participants addressing grief and loss by using their clinical values and judgment. Participant A reported increased efficacy further into her career which could be attributed to attending an ambiguous loss training and supervision focused on theoretical conceptualizations.

Self of Therapist

The theme, self of therapist, presented as two subthemes for the current study.

Participant B’s story did not include enough stories reflecting clinical values for the subtheme to emerge. However, her clinical value of “digging” and addressing core underlying issues for clients in foster care was present in her story.

Lived Experience. The self of therapist theme showed the significance of lived experiences in the participants’ clinical conceptualizations. The participants’ clinical experiences and trainings greatly expanded and contributed to the participants’ clinical conceptualizations. Major findings of this theme reflected the importance and benefits of personal and clinical experiences on conceptualizations. Participants with lived experiences had more components of grief, loss, trauma, and attachment integrated into their conceptualizations as well as greater conceptualizations of those components.

Participants without personal experiences noted more difficulty. Participants A and C were able to utilize information and knowledge gained from lived experiences to inform

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their clinical conceptualizations and were not reliant on trainings, graduate education, or supervision alone. The literature also reflected clinicians utilized familial and social understandings of relationships to guide clinical approaches and assessment practices

(Robins, 2016).

Clinical Values. The findings of Participants A’s and C’s stories reflected clinical values informed clinical conceptualizations. Participant B’s clinical value of “digging” and addressing core underlying issues motivated her to continue increasing knowledge and skills to better incorporate grief and loss into her conceptualizations. Participant A’s value of attachment included considerations of attachment styles and attachment injuries which were unique to her story. The literature regarding attachment theory reflected the importance of addressing attachment styles as well as attachment injuries (Maccallum, &

Bryant, 2018; Thomson, 2010). The other participants’ stories did not reflect the same level of research and understanding of attachment as Participant A’s story.

Major Implications for the Field

The findings of the current study reflected a need for more training, resources, education, supervision, and research regarding grief, loss, trauma, attachment and foster care youths. The need for trainings regarding grief and loss as applied to the unique circumstances of clients in foster care was significant in the stories. The participants’ stories reflected uncertainty and lack of guidance when compiling knowledge, experiences, and treatment approaches to piece together their conceptualizations. The literature also reflected a lack of research-based conceptualizations and treatment modalities for grief stemming from ambiguous loss which might have hindered clinicians’ ability to address the multiple clinical concerns of clients in foster care

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(Bellamy et al., 2010; Breen, 2011; Fineran, 2012; Mitchell & Kuczynski, 2010;

Mitchell, 2016). Clinicians working with clients in foster care could benefit from access to research-informed resources to ensure effective and appropriate clinical conceptualizations, diagnoses, assessments, treatment modalities and course of therapy

(Breen, 2011). Jordan and Litz (2014) reported the lack of a comprehensive and unified diagnostic criteria for complicated grief has hindered the advancements of empirically based grief treatments.

Research-informed clinical practice incorporating current literature and evidence- based treatment modalities have been shown to be an effective approach to ensure competent and ethical clinical practice (Johnson, Miller, Bradford, & Anderson, 2017).

2000; Mitchell, 2016). Compared to the general population foster care youths are two and a half times more likely to develop mental health disorders (Bellamy et al., 2010).

Robins (2016) noted clinical practices regarding ambiguous loss have been guided by clinical understandings of relationships due to lack of research. It was important to understand how clinicians conceptualized ambiguous loss due to the potential harm of not incorporating appropriate treatment practices and addressing the unique clinical needs of ambiguous loss (Jackson, 2018; Robins, 2016; Sampson et al., 2012). Additionally, clinicians working with clinical and maladaptive functioning in clients experiencing grief have limited empirically based clinical resources available (Breen, 2011). The few manualized treatment options were not openly accessible to clinicians (Enez, 2018).

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Regardless, clinicians continued to treat manifestations of grief without formal research- informed diagnostic guidance (Enez, 2018; Jordan & Litz, 2014).

Foster care youths might exhibit externalizing behaviors and struggled to attach to foster parents while grieving the loss of their primary attachment figures (Mitchell,

2016). Engaging in externalizing behaviors, difficulty attaching to foster parents, or accepting support from others often can lead to foster parents requesting removal of foster care youth from their foster home (Leathers et al, 2012). MFTs specialize in enhancing interpersonal relationships, and the relationship between the client and their foster parents can be incorporated into counseling sessions. Including foster parents in counseling sessions can reduce conflict in the foster home, decrease risk of removal from the foster home, and increase positive coping (Mitchell, 2016, 2018). Mental health agencies, employers, or internships involving clients in foster care need to better train and prepare clinicians before beginning clinical work. The stories reflected the multiple factors involved when working with clients in the foster care system and difficulty navigating those factors for clinicians. The literature noted corroborated this finding by reporting foster care youths had higher needs for effective mental health services and were more likely to experience multiple factors of trauma, abuse, and instability

(American Academy of Pediatrics, 2000; Mitchell, 2016).

The findings of the study also included implications for supervisors and educators. The findings of the study reported a mix of helpful and unhelpful supervision.

Supervisors that explored clinical needs of clients in foster care and focused on interactions of multiple clinical components assisted in the participants’ clinical conceptualizations. Supervision with a narrower focus on administrative concerns,

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behavioral concerns, or an emphasis of just trauma was not beneficial in developing conceptualizations for participants. The findings suggested graduate programs were one of the least salient experiences for participants in formulating conceptualizations and preparations in working with grief and loss. MFT supervisors and graduate programs were especially equipped to provide education and supervision regarding addressing the interpersonal relationships of foster care youths. The literature reflected treatment approaches incorporating the various interpersonal relationships decreased risks of removal from foster homes and increased positive coping (Mitchell, 2016, 2018).

Supervisors and graduate programs could utilize findings from the literature and the current study to assist MFTs in their clinical work with foster care youths.

The findings of the study and literature review stated grief and loss were both impactful and difficult life experiences. The findings and literature review indicated a probability of clients experiencing grief and loss (Boss, 2010; Mitchell, 2016). Educators and graduate programs can better prepare clinicians by incorporating grief and loss into coursework (Breen, 2011; Robins, 2016). Clinicians specifically working with clients in foster care needed to commit towards providing competent clinical care that has been empirically supported due to this population’s higher need for effective mental health services (Quiroga & Hamilton-Giachritsis, 2016).

However, formal research-based diagnostic criteria for ambiguous loss was currently lacking (Robins, 2016). Inaccurate clinical conceptualizations could hinder a clinician’s ability to utilize appropriate treatment modalities (Breen, 2011). Thus, clinicians may struggle to effectively address the underlying clinical concern of ambiguous loss due to a lack of research-informed assessments and treatment modalities.

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Clinicians have an ethical responsibility towards providing competent clinical care

(AAMFT, 2015). It was unclear how clinicians currently conceptualize ambiguous loss and what factors contribute to their treatment approaches of ambiguous loss.

Foster care youths grieving the ambiguous loss of primary attachment figures also have an increased risk of developing an insecure attachment style (Schade & Sandberg,

2012). Insecure attachment styles could have long term impacts on current and future relational functioning (Bowlby, 1969). Individuals with insecure attachment styles might struggle to trust others, lack a sense of safety, and view the world as unstable (Bowlby,

1969). MFTs working with clients in foster care could attend to the impact of insecure attachment styles on clients’ ability to engage in healthy relationships (Mitchell, 2018).

MFTs specialize in enhancing interpersonal relationships, and the relationship between the client and their foster parents can be incorporated into counseling sessions. Including foster parents in counseling sessions can reduce conflict in the foster home, decrease risk of removal from the foster home, and increase positive coping (Mitchell, 2016, 2018).

Clients in foster care may struggle to trust others and long for reunification with their primary attachment figures. From an attachment lens the current study aligned with the literature regarding the complexity of issues that can present when children experience attachment injuries (Schofield & Beek, 2009). Accounting for attachment was a component of all of the participants’ conceptualizations. This speaks to the interconnection of attachment onto trauma, grief and loss. Insecure attachment styles can hinder an individual’s ability to grieve and seek support from others (Maccallum &

Bryant, 2018). Foster care youths especially may struggle to accept support from foster parents when grieving the loss of their primary attachment figures. MFTs can address the

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multiple family systems clients in foster care belong to (Maccallum & Bryant, 2018;

Mitchell, 2016). Acknowledging membership in multiple family systems was reported to reduce the stigma associated with foster care and assist in clients’ abilities to cope with the ambiguity of their foster care experience and attachment injuries (Boss, 2010;

Mitchell, 2016, 2018; Tucker & MacKenzie, 2012).

Directions for Future Research

The lack of available research regarding grief stemming from the ambiguous loss of attachment figures experienced by foster care youths was found to be prominent when conducting the literature review for the current study. The literature review reflected varying conceptualizations of grief, loss, attachment, trauma, and foster care youths. The findings of the current study included all four components. More research is needed to clearly understand connections between grief, loss, trauma, and attachment injuries experienced by foster care youths, as well as to confirm how grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care manifests and presents. This would assist in confirming if participants’ conceptualizations of the current study were accurate and to determine how to utilize those components. More research guiding an appropriate diagnosis to capture the experience of grief stemming from the ambiguous loss of attachment figures would also be beneficial. The participants reported using symptoms reflecting the byproduct of grief as well as diagnoses reflecting the core clinical issues. However, the literature lacks guidance in diagnosing grief stemming from ambiguous loss. The DSM-5 contains a section for future research which indicated a need for further research regarding grief.

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In general, research regarding treatment approaches for grief stemming from ambiguous loss of attachment injuries experienced by foster care youths is lacking.

Interventions, techniques, symptoms, and assessments that would acknowledge the unique experiences of clients in foster care while addressing grief, loss, and attachment injuries would assist in meeting the needs of clients. The current research, literature, and resources available to clinicians does not clearly address the intersections of components and needs of the foster care system to effectively guide clinical conceptualizations. More research connecting grief, loss, trauma, attachment, and foster care youths would contribute to the field of counseling.

Strengths and Limitations of the Study

Strengths of the study included the impact of personal experiences of grief and loss, as well as the incorporation of spirituality from one participant. The participants’ personal experiences provided findings regarding the impact of personal experiences in conceptualizations. The literature indicated grief and loss are universal life experiences indicating clinicians are likely to encounter personal experiences of grief and loss during their career. Participant B’s story did not include personal experiences. The mix of participants with personal experiences of grief and loss and without personal experiences provided both perspectives and the impact on conceptualizations.

A limitation of the study was a lack of diversity among the participants and small sample size. Lack of diversity and small sample size hinders the ability to apply findings to the general population of clinicians. Having only female and only Caucasian participants could limit the ability to apply findings to other populations.

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Final Thoughts

The results of the study provided findings which provided an answer to the research question. Clinicians conceptualized grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care in differing manners. The differing conceptualizations, however, incorporated the same components of grief, loss, attachment, and trauma. Factors which influenced and hindered conceptualizations were present in the findings. The findings, while providing some insight into conceptualizations, left much unknown. The findings spoke to the lack of understanding, education, training, and resources regarding grief stemming from ambiguous loss of attachment figures experienced by clients in foster care. The lack of cohesive conceptualizations could be a reflection of the limited literature and trainings available to clinicians regarding the research question. The appearance of the same four components: grief, loss, attachment, and trauma could verify clinical needs of clients in foster care to contain all four of those components.

The findings also reflected the complicated experience of addressing grief and loss of attachment figures while working within the foster care system framework. The findings of the study reflected clients in foster care have experiences of grief, loss, trauma, and attachment injuries. However, there is a lack of research, trainings, education, and resources addressing the clinical needs of clients in foster care. The participants’ stories reflected the emotional pain, grief, ambiguity, and trauma clients in foster care often may experience. The findings of the current study indicated an ethical responsibility of clinicians, educational institutions, and supervisors in ensuring that the needs of clients in foster care are attended to. More research is needed to better

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conceptualize grief stemming from ambiguous loss of attachment figures experienced by clients in foster care.

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APPENDICES

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APPENDIX A:

INFORMED CONSENT

Title of Study: Clinical Conceptualizations of Grief and Loss Experienced By Clients in Foster Care

Introduction: You are invited to participate in a research project being conducted by Elizabeth Molla, a Doctoral Student in the School of Counseling, College of Health Professions at The University of Akron. The research project will be conducted under the supervision of Rikki Patton, PhD (a faculty member in the School of Counseling at The University of Akron).

Purpose: The purpose of this qualitative study is to gain a deeper understanding of the manner in which clinicians understand and attend to the clinical concerns of clients in foster care. More specifically, the researcher hopes to identify how the impact of literature and research, graduate training, and clinical experiences inform the participants’ clinical conceptualization processes.

Procedures: Data will be collected using a demographic information questionnaire and by conducting an in-depth semi-structured interview. Interviews will be conducted in person in the researcher’s clinical office to ensure privacy and confidentiality. There will be two scheduled meetings to conduct the interviews. The first meeting will encompass the demographic data questionnaire and a semi-structured interview. The second meeting will include an interview with follow-up questions based on answers from the initial interview. The second meeting will also include a collaborative analysis reviewing and analyzing interview transcripts, field texts, and co-constructing narrative stories. Interviews will be video-recorded in order to transcribe and collect data from the interview responses.

Exclusion: Participants are chosen for their expertise and knowledge of the subject matter. The criteria for inclusion in the study is: (a) hold an active marriage and family therapy license; (b) past and current clinical work with clients in foster care; (c) willingness and ability to co-construct narrative stories and actively participate in the research; (d) sufficient time to participate in the study

Risks and Discomforts: A possible psychological risk to you, the participant, is that during the interview you may recall some unpleasant memories and experiences which may stir up some negative emotions. It is expected that this will be infrequent and 210

minimal in severity. The researcher's credentials as a mental health therapist can assist in reducing the risk of negative impacts of participating in the study. Counseling referrals will be provided to each participant in the event that their past experiences are causing them psychological discomfort.

Benefits: The benefits to you for participating in this study may be a sense of furthering the field of marriage and family therapy. Your participation will help mental health professionals to better understand the manner in which clinicians understand and attend to clinical concerns of clients in foster care.

Right to Refuse or Withdraw: Participation is voluntary and refusal to participate or withdraw from the study at any time will involve no penalty or loss of benefits to which they are otherwise entitled.

Anonymous and Confidential Data Collection: Any identifying information collected will be kept in a secure location and only the researcher will have access to the data. Participants will not be individually identified in any publication or presentation of the research results. Only aggregated data will be used. Your signed consent form will be kept separate from your data, and measures will be taken to ensure your responses will not be linked to you.

Audio and Video Taping: I understand that the interviews will be video-taped and transcribed without identifying information. The video-tape will be kept in a secure cabinet in the office of the researcher and will be destroyed after 7 years.

Confidentiality of records: The video-taped interviews will be kept in a secured cabinet in the office of the researcher. The transcribed documents will not include your name; it will include a number assigned to you in order to help maintain confidentiality.

Who to contact with questions: If you have any questions about this study, you may call Elizabeth Molla at 614-961-9797 or Dr. Rikki Patton at 330-972-8158. This project has been reviewed and approved by The University of Akron Institutional Review Board. If you have any questions about your rights as a research participant, you may call the IRB at (330) 972-7666.

Acceptance & signature: Signing this consent form is an indicator that I have read the information provided above and all of my questions have been answered. I voluntarily agree to participate in this study. I will receive a copy of this consent form for my information. ______Participant Signature Date

I agree to be video recorded ______

I agree to be audio recorded ______

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APPENDIX B:

DEMOGRAPHIC QUESTIONNAIRE

Gender: ______

Sex: ______

Age: ______

Ethnicity/ Race: Please specify your ethnicity:

___ White ___ Hispanic or Latino ___ Black or African American ___ Native American or American Indian ___ Asian ___ Pacific Islander ___ Multiracial ___ Would rather not say ___ Other ______

Degree: Please specify your highest attained degree:

___ Bachelor’s Level

___ Master’s Level (M.A., M.A.Ed., etc.)

___ Doctoral Level (PhD, PsyD., etc.)

License/s: Please provide your current license/s: ______

______

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APPENDIX C:

INTERVIEW PROTOCOL

Interviews will take place at the researcher’s clinical office. The interview will either be audio or video recorded, depending on the preference of the participant. The interview will be given to 3-6 individuals who willingly agree to take part in the study. The parameters of the subject pool include actively licensed marriage and family therapists, with experience working with clients in foster care. There will be 2 scheduled meetings with each participant. During the initial meeting participants will first be asked to fill out the demographic questionnaire and participate in a semi-structured interview. The answers from the demographic questionnaire and the semi-structured interview will be reviewed and analyzed to assist with informing the questions posed during the second meeting. The second meeting will consist of an interview with follow-up questions based on answers from the initial interview. The second meeting will also include a collaborative analysis reviewing and analyzing interview transcripts, field texts, and co- constructing narrative stories.

The purpose of this qualitative study is to gain a deeper understanding of the manner in which clinicians understand and attend to the clinical concerns of clients in foster care. More specifically, the researcher hopes to identify how the impact of literature and research, graduate training, and clinical experiences inform the participants’ clinical conceptualization processes.

Research question: How do clinicians conceptualize grief stemming from the ambiguous loss of attachment figures experienced by clients in foster care?

Semi-Structured Interview

Date of initial interview: ______

Name (coded) of participant: ______

Semi-Structured Interview Questions:

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1. How do you understand and attend to the clinical concerns of clients in foster care?

What are common diagnoses, symptoms, and behaviors expressed by clients in foster

care? What assessments and treatments do you utilize with clients in foster care?

2. How do you understand and attend to the clinical concerns of clients in foster care?

What are common diagnoses, symptoms, and behaviors expressed by clients in foster

care? What assessments and treatments do you utilize with clients in foster care?

3. How do you understand attachment styles and injuries? How do you understand

attachment styles and injuries of clients in foster care?

4. How do you define experiences of loss? How do you understand and attend to

experiences of loss in your clinical practice? How do you diagnosis, assess, and treat

loss in your clinical practice? What was your understanding: Prior to graduate school?

During graduate training? Post-graduation?

5. How do you define grief? How do you understand and attend to experiences of grief in

your clinical practice? How do you diagnosis, assess, and treat grief in your clinical

practice? What was your understanding: Prior to graduate school? During graduate

training? Post-graduation?

6. How did your family norms, societal norms, and cultural values influence your

understanding of grief and loss?

7. Any further thoughts, comments, or questions?

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APPENDIX D:

INSTITUTIONAL REVIEW BOARD APPROVAL

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