Grief Counseling Preparation Among Professional Counselors

GRIEF COUNSELING PREPARATION AMONG PROFESSIONAL COUNSELORS

TANYA NICOLE TUCKER

(Under the Direction of Anneliese Singh)

ABSTRACT

Grief is defined as the emotions and behaviors an individual may experience as a result of a death or other significant loss (Worden, 2002; Zisook & Kendler, 2007). Although counselors are tasked to serve and work with grieving clients, the current Council for the Accreditation of

Counseling and Related Educational Program (CACREP) standards (2016), which provide counselor training programs with specific content required for all counselors in training, does not mention grief within the counselor education curriculum. As a result of the lack of grief training with counselor preparation programs, it has been documented that new and inexperienced counselors lack the confidence and skills to successfully work with grieving clients (Charkow,

2002; Cicchetti, McArthur, Szirony, & Blum, 2016; Kirchberg, Neimeyer, & James, 1998; Ober,

Granello, & Wheaton, 2012).

Readers are provided with a background on how grief has been addressed historically, followed by a review of current grief counseling theories and models. The research calls on and provides counselor educators and CACREP with ideas related to how grief and loss could be included in counselor preparation programs through current required coursework as well as through the use of the American Counseling Association (ACA) Advocacy Competencies (2003)

and Multicultural and Social Justice Counseling Competencies (MSJCC). This study investigated potential differences in grief counseling skills between counselors who have received grief counseling training and counselors who have received no grief counseling training. The study also investigated potential differences in grief counseling skills between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses. The study concludes with personal reflections and reflexivity regarding the process and experience of conducting research.

INDEX WORDS: Counseling, Counselor Education, Counselor Training, Grief, Grief

Counseling, Social Justice

GRIEF COUNSELING PREPARATION AMONG PROFESSIONAL COUNSELORS

TANYA NICOLE TUCKER

AA, Gainesville State College, 2004

BA, Georgia State University, 2006

MS, Mercer University, 2014

A Dissertation Submitted to the Graduate Faculty of The University of Georgia in Partial

Fulfillment of the Requirements for the Degree

DOCTOR OF PHILOSOPHY

ATHENS, GEORGIA

2019

Tanya Nicole Tucker

GRIEF COUNSELING PREPARATION AMONG PROFESSIONAL COUNSELORS

TANYA NICOLE TUCKER

Major Professor: Anneliese Singh Committee: Natoya Haskins George McMahon

Electronic Version Approved:

Suzanne Barbour Dean of the Graduate School The University of Georgia May 2019

DEDICATION

For my late mother—Because of you I had the courage to pursue this dream. I love and miss you dearly. “Grief, I’ve learned is really just love. It’s all the love you want to give, but cannot. All that unspent love gathers up in the corners of your eyes, the lump in your throat, and in that hollow part of your chest. Grief is just love with no place to go.” —Jamie Anderson

ACKNOWLEDGEMENTS

Each time I reflect on the last five years tears begin to emerge. I am still overwhelmed with emotions of excitement, grief, anxiety, and gratitude. I am so thankful for everyone who has supported me throughout the last five years, a period of constant change and growth.

To my family—thank you for always encouraging me and having faith that I could and would complete this journey. Thank you for your love and support throughout this process. Your unwavering support of my decisions in my personal life assured me I am never alone.

To Dr. Caroline Brackett, my professor from Mercer University—You introduced me to concepts related to privilege and oppression that ultimately changed my life. Your lectures inspired me to become an advocate for myself, so that in turn I can now advocate for my students.

To Dr. Mimi Gamel—Watching you complete your doctoral journey inspired me to always reach for the stars. You showed me that with hard work and dedication, anything is possible.

For Dr. Courbron and Terri Hayes—the only individuals who read this entire document outside of my committee. Thank you for serving as my editors and sounding board. I sincerely would not have made it through this process without you. I appreciate you both more than you will ever know.

To my cohort—I remember how scared I was to be in a doctoral program with nine other incredibly talented and experienced individuals. Thank you for always supporting and

vi encouraging me, even during my major periods of anxiety. I admire each one of you. You all have taught me so much about acceptance, perseverance, and unconditional support.

Last, thank you to my committee for your constant affirmation and encouragement.

Thinking back to comprehensive exams, I thought there was no way my anxiety would allow me to get this far. Thank you for your mentorship, scholarship, and unwavering belief in my abilities as a scholar.

vii

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS ...... v

LIST OF TABLES ...... x

LIST OF FIGURES ...... xi

CHAPTER

1 INTRODUCTION ...... 1

Current Conditions of Grief Training Within Counselor

Preparation Programs...... 1

Current Study ...... 3

Structure of Manuscript-Style Dissertation...... 7

References ...... 9

2 GRIEF COUNSELING AND COUNSELOR EDUCATION: A REVIEW OF THE

LITERATURE AND A CALL TO ACTION ...... 12

Introduction ...... 12

Understanding Grief and Loss...... 14

Western Counseling: Traditional Theories and Models of Grief ...... 16

Western Counseling: Contemporary Models of Grief ...... 22

Recommendations for Counselor Educators to Integrate Grief Training into

Counselor Education Curricula ...... 27

Conclusion ...... 35

viii

References ...... 36

3 GRIEF COUNSELING: AN INVESTIGATION OF PERCEIVED

COUNSELOR COMPETENCE ...... 46

Introduction and Rationale for Study ...... 46

Grief Education and Training for Counselors ...... 48

Grief Competency ...... 49

Research Questions...... 55

Method ...... 58

Results ...... 65

Limitations of the Study...... 80

Recommendations for Future Research ...... 81

Conclusion ...... 81

References ...... 83

4 GRIEVING WHILE GROWING: THE PROCESS OF RESEARCHING

AND WRITING ABOUT GRIEF WHILE EXPERIENCING GRIEF ...... 89

Introduction ...... 89

Reflexivity and Researcher Positionality ...... 92

The Process of Research ...... 96

Conclusion ...... 100

References ...... 102

APPENDICES

A RECRUITMENT LETTER ...... 104

B SURVEY INSTRUCTIONS AND SURVEY CONSENT ...... 104

C POWER ANALYSIS USING G*Power VERSION 3.1.9.4 ...... 111

LIST OF TABLES

Page

Table 1. Demographics ...... 69

Table 2. Summary of Survey Responses Part I of GCCS (Self-Perceived

Personal Grief Counseling Competency) ...... 71

Table 3. Summary of Survey Responses Part II of GCCS (Self-Perceived

Skills and Knowledge Grief Counseling Competency) ...... 72

Table 4. Summary of Survey Responses for the Marlowe Crowne Social

Desirability Scale–Form C ...... 73

Table 5. Descriptive Statistics of Grief Counseling Competency ...... 73

Table 6. Descriptive Statistics (M (SD)) of Grief Counseling Competency, by Training Experience ...... 74

Table 7. Multivariate Tests (RQ1.1) ...... 75

Table 8. Results of ANOVA (RQ1.2) ...... 76

Table 9. Results of ANOVA (RQ1.3) ...... 76

Table 10. Descriptive Statistics (M (SD)) of Grief Counseling Competency, by Training Course ...... 77

Table 11. Multivariate Tests (RQ2.1) ...... 78

Table 12. Results of ANOVA (RQ2.2) ...... 79

Table 13. Results of ANOVA (RQ2.3) ...... 80

LIST OF FIGURES

Page

Figure 1. Frequency counts of various types of postmaster’s grief training...... 70

CHAPTER 1

INTRODUCTION

Individuals often associate grief with the intense emotions that result from death

(Merriam-Webster, 2017), however grief includes feelings that occur as a result of any significant loss, such as infertility (Lee et al., 2010), family estrangement (64 Examples of

Disenfranchised Grief, 2019), divorce (Parker & Australian Early Childhood Association, 2003), job loss (Papa & Maitoza, 2013; Ramsey, 2014), loss of limb (Spiess, McLemore, Zinyemba,

Ortiz, & Meyr, 2014), loss of home (64 Examples of Disenfranchised Grief, 2019), natural disaster (Williams & Spruill, 2005), or loss of culture and traditions (64 Examples of

Disenfranchised Grief, 2019). Although these life events are often associated with adulthood, children also experience grief, commonly as a result of parental divorce, incarceration of a loved one, and deportation (Guidry, Simpson, Test, & Bloomfield, 2013). Given the vast variety of circumstances that lead to grief, it is a given that at some point everyone will experience grief in some way or another. Grief is defined as the emotions and behaviors an individual may experience as a result of a death or other significant loss (Worden, 2002; Zisook & Kendler,

2007).

Current Conditions of Grief Training Within Counselor Preparation Programs

Although counselors are tasked to serve and work with grieving clients, the content of the grief training they receive within counselor preparation programs is inconsistent (Low, 2004).

Specifically, Low (2004) found that some master’s level programs offer grief training as an elective while other programs incorporate grief content as a module within another required

2 course. Reasons cited for not incorporating grief into the curriculum included a lack of requirement from the Council for the Accreditation of Counseling and Related Educational

Programs (CACREP; Low, 2004). Although Low’s (2004) findings are over a decade old, the current CACREP standards (2016), which provide counselor training programs with specific content required for all counselors in training, still does not mention grief within the counselor education curriculum.

As a result of the lack of grief training with counselor preparation programs, it has been documented that new and inexperienced counselors lack the confidence and skills to successfully work with grieving clients (Charkow, 2002; Cicchetti, McArthur, Szirony, & Blum, 2016;

Kirchberg, Neimeyer, & James, 1998; Ober, Granello, & Wheaton, 2012). These studies lack consistency among the type of counselors surveyed, and they fail to clarify how the counselor received grief training and how this impacts their competency to work with grieving clients.

Specifically, Charkow (2002) and Ober et al. (2012) examined the confidence level of professional counselors and found that although a majority of participants reported working with at least one client experiencing grief, most had no grief-related courses in their graduate training and reported having limited competency in grief-related conceptual knowledge and skills.

Cicchetti et al. (2016) surveyed rehabilitation counselors and again found a majority had no specific grief training in their counselor preparation training. Wood (2016) completed a dissertation research study examining 153 CACREP master’s-level counseling students and their self-perceived grief training competency and skills. Results indicated no effect on perceived personal competence given demographic gender, race, and ethnicity (Wood, 2016). However, there was a significance found for age and self-perceived personal competence (Wood, 2016).

Current Study

The purpose of this study is to investigate the difference between counselors’ self- perceived competency to identify and work with individuals experiencing grief based on whether or not they have received instruction in grief training counseling. Additionally, this study also seeks to identify the difference between counselors’ self-perceived competency to assess and work with grieving clients based on whether or not they have taken a dedicated grief course as opposed to grief training incorporated throughout the counselor preparation training. Both of these investigations will control for the counselor’s age, because age was previously found to impact self-perceived personal competence when working with grieving clients (Cicchetti et al.,

2016; Wood, 2016). To appropriately control for the potential confounding variable of age of counselor, age will be incorporated into the analysis as a control variable. Therefore, the research questions are:

RQ1.1: Is there a statistically significant difference in self-perceived Grief Counseling

Competency mean scores between counselors who have received grief counseling

training and counselors who have received no grief counseling training, when controlling

for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived Grief

Counseling Competency mean scores between counselors who have received grief

counseling training and counselors who have received no grief counseling training, when

controlling for the age of the counselors.

RQ1.2: Is there a statistically significant difference in self-perceived Personal Grief

Counseling Competency mean scores between counselors who have received grief

4 counseling training and counselors who have received no grief counseling training, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived

Personal Grief Counseling Competency mean scores between counselors who have received grief counseling training and counselors who have received no grief counseling training, when controlling for the age of the counselors.

RQ1.3: Is there a statistically significant difference in self-perceived Skills and

Knowledge Grief Counseling Competency mean scores between counselors who have received grief counseling training and counselors who have received no grief counseling training, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in Skills and

KnowledgeGrief Counseling Competency mean scores between counselors who have received grief counseling training and counselors who have received no grief counseling training, when controlling for the age of the counselors.

RQ2.1: Is there a statistically significant difference in self-perceived Grief Counseling

Competency mean scores between counselors who have received grief counseling training in a designated grief course and counselors who have received grief counseling training incorporated into other required content courses, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived Grief

Counseling Competency mean scores between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief

5 counseling training incorporated into required content courses, when controlling for the age of the counselors.

RQ2.2: Is there a statistically significant difference in self-perceived Personal Grief

Counseling Competency mean scores between counselors who have received grief counseling training in a designated grief course and counselors who have received grief counseling training incorporated into other required content courses, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived

Personal Grief Counseling Competency mean scores between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, when controlling for the age of the counselors.

RQ2.3: Is there a statistically significant difference in self-perceived Skills and

Knowledge Grief Counseling Competency mean scores between counselors who have received grief counseling training in a designated grief course and counselors who have received grief counseling training incorporated into other required content courses, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived Skills and Knowledge Grief Counseling Competency mean scores between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, when controlling for the age of the counselors.

To answer the research questions, and with the approval of the University of Georgia’s

Institutional Review Board, a cross-sectional, nonexperimental quantitative research design was used. Professionally licensed counselors, licensed less than five years, who are also members of the American Mental Health Counselors Association (AMHCA) were recruited. After accepting the informed consent, participants were then surveyed using three instruments: 1) a demographic survey, 2) the Grief Counseling Competency Scale (GCCS; Cicchetti, 2010), and 3) the

Marlowe-Crowne Social Desirability Scale (Reynolds, 1982). Data was collected and stored confidentially using SurveyMonkey. Once data compilation was complete, an analysis was conducted using SPSS 23 for Windows (IBM Corp., Armonk, NY).

Next, to obtain a clear understanding of the participants’ self-perceived grief counseling competency, descriptive statistics were calculated. Further, data analysis was completed using a one-way multivariate analysis of variance (MANOVA) to answer RQ1.1 and RQ2.1, and an analysis of variance (ANOVA) for RQ1.2, RQ1.3, RQ2.2, and RQ2.3. Finally, demographic variables including the counselors’ gender, geographic region, and social desirability score were examined to determine the impact of self-perceived grief counselor competence.

As a result of this research study, a review and summary of the literature related to grief and loss was completed. Readers were provided with a background on how grief has been addressed historically, followed by a review of current grief counseling theories and models.

Additionally, this research calls on and provides counselor educators and CACREP with ideas related to how grief and loss could be included in counselor preparation programs. Finally, this study provides a lens through which counselors and counselor educators can provide culturally competent grief counseling care by incorporating the American Counseling Association (ACA)

Advocacy Competencies and Multicultural and Social Justice Counseling Competencies

(MSJCC). The ACA Advocacy Competencies provide counselors with guidelines to advocate with and on behalf of clients in three domains: client/student, school/community, and the public arena (Toporek, Lewis, & Crethar, 2009). The MSJCC focuses on the counseling relationship by exploring the counselors’ grief knowledge, skills, and competence through the lens of privilege and marginalization (Ratts, Singh, Butler, Nassar-McMillan, & Rafferty McCullough, 2016).

Using the MSJCC framework, the counselor can explore their grief awareness, their client’s worldview, and advocacy interventions while advocating for multiculturalism and social justice

(Ratts et al., 2016).

Structure of Manuscript-Style Dissertation

I used a manuscript-style format for this dissertation. This chapter (Chapter 1) is an overview of the study topic, aims, methodology, and its significance to the counseling profession. It highlights the procedures used in the study and potential limitations. Chapter 2 provides readers with an extensive review of the literature related to grief counseling, including historical and contemporary models and theories of grief. In this chapter, I issue a call to counselor educators to incorporate grief training into the current counseling curricular is provided with the goal of encouraging the CACREP to consider adding grief related standards. I also encourage professional counselors and counselor educators to use the MSJCC as a lens to explore grief with clients while also accounting for privilege and oppression of both the counselor and client. Chapter 3 is the research study using a cross-sectional, nonexperimental quantitative research design and it includes a review of grief literature, the research design, variables, instruments, methods, data analysis, findings, and implications for future research. In

Chapter 4, I describe my researcher reflexivity and positionality, including the values and

8 experiences that I held prior to and during this study, and I reflect on the use of theory and methods in my study to identify in-depth study implications.

References

64 Examples of disenfranchised grief. (2019, January 4). Retrieved from

https://whatsyourgrief.com/64-examples-of-disenfranchised-grief/

Charkow, W. B. (2002, June). Family-based death and grief-related counseling: Examining the

personal and professional factors that impact counselor competence. Dissertation

Abstracts International Section A, 62, 4070.

Cicchetti, R. J. (2010). Graduate students' self assessment of competency in grief education and

training in core accredited rehabilitation counseling programs. Retrieved from

http://proxy-remote.galib.uga.edu:80/login?url=https://search-proquest-com.proxy-

remote.galib.uga.edu/docview/305235628?accountid=14537

Cicchetti, R. J., McArthur, L., Szirony, G. M., & Blum, C. R. (2016). Perceived competency in

grief counseling: Implications for counselor education. Journal of Social, Behavioral &

Health Sciences, 10(1), 3–17. doi:10.5590/JSBHS.2016.10.1.02

Council for Accreditation of Counseling and Related Educational Programs. (2016). 2016

CACREP standards. Alexandria, VA: Author.

Grief. 2017. In Merriam-Webster.com. Retrieved from https://www.merriam-

webster.com/dictionary/grief

Guidry, K., Simpson, C., Test, T., & Bloomfield, C. (2013). Ambiguous loss and its effects on

children: Implications and interventions for school counselors. Journal of School

Counseling, 11(15), 1.

IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM

Corp.

Kirchberg, T., Neimeyer, R., & James, R. (1998). Beginning counselors' death concerns and

empathic responses to client situations involving death and grief. Death Studies, 22(2),

99–120.

Lee, S., Wang, S., Kuo, C., Kuo, P., Lee, M., & Lee, M. (2010). Grief responses and coping

strategies among infertile women after failed in vitro fertilization treatment.

Scandinavian Journal of Caring Sciences, 24(3), 507–513. doi:10.1111/j.1471-

6712.2009.00742.x

Low, L. L. (2004). Pre-service grief and loss preparation in CACREP-accredited school

counseling programs. (Doctoral dissertation, Oregon State University).

Ober, A. M., Granello, D. H., & Wheaton, J. E. (2012). Grief counseling: An investigation of

counselors' training, experience, and competencies. Journal of Counseling &

Development, 90(2), 150–159.

Papa, A., & Maitoza, R. (2013). The role of loss in the experience of grief: The case of job loss.

Journal of Loss & Trauma, 18(2), 152-169.

Parker, J. A., & Australian Early Childhood Association, I. W. (2003). Helping children in times

of need: Grief, loss, separation & divorce. A handbook for parents assisting children

through grief and loss. Watson, ACT: Australian Early Childhood Association.

Ramsey, H. (2014). Practicing social responsibility by helping severed employees grieve a job

loss. The Psychologist-Manager Journal, 17(2), 79–86. doi:10.1037/mgr0000013

Ratts, M. J., Singh, A. A., Butler, S. K., Nassar-McMillan, S., & Rafferty McCullough, J. (2016).

Multicultural and social justice counseling competencies: Practical applications in

counseling. Counseling Today, 58(8), 40–45.

Reynolds, W. M. (1982). Development of reliable and valid short forms of the Marlowe-Crowne

Social Desirability Scale. Journal of Clinical Psychology, 38, 119–125.

Spiess, K. E., McLemore, A., Zinyemba, P., Ortiz, N., & Meyr, A. J. (2014). Application of the

five stages of grief to diabetic limb loss and amputation. Journal of Foot and Ankle

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53(6), 735–739. doi:10.1053/j.jfas.2014.06.016

Toporek, R. L., Lewis, J. A., & Crethar, H. C. (2009). Promoting systemic change through the

ACA advocacy competencies. Journal of Counseling & Development, 87(3), 260–268.

Williams, J. M., & Spruill, D. A. (2005). Surviving and thriving after trauma and loss. Journal of

Creativity In Mental Health, 1(3-4), 57–70.

Wood, J. E. (2016). Master's students' self-assessment of competency in grief education and

training in CACREP-accredited counseling programs (Order No. 10137457). Available

from ProQuest Dissertations & Theses Global. (1803579682). Retrieved from

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Worden, J. W. 1. (2002). Grief counseling and grief therapy: A handbook for the mental health

practitioner (3rd ed.). New York: Springer Pub.

Zisook, S., & Kendler, K. (2007). Is bereavement-related depression different than non-

bereavement-related depression? Psychological Medicine, 37(6), 779–794.

CHAPTER 2

GRIEF COUNSELING AND COUNSELOR EDUCATION: A REVIEW OF THE

LITERATURE AND A CALL TO ACTION

Introduction

A critical skill for counselors in training now and in the coming decades is the ability to work with clients who have experienced grief (Ober, Granello, & Wheaton, 2012). For instance, researchers report that as the 75 million baby boomers begin to reach retirement age, requests for grief counseling will increase at a rapid rate (Maples & Abney, 2006; Robb, Haley, Becker,

Polivka, & Chwa, 2003). In addition, Toblin et al. (2010) in a research study of returning veterans from Iraq, found that over 80% of soldiers knew someone who had been injured or killed, an impact similar to losing a family member. Also, natural disasters such as hurricanes, tornadoes, tsunamis, earthquakes, and floods, which result in death or other losses such as homes and belongings, leave individuals in need of grief counseling services (Williams & Spruill,

2005).

Adults are not the only ones experiencing grief, it is also experienced by children and adolescents. According to Owens (2008), before age 15, one in 20 students will experience the loss of one or both parents. More recently, a survey of teachers from the American Federations of Teachers and the New York Life Foundation found that 7 in 10 teachers reported having a student who had experienced the loss of a parent, sibling, guardian, or close friend within the past year (Densen, Landsworth, & Siegel, 2012). Students today are not only experiencing grief

13 related to the death of a loved one but also a result of loss due to separation, such as divorce, incarceration, or deportation (Guidry, Simpson, Test, & Bloomfied, 2013).

Although counselors are increasingly seeing clients with grief-related symptoms (Ober et al., 2012), Kirchberg, Neimeyer, and James (1998) found that beginning professional counselors experience high levels of anxiety with working with clients with a death-related loss. Charkow

(2002) surveyed 147 family counselors, and over 50% claimed their master’s level grief training was less than satisfactory. Cicchetti, McArthur, Szirony, and Blum (2016) surveyed master’s level counselors specializing in rehabilitation counseling and found 54% had no formal training related grief and loss. Ober et al. (2012) surveyed 1000 licensed professional counselors from a

Midwestern state and found 54.8% of respondents reported not having had any grief training.

In fairness to graduate counselor preparation programs, the Council for the Accreditation of Counseling and Related Educational Programs (CACREP; 2016), which sets curriculum guidelines and standards for counseling preparation programs, has no requirements or specific standards related to grief and loss. The CACREP standards do address standards related to development across the lifespan, including mentioning systematic and environmental factors and the effects of crisis, trauma, and disasters on diverse individuals (CACREP, 2016, II.3.a, II.3.f,

II.3.g). This is problematic because without specific formal standards and training related to grief and loss, educational programs may fail to include grief within the program pedagogy, leading to practicing counselors potentially providing services beyond their expertise (Ober et al., 2012).

This poses a potential ACA Code of Ethics (ACA, 2014) violation—Standard C.2 is clear that professional counselors should only practice based on competence from education, training, and supervision.

Finally, the need to incorporate grief into counseling preparation programs is a social justice issue. Ratts (2011) describes social justice as advocating with and on behalf of an individual or group to address systematic barriers that impede on quality of life and well-being.

As mentioned previously, grief and loss result from a variety of life experiences and eventually impact every individual. Counselors, as social justice advocates, must be able to recognize when clients are experiencing grief and loss but also properly support the client throughout the grief process while using the appropriate models and theories in addition to accounting for other variables such as culture, power, and privilege.

In this chapter, the constructs of grief and loss are defined and a comprehensive review of the major grief theories and models are provided. Next, counselor educators are provided recommendations to incorporate grief training into core counselor training courses. Finally, counselor educators are encouraged to advocate with and on behalf of students/clients for additional grief standards, competencies, and the incorporation of grief and loss into counselor preparation programs using the Advocacy Competencies (2003) as a framework.

Understanding Grief and Loss

Most often when reflecting on grief, individuals relate to Merriam-Webster’s (2017) definition as the experience of deep, agonizing suffering and distress caused by death. However,

Humphrey (2009) adds that grief can result from both real and anticipated losses, meaning individuals may experience grief even before the death of another. Worden (2002) goes further to explain grief as the wide variety of feelings and behaviors that typically follow any type of significant loss. Zisook and Kendler (2007) agree that grief involves emotions and behaviors, which result from a loss of any kind, but also add awareness and changes in an individual following loss. Loss of any kind refers to non-death related loss, including experiences such as:

15 job loss (Papa & Maitoza, 2013; Ramsey, 2014), divorce (Parker & Australian Early Childhood

Association, 2003), infertility (Lee et al., 2010), loss of limb (Spiess, McLemore, Zinyemba,

Ortiz, & Meyr, 2014), or loss of home (Herrmann, 2011), just to mention a few.

Definitions of grief were developed in the mid-twentieth century in Europe and North

America as part of the Western concept of mental health and illness (Klass & Chow, 2011).

According to Klass & Chow (2011), this has unfortunately led most cross-cultural grief studies to commonly only report how North American ideas are assimilated into other cultural labels, such as Asian, South American, Hispanic, Middle Eastern, or Latino, or African American.

Curley (2013) encourages researchers and mental health professionals to seek and embrace new ideas about grief beyond the European/American viewpoint.

Despite the fact that all individuals experience grief and increased research interest, there is still much to be understood related to grief, specifically as it relates to culture (Cowles, 1996).

Within the helping professions, practitioners have long placed emphasis on understanding clients within their cultural context, however without proper knowledge, odds of committing cultural errors based on faulty assumptions are increased (Lopez, 2011). McGoldrick et al. (2004) reports that every culture, past and present, has a unique manner of mourning, including beliefs, practices, and values; therefore, health professionals must be cautious when describing what is considered normal grieving. Additionally, when considering culture, not only with grieving clients but in all counseling settings, professionals must understand that culture goes beyond race and ethnicity to include religion, spirituality, socio-economic status, gender, sexual orientation, occupational status, geographic location, and developmental stage of life (Lopez, 2011).

Western Counseling: Traditional Theories and Models of Grief

Initial research on bereavement followed a medical model as a way to diagnosis and treat symptoms, including grief (Parkes, 2011). During most of the twentieth century, medical professionals helping individuals process grief believed that individuals must completely detach, or disengage themselves from the deceased, to fully overcome grief and thereby later reattach to another person (Doughty, Wissel, & Glorfield, 2011). These traditional theories and models of grief offer sequenced, universal phases, stages, and tasks associated with the grief process that individuals complete (Doughty, 2009).

Sigmund Freud

Freud’s foundational text “Mourning and Melancholia” (1917) was written during the infancy of psychoanalysis and sought to better understand and explain mourning compared to melancholy or depression (Woodward, 1990). Freud began by describing how the two are alike—for example, both can produce similar symptoms such as painful sorrow and sadness, loss of interest in everyday activities, and inability to love (Clewell, 2004). Manifestations of both mourning and depression appear similar, and those in mourning may develop depression

(Worden, 2002). However, grieving individuals typically do not lose their self-esteem, which is more common in clinical depression (Worden, 2002). Another similarity is that both depression and mourning commonly arise from the death of a loved one or another symbolic loss, either at the time of the loss or later in life (Clewell, 2004; Worden, 2002). However, those who experience melancholia typically deny the reality of loss, which Freud considered an abnormal pathological state rather than a process (Woodward, 1990).

Freud considered mourning normal and necessary for an individual to “free” themselves

(Woodward, 1990). By detaching or releasing emotional bonds that tie a person to the lost individual or object, energy can be reinvested elsewhere (Woodward, 1990). Also known as grief

17 work, this involves acknowledging the permanency of the loss and attending to feelings and memories of the deceased (Rothaupt & Becker, 2007). A person in mourning realizes this permanency through a slow process of comparing each memory of their loss loved one to their new reality (Fiorini, Bokanowski, Lewkowicz, & Person, 2009). Woodward (1990) criticizes this process because Freud offered no details on how this worked, other than in the “passage” of time. Mourning is complete as the individual slowly comes to realize the loss is permanent. A hallmark of Freud’s mourning process is that it ends abruptly when the mourner has fully detached emotions and energy related to the loss and reattaches to a new person or object

(Clewell, 2004).

Bowlby’s Attachment Theory

Following Freud’s foundational text of mourning, Bowlby introduced attachment theory.

Worden (2002) suggests that before being able to completely comprehend the impact of loss, an understanding of attachment theory is necessary. Attachment theory was originally developed to explain why infants attached to their caregivers and later became upset and distressed when they were removed or left (Collins & Feeney, 2000). Bowlby (1977) claimed that children develop emotional bonds or attachments with a few select individuals, such as mothers or caregivers, early in life as a result from the need to feel secure and safe. When the attachment figure is withdrawn from the child, they commonly experience distress in the form of clinging, crying, and/or anger (Worden, 2002). Bowlby compared this type of reaction to adult grief and suggests that as soon as children have developed an attachment relationship, they are capable of experiencing grief (Archer, 1999). Ainsworth enhanced Bowlby’s attachment theory by describing three attachment styles that result from parenting styles: secure, anxious/ambivalent, and avoidant (Doughty et al., 2011).

Children who experience a secure attachment are confident and feel valued by their caregiver, therefore they are able to cope with separation and easily reconnect when the caregiver returns (Doughty et al., 2011). Individuals with secure attachments are comfortable with intimacy and relying on others for support (Collins & Feeney, 2000). Children who experience anxious or ambivalent attachment styles often have an unrealistic desire for dependence and exhibit high anxiety for fear of rejection (Collins & Feeney, 2000). Finally individuals with an avoidant attachment style, do not value close relationships or intimacy, rather they prefer independence and self-reliance (Collins & Feeney, 2000).

Using these attachment styles, researchers have sought to explain the varying grief reactions among individuals (Doughty et al., 2011). Bowlby later acknowledged the importance of studying attachment throughout the lifespan, claiming the basic functions of attachment continue (Field, 1996). Field added that attachment occurs at multiple stages throughout a person’s life, with a variety of people, including spouses, lovers, siblings, friends, and one’s children.

Five Stages of Grief

Following attachment styles of grieving, stage and task models were introduced. Kübler-

Ross first proposed that chronically ill patients who knew they were nearing death went through five phases, including: denial, anger, bargaining, depression, and acceptance, as explained in her book On Death and Dying (O’Rourke, 2010; Roos, 2012). The model assumes everyone nearing death experiences a linear sequence through the five stages, with a final goal of acceptance

(Carpenter, 1979). Also known as the “Stage Model,” it became the paradigm for not only how people die but also how they grieve. Kübler-Ross later suggested that family members go through similar phases (O’Rourke, 2010).

However, as early as the 1970s and extending into to 1990s, a lack of empirical evidence caused clinicians to question the validity of linear phases related to death and grief (Corr, 2015;

Roos, 2012). Specific critiques include Corr (2015), who argues that humans are not limited to five ways of acknowledging emotions or feeling when responding to death or grief. Kübler-Ross

(1969) herself acknowledged that hope exists throughout the five stages. Corr’s (2015) main point is that people live their lives experiencing many emotions, surely more than five.

Therefore, it reasonable to assume as individuals near death or experience grief, a wide range of emotions occurs as well (Corr, 2015).

Another concern is that grief viewed from the Kubler-Ross’s framework characterizes individuals’ experiences as either good or bad. For example, the first four stages—denial, anger, bargaining, and depression—are characterized as negative, followed by the final stage of acceptance (Carpenter, 1979). In this context, acceptance is described as “letting go” or “closing the circle of life” (Bregman, 1989). This assumes individuals should accept their death, potentially prematurely, to obtain a sense of peace in transitioning to the afterlife (Carpenter,

1979). Carpenter (1979) disagrees that everyone experiences acceptance, indicating that some individuals, potentially fighting their death until the end, never acknowledge having the potential to accomplish more. Finally, Kuykendall (1981) points to Kübler-Ross’s own admission that not all individuals will experience all the stages in a linear order and some may skip or repeat stages.

Worden’s Tasks of Grief

Moving away from the stages of grief, tasks of grief were introduced. Worden recognized that members of helping professions, such as clergy, social workers, funeral directors, counselors, and physicians, were already in a position to provide care to grieving or mourning individuals (Willoughby, 1993). Claiming that processing grief is an individual experience rather than sequential, routine stages that everyone passes through, Worden (2002) introduced what he

20 called Tasks of Mourning. Tasks are preferred over stages because of the assumption that tasks are more fluid and can be covered in any order and returned to or skipped as necessary (Worden

& Winokuer, 2011). By encouraging grieving clients to be an active participant in the mourning process, the Tasks approach provides individuals with a sense of power and hope (Blevins, 2008;

Worden, 2002). The next few paragraphs describe the four Tasks of Mourning.

Task One involves accepting the reality of the loss and occurs when the grieving individual fully comes to terms with the death of another and accepts that the death is permanent

(Worden, 2002). This includes both emotional and cognitive acceptance (Worden & Winokuer,

2011). Some individuals are unable to accept the death and therefore retreat into denial (Worden,

2002). According to Worden (2002), some examples of this include: denying facts,

“mummification” of belongings, denying the meaning of the loss, or selective forgetting of events. Accepting a loss takes time and varies by individual, depending on culture, beliefs, and support system (Blevins, 2008; Worden & Winokuer, 2011).

Once a person accepts the reality of the loss, the goal of Task Two is to process the physical, emotional, and behavioral pain associated with loss (Worden, 2002). Everyone experiences pain from loss differently, therefore mental health professionals aim to assist patients through the difficult process (Worden, 2002; Worden & Winokuer, 2011). Worden

(2002) warns that clients may avoid processing their pain by avoiding painful thoughts, speaking as if the deceased is still present, or abusing drugs or alcohol to suppress emotions. Without fully processing the pain of loss, it is likely to reappear later in life, potentially impacting future life events (Blevins, 2008; Worden & Winokuer, 2011).

Task Three occurs when an individual learns to cope and manage their new environment without the lost loved one. It includes external, internal, and spiritual adjustments (Worden,

2002; Worden & Winokuer, 2011). External adjustments and awareness typically arise between four and six months post-loss and involve taking on tasks and responsibilities that were once held by the deceased (Blevins, 2008; Worden, 2002; Worden & Winokuer, 2011). Internal adjustments involve how a person feels about his/herself without the deceased person and includes a person’s new definition of self, self-confidence, and self-efficacy (Worden, 2002;

Worden & Winokuer, 2011). Finally, loss can challenge a person’s sense of psychological values, assumptions, and beliefs of the world and universe (Worden & Winokuer, 2011). Janoff-

Bulman (1992) discusses three world assumptions that are commonly challenged as a result of the death of a loved one: a) the world is a good place, b) the world makes sense, and c) the value of the grieving individual. This step varies in difficulty depending on the type of loss. For example, an elderly person dying may fit our expectations of death whereas a young mother losing a child to a sudden death may challenge her understanding of the world (Worden, 2002).

Once meaning related to the loss has been found, it becomes easier to adjust to other aspects of the loss (Blevins, 2008).

Finally, Task Four occurs when the person in mourning is able to emotionally relocate the deceased individual and move on with life (Worden, 2002). This task involves accepting the loss of a loved one but also allowing oneself to continue with life in a meaningful way (Blevins,

2008; Worden, 2002). Blevins (2008) suggests a new relationship with the deceased is formed, one wherein the mourner recognizes the history of the relationship, the continued love for the person lost, and memories from the past but is still able to continue with life in a positive way

(Worden, 2002). The counselor’s role during this task is to help the client find an appropriate place to process and later store emotions related to the loss (Worden & Winokuer, 2009).

Researchers have critiqued traditional models of grief and loss (Wortman & Silver,

1989). First, there is little to no empirical evidence to support universal stages or steps of adaption involved in bereavement (Corr, 1993). Second, under traditional models, it is generally assumed that grieving happens in a specific way with those not conforming to be judged as abnormal (Wortman & Silver, 1989). Finally, undermining the “one-size fits all” approach is the increasing evidence of grieving differences between ethnic and cultural groups, ranging from subtle to drastic (Braun & Nicholas, 1997, Neimeyer, 2001).

Western Counseling: Contemporary Models of Grief

Task, stage, and phase models of grief dominated the twentieth century (Doughty, 2009).

However, in recent years, researchers have shifted away from the positivist, universal viewpoint of grief, one where everyone goes through the same phases or stages, to now focus on how each individual uniquely experiences grief while also considering their social environment (Davies,

2004). Neimeyer (1999) viewed grief as a complex process of meaning reconstruction, where individuals adapt to their changed reality with emphasis on individual experiences as opposed to everyone experiencing similar behaviors and emotions. This view included supporting ongoing relationships and emotional connections with the deceased, engaging in rituals and celebrations of special dates or events, all while recognizing that each individual experiences this uniquely

(Rothaupt & Becker, 2007). Contemporary models of grief counseling discussed in the following sections include the Dual Process Model, adaptive grieving styles, cognitive behavior therapy, and constructivism.

Dual Process Model

The Dual Process Model (DPM) was originally developed by Stroebe and Schut (1991) to describe how people recognize, acknowledge, and cope following the loss of a partner

(Stroebe & Schut, 1999, 2010). However, over the years, the DPM was applied to other death

23 losses, such as the loss of a child or bereavement among the elderly (Stroebe & Schut, 2010).

Drawing from cognitive stress theory, this model focuses on stressors associated with loss and cognitive strategies for understanding and managing related emotions (Humphrey, 2009; Stroebe

& Schut, 1999). According to this model, adjustment to a loss involves a process of alternating between confronting and avoiding a range of stressors, known as loss orientation and restoration orientation (Humphrey, 2009).

Loss orientation and restoration orientation are two categories of stressors that a grieving person must deal with (Stroebe & Schut, 2015). Loss orientation includes stressors that are associated with the loss itself, such as exploring the meaning of loss, reflecting on surrounding circumstances or events surrounding the death, yearning for the deceased, looking at old photos, or crying about the loss of the loved person (Humphrey, 2009; Stroebe & Schut, 1999). The primary focus is on the broken bond related to the deceased person (Humphrey, 2009). Loss orientation includes times when the bereaved avoids these stressors, such as blocking or avoiding thoughts related to the loss, as well as times of confronting stressors, such as sharing emotions with loved ones (Humphrey, 2009). Both avoidance and confrontation are considered routine and essential to loss orientation processes (Humphrey, 2009).

Although loss orientation dominates the early part of the DPM grief process, restoration orientation focuses on dealing with changes or secondary stressors that result from loss

(Humphrey, 2009; Stroebe & Schut, 1999). This includes adjusting to stressors that result from the death of a loved one such as revising one’s identity, adapting new family roles, learning new skills, revising plans for the future, and dealing with loneliness (Humphrey, 2009). Similar to loss orientation, both avoiding and confronting are considered natural parts of the restoration orientation process (Humphrey, 2009).

The DPM is set apart from other grief models in that it incorporates a dynamic back-and- forth coping process known as oscillation (Stroebe & Schut, 1999). Oscillation naturally occurs as the bereaved individual shifts between loss orientation and restoration orientation processes and includes both avoiding and confronting specific stressors (Humphrey, 2009; Stroebe &

Schut, 2010). Stroebe and Schut (1999) suggest that oscillation is necessary for optimal adjustment over time. Without oscillation, problems can occur. Complete avoidance of loss orientation signifies a continual denial of the reality of the loss (Humphrey, 2009). A lack of attention to the restoration orientation indicates a denial of the changes that occur as a result of the loss (Humphrey, 2009).

The DPM advances previous models of grief coping by attempting to provide a framework for grieving clients that allows for individuals to move between loss and restoration orientation based on their unique needs (Carr, 2010). Stroebe and Schut (1999) designed the

DPM to account for the grief processing differences between males and females and individuals from various cultural backgrounds. Although this model expands on the individualist process of grieving, it is not without some critiques. Stroebe and Schut (2016) have recently incorporated the concept of overload into the DPM framework. Overload occurs when the grieving individual perceives they have more to deal with than they can manage at a given time (Stroebe & Schut,

2016). Overload can lead to additional feelings of distress, exhaustion, and anxiety (Stroebe &

Schut, 2016). Future research related to the DPM needs to explore specific stressors related to overload (Stroebe & Schut, 2016). Since the introduction of the DPM, other ideas of grieving have developed, specifically adaptive grieving styles.

Adaptive Grieving Styles

The adaptive grieving styles are reflections of an individual’s unique use of cognitive, behavioral, and affective strategies to cope with loss (Martin & Doka, 2000). Using Martin and

Doka’s grief pattern inventory, researchers sought to determine an individual’s grieving style, which is dependent on how a person experiences and expresses grief, their personality, and their culture (Markin & Doka, 2000; Markin & Doka, 2011). Integrating grief, coping, and gender,

Martin and Doka (2011) developed a model of adaptive grieving styles that fall on a continuum ranging from intuitive to instrumental.

Intuitive grievers, or heart grievers, spend most of their energy on affective grieving and less on cognitive thinking (Martin & Doka, 2011). These individuals tend to outwardly express painful feelings by either crying or openly talking about their feelings (Doughty, 2009; Martin &

Doka, 2011). Intuitive grievers tend to be characterized by extreme sadness and continue to have strong emotions for a long period of time following the loss (Doughty, 2009). It is important to allow these types of grievers time for personal expression and opportunities to connect with others who have had similar experiences (Doughty, 2009).

On the other end of the continuum are instrumental grievers, also known as head grievers

(Martin & Doka, 2011). These individuals grieve in a more cognitive way, as opposed to affective. Instrumental grievers are less likely to show emotions and may claim they cannot remember the last time they cried (Doughty, 2009). Grieving is an intellectual experience and often these individuals would rather discuss problems rather than feelings (Martin & Doka,

2011). In conversations, instrumental grievers are more likely to discuss problems and solutions that arise from the loss, such as financial concerns or having to take on new responsibilities

(Doughty, 2009). Instead of sharing feelings, these individuals may process their grief by constructing memorials or by becoming involved in activities that were valuable to the deceased

(Markin & Doka, 2000).

Because Martin and Doka (2011) place the grieving styles on a continuum, there is also a blended style of grieving, or head and heart grievers. It is common for individuals to experience and express grief using both cognitive and affective styles, typically with one style more dominant than the other (Doughty, 2009). Finally, dissonance grievers, or head versus heart grievers, attempt to use an adaptive grieving style other than their natural grieving style (Martin

& Doka, 2011). Dissonance grievers commonly believe their natural adaptive grieving style is undesirable and attempt to adopt another more attractive or desirable style (Doughty et al.,

2011). In doing so, the bereaved individual may become “stuck” or unable to successfully process their grief (Doughty et al., 2011). Although adaptive grieving styles have been recognized within the field of thanatology, there is little empirical evidence to support or expand the concept (Martin & Doka, 2011).

Other Therapies

Other contemporary counseling therapies, such as cognitive behavioral theory (CBT) and constructivism may be useful to help clients process and manage their grief related to loss

(Humphrey, 2009). When working with clients using CBT, focus is placed on the connection between what people think, how they feel, and how they respond or behave as a result of stressful events in life, certainly including death or loss (Kosminsky, 2017). Humphrey (2009) adds to the definition of modern CBT as encouraging the modification of irrational or maladaptive cognitions, beliefs, and actions that limit a person’s ability to cope with loss. This is accomplished by encouraging client self-monitoring; identifying both appropriate and maladaptive thoughts, emotions, or behaviors; and evaluating their validity. Often using a story,

CBT in grief therapy involves encouraging clients to confront their new reality and expand on implications of the present and future, changing unhelpful negative thoughts and altering maladaptive behaviors of coping (Shear, Boelen, & Neimeyer, 2011).

Constructivist theory focuses on meaning making, a person’s beliefs about reality and truth (Humphrey, 2009). O’Connor (2002) defines meaning making as the discovery or creation of the significance of an event from both a cognitive and emotional perspective. Constructivist theory within bereavement involves an active effort to reconstruct or reaffirm meaning when responding to loss through three activities including: sense making, benefit finding, and identity change (Gilles & Neimeyer, 2006). Benefit finding involves an individual’s ability to find some reason for or lesson from the loss, a task most difficult for individuals who have experienced a traumatic or violent loss (Gilles & Neimeyer, 2006; Neimeyer, 2010). Benefit finding is simply the ability to indirectly find benefits from the loss, often in the form of life lessons (Neimeyer,

2010). Gilles & Neimeyer (2006) propose that as individuals reconstruct meaning to significant life events, they in turn reconstruct themselves, a process comparable to identity change.

Recommendations for Counselor Educators to Integrate Grief Training into Counselor

Education Curricula

It is clear there is a wide variety of methods and models for counselors to choose from when assisting clients who experience grief. However, a lack of grief standards allows every individual counselor preparation program to decide what theories and models related to grief counseling to include, if any. Counselor educators are in the position to advocate for curricular standards but also to ensure student competency by incorporating grief throughout the curriculum. The CACREP standards (2016) outline core content areas with specific standards that are required for all counselors in training. In the following paragraphs recommendations for incorporating grief and loss into some of these core counselor education curricular content areas are suggested.

CACREP Standards and Grief Training

Professional Counseling Orientation and Ethical Practice

In the Professional Counseling Orientation and Ethical Practice content area, Standards

II.F.1.k and I.F.1.l allow for the incorporation of grief and loss content into the curriculum.

Incorporating Standard II.F.1.k, or strategies for personal and professional self-evaluation and implications for practice (CACREP, 2016), could include having counselors-in-training evaluate their competency or emotions associated with working with clients of grief. Following a self- evaluation, Standard II.F.1.l, self-care strategies appropriate to the counselor role (CACREP,

2016) become necessary. Using grief and loss as the example, discussions can focus on maintaining professional and ethical boundaries and self-care when topics arise that create unexpected emotions for the counselor.

Social and Cultural Diversity

The Social and Cultural Diversity core content provides several opportunities to incorporate grief and loss. Standard II.F.2.d, the impact of heritage, attitudes, beliefs, understandings, and acculturative experiences on an individual’s views of others (CACREP,

2016), provides the opportunity to address how experiences related to grief are impacted by society, potentially by examining Western and non-Western cultural influences (Doughty Horn,

Crews, & Harrawood, 2013). Standard II.F.2.f, understanding help-seeking behaviors of diverse clients (CACREP, 2016), can also be connected to grief and loss. Because the term “grief” was developed as part of the Western concept of mental health and illness (Klass & Chow, 2011), it is valuable to explore how diverse cultural individuals may present an understanding of or symptoms related to grief and loss, with a focus on Eastern cultures as well. Doughty Horn et al.

(2013) suggest having counselors in training attend various grieving rituals—this can not only

29 reduce biases toward how various cultures move through grief but also attend to unacknowledged or unresolved losses in a culturally responsive manner.

Human Growth and Development

Within the Human Growth and Development content area, Standard II.F.3.g examines the effects of crises, disasters, and trauma on diverse individuals across the lifespan (CACREP,

2016), providing an opportunity to incorporate non-death grief and loss into the curriculum content. Ober et al. (2012) found counselors-in-training would benefit from increased professional development related to theories and crisis interventions for clients experiencing grief. Doughty Horn et al. (2013) suggest having counselors-in-training create a lifespan timeline of losses. The goal of this exercise is to have participants acknowledge that any significant change in life has elements of loss (Doughty Horn et al., 2013).

Career Development

A career development course is not often associated with grief, however counselors should be aware of and prepared to work with individuals who are dealing with loss related to changing or losing one’s job. Job loss can result in change to or loss of identity, financial security, and self-respect, which affects not only the worker but the entire family network

(Walsch, 2009). Job loss not only potentially creates higher levels of distress, depression, and anxiety among individuals, on a societal level unemployment precipitates poverty (Thompson,

Dahling, Chin, Melloy, 2017). Grief could be incorporated into career development courses as a way to recognize clients who may be dealing with job loss, and the most effective ways to intervene could be developed in a social justice manner (Doughty Horn et al., 2013).

Group Counseling

Group counseling and group work for counselors-in-training provides another opportunity to incorporate grief and loss examples into the curriculum. Group work has been

30 underutilized with individuals experiencing grief, yet research shows that participation in bereavement groups can be more effective than individual counseling (Knight & Gitterman,

2014). Additionally, throughout the group process, counselors can conceptualize group members from various traditional and contemporary grief theories and models (Doughty Horn et al.,

2013). CACREP (2016) Standards II.F.6.f and II.F.6.g require that counselors-in-training be prepared to facilitate groups in a variety of settings in addition to being knowledgeable of various ethical and culturally relevant strategies for implementation. Discussing grief in a group setting allows the counselor to facilitate a culture that is honest and open while also promoting cohesiveness and intimacy among members (Knight & Gitterman, 2014).

Multicultural and Social Justice Counseling Competencies

The United States is increasingly a diverse nation of many races, ethnicities, and cultures, which in turn indicates a need for healthcare professionals, including counselors, to become culturally competent while providing care (Bougere, 2008). This includes services related to grief and loss. Although grief and loss occur in all cultures, specific beliefs and practices vary depending on the individual’s cultural background (Bougere, 2008). Healthcare providers who fail to understand or are insensitive to the cultural and ethnic beliefs or grieving process of an individual are seen as ignorant, rude, or callous (Nishimoto & Foley, 2001). Additionally, an inability to provide sensitive care that allows for specific culture-related rituals to be followed can cause the client to experience unresolved loss (Hardy-Bougere, 2008).

When working with grieving clients, counselors and all healthcare professionals must evaluate and have an awareness of their own multicultural background as well as their personal beliefs and values related to grief and loss (Fiorelli & Jenkins, 2012). It is vital to examine how those beliefs and values may impact the relationship with the grieving individual. Culturally competent helping professionals are not only knowledgeable of their own beliefs, they respect

31 the grieving individual’s culture and spirituality by gaining knowledge, establishing rapport, and expressing genuineness and empathy (Fiorelli & Jenkins, 2012). Healthcare professionals working with grieving clients should avoid blanket generalizations; instead an assessment of cultural expressions and behaviors can be used to develop a culturally appropriate treatment plan

(Bougere, 2008).

It is the responsibility of healthcare providers, including professional counselors, to provide culturally sensitive care in terms of demeanor, attitude, and environment (Hardy-

Bougere, 2008). Healthcare professionals need to be aware that individuals who experience multiple losses often grieve for longer periods of time than those who have experienced a single loss, often grieving individual losses separately (Mercer & Evans, 2006). Other multi-layered cultural factors that impact the grieving process include a desire to protect family members from the pain, trauma-related responsibilities such as caring for the children, medical complications, or involvement in the justice system (Mercer & Evans, 2006). Finally, health professionals must consider of how factors such as gender, education, and socioeconomic status influence both the grief process and outcomes within the client’s culture (Granek & Peleg-Sagy, 2015).

The Multicultural and Social Justice Counseling Competencies (MSJCC) provides counselor educators another opportunity to explore grief awareness, skills, and competence through the lens of privilege and marginalization (Ratts, Singh, Butler, Nassar-McMillan, &

Rafferty, 2016). The MSJCC is a framework to explore counselor self-awareness, client worldview, the counseling relationship, and advocacy interventions while also considering both the counselor’s and client’s identities of privilege and marginalization (Ratts et al., 2016).

Further, the MSJCC aims to promote multiculturalism and social justice throughout the

32 counseling process by recognizing the effects of oppression and through the development of advocacy and action plans (Ratts et al., 2016).

ACA Advocacy Competencies

The CACREP standards framework provides space for the infusion of grief and loss into the curriculum, however without specific mention of grief and loss, the topic is not standardized among learning communities. In 2003, the American Counseling Association (ACA) adopted the

Advocacy Competencies, which provided professionals in the counseling field with guidelines on how to advocate on various levels (Toporek, Lewis, & Crethar, 2009). This chapter suggests using the ACA Advocacy Competencies (2003) as a framework because counselor educators are encouraged to advocate for grief and loss competencies on the three levels—client/student, school/community, and the public arena—by breaking down the levels into the six domains that make up the paradigm. On the client/student level, empowerment and advocacy are addressed while for the school/community level, both collaboration and advocacy are discussed. Next, considerations are made for working within the public arena and social/political advocacy. On each level, recommendations for counselor educators acting with and on behalf of students are provided.

Client/Student Level

This level focuses on the domains of student empowerment and advocacy while counselor educators advocate on behalf of and with students (Ratts, DeKruyf, & Chen-Hayes,

2007). To increase empowerment, counselor educators advocate on behalf of students by ensuring opportunities for counselors-in-training to explore their own grief and techniques for responding to grief (Horn, Crews, & Harrawood, 2013). Additionally counselor educators empower students while equally advocating for clients by encouraging counselors-in-training to

33 explore the impact of culture, experiences, personality, and expressions of grief via both didactic and experiential settings (Horn et al., 2013).

The goal for counselor educators acting with students is to promote the identification of barriers, including environmental, socio-political, and systemic, as well as strategies and resources by which to respond (Toporek et al., 2009). Because counselor educators themselves lack training related to grief counseling, counselor educators should take every opportunity to educate peers (Horn et al., 2013). It is valuable to use the language of loss, because it can be argued that almost all clients are dealing with issues of loss (Horn et al., 2013). Counselor educators should also stay abreast with current literature related to grief and loss and participate in available continuing education seminars or workshops (Horn et al., 2013).

School/Community Level

This domain calls for counselor educators to work either individually or with a larger group as allies to promote wider systemic change (Ratts et al., 2007). Often using data or personal insights from those affected most, counselor educators act on behalf of and with individuals to change the status quo (Ratts et al., 2007; Toporek, Lewis, & Crethar, 2009).

Counselor educators can advocate on behalf of counselors-in-training, veteran counselors, and clients by continuing grief training research within counselor preparation programs. This includes research investigating current training trends as well as the benefits and challenges of formal grief training as a way to advocate for CACREP standards (Horn et al., 2013).

Additionally, counselor educators can act on behalf of others by collaborating with other counselor educators to ensure grief topics are discussed within various relevant courses.

At the community level, counselor educators can act with other professionals as collaborators to increase understanding of grief and loss within the community. This might include identifying environmental factors that prevent individuals from receiving services that

34 aid the grieving process (Murray & Crowe, 2016). Additionally, counselor educators can collaborate with local schools and family agencies to provide possible resources, provide basic training to meet the needs of clients, and identify areas within counselor training that need improvement (Murray & Crowe, 2016; Ratts et al., 2007). Counselor educators can invoke change within communities and increase grief awareness, competence, and resources by finding disparities among populations (Ratts et al., 2007). This is completed by providing stakeholders with evidence as leverage to create change (Ratts et al., 2007).

Public Arena Level

There are two parts to the public arena paradigm, public information and social/political advocacy (ACA, 2003). Public information involves ensuring the community is informed of the impacts of grief and available resources by collaborating with other pertinent community members (Ratts et al., 2007). This can be accomplished by working with community agencies to ensure access to resources, particularly following a loss of any kind. This is already occurring.

Ober et al. (2012) reports about potential legislation that would allow for Medicare reimbursement for counselors. This would significantly increase access for all counseling services, including clients experiencing grief and loss.

Additionally, counselor educators advocate on behalf of the public by encouraging the inclusion of CACREP grief standards, which will ensure training becomes a requirement for all future counselors. Going beyond the CACREP standards and counselors-in-training curriculum, this advocacy domain involves ensuring the public is aware of information and resources related to grief and loss through various multimedia sources. The counselor ally may have to create and disseminate information to the public (Snow, 2013). This level requires more than daily advocacy at the office level; rather advocacy occurs at the city, state, and national level by taking on more of a leadership position (Snow, 2013).

This section provided a comprehensive definition of grief and loss, with examples of how every individual is impacted by this phenomenon. A wide variety of theories and models of grief are available to counselors-in-training, however there is a lack of research describing to what degree grief and loss topics are addressed within counselor preparation programs. Counselor educators are in the position to advocate for research and professional development of grief and loss within preparation programs. As advocates, counselor educators act on behalf of all future clients by ensuring professional counselors are competent to recognize and provide services to clients experiencing grief. Counselor educators act with counselors-in-training to increase their professional knowledge and explore the personal impact of grief and loss. As advocates for grief and loss training within programs, counselor educators serve as role models to counselors-in- training on the importance and value of advocacy in various settings.

Conclusion

In conclusion, grief and loss are phenomena that impact everyone at some point in their life. Grief training among counselors is imperative to meet the needs of clients experiencing loss.

Although there are many forms of grief counseling, additional research and advocacy is needed to ensure consistency among training programs.

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CHAPTER 3

GRIEF COUNSELING: AN INVESTIGATION OF PERCEIVED COUNSELOR

COMPETENCE

Introduction and Rationale for Study

The experience of grief and loss is part of human nature, however there is little research describing how counselors and other helping professionals are trained to provide support and services to individuals who experience this phenomenon (Hannon & Hunt, 2015; Ober, Granello,

& Wheaton, 2012). Additionally, previous research findings show counselors often report limited competency when working with grieving clients (Cicchetti, McArthur, Szirony, & Blum, 2016;

Ober et al., 2012). Most people relate grief and loss with death (Merriam-Webster, 2017), however grief includes any significant loss that results in a change within an individual (Worden,

2002; Zisook and Kendler, 2007) including experiences such as job loss (Papa & Maitoza, 2013;

Ramsey, 2014), divorce (Parker & Australian Early Childhood Association, 2003), infertility

(Lee et al., 2010), loss of limb (Spiess, McLemore, Zinyemba, Ortiz, & Meyr, 2014), or loss of home (Herrmann, 2011), just to mention a few.

Not only are professional counselors working with clients experiencing loss, school counselors are also frequently tasked with responding to children who deal with a range of grief and loss experiences, from death to separation or divorce, incarceration, loss of pet, and relocation (Guidry, Simpson, Test, & Bloomfield, 2013). Although often considered a private or family issue, grief can impact students while they attend school (Quinn-Lee, 2014). Research indicates that children who experience grief and loss may experience difficulty sleeping and

47 eating, irritability, or feeling worried when not in the presence of family members (Schonfeld &

Quackenbush, 2012). Dyregrov, Dyregrov, Endsjø, and Idsoe (2015) report students who experience loss and trauma often experience a drop in grades, while odds of dropping out of school and other risky behaviors such as using drugs and alcohol increase. Given this information, school professionals are in the perfect position to offer students and family members supportive services during this difficult time (Schonfeld & Quackenbush, 2012).

However, the Council for the Accreditation of Counseling and Related Educational

Programs (CACREP), which sets curriculum guidelines and standards for all counseling preparation programs, has no training requirements or specific standards related to grief and loss

(CACREP, 2016). This implies that counselors are potentially attempting to help clients in ways in which they have had no formal training or coursework, often leaving the counselor uncomfortable and inexperienced (Horn, Crews, & Harrowood, 2013; Ober et al., 2012).

Although there are no specific standards targeting grief and loss, there are some implications found within the CACREP Human Growth and Development standards. Specifically II.3.a and

II.3.g require curricula to address “theories of development across the lifespan” and “crisis, disasters, and trauma…. across the lifespan” (CACREP, 2016). Curricula that address lifespan, crisis, and trauma may include topics related to death, however without specific mention in the standards, content training related to grief and loss is not guaranteed (Horn et al., 2013).

Additionally, the CACREP Social and Cultural Diversity standards II.2.c and II.2.d demand counselor preparation programs ensure counselors are knowledgeable of the multicultural counseling competencies as well as “the impact of heritage, attitudes, beliefs, understandings, and acculturative experiences on an individual’s views of others” (CACREP, 2016). Again, due

48 to a lack of specific mention of grief and loss, content on this topic is not mandatory in counselor education. Therefore, a closer examination of grief education and training is warranted.

Grief Education and Training for Counselors

Grief training, for those in helping professions, actually began in the mid-twentieth century as the concept of mental health was forming (Klass & Chow, 2011; Parkes, 2011).

Traditional grief and loss models were based on the work of Sigmund Freud, in which individuals must completely detach by following sequenced, universal phases, stages, and tasks, the completion of which supposedly meant individuals were finished grieving (Doughty, 2009).

This one-size-fits-all approach includes Bowlby’s Attachment Theory, Kubler Ross’s Five

Stages of Grief, and Worden’s Tasks of Grief (Neimeyer, 2001). Recently contemporary models of grief have transitioned away from the positivist view to focus more on the unique experiences of individuals while also considering their environmental and social contexts (Davies, 2004).

Contemporary models of grief and loss include Stroebe and Schut’s (1991) Dual Process Model,

Martin and Doka’s (2002) Adaptive Grieving Styles, and the use of cognitive behavior and constructivist theories (Humphrey, 2009; Kosminsky, 2017).

However, there is limited research related to grief and loss education or the specific content of grief curricula within the field of counseling (Doughty Horn, Crews, & Harrawood,

2013; Ober et al., 2012). Low (2004) completed a dissertation that examined the content and delivery methods of grief curricula within School Counseling CACREP Programs. CACREP liaison respondents (n=79) indicated that 60% (n=46) of programs offered some type of grief and loss training. Of the 46 programs offering specific training, 23 programs offered students a full elective course and 22 programs indicated grief and loss training occurred through a module within another required course. Among the programs surveyed that included grief education and

49 training, Low found course curriculum content to be inconsistent. Four curriculum content areas—1) developmental responses to loss, 2) areas of childhood loss and grief including death and secondary losses, 3) sign and indicators of grief and 4) crisis intervention—were found to be included in at least 75% of programs that included grief training (Low, 2004).

Low (2004) expressed great concern over the number of programs, 40% (n=32), that offered no form of education or training related to grief to pre-service counselors. Reported reasons for not incorporating grief and loss into the curriculum included 1) lack of room within the curriculum, 2) lack of CACREP requirement, 3) lack of willing/able staff, 4) financial limitations, and 5) curriculum offered in another department. Not only is this research over a decade old, CACREP has added over 100 additional school counseling preparation programs since Low’s (2004) study. Although there is limited research examining the specific content of grief education and training, a few research studies have examined counselor’s self-perceived competency to assess and work with grieving clients.

Grief Competency

To help counselors be effective with clients experiencing grief, Charkow (2000) developed a set of Grief Counseling Competencies (Ober et al., 2012). Using a delphi technique and factor analysis to identify relevant personality characteristics, attitudes, knowledge, and skills necessary for counselors working with grieving clients, three rounds of surveys were e- mailed to participants (Charkow, 2000). All participants held master’s degrees or higher in human services, had at least five years of counseling in the area of grief, and identified as either educator, clinician, or researcher (Charkow, 2000).

In the first survey, 34 individuals identified as experts in counseling grieving families responded to an e-mailed demographic questionnaire (Charkow, 2000). In the second e-mail, 26

50 of the initial 34 participants responded to opened-ended questions asking participants to identify potential grief curriculum components as well as characteristics and competencies that a counselor should possess when working with grieving clients (Charkow, 2000). Additionally, in this round of e-mails, participants were provided with a list of 111 characteristics and competencies that were developed by the author based on previous literature and experiences and asked to rate importance on a scale of one to five (Charkow, 2000). The characteristics and competencies were classified by theme as follows: 1) personal characteristics and attitudes, 2) conceptual skills, 3) specific knowledge bases, 4) assessment skills, 5) treatment skills, and 6) professional skills (Charkow, 2000).

Next, Charkow (2000) compiled the results, deleted items that respondents scored as unimportant, added suggestions made by participants, and then returned the survey to the 26 respondents asking them to re-rate each item’s importance. Additionally, participants were asked to rate the competency themes. Finally, participants were asked how satisfactorily the items covered the needed characteristics and competencies for effective grief counseling (Charkow,

2000). Fifteen participants, of the initial 26, responded to the third e-mail. Ten (71.4%) participants responded that items adequately covered the necessary characteristics and competencies, and four (28.6%) participants said they completely addressed the necessary characteristics and competencies (Charkow, 2000). As a result of the study, Charkow (2000) developed the “Family-based Death and Grief-Related Counseling Competencies.” Using these competencies, Charkow (2002) created the Death Counseling Survey to measure self-perceived competencies for working with individuals experiencing grief. The 48-item survey consisted of two parts, personal competencies and skills and knowledge competencies, and was divided into

51 four subheadings: 1) personal competencies, 2) conceptual skills and knowledge, 3) assessment skills, and 4) treatment skills (Charkow, 2002; Cicchetti, 2010).

As a result, the Death Counseling Survey was piloted, refined, and then used in

Charkow’s (2002) dissertation as the instrument. The Death Counseling Survey was determined to have a Cronbach alpha of .87, indicating it as a reliable instrument (Charkow, 2002). Given the use of experts to develop the survey, content validity is supported (Charkow, 2002). Finally, construct validity was indicated after a moderate to positive correlation, r=.73, was found when compared to Bugen’s (1980–1981) “coping with others” subscale on the Bugen’s Coping with

Death Scale (Charkow, 2002).

As a result of the study, Charkow (2002) found that of the 153 professional counselor participants, 89% of respondents indicated high levels of self-perceived personal competencies when working with grieving clients. Additionally, counselors rated themselves as highly confident in the treatment skills subscale. However, participants perceived themselves as having limited competency in grief-related conceptual knowledge and skills and assessment skills

(Charkow, 2002). Additional findings from the study revealed that a majority of participants did not take a grief-related courses in their graduate training, however 98% reported having worked with at least one client experiencing grief (Charkow, 2002).

Ten years later, Ober et al. (2012) examined grief counseling training and competency in

369 licensed professional counselors from one Midwestern state using the Death Counseling

Survey (Charkow, 2002), The Texas Revised Inventory of Grief (TRIG; Faschingbauer, DeVaul,

& Zisook, 1987), and the Grief Counseling Experience and Training Survey (GCETS; Ober,

2007). Ober et al. (2002) found that 54.8% (n=190) of respondents indicated they had not completed any courses related to grief. However, a majority (69.4%, n=247) of participants

52 reported having completed some type of professional development related to grief. Results from this study were similar to Charkow’s (2002) findings, in that participants rated themselves highest on Personal Competencies and lowest on the conceptual skills and knowledge subscale.

This indicates participants positively perceived their self-awareness and self-care skills when working with clients experiencing grief but lack specific conceptual knowledge and skills, such as theories, definitions, and coping skills and interventions (Ober et al., 2012). Ober et al. (2012) highlights the importance of understanding Personal Competencies cannot take the place of specific grief counseling skills such as assessment of unresolved loss (Assessment Skills) and developing appropriate treatment plans to resolve grief (Treatment skills).

Ober et al. (2012) also examined what demographic variables best predicted grief counseling competence. Using regression analysis, Ober et al. (2012) found that having had specific training and experience in grief counseling was the strongest predictor for grief competence. Additionally, gender and age were found to be significant predictor variables to grief counseling competence. Specifically, women scored higher on personal competencies, assessment skills, and treatment skills than men. Also, younger counselors indicated higher competency levels on the conceptual skills and knowledge subscale (Ober et al., 2012).

A few years later, the Death Counseling Survey (2002) was modified and renamed the

Grief Counseling Competency Scale (Cicchetti, 2010). Items that were specific to death and bereavement were either removed or modified. The new instrument is a 46-item questionnaire that uses Likert-scale responses to assess an individual’s personal competencies, conceptual skills and knowledge, assessment skills, and treatment skills as related to interventions and skills of counselors working with clients with issues related to grief and loss (Cicchetti, 2010; Wood,

2016). The Grief Counseling Competency Scale was also found reliable, with a Cronbach alpha

53 of α =.79 on the personal competency subscale and an alpha of α = .97 on the skills and knowledge subscale (Cicchetti, 2010; Wood, 2016). Additionally, Cicchetti (2010) reported a

Cronbach alpha for each subscale within the skills and knowledge subscale: conceptual skills and knowledge subscale (α = .52), assessment skills subscale (α = .60), and treatment skills subscale

(α = .60).

Using the Grief and Counseling Competency Scale, Cicchetti et al. (2016) surveyed 93 rehabilitation counselors from various backgrounds and clinical settings. The majority of participants indicated that no courses within their counselor preparation program were available related to grief theories (71.3%) or grief intervention (80.8%) (Cicchetti et al., 2016). Eighty- three participants (89.3%) reported having had no courses in grief theories, and 86 participants

(92.1%) reported taking no courses related to grief interventions. Overall results of the study indicated participants perceived themselves as having limited competency as measured by the personal competence subscale, with most responses falling between “this somewhat describes me” and “this describes me.” However, on all three other subscales, conceptual skills and knowledge, assessment skills, and treatment skills, scores were low, ranging from 1.8 to 2.9 on the 5-point Likert scale. These results are no surprise given that 98% of the participants from the study indicated the need for additional training related to grief counseling (Cicchetti et al., 2016).

Similar to Ober et al. (2012), Cicchetti et al. (2016) sought to determine if specific demographic variables contributed to self-perceived grief competence. Results from (Cicchetti et al., 2016) indicated that participants who reported a presence of or a history of a disability had higher levels of self-perceived personal competence, assessment skills, and treatment skills. In contrast to Ober et al. (2012), no significant relationship was found between age and self- perceived grief competence (Cicchetti et al., 2016). Additionally, contrary to Ober et al. (2012),

Cicchetti et al. (2016) found no significant relationship was found between gender and self- perceived grief competence.

Also using the Grief and Counseling Competency Scale, Wood (2016) completed a dissertation research study examining 153 CACREP master’s-level counseling students enrolled in either practicum or internship courses from around the nation and their self-perceived grief training competency and skills. Ninety-nine participants (66%) reported their school offered no courses in grief theories and 95 participants (62.91%) reported their school offered no courses on grief interventions. One hundred twenty-two participants (80.26) had not taken any courses in grief theories and 113 had not taken a course in grief interventions. In this study, internal consistency was also established for the Grief Counseling Competency Scale by establishing the

Cronbach’s alpha for each section and subscale (Wood, 2016). The alpha level for the personal competency section was .69; the three subscales had the following Cronbach alphas: conceptual skills and knowledge, α =.94, assessment skills, a=.85, and treatment skills, α =.93. The alpha for the overall section of skills and knowledge, which contains the three subscales, was α = .97. All of the Cronbach alphas indicated relative high internal consistency (Wood, 2016). Additional results indicated no effect on perceived personal competence given demographic gender, race, and ethnicity. However, there was a significance found for age and self-perceived personal competence. Of greater value are findings that indicated a positive relationship between having taken a course in grief theories or interventions and competency on the conceptual skills and knowledge, assessment skills, and treatment skills subscales (Wood, 2016).

55 difference between counselors’ self-perceived competency to assess and work with grieving clients based on whether or not they have taken a dedicated grief course as opposed to grief training incorporated throughout the counselor preparation training.

Research Questions

The primary objective of this study is to investigate potential differences in grief counseling skills between counselors who have received grief counseling training and counselors who have received no grief counseling training. To appropriately control for the potential confounding variable of the age of the counselor, age will be incorporated into the analysis as a control variable. Therefore, the primary research questions are as follow:

RQ1.1: Is there any difference in self-perceived Grief Counseling Competency mean

scores between counselors who have received grief counseling training and counselors

who have received no grief counseling training, when controlling for the age of the

counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived Grief

Counseling Competency mean scores between counselors who have received grief

counseling training and counselors who have received no grief counseling training, when

controlling for the age of the counselors.

RQ1.2: Is there a difference in self-perceived Personal Grief Counseling Competency

mean scores between counselors who have received grief counseling training and

counselors who have received no grief counseling training, when controlling for the age

of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived

Personal Grief Counseling Competency mean scores between counselors who have

received grief counseling training and counselors who have received no grief counseling

training, when controlling for the age of the counselors.

RQ1.3: Is there a difference in self-perceived Skills and Knowledge Grief Counseling

Competency mean scores between counselors who have received grief counseling

training and counselors who have received no grief counseling training, when controlling

for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in Skills and Knowledge

Grief Counseling Competency mean scores between counselors who have received grief

counseling training and counselors who have received no grief counseling training, when

controlling for the age of the counselors.

A secondary objective of this study is to investigate potential differences in grief counseling skills between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, once again, after controlling for the age of the counselors. Therefore, the secondary research questions are as follow:

RQ2.1: Is there any difference in self-perceived Grief Counseling Competency mean

scores between counselors who have received grief counseling training in a designated

grief course and counselors who have received grief counseling training incorporated into

other required content courses, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived Grief

Counseling Competency mean scores between counselors who have received grief

counseling training in a dedicated grief course and counselors who have received grief

57 counseling training incorporated into required content courses, when controlling for the age of the counselors.

RQ2.2: Is there a difference in self-perceived Personal Grief Counseling Competency mean scores between counselors who have received grief counseling training in a designated grief course and counselors who have received grief counseling training incorporated into other required content courses, when controlling for the age of the counselors?

Null Hypothesis: There is no statistically significant difference in self-perceived

RQ2.3: Is there a difference in self-perceived Skills and Knowledge Grief Counseling

Method

Procedure and Sample

The population for this research study was comprised of members of the American

Mental Health Counselors Association (AMHCA), who had been licensed clinical mental counselors for less than five years. The ACA recognizes the AMHCA as a specific interest-based division for mental health counselors. Focusing on professional identity, this professional membership organization aims to ensure client access to quality mental health services. Clinical membership requires a master’s degree in counseling or another closely related field and adherence to the AMHCA’s National Standards for Clinical Practice. This population was chosen not only for its recognition within ACA but also for its ability to access a wide variety of licensed mental health counselors throughout the nation.

To determine the sample size needed to complete this study without committing a Type II error, a power analysis is used (Ellis, 2010). A power analysis was conducted based on RQ1.1 using G*Power version 3.1.4 (Faul, Erdfelder, Buchner & Lang, 2009) to determine the necessary sample size for a MANOVA with two predictors (training experience and age) and two dependent variables (personal grief counseling competency and skills and knowledge grief counseling competency) using an alpha of .05, a power of .80, and a small effect size (f2 = .10;

Chow, Shao, & Wang, 2008). Based on this information, for a small effect size and an alpha level = 0.05, the minimum sample size needed to achieve an .80 power is 70 participants for this study. See Appendix for the G*Power output of the sample size calculation.

Research Design

A cross-sectional, nonexperimental quantitative research design was employed for this study. Rather than manipulating variables, a nonexperimental group comparison design was chosen because the goal of this research study is to determine licensed counselors’ level of self-

59 perceived grief counseling competency. The study examined if differences exist as a result of taking a dedicated grief course or having grief counseling training incorporated into other required courses by statistically comparing the mean scores from the Grief Counseling

Competency Survey, Parts I: Personal Competency and Part II: Skills and Knowledge (Johnson

& Christensen, 2013; Reio, 2016). A cross-sectional research design is used because rather than collecting longitudinal data for analysis, licensed mental health workers from around the country were surveyed to collect data from one point in time (Johnson & Christensen, 2013). Cross- sectional, nonexperimental studies have been used to examine counselor competency in several research studies (Cicchetti et al., 2016; Dodson, 2013; Graham, Carney, & Kluck, 2012; Ober et al., 2012). The chosen research design involved collecting data from three instruments, including a demographic survey to describe the characteristics of the sample population (Creswell, 2014), the Grief Counseling Competency Scale (GCCS; Cicchetti, 2010), and the Marlowe-Crowne

Social Desirability Scale-Form C (Reynolds, 1982).

The purpose of using surveys within research is to summarize the trends, attitudes, or opinions of a population (Creswell, 2014). Because participants were located around the United

States, an online survey provided a means to access participants regardless of geographic location (Roberts & Allen, 2015; Tung-Zong & Voyles, 2013). In addition to being cost effective, online surveys provide participants flexibility to respond at a convenient time (Tung-

Zong & Vowles, 2013).

Variables

For RQs 1.1 and 2.1, the dependent variable was the combined portions of Part I of the

Grief Counseling Competency Scale, titled Personal Grief Counseling Competency, and Part II of the Grief Counseling Competency Scale, titled Skills and Knowledge Grief Counseling

Competency. For RQ1.2 and RQ2.2, the dependent variable was Part I of the Grief Counseling

Competency Scale. For RQ1.3 and RQ2.3, the dependent variable was Part II of the Grief

Counseling Scale.

The categorical independent variable for RQ 1.1, 1.2, and 1.3 was whether or not any grief counseling occurred during counselor preparation. Level 1 of the independent variable was a) yes, grief counseling training was part of the counselor preparation program; Level 2 of the independent variable was b) no, grief counseling training was not part of the counselor preparation program. The categorical independent variable for RQs 2.1, 2.2, and 2.3 was the two levels of grief counseling training rigor, a) have taken a dedicated grief counseling course, and b) have received grief counseling training integrated into another content area. The control variable for all RQs is the age of the participant. Age was selected as the control variable because Ober et al. (2012) and Wood (2016) found age to be a significant predictor variable of self-perceived grief counseling competency. The available response choices were a) 29 years old or younger, b)

30–39 years old, c) 40–49 years old, d) 50–59 years old, or e) 60 years or older.

Instrument

Demographics data sheet. Participants first responded to a demographics data sheet that the researcher developed. To establish the content validity of the demographic data sheet

(Johnson & Christensen, 2013), the researcher had three tenured counselor educators of diverse ethnicity and gender review the survey.

Information about each participant’s age and type of grief counseling training was collected. Other demographic was data collected, including geographic region, marital status, and sexual orientation. As previously mentioned, no significant relationship was found between grief counseling competence and gender (Ober et al., 2012; Wood, 2016) or between race and ethnicity and grief counseling competence (Cicchetti et al., 2016; Wood, 2016). However, demographics related to gender, race, and ethnicity was collected for comparison.

Grief Counseling Competency Survey. Additionally, with permission from the author, this study used a modified version of Cicchetti’s (2010) Grief Counseling Competency Survey, which was modified and renamed from Charkow’s (2002) Death Competency Survey (DCS).

The only modification made to the Grief Counseling Competency Scale for this study was the removal of the word “disability” from numbered questions 12, 14, 15, 23, 25, 30, 31, and 32. The

Grief Counseling Competency Survey is a 46-item questionnaire survey using a Likert-scale format to assess personal competencies, conceptual skills and knowledge, assessment skills, and treatment skills to work with clients experiencing issues related to grief and loss (Cicchetti,

2010; Wood, 2016). For each question, the respondent selected the number from the Likert scale of the Grief Counseling Competency Survey that most closely corresponded with the individual’s self-perceived competency. The available responses were 1 (this does not describe me), 2 (this barely describes me), 3 (this somewhat describes me), 4 (this describes me), and 5

(this describes me very well; Cicchetti, 2010).

The Grief Counseling Competency Survey consists of two parts. Part I is comprised of nine questions to assess personal competencies. Within Part II of the survey, skills and knowledge competencies are measured using three subscales as follows: assessment skills has nine questions, treatment skills has 19 questions, and conceptual skills and knowledge has nine questions (Cicchetti, 2010; Wood, 2016). Separate analyses were completed for Part I and Part II on the Grief Counseling Competency Scale. This is because the three subscales found under Part

II provide an overall score for Part II; the overall score was used for the statistical analyses. The goal of this research study was not to determine specific types of grief counseling competency but rather to determine if competency self-efficacy exists and if there is a difference in grief counseling competency self-efficacy due to type of grief training during the counselor

62 preparation program. If a significant difference is found, then future studies could examine the impact of the specific types of grief counseling competency from Part II.

Marlowe Crowne Social Desirability Scale, Form C. Finally, participants responded to the Marlowe Crowne Social Desirability Scale, Form C (M-C, Form C), consisting of 13 questions (Reynolds, 1982). The M-C, Form C was used to determine how responses to the Grief

Counseling Competency Survey were potentially influenced by social desirability.

Validity and Reliability

To establish content validity (Johnson & Christensen, 2013), the researcher had three tenured counselor educators of diverse ethnicity and gender review the demographic portion of the survey. The purpose of this process was to review the procedures, questions, and response options for clarity and comprehensiveness and to examine for potential concerns (Johnson &

Christensen, 2013). Feedback provided was taken into consideration, and adjustments were made as necessary.

The Grief Counseling Competency Scale (Cicchetti, 2010) was originally developed from the Death Counseling Scale (Charkow, 2002). Charkow (2002) found the Death Counseling

Scale to be a reliable instrument due to its Cronbach alpha (�) of .87. Specifically, the subscales indicated reliability as follows: Personal Competency Subscale had a Cronbach alpha � = .79, the Conceptual Skills and Knowledge Subscale had a Cronbach alpha � = .92, the Assessment

Skills had a Cronbach alpha � = .87, the Treatment Skills Subscale had a Cronbach alpha � =

.94, and the Professional Skills Subscale had a Cronbach alpha � = .83 (Charkow, 2002).

After modifications and a name change, Cicchetti et al. (2016) found the Grief

Counseling Competency Scale to also be reliable. Cicchetti et al. (2016) reported the Grief

Counseling Competency Scale to have a Cronbach alpha � = .79 on the Personal Competency

Subscale and a Cronbach alpha � = .97 for the Skills and Knowledge Subscale. However,

Cicchetti et al. (2016) reported lower reliability among the other three subscales: the Cronbach alpha for the Conceptual Skills and Knowledge Subscale was � = .52, the Assessment Skills

Subscale was � = .60, and the Treatment Skills Subscale was � = .60.

Finally, Wood (2016) reported the Grief Counseling Competency Scale as an internally consistent, reliable instrument after calculating the Cronbach alpha for Part I: Personal

Competency and Part II: Skills and Knowledge, as well as each of the subscales. The alpha for

Part I: Personal Competency was found to be � = .69. The alpha for Part II: Skills and

Knowledge was found to be � = .97. Within Part II, the three subscales had the following

Cronbach alphas, which indicated high internal consistency: for the Conceptual Skills and

Knowledge Subscale, the alpha was � = .94; for the Assessment Skills Subscale, the alpha was �

= .85; and for the Treatment Subscale, the alpha was � = .93 (Wood, 2016). Given this information, the Grief Counseling Competency Scale is deemed a reliable instrument. The final instrument, the Marlowe Crowne Social Desirability Scale–Form C, has a Kuder-Richardson-20 reliability of � = .76 (Reynolds, 1982) and therefore is considered reliable.

Procedures

After the University of Georgia’s Institutional Review Board approval of this study, recruitment began. Using the AMHCA online community forum, an invitation was posted using the “Recruitment Letter,” which included information about the study and a link to a Web-based platform, SurveyMonkey, to complete the survey. Accessible to all AMHCA members, the post described to participants content from the “Information Page.” The Information Page provided participants a detailed review of the nature of the study, participant’s role, informed consent information, potential benefits, and risks in participating. Additionally, both the researcher’s and

64 faculty advisor’s contact information was provided on the Information Page, in case participants had inquiries.

After clicking “I Agree,” participants were taken to another Web page to begin the demographic and content sections of the survey. Participants were able to withdraw from the study at any point, however submitted responses were kept as part of the data collection. After completing the survey, participants were taken to a final Web page with a statement of appreciation for participating in the study. E-mail addresses were not be connected to participant responses. The survey invitation and link was posted three times over a one month period.

The advantages of a Web-based survey include low cost and fast response rate but also allowing for topics to be addressed with anonymity (Sue & Ritter, 2007). Additionally, online research enables access to specialized populations while also ensuring a geographically diverse group of participants (Fielding, Blank, & Lee, 2017). The SurveyMonkey platform is an industry leader in online surveying, providing flexible question templates and real-time results

(SurveyMonkey, n.d.). Additionally, this platform incorporates SSL encryption for transmitting secure information, provides password-protected access, and allows for participant confidentiality (SurveyMonkey, n.d.).

Ethics

Before beginning the survey, all participants were provided information related to the purpose of the study, the participants role, and potential risks and benefits in participating.

Additionally, contact information of the research and faculty supervisor was provided should participants have questions or concerns. This information was provided on an “Information

Sheet” where participants were required to click “I Agree” before starting the online survey, as suggested by Mahon (2014). This provided participants with the same knowledge and information as participants in an offline survey (Roberts & Allen, 2015).

The ultimate goal of maintaining autonomy and limiting participants to a single response cannot be guaranteed in online research (Sue & Ritter, 2007). However, participant responses were not linked to any e-mail address. Additionally, results were reported in a format so that participants were not identifiable. The researcher also examined the IP addresses for each respondent to check for duplicates. Once the data was uploaded into SPSS 23 for Windows (IBM

Corp., Armonk, NY), IP addresses were deleted. Further, the researcher reviewed data sets for potential duplicates.

Participants were free to stop or withdraw from the study at any point. However, once submitted, no data was removed or deleted. There were no anticipated risks or discomforts associated with this survey, other than what would occur in day-to-day life events.

Results

The purpose of this study was to determine if there was a difference in self-perceived personal grief counseling competency and self-perceived skills and knowledge grief counseling competency (in terms of the two subscales of GCCS) 1) between counselors who have received grief counseling training and counselors who have received no grief counseling training (RQ1.1-

RQ1.3) and 2) between counselors who have received grief counseling training in a designated grief course and counselors who have received grief counseling training incorporated into other required content courses (RQ2.1-RQ2.3), when controlling for the age of the counselors. In the remainder of this chapter, the demographics of the participants are presented, followed by a summary of the GCCS and Marlowe Crowne Social Desirability Scale–Form C survey responses, and then an analysis of the results of the research questions.

Data Analysis Procedures

Data were imported into and analyzed by SPSS 23 for Windows (IBM Corp., Armonk,

NY). Only participants who 1) hold a professional certificate as a licensed professional

66 counselor, licensed clinical professional counselor, or a licensed mental health counselor in their state and 2) have held the professional certificate/licensure for five years or fewer in their career were included in the data analysis. Participants who did not answer the questions for GCCS (part

I or part II) were excluded from the data analysis.

Prior to further analyzing the data, the assumptions required for MANOVA were checked according to the guidelines put forth by Tabachnick and Fidell (1996) and Mertler and Reinhart

(2016). Given the assumptions for MANOVA were met, the assumptions for ANOVA were also met. The assumptions required for MANOVA are as follows:

1. The observations are independent (Independence of observations).

2. The dependent variables follow a multivariate normal distribution in each group

(Multivariate normality).

3. The covariance matrices for the dependent variable in each group are equal

(Homogeneity of covariance matrices).

The first assumption was met because the research used a sample of randomly selected participants (Independence of observations) (Mertler & Reinhart, 2016). The second assumption relates to multivariate normality. Initial screening for multivariate normality required the assessment for univariate normality (Mertler & Reinhart, 2016). Quantile-quantile (QQ) plots were used to assess univariate normality for each independent variable. A QQ plot is a probability plot for comparing two probability distributions by plotting their quantiles against each other. A point on the plot corresponds to one of the quantiles in the second distribution (y coordinate, normal distribution) plotted against the same quantile of the first distribution (x coordinate, respondent data). If the two distributions being compared are similar, the points in the QQ plot line will approximately fall on the y = x, the 45 degree line. Once the univariate

67 normality is established, a chi square QQ plot was examined to ensure multivariate normality of the data. The chi square QQ plot is examined based on the Mahalanobis distances for the observations by plotting the Mahalanobis distances versus the estimated quantiles for a sample size of n from a chi squared distribution with p degrees of freedom (p = # number of measures, in this study p=3 since there are 3 dependent variables). The multivariate normality assumption was met given the points lay near a straight line (Mertler & Reinhart, 2016). The third assumption, homogeneity of covariance matrices, was examined using the Box’s M test (Tabachnick &

Fidell, 1996). Tabachnick & Fidell (1996) suggested that the Box’s M test is highly sensitive; therefore, a p value < 0.001 was used to reject the null hypothesis of equal variance-covariance matrices.

Frequency tables were used to summarize the demographics of the participants and the survey responses of GCCS (Larson & Farber, 2009). The composite scores of self-perceived personal grief counseling competency and self-perceived skills and knowledge grief counseling competency were computed by summing the responses of the relevant items. Descriptive statistics of the scores of self-perceived personal grief counseling competency and self-perceived skills and knowledge grief counseling competency were computed.

Next, two MANOVAs and four ANOVAs were conducted for each set of RQs (RQ1.1,

RQ1.2, and RQ1.3 and RQ2.1, RQ 2.2, and RQ2.3). MANOVA was conducted for each of

RQ1.1 and RQ2.1, where the dependent variables were the two subscales of GCCS, self- perceived personal grief counseling competency and self-perceived skills and knowledge grief counseling competency. ANOVA was conducted for each of RQ1.2, RQ1.3, RQ2.2, and RQ2.3, where the dependent variable for RQ1.2 and RQ2.2 was self-perceived personal grief counseling

68 competency and the dependent variable for RQ1.3 and RQ2.3 was self-perceived skills and knowledge grief counseling competency.

Data Analysis Results

Demographics. 167 participants participated in the survey study. After excluding possible participants who 1) did not hold a professional certificate as a licensed professional counselor, licensed clinical professional counselor, or a licensed mental health counselor in their state, or 2) have not held the professional certificate/licensure for five years or fewer in their career, or 3) did not answer the questions for GCCS (part I or part II), the final sample size for the study was 90.

Table 1 shows the demographics of the 90 participants. Over half of the participants

(53.3%) were licensed professional counselors in their state. Nearly 40% of the participants

(37.8%) were 30–39 years old. The majority of the participants were female (88.9%) and heterosexual (90.0%). Nearly two-thirds of the participants were white (61.1%) and married

(63.3%). Slightly less than half of the participants (45.6%) were residing in the southern region.

About one-third of the participants (32.2%, N = 29) had completed postmaster’s grief training. For these 29 participants who had completed postmaster’s grief training, conference was the most common training (N = 19), followed by workshop (N = 17), and journal article reading (N = 13; Figure 1).

Nearly two-thirds of the participants (63.3%, N = 57) indicated that their counselor preparation master’s-level training included the topic of counseling clients who experience grief and loss. Furthermore, among these 57 participants, 13 (22.8%) had indicated that they had a dedicated grief course and 44 (77.2%) had grief counseling integrated in one or more of the required courses.

Table 1.

Demographics

N (%) Professional certificate Licensed professional counselor 48 (53.3) Licensed mental health counselor 16 (17.8) Licensed clinical professional counselor 3 (3.3) Other 23 (25.6) Age 29 years old or younger 19 (21.1) 30-39 years old 34 (37.8) 40-49 years old 17 (18.9) 50-59 years old 12 (13.3) 60 years old or older 8 (8.9) Gender Female 80 (88.9) Male 9 (10.0) Refused to answer 1 (1.1) Race White 55 (61.1) White, Hispanic 8 (8.9) White, Non-Hispanic 12 (13.3) Asian 1 (1.1) Asian-American 3 (3.3) Biracial 1 (1.1) Black/African-American, Non-Hispanic 7 (7.8) Jewish 1 (1.1) Latinx 1 (1.1) Refused to answer 1 (1.1) Sexuality Bisexual 1 (1.1) Gay or lesbian 1 (1.1) Heterosexual/Straight 81 (90.0) Prefer not to say 7 (7.8) Marital status Living as married/living with partner 6 (6.7) Married 57 (63.3) Separated 1 (1.1) Single, never been married 17 (18.9) Single, previously divorced 6 (6.7) Widowed 1 (1.1) Prefer not to answer 2 (2.2) Geographic region Midwest 22 (24.4) North Atlantic 12 (13.3) Southern 41 (45.6) Western 15 (16.7) Completed postmaster’s grief training No 61 (67.8) Yes 29 (32.2) Topic of counseling clients experiencing No 33 (36.7) grief and loss Yes 57 (63.3)

Figure 1. Frequency counts of various types of postmaster’s grief training.

Survey responses. Tables 2 and 3 present the summary of the survey responses of Part I and Part II of GCCS. Part I of GCCS consists of nine items measuring self-perceived personal grief counseling competency. The mean response ratings ranged from 3.80 (SD =1.21) to 4.68

(SD = 0.49), indicating a moderately high to high self-perceived personal grief counseling competency in terms of the nine survey items (Table 2). Part II of GCCS consists of 37 items measuring self-perceived skills and knowledge grief counseling competency. The mean response ratings ranged from 2.52 (SD =1.11) to 4.78 (SD = 0.44), indicating a moderately to high self-

71 perceived skills and knowledge grief counseling competency in terms of the 37 survey items

(Table 3). Table 4 shows the summary of survey responses for the Marlowe Crowne Social

Desirability Scale–Form C. The most often regarded social desirability by the participants were:

• Q7: I’m always willing to admit when I make a mistake. (75.0%)

• Q9: I am always courteous, even to people who are disagreeable. (73.9%)

• Q11: There have been times when I was quite jealous of the good fortune of

others. (63.6%)

• Q5: No matter whom I’m talking to, I’m always a good listener. (63.6%)

Table 2.

Summary of Survey Responses Part I of GCCS (Self-Perceived Personal Grief Counseling

Competency)

Frequency counts (%) of survey responses Item 1 2 3 4 5 M (SD) Q1 0 3 (3.3) 27 (30.0) 44 (48.9) 16 (17.8) 3.81 (0.76) Q2 2 (2.2) 3 (3.3) 18 (20.0) 36 (40.0) 31 (34.4) 4.01 (0.94) Q3 0 2 (2.2) 16 (17.8) 38 (42.2) 34 (37.8) 4.16 (0.79) Q4 0 0 1 (1.1) 27 (30.0) 62 (68.9) 4.68 (0.49) Q5 0 0 6 (6.7) 31 (34.4) 53 (58.9) 4.52 (0.62) Q6 1 (1.1) 1 (1.1) 13 (14.4) 30 (33.3) 45 (50.0) 4.30 (0.84) Q7 5 (5.6) 8 (8.9) 22 (24.4) 20 (22.2) 35 (38.9) 3.80 (1.21) Q8 1 (1.1) 0 5 (5.6) 18 (20.0) 66 (73.3) 4.64 (0.69) Q9 1 (1.1) 0 6 (6.7) 34 (37.8) 49 (54.4) 4.44 (0.72) Note. 1 = This does not describe me, 2 = This barely describes me, 3 = This somewhat describes me, 4 = "This describes me, and 5 = This describes me very well.

Table 3.

Summary of Survey Responses Part II of GCCS (Self-Perceived Skills and Knowledge Grief

Counseling Competency)

Frequency counts (%) of survey responses Item 1 2 3 4 5 M (SD) Q1 1 (1.1) 6 (6.7) 25 (27.8) 44 (48.9) 14 (15.6) 3.71 (0.85) Q2 3 (3.3) 4 (4.4) 17 (18.9) 46 (51.1) 20 (22.2) 3.84 (0.94) Q3 10 (11.1) 18 (20.0) 32 (35.6) 21 (23.3) 9 (10.0) 3.01 (1.14) Q4 9 (10.0) 15 (16.7) 31 (34.4) 26 (28.9) 9 (10.0) 3.12 (1.12) Q5 6 (6.7) 10 (11.1) 23 (25.6) 35 (38.9) 16 (17.8) 3.50 (1.11) Q6 2 (2.2) 5 (5.6) 13 (14.4) 46 (51.1) 24 (26.7) 3.94 (0.92) Q7 10 (11.1) 15 (16.7) 15 (16.7) 35 (38.9) 15 (16.7) 3.33 (1.25) Q8 4 (4.4) 7 (7.8) 27 (30.0) 40 (44.4) 12 (13.3) 3.54 (0.97) Q9 7 (7.8) 9 (10.0) 36 (40.0) 29 (32.2) 9 (10.0) 3.27 (1.04) Q10 0 3 (3.3) 9 (10.0) 25 (27.8) 53 (58.9) 4.42 (0.81) Q11 19 (21.1) 26 (28.9) 28 (31.1) 13 (14.4) 4 (4.4) 2.52 (1.11) Q12 6 (6.7) 16 (17.8) 26 (28.9) 30 (33.3) 12 (13.3) 3.29 (1.11) Q13 2 (2.2) 6 (6.7) 19 (21.1) 32 (35.6) 31 (34.4) 3.93 (1.01) Q14 2 (2.2) 10 (11.1) 28 (31.1) 37 (41.1) 13 (14.4) 3.54 (0.95) Q15 0 6 (6.7) 18 (20.0) 37 (41.1) 29 (32.2) 3.99 (0.89) Q16 5 (5.6) 6 (6.7) 23 (25.6) 39 (43.3) 17 (18.9) 3.63 (1.04) Q17 0 0 9 (10.0) 27 (30.0) 54 (60.0) 4.50 (0.67) Q18 0 0 4 (4.4) 31 (34.4) 55 (61.1) 4.57 (0.58) Q19 0 2 (2.2) 17 (18.9) 49 (54.4) 22 (24.4) 4.01 (0.73) Q20 3 (3.3) 9 (10.0) 23 (25.6) 48 (53.3) 7 (7.8) 3.52 (0.90) Q21 2 (2.2) 7 (7.8) 21 (23.3) 42 (46.7) 18 (20.0) 3.74 (0.94) Q22 0 0 1 (1.1) 18 (20.0) 71 (78.9) 4.78 (0.44) Q23 0 4 (4.4) 18 (20.0) 39 (43.3) 29 (32.2) 4.03 (0.84) Q24 3 (3.3) 6 (6.7) 14 (15.6) 50 (55.6) 17 (18.9) 3.80 (0.94) Q25 2 (2.2) 4 (4.4) 16 (17.8) 42 (46.7) 26 (28.9) 3.96 (0.92) Q26 4 (4.4) 11 (12.2) 28 (31.1) 36 (40.0) 11 (12.2) 3.43 (1.01) Q27 3 (3.3) 11 (12.2) 25 (27.8) 28 (31.1) 23 (25.6) 3.63 (1.10) Q28 1 (1.1) 5 (5.6) 13 (14.4) 48 (53.3) 23 (25.6) 3.97 (0.85) Q29 8 (8.9) 21 (23.3) 36 (40.0) 20 (22.2) 5 (5.6) 2.92 (1.02) Q30 3 (3.3) 8 (8.9) 30 (33.3) 40 (44.4) 9 (10.0) 3.49 (0.91) Q31 3 (3.3) 9 (10.0) 28 (31.1) 42 (46.7) 8 (8.9) 3.48 (0.91) Q32 2 (2.2) 4 (4.4) 15 (16.7) 55 (61.1) 14 (15.6) 3.83 (0.82) Q33 5 (5.6) 7 (7.8) 25 (27.8) 39 (43.3) 14 (15.6) 3.56 (1.03) Q34 4 (4.4) 8 (8.9) 33 (36.7) 34 (37.8) 11 (12.2) 3.44 (0.97) Q35 5 (5.6) 7 (7.8) 28 (31.1) 41 (45.6) 9 (10.0) 3.47 (0.97) Q36 7 (7.8) 14 (15.6) 41 (45.6) 25 (27.8) 3 (3.3) 3.03 (0.94) Q37 0 0 2 (2.2) 17 (18.9) 71 (78.9) 4.77 (0.48) Note. 1 = This does not describe me, 2 = This barely describes me, 3 = This somewhat describes me, 4 = "This describes me, and 5 = This describes me very well.

Table 4.

Summary of Survey Responses for the Marlowe Crowne Social Desirability Scale–Form C

Frequency counts (%) of survey responses Item False True Q1 57 (64.8) 31 (35.2) Q2 56 (63.6) 32 (36.4) Q3 59 (67.0) 29 (33.0) Q4 57 (64.8) 31 (35.2) Q5 32 (36.4) 56 (63.6) Q6 58 (65.9) 30 (34.1) Q7 22 (25.0) 66 (75.0) Q8 79 (89.8) 9 (10.2) Q9 23 (26.1) 65 (73.9) Q10 74 (84.1) 14 (15.9) Q11 32 (36.4) 56 (63.6) Q12 38 (43.2) 50 (56.8) Q13 58 (65.9) 30 (34.1)

Descriptive statistics of GCC. Descriptive statistics of the scores of self-perceived personal grief counseling competency and self-perceived skills and knowledge grief counseling competency were computed and presented in Table 5. The mean scores of personal grief counseling competency and skills and knowledge grief counseling competency are 38.37 (SD =

3.99) and 136.54 (SD = 22.24), respectively, indicating participants had moderately high levels of self-perceived personal grief counseling competency and self-perceived skills and knowledge grief counseling competency.

Table 5.

Descriptive Statistics of Grief Counseling Competency

Theoretical range M SD Min Max PGCC 9-45 38.37 3.99 27 45 SKGCC 37-185 136.54 22.24 61 182 Note. PGCC = personal grief counseling competency; SKGCC = skills and knowledge grief counseling competency.

Analysis results of RQ1 (RQ1.1, RQ1.2, and RQ1.3). RQ1 investigated potential differences in grief counseling competency in terms of personal grief counseling competency, skills and knowledge grief counseling competency, and overall grief counseling competency between counselors who have received grief counseling training and counselors who have received no grief counseling training, after controlling for age. Table 6 presents the descriptive statistics of personal grief counseling competency, skills and knowledge grief counseling competency, and overall grief counseling competency by training experience. Counselors who had received grief counseling training seemed to have higher personal grief counseling competency, skills and knowledge grief counseling competency, and overall grief counseling competency than counselors who had received no grief counseling training (M = 38.86 vs. M =

37.52 for PGCC; M = 138.53 vs. M = 133.12 for SKGCC; Table 5).

Table 6.

Descriptive Statistics (M (SD)) of Grief Counseling Competency, by Training Experience

Grief counseling training received Yes (N = 57) No (N = 33) PGCC 38.86 (3.89) 37.52 (4.08) SKGCC 138.53 (21.98) 133.12 (22.62)

To answer RQ1.1, a MANOVA with two dependent variables (personal grief counseling competency and skills and knowledge grief counseling competency) was performed to determine if there was a difference in grief counseling competency in terms of personal grief counseling competency and skills and knowledge grief counseling competency between counselors who have received grief counseling training and counselors who have received no grief counseling training, after controlling for age. The results of MANOVA (Table 7) indicated that there was no

75 statistically significant difference (Wilks’ Lambda = 0.958, F(2, 83) = 1.806, p = 0.171) in grief counseling competency in terms of personal grief counseling competency and skills and knowledge grief counseling competency between counselors who have received grief counseling training and counselors who have received no grief counseling training, after controlling for age.

Because the MANOVA results were not significant, no individual ANOVAs were performed.

Table 7.

Multivariate Tests (RQ1.1)

Effect Value F Hypothesis df Error df p Intercept Pillai's Trace 0.989 3594.620 2.000 83.000 < 0.001 Wilks' Lambda 0.011 3594.620 2.000 83.000 < 0.001 Hotelling's Trace 86.617 3594.620 2.000 83.000 < 0.001 Roy's Largest Root 86.617 3594.620 2.000 83.000 < 0.001 Training experience Pillai's Trace 0.042 1.806 2.000 83.000 0.171 Wilks' Lambda 0.958 1.806 2.000 83.000 0.171 Hotelling's Trace 0.044 1.806 2.000 83.000 0.171 Roy's Largest Root 0.044 1.806 2.000 83.000 0.171 Age Pillai's Trace 0.183 2.115 8.000 168.000 0.037 Wilks' Lambda 0.823 2.123 8.000 166.000 0.036 Hotelling's Trace 0.208 2.131 8.000 164.000 0.036 Roy's Largest Root 0.164 3.437 4.000 84.000 0.012

To answer RQ1.2, an ANOVA with the dependent variable, personal grief counseling competency, was performed. The results of ANOVA are presented in Table 8. There was no statistically significant difference (F(1, 84) = 3.300, p = 0.073) in self-perceived personal grief counseling competency mean scores between counselors who have received grief counseling training and counselors who have received no grief counseling training, when controlling for the age of the counselors.

Table 8.

Results of ANOVA (RQ1.2)

Source Type III Sum of Squares df Mean Square F p Corrected Model 206.011 5 41.202 2.858 0.020 Intercept 102939.949 1 102939.949 7140.998 0.000 Training experience 47.574 1 47.574 3.300 0.073 Age 168.231 4 42.058 2.918 0.026 Error 1210.889 84 14.415 Total 133897.000 90 Corrected Total 1416.900 89

To answer RQ1.3, an ANOVA with the dependent variable of skills and knowledge grief

counseling competency was performed. The results of ANOVA are presented in Table 9. There

was no statistically significant difference in self-perceived skills and knowledge grief counseling

competency mean scores between counselors who have received grief counseling training and

counselors who have received no grief counseling training, when controlling for the age of the

counselors (F(1, 84) = 1.956, p = 0.166).

Table 9.

Results of ANOVA (RQ1.3)

Source Type III Sum of Squares df Mean Square F p Corrected Model 2453.762 5 490.752 0.991 0.428 Intercept 1285978.043 1 1285978.043 2597.900 <0.001 Training experience 968.329 1 968.329 1.956 0.166 Age 1843.165 4 460.791 0.931 0.450 Error 41580.560 84 495.007 Total 1722029.000 90 Corrected Total 44034.322 89

Analysis results of RQ2 (RQ2.1, RQ2.2, and RQ2.3). RQ2 investigated potential differences in grief counseling competency in terms of personal grief counseling competency and skills and knowledge grief counseling competency between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, after controlling for age. Table 10 presents the descriptive statistics of personal grief counseling competency and skills and knowledge grief counseling competency by training course. Counselors who have received grief counseling training in a dedicated grief course seemed to have higher personal grief counseling competency and skills and knowledge grief counseling competency than counselors who have received grief counseling training incorporated into required content courses (M = 40.77 vs. M =

38.30 for PGCC; M = 142.85 vs. M = 137.25 for SKGCC; Table 9).

Table 10.

Descriptive Statistics (M (SD)) of Grief Counseling Competency, by Training Course

Grief counseling training course

Dedicated (N = 13) Integrated (N = 44)

PGCC 40.77 (2.68) 38.30 (4.03)

SKGCC 142.85 (28.48) 137.25 (19.88)

To answer RQ2.1, a MANOVA with two dependent variables (personal grief counseling competency and skills and knowledge grief counseling competency) was performed to determine if there was a difference in grief counseling competency in terms of personal grief counseling competency and skills and knowledge grief counseling competency between counselors who

78 have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, after controlling for age. The results of MANOVA (Table 11) indicated that there was no statistically significant difference (Wilks’ Lambda = 0.922, F(2, 50) = 2.118, p = 0.131) in grief counseling competency in terms of personal grief counseling competency or skills and knowledge grief counseling competency between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, after controlling for age. Because the MANOVA results were not significant, no individual ANOVAs were performed.

Table 11.

Multivariate Tests (RQ2.1)

Effect Value F Hypothesis df Error df p Intercept Pillai's Trace 0.987 1891.522 2.000 50.000 < 0.001

Wilks' Lambda 0.013 1891.522 2.000 50.000 < 0.001 Hotelling's Trace 75.661 1891.522 2.000 50.000 < 0.001 Roy's Largest Root 75.661 1891.522 2.000 50.000 < 0.001 Training course Pillai's Trace 0.078 2.118 2.000 50.000 0.131

Wilks' Lambda 0.922 2.118 2.000 50.000 0.131 Hotelling's Trace 0.085 2.118 2.000 50.000 0.131 Roy's Largest Root 0.085 2.118 2.000 50.000 0.131 Age Pillai's Trace 0.257 1.882 8.000 102.000 0.071

Wilks' Lambda 0.752 1.916 8.000 100.000 0.066 Hotelling's Trace 0.318 1.947 8.000 98.000 0.061 Roy's Largest Root 0.274 3.488 4.000 51.000 0.014

To answer RQ2.2, an ANOVA with the dependent variable personal grief counseling competency was performed. The results of ANOVA are presented in Table 12. There was a statistically significant difference in self-perceived personal grief counseling competency mean scores between counselors who have received grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses (F(1, 51) = 4.295, p = 0.043), when controlling for the age of the counselors. In particular, counselors who have received grief counseling training in a dedicated grief course had statistically significantly higher self-perceived personal grief counseling competency (M = 40.77,

SD = 2.68) than counselors who have received grief counseling training incorporated into required content courses (M = 38.30, SD = 4.03; Table 10).

Table 12.

Results of ANOVA (RQ2.2)

Type III Sum of Source Squares df Mean Square F p Corrected Model 182.245 5 36.449 2.797 0.026 Intercept 48586.955 1 48586.955 3728.279 <0.001 Training course 55.977 1 55.977 4.295 0.043 Age 120.835 4 30.209 2.318 0.070 Error 664.632 51 13.032 Total 86921.000 57 Corrected Total 846.877 56

To answer RQ2.3, an ANOVA with the dependent variable skills and knowledge grief counseling competency was performed. The results of ANOVA are presented in Table 13. There was no statistically significant difference (F(1, 51) = 0.946, p = 0.335) in self-perceived skills and knowledge grief counseling competency mean scores between counselors who have received

80 grief counseling training in a dedicated grief course and counselors who have received grief counseling training incorporated into required content courses, when controlling for the age of the counselors.

Table 13.

Results of ANOVA (RQ2.3)

Source Type III Sum of Squares df Mean Square F p Corrected Model 1852.456 5 370.491 0.750 0.590 Intercept 600694.712 1 600694.712 1216.090 <0.001 Training course 467.270 1 467.270 0.946 0.335 Age 1538.188 4 384.547 0.779 0.544 Error 25191.754 51 493.956 Total 1120848.000 57 Corrected Total 27044.211 56

Limitations of the Study

The survey instrument employed in this study relies on self-reported data. The design of these instruments could not guarantee that participants would respond honestly. However, because the survey was voluntary, was delivered privately online, and allowed participants to complete it where and when they chose, the motive to answer haphazardly or deceptively is reduced. Still however, the Grief Counseling Competency Scale is limited because it measures how the counselor “feels” about their capacity to provide grief counseling services. The scale does not specifically measure the counselor’s knowledge of specific grief counseling techniques and theories.

The second limitation of the study is that online surveys present concern about whether participants have contemplated what was being asked and whether their understanding of the

81 survey questions match that of the instrument they were designed for. To control for this potential problem, the researcher ensured that a detailed description of the instrument and directions were given to participants prior to taking the surveys.

A third limitation relates to the number of participants in each group for RQ2.1–RQ2.3.

Of the 57 participants who had specific grief counseling training in their counselor preparation program, only 13 had taken a dedicated grief course. More research is needed to examine the impact of a dedicated course related to grief counseling.

Recommendations for Future Research

For future research, it may be beneficial to collect qualitative data via focus group discussion to gain full insights of counselors’ self-perceived grief counseling competency. A longitudinal study following a group of counselors through their practice years may reveal interesting facts regarding how the perception of grief counseling competency changes after they have been practicing for a few years. More in-depth studies of how counselors have changed their perception of grief counseling competency during their practice should also be considered.

Conclusion

In conclusion, this chapter reviewed the definitions related to grief as well as prior research related to counselors’ self-perceived grief counseling competency. This study expanded on the previous research by focusing the population of participants to recently licensed counselors who are members for the AMHCA. Results indicated no difference in self-perceived grief counseling competence between counselors who received grief training and those who did not receive grief training in their master’s program. However, there is a slight increase in self- perceived personal grief counseling competence and skills among counselors who had a dedicated grief course compared to those who grief training that was integrated into other core

82 content areas. Finally, there was no statistical difference in skills and knowledge related to grief counseling competency between those who took a dedicated grief course and those who had grief training integrated throughout the program.

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CHAPTER 4

GRIEVING WHILE GROWING: THE PROCESS OF RESEARCHING AND WRITING

ABOUT GRIEF WHILE EXPERIENCING GRIEF

Introduction

Earning a doctoral degree was never part of my master plan. When I decided to seek out this program, I was in the last semester prior to earning a master’s degree in school counseling. I had purposely waited until the end of the program to take the required multicultural class. Not only was it rumored that the professor was intense, I felt insecure about the topics that were sure to be discussed. Although I had intentionally earned a bachelor's degree from a university located in one of the largest, most diverse cities in the Southeast, my master’s program was selected out of convenience. The campus location and the availability of evening classes were the determining factors. At the time, I did not realize that I had selected a private school where I, a white female, would be in the minority. This professor, an African American female, challenged my thought processes and encouraged me to confront my own privileges. She gave me my first understanding and definition of social justice.

With my heart on fire to learn more about social justice and my role as an advocate, I decided that I would apply for a doctoral program. I had always wanted to attend the University of Georgia, but due to previous circumstances, it was never an option. I am amazed and overwhelmed when I reflect on how much everything in my life has changed over the past few years through my experiences in both this doctoral program and my personal life. Although

90 qualitative research is often considered personal and researchers commonly choose their topic due to some personal connection (Hays & Singh, 2012), this intimidated me because of my past.

A few years prior to this doctoral program, my mother had passed away, which created a major shift in my personal attitude and beliefs. Midway through this program, I decided to study grief and how my own experience with grief completely altered my life. However, I was too scared of my own emotions to attempt a qualitative study, something I would have never admitted to myself or to my dissertation committee. As a new school counselor, I began to consider how the loss of my mother was impacting my work. I wondered if my experience with grief was the cause of my insecurities when working with grieving students, or was it a result of having no specific training related to grief counseling during my counselor preparation coursework? Although my study used a quantitative methodology, reflecting back, I know without a doubt that my own life experiences simultaneously intersected with my dissertation journey, a process Hays and Singh (2012) call “researcher reflexivity.”

Researcher reflexivity is the process during which the researcher maintains a continual internal dialogue, a critical self-evaluation, and an active acknowledgement that their position may affect the process of the research as well as the outcome (Berger, 2015). Effective researchers use reflexivity throughout their study starting with the development of research questions, then as participant recruitment occurs, and finally during data collection and analysis as a way to increase the overall rigor of the project (Berger, 2015). Quantitative research has often been criticized because it rarely acknowledges the researchers hidden agenda and assumptions, instead emphasizing the importance of controlling the research environment and minimizing factors that intrude on the research process (Ryan & Golden, 2006). However, no

91 research, whether quantitative or qualitative, is produced in a vacuum, irrespective of time, place, social context, authorship, and personal responsibility (Kingdon, 2005).

Because a researcher typically has different life experiences from the participants, it is even more critical to take time for self-appraisal to better understand the experiences of the participants (Fawcett & Hearn, 2004). Therefore, this chapter includes a reflection of my own experience as the researcher throughout the process, based on Pillow’s (2003) four reflexive strategies: 1) reflexivity as a recognition of self, 2) reflexivity as a recognition of other, 3) reflexivity as truth, and 4) reflexivity as transcendence. Working together, these four strategies provide the researcher with tools for personal evaluation and increased self-awareness (Pillow,

2003).

Pillow (2003) referred to the first reflexive strategy as recognition of self, which involves the researcher acknowledging their own capacity to be known and reflect. Reflecting on the past five years, I realize that I have both changed and grieved in many ways, not only within this doctoral process but within my personal life. I recognize the intense amount of change and grief that came allowed me to develop both personally and professionally. This chapter provides insight into my growth and its impact on my research.

The second reflexive strategy is known as recognition of the other (Pillow, 2003). Pillow

(2003) noted that effective research relies on capturing and fully understanding the research topic in a way that truly reflects the experiences of the participants. Therefore, this chapter also includes some personal reflection on the data collection and analysis processes and the ways that

I attempted to represent participants’ experiences using three surveys.

Pillow (2003) described the third strategy as reflexivity of truth, which is the idea that the researcher can communicate a form of truth throughout the entire research process. Effective

92 reflexivity increases validity as well as the rigor of a study (Hays & Singh, 2012; Trinh, 1991).

To support my reflexivity of truth, this chapter includes an examination of myself, the findings from participants, and the truth of my findings.

The final reflexive strategy is known as reflexivity as transcendence (Pillow, 2003).

When the researcher allows for authentic self-appraisal as it relates to the research, a recognition of the experience of the participants, and the truth of the research findings, a wholeness forms

(Pillow, 2003). This reflective process allows the researcher to move beyond their own subjectivity in a way that promotes a more accurate representation of the study (Pillow, 2003).

This chapter provides an in-depth reflection on the process of the research as it relates to transcendence.

Reflexivity and Researcher Positionality

Growth

Three women, all without knowing, encouraged me to seek this doctoral degree. I first considered pursuing a doctoral degree after taking a multicultural class in my master’s program that both challenged and excited my worldview. Finally, I was no longer bored with the coursework and felt engaged in and challenged by the learning process. This professor encouraged me to think in a different way by introducing me to the concepts of privilege, power, and oppression as they related to my personal identity. I was forced to confront my personal areas of privilege and bias. The coursework piqued my interest in how our personal identities and roles in society impact how an individual is both privileged and oppressed, depending on the context.

While coming to an understanding of my personal intersections of privilege and oppression, I was also completing the last semester of internship prior to graduating with a master’s degree in school counseling. The assistant principal at the school where I interned was

93 nearing the completion of her own doctoral degree. She talked about how much she was learning and always commented on how much she was growing as a person. As someone who I admired and respected, I felt encouraged that with effort, dedication, and time, I too could earn a doctoral degree and change my own destiny. Although these two women inspired me to seek this degree, the death of my mother was probably the biggest influence on my decision to continue my education.

While earning my bachelor's degree, my life dramatically changed when my mother was killed in a violent crime by two African American gang members. As a result of her death, I sought many years of counseling. As a result of counseling, I was not angry at the individual men, but a general sadness came over my life due to her absence. Since her death, I have felt a never-ending desire to make her proud. Equally, there was a constant reminder that my mom was missing everything. During every successful moment and every time of need, I felt sadness and jealousy that I did not have my mother here with me. With new vocabulary and definitions of social justice and oppression from the multicultural course, I began to realize that I still held biases, fears, and judgments toward individuals different than myself. I also realized that with knowledge, change occurs.

Knowing Myself

As a young child, I was aware of how differently the males in my family were treated.

The men were provided allowances, got to stay out later, and even gifted their first cars. From elementary school going forward, I remember how individuals not white, those with disabilities, members of the LGBT community, and those who did not speak English were treated differently.

My father disapproved of my boyfriend because he was a Mexican immigrant who knew little

English. I knew my father’s reactions were due to hate and ignorance. I also knew this was not the way I wanted to live. Hatred and intolerance were not the values my mother instilled in me.

Learning Spanish by conversing with coworkers and treating them like family gave me insight into another culture in my teenage years. Among a group of Hispanic women, I saw friendship, supportiveness, and acceptance, something I desperately missed from my own mother. As a result of my friendship with these Hispanic women, I knew I wanted to attend a school with diversity.

When choosing a university for my bachelor’s degree, I purposefully wanted to attend

Georgia State University because it was in the city of Atlanta and known to be diverse. I wanted to get out of the rural town where I felt a majority of people were incredibly narrow-minded.

Additionally, I had been in relationships with individuals different than myself in terms of race, religion, and educational attainment. Because of this, I had seen firsthand how there were hateful people in all races, ethnicities, genders, and religions and considered myself to be open-minded but did not quite realize what it meant to be multicultural.

When Grief Changed My Worldview

My understanding of what it means to be multicultural changed within the first year of the doctoral program. During the beginning of this doctoral journey, I got to spend a lot of time with my cohort. This allowed me to get to know each individual on a personal level. I quickly realized that everyone had their personal story of life’s hurts. Yet everyone, myself included, somehow endured, and as a result we were better and stronger versions of ourselves. As I listened to everyone’s story over the first year, my own history and grief for my mother kept surfacing. During every success and struggle, the desire to share the experience with my mother never went away, and neither did the pain. However, the coursework from the doctoral program provided me with tools to advocate for my needs as a result of my grief.

The first few semesters of this doctoral program included courses in social justice and counseling theories, both of which incorporated advocacy. In the beginning, social justice meant

95 understanding and accepting that I had both privilege and oppression, and that these affected how I felt about other people and society. The more I learned, the more it became clear that social justice is both a goal and a process in which members from all social identity groups work together through collaboration, with the complete participation of all members, to meet the needs of the people (Adams & Bell, 2016). Specifically, during an advanced theories course, the goal was to better understand social justice from an advocacy perspective. While writing we had to take a position on specific topics, provide reasons for our position, and then defend that position against oppositional views. Taking alternative positions challenged me to really see the world from different perspectives. Now that I had these alternative perspectives and a different worldview, I could no longer ignore injustices as a result of oppression and power.

Simultaneously, as I became aware of my own experiences of oppression and privilege, I began to grieve the loss of my mother in a different way. There was a constant feeling of sadness for the way her life turned out, much of which I now realize was out of her control and something that she accepted. The social justice coursework provided tools for me to be an advocate for myself and others.

Learning to advocate for myself took time. The Cycle of Liberation, the Advocacy

Competencies (Toporek, Lewis, & Crethar, 2009), and the Social Justice and Multicultural

Competencies (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016) provided a framework to initiate change starting at the personal level but slowly moved to the macro level, all while considering a person’s privilege and oppression. Using these tools as a starting point and overall framework, I began to understand my grief from a different perspective. My experience with grief was life-altering, but with courage, empowerment, and advocacy, change within myself could, and did, happen. This new perspective empowered me to advocate for

96 others who were also experiencing grief. This knowledge transformed me into a more compassionate and empathetic school counselor.

When My Life Experience Found My Research

In my role as a school counselor, I work with students every day who are experiencing grief. The grief is not always a result of death but more often due to divorce, incarceration, deportation, illness, or as a result of drugs and alcohol. Although I knew that I wanted to focus my dissertation work on grief, I also knew I did not want to let my emotions and personal experience with grief be known to participants. Reflecting back on my academic courses, I had been given specific ways to help students dealing with a variety of issues, both academic and personal, through the use of theory and the counseling process. However, though I was working with students frequently with issues related to grief, I had never had any specific training in grief.

I wondered if this was the reason I became very emotional during every conversation I had with a student related to divorce, incarceration, or just missing a loved one, or was it because of my personal experience with grief? Really wanting to advocate for my students and the entire profession, as the Cycle of Liberation, the Advocacy Competencies (Toporek et al., 2009), and the Social Justice and Multicultural Competencies (Ratts et al., 2016) encourage, I decided to find out if I was alone in my lack of grief training experience or was my lack of grief training due to my specific master’s school counseling program curriculum?

The Process of Research

During the first few semesters of the doctoral program, there were many small research projects. We were asked to explore our social identities while simultaneously learning to advocate for ourselves and others in areas where we were oppressed. By learning how to be an advocate, I felt as if I could no longer remain silent around issues of oppression. I have always felt a connection to the Hispanic community. I felt it was my duty to research and advocate for

97 this group in my role as a school counselor in a high poverty area with a large Hispanic population. However, my own grief related to my mother kept surfacing, and so did my anxiety.

The further the doctoral program progressed, the more my anxiety continued to increase.

Reflecting back, it was for several reasons, one being fear of failure. A second reason was because I was being challenged to think in a way I had never experienced. Mostly, my anxiety revolved around the hurt and pain of my mother not being here to share in what I was experiencing. I was still grieving her loss. Slowly, I allowed my research to include the topic of grief. Once I realized that grief research existed and that there were theories on the grieving process, my mind was made up. Hoping that through research I might resolve my own grief and find some closure, my research subject was finalized.

Method

Once I had the courage to begin verbalizing and researching my new topic, I was amazed at the various theories for processing grief. In all of my coursework, and even private counseling,

I had never learned of any of this. At the same time, everyone in my cohort was developing their own research topics. They all had one thing in common; they were doing a qualitative study.

From the beginning, I felt too vulnerable to sit down and interview other people about their experiences with grief. In my head, I rationalized that I knew what grief was, so I did not need to hear the specific stories of others’ similar pain. As I had learned to become an advocate, I wanted my research to be able to inform others by helping counselors in similar roles as myself, by providing them with specific tools to work with grieving clients. I decided to complete a quantitative study so that the findings could be used to promote a systematic change in counselor preparation programs.

During the research process, I anticipated the challenge of recruiting enough participants.

I knew that I wanted to use a specific group of counselors, because similar previous research did

98 not target one specific population. I knew counselors, including myself, are often members of professional organizations such as the American Mental Counseling Association and the

American School Counselor Association, but I was not sure if they would respond. Although the data collection took longer than I anticipated, eventually the posts to member group boards paid off.

In addition to the concern of getting enough participants, I was also worried about actually completing the data analysis in SPSS. Although I had taken two courses related to quantitative data and using SPSS, I was certainly no expert. Quantitative data analysis allowed me to put my feelings aside to determine if what I was experiencing, a lack of grief training and knowledge of working with grieving clients, was also being experienced by other professional counselors.

Findings

My review was of the demographics portion of the results. I was surprised at the number of participants who had sought grief counseling training after their master’s degrees. I have known the importance of attending conferences for keeping up with current counseling trends, but I did not realize the wide variety of training available at these conferences. Because I had no training related to grief counseling in my master’s program, it was astonishing to see that over

60% of counselors reported grief training in their program. My initial view of the findings did not reflect my experience of no grief counseling training during my master’s program. As I reviewed the participants’ results that indicated no difference in perceived grief counseling competency regardless of whether specific grief training occurred or not, I was forced to consider my personal history as the reason for my insecurities when working with grieving students. As I continued to review the data, I was not surprised that those participants who

99 indicated they had a specific course related to grief counseling perceived their competence level higher than those who had grief counseling training integrated into multiple classes.

Reflecting on my findings as I write the final chapter, I also now fully recognize that my personal experience with grief plays a role in my own perceived competence in grief counseling.

I realize that although I was given basic counseling skills to work with clients regardless of their reason for counseling, my own personal experience with grief impacts my ability to remain objective. Through this awareness, I can serve my clients by purposefully setting my own feelings aside to be fully present in the counseling relationship.

My Privilege in the Research Study

Without a doubt, privilege influenced the process of my grief counseling research. Black and Stone (2005) define privilege as a special advantage that is granted rather than earned, given to some individuals because of their preferred status, which provides benefits while being detrimental to others. First, my ability to pursue a doctoral degree reflects class privilege in the fact that I can afford the expense of higher education. As a student at the University of Georgia, I have had access to the most current resources while researching any topic. Once I found research related to the actual grief process and the different types of grief, I felt more equipped to explore my own grief journey. Equally, I now recognize the incredible amount of privilege in being able to seek an extensive amount of counseling after my mother’s death. As a school counselor, I am often the only counseling resource my students have, whether due to lack of health insurance, finances, geographic location, or lack of understanding the benefits of counseling.

Finally, as a result of this program and as the research study came to an end, I began to consider my privilege as a White female. I always felt comfortable and safe seeking out assistance from professors and resources such as the librarian or technology support. Although I did not disclose this to the participants, during the data analysis, I worked with the universities’

100 librarians during the research phase and the statistical department to analyze the data. I was able to seek professional educational assistance such as APA editors. I recognize that my experiences and comfort level seeking assistance is likely different than others who hold multiple intersecting marginalized identities.

Grieving While Researching and Writing about Grief

Entering into the doctoral program, I believed that I had done what I was supposed to do to grieve the death of my mother. I had completed years of counseling and felt good about the way her memory was honored. It was easy to talk about her and our memories without crying.

However, somewhere along this dissertation journey, it became apparent a huge part of me was still missing. Admittedly, a part of me did not want to complete a qualitative study out of fear of my emotions. However, setting my fears aside, my goal was to compare my experiences of grief training to my colleague’s experiences. I was unclear if I was struggling to serve grieving clients due to my lack of training or as a result of my own grief.

While researching grief literature, I began to have a new perspective of grief. As I learned about each of the different grief theories, a clearer understanding of my experiences emerged.

Slowly, my grief felt natural, almost like part of a process that I needed to complete. During the data collection process my grief turned inward. I constantly worried that others would not consider this topic important or necessary, therefore no one would participate. The data analysis and write up challenged my desire and motivation to complete the project. Reflecting back, this was still me grieving, feeling sad this journey was nearing the end, and that once again my mother would miss the celebration.

Conclusion

As my dissertation journey nears completion, I wonder if I will ever stop grieving.

Although I may always grieve the loss of my mother, through this grief I learned some things.

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While grieving in this program, I learned to trust myself and now realize that it is ok to be afraid sometimes. I recognize my fear is only as powerful as I allow it to be. My goal is to not let fear or grief hold me back, rather to be courageous in my own understanding of life as a journey.

Finally, and probably most important, I now know I am a lot more resilient than I ever thought.

In conclusion, I am excited and look forward to the opportunities to use my skills and knowledge of social justice and liberation to help other individuals who are experiencing grief. I am thankful for the opportunity to be in this program and for the knowledge, language, and tools provided that allowed me to liberate myself in coursework, research, and life. Going forward, I will continue to advocate to the Council for the Accreditation of Counseling and Related

Educational Programs (CACREP) for grief standards so that training within counselor preparation programs is consistent. Although I recognize standards cannot be created for every possible topic, having some guidance would provide clarity and guidelines for counselors, specifically those working with grieving clients.

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References

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https://doi.org/10.4324/9781315775852

Berger, R. (2015). Now I see it, now I don't: Researcher's position and reflexivity in qualitative

research. Qualitative Research, 15(2), 219–234. doi:10.1177/1468794112468475

Black, L. L., & Stone, D. (2005). Expanding the definition of privilege: The concept of social

privilege. Journal of Multicultural Counseling & Development, 33(4), 243–255.

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1912.2005.tb00020.x

Fawcett, B., & Hearn, J. (2004). Researching others: Epistemology, experience, standpoints and

participation. International Journal of Social Research Methodology, 7(3). 201–218. doi:

10.1080/13645570210163989

Harro, B. (2013). The Cycle of Liberation. In Adams, M., Blumenfeld, W.J., Castañeda, C.,

Hackman, H.W., Peters, M.L., & Zúñiga, X. (Eds.) Readings for diversity and social

justice (pp. 618–625). New York: Routledge.

Hays, D. G. & Singh, A. A. (2012). Qualitative inquiry in clinical and educational settings. New

York: Guilford Press.

Kingdon, C. (2005). Reflexivity: Not just a qualitative research tool. British Journal of

Midwifery, (10), 622.

Pillow, W. S. (2003). Confession, catharsis, or cure? Rethinking the uses of reflexivity as

methodological power in qualitative research. International Journal of Qualitative

Studies in Education, 16(2), 175–196. doi: 10.1080/095183903200006063

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Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016).

Multicultural and social justice counseling competencies: Guidelines for the counseling

profession. Journal of Multicultural Counseling and Development, 44(1), 28–48.

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Ryan, L. & Golden, A. (2006). “Tick the box please”: A reflexive approach to doing quantitative social research. Sociology, 40(6), 1191.

Toporek, R. L., Lewis, J. A., & Crethar, H. C. (2009). Promoting systemic change through the

ACA Advocacy Competencies. Journal of Counseling and Development, (3), 260.

Trinh, T. M.-H. (1991). When the moon waxes red : representation, gender, and cultural politics.

New York : Routledge.

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APPENDIX A

RECRUITMENT LETTER

for a research project entitled “Grief Counseling: An Investigation of Perceived Counselor Competence”

Dear Professional Counselor,

You have received this email as a request to participate in a research study entitled “Grief Counseling: An Investigation of Perceived Counselor Competence.” This research project aims to identify and explore professional counselor’s competency related to working with clients who experience grief and loss. Results will be used to guide the future direction of grief and loss research and training.

In order to participate in this study, there are two requirements: 1. You are a certified as a licensed professional counselor, licensed clinical professional counselor, or a licensed mental health counselor within your home state. 2. You have held this license for 5 years or less in your career.

If you chose to participate in this study, you will be redirected to a website where you will be asked to complete a survey that will take approximately 10 minutes to complete. The first page of the survey is an “Information Page” which will provide more specific details regarding the nature of this research study.

For specific questions or inquiries regarding this study, please contact me or my faculty advisor as directed on the “Information Page.”

Sincerely,

Tanya Tucker, Doctoral Candidate Department of Counseling and Human Development Services College of Education University of Georgia

LINK TO SURVEYMONKEY, INFORMATION PAGE

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APPENDIX B

SURVEY INSTRUCTIONS AND SURVEY CONSENT

Information Page

for a research project entitled “Grief Counseling: An Investigation of Perceived Counselor Competence”

Date

Dear Professional Counselor

My name is Tanya Tucker, and I am a doctoral student in the Department of Counseling and Human Services at the University of Georgia. I am conducting a research project as part of my dissertation under the direction of Dr. Anneliese Singh and I would like to invite you to participate.

This research study is designed to assess the overall perceived competence of licensed counselors when working with clients experiencing grief and loss. Additionally, this study seeks to determine if having specific training related to grief and loss impacts counselor perceived competency, as well as, whether the type of master’s level grief training (a dedicated course or integrated training into other core content area) impacts competency level.

If you choose to voluntarily participate in this study, you will click the link at the bottom of this page to complete a survey that will take approximately 10 minutes. You may stop participation at any time during the survey. However, since this survey will not collect any identifiers that connect back to the participate, once submitted data can not be removed or deleted. There are no anticipated risks or discomforts associated with this survey, other than what would occur in day-to-day life events.

Information collected from this study will be used in a doctoral dissertation, may be published in a professional journal, and/or presented at a professional meeting. All information will be collected so that no identifiers connect back to specific participants. Thus, no identifying information of any form will be included in the final results.

If you have any questions regarding this study, feel free to contact me, Tanya Tucker, by email at [email protected] or my Faculty Advisor, Dr. Anneliese Singh at [email protected]. For questions or concerns about your rights as a research participant, email [email protected] or call 706- 542-3199.

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By clicking the “I Agree” button at the bottom of this page you are agreeing to participate in this research study with a sufficient understanding of the benefits and risks involved. It is recommended that you print out this page for informational purposes. Thank you sincerely.

Demographics Questionnaire

In order to participate in this study, you must answer yes to the following statements: 3. In my state, I am certified as a licensed professional counselor, licensed clinical professional counselor, or a licensed mental health counselor. a. Yes b. No 4. I have held this license for 5 years or less in my career. a. Yes b. No If you answer yes to the previous two questions, proceed to the following. 1. What is your age? a. 29 years old or younger b. 30-39 years old c. 40-49 years old d. 50-59 years old e. 60 years or older 2. How do you describe yourself? a) Male b) Female c) Transgender d) Do not identify as male, female, or transgender. e) Prefer to not describe. f) Prefer to self describe: ______3. What is your race/ethnicity? Select all that apply a. Black/African-American b. Asian-American c. White d. Hispanic/Latino e. Native American f. Pacific Islander g. Other : ______4. Do you consider yourself to be? a) Heterosexual/Straight b) Gay or lesbian c) Bi-sexual d) Prefer to self describe: ______e) Prefer to not say. 5. What is your marital status? a) Married

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b) Separated c) Single, never been married d) Single, previously divorced e) Living as married/living with partner f) Widowed g) Prefer to self describe: ______h) Prefer not to answer. 6. Geographic Region (aligns with the American Counselor Association) a. Midwest Region: (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, Oklahoma, South Dakota, and Wisconsin). b. North Atlantic Region: (Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont). c. Southern Region: (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, and West Virginia). d. Western Region: (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington State, and Wyoming). 7. Have you had any post-master’s grief training you have completed? A) Yes B) No If yes, check all that apply. a) Conferences b) Workshops c) Webinars d) Journal article readings e) Other: ______8. Did your counselor preparation master’s level training include the topic of counseling clients who experience grief and loss? ____yes _____no 9. What format did you receive the grief counseling training? a. A dedicated grief course (entire course related to grief) b. Grief counseling was integrated or discussed (whether as a module, topic, or unit) in one or more of the required courses

Grief Counseling Competency Scale

Part I: Personal Grief Counseling Competencies 1 2 3 4 5 This Does Not This Barely This Somewhat This Describes This Describes Describe Me Describes Me Describes Me Me Me Very Well

Using the scale above, please rate how well the following items describe you.

1. I practice personal wellness and self-care. 1 2 3 4 5 2. I have experienced loss and can verbalize my own 1 2 3 4 5 grief process. 3. I have self-awareness related to my own grief issues 1 2 3 4 5 and history. 4. I believe that grief is a result of a variety of loss 1 2 3 4 5

108 experiences which include but are not limited to death. 5. I display empathy, unconditional positive regard, and 1 2 3 4 5 genuineness when talking with friends and acquaintances. 6. I view grief as a systemic as well as an individual 1 2 3 4 5 experience. 7. My spirituality is important to my understanding 1 2 3 4 5 of loss and grief. 8. I believe that there is no one right way to deal with 1 2 3 4 5 grief. 9. I have a sense of humor. 1 2 3 4 5

Part II: Skills and Knowledge Grief Counseling Competency. 1 2 3 4 5 This Does Not This Barely This Somewhat This Describes This Describes Describe Me Describes Me Describes Me Me Me Very Well

Using the scale above, please rate your confidence in your ability to currently perform the following skills.

1. I can assess for unresolved loss and grief that may not 1 2 3 4 5 be stated as a presenting problem. 2. I can provide psycho-education to clients related to the 1 2 3 4 5 grief experience for themselves and others. 3. I can facilitate family grief counseling sessions. 1 2 3 4 5 4. I can provide educational workshops and activities to 1 2 3 4 5 community members about loss and grief. 5. I can define and articulate the nature of "normal" grief 1 2 3 4 5 and loss as detailed by theoretical models. 6. I can facilitate individual grief counseling sessions. 1 2 3 4 5 7. I can provide developmentally appropriate programs 1 2 3 4 5 about grief and loss issues in schools. 8. I can facilitate group grief counseling sessions. 1 2 3 4 5 9. I can describe general differences in grief and loss as a 1 2 3 4 5 function of personality style. 10. I can conduct suicide assessments. 1 2 3 4 5 11. I can facilitate multi-family group grief counseling 1 2 3 4 5 12. I can articulate a grief consultation model for parents, 1 2 3 4 5 teachers, and other adults about how to talk to children about grief and loss. 13. I can provide crisis intervention services to schools 1 2 3 4 5 and/or community settings. 14. I can define and articulate the nature and symptoms of 1 2 3 4 5 complicated/unresolved grief situations. 15. I can teach clients how to obtain support and resources 1 2 3 4 5 in the community in relation to grief and loss. 16. I can assess a client’s sense of spirituality. 1 2 3 4 5

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17. I can develop rapport with clients of all ages. 1 2 3 4 5 18. I can work on an interdisciplinary team by interacting 1 2 3 4 5 with staff from different professions. 19. I can identify cultural differences that affect treatment. 1 2 3 4 5 20. I can utilize family assessment techniques to examine 1 2 3 4 5 interaction patterns and roles. 21. I can provide appropriate crisis debriefing sessions. 1 2 3 4 5 22. I can exhibit effective active listening skills. 1 2 3 4 5 23. I can read and apply current research and literature 1 2 3 4 5 related to grief and effective treatment interventions. 24. I can facilitate a reframe of loss experience and grief 1 2 3 4 5 reactions for client empowerment. 25. I can describe common dysfunctional coping styles of 1 2 3 4 5 a person who is grieving loss. 26. I can assess individuals' progress on theoretically 1 2 3 4 5 defined grief tasks. 27. I can use the creative arts in counseling to facilitate 1 2 3 4 5 grief expression. 28. I can appropriately self-disclose related to my own 1 2 3 4 5 grief and loss experiences. 29. I maintain an updated library of grief and loss 1 2 3 4 5 resources for clients. 30. I can identify cultural differences that affect 1 2 3 4 5 assessment in relation to loss and grief. 31. I can recognize and work with grief related resistance 1 2 3 4 5 and denial. 32. I can describe common functional coping styles of the 1 2 3 4 5 person who is grieving. 33. I can participate in informal or formal support groups 1 2 3 4 5 for professionals who work with issues of grief and loss to prevent burnout and vicarious traumatization. 34. I can describe how various individual counseling 1 2 3 4 5 theories can be applied to grief counseling with individuals and families. 35. I can recommend helpful articles and books for 1 2 3 4 5 grieving individuals and families. 36. I can describe how various family counseling theories 1 2 3 4 5 can be applied to grief counseling with individuals and/or families. 37. I can listen in a non-judgmental way to stories 1 2 3 4 5 clients tell about their losses.

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Marlowe-Crowne Social Desirability Scale–Form C W. M. Reynolds

Listed below are a number of statements concerning personal attitudes and traits. Read each item and decide whether the statement is true or false as it pertains to you.

T F 1. It is sometimes hard for me to go on with my work if I am not encouraged.

T F 2. I sometimes feel resentful when I don’t get my way.

3. On a few occasions, I have given up doing something because I thought too T F little of my ability.

4. There have been times when I felt like rebelling against people in authority T F even though I knew they were right.

T F 5. No matter whom I’m talking to, I’m always a good listener.

T F 6. There have been occasions when I took advantage of someone.

T F 7. I’m always willing to admit when I make a mistake.

T F 8. I sometimes try to get even, rather than forgive and forget.

T F 9. I am always courteous, even to people who are disagreeable.

10. I have never been irked when people expressed ideas very different from my T F own.

T F 11. There have been times when I was quite jealous of the good fortune of others.

T F 12. I am sometimes irritated by people who ask favors of me.

T F 13. I have never deliberately said something that hurt someone’s feelings.

End of survey. Thank you for your participation.

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APPENDIX C

POWER ANALYSIS USING G*Power VERSION 3.1.9.4