Death education and attitudes of counselors-in-training toward death: an exploratory study.
Mental health counselors regularly address issues of death and dying with their clients. Despite this, beginning counselors reported that discussing issues related to death and dying made them more uncomfortable than discussing other presenting problems (Kirchberg & Neimeyer, 1991), and counselors' overall level of empathy toward clients with death-related concerns was found to be low (Kirchberg, Neimeyer, & James, 1998). A possible explanation for counselor difficulty in addressing death and dying with clients may have to do with the counselors' attitude toward death and their personal fear of death (Kirchberg et al., 1998). One way to address counselors' fear of death is to incorporate death education training into counselor training programs, thereby reducing counselor anxiety regarding death and making them better able to assist clients with death-related concerns. However, Rosenthal (1981) argued--and Wass (2004) reiterated--that despite the need for death education in the curriculum to better train counseling students to address client issues of death and dying, few graduate programs in counseling incorporate courses on death and dying into their curriculum. Therefore, the purpose of this study is to examine the influence of death education on the attitudes of counselors-in-training toward death.
Efficacy of Death Education
In a review of the literature, no studies were identified that addressed the usefulness of death education in assessing death attitudes of counselors-in-training. In studies involving other vocations (e.g., college students, nursing, physicians, and emergency medical technicians [EMTs]), death education on changing death attitudes and behavior and reducing death anxiety has produced positive and negative outcomes as well as mixed results (e.g., Bugen, 1980; Hurtig & Stewin, 1990; Johansson & Lally, 1990; Knight & Elfenbein, 1993; Maglio & Robinson, 1994; Servaty & Hayslip, 1997; Smith-Cumberland, 2006; Wong, 2009). Positive effects of death education include participants reporting more comfort and increased coping while addressing death and dying with others. For example, Bugen (1980) noted that completing a seminar on death education had a positive effect on graduate and undergraduate students' coping abilities toward self and others. This positive effect was evidenced by gains in coping capacity on 23 out of 30 items; however, a control group of students who participated in only two class sessions showed gains in only one item that addressed increased coping. Examples of items that depicted positive effects include "I have a good perspective on death and dying," "I am aware of the full array of services from funeral homes," and "I know how to speak to children about death" (Bugen, 1980, pp. 179-180). Servaty and Hayslip (1997) demonstrated that death education can reduce both death fear and apprehension in individuals communicating with those who are dying. Smith-Cumberland (2006) found that after exposure to death education, EMTs reported an increased desire to change their behavior at the scene of death, and many reported at a 3-month follow-up that they had changed their behavior to include using words such as died instead of euphemisms such as passed away, which diverts individuals away from the reality of the death. EMTs also reported that they were able to provide more assistance with the families' grief (Smith-Cumberland, 2006). Finally, Wong (2009) found that participating in a death education class improved death avoidance, approach acceptance, and fear of death in university students in Hong Kong. Students were less likely to avoid discussing topics related to death, were more accepting of death, and had less fear surrounding death after attending a course devoted to the topic of death.
Although some researchers reported positive effects of death education on death anxiety for EMTs, outcome studies in nursing students have yielded mixed results. Johansson and Lally (1990) found that exposure to death education in the form of film depicting a death-related scene decreased death anxiety of some senior undergraduate nursing students but raised the death anxiety of some junior-level students. Other studies have found that death education had a more positive effect on nursing students with less exposure to death. For example, beginning nursing students with no personal experience of death in an experiential group had a more positive outcome than did students in that same group who had personal experience with death (Hurtig & Stewin, 1990).
Despite studies that show positive outcomes associated with death education, other researchers have found more negative outcomes. Negative outcomes were noted in Maglio and Robinson's (1994) meta-analysis of 62 published and unpublished research studies on the effects of death education on death anxiety. They found that, overall, death education was not a useful way to reduce death anxiety. Their findings suggested that experimental groups experienced higher levels of death anxiety after education compared with no-treatment control groups. In addition, didactic instruction increased participants' death anxiety significantly more than did experiential activities. To help explain their findings, Maglio and Robinson suggested that general information on death and dying, if not processed emotionally, may increase the participants' awareness of death, thereby increasing their death anxiety. They also stated that it is important that educators clearly identify the goals for a course on death education, because the goals for the course may not reflect a desire to reduce students' death anxiety.
Goals for Death Education
The modern-day focus on death education began in the 1950s with Herman Feifel (1955, 1959). Feifel (1977) believed that death education was important for everyone, and he is credited for infusing a humanistic perspective in death education (Wass, 2004). This humanistic focus is evident in the goals of death education that includes both the imparting of information and the personal development of the student. These two fundamental goals are reflected in the four goals for death education outlined by Meagher (1992): information sharing, values clarification, development of effective coping behaviors, and adoption of a positive attitude toward death. Each of the four goals was addressed through various means during the death education course used in the present study. Examples of information sharing included providing didactic instruction on stages, phases, and tasks of mourning, as well as principles, procedures, and techniques for working with bereaved clients. Values clarification was addressed through small group exercises and a death attitudes exercise that assisted participants in identifying their views on various types of death, including death with dignity, denial, defiance, and acceptance, as well as the meanings made from death. The development of effective coping behaviors was addressed through open discussion and the fostering of self-awareness, and the adoption of a positive attitude toward death and dying was achieved through verbal debriefing and participants' journaling. Debriefing, journaling, and role playing also addressed what Wass (2004) referred to as the personal dimension in death education, which "is the component intended to help students to deal with their anxieties, to become comfortable interacting with people in crisis, and to develop empathy" (p. 298).
The purpose of this study was to review the impact of death education on the attitudes of counselors-in-training toward death. The following research question was addressed: How does attending a 2-credit-hour, 30-hour course on death education influence the current attitudes of counselors-in-training toward death and dying, and grief and loss?
The course goals or objectives for the death education class in this study were as follows:
1. The student will increase awareness of personal and cultural attitudes, beliefs, and feelings about loss and grief.
2. The student will have an understanding of the multifaceted nature of grief, grief counseling, and the issues that inhibit successful grieving.
3. The student will understand grief as it relates to a variety of situations, including death, disability, divorce, life cycle phases, grief among children, and unacknowledged and disenfranchised situations.
4. The student will have a basic understanding of the skills and techniques for counseling the grieving client and client system.
The following topics and activities were included during the course:
Day 1: Why Study Death and Grief? Attitudes Exercise and Personal Reflection Counselor Self-Care
Day 2: Understanding Death Via Media, Literature, World Religions, and Environment Normative Losses Attachment Bereavement, Grief, and Mourning Grief Symptoms
Day 3: Mourning: Stages, Phases, and Task Mediators of Mourning Funeral Customs and Rituals Guest Speaker: Funeral Director
Day 4: Field Trip: Visit Funeral Home Grief Across the Life Span Multicultural Differences in Death Attitudes and Mourning
Day 5: Grief Counseling: Who, What, When, Where Counseling Principles, Procedures, and Techniques Role-Play Grief Counseling in Groups
Day 6: Complicated Mourning and Grief Therapy Differential Diagnosis Role-Play
Day 7: Guest Speaker: Hospice Representative Addressing Unique Losses Grief and the Family System Grief and Communities
Day 8: Compassion Fatigue Closing Activity and Processing
Participants consisted of 11 graduate counseling students enrolled in an elective summer course addressing death and dying, and grief and loss. In accordance with the institutional review board approval, students were informed that their participation was voluntary. Course credit was offered for their participation. An alternative assignment was offered to students who might not want to participate; however, all students enrolled in the course volunteered to participate in the study. The 2-credit-hour class, taught by the first and third author, consisted of 30 hours of didactic and experiential activities whereby the class was held in the mornings on Monday through Thursday for 2 consecutive weeks. Participants consisted of six women (55%) and five men (45%). Counseling majors included four participants in mental health counseling; three in school counseling; and four in marital, couple, and family counseling. Ten participants (91%) reported to be White, whereas one participant (9%) reported to be White/Hispanic. Participants ranged in age from 25 to 42 years, with a mean age of 31.45 years. Eight participants (73%) reported to be from the Church of Jesus Christ of Latter-day Saints; one participant (9%) reported to be Christian; one participant (9%) reported that she did not belong to a religion; and one participant (9%) stated that she was spiritual, not religious. One participant (9%) reported that he had previously participated in a death education course, whereas the remaining 10 participants (91%) had not. Two participants (18%) reported that they had not experienced significant personal loss through death, whereas nine participants (82%) reported having had experienced significant personal loss through death. One participant reported that he had a near-death experience as a child.
Data Collection and Trustworthiness
We addressed participants' current attitudes regarding death by using a free-response narrative (Holcomb, Neimeyer, & Moore, 1993). The research packet was administered by the third author and consisted of a brief demographic questionnaire and a form providing participants with three pages of blank lines to reply to the following: "Use the space provided below to reflect on your current thoughts regarding death and dying." Participants were asked to write this personal narrative at the beginning of the course and again at the end of the course. The narrative format was used to give participants the opportunity to uniquely express their individual beliefs and values associated with death. A coding manual from Neimeyer, Fontana, and Gold (1984) was adopted for content analysis of the narrative. This study also incorporated ideas for adaptation from Holcomb et al. (1993) and considered those found in Yang and Chen (2006). Definitions for this study included 15 death constructs divided into the following categories: purposefulness, evaluations, negative emotional state, low acceptance, understanding, suffering, personal involvement, temporal expectation, certainty, existence, choice, specificity, impact, causality, and wishful thinking. Eleven of the 15 constructs included properties with various dimensions (i.e., purposeful or purposeless, positive or negative, high or low, long range or short range, existence or nonexistence, specific or general, and known or unknown). See Holcomb et al. for a complete description of the constructs.
Trustworthiness within qualitative inquiry relates to the rigor and soundness of a study. A study is considered trustworthy if it demonstrates credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Credibility is achieved when participants are considered information-rich sources giving accurate and relevant information. In this study, participants were counselors-in-training providing insight into their beliefs and attitudes toward death at the beginning and end of a death education course. Transferability is achieved when the reader believes the information given is of value in other contexts. Essentially, this aspect of trustworthiness is accomplished when the reader deems the information useful. We believe that investigating the impact of death education on attitudes of counselors-in-training concerning death, dying, grief, and loss is an important step in understanding the value of this type of education and its role in preparing counselors. Dependability is achieved when the researcher can account for the process used in the research. We chose a free-response narrative to capture the nuance of attitudes of counselors-in-training at the beginning of a death education course and at the completion of the course. A coding manual for content analysis of death constructs was utilized because this approach has been shown to be trustworthy in previous studies (Holcomb et al., 1993; Yang & Chen, 2006). Finally, confirmability is achieved when the researcher is able to demonstrate objectivity and findings that are the logical result of the data collected. In this study, steps to maintain objectivity are described below. Without these elements of trustworthiness, research is not seen as scientific inquiry and is not deemed credible.
Several procedures are recommended to ensure trustworthiness. These include prolonged engagement, persistent engagement, triangulation, and audit trail (Lincoln & Guba, 1985). Prolonged engagement deals with our commitment to spending enough time in the environment of the phenomenon being studied. Prolonged engagement was sustained in this study by extensive research of the literature related to thanatology and death education, our experiences in previous death education courses, our prior and ongoing relationships with the participants (all students had completed 1 year of graduate studies in the current department), and time spent reviewing and coding the narratives. Persistent engagement helps to ensure that we do not lose objectivity while achieving prolonged engagement. Persistent engagement involves a process of exploring all possible alternative theories to explain findings. Triangulation involves using several resources to verify and gather information (one form is peer debriefing). Persistent engagement and triangulation were achieved through active discussions during the coding process. The audit trail documents the entire research process. We kept an audit trail of all procedures and information gathered. All data were kept in a safe and secure location throughout the process. All originals and copies of materials were kept in a manner consistent with maintaining confidentiality. Written responses were received directly and anonymously from the participants; therefore, it was not necessary to make additional member checks.
The research question for this study was as follows: How does attending a 2-credit-hour, 30-hour course on death education influence the current attitudes of counselors-in-training toward death and dying, and grief and loss? Holcomb et al.'s (1993) coding system with 15 death-related constructs provided a framework for the content analysis. Each author was provided the list of the death constructs along with a description and example of each construct. For ease of coding, the pre and post free-response narratives were transcribed and checked for accuracy. Utilizing the codes from Holcomb et al., we first independently coded the responses line by line (Corbin & Strauss, 2008). During the open coding process, we discovered that each of us identified additional constructs that were not included in the Holcomb et al. coding system. We agreed we would make note of all constructs we identified that were not included in the framework. Next, we met and engaged in a line-by-line constant comparative analysis until we reached consensus on each construct. To elaborate on and to bring in variation of the general properties and dimensions found in the prenarrative, we conducted a comparative analysis of the pre and post free-response narratives. During the process of data analysis, the third author recorded our process and content observations in the form of memos (Corbin & Strauss, 2008). Through the process of axial coding (Corbin & Strauss, 2008), three dominant developmental themes emerged in the content analysis of the pre and post free-response narratives. The themes included an increased openness to looking at death constructs, greater understanding of personal beliefs regarding death in general and one's own death, and a reduction in negative emotional state (i.e., participant's fear of death).
Several themes emerged following the death education course. One theme found in the free-response narratives was openness to examining death and death constructs. Examples of participants' statements that reflected this theme include "I want to be open with my kids in talking about this topic. ... I think it would be helpful in not making it a taboo subject and to talk about our thoughts on this topic before it occurs," "I found myself reflecting on my personal beliefs a lot more," "Before taking this class I never thought of death or dying, let alone about how I wanted to be buried," and "I can say that I have a growing interest in the subject of grief and loss and look forward to gathering a large library on the subject."
A second major theme found in the free-response narratives was a greater understanding of beliefs regarding death in general and one's own death. Examples of this shift include "I am so glad now that I have learned more about the process of the people who have had someone die and also to have my eyes open so I know what to do if someone close to me were to die," "I've learned that grieving can take a long time and that different people have individual differences in how they cope or don't cope," and "I have realized things I want and need to change, what I would do differently, and how I could do them."
A third theme derived from the analysis was reduction in negative emotional state. Namely, the postnarratives suggest a reduced fear of death after completing the course. One participant initially wrote, "Frankly, I am afraid of dying .... I also fear death not only for myself but for my loved ones and what would be left behind for them," and in the second round indicated, "I concluded that it was not death that I was scared of as much as how I have lived my life." Another participant initially wrote, "Me personally, I am scared of death, I don't want to leave my family and friends," and in the second round indicated, "Through this class I feel like I have learned so much and I feel better prepared to handle death, and I am not as scared to die as I was before." Other examples of statements suggesting a reduction of fear include "At first I felt this class was making [my fear] worse. Now I have a calm feeling in my chest. Which leads me to believe that my anxiety has gotten less" and "I think that in recognizing that this even is so much beyond my control I have changed focus some on living and enjoying life right now."
The aim of this study was to ascertain the impact of a 2-credit-hour, 30-hour death education course on the current attitudes on death and dying, and grief and loss, of counselors-in-training. The research question examined how attending a course on death education influenced the current attitudes of counselors-in-training on death and dying, and grief and loss. Three themes emerged: an increased openness to looking at death constructs, greater understanding of personal beliefs regarding death in general and one's own death, and a reduction in negative emotional state in the form of the participant's fear of death. These findings are in line with past research that found positive effects of death education on comfort and coping of participants (Bugen, 1980; Servaty & Hayslip, 1997; Smith-Cumberland, 2006; Wong, 2009).
The aforementioned findings can be attributed to several experiences within the context of the death education course. An increased openness to looking at death constructs may have been achieved by the students' exposure to constructs related to death, dying, grief, and loss, which assisted in lessening or removing the mystery surrounding grieving and what happens to the body after death. It is also plausible that individuals who signed up for a death education course were already somewhat open to learning more about the topic. A greater understanding of personal beliefs regarding death in general and one's own death may have been the result of participants engaging in exercises such as a death attitudes exercise that explored the meaning behind certain types of death (i.e., death with dignity, denial, defiance, and acceptance) and engaging in journaling after each class. Reduction in negative emotional state in terms of the participant's anxiety toward death is in line with Bugen's (1980) findings that reported more comfort and increased coping in students after attending a seminar on death education. A lessening of death anxiety could be accounted for by incorporating death and dying into the context of the life cycle and recognizing implications of the impact on loved ones when a death occurs outside of what is considered to be a normal life cycle (e.g., death of a child, death by homicide). Finally, as Maglio and Robinson (1994) pointed out, if information on death and dying is not processed emotionally, exposure to such information has the potential to increase death anxiety. In the current course, not only were the participants encouraged to process the information via journaling, but ample time was given during and at the close of each class time for processing and integrating the material.
Experience of the Authors During Coding
Several points of interest emerged during the coding process that warrant special attention. An important point of discussion for this study was our own experience during the coding process. Despite Holcomb et al. (1993) reporting a high degree of agreement on the death constructs' definitions (i.e., 89% for a subsample of 20 paragraphs), we experienced variation in our interpretation of constructs. For example, the third author did not want to categorize feelings as being "negative" and therefore rarely coded a response as including a "negative emotional state," instead using the construct of "high impact" for responses indicating emotions such as sadness, fear, or confusion. In addition, the first author saw responses in which the participant indicated death as being part of "the circle of life" or "part of the natural order" of things as having to do with the construct of "specificity-general: suggesting the generality of death," whereas the second and third authors consistently coded these types of responses as "purposeful: suggesting the meaningfulness of the death, its having some justification ethically, psychologically, or naturally." Furthermore, the second author found it difficult to use the constructs given and was consistently creating her own in an attempt to capture more nuance. For example, she noted that many of the responses were religious in nature, but there was not a construct that dealt specifically with religion and/or spirituality. These tendencies, and others, were discussed throughout the process and noted in the form of memos.
During the initial coding of the pretest, we noted several responses in which participants identified as having little to no experience with death but later in the same response spoke of death experiences. It may be that these participants did not believe that their experiences were severe enough to warrant real attention. However, we regarded many of the experiences as meaningful and sometimes disenfranchised (i.e., pet dying, ex-boyfriend dying). A possible explanation for this reluctance to acknowledge these death experiences may be the lack of public recognition of the loss or indicative of a societal message that individuals should "move on" from their grief. It is also possible that participants had such discomfort addressing issues of death and dying that they did not want to acknowledge these experiences.
Implications for Counselor Education
At the core of counselor education is the need for counselors-in-training to develop greater self-knowledge (Auger, 2004). As part of standard practice, counselors-in-training are challenged to recognize personal values and belief systems and uncover biases that may hinder work with particular clients. For some students, this awareness may include personal attitudes toward death and dying, but because death education is not required or even available in some institutions (Rosenthal, 1981; Wass, 2004), it is likely many counselors-in-training never have this type of introspection.
According to Kirchberg and Neimeyer (1991), beginning counselors reported that discussing issues related to death and dying made them more uncomfortable than discussing other presenting problems. In the present study, qualitative findings suggest that many participants were more open to analyzing and discussing issues related to death and dying following a death education course. The students' initial reluctance may be due, in part, to society's taboo attitudes toward discussing death resulting in students' lack of exposure to these issues. Once exposed to topics surrounding death, students may feel more comfortable with these topics and more willing to address them as they relate to the self, clients, and others. More research is needed to see whether death education increases students' openness to analyzing and addressing issues of death and dying.
Finally, it is important to mention as anecdotal evidence that in discussions following the course, students overwhelmingly reported that they felt better prepared to address issues of death and dying with their clients. In particular, students noted that they had learned the importance of recognizing the uniqueness of grief instead of conceptualizing from a more universal, stage perspective. Many indicated that they felt they could better recognize issues of loss and grief with their clients and would not be as fearful to address these issues in the future.
In light of the qualitative findings, for these students, attending the death education course resulted in an increased openness to looking at death constructs, a greater understanding of personal beliefs regarding death in general and one's own death, and a reduction in the fear of death. It seems that this type of course may be beneficial to counselors-in-training. As noted earlier, Kirchberg et al. (1998) suggested that fear of death among counselors-in-training may be a factor in not adequately addressing issues of death and dying with clients. If future research supports the findings of this study, students may be better equipped to effectively deal with clients' issues relating to grief and loss through death education. Currently, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) has not specifically included grief and loss in its curriculum standards. The CACREP 2009 Standards include related concepts such as understanding transitions and all aspects of human development (CACREP, 2009) but do not expressly include issues of death, dying, grief, and loss. Given the fear that some counselors-in-training have about these issues and the certainty that they will work with clients facing loss, it seems reasonable that if future research supports our findings, CACREP would include this type of course work within its standards. Increasing the number of standards may be challenging because of an already crowded curriculum, but we believe that the importance of these topics outweighs the difficulty of introducing new material to programs.
We cannot ignore the impact of participants' personal experiences of death prior to participating in the death education courses. These personal experiences shape people's death systems, resulting in differences in meaning making, and may influence participants' scores on a measure of death anxiety (Florian & Mikulincer, 1997; Hurtig & Stewin, 1990) and the contents of their personal narratives. Death systems are all encompassing. They include the words and actions used in relation to death derived from all human experiences up to the current point in time and influence cognitions, affect, and behavior. A person's death system dictates his or her thoughts, feelings, and behavior in relation to death, dying, and bereavement (Kastenbaum, 1986; Kastenbaum & Aisenberg, 1972). Participants who had experienced a death of a loved one may have attached different meaning to the experiential activities than did those who had not experienced personal loss through death.
In light of the findings, it is imperative that this line of inquiry be expanded to include a diverse group of students. The participants in the study were predominantly White and identified their religious affiliation as belonging to the Church of Jesus Christ of Latter-day Saints. It has been found that some religious variables negatively correlate with death anxiety (Alvarado, Templer, Bresler, & Thomas-Dobson, 1995; Harding, Flannelly, Weaver, & Costa, 2005; Thorson, 1991; Wink, 2006; Wink & Scott, 2005). Therefore, participants' attitude and fear toward death may have been due to preestablished levels of death anxiety mitigated by religious beliefs and practices.
Next, we acknowledge the importance of coding the free-response narratives blindly to eliminate potential bias during the coding process. The anonymity of some responses was compromised because we recognized the voices of participants from class discussions and previous written work. It may be beneficial to use participants who are not familiar to the researcher. Also, in future studies it may be beneficial to extensively discuss the alternative meanings of these constructs prior to the coding process, to use these constructs as a starting point and create more constructs, or to code without the aid of the list of death constructs (Holcomb et al., 1993).
Finally, this study focused on the development of death attitudes as a means of measuring the efficacy of a death education course. It would be beneficial in future studies to consider other measures of change, including participants' change in behavior toward clients experiencing concerns related to death and dying. For example, over time, do participants use increased empathy with clients who are experiencing grief and loss compared with those who did not participate in a death education class? Future studies with counselors-in-training might also include mixed-design methods because there are a number of quantitative instruments that assess death attitudes, such as the Multidimensional Fear of Death Scale (Hoelter, 1979; Neimeyer & Moore, 1994). We view this study as an initial attempt at investigating death education in counselors-in-training. More research needs to be conducted to provide information as to whether death education has a lasting impact on counselors-in-training.
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Laura K. Harrawood, Professional Counseling Program, McKendree University; Elizabeth A. Doughty, Department of Counseling, Idaho State University; Brandon Wilde, Department of Counselor Education, Adams State College. Correspondence concerning this article should be addressed to Laura K. Harrawood, Professional Counseling Program, McKendree University, 701 College Road, Clark Building, Lebanon, IL 62254 (e-mail: Ikharrawood@mckendree.edu).
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|Author:||Harrawood, Laura K.; Doughty, Elizabeth A.; Wilde, Brandon|
|Publication:||Counseling and Values|
|Date:||Oct 1, 2011|
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