Mary Alice Varga
University of West Georgia

Bethany Lanier
University of West Georgia

Duke Biber
University of West Georgia

Bridgette Stewart
University of West Georgia

            This study examined the relationships between holistic grief effects experi-
            enced by college students, mental health, and the use of various counseling
            supports. A total of 1,092 college students completed an online survey about
            their losses, holistic grief effects they experienced, and the various types of
            counseling support they utilized while grieving. Students also shared prior
            diagnoses of depression, eating disorders, insomnia, attention-deficit/hyper-
            activity disorder (ADHD), and post-traumatic stress disorder (PTSD). Of the
            842 students who experienced a loss, students reported emotional, cogni-
            tive, behavioral, physical, interpersonal, and world assumption grief effects.
            Approximately 10% of students utilized off-campus professional counseling
            support, and 8% used campus counseling center support. An even smaller
            number of students utilized face-to-face peer support groups or online sup-
            port groups. Students who utilized on-campus counseling and off-campus
            professional counseling reported significantly more holistic effects in all ar-
            eas. Students who utilized online support groups reported significantly more
            physical grief effects, and students who utilized face-to-face-support groups
            reported significantly more physical, cognitive, behavioral, and interperson-
            al grief effects. Statistically significant associations were found for students
            diagnosed with depression and their use of both off-campus professional
            counseling and campus counseling center support, as well as previous ADHD
            diagnoses and use of campus counseling center support. Implications for
            universities is addressed and recommendations for future research are also

Please direct inquires about this manuscript to: Mary Alice Varga, maryalice@westga.edu

College Student Affairs Journal, Volume 39(1), pp. 1 - 13				                                   ISSN 2381-2338
Copyright 2021 Southern Association for College Student Affairs All rights of reproduction in any form reserved.
2								                                          College Student Affairs Journal   Vol. 39 No. 1, 2021

      he profile of college students is chang-   Vickio, Cavanaugh, & Attig, 1990).
      ing in a variety of ways, specifically           Physical grief effects are also outlined
      regarding mental health. The World         in college student bereavement research.
Health Organization (WHO) recently re-           Crying is the most frequent physical reac-
vealed in their WHO World Mental Health          tion, followed by headaches and insomnia
International College Student project that       (LaGrand, 1981). Insomnia in bereaved
mental health disorders among college stu-       students is particularly important because
dents are rising. Commonly diagnosed dis-        those experiencing insomnia are also at risk
orders include major depression, mania/hy-       of developing complicated grief symptoms
pomania, anxiety, panic, as well as alcohol      (Hardison, Neimeyer, & Lichstein, 2005).
and drug abuse. Approximately 31% of stu-             Bereaved college students can experi-
dents met diagnostic criteria for at least one   ence cognitive grief effects. College students
of these disorders. The WHO report also in-      have shown to have statistically significant-
dicated that campuses often do not have the      ly lower grade point averages during the se-
resources to meet the demand for services        mester of a loss experience when compared
(Auerback et al., 2018). Campus counseling       to peers (Servaty-Seib & Hamilton, 2006).
centers provide services for these disorders     Students who were close to the deceased
and others with insufficient means to meet       were more likely to experience changes in
all student needs for counseling.                motivation and concentration. Furthermore,
     Another reason that students seek coun-     the closer students are with the deceased,
seling is for grief support. Approximately       the more academic struggles they encoun-
35% of undergraduate students and 25%            tered (Walker et al., 2012).
of graduate students are within 24 months             Bereaved college students can also ex-
of bereavement (Pollard, Varga, Wheat,           perience behavioral grief effects. These ef-
McClam, & Balentyne, 2017; Varga, 2015;          fects include high-risk behaviors, such as
Varga & Varga, 2019; Walker, Hathcoat, &         problematic alcohol consumption, tobacco
Noppe, 2012). Grieving undergraduate and         use, drug use, or disordered eating (Balk,
graduate students are most likely to have        2011; Balk & Vesta, 1998; Beam, Ser-
experienced the death of a family member         vaty-Seib, & Mathews, 2004). Increased
and experience various grief effects follow-     death awareness is also linked to increases
ing a loss.                                      in high-risk sexual behavior (Taubman-Ben-
     The Holistic Impact of Bereavement il-      Ari, 2004).
lustrates the multi-dimensional effects of            Bereaved college students can also
grief on college students, including physical,   experience interpersonal grief effects, in-
cognitive, behavioral, interpersonal, emo-       cluding isolation and loneliness (Balk, Ty-
tional, and spiritual/world assumption ef-       son-Rawson, & Colletti-Wetzel, 1993). Vary-
fects (Balk, 2011). Both undergraduate and       ing expectations in grief recovery between
graduate students have reported various          bereaved and non-bereaved peers can oc-
grief effects, primarily emotional and cog-      cur, thus impacting interpersonal connec-
nitive effects (Balk, Walker, & Baker, 2010;     tions (Balk, 1997). Students can perceive
Pollard et al., 2017; Varga, 2015; Walker        grief as the increasing closeness of relation-
et al., 2012). The landmark study on col-        ships, decreasing closeness, or straining re-
lege student loss showed depression as the       lationships (Vickio et al., 1990). Change in
most frequent emotion followed by empti-         peer relationships can be perceived more
ness and anger (LaGrand, 1981). Emotional        by grieving students with mental health dif-
reactions reported by students in research       ficulties (Cupit et al., 2016). Even though
have consistently included sadness or de-        peers often want to support their bereaved
pression, anger, shock, disbelief, fear, and     friends, non-bereaved peers can become
denial (Balk, 1997; Balk & Varga, 2018;          uncomfortable when finding out their friend
Holistic Grief Effects                                                                         3

has experienced a loss and is grieving (Balk      The researchers hypothesized that college
et al., 1993; Parikh & Servaty-Seib, 2013).       students would experience holistic grief ef-
     Spiritual, religious, and philosophical/     fects in all six dimensions outlined in the
world assumption effects can be experi-           Holistic Impact of Bereavement, primarily in
enced by bereaved students. Recent stud-          the dimensions of emotional and cognitive
ies have shown that college students report       effects, and that a small number of students
their world assumptions being affected by         would utilize counseling services for grief
their loss (Pollard et al., 2017; Varga & Var-    support. The researchers also hypothesized
ga, 2019). World assumptions are “changes         that there would be no significant relation-
in thoughts regarding religion or spirituali-     ship between holistic grief effects and grief
ty” (Pollard et al., 2017, p. 7). Students en-    counseling supports.
gage in religious practices as a means to
cope with loss (Balk, 1997; Balk, 2008).                             Methods
Schwartzberg and Janoff-Bulman (1991)                  This study utilized an online cross-sec-
found that bereaved students believed in a        tional survey research design. The site for
less meaningful world than non-bereaved           this study was a university located in the
students. Bereaved students also report-          Southeast United States with a student
ed believing that events happen more by           population of approximately 12,000 stu-
chance and lacked control.                        dents. Once the Institutional Review Board
     Overall, there are a variety of adverse      and the Division of Student Affairs approved
grief effects college students can experience     the study, the Office of Information Technol-
when losing a loved one. For students strug-      ogy granted permission to access student
gling with negative grief effects, campuses       email addresses. An online survey invitation
and communities are equipped with coun-           was emailed to all students at the institution
seling services to support them, although         who provided consent to have their email
students report they are more willing to talk     address shared for research purposes. Prior
about their grief with peers than counselors      to the survey, students were given an in-
(Balk, 2008; Servaty-Seib & Taub, 2010).          formed consent statement that included an
The purpose of this study was to examine          overview of the study, the voluntary nature
the holistic grief effects students experience,   of participation, safeguards taken to protect
whether students utilize counseling support       anonymity, and contact information for the
while grieving, and if differences exist be-      researchers and the Institutional Review
tween students who use various counseling         Board. Given the sensitive nature of the
supports and those who do not.                    topic, contact information was provided for
     The research questions guiding this          counseling services located on the univer-
study were:                                       sity campus and for a local 24-hour mental
     1. What holistic grief effects do college    health provider.
     students experience?
     2. What incidence of college students        Instrumentation
     utilize counseling support while griev-           The survey for this study consisted of
     ing?                                         questions developed by the researchers re-
     3. What is the relationship between ho-      garding grief experiences, holistic grief ef-
     listic grief effects and grief counseling    fects experienced, and counseling supports
     support?                                     utilized to help cope with grief. Students also
     4. Is there a statistically significant      shared prior diagnoses of depression, eating
     association between previous mental          disorders, insomnia, attention-deficit/hy-
     health diagnoses and the use of various      peractivity disorder (ADHD), and post-trau-
     grief counseling supports?                   matic stress disorder (PTSD). Loss was de-
                                                  fined as a “death-related loss” or the death
4								                                             College Student Affairs Journal   Vol. 39, No. 1, 2021

loss of a person or pet (Corr, Corr, & Doka,        ing, smoking, drinking, sexual promiscuity,
2019, p. 215). Students who did not experi-         irrational outbursts, etc. (behavioral); 5)
ence a death loss were directed to the end of       changes in thoughts regarding religion or
the survey. Those who did experience grief          spirituality, searches for life meaning, etc.
were asked the remaining survey questions.          (world assumptions); and 6) relationship
Students answered specific questions about          changes with others, feelings of isolation,
the person or pet they lost, including the          etc. (interpersonal). Students responded to
date, cause, relationship, and closeness. If        each dimension on a scale of “Not affected
they experienced multiple losses, students          at all” to “Significantly affected” with an ad-
were asked to answer questions pertaining           ditional option “Prefer not to respond.” Stu-
to the loss they considered they grieved the        dents were also asked to respond to wheth-
most.                                               er they used various counseling supports,
     Students reported holistic grief effects       including professional counseling support
they experienced outlined in six dimensions         (off-campus), counseling center on-cam-
created from the Holistic Impact of Bereave-        pus, online support groups, and face-to-
ment (Balk, 2011). The dimensions were              face peer support groups. Students select-
listed, along with examples for each one,           ed “Used this support” or “Did not use this
which included 1) feelings of sadness, anger,       support.”
guilt, regret, etc. (emotional); 2) fatigue, ill-
ness, headaches, insomnia, etc., (physical);        Sample
3) difficulty concentrating, studying, paying          The sample for this study consisted of
attention in class, etc. (cognitive); 4) cry-       1092 college students. The majority of stu-
Holistic Grief Effects                                                                       5

dents who completed the survey were female                         Results
(n = 889, 82%) and identified as white, not    Grief Effects
of Hispanic origin (n = 688, 63%). When             The first research question for this study
asked about specific diagnoses, 8% of stu-     was: What grief effects do college students
dents (n = 91) indicated having an ADHD        experience? Effects were measured on a
diagnosis. Students also reported being di-    five-point scale ranging from “Not affected
agnosed with depression (n = 207, 19%),        at all” (score of 1) to “Significantly affected”
eating disorders (n = 30, 3%), insomnia (n     (score of 5). Students reported emotional
= 67, 6%), and post-traumatic stress disor-    grief effects as the strongest followed by
der (n = 46, 4%). Most students (n = 842,      strong cognitive, behavioral, physical, and
77%) reported experiencing a loss, with        interpersonal grief effects. Moderate world
most occurring more than 36 months ago         assumption effects were also reported (see
(n = 420, 50%). Although the most com-         Table 2).
mon cause of death was illness (n = 555,              Grief effects were also examined for
67%), most losses were unexpected (n =         students who reported diagnoses of ADHD,
537, 49%). The most common relationships       depression, insomnia, PTSD, or eating dis-
to the deceased included grandparents (n       orders (see Table 3). Students who report-
= 335, 40%). When asked how close they         ed ADHD, depression, insomnia, and PTSD
were to the person they lost, more than half   diagnoses reported stronger grief effects in
of the students reported being “very close”    all six dimensions when compared to the
to this person (n = 495, 59%). Table 1 out-    overall population. Students with eating
lines all student grief experiences.           disorder diagnoses reported stronger cog-
6								                                       College Student Affairs Journal   Vol. 39, No. 1, 2021

nitive, physical, interpersonal, and world    Grief Effects and Counseling Support
assumption grief effects when compared to          The third research question sought to
the overall population.                       answer, What is the relationship between
                                              holistic grief effects and grief counseling
Counseling Support                            support? Relationships were examined spe-
    The second research question for this     cifically for professional counseling support
study was: What incidence of college stu-     (off-campus), campus counseling, online
dents utilize counseling services for grief   support groups, and face-to-face grief sup-
support? Students reported their use of       port groups. A Mann-Whitney U test was
professional counseling support, student      conducted to compare differences in holis-
counseling center on-campus, online sup-      tic grief effects based on the use of each
port groups, and face-to-face peer support    support. A Mann-Whitney U test was utilized
groups (see Table 4). Of the 842 students     because the data violated the assumption
who experienced a loss, only 10% (n = 85)     of normality, as assessed by Shapiro-Wilk’s
of students utilized professional counsel-    test. A 95% confidence level was used for
ing support (off-campus), and 8% (n = 69)     this statistical test (α = .05). The results of
used campus counseling center support. An     the Mann-Whitney U tests reveal statistical-
even smaller number of students utilized      ly significant differences in scores for pro-
face-to-face peer support groups (n = 44,     fessional counseling use on emotional (p =
5%) or online support groups (n = 13, 1%).    .000), physical (p = .000), cognitive (p =
                                              .000), and behavioral (p = .005), world as-
Holistic Grief Effects                                                                            7

sumptions (p = .000), and interpersonal (p          support. The expected frequencies profes-
= .000) holistic grief effects (see Table 5).       sional off-campus counseling, on-campus
A Mann-Whitney U test also revealed sta-            student counseling center, ADHD diagnoses,
tistically significant differences in scores for    and depression diagnoses were greater than
campus counseling use on emotional (p =             five, indicating an adequate sample size to
.002), physical (p = .000), cognitive (p =          run each chi-square test. Online support
.000), and behavioral (p = .000), world as-         groups, face-to-face support groups, eating
sumptions (p = .000), and interpersonal (p          disorders, insomnia, and PTSD did not have
= .000) holistic grief effects (see Table 6).       an expected frequency of five or greater and
Statistically significant differences in scores     were eliminated from analysis.
were found for online support groups use on              The chi-square test of independence run
physical grief effects (p = .030) (see Table        for ADHD diagnoses and use of off-campus
7). Finally, statistically significant differenc-   professional counseling showed no statisti-
es in scores for face-to-face support groups        cally significant association between ADHD
use were found for physical grief effects (p        diagnoses and use of off-campus profes-
= .004), cognitive (p = .000), behavioral (p        sional counseling, X2(2) = 1.85, p = .369.
= .043), and interpersonal (p = .022) holis-        There was a statistically significant asso-
tic grief effects (see Table 8).                    ciation between ADHD diagnoses and use
                                                    of on-campus counseling centers, X2(2) =
Previous Mental Health Diagnoses and                9.485, p = .009, although the association
Grief Counseling Support                            was small (Cohen, 1988), Cramer’s V = .111.
    The final research question examined            There was also a statistically significant as-
whether there was an association with pre-          sociation between depression diagnosis and
vious mental health diagnoses (ADHD, de-            use of off-campus professional counseling,
pression, eating disorder, insomnia, and            X2(2) = 47.80, p = .001, with a small to
PTSD) and use of various grief counseling           moderate association (Cohen, 1988), Cram-
supports (professional counseling off-cam-          er’s V = .247. Lastly, there was a statistically
pus, on-campus counseling center, online            significant association between depression
support group, and face-to-face support             diagnosis and use of on-campus counseling
group). A chi-square test of independence           centers, X2(2) = 7.917, p = .019, with a
was conducted between previous mental               small association (Cohen, 1988), Cramer’s
health diagnoses and each grief counseling          V = .101.
8								   College Student Affairs Journal   Vol. 39, No. 1, 2021
Holistic Grief Effects                                                                         9

                 Discussion                       prolonged or complicated grief (Hardison et
     The findings from this study indicate that   al., 2005). The more aware college student
a majority of college students surveyed have      personnel are of the connections among
experienced a loss. Furthermore, students         grief and these effects, the more vigilant
experienced holistic grief effects as a result    they can be to assist bereaved students.
of their loss in various dimensions, includ-           Students do not always need an abun-
ing emotional, cognitive, behavioral, phys-       dance of support while grieving. Students
ical, interpersonal, and world assumptions.       have previously reported preferring sup-
These results are consistent with previous        port from peers, especially other bereaved
research on college student grief. Students       peers, instead of counseling or other sup-
consistently report grief effects in all dimen-   ports (Balk, 2008; Servaty-Seib & Taub,
sions with emotional and cognitive effects        2010). These preferences, combined with
as the most affected (Balk et al., 2010; Pol-     the fact that campus counseling centers
lard et al., 2017; Varga, 2015; Walker et al.,    are overwhelmed and understaffed, call for
2012). Since grief can manifest in students       universities to recognize other appropriate
in many ways, it is important for students to     and welcomed grief supports for students.
be aware of the various effects experienc-        One approach is social media grief support.
ing a loss can have on them. It is also im-       Students have shown utilizing social media
perative for higher education faculty, staff,     as grief support in various ways and report
and counseling support to identify these          that support as helpful (Balk & Varga, 2018;
effects as well. Accurately identifying caus-     Varga, 2015; Varga & Varga, 2019). For stu-
es of student behavior can ensure proper          dents needing other support, college stu-
ways to determine support and healthy cop-        dent personnel can assist in various ways.
ing trajectories. As the number of mental              As university faculty, staff, and counsel-
health issues rises in college students, the      ing support become more aware of the var-
importance of addressing these grief symp-        ious ways that grief can affect students, the
toms also increases. Prolonged grieving dis-      more targeted they can come in providing
orders have been associated with bereaved         support. College campuses are already ded-
students with mental health issues (Mash,         icated to helping students in holistic ways
Fullerton, Shear, & Ursano, 2014; Salloum,        that complement the Holistic Impact of
Bjoerke, & Johnco, 2019). Grief effects, such     Bereavement (Balk, 2011). Students have
as insomnia, have been specifically linked to     suggested increasing sensitivity on college
10								                                           College Student Affairs Journal   Vol. 39, No. 1, 2021

campuses for grieving students (Cupit, Ser-        the sample of students who participated in
vaty-Seib, Parikh, Walker, & Martin, 2016).        the study were majority female (82%), thus
This can be accomplished in many ways.             not adequately representing students who
Faculty, academic advisors, and academic           identify as males. Finally, holistic grief ef-
support programs that target student ac-           fects were measured using one self-report
ademic success can be trained to become            measure. Including additional measures,
aware of cognitive effects related to grief        such as those related to depression, com-
(e.g., decreasing grades, difficulty concen-       plicated grief, disordered eating, and in-
trating, inability to complete assignments,        somnia would provide additional measures
etc.). Judicial offices, who are responsible       and concurrent validity. Additional holistic
for addressing student conduct issues such         measures, such as the Multidimensional
as those related to behavioral grief effects       Wellness Inventory, would provide a more
(e.g., drug use, alcohol use, etc.), are po-       in-depth understanding of the relationship
sitioned in a way to potentially uncover the       between multi-dimensional wellness, grief,
cause of those behaviors. Student affairs          and mental health diagnoses (Mayol, Scott,
staff, especially those who interact with          & Schreiber, 2017). Wellness is a holistic,
students on a regular basis, can identify          self-determined way of living that includes
students whose social interactions change          occupational, social, intellectual, physical,
(e.g., isolation from friends, peers, etc.),       emotional, and spiritual dimensions (Hettler,
possibly due to interpersonal grief interac-       1980; National Wellness Institute, 2019).
tions. Both student affairs staff and facul-       The World Health Organization (WHO) has
ty members could benefit from training on          adopted this multi-dimensional approach to
how to respond to bereaved students (Ser-          wellness, rather than the mere absence of
vaty-Seib & Taub, 2008). Finally, student          disease (WHO, 2013). The six dimensions of
health centers and wellness programs can           wellness are interrelated and predictive of
identify grief effects in students in all di-      successful transition to college, stress man-
mensions, especially physical effects (e.g.,       agement and resilience, and health behavior
trouble sleeping, eating, headaches, etc.).        regulation (Baldwin, Towler, Oliver, & Datta,
Campuses willing to take a holistic approach       2017; Biber & Ellis, 2017; Conley, Travers,
to address grief effects can support grieving      & Bryant, 2013). Unfortunately, students in
students during these difficult times in their     higher education have reported poor well-
lives.                                             ness across all six dimensions, including
                                                   high prevalence of obesity, chronic disease,
Limitations and Recommendations for                and physical inactivity, inadequate sleep, fi-
Future Research                                    nancial instability and student loans, as well
     Although this study provides insight into     as elevated stress, depression, anxiety, and
the holistic ways that students experience         suicide (Downes, 2015; Lau et al., 2013;
grief, there are limitations to the findings.      Montalto, Phillips, McDaniel, & Baker, 2019;
First is the limitation of self-report. Students   Twenge, Joiner, Rogers, & Martin, 2018).
who are reflecting on their grief experiences      This is important because unbalanced and
may not be cognizant of the ways in which          deficient holistic wellness is predictive of
their grief affected them. Additional insight      mental health disorders in college (Keyes et
from non-bereaved peers, family, university        al., 2012; Kosyluk, et al., 2016; Prigerson et
faculty, staff, and counseling support would       al., 2018). While wellness predicts college
strengthen the findings. Secondly, the study       student transition, health behaviors, and
was limited to students at one institution.        retention, there remains a gap in how well-
Expanding the study to include students            ness may buffer against grief and enhance
from multiple institutions would make the          grief coping (Baldwin, et al., 2017; Mayol et
findings more generalizable. Furthermore,          al., 2017).
Holistic Grief Effects                                                                      11

     Longitudinal quantitative studies or          of bereaved college students. In D. Klass
in-depth qualitative studies, such as eth-         & E. Steffen (Eds.), Continuing Bonds
nographies, could provide specific insight         (2nd ed., pp. 303-316) New York, NY:
on students as they go through the griev-          Routledge.
ing process and the transition of loss in Balk, D. E. & Vesta, L. C. (1998). Psycho-
real-time. These long-term studies would           logical development during four years
also encompass the impact of multiple loss         of bereavement: A longitudinal case
events over time, which can result in signifi-     study. Death Studies, 22, 23-41. doi:
cantly more grief effects (Schwartz, Howell,       10.1080/074811898201713
& Jamison, 2018). Students who fail to cope Balk, D. E., Walker, A. C., & Baker, A. (2010).
with grief effects properly may exhibit oth-       Prevalence and severity of college student
er problematic behaviors such as drug use,         bereavement examined in a randomly se-
sexual activity, and risky behavior. Under-        lected sample. Death Studies, 34, 459-
standing the relationship between grief and        468. doi: 10.1080/07481180903251810
problem behaviors also becomes paramount Beam, M. R., Servaty-Seib, H. L., &
for understanding student success.                 Mathews, L. (2004). Parental loss and
                                                   eating-related cognitions and behav-
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