1.Jaquayle Deonte Robinson835pmApr 16 at 835pmManage Discu

1.
Jaquayle Deonte Robinson
8:35pmApr 16 at 8:35pm
Manage Discussion Entry
The chain of events that led to the death of Robin and Allison
Lowe, were the administrating of TPN solution through
intravenous tubing, administering a prescribed solution without
prescription without an written order, failure to use the two-
nurse verification system of the written order(although in Robin
case there wasn't one), assuming the solution was appropriate
for Robin, using universal tubing, and starting the solution she
thought was TPN without the nutritionist approval first.
The pending disaster could've been stopped by the nurse upon
receiving what she believed was TPN. She should've questioned
why there wasn't an written order for the TPN present. She
could have called the nutritionist or Robin's providers. The
nurse could have raised questions of why the solution she
received didn't have adequate or any tubing as well as, a
barcode.
I believe the direction of our current processes could help
prevent medical errors. EHRs have the ability to input and
track prescription orders, approving authorities and all parties
responsible in verifying the prescription as well as,
administering the prescribed medication. Reducing the amount
of departments holding prescriptions could also reduce errors.
2.
Joshua Donyeal Smith
YesterdayApr 15 at 12:13pm
What chain of events and mistakes led to the Death of Robin
and Allison Lowe, Robin's baby?
The chain of events that lead to Robin’s and Allison’s death
stem from the tubing misconnection. The events that lead up to

the nurse placing an enteral feed into Robin’s PICC are very
questionable. The nurse without a written order from a
physician, and a second check gave her this bag of enteral
nutrition. There was even a message on the bag that stated not
for IV. The tubing for bags did not match the PICC. Yet the
nurse found a way to rig it to fit. Once the hospital discovered
the mistake that was made, their response was to send her to
another hospital. This to me seem like another failure that led to
their death.
At what point in the chain could the pending disaster have
been stopped?
The hospital must stop cases like this before they can become
cases at all. I mean to say, the access to the medicine without a
second check should be near impossible. I know that it is not
possible to prevent every misreading, mix-up, or mislabeling.
This disaster could have been stopped at the point where the
nurse overrides the hospital policy.
What processes could be put in place to prevent such an event
from occurring?
I am a strong advocate for omnicell computer systems. I know
that not all hospitals can afford these systems of have the staff
capable of operating and maintaining these machines. The added
unbiased machine helps keeps nurses and physicians honest with
time stamps, electronic orders, and ID verifications.
3.
Golnosh Sharafsaleh
WednesdayApr 14 at 6:33am
The chain of mistakes that led to the death of Robin and Allison
Lowe included Robing Receiving enteral feeds through her
PICC line. Basically, a series of assumptions and lack of
following hospital policy led to the death of Robin and her
daughter. Initially, there were no orders written by the
physician for feeding, and the nurse made an assumption based
on the plan of care rather than the actual physician's orders. The

nurse further did not follow hospital policy and have a second
nurse check orders and bag or wait for the nutritionist before
starting the bag, and the nurse didn't scan the bar code on the
medication. Unfortunately, not following protocols and taking
the steps necessary led to the death of Robin and her daughter.
At any point during the process, checking orders, having an
additional nurse check order, waiting on a nutritionist could
have prevented the mistake. Additionally, a seasoned or trained
nurse would know the difference between TPN and PPN vs.
enteral feedings. This also demonstrates that the nursing staff
did not have adequate training.
Processes that could prevent mistakes such as this include
nursing education. Changing enteral tube feeds, TPN, and PPN
tubing so that they are only compatible with the mode of
delivery. More harsh punishments when nursing staff,
physicians, and other health care staff ignore policies. In my
opinion, this nurse should have lost her license completely and
should never have worked in the medical setting or as a nurse
again. Not because of the mistake, but not following standard
protocols.
4.
Preston James Penn
6:10pmApr 16 at 6:10pm
In-group favoritism is when we have positive biases towards the
people in our group, and negative biases towards people from
another group (Robbins & Judge, 2018). According toCharness
& Chen (2020), people have a tendency to trust and cooperate
more with in-group members than out-group members because
groups comprise of a network for reputation based indirect
reciprocity, and this is a strategy to maintain a positive
reputation in the group, obtain some sort of indirect benefits
from in-group members, and avoid the cost of being disliked by
anyone in the group. This happens a lot in political circles
where people tend to favor those who have the same beliefs as

they do, and they benefit from endorsements, but also they fear
the wrath that comes with not agreeing with their in-group
members. People have grown to expect greater cooperation from
in-group members and to be more concerned about their
reputation among in-group, than out-group, members (Charness
& Chen (2020). In today’s time people are willing to make
wrong choices even when they know their choices are wrong,
they do this because it serves the greater good of their in-group,
and they are more concerned with their reputation among in-
group than out-group. According to Robbins & Judge (2018),
when there are in-groups and out-groups there is usually
hostility. Over the past few months we have seen the animosity
between Democrats and Republicans intensifying because each
group believes that they are correct compared to the other
group.
References:
Charness, G., & Chen, Y. (2020). Social Identity, Group
Behavior, and Teams. Annual Review of Economics, 12(1),
691–713. https://doi.org/10.1146/annurev-economics-091619-
032800
Robbins, S. P. (2018). Organizational behavior. New York, NY:
Pearson.
In-Group article.pdf
5.
Demarcus Jarrell Lucas
12:26pmApr 16 at 12:26pm
Greetings,
For this weeks discussion I would like to speak on the topic of
forming 'teams' in the workplace (CH.10). Over the past decade
teams in the workplace have been created and often used in
many different settings and organizations. Why are they
important and effective? "A team of people happily committed
to the project and to one another will outperform a brilliant

individual every time,” writes Forbes publisher Rich Karlgaard.
Teams can sometimes achieve feats an individual could never
accomplish.2 Teams are more flexible and responsive to
changing events than traditional departments. As we all know
the pandemic has effected us in many ways, mostly impacting
our workplace. I found a article that explains how teams were
able to work together still in the workplace even through the
pandemic but it also caused many inefficiency’s. Executives are
starting to envision post-COVID collaboration in organizational
cultures reshaped by remote work. Virtual meetings and
conferences have been keeping teams together during this
pandemic. Many workers were having trouble because all the
meetings were overwhelming and they felt "out of the loop" if
you missed a few minutes. Throughout the research, by labeling
the types of interactions a team needs and tracking the quality
of scheduled time, managers can systematically improve
collaboration. Executive's have to figure out what's effective for
their team and stick with it, in order to get projects done.
How teams work: Lessons from the pandemic. (2021, April 16).
Retrieved April 16, 2021,
from https://www.forbesindia.com/article/harvard-business-
school/how-teams-work-lessons-from-the-
pandemic/67467/1 (Links to an external site.)
Robbins, S. P., & Judge, T. (2021). Essentials of organizational
behavior. In Essentials of organizational behavior (pp. 154-
160). Hoboken, NJ: Pearson.
6.
Alicia F Jackson
YesterdayApr 15 at 11:50pm
Remote Groups
Effectively working in a group can be very rewarding but can
also be difficult. Effectively working in a group remotely can
present obstacles that employees must figure out. Remote
leadership and employees must learn how to engage, read

virtual body language, be on camera, and invest in the necessary
remote technology; the list of necessary arrangements can go on
and on.
Remote professional relationships can be difficult. Fitting in
while also in isolation can be hard. Great ideas and professional
relationships can begin around the water cooler. Remote group
leadership is also an important special skill.
As we see in the attached article, successful virtual
collaboration requires strategy, plans, and initiative!
Researchers have also labeled virtual meeting overuse as zoom
fatigue and have found psychological reasons behind it.
Sources
Lee, J. (2020, November 17). A Neuropsychological
Exploration of Zoom Fatigue. Psychiatric Times.
https://www.psychiatrictimes.com/view/psychological-
exploration-zoom-fatigue.
Sojli, E., Soattin, L., Patel, S., Lo, C., Kirshner, S. N., Oehmke,
T. B., … Cardinal, B. J. (2021). Forging remote
relationships. Science, 372(6537), 24–26.
https://doi.org/10.1126/science.abi4726
ScienceApril22021.pdf
Exhaustion Crises. Exhaustion crises are similar to pile up
crises but instead occur over a more prolonged period. These
crises occur when families experience stressors over an
extended period of time. Unlike pile up crises that involve
multiple stressors, crises of this type may be due to one stressor
that has unrelentingly beleaguered families over an extended
period of time. Take for an example a situation where a child
has a medical condition that requires repeated attention. The
medical condition is not life threateni ng but requires numerous
visits to a physician and periodic stays in the hospital. Initially
families may find this situation manageable, but after a few
months fatigue begins to take its toll on the family, disrupting
its day-to-day function. As resilience wears down and

exhaustion sets in, a crisis of some type surfaces (Patterson,
2002; Walsh, 2012b).
Ambiguous Loss. Ambiguous loss is a special type of family
crisis worth mentioning (Boss, 2006). Families having an
ambiguous crisis experience the incongruity between physical
and psychological presence and absence of family members
(Price, Price, & McKenry, 2010). Clearly an ambiguous loss
involves families with a member who is a soldier listed as
missing in action or families of passengers of the Malaysian
flight 370 that crashed and no wreckage or bodies were found.
Yet family crises of this nature also involve times when
someone may be physically present but not psychologically or
emotionally, such as family members with dementia or possibly
a chronic mental illness (Price, Price, & McKenry, 2010).
According to Price, Price, and McKenry, these crises unsettle
the functioning of families because of the lack of clarity to the
situation. The lack of clarity prevents families from
reorganizing the relationship with absent family members and
completing social rituals that enable adjustment to the loss
(Weber, 2011).
October 27, 2020 Volume 55, Number 4
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Question: How will the policy
resolutions adopted at the United
Conservative Party’s 2020 annual
general meeting affect teachers and
the Alberta Teachers’ Association?
Answer: With respect to education
and labour, the policies passed by the
UCP at its 2020 annual general meeting
run the gamut from the merely naïve to
the extraordinarily bad, and teachers
would be entirely justified in regarding
them as an attack on the profession and
the fundamental culture of education in
Alberta.
Of 30 policy resolutions considered in
virtual space by the party stalwarts, two
specifically targeted teachers as a union
and profession.
Policy 23, approved by 84 per cent,
would “prohibit any professional body
charged with regulating Teacher/
Principal certification or professional
conduct and practice from conducting
activities related to: i. collective
bargaining; ii. the administration of a

collective agreement; or iii. any matter
under the jurisdiction of the Labour
Relations Board,” effectively splitting the
Association into a union and a separate
professional body.
Policy 28, approved by 77 per cent,
w o u l d “ c r e a t e a s e l f - g o v e r n i n g
professional regulatory association for
Alberta Teachers [sic] that is responsible
for Teacher/ Principal: i. certification,
ii. professional conduct and practice,
iii. professional qualifications, and iv.
continuing teacher competency.” This
would download to a new professional
body duties currently performed
by the ATA (policing of conduct and
practice) and the Government of Alberta
(certification), while providing a structure
for compulsory, government-directed
assessment of competency, all to be paid
for out of the pockets of working teachers.
A third policy, (No. 3, conveniently),
was not specifically targeted at teachers
but would sweep up all organized labour.
Passed by 81 per cent of voting delegates,
the policy would “make Alberta a right-
to-work jurisdiction.” As defined in the
accompanying rationale, this would
entail legislation “such that no worker
can be required to join a collective
bargaining unit to be awarded or hired
in any role. Further, no employer [could]
be compelled to deduct union dues with

out [sic] the prior written confidential
consent of the employee.”
Taken together, these three policies
(and indeed many of the 27 others
passed) reveal the United Conservative
Party base to be a radical, ideologically-
driven political clique that is deeply
hostile to public services in general and
to public education and the Association
in particular. And this is why my concern
is somewhat tempered—I believe that the
several hundred delegates who voted on
these misbegotten proposals are deeply
out of touch with mainstream Alberta
and entirely ignorant of the culture of the
school and classroom that has, over the
course of many decades, made Alberta a
world leader in education.
As Premier Kenney has said previously,
he “holds the pen” and will determine
w h i c h o f t h e s e b a d i d e a s m i g h t
metastasize into legislation. Whatever
your personal beliefs about the premier,
he is a shrewd politician with a shrewd
politician’s instinct for self-preservation,
and so I expect that, discretion being the
better part of valour, these bad ideas will
be left to moulder on the shelf.
There are some important learnings to
be had here. First of all, politics in Alberta
are intensely local, and the importance
of ongoing contact with individual MLAs

cannot be underestimated. Teachers
need to exercise the skills that they
have honed in their classrooms and
communicate directly to their MLAs,
and particularly to UCP backbenchers,
why the directions proposed by these
resolutions are bad for students,
teachers, parents and the province. Our
elected representatives need to know
how having both professional and union
functions united in the Association
creates an organization that rises above
the immediate interests of its members
to consider and advance the greater
public good.
Second, Albertans tend, at the end of
the day, to be pragmatic and will reject
politicians who advance “solutions” that
are nothing more than an attack upon
deeply beloved institutions, including
p u b l i c e d u c a t i o n , a n d r e s p e c t e d
individuals, including teachers. In
the midst of a fundamental economic
transition and a global pandemic,
Albertans do not want their government
to go to war with teachers. Your MLA may
need you to remind them of this.
There are some who will regard my
comments above as being anti-UCP
and in contradiction to the Association’s
commitment to being nonpartisan. This
is mistaken. The ATA, as provided for
in its legislated objects, will always take

a position on education policy; what
we won’t do is support for election any
given candidate or party. In my 20 years
on Association staff, we have taken
on various Progressive Conservative
g ove r n m e n t s a n d eve n t h e N ew
Democratic government. I assure you,
we are equal-opportunity irritants.
Crisis levels of stress and exhaustion
are not sustainable
“I have never in my 16 years of teaching seen so many staff
members breaking down to the point
of tears. We are stressed, overwhelmed
and scared.”
This is a comment from just one of
the more than 2,700 Alberta teachers
who responded to the Association’s
most recent pandemic pulse survey.
This teacher is not alone. Eighty-
seven per cent of teachers report
feeling stressed and 93 per cent feel
exhausted by the end of the day.
The Association has conducted these
pulse surveys three times since schools
restarted, and these results have been
consistently near or above the 90 per
cent mark since the first survey on Aug.
28. We are systematically researching
the impact of COVID in schools, while
the government has decided not to do
such a study.

Obviously, teachers are dealing
with a lot this year: administering
and enforcing new protocols for every
aspect of student interaction — new
recess routines, new lunch routines,
new end-of-day routines; planning a
bunch of new lessons because previous
activities are no longer COVID friendly;
finding new resources, manipulatives
and handouts because old ones don’t
work anymore.
Some teachers are preparing for
livestreaming of classes or online
delivery as well as in-person delivery.
Many teachers have to learn new
t e c h n o l o g i e s b e i n g i m p l e m e n t e d
by school divisions. Some teachers
h a d t o c o m p l e t e l y r ev i s e c o u r s e
sequencing and timings to adjust for
new synchronized delivery plans and
quartermester systems.
Not to mention larger classes, more
supervision, in-classroom lunches and
more internal coverage when substitute
teachers are not available.
Then there’s the cleaning. Eighty-
six per cent of all teachers and school
leaders are taking on cleaning and/or
sanitization tasks in their school, and
six in 10 teachers are spending between
20 minutes and one hour each day on it.

This is all before any positive COVID
cases show up. There is definitely
workload associated with that, as isolation
protocols have to be implemented, extra
cleaning needs to happen and plans
need to be enacted to enable measures
of at-home teaching and/or learning.
Recently, we learned that principals
are even being asked by Alberta Health
Services to do contact tracing.
These problems were predictable.
The Association brought these concerns
to government, but government did not
listen.
Wh a t t h e p r o v i n c e r e f u s e d t o
acknowledge — apparently with school
board and superintendent complicity
— is that schools would not be able
to shoulder these burdens without
additional support.
The government refused to put
forward any money for schools to hire
staff to manage the unending issues
created by trying to operate schools
during a pandemic.
The premier’s glib quip that teachers
will just need to “tidy up” echoes in our
ears.
Imagine how the burden could be

better managed if we hired more janitors,
more educational assistants, more office
staff and more administrators. Imagine
how teachers could focus on teaching,
learning and supporting student well-
being if the teachers themselves were
better supported.
And, to speak in language the
government might understand, imagine
how the economy could be buoyed by
putting more unemployed Albertans to
work in a constructive and needed way
to support Alberta’s students and to help
ensure that schools stay open so parents
can keep working.
As teachers, we often do what needs to
be done and we take on what is needed
without making ourselves a priority.
That cannot happen this year.
COVID-19 is here to stay for awhile,
but this workload on school staff is just
not sustainable.
School divisions and the government
must step up and work to add in
supports for school staff, because “June
tired” can’t last for eight months.
To put it in your words, from the
survey: “I try to be positive as much as
possible and to be my best, but I can’t
keep this up.”

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Q & A
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Secretary
New UCP policies are out of touch
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218 Copyright © 2020 The Korean Movement Disorder Society
Deep Brain Stimulation Battery Exhaustion during
the COVID-19 Pandemic: Crisis within a Crisis
Vikram Venkappayya Holla,1 Koti Neeraja,1 Bharath Kumar
Surisetti,1 Shweta Prasad,1,2
Nitish Kamble,1 Dwarakanath Srinivas,3 Ravi Yadav,1 Pramod
Kumar Pal1
1Departments of Neurology, 2Clinical Neurosciences, and
3Neurosurgery, National Institute of Mental Health &
Neurosciences, Karnataka, India
ABSTRACT
ObjectiveaaThe novel coronavirus disease (COVID-19)
pandemic and public health measures to control it have resulted
in
unique challenges in the management of patients with deep
brain stimulation (DBS). We report our experience with the
manage-
ment of acute worsening of symptoms due to battery exhaustion
in 3 patients with DBS.
MethodsaaPatients with DBS for movement disorders who
visited the emergency room due to battery exhaustion during the
nationwide lockdown from April to May 2020 were included.
ResultsaaTwo patients with subthalamic nucleus-DBS for
Parkinson’s disease (PD) and one with globus pallidus interna-
DBS
for generalized dystonia presented with acute worsening of
symptoms due to battery exhaustion. Urgent battery replacement
was
performed in both patients with PD. The patient with
generalized dystonia was managed with medication adjustment

as he chose
to defer battery replacement.
ConclusionaaDBS battery replacement can be an emergency.
Decisions regarding DBS battery replacement should be
individu-
alized during this COVID-19 pandemic.
Key WordsaaBattery exhaustion; COVID-19; Deep brain
stimulation; Dystonia; Parkinson disease.
BRIEF COMMUNICATION
https://doi.org/10.14802/jmd.20073 / J Mov Disord
2020;13(3):218-222
pISSN 2005-940X / eISSN 2093-4939
JMD
INTRODUCTION
The ongoing novel coronavirus disease (COVID-19) pandem-
ic has forced several countries to impose lockdown to contain
the further spread of infection. In India, the first confirmed case
of COVID-19 was reported on 30th January 2020, and nation-
wide lockdown was imposed on 22nd March 2020, with subse-
quent extensions in three phases until 31st May 2020. During
this
period, barring a few exceptions, all modes of transport were re -
stricted, nonessential establishments were shut down, a nation-
wide curfew was imposed to prevent public gatherings, and
social
distancing and the use of face masks were advised. The lock-
down and prioritization of healthcare services for acute care of
COVID-19 may have helped to a certain extent in handling CO-
VID-19. However, it has put patients with chronic illnesses,

such
as Parkinson’s disease (PD), who need regular follow -up, at a
healthcare disadvantage.1-4 A matter of concern is that most
health
centers are postponing elective procedures to conserve hospital
resources for the management of COVID-19. Even though there
was no restriction for healthcare emergencies, elective and rou-
tine follow-up appointments were deferred to prevent the spread
of COVID-19. Furthermore, apart from the lack of public trans-
portation, which was a deterrent for patients’ to access
healthcare,
several patients harbored apprehensions about visiting hospi-
tals as they feared the possibility of contracting the infection.
The
pandemic crisis poses challenges for the management of patients
with deep brain stimulation (DBS) for various indications.
These
patients may face difficulty visiting their doctors for program-
Received: May 29, 2020 Revised: June 20, 2020 Accepted:
July 5, 2020
Corresponding author: Pramod Kumar Pal, MD, DNB, DM,
FRCP
Department of Neurology, National Institute of Mental Health &
Neurosciences (NIMHANS), Hosur Road, Bengaluru 560029,
Karnataka, India / Tel:
+91-80-26995147 / Fax: +91-80-26564830 / E-mail:
[email protected]
cc This is an Open Access article distributed under the terms of
the Creative Commons Attribution Non-Commercial License
(https://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the
original work is properly cited.
http://crossmark.crossref.org/dialog/?doi=10.14802/jmd.20073&

domain=pdf&date_stamp=2020-09-25
DBS and COVID-19 Pandemic
Holla VV, et al.
www.e-jmd.org 219
ming and for battery replacement in the case of battery exhaus-
tion, as it may not be considered a healthcare emergency. We
re-
port our experience with the management of acute worsening
of symptoms due to battery exhaustion in 3 patients with DBS
for advanced PD (two) and generalized dystonia (one).
METHODS
This study was conducted at the National Institute of Mental
Health and Neurosciences, Bengaluru, India. Patients with DBS
for movement disorders who visited the emergency room due
to DBS battery exhaustion during the nationwide lockdown from
April 2020 to May 2020 were included in this study. A chart re-
view of these cases was performed, and details pertaining to
their pre-DBS, pre- and post-DBS battery exhaustion and post
battery replacement assessments were analyzed.
RESULTS
Case 1
A 67-year-old man with advanced PD of 17 years had under-
gone subthalamic nucleus DBS (STN-DBS) implantation with a
nonrechargeable neurostimulator 4 years ago. He was indepen-
dent for activities of daily living (ADL) with a modified Rankin
scale (mRS) score of 2. He presented with an acute-onset aki-
netic rigid state of 2 days duration with no fever, seizures, loss

of consciousness, or incontinence (Figure 1). He was due for a
follow-up 2 months prior to presentation but had deferred due
to the COVID-19 pandemic. The patient was conscious, alert,
oriented, afebrile, tachycardic, tachypneic and had normal blood
pressure and oxygen saturation. He was anarthric with severe
asymmetrical parkinsonism and an akinetic rigid state. The rest
of his neurological and systemic examination was normal. His
Unified PD Rating Scale-III (UPDRS-III) OFF-state score was
79 (Table 1). On evaluation, his DBS battery was found to have
reached end-of-service status. The results of routine blood
inves-
tigations, including serum creatine kinase, were normal. Dopa-
minergic medications were optimized with mild improvement
(UPDRS-III ON-state score 51). Following screening and
testing
for COVID-19, the patient was taken up for battery replacement
under general anesthesia. Significant improvement was noted
after battery replacement and the restoration of neurostimula-
tion. At the time of discharge, he was ambulant and independent
for ADL with a UPDRS-III (DBS-ON, Drug-ON) score of 28.
Case 2
A 60-year-old woman with advanced PD of 17 years had un-
dergone STN-DBS implantation with a nonrechargeable neuro-
stimulator 4 years ago. Following this, she was independent for
ADL with an mRS score of 2. She presented with worsening
par-
kinsonian symptoms for 2 weeks prior to presentation (Figure
1).
Owing to the lockdown, she was unable to visit our hospital for
evaluation. However, she consulted a nearby neurologist and
had
her dopaminergic medications adjusted, and she noticed mild
improvement. At presentation, the patient was conscious, alert,

and oriented. She had asymmetric parkinsonism with a UPDRS-
III OFF-state score of 73 (Table 1). The rest of her neurological
and systemic examination was normal. On evaluation, her DBS
battery was found to have reached end-of-service status. Rou-
tine blood investigations, including serum creatine kinase, were
normal. Further elevation of the dopaminergic medication dose
was attempted; however, there was no significant improvement
(UPDRS-III ON-state score 64). Following screening and
testing
for COVID-19, the patient was taken up for battery replacement
under general anesthesia. Significant improvement was noted
after battery replacement and the restoration of neurostimula-
tion. At the time of discharge, she was ambulant and
independent
for ADL with a UPDRS-III (DBS-ON, Drug-ON) score of 26.
Case 3
A 33-year-old man with idiopathic gradually progressive gen-
eralized dystonia of 9 years had undergone bilateral globus pall -
idus interna DBS implantation 3 years prior to the current pre-
sentation. Following DBS, he had significant improvement in
Case 1
Lockdown imposed
25/03/2020
Lockdown lifted
01/06/2020
March
20 5
2

1
14
510 1015 1520 2025 25
April May
Case 2
Case 3
Figure 1. Timeline showing associations between lockdown and
patient-related events. Gray boxes indicate days from the onset
of the
worsening of symptoms to presentation at the emergency room.
220
J Mov Disord 2020;13(3):218-222
JMD
dystonia (Table 1) and had maintained the improvement at his
last follow-up, which was 6 months prior to the emergency pre-
sentation. He presented to our emergency room with acute over -
night worsening of dystonia, and evaluation revealed end-of-
service status of the battery. The patient was advised to undergo
a battery replacement; however, owing to financial constraints,
he deferred the surgery to a later date. His medication was opti -
mized to improve the current worsening, and he was discharged.
DISCUSSION

The lockdown and restrictions placed to prevent the spread of
COVID-19 may have significant implications for both patients
with DBS and those scheduled to undergo surgery.5 Planned
DBS
surgeries for various indications have been rightly put on hold
as
they are elective surgeries and hospitals may be burdened with
the care of patients with COVID-19. However, over time,
elective
DBS surgeries will have to be resumed as they cannot be put on
hold indefinitely, and most patients are considered for DBS sur -
geries due to inadequate management with medication. In places
where there are no limitations of resources, a proper plan of ac -
tion in consultation with the DBS team, appropriate health au-
thorities and hospital administration should be formulated to
establish a system to prioritize patients and determine extra pre -
cautions necessary during hospitalization and surgery to resume
elective DBS surgeries. However, surgical intervention is an
emer-
gency in patients with battery malfunction due to exhaustion or
other device-related issues, such as lead fracture or migration,
Table 1. Disease characteristics, disease severity scores and
DBS parameters of the patients
Patient 1 (STN/PD) Patient 2 (STN/PD) Patient 3 (GPi/dystonia)
Baseline parameters
Age at onset 50 years 46 years 24 years
Duration of illness before DBS 13 years 14 years 6 years
Duration since DBS 4 years 4 years 3 years
Baseline pre-DBS surgery

UPDRS-III*
Drug OFF 47 52 TWSTRS: 68/95
Drug ON 4 26 BFMDRS-Motor: 17/120, disability: 5/30
LEDD 1,250 880
Last follow-up before acute deterioration
DBS parameter
Right C+2-/3.6 V/60 µs/140 Hz C+1-/3.2 V/90 µs/150 Hz C+1-
/3.5 V/210 µs/180 Hz
Left C+10-/3.7 V/60 µs/140 Hz C+10-/3.7 V/90 µs/150 Hz C+9-
/3.5 V/210 µs/180 Hz
UPDRS-III*
DBS-OFF: Drug-ON/OFF 32/60 36/58 TWSTRS: 30/95
DBS-ON: Drug-ON/OFF 21/44 25/27 BFMDRS-Motor: 10/120,
disability: 3/20
LEDD 750 560 NA
After battery end of service
UPDRS-III*
Drug-OFF 79 73 TWSTRS: 45.5/95
Drug-ON 51 64 BFMDRS-Motor: 12/120, disability: 4/30
LEDD 1,350 620 NA

Post battery replacement
DBS parameter
Right C+2-/3.0 V/60 µs/130 Hz C+1-/3.0 V/90 µs/130 Hz DBS
battery yet to be replaced
Left C+10-/3.0 V/60 µs/130 Hz C+10-/3.0 V/90 µs/130 Hz
UPDRS-III
DBS-OFF: Drug-ON/OFF 40/69 34/57
DBS-ON: Drug-ON/OFF 28/41 26/44
LEDD 750 560
*patient 3 was a case of dystonia; hence, dystonia severity
scores in the on-medication state are provided for pre-DBS
surgery, DBS-ON and Drug-
ON post-DBS surgery, and on medication alone after battery
end of service. BFMDRS: Burke-Fahn-Marsden Dystonia Rating
Scale, DBS: deep
brain stimulation, GPi: globus pallidus interna, LEDD: levodopa
equivalent daily dose, PD: Parkinson’s disease, STN:
subthalamic nucleus,
TWSTRS: Toronto Western Spasmodic Torticollis Rating Scale,
UPDRS-III: Unified PD Rating Scale-III, NA: not applicable.
DBS and COVID-19 Pandemic
Holla VV, et al.
www.e-jmd.org 221

electrical malfunction or infection. These patients are at risk of
developing life-threatening complications of interrupted neuro-
stimulation, such as DBS withdrawal syndrome, acute dystonic
crisis, and the return of disabling tremor, which can be refracto-
ry to medication.
All 3 cases discussed in this report were scheduled for a rou-
tine follow-up a few months prior to the acute worsening; how-
ever, they deferred the visit as their conditions were well main-
tained, and in view of the evolving COVID-19 pandemic, they
wanted to reduce the risk of infection. As there was no restric-
tion for healthcare emergencies during lockdown, two of our
three cases visited the emergency room shortly after the onset
of symptom worsening. Two patients underwent emergency bat-
tery replacement as they did not have satisfactory improvement
with medication alone. Although it is difficult to accurately pre-
dict when exactly the battery may run out, patient-controlled
pro-
grammers can alert patients to impending end of service through
the elective replacement indicator, which appears approximately
4–6 weeks prior to complete discharge of the battery. Patients
may
notice gradual worsening in symptoms as the battery runs out;
however, there can be sudden worsening with complete drain-
age of the battery. Apart from battery exhaustion, acute worsen-
ing may also be due to lead fracture or migration, which could
occur secondary to falls or a neck injury.
All patients with DBS who are due for battery replacement
should be counseled about the need to check battery status with
the patient-controlled programmer and to contact the treating
neurologist if the programmer shows the elective replacement
in-
dicator or end-of-service status. In PD, long-standing STN-DBS
(> 5 years), advanced disease (> 15 years), low-dose dopaminer-

gic medications and older age are risk factors for DBS
withdrawal
syndrome and should be a high priority for battery replacement
in the case of battery exhaustion.6,7 Urgent battery replacement
or troubleshooting hardware malfunction is a high priority in
most patients but should be decided on an individual basis after
discussing the risk of complications, exposure risk to COVID-
19
for both patients and healthcare workers and the availability of
resources during the pandemic. If the battery cannot be replaced
immediately, patients can be temporarily managed with dose es-
calation until the battery is replaced. The dose of medication
can
also be pre-emptively escalated prior to the exhaustion of the
bat-
tery to compensate for decreasing neurostimulation and to avoid
sudden worsening of symptoms, DBS withdrawal syndrome or
acute dystonic crisis.
Programming-related follow-ups can be supplemented with
video teleconsultations and the use of the patient-controlled
pro-
grammer. First-time programming in PD can be deferred by ask-
ing patients to continue on their presurgery medication dose.
For
other indications where medications alone would not suffice and
for reprogramming in the case of symptom worsening or stim-
ulation-related side effects, video teleconsultation can be
offered,
and remote programming can be attempted with the help of the
patient-controlled programmer. If these measures fail,
individual
decisions can be made about in-person consultation or medica-
tion adjustment after discussing the various risks involved.

DBS surgeries during this pandemic may pose extra challenges
and several logistical issues. Testing for COVID-19 in those un-
dergoing surgeries should be decided based on prevailing guide-
lines issued by regulatory bodies. No emergency procedure
should
be delayed due to the lack of a COVID-19 test report. There
may
be an unprecedented increase in the total cost of DBS surgeries
during the pandemic due to the inclusion of the cost of testing
for COVID-19 and protective equipment to prevent the spread
of infection. Difficulty in procuring DBS-related hardware and
any additional costs should be discussed with the manufacturer
and suppliers, as these devices may need to be imported. These
costs may be additional expenses that insurance companies may
not be willing to cover.
CONCLUSIONS
The COVID-19 pandemic and subsequent restrictions to con-
trol it have resulted in many unprecedented challenges for DBS-
related patient management. Although the control of the pan-
demic is the first priority and of utmost importance, care should
be taken to ensure that patients with other illnesses are not side -
lined. With no clear end of the pandemic in sight, elective sur -
geries such as DBS implantation cannot be indefinitely put on
hold, and a plan of action is necessary to restart these surgeries.
Better use of telemedicine and patient-controlled programmers
should also be considered. This pandemic should motivate us
to generate better guidelines to address DBS-related issues dur-
ing such scenarios.
Conflicts of Interest
The authors have no financial conflicts of interest.
Acknowledgments
None.

Author Contributions
Conceptualization: Vikram Venkappayya Holla, Ravi Yadav,
Pramod Ku-
mar Pal. Data curation: Vikram Venkappayya Holla, Koti
Neeraja, Bharath
Kumar Surisetti, Shweta Prasad. Supervision: Dwarakanath
Srinivas, Pramod
Kumar Pal. Writing—original draft: Vikram Venkappayya
Holla, Koti Neera-
ja, Shweta Prasad. Writing—review & editing: Bharath Kumar
Surisetti, Nit-
ish Kamble, Dwarakanath Srinivas, Ravi Yadav, Pramod Kumar
Pal. Approv-
al of final manuscript: all authors.
ORCID iDs
Vikram Venkappayya Holla https://orcid.org/0000-0002-3634-
2219
Koti Neeraja https://orcid.org/0000-0003-2582-5845
222
J Mov Disord 2020;13(3):218-222
JMD
Bharath Kumar Surisetti https://orcid.org/0000-0001-9294-
1964
Shweta Prasad https://orcid.org/0000-0002-7025-4837
Nitish Kamble https://orcid.org/0000-0002-7933-8826
Dwarakanath Srinivas https://orcid.org/0000-0001-7330-0627
Ravi Yadav https://orcid.org/0000-0002-8016-9089
Pramod Kumar Pal https://orcid.org/0000-0002-4085-2377

REFERENCES
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Yadav R, et al.
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tients and caregivers. Mov Disord 2020;35:912-914.
2. Bhidayasiri R, Virameteekul S, Kim JM, Pal PK, Chung SJ.
COVID-19:
an early review of its global impact and considerations for
Parkinson’s
disease patient care. J Mov Disord 2020;13:105-114.
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Colosimo C, et al. Im-
pact of the COVID-19 pandemic on Parkinson’s disease and
movement
disorders. Mov Disord 2020;35:711-715.
4. Stoessl AJ, Bhatia KP, Merello M. Movement disorders in the
world of
COVID-19. Mov Disord 2020;35:709-710.
5. Miocinovic S, Ostrem JL, Okun MS, Bullinger KL, Riva-
Posse P, Gross
RE, et al. Recommendations for deep brain stimulation device
manage-
ment during a pandemic. J Parkinsons Dis 2020;10:903-910.
6. Azar J, Elinav H, Safadi R, Soliman M. Malignant deep brain
stimulator
withdrawal syndrome. BMJ Case Rep 2019;12:e229122.

7. Reuter S, Deuschl G, Berg D, Helmers A, Falk D, Witt K.
Life-threaten-
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FPAJournal.org34 Journal of Financial Planning | August
2019
CONTRIBUTIONS Smodic | Forst | Rauschenberger | McCoy
Shelitha Smodic, CFP®, is a private wealth adviser
at Westwood Wealth Management and is pursuing a
master’s degree in personal financial planning from
Kansas State University. She is a member of the FPA of
Houston, where she serves as the pro bono director.
Emily Forst is an adviser assistant at Resource Advisory
Services and is pursuing a master’s degree from Kansas
State University with a personal financial planning
graduate certificate, as well as a financial therapy gradu-
ate certificate. She is a student member of FPA, NAPFA,
and the Financial Therapy Association (FTA). She is

scheduled to take the CFP® examination by year-end.
John Rauschenberger is helicopter rescue pilot with
the U.S. Coast Guard, based in Kodiak, Alaska. He
is pursuing a master’s degree in personal financial
planning from Kansas State University.
Megan McCoy, Ph.D., LMFT, is an adjunct faculty
member at Kansas State University where she teaches
courses for the financial therapy certificate program. Her
research focuses on financial therapy and has been
published in several journals including the Journal of
Financial Therapy and the Journal of Financial Plan-
ning. She serves on the board of the Financial Therapy
Association and is associate editor of book reviews and
profiles for the Journal of Financial Therapy.
alzheimer’s disease is the most
common form of dementia, with a
new individual developing the disease
every 65 seconds.1 Due to the pervasive
nature of the disease, it is likely that
the majority of financial planners
will work with families dealing with

Alzheimer’s. When suffering from this
disease, the family member is alive but
by other accounts is lost, which blurs
the lines between life and death. Due to
the uncertainty caused by Alzheimer’s,
significant emotional stress can occur
and present unique challenges for the
supporting family members and the
financial planner.
Families with a member suffering
from Alzheimer’s are often experiencing
a type of grief that is overlooked, known
as ambiguous loss. Pauline Boss, Ph.D.,
first conceptualized and coined the
term “ambiguous loss” in the mid-1970s
(Boss 1977). An ambiguous loss occurs
when there is a disparity or conflict
relating to a person’s physical presence
(Type I) and/or psychological presence
(Type II). Examples of Type I ambiguous
loss include a family member who is
deployed with the military, a child who
is kidnapped, or a first-born child going
to college. In these examples, the absent
family member may still be a major
psychological focus for the family.
Examples of Type II ambiguous loss
can be seen in an actively using addict,
a spouse suffering from workaholism,
or someone who is in the midst of a
depressive episode. In these examples,
the individual may be present physically,
but psychologically unavailable. Using
Boss’ (2016) classifications, Alzheimer’s
is a Type II loss because an individual is

physically present but psychologically
absent—the family may therefore be
experiencing an ambiguous loss.
For reasons examined in the theory
section of this paper, ambiguous loss is
Financial Planning with
Ambiguous Loss from
Alzheimer’s Disease: Implications,
Applications, and Interventions
by Shelitha Smodic, CFP®; Emily Forst; John Rauschenberger ;
and Megan McCoy, Ph.D., LMFT
• By using financial therapy
techniques, mental health theories
can be applied to the financial
planning process to equip finan-
cial planners with tools to assist
families with a member suffering
from Alzheimer’s disease while
remaining within their scope of
competence.
• Through the lens of ambiguous
loss theory, this paper provides
guidelines for financial planners
working with families living through
the experience of having a family
member present but psychologi-
cally and cognitively absent.
• Implications of these guidelines
are that financial planners will be
able to develop better communi-
cation skills, deepen their relation-

ships with clients, develop more
empathy for families experiencing
ambiguous loss, and understand
the importance of a financial plan-
ners’ own self-care to ensure that
they do not experience burnout.
Executive Summary
0819JFP.indd 34 7/11/19 12:05 PM
FPAJournal.org August 2019 | Journal of Financial Planning
35
CONTRIBUTIONSSmodic | Forst | Rauschenberger | McCoy
uniquely stressful to the supporting fam-
ily and can be amplified or highlighted
in the context of financial planning.
Several studies have examined the
negative impact of Alzheimer’s on family
stress and coping processes (Au et al.
2010; Mausbach et al. 2012; Pioli 2010).
One overlooked area of exploration
related to Alzheimer’s is ambiguous loss.
To the authors’ knowledge, past research
has yet to utilize ambiguous loss theory
within the financial planning or financial
therapy fields.
Financial therapy is an emerging field
that “integrates the cognitive, emo-
tional, behavioral, relational, economic,
and integrative aspects of financial
health” (Grable, McGill, and Britt 2010,

p. 1). Financial therapy is a lens through
which to begin an examination of
therapeutic techniques that can be used
by financial planners to more effectively
support families during emotional
financial planning decisions like those
involved with Alzheimer’s.
In this paper, an application of Boss’
(2016) ambiguous loss intervention
method (specifically Type II loss)
within the financial planning process is
explored as a tool to engender deeper
empathy of clients’ stress related to an
Alzheimer’s diagnosis in the family and
to adequately equip financial planners to
navigate the emotional aspects of such a
transition.
Alzheimer’s Disease and Decision-Making
Symptoms of Alzheimer’s are related to
cognitive impairment, which includes
decision-making skills, memory,
language, and episodic memory (Albert
et al. 2011). These symptoms may be
identified in multiple ways, for example:
an individual who is an excellent cook
and never referred to a recipe, but is
now unable to create simple dishes; an
individual who may know and recognize
their environment, but within seconds
is confused about how they got there;
or a person who previously took care of
the household bills, but may no longer
remember how to sign their name or
completely fill out a personal check.

Marson et al. (2000) developed a
prototype instrument that can be used
to determine the financial capabilities
of an individual with Alzheimer’s. Their
study determined that, even in the early
or mild stages of Alzheimer’s, there
was a marked difference in financial
capacity when compared with same-
aged individuals without an Alzheimer’s
diagnosis (Marson et al. 2000). The
findings confirmed that individuals in
the early stages of Alzheimer’s may need
help managing their finances. These
individuals, with support, may be able
to maintain their ability to live on their
own for some time. However, as the dis-
ease progresses, cognitive impairments
will worsen, causing financial needs that
may require more extensive planning.
Caregiver services will also need to be
expanded to provide additional support.
Planning Needs for Families with
Alzheimer’s Disease
Financial planners, if hired by the
individual and their families, are able
to implement the necessary planning
techniques to ensure that the client’s
end-of-life wishes are documented.
However, there is a limited time period
(although it varies from case to case)
in which the diagnosed individual is
able to communicate their end-of-life
wishes before they are no longer of
sound mind (Hirschman, Kapo, and
Karlawish 2008).

Clinically and anecdotally, it is found
that many individuals, even upon an
Alzheimer’s diagnosis, do not have
necessary conversations about the
future with their loved ones or caregiv-
ers (Ryan and McKeown 2018; van der
Steen et al. 2014). Hirschman, Kapo,
and Karlawish (2008) investigated
the cause behind this observation and
found that 57 percent of families that
did have discussions about the future
noted a financial issue of another
known individual as the instigator for
those conversations. In other words,
the majority of individuals who had
financial conversations only had
those conversations because they saw
disastrous financial issues in a friend or
family member and wanted to avoid that
for their own family. The only catalyst
for financial planning was fear-based.
Three active avoidance strategies were
found to be the primary reason these
conversations did not occur, and these
strategies were used by both the client
and the family members (Hirschman,
Kapo, and Karlawish 2008). The active
avoidance strategies included: (1)
avoiding the discussions altogether; (2)
the patient’s personality being a barrier
to the conversation; and (3) the patient
being in denial of their Alzheimer’s
diagnosis.
It is essential to reflect on the

factors that will aid financial planners
in engaging clients in these types of
conversations. When Hirschman, Kapo,
and Karlawish (2008) asked research
subjects to reflect, the supporting family
members identified “non-health care
professionals… [specifically] financial
planners” as critical to the future plan-
ning process (p. 298). They further went
on to say that “[these professionals] play
an important part in helping families
begin their discussions and put together
documentation to assist these families
when their relative no longer expresses
preferences” (p. 298).
Individuals in the early
stages of Alzheimer’s may
need help managing their
finances.
0819JFP.indd 35 7/11/19 12:05 PM
2019
Impact of Alzheimer’s Disease on
Caregivers
Approximately 16.1 million Americans
provide unpaid care for someone
who has Alzheimer’s or other forms
of dementia.2 Gibson, Anderson, and
Acocks (2014) found that participants in
their study struggled with employment,

benefits, and financial issues.
Caregivers are most commonly
unpaid individuals and are usually a
family member of the person under
care.3 Oftentimes the demands of
caregiving for an individual, especially
one with Alzheimer’s, can be extremely
time intensive. Some studies have
found that advanced dementia requires
around-the-clock care (Sansoni,
Anderson, Varona, and Varela 2013).
Depending on the phase of the disease,
the patient may require almost constant
care, leaving little time for work or
personal time. Caregivers of people with
Alzheimer’s disease and other dementias
provide an estimated 21.9 hours of care
per week.4 Approximately 21.3 percent
of the caregivers interviewed in the
study by Gibson, Anderson, and Acocks
(2014) reported they were unemployed
and actively seeking employment. In a
study by Ory, Hoffman, Yee, Tennstedt,
and Schulz (1999), 10.9 percent of
non-Alzheimer’s disease caregiver
participants reported providing constant
care to their loved one, compared to 16.1
percent of Alzheimer’s disease caregiver
participants.
Caregivers have to carry the brunt of
the burden, but online and in-person
aid may be available for caregivers and
patients in many areas of the United
States. This aid can come in many
forms, whether financial, emotional,

legal, or otherwise, and aims to sup-
port and educate both caregiver and
patient.5 Respondents in the survey by
Gibson, Anderson, and Acocks (2014)
recognized financial planning and legal
planning as important (60.3 percent
and 59 percent respectively) resources
to their family. These same respondents
felt individual counseling and group/
family counseling (24.4 percent and
37.2 percent respectively) were not
important as resources to their family.
However, multiple studies have shown
the importance of early financial
planning in light of Alzheimer’s disease
to make sure protections are in place
for the inevitable decline in cognitive
abilities (Ryan and McKeown 2018;
Hirschman, Kapo, and Karlawish 2008;
van der Steen et al. 2014).
The burden felt by caregivers has
many contributors, including the
caregiver’s emotional reactions to their
PRACTICE MANAGEMENT
FPAJournal.org June 2019 | Journal of Financial Planning
25
planner. It provides crucial intelligence
to gauge what works and what needs
improvement. VOC allows you to
leverage one of the skills clients value
the most: your willingness to listen.
Build an emotional connection.

In the words of Simon Sinek, author
of Start With Why, “People don’t buy
what you do, they buy why you do
it.” Therefore, make emotional connec-
tions with your clients your competitive
advantage.
The best customer experiences are
grounded in emotional connections.
Research confirms that emotions shape
attitudes and drive decisions. Loyalty
is directly correlated to a customer’s
emotional attachment to a brand.
According to leaders at the consumer
intelligence firm Motista, “When
companies connect with customers’
emotions, the payoff can be huge.”3
Deliver omnichannel customer
experiences. Clients expect from you
the same level of multichannel engage-
ment they receive from companies like
Amazon and Zappos. To be effective,
your omnichannel engagement must go
beyond the mere distribution of infor-
mation through different channels and
must match clients’ preferred means
of communication. The line between
online and offline engagement is blur-
ring, and clients demand engagements
that allow them to seamlessly switch
channels or devices while interacting
with your brand.
Consumers have developed high
expectations as a result of interacting
with brands that offer them a user-cen-

tric CX. As a result, financial planners
should switch their focus from customer
service to CX as a way to prove to
their clients a genuine commitment to
customer satisfaction. Allocating time
and resources today to deliver an engag-
ing and compelling CX will put planners
ahead of the curve.
Endnotes
1. See the 2014 Deloitte report, “Customer-
Centricity: Embedding It into Your Organiza-
tion’s DNA,” available at www2.deloitte.com/
content/dam/Deloitte/ie/Documents/Strategy/
2014_customer_centricity_deloitte_ireland.pdf.
2. See “The Voice of the Customer,” in the Winter
1993 issue of Marketing Science, available at
mit.edu/~hauser/Papers/TheVoiceofthe
Customer.pdf.
3. See the whitepaper, “The New Science of
Customer Emotions,” by Scott Magids, Alan
Zorfas, and Daniel Leemon, published in the
November 2015 issue of Harvard Business

Review and available at hbr.org/2015/11/the-
new-science-of-customer-emotions.
Claudio Pannunzio is the managing director of Cürex
Group Holdings. He was formerly the president
of i-Impact Group Inc. in Greenwich, Conn.
This column originally appeared on the Journal of
Financial Planning’s Practice Management blog.
Read more at FPABlog.org.
0619JFP.indd 25 5/15/19 12:12 PM
0819JFP.indd 36 7/11/19 12:05 PM
37
patient and the behavioral problems that
are trademarks of Alzheimer’s disease
and dementia. Behavioral problems
and other patient issues contribute to
caregiver stress and negative health
issues (de Vugt et al. 2006).
Long-term stress associated with
caregiving can present emotionally
as compassion fatigue, also known as

secondary trauma (Figley 1995). Com-
passion fatigue is “the combination of
helplessness, hopelessness, an inability
to be empathic, and a sense of isolation
resulting from prolonged exposure to
perceived suffering” (Day, Anderson,
and Davis 2014, p. 796). Day, Anderson,
and Davis (2014) also pointed out that
several studies have been conducted on
compassion fatigue in professionals, but
the familial study of compassion fatigue
needs further research.
Interacting daily with an ill relative
can put the familial caregiver at risk
of developing compassion fatigue. For
instance, a study found that familial
caretakers were just as at risk, or poten-
tially more at risk, than professional
caretakers for experiencing compassion
fatigue (Day and Anderson 2011). While
the study did not definitively diagnose
any of the participants with compassion
fatigue, the work caregivers do for their
patients is very similar to the work
nurses perform for the same type of
patients.
Ambiguous Loss Theory and
Intervention
The challenge for families facing both
types of ambiguous loss is to create
resilience in their lives to effectively
deal with the paradox of having a
person be both present and absent (Boss
2016). Although each situation of loss
has many factors, ambiguity can cause

particularly destructive effects, such
as halting the grief process and coping
mechanisms; immobilizing individuals
and their relationships; and confusing
decision-making processes (Boss 2016).
Ambiguous loss fundamentally
prevents closure and can lead to feelings
of helplessness, hopelessness, and
exhaustion. With many daunting chal-
lenges, individuals are more susceptible
to depression, anxiety, substance abuse,
violence, and suicide. Impacts on the
individual can also carry over into their
relationships. Ambiguous loss can cause
conflict in couples and families, includ-
ing isolation of family members, divorce,
muting of family rituals or traditions,
and anger at authority (Boss 2016).
Generally, when dealing with grief,
an individual seeks closure as a means
of coping with loss. One of the most
difficult aspects of dealing with ambigu-
ous loss is that this type of loss does
not have a perceived natural or societal
closure event associated with it, such as
a funeral (Betz and Thorngren 2006).
Many individuals experiencing ambigu-
ous loss cannot fully express their loss
due to the uncertainty surrounding
their circumstances, which can cause
ambivalence and denial (Boss 1999). For
this reason, building personal resilience
to help cope with the ambiguity of plan-
ning for and taking care of loved ones
experiencing Alzheimer’s is key to being

able to appraise the situation at hand,
make decisions, and take action (Boss
1999). In addition to personal resilience,
the family construct—both physical
and psychological—can be additional
sources of resilience. The psychological
family (one’s own consideration of their
family) can include friends, biological
family, pets, and people in the future
and the past (Boss 2016).
Incorporating 6 Treatments for Ambiguous
Loss into Financial Planning
Boss (2016) presents six guidelines for
treating ambiguous loss for individuals
and families: (1) finding meaning; (2)
adjusting mastery; (3) reconstructing
identity; (4) normalizing ambivalence;
(5) revisiting attachment; and (6) dis-
covering new hope. These guidelines are
not meant to be used in a rigid sequence
or application, but are a cyclical process
starting and ending with finding mean-
ing (Boss 2011). The ultimate goal of
all six guidelines is to help clients build
resiliency.
In the proposed interventions that
follow, each of the six guidelines are
explained and examples of how to
incorporate the guidelines into financial
planning are suggested. References to
the “client” in the following sections
denotes both the Alzheimer’s patient
and supporting family members

engaged in financial planning until the
disease advances to the point where
the individual diagnosed can no longer
actively participate in financial planning
sessions due to cognitive, psychological,
or physical impairments.
Finding Meaning
Finding meaning while caring for a
loved one with Alzheimer’s means being
able to understand the unique experi-
ence of ambiguous loss. The ability to
identify and understand ambiguity is
the key to accepting the incongruity
of managing a relationship that has
simultaneously been lost, yet still exists
(recall that with Alzheimer’s, the loved
one may be psychologically absent yet
still present in their life (Boss 1999)).
For many, the inability to find
meaning while caring for a loved one
with Alzheimer’s creates a feeling of
hopelessness and can lead to a state of
Interacting daily with
an ill relative can put
the caregiver at risk of
developing compassion
fatigue.
PRACTICE MANAGEMENT
FPAJournal.org June 2019 | Journal of Financial Planning
25
planner. It provides crucial intelligence

to gauge what works and what needs
improvement. VOC allows you to
leverage one of the skills clients value
the most: your willingness to listen.
Build an emotional connection.
In the words of Simon Sinek, author
of Start With Why, “People don’t buy
what you do, they buy why you do
it.” Therefore, make emotional connec-
tions with your clients your competitive
advantage.
The best customer experiences are
grounded in emotional connections.
Research confirms that emotions shape
attitudes and drive decisions. Loyalty
is directly correlated to a customer’s
emotional attachment to a brand.
According to leaders at the consumer
intelligence firm Motista, “When
companies connect with customers’
emotions, the payoff can be huge.”3
Deliver omnichannel customer
experiences. Clients expect from you
the same level of multichannel engage-
ment they receive from companies like
Amazon and Zappos. To be effective,
your omnichannel engagement must go
beyond the mere distribution of infor-
mation through different channels and
must match clients’ preferred means
of communication. The line between
online and offline engagement is blur-
ring, and clients demand engagements
that allow them to seamlessly switch

channels or devices while interacting
with your brand.
Consumers have developed high
expectations as a result of interacting
with brands that offer them a user-cen-
tric CX. As a result, financial planners
should switch their focus from customer
service to CX as a way to prove to
their clients a genuine commitment to
customer satisfaction. Allocating time
and resources today to deliver an engag-
ing and compelling CX will put planners
ahead of the curve.
Endnotes
1. See the 2014 Deloitte report, “Customer-
Centricity: Embedding It into Your Organiza-
tion’s DNA,” available at www2.deloitte.com/
content/dam/Deloitte/ie/Documents/Strategy/
2014_customer_centricity_deloitte_ireland.pdf.
2. See “The Voice of the Customer,” in the Winter
1993 issue of Marketing Science, available at
mit.edu/~hauser/Papers/TheVoiceofthe
Customer.pdf.
3. See the whitepaper, “The New Science of
Customer Emotions,” by Scott Magids, Alan

Zorfas, and Daniel Leemon, published in the
November 2015 issue of Harvard Business
Review and available at hbr.org/2015/11/the-
new-science-of-customer-emotions.
Claudio Pannunzio is the managing director of Cürex
Group Holdings. He was formerly the president
of i-Impact Group Inc. in Greenwich, Conn.
This column originally appeared on the Journal of
Financial Planning’s Practice Management blog.
Read more at FPABlog.org.
0619JFP.indd 25 5/15/19 12:12 PM
0819JFP.indd 37 7/11/19 12:05 PM
2019
frozen grief by not adequately address-
ing the issue at hand (Boss 2006).
Finding meaning allows individuals to
foster a sense of hope while actively

living through the challenges of caring
for someone with Alzheimer’s. Because
there is no solution to the ambiguous
loss associated with Alzheimer’s, the
ability to find meaning in the experience
can be key to being able to cope with the
inherent stress and grief associated with
the experience (Boss 2006).
Financial planners can help their
clients find meaning in several ways.
It will be a unique journey for each
client. Some find meaning simply by
understanding the concept of ambigu-
ous loss and by being able to put a name
to the feelings they are experiencing.
Therefore, financial planners being
able to provide education about the
term ambiguous loss can be healing to
the client. Others find that embracing
the experience of caring for their loved
ones throughout the rest of their lives
is a meaningful experience (Harris,
Adams, Zubatsky, and White 2011;
Stuckey 2001). Often, others are able
to find meaning through their cultural
or spiritual beliefs (Boss 2011). Allow-
ing clients to share how their religion
and spirituality processes loss can be
beneficial to helping clients see their
experience in a different light.
Two common hindrances to individu-
als finding meaning are secrecy and
disillusionment (Boss 2006). In the case
of Alzheimer’s, it is a common desire

to keep the psychological decline of a
loved one secret from close social circles
(George, Whitehouse, and Whitehouse
2016). This aim can be potentially
harmful as the caregiver may not take
steps necessary to ensure the long-term
well-being of the Alzheimer’s sufferer
and/or themselves. The secrecy from
others will allow the denial of the diag-
nosis to fester and may cause the clients
to increase avoidance techniques.
Secrecy can also augment the ambiguity
of the situation by keeping the status
of the individual with Alzheimer’s
unclear (Boss 2006). Secrets among
close social circles can lead to rifts in
personal relationships, and it is often
better for a person to accept the truth
of ambiguity, rather than struggle with
a lack of information or the betrayal
of secrecy—especially amongst family
members (Boss 2006).
Financial planners should encourage
their clients to remain engaged within
their social circles. Disillusionment
occurs when a person is clinging to hope
and does not acknowledge the severity
of a situation, often leading to ambiva-
lence (Boss 2006). Financial planners
will be able to break through disillusion-
ment by presenting different timelines
with their forecasting. However,
planners should remember that if their
client is experiencing disillusionment,
they may need more support and more
focus on instilling hope through these

conversations. Regardless, it is essential
for planners to remember that both
secrecy and disillusionment can cause a
delay in recognizing the loss that occurs
with Alzheimer’s and stall the progress
of finding meaning within the situation.
Financial planners can also help
clients find meaning while dealing with
ambiguous loss by making time for
clients to tell their story. All planning
engagements should have a clear set
of goals that the planner and client are
working to achieve. For clients planning
for loved ones with Alzheimer’s, it can
be beneficial to leave time available
for the client to discuss their story and
share details about their loved one suf-
fering from the disease. Klontz, Kahler,
and Klontz (2016) provided tools for
financial planners called exquisite
listening that can aid in hearing your
clients’ stories. With exquisite listening,
the listener becomes consumed by the
listening process. Klontz, Kahler, and
Klontz (2016) recommended reading
about exquisite listening or other forms
of active listening to aid your clients in
telling their story.
Adjusting Mastery
Most people strive to have a certain
amount of control over their lives.
When problem-solving and mastery
over one’s life are highly valued, accept-
ing the ambiguity of Alzheimer’s can

imply failure (Boss 2011).
Mastery is commonly defined as the
ability to have power or control over
something or someone. Boss (2016)
adapted this term to mean the sense
of power or control over one’s life.
Understanding what is and is not within
a person’s control helps to ensure that
a caregiver does not place blame on
themselves or others for not being able to
solve the problem of Alzheimer’s itself.
Mastery of one’s self and one’s
circumstances is a fine line in ambigu-
ous loss. On the one hand, having too
little desire for mastery and control
over one’s circumstances can lead to a
lack of action when it comes to plan-
ning and caring for a loved one with
Alzheimer’s disease. However, striving
for too much control over the situation
can be destructive simply because of
the nature of the disease. The feeling of
life being out of their control can often
cause individuals to lash out at others
or to remain in a state of denial.
One essential element to mastery
during these times is to determine
when to increase or decrease one’s
Financial planners should
encourage their clients to
remain engaged within
their social circles.

0819JFP.indd 38 7/11/19 12:05 PM
39
feeling of control so that they can bal-
ance what they can and cannot control
no matter how large or small (Boss
2011). During this stage, Boss (2006)
suggested that one of the strongest
ways practitioners can empathize with
their clients is to do their own work
in terms of mastery. In other words,
it is essential for fi nancial planners to
explore what is and is not within their
own control and refl ect on their past
struggles around mastery. This internal
work will then prepare the fi nancial
planner to better empathize with the
anger, blame, and frustrations that
many clients will experience when
they feel out of control. In that way,
the fi nancial planner will be able to
be non-reactive in these conversations
about what feels out of control in their
lives and recognize where their sense
of “fairness” in the universe is originat-
ing from in popular discourses.
Financial planners can help clients
to feel more control or mastery over
their circumstances by guiding them
through the fi nancial planning process
and advising them on how to plan for

various future circumstances.
For example, when looking at a
long-term cash fl ow for a client with
a partner suff ering from Alzheimer’s,
a fi nancial planner is providing his or
her clients with a sense of control by
beginning with their current fi nancial
situation, but also presenting multiple
future scenarios that incorporate
variables such as increased medical
expenses or a move into an assisted
living community.
Having a plan for at least the finan-
cial side of caregiving can provide
valuable comfort during tumultuous
times for clients who crave stability
and a sense of control. It can also be
valuable to reinforce the idea that
the financial planner is available
as a resource for the client should
circumstances change. In this way, the
relationship with the financial planner
can provide a sense of community to
a client that may be facing several dif-
ficult financial decisions in the future
and reinforce the notion that they
are not alone when things do not go
according to plan. Therefore, financial
planners may need to step in to a
more active role as taskmaster within
the family either by assigning certain
family members financial tasks or
providing referrals for services, such
as bookkeeping, that were previously
done by the client with Alzheimer’s.

0819JFP.indd 39 7/11/19 12:05 PM
2019
Reconstructing Identity
The onset of Alzheimer’s reconstructs
the family dynamic in several ways that
can be confusing to a person’s identity
(Boss 2006). A husband may wonder
if he is still married if his wife of 30
years no longer recognizes him. A wife
may be uncomfortable or unwilling to
take on the role of provider and money
manager, if this had always been the
role of her husband, despite the fact
he can no longer handle these respon-
sibilities. A child may feel more like
the parent of their mother or father
when stepping into the caregiving role.
In each of these instances, the family
member and individual with Alzheim-
er’s must reconstruct their identity
to fit the changing dynamics of their
relationships; this can be emotionally
challenging.
For many, these situations may
constitute a break from an individual’s
view of self and their role within a
relationship (Boss 2006). To cope
with the changing relationships

with Alzheimer’s sufferers, it can be
beneficial to adopt a more fluid manner
of thinking about family boundaries,
gender and generational roles, recog-
nizing ex-identities, and revising family
roles (Boss 2006).
Although reconstructing one’s iden-
tity is primarily a personal experience,
financial planners are uniquely quali-
fied to help in a specific role recon-
struction through the transition to
primary money manager of the home.
For many families, one primary person
manages all financial matters. When
that primary money manager becomes
unable to fulfill this role and is unable
to transition their knowledge, a major
sense of upheaval and confusion is
common as another person attempts to
figure out the family finances.
Financial planners can take preventa-
tive measures to create a smooth transi-
tion of financial responsibilities by
ensuring that both the individual with
Alzheimer’s and the future caregiver
(the partner, child, sibling, etc., who
will eventually serve as the caregiver
when symptoms advance) are present
in client meetings that discuss where
assets are held, what insurance policies
are in place, where estate planning
and incapacity planning documents
are held, and how long their assets are
projected to last.

When the caregiver has a baseline
knowledge of the family’s financial
status and a relationship with their
financial planner, future transitions
of financial responsibilities are much
easier. Financial planners can also
set up multi-generational family
meetings where clients can begin to
pass down financial education and
responsibilities to their children and
grandchildren and formally establish
powers of attorney, both medical and
financial. In this way, the financial
planner serves as a trusted family
adviser as family members shift roles
and provides the caregiver with a
resource for asking future questions.
Normalizing Ambivalence
Ambiguous loss can lead to a strong
sense of ambivalent feelings and
thoughts, causing a person to be
more often in a state where they are
not quite sure what they should do
or how they should feel (Boss 1999).
An example of this is a wife whose
husband has been in the memory care
unit of a retirement facility for several
years with little to no mobility, and
the wife’s sentiments on the situa-
tion—ranging from being thankful
that her husband is alive to wishing
he was dead so that he did not have to
suffer any longer and she did not have
to see him in such a state.

These types of conflicting feelings—
along with angry outbursts and periods
of extreme guilt—are common for
someone experiencing ambiguous loss
(Boss 1999). The primary approach
to tackling these mixed emotions is
for the person to normalize the guilt
and its associated negative feelings
by understanding that it is part of the
feeling of loss, and they should not take
harmful actions or assign misplaced
blame (Boss 2006). Coming together
with family and a greater support
system to express ambivalent feelings
can be therapeutic to an individual and
help manage ambivalence.
An ability to identify situations
where ambiguous loss may be present
and understand the potential psycho-
logical impacts on a client can help a
financial planner better empathize with
their client as they address any relevant
financial matters. This is another time
where exquisite listening skills could
benefit the financial planner’s relation-
ship with his or her clients (Klontz,
Kahler, and Klontz 2016).
Although helping a client address
ambivalence may be one of the inter-
vention guidelines that strays furthest
from a financial planner’s competen-
cies, knowing that a client’s changing
moods or outbursts could be caused
by an underlying feeling of ambiguous
loss could help to build tolerance
and understanding in the client

relationship. This may allow financial
planners to begin overtly normalizing
feelings of guilt or shame so the client
can move past those emotions. Again,
this is a time where financial planners
simply need to educate clients on this
A child may feel more like
the parent of their mother
or father when stepping
into the caregiving role.
0819JFP.indd 40 7/11/19 12:05 PM
41
phenomenon. For example, planners
could use phrases like:
“I once read about this concept
of ambiguous loss; it is a kind of
anticipatory grief that I think you may
be experiencing right now. When I was
reading about this concept, I learned
that it is incredibly normal to feel guilt
and/or shame as part of the process,
and that those emotions can often
present as anger or frustration. This is
such a normal experience and without
knowing about how these feelings
may be eating away at you...you may

lash out by accident. Do you think
that could be part of why things are so
tense today?”
This process of normalizing can
be freeing for clients, and it can be
powerful to explain that some conflict
can be positive (Laursen and Hafen
2010). Couples can use conflict as
a way of gaining new insights on
each other’s internal processing of
these ambiguous events. Oftentimes,
expressing that fact can help clients
to see the fights as more normal and
less catastrophic and also help them
decrease any shame they may feel
from fighting in front of you.
Revising Attachment and Discovering Hope
The last two intervention guidelines
mark a turning point in the relationship
with someone who has Alzheimer’s and
begins the process of moving forward.
The process of being separated from
someone as a result of ambiguous loss
can cause a person to experience grief
that is more traumatic than the death
of a loved one (Boss 1999). Alzheimer’s
disease causes relationships to be
increasingly more one-sided over time
and increasingly more difficult despite
the physical presence of the person
(Boss 2011).
Despite the ongoing ambiguity of
relationships with the patient with
Alzheimer’s, people close to them must

continue to live their lives; they must
revise their attachment to the patient
by acknowledging that they are both
present and absent in their lives (Boss
2011). Successfully revising attachment
to a person with Alzheimer’s requires
an ability to live with these opposing
views without relying on closure and
being able to accept the altered state of
the relationship.
Once a person has gone through the
applicable steps of Boss’ intervention
guidelines, the goal is for the person to
arrive at the final intervention step with a
greater sense of resilience and newfound
hopefulness for the future, despite the
alterations from ambiguous loss (Boss
2006). A person discovering new hope
is at a point in their grieving process
where they have learned to cope with the
ambiguous loss in their lives and now
have the desire to build new connections
with others and imagine new options for
themselves in the future.
Throughout the process of planning
with a family who supports a patient
with Alzheimer’s, it is inevitable that
relationships shift and the financial
goals and objectives of the clients will
change. During this time, it is helpful
for financial planners to reevaluate with
the client the best way to incorporate
their new goals and objectives while still
maintaining the lifestyle and comfort of
the loved one living with Alzheimer’s.

As this is a period of time where the cli-
ent may be feeling more hopeful about
the future, financial planners should
strive to communicate with a sense of
hopefulness and encourage the client
to think about what is next for them
by asking probing questions regarding
their goals and desires beyond being a
caregiver, as they will need to have a
sense of identity outside of that to avoid
compassion fatigue (Boss 2006).
Scope of Competence
This paper suggests that financial plan-
ners use therapeutic skills in a form of
financial therapy aligned with financial
planning practices. These basic skills
are appropriate for financial planners
as long as they can assess when they
have reached the boundaries of their
scope of competence. Ross, Gale, and
Goetz (2016) urged professionals to
explore their own professional standards
and ethical codes when entering into
financial therapy and to be proactive
in determining when the clients’ needs
require services outside of his or her
scope in order to make appropriate
referrals. That claim is reiterated here.
Many financial planners may find it
more natural to know when to refer a
client to accountants, lawyers, etc., than
making referrals to mental health pro-
fessionals due to the common stigmas
attached to mental health services in our

country (Stroope, Walker, and Franzen
2017). To make this process easier,
financial planners may find it helpful
to know how to assess when there is
a need to refer to a mental health profes-
sional. Financial planners can further
prepare themselves to make referrals to
therapists by creating a sample script
for referring clients to a mental health
professional and by building out their
referral network.
Archuleta (2015) provided a simple
way of assessing the need for therapy. She
pointed to doing a self-check, a client-
check, and a problem-check. A self-check
means assessing how you feel toward the
client. Do you constantly worry about
them, feel drained after seeing them, feel
like you are working harder than them,
and dread their meetings?
Second, do a client-check. Is the client
breaking down constantly in meetings?
Are their emotional reactions slowing
down progress? Are the clients unable to
emotionally regulate themselves?
Finally, do a problem-check. Are
you unable to accomplish any of your
financial planning goals or agenda
items? Is their conflict becoming the
focus of your planning sessions? Is there
a clear diagnosis that is preventing the
0819JFP.indd 41 7/11/19 12:05 PM

2019
focus on financial planning (e.g., com-
pulsive spending, gambling, depression,
anxiety)?
If one or all the answers to these
questions is yes, there is a need for
additional support and a referral to an
appropriate mental health professional
may be appropriate.
If the financial planner does deter-
mine more support is needed, that
planner needs to be comfortable with
the referral process. Like any other
allied professional, it is beneficial to
get to know therapists in the area and
their specialties. By building a trusted
network of mental health professionals,
financial planners can speak clearly and
eloquently about how the mental health
provider will be able to help their client
during the referral process. If a financial
planner does not understand what
therapy looks like nor the benefits of
mental health services, the referral may
sound hesitant, potentially reinforc-
ing the underlying societal discourse
that mental health services are taboo
(Stroope, Walker, and Franzen 2017).
Finally, it is essential that financial plan-
ners understand the basic differences
between mental health providers so that

their referral is to the appropriate care
provider.6
Although financial planners may
be hesitant to incorporate aspects of
financial therapy into their practice,
Dubofsky and Sussman (2009) found
that financial planners were already
being placed in the position of counsel-
ing, in that their clients were having
strong emotions and needed more than
just financial support. Although it is
essential to acknowledge the ethical
implications of integrating aspects
of therapy into a financial planning
practice, by not addressing the clients’
holistic health, financial planners are
missing an opportunity to truly connect
with their clients, foster trust, and
support their clients in a way that will
increase their overall well-being.
Implications for Practice
First and foremost, financial planning
is a relationship-driven profession,
especially as personal finance remains
one of the most intimate topics for
most people to discuss. Although
addressing ambiguous loss is not the
direct responsibility of a financial plan-
ner, an ability to communicate with
clients to aid in the acceptance of their
circumstances using the intervention
guidelines presented here can provide
valuable assistance in the successful
progression of a client with Alzheimer’s

through the financial planning process
and in the creation of trust between
clients and financial planners.
More effective communication.
Effective communication with clients
experiencing ambiguous loss can
encourage them to move forward,
implementing necessary adjustments
to a financial plan after a loved one is
diagnosed with Alzheimer’s disease,
breaking the cycle of ambivalence
and denial. Simply having the ability
to identify clients who may be expe-
riencing this form of grief can make
seemingly irrational client behavior
(such as mixed emotions or angry
outbursts) seem less unusual, and allow
the financial planner to think through
how to handle the client’s processing of
these feelings beforehand.
The guidelines presented in this
paper allow planners to help set clients
experiencing ambiguous loss on a path
to resilience and progression by com-
municating in ways that are consistent
with where they are on their path to
dealing with ambiguous loss. None
of the suggestions made in this paper
require extensive therapeutic training or
techniques, but rather outline methods
that are intuitive when a planner has an
awareness of the underlying situation.
Client relationships and trust.
Supporting a family during difficult
times such as these with an understand-

ing of the family dynamics at play is
an effective way to deepen the client
relationship across multiple generations
and protect against the high attrition
rates generally associated with the death
of a primary client if no relationship was
built with the partner or the children.
Becoming aware of the challenges that
clients are facing with ambiguous loss
and practicing active and exquisite lis-
tening also gives the planner the ability
to assess red flags if mental health issues
have escalated from grief to depression.
The main differentiating factor
between grief and depression is time.
Grief’s pain should lessen over time,
and if there is no improvement after
three months, it is important to assess
for depression. In addition, financial
planners should listen for any signs
of a sense of worthlessness, extreme
shame or guilt, and an impairment
of functioning in the client’s daily
activities of life as these often mark the
onset of depression.7 In return, clients
are receiving financial planning that is
tailored to their individual needs.
Fostering self-care in financial
planners. The analysis of the need for
self-care in mental health is abundant in
the literature (see Cocker and Joss 2016
for a systematic review). The emotion-
ally laden nature of therapeutic work
can often cause compassion fatigue
(Weiss 2004). Compassion fatigue is
linked to depression and anxiety in the

practitioner (Radeke and Mahoney
2000; Tyssen, Vaglum, Gronvold, and
Like any other allied
professional, it is beneficial
to get to know therapists
in the area and their
specialties.
0819JFP.indd 42 7/11/19 12:05 PM
43
Ekeberg 2001), as well as decreased
capabilities to work with clients (Enochs
and Etzbach 2004; Shapiro, Brown,
Biegel 2007; Skosnik, Chatterton,
Swisher, and Park 2000).
Mental health professionals are pro-
vided with trainings and tools to combat
compassion fatigue; however, research-
ers and practitioners have yet to explore
compassion fatigue in financial plan-
ners. The personal financial planning
profession would benefit from future
studies on the rates of and protective
factors against compassion fatigue, as
this paper suggests that financial plan-
ners will have to face similar emotions
as their mental health counterparts.
In addition, financial planners can

begin to explore their own self-care
regimen and strategies to avoid compas-
sion fatigue. Figley (2002) is a resource
for practitioners of any discipline
who may be experiencing compassion
fatigue. He suggested that it is essential
for practitioners to understand the
phenomenon of compassion fatigue to be
able to normalize their experience and
feel comfortable asking for help. He also
suggested that it is essential to take stock
of our personal relationships to ensure
that we have a support system that is not
one-sided. Figley (2002) provided a list
of resources that may be helpful for a
financial planner who may be experienc-
ing compassion fatigue. Another resource
is the list of do’s and don’ts (see Table 1)
created by Pfifferling and Gilley (2000).
Limitations and Future Research
This paper presented an intervention
method that may be beneficial for
financial planners to employ when
dealing both with ambiguous loss and
compassion fatigue within the families
they serve. However, it is based on
a very small subset of case examples
from the authors’ practical experiences.
More research is needed to explore the
efficacy of applying these steps to the
financial planning process.
This paper also sought to provide
financial planners tools to better serve
their clients’ overall well-being after

receiving an Alzheimer’s diagnosis.
Limited studies are available for most
of the topics presented in this paper,
and most of the research has been
performed in Western cultures. This
may limit the efficacy of the proposed
intervention across cultures. Henrich,
Heine, and Norenzayan (2010) pointed
out the drawbacks of using only this
subset of the world and against making
generalizations across cultures. Future
research would benefit from explor-
ing how ambiguous loss looks across
cultures and other suprasystems.
Conclusion
This paper provided financial planners
with a framework to employ when
working with clients experiencing
ambiguous loss. This framework
incorporates therapeutic techniques
that can help elevate the financial
planning process and strengthen the
bond between planner and client.
As Dubofsky and Sussman (2009)
noted: “Spreadsheets, optimization
algorithms, Monte Carlo simulations,
economic forecasts, and actuarial tables
have been and will continue to be
necessary tools for financial planners.
But our study underscores and empiri-
cally supports the thesis highlighted
in our introduction: financial acumen
is necessary for financial planning but
not sufficient (p. 56).”

The growing field of financial
therapy will provide the tools to fill the
void Dubofsky and Sussman (2009)
referred to. This is because financial
therapy interventions, like the one
described in this paper, allow financial
planners to connect to the human
sitting across from them in a more
complete way to engender fuller client
relationships built on strong communi-
cation and trust.
Endnotes
1. See “2018 Alzheimer’s Disease Facts and
Figures,” from the Alzheimer’s Association.
Available at alz.org.
2. Ibid.
3. Ibid.
4. Ibid.
5. Ibid.
6. See the National Alliance on Mental Illness
to learn more about the differences between
various mental health providers (nami.org/
learn-more/treatment/types-of-mental-health-
professionals).

7. See “How to Tell the Difference Between
Sadness, Grief, and Depression,” by Amy
Marturana, posted October 1, 2016 at self.com/
story/the-difference-between-sadness-grief-
depression.
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Table 1:
Do Don’t
Do’s and Don’ts of Self-Care for Compassion Fatigue
Find someone to talk to.
Take some time o�.
Develop interests outside of work.
Identify what's important to you.

Source: P��erling and Gilley (2000)
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Work harder and longer.
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