Crisis With Individuals, Couples, and Families

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

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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.

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FPAJournal.org36 Journal of Financial Planning | August 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

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

CONTRIBUTIONS Smodic | Forst | Rauschenberger | McCoy

0819JFP.indd 36 7/11/19 12:05 PM

FPAJournal.org August 2019 | Journal of Financial Planning 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

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

CONTRIBUTIONSSmodic | Forst | Rauschenberger | McCoy

0819JFP.indd 37 7/11/19 12:05 PM

FPAJournal.org38 Journal of Financial Planning | August 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.

CONTRIBUTIONS Smodic | Forst | Rauschenberger | McCoy

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