Attachment,Continuing Bonds,and Complicated Grief Following Violent Loss: Testing a Moderated Model

There is increasing consensus that mourners’ general attachment security and ongoing sense of connectedness to the deceased figure prominently in adjustment to bereavement. However, the interplay between these variables has not been investigated thoroughly. We therefore studied 195 young adults who were bereaved by violent causes (homicide, suicide, and fatal accidents) in the previous 2 years, measuring their attachment-related insecurities (anxiety and avoidance), their specific ongoing attachment or “continuing bond” (CB) to the deceased, and their complicated grief (CG) symptomatology over the loss of this relationship. Analyses indicated that CBs were concurrently linked with greater CG symptomatology. However, other results also suggested that attachment could moderate the adaptiveness of maintaining a sense of connection to the deceased loved one. Specifically, CBs were less predictive of CG symptomatology for individuals with high anxiety and low avoidance, and most predictive of intense grieving for bereaved people whose attachment styles were more highly avoidant and minimally anxious. These findings suggest the relevance of evaluating the appropriateness of clinical techniques that emphasize or deemphasize the CB for mourners who differ in their styles of attachment. Such studies could potentially promote a better match of interventions to clients whose styles of coping are congruent with these procedures.     

Continuing Bonds and Reconstructing Meaning: Mitigating Complications in Bereavement

Drawing on attachment theory and constructivist conceptualizations of bereavement, the authors assessed the relation between continuing bonds coping and meaning reconstruction following the death of a loved one and complicated grief symptomatology. Five hundred six young adults in the first two years of bereavement from a variety of losses completed the Inventory of Complicated Grief along with measures of the strength of their ongoing attachment to the deceased and their capacity to make sense of the loss, find benefit in the experience, and reconstruct a progressive sense of identity following the death. Several variables concerning the survivor, his or her relationship to the deceased, and the nature of the death functioned as risk factors for heightened distress, but their role was generally moderated by meaning-making, often to the point of non-significance. In contrast, higher levels of benefit-finding and positive identity change were associated with lower levels of bereavement complication. Finally, an interaction emerged between sense-making and ongoing attachment to the deceased, suggesting that strong continuing bonds predicted greater levels of traumatic and especially separation distress, but only when the survivor was unable to make sense of the loss in personal, practical, existential, or spiritual terms.     

Continuing bonds and reconstructing meaning: mitigating complications in bereavement

Drawing on attachment theory and constructivist conceptualizations of bereavement, the authors assessed the relation between continuing bonds coping and meaning reconstruction following the death of a loved one and complicated grief symptomatology. Five hundred six young adults in the first two years of bereavement from a variety of losses completed the Inventory of Complicated Grief along with measures of the strength of their ongoing attachment to the deceased and their capacity to make sense of the loss, find benefit in the experience, and reconstruct a progressive sense of identity following the death. Several variables concerning the survivor, his or her relationship to the deceased, and the nature of the death functioned as risk factors for heightened distress, but their role was generally moderated by meaning-making, often to the point of non-significance. In contrast, higher levels of benefit-finding and positive identity change were associated with lower levels of bereavement complication. Finally, an interaction emerged between sense-making and ongoing attachment to the deceased, suggesting that strong continuing bonds predicted greater levels of traumatic and especially separation distress, but only when the survivor was unable to make sense of the loss in personal, practical, existential, or spiritual terms.     

Craving love? Enduring grief activates brain's reward center

Complicated Grief (CG) occurs when an individual experiences prolonged, unabated grief. The neural mechanisms distinguishing CG from Noncomplicated Grief (NCG) are unclear, but hypothesized mechanisms include both pain-related activity (related to the social pain of loss) and reward-related activity (related to attachment behavior). Bereaved women (11 CG, 12 NCG) participated in an event-related functional magnetic resonance imaging scan, during grief elicitation with idiographic stimuli. Analyses revealed that whereas both CG and NCG participants showed pain-related neural activity in response to reminders of the deceased, only those with CG showed reward-related activity in the nucleus accumbens (NA). This NA cluster was positively correlated with self-reported yearning, but not with time since death, participant age, or positive/negative affect. This study supports the hypothesis that attachment activates reward pathways. For those with CG, reminders of the deceased still activate neural reward activity, which may interfere with adapting to the loss in the present.     

Loss upon loss: The impact of death after divorce

Studies of grief and bereavement have long recognized that attachment and relationship to the deceased is a critical determinant of the intensity of grief. Research has also noted the effect of ambivalent relationships on grief resolutions. Yet, most studies have tended to focus on the bereavement of immediate family and close kin.

This study explores the bereavement of persons who have been divorced and then experienced the death of their ex-spouse. Based upon indepth interviews with a limited sample, this exploratory study considers the ways in which the grief of ex-spouse differs from and its similar to the grief experienced by widows, with rising divorce rates, this is likely to be an increasing issue in the future.

Generally, if there was sufficient time, the loss due to divorce was completed and this minimized the impact of the death. When there was not time for the initial loss to be resolved, grief was complicated. Funeral rituals, the fact that the loss was not socially recognized, the lack and/or nature of social support, and the reactions of children tended to create special difficulties for the ex-spouse. Implications of this research for grief counselors, death educators, and for further research are considered.     

Investigating risk for grief severity: Attachment to the deceased and relationship quality

Abstract

Previous research examining the interrelationship between attachment, relationship quality, and bereavement outcomes suffers from a lack of precision and sophistication in the measurement of the core constructs of interest. The present study adapted an existing measure of attachment and employed a novel instrument of relationship quality to examine specific attachment to and relationship quality with the deceased as contributors to grief symptom severity. A sample of 385 bereaved college students completed measures retrospectively assessing relationship quality, attachment to the deceased, and grief symptomatology. Findings indicate that specific attachment to the deceased differs significantly from global attachment style and that relationship quality and attachment anxiety and avoidance interact in significant ways to predict the risk of grief severity. Specifically, individuals with a Preoccupied attachment style (high anxiety, low avoidance) are most at risk for adverse grief reactions in the context of high relationship closeness and conflict. This study is limited by an over-representation of extended family loss, which may have unique implications for attachment and relationship quality. Grief therapists should consider the implications of attachment and relationship quality with the deceased in the selection of relationship-enhancing or relational problem-solving interventions.     

Silent sorrow: Grief and the loss of significant others

Studies of grief and bereavement have long recognized that relationship and attachment to the deceased is a critical determinant of the intensity of grief. Yet most studies only examine the impact of death on the immediate family or close kin. There is often an implicit assumption that such close relationships only exist among spouses or other members of the immediate family.

This paper considers the impact of grief on nontraditional relationships. These include extramarital affairs, cohabitation, and homosexual relationships. Utilizing existing literature and case studies, the paper discusses the ways in which the tasks of bereavement can be complicated in nontraditional relationships. While grief may be intensified, resources for resolving grief are often limited. It may not be possible to utilize formal and informal support systems effectively. Religion and rituals may constrain, rather than facilitate, grief work.

The paper describes five dimensions that bear upon the resolution of grief in nontraditional relationships. These include affect/meaning, openness-secrecy, acceptance-rejection, opportunity for replacement, and social support. The paper also describes the ways in which such grief might be manifested and offers suggestions for assisting people in recognizing and resolving grief.     

Silent sorrow: Grief and the loss of significant others

Abstract

Studies of grief and bereavement have long recognized that relationship and attachment to the deceased is a critical determinant of the intensity of grief. Yet most studies only examine the impact of death on the immediate family or close kin. There is often an implicit assumption that such close relationships only exist among spouses or other members of the immediate family.

This paper considers the impact of grief on nontraditional relationships. These include extramarital affairs, cohabitation, and homosexual relationships. Utilizing existing literature and case studies, the paper discusses the ways in which the tasks of bereavement can be complicated in nontraditional relationships. While grief may be intensified, resources for resolving grief are often limited. It may not be possible to utilize formal and informal support systems effectively. Religion and rituals may constrain, rather than facilitate, grief work.

The paper describes five dimensions that bear upon the resolution of grief in nontraditional relationships. These include affect/meaning, openness-secrecy, acceptance-rejection, opportunity for replacement, and social support. The paper also describes the ways in which such grief might be manifested and offers suggestions for assisting people in recognizing and resolving grief.     

Trauma and bereavement: conceptual and clinical issues revolving around relationships

The article re-examines trauma and bereavement and the category of loss considered to be traumatic bereavement. It is argued that the perspective of the relation to the deceased is an insufficiently acknowledged source of traumatic disruption following bereavement.The significance of the relational aspect in bereavement is present in the paradigm of the Two-Track Model of Bereavement (S. Rubin, 1981, 1999). The implications of this approach are examined in the case of a soldier exposed to trauma and death.The case is examined from a traditional trauma perspective stressing exposure to life threat and again from a perspective stressing the significance of the relationship to the deceased. An examination of the different intervention strategies and their outcome lends support to the importance of the relational aspects in this case of trauma and supports the use of the Two-Track Model of Bereavement.The location of trauma as basic to the experience of all bereavement for its impact on the reorganization vis a vis the representation of the loved one now deceased is considered as fundamental to the trauma of all bereavement. The additional contribution of bereavement occurring under conditions of life threat (traumatic situations) is an important feature potentially impacting the bereavement process, but it is not what makes bereavement traumatic per se. An additional source of trauma in bereavement, occurring when the previous representation or introject of the deceased is shattered, is considered for its status as an additional source of complication in the traumas of bereavement.     

Continuing bonds in bereavement: an attachment theory based perspective

An attachment theory based perspective on the continuing bond to the deceased (CB) is proposed. The value of attachment theory in specifying the normative course of CB expression and in identifying adaptive versus maladaptive variants of CB expression based on their deviation from this normative course is outlined. The role of individual differences in attachment security on effective versus ineffective use of CB in coping with bereavement also is addressed. Finally, the moderating influence of type of loss (e.g., death of a spouse vs. child), culture, and religion on type of CB expression within an overarching attachment framework is discussed.     

The experience of Chinese bereaved persons: a preliminary study of meaning making and continuing bonds

This study explores the bereavement process of Chinese persons in Hong Kong, with the focus on how they make meaning of the death as well as how they maintain a bond with the deceased. A review of video- and audiotapes of 52 bereaved persons in bereavement counseling pointed to how these concepts are reflected in key themes that appeared throughout these interviews. The way this bereaved population found meaning in the death was reflected in how they understood the cause of death, their observations at the death moment, their understanding of the life of the deceased after the death, the life of the bereaved after the death, and the burial and mourning rituals that were followed. The continuing bond the bereaved felt with the deceased was experienced by the bereaved as either initiated by the deceased, for example by the deceased appearing in dreams or initiated by the bereaved themselves in their talking with the deceased. These 2 aspects of the bereavement process seem to be similar to those found in other societies, but the ways in which they were manifested were unique to the Chinese culture. Based on these findings, the authors conclude with implications for intervention with this bereaved population.     

Qualitative study of Chinese widows in Hong Kong: insights for psycho-social care in hospice settings

In an exploratory, phenomenological study of seven Chinese widows in Hong Kong, five major themes are identified: relationship with the deceased, relationship with others, grief reactions, coping and emotional expression. This paper focuses on the first theme: the widows' relationship with the deceased husband along a timeline from the time of diagnosis to after death. The experiences in the final days with the deceased were frequently referred to when the informants talked about this theme. This paper aims to give added voice, based on the experience of Chinese widows, to the possible role of hospice and palliative care on influencing the bereavement experience. Issues of awareness and acceptance of death, the supportive environment and support for family carers, the moment of death, creation of legacies, and sensitivity towards cultural embedded practices, are discussed. It is hoped that the experiences of these bereaved widows will stimulate new research to elucidate and verify the findings reported in this paper.     

The Experience of Chinese Bereaved Persons: A Preliminary Study of Meaning Making and Continuing Bonds

ABSTRACT

This study explores the bereavement process of Chinese persons in Hong Kong, with the focus on how they make meaning of the death as well as how they maintain a bond with the deceased. A review of video- and audiotapes of 52 bereaved persons in bereavement counseling pointed to how these concepts are reflected in key themes that appeared throughout these interviews. The way this bereaved population found meaning in the death was reflected in how they understood the cause of death, their observations at the death moment, their understanding of the life of the deceased after the death, the life of the bereaved after the death, and the burial and mourning rituals that were followed. The continuing bond the bereaved felt with the deceased was experienced by the bereaved as either initiated by the deceased, for example by the deceased appearing in dreams or initiated by the bereaved themselves in their talking with the deceased. These 2 aspects of the bereavement process seem to be similar to those found in other societies, but the ways in which they were manifested were unique to the Chinese culture. Based on these findings, the authors conclude with implications for intervention with this bereaved population.     

TRAUMA AND BEREAVEMENT: CONCEPTUAL AND CLINICAL ISSUES REVOLVING AROUND RELATIONSHIPS

The article re-examines trauma and bereavement and the category of loss considered to be traumatic bereavement. It is argued that the perspective of the relation to the deceased is an insufficiently acknowledged source of traumatic disruption following bereavement. The significance of the relational aspect in bereavement is present in the paradigm of the Two-Track Model of Bereavement (S. Rubin, 1981, 1999). The implications of this approach are examined in the case of a soldier exposed to trauma and death. The case is examined from a traditional trauma perspective stressing exposure to life threat and again from a perspective stressing the significance of the relationship to the deceased. An examination of the different intervention strategies and their outcome lends support to the importance of the relational aspects in this case of trauma and supports the use of the Two-Track Model of Bereavement. The location of trauma as basic to the experience of all bereavement for its impact on the reorganization vis á vis the representation of the loved one now deceased is considered as fundamental to the trauma of all bereavement. Theadditional contribution of bereavement occurring under conditions of life threat (traumatic situations) is an important feature potentially impacting the bereavementprocess, but it is not what makes bereavement traumatic per se. An additional source of trauma in bereavement, occurring when the previous representation or introject of the deceased is shattered, is considered for its status as an additional source of complication in the traumas of bereavement.     

CONTINUING BONDS IN BEREAVEMENT: AN ATTACHMENT THEORY BASED PERSPECTIVE

ABSTRACT

An attachment theory based perspective on the continuing bond to the deceased (CB) is proposed. The value of attachment theory in specifying the normative course of CB expression and in identifying adaptive versus maladaptive variants of CB expression based on their deviation from this normative course is outlined. The role of individual differences in attachment security on effective versus ineffective use of CB in coping with bereavement also is addressed. Finally, the moderating influence of type of loss (e.g., death of a spouse vs. child), culture, and religion on type of CB expression within an overarching attachment framework is discussed.     

Complicated grief and need for professional support in family caregivers of cancer patients in palliative care: a longitudinal cohort study

Objectives

There is little research on complicated grief (CG) in family caregivers in palliative care. The aim of the study was to assess the levels of complicated grief and depression in family caregivers after the death of a relative with cancer, to identify their need for support, to compare the palliative team staff’s risk assessment of the relatives’ grief reaction with measured levels of CG and depression, and to assess the use of bereavement support.

Methods

All 114 eligible family caregivers to deceased patients treated in a palliative care unit in the year 2006 were asked to participate in the study, and 87 (77%) accepted. The participants completed a postal questionnaire 2, 6, 13, and 18?months after the loss measuring complicated grief (Inventory of Complicated Grief, Revised), depression (Beck’s Depression Inventory II), and their use of bereavement services. The palliative team staff completed a form 1?month post-loss with their clinical risk assessment of the family caregivers’ levels of complicated grief and need for support.

Results

The prevalence of moderate to severe depression and CG was 15% and 40%, respectively, at 6?months post-loss. Professional risk assessment showed a sensitivity of 55% for CG and of 27% for depression and a specificity of 86% for depression and 63% for CG. The positive predictive value was 27% for depression and 21% for CG. Use of bereavement services was observed in 36% of the cases at 6?months after the loss. The proportion of bereaved with CG or depression at 6?months who had received bereavement services was 47% and 64%, respectively.

Conclusions

The results suggest that a substantial number of family caregivers of diseased palliative care patients are at risk of developing CG and depression following their loss. While early identification of those at risk of developing CG could be helpful, the risk assessment of professionals may lack in precision. The results indicate that bereavement services could be utilized in a more targeted and perhaps more efficient manner. Guidelines for bereavement planning in palliative care are indicated.     

Parental Perceptions of Siblings’ Grieving After a Childhood Cancer Death: A Longitudinal Study

We investigated longitudinally parental perceptions of siblings' bereavement after childhood cancer death. Parents were interviewed 6 months (n = 25) and 18 months (n = 15) post-death. Data are analyzed combined and over time. The following themes emerged: (a) expression of grief: missing deceased child (verbally, crying), behavioral problems, difficulty understanding the meaning of death (pre-schoolers), and avoiding talking with parents about feelings (adolescents); (b) what helps siblings grief: moving on, talking about deceased child and social support; (c) relationship with parents improved for most siblings; and (d) bond with deceased sibling: pretend-play (preschoolers), dreaming, and career choices (adolescents). Over time, themes reflected stability and change.     

End-of-life communication and adjustment: pre-loss communication as a predictor of bereavement-related outcomes

Although bereavement-related emotional distress usually remits on its own over time, approximately 20% of bereaved individuals experience chronic emotional difficulties following the loss (Prigerson & Jacobs, 2001). Although several factors have been shown to be associated with poor outcomes post-loss, few studies have examined the relationship between pre-loss communication and bereavement-related depression, and none have examined its relationship to complicated grief. The present study examined how pre-loss communication between the bereaved and the deceased is related to post-loss outcomes within a sample of 60 members of online bereavement support groups. Results indicated that developing acceptance of an expected loss is strongly associated with bereavement outcomes. This finding persists even after controlling for relationship closeness and time elapsed post-loss.     

Complicated grief after suicide bereavement and other causes of death

The authors compared baseline demographic characteristics, clinical features, and grief-related thoughts, feelings, and behaviors of individuals bereaved by suicide, accident/homicide and natural causes participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression and current depression diagnosis did not vary by loss type. After adjusting for baseline demographic features, time since death and relationship to the deceased, those with CG after suicide had the highest rates of lifetime depression, preloss passive suicidal ideation, self-blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking sample of research participants with CG, suicide survivors may face unique challenges.     

The impact of complicated grief on mental and physical health at various points in the bereavement process

The purpose of this cohort sequential study was to determine whether the presence of complicated grief (CG) measured at various points in the spousal bereavement process is associated with an increase in mental and physical health problems 18 months later. One hundred twelve participants provided data at four points in time. CG was measured with the Inventory of Complicated Grief (ICG), and mental health was measured with the Integra Outpatient Tracking Assessment, Mental Health Index (MHI), and illnesses by self-report. Twenty-nine participants were identified as experiencing CG. Beginning at 6 months after the death, MHI scores were significantly lower for the CG group and those results were persistent. The CG group experienced more additional life stressors, perceived less social support, and achieved less clinically significant change in MHI than the NCG group. Identification of CG at any point at 6 months or later in bereavement indicates a need for professional intervention. Implications for establishing CG as a DSM diagnosis are discussed.