Article
Insecure Attachment Styles and Complicated Grief Severity: Applying What We Know to Inform Future Directions
OMEGA—Journal of Death and Dying 2016, Vol. 73(3) 231–249 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0030222815576124 ome.sagepub.com
Laura K. Schenck1, Kiersten M. Eberle1, and Jeffrey A. Rings1
Abstract A growing body of evidence supports links between attachment style, complicated grief (CG), and coping mechanisms in bereavement. In general, adults with insecure attachment styles are at an increased risk for developing CG when faced with the death of a loved one. However, much remains unknown regarding this complex interaction. This article provides a comprehensive synthesis of this literature base, offering future directions for attachment-informed CG research, clinical assessment, and treatment. The clear risk posed by an insecure attachment style on CG highlights the need for a proper and thorough assessment of attachment style as part of standard practice in grief-related treatment as well as the importance of meeting the unique clinical needs of the bereaved in consideration of one’s attachment style. Further emphasis also should be placed on the mediating impacts of sociocultural variables, any of which could help to mitigate one’s return to a level of preloss functioning.
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Department of Applied Psychology and Counselor Education, University of Northern Colorado, Greeley, CO, USA Corresponding Author: Jeffrey A. Rings, Department of Applied Psychology and Counselor Education, University of Northern Colorado, 501, 20th Street, McKee Hall 201 A, CB 131, Greeley, CO 80639, USA. Email:
[email protected]
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Keywords attachment, bereavement, complicated grief, counseling, treatment
Introduction A man’s dying is more the survivor’s affair than his own.—Thomas Mann
Methods of coping with bereavement vary between individuals, with some people demonstrating more adaptive coping mechanisms than others. Attachment theory (Bowlby, 1982), recognized as one of the essential paradigms for understanding adaptive adjustment to bereavement (Shaver & Fraley, 2008) and for conceptualizing complicated grief (CG) (Lobb et al., 2010), provides a lens through which to better understand such individual differences in this regard. A growing body of research supports unique and direct linkages between attachment-related anxiety and several concerns commonly experienced in bereavement, including complicated grief symptomatology (CGS) (Meier, Carr, Currier, & Neimeyer, 2013), physical and psychological health issues (e.g., De Rick & Vanheule, 2007), dissociative and anxiety-related symptoms (Lyons-Ruth & Jacobvitz, 2008), and bereavement-related symptoms otherwise indicative of posttraumatic stress (Besser & Neria, 2012). Evidence supports links between attachment styles, CG, and coping in bereavement; however, much is still unknown regarding how these connections may inform treatment directions. In light of this, a synthesis of the current state of the literature is warranted in an effort to provide guidance on future directions for the roles of research, clinical assessment, and treatment of CG according to differences in attachment style.
Grief in Brief For most if not all persons, the grief response due to bereavement is an inevitable encounter within the human experience. It is natural to experience intense emotional pain in response to the death of a loved one; this acute grief response is not necessarily indicative of pathology. This normative, acute grief response may involve a general sense of disbelief, a painful mix of emotions, preoccupying thoughts of the deceased, and difficulty accepting the loss; for many, this experience can last for roughly 6 months (Shear & Mulhare, 2008). Inevitably, most people manage to regain vitality, engagement, and meaning in their lives, eventually adjusting to loss without significant or extended impairment (Bonanno, 2004). These individuals often do so without any need for clinical intervention.
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In fact, some suggest that for many, more formal bereavement-related interventions potentially could exacerbate grief symptoms (Jordan & Neimeyer, 2003). This majority of bereaved individuals are able to progress from acute grief into a state of integrated grief, no longer experiencing the same degree of emotional distress or preoccupying cognitions (Shear & Mulhare, 2008). The shift from acute to integrated grief allows the bereaved individual to experience grief as a background emotional and cognitive state rather than a pronounced grief response. However, approximately 10% to 20% of people do not successfully transition as such (Bonanno & Kaltman, 2001) and instead may develop CG. Typical symptoms of CG can persist well beyond 6 months and include intense yearning for the deceased person, intrusive thoughts or images of the deceased, excessive ruminations related to the death, and recurrent feelings of bitterness or anger surrounding the death (Shear & Mulhare, 2008; Simon, 2012). Individuals with CG are commonly derailed from reengagement with their lives due to guilt, unresolved inner conflicts, and inadequate emotional processing specific to the death or deceased (Middleton, Burnett, Raphael, & Martinek, 1996; Prigerson & Jacobs, 2001; Simon, 2012). While uncomplicated grief has been linked to increased physical health concerns, most of which begin to dissipate along with grief symptoms within the first 6 months following the death (Utz, Caserta, & Lund, 2012), CG may result in chronic medical and mental health problems without effective treatment (Prigerson et al., 2009). Furthermore, those with CG are at an increased risk for suicidal ideation and suicidal behaviors significantly more so than those with acute or integrated grief responses (Dell’osso et al., 2011); this elevated risk for suicidal ideation may persist even when controlling for posttraumatic stress disorder and depression (Latham & Prigerson, 2004). With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), diagnostic considerations related to bereavement have garnered significant attention and widespread discussion as of late. Perhaps, the greatest amount of controversy has regarded the DSM-5 committee’s decision to drop the bereavement exclusion from major depressive disorder. While a depiction of this debate is beyond the scope of this article (see Thieleman & Cacciatore, 2014, for example), one primary argument for its elimination was that its otherwise inclusion could have been inhibiting those who experience a bona fide depressive episode during acute bereavement from accessing needed mental health services (Zisook, Shear, & Kendler, 2007). While on the other hand, others have argued that this exclusion may lead to increasingly misattributing more normal grief responses as in fact pathological (Wakefield & Schmitz, 2012). Perhaps less frequently discussed yet still salient and controversial nonetheless, the DSM-5 committee also decided against the inclusion of CG as a new disorder and instead included persistent complex bereavement-related disorder
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as a condition within the Disorders for Further Study section (Bryant, 2014). This was despite researchers (e.g., Parkes, 2007; Prigerson et al., 2009) having identified CG to be a separate diagnostic construct with symptomatology that is distinct from other conditions such as major depressive disorder, adult separation anxiety, or posttraumatic stress disorder (Boelen, 2013; Rando et al., 2012; Simon, 2012) as well as from normal, uncomplicated grief reactions (Boelen & van den Bout, 2008). Also interestingly, the diagnostic criteria for persistent complex bereavement-related disorder put forth in the DSM-5 consists of a combination of two previously proposed CG criterion sets (Prigerson et al., 2009; Shear et al., 2011) along with other criteria that has been criticized as lacking any adequate, empirical rationale (Thieleman & Cacciatore, 2014). Arguably, one key direction at this time is the graduated need to examine for and develop empirically validated diagnostic CG criteria that can more easily assist professionals to differentiate between this condition (whatever its future moniker might be), a major depressive episode subsequent to bereavement, and a more normative grief response. It also is probable that the upcoming revision of the International Classification of Diseases (ICD-11) will offer up a differing set of diagnostic criteria for CG as well (Bryant, 2014). Nevertheless, as such research continues and greater diagnostic consensus is reached in kind, such high degrees of confusion and the risk of improper diagnosis both appear inevitable. Despite the debate over the effectiveness of grief counseling for uncomplicated grief, most studies still agree that treatment is beneficial for CG (Jordan & Neimeyer, 2003; Zhang, El-Jawahri, & Prigerson, 2006). The continued, albeit slow, movement toward increased recognition of the unique, complex nature of CG in turn may benefit all bereaved individuals, differentiating between those who are coping with grief more effectively and those who may benefit from clinical intervention. Increased sensitivity to individual differences in methods of coping with bereavement and expressing grief is a key factor in treating CG effectively (Rando et al., 2012). Altogether, by acknowledging CG as a distinct disorder, clinicians may better understand those with CGS as a unique group with unique treatment needs. Further research is also needed to enhance our understanding of how individual differences among those with CG may impact its course and treatment outcome.
Bereavement and Attachment Theory Professionals can better understand the intense emotional, psychological, and physical effects of CG as they factor the bereaved person’s typical interpersonal expectations and interactions (i.e., one’s attachment style) into the equation. Attachment theory posits that infants are born with an intrinsic motivational system for physical and emotional proximity to attentive, available, and responsive caregivers. The attachment system serves the functions of maintaining proximity to attachment figures and relieving distress through contact with these
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figures when faced with real or perceived threats (Bowlby, 1980). This intrinsic attachment system serves as a motivational framework within which human behavior can be conceptualized, predicted, and understood. During times of distress, the attachment systems of securely attached individuals are activated in an adaptive manner, as evidenced by the desire for proximity and retrieval of comforting thoughts of the attachment figure (Mikulincer, Gillath, & Shaver, 2002). Securely attached adults have relatively little difficulty getting close to others and tend to express low levels of anxiety and avoidance behaviors in relationships (e.g., Feeney, 1999). By contrast, insecurely attached individuals may develop either more anxious (feelings of uncertainty toward, and preoccupation with, the responsiveness and availability of relationship partners) or avoidant (the placing of a value on self-reliance and the expression of discomfort with relying on others) attachment styles (Brennan, Clark, & Shaver, 1998). If attachment figures are not perceived as reliable sources of comfort, protection, and support, one may develop an insecure attachment style, resulting in a “predictable, sequenced response to separation” (Shear & Shair, 2005, p. 254). Bowlby (1980) described grief as a natural response to the loss of an attachment figure, wherein the bereaved individual reaches a state of integrated grief upon when she or he experiences “recognition that loss has occurred and a feeling that links with the dead none the less persist” (p. 140). From an attachment perspective, integrated grief involves simultaneous acceptance of the loss with ongoing emotional bonds with the deceased, resulting in “a comforting sense of the continuing presence of the lost person” (Bowlby, 1980, p. 140). Through the lens of attachment theory, adaptive coping with grief is more likely to occur when the bereaved individual integrates acceptance of the death with her or his pre-existing working model of the deceased attachment figure. One way to conceptualize symptomatology consistent with CG “is in terms of the loss of a major attachment figure and the concomitant security that person provided” (Mancini & Bonanno, 2012, p. 257). Within an attachment framework, preoccupation with the deceased loved one may be associated with protest reactions and persistent longing for resumed proximity. Shear and Shair (2005) proposed that the bereaved person is more likely to experience CG if the reality of the loss is not sufficiently integrated into her or his internal working model, or mental representation, of the deceased. Complicated grief and the activated attachment system. One’s attachment system typically becomes activated to varying degrees during times of real or perceived danger, threat, or in the absence of an attachment figure. If functioning adequately, thoughts of specific attachment figures become easily accessible, consequently bringing a sense of relief to the individual when perceiving such a threat or great stress. Given the clear connection between activation of the attachment system and the loss of an attachment figure through death, an examination of
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the relationship between CG and the attachment system is warranted. Consistent with Bowlby’s original hypothesis, Lobb et al. (2010) explicitly referred to “CG [as] fundamentally an attachment disorder” (p. 690), drawing attention to individual differences in attachment as either protective (i.e., secure) or risk (i.e., insecure) factors in the development of CG. Anxiously attached individuals tend to experience chronic activation of the attachment system accompanied by hyper-accessibility of attachment figures, even when threat is absent. Rather than bringing relief, this continual accessibility of thoughts of lost loved ones may lead to the excessive yearning associated with CG (Mancini & Bonanno, 2012). The attachment system of those with more avoidant dynamics tends to respond to attachment threat with marked deactivation or by disregarding threat- and attachment-related cues. This subsequently results in a loss of cognitive access to thoughts and images of such attachment figures (Mikulincer et al., 2002). While avoidant strategies (e.g., dissociating from or minimizing one’s awareness of those negative emotions related to the loss) may be adaptive in some situations (Bonanno, Keltner, Holen, & Horowitz, 1995; Mancini & Bonanno, 2012), research also points to the potential for maladaptive outcomes when avoidantly attached persons employ such avoidant strategies in bereavement, particularly if grieving a traumatic or sudden loss (Meier et al., 2013). Future clinical application of this knowledge can serve to “alert clinicians to the limits of avoidance strategies in mitigating grief and the importance of distinguishing between avoidance and genuine resilience in the context of bereavement” (Meier et al., 2013, p. 330). In a comparison study of widowed persons with and without CG, Mancini and Bonanno (2012) assessed for differences in their ability to access mental representations of their deceased spouses under various circumstances. To do so, participants completed an emotional Stroop task where they were asked to respond to their deceased spouses’ names after being subliminally primed beforehand with either a threatening or innocuous word. Those with CG responded no differently between the two priming conditions, possibly indicative of them being in a state of constant yearning for the deceased spouse for whom they grieve. On the other hand, those without CG responded more quickly when given the threatening word. This perhaps was demonstrative of the ability for them to neutralize thoughts and feelings related to their deceased spouses in such situations, likely an adaptive coping mechanism in bereavement. Among all participants in Mancini and Bonanno’s (2012) study, those with insecure attachment styles took significantly longer to respond following the threatening word than otherwise; no such differences were found for securely attached individuals. The authors interpreted this to mean that such persons may have a greater tendency to feel an ongoing preoccupation with their deceased loved ones. Further, they inferred that the attachment styles of those with CG might hamper their cognitive abilities, such as in being able to discriminate appropriately or to engage with others in a flexible manner. Their results
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were also consistent with previous research (e.g., Fraley & Bonanno, 2004; Wijngaards-de Meij et al., 2007) that has found generally more insecure attachment styles among those with CG than bereaved persons without CG. Future research directions based on their results point toward the need to develop novel treatment interventions geared to help in reducing the hyperactivation of the attachment system during the course of CG treatment.
Coping with Grief Emotional and Continuing Bonds Given the universality of the grief experience and the potential dire consequences of CG, further exploration of adaptive versus maladaptive coping styles is warranted. The adaptive importance of breaking bonds (i.e., the task of accepting the reality of the loss and moving forward with one’s own life) has pointed researchers’ attention toward how bonds are created and maintained over time (e.g., Stroebe, Gergen, Gergen, & Stroebe, 1992). Klass, Silverman, and Nickman (1996) proposed that the retention of these natural bonds to deceased loved ones is a normal part of the grieving process and that their continuation may be a “healthy part of the survivor’s ongoing life” (p. 22), while others (e.g., Stroebe, Schut, & Stroebe, 2005) have pointed out that the maintenance of these emotional ties also may have maladaptive consequences such as social isolation. Overall, research has produced mixed results on whether these emotional ties with the deceased, or continuing bonds (CB), can be a piece of healthy grief resolution or are a contributing factor to CG (Gassin & Lengel, 2014). Either way, the nature of bereaved individuals’ emotional bonds with deceased attachment figures appears to have a significant impact on one’s ability to cope with grief. Some theories propose to explain such inconsistent results regarding the relationship between CB and CG. From an intrapsychic perspective, CB may be defined as the bereaved person’s subjective experience of an ongoing internal relationship with the deceased (Field, Gal-Oz, & Bonanno, 2003). This experience may be affected by the attachment style of the griever. Some research suggests that CB may be a normal and healthy response to grief for securely attached persons, permitting them to slowly relocate and loosen the bond with the deceased attachment figure while allowing for “a sense of continued remembrance” (Stroebe, Schut, & Boerner, 2010, p. 263). On the other hand, those individuals with anxious attachment styles may rigidly cling to the CB, leading to the hyperaccessibility and rumination of the deceased as seen in those with CG. Further, the avoidantly attached may find no use for CB in grief resolution (Stroebe et al., 2010). Therefore, the differing results on how CB interact with and impact grief and coping responses may be better explained by differences in attachment style.
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Other research has shown that CB may be split into two distinct experiences that interact with CG and attachment style differently: externalized CB and internalized CB. According to Field and Filanosky (2010), externalized CB typically involves perceptual disturbances related to the deceased’s presence, such as via hallucinations or illusions. These may range from the griever momentarily believing that she or he has heard a deceased loved one’s footsteps to feelings of being haunted by the deceased (Ho, Ide, Chan, Ma, & Field, 2013). Internalized CB instead refer to “use of the deceased as an autonomy promoting secure base,” seen through such statements as “I experienced the deceased as continuing to live on through his impact on who I am today” (Ho et al., 2013, p. 250). Ho et al. (2013) found that insecurely attached bereaved persons were significantly more likely than were the securely attached to express externalized CB with the deceased. Their findings supported past research (e.g., Fraley & Bonanno, 2004) that demonstrated significant positive correlations between CB, grief symptoms, and anxious attachment styles. Results also indicated that a strong reliance on both externalized and internalized CB was associated with increased severity of grief symptoms, although only externalized CB showed a unique relationship with anxious attachment. In other words, anxiously attached adults tended to experience greater difficulties with postbereavement adjustment (Ho et al., 2013), strengthening the need for further research on the role of insecure attachment patterns in coping with CG and how an assessment of one’s attachment style can inform more effective treatment of CG. Continuing bonds are not just an intrapsychic phenomenon but a social and cultural one as well. Many cultures encourage the use of rituals, both private and social, that allow individuals to maintain a relationship with the deceased (Klass, 2001; Lalande & Bonanno, 2006). Bereaved individuals in America often feel pressured to resolve grief and break bonds (Maple, Edwards, Minichiello, & Plummer, 2013); despite this pressure, continued bonds are still seen in western culture. Klass (2006) reported that among those who attend self-help groups for bereaved parents, “one of the primary dynamics is making the bond with the child a social reality” (p. 845), and in today’s Internet age, individuals now are using social networks such as Facebook to maintain relationships with the deceased through memorial groups (DeGroot, 2012). Given the interpersonal nature of attachment, how bereaved individuals take part in, and are affected by, these social rituals and collective continued bonds may be greatly affected by attachment style. Further research should assess for how insecure attachment styles may interact uniquely with these cultural and social rituals.
Cognitive and Behavioral Processes In addition to emotional bonds, cognitive and behavioral processes such as avoidance behaviors and negative cognitions may play meaningful roles in the potential development of CG, possibly lending support for the development of
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novel treatment interventions that specifically address these processes. Boelen, van den Hout, and van den Bout’s (2006) cognitive behavioral model of CG posits that three core processes serve as mediators between individual risk factors and likelihood of developing CG. The first core process involves insufficient connectedness within the bereaved individual’s autobiographical memory between fact-based knowledge about the irrevocable nature of the loss, schematic knowledge of one’s own identity, and the relationship with the lost loved one (Boelen & Klugkist, 2011). This internal disconnection between the reality of the loss and one’s relationship with the deceased, often leading to thoughts such as “It feels unreal that [-] is gone forever,” is thought to perpetuate the experience of shock surrounding the death and the irrational belief that the loss is transitory rather than permanent (Boelen & Klugkist, 2011, p. 295). The presumed result of this disconnected thought process is ongoing yearning and a desire to maintain and restore closeness with the deceased (Boelen & Klugkist, 2011). The second process involves an intensified focus on chronic negative thought processes and catastrophic misperceptions of one’s personal grief reactions, perhaps reflected via statements such as, “If I would fully realize what the death of [-] means, I would go crazy” (Boelen & Klugkist, 2011, p. 296). In combination, these could impede psychological adjustment to the death by increasing distress. Lastly, the third process relates to avoidance behaviors, such as avoiding reminders of the loss (anxious avoidance) and avoiding events that may facilitate adjustment to the loss (depressive avoidance). Proper and thorough assessment of attachment style ultimately may improve treatment outcomes among those with CG (Lobb et al., 2010). And importantly, with this cognitive behavioral model of CG (Boelen et al., 2006) in mind, an important future direction to consider could be the potential impact of cognitive and behavioral processes on the relationship between insecure attachment style and CG. Through mediational analyses, Boelen and Klugkist (2011) examined the roles of Boelen et al.’s (2006) three core cognitive processes with neuroticism, insecure attachment style, and CG. Significant relationships were found between CG and measures of neuroticism, attachment avoidance, and attachment anxiety, with CG and neuroticism exhibiting the strongest correlation among the three relationships (Boelen & Klugkist, 2011). Results also supported the significant relationships between attachment anxiety and avoidance among those with intensified CG, lending additional credence to the importance of assessing attachment style as part of standard practice in griefrelated treatment interventions.
Specific Attachment Styles and Coping Just as having an insecure attachment style appears to serve as a risk factor for ineffective coping with bereavement, having a secure attachment style instead
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may serve as a safeguard. Meier et al. (2013) provided support for the protective role of a secure attachment style in coping effectively with bereavement while lending additional support to prior research finding unique linkages between attachment-related anxiety and higher levels of CGS (Prigerson, Maciejewski, & Rosenheck, 2000; Wijngaards-de Meij et al., 2007). Research on the role of attachment in coping with the loss of a loved one has found significant direct relationships between attachment-related anxiety and CGS, such as intense separation distress from the deceased (Meier et al., 2013). These findings were buffered by previous research supporting the significant impact of attachment anxiety on poorer coping with bereavement (Fraley & Bonanno, 2004; Wayment & Vierthaler, 2002; Wijngaards-de Meij et al., 2007). Also, defensive attachment avoidance could serve as a substantial risk factor for CGS (Wayment & Vierthaler, 2002). Individuals with an avoidant attachment style who also are struggling with CG may experience negative outcomes from their more commonly employed coping mechanism of avoidance (e.g., Bonanno et al., 1995). While an avoidant coping style arguably may serve an adaptive function in some contexts, it also can become maladaptive when utilized as a defensive maneuver following the death of an attachment figure (Bonanno et al., 1995). Based on the potential for insecurely attached individuals with CG to utilize ineffective coping mechanisms, such persons may benefit from treatment interventions designed to assist them in developing more adaptive coping skills. In kind, future research could integrate assessment of attachment style (e.g., anxious or avoidant) with existing knowledge of empirically supported attachment-based treatments, for example, interpersonal psychotherapy (IPT; Weissman, Markowitz, & Klerman, 2007) as well as perhaps the more recently devised and promising complicated grief therapy model (CGT; Shear, Frank, Houck, & Reynolds, 2005). Anxious versus avoidant attachment and complicated grief risk. In addition to the value of helping those with CG to develop more effective coping mechanisms, another important future direction would be to strive to better understand what distinctions might exist between the different insecure attachment styles according to CG risk. For instance, anxiously attached adults with CG tend to exhibit a unique CG symptom presentation than do avoidantly attached adults with CG. Research consistently has found a significant positive relationship between anxious attachment and CGS (e.g., Fraley & Bonanno, 2004), although evidence for a similar relationship between avoidant attachment style and CG has been somewhat lacking (Wayment & Vierthaler, 2002). To date, only Wijngaards-de Meij et al. (2007) have found a positive relationship between avoidant attachment style and CGS. More recently, other literature has added to this vital research direction. Jerga, Shaver, and Wilkinson (2011) explored the relationship between griefrelated symptoms and insecure attachment styles in greater depth, placing an
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additional focus on distinctions between general and relationship-specific attachment styles as predictive of CGS. Overall, findings revealed that both general and specific insecure attachment styles accounted for over 18% of the variance in CG symptoms. Both general (i.e., not related to a specific relationship) anxious and avoidant attachment styles were found to have predicted CGS, although no relationship was found between having an insecure attachment style and the presence of more normative grief symptoms (e.g., missing or yearning for the deceased without significantly impacting the bereaved person’s basic level of daily functioning). Further, relationship-specific anxious attachment style was predictive of CGS, whereas relationship-specific avoidant attachment style was negatively related to CGS (Jerga et al., 2011). Bereaved persons with both anxious and avoidant attachment styles are at a significantly greater risk for developing CG than those with a secure attachment style. Given the importance of insecure attachment orientations on CG reactions, it is worthwhile to consider the role of insecurely attached individuals’ attachment systems in response to grief severity and to implement treatment interventions to fit the specific needs of the individual. Other factors affecting grief. Although the primary focus of this article is on attachment and grief symptomatology, other psychosocial factors that have been shown to impact one’s grief response also should be mentioned. Attachment style does not interact with grief within a vacuum. Grief is a social and cultural phenomenon, one which occurs within an individual’s context. Various factors surrounding the death have been found to affect the likelihood of developing CG, including the relationship to the deceased (e.g., spouse or child), type of illness, the location of the death (e.g., hospital or at home), amount of time spent with the deceased preceding the death, and the unexpectedness of the death (Fujisawa et al., 2010; Lobb et al., 2010). Additionally, personal factors of the griever such as age, gender, and socioeconomic status have been related to the development of CG (Kersting, Bra¨hler, Glaesmer, & Wagner, 2011; Lobb et al., 2010). Future research should more thoroughly examine the relationship between these other factors, attachment styles, and CG. Given that attachment, while considered intrapersonal (Stroebe, Folksman, Hansson, & Schut, 2006), is created through (and affects) social relationships, special attention should be paid to social context and grief. Most research agrees that for many, there is a need to talk about the death of a loved one with others; many people actively seek out family members and, less often, friends for support in processing the death (Pressman & Bananno, 2007). Similarly, family dynamics can affect how individuals respond to death (Stroebe et al., 2006). If attachment is formed from early childhood interactions with these same family members and if it affects how individuals interact within their families as adults, a more complex picture begins to arise. More research should examine
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the relationship between attachment, current family dynamics, support mechanisms, and grief. Lastly, it must be noted that grief and attachment are culturally bound constructs. Grief is, of course, a cross-cultural phenomenon in the sense that people in every culture must experience and deal with death throughout their lifespans. However, how grief is expressed varies vastly across different countries from cultures where “muted grief” is the norm compared with cultures that express what is deemed as “excessive grief” by United States’ standards (Rosenblatt, 1993, p. 15). Therefore, the exact definition of what is “complicated” grief would vary as well depending on cultural norms. Similarly, attachment theory has been found to be relevant across a wide range of cultures (Rothbaum & Morelli, 2005). However, research has shown that the exact definition of concepts such as security and sensitivity may vary depending on cultural values and practices (Rothbaum & Morelli, 2005). These findings emphasize the need to study CG and attachment in the context of family, social relationships, and culture in order to form the most accurate picture possible.
Future Directions While this article presents on a wide range of studies depicting various aspects regarding the relationship between CG and attachment, much more still remains unknown about this complex interaction and its implications for treatment. Research has demonstrated mitigating effects of developing a sense of purpose and meaning on the development of CG, lending credence to the value of future research that focuses on the efficacy of attachmentoriented, constructivist, and cognitive-behavioral approaches for making meaning following the death of a loved one (Lobb et al., 2010). Future research also could follow up on Mancini and Bonanno’s (2012) results, specifically exploring for interventions to reduce hyperactivation of the attachment system, likely reducing CG symptoms by proxy. Additional research also could examine the complex interaction between internalized and externalized CB and the various attachment styles. Given the inconsistencies in current studies on CB (e.g., Field et al., 2013; Gassin & Lengel, 2014; Stroebe et al., 2005), it is possible that the different styles of attachment interact uniquely with both internalized CB and externalized CB and may effect coping and CG reactions in a more complex manner than so far understood (Gassin & Lengel, 2014; Ho et al., 2013). Further research also can attempt to better understand the connection between cognitive and behavioral processes (as explained in Boelen et al., 2006), insecure attachment, and CG. Overall, the relationship between insecure attachment and CG appears to exist, but the specifics of this interaction arguably are complex, and more research is needed to explore this relationship.
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Attachment-Informed Complicated Grief Assessment and Treatment The clear connection between CGS and subjective emotional bonds to attachment figures naturally leads to the question of how to most effectively provide clinical services to bereaved individuals on the basis of their attachment orientations. Clinical interventions with clients who struggle with CGS have the potential to be better informed through initial assessment of her or his attachment style. Recent findings (e.g., Ho et al., 2013) should serve as an impetus for mental health professionals to assess for attachment orientations (e.g., Adult Attachment Interview [AAI]; George, Kaplan, & Main, 1985) among bereaved clients as part of standard practice. Assessment of attachment style with an instrument such as the AAI, a reliable instrument in determining resolution of previous losses (Thomson, 2010), could be useful in producing positive clinical outcomes for those with CG by attending to the specific needs of those with insecure attachment styles. Future research is warranted into how bereaved individuals may benefit therapeutically from the integration of personal attachment dynamics with their presentations of CG symptoms. The current state of the literature on the role of attachment style among those with CG provides a variety of promising clinical and theoretical applications. Smith, Kalus, Russell, and Skinner (2009) pointed to the importance of examining the subjective experiences of adults with CG to better elucidate what therapeutic interventions are reportedly helpful and to allow space for those with CG to discuss their potential feelings of stigmatization. To wit, CGT (Shear et al., 2005)—although only one option—is a highly promising new treatment approach for CG that is grounded in attachment theory (Bowlby, 1982). Over a 16-week protocol, CGT utilizes empirically supported IPT and cognitive behavior therapy interventions to address behavioral avoidance, intrusive memories, and restoration of meaningful relationships (Shear, Ghesquiere, & Glickman, 2013; Wetherell, 2012). CGT differs from IPT grief treatment though through incorporating cognitive behavior therapy techniques designed to target grief-related cognitions. In addition to needing further research to assess for both its efficacy and effectiveness, future directions for CGT research may focus on incorporating an assessment of attachment style at the beginning treatment stage and then examining for any between-group differences according to attachment style. Doing so would be crucial in order to shed much-needed light on whether individuals with anxious or avoidant attachment styles respond any differently to the specific treatment interventions comprised within this very promising modality.
Concluding Thoughts Attachment theory (Bowlby, 1982) is generally accepted as a framework through which to understand the impact of interpersonal relational styles in transitioning
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from acute grief to integrated grief, as well as in considering the potential for bereaved adults with insecure attachment styles to develop CG. The current body of literature assessing the linkages between attachment style and CG consistently points to an increased risk of CG for adults with both anxious and avoidant attachment styles (e.g., Ho et al., 2013; Mancini & Bonanno, 2012; Meier et al., 2013). The clear risk factor posed by an insecure attachment style on CGS highlights the need for further understanding of how to develop effective treatment interventions for these individuals when needed. It is possible that once the unique treatment needs of insecurely attached individuals with CG are much better understood, helping them to instill more effective coping mechanisms to support them in reengaging with life and finding meaning once again following the death of a loved one would still remain vital. At this time, additional research is highly recommended in order to further understand the specific grief-related treatment needs of those adults with more anxious and avoidant attachment styles, along with specific community and family supports, which can mitigate the affect of attachment on grief. For instance, one possibility could be to compare treatment outcome differences between two groups of bereaved adults—one assessed for attachment style beforehand and one not. Between-group differences may indicate whether the therapists’ knowledge of the group members’ attachment styles provides any useful clinical information in guiding treatment. Another avenue for future research involves comparing differences in IPT for the treatment of grief between groups of adults with acute grief and CG. However, until future research sheds light on more effective treatment of CG among adults with such insecure attachment styles, such bereaved individuals may not receive clinical interventions tailored to their specific needs. From a nonclinical perspective, families and communities also can offer support to individuals more susceptible to CG due to insecure attachment styles. For example, numerous studies have shown the importance of social support in working through grief (Dyregrov, 2003–2004; Pressman & Bonanno, 2007). Yet individuals who lost loved ones in traumatic or sudden ways—the same individuals at higher risk for developing CG—often face social ineptitude or a lack of awareness on the part of social networks regarding how to best support them (Dyregrov, 2003–2004). While Dyregrov (2003–2004) found that openness on the part of the survivors and a willingness to inform others of their needs each helped to buffer this effect, individuals with an insecure attachment style may struggle more mightily to reach out in the first place. Family and friends can support these individuals by proactively reaching out to them and asking them for what they need, rather than waiting for the bereaved individuals to solicit help themselves. This may take a greater degree of awareness on part of our society as a whole on how to best handle death and mourning. Additionally, cultural practices such as the eulogy can be used to encourage healthy expression and processing of grief (Kunkel & Dennis, 2003). However, more research must
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be done to understand how such social practices affect individuals with specific attachment styles and how the presence of such attachment styles in turn may affect how individuals actually engage in such practices. The advent of attachment-specific treatment of CG may offer hope to insecurely attached bereaved adults as they navigate the process of making meaning from their loss and regaining a sense of vitality. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Laura K. Schenck is a doctoral student in Counseling Psychology at the University of Northern Colorado. Her research interests include attachment theory, mindfulness, emotional intelligence, and the intersection between mental health and technology. Kiersten M. Eberle is a doctoral student in Counseling Psychology at the University of Northern Colorado. Her research interests include bereavementrelated concerns and mental health problems related to trauma and loss. Jeffrey A. Rings is an assistant professor of Applied Psychology and Counselor Education at the University of Northern Colorado. His research interests include bereavement-related concerns, clinical supervision, suicide risk assessment and prevention, and veteran mental health issues.
