Attachment, loss, and complicated grief

Abstract

Bereavement is a highly disruptive experience that is usually followed by a painful but time-limited period of acute grief. An unfortunate minority of individuals experience prolonged and impairing complicated grief, an identifiable syndrome that differs from usual grief, major depression, and other DSM IV diagnostic entities. Underlying processes guiding symptoms are not well understood for either usual or complicated grief. We propose a provisional model of bereavement, guided by Myron Hofer's question "What exactly is lost when a loved one dies?" We integrate insights about biobehavioral regulation from Hofer's animal studies of infant separation, research on adult human attachment, and new ideas from bereavement research. In this model, death of an attachment figure produces a state of traumatic loss and symptoms of acute grief. These symptoms usually resolve following revision of the internalized representation of the deceased to incorporate the reality of the death. Failure to accomplish this integration results in the syndrome of complicated grief.

An attachment-based model of complicated grief including the role of avoidance

“…Eighty (63%) met criteria for current Major Depression. Severity of depression and anxiety were assessed using the rater-administered 17-item Hamilton Depression (HRSD) [18] and Hamilton Anxiety (SIGH-A) [43,46] Rating Scales. Complicated grief severity was assessed using the Inventory of Complicated Grief (ICG) [39].…”

“…We believe the effectiveness of this complicated grief treatment provides indirect support for the validity of the underlying model, though clearly there is a need for studies directly testing specific components of this model. Distribution of Scores on the Grief-related Avoidance Questionnaire Complicated grief pathway elaborated from Shear and Shair [46] Table 2 Complicated grief treatment goals and strategies…”

“…Our group has been studying assessment and treatment of bereavement-related mental health problems for more than a decade [e.g., 16 [21,46]. The current paper further develops this by focusing on (1) a biobehavioral explanation for grief symptoms and (2) a more detailed description of complicated grief.…”

“…In Shear and Shair [46] we posit that the symptoms of acute grief result from a temporary failure of biobehavioral regulatory functions subserved by the mental representation of the deceased person. Our model, integrates ideas proposed by Hofer [22] with findings from adult attachment studies, adult bereavement studies and clinical observations of bereaved people with complicated grief.…”

Cognitive therapy and eye movement desensitization and reprocessing for reducing psychopathology among disaster-bereaved individuals: study protocol for a randomized controlled trial

“…homicide/accident/disaster-related loss) has been associated with higher PG, PTS, and depression levels compared with non-violent loss (Boelen, de Keijser, & Smid, 2015; Kaltman & Bonanno, 2003; Kloep, Lancaster, & Rodriguez, 2014). Empirical work, drawing from cognitive-behavioural theories of grief (Boelen, van den Hout, & van den Bout, 2006a; Maccallum & Bryant, 2013; Shear & Shair, 2005), has shown that negative cognitions and avoidance behaviour may explain the debilitating impact of traumatic loss (Boelen et al, 2015; Mancini, Prati, & Black, 2011). According to Boelen et al’s (2006a) cognitive-behavioural model, three processes play a crucial role in the onset and maintenance of post-loss psychopathology: insufficient integration of the loss into the autobiographical knowledge base, negative cognitions, and avoidance behaviour.…”