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Grief, as conceived on the Kübler-Ross model, involves five stages: denial, sadness, anger, bargaining, and acceptance.10
After the loss of a loved one, you may first deny that the person is gone, simply refuse to believe it. When reality sets in, you may find yourself repeatedly going over things that happened, asking a lot of “what if” questions, and wishing you could go back and change things.5,9
Once you realize things are not going to change, you may experience intense sadness and longing and intrusive thoughts and images and temporarily lose interest in activities that you normally took pleasure in.
However, each of us experiences grief in a unique way, and the process of grieving need not follow this pattern.5,18 You may experience the intense emotions of grief in a different order, cycle through them many times, only experience some of the intense emotions, or experience several conflicting emotions at once.
For most of us, however, the intensely unpleasant emotions of grief will eventually subside, enabling us to return to former activities or begin new activities that allow us to find meaning in the loss. This is the acceptance stage, also known as the adaptive process or the healing process,
On average, it takes us around six months to reach the adaptive process during which our suffering and pain gradually diminish in intensity and frequency. Ultimately, memories of our lost loved ones may bring a smile rather than tears.
About 10-20 percent of people, however, experience intense and disabling grief for significantly longer than the average of six months. This is also known as complicated grief.19
Studies of complicated grief have yielded inconsistent results
Attachment theory has become one of the primary tools for understanding complicated grief.17,2
John Bowlby, the founding father of attachment theory, originally suggested that insecure attachment can disrupt the adaptive process of grief.4
Individuals with an insecure attachment deviate significantly in attachment anxiety or attachment avoidance from the population average.
However, empirical investigations into the link between insecure attachment and complicated grief have yielded inconsistent results, with some studies finding an association and others finding no such link.2,3,6,7,11,12,13,14,15
A new study seeks to make sense of these inconsistencies
To explain these conflicting findings, Russ et al. (2022) conducted a meta-analysis of 22 studies of attachment and complicated grief, which were published between 2003 and 2020 and met their inclusion criteria.
The authors found that studies taking a categorical approach to attachment did not consistently find an association between insecure attachment and complicated grief.
In the categorical approach, study participants are divided into attachment types, such as high anxiety-low avoidance (fearful-preoccupied), high anxiety-high avoidance (fearful-avoidant), and low anxiety-low avoidance (dismissive-avoidant), which then serve as the framework for gathering data.1
The categorical approach, however, has been shown to be unreliable,8,16 which may explain the inconsistent findings in the categorical studies.
A more reliable approach treats attachment avoidance and attachment anxiety as dimensions of attachment.
The dimensional approach is modeled on dimensional approaches to personality—also known as factor analyses. The perhaps best-known dimensional approach to personality is the five-factor model (“the Big Five”).
Dimensional approaches to personality have not relinquished the language of personality types. For example, the Dark Triad of personality—narcissism, psychopathy, and Machiavellianism—consists of three personality types (or categories). But the personality types are not employed in the gathering of data but only in the interpretation of above-threshold scores on certain dimensions of personality.
Likewise, a dimensional approach to attachment does not employ attachment types (or categories) like fearful-preoccupied, fearful-avoidant, and dismissive-avoidant in the data collection but only in the interpretation of above-threshold scores on the two dimensions of attachment.
Russ et al. (2022) confirmed that both higher levels of attachment anxiety and attachment avoidance were positively correlated with complicated grief symptoms in the dimensional studies, but different factors turned out to mediate these associations.
How different attachment patterns complicate grief
Russ et al.’s (2022) results indicated that in individuals who are high in attachment anxiety and low in attachment avoidance (“fearful-preoccupied”), a mediating factor was their tendency to respond to stress, fear, and threats by hyper -activating the attachment system. Their hyper-activated attachment system compromised their ability to cope with unpleasant emotions and made them prone to rumination and generalized anxiety.
In individuals who are high in attachment anxiety and high in attachment avoidance (“fearful-avoidant”), the authors found that the tendency to maintain a symbolic relationship with the deceased—eg, communicating with the beloved or undergoing hallucinations of them—was a mediating factor interfering with the healing process in grief.
Maintaining a symbolic relationship with the deceased made them less likely to find comfort and security in their relationships with other people in their lives and ultimately delayed their healing process.
In individuals low in attachment anxiety and high in attachment avoidance (“dismissive-avoidant”), the researchers identified the tendency to respond to fear, stress, and threat by deactivating the attachment system as a mediating factor in complicated grief. The deactivated attachment system of dismissive-attached individuals was found to interfere with the tendency of these individuals to share their painful emotions with others.
Rus et al.’s (2022) findings furthermore revealed that whether dismissive-avoidant individuals were able to deal adequately with their grief on their own dependent on the quality of the relationship they had with the deceased.
In the case of high-quality relationships, dismissive-avoidant individuals were able to take comfort in the positive memories of good times with the deceased, which helped them come to terms with their loss more quickly. Dealing with grief on their own, however, was counterproductive to healing when there had been a lot of conflicts in the relationship with the deceased.
In individuals with high attachment anxiety, by contrast, both high-quality and high-conflict relationships contributed to a postponement of the healing process and the development of complicated, regardless of these individuals’ degree of attachment avoidance.