Attachment & Loss

1. Attachment & Loss

4. Attachment Theory • Definition of Attachment: • An enduring emotional tie to a special person, characterized by a tendency to seek and maintain closeness, especially during times of stress.

5. Roots of Attachment Theory • John Bowlby applied ethology to infants • Influenced by Konrad Lorenz • Infant’s innate behaviours are evolved responses which promote survival • These behaviours include: sucking, crying, smiling, clinging, and following. • Behaviours are modified from inception by the behaviour of the Primary Care Figure (PCF).

7. PCF reactions... • Bowlby found that temporary separations from PCF evoked distinctive type of reactions (separation anxiety) from infant, toddler, etc. • More importantly, he showed how infant/toddler’s reactions upon PCF return may evoke the very behaviour the infant/toddler intended to prevent.

8. Enter: Mary Ainsworth • “Is the child who clings to his mother - who is afraid of the world and the people in it, and who will not move off to explore other things or other people - more strongly attached or merely more insecure?” • Ainsworth • Made the distinction between strength of attachment and security of attachment. • The natural question that had to be asked was:

9. Secure Attachment • Infant / toddler uses • caregiver as a secure base • May show distress at • separation, but the baby • can be soothed at reunion • Parents of these children • display sensitivity to • infants/ toddlers needs

10. Secure Attachment (cont.) • Some parents report having attachment issues of their own from the past, but have gotten over them. • Interestingly, their marriages are also less likely to be conflicted than those of the parents of insecurely attached children.

11. Development of the Strange Test • A colleague of Bowlby’s (Ainsworth) developed experiment /method to classify patterns of attachment between infants and mothers: Strange Situation Test (SST) during separation. • Led to the development of 2 categories of attachment • 1 type being Secure and 3 types of Insecure.

12. Strange Situation

13. Insecure - Anxious / ambivalent • Infant/toddler(s) (IFT) found on the SST who have PCF’s who are over-anxious, insensitive to their child’s needs, and discourage exploration. • (IFT) • Shows great distress during separation • Clings and cries angrily upon return • Distress continues after reunion for much longer than securely attached infants

14. Insecure / Avoidant • Are infant/toddler(s) (IFT) found on the SST who have PCFs who do not show feelings, cannot tolerate closeness, punish child’s attachment behaviour. • (IFT) then learns to: • Inhibit their tendency to cling and cry

15. Insecure / Avoidant • During the SST when (PCF) re-appears (IFT) appears indifferent and uncaring will even ignore (PCF). But this is not the true case as inside they are physiologically aroused. • Research has showed that (PCF’s) can be responsive to (IFT’s) under low levels of stress, but under high levels become less responsive.

16. Disorganized / disoriented • In this case the IFT has a PCF who often feel helpless, and are frightened by their own children. • The PCF often lacks in confidence with respect to their ability to care for and control their child and they may see their child as more powerful than themselves. • Ultimately, this conditions the (IFT) to develop disorganized and contradictory behaviour.

17. Disorganized / disoriented (cont.) • (IFT’s) may cry during separation but avoid the PFC upon return or they may approach the PFC upon return then freeze/fall, hit themselves, rock back and forth, etc. • This group shows the greatest distress and in adult life have the most problems in living.

18. The Disorganized / Disoriented PCF: Why? • Experience of their own childhood trauma • Active addictions • Loss of parent before birth of child • Currently experiencing a trauma / related problem

19. Function of Insecure Attachments • WHY WOULD CHILDREN CONTINUE TO ACT APPARENTLY INSECURELY ? • ANXIOUSNESS / AMBIVALENCE (Cling / Stay close / Protest) • AVOIDANT (Stands of own two feet / seek dependence / inhibit feelings) • DISORGANIZED / DISORIENTED (Stands of own two feet / seek dependence / inhibit feelings / act inconspicuous / withdraw / freeze / ) • Thoughts folks?

20. Attachments in later childhood What do we think we Know?

21. Attachments patterns that have been established by two years of age appear to remain stable and predict quality of relationships in later childhood • Anxious / ambivalent school children seem to lack confidence and assertiveness necessary for interaction with peers. • Avoidant children show more aggression to other children and teachers rate them as more hostile, impulsive, and withdrawn.

22. Attachments in later childhood what do we think we know? • Meanwhile, disorganized children appear to be a risk for psychiatric problems in later childhood (12 and beyond). • Further research has demonstrated that attachment patterns are indeed hard to break and that the assumptive world that the child experienced between 0 - 2 is the lens in which they view world as older children. • This is important because ... It’s all about building trust!

23. Four Categories of Basic Trust Other Trust Self Trust High High Secure Attachment Insecure Anxious / Ambivalent Low High Avoidant High Low Disorganized Low Low

24. Determinants of Outcome after Bereavement: Research says... • Risks factors for chronic bereavement • Personal vulnerability of the bereaved • Attachment to the deceased • Events / circumstances lead up to and including death • Social supports and other circumstances taking place after death • Dependent relationships • Ambivalent relationships

25. The Research Project • Test clinical impressions/hypothesis which suggest that: • Love and loss are intertwined • Childhood attachments patterns / separation from parents / relationships in later life influence how we cope with stress and loss, and; • Understand the problems/dynamics which cause people to seek help after bereavement in adult life. • And ultimately, to understand the chains of causation and to clarify the reasons why some people come through the pain of bereavement and emerge stronger and wiser than before while others suffer lasting damage to their mental health.

26. Bereaved participants • 181 patients who attended Royal London Hospital • 43 men • 138 women • 74% had been bereaved for over a year before entering into the study • average age 41

27. Relationship of the dead person to the respondent • Spouse or partner • Mother • Father • Child • Stillbirth • Miscarriage • Sibling • Other • Multiple n = 34 n = 31 n = 9 n = 25 n = 1 n = 3 n = 12 n = 12 n = 33

28. Scoring ExceptionsMost Yes/No questions are scored Yes = 1 No = 0 Except for: Section 1 question (1) No = 1Section 1 question (2a) No = 1Section 1 question (29) No = 1Section 11 32 = score 1 PT. FOR NEVER OR 1 PT. FOR OFTEN

29. FINDING YOUR ATTACHMENT TYPE: INSECURE / SECURE Do not score section 1I 34 and 35 Section 1: Parenting Section 11: Childhood Vulnerability 11, 15, 16, 28 17, 18, 19, 20 7, 8, 9a, 9b, 12 1, 3, 4, 5, 14 6, 24 10, 13, 25, 26, 27 Corresponding numbers Corresponding numbers • Parental distant control • Parental over protection • Parental depression / psych • Parental separation • Parental unusual closeness • Parental rejection / violence 5, 6 7, 10, 12, 15, 16, 24, 25 20, 26, 27, 28, 29, 30, 31 8, 14, 17,18, 19 9, 32, 33 11, 23 • Childhood illness • Childhood timidity • Childhood aggressive distrust • Childhood Dresden vase • Childhood unhappiness • Childhood care giving • Parental violent aggression If “yes” is chosen for any indicated number give 1 point, if “no” zero point

30. FINDING YOUR ATTACHMENT TYPE: INSECURE / SECURE • If you score 11 or less attachment style = secure • More than 21 attachment style = insecure • Average score from bereaved study participants was 17 • Other subcategories scoring to follow

31. SCORING YOUR ANXIOUS / AMBIVALENT SCORE • SUM THESE CATEGORIES • PARENTAL UNUSAL CLOSENESS SI - 6, 4 • PARENTAL OVERPROTECTIVENESS SI -17, 18, 19, 20 • CHILDHOOD TIMIDITY SII - 7, 10, 12, 15, 16, 24, 25 • DRESDEN VASE SII - 8, 14, 17,18, 19 • 10 MORE = INDICATES ANXIOUS AMBIVALENT ATTACHMENT • SCORE = 7 WAS AVERAGE SCORE FOR BEREAVED PARTICIPANTS

32. SCORING AVOIDANT ATTACHMENTS • SUM THESE CATEGORIES • PARENTS INTOLERANT OF CLOSENESS SI - 28 • CHILD INTOLERANT OF CLOSENESS SII - 26 • CHILDHOOD AGGRESSIVENESS / DISTRUSTSII 20, 27, 28, 29, 30, 31 • SCORE OF 6 OR MORE INDICATES AVOIDANT ATTACHMENT • SCORE 3.8 WAS AVERAGE SCORE FOR BEREAVED PARTICIPANTS

33. SCORING DISORGANIZED ATTACHMENTS • SUM THESE CATEGORIES • FAMILY EXPERIENCE DANGER / PERSECUTION SII - 4 • PARENTAL REJECTION / VIOLENCE SI - 10, 13, 25, 26, 27 • PARENTAL DEPRESSION / PSYCH SI - 7, 8, 9a, 9b, 12 • CHILDHOOD UNHAPPINESS SII - 9, 32, 33 • COMPULSIVE CAREGIVING SII - 11, 23 • SCORE OF 6 OR MORE INDICATES DISORGANIZED ATTACHMENT • SCORE 4.5 WAS AVERAGE SCORE FOR BEREAVED PARTICIPANTS

34. SECURE ATTACHMENTS • The more reported security of attachment the less severe distress reported AFTER BEREAVEMENT • Why?

35. Correlations Low Secure Attachment = secure parenting harmonious adult relationships Low Marital Disharmony Score Low Problematic Coping Score Low Overall Distress Score

36. Securely Attached will still seek and Sometimes need treatment • Securely attached are not free from distress, but more likely to cope better and have lower levels of distress • Those that sought help and who had low insecure scores suffered from • Obsessional symptoms, sleep disorders, symptoms of post-traumatic stress, depression and anxiety • Causes of the latter symptoms: unexpected, untimely, or violent bereavements • Ultimately, it appeared secure attachments sometimes leave us unprepared for traumatic events that occur over a lifetime.

37. Summary secure Attachments = Less distress after bereavement • Secure attached are: • More self-confident • Seek out support and help when needed • Have a reasonable sense of autonomy • Marriage is more harmonious and provide a buffer from distress

38. Shows great distress during separation • Clings and cries angrily upon return • Distress continues after reunion for much longer than securely attached infants Anxious / Ambivalent • Remember these are the folks who scored high on Parental Unusual closeness and/or Overprotection along with Childhood timidity and/or high ‘Dresden Vase scores. • Results showed that participants who scored high on Anxious/ Ambivalence bereaved for protracted periods of time and had difficulty with loneliness. • However, anxious/ambivalent attachment in childhood and long lasting severe grief after bereavement could not be explained by the anxious/ambivalent dependence on the lost person. • So what explains the persistence of grief for these folks?

39. Persistence of Grief? • Long lasting grief appeared to be entangled with anger and resentment - freezing the ability to let go the deceased. • What else do folks think is going on here?

40. Correlations Anxious/Ambivalent = insecure parenting conflicted adult relationships Marital Disagreements Disagreements with deceased Chronic Grief Cling attach to / push away

41. Anxious / Ambivalence: In light of bereavement Summary • People who experience anxious / ambivalent relationships in childhood and people who make dependent attachments in adult life are both likely to suffer severe and lasting grief and loneliness after bereavement. • It appears that these persons do not see love as something that is given, but is demanded - a la from parents. • In adulthood then so-called love is lost (via death) and their fear and rage complicates and magnifies grief • They are caught in a web of needing to cling and holding back from clinging = high anxiety. So when their loved one dies - who do they cling to or go for support?

42. Avoidant Attachments • Parents intolerant of closeness / do not mirror • IFT inhibit their tendency to cling and cry • During the SST when (PCF) re-appears (IFT) appears indifferent and uncaring will even ignore / avoid (PCF). • Avoidant attachments in childhood were highly correlated in adult life with difficulty in showing affection and with high scores on emotional Inhibition/Distrust and Aggression /Assertiveness • Avoidant attachments was also highly correlated with Marital Disagreements. • Avoidant attachments were also found to correlate with Disagreements with the now deceased and that the bereaved person never cries - and the prediction of delayed grief... • Interestingly, the avoidant attached person did say that they would like to cry more. Inability to express grief

43. The Avoidant Griever • Five out of 10 participants who said they never cry received diagnosis as having a psychosomatic disorder. • However, psychosomatic diagnosis was not a key ingredient to the avoidant griever. • Inability to grieve and delayed grief, although related to avoidant attachments, appeared to also be correlated with need to control...

44. Avoidance and Need to Control • The bereaved delayed grief because: • They were holding grief in check because need to look after a parent / child • Lifelong neurosis • Past bouts with depression • Post-traumatic stress reactions • Alcoholism • Personality disorders

45. The Avoidant Griever • Ultimately, the findings confirm that children of parents who discouraged the expression of attachment (hugging/cuddling, sharing feelings) will find it difficult to acknowledge and express both grief and affection. • This was found to persist in adult life, to increase the risk of interpersonal conflicts and to inhibit the expression of grief.

46. Mapping the Avoider • Continuous lines indicate significant correlations • Interrupted lines indicate non-significant trends

47. Why Do Patterns of Childhood Remain into Adulthood • A clinical insight: • We return to old conditioning under stress and in times of survival... • Avoidant attachments only make children independent of their parents, they have not survived because of keeping away, but because they have found a safe proximity and they are rewarded for it (are continued to be fed and protected). • Thus, they will find people who perpetuate assumptive world, but upon death this separateness is “forever” - thus what do I do and who do I turn to.

48. The PCF lacks in confidence with respect to their ability to care for and control their child and they may see their child as more powerful than themselves. (IFT’s) may cry during separation but avoid the PCF upon return or they may approach the PCF upon return then freeze/fall, hit themselves, rock back and forth, etc. Disorganized Attachments • These are participants who scored high on Parental Depression / Psychiatric Problems; Parental Violence; Childhood Unhappiness; Compulsive Caregiving; Family Persecution. • During childhood these folk often felt helpless / hopelessness and may have become caregivers for their parents / siblings.

49. Disorganized Findings and Patterns of Behaviour • Findings revealed that disorganized type after bereavement suffered from depression, anxiety, and panic and used alcohol to self medicate. • There is also a tendency for these folk to feel extreme guilt and report suicidal behaviour • Interestingly, findings did indicate the disorganized type would seek help from a professional, but not turn to family members for support. • Findings also revealed that the disorganized type indeed has characteristics of the avoidant and anxious/ambivalent type.

50. Disorganized Findings and Patterns of Behaviour • Clinical Insight • Findings also reveal that the disorganized type display a serious need to protect oneself and distrust others. But, interestingly enough, the disorganized type can trust enough in so much as their trust leads to a confirmation of their assumptive world