460 - Complicated Grief and Attachment

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Complicated Grief and Attachment Dr. Dawn-Elise Snipes PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn't Brain Surgery Objectives ~ Define Complicated Grief ~ Identify how loss of or lack of an attachment relationship may represent a loss that needs to be grieved. ~ Explore the overlap between complicated grief and trauma ~ Identify risk factors for CG ~ Explore tasks for successful grief resolution Definitions: ~ Loss: Change that includes being without someone or something in this case the primary attachment relationship ~ Secondary loss: Other losses as a result of a primary loss. Example, loss of security when rejected by primary caregiver ~ Grief: Reaction or response to loss; includes physical, social, emotional, cognitive and spiritual dimensions. ~ Trauma: Any situation that causes the individual to experience extreme distress

Attachment ~ Attachment ~ Attachment is the quality of the relationship with the caregiver characterized by trust, safety and security. ~ The quality of the infant-parent attachment is a powerful predictor of a child's later social and emotional outcome ~ Determined by the caregiver's response to the infant and toddler when the child's attachment system is 'activated' Internal Working Model ~ Children's attachment with their primary caregiver leads to the development of an internal working model which guides future interactions with others. ~ 3 main features of the internal working model ~ a model of others as being trustworthy (what is the loss here?) ~ a model of the self as valuable (what is the loss here?) ~ a model of the self as effective when interacting with others. (what is the loss here?) ~ Secure attachments also help children ~ Feel loved and accepted ~ Learn to manage their emotions ~ Address dichotomous thinking and cognitive distortions

Bowlby on Attachment and Grief ~ Attachment Relationships Help Regulate Psychological And Biological Functions Including: ~ Mastery and performance success ~ Learning and performing ~ Relationships with others (and future attachment) ~ Cognitive functioning ~ Coping and problem solving skills ~ Self-esteem ~ Emotion regulation ~ Sleep quality ~ Pain intensity (physical and emotional)

Bowlby ~ Attachment and safety stimulate a desire to learn, grow and explore ~ Caregivers provide support and reassurance (Safe haven) ~ Encouragement and pleasure (secure base) Feeney J Pers Soc Psych 631 -648 2004

Bowlby ~ Loss of an attachment relationship ~ Disrupts attachment, caregiving and exploratory systems ~ Attachment: Activates separation response and impacts restorative emotional, social and biological processes ~ Exploratory system: Inhibits exploration with a loss of a sense of confidence and agency. ~ Caregiving: Produces a sense of failure and can include self blame and survivor guilt

Trauma ~ Trauma is any event that is distressing or disturbing ~ How do we know what is distressing or disturbing ~ Erodes a sense of safety (Triggers fight or flight) ~ Emotional (including dysregulation) ~ Mental (interpretations and schemas) ~ Physical (object permanence, darkness, pain, prior experiences) ~ Adverse Childhood Experiences that may disrupt primary attachment ~ Immediate family member with a mental health or addiction issue ~ Immediate family member who is incarcerated ~ Divorce ~ Abuse (child or DV) ~ Neglect

How Can Disrupted Attachment Trauma ~ The primary attachment figure remains crucial for approximately the first 5 years of life ~ Trust/mistrust (Ages 0-2) ~ Object Permanence ~ Autonomy/shame (Ages 2-7) ~ Egocentrism: children assume that other people see, hear, and feel exactly the same as they do ~ Children's moral sense in this phase of development is rigid and believe that a punishment is invariable, irrespective of the circumstances. ~ They regard bad things that happen as a consequence for misdeeds and a punishment for misbehavior. http://www.childhealth-explanation.com/cognitive-development.html Attachment and Discussion ~ What is a child supposed to have from a caregiver? ~ Emotionally ~ What happens when this doesn't occur? ~ How is that traumatic? ~ Cognitively ~ What happens when this doesn't occur? ~ How is that traumatic? ~ Physically ~ What happens when this doesn't occur? ~ How is that traumatic? ~ What is a caregiver supposed to be like? ~ What happens when this doesn't occur? ~ How is that traumatic? ~ How might these traumas also represent a loss?---Let's look

Complicated Grief ~ Symptoms ~ Separation distress involving intrusive, distressing preoccupation with the loss ~ Traumatic stress reflecting specific ways the person was traumatized by the loss ~ Avoidance of reminders ~ Intrusive painful thoughts ~ Emotional numbing ~ Irritability ~ Feelings of hopelessness and purposelessness ~ Shattered self identity Risk Factors for Complicated Grief Related to Attachment ~ Child ~ Age ~ Physical issues ~ Emotional issues (pre-existing) ~ Cognitive understanding ~ Personality and character traits ~ Nature of the loss ~ Number of losses ~ Circumstances of the loss ~ Resources available ~ Nature of the relationship ~ Length/duration ~ Importance ~ Culture/Roles ~ Quality ~ Dependence ~ Hopes and Dreams (retrospectively) ~ Amount of Daily Change (foster care, relative placement)

Emotional Effects of Trauma and Complicated Grief ~ Dysregulation ~ Anxiety ~ Separation anxiety ~ Reactive Attachment ~ Angry/Irritable/Oppositional ~ Depressed ~ Lonely/Isolated ~ Guilty/Regretful Physical Effects of Trauma and Complicated Grief ~ Appetite (eating) disturbances ~ Energy, fatigue, lethargy ~ Sleep disturbance ~ Anxiety ~ Gastrointestinal disturbance ~ Compromised immune response; increased illness

Intellectual Effects of Trauma and Complicated Grief ~ Confusion; “What is real? ~ Difficulty concentrating; ex. Read the same page several times ~ Short attention span; ex. Can't finish a 30 minute TV program ~ Difficulty learning new material; short term memory loss; ex. Income taxes ~ Difficulty making decisions ~ Lack of a sense of purpose ~ Inability to find meaning in the events and life itself

Social Effects of Trauma and Complicated Grief ~ Withdrawal ~ Isolation ~ Searching ~ Avoidance ~ Self absorption ~ Clinging/dependence Reconciliation Tasks ~ To help adults or adolescents who never formed that attachment ~ Acknowledge the reality of the loss. ~ Move toward the pain of the loss while being nurtured physically, emotionally, and spiritually. ~ Develop a new self identity based on a life without that relationship. ~ Experience a continued supportive presence in future years Reconciliation ~ Learn basic trust, which serves as a basis for all future emotional relationships ~ Learn how to develop fulfilling intimate relationships ~ Develop strategies to maintain emotional balance and resiliency ~ Develop the ability to control behavior, which results in effective management of impulses and emotions ~ Enhance confidence and self-esteem ~ Learn how to share feelings and seek support

Reconciliation ~ Create a foundation for the development of identity, which includes a sense of capability, self-worth, and a balance between dependence and independence ~ Establish a core set of beliefs that leads to empathy, compassion, and conscience ~ Begin exploring the environment with feelings of safety and security, which leads to healthy intellectual and social development

AVOIDANCE ~ Recognize the loss ~ Acknowledge the loss of or lack of establishment of the attachment relationship ~ Understand the losses as a result of the lack of attachment

CONFRONTATION ~ React to the realization of the loss ~ Experience the pain ~ Feel, identify, accept, and give some form of expression to all the emotional, cognitive and physical reactions to the lack of or loss of the attachment figure ~ Identify and mourn secondary losses ~ Loss of safety ~ Loss of happiness (distress) ~ Loss of the childhood I should have had ~ Loss of self esteem ~ Loss of success

CONFRONTATION ~ Recollect and re-experience the relationship ~ Review and remember realistically ~ Revive and re-experience the feelings ~ Relinquish the old attachments to the old assumptive world

ACCOMMODATION ~ Readjust to move adaptively into the new world without forgetting the old ~ Revise the assumptive world ~ Develop a new relationship with the self ~ Adopt new ways of being in the world ~ Form a new identity ~ Reinvest

Summary ~ Failure to develop a primary attachment relationship can be viewed as a loss (or something that was needed that was never achieved) ~ When examining the behaviors of adult or adolescent clients whose primary attachment was disrupted, the traumatic impact can be seen. ~ In order to help people reconcile the trauma it is essential to help them ~ Identify and grieve the losses ~ Review and remember realistically what happened (to combat inaccurate schema) ~ Review the assumptive world (if I just…then she will be love me) ~ Develop a new loving relationship with the self ~ Learn how to trust the self and others to form meaningful and supportive relationships