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Complicated Grief and Attachment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
Podcast Host: Counselor Toolbox

CEUs are available for this presentation at AllCEUs

~ 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
~ 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 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)

~ 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

~ 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 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.
Attachment and “Supposed Tos” 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
~ 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

~ 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

~ 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

~ 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

~ 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

~ 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

~ 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