continuing bonds, attachment style, and adjustment in the conjugal bereavement among hong kong...

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Continuing Bonds, AttachmentStyle, and Adjustment in theConjugal Bereavement AmongHong Kong ChineseSamuel M. Y. Ho a , Ide S. F. Chan b , Ernie P. W. Ma c

& Nigel P. Field da Department of Applied Social Studies , CityUniversity of Hong Kong , Hong Kongb Department of Clinical Psychology , QueenElizabeth Hospital , Hong Kongc Department of Clinical Psychology , KowloonHospital , Hong Kongd PhD Program in Clinical Psychology , Palo AltoUniversity , Palo Alto , California , USAAccepted author version posted online: 11 Dec2012.Published online: 18 Jan 2013.

To cite this article: Samuel M. Y. Ho , Ide S. F. Chan , Ernie P. W. Ma & Nigel P.Field (2013) Continuing Bonds, Attachment Style, and Adjustment in the ConjugalBereavement Among Hong Kong Chinese, Death Studies, 37:3, 248-268, DOI:10.1080/07481187.2011.634086

To link to this article: http://dx.doi.org/10.1080/07481187.2011.634086

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CONTINUING BONDS, ATTACHMENT STYLE, ANDADJUSTMENT IN THE CONJUGAL BEREAVEMENT

AMONG HONG KONG CHINESE

SAMUEL M. Y. HO

Department of Applied Social Studies, City University of Hong Kong,Hong Kong

IDE S. F. CHAN

Department of Clinical Psychology, Queen Elizabeth Hospital, Hong Kong

ERNIE P. W. MA

Department of Clinical Psychology, Kowloon Hospital, Hong Kong

NIGEL P. FIELD

PhD Program in Clinical Psychology, Palo Alto University,Palo Alto, California, USA

The present study examined the effects of attachment style and continuing bonds,defined as the extent to which a bereaved individual feels that the deceasedremains a part of his=her life, on postbereavement adjustment among 71 conju-gally bereaved individuals. It was shown that bereaved individuals with ananxious attachment style tended to show more externalized continuing bonds aswell as more grief symptoms. An anxious attachment style played a direct andsignificant role in postbereavement adjustment over and above the contributionof externalized continuing bonds. Interventions to facilitate restoration tasksand to reduce externalized continuing bonds would be discussed.

The loss of a spouse is recognized to be one of the most stressful lifeevents (Holmes & Rahe, 1967).Yet there is considerable variability

Received 14 May 2011; accepted 20 September 2011.This study was supported by the Earmarked Research Grant of the Research Grant

Council (RGC Reference Number: HKU 7428=05H). We thank the Jessie and ThomasTam Centre, Comfort Care Concern Group, and Haven of Hope Hospital for helping withdata collection.

Address correspondence to Nigel P. Field, Palo Alto University, 1791 Arastradero Rd.,Palo Alto, CA 94304. E-mail: [email protected]

Death Studies, 37: 248–268, 2013Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print=1091-7683 onlineDOI: 10.1080/07481187.2011.634086

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in the duration and the severity of grief reactions among thebereaved (Bonanno & Kaltman, 1999, 2001; Wortman & Silver,1989, 2001). Some people exhibit extreme signs of grief whileothers appear to be relatively unaffected by the loss. The presentstudy investigated the effects of continuing bonds (CB) and attach-ment style on postbereavement adjustment. A review of literatureon CB and attachment style is described below.

Continuing Bonds

CB is generally understood as the presence of an ongoing innerrelationship with the deceased person by the bereaved individual(Field, Gal-Oz, & Bonanno, 2003; Shuchter & Zisook, 1993) andis a common experience amongst the bereaved across ages andcultures (Klass, Silverman, & Nickman, 1996; Shuchter & Zisook,1993). Early theories posit that relinquishing the tie to the deceasedcan, in turn, free the emotional energy of the bereaved to reinvestin new relationships (Freud, 1917=1957; Parkes, 1972; Rando,1984; Sanders, 1989). The above proposition implies that CB is anegative response that may hinder successful grieving. On theother hand, no systematic empirical studies so far have found sup-port for the theoretical notion that bereaved people need to relin-quish their ties to the deceased before positive adjustment canbegin. Similarly, evidence is lacking to indicate that the mainte-nance of CB would lead to good adaptation (see M. S. Stroebe,Schut, & Stroebe, 2005, for a review). Thus, the extent to whichmaintaining a CB either helps or hinders the process of postberea-vement adjustment is unclear. In the 1990s, a shift in view tookplace where CB is viewed as part of a successful mourning ratherthan a symptomatic response (Attig, 1991; Silverman & Klass,1996; M. S. Stroebe, 1992; Worden, 1996). Accordingly, CB canprovide a secure base and a safe haven to facilitate coping andmood regulation after bereavement. In other words, a CB canserve as a reminder of the rewarding relationship that can in turnenable the bereaved to experience a sense of fulfillment andemotional sustainability (Field, Nichols, Holen, & Horowitz,1999; Field & Friedrichs, 2004; Klass & Walter, 2001). Hence,two opposing functions of CB were proposed. On the one hand,CB may serve an adaptive function by fostering continuity of ident-ity, reinforcing coping efforts, and providing comfort and support

Attachment Style and Conjugal Bereavement 249

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in stress (Bonanno & Kaltman, 1999), but on the other hand it mayalso perpetuate ruminative thinking and impede forward movingon the other hand (Field et al., 1999; Field, Gal-Oz, & Bonanno,2003).

The effects of CB on grief reaction may depend on time afterbereavement. A study by Field et al. (2003) indicated that more fre-quent use of CB at 5 years after loss was associated with moresevere grief symptoms. Field and Friedrichs (2004) proposed thatthe duration of bereavement might moderate the effect of CB onpostbereavement adjustment. They reported a positive relation-ship between CB and positive mood in the later period of bereave-ment (after 24 months), but not in the early bereavement period.These results suggest having an emotional tie with the deceasedcan be comforting once the acute period of grief has passed.

Besides postbereavement duration, research is also beginningto consider whether different types of CB might influence bereave-ment outcomes. There has been no consensus among researcherson the subtypes of CB variants and how they affect postbereave-ment adjustment (Rando, 1993; Vickio, 1999; Field et al., 2003;M. S. Stroebe et al., 2005). Field and his colleagues have developedan 11-item Continuing Bonds Scale (CBS; Field et al., 1999; Fieldet al., 2003) which accounts for the different ways of maintaining atie with the deceased: memories, maintenance of possessions,sense of presence, identification with the deceased, internalizationof the deceased, the deceased as a standard, and reminiscence ofthe deceased.

Recently, Field and Filanosky (2010) expanded the 11-itemscale into a 47-item questionnaire to cover as comprehensive aspossible the variants of CB. Subsequent factor analysis resultedin a 16-item measure with two subscales: internalized CB andexternalized CB. The authors defined internalized CB asexpressions involving use of the deceased as an autonomy promot-ing secure base and externalized CB as expressions involving illu-sions and hallucinations with the deceased (Field & Filanosky,2010). Field and Filanosky (2010) reported that externalized CBwas positively associated with both the violent death of the lovedone and the bereaved’s sense of responsibility for the death;whereas internalized CB was negatively associated with thesefactors but positively related to personal growth (Field & Filanosky,2010).

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Attachment Styles

Another construct that is both theoretically and empirically relatedto post-bereavement adjustment is attachment style (Archer, 1999;Shaver & Tancredy, 2001; M. S. Stroebe et al., 2005). From theperspective of attachment theory, the nature of the conjugalrelationship is an expression of an individual’s general attachmentstyle to another significant person (Bowlby, 1980; Parkes & Weiss,1983). It has been shown that adults with a secure attachment stylefind it relatively easy to get close to and depend on others, andthey present with both low anxiety and low avoidance in closerelationships (Collins & Read, 1990; Feeney, 1999). Accordingly,individuals with secure attachment style should show better post-bereavement adjustment. There are also two forms of insecureattachment: anxious attachment and avoidant attachment (Bowlby,1980; Brennan, Clark, & Shaver, 1998). Individuals with anxiousattachment styles are more preoccupied with and uncertain aboutthe responsiveness of their partners and report a history of rejec-tion in their close relationships. Avoidant adults are uncomfortabledepending on others and generally strive to be self-reliant andindependent. Previous studies have consistently shown a positiverelationship between anxious attachment and bereavement-relatedsymptomatology, whereas the roles of avoidant attachment in post-bereavement adjustments are still not clear (Field & Sundin, 2001;Fraley & Bonanno, 2004). An objective of the present study is toinvestigate the roles of attachment styles in postbereavementadjustment among the Chinese.

The Roles of Continuing Bonds and Attachment Stylesin Postbereavement Among the Hong Kong Chinese

To date, systematic reviews of the bereavement experience of theChinese people in Hong Kong is sparse, with mostly anecdotalobservations and cases studies. We believe that CB should havean important role to play in the bereavement experience of the Chi-nese. For instance, Pang and Lam (2002) proposed that many Chi-nese death rituals helped to maintain CB between the bereaved andthe deceased, which could facilitate positive adjustment. Chan et al.(2005) also observed that many bereaved Chinese adults reported acontinuation of their relationship to the deceased through


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traditional rituals and festivals, and these practices were perceivedas comforting and made CB a normal and acceptable experiencein the Chinese culture. In summary, the findings in these studiessuggest that having a CB is normative among Chinese bereaved.The studies also highlight the positive utility of a CB in helping withpostbereavement in the Chinese culture. To date, there is also nosystematic measure of CB among the Chinese. The English versionof the CBS (E-CBS, Field & Filanosky, 2010) is a potentially usefulmeasure for the Chinese population. Nevertheless, CB expressionsare culturally bound behavior, and it is not sure if the E-CBS couldbe applied directly to our Hong Kong Chinese subjects withoutmodification. Our first aim was to perform an exploratory factoranalysis on a translated Chinese version of the E-CBS (the ChineseCBS; C-CBS), and we expected to find a comparable two-factor-structure to the one reported by Field and Filanosky (2010). Con-firmatory factor analysis was not performed because of the explora-tory nature of this study and sample size limitation. The second aimwas to demonstrate concurrent validity of the externalized factor ofthe C-CBS and, based on the findings of Field & Filanosky (2010),we hypothesized that an externalized CB would be positivelyrelated to both an anxious attachment style and grief symptoms,and internalized CB would be associated with less grief symptoms.The third aim of the study was to determine the unique contri-bution of each variable (externalized CB and an anxious attach-ment style) to the prediction of grief symptoms.

It should be noted that Hong Kong is a westernized city andour participants were drawn from settings where the Westernunderstanding of grief reaction is known to many people in HongKong. This sample may not represent the characteristics of Chinesepeople in Mainland China. On the other hand, traditional Chinesebeliefs and rituals on grief, death, and dying are commonly prac-ticed by most Chinese people in Hong Kong and our sampleshould shed light on the cross-cultural aspects of the above issues.

Methods

Participants and Procedures

Seventy-one bereaved individuals who had lost a spouse in the past12 to 36 months (M¼ 19 months; with a range from 12 months to


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34 months) were recruited. The majority of the participants wererecruited through two voluntary bereavement services centers inHong Kong and the remaining came from a rehabilitation-orientedhospital as well as open recruitment in the community. All eligibleparticipants were Chinese, between 30 and 65 years of age, spokeCantonese as their mother tongue, and were able to read andunderstand Chinese. Participants responded to a yes–no questionon whether they had formal religion or not. Forty-five (37.0%)mentioned they had a formal religion. They indicated no loss ofa significant person other than their spouse in the past 3 years.The exclusion criteria were (a) evidence of Axis I psychopathologyunrelated to bereavement, and (b) presence of a substance use dis-order in the prior 3 years. Table 1 shows the demographic and thebackground information of the participants. The sample ranged inage from 35 to 64 years old with a mean age of 45.55 years(SD¼ 7.43); 87% were female and 13% were male (Table 1). Morethan half (53%) of the participants had lost their spouse throughchronic illness, and approximately one quarter (27%) had lost theirspouse unexpectedly through accident or acute illness. It should benoted that 20% of the participants lost their spouse to suicide.

Ethical approval was sought from and granted by the Facultyof Social Sciences Research Committee of the University of HongKong and the Institutional Review Board of the various recruit-ment centers. Once the eligibility of the participants was con-firmed, a packet of questionnaires was mailed to the participantstogether with a description of the study and an informed consentform. A research assistant made appointments with the participantsfor an experimental session for a larger study to be conductedwithin 2 weeks after the questionnaires were sent out. Participantswere asked to bring the completed questionnaires and theinformed consent form to the experimental session. The followinginventories were used in this report.

Measures

THE CHINESE CONTINUING BONDS SCALE (C-CBS)

A 47-item English version of the CBS was developed by Fieldand Filanosky (2010) to measure how frequent a bereaved individ-ual feels the deceased remains a part of his or her life. Thereliability of the internalized and externalized CB is .92 and .73,


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respectively (Field and Filanosky, 2010). The items are rated from1 (none) to 4 (almost daily). The English version of the CBS wastranslated first into Chinese by one of the authors (Chan), who isbilingual in Chinese and English and who had clinical experiencein working with bereavement. The Chinese version was thenback-translated into English by another bilingual person. The

TABLE 1 Participant Profile

Group n %

GenderMale 9 13Female 62 87

Age group30–40 16 2340–49 30 4250 or above 25 35

Education levelPrimary 12 17Secondary 46 65Tertiary and above 13 18

EmploymentWorking 45 63Nonworking 26 37

IncomeBelow $10,000 28 40$10,000–$30,000 33 47Above $30,000 9 13

ReligionWithout religion 26 37With religion 45 63

ChildrenNo 14 20Yes 57 80

Mode of deathExpected – chronic illness 38 53Unexpected – acute illness and accident 19 27Suicide 14 20

Period after death2–24 months 50 7025–36 months 21 30

Year of marriageLess than 10 years 21 30Over 10 years 50 70


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back-translated version was then compared with the original ver-sion by the research team, and some words were refined for cul-tural relevance.

GRIEF REACTION ASSESSMENT FORM

The Grief Reaction Assessment Form (GRAF; Ho, Chow,Chan, & Tsui, 2002) is a Chinese psychological measure to indicategrief reaction. It is composed of 21 items on an 11-point scale from0 (none) to 10 (all of the time). The GRAF has shown good internalreliability (Cronbach’s alpha ¼.89). In this sample, the scale had areliability of .87. The GRAF can discriminate between the griefreaction of people experiencing anticipated and those experienc-ing unanticipated death (Ho et al., 2002).

RELATIONSHIP STYLE QUESTIONNAIRE

The Relationship Style Questionnaire (RSQ) is a self-reportinventory to measure attachment styles (Griffin & Bartholomew,1994). It consists of 30 questions. Participants rate on a 5-pointscale regarding how well each item fits their characteristic stylein close relationships. Translation and back-translation of this ques-tionnaire into Chinese has been completed by one of the authors(Samuel M. Y. Ho), and the Chinese version was used in thepresent study. Following procedures devised by Fraley andBonanno (2004) for determining attachment anxiety and avoid-ance in the RSQ, individual scores for each of these attachmentstyle dimensions were derived for each participant. Because onlyanxious and avoidant attachment styles were relevant to theresearch questions of the present study, only these two attachmentstyles were addressed in the analyses. The anxious and avoidantattachment style scales demonstrate acceptable internal consist-ency at .84 and .70, respectively (Fraley & Bonanno, 2004). In thissample, the anxiety and avoidance attachment scales also showgood alpha reliability at .81 and .72, respectively.

Results

Exploratory factor analysis was used to explore the factor structureof the C-CBS. As the factors were expected to be correlated, anoblimin rotation was used in the exploratory factor analysis. Atwo-factor solution was specified based on the resulting scree plot.


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A Kaiser-Meyer-Olkin (KMO) measure of sample adequacy was.84 indicating that the sample size (N¼ 71) was adequate forexploratory factor analysis (Kaiser, 1974). Nineteen items wereretained based on the criteria that their loadings on a factor shouldexceed .50 without loading above .40 on another factor, and thedifference between an item’s loading on two factors should be lar-ger than .30 (Ho, Chan, & Ho, 2004). This 19-item scale accountedfor 55% of the total variance (Table 2).

Factor 1 contained 14 items, explaining 42% of the total vari-ance. This factor was termed internalized because the items captureboth the sense of a loving presence of the deceased as well as usingthe deceased as an autonomy-promoting secure base. Some exam-ples are ‘‘I experienced the deceased as continuing to live onthrough his impact on who I am today’’ and ‘‘I thought abouthow the deceased would have enjoyed something I saw or did.’’

Factor 2 consisted of 5 items, which accounted for 13% of thetotal variance. This factor was named externalized as it was charac-terized by the lingering on of the physical presence of thedeceased. Some examples are ‘‘Even if only momentarily, I havemistaken other sounds for the deceased’s voice, footsteps, ormovements,’’ and ‘‘I had the feeling that the deceased washaunting me.’’

The Cronbach’s alpha of the total 19-item scale was .92 andthe split-half reliability coefficient was also .92. The reliabilityalpha of the internalized and the externalized CB subscales was.92 and .84, respectively. The results indicate good internal consist-ency and adequate reliability of the scale. There were no group dif-ferences in all demographic variables except religion. Participantswith religion had less externalized CB, t(69)¼ 2.10, p¼ .040, andless avoidant attachment, t(69)¼ 2.13, p¼ .037, in comparison tothose without religion. Moreover, there was no significant relation-ship between the psychological variables and the duration ofbereavement; however, when comparing participants based onhow their partners died (suicide, chronic illness, and unexpecteddeath) participants whose partner committed suicide showed lessinternalized CB when compared with the other two groups,F(1,2)¼ 4.70, p¼ .012. Therefore, both religion and mode of deathwere controlled for in the subsequent analyses. Table 3 shows themean scores and the standard deviations of the measures by modeof death and religion. The results showed that participants with


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TABLE 2 Exploratory Factor Analysis Result of the Chinese Continuing BondsScale

Factor

Item I II

1. I imagined the deceased’s voice encouragingme to keep going.

.83

2. I thought about how the deceased would haveenjoyed something I saw or did.

.78

3. I thought about the deceased as a role modelwhom I try to be like.

.77

4. I was aware of attempting to carry out thedeceased’s wishes.

.74

5. When making important decisions, I thoughtabout what the deceased might have done andused this to help me make my decision.

.73

6. I felt the deceased heard my prayers. .727. I did things that the deceased liked to do such

as watch his favorite TV program in order tofeel closer to him.

.71

8. I experienced the deceased as continuing to liveon through his impact on who I am today.

.71

9. I attended special events or celebrations inmemory of the deceased.

.67

10. I imagined reuniting with the deceased inheaven.

.65

11. I wrote to or about the deceased. .6212. I was aware of how I try to live my life the way

the deceased would have wanted me to live..60

13. I imagined sharing with the deceasedsomething special that happened to me

.59

14. I thought about the positive influence of thedeceased on who I am today.

.56

15. Even if only momentarily, I have mistakenother sounds for the deceased’s voice,footsteps, or movements.

.84

16. I briefly acted as though the deceased were notdead – such as calling out loud his name orpreparing the table for two.

.74

17. Even if only momentarily, I have mistakenother people for the deceased.

.73

18. I had the feeling that the deceased washaunting me.

.70

19. I imagined that the deceased might suddenlyappear as though still alive.

.68

Percentage of variance explained 42% 13%


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TABLE

3Meansan

dStan

dardDeviation

sof

theMeasuresbyMod

eof

Death

andReligion

Mod

eof

death

Religion

Total

Chronic

illness

(n¼38

)Unex

pected

death(n¼19

)Su

icide

(n¼14

)F

Withou

trelig

ion

(n¼26

)W

ithrelig

ion

(n¼45

)

Stud

yvariab

les

MSD

MSD

MSD

MSD

MSD

MSD

t

Grief

symptoms

50.00

29.89

50.24

31.66

48.74

27.19

51.07

30.51

0.03

52.92

29.23

48.31

30.46

0.62

Anxiou

sattach

men

t29

.96

10.00

2.63

.72

2.73

.89

2.62

.69

0.13

2.73

.77

2.61

.75

0.64

Avo

idan

tattach

men

t8.41

3.53

3.08

.56

3.19

.65

3.23

.43

0.43

3.32

.44

3.03

.59

2.13

�

Internalized

CB

3.14

.56

29.81

8.98

34.47

10.95

24.21

8.73

4.70

�28

.46

8.56

30.84

10.76

�0.96

Externalized

CB

2.66

.76

7.95

3.32

8.89

3.71

9.00

3.92

0.69

9.54

3.78

7.76

3.25

2.10

�

Note.CB¼continuingbon

ds.N¼71

.� p

<.05.

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religion, as compared to those without religion, tended to show lessexternalized CB as well as exhibit less avoidant attachment styles.

Partial correlations were conducted to examine the linear rela-tionships among the two types of CB, attachment styles measures,and grief symptoms. Religion and mode of death were controlledas covariates. The correlation between externalized CB and inter-nalized CB was moderate (r¼ .52, p< .01), indicating that theywere related but separate constructs. As expected, externalizedCB was positively correlated with both grief symptoms (r¼ .36,p< .010) and anxious attachment style (r¼ .29, p< .050). Interest-ingly, internalized CB was positively correlated with grief symp-toms (r¼ .29, p< .050). No significant correlations betweeninternalized CB and any of the two attachment styles wereobtained. Grief symptoms were positively associated with anxiousattachment (r¼ .51, p< .010), but no significant correlation wasfound between grief symptoms and avoidant attachment (Table 4).

Becuase externalized CB, grief symptoms, and anxious attach-ment styles were positively correlated with each other, hierarchicalregression analysis was conducted to examine the relative predic-tive power of externalized CB and anxious attachment style ongrief symptoms post conjugal loss. Four variables were includedas predictors: mode of death, religion, anxious attachment, andexternalized CB. The results are shown in Table 5.

Mode of death and religion were entered in Step 1 of theregression analysis. The first regression indicated that both of theabove variables were not significant predictors of grief symptoms.Anxious attachment and externalized CB were entered in Step 2.

TABLE 4 Partial Correlations Among Continuing Bonds, Grief Symptoms, andAttachment Style

Variable 1 2 3 4 5

1. Internalized CB 1 .52�� .29� .11 �.192. Externalized CB 1 .36�� .29� .013. Grief symptoms 1 .51�� .094. Anxious attachment 1 �.035. Avoidant attachment 1

Note. CB¼ continuing bonds. N¼ 71. Partial correlation coefficients controlling for religi-on and mode of death.

�p< .05. ��p< .01. ��p< .001.


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This final regression model was significant (DR2¼ .30, p< .001).Both anxious attachment (b¼ .46, t¼ 4.43, p< .001) and externa-lized CB (b¼ .22, t¼ 2.00, p¼ .05) individually predicted griefsymptoms, each explaining 20% and 4% of the variance,respectively.

Discussion

One objective of the present study was to examine the factor struc-ture and psychometric properties of the C-CBS, translated from theEnglish version of the same scale developed by Field and Filanosky(2010). The results of the present study show that the Chineseversion of the CBS has good internal consistency, with Cronbach’salpha and split-half reliability coefficient exceeding the criteria of.9. The C-CBS is significantly associated with the grief reaction ofbereaved individuals, as suggested by the existing literature (Field& Friedrich, 2004). The exploratory factor analysis of the C-CBSrevealed a meaningful solution, comparable to the one reportedby Field and Filanosky (2010). The internalized subscale representsa positive continuing connection with the deceased, consisting ofitems that relate to identification with the deceased (taking on thedeceased’s value and carrying out the deceased’s wishes), usingthe deceased as a standard (using the deceased’s viewpoint indecision-making), internalization of the deceased (keeping andcarrying on the positive influence of the deceased), reminiscence

TABLE 5 Summary of Hierarchical Regression Analysis for VariablesPredicting Grief Symptoms in the Conjugally Bereaved

Variable B SE B b

Step 1Mode of death �5.32 4.59 �.14With=without religion �6.16 7.50 �.10

Step 2Mode of death �4.27 3.93 �.11With=without religion �.40 6.58 �.01Anxious attachment 18.23 4.12 .46��

Externalized continuing bonds 1.83 0.92 .22�

Note. N¼ 71. R2¼ .03 for Step 1, F(2,68)¼ .87, p> .05; DR2¼ .30 for Step 2, F(2,66)¼ 7.83,p< .001.

�p <.05. ��p< .001.


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of the deceased (reminiscing with others experiences with thedeceased), and having a sense of loving presence of the deceased(sharing interesting life experiences or daily tasks with thedeceased). The externalized CB subscale contains items that arerelated to illusory types of contact with the deceased. Thesequasiperceptual experiences consist of misconstructions of theexternal presence of the deceased in the visual, auditory, and tactilemodalities (Reisman, 2001; Boerner & Heckhausen, 2003; Field,2006). The present study has established a valid adapted versionof the CBS for future research among the Chinese.

In line with previous studies (Field & Sundin, 2001; Fraley &Bonanno, 2004), the results of the present study show that CB,anxious attachment, and grief symptoms are all positively corre-lated with each other. More specifically, our results have demon-strated that a stronger reliance on either an internalized orexternalized CB is associated with more severe grief symptomsafter the loss of a loved one, but that only externalized CB are asso-ciated with having an anxious attachment style. The positiverelationship between an internalized CB and grief symptoms mightbe an indicator of an extremely close relationship to the bereaved,thereby creating more difficulties in bereavement adjustment(Field & Filanosky, 2010).

An externalized CB represents an illusion or belief that thedeceased is somehow experienced as being present. As mentionedearlier, individuals with an anxious attachment style are more vig-ilant and insecure regarding the psychological accessibility and theavailability of their loved ones. In the context of conjugal loss, itmay be possible that episodes in which the loved one is experi-enced as absent could trigger individuals with an anxious attach-ment style to search for the deceased through an externalizedCB. For example, if someone resembles the deceased in somephysical characteristics, the bereaved might misperceive the per-son as the deceased loved one. Based on clinical observation, suchquasiperceptual and distorted experiences tend to surface momen-tarily, in the form of an illusion. It has been observed clinically bythe authors that the bereaved often feel more distressed once theillusions have ceased to occur and this has been attributed to thebereaved having to once again confront the reality of the loss oftheir loved ones. Thus, external CB can increase the grief symp-toms of the anxiously attached individuals by reminding them


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regarding the unavailability of their attachment figures. In effect,the uncertainty and the insecurity are further reinforced by theillusory experiences, leading to more grief symptoms. However,it should be noted that a causal relationship cannot be establishedby the correlations among externalized CB, anxious attachmentstyle, and symptoms of grief in bereavement. It is possible thatthe grief symptoms strengthen the inclination of the bereaved tocling onto the deceased, creating a stronger externalized CB anda more pronounced anxious attachment style. Further research isneeded to clarify the above relationships.

Although not a main focus of this study, our results showedthat participants with religion had less externalized CB and lessavoidant attachment style. This result is in line with other findingsabout positive role of religion in the process of coping withbereavement (Benore & Park, 2004; Hussein & Oyebode, 2009;Mantala-Bozos, 2003; Park & Cohen, 1993; Rubin &Yasien-Esmael, 2004). It is possible that bereaved individuals withreligion tended to use less externalized CB which, in turn, mayfacilitate their adjustment to their conjugal loss. This propositionis consistent with existing findings regarding beneficial effects ofreligion on post-bereavement adjustment. Benore and Park(2004) found that religious belief in continued attachment, definedas a sustained relationship with the deceased, was beneficial to theprocess of coping with bereavement. Continued attachment is con-ceptually similar to CB and the result of Benore and Park (2004)provides an indirect support to our current findings.

Our results have some important clinical implications. Forexample, given the negative impact that having an anxious attach-ment style can have on grief adjustment, our results suggest thatgrief related to bereavement might be attenuated by addressingthe attachment style itself. This would require changing an indivi-dual’s internal working models of both the self and others throughincorporating new information and experience. However, attach-ment security is usually moderately stable from infancy and child-hood through early adulthood (Fraley, 2002), and individuals varyin the extent to which their working models are open to updatingand revision (Bowlby, 1988). Attachment theorists neverthelessrecognize that changes can occur across one’s life span (Simpson,Rholes, Campbell, & Wilson, 2003). When changes occur, it islikely to be the result of either new experiences with the


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attachment figures or re-conceptualization of past experiences withthe attachment figures (Davila & Cobb, 2004; Davila, Burge, &Hammen, 1997). During times of dramatic change such as lossof a significant relationship, an individual is exposed to a radicallynew situation. Such experience can facilitate the accommodationprocess and help to revise the internal working models (Bowlby,1980; Davila & Cobb, 2004; Davila, Burge, & Hammen, 1997;Simpson et al., 2003). Nevertheless, intervention to facilitatechange in attachment styles during the acute grieving processwould be untimely. More research should be conducted to informthe most appropriate time to conduct such intervention.

Our results suggest that another potentially effective approachto reducing grieving during bereavement might be to address theCB with the deceased. Some researchers suggest a theoreticalframework, called the dual-process model, to understand the nat-ure of effective coping with bereavement (Neimeyer, 2001; M. S.Stroebe, Hansson, & Stroebe, 2001). The dual-process model pos-tulates that the bereaved needs to work through both loss and res-toration through the process of oscillating between these two tasks.Therapeutic intervention would focus on helping those individualswho find themselves ‘‘stuck’’ with an externalized CB to engage inthe oscillation process required to work through their grief. There-fore, for the anxiously attached, they may need to be helped toattend to restoration tasks, that is, to reduce their heavy relianceon maintaining an externalized CB to decrease their ruminationsabout the deceased, and to reappraise their lost relationship morepositively. Skills used in working with trauma can be borrowed towork with and help resolve the illusory type of experience com-mon in people relying on externalized CB to cope with their loss.Recent studies indicate that this type of dual-process andtrauma-focused approach toward complicated grief treatment iseffective (Shear, Frank, Houck, & Reynolds, 2005).

Rubin (1999) has suggested a two-track model of bereave-ment. The two tracks are distinct but interrelated in mourning pro-cess. Track I emphasizes how the bereaved function in response toloss (Malkinson, Rubin, & Witztum, 2006; Rubin, 1999). Function-ing includes ability to live in a reality without the presence of thedeceased. Track II focuses on the bereaved involvement in main-taining and changing their unique emotional bond with thedeceased (Malkinson et al., 2006; Rubin, 1999). The concept of


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Track II, which is about relationship between the bereaved and thedeceased, is more relevant to CB (Rubin, 1999). Malkinson et al.used two cases study to illustrate that the bereaved could at thesame time maintain a relationship with the deceased and adaptedto life which the deceased was absent. When applied to our presentfindings, it is possible according to the two-track model that atherapist can reduce externalized CB and increase internalizedCB at the same time.

The present study has several limitations. First, all participantswere conjugally bereaved adults and so the results may not be gen-eralized to other types of bereavement (e.g., loss of a child) or toother age groups (e.g., children facing parental loss). CB in othertypes of relationship may show different expressions. Second, part-icipants of the present study were recruited through voluntarybereavement centers and our results may not be generalizable toother bereaved individuals not in bereavement services. Third,because of the limited number of male participants involved in thisstudy, the results may not reflect the unique features of malebereavement, which are noted to be different from female reac-tions (Carr, 2004; Chen et al., 1999; W. Stroebe, Stroebe, &Abakoumkin, 1999). Fourth, this study used a cross-sectionaldesign, and thus firm statements on directionality of the relation-ships cannot be made. Longitudinal studies conducted both priorto and after death would clearly be more helpful to elucidate therelationship among the different variables. Fifth, our participantswere recruited from Hong Kong which, unlike other cities inMainland China, is a highly Westernized city. Both the publicand health care professionals tend to use Western models toconceptualize grief. This limitation prevents the present study todiscuss cultural factors in affecting CB and grief reaction. Finally,we had only asked participants if they have any formal religion.Because different religions have different views regarding life afterdeath, and continuing relationships with the deceased, we antici-pate that types of religious belief would have an important effecton our present results, and such effects could not be addressedby our current findings. Future studies should be conducted toaddress the above issues.

Despite the above limitations, the present study has estab-lished a valid Chinese questionnaire to measure CB, which shouldbe useful for future research on the topic. In addition, both anxious


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attachment style and to a lesser extend externalized CB are impor-tant factors affecting postbereavement adjustment. Future studiesamong the Chinese should clarify the role of attachment styles inbereavement adjustment further.

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continuing bonds, attachment style, and adjustment in the conjugal bereavement among hong kong...

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