loss and disorganization from an attachment perspective
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This article was downloaded by: [University of Kent]On: 19 November 2014, At: 17:17Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK
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Loss and Disorganization froman Attachment PerspectivePaula Thomson aa Department of Kinesiology , College of Health andHuman Development, California State University ,Northridge, California, USAPublished online: 27 Oct 2010.
To cite this article: Paula Thomson (2010) Loss and Disorganizationfrom an Attachment Perspective, Death Studies, 34:10, 893-914, DOI:10.1080/07481181003765410
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LOSS AND DISORGANIZATION FROM ANATTACHMENT PERSPECTIVE
PAULA THOMSON
Department of Kinesiology, College of Health and Human Development,California State University, Northridge, California, USA
In this article, it is hypothesized that disorganizing, disorienting, and unresolvedstates of mind about loss experiences, as classified by the Adult Attachment Inter-view (AAI) coding system, may offer insight into the bereaved mind and mayguide clinical treatment approaches. This article discusses pre-loss attachmentorganizations and the disorganizing=disorienting markers of unresolved lossfound in the AAI. Although sometimes subtle in nature, the unresolved, disorga-nized, and disorienting indices—defined as lapses in monitoring of reason, dis-course and behavior—provide concrete markers for assessing the degree ofresolution for loss experiences. An attachment-based grief treatment model canadd to existing models implemented in prolonged grief disorder treatment.
Loss of a loved person is one of the most intensely painful experiences anyhuman being can suffer. And not only is it painful to experience but it isalso painful to witness, if only because we are so impotent to help. Tothe bereaved nothing but the return of the lost person can bring true com-fort; should what we provide fall short of that it is felt almost as an insult.(Bowlby, 1980, p. 7–8)
The duration of grief is long, painful, and inherently disorganizing=disorienting for many individuals. In fact, research in deathstudies seems to indicate that successful grieving does not mean
Received 5 January 2009; accepted 17 August 2009.Special thanks to California State University, Northridge, Department of Kinesiology;
members of the research team: S. Victoria Jaque, E. B. Keehn, Thomas Gumpel and KellyForrest, and generous advisement from Maurice Godin, Erik Hesse, Mary Main, JessicaRawles, Allan Schore, Wanda Thomson, and all the participants who completed the AdultAttachment Interview thus far for this research study. And lastly, thank you to the manybrave patients who openly shared their profound grief in a time when life felt meaninglessand death was welcomed as an opportunity to join their loved one and leave behind thefutility of mortality.
Address correspondence to Paula Thomson, Psy.D., Department of Kinesiology, Col-lege of Health and Human Development, California State University, 18111 Nordhoff St,Northridge, CA 91330. E-mail: [email protected] or [email protected]
Death Studies, 34: 893–914, 2010Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print=1091-7683 onlineDOI: 10.1080/07481181003765410
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‘‘recovery’’ (Paletti, 2008), because many individuals never‘‘recover’’ to a pre-loss sense of ‘‘self’’ and ‘‘self-in-the-world’’(Arnold & Buschman Gemma, 2008; Malkinson, Rubin, &Witztum, 2006). Other researchers have suggested that the culmi-nation of grieving should be described as a process of contextualresilience (Sandler, Wolchik, & Ayers, 2008), restoration (Paletti,2008), adaptive continuing bonds (Field, 2006; Field, Gao, &Paderna, 2005), or re-integration (Bowlby, 1980). Constructivisttheory claims that ‘‘grief can be viewed as a struggle to reaffirmor reconstruct a world of meaning that has been challenged byloss’’ (Neimeyer, Holland, Currier, & Mehta, 2008, p. 270). Thesedescriptions incorporate the efforts of the bereaved to adapt andshape a life that includes the irrevocable loss of their loved one.It is certainly a world that is much different from the pre-loss worldthey once knew.
In this article, it is hypothesized that disorganizing, disorient-ing, and unresolved states of mind about loss experiences, as classi-fied by the Adult Attachment Interview (AAI) coding system(Main, Goldwyn, & Hesse, 2003), may offer further insight intothe bereaved mind and may guide clinical treatment approaches.This article will discuss pre-loss attachment organizations andhow these attachment patterns influence the grieving process.The disorganizing=disorienting markers of loss found in the AAI,although sometimes subtle in nature, provide evaluative indicesfor assessing the degree of resolution for loss experiences. Further,when a classification of ‘‘unresolved states of mind with respect toexperiences of loss’’ is given to a parent, it is highly predictive oftheir infant’s disorganized=disoriented attachment classificationas measured by the Strange Situation laboratory test (Hesse,2008). Given this empirically rooted prediction, that a parent’s‘‘unresolved state of mind’’ is generationally transmitted, thetherapeutic need to help these individuals integrate experiencesof loss is even more significant because it has measurable attach-ment repercussions with other family members. In this article,the AAI coding markers for disorganization=disorientation willbe applied to clinical treatment approaches for patients presentingwith unresolved loss, a classification that shares similar featureswith a diagnosis of prolonged grief disorder (Goldsmith, Morrison,Vanderwerker, & Prigerson, 2008), previously termed complicatedgrief (Prigerson & Maciejewski, 2005–2006).
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The AAI coding indices will be illustrated by examplesderived from clinical observation and from emerging researchgathered in our laboratory at California State University,Northridge.1 Although the data is still being collected, we havestrong examples that portray unresolved states of mind about lossand how these disorganized and disorienting states reflect aninability to maintain coherence of narrative and discourse. It ishypothesized (and supported by personal clinical practice) thatunresolved and disorganizing states of mind regarding loss, whendefined and treated, offer greater clinical understanding andeffective treatment outcome.
Attachment Theory
According to attachment theory, the repeated interactions betweeninfants and their primary caregivers during the first year of lifeestablish predictable ‘‘internal working models’’ about caregiverbehavior in response to the infant’s attachment needs (Bowlby,1988). Attachment behaviors, both the signaling calls of distressand the engaging sounds and gestures of pleasure, are fundamentalto the offspring’s survival. Infants’ physical features amplifyemotional expression and elicit greater adult responsiveness. Forexample, infants have proportionally larger eyes and larger headsand motor behaviors that engage in proximity seeking. Theircaregivers are also psychobiologically predisposed to respond totheir infant’s expressive interactive cues (Schore, 2001). Theseearly dyadic engagements are deeply etched into implicit memorysystems of parents, who will then implicitly enact these dyadicexperiences when they interact with their own offspring. As the
1Approval by the Office of Research Human Subjects Review Protocol at CaliforniaState University, Northridge, is granted to this ongoing research project. Data has been col-lected from a population of elite performing artists (United States, Canada, South Africa,and Europe), elite athletes (United States, Canada, and Europe), and patients suffering frompsychiatric and functional disorders. This multivariate research design involves researchersfrom diverse disciplines (genetics, exercise physiology, psychology, and psychophysiology).All participants completed informed consents, including granting consent for excerpted ver-batim citations drawn from their Adult Attachment Interview to be presented at professionalconferences or in scholarly journals. All personal indicators have been removed from thetranscript citations. Dr. Paula Thomson is a highly reliable coder of the Adult AttachmentInterview and received her training from Mary Main, Erik Hesse, Sonia Gojman de Milan,June Sroufe, and Kazuko Behrens. Training in the Infant Attachment Assessment was givenby Alan Sroufe and Betsy Carlson.
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individual develops, these repeated attachment experiences shapesubsequent relational interactions and inform coping behaviorduring stressful situations. These behaviors are transmitted tofuture generations unless some major perturbing life event altersthese ‘‘internal working models’’ (Hesse, Main, Abrams, &Rifkin, 2003; Hughes, Turton, McGauley, & Fonagy, 2006; vanIjzendoorn, 1995).
Attachment behavior is activated in both caregiver and childduring all threat situations, including the inherent dangers thatloom during separation experiences (Bowlby, 1988). During separ-ation, the psychobiological response of parents is to protect theiroffspring. Active seeking behaviors are necessary to find, console,and protect their child, and the child’s attachment behaviors are toactively seek the caregiver for safety and comfort. The optimalsecure=autonomous attachment behavior provides predictabilityand a sense of safety for the offspring. Based on these experience-dependent responses, the child acquires an abiding faith that allwill work out and that safety and comfort are reliable ingredientsoffered to them during their developmental years (Sroufe, Egeland,Carlson, & Collins, 2005). For this child, security found in attach-ment experiences promotes healthy and robust endeavors toactively explore the world. They will use secure attachment experi-ences to buttress the acquisition of new skills and to organize effec-tive coping strategies during threat. Individuals with secure=autonomous states of mind are able to renegotiate their identity,especially during times of bereavement. Many are able to resolvedisorganized and disorienting responses of loss through effectiveinteractions with others. They are able to activate attachmentbehaviors of proximity and comfort seeking during these painfultimes and openly discuss previous and current difficulties. Theycan usually flexibly regulate their attentional and emotional pro-cesses of bereavement as they struggle to redefine their sense ofself (Main, 2000).
Although secure attachment behavior is established for many,this is not true for all. Two organized but insecure and anxiety-provoking patterns can manifest from very different child-caregiver experiences (Ainsworth, Blehar, Waters, & Wall, 1978).First, the ambivalent-resistant behaviors of an offspring appearwhen the caregiver is not able to adequately attune to the infant’sneeds. These parents are frequently preoccupied with their
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own attachment needs and so transmit feelings of anger, passivity,or fear. Parents’ preoccupied states of mind interfere with theirability to attend successfully to the attachment needs of theiroffspring. And so the infant remains distressed for prolongedperiods of time, even though the source of comfort, the parent, isphysically, but not emotionally, present. Ambivalent-resistant chil-dren internalize the feeling that the world is not safe or reliable;hence they are not able to adequately disengage their attachmentneeds and explore the world around them (Main, 2000). Bothparent and child have great difficulty disengaging from each otherand yet neither is able to reduce anxiety and feel secure. Althoughthese experiences are unsatisfying, they are predictable for bothparent and child, and so they are encoded as organized internalworking models that are operational during all stressful situationsand all attachment interactions (Creasey, 2002). It is difficult forthese individuals to maintain enough coherence to form a senseof self that is not infused with the behaviors and responses of theirattachment figures. This same preoccupation tends to persistduring experiences of loss (Main, Hesse, & Kaplan, 2005; Sroufeet al., 2005). They remain insecure and fixated on unmetattachment needs.
The second organized but insecure pattern of attachment isthe anxious avoidant behavior of the infant and the dismissing,rejecting responses of the caregiver (Main, 2000). What transpiresin this attachment relationship is a repeated history of turning awayfrom others during times of attachment needs. And so this dyad ismarked by increased disengagement of the other during threatexperiences. Although it appears to an outside observer that thesedyads operate effectively and independently, the physiologicalstress of increased heart rate and elevated cortisol levels beliesthe outward appearance of security and autonomy (Fox & Hane,2008). This deactivation of attachment needs reduces the pain offeeling rejected; however, it amplifies the necessity for establishingindependence. The pattern of turning away from attachment needswhen under stress, including experiences of loss, frequently leadsto minimizing behaviors, including actively forgetting painful situa-tions, derogating or dismissing others who show signs of bereave-ment, and shifting focus to external activities such as career plansand material acquisitions (Main et al., 2005). This avoidant=dismissing adaptive coping strategy ultimately compromises the
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establishment of future attachment bonds and deters self-reflectiveidentity formations (Sroufe, 1995).
As outlined above, the three major organized attachmentpatterns of behavior—(a) secure=autonomous, (b) ambivalent-resistant=preoccupied, and (c) avoidant=dismissing—are usuallyoperational in all individuals, regardless of cultural influences(Hesse, 2008); however, there are patterns of attachment thatappear disorganized. Disorganized behavior is evident either ona global level or only during discrete periods of loss or abuse. Ininfants, these discrete disorganized patterns are markers of collaps-ing coping strategies during times of stress (Main & Solomon,1990). The disorganized infant is not able to mobilize coherentbehavior essential for survival. Their responses mimic those ofposttraumatic stress disorder, in which they are stuck in oscillatingpatterns of extreme fight=flight=freeze responses (Thomson, 2007).They are not able to run toward the caregiver and seek safetybecause the caregiver may in fact be the source of threat, andyet these small children are biologically driven to find their care-giver in an effort to gain safety. This leaves the child in a situationwhere no organized attachment strategy will resolve their distress(Hesse & Main, 2006). As adults this disorganized behavior isevident in collapsing states of mind as they attempt to describeexperiences of abuse or loss. In the AAI, these experiences arethen coded as ‘‘unresolved=disorganized=disoriented’’ and reflectthe inability of the adult to coherently manage the stress of past lossor trauma experiences (Hesse & Main, 2000; Main et al., 2003;Hesse et al., 2003). A more global and pervasive pattern of disor-ganization prevails when early attachment experiences are unpre-dictable, threatening, and massively misattuned. These individuals,given a coding of cannot classify, are greatly compromised in theirability to function in most settings (Hesse, 1996; Lyons-Ruth,Melnick, Patrick, & Hobson, 2007). For individuals in this group,they experience marked identity confusion and display maladap-tive behavior during most daily demands (Hesse, 1996; Cloitre,Stovall-McClough, Zorbas, & Charuvastra, 2008).
Death of Someone Close
The ability to redefine the self and the self-in-the-world and to findmeaning in a life that must continue without a loved one is a
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challenge for most bereaved individuals (Matthews & Marwit,2004; Neimeyer, Baldwin, & Gillies, 2006; Rubin, 1999). Thischallenge may be amplified for those who are already strugglingwith pre-loss insecure attachment states of mind. When the lossis a result of a sudden violent act (suicide, homicide, or fatalaccident), the grieving process is often further compounded forall individuals (Anderson, Marwit, Vandenberg, & Chibnall,2005; Currier, Holland, & Neimeyer, 2006; Davis, Wohl, &Verberg, 2007). These individuals are vulnerable to complicationsinherent in traumatic loss (Currier et al., 2006), and their earlyattachment histories will further color how effective they are atnavigating their grief (Shaver & Fraley, 2008).
According to John Bowlby (1980), the mourning process gen-erally flows through four stages. He describes the first stage as oneof numbness; family members are left in shock and are unable tofully comprehend that their loved one will no longer progressthrough the natural phases of development. Bowlby describedthe second stage as yearning and searching for the deceased. Inattachment theory, this is the natural behavioral responses acti-vated during separation experiences. The third stage is markedwith disorganization and disorientation. It is this stage that isfurther complicated when pre-existing disorganized patterns ofattachment are already embedded within the implicit ‘‘internalworking models’’ of grieving family members. The fourth and finalphase of mourning is described as the ‘‘[p]hase of greater or lessdegree of re-organization’’ (Bowlby, 1980, p. 85). Bowlby claimedthat this fourth stage was not a stage of detachment from the loss;rather it required a re-evaluation and re-integration of the lossexperience. These four stages outline the bereaved individual’sefforts to comprehend the loss and revise a sense of self and worldthat must co-exist without the loved one. And the final phase ofre-organization merely indicates a decrease in disorganized anddisoriented responses.
The notion of decreasing disorganization and disorientation isexactly what is assessed in the Adult Attachment Interview for lossexperiences. To continue to feel sad and distressed or to exhibitmoderate states of disorganization is not considered evidence fora classification of unresolved=disorganized=disoriented in theAAI coding system. Rather, what is noted is how the individualmanages to reorganize and reorient attachment behavior and
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internal representations of the self and the world (Main et al.,2003). This re-integrating process is similar to what is beingproposed in treatments such as cognitive-behavioral therapy forcomplicated grief (Matthews & Marwit, 2004), narrative construc-tivist perspectives (Currier et al., 2006), narrative integration(Currier & Neimeyer, 2006–2007), and the two-track model ofbereavement that emphasizes the person’s functioning in the worldand the ongoing relationship with the memories of the deceasedperson (Malkinson et al., 2006; Rubin, 1999). All these approacheshelp the individual redefine and reorganize their sense of selfpost-loss and the AAI assesses the effectiveness of this reorganizingstate of mind processes.
Assessing the Degree of Resolution of LossExperiences
Our current assessment abilities are limited by the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV TR; American Psychi-atric Association, 2000). Although eloquent research studies haveshaped criteria listed within such proposed diagnostic nosologyas Complicated Grief or Prolonged Grief Disorder (Dillen,Fontaine, & Verhofstadt-Deneve, 2009; Goldsmith et al., 2008),we are presently constrained by the DSM-IV TR. What is frequentlydiagnosed is bereavement comorbid with major depressive disorder,anxiety disorder, sleep disorder, somatoform disorder, posttrau-matic stress disorder and=or dissociative disorder.
Future diagnostic manuals should include criteria for a diag-nosis of Prolonged Grief Disorder or Complicated Grief; however,we presently have another research instrument that is very reliablein determining whether past loss remains resolved or unresolved.AAI, a cross-culturally stable research instrument, offers a classi-fication regarding the degree of resolution of loss experiences(Hesse, 2008). This semistructured interview, originally createdby Mary Main and Ruth Goldwyn, gathers verbatim reports fromindividuals about their states of mind regarding attachment,trauma, and loss experiences (Main et al., 2003). The interview isaudiorecorded, transcribed verbatim, and coded by reliabletrained coders. It does not attempt to gather historical facts aboutattachment, trauma, or loss experiences, rather it yields infor-mation about the state of mind of the speaker such as degree of
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coherence, balance, valuing, and monitoring that exists during thecourse of the interview. The challenge for the interviewee is toremain in discourse with the interviewer while actively organizingand recounting experiences about past and present attachment-related events. When coding for the degree of resolution fortrauma and loss, lapses of monitoring of reason, discourse, andextreme behavioral reactions are evaluated and ranked on a9-point scale ranging from 1 (no evidence of disorganization=disorientation in discussions of loss) to 9 (marked disorganization=disorientation; Main et al., 2003).
It is proposed that, based on information gathered fromthe AAI, the degree of resolution regarding loss can be quantifiedand treatment practices can be tailored to support the resolutionand integration of these loss experiences. Attachment theory, andin particular, the AAI, does not suggest that successful resolutionof loss means a loss of pain. In fact, one of the hallmarks of a coher-ent state of mind about attachment includes the validation andownership of pain, regret, disappointment, and rueful recognition.At this point, it is also important to clearly differentiate some ofthe language found in the attachment literature. First, attachmentresearchers report findings that describe ‘‘attachment styles’’ thatare determined by self-report assessments, whereas ‘‘states of mindabout attachment, loss and trauma’’ describe what is gleanedfrom narrative coding of the AAI. What is essential to note isthat attachment self-reports are not significantly correlate to AAIclassifications (Crowell, Fraley, & Shaver, 2008). Further, the AAInarrative is a collaborative discourse process with another, theinterviewer, which somewhat differentiates it from other narrativeanalysis such as the disruption narratives of fragmented loss thatis eloquently described by Neimeyer (2006).
Application of the Adult Attachment InterviewCoding Criteria for Unresolved Loss and
Treatment Implications
The statements below are formulated from personal clinical treat-ment observations and findings from our ongoing AAI laboratoryresearch. Informed by this, what is becoming apparent is thatindividuals classified as ‘‘unresolved with respect to loss’’ (Mainet al., 2003) demonstrate many of the same symptoms described
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in prolonged grief disorder (Neimeyer et al., 2008). They sufferfeelings of futility, emptiness, and meaninglessness; reportrecurring bouts of numbness, detachment, depersonalization andderealization; and describe great difficulty imagining a life withouttheir loved one. They feel that part of their ‘‘self’’ died with theloved one. Often their worldview is shattered, and they have dif-ficulty acknowledging that the death is real. Further, many sufferprolonged states of irritability, anger, or bitterness, and when theseheightened arousal states diminish they are replaced by a baselinestate of anhedonia. Although they may return to a modicum offunctioning, they often are not able to return to levels of pre-lossfunctioning. And their health is frequently compromised, oftenresulting from increased sympathetic nervous system activation(heart palpitations or tachycardia; reduced ability to regulate tem-perature, appetite, and sleep; decreased heart rate variability;Hagemann, Waldstein, & Thayer, 2003). Further, unresolved statesof mind about loss frequently include recurring nightmares inwhich the violent moments of the death are replayed or displacedso that the dreamer or other family member must now experiencetheir loved one’s sudden death. Sometimes bereaved dreamersfeel the dead loved one beckoning them to join them in deathor entreating them to rescue them from the agony they sufferedwhile dying (Barrett, 1996). These dreams disrupt sleep and areindicative of an overactive stress response (van der Kolk, 1997).Other physiological stress markers are evidenced in the hollowor haunted appearance in the bereaved eyes, sallow complexion,and collapsed, sunken posture.
Beyond classifying an individual with an organized secure orinsecure state of mind regarding attachment, the AAI determinesthe degree of disorganization=disorientation for all loss and traumaexperiences. The three major categories to assess an unresolvedstate of mind are (a) lapses in monitoring of reason, (b) lapses inmonitoring of discourse, and (c) lapses in monitoring of behavior(Main et al., 2003). It must be stated that these lapses are not codeduntil after the first year of bereavement is completed, because themourning process naturally involves pronounced states of disorga-nization and disorientation. These AAI criteria will be applied andillustrated in a clinical treatment context and will form the basis foran attachment-based grief treatment model. It must be noted thatthe attachment-based grief treatment model is not claiming to alter
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the underlying organized attachment classifications of ‘‘secure=autonomous,’’ ‘‘insecure=preoccupied,’’ or ‘‘insecure=dismissing’’;rather it is the disorganized ‘‘insecure=unresolved with respect to loss’’classification (Main et al., 2003) that is the focus of attachment-basedgrief treatment.
Lapses of Monitoring of Reason
Helping the individual grasp that the loved one is really dead iscritical in therapeutic treatment. Even if they hold an internalizedbond of love and continue to value the attachment relationship,they must acknowledge that the death of the loved one is perma-nent and irreversible. This truth is painful but it is also healing.Generally, the bereaved know this to be true, even when theycontinue to engage searching behaviors in a frantic hope of findingtheir lost loved one. And despite recent support for the concept ofthe healing power of continuing bonds with the deceased (Field,2006; Field et al., 2005; Packman, Horsley, Davis, & Kramer,2006), a qualitative difference exists between the conscious aware-ness that the loved one is dead and the unconscious belief that theyare alive. When the dead loved one ‘‘actively’’ invades the mindand operates as if he or she co-exists, it is not internally coherent(Main et al., 2003). This condition is described as ‘‘dead not dead’’in the coding for unresolved loss in the AAI and is not representa-tive of the continuing bonds theory described in death studiesliterature (Field, 2006; Packman et al., 2006). Indicators of disbeliefthat the person is dead are often manifested in small tense shiftswhere the dead person seems to co-exist in time and space. Thedead person is literally alive in the mind of the speaker. An AAIexample drawn from our research sample illustrates the ‘‘deadnot dead’’ dynamic (note that the italics indicate the markers forlapses in monitoring of reason in this passage). The speaker is dis-cussing the loss of a late adolescent cousin, with whom he was veryclose: ‘‘He was, he didn’t die or something, he was murdered, hewas shot in his car. He is a song-writer and lots of friends andfamily came to the memorial. He is a lovin’ type of guy, he hada beer belly and he is really funny.’’ These micro tense shifts,although brief, indicate lapses in reasoning and suggest a lack ofattentional flexibility, which often negatively influence presentongoing caregiving, relational, or career activities (Hesse & Main,
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2000). Further, these momentary lapses are qualitatively differentfrom the attentional flexibility and enhanced functioning providedby continuing bond experiences (Becker & Knudson, 2003). Infact, resolution of loss may include the solace and strength derivedfrom an internalized sense of the existence of the loved one.Certainly a ‘‘continuing bond’’ can be maintained with a lovedone while maintaining awareness that they are dead (Field, 2006;Packman et al., 2006).
Beyond the ‘‘dead not dead’’ lapse, other lapses of reasoninginclude feelings of being causal for the death of a loved one (Mainet al., 2003). This can be particularly challenging when the loss wassudden and violent. Many suffer survival guilt and long to take theplace of their loved one. During therapeutic treatment, the thera-pist must willingly revisit these feelings of guilt and help thebereaved understand their limitations in providing safety. Thistherapeutic process may shatter the fantasies of omnipotence thatthe bereaved hold. For example, while they may state that life isfragile and the world is fundamentally dangerous and unpredict-able, they make contradictory claims that they should haveprovided safety and protection, even when they ‘‘know’’ they weremiles from their dying loved one. These omnipotent magicalfantasies shape their belief that they are causal of the death. Somebereaved even claim that they could have succeeded in savingtheir loved one if they were more attentive, quicker, or had pro-phetic vision. This lapse of reasoning is a form of irrational logicand is described as trance-logic (Crabtree, 1993). Trance-logic, astrong indicator of dissociation, feels rational to those who havebeen thrust into a state of overwhelming terror and pain. And inthese conditions, dissociative processes such as depersonalizationand derealization actually serve as protective defenses; however,they also heighten trance-logic (Spiegel, 2003). In trance-logic itis not impossible for a bereaved family member to believe thatthey can simultaneously co-exist in two geographic locations wherethey can maintain their current living situation, while attending tothe loved one in need. Helping patients understand how theselapses in reasoning and trance-logic operate may enable greaterrecognition of their distress. However, surrendering trance-logicand feelings of being causal of their loved one’s death also meansthat they must surrender the illusion of omnipotence. And this lossof illusion often makes the death of their loved one more painful.
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Frequently, torrents of uncontrollable crying results during thesemoments of surrender, but once trance-logic dissolves many feelsomewhat calmed and re-oriented.
Other lapses of reasoning are found in psychologically con-fused statements such as when someone claims they can put theirgrief in a little box and not open it anymore, they can arrange a‘‘wedding’’ for their loved one while they are in fact preparingfor the funeral, or they can remove the ‘‘bad’’ and elevate theirloved one to sainthood. Again, dissociative trance-logic is oper-ational during these brief moments of disorganization and disorien-tation; however, these psychologically confused statements by thebereaved may cause significant distress for others. Therapists needto be alerted to these lapses in reasoning and help the bereavedunderstand how this trance-logic alienates them from those whoare alive (Hesse & Main, 2006; van Ijzendoorn, 1995). Sometimesgaining an awareness of this form of lapse of reasoning helps themmonitor psychologically confused beliefs and re-engage with thosearound them. And as they re-engage, a potential for resolution isincreased, and with it, their narrative discourse may become morecoherent and consistent.
A more pronounced lapse of monitoring of reason is con-fusion between the dead person and the self. Individuals literallystate that they died and their loved one lives. It is necessary forthe therapist to help the bereaved acknowledge that they are alive.It is therapeutically prudent to investigate what parts of the selfdid ‘‘die’’ with the loved one and explore whether they can bere-kindled back to ‘‘life’’ or if they will remain ‘‘dead.’’ Someactually prefer to have part of their self ‘‘die’’ and remain with theirloved one; however, these individuals are now consciously awareof this intrapsychic dynamic and can organize their feelings withgreater coherence and less disorganization.
Lapses of Monitoring of Discourse
Lapses in monitoring of discourse are equally strong indicators ofan unresolved state of mind about loss. Careful attention to state-ments that involve unusual attention to detail or a sense of poeticeulogistic speech often indicates absorbed dissociative states ofmind. They reveal the speaker’s inability to shift attention awayfrom the loss experience (Hesse & Main, 2000). An example of this
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form of absorption is taken from an AAI interview. The speaker isdescribing the funeral that he attended for a murdered oldersibling. This event occurred ten years prior to the interview: ‘‘soit was at a very, very big church, big big white church, two floorswas all filled, it was filled with a lot of people but the space wasvery small, there was like burgundy walls and like two lights ineach corner, so it was kind of dark and uh . . . [prolonged silenceof 35 seconds] . . . I just remember it being in a small room and itwas dark, and there was like brown or burgundy walls.’’ It is sug-gested that during treatment it may help to linger on the detail sothe individual can begin to perceive the degree of their dissociatedabsorption. As they begin to ‘‘hear’’ the detail, they have anopportunity to integrate the loss experience. Rather than being dis-sociated, it can be processed within a meaningful relationshipbetween the individual and the therapist. Both are alerted to thesemarkers of distress and they can acknowledge the degree of painhidden within the details and eulogistic speech. It actually helpsthe bereaved move the experience nearer, rather than distancingthrough the dissociative recounting of these details.
Other lapses in monitoring of discourse include prolongedsilences (Main et al., 2003). When prolonged periods of silenceoccur, it is helpful to join the patient in their reverie. If willing, theycan guide the therapist through the inner landscape of grief. Fre-quently during these silences the bereaved suffers bouts of extremedisorientation, depersonalization, and derealization. Subjectively,they describe intense emptiness and feel lost and isolated fromtheir loved one, themselves, and the world. Often, the ‘‘blank’’emptiness is so distressing that they remain mute and frightened.There seems to be no exit from their painful emptiness and theworld as they once knew it is gone. They may reveal trance-logicas they claim an inability to return to life unless the deceased alsoreturns. In their silent emptiness they cannot sustain a feeling ofcontinuing bonds with their loved one and they cannot re-locatethemselves in the world without their loved one. Clinically, it ismeaningful to follow the bereaved into their lapses of silenceand explore the significance of these silences with them.
Invasions of death while discussing other topics are alsoregarded as a lapse of monitoring in discourse. These invasionsclearly reveal preoccupations of loss for the bereaved (Mainet al., 2003). With increased awareness of these invasions, the
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individual may realize the depth of their grief and will hopefullyoffer contextual statements that alert others to their pain, ratherthan unpredictably invading benign conversations with loss. Soonthe bereaved will perceive how much their focus is directed towardloss. And although they may not be able to redirect their focus,they will be aware that they are not yet able to re-organize theirloss experiences and adapt to life without their loved one. Thisknowledge actually helps them accept their grief and re-orientsthem as they struggle to gain deeper understanding and acceptance.
Other lapses of monitoring in discourse include unsuccessfulmoves away from the loss evidenced in patterns of incompletethoughts and sentences, abrupt changes in topic, or overt state-ments of feeling lost in the conversation (Main et al., 2003). Likethe other lapses discussed above, these lapses suggest that thebereaved remain disorganized and disoriented. An example takenfrom an AAI interview with an individual who suddenly lost anattachment figure portrays these lapses of monitoring of discourse.While speaking about a past experience with his attachment figure,he stated, ‘‘mm. Umm-m-m-m- . . .Bom-bom-bom-mmm, mm-mm(singing) . . . (8 sec) There’s, oh I mean there was times when . . . Iwould get in trouble . . .what are we talking about?’’, and later inthe interview: ‘‘it just got worse and worse and snowball and snow-ball she got r-really sick. . . .And then I guess she just got worse andworse and worse in the hospital. . . .Like between ten and twentydays, it just got like worse and worse and worse and worse andworse.’’ This passage portrays multiple lapses in discourse: changeof topic (singing), incomplete sentences and thoughts, statement oflosing track of the topic being discussed, and repetition of wordssuggestive of absorption. Based on these and other markers of dis-organization not presented above, this individual was classified asunresolved with respect to loss and eventually sought therapeutictreatment.
Lapses of Monitoring of Behavior
Lastly, the AAI coding for unresolved loss evaluates lapses inmonitoring of behavior. Efforts to redirect distress may be indica-tors of unresolved grief, even though others may believe theseredirections suggest a return to functioning. For example, some-times unresolved grief may be provoked by a seemingly minor loss
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event. One parent returned to work shortly after the death of herdaughter and 2 years later she was unable to function whenshe heard news of the death of a remote family friend. Thisextreme reaction suggests a delayed grief response. AlthoughAAI coders are trained to detect delayed grief and redirectingbehavior, clinicians must be careful not to misinterpret more orga-nized strategies of dismissing or derogating states of mind aboutattachment and loss as redirected grief. When a speaker, classifiedas Dismissing of Attachment, states that the loss did not affect themmuch and that they simply and quickly returned to normal dailyactivities, their reports are psychobiologically accurate (Shaver &Fraley, 2008). These individuals show no physiological signs ofstress, and they do not demonstrate lapses in monitoring of reason,discourse or behavior. They clearly state in their AAI that the lossof a close loved one did not cause them to suffer and it has no effecton their present life. Many therapists believe that these people arerepressing deep feelings of grief that will surface later or manifestas somatic symptoms. Research studies do not support this stance(Shaver & Fraley, 2008).
Other markers of extreme behavioral responses may includesuicidal ideation or attempts, incongruous risk behaviors, neglectof personal hygiene, extreme phobic responses, agoraphobia,intermittent explosive episodes, dissociative fugue or amnesticstates, or transient psychotic episodes. For example, one researchparticipant showed multiple lapses. Their transcript containedmarked efforts to avoid painful topics, especially during loss andseparation questions, and they openly described avoidant behaviorthat could be classified as phobic. This is evident in the followingexcerpt from the transcript:
Um, so there was that, tha’s my first experience, with death and, it kindaem, it really weirded me out. Um, for awhile. Okay we got, we got a-a,an, an afghan, and a pillow? From my great-grandma? And, I don’t knowhow long this went on for, in my mind it’s a couple of years. It may’ve been,it may’ve been, not that, long but in in my brain it was like, at least a year,maybe two. Er, or more, I’m not sure. We got a pillow and an afghan, and,they were in the living room upstairs in my house. And any time, like ifI would see, if I-, if I saw the pil- I just, I couldn’t touch them? Um, I g-,I dun-, I don-, like it wasn’t, I don’t-, it wasn’t so much like, germs? Ijus-, I could-, I couldn’t touch them. Um, I couldn’t really, pinpoint why?But it was like, gs-, y’er great gandma’s and she was dead so, eh-eh-eh-, they
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were, sort of I guess tainted in some way? S-, and if I was the, if I saw thepillow like, lying on one of the chairs? I couldn’t sit on that chair? And then,if I saw the pillow lying on a cushion of the couch? I couldn’t sit, I couldn’tsit on that couch? Uh, on that, or on that part of the couch? So as time wenton, I progressively had less and less places to sit. [The speaker continues inthis fashion detailing the progression of diminished space that was availableto him and concludes this passage with the following remark.] So it got tothe point where there was only, one, little spot on the floor that I could siton. Yeah. So that’ was, tha’ was, s-sort o’ biggest thing.
Any reporting of such behaviors, even if they are currentlymanaged or terminated, are suggestive to a trained coder thatunresolved markers of loss may still persist (Main et al., 2003),and clinical treatment is recommended. Another example ofextreme behavioral responses is indicated in the following AAIexcerpt. The speaker described behavioral responses that beganafter a significant loss: ‘‘And then at some point the first time it everhappened I was sitting uh, eating lunch at school and I lost all feel-ing from my neck down (mmhm). And I didn’t understand thatone {subj. laughs} And that was pretty scary. Uh and it took a longtime for the feeling to come back . . . . I went completely numb,completely. I didn’t feel anything . . . I had pains that sent me tothe ground.’’ Careful and prolonged monitoring of individualswho report extreme behavioral reactions is critical. They will needsupport as they revise their self-identity, one that incorporates theloss of their loved one (Robinson & Marwit, 2006). Although theymay never return to a pre-loss state, they do have an opportunity tore-integrate and re-organize their disorganized and disorientedstates of mind and behavior.
Concluding Remarks
Meeting the haunted eyes of the bereaved is often painful for all,including the therapist. Many patients have reported that othershave wanted the bereaved to find meaning in life, to form continu-ing bonds with the deceased, to relocate the deceased into heavenor a reincarnated state, to avoid grief and re-engage in daily tasks,or to positively reframe their loss and aspire for growth andredemption acquired through adversity or suffering. In short, theywanted the bereaved to stop grieving and get on with living. How-ever, for those with unresolved states of mind regarding loss, they
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are not able to mobilize these coping strategies, even when theylong to do so. They are not resisting resolution; they are simplyunable to achieve it. And that is where therapeutic treatmentneeds to offer support (Malkinson et al., 2006; Neimeyer, 2006;Neimeyer et al., 2008).
Careful monitoring of lapses of reason, discourse, and beha-vior can alert therapists to their patients’ pockets of pain. Withrepeated attuned interactions between the therapist and thebereaved individual, a gradual sense of self and meaning mayemerge. Years later, one bereaved individual reported how muchit mattered that she was brought back to the painful topic of herdaughter’s untimely death, even when she believed the topicshould be changed. This patient expressed her surprise andgratitude as she learned that her lapses in monitoring containedelements of her grief that had previously remained out of herawareness.
By applying the AAI indicators for unresolved states of mindregarding loss, therapists have an opportunity to monitor the pro-gress of their bereaved patients. They can help them move towardgreater resolution, a state of mind that is marked with minor lapsesof discourse and reasoning and low levels of behavioral reactionsthat reflect the ability to monitor and contain the disorganizingeffects of loss (Main & Hesse, 2000). Fundamentally, therapistscan help them tolerate and contain the monstrous pain of loss.For those with strong attachment connections to the loved onewho died, the grieving process is ultimately a prolonged nightmarethat they cannot escape. It is not surprising that these bereavedindividuals collapse into protracted silences, respond with incom-plete sentences and thoughts and maintain reasoning that ismarked by trance-logic. They must struggle to accept that theirloved one is gone. These bereaved individuals must revise andre-establish a new identity that includes the loss of their lovedone (Riley, LaMontagne, Hepworth, & Murphy, 2007). This isthe ultimate work of attachment-based grief therapy. And throughthe powerful relational interactions with an attuned therapist, onewho is trained to monitor the disorganized and disorienting lapses,the bereaved individual may find a relationship where painfulfeelings are invited, unresolved trance-logic is explored, and lapsesof reason, discourse, and behavior are monitored, contained, andmodified into more coherent states of mind about loss. This
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interactive therapeutic relationship has the potential to assist in theresolution of disorganization and disorientation, it has the potentialof making the painful journey less isolating, and it may help thebereaved find meaning in their loss (Currier et al., 2006; Neimeyeret al., 2006) as they re-integrate and return to a life that is foreverchanged.
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