Exploring the Role of Experiential Avoidance from the Perspective of Attachment Theory and the Dual Process Model

Article (PDF Available)inOMEGA--Journal of Death and Dying 61(4):357-69 · December 2010with342 Reads
DOI: 10.2190/OM.61.4.f · Source: PubMed
Abstract
Avoidance can be adaptive and facilitate the healing process of acute grief or it can be maladaptive and hinder this same process. Maladaptive cognitive or behavioral avoidance comprises the central feature of the condition of complicated grief. This article explores the concept of experiential avoidance as it applies to bereavement, including when it is adaptive when it is problematic. Adaptive avoidance is framed using an attachment theory perspective and incorporates insights from the dual process model (DPM). An approach to clinical management of experiential avoidance in the syndrome of complicated grief is included.
OMEGA, Vol. 61(4) 357-369, 2010
EXPLORING THE ROLE OF EXPERIENTIAL
AVOIDANCE FROM THE PERSPECTIVE
OF ATTACHMENT THEORY AND THE
DUAL PROCESS MODEL*
M. KATHERINE SHEAR, M.D.
Columbia University School of Social Work, New York
ABSTRACT
Avoidance can be adaptive and facilitate the healing process of acute grief
or it can be maladaptive and hinder this same process. Maladaptive cognitive
or behavioral avoidance comprises the central feature of the condition of
complicated grief. This article explores the concept of experiential avoidance
as it applies to bereavement, including when it is adaptive when it is prob-
lematic. Adaptive avoidance is framed using an attachment theory perspec-
tive and incorporates insights from the dual process model (DPM). An
approach to clinical management of experiential avoidance in the syndrome
of complicated grief is included.
Avoidance is sometimes an adaptive strategy in coping with adversity and some
-
times maladaptive. In the case of bereavement, experiential avoidance usually
plays a role in facilitating the healing process. The emotional pain associated with
new information that a loved one has died is so severe that people need time
interspersed with periods of respite in order to be able to fully acknowledge
the unwanted reality. Respite can be achieved using cognitive avoidance, and
*This work was supported by a grant from the National Institute of Mental Health: R01
MH70741.
357
! 2010, Baywood Publishing Co., Inc.
doi: 10.2190/OM.61.4.f
http://baywood.com
sometimes by also avoiding contact with triggers of emotion. When avoidance
is used adaptively, it facilitates processing of the painful information as well
as restoration of the capacity for a satisfying ongoing life. As processing and
restoration are achieved, the need for avoidance diminishes and the strategy
must be relinquished. If it is not, or if avoidance is over-used in the wake of
bereavement, the strategy can backfire. Processing difficult information is
impeded rather than facilitated and acute grief is prolonged.
This article explores the boundary of adaptive and maladaptive use of avoidance
during acute grief, considering both behavioral and cognitive strategies. We
define acute grief as the abrupt onset of a bereavement response that is usually
severe and that has a relatively short course, measured in months rather than
years. Acute grief, analogous to acute inflammation, is a painful healing process
that usually resolves over time if there are no complications. Healing is associated
with restoration of functioning and a permanent residue of integrated grief.
The discussion that follows is framed using an attachment theory perspective
and incorporates important insights from the dual process model (DPM). The
hypothesis is that avoidance facilitates the healing process, providing a needed
respite from severe emotional pain. On the other hand, over-use or persistence
of avoidance strategies beyond a certain point can hamper mourning and
complicate acute grief. Once established, complicated grief is often chronic
and unremitting with experiential avoidance at its core. Avoidance is notoriously
difficult to bring to light as it can be overlooked by clinicians. Focused assessment
and intervention are usually needed to identify and ameliorate the problem. This
article concludes with a summary of our approach to clinical management of
bereavement-related avoidance.
Avoidance is often used as a method of evading external situations that are
appraised, accurately or not, as dangerous. Avoidance is adaptive when real
danger is present. However, people with anxiety disorders over-estimate the
probability that a situation is dangerous and misjudge the likely consequences.
For example, people with post-traumatic stress disorder often appraise neutral
situations as dangerous because they have become associated with a life
threatening event. These people fear that the external danger will strike again.
Avoidance is also used as a way of achieving distance from emotions and other
internal experiences. This type of avoidance, called “experiential,” was defined
by Haves, Wilson, Strosahl, Gifford, and Follette (1996) as “the phenomenon
that occurs when a person is unwilling to remain in contact with particular
private experiences (e.g., bodily sensations, emotions, thoughts, memories,
behavioral predispositions) and takes steps to alter the form or frequency of these
events and the contexts that occasion them” (Haves et al., 1996, p. 1154).
Bereaved people utilize avoidance to manage perceived internal rather than
external threats. Haves and colleagues outline a number of ways that experiential
avoidance can be adaptive, yet they contend that experiential avoidance is not
advisable during grief: “When an unchangeable loss occurs, the healthy thing to
358 / SHEAR
do is to feel what one feels when losses occur” (Haves et al., 1996, p. 1157). Their
belief in the categorical need to experience painful grief, disputed by grief
researchers, is a good example of the confusion engendered when the process
and goals of healing after bereavement are not spelled out. Bereaved people
regularly utilize experiential avoidance in the process of adapting to a painful loss.
Bowlby (1980) is clear that experiential avoidance used judiciously is a natural
feature of acute grief. In fact, Bowlby goes farther and posits that there is an
adaptive form of defensive exclusion (i.e., cognitive avoidance) in the resolution
of acute grief. In the discussion that follows we consider adaptive as well as
maladaptive use of experiential avoidance during acute grief. We first discuss
adaptive avoidance using an attachment theory perspective on bereavement to
provide the context for the discussion (Bowlby, 1980).
ATTACHMENT, LOSS, AND ADAPTIVE
AVOIDANCE
There is good evidence that humans are instinctively oriented to seek, form,
and maintain close relationships and to respond to separation and loss of these
relationships. The biobehavioral attachment system underlying these innate ten-
dencies operates throughout the lifespan. Attachment security contributes to
optimal psychological functioning and fosters a sense of wellbeing. Attachment
relationships impact daily life in countless ways, including learning, mastery and
performance success, overall effective functioning, emotion regulation, psycho-
physiological reactivity, sleep quality, self-esteem and self-concept, cognitive
functioning, coping skills and problem solving, and general interpersonal func-
tioning (e.g., Carmichael & Reis, 2005; Cassidy, 1994; Feeney & Collins, 2003;
Gillath, Bunge, Shaver, Wendelken, & Mikulincer, 2005; Kim, Carver, Deci, &
Kasser, 2008; Mikulincer, Dolev, & Shaver, 2004; Mikulincer, Florian, Cowan, &
Papa, 2002; Mikulincer, Shaver, & Pereg, 2003; Pereg & Mikulincer, 2004). The
attachment working model is an internal mental representation thought to entail
episodic and semantic memory systems that specifically map each attachment
relationship. Attachment working models are believed to be dynamic both in the
sense of their day-to-day operations and in the sense of being altered as needed by
important changes in the actual relationship to the attachment figure (Collins &
Feeney, 2004; Mikulincer & Shaver, 2003). The working model is thought to be
the mechanism by which the impact of attachment on psychological functioning
operates (Bowlby, 1980; Bretherton, 1999; Collins, 1996; Collins & Feeney,
2004; Gillath, Makulincer, Fitzsimons, Shaver, Schachner, & Bargh, 2006;
Grossman, 1999; Meins, 1999; Mikulincer & Shaver, 2003; Roisman, Collins,
Sroufe, & Egeland, 2005; Shaver & Mikulincer, 2002; Simpson, Winterheld,
Rholes, & Oriña, 2007; Waters & Waters, 2006; Zimmermann, 1999).
The working model makes it possible to experience day-to-day physical
separation from an attachment figure without distress. However, people resist
ATTACHMENT, LOSS, AND AVOIDANCE / 359
prolonged separation and react strongly to perceived uncertainty about a loved
one’s safety. The permanent loss of an attachment relationship is highly impactful.
Bowlby posited that when the death of a loved one occurs, the unwanted
and emotionally painful reality of its finality is only gradually accepted and
integrated into the attachment working model. He contended that the response
to bereavement evolves in quality during the process of integration and that
avoidance regularly plays a role in this process (Bowlby, 1980).
In the early aftermath of a death most bereaved people naturally employ
strategies to avoid the severe pain entailed in fully acknowledging its decisive
-
ness and consequences, nourishing instead a hope, however vague and slender,
that reunion is possible. The hope grows primarily from the fact that the attach
-
ment working model does not initially register the meaning of the death. In
this situation a separation response is instinctively activated and generates an
irrational feeling, often unsettling, that the person could reappear. This is asso
-
ciated with yearning and searching for the deceased and preoccupation with
thoughts and memories of this person. Inevitably, though, a belief in reunion is
on a collision course with reality. Bowlby suggests that this means a newly
bereaved person faces a painful dilemma:
So long as he does not believe that his loss is irretrievable, a mourner is
given hope and feels impelled to action; yet that leads to all the anxiety
and pain of frustrated effort. The alternative, that he believes his loss is
permanent, may be more realistic; yet at first it is altogether too painful and
perhaps terrifying to dwell on for long. (Bowlby, 1980, p. 139)
The private experience of the recent death of an attachment figure is extremely
painful and it is natural for a person to be unwilling to remain in contact with
this experience. Bowlby calls attention to the instinctive use of cognitive and
behavioral avoidance strategies that are observed in this situation. He then alerts
us to the limitations of these strategies and the need for a permanent adaptive
resolution of the bereavement dilemma:
It may be merciful, therefore, that a human being is so constructed, that
mental processes and ways of behaving that give respite are a part of
his nature. Yet such respite can only be limited and the task of resolving
the dilemma remains. On how he achieves this turns the outcome of his
mourning—either progress toward a recognition of his changed circum
-
stances, a revision of his representational models, and a redefinition of his
goals in life, or a state of suspended growth in life in which he is held prisoner
by a dilemma he cannot solve. (Bowlby, 1980, p. 139)
He provides specific examples of avoidance behavior:
[the mourner] may then oscillate between treasuring . . . reminders and
throwing them out, between welcoming the opportunity to speak of the
dead and dreading such occasions, between seeking out places where they
have been together and avoiding them. (Bowlby, 1980, p. 92)
360 / SHEAR
He cites Parkes who listed types of processes of “defensive exclusion,” that are
strategies for cognitive avoidance:
(a) processes that result in a bereaved person feeling numb and unable to
think about what has happened
(b) processes that direct attention and activity away from painful thoughts
and reminders and towards more neutral or pleasant ones
(c) processes that maintain the belief that the loss is not permanent and
reunion is still possible
(d) processes that result in recognition that loss has in fact occurred combined
with the feeling that links with the dead nevertheless persist, manifest often
in a continuing sense of the continuing presence of the lost person. (Bowlby,
1980, p. 140; Parkes, 1970)
Bowlby posits that the bereavement dilemma is best resolved through gradually
integrating the emotionally painful information about the death with positive
thoughts and memories of the deceased person. Although not mentioned by
Haves, the existence of contradictory elements of the private experience is another
example of a situation in which avoidance of one or the other of these elements
might be adaptive until the conflict is resolved. In the case of acute grief there
are contradictory experiences of belief in the possibility of union and appraisal
of the reality of the death. To manage this conflict, people experiencing acute grief
make use of cognitive avoidance strategies to alternately dismiss either the belief
that reunion is possible (bouts) or painful awareness of the death (moratoria.)
Bowlby explains the process as follows:
When an affectional bond is broken there is usually a preliminary registering
of the relevant information combined with the inability to evaluate it to
more than the most cursory extent. . . . Thereafter further evaluation proceeds
in bouts plentifully interspersed with moratoria. During a bout certain of
the implications already received are considered or reconsidered though
others are still avoided; whilst additional information may be sought. . . .
During each moratoria by contrast, some or all of the information regarding
change already received is likely to be excluded and the old models partially
or wholly reinstated. Hence the oscillation of feeling already documented.
(Bowlby, 1980, p. 239)
According to this view the response to bereavement is an evolving process in
which avoidance is a dynamic and adaptive element. To say that avoidance is
maladaptive following loss is to oversimplify the process of adjustment. To decide
if experiential avoidance is adaptive during bereavement, we must consider
when and how it occurs. Ultimately, a bereaved person must relinquish experi
-
ential avoidance focused on evading painful thoughts and emotions associated
with acknowledging the reality of the death. Bowlby suggests the best way to
resolve the dilemma is by merging love and loss. The bereaved person links
recognition of the loss with ongoing feelings of love in the form of a continued
sense of connectedness. Bowlby (1980) and Parkes (1970) label this sense of
ATTACHMENT, LOSS, AND AVOIDANCE / 361
connectedness in the face of a death as defensive exclusion, a form of experiential
avoidance, and this is considered adaptive.
In summary, an attachment theory view of successful outcome of bereavement
centers on the need to reconcile the dilemma of conflicting inner experiences of
love and loss, and places experiential avoidance at the center of the adaptive
process by which these conflicting realities are ultimately combined. There is both
a sense of ongoing connection to the deceased and awareness of the painful reality
that they are gone. Bowlby suggests that the two sides of the bereavement dilemma
are gradually integrated during a process of oscillation between processing and
excluding private experiences of each. Most people achieve this. People do not
forget loved ones who die, nor do they stop caring about them. Instead they feel
a permanent sense of connection and responsibility to the person who died.
OTHER CONSIDERATIONS RELATED TO THE
PROCESS OF ACUTE GRIEF
Two other biobehavioral motivational systems are linked to the attachment
system and are affected by the loss. Attachment relationships are dyadic and
require a caregiver. In an adult attachment relationship giving and receiving
care are shared functions, so that loss of an attachment figure is also loss of
a caregiving recipient. Caregiving is also thought to have instinctive roots
focused on sensitive and responsive attention to nurturing and protecting others
(Feeney & Collins, 2003; Gillath et al., 2005; Kim & Carver, 2007; Mikulincer &
Goodman, 2006). Caregiving loss instinctively triggers a sense of failure of the
protector role. Anger is triggered if it seems that the death could have been
prevented by others. From the standpoint of caregiving, fully acknowledging
the death evokes a painful sense of failure, with self-blame or anger. Adaptive use
of experiential avoidance pertains to these difficult feelings as well as those
associated with attachment. These feelings may also be the reason for over-use
of avoidance strategies.
Exploration is another instinctive system that is related to attachment. The
exploratory system provides instinctive motivation for learning, mastery, and
performance (Elliott & Reis, 2003). Both acute stress and threatening separation
experiences inhibit the exploratory system. This system could play an important
role in effective restoration of a satisfying life, yet the initial effect of bereave
-
ment is to shut it down. Inhibition of exploration impedes restoration through
reducing enthusiasm for, and confidence in doing new activities and taking on
new roles. Reconciling the bereavement dilemma reactivates exploration and
fosters restoration activities.
In resolving the instinctive attachment dilemma as well as responses related
to the caregiving and exploration systems, a bereaved person must find ways to
adjust to changes relevant to her or his unique situation. How does this process
occur? The DPM (Stroebe & Schut, 1999) provides a framework for thinking
362 / SHEAR
about how coping occurs during the process of adaptation and considers this a
different problem from that of processing bereavement-related information. The
model posits that there are countless stressors contained in any bereavement
episode and that these can be generally grouped as loss-related or restoration-
related. Restoration-focused coping includes attending to life changes, doing new
things, taking on new roles and identities, as well as distraction from, denying/or
avoiding grief. By contrast, the loss focus includes grief work, intrusion of
grief, breaking bonds/ties/ relocation, as well as denial/avoidance of restoration
related changes.
The DPM is consistent with Bowlby’s premise that acknowledgment of the
finality of the loss and its consequences leads the mourner to appropriately revise
the working model (loss) and redefine life plans and goals (restoration). However,
the DPM places a focus on stresses related to these objectives rather than the
processing of new information, and introduces the seminal insight that loss and
restoration-related processes proceed in tandem. Bowlby believed that bereaved
people must “resolve the loss” before they “move on.” The DPM suggests
otherwise. This model posits that people begin to cope with restoration-related
stress even as they work to cope with acceptance of the loss. This is an important
idea because progress in restoration-related activities can facilitate processing
of the loss needed to revise the working model. Coping with restoration-related
stressors makes the finality of the loss less frightening. Addressing issues per-
taining to ongoing life in the absence of the deceased loved one opens possibilities
for satisfaction and pleasure in this new situation. A daunting problem of daily
life not only stymies restoration-related coping but also complicates acute grief.
The DPM concept of a partnership between loss and restoration is therefore
very important. However its authors propose that mourners oscillate between
loss and restoration-focused coping. Bowlby’s description of oscillation toward
and away from emotional pain is closer to the bereaved person ’s lived experience
than is oscillation between loss and restoration coping. Avoidance of grief is
not necessarily focused on restoration, and restoration-related coping strategies
are not necessarily associated with respite from grief. Sometimes restoration-
related coping entails activities that directly foster coping with the loss. Loss and
restoration might better be illustrated visually as overlapping Venn diagrams
that progress in tandem than as separate activities that are undertaken in an
oscillating sequence. What oscillates is the private experience of thoughts and
emotions. Oscillation progresses through use of experiential avoidance.
A useful strategy for experiential avoidance of emotional pain includes
directing attention and activity away from painful thoughts and reminders and
toward more neutral or pleasant ones. There is now extensive data on the impor
-
tance of positive emotion to psychological as well as physical health (Fredrickson,
1998, 2001; Fredrickson & Joiner, 2002; Fredrickson & Levenson, 1998;
Fredrickson, Tugade, Waugh, & Larkin, 2003; Tugade & Fredrickson, 2004).
Successful mourning is likely to be facilitated when periods of emotional pain
ATTACHMENT, LOSS, AND AVOIDANCE / 363
oscillate with respite from that pain, and preferably with thoughts or activities
associated with positive emotions. There is some empirical support that such
oscillation in emotion might occur (Ong, Bergeman, & Bisconti, 2004). Positive
emotion may be elicited by fond memories or amusing anecdotes that are loss-
rather than restoration-related. On the other hand, restoration-related coping
processes may be associated with emotionally painful anxiety or self-doubt.
The notion of a partnership between loss and restoration coping during acute
grief makes sense. The proposed oscillating pattern of attention of the two
foci may not be as helpful.
AVOIDANCE THAT COMPLICATES
ACUTE GRIEF
There is good evidence that most bereaved people find a way to adjust to
the loss. However, a subgroup of about 10% experiences complicated grief in
which avoidance often plays a central role. From the discussion above, we might
conclude that experiential avoidance can become a hindrance to adjustment if
avoidance strategies are not used judiciously or effectively or if they are not
adaptively altered as healing progresses. People with complicated grief (CG) are
held prisoner by a dilemma they cannot solve, just as Bowlby (1980) suggests
above. Maladaptive use of experiential avoidance is often an important hindrance
to the resolution process. Avoidance of private experiences of grief, including
thoughts and emotions, through cognitive or behavioral strategies is a core symp-
tom of complicated grief.
Adaptive avoidance is dynamic in the sense that it is active and changing and
fluid in the sense that it is not stable and fixed but rather responsive to the need
for respite in the service of resolution. Maladaptive avoidance is more stable and
less sensitive and responsive. Resolution of the bereavement dilemma requires
cognitive engagement, including consideration of different ways of appraising
new information. Excessive and fixed use of defensive exclusion of this infor
-
mation blocks this process. Processing new unwanted information about the
death also requires some respite. A natural avenue for respite is through irrational
hope for reunion. Defensive exclusion of the belief in reunion can also be
employed excessively and this can lead the bereaved person to be barraged by
the reality to an extent that they cannot engage in processing activities. Coming
to terms with the death is a process that works best if it is grappled with, set
aside, and revisited. Each mourner must find an effective balance between bouts
and moratoria.
Behavioral strategies are less sensitive and less effective than cognitive strate
-
gies for experiential avoidance. This is because cognitive strategies are also
private experiences and can be implemented quickly and extensively. Moreover,
there is less ambivalence about their use. Behavioral avoidance frequently
entails situations that are both aversive and desirable. Perhaps for this reason,
364 / SHEAR
behavioral avoidance is more variable in frequency and extensiveness among
people with CG than is cognitive avoidance.
In the presence of unremitting pain related to the reality of the death, some
people resort to behavioral avoidance as a desperate measure to try to control
experiential stimuli. Examples of this kind of avoidance includes visiting the
final place of rest, going to the place where death occurred, reading the obituary
or reading letters of condolence, looking at photographs, thinking about the
person, talking about the person, dealing with personal belongings, spending time
in certain rooms of home, eating certain foods, listening to favorite music or
watching favorite movies, going to places they went with the person, or going out
with others. Many of these activities were a source of pleasure or satisfaction and
avoidance not only leads to ineffective processing of the death but also impedes
restoration of the capacity for joy and satisfaction in life. Moreover, we found that
grief-related avoidance correlates with intrusive thoughts (r = 0.37) suggesting
that extreme efforts to avoid reminders of the loss may oscillate with intrusive
thoughts and each may fuel the other. Both avoidance and intrusions can interfere
with information processing.
There is evidence that avoidance behavior is related to poor outcomes of bereave-
ment. For example, Bonanno, Papa, Lalande, Nanping, and Noll (2005) found that
avoidance 4 months post loss is related to avoidance at 18 months and to worse
physical health at 18 months. In a clinical population of individuals with CG, more
avoidance scores correlate with CG severity (r = 0.40) and with impairment from
grief (r = .33) (Shear, Monk, Houck, Melhen, Frank, Reynolds, et al., 2007). In
another study, experiential avoidance correlated with CG (r = 0.63) (Boelen &
Reijntjes, 2008). However, avoidance behavior can be difficult to recognize
because people evade thinking and talking about situations that they are avoiding.
SUGGESTIONS FOR CLINICAL WORK WITH AVOIDANCE
BEHAVIOR IN COMPLICATED GRIEF
Complicated grief appears to be a unique syndrome that occurs when a person
bereaved of an attachment figure is unsuccessful in resolving the bereavement
dilemma and is held prisoner by the continued pain and disruption of a prolonged
period of acute grief. Acute grief can become complicated by a range of different
pathways. However, all result in an internal response that is painful and a focus
of experiential avoidance. We designed a targeted complicated grief treatment
(CGT) that addresses experiential avoidance in several ways. Additionally,
the treatment accepts the DPM premise that grief progresses most successfully
when loss and restoration are addressed contemporaneously. Therefore, each
of the 16 sessions of CGT addresses both loss- and restoration-oriented issues.
Our objective is to help individuals caught in a seemingly endless cycle of grief
to re-imagine their ongoing relationship to their deceased loved one and to
re-envision their own lives in the present and future.
ATTACHMENT, LOSS, AND AVOIDANCE / 365
We address cognitive avoidance using a technique called imaginal revisiting
similar to prolonged exposure developed for treatment of posttraumatic stress
disorder. Imaginal revisiting is modified in order to foster the processing of the
bereaved person’s private grief experience. We followed Bowlby in designing the
treatment to encourage a pattern of oscillating confrontation with, and respite
from, the loss. The technique entails visualizing the experience of having learned
of the loved ones death with eyes closed, telling the story of that period of time
out loud and in the present tense, while visualizing the scenes, and responding to
the therapist’s periodic queries about emotional intensity (subjective units of
distress.) At the end of about 15 minutes, the person opens her eyes and debriefs
the visualization/story telling experience. During this period the therapist facili
-
tates identification and processing of emotionally painful complicating thoughts
or beliefs. At the end of the debriefing period, the therapist does another visuali
-
zation exercise in which the person imagines rewinding a tape with the story on it,
and putting it away in a safe place. The therapist then asks the bereaved person to
think about how she might reward herself for this hard work and makes a concrete
plan to do so. The remainder of the session is focused on activities expected to
generate positive feelings.
Goals work is the primary method for generating positive emotions and for
working on restoration. CGT includes a segment of each session that focuses on
considering what the bereaved person would want to do with her life if her grief
were at a manageable level. The person is encouraged to think of long-term goals
that she believes will provide significant gratification. The therapist talks with
the person about how she will know that she is working toward her goal, how
committed she is to her goal, and what she might expect could stand in her way.
The therapist asks if there is anyone else who can help the person achieve her
goal and together they make a specific plan for the upcoming week.
Situational revisiting exercises are used to address experiential avoidance using
behavioral changes. The approach is to identify activities that the patient is not
doing because they do not want to be reminded that their loved one is gone and
to rate these according to their desirability. Ideally the situational revisiting
exercise will entail activities that have been pleasurable or satisfying in the past,
have the potential to be so again, and that the person would like to be doing.
This procedure helps with processing information about the finality of the death
and it also helps restoration of ongoing life by reducing restrictions.
There are other elements of the treatment approach that help to engage the
person with complicated grief and provide a space in which she can feel safe. The
person is provided with a handout that describes a model of complicated grief
similar to the one presented in this article. Other work is done to help with
integrating loss and love in order to facilitate resolution of the bereavement
dilemma. We evaluated this treatment in a pilot study (Shear, Frank, Foa, Cherry,
Reynolds, Vander Bilt et al., 2001) and tested it in a prospective randomized
controlled trial (Shear, Frank, Houck, & Reynolds, 2005).
366 / SHEAR
CONCLUSION
Avoidance is an important strategy used by bereaved people and is focused
on private experiences rather than external danger. Experiential avoidance is
identified by the DPM as a component of the normal process of coping with
loss and restoration and is also described as a natural aspect of the loss of an
attachment figure. Experiential avoidance can function as an adaptive strategy in
the difficult process of resolving the bereavement dilemma. However, this strategy
must be used judiciously and in a fluid dynamic way in order to facilitate healing.
When over-used or when used in a rigid unchanging way throughout the acute
grief period, avoidance can become an encumbrance to mourning and lead to
the development of complicated grief. When this occurs, the bereaved person
often needs assistance in decreasing cognitive and behavioral avoidance and
facilitating a dual process model of coping.
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Direct reprint requests to:
Katherine Shear, M.D.
Marion E. Kenworthy Professor of Psychiatry
Columbia University School of Social Work
1255 Amsterdam Avenue
New York, NY 10027
e-mail: ks2394@columbia.edu
ATTACHMENT, LOSS, AND AVOIDANCE / 369
    • "Recent work by Shear (2010) has suggested that oscillation may be better understood as an " overlapping " of loss-and restoration-oriented activities. This overlapping may account for the value that effective grievers find in distraction and new activities (Bennett, Gibbons, & MacKenzie-Smith, 2010), whereas among complicated grievers, long-term use of distraction may translate into avoidance that prevents re-experiencing formerly pleasurable activities and relationships in new ways (Shear, 2010). As Supiano (2013) notes, there is a complementary relationship between the attachment and dual-process theories, which suggests that individuals with insecure attachment histories have poor grief experiences, are less able to navigate the process of grief, and thus, are more predisposed to complicated grief. "
    [Show description] [Hide description] DESCRIPTION: Individuals coping with the sudden or traumatic loss of a loved one typically grieve in one of three general ways: common grief, minimal grief, or complicated (traumatic) grief. While the former two patterns are generally considered adaptive and non-pathological, the significant minority who experience complicated grief struggle to navigate bereavement and return to pre-loss levels of functioning. Many of these individuals instead remain engaged “in a persistent search for some reason, explanation, or meaning in their loss” (Davis, Wortman, Lehman, & Silver, 2000, p. 498). This article discusses this persistent search for meaning, as well as the psychopathological outcomes following traumatic bereavement experiences. Subsequent to that discussion is an exploration of three psychotherapeutic approaches — complicated grief therapy, restorative retelling therapy, and existential therapy — all of which seek to ameliorate persistent or traumatic loss experiences by way of meaning-reconstruction.
    Full-text · Working Paper · Mar 2016 · Clinical Psychological Science
    • " and avoid homerelated triggers, which may not be adaptive either; home links should also be a part of being away (without getting trapped in rumination). So although avoidance can be an important, normal coping strategy with regard to separation and loss, when overused or used in a rigid manner, it can lead to the development of complications (cf. Shear, 2010), rigid avoidance of home-related thoughts and may lead to or maintain HS. However, it may still be difficult to predict the nature of the HS outcome. SA may be evident, but it could also lead to depression (or loneliness) or other anxiety disorders, including social phobia (avoidance of others). Again, such concerns call for further em"
    [Show abstract] [Hide abstract] ABSTRACT: Homesickness (HS) is associated with mental and physical health problems and is thus of clinical concern. In some highly influential theoretical models and widely used questionnaires, HS spans home-related losses and new-locality adjustments. A differentiated approach is needed: Evidence suggests that distinct manifestations are associated with these two domains. Collapsing home- and new-place-related phenomena has impeded understanding of separation-from-home-specific aspects. Thus, we propose a dual process model of coping with HS (DPM-HS). According to this framework, HS is fundamentally a separation phenomenon, a “mini-grief,” involving different (though possibly mutually exacerbating) stressors from new place ones. It follows that HS should be narrowly defined; separate examination of home–new place stressors, correlates, and consequences is mandatory; regulatory cognitive-emotional processes and incremental effects due to new place stressors need charting. Following DPM-HS principles, HS prevention and treatment should not only focus on distraction and adjustment, but also pay attention to missing home aspects and emotion-regulation strategies.
    Full-text · Article · Jul 2015
    • " and avoid homerelated triggers, which may not be adaptive either; home links should also be a part of being away (without getting trapped in rumination). So although avoidance can be an important, normal coping strategy with regard to separation and loss, when overused or used in a rigid manner, it can lead to the development of complications (cf. Shear, 2010), rigid avoidance of home-related thoughts and may lead to or maintain HS. However, it may still be difficult to predict the nature of the HS outcome. SA may be evident, but it could also lead to depression (or loneliness) or other anxiety disorders, including social phobia (avoidance of others). Again, such concerns call for further em"
    Full-text · Article · Jan 2015
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