The Complexities of Continuing Bonds

What Are Continuing Bonds Anyway?

Chances are if you have recently experienced a death of a loved one, you have heard, read, and/or experience "continuing bonds" with your deceased parent, sibling, spouse, fried, and child. Continuing bonds for the deceased are defined as deep emotional attachments maintained and persisted through memories, maintenance of possessions, the desire to carry on a legacy or complete the tasks of their deceased loved one, and so forth (Moss & Moss, 1996). In other words, attachment theory explains continuing bonds as continued attachment with your loved one, despite the physical death, through an emotional, spiritual, and/or cognitive attachment with your deceased love one.

Two Theoretical Approaches to Continuing Bonds

Traditional psychoanalytical bereavement theories of the past (think Freud and Worden) emphasized emotional disengagement from the deceased as the final and necessary step in successful bereavement adaptation (Field, Gal-Oz, & Bonanno, 2003; Humphrey, 2009). As the final stage of bereavement adaptation, these perspectives stress the need for the bereaved to eventually to let go of the former bond or relationship to establish new and different attachments with living persons. This past view, which lives on in euphemisms from relatives and friends who have not yet experienced death of a close loved one, continues to provide added and unnecessary guilt and shame for those bereaved facing significant losses to children, spouses/partners, siblings, and parents. Many bereaved may begin to doubt their own coping, as they experience inner conflict among the desire and actual attachment they still have for their deceased love one and the external messages internalized about this idealized "letting go."

In contrast, modern bereavement theorists (Klass, Silverman, & Nickman, 1996; Field et al., 2003; Field & Filanosky, 2010) have asserted that continued emotional attachment to the deceased is a normative and even positive part of bereavement adaptation. Klass and colleagues in Continuing Bonds: New Understandings of Grief (Death Education, Aging and Health Care) (1996), book suggested that a new paradigm of health grief accepted that the bereaved continued in a new relationship with the deceased. In other words, over time the bereaved adjusts and redefines his/her relationship with the deceased, which allows the attachment to continue throughout his/her life, but in a new way. This theory suggests that continuing bonds are both normal and healthy, and an important part of grief adaptation.

The Dual Model of Continuing Bonds

More recently, Field and colleagues (2003; 2010), developed a theoretical model and researched assessment on continuing bonds which theorizes and emphasizes both the adaptive and maladaptive potential of continuing bond expressions. Field and colleagues (2003; 2010), influenced by Bowlby’s attachment concepts of proximity maintenance, secure base, and safe haven, highlight both the internalized or adaptive and externalized or maladaptive potential of continuing bond expressions. Both the psychoanalytical and Klass theories, Field and colleagues suggest, fall short as linear models of continuing bonds. This dual model allows more for the notion of both "healthy grieving" (as adaptive grieving) or "unhealthy grieving" or "complicated bereavement" or "prolonged grief disorder" (as maladaptive grieving patterns). Adaptive or internalized continuing bond expressions are said to offer the bereaved psychological proximity maintenance (the tendency to be near the deceased) and a safe haven (the tendency to seek the deceased spouse for reassurance and safety during stress) (Field et al., 2003). On the other hand, maladaptive or externalized continuing bond expressions (involving illusions and hallucinations with the deceased) are said to be related to elevated psychological distress symptoms and complicated or prolonged grief (Field et al., 2003; Field & Filanosky, 2010).

What the Research Implies About Continuing Bonds

Research on continuing bonds has suggested that maintaining and destructive over-dependence (nonreciprocal and indiscriminate dependence) to the deceased versus relinquishing and avoiding attachment, correlates to prolonged grief disorder and to psychological dysfunction (Field et al., 2003; Field & Friedrichs, 2004; Field & Filanosky, 2010; Denckla, Mancini, Bornstein, & Bonanno, 2011). What follows are two research articles summarized that explore the mental health implications of continuing bonds in spousal bereavement.

Continuing Bonds at Five Years Post-Spousal Bereavement

Field and colleagues (2003) conducted a quantitative study to examine the role and relationships of continuing bonds on adjustment in bereaved spouses at five years post-loss, observed affective helplessness and self-blame expression type at six-months post-loss, attachment quality, and death expectancy. Thirty nine (26 women, 13 men; M = 48.7 years, SD = 6.9; 92% Caucasian; M years married = 17.9 years, SD = 11.7) of the original 89 paid volunteer participant sample from Field, Nichols, Holen, and Horowitz (1999) study were located and recruited to complete survey measures at 60 months post-spousal or partner loss (Field et al., 2003). At 6, 14, and 25, and 60 months, participants completed assessments of grief symptoms using the Texas Revised Inventory of Grief (TRIG; Fashingbauer, 1981), depressive symptoms using the Beck Depression Inventory (BDI; Beck & Steer, 1987), overall psychological distress symptoms using the Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1983), and psychological well-being using the Positive States of Mind (PSM; Horowitz, Adler, & Kegeles, 1988) (Field et al., 2003). At six months, participants completed relationship attachment measures using the Dyadic Adjustment Scale (DAS; Spanier, 1976), the Reciprocal Attachment Questionnaire (RAQ; West & Sheldon-Keller, 1994), and empty-chair monologue task (Field & Horowitz, 1998). To assess the adaptive role of continued attachment with the deceased at 60 months, Field et al. (2003) developed the 11-item 5-point Continuing Bonds Scale (CBS), with a strong internal consistency reliability.

Field and colleagues (2003) determined that five of the 11 continuing bond items remained moderately true for participants at five years post-loss. Secondly, the researchers determined that the CBS is correlated with greater grief symptoms at five years post-loss. Thirdly, higher helplessness observed at six months post-loss is associated with more continuing bond use at five years, whereas higher blame of the deceased is associated with less continuing bond use at five years. Fourthly, the study determined that DAS was significantly positively correlated with CBS, while RAQ Compulsive Care-Seeking (anxious attachment) was not related to CBS. Lastly, the authors determined that there was no significant relationship amongst continuing bonds and loss expectancy.

Continuing Bonds and Adjustment to Bereavement

Field and Filanosky (2010) conducted a quantitative survey study to examine the impact of relationship closeness, time since death, type of death type, and feelings of preventing the death on continuing bonds (externalized and internalized) on bereavement adjustment (complicated grief versus personal growth) in bereaved adults. Five hundred two bereaved adults (79 women, 423 men; M = 34.45 years, SD = 12.3) who were related to the deceased through parent, spouse/partner, sibling, or friend relationship were recruited via requests online and via email, and direct personal solicitations. The participants were invited to complete on-line survey measures if met eligibility requirements which included being at least 18 years, fluent in English, and having a deceased child, spouse or partner, parent, or close friend relationship (Field & Filanosky, 2010). Participants completed demographic items, cause of death, and assessments of responsibility for the death (a single-item measure, on a No/Yes dichotomous scale), Inclusion of Other in Self Scale (IOS; Aron, Aron, & Smollan, 1992) (with good test-retest reliability and convergent and discriminant validity) to assess the perceived quality of the past relationship with the deceased, Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991) of the four attachment styles (secure, fearful, preoccupied, and dismissing), the modified 16-item CBS (Field, 2005) which includes the 6-item externalized CB subscale and 10-item internalized CB subscale to measure internalized and externalized CB use, complicated grief symptoms using the 9-item Inventory of Complicated Grief Screen (ICGS; Prigerson & Jacobs, 2001) with a strong internal consistency in present study sample, perceived physical health via three self-report National Center for Health Services Research items (Stewart, Ware, Brook, & Davies-Avery, 1978), and personal growth using the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996).

Using partial correlation and multiple analyses of covariance (ANCOVAs), Field and Filanosky (2010) found a positive relationship among externalized continuing bond usage and violent death and responsibility for the death, while internalized continuing bond usage was negatively associated with negative psychological symptoms and uniquely positively correlated to post-traumatic growth. The study also found that both anxious and avoidant attachment styles were related to complicated grief symptoms and to either externalized or internalized continuing bond usage. Lastly, the study found that internalized continuing bond usage was not associated with violent death and feelings of responsibility for the death.

Conclusions

What are we to ultimately make of continuing bonds? The research demonstrates that continuing bonds are much more complex than than the linear Freudian/Worden and Klass and colleagues suggest. In fact, it appears that assessing the health and nature of continuing bonds is more complex than a adaptive or maladaptive or either/or theory, in that the nature of continuing bonds may be impacted by the attachment style of the bereaved (anxious, avoidant, or secure), the type of death of the bereaved, and many unexplored factors that may or may not be associated with post-traumatic growth and healthy attachment. In conclusion, it is safe to suggest that continuing bonds may or may not be healthy, and it really depends on many factors.

It is also important to relay, that continuing bonds do not just exist as a construct in grief. Amato's (2010) literature review on divorce, for example, proposed that continuing bonds exist in the case of divorced adults. It seems like common sense that one has a continuing bond with one's ex-spouse and ex-in-laws, despite remarriage, especially in divorced marriages which involve shared children.

Wilber's Integral Theory allows for us to incorporate and view continuing bonds as a both/and construct, in that continuing bonds have the potential to be both health and unhealthy (akin to a polarity construct). Modern day bereavement theories, as established in research, also suggests that many people do grow in grief and explore deeper meanings in grief. We may interpret this as suggesting that continuing bonds do not necessarily interfere with post-traumatic growth, exploration, meaning, and may actually allow for these developments. Grief and continuing bonds are complicated, and it is worthwhile to accept or consider this both/and reality.

To address how the complexity of continuing bonds may impact the bereaved's current physical relationships and new formed relationships, we will explore this in a future blog article. I will examine how the past and continued attachments may form a triadic relationship with the present.

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References

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Amato, P. R. (2010). Research on divorce: Continuing trends and new developments. Journal of Marriage and Family, 72, 650-666.

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226–244.

Beck, A. T., & Steer, R. A. (1987). Beck Depression Inventory manual. San Antonio, TX: The Psychological Corporation, Harcourt Brace Jovanovich.

Derogatis, L. R. (1983). SCL-90-R Administration, scoring, and procedures Manual II (2nd ed.). Towson, MD: Clinical Psychometric Research.

Field, N. P., Gal-Oz, E., & Bonanno, G. A. (2003). Continuing bonds and adjustment at 5 years after the death of a spouse. Journal of Counseling and Clinical Psychology, 71(1), 110-117.

Field, N. P., Nichols, C., Holen, A., & Horowitz, M. J. (1999). The relation of continuing attachment to adjustment in conjugal bereavement. Journal of Consulting and Clinical Psychology, 67, 212-218.

Horowitz, M. J., Adler, N., & Kegeles, S. (1988). A scale for measuring the occurrence of positive states of mind: A preliminary report. Psychosomatic Medicine, 50, 477-483.

Humphrey, K.M. (2009). Counseling strategies for loss and grief. Alexandria, VA: American Counseling Association.

Klass, D., Silverman, P. R., & Nickman, S. (1996). Continuing bonds: New understandings of grief (pp. 163-176). Washington, DC: Taylor and Francis.

Prigerson, H. G., & Jacobs, S. C. (2001). Traumatic grief as a distinct disorder: A rationale, consensus criteria, and a preliminary empirical test. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 613–645). Washington, DC: American Psychological Association.

Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15-28.

West, M. L., & Sheldon-Keller, A. E. (1994). Patterns of relating: An adult attachment perspective. New York: Guilford Press.