Grief has been examined extensively in terms of a variety of factors which impact an individual’s psychological, biological, and socio-cultural identity. Theoretical models of bereavement offer different perspectives on the development, maintenance, and treatment of grief. Understanding these models in conjunction with an appreciation for the uniqueness of various patient-family dynamics may contribute to a more refined approach to assisting individuals struggling with grief or in providing an appropriate outside referral. Putting these theoretical models to use in clinical care requires providers to remain open-minded about the various aspects of an individual’s life which may help or hinder his ability to cope with the death of a loved one (12
One of the most widely acknowledged paradigms of loss is Bowlby’s attachment theory. According to Bowlby (1980) (13
), the loss of a loved one may be the most devastating experience a person can endure in his/her lifetime. His theory is based on the concept of attachment, the idea that early on, children form intense bonds with their caregivers in order to receive the care and nourishment they require to survive. A stable and consistent bond is referred to as secure, while a less reliable relationship is termed insecure. Bowlby suggests that insecure attachment styles may be related to difficulties later in life including emotional distress, personality disorders, anxiety, depression, and emotional detachment (13
) and others have suggested that insecure attachments may contribute to greater difficulty in dealing with loss later in life, including a greater risk for severe grief reactions (9
). Individuals with secure attachments, however, may internalize memories of the deceased in a way that allows them gradually to accept the loss of a physical connection with that person.
Psychodynamic frameworks for understanding grief also focus on the importance of early mother-child relationships as internalized schemas for individuals’ abilities to handle separation. In object relations theory, the initial separation between a child and his/her mother is seen as the foundation of reactions to emotional separations later in life. As with the attachment theory, a constant and reliable early relationship will impact an individual’s ability to separate from a lost loved one in an autonomous, healthy manner. However, those individuals with more unpredictable early relationships may experience more distress in separating from the deceased (15
According to interpersonal theories of grief, the quality of relationships of those experiencing loss are significant. This theory is based on the concept that the way in which individuals interact with one another becomes a part of how they define themselves, regulate their emotions, and develop a sense of appropriate social roles. These interactions may impact their ability to recover and move on after losing a loved one (16
Other researchers suggest that cognitive processes are the key to understanding how individuals cope with loss (3
). Bereaved individuals may experience intrusive thoughts, frequent distractions, or catastrophic beliefs about the world (8
). In particular, cognitive behavioral theories are based on the idea that a loss must be incorporated consciously into the bereaved individual’s understanding of the world and his/her place in it (8
). Integrating a loss is often very challenging and may result in maladaptive thoughts, feelings and behaviors which prolong the period of grief. Specifically, individuals who have this difficulty accepting the loss as a reality may also have particularly negative beliefs about the world, misinterpret their own reactions to the loss, and/or display anxious and avoidant strategies (8
). According to cognitive behavioral theories, although individual personalities and mental health may play a role in a bereaved person’s ability to cope with grief, maladaptive cognitions and behaviors may contribute to the development and maintenance of more serious grief reactions (8
Some models of grief focus on the sociological and cultural implications of an individual’s background on his/her ability to handle loss. Rosenblatt (2001) (12
) suggests that although the experience of grief may be common to all humans, there is no universal way of encapsulating the thoughts, feelings, and rituals of coping with grief. He suggests that clinicians and researchers who encounter or study grief must become familiar with the language and practices of people in a variety of societies in order to best understand and assist them.
Stroebe and Schut’s dual process model (1999) (17
) is one of the most comprehensive theories of grief and suggests that bereavement consists of two kinds of coping: loss-oriented coping and restoration-oriented coping. Loss-oriented coping involves ruminating about the loss and yearning for life with the deceased, which may bring on both positive and negative emotions. Restoration-oriented coping centers on adjusting to life without the deceased person. As with loss-oriented coping, restoration-oriented coping may result in a variety of emotions. For example, a person may experience anxiety about creating a new lifestyle as well as pride or relief at succeeding at various tasks or accomplishments. The vacillation between rumination about the loss and conscious attempts to redefine life contribute to recovery from grief (17
Recent functional neuroimaging studies have begun exploring the neural basis of grief, identifying brain regions activated during the elicitation of grief with the ultimate goal of improving psychopharmacotherapy for PGD (18
). Grieving individuals exhibit increased activation of several brain regions involved in the processing and regulation of emotional pain, including the anterior cingulate cortex, insula, and amygdala. Freed et al. (19
) also identified differential patterns of activation between two symptoms commonly seen in PGD – intrusive and avoidant thoughts. Intrusive thoughts were associated with activations of the ventral amygdala and rostral anterior cingulate, while avoidant thoughts were associated with deactivation of the dorsal amygdala and dorsolateral prefrontal cortex. Extending neuroimaging research toward PGD, O’Connor et al. (20
) found that while subjects with normal and prolonged grief exhibited similar activation of emotional pain-related regions, only those with PGD demonstrated activation of the nucleus accumbens. The increased activity in the nucleus accumbens correlates with higher levels of self-reported yearning for the deceased. Overall, these results suggest grief is mediated by pathways involved in emotional pain, but PGD may involve abnormal activation of neural reward pathways that ultimately interferes with adaptation to the loss. While future studies should further explore these findings, the potential association between PGD and abnormalities in reward neuro-circuitry holds significant implications for treatment.