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Continuing Bonds, Attachment Style, and Adjustment in the Conjugal Bereavement among Hong Kong Chinese

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Title: Continuing Bonds, Attachment Style, and Adjustment in the Conjugal Bereavement among Hong Kong Chinese
Language: English
Authors: Ho, Samuel M. Y., Chan, Ide S. F., Ma, Ernie P. W., Field, Nigel P.
Source: Death Studies. 2013 37(3):248-268.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 21
Publication Date: 2013
Document Type: Journal Articles
Reports - Research
Descriptors: Attachment Behavior, Grief, Death, Foreign Countries, Measures (Individuals), Statistical Data, Correlation, Regression (Statistics), Questionnaires, Factor Analysis, Adults
Geographic Terms: Hong Kong
DOI: 10.1080/07481187.2011.634086
ISSN: 0748-1187
Abstract: The present study examined the effects of attachment style and continuing bonds, defined as the extent to which a bereaved individual feels that the deceased remains a part of his/her life, on post bereavement adjustment among 71 conjugally bereaved individuals. It was shown that bereaved individuals with an anxious attachment style tended to show more externalized continuing bonds as well as more grief symptoms. An anxious attachment style played a direct and significant role in post bereavement adjustment over and above the contribution of externalized continuing bonds. Interventions to facilitate restoration tasks and to reduce externalized continuing bonds would be discussed. (Contains 5 tables.)
Abstractor: As Provided
Number of References: 59
Entry Date: 2014
Accession Number: EJ1010349
Database: ERIC
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  Value: <anid>AN0085019687;dea01mar.13;2019Mar30.06:29;v2.2.500</anid> <title id="AN0085019687-1">Continuing Bonds, Attachment Style, and Adjustment in the Conjugal Bereavement Among Hong Kong Chinese. </title> <p>The present study examined the effects of attachment style and continuing bonds, defined as the extent to which a bereaved individual feels that the deceased remains a part of his/her life, on postbereavement adjustment among 71 conjugally bereaved individuals. It was shown that bereaved individuals with an anxious attachment style tended to show more externalized continuing bonds as well as more grief symptoms. An anxious attachment style played a direct and significant role in postbereavement adjustment over and above the contribution of externalized continuing bonds. Interventions to facilitate restoration tasks and to reduce externalized continuing bonds would be discussed.</p> <p>The loss of a spouse is recognized to be one of the most stressful life events (Holmes & Rahe, [<reflink idref="bib29" id="ref1">29</reflink>]).Yet there is considerable variability in the duration and the severity of grief reactions among the bereaved (Bonanno & Kaltman, [<reflink idref="bib4" id="ref2">4</reflink>], [<reflink idref="bib5" id="ref3">5</reflink>]; Wortman & Silver, [<reflink idref="bib58" id="ref4">58</reflink>], [<reflink idref="bib59" id="ref5">59</reflink>]). Some people exhibit extreme signs of grief while others appear to be relatively unaffected by the loss. The present study investigated the effects of continuing bonds (CB) and attachment style on postbereavement adjustment. A review of literature on CB and attachment style is described below.</p> <hd id="AN0085019687-2">Continuing Bonds</hd> <p>CB is generally understood as the presence of an ongoing inner relationship with the deceased person by the bereaved individual (Field, Gal-Oz, & Bonanno, [<reflink idref="bib20" id="ref6">20</reflink>]; Shuchter & Zisook, [<reflink idref="bib49" id="ref7">49</reflink>]) and is a common experience amongst the bereaved across ages and cultures (Klass, Silverman, & Nickman, [<reflink idref="bib32" id="ref8">32</reflink>]; Shuchter & Zisook, [<reflink idref="bib49" id="ref9">49</reflink>]). Early theories posit that relinquishing the tie to the deceased can, in turn, free the emotional energy of the bereaved to reinvest in new relationships (Freud, 1917/[<reflink idref="bib23" id="ref10">23</reflink>]; Parkes, [<reflink idref="bib39" id="ref11">39</reflink>]; Rando, [<reflink idref="bib41" id="ref12">41</reflink>]; Sanders, [<reflink idref="bib46" id="ref13">46</reflink>]). The above proposition implies that CB is a negative response that may hinder successful grieving. On the other hand, no systematic empirical studies so far have found support for the theoretical notion that bereaved people need to relinquish their ties to the deceased before positive adjustment can begin. Similarly, evidence is lacking to indicate that the maintenance of CB would lead to good adaptation (see M. S. Stroebe, Schut, & Stroebe, [<reflink idref="bib54" id="ref14">54</reflink>], for a review). Thus, the extent to which maintaining a CB either helps or hinders the process of postbereavement adjustment is unclear. In the 1990s, a shift in view took place where CB is viewed as part of a successful mourning rather than a symptomatic response (Attig, [<reflink idref="bib2" id="ref15">2</reflink>]; Silverman & Klass, [<reflink idref="bib51" id="ref16">51</reflink>]; M. S. Stroebe, [<reflink idref="bib52" id="ref17">52</reflink>]; Worden, [<reflink idref="bib57" id="ref18">57</reflink>]). Accordingly, CB can provide a secure base and a safe haven to facilitate coping and mood regulation after bereavement. In other words, a CB can serve as a reminder of the rewarding relationship that can in turn enable the bereaved to experience a sense of fulfillment and emotional sustainability (Field, Nichols, Holen, & Horowitz, [<reflink idref="bib21" id="ref19">21</reflink>]; Field & Friedrichs, [<reflink idref="bib19" id="ref20">19</reflink>]; Klass & Walter, [<reflink idref="bib33" id="ref21">33</reflink>]). Hence, two opposing functions of CB were proposed. On the one hand, CB may serve an adaptive function by fostering continuity of identity, reinforcing coping efforts, and providing comfort and support in stress (Bonanno & Kaltman, [<reflink idref="bib4" id="ref22">4</reflink>]), but on the other hand it may also perpetuate ruminative thinking and impede forward moving on the other hand (Field et al., [<reflink idref="bib21" id="ref23">21</reflink>]; Field, Gal-Oz, & Bonanno, [<reflink idref="bib20" id="ref24">20</reflink>]).</p> <p>The effects of CB on grief reaction may depend on time after bereavement. A study by Field et al. ([<reflink idref="bib20" id="ref25">20</reflink>]) indicated that more frequent use of CB at 5 years after loss was associated with more severe grief symptoms. Field and Friedrichs ([<reflink idref="bib19" id="ref26">19</reflink>]) proposed that the duration of bereavement might moderate the effect of CB on postbereavement adjustment. They reported a positive relationship between CB and positive mood in the later period of bereavement (after 24 months), but not in the early bereavement period. These results suggest having an emotional tie with the deceased can be comforting once the acute period of grief has passed.</p> <p>Besides postbereavement duration, research is also beginning to consider whether different types of CB might influence bereavement outcomes. There has been no consensus among researchers on the subtypes of CB variants and how they affect postbereavement adjustment (Rando, [<reflink idref="bib42" id="ref27">42</reflink>]; Vickio, [<reflink idref="bib56" id="ref28">56</reflink>]; Field et al., [<reflink idref="bib20" id="ref29">20</reflink>]; M. S. Stroebe et al., [<reflink idref="bib54" id="ref30">54</reflink>]). Field and his colleagues have developed an 11-item Continuing Bonds Scale (CBS; Field et al., [<reflink idref="bib21" id="ref31">21</reflink>]; Field et al., [<reflink idref="bib20" id="ref32">20</reflink>]) which accounts for the different ways of maintaining a tie with the deceased: memories, maintenance of possessions, sense of presence, identification with the deceased, internalization of the deceased, the deceased as a standard, and reminiscence of the deceased.</p> <p>Recently, Field and Filanosky ([<reflink idref="bib18" id="ref33">18</reflink>]) expanded the 11-item scale into a 47-item questionnaire to cover as comprehensive as possible the variants of CB. Subsequent factor analysis resulted in a 16-item measure with two subscales: internalized CB and externalized CB. The authors defined <emph>internalized CB</emph> as expressions involving use of the deceased as an autonomy promoting secure base and externalized CB as expressions involving illusions and hallucinations with the deceased (Field & Filanosky, [<reflink idref="bib18" id="ref34">18</reflink>]). Field and Filanosky ([<reflink idref="bib18" id="ref35">18</reflink>]) reported that externalized CB was positively associated with both the violent death of the loved one and the bereaved's sense of responsibility for the death; whereas internalized CB was negatively associated with these factors but positively related to personal growth (Field & Filanosky, [<reflink idref="bib18" id="ref36">18</reflink>]).</p> <hd id="AN0085019687-3">Attachment Styles</hd> <p>Another construct that is both theoretically and empirically related to post-bereavement adjustment is attachment style (Archer, [<reflink idref="bib1" id="ref37">1</reflink>]; Shaver & Tancredy, [<reflink idref="bib47" id="ref38">47</reflink>]; M. S. Stroebe et al., [<reflink idref="bib54" id="ref39">54</reflink>]). From the perspective of attachment theory, the nature of the conjugal relationship is an expression of an individual's general attachment style to another significant person (Bowlby, [<reflink idref="bib7" id="ref40">7</reflink>]; Parkes & Weiss, [<reflink idref="bib40" id="ref41">40</reflink>]). It has been shown that adults with a secure attachment style find it relatively easy to get close to and depend on others, and they present with both low anxiety and low avoidance in close relationships (Collins & Read, [<reflink idref="bib13" id="ref42">13</reflink>]; Feeney, [<reflink idref="bib16" id="ref43">16</reflink>]). Accordingly, individuals with secure attachment style should show better postbereavement adjustment. There are also two forms of insecure attachment: anxious attachment and avoidant attachment (Bowlby, [<reflink idref="bib7" id="ref44">7</reflink>]; Brennan, Clark, & Shaver, [<reflink idref="bib9" id="ref45">9</reflink>]). Individuals with anxious attachment styles are more preoccupied with and uncertain about the responsiveness of their partners and report a history of rejection in their close relationships. Avoidant adults are uncomfortable depending on others and generally strive to be self-reliant and independent. Previous studies have consistently shown a positive relationship between anxious attachment and bereavement-related symptomatology, whereas the roles of avoidant attachment in postbereavement adjustments are still not clear (Field & Sundin, [<reflink idref="bib22" id="ref46">22</reflink>]; Fraley & Bonanno, [<reflink idref="bib25" id="ref47">25</reflink>]). An objective of the present study is to investigate the roles of attachment styles in postbereavement adjustment among the Chinese.</p> <hd id="AN0085019687-4">The Roles of Continuing Bonds and Attachment Styles in Postbereavement Among the Hong Kong Ch...</hd> <p>To date, systematic reviews of the bereavement experience of the Chinese people in Hong Kong is sparse, with mostly anecdotal observations and cases studies. We believe that CB should have an important role to play in the bereavement experience of the Chinese. For instance, Pang and Lam ([<reflink idref="bib37" id="ref48">37</reflink>]) proposed that many Chinese death rituals helped to maintain CB between the bereaved and the deceased, which could facilitate positive adjustment. Chan et al. ([<reflink idref="bib11" id="ref49">11</reflink>]) also observed that many bereaved Chinese adults reported a continuation of their relationship to the deceased through traditional rituals and festivals, and these practices were perceived as comforting and made CB a normal and acceptable experience in the Chinese culture. In summary, the findings in these studies suggest that having a CB is normative among Chinese bereaved. The studies also highlight the positive utility of a CB in helping with postbereavement in the Chinese culture. To date, there is also no systematic measure of CB among the Chinese. The English version of the CBS (E-CBS, Field & Filanosky, [<reflink idref="bib18" id="ref50">18</reflink>]) is a potentially useful measure for the Chinese population. Nevertheless, CB expressions are culturally bound behavior, and it is not sure if the E-CBS could be applied directly to our Hong Kong Chinese subjects without modification. Our first aim was to perform an exploratory factor analysis on a translated Chinese version of the E-CBS (the Chinese CBS; C-CBS), and we expected to find a comparable two-factor-structure to the one reported by Field and Filanosky ([<reflink idref="bib18" id="ref51">18</reflink>]). Confirmatory factor analysis was not performed because of the exploratory nature of this study and sample size limitation. The second aim was to demonstrate concurrent validity of the externalized factor of the C-CBS and, based on the findings of Field & Filanosky ([<reflink idref="bib18" id="ref52">18</reflink>]), we hypothesized that an externalized CB would be positively related to both an anxious attachment style and grief symptoms, and internalized CB would be associated with less grief symptoms. The third aim of the study was to determine the unique contribution of each variable (externalized CB and an anxious attachment style) to the prediction of grief symptoms.</p> <p>It should be noted that Hong Kong is a westernized city and our participants were drawn from settings where the Western understanding of grief reaction is known to many people in Hong Kong. This sample may not represent the characteristics of Chinese people in Mainland China. On the other hand, traditional Chinese beliefs and rituals on grief, death, and dying are commonly practiced by most Chinese people in Hong Kong and our sample should shed light on the cross-cultural aspects of the above issues.</p> <hd id="AN0085019687-5">Methods</hd> <p></p> <hd id="AN0085019687-6">Participants and Procedures</hd> <p>Seventy-one bereaved individuals who had lost a spouse in the past 12 to 36 months (<emph>M</emph> = 19 months; with a range from 12 months to 34 months) were recruited. The majority of the participants were recruited through two voluntary bereavement services centers in Hong Kong and the remaining came from a rehabilitation-oriented hospital as well as open recruitment in the community. All eligible participants were Chinese, between 30 and 65 years of age, spoke Cantonese as their mother tongue, and were able to read and understand Chinese. Participants responded to a yes–no question on whether they had formal religion or not. Forty-five (37.0%) mentioned they had a formal religion. They indicated no loss of a significant person other than their spouse in the past 3 years. The exclusion criteria were (a) evidence of Axis I psychopathology unrelated to bereavement, and (b) presence of a substance use disorder in the prior 3 years. Table 1 shows the demographic and the background information of the participants. The sample ranged in age from 35 to 64 years old with a mean age of 45.55 years (<emph>SD</emph> = 7.43); 87% were female and 13% were male (Table 1). More than half (53%) of the participants had lost their spouse through chronic illness, and approximately one quarter (27%) had lost their spouse unexpectedly through accident or acute illness. It should be noted that 20% of the participants lost their spouse to suicide.</p> <p>TABLE 1 Participant Profile</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Group</td><td><italic>n</italic></td><td>%</td></tr></thead><tbody><tr><td>Gender</td><td /><td /></tr><tr><td> Male</td><td>9</td><td>13</td></tr><tr><td> Female</td><td>62</td><td>87</td></tr><tr><td>Age group</td><td /><td /></tr><tr><td> 30–40</td><td>16</td><td>23</td></tr><tr><td> 40–49</td><td>30</td><td>42</td></tr><tr><td> 50 or above</td><td>25</td><td>35</td></tr><tr><td>Education level</td><td /><td /></tr><tr><td> Primary</td><td>12</td><td>17</td></tr><tr><td> Secondary</td><td>46</td><td>65</td></tr><tr><td> Tertiary and above</td><td>13</td><td>18</td></tr><tr><td>Employment</td><td /><td /></tr><tr><td> Working</td><td>45</td><td>63</td></tr><tr><td> Nonworking</td><td>26</td><td>37</td></tr><tr><td>Income</td><td /><td /></tr><tr><td> Below $10,000</td><td>28</td><td>40</td></tr><tr><td> $10,000–$30,000</td><td>33</td><td>47</td></tr><tr><td> Above $30,000</td><td>9</td><td>13</td></tr><tr><td>Religion</td><td /><td /></tr><tr><td> Without religion</td><td>26</td><td>37</td></tr><tr><td> With religion</td><td>45</td><td>63</td></tr><tr><td>Children</td><td /><td /></tr><tr><td> No</td><td>14</td><td>20</td></tr><tr><td> Yes</td><td>57</td><td>80</td></tr><tr><td>Mode of death</td><td /><td /></tr><tr><td> Expected – chronic illness</td><td>38</td><td>53</td></tr><tr><td> Unexpected – acute illness and accident</td><td>19</td><td>27</td></tr><tr><td> Suicide</td><td>14</td><td>20</td></tr><tr><td>Period after death</td><td /><td /></tr><tr><td> 2–24 months</td><td>50</td><td>70</td></tr><tr><td> 25–36 months</td><td>21</td><td>30</td></tr><tr><td>Year of marriage</td><td /><td /></tr><tr><td> Less than 10 years</td><td>21</td><td>30</td></tr><tr><td> Over 10 years</td><td>50</td><td>70</td></tr></tbody></table> </ephtml> </p> <p>Ethical approval was sought from and granted by the Faculty of Social Sciences Research Committee of the University of Hong Kong and the Institutional Review Board of the various recruitment centers. Once the eligibility of the participants was confirmed, a packet of questionnaires was mailed to the participants together with a description of the study and an informed consent form. A research assistant made appointments with the participants for an experimental session for a larger study to be conducted within 2 weeks after the questionnaires were sent out. Participants were asked to bring the completed questionnaires and the informed consent form to the experimental session. The following inventories were used in this report.</p> <hd id="AN0085019687-7">Measures</hd> <p></p> <hd id="AN0085019687-8">The Chinese Continuing Bonds Scale (C-CBS)</hd> <p>A 47-item English version of the CBS was developed by Field and Filanosky ([<reflink idref="bib18" id="ref53">18</reflink>]) to measure how frequent a bereaved individual feels the deceased remains a part of his or her life. The reliability of the internalized and externalized CB is.92 and.73, respectively (Field and Filanosky, [<reflink idref="bib18" id="ref54">18</reflink>]). The items are rated from 1 (<emph>none</emph>) to 4 (<emph>almost daily</emph>). The English version of the CBS was translated first into Chinese by one of the authors (Chan), who is bilingual in Chinese and English and who had clinical experience in working with bereavement. The Chinese version was then back-translated into English by another bilingual person. The back-translated version was then compared with the original version by the research team, and some words were refined for cultural relevance.</p> <hd id="AN0085019687-9">GRIEF REACTION ASSESSMENT FORM</hd> <p>The Grief Reaction Assessment Form (GRAF; Ho, Chow, Chan, & Tsui, [<reflink idref="bib28" id="ref55">28</reflink>]) is a Chinese psychological measure to indicate grief reaction. It is composed of 21 items on an 11-point scale from 0 (<emph>none</emph>) to 10 (<emph>all of the time</emph>). The GRAF has shown good internal reliability (Cronbach's alpha =.89). In this sample, the scale had a reliability of.87. The GRAF can discriminate between the grief reaction of people experiencing anticipated and those experiencing unanticipated death (Ho et al., [<reflink idref="bib28" id="ref56">28</reflink>]).</p> <hd id="AN0085019687-10">RELATIONSHIP STYLE QUESTIONNAIRE</hd> <p>The Relationship Style Questionnaire (RSQ) is a self-report inventory to measure attachment styles (Griffin & Bartholomew, [<reflink idref="bib26" id="ref57">26</reflink>]). It consists of 30 questions. Participants rate on a 5-point scale regarding how well each item fits their characteristic style in close relationships. Translation and back-translation of this questionnaire into Chinese has been completed by one of the authors (Samuel M. Y. Ho), and the Chinese version was used in the present study. Following procedures devised by Fraley and Bonanno ([<reflink idref="bib25" id="ref58">25</reflink>]) for determining attachment anxiety and avoidance in the RSQ, individual scores for each of these attachment style dimensions were derived for each participant. Because only anxious and avoidant attachment styles were relevant to the research questions of the present study, only these two attachment styles were addressed in the analyses. The anxious and avoidant attachment style scales demonstrate acceptable internal consistency at.84 and.70, respectively (Fraley & Bonanno, [<reflink idref="bib25" id="ref59">25</reflink>]). In this sample, the anxiety and avoidance attachment scales also show good alpha reliability at.81 and.72, respectively.</p> <hd id="AN0085019687-11">Results</hd> <p>Exploratory factor analysis was used to explore the factor structure of the C-CBS. As the factors were expected to be correlated, an oblimin rotation was used in the exploratory factor analysis. A two-factor solution was specified based on the resulting scree plot. A Kaiser-Meyer-Olkin (KMO) measure of sample adequacy was.84 indicating that the sample size (<emph>N</emph> = 71) was adequate for exploratory factor analysis (Kaiser, [<reflink idref="bib31" id="ref60">31</reflink>]). Nineteen items were retained based on the criteria that their loadings on a factor should exceed.50 without loading above.40 on another factor, and the difference between an item's loading on two factors should be larger than.30 (Ho, Chan, & Ho, [<reflink idref="bib27" id="ref61">27</reflink>]). This 19-item scale accounted for 55% of the total variance (Table 2).</p> <p>TABLE 2 Exploratory Factor Analysis Result of the Chinese Continuing Bonds Scale</p> <p> <ephtml> <table><thead valign="bottom"><tr><td /><td>Factor</td></tr><tr><td>Item</td><td>I</td><td>II</td></tr></thead><tbody><tr><td>1. I imagined the deceased's voice encouraging me to keep going.</td><td char="." charoff="50">.83</td><td /></tr><tr><td>2. I thought about how the deceased would have enjoyed something I saw or did.</td><td char="." charoff="50">.78</td><td /></tr><tr><td>3. I thought about the deceased as a role model whom I try to be like.</td><td char="." charoff="50">.77</td><td /></tr><tr><td>4. I was aware of attempting to carry out the deceased's wishes.</td><td char="." charoff="50">.74</td><td /></tr><tr><td>5. When making important decisions, I thought about what the deceased might have done and used this to help me make my decision.</td><td char="." charoff="50">.73</td><td /></tr><tr><td>6. I felt the deceased heard my prayers.</td><td char="." charoff="50">.72</td><td /></tr><tr><td>7. I did things that the deceased liked to do such as watch his favorite TV program in order to feel closer to him.</td><td char="." charoff="50">.71</td><td /></tr><tr><td>8. I experienced the deceased as continuing to live on through his impact on who I am today.</td><td char="." charoff="50">.71</td><td /></tr><tr><td>9. I attended special events or celebrations in memory of the deceased.</td><td char="." charoff="50">.67</td><td /></tr><tr><td>10. I imagined reuniting with the deceased in heaven.</td><td char="." charoff="50">.65</td><td /></tr><tr><td>11. I wrote to or about the deceased.</td><td char="." charoff="50">.62</td><td /></tr><tr><td>12. I was aware of how I try to live my life the way the deceased would have wanted me to live.</td><td char="." charoff="50">.60</td><td /></tr><tr><td>13. I imagined sharing with the deceased something special that happened to me</td><td char="." charoff="50">.59</td><td /></tr><tr><td>14. I thought about the positive influence of the deceased on who I am today.</td><td char="." charoff="50">.56</td><td /></tr><tr><td>15. Even if only momentarily, I have mistaken other sounds for the deceased's voice, footsteps, or movements.</td><td /><td char="." charoff="50">.84</td></tr><tr><td>16. I briefly acted as though the deceased were not dead – such as calling out loud his name or preparing the table for two.</td><td /><td char="." charoff="50">.74</td></tr><tr><td>17. Even if only momentarily, I have mistaken other people for the deceased.</td><td /><td char="." charoff="50">.73</td></tr><tr><td>18. I had the feeling that the deceased was haunting me.</td><td /><td char="." charoff="50">.70</td></tr><tr><td>19. I imagined that the deceased might suddenly appear as though still alive.</td><td /><td char="." charoff="50">.68</td></tr><tr><td>Percentage of variance explained</td><td char="." charoff="50">42%</td><td char="." charoff="50">13%</td></tr></tbody></table> </ephtml> </p> <p>Factor 1 contained 14 items, explaining 42% of the total variance. This factor was termed <emph>internalized</emph> because the items capture both the sense of a loving presence of the deceased as well as using the deceased as an autonomy-promoting secure base. Some examples are "I experienced the deceased as continuing to live on through his impact on who I am today" and "I thought about how the deceased would have enjoyed something I saw or did."</p> <p>Factor 2 consisted of 5 items, which accounted for 13% of the total variance. This factor was named <emph>externalized</emph> as it was characterized by the lingering on of the physical presence of the deceased. Some examples are "Even if only momentarily, I have mistaken other sounds for the deceased's voice, footsteps, or movements," and "I had the feeling that the deceased was haunting me."</p> <p>The Cronbach's alpha of the total 19-item scale was.92 and the split-half reliability coefficient was also.92. The reliability alpha of the internalized and the externalized CB subscales was.92 and.84, respectively. The results indicate good internal consistency and adequate reliability of the scale. There were no group differences in all demographic variables except religion. Participants with religion had less externalized CB, <emph>t</emph>(<reflink idref="bib69" id="ref62">69</reflink>) = 2.10, <emph>p</emph> = .040, and less avoidant attachment, <emph>t</emph>(<reflink idref="bib69" id="ref63">69</reflink>) = 2.13, <emph>p</emph> = .037, in comparison to those without religion. Moreover, there was no significant relationship between the psychological variables and the duration of bereavement; however, when comparing participants based on how their partners died (suicide, chronic illness, and unexpected death) participants whose partner committed suicide showed less internalized CB when compared with the other two groups, <emph>F</emph>(<reflink idref="bib1" id="ref64">1</reflink>,<reflink idref="bib2" id="ref65">2</reflink>) = 4.70, <emph>p</emph> = .012. Therefore, both religion and mode of death were controlled for in the subsequent analyses. Table 3 shows the mean scores and the standard deviations of the measures by mode of death and religion. The results showed that participants with religion, as compared to those without religion, tended to show less externalized CB as well as exhibit less avoidant attachment styles.</p> <p>TABLE 3 Means and Standard Deviations of the Measures by Mode of Death and Religion</p> <p> <ephtml> <table><thead valign="bottom"><tr><td /><td /><td /><td>Mode of death</td><td /><td>Religion</td></tr><tr><td /><td>Total</td><td>Chronic illness (<italic>n</italic> = 38)</td><td>Unexpected death(<italic>n</italic> = 19)</td><td>Suicide(<italic>n</italic> = 14)</td><td><italic>F</italic></td><td>Without religion (<italic>n</italic> = 26)</td><td>With religion (<italic>n</italic> = 45)</td><td /></tr><tr><td>Study variables</td><td><italic>M</italic></td><td><italic>SD</italic></td><td><italic>M</italic></td><td><italic>SD</italic></td><td><italic>M</italic></td><td><italic>SD</italic></td><td><italic>M</italic></td><td><italic>SD</italic></td><td /><td><italic>M</italic></td><td><italic>SD</italic></td><td><italic>M</italic></td><td><italic>SD</italic></td><td><italic>t</italic></td></tr></thead><tbody><tr><td>Grief symptoms</td><td char="." charoff="50">50.00</td><td char="." charoff="50">29.89</td><td char="." charoff="50">50.24</td><td char="." charoff="50">31.66</td><td char="." charoff="50">48.74</td><td char="." charoff="50">27.19</td><td char="." charoff="50">51.07</td><td char="." charoff="50">30.51</td><td char="." charoff="50">0.03</td><td char="." charoff="50">52.92</td><td char="." charoff="50">29.23</td><td char="." charoff="50">48.31</td><td char="." charoff="50">30.46</td><td char="." charoff="50">0.62</td></tr><tr><td>Anxious attachment</td><td char="." charoff="50">29.96</td><td char="." charoff="50">10.00</td><td char="." charoff="50">2.63</td><td char="." charoff="50">.72</td><td char="." charoff="50">2.73</td><td char="." charoff="50">.89</td><td char="." charoff="50">2.62</td><td char="." charoff="50">.69</td><td char="." charoff="50">0.13</td><td char="." charoff="50">2.73</td><td char="." charoff="50">.77</td><td char="." charoff="50">2.61</td><td char="." charoff="50">.75</td><td char="." charoff="50">0.64</td></tr><tr><td>Avoidant attachment</td><td char="." charoff="50">8.41</td><td char="." charoff="50">3.53</td><td char="." charoff="50">3.08</td><td char="." charoff="50">.56</td><td char="." charoff="50">3.19</td><td char="." charoff="50">.65</td><td char="." charoff="50">3.23</td><td char="." charoff="50">.43</td><td char="." charoff="50">0.43</td><td char="." charoff="50">3.32</td><td char="." charoff="50">.44</td><td char="." charoff="50">3.03</td><td char="." charoff="50">.59</td><td char="." charoff="50">2.13<xref ref-type="fn" rid="fn2" /></td></tr><tr><td>Internalized CB</td><td char="." charoff="50">3.14</td><td char="." charoff="50">.56</td><td char="." charoff="50">29.81</td><td char="." charoff="50">8.98</td><td char="." charoff="50">34.47</td><td char="." charoff="50">10.95</td><td char="." charoff="50">24.21</td><td char="." charoff="50">8.73</td><td char="." charoff="50">4.70<xref ref-type="fn" rid="fn2" /></td><td char="." charoff="50">28.46</td><td char="." charoff="50">8.56</td><td char="." charoff="50">30.84</td><td char="." charoff="50">10.76</td><td char="." charoff="50">−0.96</td></tr><tr><td>Externalized CB</td><td char="." charoff="50">2.66</td><td char="." charoff="50">.76</td><td char="." charoff="50">7.95</td><td char="." charoff="50">3.32</td><td char="." charoff="50">8.89</td><td char="." charoff="50">3.71</td><td char="." charoff="50">9.00</td><td char="." charoff="50">3.92</td><td char="." charoff="50">0.69</td><td char="." charoff="50">9.54</td><td char="." charoff="50">3.78</td><td char="." charoff="50">7.76</td><td char="." charoff="50">3.25</td><td char="." charoff="50">2.10<xref ref-type="fn" rid="fn2" /></td></tr><tr><td /></tr><tr><td /></tr></tbody></table> </ephtml> </p> <p>Partial correlations were conducted to examine the linear relationships among the two types of CB, attachment styles measures, and grief symptoms. Religion and mode of death were controlled as covariates. The correlation between externalized CB and internalized CB was moderate (<emph>r</emph> = .52, <emph>p</emph> < .01), indicating that they were related but separate constructs. As expected, externalized CB was positively correlated with both grief symptoms (<emph>r</emph> = .36, <emph>p</emph> < .010) and anxious attachment style (<emph>r</emph> = .29, <emph>p</emph> < .050). Interestingly, internalized CB was positively correlated with grief symptoms (<emph>r</emph> = .29, <emph>p</emph> < .050). No significant correlations between internalized CB and any of the two attachment styles were obtained. Grief symptoms were positively associated with anxious attachment (<emph>r</emph> = .51, <emph>p</emph> < .010), but no significant correlation was found between grief symptoms and avoidant attachment (Table 4).</p> <p>TABLE 4 Partial Correlations Among Continuing Bonds, Grief Symptoms, and Attachment Style</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Variable</td><td>1</td><td>2</td><td>3</td><td>4</td><td>5</td></tr></thead><tbody><tr><td>1. Internalized CB</td><td>1</td><td char="." charoff="50">.52<xref ref-type="fn" rid="fn4" /><xref ref-type="fn" rid="fn4" /><xref ref-type="fn" rid="fn4" /></td><td char="." charoff="50">.29<xref ref-type="fn" rid="fn4" /></td><td char="." charoff="50">.11</td><td char="." charoff="50">−.19</td></tr><tr><td>2. Externalized CB</td><td /><td char="." charoff="50">1</td><td char="." charoff="50">.36<xref ref-type="fn" rid="fn4" /><xref ref-type="fn" rid="fn4" /></td><td char="." charoff="50">.29<xref ref-type="fn" rid="fn4" /></td><td char="." charoff="50">.01</td></tr><tr><td>3. Grief symptoms</td><td /><td /><td char="." charoff="50">1</td><td char="." charoff="50">.51<xref ref-type="fn" rid="fn4" /><xref ref-type="fn" rid="fn4" /></td><td char="." charoff="50">−.09</td></tr><tr><td>4. Anxious attachment</td><td /><td /><td /><td char="." charoff="50">1</td><td char="." charoff="50">−.03</td></tr><tr><td>5. Avoidant attachment</td><td /><td /><td /><td /><td char="." charoff="50">1</td></tr><tr><td /></tr><tr><td /></tr></tbody></table> </ephtml> </p> <p>Becuase externalized CB, grief symptoms, and anxious attachment styles were positively correlated with each other, hierarchical regression analysis was conducted to examine the relative predictive power of externalized CB and anxious attachment style on grief symptoms post conjugal loss. Four variables were included as predictors: mode of death, religion, anxious attachment, and externalized CB. The results are shown in Table 5.</p> <p>TABLE 5 Summary of Hierarchical Regression Analysis for Variables Predicting Grief Symptoms in the Conjugally Bereaved</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Variable</td><td>B</td><td>SE B</td><td>β</td></tr></thead><tbody><tr><td>Step 1</td><td /><td /><td /></tr><tr><td>  Mode of death</td><td char="." charoff="50">−5.32</td><td char="." charoff="50">4.59</td><td char="." charoff="50">−.14</td></tr><tr><td>  With/without religion</td><td char="." charoff="50">−6.16</td><td char="." charoff="50">7.50</td><td char="." charoff="50">−.10</td></tr><tr><td>Step 2</td><td /><td /><td /></tr><tr><td>  Mode of death</td><td char="." charoff="50">−4.27</td><td char="." charoff="50">3.93</td><td char="." charoff="50">−.11</td></tr><tr><td>  With/without religion</td><td char="." charoff="50">−.40</td><td char="." charoff="50">6.58</td><td char="." charoff="50">−.01</td></tr><tr><td>  Anxious attachment</td><td char="." charoff="50">18.23</td><td char="." charoff="50">4.12</td><td char="." charoff="50">.46<xref ref-type="fn" rid="fn6" /><xref ref-type="fn" rid="fn6" /><xref ref-type="fn" rid="fn6" /></td></tr><tr><td>  Externalized continuing bonds</td><td char="." charoff="50">1.83</td><td char="." charoff="50">0.92</td><td char="." charoff="50">.22<xref ref-type="fn" rid="fn6" /></td></tr><tr><td /></tr><tr><td /></tr></tbody></table> </ephtml> </p> <p>Mode of death and religion were entered in Step 1 of the regression analysis. The first regression indicated that both of the above variables were not significant predictors of grief symptoms. Anxious attachment and externalized CB were entered in Step 2. This final regression model was significant (<emph>ΔR</emph><sups><emph>2</emph></sups> = .30, <emph>p</emph> < .001). Both anxious attachment (β = .46, <emph>t</emph> = 4.43, <emph>p</emph> < .001) and externalized CB (β = .22, <emph>t</emph> = 2.00, <emph>p</emph> = .05) individually predicted grief symptoms, each explaining 20% and 4% of the variance, respectively.</p> <hd id="AN0085019687-12">Discussion</hd> <p>One objective of the present study was to examine the factor structure and psychometric properties of the C-CBS, translated from the English version of the same scale developed by Field and Filanosky ([<reflink idref="bib18" id="ref66">18</reflink>]). The results of the present study show that the Chinese version of the CBS has good internal consistency, with Cronbach's alpha and split-half reliability coefficient exceeding the criteria of.9. The C-CBS is significantly associated with the grief reaction of bereaved individuals, as suggested by the existing literature (Field & Friedrich, [<reflink idref="bib19" id="ref67">19</reflink>]). The exploratory factor analysis of the C-CBS revealed a meaningful solution, comparable to the one reported by Field and Filanosky ([<reflink idref="bib18" id="ref68">18</reflink>]). The internalized subscale represents a positive continuing connection with the deceased, consisting of items that relate to identification with the deceased (taking on the deceased's value and carrying out the deceased's wishes), using the deceased as a standard (using the deceased's viewpoint in decision-making), internalization of the deceased (keeping and carrying on the positive influence of the deceased), reminiscence of the deceased (reminiscing with others experiences with the deceased), and having a sense of loving presence of the deceased (sharing interesting life experiences or daily tasks with the deceased). The externalized CB subscale contains items that are related to illusory types of contact with the deceased. These quasiperceptual experiences consist of misconstructions of the external presence of the deceased in the visual, auditory, and tactile modalities (Reisman, [<reflink idref="bib43" id="ref69">43</reflink>]; Boerner & Heckhausen, [<reflink idref="bib3" id="ref70">3</reflink>]; Field, [<reflink idref="bib17" id="ref71">17</reflink>]). The present study has established a valid adapted version of the CBS for future research among the Chinese.</p> <p>In line with previous studies (Field & Sundin, [<reflink idref="bib22" id="ref72">22</reflink>]; Fraley & Bonanno, [<reflink idref="bib25" id="ref73">25</reflink>]), the results of the present study show that CB, anxious attachment, and grief symptoms are all positively correlated with each other. More specifically, our results have demonstrated that a stronger reliance on either an internalized or externalized CB is associated with more severe grief symptoms after the loss of a loved one, but that only externalized CB are associated with having an anxious attachment style. The positive relationship between an internalized CB and grief symptoms might be an indicator of an extremely close relationship to the bereaved, thereby creating more difficulties in bereavement adjustment (Field & Filanosky, [<reflink idref="bib18" id="ref74">18</reflink>]).</p> <p>An externalized CB represents an illusion or belief that the deceased is somehow experienced as being present. As mentioned earlier, individuals with an anxious attachment style are more vigilant and insecure regarding the psychological accessibility and the availability of their loved ones. In the context of conjugal loss, it may be possible that episodes in which the loved one is experienced as absent could trigger individuals with an anxious attachment style to search for the deceased through an externalized CB. For example, if someone resembles the deceased in some physical characteristics, the bereaved might misperceive the person as the deceased loved one. Based on clinical observation, such quasiperceptual and distorted experiences tend to surface momentarily, in the form of an illusion. It has been observed clinically by the authors that the bereaved often feel more distressed once the illusions have ceased to occur and this has been attributed to the bereaved having to once again confront the reality of the loss of their loved ones. Thus, external CB can increase the grief symptoms of the anxiously attached individuals by reminding them regarding the unavailability of their attachment figures. In effect, the uncertainty and the insecurity are further reinforced by the illusory experiences, leading to more grief symptoms. However, it should be noted that a causal relationship cannot be established by the correlations among externalized CB, anxious attachment style, and symptoms of grief in bereavement. It is possible that the grief symptoms strengthen the inclination of the bereaved to cling onto the deceased, creating a stronger externalized CB and a more pronounced anxious attachment style. Further research is needed to clarify the above relationships.</p> <p>Although not a main focus of this study, our results showed that participants with religion had less externalized CB and less avoidant attachment style. This result is in line with other findings about positive role of religion in the process of coping with bereavement (Benore & Park, [<reflink idref="bib6" id="ref75">6</reflink>]; Hussein & Oyebode, [<reflink idref="bib30" id="ref76">30</reflink>]; Mantala-Bozos, [<reflink idref="bib35" id="ref77">35</reflink>]; Park & Cohen, [<reflink idref="bib38" id="ref78">38</reflink>]; Rubin & Yasien-Esmael, [<reflink idref="bib45" id="ref79">45</reflink>]). It is possible that bereaved individuals with religion tended to use less externalized CB which, in turn, may facilitate their adjustment to their conjugal loss. This proposition is consistent with existing findings regarding beneficial effects of religion on post-bereavement adjustment. Benore and Park ([<reflink idref="bib6" id="ref80">6</reflink>]) found that religious belief in continued attachment, defined as a sustained relationship with the deceased, was beneficial to the process of coping with bereavement. Continued attachment is conceptually similar to CB and the result of Benore and Park ([<reflink idref="bib6" id="ref81">6</reflink>]) provides an indirect support to our current findings.</p> <p>Our results have some important clinical implications. For example, given the negative impact that having an anxious attachment style can have on grief adjustment, our results suggest that grief related to bereavement might be attenuated by addressing the attachment style itself. This would require changing an individual's internal working models of both the self and others through incorporating new information and experience. However, attachment security is usually moderately stable from infancy and childhood through early adulthood (Fraley, [<reflink idref="bib24" id="ref82">24</reflink>]), and individuals vary in the extent to which their working models are open to updating and revision (Bowlby, [<reflink idref="bib8" id="ref83">8</reflink>]). Attachment theorists nevertheless recognize that changes can occur across one's life span (Simpson, Rholes, Campbell, & Wilson, [<reflink idref="bib50" id="ref84">50</reflink>]). When changes occur, it is likely to be the result of either new experiences with the attachment figures or re-conceptualization of past experiences with the attachment figures (Davila & Cobb, [<reflink idref="bib15" id="ref85">15</reflink>]; Davila, Burge, & Hammen, [<reflink idref="bib14" id="ref86">14</reflink>]). During times of dramatic change such as loss of a significant relationship, an individual is exposed to a radically new situation. Such experience can facilitate the accommodation process and help to revise the internal working models (Bowlby, [<reflink idref="bib7" id="ref87">7</reflink>]; Davila & Cobb, [<reflink idref="bib15" id="ref88">15</reflink>]; Davila, Burge, & Hammen, [<reflink idref="bib14" id="ref89">14</reflink>]; Simpson et al., [<reflink idref="bib50" id="ref90">50</reflink>]). Nevertheless, intervention to facilitate change in attachment styles during the acute grieving process would be untimely. More research should be conducted to inform the most appropriate time to conduct such intervention.</p> <p>Our results suggest that another potentially effective approach to reducing grieving during bereavement might be to address the CB with the deceased. Some researchers suggest a theoretical framework, called the dual-process model, to understand the nature of effective coping with bereavement (Neimeyer, [<reflink idref="bib36" id="ref91">36</reflink>]; M. S. Stroebe, Hansson, & Stroebe, [<reflink idref="bib53" id="ref92">53</reflink>]). The dual-process model postulates that the bereaved needs to work through both loss and restoration through the process of oscillating between these two tasks. Therapeutic intervention would focus on helping those individuals who find themselves "stuck" with an externalized CB to engage in the oscillation process required to work through their grief. Therefore, for the anxiously attached, they may need to be helped to attend to restoration tasks, that is, to reduce their heavy reliance on maintaining an externalized CB to decrease their ruminations about the deceased, and to reappraise their lost relationship more positively. Skills used in working with trauma can be borrowed to work with and help resolve the illusory type of experience common in people relying on externalized CB to cope with their loss. Recent studies indicate that this type of dual-process and trauma-focused approach toward complicated grief treatment is effective (Shear, Frank, Houck, & Reynolds, [<reflink idref="bib48" id="ref93">48</reflink>]).</p> <p>Rubin (1999) has suggested a two-track model of bereavement. The two tracks are distinct but interrelated in mourning process. Track I emphasizes how the bereaved function in response to loss (Malkinson, Rubin, & Witztum, [<reflink idref="bib34" id="ref94">34</reflink>]; Rubin, [<reflink idref="bib44" id="ref95">44</reflink>]). Functioning includes ability to live in a reality without the presence of the deceased. Track II focuses on the bereaved involvement in maintaining and changing their unique emotional bond with the deceased (Malkinson et al., [<reflink idref="bib34" id="ref96">34</reflink>]; Rubin, [<reflink idref="bib44" id="ref97">44</reflink>]). The concept of Track II, which is about relationship between the bereaved and the deceased, is more relevant to CB (Rubin, [<reflink idref="bib44" id="ref98">44</reflink>]). Malkinson et al. used two cases study to illustrate that the bereaved could at the same time maintain a relationship with the deceased and adapted to life which the deceased was absent. When applied to our present findings, it is possible according to the two-track model that a therapist can reduce externalized CB and increase internalized CB at the same time.</p> <p>The present study has several limitations. First, all participants were conjugally bereaved adults and so the results may not be generalized to other types of bereavement (e.g., loss of a child) or to other age groups (e.g., children facing parental loss). CB in other types of relationship may show different expressions. Second, participants of the present study were recruited through voluntary bereavement centers and our results may not be generalizable to other bereaved individuals not in bereavement services. Third, because of the limited number of male participants involved in this study, the results may not reflect the unique features of male bereavement, which are noted to be different from female reactions (Carr, [<reflink idref="bib10" id="ref99">10</reflink>]; Chen et al., [<reflink idref="bib12" id="ref100">12</reflink>]; W. Stroebe, Stroebe, & Abakoumkin, [<reflink idref="bib55" id="ref101">55</reflink>]). Fourth, this study used a cross-sectional design, and thus firm statements on directionality of the relationships cannot be made. Longitudinal studies conducted both prior to and after death would clearly be more helpful to elucidate the relationship among the different variables. Fifth, our participants were recruited from Hong Kong which, unlike other cities in Mainland China, is a highly Westernized city. Both the public and health care professionals tend to use Western models to conceptualize grief. This limitation prevents the present study to discuss cultural factors in affecting CB and grief reaction. Finally, we had only asked participants if they have any formal religion. Because different religions have different views regarding life after death, and continuing relationships with the deceased, we anticipate that types of religious belief would have an important effect on our present results, and such effects could not be addressed by our current findings. Future studies should be conducted to address the above issues.</p> <p>Despite the above limitations, the present study has established a valid Chinese questionnaire to measure CB, which should be useful for future research on the topic. In addition, both anxious attachment style and to a lesser extend externalized CB are important factors affecting postbereavement adjustment. Future studies among the Chinese should clarify the role of attachment styles in bereavement adjustment further.</p> <hd id="AN0085019687-13">Acknowledgments</hd> <p>This study was supported by the Earmarked Research Grant of the Research Grant Council (RGC Reference Number: HKU 7428/05H). We thank the Jessie and Thomas Tam Centre, Comfort Care Concern Group, and Haven of Hope Hospital for helping with data collection.</p> <ref id="AN0085019687-14"> <title> References </title> <blist> <bibl id="bib1" idref="ref37" type="bt">1</bibl> <bibtext> Archer, J. (1999). The nature of grief: The evolution and psychology of reactions to loss. New York, NY: Routledge.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref15" type="bt">2</bibl> <bibtext> Attig, T. (1991). The importance of conceiving of grief as an active process. Death Studies, 15, 385–393.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref70" type="bt">3</bibl> <bibtext> Boerner, K., & Heckhausen, J. (2003). 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O.Hansson, W.Stroebe & H.Schut (Eds.), Handbook of bereavement research: Consequences, coping and care (pp. 405–429). Washington, DC: American Psychological Association.</bibtext> </blist> </ref> <ref id="AN0085019687-15"> <title> Footnotes </title> <blist> <bibtext> <emph>Note</emph>. CB = continuing bonds.<emph>N</emph> = 71.</bibtext> </blist> <blist> <bibtext> *<emph>p</emph> < .05.</bibtext> </blist> <blist> <bibtext> <emph>Note</emph>. CB = continuing bonds.<emph>N</emph> = 71. Partial correlation coefficients controlling for religion and mode of death.</bibtext> </blist> <blist> <bibtext> *<emph>p</emph> < .05. **<emph>p</emph> < .01. +++<emph>p</emph> < .001.</bibtext> </blist> <blist> <bibtext> <emph>Note</emph>.<emph>N</emph> = 71.<emph>R²</emph> = .03 for Step 1, <emph>F</emph>(2,68) = .87, <emph>p</emph> > .05; <emph>ΔR²</emph> = .30 for Step 2, <emph>F</emph>(2,66) = 7.83, <emph>p</emph> < .001.</bibtext> </blist> <blist> <bibtext> *<emph>p</emph> <.05. +++<emph>p</emph> < .001.</bibtext> </blist> </ref> <aug> <p>By SamuelM. Y. Ho; IdeS. F. Chan; ErnieP. W. Ma and NigelP. Field</p> <p>Reported by Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib29" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib58" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib59" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib20" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib49" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib32" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib23" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib39" firstref="ref11"></nolink> <nolink nlid="nl9" bibid="bib41" firstref="ref12"></nolink> <nolink nlid="nl10" bibid="bib46" firstref="ref13"></nolink> <nolink nlid="nl11" bibid="bib54" firstref="ref14"></nolink> <nolink nlid="nl12" bibid="bib51" firstref="ref16"></nolink> <nolink nlid="nl13" bibid="bib52" firstref="ref17"></nolink> <nolink nlid="nl14" bibid="bib57" firstref="ref18"></nolink> <nolink nlid="nl15" bibid="bib21" firstref="ref19"></nolink> <nolink nlid="nl16" bibid="bib19" firstref="ref20"></nolink> <nolink nlid="nl17" bibid="bib33" firstref="ref21"></nolink> <nolink nlid="nl18" bibid="bib42" firstref="ref27"></nolink> <nolink nlid="nl19" bibid="bib56" firstref="ref28"></nolink> <nolink nlid="nl20" bibid="bib18" firstref="ref33"></nolink> <nolink nlid="nl21" bibid="bib47" firstref="ref38"></nolink> <nolink nlid="nl22" bibid="bib40" firstref="ref41"></nolink> <nolink nlid="nl23" bibid="bib13" firstref="ref42"></nolink> <nolink nlid="nl24" bibid="bib16" firstref="ref43"></nolink> <nolink nlid="nl25" bibid="bib22" firstref="ref46"></nolink> <nolink nlid="nl26" bibid="bib25" firstref="ref47"></nolink> <nolink nlid="nl27" bibid="bib37" firstref="ref48"></nolink> <nolink nlid="nl28" bibid="bib11" firstref="ref49"></nolink> <nolink nlid="nl29" bibid="bib28" firstref="ref55"></nolink> <nolink nlid="nl30" bibid="bib26" firstref="ref57"></nolink> <nolink nlid="nl31" bibid="bib31" firstref="ref60"></nolink> <nolink nlid="nl32" bibid="bib27" firstref="ref61"></nolink> <nolink nlid="nl33" bibid="bib69" firstref="ref62"></nolink> <nolink nlid="nl34" bibid="bib43" firstref="ref69"></nolink> <nolink nlid="nl35" bibid="bib17" firstref="ref71"></nolink> <nolink nlid="nl36" bibid="bib30" firstref="ref76"></nolink> <nolink nlid="nl37" bibid="bib35" firstref="ref77"></nolink> <nolink nlid="nl38" bibid="bib38" firstref="ref78"></nolink> <nolink nlid="nl39" bibid="bib45" firstref="ref79"></nolink> <nolink nlid="nl40" bibid="bib24" firstref="ref82"></nolink> <nolink nlid="nl41" bibid="bib50" firstref="ref84"></nolink> <nolink nlid="nl42" bibid="bib15" firstref="ref85"></nolink> <nolink nlid="nl43" bibid="bib14" firstref="ref86"></nolink> <nolink nlid="nl44" bibid="bib36" firstref="ref91"></nolink> <nolink nlid="nl45" bibid="bib53" firstref="ref92"></nolink> <nolink nlid="nl46" bibid="bib48" firstref="ref93"></nolink> <nolink nlid="nl47" bibid="bib34" firstref="ref94"></nolink> <nolink nlid="nl48" bibid="bib44" firstref="ref95"></nolink> <nolink nlid="nl49" bibid="bib10" firstref="ref99"></nolink> <nolink nlid="nl50" bibid="bib12" firstref="ref100"></nolink> <nolink nlid="nl51" bibid="bib55" firstref="ref101"></nolink>
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Continuing Bonds, Attachment Style, and Adjustment in the Conjugal Bereavement among Hong Kong Chinese
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Ho%2C+Samuel+M%2E+Y%2E%22">Ho, Samuel M. Y.</searchLink><br /><searchLink fieldCode="AR" term="%22Chan%2C+Ide+S%2E+F%2E%22">Chan, Ide S. F.</searchLink><br /><searchLink fieldCode="AR" term="%22Ma%2C+Ernie+P%2E+W%2E%22">Ma, Ernie P. W.</searchLink><br /><searchLink fieldCode="AR" term="%22Field%2C+Nigel+P%2E%22">Field, Nigel P.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Death+Studies%22"><i>Death Studies</i></searchLink>. 2013 37(3):248-268.
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  Label: Availability
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 21
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2013
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Attachment+Behavior%22">Attachment Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Grief%22">Grief</searchLink><br /><searchLink fieldCode="DE" term="%22Death%22">Death</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Measures+%28Individuals%29%22">Measures (Individuals)</searchLink><br /><searchLink fieldCode="DE" term="%22Statistical+Data%22">Statistical Data</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Regression+%28Statistics%29%22">Regression (Statistics)</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Factor+Analysis%22">Factor Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Hong+Kong%22">Hong Kong</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07481187.2011.634086
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0748-1187
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The present study examined the effects of attachment style and continuing bonds, defined as the extent to which a bereaved individual feels that the deceased remains a part of his/her life, on post bereavement adjustment among 71 conjugally bereaved individuals. It was shown that bereaved individuals with an anxious attachment style tended to show more externalized continuing bonds as well as more grief symptoms. An anxious attachment style played a direct and significant role in post bereavement adjustment over and above the contribution of externalized continuing bonds. Interventions to facilitate restoration tasks and to reduce externalized continuing bonds would be discussed. (Contains 5 tables.)
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  Data: As Provided
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  Data: 59
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  Label: Entry Date
  Group: Date
  Data: 2014
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  Label: Accession Number
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  Data: EJ1010349
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        Value: 10.1080/07481187.2011.634086
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 21
        StartPage: 248
    Subjects:
      – SubjectFull: Attachment Behavior
        Type: general
      – SubjectFull: Grief
        Type: general
      – SubjectFull: Death
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Measures (Individuals)
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      – SubjectFull: Statistical Data
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      – SubjectFull: Correlation
        Type: general
      – SubjectFull: Regression (Statistics)
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      – SubjectFull: Questionnaires
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      – SubjectFull: Factor Analysis
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      – SubjectFull: Adults
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      – SubjectFull: Hong Kong
        Type: general
    Titles:
      – TitleFull: Continuing Bonds, Attachment Style, and Adjustment in the Conjugal Bereavement among Hong Kong Chinese
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