Death Studies, 39: 158–164, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2014.923069

Grief and Growth of Bereaved Siblings as Related to Attachment Style and Flexibility Orit Cohen and Michael Katz Department of Psychology, Haifa University, Haifa, Israel

This study examined the relationship between attachment style, coping flexibility, military/non-military cause of death, levels of grief reactions and posttraumatic growth (PTG), in 150 bereaved adult siblings in Israel. Insecurely attached participants, 72% of the sample, reported more grief and less PTG than did securely attached ones. Highly avoidant individuals exhibited the least amount of PTG. Securely attached siblings were more flexible and flexibly coping participants reported less grief and higher PTG. Cause of death was not related to grief and PTG. Discussion of these findings yields conditions enabling PTG after a sibling loss.

Sibling relationships share aspects inherent in all personal relationships; however, it is still a unique bond that lasts a lifetime (Davies, 2002). Siblings use one another as a source of major influences or milestones in their search for personal identity (Devita-Raeburn, 2004) and for understanding the world around them. The death of a sibling constitutes a multiple loss of a playmate, confidante, role model, and friend. In addition, grieving parents, overwhelmed by their own grief, may have limited capacity to look after the needs of the surviving siblings (Packman, Horsley, Davies, & Kramer, 2006). Therefore, bereaved siblings often become ‘‘invisible mourners,’’ receiving overt and covert messages from significant others to repress and deny their grief (Devita-Raeburn, 2004). Most research on sibling loss paid little attention to adult siblings. An exception is Moss and Moss (1986), who found that bereaved adult siblings show more concern to threatened family unity than adult siblings not bereaved. In addition, adult siblings experience a change in the sense of self that may lead to feelings of emptiness and hoplessness and fear of dying (Pape, 1999). Lastly, potential comforters often disregard adult

Received 23 March 2014; accepted 5 May 2014. This paper is based on parts of the MA thesis of the first author conducted under the supervision of the second author. Address correspondence to Michael Katz, Department of Psychology, Haifa University, Haifa, Israel. E-mail: mkatz@psy. haifa.ac.il

siblings’ grief, directing comfort instead to the deceased person’s parents and the family. Much evidence shows that bereavement, like other traumatic events, can produce negative physical and psychological consequences (McDermott, Prigerson, & Reynolds, 1997). However, a growing body of research indicates that traumatic events, including bereavement, can also elicit personal growth (Garbarino, 2001). Posttraumatic growth (PTG) can be a positive outcome of traumatic events such as the loss of a sibling (Tedeschi & Calhoun, 2004). Grief intensity correlates inversely with PTG (Engelkemeyer & Marwit, 2008). Research on bereaved siblings, usually adolescents, reports significant positive results, such as maturity, personal strength, independence, improved communication skills, compassion, and spirituality (see, e.g., Batten & Oltjenbruns, 1999). Also, bereaved individuals (2 years after the death) generally endorsed greater religiousness than nonbereaved (Currier et al., 2012). This article focuses on two factors contributing to the grieving and growth processes: attachment style and coping flexibility. Cause of death is also examined here as potential contributor. Attachment theory, first conceptualized by Bowlby (1973) deals with the formation, maintenance, and dissolution of interpersonal relationships and on adjustment after separation (Main, 1996). Adult attachment patterns are created in early childhood relationships, usually with the mother, and are incorporated as working models that organize emotions, cognitions, and behaviors. Self-report methods are used to understand

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how secure and insecure individuals feel about themselves and the ways they behave in significant relationships (N. L. Collins, 1996). Attachment theorists conceptualize attachment strategies in terms of two major dimensions: anxiety and avoidance (Brennan, Clark, & Shaver, 1998; Fraley, Waller, & Brennan, 2000). The anxiety dimension is how much individuals worry that their partners will not be available when needed (Mikulincer, Gillath, & Shaver, 2002). The avoidance dimension is how much individuals maintain autonomy and emotional distance from their partners. The two dimensions yield four attachment patterns. Low on both dimensions is secure; low on anxiety and high on avoidance is avoidantdismissing; high on anxiety and low on avoidance is preoccupied; and high on both is avoidant-fearful. Research on spouses uses these dimensions (Waskowic & Chartier, 2003), yet only a few studies have explored attachment after bereavement (Wayment & Vierthaler, 2002). In one study, avoidant-dismissing or avoidant-fearful individuals, showed lower grief, depression, anxiety, and posttraumatic stress reactions than preoccupied individuals (Wayment & Vierthaler, 2002). However, in another study avoidant-fearful and preoccupied individuals showed higher distress than did secure and avoidant-dismissing individuals (Field & Sundin, 2001). Avoidant-dismissing individuals may only appear resilient after bereavement, but after prolonged, highly demanding, stressful experiences, and deactivating strategies, they may collapse, exhibing incompetent coping and decline in functioning (Wijngaards-de Meij et al., 2007). Although the association between attachment patterns and adaptation to loss has been studied intensively, the possible relationship between attachment and growth is practically ignored and is an objective of the current study. The clinical field has witnessed rapidly growing literature on the role of coping in confronting stressful life events such as bereavement. There are dispositional and contextual approaches. Coping style or disposition approaches assume that people have relatively stable, person-based factors that underlie their habitual coping efforts. Contextual approaches assume that transitory, situation-based factors shape individuals’ cognitive appraisals and specific coping responses (Thornton & Perez, 2006). One of these approches addresses the flexibility feature as prominent in determining distress in response to a crisis. Flexibility, from this perspective, is the ability to enhance or suppress emotional expression in accordance with situational demands (Cheng, 2001; Cohen et al., 2002). Based on these findings, we assumed that flexibility might be related to less grief reactions and more growth after bereavement. In addition to attachment and coping styles, cause of death can also make a difference in bereavement.

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Suicide bereavement is associated with more pathology and grief reaction than other causes of death (Feigelman & Feigelman, 2009). However, in Israel, few studies examined possible connections between adjustment and cause of death. Studies investigating bereavement in Israel dealt with the bereaved siblings of people who died during their military service (Itzkovich & Glovman, 1992). Israel has been through violent conflict for more than 60 years. Most 18-year-olds in Israel spend 3 years in mandated army service. Between 1947 and 2011, Israelis suffered 22,867 casualties of war (almost 0.5% of the population). Bereaved families of soldiers in Israel are revered, and deceased loved ones are considered heroes. This approach toward death leads to a sociocultural distinction between soldiers’ death in combat and death under other circumstances. In recent decades, another cause of death has gained the same distinction. Since the 1960s, more than 2,400 civilians in Israel have been killed in terror attacks. In 1998, civilians killed in terrorist attacks were also recognized as casualties of war. Therefore, they are mentioned together with the fallen soldiers in memorial days, and their families, too, receive governmental support. In contrast, bereaved families of individuals who die under other circumstances (car accidents, homicide, suicide, and illness) receive no governmental social support and usually have to seek assistance from relevant voluntary organizations (Florian et al., 1998). Thus, we expected that, after a sibling’s death, (a) securely attached siblings would report lower grief reactions and more PTG than all others; (b) avoidant-fearful or avoidant-dismissing would report lower grief reactions and more PTG than preoccupied siblings; (c) siblings with higher flexibility in coping strategies would experience lower levels of grief and higher PTG; and (d) siblings bereaved as a result of military service would exhibit less grief and more PTG than those bereaved due to nonmilitary causes (car accident=illness=homicide=suicide). METHOD Participants Participants were 150 adults (105 women, 45 men) from all parts of Israel. They ranged in age from 18 to 72 (M ¼ 34.48, SD ¼ 12.41). Their siblings died from army service (70, 46.7%), terror attacks (28, 18.7%), suicide (19, 12.7%), illness (15, 10%), car accidents (11, 7.3%), homicide (1, 0.7%), and other causes (6, 4%). Average age of the deceased was 22.9 (SD ¼ 7.38). The mean time since the loss was 13 years (SD ¼ 12.83, Mdn ¼ 8). Participants completed the study online (n ¼ 130) or in person (n ¼ 20). Of the 150 participants, 148 completed all questionnaires.

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Materials Experiences in Close Relationships (ECR; Brennan et al., 1998), adapted for Hebrew speakers (Mikulincer & Florian, 2000), contains 36 anxiety and avoidance items rated from 1 (strongly disagree) to 7 (strongly agree). High scores indicate more anxiety or avoidance. In the present study anxiety and avoidance were internally consistent (as ¼ .87 and .90, respectively). The mean anxiety score was 3.45 (SD ¼ 1.18) and the mean avoidance score was 3.25 (SD ¼ .96), both of which are higher than those observed of college students (Fraley, 2005). In addition, we classified our participants into Bartholomew and Shaver (1998)’s four prototypes: secure (S), avoidant-dismissing (AD), preoccupied (P) and avoidant-fearful (AF). The Hogan Grief Reaction Checklist (HGRC; Hogan, Greenfield, & Schmidt, 2001), Hebrew version (Bitton, 2009), is 61 items concerning respondents’ experience in the past 2 weeks, rated 1 (does not describe me at all) to 5 (describes me very well). It has 6 subscales (Personal Growth, Disorganization, Detachment, Guilt and Anger, Panic, Despair). We used the HGRC, rather than the Post-Traumatic Growth Inventory (Tedeschi & Calhoun,2004), because the HGRC distinguishes between normal and complicated grief and includes growth and grief subscales. In the present study, the subscales were internally consistent (as ¼ .76 to .86) The Percived Ability to Cope with Trauma scale (PACT; Bonnano, Pat-Horenczyk, & Noll, 2011) is of 20 items split into two scales: Forward-focus (12 items) assesses coping abilities related to thinking optimistically, attending to the needs of others, maintaining plans and goals, remaining calm, reducing painful emotion, and being able to laugh; Trauma-focus (eight items) assesses the ability to remain focused on and fully experience the emotional and cognitive significance of the traumatic event, temporarily withdraw from social interactions, revise goals and plans, and think realistically. Each item on one of the two scales has its conterpart on the other scale. For example, ‘‘experience of emotion’’ vs. ‘‘emotional control,’’ ‘‘social distance’’ vs. ‘‘social

interest.’’ The scales contain statements concerning different kinds of behaviors and strategies that people use following potentially traumatic events. Participants state which of these behaviors and strategies they might be able to use, rated on a scale from 1 (not at all able to) to 7 (extremly able). In the present sample, the internal consistancy was high (a ¼ 0.90). The flexibility score is calculated in three stages. First, a total coping ability score is created by standardizing scores for the Forward Focus and Trauma Focus scales and adding them together; next, a coping polarity score is calculated as the absolute value of the discrepancy between the standardized scores on the two scales; finally, a flexibility score is calculated as total coping ability minus coping polarity. Procedure Researchers contacted organizations that support bereaved individuals, asking them to post an advertisement on their websites and to send out notices on their electronic mailing lists. The ad asked bereaved siblings to volunteer for a study about coping with the loss of a sibling. Participants could choose between completing on-line questionnaires, accessed by a link, and having the questionnaire mailed to their home address. In addition, one of the researchers visited two conferences that were held in north Israel, asked for study participants, and handed out 25 questionnaires. Also, researchers posted flyers at three universities in Israel, and posted ads on Internet forums. Recruitment continued for 3 months.

RESULTS Of the 148 participants who completed all questionnaires, 40 (38%) were classified as S; 36 (33%) were AD, 27 (25%) were P, and 45 (41%) were AF. See Table 1 for means and standard deviations. Concerning Hypothesis 1, a multivariate analysis of variance (MANOVA) contrasting secure and insecure individuals on grief and flexibility yielded significant

TABLE 1 Means (Standard Deviations) for Different Attachment Patterns

Grief reactions Growth Disorganization Detachment Guilt and Anger Panic Despair a b

Secure (S) N ¼ 40

Avoidant-dismissing N ¼ 36

Preoccupied N ¼ 27

Avoidant-fearful N ¼ 45

3.72 (.75) 1.78 (.76) 1.56 (.63) 1.57 (.68) 1.77 (.74) 1.7 (.59)

3.16 (.60) 1.95 (.85) 1.85 (.93) 1.63 (.61) 1.93 (.69) 2.1 (.73)

3.29 (.55) 2.07 (.85) 2.2 (.88) 1.85 (.66) 2.15 (.77) 2.1 (.62)

3.37 (.75) 2.6 (.88) 2.45 (.79) 2.04 (.66) 2.42 (.69) 2.45 (.59)

Total insecurea N ¼ 108 3.28 2.55 2.19 1.85 2.19 2.25

(.66) (.91) (.89) (.66) (.74) (.66)

Total insecure ¼ avoidant-fearful þ avoidant-dismissing þ preoccupied. The total number in this table is 148, because two of the 150 respondents did not complete the Grief Reaction Checklist.

Totalb N ¼ 148 3.4 (.71) 2.12 (.89) 2.02 (.88) 1.78 (.67) 2.08 (.76) 2.1 (.69)

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TABLE 2 Pearson Correlations of Grief Reactions and Growth With Anxiety, Avoidance, and Flexibility Predictors(r) Anxiety Avoidance Flexibility 

Detachment

Despair

Panic

Disorganization

Guilt and anger

Growth

.52 .46 .28

.43 .46 .29

.44 .31 .31

.44 .33 .23

.34 .31 .30

0.02 .30 .31

p < .05.  p < .001.

results, F(6,141) ¼ 5.60, p < .001. Follow up analyses of variance (ANOVAs) indicated that, as expected, secure individuals reported significantly higher PTG, F(1,146) ¼ 12.23, p < .001, R2 ¼ .08, and flexibility (M ¼ 4.50, SD ¼ 1.71, vs. 3.82, SD ¼ 1.51); and significantly lower grief disorganization, F(1,146) ¼ .8.68, p < .005, R2 ¼ .056; detachment, F(1,146) ¼ 16.44, p < .001, R2 ¼ .101; guilt, F(1,146) ¼ 5.12, p < .005, R2 ¼ .034; panic, F(1,146) ¼ 9.52, p < .005, R2 ¼ .061; and despair, F(1,146) ¼ 20.84, p < .001, R2 ¼ .125 (Table 1). Partly as expected, P (and AF) individuals reported more grief than AD. Interestingly, however, anxiety was not significantly correlated with PTG, but avoidance was inversely correlated with PTG, r ¼ .30, p < .001 (see Table 2). Concerning Hypothesis 2, a MANOVA comparing AD, P, and AF was significant, F(12,108) ¼ 1.85, p < .05. Follow-up ANOVAs indicated significant differences in disorganization, F(2,105) ¼ 6.44, p < .005, R2 ¼ .109; detachment, F(2,105) ¼ 4.68, p < .05, R2 ¼ .082; guilt, F(2,105) ¼ 4.18, p < .05, R2 ¼ .074; panic, F(2,105) ¼ 4.81, p < .05, R2 ¼ .084; and despair, F(2,105) ¼ 3.56, p < .05, R2 ¼ .063; but no differences in PTG. Post-hoc analysis revealed that AD people reported lower detachment, guilt, and panic than P and AF, and AF had higher disorganization than AD and P. P and AF people did not significantly differ in PTG. Concerning Hypothesis 3, flexibility was significantly positively correlated with PTG, r ¼ 0.31, p < .001, and significantly inversely correlated with the five grief reaction variables, rs ¼ .23 to .30 (see Table 2). Unexpectedly, concerning Hypothesis 4, cause of death (military or nonmilitary) had no significant impact on grief or flexibility. In addition, using the conventional division of previous studies, we found no significant differences in grief or flexibility depending on whether the death was under natural circumstances, unexpected circumstances, or suicide.

DISCUSSION The fact that more than 72% of present Israeli bereaved adults reported an insecure attachment style differs from classifications found in other studies, which suggest that

around 45–65% of a sample should be classified as secure (e.g., Fraley, 2005). Two possible explanations may account for this finding. One explanation stems from a methodological problem owing to the considerable difficulty in tracing potential participants. We did not use a random sample and had no control group of non-bereaved siblings. Another explanation is that the experience of bereavement perhaps undermines attachments that the bereaved person may have enjoyed, resulting in a change of attachment style in adulthood. The assumption of changeability of attachment style after stressful or traumatic events, was raised in previous studies (e.g., Davila et al., 1997; Cozzarelli, Karafa, Collins, & Tagler, 2003). An unpublished qualitative study of people who lost a spouse suggested that the death was connected to changes in thinking and acting (Peters, 2008), which suggests that a loss can disturb a person’s attachment style in future relationships. This disturbance can be especially relevant to bereaved siblings, which in our study were relatively avoidant (about 70% of the insecure group). People regard their grief as less painful than the grief of parents (Devita-Raeburn, 2004). In addition, the siblings are seen as obliged to support their parents (Packman et al., 2006). Hence, bereaved siblings may tend to repress their distress and avoid seeking comfort, which in turn may lead to developing avoidant patterns of reacting in future relationships. Secure siblings (low on avoidance and anxiety) showed higher PTG and lower grief than did insecure siblings. This finding corresponds to previous studies, wherein insecure attachment correlated with pathological grief (Waskowic & Chartier, 2003) and secure attachment correlated with post-traumatic growth (Dekel, 2007). These studies dealt with loss of a spouse or with imprisonment trauma. The uniqness of the present study is that it is the first one to consider this issue after loss of a sibling among adults. In any case, the findings that secure siblings show relatively high levels of PTG and low levels of grief reactions can be due to people with secure attachment having positive beliefs about the world and the self, and being less prone to interpreting events as threatening. In addition, the activation of a secure attachment matrix has a comforting and relaxing effect. Thus, securely attached people are more likely to seek social support

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(Mikulincer, 1998). In contrast, insecure people overrate the threatening potential of a situation and lack confidence in their coping capability, and thus experience higher grief reactions (Kobak & Sceery, 1988). For them the activation of the attachment matrix does not result in relaxation. In addition, they are either self-reliant (the avoidant style) or seek dependence on others but do so in an inadequate manner (the anxious style). Therefore, they hardly benefit from social support (Mikulincer et al., 2002), which is another reason why they are less likely to acquire positive views about themselves, others and the world, and more likely to experience PTG. The association between posttraumatic growth and attachment patterns suggests that secure attachment involves also positive changes following a crisis. In accordance with previous studies (Dekel, 2007), we found differences in PTG between secure and insecure people but not between different insecure patterns. The fact that avoidant people reported more well-being than preoccupied people corresponds with earlier studies (Field & Sundin, 2001; Wayment & Vierthaler, 2002). Also, avoidance correlated negatively with PTG, but there was no significant association between anxiety and PTG. This finding does not accord with previous studies on PTG, where PTG coexisted with grief reactions (Solomon & Dekel, 2007). Tedeschi and Calhoun (2004) argued that PTG is the outcome of the posttrauma psychological struggle. Stress-induced cognitive rumination transforms into constructive processes, which in turn initiate the development of PTG. Yet it may be that the relation between anxiety and PTG is more complex. Acoording to Butler et al. (2005), some measure of significant distress may be necessary for PTG to occur, although too much distress may impair bereaved people and render them unable to engage in the PTG process. The negative correlation between avoidance and PTG corresponds with the assumption that PTG can take place if the individual has an inquisitive state of mind, challenging personal assumptions about the world, people, and self (Neimeyer & Anderson, 2002; Tedeschi & Calhoun, 2004). Avoidant people may only appear to be resilient in a situation of bereavement, whereas under conditions of prolonged, stressful experiences, and deactivating strategies, they may collapse, revealing incompetence of coping and decline in functioning (Wijngaards-de Meij et al., 2007). Also they tend to repress negative emotions, thoughts, and memories relating to the trauma (Shaver & Mikulincer, 2002) and are less likely to seek help that may facilitate the recovery process (Fraley, Fazzari, Bonanno, & Dekel, 2006). Hence, they are less likely to experience stressrelated growth and more likely to experience distress for the long run.

The findings of positive correlations between flexible coping, low grief reactions, and higher PTG accord with previous studies showing that flexibility facilitates adequate coping and enables adjustment in facing traumatic events (Cohen et al., 2002; Cheng, 2001). Furthermore, the ability to draw among several strategies enhances adjustment after a crisis more than does being attached to one constant strategy (R. L. Collins, Taylor, & Skokan, 1990). It should be noted that these studies referred to resilience, which is different from PTG. Some researchers speculate that PTG is a kind of resilience, whereas others suggest that resilience plays an important role in the development of PTG (Lepore & Revenson, 2006). Tedeschi and McNally (2011) showed an inverse relationship between PTG and resilience. Highly resilient individuals may have stronger coping skills and be less likely to struggle with the psychological consequences of trauma, but also less likely to experience opportunities for change that proceed from the emotional wrestling with trauma. Flexibility enables realization of the possibility of a more complicated experience that helps the bereaved person to adjust to life after the loss, alongside a positive change in self-growth. Thus, flxibility leads to enhancing or suppressing emotional expression in accordance with situational demands. The individual can then seek help actively, or take part in distracting activities at times, but can also be alone and in touch with the pain, thus facilitating growth and a sense of self-efficiency. The relationship between attachment style and flexibility is interesting and fits well with other findings regarding coping and attachment. For example, secure individuals relied more than insecure ones on their ability to regulate stress and, therefore, were more likely to expose themselves to new and possibly threatening information (Mikulincer, 1998). Thus, secure people were more capable of processing new information and integrating it into existing schemes, resulting in better adaptation to new situations. In order to use different strategies in the face of trauma, one must think flexibly, analyze the situation and its demands, and regulate emotions. A trauma is an unexpected and threatening event that challenges internal working schemes and endangers one’s ability to function. Thus adjustment and, moreover, PTG require openness to re-examine perceptions, ability to integrate the negative experience into new schemes, and utilization of social support (seeking comfort). Therefore, it may well be that flexibility is a kind of behavioral manifestation of the attachment pattern, guiding responses to traumatic events and resulting in adaptation. It may also be that flexible coping reinforces security in attachment and enables its continuance.

GRIEF AND GROWTH OF BEREAVED SIBLINGS

Theoretically, experts view cause of death as a central predictor of severe mourning reactions (Janoff-Bulman, 1992). The approach adopted in the present study assumes that the meanings given to circumstances, more than the circumstances themselves, determine the course and outcomes of grieving. Meaning, in our view, taking the socio-cultural context into consideration, is determined not just by the individual’s own reflections but also by the norms and views of the society in which one lives. Present results, however, did not support our assumption. Despite the social support and the positive perception of death in combat in Israel, siblings of fallen soldiers were no different in PTG and grief reactions from bereaved siblings because of other forms of tragic and sudden deaths (e.g., homicide, suicide). One explanation for this finding may be that those bereaved from military deaths receive institutional support, so that society recognizes their loss, but this recognition can constitute a double-edged sword, for it may lead to an idealization of the deceased and a view of the death as mythic and heroic. These perceptions may interfere with mourning in the context of sibling relationships. For PTG to occur, the bereaved person must mourn in private and integrate the loss into the mourner’s interpretative framework. Bereaved siblings of a nonmilitary death must create private meaning for their loss to process it and grow in its wake, for there is no meaning dictated in advance. Frydman-Helfant (1994) found that the more siblings idealized the deceased, the more they reported situational anxiety. Nevertheless, because we did not assess relationships with the deceased, this assumption requires further investigation. Another explanation can be drawn from the assumptions of the PTG model. This model suggests that some measure of significant distress may be necessary for PTG to occur, although too much distress may impair the bereaved and render them unable to engage in the growth process (Butler et al., 2005). It may well be that siblings bereaved by military death are highly distressed, and that support systems unintentionally enhanced the distress, serving as secondary gain and reducing the ability to grow. Lastly, we need to address the fact that no differences were found in this study along the conventional division of causes of death. First, perhaps the explanation has to do with the fact that, in the course of time, cause of death is less important and the loss remains a loss. Second, there may have been a methodological failure, because the groups falling under suicide and natural causes of death were too small to find statistically significant effects. The main contribution of the present article is pointing to the importance of the attachment system in times of distress. Contrary to other patterns, insofar as processing the loss is concerned, avoidance does not protect against psychopathology, and may impede PTG,

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whereas anxiety elicits grief and distress but does not necessarily interfere with personal growth. Bereaved siblings have a scratch. Have some kind of split. On the one hand they are very sensitive to others, on the other hand they suffer an emotional disability. There is a kind of opacity . . . I have always been doing many things. Why? Because you have to hold to many things. Once your security in the family, in the universe, were cut off you need to accumulate a lot of things to be bound to. Nothing is safe anymore. (Alon, a bereaved sibling, who lost his younger brother in a war)

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Grief and growth of bereaved siblings as related to attachment style and flexibility.

This study examined the relationship between attachment style, coping flexibility, military/non-military cause of death, levels of grief reactions and...
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