Grief's paradox: Approach and avoidance in prolonged grief disorder


Approximately 10% of bereaved persons develops severe, disabling and persistent grief, termed Prolonged Grief Disorder (PGD), which will highly likely be included in the 11th International Classification of Diseases’ (ICD-11) in 2018.
Approach of lost-person reminders is presumed to be a central mechanism perpetuating PGD and laboratory research indeed demonstrates persons with PGD show heightened approach of lost-person reminders. Yet, grief theorists also near-universally assume that avoidance of lost-person reminders perpetuates PGD and countering such avoidance is a critical ingredient of PGD treatment. This yields what I term grief’s paradox: approach and avoidance of lost-person reminders are both presumed to sustain PGD.
Current theories and empirical studies fail to explain grief’s paradox, for three reasons. First, laboratory studies overlook the fact that cognitive-behavioral theories do not presume persons with PGD avoid lost-person cues per se, but rather those cues that signal the permanence of separation with the deceased (loss-reality). Second, pioneering research has shown multiple lost-person approach behaviors (e.g. rumination, yearning) sustaining PGD may serve to avoid this loss-reality. Third, such behaviors are self-perpetuating not only because they avoid the loss-reality (and related distress) but also because they are intrinsically rewarding.
Therefore I will test the newly-devised Approach-avoidance Processing Hypothesis (APH), which implies that PGD is characterized by multiple, self-perpetuating, repetitive behaviors that simultaneously approach the lost-person, yet paradoxically serve as loss-reality avoidance. APH’s clinical translational implication is that effective exposure reduces (the reward-value of) approaching reminders of the lost-person and avoidance of lost-person reminders that signal the loss-reality.
This project’s key objective is providing a rigorous empirical test of APH with cutting-edge laboratory studies and a randomized controlled trial. This will clarify which approach and avoidance mechanisms underlie PGD. Additionally, it will provide critical clues to improve existing interventions, by showing how effective exposure for PGD works.


Project number


Main applicant

Dr. M.C. Eisma

Affiliated with

Rijksuniversiteit Groningen

Team members

Dr. M.C. Eisma


01/02/2019 to 01/10/2022