INTRODUCTION
Parental bereavement affects approximately two million children and adolescents in the United States (U.S. Department of Commerce, 2010). Complicated bereavement can result in depression, poor school performance, and risky sexual behavior (Weinberg et al., Reference Weinberg, Dietz and Stoyak2013; Gray et al., Reference Gray, Weller and Fristad2011; Cerel et al., Reference Cerel, Fristad and Verducci2006). Experiencing the death of a parent is a complex event in the life of an adolescent. Therefore, measures that might mitigate complicated bereavement through sense making and potentially enhance family relationships are imperative.
A common post-death experience that may be useful in mitigating complicated bereavement and promoting family relationships, even beyond death, is the experience of a continued bond. The experience of feeling the presence of someone who has died is common and has been termed a “continued bond” (Klass, Reference Klass2006). Continued bonds may be present in a variety of ways. For example, one may be thinking about their deceased loved one or keeping possessions as a way to stay connected (Sanger, Reference Sanger2009). We do not often think of death as an opportunity to extend our relationship with another; it is more often conceived as the irrevocable closure of a relationship. However, a continued bond or extension of a relationship may be instrumental in promoting effective bereavement and is tied to making sense of loss.
Field (Reference Field2006) suggests that an ongoing relationship with the deceased is a normal response and may be helpful in terms of adaptation during bereavement. In the adult population, the experience of a continued bond appears to be common across cultures (Sanger, Reference Sanger2009; Suhail et al., Reference Suhail, Jamil and Oyebode2011; Chan et al., Reference Chan, Chow and Ho2005). However, there is little literature on how adolescents experience continued bonds with a deceased parent and whether this experience is useful in helping them create meaning out of a difficult situation.
Making meaning out of a difficult situation is a process that can lead to effective bereavement. In their work, Meleis and colleagues (Reference Meleis, Sawyer and Im2000) suggest that, for a transition to occur, in this case a transition to life without a parent, meaning must occur as a precipitating event. Meaning can be neutral (no recognition of the important event) or positive (the event was important and therefore creating meaning was possible). Neimeyer and coworkers (2006) postulated that successfully creating meaning out of the loss of a loved one and having a positive continued-bond experience predict positive bereavement outcomes.
The purpose of our study was to describe adolescents' continued relationships with a deceased parent. The study extends prior work on examining family relationships at the end of life (Hansen et al., Reference Hansen, Higgins and Warner Beckette2014) by examining continued bonds as part of the family relationship and the process for creating meaning in order to achieve effective bereavement.
METHODS
Participant Recruitment and Data Collection
Families of adolescents with a parent in hospice were recruited from a large hospice program in northeast Ohio for the parent study, “Strategies to Help Adolescents with a Parent in Hospice” (Sheehan, et al., 2014a). The institutional review board at the principal investigator's university approved the study. Some 61 participants from 26 families were interviewed for the parent study, including 30 adolescents, 20 well parents, and 11 ill parents. Post-death interviews were conducted with 15 participants (1 adolescent and 6 adults) from 6 families to demonstrate feasibility for a longitudinal study. We herein present the findings from the post-death interviews of the nine adolescents.
The surviving parents from the six families were contacted to determine their interest in participating in a post-death interview, and all of them readily agreed. Assent was obtained from the adolescents after their parents consented for themselves and their children (n = 9). Individual interviews were conducted between October of 2011 and August of 2012 in participants' homes.
The interviews included open-ended questions asking participants to describe the experiences from the time of the ill parent's death until the day of the interview, including management of the stressors involved in losing a parent. The interviews began by asking participants about the death event itself. Most participants provided vivid descriptions of the events that occurred since the death of their loved one; however, additional prompts such as “Can you tell me more about that?” were also employed by the research associate to elicit richer descriptions. Participants who became distraught during an interview were asked if they would like to end the interview, but none accepted this offer. Each participant was assessed for emotional distress following their interview, but none claimed distress. The interviews were conducted 2 to 13 months after the death. Each participant was given a $35 honorarium immediately after signing the consent and assent forms. Interviews and fieldnotes were digitally recorded and transcribed verbatim. Each transcript was reviewed by the interviewer for accuracy.
Data Analysis
The research team included four doctorally prepared nurse researchers. The team analyzed data gathered from interview narratives and fieldnotes using conventional content analysis methods (Hsieh & Shannon, Reference Hsieh and Shannon2005), first reading the data in their entirety and then via word-by-word coding and categorization. Through this process, the research team became familiar with the data as a whole. Data about continued bonds were extracted as individual text units by each member of the team prior to discussing them at weekly team meetings, and themes were determined by consensus.
Several procedures were used to enhance the trustworthiness of our findings. The perspectives of the two groups (i.e., adolescents and surviving parents) were utilized, though the data reported are from the adolescents' experiences of continued bonds. In addition, trustworthiness was enhanced by conducting the analysis with a research team. During weekly team meetings, peer debriefing and discussion of emerging findings occurred, and all methodological and analytic decisions were documented in an audit trail. The sample is described with detailed information related to demographic characteristics.
RESULTS
All but one adolescent (a 14 year old) described continued bonds in their stories about a deceased parent. All where white, with annual household incomes of $10,000–70,000, and their ages ranged from 12 to 18. The adolescents described 21 stories about continued-bond experiences. From these stories, three types of continued bonds emerged: an inner guide, encounters, and mementos. Exemplars for each of the three types of continued bonds are presented in Table 1.
Exemplars of continued bonds
Inner Guide
An inner guide was the most frequently (11 experiences) reported continued bond. Adolescents described the inner guide as an enduring voice of or messages from the deceased parent. The adolescents, especially males who had lost a father, stayed connected by playing back the words of the deceased parent in their heads or by being the person they thought their deceased parent wanted them to be. One 18-year-old son described his father as his inner guide thus:
Throughout the entire ceremony, I kept telling myself I'm going to keep strong because that's what my dad wanted me to do, and that really helped a lot. I was thinking of him the entire time, and that really helped me hold things together.
As the adolescents described the inner voice, it was clear that having this connection was important to them, and for the adolescent sons it served as a way to guide them in being the “man of the house.” One son described the purchase of a car for his mother after his father died. He spent a lot of time researching what car they should buy, and he equated this to something his father would have done.
Encounters
Encounters was the second most frequently (seven experiences) reported continued bond. Adolescents described encounters as unexpected experiences with a deceased parent and perceived them as positive or negative. Though most of the encounters were positive, one was a warning sign for a potential complicated bereavement. This can be seen in the experience described by the son of a father who had died:
I talk to my Dad when I am lying in bed and tell him I wish he could come back. (14 years old)
Mementos
Mementos was the least frequently (three) reported continued bond and was the act of keeping special items (mementos) as a way to connect with a deceased parent. Keeping mementos is part of staying connected with the past, and in the case of adolescents who have lost a parent, this can be an important part of their bereavement journey. Adolescents described staying connected by keeping things that reminded them of the deceased. As one 16-year-old son stated:
I always kept all those [text] messages regarding my mom because I just thought it was a good thing to do, and also it helped me remember exact dates—like everything is on my phone right now.
Evidence of Meaning Making
In this study, seven of the adolescents who expressed continued bonds also expressed attitudes of adjustment to life without a parent. This is an indication that they have been able to create meaning out of the death of their parent and experience a successful transition from life with that parent to life without them. For example, one 16-year-old daughter recounted,
I am comfortable. I am content with my life right now. I am alright.
A 16-year-old son explained that
She would want me to just to move on because, if I think about her, all it does is really hold me back. It is nice to think about her every now and then, but it is not really worth getting all worked up over things.
DISCUSSION
Sheehan and colleagues (Reference Sheehan and Draucker2011) described a theme of “extending our time together.” That theme identified the ways by which ill parents and adolescents worked to stay together, realizing that, no matter how much time they spent together, it would never be enough. After the parent died, they found ways to maintain their relationship by transcending the boundaries of time and death. We found similar results in the attempt of adolescents to continue the bond with their deceased parents.
Inner Guide
Adolescents described the inner guide as the enduring voice of or messages from the deceased parent. Our adolescents, especially males who had lost a father, stayed connected by thinking about the words of the deceased parent or being the person they thought their deceased parent wanted them to be. Current views of grief and bereavement suggest that, when an attachment figure is lost through death, there is an emphasis on adapting to the new roles and retaining the bonds that existed rather than surrendering those bonds (Mitchell et al., Reference Mitchell, Stephenson and Cadell2012). This response has been discussed in the literature based on attachment theory; however, it is a change from the earlier belief that one should end the bond in order to obtain complete closure (Neimeyer et al., Reference Neimeyer, Baldwin and Gillies2006).
Encounters
Although most encounters were positive, one was a warning sign for potential complicated bereavement. Not all continued bonds lead to finding meaning; instead, they can become maladaptive and hinder bereavement (Field, Reference Field2006; Klass, Reference Klass2006; Neimeyer et al., Reference Neimeyer, Baldwin and Gillies2006). The longing for attachment that was expressed by one of the younger adolescents signifies that he was experiencing greater grief-related distress than what is expected (Neimeyer et al., Reference Neimeyer, Baldwin and Gillies2006). This adolescent, along with the other younger adolescent who did not report continued bonds, suffered intense emotional distress as a result of the death of their parent.
Mementos
Keeping mementos of the deceased and death rituals date back to ancient times (Groves & Klauser, Reference Groves and Klauser2005). Some of our adolescents stayed connected by keeping things that reminded them of the deceased. Having mementos was the least frequently reported continued bond. However, Sheehan and coworkers (Reference Sheehan and Draucker2011) found that adolescents find ways to continue their bond with their deceased parent by keeping such mementos as a ring or a cross. Adolescents in two of our families reported keeping mementos as a way to connect with their deceased parent. Interestingly, two of these examples dealt with social media and technology, a sign of how contemporary adolescents view this way of continuing a bond with the deceased compared with how this type of bond was traditionally viewed. In the past, a memento was a piece of jewelry or photo album. While these types of mementos still exist, people today are incorporating technology into their continued-bond experience (Gibbs et al., Reference Gibbs, Meese and Arnold2015; Pennington, Reference Pennington2013; Mitchell et al., Reference Mitchell, Stephenson and Cadell2012). We know this to be a common and important continued bond, and it constitutes a tangible item or place to go to remember the loved one.
Creating Meaning
Victor Frankl's seminal work (Reference Frankl1962) provided the insight that, even when faced with terrible circumstances, it is possible to transcend and create meaning out of the experience. Current research in meaning making suggests that one's ability to make meaning out of a loved one's death is a predictor of positive bereavement outcomes (Neimeyer et al., Reference Neimeyer, Baldwin and Gillies2006). The loss of a loved one disrupts what was once a comforting and “known” life to one that is unsettled and uncertain, which may lead to loss of meaning, goals, and sense of self (Janoff-Bulman & Frantz, Reference Janoff-Bulman, Frantz, Power and Brewin1997; Taylor, Reference Taylor1983). When a loved one dies, individuals find ways to adjust or transition into a new relationship with that person versus working through grief in a linear fashion. Individuals often strive to create meaning out of the loss of a loved one. They do this to make sense of the loss, find benefit from it, and adjust to their own identity as a survivor (Gillies & Neimeyer, Reference Gillies and Neimeyer2006).
As adults, we can rely on our past experiences to know what coping mechanisms have been effective in helping us to grieve effectively. However, for many adolescents, the death of a parent may be their first experience of grief, and they do not have experience to rely on to help them create meaning. This watershed moment in an adolescent's life will lay the foundation for dealing with future loss and assist in transitioning to a new normal—life without a parent. Restoration of meaning is an important factor in being able to adjust to life without a loved one and to adapt to the changed relationship they now have with that loved one (Christ et al., Reference Christ, Siegel and Christ2002; Neimeyer et al., Reference Neimeyer, Baldwin and Gillies2006).
The continued-bonds experience for the adolescents in our study assisted them in creating meaning out of their loss and adjusting to life without their parent. While our findings do not answer the question of whether a continued bond helps an adolescent create meaning out of either the life or death of their parent, it does provide additional understanding of meaning making and continued bonds. Our findings are similar to those in adults, where meaning making and continued bonds were found to be connected and to assist in achieving effective bereavement (Brewer & Sparkes, Reference Brewer and Sparkes2011; Howell et al., Reference Howell, Shapiro and Layne2015; Boerner & Heckhausen, Reference Boerner and Heckhausen2003).
LIMITATIONS
Several limitations provide context for our findings. Recall bias may have been introduced with participants' retrospective descriptions of continued bonds. Parents and adolescents describing the same experience somewhat offsets this limitation. Generalizability is limited because our sample was drawn from a single hospice facility. Also, our sample size did not allow us to explore how variations in family relationships and characteristics may have influenced adolescents' experiences with the deceased parent. A longitudinal study with a larger sample and robust representation from different demographic groups would permit such an exploration.
COMPETING INTERESTS
The authors state that they have no competing financial interests to declare.
FUNDING
This study was supported by the National Institute of Nursing Research (R21 NR012700), Denice Sheehan, principal investigator, and the Kent State University Research Council.
