Anna Gribetz Dissertation

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Continuing Bonds into Adulthood Following an Early Parental Loss

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Abstract This qualitative study sought to explore the lived experience of young adults who have a history of parental loss (before the age of 18) and the ways they have continued the bonds with the deceased over time. Participants were selected if they were between the ages of 23 and 45, allowing for reflective data. To ensure homogeneity of the same, participants were excluded if the parent died by suicide, homicide, they were estranged from the parent at the time of death, or they lost both parents. This study provides a rich and detailed experience of continuing bonds through an Interpretative phenomenological analysis (IPA). Seven participants took part in two semi-structured interviews. Based on the interviews, the following themes were identified: continuing the bond on my own, finally feeling ready, it’s every emotion, looking for love, and internalized continuing bond. The results and findings demonstrate that continuing bonds are multidimensional and dynamic. It affects people on all dimensions and is influenced and informed by various factors, including emotions linked to continuing bonds, time since the death, relationships with living family members, and new experiences. In addition, the continuing bond relationship continued to influence the participant’s sense of self and identity long after the parent passed away. This can be seen in the participants' career choices, values, and beliefs.

Implications for practice and research were explored as well as limitations of the study.

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For my dad, who was always my cheerleader and would have been so proud of me. To my children, Josie, Allen and Dylan, thank you for adding so much meaning and love into my life.

To my husband, Jon, thank you for unending support and encouraging me to pursue my PhD.

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Acknowledgments I would like to acknowledge and express sincere appreciation for my dissertation committee, Denise Duval Tsioles, PhD, LCSW, Mead Goedert, PhD, LCSW and Karen Baker, LMSW. Thank you to my readers Kerstin Blumhardt, PhD and Amy Groessl, PhD, LCSW.

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Chapter I Introduction General Statement of Purpose The purpose of this qualitative study was to explore the lived experience of young adults who have a history of parental loss (before the age of 18) and the ways they have continued the bonds with the deceased over time. I was specifically interested to gain insight from participants into their subjective view and experience of continuing bonds. The research study aimed to understand how the relationship to the deceased had changed over time. The participants were asked to recall their relationship with their parents immediately following the death, presently, and how it has evolved over time. I explored the relationship the participant had with the parent while they were living as it connects to the continuing bond relationship.

Historically, from a Freudian and medical model perspective, the bereaved was encouraged to disengage emotionally from the deceased as this was thought to be essential to the mourning and bereavement process. Recent studies suggest that bereavement is a process that does not end, but bereavement affects the mourner in different ways for the rest of his or her life.

The bereaved are changed by the experience; “they do not get over it, and part of the change is a transformed but continuing relationship with the deceased” (Baker, 2001).

A phenomenological study design was used for this research in order to allow for rich and descriptive data. More specifically, I followed the Interpretive Phenomenological Analysis (IPA), an approach that enabled me to examine how people make sense of this major life experience (Smith et al., 2009). Open-ended interviews were conducted in order to get rich and

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individualized narratives from the participants. This study selected seven young adults (under the age of 45) who had a parental loss during childhood. The participants experienced this loss more than five years ago to allow for reflective data. Individuals who had a death from homicide, suicide or were estranged from the lost parent prior to their death, were excluded from this study.

My goal with this exclusion was to provide a more homogenous sample.

Theoretical Framework The major theoretical underpinnings of this research were object relations through a bereavement lens. I had also hoped to use attachment theory, but ultimately found it less relevant to the study. Object relations theory, developed by Melanie Klein and later Donald Winnicott, is based on the belief that all people have within them internal representations of others (Berzoff & Silverman, 2004). This is connected to the idea of continuing bonds since even though someone has passed away, the mourner will continue to hold the relationship internally. In addition, attachment theory, developed by Mary Ainsworth and John Bowlby, is based on the idea that our earliest relationships with primary caregivers are crucial and will determine one’s attachment style as secure or insecure. This will inform later relationships with important others, possibly including continuing bonds. I was hoping this study may shed light on whether attachment style affects this process, but ultimately did not find this framework was relevant to the data and themes that emerged. I will discuss this further in later chapters.

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Importance of the Study By the age of 11, 3% of children in this country will have been affected by parental death. By the age of 16, this rises to above 5%, this shows that a significant minority of adolescents will experience parental death (Keenen, 2014). Experiencing the death of a parent at a young age is a life-altering event and can feel as if the world “has turned upside down, as if the universe has fallen apart” (Schlesinger, 2014). Given the magnitude of this event, one would expect that this loss and the relationship to the deceased is carried into adulthood in a multitude of ways, both consciously and unconsciously. It is critical to understand not only how the relationship is carried through into adulthood, but also the way it can promote and thwart development throughout adulthood.

Root and Exline (2014) who conducted studies in continuing bonds recently urged researchers to conduct future studies on the bereaved individual’s subjective experience associated with the continued bond expression, as well as whether they view it as positive or negative. My goal was for this dissertation to fill this gap in the literature and answer the call for this research.

Significance of Clinical Social Work The purpose of this study was to provide a deeper psychological understanding into how young adults continue bonds with this major loss from childhood. It is clear that one of the hallmarks of social work practice is the emphasis on relationships and connection. According to NASW, “social workers seek to strengthen relationships among people in a purposeful effort to promote, restore, maintain, and enhance the well-being of individuals, families, social groups, organizations, and communities” (National Association of Social Workers, 1999). In addition,

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the parent-child relationship is emphasized and highlighted throughout theory and literature as the most vital relationship. Therefore, continuing bonds allows for a more relational version of grief (Hedtke & Winslade, 2017).

Grief work can often emphasize a severing of the relationship with the dead, and clinical practice is often centered around this idea of “moving on” or “saying goodbye” (Hedtke & Winslade, 2017). However, this may not be informed or reflected in the wishes of the griever. It is also not reflected in psychoanalytic theory of the human mind as we know that relationships do not just exist in an external form, but they exist within the mind as well. Therefore, this research informs clinical work and ways therapists can bring the idea of continuing bonds into their practice.

Epistemological Frame I came into this study from a social constructivist perspective. Social constructivism understands individuals as constructing meaning and understanding in the world in which they live and work. “They develop subjective meanings of their experiences- meanings directed toward certain objects or things” (Creswell, 2017, p. 24). These meanings are developed through the culture and environmental context in which the participants develop and these factors shape the participants’ narratives.

From the social constructivist viewpoint, I recognized how my own background shaped my interpretations and will “position” myself in the research. In addition, I held during the study that someone’s grief and understanding are in the context of another. Meaning is always relational from a social constructivist background. I was also aware that my participation impacted the study as I constructed meaning alongside the participants. During the study, I paid

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particular attention to each participant's multiple realities and recognized that my own background, meanings, and experience were sometimes different from the participants (Creswell, 2017).

In my research, I made the questions broad and general so the participants shared and constructed their own meaning. Since my questions were open-ended, I listened more carefully to each participant's multiple realities within their life setting (Creswell, 2017). This perspective allowed the participants to provide in depth narratives of their own personal experience. This enabled me to find patterns and connections using theory.

Operational Definitions The following constructs and operational definitions were used in my research study: Parent: biological parent for the purpose of the study Death: the end of the life of a person, not including homicidal or suicidal deaths Untimely loss of a parent- the loss of a parent in childhood, adolescence or young adulthood.

Mourning or grief- These terms were used synonymously in this research and refer to a painful intrapsychic process that occurs in response to the loss of an important object relationship (Auchincloss & Samberg, 2012). In this research, I used it to mean specifically the response to a significant death of a loved one. A postmodern view of mourning does not see grief as universal or essential. “There are no fixed stages in which mourners move in lock step. Instead, persons who are grieving are always active participants in the process” (Berzoff & Silverman, 2004, p.

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225). Grief is an ongoing process of making meaning and a process in which new roles, adaptation and assumptions are created in relation to the person who died (Berzoff & Silverman, 2004, p. 256).

Bereavement- Grief and mourning happen during a period called bereavement. Bereavement refers to the time when a person experiences sadness after losing a loved one (American Cancer Society, 2019).

Continuing Bond- continuing relationship with loved ones even after they've died. Continuing bonds theory holds that, while relationships necessarily do change when someone dies, they do not end (Klass, Silverman & Nickman, 1996).

Rituals- a series of actions or type of behavior regularly and invariably followed by the bereaved as a way to continue to the bond with the deceased Statements of Assumptions I used the following assumptions when engaging in my research study: 1. People who lost a parent in childhood experience some level of mourning or grief. The loss of a parent has an impact on the well-being of a child and this continues throughout the lifespan.

2. Death is personal and will be impacted by the person’s culture and context (family, money, religion, community etc.).

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All children have ways they continue the bond with the deceased parent, even if it is unconscious.

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4. The relationship with a parent changes over time from childhood to young adulthood.

Questions to be considered The following questions and sub-questions guided my research study: 1. How do people who lost parents as children (under 18) continue the bond/relationship with the deceased into adulthood?

2. In what ways is their subjective experience of this continued relationship comforting, sustaining and invigorating?

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In what ways is their subjective experience of this continued relationship maladaptive and harmful?

4. How does the relationship to the deceased evolve and change over time from childhood to young adulthood?

5. How does a person’s relationship with their parents while they were alive impact the continuing bond once they have died?

Foregrounding I want to acknowledge that I came to this research with biases and beliefs related to the chosen topic. This is partly from my personal experience as I lost my own father when I was an adolescent. Prior and during my research study, I spent time reflecting on my own grief experience of the sudden loss of my father. I had a very close, positive, and loving relationship with my father. I remember him as responsive, patient and attentive, and I believe this has helped me develop secure attachments in life and minimize my experience of complicated grief.

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However, I found it difficult after this loss to be open and share about him or the trauma of his sudden passing; I often avoided ways to stay connected to him. More recently, I have started to find ways to bring him into my life in more conscious and ritualistic ways. I was mindful that the ways that have been invigorating for me to bring him into my life as well as the ways that have been maladaptive, might be completely different for someone else.

I also want to note that I identify as a Modern Orthodox Jew. This means that many of my beliefs about death are woven with Jewish tradition. I was cognizant of the ways my own spiritual and religious beliefs are influencing my views of the death, dying and the mourning process in this research study.

Theoretical Problem Psychodynamic literature focuses on the relationship between people who are living or how to move on from a death. There is little research or theoretical understanding of the experience of continuing a bond with the deceased from childhood into adulthood.

Much theorizing in the bereavement field has been influenced by Freud's (1917) paper ‘Mourning and Melancholia.’ According to this psychoanalytic approach, when a loved one dies, the bereaved person is faced with the struggle to sever ties and detach the energy invested in the deceased person. Bowlby (1980) advanced the existing psychoanalytic idea of grief work by addressing the interpersonal part of the process. Drawing on the basic tenets of his attachment theory, Bowlby conceptualized grieving as a form of separation anxiety, similar to the experience of infants being separated from their caregivers. He posited that attachment comes from a need for security and safety, usually directed at a caregiver that develops early in life and tends to endure throughout a large part of the life cycle (as cited in Worden, 2009, p. 14). It is

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important to note Bowlby (1980) revised his stages of grieving, but was still proposing a relinquishing theory. He included these four stages (a) numbness, (b) yearning and searching, (c) disorganization and despair, and (d) reorganization. Successful grieving, according to Bowlby, was accepting the death of the attachment figure, returning to activities, forming new attachment bonds, and integrating the loss into a new reality.

While Bowlby’s work is useful in many ways and will be one of the frameworks for this study, his theory along with many of the theorists before him, describe grief work as “moving on” or disconnecting from the deceased. This study aimed to look at how participants stay connected to the deceased parent and their experience of this relationship as part of their life.

Summary of the literature As mentioned earlier, the historical belief about grieving was that the bereaved should seek closure, “move on '' from the deceased, and the notion of continuing bonds was viewed as pathological. It was Dennis Klass, Phyllis Silverman, and Steven

Nickman who were the first

bereavement scholars to challenge this paradigm. They argued that even though the deceased was no longer physically present, a relationship with that person could still be maintained and this is not necessarily pathological (Paxton, 2015).

In general, the research in this area substantiates the need for the bereaved to maintain some form of bond with the deceased, and that this facilitates coping with grief and aides continued development and growth. Researchers have found that continuing bonds were expressed through telling stories and having conversations with the deceased, celebrating their

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birthdays and anniversaries, and keeping artifacts that belonged to them or represented them (Paxton, 2014).

Silverman and Worden (1992) conducted an extensive longitudinal study where they interviewed 125 children (ages 6 to 17) who had experienced the death of a parent. They found that most children maintained a connection to the parent through dreams, waking memories, and keeping personal objects. More than half of the children reported having mental conversations with the deceased, which ranged from basic accounts of the day to accomplishments in the life of the child. Another study also found that children often saved personal keepsakes of the lost parent, such as a piece of worn clothing, “as this transitional object provided an evocative, sensory pathway to the beloved” (Sussillo, 2005, p. 510).

In a study conducted of widows and widowers, the researchers found that a significant percentage of bereaved individuals developed ways to continue their ties to their spouses. The study found the bonds were continued through dreams and memories, by holding onto personal possessions, taking on behaviors and traits of the deceased, or by experiencing some type of continuing contact (Baker, 2001). The researchers concluded from the data that the “task” of mourning is not the “decathexis of the dead spouse but the establishment of a form of continuing relationship that both satisfies the emotional need of the bereaved to maintain their ties and allows for grieving and living to proceed” (Baker, 2001, p. 63).

A comprehensive longitudinal study from the Harvard Medical School Child Bereavement Study looked at the impact of a parent's death on children ages 6 to 17. This study substantiates the need for an ongoing and continued relationship with the deceased parents. The study found that the children maintained conscious and unconscious connections to their dead parents. They found that fifty-seven percent of the children spoke to the deceased parents and

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43% felt they received an answer from the parents. Many of the children dreamed about their parents and the parents were alive in the dreams. A large majority of the children felt their parents were watching them. Seventy-seven percent of the children had something personal that belonged to their parents, either something the deceased had given them or something they had taken after the death (Silverman et al., 1996).

The research has become more robust in the area of continuing bonds, but there are gaps in the literature related to the specific focus of this research study. In my exhaustive search, I was unable to find research on continuing bonds from the experience of young adults who lost a parent as a child and how this relationship has evolved over time. This project hopes to fill in part of this gap in the literature.

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Chapter II Literature Review

In this chapter, the literature review will outline theory and concepts related to continuing bonds into adulthood from those who have lost a parent in childhood. I will review the historical perspective on grief, studies on continuing bonds, relevant psychoanalytic theory, and early parental loss and its impact on adulthood. These themes cast a wide enough net to capture the literature and research relevant to this study.

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Historical Perspective on Grief Historically, the view of grief has been that successful mourning involves disengaging

from the deceased and letting go of the past. To experience a continuing relationship with the deceased has been thought of as pathological or indicative of psychological issues (Klass et. al, 1996).

Sigmund Freud (1917) in his work “Mourning and Melancholia” theorized that grief work is to free the ego from the attachment “when the work of mourning is completed the ego becomes free and uninhibited again”. From this perspective, the goal is to detach from the deceased and accept the finality of the loss. He described the period of mourning being completed when the reality testing has shown that the “love object no longer exists, and it proceeds by demanding that all libido shall be withdrawn from its attachment to that object” (p.

153).

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However, recently in the past few decades, there has been a shift among bereavement theorists away from the idea of detachment towards staying connected with the deceased as a healthy part of the bereavement process. Klass et al (1996) in their book “Continuing Bonds: New Understanding of Grief '' propose that the “the resolution of grief involves continuing bonds that survivors maintain with the deceased and that these continuing bonds can be a healthy part of the survivor’s ongoing life” (p. 22).

According to the continuing bonds model, the bereaved remains attached to the deceased through the active construction of inner representations of their lost loved one. The mourner may gain solace and comfort during the process of mourning by maintaining the tie to the deceased.

Continuing bonds might also act as a means of coping by providing a connection to the deceased and lessens the pain associated with the death (Root and Exeline, 2011). The deceased's influence in the bereaved life is not viewed as static, but “an evolving process of adaptation and construction of a transformed connection” (Root and Exelne, 2011).

II.

Prior research on Continuing Bonds Although considered a fairly modern concept, there have been numerous research studies on

continuing bonds. One of the most comprehensive studies in the theory of continuing bonds is the “Childhood Bereavement Study”. A total of 70 families with 125 children were interviewed 4 months after the death of a parent and then 1 and 2 years later. The study found that children engaged in five types of activities that seemed to lead to their maintaining a connection with the deceased 1. Locating the deceased: when participants were asked where they thought the parent was now, seventy four percent located them in heaven.

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2. Experiencing the deceased: children reported believing their deceased parent was watching them or communicating with them.

3. Reaching out to the deceased: participants reported visiting the cemetery and speaking to the deceased as a way of bringing them into their life.

4. Remembering: the parent was present in the children’s waking thoughts as well.

5. Keeping something that belonged to the deceased.

Foster and her colleagues (2011) conducted a mixed-method study comparing how parents and siblings experienced continuing bonds. They looked at 40 families who lost a child to cancer 3-12 months post-loss. They looked at purposeful bonds, which are conscious and active, and non-purposeful bonds, which are unconscious and involuntary connections. Nearly all participants (97%) reported engaging in purposeful bonds with deceased children, and only 14% reported non-purposeful connections. Over half of participants (58%) experienced comfort from reminders of the deceased child, and only 10% of family members experienced discomfort from the connections.

In this study, they found the following purposeful ways participants continued the bonds with the deceased children: 1) Connecting through visual representations, including photographs, videos, scrapbooks and stuffed animals.

2) Communicating with the deceased through talking, writing letters, or praying to deceased children.

3) Being with deceased children's personal belongings was an important way they stayed connected to the deceased. Participants chose to keep personal belongings, including bedding, clothing, and toys.

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4) Thinking about deceased children 5) Visiting places deceased children went when they were alive.

6) Engaging in activities honoring deceased children, such as special events and projects.

7) Doing things deceased children would have liked or chosen, such as listening to music, eating foods, and choosing room decorations.

However, as noted above, 14% of the participants had non-purposeful engagements with the deceased including: 1. Deceased children's presence 2. Signs/visits from deceased 3. Dreams In a study done by Hansen and her colleagues (2016), they looked at adolescents' experience of continued bonds with a parent who died. Families of adolescents with a parent in hospice were recruited from a large hospice program, and looked at interviews of nine adolescents after the loss of a parent. The interviews consisted of open-ended questions asking participants to describe the experiences from the time the parent died until the day of the interview, including how they managed the stress involved in losing a parent.

The researchers found the adolescents described 21 stories of a continuing bond experience. From these stories, three types of continued bond themes emerged: 1) Inner guide- the enduring voice of or messages from the deceased parent.

2) Encounters- unexpected experiences with the deceased parent.

3) Mementos- staying connected by keeping things that remind them of the deceased parent.

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In addition, the continued bond experience assisted the participants in creating meaning out of their loss and adjusting to life without their parents. A majority of the adolescents who experienced continued bonds also expressed attitudes of adjustment to life without a parent.

Experience of continued bond in bereavement process It is relevant and important to look further at the subjective experience of continuing bonds and the ways it is viewed by participants as this will be part of the proposed research study. Such factors as the type of continuing bond expression or the prominence of continuing bonds after the death could be important in the type of feelings the continuing bond evokes. In this section, I will further explore studies focusing on the emotions associated with continuing bonds and whether they were positive or negative.

Affect connected with Continuing Bonds Field and Friedrichs (2004) examined the continuing bonds to the deceased in coping with the death of a husband. Recruited for this study were fifteen widows whose husband had died 4 months prior to the study and 15 widows whose husband had died more than 2 years before. Participants were electronically signaled every 3 hours to complete a set of measures that included the Positive and Negative Mood Scales (PANAS) and Continuing Bond (CB) coping scale. Participants completed these scales 4 times each day for 14 consecutive days.

The PANAS is a 10-item Positive Affect (PA) and a 10-item Negative Affect (NA). The PA scale measures the level that an individual feels alert, enthusiastic, and active. The NA scale looks at negative mood states such as anger, contempt, disgust, guilt, fear, and nervousness. The CB coping scale consists of the following CB expressions: (a) had an imaginary conversation with my husband (b) tried to do things that would have made my husband happy (c) tried to think

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of good memories of my husband (d) imagined reuniting with him in heaven (e) used photos or his belongings to feel closer to him (f) imagined or felt him guiding me, watching over me, or comforting me. Participants rated (on a scale from 0 not at all to 4 constantly) how often during the past three hours they used each of these CB expressions to help them cope with their emotions related to the loss.

Researchers found a positive correlation between continuing bonds and positive mood for the later-bereaved widows, but not for the early-bereaved group. However, continuing bond coping was also positively related to negative mood for both early, and later-bereaved widows.

The results from this study highlight the complex relationship between continuing bonds and adjustment (Field, 2004).

Field et al. (1999) conducted a study of 70 bereaved spouses 6 months post loss to look at different forms of continuing attachment. The participants engaged in a monologue role-play with their deceased spouse as a behavioral measure of grief-related distress. In addition, they completed general and grief-specific symptom scales at 6 months and later at 14 and 25 months post loss. Researchers found that continuing bond expressions that were more closely linked to reestablishing physical proximity, including holding onto the deceased’s possessions or excessive use of these belongings for comfort, were correlated with more severe grief symptoms and greater distress. In contrast, obtaining comfort through evoking fond memories was predictive of less distress. This study shows that continuing bonds are not unidimensional and the importance of the type of continuing bond expression.

In a different study, thirty-nine individuals who lost a spouse completed the Continuing Bonds Scale (CBS), to assess different ways in which the bereaved maintains an ongoing psychological connection with the deceased at a later point after the death. The participants

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completed symptom measures at 6, 14, 25 months post loss, and 5 years post loss. The CBS consists of 11 items covering a range of ways of maintaining a bond with the deceased including memories, maintenance of possessions, sense of presence, identification with deceased, legacy of deceased, deceased as a standard (attempt to carry out deceased’s wishes; use of deceased’s viewpoint in decision-making), and reminiscing about the deceased. Participants rated the degree to which each of the items is true on a 5-point scale, ranging from 1 (not at all true) to 5 (very true) (Field et al., 2003).

The results indicated that some continuing bond expressions remained well after the death. However, they found no support for their long-term adaptiveness of continuing bonds. In fact, greater continuing bonds involvement was correlated with more severe bereavement-related distress over the course of the 5-year period following the death of a spouse, regardless of type of expression (Field et al., 2003).

In a different study of 65 widows and continuing bonds, women maintained the bond in a variety of ways. The researchers found widows continued to seek their husbands’ approval by doing things “for his sake,” or continuing to ask their advice. The study showed that preserving the relationship with the deceased spouse was an important and healthy part of the widows life, participants frequently reported they believed it was the dead husband that gave them strength to carry on alone (Bennett, 2010). It is also interesting to note that widows reported a “loosening of bonds”, and began to reconstruct their identities and reported thinking and communicating to their husbands less often over time (Bennett, 2010).

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III. Psychodynamic Theory Object Relations Object relations theory is based on the belief that all people have within them an “internal, often unconscious world of relationships that is different in many ways more powerful and compelling than what is going on in their external world of interactions with ‘real” and present people” (Berzoff et al., 2011, p. 125). Therefore, object relations refers not only to real relationships with others, but also to the internal representations of others and to internal images of self as well (Berzoff et al., 2011).

Object relations is not synonymous with the regularly used term relationships. Object relations does partially refer to the complexity of external relationships with others, but it also includes a whole internal world of relations between self and others, which become part of the self. “Internal object relations are complex; they consist of an image of the object, an image of the self relating to the object, and an affective valence reflecting the experienced relationship between self and other” (Baker, 2001, p. 68).

Melanie Klein is considered one of the primary developers of object relations theory. In her work, she stresses these processes of internalization which a child goes through first with their mother and then the father. Klein (1940) theorized that the baby having incorporated his parents “feels them to be live people inside his body in a concrete way in which deep unconscious fantasies are experienced- they are, in his mind, internal or inner objects” (Klein, 1940, p. 126). The child’s unconscious mind corresponds to the actual experiences from others in the world, but is altered by their fantasies and perceptions (Klein, 1940).

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When it comes to the idea of mourning, Klein explains that this process involves the mourner deepening their connection to their inner objects, and joy and relief in regaining that relationship with the lost object (Klein, 1940). Klein’s emphasis is on preserving and restoring the object relationship in the mourner's personality (Baker, 2001). Klein (1940) states in Mourning and the Depressive Position that: Grief is experienced to the full despair at its height, the love for the object wells up and the mourner feels more strongly that life inside and outside will go on after all, and that the lost loved object can be preserved within (p. 143).

Therefore, Klein’s view of mourning involves the bereaved person slowly developing a changed, but ongoing, relationship with the deceased (Klein, 1940).

One of the results of mourning is the creation of an internal relationship that allows the bereaved to maintain an inner representation of the lost object but also leaves space for new relationships. The inner relationship looks different than the object relationship because the deceased is not physically present to provide real world experience. There are several important features and uses of this internal object relationship with the deceased individual.

1. The bereaved individual, at times of stress, could turn to the object relationship and experience emotional nurturance and comfort 2. There is a problem solving aspect, widowed adults in a study shared that it was helpful to them to “talk out” problems internally with a deceased spouse 3. It can be used to define and maintain a sense of identity (Baker, 2001)

Winnicott

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D.W Winnicott, a major object relations theorist, discussed the ways the psyche takes in what it experiences with others and processes it to become part of the psychological self (Berzoff et al., 2011). Winnicott studied the idea of a “transitional object” or an object that becomes important to the child as a defense against anxiety. This could be a bundle of wool, a blanket, a word, song, or a mannerism. As this object continues to be important, the parent learns the value of the object in lessening the child’s anxiety.

This object goes on being important. The parents get to know its value and carry it round when traveling. The mother lets it get dirty and even smelly, knowing that by washing it she introduces a break in continuity in the infant’s experience, a break that may destroy the meaning and value of the object to the infant (Winnicott, 1971, p. 3).

The transitional object is an important concept in the field of mourning. Often, it is the bridge to the possibility that a person continues to exist even if they have died. This concept is extremely helpful for those who have trouble holding on to the mental representations of others in their absence and are unable to form a transitional object from within. This is why so much of grief work requires the use of transitional objects: pictures, journals, and other personal or meaningful objects that represent memories of the deceased (Berzoff et al., 2011) Shlesinger (2014) shares that when patients who have lost a parent during childhood and adolescence are able to retrieve the object representation of the deceased parent, the pain of the loss is lessened when they can recall positive memories as it makes the child feel they have the deceased parent within. When a child does not have an inner representation of the parent it is a double loss: the actual loss due to death, and the loss due to a lack of memory and inner connection to the deceased. In her clinical work with adults who had early parental loss, Shlesigner helps her patients to reconnect to who this parent was, the role the parent played in

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the child’s life, and reconstruct positive identifications with this parent. She describes the importance of having in mind that the adult was a child at the time her mother or father died (Schlesinger 2014).

Attachment Theory Attachment theory was developed by John Bowlby and is widely used today to hypothesize the strong impact that early relationships have on adult relationships (Sirrine, 2016).

Bowlby (1980) stressed the following At every age, people’s lives revolve around the intimate attachments they form and that a child’s sense of felt security was contingent not only on physical proximity to the attachment figure but also on the attachment figure’s responsiveness to his or her emotional needs, especially when under stress (Field et al., 2003).

Bowlby along with Mary Ainsworth looked at internal models or styles of attachment, originally identifying three, and later four styles: secure, dismissing, preoccupied, and disorganized. Adults with a secure attachment style find it easier to get close to others and can have mutually reliant relationships. Secure attachment allows individuals to express distress and receive comfort and support. Dismissing, preoccupied, and disorganized styles of attachment are all classified as insecure (Stroebe et al, 2018) Loss is always mediated by the individual's attachment style. Those who have secure attachment styles are able to hold on to clear and coherent memories of the deceased. Individuals with less secure attachment styles fall into three groups.

1) Avoidant attachment or in adulthood are dismissive and tend to suppress the need for others.

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2) Anxious or preoccupied attachment styles, while they may be highly expressive, they are unable to cope with the loss and maintain coherent memories of the deceased.

3) Disorganized attachments are those who cannot create an organized narrative of the other in their absence (Berzoff, 2003).

Bowlby (1980) defines grief through his attachment theory. He conceptualizes grief as a form of separation anxiety resulting from the disruption of an attachment bond, such as the death. Bowlby (1980) described four phases of mourning experienced in the weeks and months following a death. These phases are characterized by numbness and shock, yearning and searching, despair and disorganization, and reorganization. Bowlby described the stages as consecutive and postulated that the bereaved often go between and among them (Sirrine, 2013).

I plan to use the lens provided by object relations and attachment theory to both understand and inform my research on the subjective experience of continuing bond as comforting and sustaining as well as difficult or unhelpful.

IV. Early Parental Loss and the Impact on Adulthood In this section I will explore the impact of early loss on adulthood and childhood mourning. Although my study will not be looking directly at childhood or adult mourning processes, it will act as a backdrop to the study and facilitate a generalized understanding of the experience of the participants.

The death of a caregiver, sibling, or loved one is one of the most commonly reported and most distressing forms of trauma among youth (Alvis et al, 2021). Childhood bereavement is correlated with a range of mental, emotional and behavioral problems. This includes depression, posttraumatic stress, substance use, suicide-related behaviors, poor academic performance, and

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impairments in developmental tasks (Alvis et. al., 2021). However, the research is inconclusive when it comes to the long term impacts of this loss in adulthood. In two studies in Denmark and Sweden, parental death during childhood was associated with an increased risk of hospitalization for depression. In contrast, in a previous Dutch study, they found no link between parental death and increased risk of mental disorders in adulthood, including depression (Berg, Rosita).

Ragan and McGlashan (1986) in their study found that people who grew up in families where one or both parents died were more likely to have difficulty forming stable adult relationships. Since the death of a parent is associated with interpersonal difficulties, it likely reduces the amount of support the child or later the adult receives from friends or family (Claudine and Wang).

Deaths, as events, seem to be different from one another. In a study done by Berg and colleagues, they found that parental loss to death from natural causes during childhood is associated with a small increased risk of long-term consequences for psychological health.

Children who lose their parents to death from external causes, that is suicides, accidents or homicides are at higher risk for poor psychological health.

Palumbo also theorizes about variables that distinguish the event for each child. Palumbo (1981) outlines eight variables below: 1. The cause and type of death- there are violent deaths and peaceful deaths, accidental deaths and deaths from natural causes, sudden deaths and delayed deaths.

2. The factors associated with which parent dies, father, or mother, adoptive parent, surrogate parents 3. Factors related to the child’s age, sex, and developmental level

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4. The manner in which the child is informed of the event and whether the event was witnessed or not 5. The nature of the relationship of the child to the parent 6. Whether the child suffered from prior psychopathology 7. The child’s cognitive grasp of what occurred 8. The nature of the support system around the child

Children and Mourning Knowing the particular phase of development of the child at the time of the loss is important since this will impact adaptability and understanding of death (Schlessinger, 2014).

One also has to take into account such variables as the quality of object relationships, the impact of the event on other people in the child's life, and the level of ego maturity prior to the loss Schlessinger, 2014). There are also varying opinions on children’s ability to understand and mourn the death of a loved one. Children’s bereavement process will depend on their ability to gain an understanding of the four components of death.

1) Universality- when children gain an awareness that death happens to all people and all living things.

2) Irreversibility- when children learn that death is final and cannot be reversed.

3) Non-functionality- when children understand that death happens because the physical body stops working and all bodily functions cease after someone dies.

4) Causality- when children learn that there are many different causes of death. An understanding of the variation in death increases as his or her developmental age, exposure, and education about death increases.

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(Sirrine, 2010) Polumbo (1981) also considers children’s ability to mourn. He summarizes Mendhelson’s theory describing that children cannot mourn because of: 1) Insufficient differentiation of ego 2) Lack of object constancy, a term chosen by Margeret Mahler to refer to the “establishment in the psyche of a relatively stable, benign and positive representation first of the mother, and eventually of others that “holds: even in the face of absence, disappointment or anger” (Berzoff & Silverman, 2004, p. 152) 3) Lack of full development of reality testing and reality awareness 4) Short sadness span with an incapacity to sustain mourning 5) Extensive use of denial or reversal of affect 7) Use of regressive defenses with development of symptom formation or behavioral pathology Qualitative studies on Early Loss and the Impact on Adulthood Meyer Lee et al (2020) conducted a qualitative study examining the long-term experience of childhood parental death by exploring how adults (a) retrospectively conceptualize their experiences of childhood parental death and (b) currently experience their parent’s death. An analysis of interviews with 12 adults identified six themes centered on the impact of parental death circumstances: 1. Initial reactions 2. Circumstances surrounding the parents death 3. Family relationships 4.

Loss of structure, support, and personal identity

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5. Long-term grief triggers 6. Long-term impact of parental death on life (Meyer Lee, 2020) During the interviews, many participants reflected on their life and how it might have differed if their parents had not died. All but one participant believed their lives were worse with the loss of their parents. One participant compared his life to his friends who appeared to have more successful lives that included marriage, children, career, and financial stability: [here you are] trying to explain where you’ve been the last 20 years of your life. Sitting in prison or jail or doing dope or doing nothing; chasing rainbows...I’ve done a lot of that.

It’s directly correlated, probably, to the loss of my mother.

Another participant, who left home at the age of 15, also reported thinking her life would have been dramatically different if her father had not died. She reported that she would not have left home if her father had not died because, whereas her mother “was a very immature, very mentally unstable person,” her father “liked being a father and had the maturity to take care of kids.” (Meyer Lee et al., 2020).

The main theme that emerged from the interviews was that the grief experience is closely tied to an individual's attachment needs. Feelings of grief would arise when attachment needs were unmet and then lessen when attachment needs were fulfilled. Participants continuously shared grieving when they felt lonely, unsuccessful, in need of emotional support, or when they experienced other losses. They also reported heightened grief during important life events, including weddings, graduations, and job promotions. They wished their deceased parents could have been present to not only witness the achievement, but express pride in them( Meyer Lee, 2020).

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In a different qualitative study, Koblenz (2016) looked at adults (N =19) who experienced a loss during childhood. The interviews explored and assessed the long-term impact of parental death on life, what was most helpful and most harmful in coping through the years following the death. The qualitative descriptions were coded and analysis of common themes determined. Five theoretical constructs were found: 1. Adjustment to catastrophe- “My life was different, everything changed, I was treated differently. Part of this theme was the idea that “the loss created permanent changes in me”, which was described by 89% of the participants. They shared being curious about how they would have been different if they had not lost the parent. They reported feeling like they have separation anxiety with important others in their life, and feeling dread around Mother’s/Father’s Day/holiday and death anniversaries.

2. Support- Deferring to self-reliance was a coping strategy that the participants used since they felt they could no longer depend on others. It was easier to express they “were strong” and “could handle it alone,” than acknowledge their loneliness. The idea of “needing to be strong” was expressed by many participants and reflects a difficulty in being vulnerable.

3. Therapy- The participants reported that they had difficulty utilizing individual therapy directly after the loss,but with time found it more helpful and effective.

There were a few factors that improved their experiences: the choice to go to therapy, the good fit between patient and therapist, flexibility in the therapy, and understanding the reasons for attending.

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4. Continuing a connection with the deceased parent- Participants in the present study shared often keeping mementos of the deceased. These included pictures on key chains that were held daily and gifts that they received from the person who died. Participants expressed that having a connection to the person they lost was important to them. The participants reported that the absence of this bond often led to unresolved feelings, frustration, and sadness. Participants wished that their parents discussed the deceased more in the home, highlighting that knowing more about the person who had died was crucial for their own identity development.

5. Reinvestment- “losing a parent will always be a part of who I am, but I need to find a way of moving on and investing in something else”. After accepting that the loss was permanent, the participants described having the desire to do something productive. In contrast to the unpredictability inherent in the death, the children began to yearn for the parts of life that were predictable In an exploratory qualitative study done by Ellis and her colleagues (2013) they looked at individuals who had lost a parent(s) before the age of 18, and how these experiences were perceived to impact adult life. They looked at 33 adults, some participants used written narratives (n = 5) and others used oral narratives (n = 28). The results indicated that while individual experiences of bereavement in childhood were unique, the narratives were organized around three common themes: 1. Disruptions and continuity- in the narratives, the participants highlighted the idea of how continuity was also affected by a reduction in parental capacity of the surviving parent which the participants had trouble understanding. One participant, Winifred, who lost her father, believed that her mother appeared to be

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no longer interested in where she went or what she was doing. Winifred stated “And it was a strange feeling on my part – I don't think it was exactly that I had lost two parents but that I lost [one] parent and the other one had changed so much.”

Another participants, Jane who also lost her father, stated “She [mother] was throwing everything out in the house that belonged to me dad and I was gutted … but she started throwing things of mine out then and I just felt alone; I had no one to back me up and I couldn't talk to her about it.”

2. The role of social networks and affiliations- this is the way social and institutional affiliations (e.g. schools, religious organizations, neighbors and friendship networks) mediated the impact of parental death. For some of the participants this formal and informal support provided access to role models, a sense of security, and moral guidance.

3. Communication- The distress was heightened in cases where adult figures did not communicate with children and give accurate information at the time of the death.

This lack of information seemed to contribute to the confusion and fear experienced. In some families the deceased parent could not be talked about at all by the children because they worried the surviving parent might not be able to cope with the emotions triggered (Ellis et al, 2013).

In this section, it was my goal to lay the foundation for my research study by presenting the existing literature surrounding my chosen topic. This process has been crucial in understanding

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my topic as well as identifying gaps in the literature. The main themes that have been identified are the following: 1. Historically, the view of grief has been that successful mourning involves disengaging from the deceased and letting go of the past. However, many theorists have now shifted to the idea that holding the deceased in loving memory for and maintaining a connection to them is normal.

2. From the various studies, one can see that some of the common ways people continue bonds with the deceased are a) connecting through visual representations or mementos, b) communicating with the deceased and c) thinking about deceased 3. There is varying research on the relationships between continuing bonds and adjustment.

Some research has indicated that the type of bond and time since death may indicate how it impacts the mourner.

4. From an object relationship standpoint, continuing bonds can be seen as a process that involves the mourner deepening their connection to their inner objects, and joy and relief in regaining that relationship with the lost object.

5. Loss and continuing bonds is likely mediated by the individual's attachment style. Those who have secure attachment styles are able to hold on to clear and coherent memories of the deceased.

6. Each loss is mediated by a variety of factors and the research has been mixed in regards to whether childhood bereavement is correlated with a mental, emotional and behavioral problems.

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Chapter III Methods

This research study employed Interpretative Phenomenological Analysis (IPA) in order to gain deeper insight into how young adults continue their bonds with a parent who died when they were a child. Through the IPA approach, I explored this phenomenon through the following questions: 1. How do people who lost parents as children (under 18) continue the bond/relationship with the deceased into adulthood?

2. What is your subjective experience of continuing bonds?

3. How does the relationship to the deceased evolve and change over time from childhood to young adulthood?

4. How does a person’s relationship with their parents while they were alive impact the continuing bond once they have died?

The following chapter will outline the (a) rationale for the research approach, (b) scope of study, (c) data collection process, (d) ethical considerations, (e) limitations and, (f) issues of trustworthiness.

Rationale for Research Approach IPA is an approach that was developed by Smith, Flowers, and Larkin (2009). “IPA is a qualitative research approach committed to the examination of how people make sense of their major life experiences. IPA is phenomenological in that it is concerned with exploring

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experience in its own terms” (Smith et al., 2009). This method is fitting for my research topic since my aim was to explore lived experience and understand how participants make sense of the experience.

IPA is grounded in Hursselein philosophy, it aims to understand an experience in the way that it occurs while stepping outside of one’s natural attitude. This process means adopting a phenomenological attitude where we turn our gaze from objects in the world and direct it inward towards our perceptions of those objects. While Husserl was concerned to find the essence of the experience, IPA has a more modest ambition of trying to capture particular experiences as experienced for particular people (Smith et al., 2004). Since IPA is aimed at finding a detailed and nuanced account rather than larger scale patterns, it was fitting for my study.

Scope of Study Participants were selected to be part of the study if they meet the following criteria: 1. One parent died when they were under 18 years old 2. Currently between the ages of 23 and 40 years old In order to create a more homogeneous sample, certain participants were excluded: 1. Lost a parent to homicide or suicide 2. Both parents have passed away 3. Had an estranged from the parent who died

In addition, participants were only included if they were able to provide detailed reflection of their experience. This was evaluated and assessed during the phone screening interview.

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I recruited seven participants for this study as this follows with the IPA approach. “IPA studies are conducted on relatively small sample sizes and the aim is to find a reasonably homogeneous sample, so that, within the sample, we can examine convergence and divergence in some detail” (Smith et. al, 2009, p. 49). I used purposeful sampling because it offered the research insight into the experience being studied. “Participants are selected on the basis that they can grant us access to a particular perspective on the phenomena under study. That is they represent a perspective rather than a population” (Smith et al., 2009, p. 49).

Data Collection Process Once the study was approved by the Institutional Review Board (IRB) through the Institute of Clinical Social Work (ICSW), I took the following steps to recruit, screen, and interview the participants: 1. I networked with colleagues to find participants to speak to this phenomenon. I distributed the information to all my personal contacts, including other psychotherapists, classmates, physicians, and community leaders. I also posted the flier on various online psychotherapy forums, including Hello Alma and Women’s Mental Health Consortium. I used snowball sampling to gather more participants. The information given for recruitment was as follows: PARTICIPANTS NEEDED FOR RESEARCH STUDY Purpose: I am seeking participants for my dissertation research study, which will be completed through The Institute of Clinical Social Work. The study is looking for participants who are between the ages of 23 and 40 and lost a parent when they were a child (under 18). I am looking to understand the experience of continuing bonds, which is

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the way we stay connected to those who have died. Participants will receive a $50 gift card for participation.

Participation is 2 hours of interviews either via zoom or in person and journaling prior to each interview.

2. Each potential participant were asked to take part in an initial phone screening interview.

During this phone call, participants were screened for eligibility in the study. I also outlined the commitment to the research which included two 60 minute interviews and journaling. The questions on the phone survey were as follows: a. Did you lose one parent under the age of 18 years old? b. Are you currently between the ages of 24 and 40 years old? c. Did your parent die by suicide, homicide or were you estranged from them at the time of death? d. Would you be willing to participate in two 60 minute interviews? The first will be within the next month and then the second interview will be 2 weeks after the first interview. e. Would you be willing to take part in 2 journaling exercises? I will be asking for at least one journal entry prior to the first interview and another one prior to the second interview.

2.

If the person was eligible based on the answers to the questions above, additional study details were provided and contact information gathered. The participants were then consented for the interview.

3. Subjects then participated in two 60 minute interviews. The interviews were conducted within one month of the screening. All interviews were conducted via zoom. All

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interviews were recorded and transcribed. The interviews were semi-structured to allow space for the participant to have a voice in what is covered.The questions were open and expansive to encourage the participant to talk at length. a. Tell me about your relationship with the deceased before their passing. b. Tell me about the ways you have stayed connected or “continued the bond” with the person who died. c. When thinking about the ways you have stayed connected, in what ways has it been helpful? Please go through each one and discuss the ways it may have created growth or improved your psychosocial health. d. When thinking about the ways you have stayed connected, in what ways has it been harmful? Please go through each one and discuss the ways it may have thwarted growth or negatively impacted your psychosocial health.

4.

After the first interview, I reviewed the information in order to prepare myself for the follow up interview. I reviewed this information with the participant in the second interview in order to ensure that the assumptions and summary of the first interview was correct.

5. I took notes during the interview to ensure I remembered thoughts and feelings that arose during the process. I also wrote down my recollections of the interview experience itself and observations, in order to ensure I used my “first reactions” in understanding the data (Flowers et al., 2009).

6. Given the sensitive nature of the information discussed, referrals for psychotherapists were offered and provided if the participant expressed interest. All transcribed information was kept locked in a file cabinet. Any electronic data was encrypted.

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7. I utilized member checking by summarizing my assumptions and confirming them with the participants. I asked participants to edit, clarify, and elaborate as needed (Carlson, 2010).

Data Analysis Since there were seven participants and each had two 60 minute interviews, this yielded fourteen hours of verbal data transcription. The interviews were recorded and then transcribed using transcription puppy. I used the IPA method which includes four steps 1) Reading and rereading, 2) Initial Noting, 3) Emergent Themes, 4) Searching for connections across emergent themes.

Step 1: Reading and re-reading: I immersed myself in the original data, which were recordings of the interviews and written transcripts. This was reading and re-reading the data and listening to the recordings as well. Flowers and his colleagues (2009) recommend “it is helpful to listen to the audio recording at least once while first reading the transcripts. Imagining the voice of the participants during subsequent reading of the transcript assists with a more complete analysis” (p. 82).

Step 2: Initial Noting: I maintained an open mind and noted anything of interest within the transcript. During this part of the analysis, I underlined text which seemed important and wrote in the margins why I thought it was important. I also freely associated from the participants' text and wrote down whatever came into my mind when reading certain sentences and words (Smith, et al, 2009). Smith and his colleagues (2009) state Overall, as you move through the transcript, you are likely to comment on similarities and differences, echoes, amplifications, and contradictions in what the person is saying. It is important to engage in analytic dialogue with each line of the transcript, asking

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questions of what the word, prase, distance means to you, and attempting to check what it means for the participant (p. 87) Step 3: Developing Emergent Themes: Once I had read and re-read the transcripts multiple times and taken sufficient notes, I started to develop emergent themes. I made a list of all the potential themes for each participant. In looking for emergent themes, the task of managing the data changes as the “analyst simultaneously attempts to reduce the volume of detail whilst maintaining the complexity , in terms of mapping the interrelationships, connections, and patterns between exploratory notes” (Smith et al., 2009, p. 91).

Step 4: Searching for Connections Across emerging themes I used charting and mapping to make sense of how the themes fit together. Some of the themes were used while others were discarded. There were several strategies in IPA that can be used for making connections between emerging themes, including abstraction and subsumption. The abstraction method involved developing super-ordinate themes, which meant I put like with like and developed a new name for the cluster. Subsumption is similar to abstraction but operated where an emergent theme itself required a superordinate status as it helped bring together a series of related themes (Smith et al., 2009).

Ethical Considerations

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This study was submitted to the IRB at ICSW for approval and was maintained throughout the study. Informed consent was gained prior to the interview process and was revisited within the interview itself.

A possible ethical consideration was the sensitivity of the material. The loss of a parent is considered traumatic and this process may bring up unconscious and difficult material for the participant. I made sure to have resources on hand if participants needed further support and wanted a space to continue to process their loss. I ensured the participant knew that their participation is voluntary and they can drop out of the study at any point. Participants were informed that they could decline to discuss any aspects of their loss or continuing bond if it felt too distressing. I also monitored the effect of the interview on the participant. If I noted that they felt uncomfortable with a particular line of questioning, I used my clinical judgment to figure out the best way forward (Smith et al., 2009).

At the close of the interview, I debriefed with the participants to provide an additional opportunity to process the material discussed in the interview. I also provided each participant with my contact information if they have any additional reactions from the line of questioning or information discussed. As mentioned above, I provided a referral to a professional therapist if the participant was interested.

I was diligent about confidentiality throughout the entirety of the study and informed the participants of the ways their information is being protected. I conducted the interviews on a HIPAA compliant zoom line. In addition, I used pseudonyms for all participant names in the transcripts. Furthermore, participants were made aware that all identifying information will be removed from the transcripts and write-up. Even members from my dissertation committee only looked at the transcript with pseudonyms.

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Limitations Given the small sample size, the study was not generalizable. However, my goal was to discover a deep and meaningful understanding of the phenomena (Cresswell, 2018). Since I was trying to focus on attending to the participant’s' world, it was important to bracket my own hunches and theories about the phenomena under study. By journaling and recording some of my own personal experiences and responses to the interview, I was able to understand how they may be tainting the data. To ensure I did not have any leading or closed questions, I reviewed my interview questions with my research committee (Smith et al., 2009). I also reviewed my analysis with my committee to ensure it lacks biases.

Issues of Trustworthiness: While there are many ways to assess the quality of this research, Smith et al. (2009) recommend adhering to Lucy Yardley’s four principles: 1) Sensitivity to context, 2) Commitment and Rigor, 3) Transparency and Coherence, 4) Impact and importance 1. Sensitivity to context: Conducting a good IPA interview requires skill, awareness and dedication. I did this by paying attention to the existing literature on the topic, and the material obtained from the participant. I conducted a thorough review of the existing literature including any studies and theories around my chosen topic. In order to conduct a good interview, it requires showing empathy, putting the participant at ease, and recognizing interactional difficulties. It is important to conduct a good interview to really understand how the participant is making sense of their experience.

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2. Commitment and Rigor- Yardley also highlights the importance of thoroughness of the study and the completeness of the analysis undertaken: One needs to be careful to keep the balance between closeness and separateness, to be consistent in one’s probing, picking up on important cues from the participants and digging deeper, novice researchers find doing this demanding, and training and supervision is important in helping to ensure qualitative psychology is done rigorously.

I worked closely with my committee to prepare and gain skills to ensure that my interview and analysis is thorough and complete.

3. Transparency and Coherence A researcher using IPA may attempt to enhance transparency by carefully describing how participants were selected, how the interview schedule was constructed and the interviews conducted, and what steps were used in analysis. I was transparent with all the steps taken from start to finish in my dissertation write up. In terms of coherence, it is referring to the degree of fit between the research which is done and the underlying theoretical assumptions of the approach being implemented. I worked to be mindful and clear about how my assumptions and approach were aligned.

4. Impact and importance- The last of Yardley’s four principles states that the most effective way of evaluating the research is whether it tells the reader something useful or important. I feel confident that this is a topic that is significant, clinically relevant, and will add to the body of research in this area.

In order to ensure validity, I use triangulation of the data through interviews, diaries, and journaling. I also utilized ongoing meetings with my committee to ensure the study was valid and

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reliable. I fully reviewed the information with my dissertation committee from my initial notes, interviews, themes and then the final report to ensure “a coherent chain of arguments runs from the initial raw data to the final write up” (Smith et al., 2009). In addition, I utilized member checking as this enabled me to see whether the data analysis is congruent with the participants' experiences (Carlson, 2010).

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Chapter IV

Findings

The following is a presentation of my findings from interviews collected from 7 participants between the ages of 23-42 who lost a parent before the age of 18. By using an IPA study, I aim to understand the experience of continuing bonds with the lost parent. I will ground the study in the individual, subjective lived experience by beginning with a brief description of each of the participants. I will then move to discuss the core themes among the participants.

Before I introduce the participants, I wanted to share about part of my experience when I first posted the study information on two forums, Hello Alma and Women’s Mental Health Consortium. I was astonished by the influx of responses I received from so many different people. Within a few days, I had filled up the slots in my study and participants seemed so eager to get started. I wanted to share some of them below to further highlight this point:

I am so interested in this study! I am outside of your parameters (was 19 and 25 when my parents died and am 50 now; my sister was young enough -- was 16 and 21, but is also too old at 46) but really jive with continuing bonds and would love to read this study when it is published.

If you think of it, as I know that will be a ways out, please let me know when you write it up.

Hi. I saw your ads about the above study and will be happy to participate in this study. I am 30yrs old and I got my Dad when I was just 15yrs old, will be glad to share my experience with you. Look forward to hearing from you.

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My name is X and I am interested in being a part of your study. I lost my mom when I was 11 and I am now 23. If you need more participants, I am available. Let me know! As a fellow psych graduate, I think what you are doing is really neat! Good luck.

I received dozens of emails such as the ones above. The reason it felt important to share about this part of the study journey, is that for me it highlighted the longing these adults had for their parents who passed away. I also wondered whether participants had not been asked about their deceased parents in so long and used this study as a way to share and connect to the lost loved one.

Introduction to Participants

Pseudonym

Current Age

Age at time of loss

Deceased Parent

Identified Gender

Race/Ethnicity

Stephanie

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15

Father

Female

White

Kiara

25

15

Father

Female

Black

Josh

35

13

Father

Male

White Hispanic

Tamara

25

16

Father

Female

Black

Abby

28

4

Father

Female

Black

Judy

35

8

Mother

Female

White

Sofia

42

7

Mother

Female

White

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Stephanie.

Stephanie is a 34 year old single heterosexual woman who identifies as Caucasian and Jewish. At the time of the interview, she reported that she was starting a job in the coming weeks in marketing. Her father passed away when she was 15 years old suddenly from an acute accident. Stephanie identifies her sister (3 years younger) and mother as her primary family.

When sharing about her father’s passing, Stephanie described that her father’s passing was followed by the uncovering of severe financial distress since her father was spending a lot of money to keep up with their lifestyle: He left us in a precarious position. I think he just wanted to keep up a certain lifestyle that we probably could not, that we couldn't. My mom was a very, very successful businesswoman, totally very well respected and we sort of had nothing when he passed away.

Stephanie fiercely tries to protect her father’s positive memory despite the “post-death money stuff.” When she described her father, she shared that he was a big shopper, he loved all that stuff and he was very focused on health and wellness, working out every day. She smiled when sharing that he was just a fun guy, a very good, normal person… “We had dinner together every night, he usually brought us to school in the morning. He was a very present father… I just feel like he was involved in my social life and my friends and hearing about everyone”.

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Kiana.

Kiana is a 25 year heterosexual old black woman. Kiana is a journalist and has her own online blog. Her father passed away 10 years earlier, when she was 15 years old from an illness, he had been sick for 3 years. She is the youngest of three children and her mother and father were married prior to his passing. Kiana described her relationship with her father as “very close” and shared that “he was a nice person. The nicest person I've ever met in my entire life. And he was a sweet dad. He was more like a best friend at the time.” Kiana was one of the few people who described and felt her father was now in heaven. This seemed to be important and meaningful for her and made her “happy” to think of him there.

Josh.

Josh was the only male identifying participant in the study. He identified as heterosexual, white and hispanic. He is 35 years old and was 13 years old when his father passed away from cancer.

His parents were married and he has no full siblings, but reported that he has a half sister. When asked to described his father, he shared My dad was a very wonderful person. He was very, very smart and very gentle and kind and good-hearted, all at the same time… He was very, very intelligent, but what I remember most growing up about him is not his intelligence, which I understood better as an adult, but just how kind and good he was. He was a beautiful soul, he was just very sweet and strong. Just a great human being…Everyone who talked to him said he's so

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patient and kind and open, and yet he has these nerves of steel and this inner strength, so he was a very remarkable, a very remarkable person.

Josh continued to share that his father was often away for work, but when he was home, they spent real quality time together. He told me about one of his earlier memories with his father “when he came home and I managed to run across the living room to hug him, and so I always remember him being very affectionate and kind with me, and tender and teaching me things, showing me things.” Josh described that his father got him interested in science fiction. In addition, his father would take me to school and they would walk hand in hand, and shared warm memories of a vacation where they watched movies together and swam around in the hotel pool together.

Abby.

Abby is a 28 year old heterosexual, black female. She was the youngest participant to experience the loss as she lost her father at the age of 4 years old. She reports her parents were married prior to her fathers passing and she has a brother and sister. She identifies as Christian and often spoke about prayer and church during the interview. When describing her father, she shared Okay. So he's a very hard working person [inaudible] for sure. He was a person that like wants to provide for his family and he loves his kids. And unfortunately, I don't have much memory of him. So the ones I know are the ones that were told and from pictures and still believe so I could remember and I was kid.

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Abby’s father was a medical doctor and placed a strong emphasis on education. She shared that his last words were emphasizing her education and because he really wanted them to graduate from school. She is a nurse and spoke about how this is connected with her father’s profession.

Judy.

Judy is a 35 year old heterosexual female who is married with a young baby. She lost her mother when she was eight years old after she had been sick with cancer. Judy has one younger brother and her father remarried after her mother passed away.

When I think back to that time, I'm always kind of filled with like, that was like my person. We were super close. She was sick for quite some time. She was sick for 3 years prior to her death, but in all of my memory, I don't really have too many memories of the sickness so much, like a few distinct ones here and there, but overall, those last 3 years were still filled with happy memories…don't know if I'm just idealizing it later, but when I think back to that time, it was kind of one of those ideal mother-daughter relationships.

Judy described some of her memories as her mother being very involved in her school stuff. Her mother was on the PTA, volunteered to make costumes for school, and always came to all of Judy’s plays. She described remembering her mother;s work as a nurse being a source of pride for Judy at a young age. She also shared having vivid memories of her mother running and spoke about a perfume that her mother used to wear. Judy became tearful when sharing about one of the last memories with her mother.

One, they gave us, us being myself and my brother, a Nala, and a Simba, like from the Lion King stuffed animal. I remember she said, this is like, sorry. She said that she had

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kissed it infinitely times like if I ever needed it, it would be there for her, and that she had kissed it forever, and that was really special.

Sofia.

Sofia is a 42 year old white heterosexual female. Sofia lost her mother when she was seven years old. Her parents were married prior to her mother’s loss and her father has since remarried. Sofia is married with two young children. Sofia has a younger brother and shared having step siblings as well. When asked about memories with her mother, she shared: Sometimes I wonder if my memories are conflated with memories that people have told me. I don't think that I have very many of my own. I have a few. One is connected to a chair that I still have actually, it's like an armchair. I remember sitting in her lap with her reading to me in that chair. That chair is very important to me.

Sofia continued to describe her childhood in the “country” and remembering “her laughing when she was sharing a particular song with someone that she just thought was hilarious and just such a joyful, genuine big laugh…She loved Amy Grant, and so I definitely listened to a ton of Amy Grant”.

Sofia spoke about remembering her mother throwing her a birthday party. “That was fun.

It was like a tea party with a few other girls, and we did the whole dress up thing and I think she got special china out and that kind of stuff. I remember that and having a really good time”. She described her mother as a people person “she just liked people, and she liked having people

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around, and she liked welcoming people. She always had the bible studies that she was a part of, people were over at our house a lot. She just liked having people over, and being with people''.

Tamara.

Tamara is a twenty seven year old heterosexual black female who is married with a young baby. She lost her father when she was sixteen from an illness. He was sick for about 5 years before he passed away. Tamara’s parents were married prior to her father’s passing and she is the youngest of four siblings in the family. Tamara’s main memories of her father include hunting and sketching in his gallery. When asked about her father, Tamara shared He was a great man. He was too good to be true. He was an extrovert. He was always the life of the party. My mom is an introvert. A very quiet person. She's basically like me. I mean, I got the attitude from her. I don't really talk. So he tries to shake that out from me.

I guess that's the reason I was his favorite child because all my other siblings are extroverts. They joke around, they play a lot, and I'm always by myself. So he tried to keep me around himself, tried to shake out the quietness from me. He tried to make me very lively because I'm always very quiet.

Themes I will now present thematic data derived from the interviews with the seven participants. Each participant was interviewed twice for approximately one hour each. My interviews were coded and then compiled and clustered into core themes. My analysis yielded five core themes: 1. Continuing the bond on my own

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2. Finally feeling ready 3. It’s every emotion 4. Looking for love 5. Internalized continuing bond

1. Continuing the Bond on my Own

The first, and likely the most present theme, was this idea that the practices and rituals of continuing bonds were done by participants mostly on their own. Participants described thinking about the deceased, looking at pictures, visiting the cemetery, doing activities that reminded them of the deceased, but they would do these rituals alone. Many of the participants also reported that they did not share about the deceased with others and continued the relationship with the deceased on their own. Participants described that is often something that was “unsaid” or “unspoken”, specifically with immediate family members who also experienced the impact of the death.

Sofia, who lost her mother at seven years old, shared:

(Sofia) But as a child, I felt very isolated, I think, because we just didn't talk about stuff. Again, it's not because it was explicitly taboo, it just wasn't brought up very often. Or at all…I think that goes back to when you were asking about, you know, just how much was it discussed and the fact that we really didn't, it just was much more of an unsaid understanding with each other. I think an unsaid, caring understanding, but it was still unsaid.

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There was an emotional and delicate way that participants spoke about the lack of sharing continuing bonds with others. When exploring this further, it seemed that the reasoning or meaning differed between participants. As indicated in the excerpts below, some of the participants shared fears that if they spoke about the deceased it would upset others. For example, Kiana who lost her father when she was 5 years old, described that her brothers and mother would become too emotional or upset when she would bring up her father. Kiana shared the following:

(Kiana) Yeah, we all get so emotional whenever we're talking about him but most of the time they do not like talking about him because they do not want that emotional part of them to come out. So they prefer to keep it inside of them. They'll feel like the memories are better off inside rather than sharing out and kind of bringing those memories because they feel like they are living that moment of pain again…I don't really like talking about him with my mom because I know that mom might not hold it. She would just tear up and I would tear up and I'll feel guilty.

Sofia also shared feeling worried how talking about her mother would impact others:

I didn't want to talk about it because I didn't know if somebody else was going to be uncomfortable, and then I was going to feel uncomfortable and then well, I've messed up the happiness or equilibrium of whatever's happening.

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For some, the need to hold it on their own seemed like a defense against the pain and magnitude of the loss. For example, Stephanie, who lost her father when she was a teenager, shared the following:

I just don't like to talk to them about it. I would get emotional and I just like prefer not to. So, unless something comes up or there's a reason to, it's not something we like talk about…I think the past five years, I moved to Chicago seven years ago and I think since I've been able to separate from my mom and sister physically, I've been able to focus more on myself and handling things… We'll text the three of us and acknowledge it but I typically just on his birthday, I usually will do something for myself. Like, I think this year I took like a tennis lesson and a massage and that to me is ideal.

Stephanie shared that she does solo activities to honor or remember her father. She will go get a massage, look at picture albums, or listen to songs that remind her of him. She has purposefully avoided sharing this experience with others and especially her mother and sister.

Two of the participants spoke about how their surviving parents had remarried and they were unsure how to navigate bringing the deceased parent into this new family dynamic. When Sofia described how she recently started to continue the bond more, she stated:

(Sofia) And so, wanting to be more okay with and not feel badly about needing that connection or just even just admitting how much I wished my mom was here and that that wasn't a slight to my stepmother or to my current family.

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Judy, who lost her mother at 8 years old, shared a similar experience to Sofia. She described that part of her reasoning for internalizing this connection was to protect her stepmother and the role she played in Judy's life:

So it's like I've always had this kind of funky family dynamic where it's like she's my stepmom, but not really. A lot of stuff I did or a lot of the things that I think were kind of maybe more internalized because I didn't want to offend her now in this kind of new role. I feel like I keep a lot of thoughts about her inside rather than expressing that out.

Judy's main ways she connected with her mother was through active thoughts and looking at possessions or keepsakes from her mother. This included a baby book and a stuffed animal her mother gave her. She described that when she sees a beautiful sunset she thinks about her mother. While Judy did not continue the bond with her immediate nuclear family, she did stay very connected to her mothers and cousins which she saw as a direct link to her mother.

In contrast to the experiences noted above of practicing continuing bonds on their own, two of the eight participants shared finding comfort in revisiting memories of the lost parent with others.

Ashley, who lost her father when she was four, shared in this quote below that she found it bonded her with others and gave her family strength following her father’s death:

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(Ashley): That's the main thing we do and we stay connected to him by being together, for my family most of the time. That's also a very strong bond to stay connected because we were all together. We think about him a lot. And then, we start to talk about him most of the time, and share memories about him, and talk about the things he has done and what he would have say.

We share literally almost everything with our family. Because we have to stay strong together.

We just have to stay strong together for one another. And, because we, it's literally things that like, heavy for all of us, it's literally the same pain for all of us. So, we just have to stay strong for one another, and be there for one another when the breakdown sets in.

John, who lost his father when he was 12 shared that it helped him continue the bond by making them feel present:

I think it's good, so I always appreciate when a conversation turns to one of my family members who has passed away, like my dad, because it's, it's a nice opportunity to make them present in that moment.

It seemed that many of the participants had varying reasons for continuing the bond. I wondered whether keeping it inside created shame and guilt around the need to stay connected. It also fostered silence around the deceased person, not allowing the participant to learn about their loved one and hear stories.

2. Finally Feeling Ready

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In this study, I was also working to answer the questions: How does the relationship to the deceased evolve and change over time from childhood to young adulthood? One of the central themes deduced from this question is that many of the participants did not continue the bond consciously immediately following the death, but took a more active approach once they felt “ready.” For some participants, this was only a few months and for others it seemed more like years. For some it was a specific event that precipitated wanting to start connecting more, such as a wedding or moving away from family. Some of the participants seemed driven by a fear of further losing the parent as they felt the memories fading, such as the sound of the parent’s laugh, smell, and feeling of their touch.

Stephanie described that as she was getting older, she worried if she did not bring her deceased father into her life now, she would struggle to remember him:

(Stephanie) I think I just was like, I had a dad and I missed that and wanted to make sure that I didn't... I'm at a very pivotal age, in my early 30s, if I don't do this now, I probably never will have the opportunity to remember him well and I remember him pretty well. It just seems like a different lifetime ago because it was a pretty long time ago. Almost 20 years. So, it gets harder to remember the least you do and it's obviously sometimes hard to think through all the things and the memories because it's sad obviously, but it's good to...

Stephanie continued to share how she has started to connect with him more recently:

So it's kind of an array of things but I think over the past five years I've started to figure out how I can connect with him more just because I really didn't for so long and it's how can I... and I

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regret it, I tell people who lose someone really quickly or young, you need to have pictures around, you need to have the conversations, you need to talk about him or her or whomever because it helps. Pictures help, whatever.

While for Stephanie it took many years to feel ready, for Kiana it was just five months that she needed. She described feeling angry right after her father passed that she was not emotionally ready to attend his funeral, she said.

(Kiana) I couldn't go. After I guess 5 months, I felt that I should go. I should get over it. And I just woke up at night, I guess by 9 or 10. I just woke up and went to where he was buried and I stood there. And tears were rolling down my cheeks. I felt his arm around me and I cleaned my eyes and I was like talking and I felt like he said something in my head. I don't know if it was an imagination, but I felt like I had his voice in my head and he was like "You'll be fine, you need to be strong as I told you. No matter what the problem is, everything will pass.

Sofia described in the past five years she sent emails to her mother’s friends to gather stories about her mother. She reached out to them and asked for a letter or a story, “just tell me what your memories are of her and your friendship and who she was? I was able to get some of those things.” Sofia continue to describe:

Let's see. It's been pretty recent, in the past five years or so that I sent emails to friends. I'm just trying to think about other things as I go through. I think as I got older, as an older child and a teenager, if somebody were to mention her, I felt more I could ask about her. One of my best

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friends, her mom may have said something about my mom..But I got a little bit more able to engage. Instead of listening and being passive, I was able to engage more..

For Sofia, she also shared about the event that precipitated her starting to continue the bond more with her deceased mother. She described, that when she got married her step mother honored her mother and this was very meaningful for her and pushed her to start doing more like this:

She put a vase up on the altar. And put a rose in it after walking me down the aisle in memory of my mom. She's going to start making me cry. I didn't know that she was going to do that and that was very meaningful to me because we never talked about it…But also, as I can think larger, outside of just myself and my own human experience of it, that should be something that people just do. Or something of the sort, to know that there's a significant person that's missing, from that type of ritual or whatever. I think things like that, that might have happened also helped because of how overwhelmingly that affected me in the moment, I realized I need more of that.

Clearly, there's something about that that I need more. But I was still pretty young, 22 is still pretty young.

Sofia continued to describe how this act at her wedding impacted her. She also described how maturing over time helped her understand her family dynamics more and enabled her to bring her mother more into her life.

The timing just sort of coincided, right? Like, I happened to get married all the time and she did this really beautiful thing that just so affected me at the same time over the following years that I would feel less and less attached and integrated, and realized that I hadn't been when I thought I was. And so, wanting to be more okay with and not feel badly about needing that connection or

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just even just admitting how much I wished my mom was here and that that wasn't a slight to my stepmother or to my current family. That it was okay to really want and need that, I think. I think it's just all those pieces of like, you know, your 20s, you learn so much.

Josh shared that it was not a precipitating event, but for him it happened over time slowly. For him specifically it was staying connected to his father through his other family members.

It was slowly over time that I learned to reintegrate family bonds without feeling that they were strictures, without feeling that there would be regressions. But that synthesis came about, I would say, over the course of my mid-to-late twenties.

The participants seemed to have different trajectories, precipitating events that altered the continuing bonds, and varying time frames, but for most of them there was a change over time in “finally feeling ready”.

3. It’s Every Emotion This theme captures the emotions that are evoked when continuing the bond with the deceased, which as one participant put it, is "every emotion". It seemed continuing bonds brought up both feelings of comfort and pain, happiness and sadness, and others in between. This theme is connected to the following questions that the study was looking to address: What is your subjective experience of continuing bonds?

I am theorizing from the interviews that the emotions experienced while continuing the bond is connected with various factors including: the type of continuing bond, time since the death, and whether the activity was planned or unplanned. Continuing bonds also comforted

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participants by enabling them to connect to the loved one's presence, but it also brought up pain around their absence.

Ashley described that for her it was more dependent on the day, some days she finds feeling happy and relieved, while other times she breaks down.

Ashley: Well, it's two-sided because sometimes I might look at it and feel happy, saddened and just feel relieved looking at them (pictures) or reading through the diary. And then, some days, I just break down looking at that or reading the diary. I just break down.

Judy also described feeling a range of emotions when engaging in continuing bonds.

Yeah. It's weird. It's emotional but happy, but also, I don't know, it's like every emotion. I'm sure that's probably what everyone says. But, yeah. And I know it's not a light thing, so it's like I don't really go out of my way to do it unless I want to look back on something. But I think overall, I guess, even now thinking about it's like a warm kind of happy feeling, but then also just emotional and sad too.

Kiana, John, and Ashely all shared a similar sentiment around feeling comfort in connecting to them again, but also pain in not fully being able to experience their presence. Kiana shared the following.

Kiana shared: I’m happy like I just get excitement inside of me, but at the same time I cry because he is not here with us and we know he's now in our memory and we no longer see him and stuff like that.

So that will make us cry. And that day he left. Whenever we talk about that day, that part makes

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me cry very much because it still hurts so much…whenever I go to the cemetery, I just get so emotional. Most of the time I weep, I cry because I just feel like, it feels like I was looking at him yesterday, and today he is no more. And I'm looking at him that it's down there in another world.

So it feels so emotional and at the same time, I get this energy whenever I go there, no matter how worried I am when I just go there, I just feel at ease because I feel like he's there with me…

I would say I feel happy that I'm still seeing this, that they belong to my dad and I can still see them and feel them. And at the same time, I just have these memories that I wish he was still here. A little bit of sadness that I wish he was just here with us just putting on those caps. So that's it.

Ashley shared about her wedding day specifically and the pain in feeling his absence:

Well, it feels difficult in a situation where maybe if you feel like, if he was here he would have done this. A situation where you feel like if he was here, this was what he would have been doing or maybe let's say, a situation whereby you need a father figure for me. So, that's a very difficult situation for me to think of whenever I feel like, just for example, I talk about my wedding day.

So, on my wedding day, that was so difficult for me because if he was here, this is his rights, this is what he would have done, this is just his place, you get? Like, this is where he's supposed to be. So, in a situation, which you think of, if he would have been here, this is what he would have been doing, it's just what we find difficult. And the comforting one is, sometimes, you just feel like talking and seeing things. And then, when you remember the good memories are the comforting ones.

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John shared feeling similarly:

I'm just very grateful for all the things in which I do feel them present, like, in the things they taught me, the ways they've influenced me, the ways they've influenced my loved ones, my mom in this case. And the negative is just wishing that they could experience the nice things today with you, like, the upcoming birth of my child.

Stephanie shared how her feelings are connected to whether the continuing bond was expected or unexpected. In addition, she shared being intentional about creating separate spaces to experience the different feelings.

I mean it depends on the setting where you are because if you're hit with it kind of randomly sometimes walking somewhere even like a smell it could be overwhelming, but if I choose to do something, choose to put on a playlist, typically just a relaxing type of thing, I think maybe two to four times a year I'll have a crying session type of thing where it's just emotional and they're usually around his birthday, the anniversary, the very pivotal type of times just because it all hits you… I just like reminiscing. I like looking back on things. I like the memories because it was all very happy and positive.

Kiana was one of the few participants that spoke about believing her father was in heaven. She shared that it gives her both peace and comfort, but at the same time she wishes he was here with her.

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Okay, so there is this song that they say in heaven, they sing hallelujah songs every time. So I'm just like seeing him, is he putting on the garment there and is he singing hallelujah to God? How's he coping? How is he doing over there? What's it like over there? And whenever I think about that, there's a little bit of sadness that comes because I feel like he should have been here with me till now, but at the same time I'm happy that wherever is, I just hope that he's in heaven and I pray that he's safe there and yeah, he's watching over me and my siblings and my mom. So, I would say it's a little both emotions, a little bit of sadness, but more of happiness because I feel everybody would want their parents or their loved ones to be in heaven because there's peace there and that's why everyone would want to be after death.

The interview was helpful in understanding that continuing bonds is complicated and multidimensional. There are aspects of it that bring people warmth and comfort while other parts that bring pain and sadness.

4. Looking for love As I have heard people say, “there is no love like a parent’s love.” A theme that seemed to come up often, is that the participants were really yearning for this love, and were continuing bonds in ways that connected them to this love. While people were looking to connect with the deceased through the continuing bond, it also seemed like a search for the comfort and love that the parents provided. Participants also spoke a lot about longing for the love of their parents in their biggest accomplishments. The life events that were brought up in the interview included graduating from school, getting your own apartment, starting a new job, marriage, and children.

Since the participant did not have the parent physically there during many of the big life milestones, they described wanting to feel the love or pride from them internally.

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Judy shared about missing her mother’s love especially after having her own baby.

(Judy): Yeah, I'm very lucky about that. So, Chris's mom was eager, like, so excited, and wanted to help. And then I was going to ask my mom, I call her my mom, she's my stepmom. I was going to ask my mom, but I knew that she wasn't going to want to and I felt like I should still ask because Chris' mom wants to do it three days a week, shouldn't my own mom want to be spending time with her grandson? I asked her and she said, no, she said that she couldn't commit or whatever, and immediately, it just brought me back to thinking about how my mom was so present in my life as a child. I told you before she was on the PTA and Elementary School and put together all my costumes for the little plays that I did and stuff and I just thought to myself if she were here, she would be, like, "Bring him to me," or, "I'm moving in," essentially. Like, "He's my son now." Do you know what I mean? She would be over the moon at the opportunity.

Judy continued to share that her wanting to preserve the relationship with her mother’s family to continue the bond was really a search for the love her mother provided.

It feels like, I don't know, it feels like my people. Obviously, I'm accepted within my own family.

My dad loves me unconditionally. My stepmom, I think, loves me unconditionally to the degree in which she can, but I've always felt like, I don't know, and I feel like it now and I know we'll probably talk about this again, but I feel like it now as a mom that there's no one that loves you as your mom loves you. And so I think my whole life, I've been searching for that unconditional love.

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Sofia shared about the objects left to her from her mother, including a couch and Christmas ornaments as a way for her to feel connected to her mother’s love.

Yeah. Or just trying to feel it. Like, if I can sit in the chair and just be like, that's how I would've felt if she were here. And so, I do belong and I do, you know, I am important in this family and I am, you know, it is a way of me trying to be able to touch it since I don't have a mom to hug me and tell me that. And so, yeah, I think that those objects help, you know, and the fact that she made specific things for me because they were fun or they were meaningful and special. Like, she made them for me. It wasn't just like, eh, yeah, I guess you can have it. You know, it was with me, me in mind, and that I was important enough for her to take time and do something beautiful, and that kind of thing, for me.

Kiana shared wanting to feel her father’s love or pride in the big moments of her life And I just told my mom that, if dad was here now you would be happy to see us like this... So, whenever I remember those moments and I remember how he's going to be picturing me and how he's going to be feeling proud for what I and my siblings have accomplished now in that fact that we didn't stop, we kept pushing for work. So that's a genuine feeling and a very important thing because of the fact that he is not here but at least wherever he is, he's going to be proud of his children…When I got my own apartment, I feel like wherever he is in heaven he would be so happy for me because I am now becoming a woman that I dream of becoming and all the he wanted me to be… I feel like he would be happy and glad that I didn't give up and I kept pushing forward. I feel he would be super happy that his daughter is now a journalist, and now, she’s about to begin her life where she has to be self dependent and stuff like that. At that moment, i feel like wherever he is, he was super proud.

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Ashley also shared bringing her father with her to the big moments as a way to feel his pride and love.

Well, because given into mind already, he's already part of that. And me which missing the fact that he said so. That was his last wish. I literally took him along. I feel like he's always there with me every time, every step I took when it comes to education. So, on my graduation day, my mom and my family were there. And, I just feel like he was there ,too, with me. Since the feelings are fixed in your heart so, I just feel like he was there and my graduation went smoothly. Just okay, and then I graduated with a very good grade. Very good results. We're so happy because I feel like he would have been proud of me if he was there.

Josh described beautifully the way he will continue the bond by giving his son the love he felt from his father. It seemed that by loving his children, he was feeling the love and lessons his father gave him.

Yes, so I'm older than my dad was, and I'm going to be going through residency, which means I won't be physically present all the time, but I'll have a lot less free time, so that challenge is always on my mind. Like, how do I give my child or children, all of the emotional energy and time that my dad did, and I guess my best answer so far is that the quality time matters. Like when I'm there, then it's about being really present and really having meaningful time, and there's lots of parents I can imagine are home all the time, but in their newspaper or on TV and not really spending quality time, so I think that that's where I will try to sort of give the same emotional inheritance, and love and energy that my dad did to me, to my child or children.

It seemed that the participants really missed the love their deceased parent showed them

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and found ways to connect to that love. Whether it was through connecting to their own children, keepsakes, or feeling their pride, they seemed to feel comforted by reconnected to that love. It was clear that the void created from the loss was also a loss of love. By connecting to the love and continuing the bond, it may have helped to fill that gap and ease the pain of the loss.

5. Internalized Continuing Bonds This theme, internalized continuing bond, is conceptualizing how participants continue the bond in more of an internalized and unconscious way. It is answering both the questions 1. How do people who lost parents as children (under 18) continue the bond/relationship with the deceased into adulthood?

2. How does the relationship to the deceased evolve and change over time from childhood to young adulthood?

There was a sense when participants were talking about the internalized ways they continue the bond, they struggled more with how to verbalize it. Since so much time has gone by (ranging from 10-34 years since the loss), participants seemed to have adapted fewer active or externalized continuing bonds, such as visiting the graveside, engaging in rituals, or using the deceased personal belongings for comfort. Instead, they had strengthened their parents as the internalized secure base and maintained the connection within themselves. Some often shared feeling guilty about not doing observable things actively to remember the parent all the time, but it seemed that it had been transformed from external to internal. While they do not consciously hold the parent with them, it seems the parent almost becomes something else, something internally there.

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Some of the ways that participants shared internalized continuing bond is the parent becoming part of them, feeling valued because of how the parents were valued, holding memories, and using the parent as a guide. For example, one participant shared feeling important because their mother was important.

In the present, it seemed that participants felt comforted from the parts of their deceased parents that became part of their identity. In this quote below, Judy shared that she holds her mother in more of an internalized way and sometimes feels the need to connect to her more outwardly.

I think, in general, now that I'm older I think of her more in a memorialized way, whereas when I was younger she was still a person, more a real person, and I don't know if it's just so much time has gone by now but I feel like I memorialized her. I know she was a real person but not that I forget that she was but I don't think about that in my mind. Am I describing that right?

Stephanie shared how continuing bonds for her is more unconscious or in her memory. and it's almost like sometimes you do it so that it's like an unconscious awareness or whatever you call it. It's like an everyday thing that's all in the background and you're like, "Oh this was dad." But I'm not sitting just to think about him. It's just like keeping him alive in my memory and of course, yeah, I think it's just comforting.

Josh shared that he is so busy that he often does not have time to actively reflect, but has started to continue the bond by seeing traits from his father.

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I don't think I really have. I think that I've had the opposite challenge, which is like, life is so busy that I rarely take the time to just reflect within myself and think about like, explicitly take time and think about a memory…and I think that is the most beautiful way. I mean, I think that there's something very nice and looking at yourself and seeing this comes from my dad and many people remark on that.

Ashley described her graduation how her father was within her heart and this was really important to her.

And, I just feel like he was there ,too, with me. Since the feelings and [inaudible] fixed in your heart so, I just feel like he was there and my graduation went smoothly.

Tamara described using her father as a moral compass or inner guide. She also used his memory as a source of courage and confidence during hard times. It is clear that her father became her internal secure base.

I mean, I really hope that he doesn't stop being by my side or he doesn't stop encouraging me because I know that I do a lot of things that I feel that his peace with me. And so, I don't mean to be superstitious or sad, but I believe that he is with me and he tries to like tell me the right thing..And I feel like he's always with me, encouraging me. Telling me to do this and trying to direct me on what not to do…Well, I want to say that at work, even up till now, when I'm not doing really well, especially when I have presentations at work to give. I just remember when he tried to make me bring out something good from the terrible things I usually drew or sketched for him. He just tried to make it make sense.

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Sofia shared that she held onto her faith as a way to hold onto her mother internally. She also did that as a way to get advice from her mother.

I felt that as well. I knew that her faith was very important to her, and so, that certainly was grounding ease for me. It was important for her and it helped her, so maybe it will help me and should be important to me also. And hopefully, that will also then give me wisdom and, you know, somehow try to infuse advice that she would give me that she can't give me directly.

Sofia also shared that idealizing her mother and this was a way to foster confidence and a sense of belonging And so, I think that that was certainly a very lucky thing for me, that when I could think about her, I could almost idolize her in some ways, to try to help me along and to... I think it was part of feeling important and belonging too. Like, my mom was important, so I'm important. And not like in a self-grandiose way. I think, again, just more in wanting to have belonging and not feeling like I really had that in the family.

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Chapter V Discussion and Findings

The intended unit of study in this research project was looking specifically at how young adults who lost a parent as a child continue the bonds into adulthood.

The following questions and sub-questions guided my research study: 1. How do people who lost parents as children (under 18) continue the bond/relationship with the deceased into adulthood?

2. What is the subjective experience of continuing bonds?

3. How does the relationship to the deceased evolve and change over time from childhood to young adulthood?

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4. How does a person’s relationship with their parents while they were alive impact the continuing bond once they have died?

Based on the data and analysis of continuing bonds in young adults who had a parent die before the age of 18, five core themes were identified:

1. Continuing the bond on my own: Practices and rituals of continuing bonds were done by participants mostly on their own. Participants described thinking about the deceased, looking at pictures, visiting the cemetery, doing activities that reminded them of the deceased, but they would do these rituals alone. Many of the participants also reported that they did not share about the deceased with others and continued the relationship with the deceased on their own. The reasoning behind this differed among participants. Some reported fears around upsetting others if they were to bring up the deceased. For some, the need to hold it on their own seemed like a defense against the pain and magnitude of the loss. There were two participants whose father’s remarried and they were unsure how to navigate bringing the deceased parent into these new family dynamics.

2. Finally feeling ready- Participants did not continue the bond consciously immediately following the death, but took a more active approach once they felt “ready”. For some participants, this was only a few months and for others it took years to be ready to continue the bond.

3. It’s Every Emotion- This theme captures the emotions that are evoked when continuing the bond with the deceased, which as one participant put it, is "every emotion". It seemed

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continuing bonds brought up both feelings of comfort and pain, happiness and sadness, and others in between.

4. Looking for love- Participants were really yearning for this love, and were continuing bonds in ways that connected them to this love. While people were looking to connect with the deceased through the continuing bond, it also seemed like a search for the comfort and love that the parents provided.

5. Internalized Continuing Bond- conceptualizing how participants continue the bond in more of an internalized and unconscious way. Some of the ways that participants shared internalized continuing bond is the parent becoming part of them, feeling valued because of how the parents were valued, holding memories, and using the parent as a guide.

Findings Based on the data interpretation and analysis in this study, two main findings emerged from the participants experience: 1. Continuing bonds are multidimensional and dynamic. It is influenced and informed by various factors, including emotions linked to continuing bonds, time since the death, relationships with living family members, and new experiences.

2. The continuing bond relationship continued to influence the participant’s sense of self and identity long after the parent passed away. This can be seen in the participants' career choices, values, and beliefs.

Multidimensional and Dynamic

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From the data derived, I found that continuing bonds are both multidimensional and dynamic. Continuing bonds are multidimensional in that they are expressed and experienced by participants in many different ways. They are expressed emotionally, behaviorally, cognitively and relationally.

The first dimension I want to address is the emotional one, as continuing bonds seemed to involve and evoke a range of emotional responses. For some participants, the emotions expressed were linked to the type of continuing bond and time since the loss. Another factor that seemed to link with the emotional reaction was whether they were actively seeking out the connection. For example, Samantha described that when she was not anticipating connecting with her father, such as a song he enjoyed playing somewhere, she was more likely to have a negative emotional response.

Participants also described feeling grief, longing, sadness, as well as joy and relief in reconnecting with the deceased. Participants shared that while feeling glad to still be holding the parents internally, they also experienced grief and yearning for their physical presence and real life guidance. For example, Ashley shared feeling sad during her wedding because that is a place where “because if he was here, this is his rights, this is what he would have done, this is just his place.” She described feeling sad and angry that he was not able to be present as it was his right to be there. However, when she thought about her father and the happy memories, she described feeling comforted. In contrast, Ashley felt strength from her fathers emotional presence at her graduation “And, I just feel like he was there ,too, with me. Since the feelings are fixed in your heart so, I just feel like he was there and my graduation went smoothly.” In contrast, Judy on her wedding day allowed herself “10 or 15 seconds to cry and then I was like, compose yourself again, let's bring it back to happiness. Josh also shared feeling appreciative and grateful for the

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memories and influence he has of his father in his life, but saddened that his father will not be there for the birth of his child. Kiana was one of the few participants to describe her father as located in heaven, which brought her happiness to think of him there in peace. However, like the other participants described here, she was sad that he was no longer physically present in her life.

Continuing bonds are also multidimensional in terms of how they are expressed behaviorally. Each participant had different rituals and ways they stayed connected to the deceased. Sofia described having an “obsession” with keepsakes and objects related to her mother, while Josh felt this idea did not resonate with him. Kiana shared that she went to the cemetery often and found comfort in being there, but Judy rarely visited the cemetery as she said “I think it feels too final”. In addition, Sofia described that she reached out to her deceased mother’s friends to gather stories and words about her. However, Stefanie said she found it too painful to speak about her father with his friends and seemed to avoid this relational aspect of continuing bonds.

Continuing bonds also are expressed cognitively in the ways that people used the deceased parent in decision making, as a moral compass, or in remembering the person through memories. Many participants shared how their parents' values and beliefs were connected to their own. As Tamara described, she hears her father’s voice telling her what to do and what not to do.

Josh shared throughout the interview about how important it was for him to think and recall memories about his father. He would remember how he walked with his father to school hand in hand or the way his father greeted him after a work trip. Stephanie also shared feeling very connected to the memories of her father. She said in the interview “I just like reminiscing. I like looking back on things. I like the memories because it was all very happy and positive.”

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There is also a relational dimension to continuing bonds. As described in the theme “continuing bonds on my own”, there was a relational way that continuing bonds are expressed or not expressed. While most participants did not engage with direct family members on continuing bonds, there were other ways they expressed this relationally. For example, in the way they continued the bond through their relationship with their own children. For example, as discussed before, the way Sofia reached out to her mother’s old friends. Also, Judy who felt the most meaningful way she stayed connected to her mother was through her aunts and cousins on her maternal side. In addition, the lack of expressing the bond relationally for many and the need to keep it internally was significant as well.

Continuing bonds as dynamic Continuing bonds are dynamic in that there is an evolution over time as one navigates their grief journey. Based on the data derived from participants, I found that participants were at first not ready to engage in continuing bonds activities, then moved to valuing more externalized ways of connecting to the deceased, and then it shifted to connecting with the person internally.

Grief is so personal and each person does not experience the same reaction or trajectory, however this seemed to be a more general trend among participants.

As described in the previous chapter, immediately following the loss, participants described not being ready to continue the bond. For some participants, this was only a few months and for others it took years to be ready. This may be partly due to themselves emotionally against the magnitude of the loss. In addition, participants were children when the parent died and may not have been developmentally ready to understand the loss and how to grieve.

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Once participants were ready to grieve, they described the active ways that they attempted to connect with the deceased parent. For some, it was reconnecting with the deceased’s friends. For others, it was going to the cemetery, while for others it was looking at pictures, journals, and other keepsakes. In the present, at the time of the study, many participants described more of an internalized bond. While they did not actively think about their deceased parent all the time or engage in as externalized activities described above, the parent had become part of their identity and a guiding force. See below for a visual representation of this process.

Internalized continuing bond, part of the identity

Externalized continuing bonds

Not yet ready to continue bond, defensive behavior

Theoretical Integration Winnicott's theories about the concept of transitional objects offers insight into understanding this pattern of continuing bonds. According to his theory, the transitional object can function as a bridge to the possibility that a person continues to exist even if they are not in their presence or

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the person has died. Winnicott suggests that transitional objects are extremely helpful for those who have trouble holding on to the mental representations of others in their absence and are unable to form a transitional object from within. Transitional objects help during times of change and separation, and can be used by people during moments of grief and loss. At first, the participants may have struggled to hold the parent within and needed transitional objects to connect with the deceased. For example, this was seen in the way Judy looked at her memorial box and baby albums, but then slowly started to describe her mother as an essence in her life.

Also, Josh who always created newsletters to honor his father, but moved towards internalizing his father’s attributes, such as calm demeanor and fatherly traits. Ultimately, it seemed that most participants found a way to hold the parent internally and had less of a need for externalized objects for connection.

This pattern of continuing bonds also fits well with Bowlby’s (1980) phases of grief.

Bowlby advanced the existing psychoanalytic idea of grief work by addressing the interpersonal aspects of the process. Drawing on the basic tenets of his attachment theory, Bowlby conceptualized grieving as a form of separation anxiety, similar to the experience of infants being separated from their caregivers. He theorized that there were four stages of grief (a) numbness, (b) yearning and searching, (c) disorganization and despair, and (d) reorganization.

Successful grieving, according to Bowlby, was accepting the death of the attachment figure, returning to activities, forming new attachment bonds, and integrating the loss into a new reality.

When analyzing the trajectory of continuing bonds as described above, it fits into Bowlby’s stages of grief. At first, participants were “numb” and were not able to engage in the continuing bonds. Then, they moved to “yearning and searching” where they searched for the comfort they previously experienced from their parents through the process of continuing bonds.

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This is seen in the active ways participants tried to engage in the continuing bonds. Eventually the participants moved to the “reorganization” stage where they were able to internalize the bond to their deceased parent and carry it along with them. Rather than it being something separate, it was organized or integrated into their life in a more seamless way. This was noted in the way they carried the image of their deceased parent into the important moments of their life or wanted to embody their deceased parents in their own parenting or work.

Grief and attachment theorists have described loss and continuing bonds as mediated by the individual's attachment style. Those who have secure attachment styles are able to hold on to clear and coherent memories of the deceased. I want to note that all the participants in the study reported having a very positive and close relationship with the parents before they died. Based on the interview, I would hypothesize that participants exhibited behaviors that seemed to align more with a secure attachment style. I had planned to use an attachment theory lens to compare the different ways participants continued the bond based on their relationship with the deceased.

However, it seemed that all the participants described the parent and the relationship as positive and loving.

In conclusion, it seems that while there are universal themes and trends with continuing bonds, it is important to note that it is not unidimensional and static. It is very personal, intricate, and always developing. Since it is so closely connected with the participant, the person that passed away, and their relationship, it will often be exhibited differently for everyone. That being said, as indicated above, there seemed to be general trends for participants in how the relationship shifted and changed over time.

Integration into their Identity

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Participants described the ways that the deceased continued to influence and inform their identity. From what the participants described, continuing bonds allowed the deceased to be integrated into their identity. Since the participants are young adults who lost a parent as a child, their identity and bond to the deceased would naturally evolve through development and life transitions. Some of the ways the deceased parent impacted their identity development was through their life choices, relationships, values and beliefs, hobbies and self-confidence.

Many participants described how their personal life choices continued to be informed by their deceased parents. It also enabled a sense of personal and professional growth for many of the participants. For example, Abby described how her decision to become a nurse was directly connected with her father’s profession. Kiana shared how her professional pursuits were related to her father’s wishes for her to be successful and how proud he would be of her decision to become a journalist. Sofia described that since faith was important to her mother, it was important to her as well and could be a grounding force.

In terms of relationships patterns, Josh described how he wants to be a father to his son the way his father was to him. He shared hoping to have the emotional inheritance, and love and energy that his father had for him. It was important for him to be able to look at himself and notice the characteristics that came from his father. For Judy and Sofia, there were times it was difficult to know how to integrate their step mother’s into their life and still leave room for their deceased mother. Therefore, continuing bonds may have impacted their emotional availability to connect with new figures in their life or allow space for their deceased parent.

Another manifestation of the internalization of their deceased parent and their identity development was seen in the adoption of hobbies that were important to the deceased.

It also

seemed to come up that people adapted hobbies that were important to the deceased, which is

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another important facet of how continuing bonds informs identity development. Stephanie described how she loves traveling, shopping, tennis and certain songs because her father found joy in those hobbies. Josh described how he was always drawn to technology because of how he watched his father’s fascination with it. Tamara also shared how her father’s excitement for hunting and art stayed part of her life even after he passed.

Continuing bonds also seemed to have provided a moral compass for participants that helped shape their own values and beliefs. Some participants described actively talking to the deceased or thinking about what the deceased would say or do in various areas of their life. This is exemplified in the way Sofia shared how her faith is fundamental to her because of how her mother valued it. Josh also described how he started his medical residency by wanting to embody his father by always being available and present for his children when he was home. He shared that he valued quality and meaningful time with family and loved them the same way his father did.

The findings also indicated that there seemed to have been an internalized sense of pride and confidence from their deceased parents. This internalization seems to have assisted the participants in feeling a sense of love, belonging and security. This is seen in the way Sofia described feeling important because her mother was important. She also described how the objects her mother made for her, helped remind her that she is special and loved. Judy also described a sense of pride in knowing her mother was a good person who was loved by so many people. Tamara shared that when she is struggling at work, she thinks about how her father tried to bring out something good from the bad things she did. It seemed that this gave Tamara a sense of confidence and security at work and other facets of her life. Kiana described how she would internally hear her father tell her to “be strong” and this gave her courage to face challenges.

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All the participants seemed to hold onto memories of the deceased. For example, Josh describing his father as very present and holding his hand to school, shapes his identity as someone who was loved. It seemed that it was also important to Josh that his father was a world renowned chess player. His father's impact on the world made him feel important too. Stephanie holding onto the memories of her father spending time with her friends or taking an interest in her hobbies, also helped her feel valued and important. All participants shared happy and positive memories, which seemed important to their sense of self.

Theoretical Integration While Klein did not actively discuss continuing bonds, the theory is critical to my study in understanding how internalized relationships can continue to shape an individual's inner world even if they are not physically present. Klein described how internal relationships inform identity development and self concept. These relationships could impact how people perceive themselves and others. It is evident from the study that participants' identities continued to be informed by these internalized relationships even when the parent was deceased. Continuing bonds are essentially drawing upon their internalized objects and continue to impact the relationship throughout the lifespan.

Good Object and Defense Mechanisms I found myself curious about this phenomenon and wondered if the participants were unconsciously stuck in what Klien called the paranoid schizoid position. All participants (besides one) did not address any of the negative or complex parts of the relationship. Based on the responses of six of the participants, it seems that they integrated only the positive parts of their relationship with their parents into their identity. It seems that they were engaging in“splitting” and may have been stuck in Klein’s paranoid schizoid. She describes the paranoid schizoid

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position as “all objects are part-objects, and part objects are either good or bad. There is no ambivalence, there isn’t a little bit good, a little bit bad. It is all or nothing” (Brodie, p. 120). All the participants focused on the positive aspects of the relationship or the “good object” and did not acknowledge any of the negative feelings or the “bad object”.

I was curious about whether participants feared they would destroy the connection to the deceased if they engaged with any of the ambivalence. It seemed that the idealization of the deceased served an important function for the participants. Like in infants, this could be understood as a way to manage the anxiety and distress that is often present after the loss of a loved one. It also seemed that the way they viewed the deceased parent was connected to their self identity, thus possibly making it more difficult to acknowledge the complex or ambivalent feelings. By idealizing the deceased person, they were protecting the sacred relationship to the deceased. This was described well by Sofia who said “And so, I think that that was certainly a very lucky thing for me, that when I could think about her, I could almost idolize her in some ways” In terms of other defensive behaviors, I would also hypothesize that the participants may have chosen to engage in rituals alone because of an unconscious fear that the surviving parent would not be able to fully engage with them in the ritual. Therefore, as a defense they engaged in the bond alone so as to not re-experience the second loss of a parent.

Given that the surviving parent is often entangled in their own grief, the child may work to protect the parent as well as themselves. Sofia described that she did not bring up continuing bonds with her family out of fear of messing up the “happiness or equilibrium”. Kiana shared a similar sentiment, “I don't really like talking about him with my mom because I know that mom

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might not hold it. She would just tear up and I would tear up and I'll feel guilty”. The participants seemed to worry about furthering the grief of the surviving parent.

Limitations One of the limitations in the research is the homogeneity of the sample. All seven participants identified as heterosexual. In addition, in terms of gender identity, six participants were female and only one identified as male. In terms of race, the small sample was relatively diverse; three participants identified as white, three identified as black and one was white hispanic.

The small sample size of only seven participants, while normal for an IPA study, presents a limitation. While it allows for in depth discoveries, it is not generalizable and the results are limited to the lives of those that were interviewed. However, my goal was to discover a deep and meaningful understanding of the phenomena (Cresswell, 2018).

I also want to acknowledge that the study is seen through the subjective lens of the researcher. I employed various methods to address the subjectivity by bracketing my own hunches and theories about the phenomena under study. By journaling and recording some of my own personal experiences and responses to the interview, I aimed to understand how they may have tainted the data. I was also transparent with my committee by having them review the interview questions and share my analysis.

As described in previous chapters, the purpose of this study was to provide a deeper psychological understanding into how young adults continue bonds with this major loss from childhood. It is clear that one of the hallmarks of social work practice is the emphasis on relationships and connection. Continuing bonds should be an important part of clinical practice with people experiencing loss and grief. This study highlighted important patterns that are

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helpful to understand when working with this specific population. For example, given that participants fear continuing the bond with others, it is important to address this piece in the clinical space. The clinical relationship might be an opportunity to learn how to do this relationally. In addition, since so much of our work is centered around identity, values, and relationships, it is clear from this study that continuing bonds should be a crucial part of that work.

Future Research Future research could look specifically at different developmental stages in childhood and how the continuing bond differs based on the development and the age of the individual. I would also be interested to investigate further how attachment style impacts relationships, children from divorced families, or a parent who was estranged. Future research should also include looking further into culture and how that impacts continuing bonds. It would be useful to look at clinical interventions that would be helpful in developing healthy and adaptive continuing bonds. A more broad qualitative study would be a good addition to this study to understand the more broad patterns. More generally, I would like to see grief research and clinical practice move forward with work that holds continuing bonds as highly important.

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