Death Studies, 39: 75–83, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2014.890680

Internalized and Externalized Continuing Bonds in Bereaved Parents: Their Relationship with Grief Intensity and Personal Growth Dianna Scholtes and Matthew Browne School of Human, Health and Social Sciences, CQ University, Rockhampton, Australia

Continuing bonds (CBs) expression appears especially prevalent among bereaved parents. This study examined the relationship between CBs and grief outcomes for this population. A customized CB scale for use with bereaved parents was derived from the literature. Three hundred fifty-four participants (10 male) recruited from online support groups completed an internet questionnaire. A 3-factor dimensional structure of CB (internalized, externalized, and transference) was supported. Structural equation modeling showed clear links between internalized bonds and a more positive grief status; externalized bonds showing an opposite relationship. Weaker effects were found for child’s age, time since death, and type of death.

Historically, theoretical frameworks of grief have regarded continued connections with the deceased as an abnormal, pathological way to deal with bereavement. Klass, Silverman, and Nickman (1996) offered a different perspective of this model of grief, proposing that the continuing bond (CB) that the bereaved maintain with the deceased are an adaptive part of the grieving process. Historically, there has been disagreement as to whether CBs with the deceased is adaptive or maladaptive. However, recent works (Field & Friederich’s, 2004; Field, Gal-Oz, & Bonanno, 2003; Field, Gao, & Paderna, 2005; Field et al., 2013) have provided a more nuanced approach to the question considering subdimensions of CB with respect to association with grief status. Bereavement literature suggests that the type of relationship established between the deceased and the bereaved affects the type and intensity of grief experienced (Weiss, 2001). The death of a child is thus widely held to be one of the most intense and complex forms of loss (Finkbeiner, 1996; Kubler-Ross, 1997; Riches & Dawson, 2000). The special nature of the parent–child Received 29 May 2013; accepted 21 January 2014. Address correspondence to Dianna Scholtes or Matthew Browne via e-mail: [email protected] or [email protected]

relationship therefore suggests that the impact of the death of a child can have a unique and significant effect on the parent and the adjustment process for bereaved parents may be more intense and more prolonged than other forms of loss (Anastasi, 2011; Field et al., 2013). In line with Klass et al.’s (1996) concept on CB, research on child loss demonstrates that the expressions of ongoing connections are a prevalent characteristic of parental bereavement (Riches & Dawson, 2000). Thus, understanding the relationship between expressions of CB and grief outcomes appears to be particularly relevant in the case of parental bereavement.

EXPRESSIONS OF CB Continuing bond is defined as an ongoing connection between the bereaved individual and the deceased loved one with these connections being, in some circumstances the focus of the practice of grief (Klass et al., 1996). These connections can take on a variety of expressions that are woven into the fabrics of the daily life of the bereaved. Examples of these connections include visiting the resting place, talking to the deceased, dreaming of the deceased, keeping belongings of the deceased, believing that the deceased was watching over them, thinking

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about the deceased, linking objects, continued conversations, and a sense of ongoing influence (Klass et al., 1996). Thus, CB as a model of grief proposes that interdependence is continued even without the deceased in the bereaved person’s life. This model with reference to bereaved parents suggests that they maintain a connection with their deceased child and create an inner representation of the deceased child (Klass et al., 1996). Theoretical analysis of the variety of observed CB has used attachment theory to group CBs into two broad forms. Firstly, internalized or mature forms of bonds, which may take time to develop, sees an abstract internal representation of the deceased is maintained to progress with life after the loss. Secondly, externalized or immature forms of bonds, thought to be more prevalent in early or unresolved stages of grieving, and characterized by an inability to come to terms with the physical absence of the loved one (Field et al., 2013). Early treatments of CB (e.g., Klass et al., 1996) tended to focus on the internalized interpretation of CB, considering this type of connection to be symbolically based, representing a greater acceptance of the death and indicative of positive grief outcomes. The adaptiveness of these CB expressions, based on evocative memory, were evaluated by Field et al. (2005) who found that such internalized CB expressions may imply healthy CBs adaptation. More recent work has indicated that CB may not always be associated with an adaptive or mature coping with loss. Field, Nichols, Holen, and Horowitz (1999) found that a CB expression may be considered maladaptive when an effort to retain a more concrete externalized connection is displayed. Field (2006a) identified a maladaptive CB expression as one in which the bereaved searched to reclaim the deceased and was unable to accept the loss. Expressions considered to be indicative of more severe or unresolved grief include seeing the deceased’s face; hearing their voice; and maintaining the deceased’s possessions in the same way prior to death. These CB expressions, reflecting a concrete and externalized evocation of the deceased are found to be related to negative grief outcomes. Congruent with this perspective, Field et al. (2013) found that bereaved mothers whose child died as a result of violent or accidental death tended to use more of these externalized types of CB expressions. The outcome of quantitative empirical research by Field et al. (2013), Field and Filansky (2010), Field et al. (2005), Field, Packman, Davies, and Kramer (2004), Field et al. (2004), and Field et al. (2003) has supported the existence of differentiated CB expressions in terms of either internalized or externalized connections. Further, these distinct forms of CB expressions appear to indicate important differences in how the bereaved integrated their loss, which correspond to different grief=personal growth outcomes. In a study

involving 28 bereaved mothers, Field et al. (2013) found that CB expressions involving illusions and hallucinations (i.e., externalized) were predictive of greater distress. However, dream-like or transcendent expressions that appeared to involve a component of spiritual belief, or were reported as comforting rather than distressing, had lower symptom ratings.

PRESENT STUDY Research on CB clearly demonstrates that continued connections with the deceased are maintained especially by bereaved parents (Harper, O’Connor, Dickson, & Carroll, 2011; Klass, 1997; Klass et al., 1996). However, findings are subject to limitations, such as (a) presupposing an externalized–internalized dichotomy (Field et al., 2009), (b) not applied specifically to bereaved parents (Boelen, Stroebe, Schut & Zijerveld, 2006; Field et al., 2010; Neimeyer, Baldwin, & Gillies, 2006), or (c) possessing a limited sample size (Boelen et al., 2006; Field et al., 2013; Field et al., 2004). The present study begins with identifying those CB expressions commonly employed by bereaved parents, without regard to externalized– internalized type. This is followed by a survey using a substantial sample of bereaved parents (predominantly mothers), with which an exploratory factor analysis is used to determine whether the externalized–internalized dichotomy is supported by the covariance structure. Finally, we examine the utility of the factor structure in predicting grief and personal growth outcomes. In sum, we aim to test whether: 1. Individual differences in CB expressions among bereaved parents are appropriately described by a multi-dimensional structure. 2. These subdimensions are appropriately described in terms of externalized=internalized labels. 3. Subdimensions of CB are differentially associated with grief intensity and personal growth in bereaved parents. METHOD Participants The participants consisted of 354 bereaved parents recruited from Facebook bereavement support groups, aged between 19–72 years (M ¼ 45, SD ¼ 11.5). The sample consisted largely of bereaved mothers (97.2%) and included 11 different nationalities, including American (36.4%), Australian (42.1%), British (6.2%), and Canadian (4%), with the remainder of the nationalities making up 11.3%. Time since death of the child ranged from under 3 months (7.9%) to over 10 years (10.5%). The age of

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the deceased child ranging from miscarriage (4.8%) to over 20 years of age (39.5%); 61.6% of the deceased were male, whereas 36.2% were female, and the remainder unknown. Death of the child was a result of accident (30.2%), illness (20.6%), stillbirth (13.6%), and suicide (10.6), making up the majority of the losses in the sample. Procedure Facebook was used to search for bereavement support groups appropriate for use in the present study, with groups specifically intended to provide support to bereaved parents targeted. The moderators of 20 support groups were contacted. Seven of these groups responded and gave us their support to place an invitation to participate in the study on their Facebook walls for all members to read. The invitation directed participants to an anonymous online survey, which primarily consisted of the Hogan Grief Reaction Checklist (HGRC; Hogan, Greenfield, & Schmidt, 2001) and a Continuing Bonds Scale. These measures are described in detail below. The survey also included demographic questions: gender, age, birth country, country of residence, marital status, and religious affiliation. Characteristics of the deceased and death were also assessed: age and gender of the deceased child, years since death, and cause of death. Continuing Bonds Scale Studies involving CB have used various scales and questions to measure the continued connections which bereaved individuals have with their deceased loved one. In considering a suitable scale for use in our study we considered previous CB scales (Field et al., 2003; Field et al., 2004; Field, 2005; Waskowic & Chartier, 2003) along with other literature (Davies, 2004; Klass et al., 1996; Riches & Dawson, 2000; Rosenblatt, 2000; Talbot, 2002; Wheeler, 1999). The questions in these CB scales focus on the loss of a spouse. For the present CB scale we selected, and in some instances, modified, appropriate questions from the original scales based on our monitoring of Facebook bereavement support groups. This monitoring identified that the previous CB scales appeared to be missing some key expressions, and in some cases the questions and wording were not specific enough for our present population of bereaved parents. In addition to the derived questions from previously published scales, three of our own questions were added. Because of our sample using participants from Facebook bereavement support groups a question in relation to ‘‘finding comfort in partaking in support groups’’ was considered appropriate within this scale. Partaking in ritualistic behaviors such as candle lighting

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and balloon and butterfly releasing was also included on the basis of conversations and events held by several bereavement organizations, including The Compassionate Friends, a widely recognized organization for those dealing with the grief of a child. The Compassionate Friends and similar organizations hold yearly candle lighting and balloon and butterfly releasing events to honor and remember children who have died. In addition, literature (Anderson, 2001; Doss, 2002) and Facebook bereavement support group conversations on CB describe memorial tattoos as a symbolic act being commonly employed by bereaved mothers. An item describing this act was therefore added to our Continuing Bonds Scale. HGRC A 61-item questionnaire developed to measure the multidimensional nature of the bereavement process was used in this study due to its well-documented validity and reliability (e.g., internal consistency a ¼ .90) and its use in similar bereavement studies (e.g., Field et al., 1999; Field et al., 2003). Items in the HGRC have been developed through a qualitative analysis of grief narrative and written texts of bereaved adults and are phrased as declarative statements (e.g., ‘‘My hopes are shattered’’; ‘‘I have learnt to cope better with life’’). The 61 items factor into six empirically derived subscales: Despair (13 items); Panic Behavior (14 items); Personal Growth (11 items); Blame and Anger (seven items); Detachment (eight items); and Disorganization (eight items). Five of the six subscales (not including Personal Growth) make up the total Grief Intensity Score.

ANALYSIS AND RESULTS The aim of the analysis was to determine the contribution of CB expressions and bereavement characteristics in predicting levels of grief intensity and personal growth. An intermediate objective was to determine the most appropriate dimensional structure of the CB items in terms of internal consistency, face validity, and predictive power in terms of explaining grief outcomes. Exploratory factor analysis on the 25 CB items was considered most appropriate, because we did not wish to assume, at the outset, a particular factor structure solution. After establishing aggregate CB dimensions, a path-analytic regression model was used. This was considered appropriate as it provided (a) methods for assessing mediation functions of CB variables, (b) omnibus criteria for assessing model structure, and (c) simultaneous assessment of effects on the multidimensional grief response.

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Factor Structure of CB Items (Exploratory Factor Analysis) The correlation matrix of the CB items was checked for suitability for factor analysis. The Kaiser-Meyer-Olkin measure of sampling adequacy was .86 and Bartlett’s test of sphericity was significant, v(300) ¼ 3089.154, p < .0001, v(300) ¼ 3089.154, p < .0001 indicating there was a more than adequate degree of covariability among the CB items for analysis of latent factor structure. Factor analysis were undertaken using the psych package in the statistical programming environment R (R Core Team, 2011). As we expected some communality between variants of CB, oblique rotation of factors was used. Results regarding dimensionality of CB (number of factors to retain); information based on the internal covariability of the 25 CB expressions did not provide unambiguous support for a single solution. All items loaded moderately positively on the first principal component, which accounted for 29% of the variance, providing some support for the idea that CB expression is a unidimensional construct. However, other indices suggested a more complex factor structure. An inflection point was observed on the principle component scree plot, suggesting a two-factor solution. However, parallel analysis (which compares the obtained eigenvalues with those corresponding to matched random data via Monte Carlo simulation) suggested that eight factors were significant. Examination of other statistics based on the proportion of correlation matrix explained by various n-factor solutions suggested an intermediate model; root mean square of square of approximation (RMSEA)=residuals of the correlation matrix approached a satisfactory criterion of .05 at three and five extracted factors, respectively. Based on the above it was concluded that insufficient internal statistical evidence was present to decide on the appropriate number of factors to extract. We therefore considered the interpretability of the derived factors for a two-, three-, five-, and eight-factor solutions. We failed to determine a clear interpretation of the twofactor solution based on item content. However, each of the higher-order solutions appeared to possess an interpretable structure, with differing levels of specificity. For example, with reference to the item numbering in Table 1, an eight factor solution yielded the following factor labels; Intimate Connections (Items 3, 4, 18, 19), Ritual Observance (Items 11, 12, 16), Spiritual=Supernatural (Items 1, 5, 20), Mature=Internalized Remembrance (Items 10, 8, 2, 6), Conversations (Items 17, 15), Imagery (Items 9, 7, 25), Visiting Places (Items 24, 14), and Transference (Items 21, 23, 22). In sum, our strong impression after a detailed analysis was that variation in CB expressions among bereaved

mothers is not unidimensional, but rather characterized by a somewhat complex hierarchical structure. As exploration of the complex structure of CB was beyond the scope of the present study, we opted for the most parsimonious factor structure with satisfactory psychometric properties. A three-factor solution yielded the following factor labels based on item content: Transference, Externalized Expressions, and Internalized Expressions. The items and the factor loadings for the three factor oblique solution are summarized in Table 1. Excluding loadings below .30, the three-factor solution showed almost simple structure, with only Item 6 showing a cross-loading above this threshold. Items 11, 19, and 20 did not load above .30 on any one factor, and displayed little communality (.07–.17) overall. Table 2 shows the correlations between factors, showing that all three were moderately positively correlated with one another, consistent with our interpretation of CB as possessing hierarchical factor structure. Items were allocated to measures for each factor as per the shaded cells of Table 1 and internal reliability of each scale was evaluated using Cronbach’s alpha and the more accurate and unbiased Guttman’s lambda6. These statistics are presented in Table 3 along with the average item intercorrelation, indicating adequate to good reliability of the first two factors, with the transference scale showing somewhat weaker coherence. It should be noted that both measures of internal consistency are known to increase as a function of the number of items, partly explaining the lower reliability estimates for Factors 2 (Externalized) and 3 (Transference). Table 3 also includes the 1st and 3rd quartiles of the average item score for each measure, along with the mean item score. It can be seen from Table 3 that the mean score for both internalized and externalized expressed bonds was quite high (given the 1–5 Likert response scale), indicating that these categories of CBs had a high prevalence in the current sample of bereaved parents. As a result, the distributions of scores on the first two measures were quite negatively skewed. Measure 3 (Transference) was less prevalent and normally distributed with a mean near the center of the Likert scale. Relationship of CB Expression to Grief Status The final aim of the analysis was to explore the relationship between CB expression and grief status. As already mentioned, although unambiguous support was not found favoring one factor solution over another, in the interests of parsimony, a tridimensional (Externalized, Internalized, Transference) subdimensional structure was shown to be both parsimonious, and display good face validity and internal consistency. It was therefore

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TABLE 1 Obliquely Rotated Component Loadings of the Continuing Bonds Items Factor Item content

1

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

.73 .71 .71 .64 .62 .57 .57 .56 .50 .49

I imagine my child as watching over me I am aware of the positive influence of my child on who I am today At times I have a real sense of presence of my child I believe that I have an ongoing connection with my child I experience my child as continuing to live on through their impact on who I am today Doing things that show my ongoing love for my child brings me comfort My dreams about my child bring me comfort I find comfort in looking at pictures=videos=DVDs of my child I dream about what my child might look like or what they might be doing I am comforted by memories of my child I find comfort in partaking in support groups for the bereaved I have kept objects=possessions that belonged to my child because they comfort me I believe that I could never let go of my ties with my child I visit the cemetery and memorial site to see and be close to my child Stories involving my child will continue in my family I partake in rituals such as candle lighting, balloon or butterfly releasing in remembrance of my child I tell others I miss my child I have inner conversations with my child I wear jewelry that belonged to my child and=or I have purchased in remembrance of my child Knowing that I will eventually be reunited with my child again brings me comfort I attempt to carry out my child’s wishes I am aware of having taken on many of my child’s habits, values and=or interests I find comfort in going places my child enjoyed or where they spent a lot of time I find comfort being in my child’s room I have a tattoo in remembrance of my child

2

3

.32

.76 .72 .47 .42 .40 .38 .33

.70 .67 .61 .47

h2=th .44 .55 .53 .47 .40 .54 .44 .40 .20 .42 .11 .56 .44 .22 .33 .35 .30 .40 .17 .20 .56 .44 .43 .30 .07

Notes. Factor labels: Factor 1 ¼ Internalized Bonds; Factor 2 ¼ Externalized Bonds; Factor 3 ¼ Transference. Factor loadings .05) standardized regression coefficients. Final Model Structure and Fit The model structure and standardized regression coefficients are shown in Figure 1. As well as the relationships shown, the model also incorporated covariances between grief outcomes (r ¼ .38 ) and between CB expressions (internalized–transference: r ¼ .46 ; internalized–externalized: r ¼ .56 ; externalized–  transference: r ¼ .51 ). The final sample size was 354; there were no missing data. The model converged normally, with v2(13) ¼ 23.86, p ¼ .033, as compared with a fully saturated model. The comparative fit index ¼ .98, the Tucker-Lewis fit index ¼ .96, and the RMSEA ¼ .05. Those values indicate a good fit between the model and the observed data. In line with expectations, a symmetrical relationship between externalized=internalized CB and grief intensity=personal growth was observed. As the loadings in Figure 1 show, each of the direct effects of CB on the two grief measures were moderately large in magnitude and significant at the .01 criterion level. Child’s age at death was positively associated with transference CB and had a small direct negative relationship with personal growth. As hypothesized, VoA death was positively related to grief intensity, although the effect size

was small. However, the expected relationship between VoA death and personal growth was not supported. As hypothesized, time since death was positively related to internalized CB expressions, although the effect size was small and not significant. The hypothesis that time since death would be related to less externalized CB expressions was not supported. The results were confirmed via two multiple regressions for grief intensity and personal growth, including only linear effects without interactions. Regression analysis confirmed that 15% of the variance in grief intensity, F (3,349) ¼ 15.28, p < .001, and 18% of the variance in personal growth, F (3,349) ¼ 19.34, p < .001, can be explained by the four predictors with direct links to grief outcomes shown in Figure 1. Potential interaction effects between bereavement characteristics and CB expressions were checked by comparing nested models with and without interaction effects between the two CB dimensions and the three bereavement characteristics. Addition of interaction effects did not yield a more effective model of grief intensity, F(2,349) ¼ .46, ns, but a marginal improvement was detected for personal growth, F(2,349) ¼ 3.1, p ¼ .047. However, individual interaction terms in the more complex models were not found to be significant. The main effects of the two CB dimensions were robust to inclusion of interaction effects in the directions as indicated in Figure 1 and highly significant in all models (p < .001 in all cases).

FIGURE 1 Final path model on the relationship between three continuing bond (CB) dimensions and grief outcomes.

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DISCUSSION The study supports the idea that CB expression is a multidimensional construct, and that consideration of these subdimensions is critical in determining the relationship to grief outcomes, and in mediating the effects of bereavement characteristics. Motivated by recent prior conceptualizations of CB, we have labeled the two instrumental CB subdimensions as externalized and internalized expressions. We recognize these labels are somewhat tentative and that alternative labels may be considered (i.e., concrete expressions and evocative expressions). Further theoretical work on delineating exactly what are the key characteristics that differentiate these dimensions is certainly warranted, given their relative efficacy in explaining grief and self-actualization outcomes. The results of our study appear to be consistent with Field et al.’s (2009) confirmatory factor analysis on survey data, and with Field et al.’s (2013) structured interviews with bereaved mothers. However, our iteminclusion criteria considered only CB expressions typically used by bereaved mothers, and as a result did not, for instance, make reference to hallucinations or pathological symptoms. This complements previous research (Field et al., 2012), which has tended to focus on clinical CB expressions, rather than those more commonly evidenced in the general population of bereaved parents. The current methodology also involved the selection and wording of items based on language used by participants in discussion groups to describe their activity. In other words, item-inclusion criteria were driven by the voice of the bereaved parents within the support groups, who tended to use this terminology. This yielded some questions that were phrased in terms of providing comfort (e.g., ‘‘I am comforted by memories of my child’’) and others which were not (e.g., ‘‘I have inner conversations with my child’’). This may be viewed as a limitation of the study in terms of providing a psychometrically valid instrument. The fact that positively worded items were spread across the two instrumental factors suggests that item wording did not unduly influence the factor structure. Nevertheless, future psychometric development of a multidimensional CB scale should take care to avoid positive or negative wording of CB items. Items within the factor labeled externalized expressions in the current study included ritual observance, visiting a memorial site, or retaining objects belonging to the deceased. For the most part, our label of externalization relies on the idea that these expressions relate to concrete actions or activities in the external, rather than the internal world. The exception to this is the item of inner conversations, which nevertheless indicates the

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maintenance of an externalized construct of the child, with whom dialogue is maintained. When compared with prior work on externalized expressions, our items clearly sample those CB expressions on the less intense end of the spectrum. This was a natural consequence of our item-inclusion criteria, aimed to sample CB expressions that were most prevalent, rather than expressions that typified the extremities of the external– internal dichotomy. Nevertheless, this dimension was highly predictive of grief outcomes. If our dimension does conform theoretically with previous conceptualization of externalized expressions, it would argue for a useful broadening of this construct, which has hitherto focused on intense externalization, such as hallucinatory experiences. In addition to the two CB factors that appear to be important in determining grief outcomes, the present study found a further factor that included items describing carrying out the deceased child’s wishes, taking on their habits, values and=or interests, going places they enjoyed, and being in the deceased room. We would argue that the label of transference expressions given to this dimension is relatively unambiguous, as each item involves acting or thinking in a manner that in some way imitates the deceased. Our theoretical interpretation of transference in terms of its relationship to grief outcomes is that it is a form of externalized expression, as it represents a more concrete and less elaborated mechanism for integrating the deceased child into one’s life. This interpretation is supported by the statistical evidence: Transference has a bivariate positive relationship to grief intensity, t(349) ¼ 3.19, p ¼ .0016, which disappears when externalized (but not internalized) CB expressions are added to the model. In other words, the explanatory variance of transference on grief intensity is shared with externalized (but not internalized) CB expressions. Thus, the statistical properties of the transference dimension would appear to support the theoretical grounds for treating it as a form of externalized CB expression. Putting aside the question of the conceptual boundaries of the subdimensions of CB, the study confirmed that expressions of CB are high among bereaved parents, that each form of CB are moderately positively correlated, but that they nevertheless have clear differences in terms of their relationship to grief status. Externalized CB expressions were associated with a negative grief outcome and less personal growth, whereas internalized CB expressions were associated with a positive grief outcome and more personal growth. These results are in accordance with recent findings on externalized and internalized expressions. For example Field et al. (1999) found that externalized CB expressions such as keeping and using the child’s possessions for comfort were associated with more negative grief outcomes.

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Field et al. (2010) believed externalized CB expressions such as visiting the cemetery and conversations and rituals to possess a perceptual quality, indicative of a disbelief of the death. Such externalized expressions result in a failure to integrate the loss, which presents significant challenges in the ability to experience personal growth (Field et al., 2010). Our factor of internalized CB expressions aligned with those of Field et al. (2013), Field et al. (2010), and Field et al. (2004) in including such items as obtaining comfort through fond memories, dreams, looking at photographs of the deceased, and a subjective sense of presence which were predictive of more positive grief outcomes. Furthermore, our results linking internalized CB expressions to personal growth was consistent with the results of Field et al. (2010) and Field et al. (2004). One note of caution is that although the factor-analytic results confirmed that the externalized-internalized category of CB expression is a valid level of description, it may not be the only useful level of description. As the results show, CB expression does show a unidimensional super-structure (as the three-factor dimensions are moderately positively intercorrelated). Also, there appears to be some validity to considering a more fine-grained delineation of CB (e.g., considering spiritual expressions specifically). Further exploration of the hierarchical structure of patterns of CB expression between individuals presents an intriguing direction for future research. Little research exists on the impact of the child’s age at death on parental bereavement. We found that child’s age at death was positively associated with transference and negatively associated with personal growth. According to Field et al. (2009), this result would suggest that the bereaved parent has not achieved personal growth, which is symbolized by the successful integration of the parent’s loss of their child. This finding links with George and Soloman’s (1999) ‘‘caregiving behavioral system’’ in that the bereaved parent is motivated to provide protection to the deceased child. Therefore, to provide protection the bereaved parent will attempt to recover the deceased child, which may produce searching behaviors or transference to reinvoke feelings experienced prior to the child’s death. Klass (1993) believed that the type of CB a bereaved parent uses is conditional on the age of the child at the time of death. The death of an older or adult child according to The Compassionate Friends comprises a relationship in which a lot of emotional and financial investment has been made and as such the death signifies everything they invested in their child is now gone. Therefore, the bereaved parent of an older child may carry out the child’s wishes, and=or take on their habits, values, and interests, whereas the death of a younger child is less likely to invoke such connections.

Consistent with previous studies (Jordan, 2001; Wood, Byram, Gosling, & Stokes, 2012) we found that VoA death was positively associated to grief intensity. VoA deaths are said to have unique properties which result in poorer grief outcomes than other modes of death (Currier, Holland, & Neimeyer, 2006). Experiencing the death of a child through a traumatic event may interfere with the parent’s ability to accept the death, and this is reflected in a relative lack of adaptive CB expressions (Wood et al., 2012). As hypothesized, time since death was positively related to internalized CB expressions, less grief intensity and more personal growth. This result is consistent with the findings of Hogan and DeSaints (1996) who argue that ongoing connections accelerate personal growth over time. It also supports externalized– internalized models of CB, which state that the early grieving process is characterized by more intense grief, and more externalized CB versus internalized CB. We conclude that it is critical to consider the different forms of CB expressions when relating CB to either positive or negative grief outcomes. Although our results are neutral with respect to causality, it is tempting to speculate on the adaptive or maladaptive nature of CB expressions. Bereaved parents who continue a bond with their deceased child through externalized expressions in a highly preoccupied manner and are unable to move on may require professional intervention. In contrast, those bereaved parents who continue a bond with their deceased child through internalized expressions, which do not interfere with their daily life or relationships, may have a vital role in the development of positive grief outcomes for many bereaved parents (Stroebe, Schut, & Stroebe, 2005; Wood et al., 2012). The current findings provide insight into how bereaved parents in a nonclinical population respond and cope with such a significant loss. It highlights that certain forms of continued connections with their deceased child can be a purposeful, growth-enhancing, and an adaptive component of bereavement allowing parents to reinvest in their own lives. Other concrete or externalized expressions of CB, though not necessarily symptomatic of a clinical diagnosis, nonetheless appear to be markers for an inability to comprehend and integrate the loss. Whether indicating an adaptive or maladaptive state of grief, it should be recognized that many bereaved parents do in fact maintain some form of CBs long after the child has gone. The implication for practice with bereaved parents struggling with bereavement is certainly to monitor the form of CB expression, and perhaps encourage a gradual shift from externalized to internalized expressions.

CONTINUING BONDS IN BEREAVED PARENTS

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