Type of continuing bonds expression and its comforting versus distressing nature: implications for adjustment among bereaved mothers

Perceptions of internal and external continuing bonds in bereaved individuals with and without prolonged grief disorder

This study aimed to compare individuals with and without a diagnosis of Prolonged Grief Disorder in terms of the intensity of internal and external continuing bonds, as well as the extent to which they interpret these bonds as comforting, socially acceptable, and an inseparable part of their self-identity. The sample consisted of 229 bereaved adults (PGD: N = 27; non-PGD: N = 202). Results indicated that the PGD group experienced internal and external bonds more intensely, reporting higher scores for interpreting them as an inseparable part of self-identity and lower scores for interpreting them as socially acceptable. While the PGD group found external bonds more comforting than the non-PGD group, no such difference was observed for internal bonds. These findings suggest that, when assessing whether continuing bonds are adaptive or maladaptive, it is crucial to consider not only their internal or external nature but also how they are interpreted.

Consequences of Unexplained Experiences in the Context of Bereavement - Qualitative Analysis

Unexplained experiences are common among bereaved people and are a natural part of grieving, but their consequences may affect their coping with grief. However, professionals lack awareness of these unexplained experiences, which may lead to an unnecessary pathologising of the experiences and a lack of opportunity for the bereaved to process their experiences in a safe environment. The study involved an inductive content analysis of 408 narratives of the consequences of unexplained experiences shared by 181 bereaved individuals. The consequences of the unexplained experiences were: (1) Experiencing after-effects which may alleviate or aggravate wellbeing, as well as be life-affecting; (2) consequences related to sharing or concealing the experiences, and the reactions of others to recounting the experience; (3) documenting the experience through videography, photography and keeping mementos. In conclusion, these experiences have consequences to bereaved which needs to be taken account in support interventions aimed at bereaved individuals.

Exploring an Extended Conception of Grief: Sense of Presence and Grief Reactions in German Widows

This study explores sense of presence (SOP) as an important feature of continuing bonds (CB) in the context of normal grief. A community sample of widows (N = 51) filled in a multidimensional grief questionnaire and a depression scale. A moderate positive association between sensing the deceased husband´s presence and cognitive and emotional impairments emerged. A positive relationship between SOP and guilt was found only if the influence of religiosity was controlled for statistically. There were no significant associations of SOP with long-lasting positive reactions to loss, such as personal growth and increase in sensitivity for others. Widows with clinically relevant depression indicated a stronger SOP than those with lower depression scores. These differentiated findings may stimulate the elaboration of an extended conception of grief beyond the focus on clinically relevant impairments.

The International Grief Questionnaire (IGQ): A new measure of ICD-11 prolonged grief disorder

Prolonged grief disorder (PGD) is included in the 11th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). This study sought to test the validity and reliability of a new brief measure to screen for ICD-11 PGD-the International Grief Questionnaire (IGQ). The psychometric properties of the IGQ were tested using data collected from two bereaved samples of adults from the United Kingdom (n = 1,012) and Ireland (n = 1,011). Confirmatory factor analysis demonstrated that a correlated two-factor model best captured the latent dimensionality of the IGQ in both samples. Estimates of internal reliability were high, whereas the convergent and concurrent validity of the scale were supported through strong associations with external measures. Measurement invariance and differential item functioning testing showed no statistically significant difference in the latent structure of the IGQ nor the functioning of the IGQ items by age, sex, and nationality. For participants who were bereaved for more than 6 months, the rates of probable PGD derived from the IGQ were 10.9% and 15.3% for the Irish and U.K. samples, respectively. The IGQ is a brief, easy-to-use, self-report screening measure that captures all diagnostic criteria of PGD set forth in the ICD-11. Findings from this study provide initial support for the validity, measurement invariance, and reliability of the IGQ among two national samples.

Factors Involved in Posttraumatic Growth in Mothers Experiencing Fetal and Infant Death

Factors associated with posttraumatic growth (PTG) are investigated in mothers who have suffered fetal or infant death. Mothers (N = 66) completed the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996), the Core Beliefs Inventory (CBI; Cann et al., 2010), and answered questions about the severity of their loss, age of fetus or infant, time since loss, social support, finding meaning, and involvement in loss-related behavior. Results indicate a greatly traumatic loss (M = 4.41), a great degree of core belief disruption (M = 3.57), and a moderate level of PTG (M = 2.80). CBI scores are positively correlated with severity of the loss and age of the fetus or infant. PTGI scores are positively related to CBI scores and to social support from family and friends who have suffered similar losses and support groups. PTG and finding meaning are positively correlated with involvement in loss-related activities and supporting others.

Continuing bonds in parents after a loss in pregnancy, or a death at or shortly after birth: A population-based study

In this study, we describe continuing bonds and grief reactions and assess their association in 980 parents bereaved in pregnancy, at or shortly after birth. We found that most parents experienced continuing bonds. However, they differed by type of loss. Parents losing their child due to termination of pregnancy or miscarriage experienced bonds less frequently and had the least intense grief reaction. Parents losing their child postpartum experienced bonds most frequently and had the most intense grief reaction. Continuing bonds were associated with intensified grief in parents losing their child after termination or miscarriage, while this relationship was less obvious after stillbirth or postpartum death.

Changes in Relationships in Bereaved Families: Perspectives of Mothers Who Lost a Child to Cancer

The loss of a child greatly affects the dynamics of interpersonal relationships in bereaved families. This study explored the relationships in bereaved Korean families from the perspectives of mothers after the death of a child due to cancer. We conducted in-depth interviews with 15 bereaved mothers of a deceased child with childhood cancer. Thematic analysis identified 12 subthemes related to bereaved mothers' struggles in grief within three significant themes based on family relationships: (a) relationship with husband; (b) relationship with surviving child or children; and (c) relationships with extended family members. Findings highlight bereaved mothers' need to build supportive family relationships while acknowledging bereaved family members' different grieving styles and their own challenges in grieving the loss of a child.

Continuing bonds of bereaved Muslims mothers with their young dead child

Based on continuing bonds theory, this research examined the experience and manifestations of continuing bonds of bereaved Muslim mothers with their children who died in home accidents. This qualitative phenomenological study is based on interviews with 15 bereaved mothers (aged 28-46 years) whose children (aged 1-6 years) died 2-7 years before the interviews. Analysis revealed three themes: efforts to continue the physical bonds, challenges in the continuing bonds in cases of traumatic death, and belief in afterlife as the main element of the continuing bonds. The traumatic circumstances of the death challenged the ability to maintain the bond based on positive memories without it being overwhelmed by the traumatic memories of the last moments of the child's life. Religious beliefs played an important role in the characteristics of the bond. Maintaining the bond requires professionals to provide a therapeutic environment where bereaved mothers feel safe talking about it.

A Mother's Voice: The Construction of Maternal Identity Following Perinatal Loss

BACKGROUND

Maternal identity, a mother's internalized view of self as mother, has not been studied in relation to perinatal loss. This study aimed to investigate how women construct a sense of maternal identity after the loss of a baby.

METHODS

We interviewed 10 mothers who had experienced perinatal loss. A Listening Guide framework for narrative analysis was used to identify patterns of giving voice to the mother's own story.

RESULTS

We identified 12 overarching voices which fell within three distinct groupings: voices of motherhood, voices of grief, and voices of growth. Although bereaved mothers grappled with constructing their maternal identity, they also demonstrated how maternal identity is individually and intuitively created through an honouring and remembering of the child that was lost, resulting in significant growth.

CONCLUSIONS

There is need for a broader definition of what constitutes motherhood to encapsulate diverse mothering experiences, including perinatal loss.

Mitigating Loss and Trauma: The Continuing Bonds Experience of Daughters Bereaved to Intimate Partner Femicide

The current study sheds light on the continuing bonds experience of adult Israeli daughters whose mothers were murdered by their fathers. Through 11 semi structured interviews, common externalized and internalized continuing bonds with the deceased mothers were closely examined. The interpreted results supported the existence of bonds, yet revealed a unique manifestation; the bonds were purposefully and defensively restricted, which seemed to be an adjustive compromise in light of the strong traumatic component of the loss. Our results contribute to the theoretical and clinical understanding of the restrictive effect that trauma components have on loss components in cases of traumatic bereavement.

The impact of continuing bonds following bereavement: A systematic review

Following bereavement, continuing bonds (CBs) include engaging with memories, illusions, sensory and quasi-sensory perceptions, hallucinations, communication, actions, and belief that evoke an inner relationship with the deceased. To date, the literature has been unable to confirm whether retaining, rather than relinquishing, bonds is helpful. A mixed studies systematic literature search explored how CBs affect grief. Studies on the effect or experience of CBs on adjustment following bereavement were eligible for inclusion. Six computerized databases were searched. A total of 79 of 319 screened studies were included. Three themes were derived from the thematic analysis: (1) comfort and distress, (2) ongoing bonds and relational identity, and (3) uncertainty, conceptualizing, and spirituality. Themes describe the role of CBs for the accommodation of the death story, transformation of the relationship, meaning reconstruction, identity processes, and affirmation of spiritual belief. Results shed light on the adaptive potentials for CBs.

Fathers' Relational Experiences of Stillbirth: Pre-natal Attachment, Loss and Continuing Bonds Through Use of Objects

This study aimed to investigate fathers' lived experiences of stillbirth through the lens of continuing bonds and use of objects. Semi-structured interviews were conducted with six fathers who had experienced stillbirth from 20 weeks gestation. Interpretative phenomenological analysis revealed five themes: loss and continued bonds in a mother-mediated dynamic, objects as manifestations of relational and meaningful memories, exerting existence and continued connection to others, continued bond through physical presence and evolving expressions of love and fatherhood. Findings offer a novel understanding of the relationship between objects and continued bonds, where objects are seen to facilitate this bond through varying means, including physical manifestation of the deceased and representation of the father-infant relationship. The study places importance on fathers' involvement in creating objects permeated with meaning and memories, and of validating fathers' experiences of loss rather than considering these men merely as partners of a mother who lost their own baby.

Not all dogs (and goals) were created equal: an existential perspective on helplessness

Building on the framework of learned helplessness, and applying a behavioural perspective, Boddez et al. theorise that consecutive failures in various life domains might be generalised and cause a general sense of helplessness, which leads to, and can be conceptualised as, human suffering. We argue that this perspective fails to address the complexities of human suffering and the motivational sources of feelings of helplessness. We provide an existential-social psychological perspective on helplessness, highlighting the need for psychological protection and the mechanisms by which it is achieved. We draw upon attachment, terror management, and motivated helplessness theories in order to demonstrate the anxiety-buffering function of goal attainment in major life domains (e.g. self-esteem and close relationships) and its influence on helplessness and suffering.

Bereaved Families: A Qualitative Study of Therapeutic Intervention

Background

A child's death is the most stressful event and the most complex grief that families face. The process of psychological adaptation to the illness and death of a child is difficult due to a variety of emotional reactions. Parental grief had received the attention of researchers only in recent years when it became clear that this reality differs substantially from the general grief process.

Objective

This work aims to highlight the needs of bereaved parents; increase the specificity and effectiveness of the therapeutic approach to prevent complications in the process of loss-making; and find the recurrent thematic nuclei in the development of bereavement present in a therapeutic group of parents who have lost their child to an onco-hematological disease.

Method

Between 2011 and 2016, five therapeutic groups for the grief elaboration were made. The sample included a total of 50 parents of children who died from cancer between the ages of 0 and 21 years.Content analysis was carried out as a qualitative analysis method. The SAS^® Text Miner software (SAS Institute Inc, 2004) was used to read, interpret, classify and integrate the data from numerous sources.

Results

The development and consecutive interpretation of the 5 clusters have been carried out to analyze the related topics using the node "Topic Analysis" and requesting the subdivision into five topics. Four topics have been well defined. Clear topics are reducible to categories of emotional relief, tools, legacy, and unfinished business. The topic analysis provides interesting indications about the different interpretive journeys of the bereavement situation and offers ideas regarding the different types of social responses.

Conclusions

After reviewing the existing bibliography, we have confirmed the lack of specific literature on the problem of grief in parents whose children have died from cancer. Much research has shown that parents who lose a child to cancer want support, and there are still few studies on the most effective interventions for this group.

An attachment perspective on loss and grief

Attachment theory provides a useful framework for understanding emotional reactions to separation and loss and the process of adapting to these painful events. In this article, we review adult attachment studies that have examined emotional reactions and adjustment to separation and loss in romantic and marital relationships. We begin with a brief account of attachment theory. Next, we review studies examining the emotional consequences of losing a relationship partner and the coping responses that can help a person adjust to this loss. Throughout the article, we also summarize research documenting attachment-related individual differences in responses to separation and loss. (99 words).

"Parenting Beyond the Veil": The Continued Parenting Relationship After a Child's Death Due to Cancer

Background: Childhood cancer is the leading cause of illness-related death, leaving thousands of parents to experience bereavement. This article presents select findings about the nature of the continued parenting relationship, which is an essential theme of the parental bereavement experience. Method: Heideggerian phenomenology provided the philosophical underpinnings of this study, which aimed to describe the lived experience of bereaved parents who experienced the death of a child due to cancer. Van Manen's (1997) method guided data collection and analysis. Six parents participated in interviews to share what it has been like for them since their child's death. The researcher wrote analytic memos, documented detailed field notes, and used a member checking process to ensure trustworthiness of findings. Results: A structure of the lived experience of parental bereavement emerged, which included the essential theme of the continued parenting relationship. The parenting relationship continues throughout a parent's lifetime in spite of the child's physical absence, albeit in a different manner. This different nature of parenting is known as parenting beyond the veil. Bereaved parents continue to parent beyond the veil by engaging in meaningful activities, seeking activities that strengthen a deep connection with the child, and being open to comforting signs that enhance their continued relationship. Discussion: Parents believe sharing their experience can help nurses and other professionals understand the importance of their continued parenting relationship and their need to parent beyond the veil so that they can provide high quality care to bereaved parents in the future.

Maternal grief: analysis and therapeutic recommendations

The following self-analysis contains key experiences of maternal grief over the course of the first 2 years following the death of a child, with specific examples and observations from bereaved mothers shared with the author. The references provide supporting evidence for commonality of the lived experience and observations. Therapeutic responses for clinicians give concrete direction for providing effective comfort. Self-care suggestions for mothers provide specific guidance for the readers. A 14-year retrospective epilogue puts the charged emotional description into a context of healing.

Sensory and Quasi-Sensory Experiences of the Deceased in Bereavement: An Interdisciplinary and Integrative Review

Bereaved people often report having sensory and quasi-sensory experiences of the deceased (SED), and there is an ongoing debate over whether SED are associated with pathology, such as grief complications. Research into these experiences has been conducted in various disciplines, including psychiatry, psychology, and anthropology, without much crossover. This review brings these areas of research together, drawing on the expertise of an interdisciplinary working group formed as part of the International Consortium for Hallucination Research (ICHR). It examines existing evidence on the phenomenology, associated factors, and impact of SED, including the role of culture, and discusses the main theories on SED and how these phenomena compare with unusual experiences in other contexts. The review concludes that the vast majority of these experiences are benign and that they should be considered in light of their biographical, relational, and sociocultural contexts.

Preparing Nurses for Palliative Care in the NICU

BACKGROUND

Neonatal intensive care unit (NICU) nurses require knowledge and skill to meet the unique needs of infants and families. Increasingly, principles of palliative care are being integrated into the NICU setting to improve the quality of care.

PURPOSE

The purpose of this article is to describe the efforts of the End-of-Life Nursing Education Consortium (ELNEC) project and its Pediatric Curriculum, which began in 2003 to provide this education, and to also describe efforts by nurses to implement the training into their practice settings.

METHODS

The ELNEC Pediatric Palliative Care (ELNEC-PPC) project is a train-the-trainer educational program and evidence-based curriculum.

FINDINGS/RESULTS

Participants attend a course or receive online training and then apply the education to implement improved practices in areas such as symptom management, care at the time of death, and bereavement support for families.

IMPLICATIONS FOR RESEARCH

Experiences with ELNEC-PPC have demonstrated that nurses can implement the curriculum to improve care.

IMPLICATIONS FOR PRACTICE

Continued attention to palliative care in this setting is needed, and future research is needed to evaluate the outcomes of this education and practice change.

Internalized versus externalized continuing bonds: Relations to grief, trauma, attachment, openness to experience, and posttraumatic growth

This research investigated the predictors of internalized versus externalized continuing bonds to examine whether internalized bonds are more associated with adaptive adjustment to bereavement than externalized. Four studies were conducted: two of romantic partner loss (n = 268 & 218), one of dog or cat loss (n = 199), and one of prenatal loss (n = 226). Participants completed questionnaires online. As predicted, the use of internalized continuing bonds was related to indicators of positive adaptation to grief (e.g. more secure attachment to deceased) while externalized was more strongly associated with indicators of clinical distress (e.g. greater trauma symptomatology).

Comforting Versus Distressing Dreams of the Deceased: Relations to Grief, Trauma, Attachment, Continuing Bonds, and Post-Dream Reactions

Why are some dreams of the deceased experienced as comforting, while others are distressing? We propose that there are different types of dreams serving diverse functions. In particular, we considered three: processing trauma, maintaining a continuing bond, and regulating emotion. We also examined the impact of post-dream reactions on the bereaved's experience of their dreams. Participants were 216 individuals whose romantic partner or spouse had died. They provided reports of dreams of the deceased that were content analyzed and completed measures of grief intensity, posttraumatic symptoms, attachment style, internalized versus externalized continuing bonds, as well as questions about the death, and ratings of how they experienced the dream after awakening. Support was found for the three proposed functions, suggesting dreams of the deceased can actively facilitate adjustment to bereavement. In addition, there was evidence that post-dream reactions can impact both the perception of the dream and grief.

Continuing bonds and dreams following violent loss among Cambodian survivors of the Pol Pot era

In non-Western societies, two-way communication between the bereaved and deceased is important in distinguishing adaptive versus maladaptive continuing bonds (CBs). We examined CBs expressed in dreams among Cambodian survivors during the Pol Pot era. Participants completed measures addressing dreams of the deceased, complicated grief (CG), and post-traumatic stress disorder (PTSD) symptoms. Participants who reported distressing dreams were more likely to have witnessed violent deaths of loved ones during the Pol Pot era and reported more severe CG and PTSD symptoms relative to those reporting other types of dreams. Distressing visitation dreams were shown to mediate the effect of violent loss on CG but not on PTSD.

How many bereaved people hallucinate about their loved one? A systematic review and meta-analysis of bereavement hallucinations

BACKGROUND

Bereavement hallucinations (BHs) entail a perception of a deceased in any sense modality or as a quasi-sensory sense of presence. BHs are an associated feature of the proposed Persistent Complex Bereavement Disorder (PCBD) in DSM-5. The goals of this review are to estimate the prevalence of BHs, identify possible moderators, and review the methodological status of this research field.

METHODS

A systematic literature search was conducted through the databases PubMed, PsycINFO, and CINAHL. Studies systematically assessing the prevalence of BHs of a relative or friend were included.

RESULTS

Twenty-one eligible studies were identified and 8 meta-analyses of BHs in different sense modalities were conducted. The prevalence of having one or more BHs was estimated to be 56.6% (95% CI 49.9-63.2), and the estimated prevalence of BHs in specific sense modalities ranged within 7.0-39.7%. Meta-regression analyses revealed associations to age and conjugal bereavement, but results are tentative and dependent on the type of BH in question.

LIMITATIONS

The included studies were methodologically heterogeneous. Limitations included the lack of a valid measure of BHs and low sample generalizability.

CONCLUSION

This first systematic review and meta-analysis of BHs suggests that more than half of the bereaved people experience some kind of BH. However, there are considerable methodological limitations in the research of BHs, which is of pertinent interest as BHs have been linked to the development of a future diagnosis of clinically impairing grief. A valid measure of BHs needs to be developed and used in high-quality epidemiological research using population-based designs.

Pet loss and continuing bonds in children and adolescents

There is little research available regarding the impact of pet loss on children. In the current mixed-methods study, we explored the different ways that children use continuing bonds (CB) to cope following the death of a pet. We studied 32 children (5-18 years) and their parents. Children answered four questionnaires and the Continuing Bonds Interview. Parents answered a demographic questionnaire. Results suggest that all children utilize CB while grieving the loss of a pet, although CB expression varies depending on the age of the child, the level of grief following the loss, and the strength of attachment to the pet.

Clinical work with suicide loss survivors: Implications of the U.S. postvention guidelines

The loss of a loved one to suicide can present difficult challenges for suicide loss survivors (people bereaved by suicide) as well as for clinicians who would seek to help them. Building on the recommendations in the new document Responding to Grief, Trauma, and Distress after a Suicide: U.S. National Guidelines, this article provides an overview of clinical work with suicide loss survivors. It includes discussions of the common themes of suicide bereavement, the psychological tasks for integration of a suicide loss, and the options for providing grief therapy after a suicide. The article will be of value to caregivers who work with suicide loss survivors in counseling or therapeutic context.

Continuing Bonds and Bereavement Adjustment Among Bereaved Mainland Chinese

Given the important role of continuing bonds (CBs) in bereavement adjustment, the aim of this study was to examine the relationship between CBs and bereavement adjustment and identify influences on CB among bereaved mainland Chinese. The Continuing Bonds Scale, Prolonged Grief Questionnaire 13, and Posttraumatic Growth Inventory were administered to 273 bereaved participants. Findings in the current study suggest psychometric validity of the Continuing Bonds Scale in a mainland Chinese sample and confirm that externalized CB is positively associated with severity of grief symptoms, and internalized CB is positively associated with the respondent degree of posttraumatic growth and identifies influences on externalized CB and internalized CB. These findings clarify the complex influence of CB in grieving process and highlight the need of incorporating CB into grief counseling.

How do attachment dimensions affect bereavement adjustment? A mediation model of continuing bonds

The current study aims to examine mechanisms underlying the impact of attachment dimensions on bereavement adjustment. Bereaved mainland Chinese participants (N=247) completed anonymous, retrospective, self-report surveys assessing attachment dimensions, continuing bonds (CB), grief symptoms and posttraumatic growth (PTG). Results demonstrated that attachment anxiety predicted grief symptoms via externalized CB and predicted PTG via internalized CB at the same time, whereas attachment avoidance positively predicted grief symptoms via externalized CB but negatively predicted PTG directly. Findings suggested that individuals with a high level of attachment anxiety could both suffer from grief and obtain posttraumatic growth after loss, but it depended on which kind of CB they used. By contrast, attachment avoidance was associated with a heightened risk of maladaptive bereavement adjustment. Future grief therapy may encourage the bereaved to establish CB with the deceased and gradually shift from externalized CB to internalized CB.

Meaning making during parent-physician bereavement meetings after a child's death

OBJECTIVE

Our goal was to identify and describe types of meaning-making processes that occur among parents during bereavement meetings with their child's intensive care physician after their child's death in a pediatric intensive care unit.

METHODS

Fifty-three parents of 35 deceased children participated in a bereavement meeting with their child's physician 14.5 ± 6.3 weeks after the child's death. One meeting was conducted per family. Meetings were video recorded and transcribed verbatim. Using a directed content analysis, an interdisciplinary team analyzed the transcripts to identify and describe meaning-making processes that support and extend extant meaning-making theory.

RESULTS

Four major meaning-making processes were identified: (1) sense making, (2) benefit finding, (3) continuing bonds, and (4) identity reconstruction. Sense making refers to seeking biomedical explanations for the death, revisiting parents' prior decisions and roles, and assigning blame. Benefit finding refers to exploring positive consequences of the death, including ways to help others, such as giving feedback to the hospital, making donations, participating in research, volunteering, and contributing to new medical knowledge. Continuing bonds refers to parents' ongoing connection with the deceased child manifested by reminiscing about the child, sharing photographs and discussing personal rituals, linking objects, and community events to honor the child. Identity reconstruction refers to changes in parents' sense of self, including changes in relationships, work, home, and leisure.

CONCLUSIONS

Parent-physician bereavement meetings facilitate several types of meaning-making processes among bereaved parents. Further research should evaluate the extent to which meaning making during bereavement meetings affects parents' health outcomes.

Insecure Attachment Styles and Complicated Grief Severity

A growing body of evidence supports links between attachment style, complicated grief (CG), and coping mechanisms in bereavement. In general, adults with insecure attachment styles are at an increased risk for developing CG when faced with the death of a loved one. However, much remains unknown regarding this complex interaction. This article provides a comprehensive synthesis of this literature base, offering future directions for attachment-informed CG research, clinical assessment, and treatment. The clear risk posed by an insecure attachment style on CG highlights the need for a proper and thorough assessment of attachment style as part of standard practice in grief-related treatment as well as the importance of meeting the unique clinical needs of the bereaved in consideration of one's attachment style. Further emphasis also should be placed on the mediating impacts of sociocultural variables, any of which could help to mitigate one's return to a level of preloss functioning.

The Dead Who Become Angels

Some 21st-century mourners describe the deceased as becoming an angel. Using published research, along with opportunist and anecdotal sources, the following questions are explored: who becomes an angel? Who addresses them as angels? What do once-human angels do? What are they? Where and when are they encountered? And in what sense are they believed in? Once-human angels are found in cemeteries, in memorial tattoos, at the deathbed, but mainly online—both internet and angel are mediums or messengers linking this world and the next. Unlike passive souls cut off in heaven from the living, angels have agency, (a) continuing their earthly activities in heaven and (b) looking after those on earth who still need their care and guidance. The once-human angel thus expresses a continuing bond between the living and the dead, particularly important for younger mourners who may live many decades before joining the deceased in heaven. This notion is taught by neither churches nor popular culture; it is not a creedal belief, but an idea, a meme, that some mourners use—and creatively develop—in particular contexts and may be understood as vernacular religion.

Internalized and externalized continuing bonds in bereaved parents: their relationship with grief intensity and personal growth

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.