the continuing process of parental grief

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The Continuing Process ofParental GriefJoan Arnold PH.D., RN a b & Penelope BuschmanGemma MS, RN, PMHCNS-BC, FAAN c da School of Nursing, The College of New Rochelle ,New Rochelle, New York, USAb NYC Sudden Infant Death Satellite Office/PHS, NYSCenter for Sudden Infant Death , New York, NewYork, USAc School of Nursing, Columbia University , New York,New York, USAd St. Luke's-Roosevelt Hospital Center , New York,New York, USAPublished online: 06 Aug 2008.

To cite this article: Joan Arnold PH.D., RN & Penelope Buschman Gemma MS, RN,PMHCNS-BC, FAAN (2008) The Continuing Process of Parental Grief, Death Studies,32:7, 658-673, DOI: 10.1080/07481180802215718

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THE CONTINUING PROCESS OF PARENTAL GRIEF

JOAN ARNOLD, PH.D., RN

School of Nursing, The College of New Rochelle, New Rochelle, New York, USAand NYC Sudden Infant Death Satellite Office=PHS, NYS Center for Sudden

Infant Death, New York, New York, USA

PENELOPE BUSCHMAN GEMMA, MS, RN, PMHCNS-BC, FAAN

School of Nursing, Columbia University, New York, New York, USA andSt. Luke’s-Roosevelt Hospital Center, New York, New York, USA

The death of a child is an incomprehensible and devastating loss. Grief forparents is lifelong, becoming the connection between parent and child. To extendand deepen current understanding of parental grief, a new survey instrument wasdeveloped, combining quantitative and qualitative measures. The qualitativefindings from this combined methodological study are presented. Parental griefthemes are derived from the respondents’ descriptions of their grief resulting ina reformulation of parental grief.

The death of a child is an incomprehensible and devastating loss.The associated lifelong grief for parents becomes the connectionbetween parent and child beyond the child’s death. As parentsgrieve for their child, the breadth and depth of loss are enfoldedinto their lives, defining a new identity shaped by grieving. Griefunfolds as the parent lives with loss and without the dead childin a new and transformed reality (Arnold & Gemma, 1994).

Received 23 September 2006; accepted 12 July 2007.We are profoundly grateful to friend and colleague Linda F. Cushman, Ph.D for her

expertise and guidance in the development of the survey instrument. We also thank thefollowing organizations for their support in funding the development of the instrument:Lucie S. Kelly Research Award Grant, Alpha Zeta Chapter of Columbia University, SigmaTheta Tau International; Frances G. Crane Research Grant, Foundation of the New YorkState Nurses Association; Nursing Research Grant, Columbia University-Presbyterian Hos-pital School of Nursing Alumnae Association; Faculty Fund, The College of New Rochelle.We also thank the Columbia University-Presbyterian Hospital School of Nursing AlumnaeAssociation for providing access to the alumni who so graciously participated in this study.

Address correspondence to Joan Arnold, The College of New Rochelle School ofNursing, 29 Castle Place, New Rochelle, NY 10805. E-mail: [email protected]

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Death Studies, 32: 658–673, 2008Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print/1091-7683 onlineDOI: 10.1080/07481180802215718

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The experience of grief is paramount in the lives of bereavedparents. The nature of parental grief and its dimensions have beendetailed in clinical literature (Arnold & Gemma, 1983, 1994;Capitulo, 2005; Gemma & Arnold, 2002; Hutti, 2005; Kavanaugh& Moro, 2006) and research studies (Arnold, Gemma, & Cushman,2005; Davies, 2004; Hutti, 1984; Krueger, 2006; Martinson, 1992;McClowry, Davies, May, Kulenkamp, & Martinson, 1987; Miles,1985; Miles & Demi, 1986; Moules, Simonson, Prins, Angus, &Bell, 2004; Murphy, 1983; Murphy, Johnson, & Lohan, 2003;O’Leary, 2004; Uren & Wastell, 2002). In her landmark studycomparing adult bereavement following the death of a parent,spouse, and child, Sanders (1980) found significantly higher inten-sities of grief among those surviving the death of a child. Parentalgrief on the death of a child is profound regardless of the yearssince death, the age of the child at the time of death, and the causeof the child’s death. An understanding of parental grief, whenbound to segmented approaches emphasizing the period of timein the child’s life in which death occurred (i.e., perinatal period,infancy, childhood, adolescence, adulthood) and the cause, cir-cumstances, or context of the child’s death (i.e., sudden, acute,chronic or terminal illness, accident, violence) is incomplete.Although these are efforts to elucidate grief, grief becomes knownby the delimiting characteristic and loses the commonality ofexperience that bereft parents may share. Parental grief is felt asa deeply personal and unique response to the death of a childyet bereaved parents are joined by their experience, which isunparalleled and known only to them in ways that cannot be easilycommunicated to others.

Purpose

This study expands and supports an understanding of parentalgrief as a continuing evolving process by using a newly developedinstrument combining quantitative and qualitative measures ofparental grief (Arnold, Gemma, & Cushman, 2000). The sampleincluded those whose children had died, regardless of the time thathad passed since the death, the age of the child at the time of death,and the cause of death using a sample of nursing alumni from a sin-gle School of Nursing spanning three-quarters of the 20th century.We identified no studies that have examined the grief of parents as

Process of Parental Grief 659

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an evolving process using both quantitative and qualitativemeasures in combination spanning decades of time.

Study Design and Methods

This was a cross-sectional retrospective, self-administered surveyby mail. An adaptation of the Dillman method was used to maxi-mize the respondents’ understanding of and participation in thestudy (Dillman, 1978). The only eligibility requirement was havingexperienced the death of a natural-born or adopted child.

Data Collection

An introductory letter with a stamped postcard was sent to all5,211 nursing alumni described in the Sample section. Of the 101eligible respondents who indicated a willingness to participate,74 (72%) reported that they had experienced the death of a livingchild and 29 (28%) reported that they had experienced a stillbirth.The 74 respondents constitute the sample population of this study.Their questionnaires were returned by mail without identifyingdata and their confidentiality was protected.

Instrument

We designed a new survey instrument, ‘‘Grief Over a Lifetime: AStudy of the Lifelong Effects of Child Death on Parents,’’ toexplore the premises that child death has lasting effects on parentsand that parental grief is an ongoing process (Arnold et al., 2000).The instrument of 80 questions included standard demographicitems (17), quantitative items (52), as well as qualitative measuresof grief and loss (11). Institutional review board approval wassought and received for the pretest phase and study. A panel ofexperts on grief reviewed the quantitative and qualitative itemsfor content and completeness. Two rounds of pretesting wereconducted. The construct validity of the key outcome variable(whether respondents felt their grief had ended or continues)received preliminary support in the bivariate analysis. Thereliability of the instrument was not tested.

660 J. Arnold & P. Buschman Gemma

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Analysis

Quantitative data were entered into an SPSS data file, cleaned forwild codes and inconsistencies, and analyzed by the authors usingstandard bivariate techniques. We analyzed qualitative data andindependently read all open answers and developed a codingscheme. Coded domains were compared and reconciled.

Sample

The sampling frame for the study consisted of the comprehensivelist of members of the Columbia University-Presbyterian HospitalSchool of Nursing Alumni Association, Inc. (1926–2000). All par-ents had experienced the death of a child during their adult lives.Sociodemographic characteristics of the sample are summarizedin Table 1.

Causes of child death were wide ranging, reflecting commonas well as rare causes for death in infancy, childhood, adolescence,and adulthood. These were assigned to one of four categories: con-genital (12%), prematurity=birth-related complications (26%),unexpected (40%), and illness (22%).

Characteristics related to child death included 40% of thesample reported their children had died at the age of one yearor younger; the age of the child at the time of death ranged frombirth to 48 years (M ¼ 13 years); the mean age of children whodied older than one year was 22 years; 15% of parents indicatedtheir child’s death was expected; the range of years since thechild’s death was 1 year or less to 62 years; the mean number ofyears since the child’s death at the time of the survey was 24.4years; and finally, parents’ ages ranged from 22 to 80 years atthe time of death (M ¼ 42).

Results

A detailed analysis, emphasizing quantitative findings, has beenreported previously (Arnold et al., 2005). The findings of this studysupport an understanding of parental grief as complex, ongoing,and non-linear. Findings suggest that grieving continues and canbe associated with a myriad of other emotions, including those thatare positive and life-transforming. Continued grieving, while


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highly individualistic, can be associated with heightened and vari-able emotionality, life satisfaction, and improved relationships withsurviving children. Parental grief on the death of a child is pro-found, regardless of the years since the death, the age of the childat the time of death, and the cause of the child’s death.

The qualitative findings from this combined methodologicalstudy of the ongoing nature of parental grief are presented here.These findings enhance an understanding of the breadth and depth

TABLE 1 Socio-Demographic Characteristics of Sample

Characteristic Data

RaceWhite 99%

GenderFemale 97%

MeanMean age 66 yearsAge range 42–90 years

EducationBaccalaureate degree or higher 84%Completed some graduate study

or graduate degree54%

Marital statusLegally married 68.5%Widowed 36%Divorced 35%

ReligionProtestant 59%Very=somewhat religious 66%

BirthsLive births 1–102–4 live births 74%

Employment=volunteer in past yearWorked for salary 40%Volunteered 84%

Household composition2 individuals 51%Live alone 31%Between 3–5 18%

Income$75,000 or higher 45%$35–74,999 30%Less than $35,000 25%


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of parental grief that cannot be fully communicated through aquantified approach. Of the 11 qualitative items, 5 dealt with spe-cific images of grief whereas 6 open-ended questions providedopportunity for respondents to describe varying ways in whichtheir lives were changed by their child’s death. The process usedto analyze data from these 6 items was guided by the premise thatgrief is an individualized experience and each respondent’scomments would clarify what it means to be bereft. Rather thanlooking only for common themes in expressions of grief, eachunique experience was captured and reported. Each questionnairewas carefully read by the clinical researchers who individuallyrecorded statements synthesizing their intended meaning. Bothsets of statements were compared and combined to assure therewere no omissions. Subsequently, the statements generated fromanalyses of all respondents’ comments were reported in narrativeform and organized according to each qualitative item. To honorthe responses of those who participated in this study of parentalgrief, the qualitative components are presented fully. The openended questions posed with a synthesis of responses, based on asample of 74, are presented. Further discussion will identifythreads or themes that shape a deeper understanding of parentalgrief for caregivers.

Images as Reflective Measures of Grief

Based on clinical experience caring for grieving families sub-sequent to child death, innovative qualitative measures weredeveloped in an attempt to describe with more texture and depththe emotions of parental grief. These measures were conceived asimages representing the experience of grief, including an eruptingvolcano; a well into which one descends; a tree that has lost a limb;and finally a hollow or empty space. For each qualitative measurethere was a dichotomous item that asked, ‘‘Has this image of griefapplied to you since the death of your child?’’ In addition, a num-ber of open-ended questions provided opportunity for respondentsto describe freely the varying ways their lives were changed bytheir child’s death.

Three of the images—‘‘a volcano that could erupt,’’ ‘‘descend-ing into a well,’’ and feeling like their ‘‘tree of life has lost a limb’’—had meaning only for a minority of parents, although nearly


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one-quarter responded in the affirmative to the latter construct. Forthese images, the only difference between parents whose grief con-tinues and those whose grief has ended was observed for the ‘‘des-cending into a well’’ construct, with the former group more likelyto feel the image applied to their experience of grief (21% vs. 4%).It should be noted, however, that the relationship only approachesstatistical significance (p ¼ .058). In contrast, the fourth image, ‘‘ahollow or empty space inside,’’ was described by the majority(approximately 75%) with regard to their child’s death. Therewas no difference observed between grief continuers and endersrelated to this last image. Moreover, multiple expressions of emp-tiness were reported by 45 respondents as a hollow or emptyspace, specifically describing a hole in the fabric of life, a void, abroken place in the heart forever, empty arms and belly, and anempty chair. Associated emotions included loneliness, never beingable to feel pure joy again, hopelessness, an emptiness that cannever be filled or recovered, and despair. This critical qualitativefinding illustrates the meaning of the quantitative item ‘‘a hollowor empty space inside,’’ regardless of whether grief continues orends, and the age of the child at death, or cause of death.

Parents were asked if other images had meaning, to which 41responded with a plethora of their own images that seemed toenhance connectedness to their child in a highly individualizedfashion. In this way, images are consoling and represent emotionsof grief. Some of images offered included a beautiful child happy inheaven or waiting in heaven to be reunited, angels and cherubsplaying in the clouds, an empty space at the table, the absenceof light, a soul joining other souls, a broken heart and being con-nected to other women past and present who had experiencedchild death.

Responses to Open Ended Questions

Relationships with Subsequent Children

Respondents were asked if their child’s death affected theirrelationship with children born or adopted after the death and inwhat way. Twenty nine of the 74 offered hand-written commentsdescribing a continuum of responses; ranging from difficulty lovingtheir remaining children, being anxious, guarded, and overly


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cautious in their relationship, to experiencing a heightened senseof love and attachment with the need to protect from harm withoutimpeding the surviving child’s growth. What may appear to becontradictory emotions are in actuality aspects of parental lovingand caring.

Life Changes

When asked about other changes in their lives related to the deathof their children, 34 of the 74 respondents reported a wide range oflife changes attributed to the impact of the death, including strainin their marriage relationship, reduced communication betweenspouses, and significant distancing leading to divorce and remar-riage. Some respondents felt less competent, less in control, whileothers felt stronger, bolder, more sensitive, with renewed faith.Thirteen respondents described the transforming nature of theirgrief reflected in changed careers, work in labor and deliveryand midwifery to ‘‘make a difference’’ for other families, volunteerefforts, the desire to speak with other grieving families, and ademonstration of greater compassion. Two respondents reportedchange in their awareness of no longer possessing a legacy. Thewide range of life changes related to child death points to the trans-forming nature of grief in the lives of individuals and families.

Life History Influences

Respondents were asked to identify circumstances in their back-grounds that shaped or provided a perspective for the experienceof grief. There were several factors in the backgrounds reported byfifty five of the seventy four respondents which shaped a perspec-tive of grief, including family traditions, communication and beliefsystems, exposure to other losses and deaths, family coping styles,and previous child deaths. One respondent referred to a grand-father who had communicated his grief over the death of hisson—as though grief had been passed down through the family lin-eage. Another referred to the significance of having lost a parent asa child recognizing that this experience of loss had shaped perspec-tive. Family members become role models in their losses—forsome, role models for healthy grieving. Where there had been ahistory of child death in the family of origin, the death of one’s


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child provided a common bond. Likewise, the ability to grievecould be thwarted by roles and expectations in the family of originsuch as the inability to express grief because it had not been per-mitted during childhood; one respondent had been given greaterresponsibility when a father died and another was not able to talkabout a mother’s death but told to accept it. One respondent feltalone when the family of origin would not discuss feelings andtreated the situation as though baby had not been born or died.Multiple losses in the family were cited as significant in shapingperspective. One respondent felt her husband’s death was a worseloss for her than the death of her child. Another respondent saidbeing exposed to frequent deaths of animals was helpful in shapingher perspective.

Religion and Spirituality

Another factor shaping perspective was religion and spirituality.Some parents described the church as the center of their lives,particularly when family support was unavailable. Others referredto their spirituality as providing the strength to endure their child’sdeath. Belief in life after death offered support—knowing in thisbelief that their child was not suffering, that they would bereunited, that the dead child would be looking after the survivingchildren. Dreams were described as a way of communicating withthe dead child who sent messages through dreams. One respon-dent empathized with the Mother of Jesus in her suffering andfound this identification to be supportive. Respondents found thatmaturity was gained in knowledge of God’s sovereignty; that Godtook the best, and that religious conversion to Catholicism andbecoming more religious was helpful. Another respondent whowas inspired by a Buddhist acquaintance, viewed life as a journeyand found meaning or reason for death. Spirituality could hamperthe ability to express grief and receive help when the image ofstrength must be maintained in the religious tradition. A respon-dent felt that having lived in different cultures contributed to herphilosophy and influenced her perspective on death. Given theunique demographics of this sample, many respondents referredto the significance of their nursing education and clinical expertisein helping them understand and be prepared for this loss and the


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associated grief. One respondent noted that knowledge preparesone, even for loss.

Sources of Support

Overall, support came from family, friends and faith. Knowing thatother parents have survived their children’s death made survivalpossible and going to support groups with other bereaved parentswas pointed out as helpful. Joy was found in subsequent childrenand in the rationalization that other children were born becauseof the child who died. One respondent felt the loss was not great,since they had too many children in a short time. However, aslikely as support is from family, friends and faith, it can also be per-ceived as non-supportive. One respondent said nothing gave herperspective or readiness for the grief experienced when her childdied.

The Meaning of Acceptance

The word acceptance is often used in relation to loss and grief.Respondents were asked to describe what the word acceptancemeant for them in thinking about their grief for their child. Sixtyfour parents offered two distinctly different descriptions of accept-ance; death must be accepted because it could not be changed, andacceptance was not possible because the loss was intolerable. Thefinality of death cannot be changed. Acceptance also refers to theinevitability of death, as in conditions that are not compatible withlife. Acceptance is inevitable if one continues to function in life, tomove on. Acceptance means resignation to the fact of death, to thefact the child is gone and death is an unalterable reality. Accept-ance means gradually knowing the child cannot be brought backto life and focus must be on memories and the living children.Belief in God was also tied to acceptance. God’s will must beaccepted. Belief that the child is with God and cared for now byGod, a turning oneself over to the power of God was a way of deal-ing with the loss. There is hope in being reunited with the childafter the parent’s death. There is also a turning away from God.

The refusal of acceptance was also described. Respondentsdeclared ‘‘I will never accept that my child had to die;’’ ‘‘I cannotaccept the death rather I have learned to live next to it;’’ ‘‘I live


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with the reality I cannot change;’’ ‘‘acceptance means a quieting ofmy soul about the loss – the rawness is gone but it does not mean itis all right to have happened.’’ This dilemma is well expressed byparents who declared ‘‘one has to accept loss or end one’s own life- there is no choice;’’ ‘‘acceptance forces continued living;’’ ‘‘I donot accept, I grieve endlessly;’’ ‘‘acceptance means there is noanswer—the death occurred without reason.’’

For some respondents, the word acceptance was linked to theconditions of the child’s death, that is, death could be acceptedwhen contemplating the physical suffering of the child; at leastthe child did not suffer. If the child’s illness were life threatening,there was an acceptance of death and heroic measures were notinstituted. Acceptance has many facets: dealing with the realityand inevitability of death, the necessity of going on without one’schild; a measure of God’ will, and the inability to ever acceptthe death of one’s child.

The Factor of Time

Time was referred to as an important factor, promoting healing butnot obliterating memory. A sudden lifting of spirits occurred threeyears after the death. Heightened empathy occurred making itpossible to help other bereaved parents. Finding some positive rea-son for the death means the child did not die in vain. Respondentstook the opportunity to express ways they keep connected to theirchildren, by creating memorials, saying goodnight to a photo-graph, writing poetry, recognizing the need to nurture living thingsand reliving the day the child died. A mother remembers kissingthe head of her dying 18-year-old son and finding a loving connec-tion through the scent of his hair which she carried with her afterhis death. There was also recognition that certain songs, hymns,and places intensify the pain of loss. Sensing the presence of thechild’s soul was regarded as a message from her that she was allright. There was strong desire expressed to replace the dead childthrough pregnancy, adoption, or a foster child.

Special Circumstances

Circumstances of the child’s life and death influence parental griefand bespeak the regrets of the lamenting parents. Death by suicide


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and homicide was found to intensify shame, guilt, and anger.Shame related to the cause of death (cocaine overdose) made itdifficult to talk about the death. The persistent struggle to forgivethe child and=or the perpetrator was described. Respondentsexpressed missing their children who had been chronically andprofoundly ill while not wanting the children to ‘‘survive them.’’The parent of an adult child wondered if getting medical caremight have saved him because they lived far away and had beenseparated for nine months before the death. Another respondentwhose young child died of cancer felt various emotions duringhis dying but was able to release him at death. Respondents whohad not been able to see or touch their child expressed deepremorse: ‘‘The part I cannot seem to get over is that I never heldmy baby—I never even saw her.’’ ‘‘I was encouraged not to see mybaby by my spouse, physician and pastor and now I wonder whyI ever agreed.’’

Final Reflections

When parents were asked if there were anything else to tell regard-ing the death of their child or their grief, 52 answered with varyingstatements. Grief was described as always under the surface,always there; ‘‘grief may be buried but never goes away.’’ Whenothers do not speak about the dead child, the parent feels ‘‘cutoff,’’ as though the child was non-existent. Grief was also foundto be overwhelming and one parent can ‘‘abandon’’ another whenoverwhelmed. ‘‘Marriage was held together mostly one day at atime, sometimes one hour, sometimes one minute.’’ Grief for one’schild can also become complicated by loss through divorce, com-pounding grief. Being a survivor means being left behind and leftmissing the child. This is an unimagined grief. Helping otherbereaved parents can be a way of self help. The profound silenceof grief meant not having anyone with whom to talk about thechild’s death.

At the conclusion of the survey, parents were asked questionsabout the survey instrument. Fifty-seven respondents offered theirthoughts about the survey’s strengths and limitations and took thislast opportunity to write about their grief. Respondents used thisfinal space to write not only on the lines provided but also on everyavailable space left on the survey to communicate descriptions of


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their grief. At the time of the survey, the responding parents foundthemselves somewhere along the continuum of grief. The surveycaptured their emotions and reactions at this particular momenton the continuum. This view into grief became a snapshot takenat a point in time.

Thematic Analysis

The following themes emerged from the qualitative componentsof this study and these shape a deeper understanding of parentalgrief.

. When a child dies, the resultant grief is a complex array ofemotions and sensations that persist across a parent’s life.

. Parents find a multitude of ways to remain connected to theirdead child, including using the senses like smell and sight,images, and rituals.

. Difficult emotions like remorse, regret, guilt, shame, sorrow, andanger are inherently present in grief.

. Memories of the child’s life and death remain fresh despite theyears that have passed.

. Sharing keeps memories vivid and parents are happy to talkabout their child’s life and death and memories.

. Expressions of loss are always close to surface.

. Bereaved parents desire to share their grief but so few ask orwillingly listen.

. It may be painful for parents to talk about their loss butcommunicating also provides strength and is gratifying.

. Support varies and comes from expected and unexpectedpeople and places.

. Family history and experience provide perspective but nothingprepares parents for the death of their child.

. Anticipated and unanticipated life changes (marriage, family,friends, work) occur after child death and can be viewedpositively and negatively.

. Religion and spirituality can be strengthened or abandoned.

. Relationships with surviving and subsequent children arestrengthened.

. The term acceptance must be reconsidered in light of the lifelongnature of parental grief and does not have one meaning.


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. Parenting continues beyond death through remembering, lov-ing, and caring.

. Parental grief is transformative.

. Research on parental grief is fruitful and bereaved parents arewilling to help others by participating in research—given theopportunity to communicate about their dead child and theirgrief, bereaved parents will write beyond the margins!

Study Limitations

This study has several limitations that should be considered ininterpreting the results. These limitations lie in three areas: sample,time frame, and omitted questions. First, the size of the sample lim-its generalizabiltiy. The sample is comprised exclusively of nurses,predominately female, who graduated from one school of nursingwith very similar demographic characteristics. Second, theextended time frame for the study spans the entire 20th century.This was a time during which there were dramatic changes in ser-vices, policies, and procedures for childbirth and for hospitalizedchildren and their families. Despite high infant and child mortalityrates, perinatal and child death were devalued and parents werenot given support for the expression of their grief. Data presentedhere were undoubtedly influenced and shaped by this milieu. Astudy with a shorter and more well-defined time frame would havestandardized the effect of the milieu. Another limitation addressesa small number of respondents who stated they wished there hadbeen attention given to: the somatic reactions of grief; survivingsibling reactions; parental dreams following the death of a child;and peer contact with other bereaved parents.

It should be noted that this study did not collect in-depth datafrom parents who experienced miscarriage and stillbirth. Clearly,these profound losses need to be studied, but at this juncture, wecannot generalize their findings to these losses. Further, the impactof multiple child death was not explored. This too requires furtherinvestigation.

Summary

Parental grief is best appreciated as grief over a lifetime. Parentalgrief is a universal connection among those who have suffered


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and sustained the loss of a child by death. At the same time, eachexperience of child death is unique. Regardless of time, age, cause,and circumstance child death is an unparalleled loss that leads to alifetime of grieving.

Parental grief is the lifelong transformative connection sus-tained by parents as they enfold their profound loss and live withthe memories of their dead child. When a child dies, the parents’grief continues over their lifetime. Their grief maintains their con-nectedness to the child. Grieving is a process of taking in the pro-found nature of their loss and integrating the loss into their lives.Through this enfolding, parents are forever changed by their grief,which transforms their identities and perspectives on living. Theyare always parents of their dead child. Parental grief is character-ized by this enfolding and unfolding as the self is transformed con-tinuously through this process. Qualitative measures add to a richcontextual appreciation of the grief experience of parents on thedeath of their child.

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the continuing process of parental grief

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