Sense and Significance: A Mixed Methods Examination of Meaning Making After the Loss of One’s Child

Abstract

The purpose of this mixed methods study was to identify specific themes of meaning making (sense making and benefit finding) among bereaved parents, as well as to examine associations of these themes to the severity of grief symptomatology. A sample of 156 bereaved parents responded in writing to open-ended questions about sense making and benefit finding. We assessed normative grief symptoms with the Core Bereavement Items (Burnett, Middleton, Raphael, & Martinek, 1997) and maladaptive grief symptoms with the Inventory of Complicated Grief (Prigerson et al., 1995). Qualitative analyses revealed 45% of the sample could not make sense of their loss, and 21% could not identify benefits related to their loss experience. These parents had more severe normative and maladaptive grief symptoms. Overall, parents discussed 32 distinct approaches to finding meaning in their child’s death, 14 of which involved sense making, and 18 involved themes of benefit finding. The most common sense-making themes involved spirituality and religious beliefs, and the most common benefit-finding themes entailed an increase in the desire to help and compassion for others’ suffering. These results further reinforce the importance of meaning making for many bereaved parents and suggest the utility of developing and evaluating meaning-centered grief interventions with this population.

The loss of a child is widely accepted as one of the most profoundly painful, intense, and devastating types of bereavement. It has been associated with heightened risk for various poor psychosocial and physical health outcomes, including psychiatric illness, existential suffering, marital problems, and even mortality (see Davies, 2004; for review; Kreicbergs, Valdimarsdottir, Onelov, Henter, & Steineck, 2004; Li, Precht, Mortensen, & Olsen, 2003; Middleton, Raphael, Burnett, & Martinek, 1998; Oliver, 1999). Grief also tends to persist longer among bereaved parents than for other bereaved populations, often lasting in some intensity for the remaining duration of the parent’s life (Malkinson & Bar-Tur, 1999; Malkinson & Bar-Tur, 2004). This longevity of suffering largely may be due to the struggle parents frequently encounter in making meaning of their untimely loss. Prior studies have in fact demonstrated that parents’ difficulties with finding meaning often persist for years, and for those who initiate a search for understanding but fail in their quest, the risk for poor adjustment increases considerably (Lehman, Wortman, & Williams, 1987; Murphy, Johnson, & Lohan, 2003).

Following the loss of a loved one, individuals are often driven to search for meaning in both the loss and their lives (Neimeyer, 2000). The loss of a child can be especially disruptive to one’s meaning structures; it is often perceived as “senseless” (Davis, Nolen-Hoeksema, & Larson, 1998) and can rattle a parent’s sense of understanding about the way the world works and his or her purpose in life. Forced to transform their identity as a “parent,” a bereaved mother or father frequently faces a unique existential crisis (Wheeler, 2001). A large proportion of these parents must somehow reconcile an event that challenges the expected order of life events and threatens their sense of identity, purpose, and legacy as well as the very meaning of their child’s life (Davies, 2004; Rubin, 1989).

Bereavement experts have proposed that finding meaning in the loss experience and restoring a sense of purpose in a world without the deceased loved one may be therapeutic and reduce suffering for many persons (Davis et al., 1998; Neimeyer, 2000). Meaning-centered interventions, designed to enhance meaning and purpose, have been empirically examined in nonbereaved populations (e.g., advanced cancer patients; Breitbart, Gibson, Poppito, & Berg, 2004; Greenstein & Breitbart, 2000). However, there have been few efforts to develop theory-driven, empirically supported interventions that focus on meaning making to assist bereaved parents with coping and adjustment (Murphy, 2000). To develop effective interventions that address the unique challenges bereaved parents confront in healing themselves from their loss, it is essential to determine which aspects of meaning-making processes are critical for this population and associated with severity of grief symptoms.

Given the various domains of “meaning” that might be challenged with the loss of a child, meaning making among bereaved parents is a complex phenomenon that many researchers have studied over recent years. In turn, meaning making has become something of an umbrella term that may describe several specific processes that contribute to adaptation to bereavement and other stressful life experiences (see Park & Folkman, 1997 for review). Two of the most common conceptualizations of meaning have been labeled sense making and benefit finding (Davis et al., 1998; Janoff-Bulman & Frantz, 1997). Sense making (initially termed meaning-as-comprehensibility by Janoff-Bulman & Frantz, 1997) refers to constructing an explanation of a loss based on one’s beliefs/worldviews, such as the death being God’s will or due to unhealthy behaviors (Davis et al., 1998; Janoff-Bulman & Frantz, 1997). Benefit finding (similar to the term, meaning-as-significance; Janoff-Bulman & Frantz) refers to the value of an event in one’s life more globally, which often involves positive changes such as increased appreciation of life and improved relationships (Davis et al., 1998; Janoff-Bulman & Frantz, 1997). Similar to posttraumatic growth, the concept of benefit finding refers to the positive consequences that may paradoxically follow stressful life events. However, whereas benefit finding has been defined as the identification of any type of benefit after an adverse event (Sears, Stanton, & Danoff-Burg, 2003), posttraumatic growth is often used to describe long-term positive personal changes that may develop (Tedeschi & Calhoun, 2004).

What Do We Mean by Meaning Making in Bereaved Parents?

Although details are limited about the ways in which bereaved parents negotiate the processes of sense making and benefit finding, both quantitative and qualitative studies have demonstrated that parents frequently struggle with issues around making meaning of their loss (Lang, Gottlieb, & Amsel, 1996; Lehman et al., 1987; McIntosh, Silver, & Wortman, 1993; Murphy et al., 2003; Wheeler, 2001). The relations between meaning making and adjustment were also recently suggested by Wu et al. (2008), who examined the impact of searching for and finding meaning among mothers whose children were undergoing haematopoietic stem cell transplantation. Searching for meaning in their child’s illness prebereavement (at the time of transplant) was associated with increased postbereavement distress, whereas finding meaning before the child’s death predicted decreased postbereavement distress (Wu et al., 2008). Similarly, Uren and Wastell (2002) examined the search for meaning among mothers who experienced perinatal bereavement and found that the degree of meaning making predicted grief acuity when controlling for time since loss, distress, and intrusive thoughts. Most recently, Engelkemeyer and Marwit (2008) found that bereaved parents commonly reported posttraumatic growth following their child’s death and, more important, such positive life changes were inversely associated with the severity of grief symptoms.

Qualitative studies have also enriched our understanding about the lived experiences of bereaved parents. Wheeler (2001) observed a “crisis in meaning” among 176 bereaved parents who responded to open-ended questions about their loss experience and what gave their life meaning after the loss of their child. Themes from this study included parents’ struggle with making sense of why the loss occurred and what could have been done to prevent the loss, preserving the significance of their child’s life, and positive gains related to the loss. Parents responded that their lives were made meaningful by contact with people, activities, beliefs and values, connection with the dead child, and personal growth (in that order). The frequencies with which these themes emerged were not reported, although Wheeler (2001) noted that 10% of parents reported that nothing gave their life meaning since their child’s death. Interviewing 39 parents who had lost a child to cancer, Barrera et al. (2009) found that meaning making was a key theme. These authors described how parents accommodated their worldviews to comprehend their loss and the common theme of posttraumatic growth. However, similar to Wheeler (2001), Barrera et al. did not include the specific frequencies with which these themes emerged in their report and did not examine links between the qualitative findings and quantitative measures of adjustment. Broad frequency ranges of themes (80%–100%, 60%–80%, and 30%–60% of parents) were provided by Meert, Thurston, and Briller (2005), who examined the spiritual needs of bereaved parents. The most common theme identified was maintaining a connection to their deceased child (80%–100% of parents), and 60%–80% of parents described a need for meaning and purpose (Meert et al., 2005).

Murphy et al. (2003) also asked parents how they searched for meaning in their child’s death by suicide, homicide, or accident. They found none of the parents perceived any positive significance at 4 months postloss, but 12% found some benefit by 12 months postloss, and 57% were able to identify positive significance by 60 months (5 years). Significantly, quantitative analyses revealed that those who found meaning had less mental distress, greater marital satisfaction, and better physical health. Murphy et al. described a movement from protest to sense making in the first 4 to 12 months postloss, characterized by themes of unfairness of death, seeking information and explanations for the deaths, making causal attributions based on information obtained, and parents’ self-questioning of their responsibilities for the deaths. From 12 to 60 months, important themes included establishing rituals/memorials, seeking justice/revenge/fear for personal safety, and realistic acceptance of the deceased children’s lives as they were lived. Benefit finding seemed to have special relevance 5 years postloss, as parents discussed such themes as new insights into the meaning of life and reordering priorities, deepening of existential beliefs, valuing the deceased child, the belief that the child’s suffering had ended, becoming more altruistic, and learning of one’s strength in the face of adversity. Although this study provided rich longitudinal data about the meaning making process of bereaved parents, the frequencies of themes were not reported. Also, consistent with other studies, Murphy et al. did not include an assessment of grief symptomatology.

Meaning-Making and Prolonged Grief Disorder

Given the intensity and persistence of grief symptoms among bereaved parents (Arnold, Gemma, & Cushman, 2005; Kreicbergs, Lannen, Onelov, & Wolfe, 2007; Talbot, 1997), they are at heightened risk for maladaptive postbereavement syndromes like prolonged grief disorder (PGD; Prigerson et al., 2009; Prigerson, Vanderwerker, & Maciejewski, 2008). PGD, previously referred to as complicated grief and traumatic grief, is a painful and debilitating reaction to bereavement that has been empirically distinguished from bereavement-related depression and anxiety and is associated with negative mental and physical health outcomes (Lichtenthal, Cruess, & Prigerson, 2004; Prigerson, Vanderwerker, & Maciejewski, 2008). Evidence suggests that PGD represents the extreme end of a continuum whose contrast is normative grief, such that individuals with PGD suffer more intensely and appear “stuck” in their anguish for an extended period (Holland, Neimeyer, Boelen, & Prigerson, 2009). PGD symptoms include disturbances in meaning making, such as feeling that life is unfulfilling, empty, or meaningless since the loss, and feeling confused about one’s role in life or about one’s identity (Prigerson et al., 2009; Prigerson et al., 2008). It is, therefore, not surprising that studies have demonstrated an association between PGD symptoms and challenges in meaning making, including difficulty making sense of a loss (Holland, Currier, & Neimeyer, 2006). However, because PGD symptom criteria were empirically derived and validated using data from mid-life to late-life conjugally bereaved individuals (Prigerson et al., 2008), it is important to gain a greater understanding of how meaning-making processes are associated with PGD among bereaved parents. Furthermore, to the extent that interventions may be most appropriate for individuals exhibiting clinical levels of maladaptive grief (Currier, Neimeyer, & Berman, 2008), determining whether distinct meaning-making themes actually predict maladaptive grief symptoms can assist in the development of interventions for bereaved parents.

Study Aims

In summary, research on the ways in which these processes are associated with adjustment to bereavement among parents who lose a child is limited. Based on qualitative and quantitative data on meaning making (sense making and benefit finding), the current investigation is a follow-up and expansion on an earlier study on the contribution of these processes to grief severity in a sample of bereaved parents (Keesee, Currier, & Neimeyer, 2008). Using standardized measures of grief, Keesee et al. assessed normative and maladaptive grief severity in a sample of parents bereaved by a range of causes and recruited through support groups and the Internet. Both sense making and benefit finding were assessed quantitatively with a single-item rating scale. Through their examination of the relative contribution of meaning making to grief severity, Keesee et al. found normative grief symptoms were associated with the amount of sense making that bereaved parents reported, accounting for 10% of the unique variance, but not with the amount of benefit finding. Maladaptive grief was associated with both sense making (15% of the unique variance) and benefit finding (3% of the unique variance), factors that greatly eclipsed the role played by the cause of death or the amount of time since the loss in predicting adjustment.

Given the important clinical implications of these findings, as well as the overall complexity of meaning making in adaptation to bereavement, we sought to expand upon the findings of Keesee et al. (2008) by exploring the nature of qualitative responses to an open-ended item assessing meaning making in the same bereaved parents sample. Whereas Keesee et al. quantitatively evaluated the associations of sense making and benefit finding and grief outcomes, the present investigation focuses on qualitative analyses of narrative data. Using content coding, we aimed to describe the specific themes of meaning making that parents offered in response to meaning-making assessments. Similar to the initial study from these data on quantitative assessments of sense making and benefit finding, we examined the association of these specific qualitative themes with the severity of their grief symptomatology.

To our knowledge, the number of mixed methods studies of bereaved parents is limited (Arnold, Gemma, & Cushman, 2005). The present study involved qualitative analysis of the responses of 156 bereaved parents to open-ended questions using thematic content coping and then compared the qualitative findings with data derived from quantitative self-report measures. This investigation was an effort to expand upon our initial quantitative analyses, summarized in Keesee et al. (2008), to provide a more nuanced understanding of sense making and benefit finding after the death of a child and how different approaches to meaning making relate to adjustment. Therefore, the first aim of this study was to identify themes in response to qualitative assessments of sense making and benefit finding among bereaved parents. The second aim was to determine whether responses from the qualitative data were associated with normative grief and PGD symptoms, the latter of which has not been routinely assessed in bereaved parents despite the general consensus that these individuals are at heightened risk for enduring difficulties moving forward with life following the loss of a child.

Methods

Participants and Procedures

Following institutional review of the project, 156 participants were recruited in the following ways: (a) direct advertising to two Southeastern United States chapters of The Compassionate Friends, a support group network for bereaved parents, or (b) Internet search engines and links from Internet sites that provided resources for bereaved parents to a Web site designed for the present study. This Web site described the primary aim of the study as improving the understanding of the grief process for bereaved parents and afforded the opportunity for bereaved parents to participate anonymously online. The data were either collected electronically via this Web site or by allowing participants to print and complete the online forms and return them by postal mail. Altogether, 95 participants completed surveys electronically, and 61 completed pencil and paper copies; there were no significant differences in identifying characteristics or grief outcomes between the two groups. Of those respondents who submitted surveys online, data received at the Web site were automatically downloaded into a secure file such that the respondents’ e-mail addresses did not appear on the returned surveys. Inclusion criteria stipulated that all of the participants had to be at least 18 years of age. So as to avoid problems with nonindependence by treating individuals from the same parental dyad as separate observations in the analyses, all of the participants came from different families and had lost different children.

Participants had a mean age of 49.41 years (standard deviation [SD] = 10.58 years; range: 23–77 years). The majority of participants were mothers (81%) and Caucasian (93%). African American (4%) and Hispanic/Latino and biracial (3%) parents also participated. Parents reported a range of causes of their child’s death, including miscarriage or stillbirth (6%), natural anticipated (e.g., cancer; 12%), natural sudden (e.g., heart attack; 20%), accident (e.g., motor vehicle accident; 45%), suicide (11%), and homicide (6%). The average length of time since the death was 6 years (SD = 6.14 years; range: 0–40 years). The mean age of the child at the time of death was 17 years (SD = 10.54; range: 0–47). Most parents (91%) had at least one other child at the time of the study. The sample was geographically diverse, residing in 32 different U.S. states, two Canadian provinces, and Australia. See Table 1 for a summary of participant characteristics. It should be noted that data from these same participants were examined by Keesee et al. (2008); however, we focused on qualitative data that these authors were not able to examine in depth in the prior paper.

Table 1. Participant Characteristics.

Demographic characteristics	% (n)
Age, M (SD)	49.4 (3.0)
Relationship to child [N (%)]
Mother	124 (79.5)
Father	29 (18.5)
Ethnicity
Caucasian	144 (92.3)
African American	6 (3.8)
Other	5 (3.2)
Death-related circumstances
Years since loss, M (SD)	5.9 (6.1)
Child age at death (in years)	16.7 (10.5)
Number of surviving children	1.6 (1.1)
Number of other significant losses	2.6 (2.3)
Cause of death, N (%)
Perinatal loss (e.g., stillbirth)	10 (6.4)
Natural anticipated (e.g., cancer)	18 (11.5)
Natural sudden (e.g., heart attack)	31 (19.9)
Accident (e.g., motor vehicle accident)	69 (44.2)
Suicide	17 (10.9)
Homicide	10 (6.4)
Child gender
Son	96 (61.5)
Daughter	55 (35.3)

M = mean; SD = standard deviation.

Measures

Sense making

Sense making was assessed by having participants respond to an open-ended question in writing: Have there been any ways in which you have been able to make sense of the loss of your child? If so, please, in a brief paragraph, describe that experience.This method corresponds closely to the manner in which other researchers have measured meaning making in prior studies (e.g., Davis et al., 1998; Lehman et al., 1987; McIntosh et al., 1993; Uren & Wastell, 2002).

Benefit finding

Benefit finding was also assessed by asking participants a qualitative question: Despite the loss, have you been able to find any benefit from your experience of the loss? If so, please, in a brief paragraph, describe the benefits you have found.

Core Bereavement Items (CBI; Burnett et al., 1997)

The CBI is generally viewed as a measure of normative grief (see Neimeyer, Hogan, & Laurie, 2008, for review). It is a self-report measure comprising 17 items that focus on the personal, cognitive, and emotional elements of grief currently experienced by the bereaved. Each item is presented as a question, such as: Do you find yourself preoccupied with images or memories of —? Do you find yourself thinking of a reunion with —? Responses are given on a 4-point Likert-type scale based on how often the respondent experiences that item, with options of never, a little bit of the time, quite a bit of the time, or always. Responses are scored 0, 1, 2, and 3, respectively, with the overall score being determined by the sum of the individual items, ranging from 0 to 51. The scale’s authors report high internal consistency (α=.92) with a sample of 158 bereaved adults (Burnett et al., 1997). The authors also found evidence for construct validity in that the CBI discriminated between different subsets of the bereaved on the basis of varying levels of grief severity, which included differentiating between expected and sudden causes of death (Middleton et al., 1998). In the current sample, Cronbach’s α was .94 and the average inter-item correlation was .48 for the CBI.

Inventory of Complicated Grief (ICG; Prigerson et al., 1995)

In contrast to the CBI, the ICG was developed specifically to assess maladaptive reactions to bereavement (Neimeyer et al., 2008; Prigerson et al., 1995; Prigerson et al., 1999). The version of the ICG¹ used in the present study includes 19 statements, such as I can’t help feeling angry about his/her death, Ever since [the deceased] died, I feel like I have lost the ability to care about other people, or I feel distant from people I care about, to which responses are made on a five-point Likert scale describing the frequency of symptoms from 0 (never) to 4 (always). Scores can range from 0 to 76, with a clinical cutoff around 25 (Neimeyer et al., 2008; Prigerson et al., 1995). Items assess preoccupation with thoughts of the deceased, hallucinations, feelings of being shocked and overwhelmed, numb, out of control, anxious, and unsafe, and, in addition to avoidance behaviors, sense of purposelessness about the future and disturbances in sleep. As with the strong psychometric properties of the ICG displayed in a number of other studies (Chen et al., 1999; Neimeyer et al., 2008; Prigerson et al., 1997; Prigerson et al., 1999), the ICG yielded a Cronbach’s α of .94 and average inter-item correlation of .43 in the current sample. In support of its validity, the ICG has been shown to predict a range of serious long-term health and mental health consequences of bereavement (e.g., Neimeyer et al., 2008; Prigerson et al., 1997; Prigerson et al., 1999), justifying its use as a measure of maladaptive responses to loss.

Data Analysis

To expand upon the quantitative analyses of Keesee et al. (2008), a content coding system was developed for qualitative analyses of the open-ended sense-making and benefit-finding responses. Participants’ written responses to qualitative questions were first parsed and organized into meaning units by the first author. Meaning units were defined as segments of the responses that seemed to capture a distinct aspect of the meaning-making process. Ranging in length from 1 to 92 words, 796 independent meaning units were identified across participants’ responses to the sense-making and benefit-finding items. These meaning units were organized into 42 content categories by the first and second authors through an inductive process that involved comparing and differentiating each meaning unit from the other meaning units. Three higher order categories were derived through examination of the 42 content categories: (a) sense-making themes, (b) benefit-finding themes, and (c) other salient meaning-making themes. Units that reflected themes related to comprehending reasons for why the death occurred (e.g., cause of death, the well-being of the child) were grouped as sense-making themes. Units that reflected themes related to positive consequences associated with the loss were grouped as benefit-finding themes. The third category involved other salient themes that did not necessarily involve sense making or benefit finding, but appeared informative about commonalities in the parents’ bereavement experiences, such as parents reporting what has provided comfort to them or discussing how their grief has persisted over time. Each of these three higher order themes comprised varying numbers of the basic content categories.

Two independent coders (the first and second authors, both of whom possess strong research and clinical interests in parental bereavement) independently coded the meaning units. Using the 42 content categories, the coders achieved a kappa of .80 (Fleiss, 1981). The two coders had 157 (20%) disparities across the meaning units, all of which were resolved by consensus. So as not to put undue weight on the responses of participants who provided longer written narratives and to avoid problems with nonindependence, meaning units were aggregated to the level of the respondent. Specifically, 42 variables were created (one for each category) by assigning a value of 0 (no) or 1 (yes) to indicate whether a participant gave a response that fell into a given category. Also, this approach had the advantage of allowing the calculation of the proportion of parents who discussed a particular category of meaning making, in such a way that results would be unbiased by the length of their response.

For each thematic category identified, we therefore calculated the number of times that the theme was offered by a participant. Parents often discussed multiple themes, and each theme was counted in its respective thematic category. Gender differences were evaluated using χ² tests. Although the first author parsed the meaning units, both coders were blind to whether a meaning unit was in response to the sense-making or benefit-finding questions. We noted that several parents touched on benefit-finding themes in response to the open-ended sense-making item, and that likewise, many parents discussed sense-making themes in response to the benefit-finding item. Hence, the presence of a theme was counted in the calculations of frequencies and percentages, regardless of whether it was offered in response to the sense-making or benefit-finding item. Also, 15.4% (n = 24) of parents did not provide a response to the sense-making or benefit-finding items. Ten of the 42 content categories were other salient themes that could not be captured by sense-making or benefit-finding categories. The 32 remaining content categories were either sense-making (14 themes) or benefit-finding (18 themes) categories. These 32 meaning-making categories will be the focus of this report. To examine the relationships between the sense-making and benefit-finding themes and severity of grief, we selected those themes that occurred with a frequency of at least 5% for inclusion in hierarchical regression analyses. After entering demographic and background risk factors simultaneously in step 1, sense-making and benefit-finding content codes were entered in step 2 as predictors of grief outcomes using linear regression analyses and as predictors of possible cases of PGD using logistic regression.

Results

Sense-Making Themes

We identified 14 sense-making themes, each of which characterized parents’ attempts to understand causes of the death (e.g., God’s will, child’s behavior) or ways in which the death was somehow made comprehensible to them (e.g., that the child was no longer suffering). The most common thematic response, given by 44.9% of the parents to the open-ended sense-making item, was that no sense could be made of the loss. Such responses ranged from a simple, “no,” to more elaborate statements, such as the reply of a 49-year-old mother who had suddenly lost her 24-year-old son: “No, I have found no sense in the death of my child or any other child…none whatsoever. It should not have happened.” Similarly, a 52-year-old mother whose 18-year-old son died in a fatal accident responded, “No, there are no ways. I try to understand why, but just can’t. How does one make sense of the death of their child?”

A little over half of the sample (52.6%; n = 82) offered at least one way they had made sense of their loss. Among these participants, 21% (n = 32) offered one way of making sense of their loss, 22% (n = 34) offered two different ways, and 10% (n = 16) offered three or more different ways. These themes are detailed in Table 2. The most prevalent sense-making theme involved believing that the child’s death was God’s will (17.9%). For example, a 40-year-old mother who lost an infant 3 years prior offered, “Knowing that God is in control is what helps me. I don’t understand His ways but I can try to accept that His plan for my life is perfect.” As a related but distinct theme, 16% of parents offered beliefs related to the existence of an afterlife, such as knowing that the child was safe in Heaven or believing they would be reunited with the child. Another common theme was reflected in responses indicating beliefs about the brevity of human life (10.9%). For example, almost 12 years after losing her 21-year-old daughter in a fatal accident, a 56-year-old mother responded to the question regarding sense making: “No, not really, but I do believe we all have our time to die. Believing this is the only thing that has kept me going.” Themes that occurred at low frequencies and did not fit into any of the other categories were grouped in an “other sense-making themes” category.

Table 2. Sense-Making Themes Invoked by Bereaved Parents (N = 156).

Sense-making theme	Coding definition	% (n)
No sense	Provided explicit response of “no” to sense-making  question or elaboration indicating no sense could be  made of the loss	44.9 (70)
Death was God’s will	Discussed God’s will, plan, or that God knows what is  best	17.9 (28)
Theme of an afterlife	Discussed existence of afterlife, continuum between life  and death, or the belief that deceased child is safe in  afterlife or parent will be reunited with child	16.0 (25)
Beliefs about human existence,  the imperfection of the world,  and the brevity of life	Discussed beliefs about the inevitability of death,  suffering, negative life events, or the fragility or  brevity of life	10.9 (17)
Death attributed to fate/spiritual  journey	Discussed fate, destiny, or spiritual journey without  mention of God	9.0 (14)
Child is no longer suffering	Discussed how child was no longer physically or  mentally suffering as a result of their death	7.7 (12)
Biological/medical explanations	Offered concrete biological or medical explanations for  death	7.1 (11)
Purpose of child’s life/death	Discussed the purpose of the child’s presence in the  world or lessons learned through the child’s death in  the context of why the death occurred	3.8 (6)
Parent’s role in death	Discussed own actions (positive, negative, or neutral)  that were believed to be related to death	3.2 (5)
Child’s behavior	Discussed child’s actions (positive, negative, or neutral)  that were believed to be related to death	3.2 (5)
Information seeking about cause  of death	Discussed obtaining information about the death in  context of understanding why the death occurred	3.2 (5)
Random	Discussed death as a random event	1.3 (2)
Laws of physics	Discussed the laws of physics in the context of  understanding why the death occurred	0.6 (1)
Other sense-making themes	Discussed another sense-making theme/explanation not  listed above to come to terms with their child’s death	13.5 (21)

Note. Numbers in this table reflect the percentage and amount of parents that discussed a given theme. Parents may have discussed multiple themes, and, therefore, this table details how common discussion of a theme was in the narrative responses.

We found a significant gender difference in these responses, such that mothers discussed the death as God’s will significantly more than fathers, χ²(1, N = 153) = 4.96, p<.05. No other gender differences in the themes in parents’ responses were observed (all ps>.10).

Benefit-Finding Themes

Eighteen benefit-finding themes emerged from the participants’ narrative responses (see Table 3). Similar to responses to the question regarding sense making, the most prevalent responses to the item regarding benefit finding involved the parents’ expression that they had not been able to find any benefit in their loss experience, which was offered by 21% (n = 32) of the sample. Some parents simply replied that there were no benefits, and others actually reacted negatively to the use of the term, such as the response from a 59-year-old mother who suddenly lost her 40-year-old son to natural causes 3 years prior: “Benefits—of course there are no benefits when your child dies!”

Table 3.

Benefit-Finding Themes Invoked by Bereaved Parents (N = 156)

Benefit-finding theme	Coding definition	% (n)
No benefit	Provided explicit response that no benefits were related  to the loss experience	20.5 (32)
Help others who have  experienced loss	Discussed actions taken to help others or desire to help  others who have experienced loss	20.5 (32)
Increased compassion/empathy/  sensitivity in general	Discussed increases of compassion, empathy, or  sensitivity in general, with no direct mention of its  relationship to relating to bereaved individuals	16.7 (26)
Greater appreciation of life/do  not take life for granted	Discussed heightened appreciation of life, staying in the  moment, taking one day at a time, and/or not taking  life for granted	14.7 (23)
Learned about the pain of loss  and can relate to others	Discussed increases of compassion, empathy, or  sensitivity towards other bereaved individuals	13.5 (21)
Enhanced spirituality	Discussed increases in spirituality, faith, or religiosity	13.5 (21)
Other themes of personal  improvement/growth	Discussed themes of personal growth other than those  detailed separately in this table (e.g., other than  increased sensitivity), such as being wiser, more  patient, or more tolerant	12.8 (20)
Relationships strengthened or  developed	Discussed the strengthening of current relationships or  the formation of new personal relationships	12.2 (19)
Benefits to others/society	Discussed how consequences of child’s death benefitted  others (e.g., organ donation) or society (e.g., laws  passed)	10.3 (16)
Stronger, improved coping, or  less afraid	Discussed ways in which felt stronger, that could cope  with difficult situations, or was less afraid in general  or of specific issues, like dying	8.3 (13)
Development of relationships to  other children	Discussed giving birth to or adopting other children or  improvement of relationships with other children	7.7 (12)
Expression of appreciation of  relationships	Discussed increased appreciation of others or heightened  ability to express appreciation of others (distinct from  mentioning strengthening of relationships)	7.7 (12)
Changes in priorities	Discussed changes in priorities, or changes in the importance of roles, relationships, time spent, or what  is distressing	7.1 (11)
Furthered education or changed  careers	Discussed pursuing classes, higher education, or a  desired change in careers	3.8 (6)
Others demonstrated support  and care	Described efforts made by friends and family following  their loss	3.2 (5)
Lifestyle improvements	Discussed positive changes in life that include moving,  ending a difficult marriage, etc.	2.6 (4)
Learned valuable lesson or about  something valued	Described lesson learned about life, death, relationships,  etc.	1.3 (2)
Other benefit-finding themes	Described another positive consequence/benefit not  listed above (e.g., freedom, travel, legacy)	16.7 (26)

Note. Numbers in this table reflect the percentage and amount of parents that discussed a given theme. Parents may have discussed multiple themes, and, therefore, this table details how common discussion of a theme was in the narrative responses.

Almost three-quarters of parents (73.7%; n = 115) noted at least one positive consequence related to their loss. Twenty-seven percent (n = 41) of these participants offered one benefit, 21% (n = 32) offered two benefits, 11% (n = 17) offered three, 10% (n = 15) offered four, 3% (n = 4) offered five, 2% (n = 3) offered six, and 1% (n = 2) offered seven. The most frequent theme was the newfound ability to help others who experienced loss, endorsed by 21% (n = 32) of the sample. For instance, when asked about whether there were any benefits related to the natural anticipated loss of her 24-year-old son, a 54-year-old mother replied:

By reaching out to others who have suffered losses, I find some meaning to my life. My kids were brave when they fought their battles with catastrophic illnesses and lived each day to the fullest, and because of their strength, I, too, will attempt to be brave.

Another common theme involved an increase in compassion or sensitivity, which 16.7% (n = 26) of parents expressed. Other prevalent themes were reports of a greater appreciation of life (14.7%, n = 23), learning about the pain of loss and the ability to relate to others (13.5%, n = 21), enhanced spirituality (13.5%, n = 21), themes reflecting additional aspects of personal growth (12.8%, n = 20), and the strengthening or development of relationships (12.2%, n = 19). Many of the parents reported several of these positive life changes. For example, a 49-year-old father, who had lost his 2-year-old son over 9 years ago, replied to the question about benefit finding:

Yes, I have benefited greatly. My son’s death gave me a far greater sense of appreciation for my wife, daughter, and second son. I also became more tolerant, patient, and caring. Much more sensitive to the needs of others. And I found out a lot of people really cared for me that I was unaware of.

We grouped themes that were not subsumed by other categories as “other benefit-finding themes.” Altogether, 17% of the participants offered a response that fell in this general category. No gender differences in the benefit-finding themes were observed (ps>.10). Other salient themes that emerged in coding the qualitative data are summarized in Table 4.

Table 4.

Other Salient Themes Invoked by Bereaved Parents (N = 156)

Theme	% (n)
Discussion of what has been comforting, helpful, or healing	14.7 (23)
Continue to grieve/feel the loss (mention of pain, sadness,  current negative emotion related to loss)	14.1 (22)
Appreciation of child/time with child	12.2 (19)
Theme of acceptance/that cannot change circumstances	10.3 (16)
Choices/actions made to honor child	5.8 (9)
Statement that different person than before the loss	5.8 (9)
Other consequences of loss (negative or neutral)	5.1 (8)
Feels support of child’s spirit	2.6 (4)
Absence of acceptance/have not yet accepted	1.9 (3)
Continued bond to child	1.9 (3)

Note. Numbers in this table reflect the percentage and amount of parents that discussed a given theme. Parents may have discussed multiple themes, and, therefore, this table details how common discussion of a theme was in the narrative responses.

Relations of Meaning-Making Themes and Grief Symptoms

Data for individual items on the ICG and CBI were missing for 6% of the sample. We employed the same approach to handle missing data as was used in the previous report (Keesee et al., 2008). For these participants, we used the average of the completed items as the participant’s overall score. This score was then employed as the dependent variable in the analyses. As Keesee et al. highlighted, participants were generally quite distressed, with over 55% of the sample scoring above the ICG clinical cutoff of 25 (mean [M] = 29.8, SD = 16.1). In terms of CBI results, mothers had significantly higher scores than fathers, t(151) = −2.10, p<.05. As reported previously, higher ICG scores were associated with more recent losses (r = −.42, p<.001) and the loss of an older child (r = .19, p<.05). Parents who lost a child to a violent death also had significantly higher ICG scores than parents bereaved by natural anticipated causes (p<.001).

In applying a mixed methods approach, we explored relations between the presence of specific meaning-making categories identified in the qualitative data and grief outcomes. Specifically, we conducted hierarchical multivariate regressions to determine which themes were associated with CGI scores (linear regression), ICG scores (linear regression), and PGD caseness (logistic regression). In step 1, we simultaneously entered the risk factors of parent gender, cause of death (violent vs. non-violent), parent age, time since loss, and child age at death in the analyses (all of which had emerged as significant univariate predictors of grief in our earlier study). In step 2, we simultaneously entered those specific dichotomous (presence/absence) meaning-making thematic categories that occurred with a frequency of 5% or greater into the regression equation.

Predicting CBI scores

When controlling for other risk factors, we found that parents who explicitly stated that there was no sense in the loss (β = .24, p<.002) or no benefit related to the loss (β = .17, p<.002) had higher CBI scores. Lower CBI scores were associated with the discussion of at least one benefit (β = −.21, p<.01).Less severe symptoms of normative grief were also associated with a greater number of ways parents made sense of their loss (β = −.18, p = .01), and a greater number of benefits related to their loss (β = −.16, p<.05). Hierarchical regressions were conducted to examine the relative contribution of specific themes to normative grief symptoms. A regression analysis that included sense-making themes as predictors was conducted separately from the regression analysis that included benefit-finding themes. Demographic and background risk factors were entered in the first step, and specific themes occurring with a frequency of at least 5% were entered in the second step. The F statistic for the overall regression model that included sense-making themes was statistically significant, F(17, 120) = 5.69, p<.001, R² = .33, δR² = .06. However, none of the individual themes reflecting how parents made sense of their loss was significantly associated with CBI scores (all ps>.10). When the “no sense” theme was included as an independent variable, it remained the only significantly associated predictor. See Table 5 for these and other details about associations between the sense-making themes and grief outcomes.

Table 5. Associations of Sense-Making Themes to Grief Measures.

Sense-making theme	% (n)	CBI		ICG		PGD caseness
		β	p a	β	p a	OR	CI	p b
Death was God’s will	17.9 (28)	−.11	.140	−.19*	.017	0.18**	0.06 – 0.60	.005
Beliefs about the afterlife	16.0 (25)	.09	.237	−.06	.492	0.76	0.23 – 2.50	.652
Beliefs about human existence,  the imperfection of the world,  and the brevity of life	10.9 (17)	−.04	.612	−.07	.412	2.09	0.53 – 8.20	.292
Death attributed to  fate/spiritual journey	9.0 (14)	.03	.739	−.03	.716	0.54	0.12 – 2.49	.431
Child is no longer suffering	7.7 (12)	−.13	.115	−.18*	.034	0.05*	0.00 – 0.56	.016
Biological/medical explanations	7.1 (11)	−.11	.141	.01	.909	0.95	0.19 – 4.76	.950

Note. CBI = Core Bereavement Items; ICG = Inventory of Complicated Grief; PGD = prolonged grief disorder; OR = odds ratio; CI = confidence interval. Sense-making themes occurring with a frequency of at least 5% were included in these analyses. When the “no sense” code was included in step 2 of the CBI regression equation, it was a significant predictor (β = .22, p < .01) of CBI scores, while the other themes remained ns. When “no sense” was included in step 2 of the ICG regression equation, it was similarly a significant predictor (β = .26, p<.01) of ICG scores; “death was God’s will” remained a significant predictor but “child is no longer suffering” did not. When “no sense” was included in step 2 of the PGD caseness logistic regression equation, it was significantly associated with PGD caseness as well (adjusted OR = 3.02, 95% CI, 1.24-7.34, p<.02), and “help others who have experienced loss,” “enhanced spirituality,” and “changes in priorities” remained significant predictors (ps<.05).

^*p<.05.

^**p<01.

^***p<.001.

^aThe p values for the linear regressions are for the individual β statistics.

^bThe p values for the logistic regression are for the test of the individual Wald statistics.

The F statistic for the final regression model that included the individual benefit-finding themes was also significant, F(17, 121) = 2.96, p<.001, R² = .29, δR² = .10. One benefit-finding theme, “changes in priorities,” was significantly associated with CBI scores (β = −.18, p<.05). Individuals who reported changing their priorities following the loss of their child had lower normative grief scores. Table 6 details the associations between the benefit-finding themes and the grief measures.

Table 6. Associations of Benefit-Finding Themes to Grief Measures.

Benefit-finding theme	% (n)	CBI		ICG		PGD caseness
		β	p a	β	p a	OR	CI	p b
Help others who have  experienced loss	20.5 (32)	−.03	.682	−.13	.111	0.27*	0.09 – 0.76	.014
Increased compassion/empathy/  sensitivity in general	16.7 (26)	−.06	.499	−.06	.536	0.87	0.23 – 3.23	.830
Greater appreciation of life	14.7 (23)	.12	.153	−.01	.934	1.04	0.27 – 3.98	.956
Learned about the pain of  loss/relate to others	13.5 (21)	.02	.768	.01	.894	1.58	0.39 – 6.46	.522
Enhanced spirituality	13.5 (21)	−.06	.452	−.17*	.040	0.17*	0.04 – 0.71	.014
Other themes of personal  improvement	12.8 (20)	−.03	.774	−.09	.358	0.32	0.07 – 1.55	.156
Relationships strengthened/  developed	12.2 (19)	.02	.792	.03	.748	3.22	0.66 – 15.76	.149
Benefits to others/society	10.3 (16)	−.03	.742	−.01	.904	1.52	0.37 – 6.20	.560
Stronger, improved coping,  or less afraid	8.3 (13)	−.06	.484	−.10	.253	0.26	0.05 – 1.39	.116
Development of relationships  to their other children	7.7 (12)	.04	.608	−.06	.458	0.95	0.18 – 5.16	.955
Expression of appreciation  of relationships	7.7 (12)	−.02	.846	−.06	.458	0.89	0.16 – 5.13	.900
Changes in priorities	7.1 (11)	−.18*	.030	−.16*	.047	0.07**	0.01 – 0.47	.006

Note. CBI = Core Bereavement Items; ICG = Inventory of Complicated Grief; PGD = prolonged grief disorder; OR = odds ratio; CI = confidence interval. Benefit-finding themes occurring with a frequency of at least 5% were included in these analyses. When the “no benefit” code was included in step 2 of the CBI regression equation, it was not significantly associated with CBI scores, while “changes in priorities” remained a significant predictor. When “no benefit” was included in step 2 of the ICG regression equation, there was a trend towards significance in the relation between this variable (β = .15, p<.10) and ICG scores, but the other predictors failed to reach statistical significance. When “no benefit” was included in step 2 of the PGD caseness logistic regression equation, it was not significantly associated with PGD caseness, but “help others who have experienced loss,” “enhanced spirituality,” and “changes in priorities“ remained significant predictors of grief symptomatology.

^*p<.05.

^**p<.01.

^***p<.001.

^aThe p values for the linear regressions are for the individual β statistics.

^bThe p values for the logistic regression are for the test of the individual Wald statistics.

Predicting ICG scores

We also examined the relations between the themes and maladaptive grief symptoms (see Tables 5 and 6). When controlling for objective risk factors, higher ICG scores were associated with an explicit statement that there was no sense (β = .30, p<.001) or no benefit in the loss (β = .22, p<.01). Lower maladaptive grief symptoms were associated with discussion of at least one way in which parents made sense of their loss (β = −.24, p<.01) and discussion of at least one benefit (β = −.29, p<.001). Consistent with results for the CBI, lower ICG scores related with a greater number of ways parents made sense of their loss (β = −.33, p<.001), and a greater number of benefits related to their loss (β = −.31, p<.001).

Similar to our approach with the CBI, two hierarchical regression analyses were conducted to determine the relations of the themes to ICG scores: one that the included the sense-making themes as predictors and another that included the benefit-finding themes as predictors. The test of the fit of model in which sense-making themes were examined was statistically significant, F(11, 127) = 4.70, p<.001, R² = .29, δR² = .10. Significant predictors of fewer maladaptive grief symptoms included the beliefs that the death was God’s will and that the child is no longer suffering (all ps<.05; see Table 5). As presented in Table 6, ICG scores were significantly inversely related to two benefit-finding themes: enhanced spirituality and changes in priorities (ps<.05). Parents who expressed an increase in spirituality or positive changes in their priorities had lower ICG scores. The test of the fit of this two-step regression model was also statistically significant, F(17, 121) = 2.96, p<.001, R² = .29, δR² = 10.

Predicting possible “cases” of PGD

Although the use of a self-report measure precludes definitive clinical diagnosis of PGD, we nonetheless explored possible “cases” of PGD based on the most recent criteria proposed by Prigerson et al. (2008). To be considered a possible “case” of PGD, participants had to endorse that they “often” or “always” experienced at least one symptom of separation distress (Criterion B), at least four cognitive, emotional, and behavioral symptoms (Criterion C), and at least one type of functional impairment (Criterion E). All participants met the bereavement criterion (Criterion A), but 11 parents were eliminated from analyses because their loss occurred less than 6 months prior (Criterion D).² Using this approach, 43 potential cases of PGD (~28%) were identified for the final set of analyses.

Results showed that parents were at greater risk of possible PGD caseness when they explicitly stated that they could not make sense of their loss (odds ratio [OR] = 4.64, 95% confidence interval [CI], 2.07–10.44, p<.001). The odds of being a potential case of PGD were over four times greater for individuals who expressed that they could not make sense of their loss. The converse held as well: parents who were able to provide at least one way in which they made sense of their loss were significantly less likely to be meet potential PGD caseness, OR = 0.30, 95% CI, 0.14–0.67, p<.005. An explicit statement that there were no benefits related to the loss was also associated with being a possible PGD case, OR = 4.08, 95% CI, 1.33–12.49, p<.02. Similar to the increased risk of potential PGD observed among parents who expressed that they could not make sense of their loss, the odds of being a potential case of PGD were over four times greater for individuals who expressed that they could not find any benefits. In contrast, those parents who described at least one benefit associated with their loss experience were significantly less likely to be a potential PGD case, (OR = 0.22, 95% CI, 0.08–0.63, p<.005. Using hierarchical logistic regressions we examined the relations between specific sense-making themes (entered simultaneously in step 2) that were associated with reduced likelihood of potential PGD caseness. The omnibus test of this model was statistically significant, χ²(13) = 50.63, p<.001, R² = .31. Themes associated with a decreased likelihood of potential PGD caseness included the beliefs that the death was God’s will (OR = 2.35, 95% CI, 1.29–4.27, p<.01) and that the child is no longer suffering (OR = 4.59, 95% CI, 1.33–15.77, p<.05). Benefit-finding themes associated with a decreased probability of possible PGD caseness included helping others who have experienced loss (OR = 1.94, 95% CI, 1.15–3.28, p<.05), enhanced spirituality (OR = 2.40, 95% CI, 1.19–4.82, p<.05), and changes in priorities (OR = 3.69, 95% CI, 1.46–9.30, p<.01). The fit of this model was also significant, χ²(19) = 55.27, p<.001, R² = .33.

Discussion

This study examined themes of meaning making among parents bereaved by a range of causes who were at various time points in the adjustment process. Consistent with previous research on bereaved parents (Barrera et al., 2009; Murphy et al., 2003; Talbot, 1997; Wheeler, 2001), we found qualitative evidence of the struggle that people who lose a child frequently face with making meaning of their loss. Nearly half the sample explicitly expressed that they could not make sense of their loss in their written narratives, and approximately one-fifth explicitly stated that they could not identify benefits related to their loss experience. These findings are congruent with our earlier report that relied on quantitative assessments of meaning making (Keesee et al., 2008). Notably, those parents who could not make sense of or find benefits associated with their loss had higher levels of normative and maladaptive grief and were over four times more likely to be possible cases of PGD.

We found, similar to previous studies (Davis et al., 1998; McIntosh et al., 1993; Murphy et al., 2003), that the most common sense-making themes involved a reliance on spirituality and religious beliefs about God’s plan or the continuity of life beyond death. Notwithstanding a relatively large subset of parents (~14%) indicating that their sense of spirituality increased as a result of their loss, the cross-sectional nature of the study makes it difficult to examine whether parents discussing these themes were able to fit the loss into their pre-existing worldviews or had accommodated their worldviews as part of their sense-making process. Future work would do well to flesh these possible patterns out using prospective longitudinal designs.

We found it interesting that although we found that lower maladaptive grief symptoms were associated with sense making via spirituality (the belief that the death was God’s will) and the benefit of enhanced spirituality, lower normative grief symptoms were not significantly associated with any of the sense-making themes. Why might these differences have emerged? It may be that there are numerous sense-making paths that result in the natural, normative adaptation to the loss of a child. Spiritual worldviews may be particularly comforting and uniquely protective against getting “stuck” and developing PGD symptoms. Lower levels of maladaptive grief symptoms and decreased likelihood of PGD caseness were also significantly related to the consoling belief that the child is no longer suffering. It is our clinical experience that ruminations about suffering are particularly prevalent among bereaved parents exhibiting maladaptive grief. Utilizing the perspective that the child is no longer suffering as a way to make sense of the loss may, therefore, decrease risk for prolonged grief symptoms.

The most common benefit-finding themes centered around a desire to help others and an enhancement in compassion and understanding of deep pain. Overall, it seemed that the unique and profound anguish that followed the loss of their child for the majority of the parents heightened their sensitivity to the distress of others also contending with emotional pain. In fact, parents who reported helping other bereaved individuals were less likely to meet potential criteria for PGD. A linear association between helping others and lower levels of maladaptive grief was not found, however, which may reflect the double-edged sword of the anguish of grieving; some parents expressing a heightened drive to help others and increased sensitivity may have endorsed more severe symptoms. Lower normative and maladaptive grief symptoms and decreased risk of possible PGD caseness were, however, related to one benefit-finding theme: changes in priorities. This pattern may speak to the potent role that finding a greater significance in a loss can play. Individuals whose priorities change following a death may move towards living more meaningful and authentic lives that bring fulfillment even in the face of the profound pain that results from the loss of a child. Finding fulfillment in the here and now in spite of their grief may help prevent them from getting “stuck.”

Of note, the amount of benefit finding did not predict normative grief symptoms in the earlier report on these data by Keesee et al. (2008). The discrepancy between their findings and those of the current study may be explained by our inclusion of specific benefit-finding themes as predictors in the regression models rather than global benefit-finding ratings, as used in the earlier report. Such differences between the studies highlight the advantages of a mixed methods approach, which permits a fuller exploration of factors associated with adjustment. Certain types of benefit finding appear to be associated more strongly with normative grief symptoms than the degree of benefit finding per se.

Similar to Davis et al.’s (1998) results, we found more severe grief symptoms and a greater prevalence of potential PGD caseness among those parents who expressed that they could not make sense of their loss and those parents who stated that no benefits were to be found in their loss experience. However, Davis et al. did not find significant associations between the specific sense-making and benefit-finding themes and levels of adjustment. This may reflect differences in the level of detail captured by the themes in our respective studies. Davis et al. (1998) identified sense-making and benefit-finding themes that were broader than the themes identified in the current study. In addition, while we examined specific normative and maladaptive grief symptoms, Davis et al. assessed “distress” using a composite measure comprised of measures of depression, positive affect, and posttraumatic stress symptoms. Researchers have indeed noted that it may be misleading to reduce bereavement outcomes to generic distress when the goal is to understand grief reactions (Neimeyer et al., 2008; Shaver & Tancredy, 2001). It, therefore, seems important to examine the relations between grief symptoms, as was done in our study, and meaning making, given their theorized link in the process of adapting to bereavement. Our identification of associations between specific themes and maladaptive grief symptoms suggests the utility of incorporating these topics into interventions designed for “complicated” or “prolonged” grievers.

By supplementing the quantitative sense-making and benefit-finding ratings with parents’ narrative responses to questions about these meaning-making processes, we were better able to observe the subtle complexities in meaning making among the parents. The overlap between sense making and benefit finding was substantial, as parents touched on the potential for “good” to come out of tragedy. In turn, perceptions of benefit were often used to make sense of, or “justify,” the loss to some extent. A 31-year-old mother who suddenly lost her infant son provided an example:

I believe that my baby John’s purpose in life was to bring us great joy and love in the 3 short days he was here on this earth. I believe that he helped strengthen my marriage and, more importantly, mine and my husband’s and my family’s faith in God.³

The overlap that we observed is consistent with Murphy et al. (2003), whose qualitative findings suggested the dynamic nature of meaning-making processes among bereaved parents.

Limitations

This study has several limitations that should be considered when evaluating the present conclusions. The cross-sectional design limits our ability to make causal inferences about the relations between the presence of the various categories of meaning-making responses and grief symptoms. In addition, although rigorous standards for coding the qualitative data were applied, we acknowledge possible subjectivity in interpretation of the narrative data. Furthermore, although the study was strengthened by its use of a relatively large and diverse sample with respect to cause of death and time since loss, the findings may be limited in their generalizability because the majority of the sample was Caucasian and female, and was recruited through support groups and the Internet. Finally, the current study was possibly limited by the absence of an interviewer to guide participants and to provide support with the discussion of sensitive topics. It is possible that some of those parents who did not provide a response to the sense-making or benefit-finding items (15.4%; n = 24) may have felt more comfortable doing so with the presence of another individual or with clarification of the terms.

Future Directions and Clinical Implications

Meta-analyses of bereavement intervention outcome studies demonstrate the importance of targeting distressed populations (Currier et al., 2008). The current study suggests that in addition to previously identified demographic and contextual risk factors (Keesee et al., 2008; Wijngaards-de Meij et al., 2005), deficits in meaning making may be useful for screening parents to determine who is most appropriate for psychosocial services. Future studies should focus on developing reliable measures of meaning-making constructs (see Gillies & Neimeyer, 2006). This will advance our understanding of the role of meaning making in adaptation to bereavement, including investigation of individual differences that may facilitate or hinder the meaning-making process (e.g., attachment style, religiosity). Another clinical issue suggested by our findings is the importance of sensitive wording in the assessment of such processes (e.g., benefit finding) and outcomes among bereaved parents; special care should be taken to validate parents’ unique loss experience in future clinical and research endeavors.

The promise of meaning making as a psychotherapeutic approach for bereaved individuals has been widely discussed in the bereavement literature (Neimeyer, 2000; Stroebe & Schut, 2001; Tedeschi & Calhoun, 2004). However, research on the development of empirically supported interventions promoting meaning making among bereaved parents is lacking. Breitbart and colleagues (2004; Greenstein & Breitbart, 2000) have found that a manualized meaning-centered psychotherapy is efficacious in enhancing meaning and purpose among advanced cancer patients. Use of a similar approach tailored to the unique needs of bereaved parents may address the fundamental challenges with meaning making that many parents who lose a child face.