Sibling Bereavement and Continuing Bonds

Article (PDF Available)inDeath Studies 30(9):817-41 · December 2006with179 Reads
DOI: 10.1080/07481180600886603 · Source: PubMed
Abstract
Historically, from a Freudian and medical model perspective, emotional disengagement from the deceased was seen as essential to the successful adaptation of bereavement. A major shift in the bereavement literature has occurred and it is now generally accepted that despite the permanence of physical separation, the bereaved remains involved and connected to the deceased and can be emotionally sustained through continuing bonds. The majority of literature has focused on adults and on the nature of continuing bonds following the death of a spouse. In this article, the authors demonstrate how the continuing bonds concept applies to the sibling relationship. We describe the unique continued relationship formed by bereaved children and adolescents following a sibling loss, highlight the factors that influence the siblings continuing bonds expressions, and offer clinical interventions. In our view, mental health professionals can play an important role in helping parents encourage activities that may facilitate the creation and maintenance of continuing bonds in their children.
SIBLING BEREAVEMENT AND CONTINUING BONDS
WENDY PACKMAN
Pacific Graduate School of Psychology, Palo Alto, California, USA
HEIDI HORSLEY
FDNY=Columbia University Family Assessment and Guidance Program,
Columbia University School of Social Work, New York, New York, USA
BETTY DAVIES
Family Health Care Nursing, University of California, San Francisco,
California, USA
ROBIN KRAMER
Pediatric Palliative Care Program, Children’s Hospital,
University of California, San Francisco, California, USA
Historically, from a Freudian and medical model perspective, emotional
disengagement from the deceased was seen as essential to the successful adaptation
of bereavement. A major shift in the bereavement literature has occurred and it is
now generally accepted that despite the permanence of physical separation, the
bereaved remains involved and connected to the deceased and can be emotionally
sustained through continuing bonds. The majority of literature has focused on
adults and on the nature of continuing bonds following the death of a spouse.
In this article, the authors demonstrate how the continuing bonds concept applies
to the sibling relationship. We describe the unique continued relationship formed
by bereaved children and adolescents following a sibling loss, highlight the factors
that influence the siblings continuing bonds expressions, and offer clinical inter-
ventions. In our view, mental health professionals can play an important role
in helping parents encourage activities that may facilitate the creation and
maintenance of continuing bonds in their children.
‘‘It has been said that death ends only a life, it does not end a relationship.
This statement is especially true when a sibling dies in childhood,
adolescence or early adulthoodan untimely death whose unhealthy
consequences can endure long after the farewell at the graveside.’’
(Bank & Kahn, 1982, p. 271)
Received 1 April 2006; accepted 29 May 2006.
Address correspondence to Wendy Packman, Pacific Graduate School of Psychology,
935 East Meadow Drive, Palo Alto, CA 94303.
817
Death Studies, 30: 817–841, 2006
Copyright # Taylor & Francis Group, LLC
ISSN: 0748-1187 print/1091-7683 online
DOI: 10.1080/07481180600886603
History and Background of Continuing Bonds
Prior to World War I, it was universally accepted that death had a
lifelong impact on the survivors (Devita-Raeburn, 2004). Indeed,
the accepted thinking on the grief process incorporated the con-
cepts of continuing bonds and ongoing attachment to the deceased.
Victorian widows grieved literally and figuratively for years
(Neimeyer, as cited in Devita-Raeburn, 2004). A major shift in
thinking occurred in the aftermath of WWI throughout Europe.
In Britain alone, there were hundreds of thousands of war-related
deaths (Devita-Raeburn, 2004). The sheer number of deaths liter-
ally overwhelmed those left behind and ‘‘almost overnight,’’ said
Neimeyer, ‘‘there was a new posture toward loss. It became a patri-
otic duty to repress one’s grieving, and to distance oneself from it.
This model of self constraint, rather than self expression, became
the approved way of reacting to loss’’ (Neimeyer, as cited in
Devita-Raeburn, 2004, p. 140).
Since that time, emotional detachment, which included sever-
ing ties with the deceased, was seen as a critical part of the grief
process (Klass, Silverman, & Nickman, 1996). In fact, from a
Freudian and medical model perspective, emotional disengage-
ment was essential to the successful adaptation of bereavement
(Field, Gal-Oz, & Bonnano, 2003; Freud, 1917=1957; Klass &
Walter, 2001; Raphael, 1983).
Historically, the study of bereavement has been focused on
the psychology of grief as an individual, mostly internal, experi-
ence. Emphasis has been on the pathological aspects of grief and
has advocated for emotional detachment or letting go to achieve
closure. Such views were reinforced by the medical model that
compared grief to a wound that eventually heals, perhaps leaving
some scar tissue; and once it has healed, the wound is forgotten
(Davies, 1999).
Alternative views of grief and grief resolution have been
developed more recentlyperceiving grief as ‘‘work’’ (Worden,
2004) and active coping (Attig, 2001) and as continuing bonds
(Klass et al., 1996). There has been a shift from emotional disen-
gagement and detachment to working through the loss by relearn-
ing the world in a way that helps one accommodate and live with
the loss (Attig, 2001). In the view of Neimeyer (2001) and Attig
(2001), we have a continuing relationship with the deceased:
818 W. Packman et al.
‘‘the premise that moving on means letting go is wrong’’ (Neimeyer
& Attig, as cited in Devita-Raeburn, 2004, p. 143).
A major shift has become evident in bereavement research as
well. Findings have supported the significance of ongoing connec-
tions with the deceased (Klass et al., 1996). There has been increas-
ing attention in the bereavement literature focusing on the function
of a ‘‘continuing bond’’ in relation to coping (Field, Nicholas,
Holen, & Horowitz, 1999; Field & Friedrichs, 2004; Field, Gao,
& Paderna, 2005; Klass & Walter, 2001; Klass et al., 1996; Stroebe,
Gergen, Gergen, & Stroebe, 1992) and adaptation following the
death of a loved one (Klass et al., 1996). It is now generally
accepted that despite the permanence of physical separation, the
bereaved can nevertheless be emotionally sustained through a con-
tinuing bond to the deceased (Field et al., 1999). The majority of
this research has focused on adults and on the nature of continuing
bonds following the death of a spouse. The concept of ‘‘continuing
bonds’’ has been discussed in relation to children’s grief but it
has occurred only in the context of parental loss (G. H. Christ,
2000, 2002; Silverman, Nickman, & Worden, 1992; Silverman &
Worden, 1992). These studies specifically describe how children
maintain a continuing bond to the deceased parent in an attempt
to preserve this relationship. The phenomenon of ‘‘continuing
bonds’’ has not been labeled as such in the sibling bereavement
literature, which in general has been quite limited to date, although
similar concepts have been described in relation to sibling bereave-
ment (Davies, 1991, 1999; Devita-Raeburn, 2004; Hogan &
DeSantis, 1992). In this article, the authors demonstrate how the
‘‘continuing bonds’’ concept applies to the sibling relationship
and we describe the unique, ongoing relationships and bonds
formed by children and adolescents following sibling loss.
Uniqueness of Sibling Relationships
‘‘Sibling relationships are the total of the interactions (physical, verbal, and
nonverbal communication) of two or more individuals who share knowl-
edge, perceptions, attitudes, beliefs, and feelings regarding each other, from
the time that one sibling becomes aware of the other.’’ (Cicirelli, 1995, p. 4)
Sibling relationships have attributes in common with all
interpersonal relationships, but in addition they have certain
Sibling Bereavement 819
characteristics that address the extent of their unique bond (Davies,
1999). Sibling relationships last a long time, essentially a lifetime.
In fact, it has been determined that siblings are likely to spend at
least 80–100% of their lifespans with each other, more time than
with any other family member (Bank & Kahn, 1982). Even when
parents divorce, the marriage relationship ends, but it does not
end the relationship between the siblings (Davies, 1999).
Sibling bonds develop because there is high access and con-
tact between siblings. Further, siblings use each other as major
influences or touchstones, in a search for personal identity (Bank
& Kahn, 1982) and understanding the world around them. Siblings
play a crucial role in identity development, by way of personal
exchanges through which they define one another (Bank & Kahn,
1982). Research also highlights the importance of the sibling bond
(Packman et al., 1997b; Wiley et al., 1984). The pediatric bone
marrow transplantation (BMT) literature has shown that the sibling
bond between the patient and sibling donor actually intensifies fol-
lowing BMT (MacLeod et al., 2003; Packman et al., 1997b; Wiley
et al., 1984) where one sibling’s provision of a life-saving measure
for a brother or sister connects them in a unique way.
The significance and uniqueness of the sibling relationship
portends the profound effect that the death of one child can have
upon brothers and sisters (Davies, 2002). The death of a sibling
means loss of a playmate, confidante, role model, and friend:
Nothing can prepare the survivor for such a myriad of losses
(Davies, 1995). Siblings’ identities are intricately connected because
they share similar histories, so that when one sibling dies, the survi-
vors essentially lose part of themselves (Devita-Raeburn, 2004).
The Concept of Continuing Bonds with Siblings
The concept of continuing bonds with regard to sibling bereave-
ment was initially examined by Davies (1991, 1999) and Hogan
and DeSantis (1992). Among the long-term effects of sibling
bereavement in childhood, bereaved siblings maintain connections
with their deceased brother or sister by engaging in specific actions
that serve to keep them in touch. Nineteen-year-old Rod, whose
brother died when Rod was 10, says, ‘‘I think about him a lot.
I’ve got a picture of him by my bed ...and we’ve got pictures of
820 W. Packman et al.
him all over this [parents’] house, so it’s ...like he’s still here.’’
Other siblings purposefully include the deceased sibling in their
ongoing lives, often by incorporating some favorite memento into
special events: Candace, for example, had her sister’s favorite
peach colored roses for her wedding: ‘‘We used peach roses for
her funeral. And for my wedding ...it was just a real sense of hav-
ing her there with us.’’ Many siblings have ongoing conversations
with their sibling, or pray to them for protection or guidance dur-
ing difficult times: Janice, now 21, was 12 when her sister died and
prays to her sister ‘‘Jackie, watch over me, take care of me.’’
Although some siblings must disentangle from destructive aspects
of relationships, such as abusive or friction-filled relationships,
bereaved siblings allow their siblings’ influences to shape their
lives and characters. In fact, some have noted that their wish to stay
connected or reconnect to their deceased sibling is even stronger as
they grow older (Davies, 1999, pp. 191–193).
Hogan and DeSantis (1992) referred to continuing bonds as
‘‘an ongoing attachment.’’ The ‘‘ongoing attachment categories’’
include:
1. regrettingdesiring to have a better relationship; wishing to
continue a shared relationship;
2. endeavoring to understandsearching for reasons for the
sibling’s death; wanting to know circumstances of the death;
3. catching upasking what heaven is like; how are things? bring-
ing the siblings up to date;
4. reaffirmingloving and missing the sibling;
5. influencingseeking guidance from the sibling; and
6. reunitinganticipating reunion in heaven.
Many of these categoriesreaffirming, catching up, influencing,
reunitingspeak to the desire of the bereaved sibling to maintain
a continuing bond with the deceased sibling.
Batten and Oltjenbruns (1999) also reported that bereaved
siblings experi enced an ongoing a ttachment with their deceased
brother or sister manifest ed i n two ways: first by acknowledgi ng
a continuing bond with the de cease d, who altho ugh no longer
physically alive, seems to exert a presence felt by the survivor.
Although the r elatio nship has change d, in a sense, i t co ntinu es.
‘‘It’s ...like he’s still here ...It’s ki nda l ike there is still a piece of
Sibling Bereavement 821
him with me ...Sometimes that is fairly comforting’’ (p. 540).
Second, through ‘‘con tinua tion’’ the memory lives on through
the things the deceased sibl ing did and the kind of person
he=she was.
In their study of inte rviews with bereaved adolescent sib-
lings, Forwar d and Gar lie (200 3) f ound t he mo st importa nt v ari-
able in the grief process was a search for new meaning that
encompassed ‘‘continuing the bond.’’ This sear ch for new mean-
ing took years and for some it remained ongoing. Bereaved sib-
lings examined their live s and wanted to know what their
purpose was, how to make meaning out of the loss, and how
to go on despite the fact that their sibli ng ha d die d. Specifically ,
spiritual beliefs contributed to this sense of a continuing bond
and provided comfort, in that the majority of teens believed
the sibling was in a better place and they would be reunited
again. They believed the deceased sibling was still with them,
even ‘‘watching over them.’’ Bereaved siblings also reported it
was helpful to have or wear the deceased sibling’s possessions
(i.e., photos, wallet, clothing, watch). Keeping memories alive
by sharing positi ve recollections of the deceased sibli ng was
yet another way to maintain the connection. Two bereaved sis-
ters who lost their firefighter brother in the World Trade Center
attacks designed a book of photos, cards, and poems to com-
memorate their deceased sibling . For these sisters, maintaining
a bond with their brother helped them come to terms with their
sibling’s death and find meaning out of their loss.
In her 2004 book, The Empty Room: Surviving the Loss of a
Brother or Sister at Any Age, Elizabeth Devita-Raeburn referred to
continuing bonds as the phenomenon of ‘‘Carrying.’’ Based on
interviews with 77 bereaved siblings, she found the surviving sib-
lings carry, or bring forward, their deceased sibling into their cur-
rent lives without attempting to replace them. The deceased
siblings remain part of their identity as parallel travelers in life.
Thus, bereaved siblings were ‘‘carrying’’ their deceased sibling
with them and continuing the very bonds that had always defined
the relationship. In the book, Meredith provides an example: She
runs marathons in memory of her brother, Jon. This allows her to
travelwhich her brother loved to doand the money she raises
is donated to neuroblastoma research, the cancer Jon died from.
Devita-Raeburn insightfully explains:
822 W. Packman et al.
Running has given Meredith a way to keep Jon with her as she moves into
the terrain of her own future, one that she looks to more willingly now. She
has invented a new relationship with him, one that acknowledges that he is
dead, gone from her life but present too. Running has helped Meredith to
redefine life after loss. (p. 136)
Like Meredith, bereaved siblings may feel disloyal in moving
ahead and leaving their deceased sibling behind. Their love for
them and sense of connection lives on despite the fact that they
are not physically present (Devita-Raeburn, 2004).
It is important to note that grieving siblings’ continuing bonds
expressions are likely to be influenced and shaped by their former
relationship with their siblings (Davies, 1988a, 1999; Devita-
Raeburn, 2004). Although some sibling relationships are marked
by warmth and caring, others are hostile and adversarial. Moder-
ate amounts of sibling conflict exist in even the most optimal
sibling relationships, but this is balanced with support and close-
ness (Newman, 1994). However, in instances where the relation-
ship between the siblings was primarily ambivalent or
conflictual, the connection to their deceased siblings may be dis-
turbing or even frightening (Normand, Silverman, & Nickman,
1996). For example, a bereaved teenager had a conflictual sibling
relationship wrought with competition and fighting. After his
brother’s death he had numerous nightmares and was disturbed
by the feeling of his brother’s presence in the home. Moreover,
bereaved siblings may be contending with negative things they
said or did prior to the sibling’s death, which can intensify feelings
of guilt. In addition, siblings may have unfinished business, if they
did not have a chance to say good-bye, apologize, or tell the sibling
how much they meant to them, leaving them with lingering regret.
In such instances, the grieving siblings’ continuing bonds expres-
sions may not be comforting.
Overall, it is now widely accepted that maintaining an
ongoing connection and continuing relationship with the deceased
does not end after a death but remains and becomes an integral
part of successful adjustment (Attig, 2001; Field & Friedrichs,
2004; Klass & Walter, 2001; Stroebe et al., 1992). So we find that
bonds do not need to be broken and that individuals maintain
them in many different ways, continuing to experience the pres-
ence of the deceased in their lives.
Sibling Bereavement 823
The experience of a sibling’s death has profound and long-
lasting effects on the surviving siblings (Horsley & Patterson,
2006). The depth of the emotional closeness that existed between
siblings prior to the death influences the surviving child’s grief pro-
cess (Davies, 1995). Surviving siblings will need to learn to define
their roles and relationships in the absence of their primary refer-
ent (Balk, 1991; Bank & Kahn, 1982; Devita-Raeburn, 2004). It is
not unusual for the impact of sibling bereavement to last a lifetime.
For years following the death, many bereaved siblings report that
they still actively miss their deceased brother or sister, and often
experience renewed and intense grief on occasions that would
have been significant in their lives together (such as births, gradua-
tions, weddings, retirements; Davies, 2002). To help process this
devastating loss, surviving siblings continually renegotiate the
‘‘relationship’’ with their deceased sibling as they reach successive
developmental stages (Devita-Raeburn, 2004).
In the next section, we examine how children and adolescents
preserve and maintain an ongoing attachment to the deceased and
highlight the crucial role of the family system in supporting chil-
dren and adolescents.
Role of the Family
‘‘Of all life experiences, death poses the most painful adaptational chal-
lenges for the family as a system and for every surviving member, with
reverberations for all other relationships.’’ (Walsh & McGoldrick, 1991, p. 3)
One cannot adequately look at the bereavement process of sur-
viving siblings without taking into account the entire family system.
Death within the family has been found to be one of the most painful
events that individuals can experience, creating what amounts to a
total disruption of family equilibrium, putting the entire family in
crisis (Bowlby, 1980; G. Christ, 2006; Walsh & McGoldrick,
1991). Bank and Kahn (1982) found that after the death of a
child, family life is forever modified, including the sibling subsys-
tem. Because the grief process is both an individual and family pro-
cess, a child’s death disrupts the way the family functions, alters the
way parents and surviving siblings relate to each other, and changes
the expectations family members have for themselves and for the
family as a unit (Detmer & Lamberti, 1991).
824 W. Packman et al.
After any death, the family must restructure and readjust, but
doing so after the death of a child is exceedingly difficult (Davies,
1999; McCown & Davies, 1995). How families manage this pro-
cess of adaptation is greatly influenced by the degree of communi-
cation and cohesiveness in the family as well as the amount of
support the family receives from extended family members and
friends (Christ, 2006; Davies, 1988b, 1999; Horsley & Patterson,
2006; McCown & Davies, 1995; Spinetta, 1981). These conditions
very much affect how surviving siblings adapt to the loss. When
siblings experience closeness or a sense of togetherness in their
family and when they share in the support offered by friends
and family, they demonstrate fewer behavioral problems following
the death (Davies, 1995; McCown & Davies, 1995).
Impact of Parental Grief on Siblings
Parental reactions to the death of a child and parents’ patterns of
grief have a significant impact on the surviving siblings who them-
selves are going through a grief process morning the death of a
brother or sister (Balk, 1991; Bank & Kahn, 1982; Cain, Fast, &
Erikson, 1964; Davies, 1995; Horsley & Patterson, 2006; Rosen
& Cohen, 1981; Rubin & Malkinson, 2001). After a child’s death,
just when surviving siblings most need the stability and security in
their family, parents may not be able to support them (Davies,
1995). A number of authors (e.g., Bank & Kahn, 1982; Cain
et al., 1964; Davies, 1995; Devita-Raeburn, 2004; Mufson, 1985;
Pollock, 1986; Rosen, 1986) refer to sibling loss as a double
lossnot only the death of the sibling, but also the loss of their par-
ents’ support. Overwhelmed by their own grief, parents’ capacity to
look after the needs of the surviving children is sorely limited even
though they remain concerned for their children. They often just do
not have the emotional energy to adequately reach out to them.
Children’s grief and fear may be compounded by witnessing
parents’ distress and vulnerability along with the explosive nature
of their parents’ feelings; they often attribute their parents’ beha-
vior to some fault or failing of their own (Horsley & Patterson,
2006). Nothing in their previous experience gives the surviving
children an accurate idea of the depth of their parents’ grief or
how long grief lasts, so they may become overwhelmed and
impatient with their parents’ grief reactions. Whether children
Sibling Bereavement 825
are suppressing or expressing their feelings, they are nevertheless
grieving and are affected by their parents’ expression of their
own sorrow and vulnerability (Davies, 1995). The parents’ distress
is often so intense that bereaved children and adolescents protect
their parents by not mentioning the deceased as they believe it
will upset them even more (Balk, 1983; Forward & Garlie, 2003;
Horsley & Patterson, 2006).
Sibling grief may be further complicated by the failure of
those around the bereaved siblings to acknowledge that they suf-
fered a significant loss as well (Davies, 1995; Devita-Raeburn,
2004). Bereaved siblings are often ‘‘the forgotten or invisible mour-
ners’’ receiving overt and covert messages from significant others
to repress and deny their grief (Devita-Raeburn, 2004; Rosen,
1985). Bereaved adolescents, for example, are frequently given
messages to ignore and=or postpone their own grief and ‘‘remain
strong for their parents.’’ These teens reported being told, ‘‘The
death must have been really difficult for your parents.’’ Such state-
ments minimized their grief, leaving them feeling invalidated,
unacknowledged, and ignored (Horsley & Patterson, 2006).
In addition, the nature of continuing bonds expressed by par-
ents plays a role in how siblings cope. For example, if parents are pre-
occupied with the immortalization of the deceased child (altars
throughout the house, numerous photos of only the deceased child,
daily visits to the graveyard), this may leave parents without any
emotional energy, space, or time to deal with surviving siblings. This
may, in turn, affect siblings well-being and cause them to assume
grown-up roles and, in essence, lose their childhood. In contrast, par-
ents who are avoidant, that is, parents who demonstrate no activities,
behaviors, or conversations about the child who died, may be limited
in their ability to tolerate continuing bonds expressions, as well as be
unavailable emotionally for the surviving siblings.
In sum, the importance of parental support cannot be under-
estimated in mediating surviving children’s experiences of a sib-
ling’s death. Parents play an essential role in helping siblings
cope and adapt to the loss (McCown & Pratt, 1985).
Family Communication
Open communication in the family is crucial in the aftermath of a
sibling death. Unfortunately, in families where children are not
826 W. Packman et al.
allowed to frankly express their feelings or talk about the deceased,
the surviving children often feel overlooked and consequently
alone in their grief (Davies, 1988b, 1999; Horsley & Patterson,
2006; Rosen, 1991; Spinetta, 1981). The presence of open family
communication, along with the candor with which the death is dis-
cussed provides a supportive environment for the remaining chil-
dren, helping them work through a range of emotions (Cain
et al., 1964; Horsley & Patterson, 2006; Siegel, Mesagno, & Christ,
1990; Spinetta, 1981). Most bereaved siblings can benefit from
opportunities to talk about their responses not only at the time of
the death but for many years to come as they reach new developmen-
tal levels of understanding death. If they are denied opportunities to
talk about the death and their reactions, children will suffer needlessly
(Davies, 2002). Thus, open communication and parental support
are crucial in helping the surviving sibling adjust to the loss (Davies,
2002; Horsley & Patterson, 2006; McCown & Pratt, 1985).
Studies on Sibling Loss: Negative Consequences and
Opportunities for Growth
Bereaved children have been found to exhibit psychosomatic dis-
orders and behavior problems, and attempt to restore order to
their lives through dreams, art, play, sports, and school (Cicirelli,
1995; Davies, 1983, 1999; Eth & Pynoos, 1985; Lieberman,
1979). Reactions among some children may not become evident
until later on as they may tend to use denial for a longer period
of time than adults (Bowlby, 1980; McCown & Davies, 1995). In
one study, about 25% of bereaved siblings demonstrated beha-
vioral problems at levels comparable to those children referred
to mental health clinics (McCown & Davies, 1995). In the general
population, only 10% of children have behavior problems that
reach this level. Researchers have noted (Bank & Kahn, 1982;
Christ, 2000; Christ, Siegel, & Christ, 2002) that adolescents often
appear unemotional and avoid discussion of the deceased in order
to control powerful emotions. Adolescents often make efforts to
appear normal despite their loss, so that they will not appear differ-
ent from their peer group (Christ, 2000; Christ, 2002). Studies
investigating the effects of loss on adolescents report that common
grief reactions include anger, depression, anxiety and guilt (Balk,
1983; Mufson, 1985).
Sibling Bereavement 827
Beyond the negative consequences and problematic outcomes
of a sibling loss, there are also opportunities for growth (Davies,
1991, 1999; McCown & Davies, 1995). Following the death of a
sibling, bereaved adolescents reported psychological growth evi-
denced in increased maturity, improvement in academics, higher
moral values, and a more mature attitude (Balk, 1983). Looking
back, many siblings perceived some positive outcomes of the
experience. They felt more comfortable with death and were able
to help, rather than avoid, other individuals who were facing a
death in the family (Davies, 1991; McCown & Davies, 1995). They
felt their experience facilitated the development of a sensitive out-
look on life; and their learning had been enriched in the sense that
they had matured and they felt better about their abilities to handle
adversity (Davies, 1991, 2002). One teenage boy commented: ‘‘I
have a better outlook on life now; I mean, I realize how important
life is as a result of my sister’s death.’’ Interviews with parents also
indicated that they perceived their children as more sensitive and
compassionate, and more aware of the problems of others as a
result of their experience with death (Davies, 1999, p. 90).
Similarly, Forward and Garlie (2003) reported that
bereaved adoles cent siblings reported positiv e change s incl ud-
ing (a) more maturity, (b) deeper appreciation for life=living life
to i ts fullest, (c) taking less risk, (d) expr essing affection toward
significant others in their lives, and (e) a greater pu rpos e of their
life. In more c oncrete terms, one study reported that bereaved
siblings scored higher than the sta ndard iz ed norms on a mea-
sure of self-concept (McClowry, Davies, May, Kulenkamp, &
Martinson, 1987).
Growing through adversity is not unique to siblings who
experience the death of a brother or sister; their growth may begin
even before the death, and may be a pattern that is set earlier in the
course of the sick child’s illness. For example, Kramer’s earlier
research (1981, 1984) with siblings of children with cancer showed
that when a child is diagnosed with a life-threatening illness, the
shift in family responsibilities and the new atmosphere of unpre-
dictability provided opportunities for growth for well siblings. Well
siblings matured earlier, were less dependent on others, contem-
plated life and death, and learned at a young age that life holds
many disappointments and challenges that forced them to become
more adaptable and flexible. They developed a greater capacity
828 W. Packman et al.
for empathy, cooperation, and compassion. They developed a
great respect for the ill child and all he=she had to endure.
Through all these insights, they came to realize the importance
of making the most of each day.
In a related vein, in a study of the psychosocial impact of
BMT on donor and nondonor siblings, donors were rated by tea-
chers as having significantly more adaptive skillssocial skills and
leadership characteristicsthan non-donor siblings on a behavior
rating scale (Packman et al., 1997a). Parents also described positive
changes in donors as a result of the BMT experience, for example
being, ‘‘more mature, getting better grades, and gaining leadership
skills.’’ It is possible that the donor’s role in the treatment process
may have a positive effect on their development. Sibling donors
may have emerged from the BMT experience ‘‘curiously ripened’’
(Freud, 1952) with increased sensitivity and enhanced personal
maturity. Thus, BMT can be seen as a life-growing experience
(MacLeod et al., 2003).
Indeed positive outcomes or potential for growth can be
enhanced when parents and other adults validate and support
the unique reactions of the healthy siblings when their brother or
sister is seriously ill or dies (Davies, 1990, 1991; McCown &
Davies, 1995).
Uniqueness of Sibling Bereavement: Factors that
Influence Sibling Reactions
The impact of a child’s death on siblings is manifested in four gen-
eral responses, best characterized in the words of the siblings them-
selves (Davies, 1999, p. 199). Not all children who have had a
brother or sister die will experience all responses, but most
bereaved siblings will demonstrate these responses to varying
degrees.
‘‘I Hurt Inside’’
This first response focuses on emotional and psychophysiological
responses normally associated with grief, including for example,
sadness, anger, frustration, loneliness, fear, anxiety, irritability,
and guilt. However, unlike adults who more readily describe their
emotions and reactions, children manifest their hurt in other ways.
Sibling Bereavement 829
They may cry, withdraw, seek attention, misbehave, complain of
aches and pains, pick fights easily, argue, have nightmares, fear
the dark, lose their appetites, or overeat. In addition, a study by
MacLeod et al. (2003) found that when a sibling dies, the donor
sibling often feels guilty, angry, and blames him=herself.
‘‘I Don’t Understand’’
Children begin to make sense of death depending in large part on
their level of cognitive development. Findings from several studies
indicate that reactions to loss, the understanding of the finality of
death, and mourning are influenced by the age and developmental
stage of the bereaved child (Christ, 2000; Fanos, 1996; Forward &
Garlie, 2003; Leon, 1986; McCown & Davies, 1995). As children
mature, they move from concrete operational ways of thinking
toward more abstract or conceptual ways of thinking. If children
are not assisted or guided in their understanding of the death
and related events, they become very puzzled and confused. When
children reach new developmental levels, they need to re-process
the events around their brother or sister’s death.
‘‘I Don’t Belong’’
A death in the family disrupts the usual day-to-day activity of fam-
ily life. Parents are distressed, familiar and unfamiliar visitors
invade the home, and children feel overwhelmed by all this
activity. They may feel as if they are not a part of it, they are in
the way, and they don’t belong. Any sense of normalcy is lost. Rea-
lignments in the family also may make siblings feel as if they have
‘‘lost their place.’’ Moreover, bereaved children frequently feel dif-
ferent from their peers; again, this may contribute to their feelings
of not belonging.
‘‘I’m Not Enough’’
This response may result when children feel as if the child who
died was a favored or perfect child, particularly as parents become
pre-occupied or all consumed with their grief. Such children may
conclude that they should have been the one to die because no
matter what they do, they are ‘‘not enough’’ to make their parents
830 W. Packman et al.
happy. Some siblings react by striving to be good at all they do,
trying to prove they are good enough, that they are worthy; others
will tend to respond in the exact opposite way, seeking ‘‘proof’’
that their parents still love them. In their grief, parents, other fam-
ily members, and friends tend to immortalize the deceased child,
overemphasizing their admirable qualities. The surviving sibling
often feels inadequate compared with the sibling who has died.
Everyone always asks about how their parents ‘‘are doing,’’ not
recognizing or validating their own grief or needs.
Siblings’ reactions to the death of a brother or sister do not
occur in isolation (Davies, 1983, 1999; McCown & Davies,
1995). Characteristics of the children themselves, the circum-
stances surrounding the death, and environmental factors play a
role. These various factors, categorized as individual, situational,
and environmental characteristics, interact with one another, com-
ing together to influence siblings’ responses to the death of a
brother or sister:
1. Individual characteristics include physical characteristics as well
as the following: gender and age, health status, coping style,
temperament, self-concept, and experience with loss and death.
2. Situational characteristics include circumstances surrounding the
death such as cause of death, duration of illness, place of death,
time elapsed since death, involvement in events surrounding
the illness and death, such as visiting in the hospital or partici-
pating in the funeral.
3. Environmental variables constitute the third category of factors
that influence siblings’ bereavement responses. These include
shared life space, centrality, family environment, parent–child
communication, parental grief, family functioning, continuing
bonds expressions of parents, and ability of parents to foster
continuing bonds expressions in the surviving children.
The previous factors (individual, situational, and environmental)
coupled with parental responses (Rubin & Malkinson, 2001) and
the parents’ own use of continuing bonds expressions (adaptive
vs. maladaptive), play a large part in determining how children
cope with death. Furthermore, parents’ tolerance toward fostering
continuing bonds expressions in their children may lead to
Sibling Bereavement 831
adaptive and maladaptive outcomes (Silverman, Baker, Cait, &
Boerner, 2003).
Clinical Implications
Fostering Continuing Bonds Expressions in Siblings
Articles that have addressed continuing bonds expressions and
clinical implications have been written with adults in mind. In
our view, these concepts are equally applicable to children. One
thing that has been amply observed and demonstrated in the lim-
ited research on siblings is that parental support is important in
mediating the child’s experience of death and helping the child
adjust to the loss. Accordingly, collateral work with parents, by
clinicians, can serve an integral role in helping their children facili-
tate adaptive use of continuing bonds. We know children learn
most things by observing their parents’ behavior and it is no differ-
ent when it comes to the mourning process. For this reason, it is
important that parents use continuing bonds adaptively, and give
their children permission to do so as well. It can be very helpful
if the clinician works with the entire family, because the parents
are often so deeply absorbed in their own grief experience that
they feel helpless in assisting their surviving children through the
bereavement process (Bank & Kahn, 1982; Christ, Siegel, & Christ,
2002; Furman, 1983; Horsley & Patterson, 2006; Rosen, 1991;
Siegel et al., 1990). The task of mourning ‘‘successfully’’ is linked
to the ability to use continuing bonds in adaptive ways: figuring
out how to preserve and continue a connection to the love that
existed prior to the death.
How to Help Siblings: Opportunities and Interventions
Siblings work through their grief in bits and pieces. Play, school,
and continuing with normal activities can be powerful tools that
help children cope by modulating their grief, allowing them to
‘‘take breaks’’ from both their own and their parent’s intense grief.
Sometimes parents misinterpret this kind of behavior, believing
that the children’s ‘‘normal’’ behavior signifies that they are not
affected by the death and are not grieving. Parents need to be pre-
pared to expect children to reprocess the death and its impact over
832 W. Packman et al.
time, as the surviving children mature and build their own identity.
Parents (and other adults) must also realize that some siblings may
not be as verbal as adults in expressing their feelings and memor-
ies, or may not be as willing to talk about the deceased sibling.
Instead of talking with their parents, perceived as overburdened
with grief, surviving children may turn to a trusted teacher, aunt,
uncle, or friend for support, sometimes done to protect the parents.
Of central importance is respecting the individual coping style of
each surviving sibling.
Siblings’ memories may be triggered by particular objects,
other people, certain places or familiar songs. Because our connec-
tions to the deceased continue through our memories, this waxing
and waning of emotionally charged memories are to be expected.
It is important to prepare siblings for these experiences and let
them know this is part of grief. Talking about these experiences
when they occur is helpful. It would also be useful for parents to
share memories and their own personal triggers when they occur
as a way of preparing children for these experiences.
Many siblings say that in an ongoing way, they continue to
think about their deceased brother or sister at special times, such
as starting high school, graduations, birthdays, weddings, or family
reunions. Thus, it would be helpful to anticipate and openly talk
with surviving siblings about these important life events and the
keen absence everyone feels. Parents can encourage them to think
of such times as opportunities to think fondly of their brother or
sister rather than triggers for only feeling sad. Of importance, sib-
lings need the consistency of continuing important family and hol-
iday celebrations, even though this can be emotionally draining for
parents. It is helpful to think and plan ahead about how to
approach these important events. Sometimes, it helps to start
new family rituals or traditions, which incorporate the memory
of the deceased child in some way.
Adults might share with the bereaved children what other sib-
lings have done in similar circumstancescarry their sibling’s
photograph in their wallet, keep belongings that have special
meaning (e.g., one child kept her brother’s stuffed animals on
her bed and found comfort in them every night). Many siblings
continue to talk to their sibling quietly or internally. Keeping in
touch with one’s sibling can be a life-long activity for manyfor
example, the young woman who chose peach colored roses for
Sibling Bereavement 833
her wedding flower to commemorate her sister’s ‘‘presence’’ at this
special event. Finding comfort in remembering the deceased sib-
lings can be particularly helpful during times of loneliness. Some
siblings turn to their deceased brother or sister in conversation
or by offering prayers to them during difficult times. Adults can
reassure siblings that many siblings do this even though they are
sometimes embarrassed to tell anyone that they do it.
Encouraging siblings to attend bereavement groups can be
helpful because in such groups, children and adolescents learn that
they are not alone in experiencing grief. Through sharing in the
group, siblings learn about what others do to manage the situation
and learn to share their own thoughts, feelings, and strategies.
One of the most important things for caregivers=adults to do is
to model the kinds of actions and activities that allow for the
development of continuing bonds: listen sympathetically and non-
judgmentally, offer comfort, and offer presence. Caregivers them-
selves cannot make the connections for grieving siblings; they can
only offer suggestions, encouraging actions and activities that may
facilitate the creation and maintenance of continuing bonds. The
nature of such actions and activities, and the nature of the bonds,
are individually developed and expressed, being highly personal
for the surviving sibling. Adults can offer suggestions or share stor-
ies of what other siblings have done, but must refrain from offering
pat answers, simple formulas, procedures or directions.
How parents handle the siblings continuing bonds’ expres-
sions is critical. Some parents get worried or frustrated when sib-
lings rarely talk about or express their feelings about the deceased
child. Parents need to be reminded that they can gently encourage
siblings to share feelings but sometimes siblings choose more priv-
ate ways of expressing their thoughts or feelings, for example, by
keeping a journal or writing poetry=music. Parents need to foster
and tolerate various continuing bonds expressions from the sib-
lings; this may be difficult for parents to do sometimes, as it was
for the parents of 14-year-old Johnny who insisted on wearing the
football jacket of his older deceased brother. It is also important
to let siblings know that the strength of the connection to their
deceased brother or sister may change over time. It may lessen,
strengthen, or take on a different meaning as the sibling matures.
Adults also must listen to and support siblings as they puzzle
over who they are now or how they are different without their
834 W. Packman et al.
sibling’s presence. Adults can help them to rediscover self-confi-
dence by reassuring them that they can retain ‘‘lessons learned’’
from their deceased sibling, by remembering the positive aspects
of their relationship and by talking about the difficult aspects of
the relationship as every relationship has many dimensions.
Although their identity is influenced by the sibling relationship,
siblings’ individuation needs to be supported. We need to give
them permission and encouragement to not feel guilty about going
on with their life. It is critical that surviving siblings are encouraged
in their efforts to pursue activities and interests that enhance their
self-concept and the establishment of their own life-goals.
In instances where the relationship between the siblings may
not have been a good one, such as in abusive or manipulative situa-
tions, reinforcing the development of ‘‘positive’’ continuing bonds
may not be a good idea. Because negative ties can sometimes bind
more tightly than positive ones, it becomes even more critical to
listen to siblings about their thoughts and feelings; explore if there
was anything ‘‘good’’ or ‘‘pleasant’’ or even funny aspects about
the relationship, or events, that the surviving siblings can remem-
ber. And, for all siblings, do not burden them with expectations
that they ‘‘should develop continuing bonds.’’ Such bonds may
develop and change over time and are unique to each sibling.
It is important for adults to take into account any special cir-
cumstances (i.e., developmental delays, cognitive impairments,
past history of depression or other such challenges) about siblings
that may affect their grieving. We want to help siblings develop
‘‘healthy’’ bonds, but not to the extent that they are totally preoccu-
pied with the deceased sibling for a long period of time. As well,
the siblings may have to contend with things said or done that they
wished they had not said or done; or the oppositewishing they
had said or done certain things. The greater the siblings’ experi-
ence of unfinished business the greater is their difficulty in adapt-
ing to the loss. This may affect the developing of continuing
bonds that are not necessarily helpful or comforting.
Adults need to realize that even very young siblings
experience grief and they must pay attention to their needs and
experiences. For example, parents and other adults sometimes
tend to dismiss the significance of the sibling’s relationship to the
child who diedparticularly when the child was a neonate or
when the ill sibling was hospitalized for a long period of time
Sibling Bereavement 835
before dying. It is helpful to include siblings in the events sur-
rounding the death (in the hospital or at the bedside at home) so
that they will feel part of what is going on. Parents should talk with
siblings directly to ascertain at what level they want to be involved;
some siblings want to visit every day and help in the care of the
child, others prefer to watch from the sidelines. Taking photo-
graphs of the siblings with the ill child provides concrete evidence
of the sibling’s involvement with the child who died. These photos
and videos can be particularly meaningful for very young siblings
who may not remember the circumstances and their own involve-
ment around the time of the death.
It is important to identify when siblings are at risk of compli-
cated grief and more likely to need specialized professional ser-
vices, such as in cases of traumatic or sudden death. Dealing
with the immediate crises and the siblings’ response to it are of pri-
mary importance, but later on, it can be helpful for parents or other
adults to review the event with the siblings, again emphasizing the
importance of the role they played, talking with them about the
facts of the situation and about their reactions and feelings.
It is useful to emphasize to siblings that finding ways of staying
connected with the deceased child occurs naturally as a part of the
human experience of grief. Continuing bonds are not something to
‘‘create’’ but to foster through listening and accepting whatever is
meaningful to the siblings. Emphasize that continuing bonds
develop over time, that is, they are not something that are sud-
denly created at the time of death.
Future Directions
Within the areas covered in this article, new questions are raised
for future investigations that elucidate the uniqueness of sibling
loss. In particular, we need to place sibling grief in its family con-
text to increase understanding of how the nature of the family sys-
tem may affect the course of grieving in siblings and the nature of
siblings’ continuing bonds expressions. Of course, we must also
explore the impact of the larger community and society on
siblings’ capacity to develop, maintain, and adapt continuing
bonds throughout their lives.
Most of the existing literature focuses on expressions of adapt-
ive continuing bonds in siblings. It would be fruitful for future
836 W. Packman et al.
research to examine maladaptive as well as adaptive expressions of
continuing bonds expressions. Related research has described par-
entally bereaved ‘‘high-risk’’ children and adolescents as having
had a continuing bond with the deceased that was primarily
negative (Silverman et al., 2003). In the case of siblings, an investi-
gation of unhealthy=maladaptive continuing bonds would be of
particular interest in the context of an unhealthy or dysfunctional
family (i.e., where there is lack of good caregiving, lack of talking
about the death, parentification, neglectful=abusive parents). For
example, in the latter situation of abuse, there may be unhealthy=
maladaptive continuing bonds expressions by siblings. When the
sibling was alive, there may have been a very strong bond between
the siblings that the survivor maintains with the deceased sibling.
This could be maladaptive in that surviving siblings may become
totally engrossed in their private world where they keep the other
sibling alive. Of concern, siblings may only hold onto the relation-
ship with their deceased sibling and this would prevent them from
moving out into the world.
In contrast would be the use of healthy=adaptive continuing
bonds expressions by siblings in a dysfunctional family. Here,
the continuing bond to the deceased sibling could be important
to compensate for a poor relationship with the family. This could
be the case where the siblings were confidants and there has
always been a close sibling tie. When one sibling dies, they are still
there internally for the surviving sibling and the continuing bond
functions in a healthy manner.
Future studies could focus on distinguishing sibling loss from
other kinds of losses (spousal, parental, loss of a child) and investi-
gating what factors are unique to sibling loss. Possible factors to
explore include sibling birth order. For example, loss of a younger
sibling may involve issues of protection especially if the death
involves a sibling who died of a chronic illness which proved fatal.
On the other hand, loss of an older sibling could involve loss of an
important role model.
Ultimately, life is an ongoing process and so is grief; we all
form and then reformulate our bonds to others while figuring out
how to continue those bonds throughout our lives. When one child
dies, the remaining children in the family still think of that child as
one of their siblings. The sibling is an integral part of one’s past and
present and the relationship is naturally expected to continue
Sibling Bereavement 837
throughout adulthood and into old age (Horsley & Patterson,
2006). The bond itself is going to change over timethe task is
how to learn again how to be and act in the world without those
we love by our side (Attig, 2001).
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Sibling Bereavement 841
    • "Parents are the protagonists of symbolic stories exchanged with the deceased child, on a journey of reconstruction towards a " new normal " , towards recovery. It´s a framework in which the personal and family itineraries of the bereaved are built, charged with the meanings they are looking for, the longing for a reunion, giving meaning to their personal and social world that has been transformed by the loss [1,5,6,7, 21,22,23,24,34]. The 50 parents, informants and members of a grieving group in Tenerife called Forever in my Heart, that had lived through the experience of losing a child, had not mourned the death of their children, except in two cases, and, although they referred to the death of a child as the most painful experience of their lives, they had not expressed their pain in the colour of their clothes, as was the social norm in the Canaries, no longer than 30 years ago, but rather through talking and their behaviour. "
    [Show abstract] [Hide abstract] ABSTRACT: This qualitative study, with a phenomenological focus, explores the use of objects that evoke memories held by mothers and fathers mourning the death of their children. The objects that facilitate a closeness to the children who are no longer there. In this analysis of these objects, we pay particular attention to understanding their description and to the meaning that they have for mothers and fathers, revealing the existence of a repertoire of objects that connects parents with mourning through a daily spatial link, which is, on occasion, a relationship charged with creative and dynamic meaning. As such, these objects, together with physical spaces, are reserved or created by parents who incorporate them into their lives, defining them as spaces of existence, presence or absence, making them shared, liveable places. The continuity of living in the spaces that a loved one once occupied becomes an experience of reinhabiting, of reconstructing the environment. An experience of newly adopting a space and being able to do things there that define and determine it.
    Full-text · Article · Aug 2016 · Journal of Family Communication
    • "In contrast, those who believed that their sibling was still with them were better able to overcome the initial shock and find peace. These findings support previous research showing that developing " continuing bonds " with a deceased sibling can facilitate healthy adjustment and provide comfort during challenging times (Packman et al., 2006). For example, one bereaved sibling described how feeling her brother's presence brought her peace: " It killed me for the fact that he wasn't able to see his son's first birthday party, but it eased me a little that he came to me in a dream telling me he was gonna be there in spirit. "
    [Show abstract] [Hide abstract] ABSTRACT: The present study applied relational dialectics theory to explore the competing discourses that animate bereaved siblings’ online stories about their loss, as well as to understand how the interplay of these discourses constitutes meaning of sibling bereavement. Analysis of over 70 message board postings retrieved from online support groups revealed two main discursive struggles that characterize siblings’ experiences of grief and loss: grieving as deviant behavior versus grieving as a normal process and the deceased as gone forever versus the deceased as still present. These findings illuminate the challenges bereaved siblings face as they attempt to mourn their deceased brother or sister and make sense of their grief within a societal context that oftentimes forgets or overlooks how traumatic it can be to lose a sibling.
    Full-text · Article · Jun 2016
    • "In the United States, more than 42,000children (newborn-19 years) die each year [3], half of these deaths occurring in hospitals [3] and most in intensive care units [4]. Each year approximately 2 million children experience the loss of a sibling, leaving 25% in need of clinical intervention and more than 50% with significant behavioral problems [5,6]. However the research on children's responses to the death of a sibling is limited, heavily focused on sibling deaths from cancer and reported from the parent's perspective. "
    Full-text · Article · Jun 2016 · Journal of Family Communication
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