The experience of internal and external supporting objects from the perspective of six young women who have lost a parent to cancer- An interpretative phenomenological analysis

Background: Adolescents losing a parent are a risk group for future complications in their ongoing live such as higher rate of mortality, self- harm and other mental health problems. There is a lack of knowledge in what, how and when to offer help as well as no concluding theoretical model to understand the whole process of losing a parent. The objective of this study was to examine how the relationships of some young people are affected by the loss of a parent to cancer during their teenage years.

Method: Six women aged between 18 and 25 participated in the study. An Interpretative Phenomenological Analysis (IPA) method was used.

Result: The theme of loneliness was cemented with the two main themes, into loneliness and out of loneliness and sub-themes such as, cancer comes along, silence, hold on to and miss, those closest, the supporters, independence, closeness and distance.

Conclusion: The parent who has died lives on as an inner object and the support from the remaining parent is viewed very important. The process to be back on track seems diverse and continues for a long time and outside help needs to tune in with this.

Background

Losing a parent when growing up is one of the most difficult experiences a child can go through [1,2]. There are shortcomings in the care and routines for children who lose a parent to cancer [3,4]. There is also a lack of knowledge about what children should be offered during the parent’s illness and in the years after a parent has died [5,6]. Each year in Sweden, around 3,000 children under the age of 18 lose a parent. An estimated 40% of these deaths are due to cancer. Children who lose a parent fall into a risk group for serious illnesses. Research shows that the mortality rate is higher amongst children and young people who have lost one parent [4,7], this includes losing a parent to cancer [8]. It is therefore of the greatest importance to deepen knowledge of the health effects of grief

to reduce risk factors and strengthen what protects the child and increase the capacity for recovery [5]. The path to resilience and relations must be better understood.

A Swedish study, Teenagers losing a parent to cancer: Experiences, modifiable risk-factors and long-term outcome, which examined the experiences of teenagers who had lost a parent to cancer, concluded that self-harm is twice as common amongst young people who have lost a parent to cancer compared to those who had not [3]. Poor family relationships both before and after the loss increase the risk of self-harming. 20% of the young people stated that they were unable to put their trust in the care administered to their parents in the final week of their life. Information from doctors about the end stages of life reduced this distrust of health care services. Almost all of the teenagers wanted to know when the parent’s death was close at hand, but many were not given this information.

To lose a parent during teenage years – the point in life, which normally deals with learning how to manage separations and losses – can be incredibly sensitive [9]. The intensity of the feelings can lead to a teenager burying painful and complicated feelings more so than children of other ages. The teenagers may instead relieve their sorrow through negative behavior and conflicts [2]. Few studies have explored the impact on development on adolescent’s experience and expression of grief and their way to resilience [6]. Few studies exist that examine how young people experience and are affected by a parent dying [10].

The scientific literature has developed several theories concerning the adaptive functions of continuing versus relinquishing bonds to diseased persons but clarity is absent [11]. Stroebe and colleagues [11], outline an integrative model, however not yet studied and cover not children or adolescents. Many studies and theories about bereavement concerns adults, but the living circumstances for adolescents are very different from adults. The scarcity of studies covering this group, both theoretically and by empirical research need to be filled.

As far as we know, the ways in which young people are affected by losing a parent to cancer is an under-researched area, and the purpose of this study was to examine and describe how the relationships of some young people are affected after having lost a parent to cancer during their teenage years.

Method

For this study, the Interpretative Phenomenological Analysis (IPA) was chosen. It is a qualitative method that was developed during the 1990s in the United Kingdom by psychologist Jonathan Smith, whose aim was to examine how people create meaning from their experiences [12]. IPA was chosen based on the evaluation that the method fit the purpose and could investigate and describe the participant’s personal and relationship experiences in the light of the death of a parent. The aim of IPA is to generate idiographic knowledge – knowledge that aims to highlight unique individual events [12], do not exclude the value of generalizations, saying that over time the microanalyses of IPA can contribute to knowledge at a macro level. What differentiates IPA from other qualitative methods is that to a greater extent, IPA emphasizes the active role of the researcher in the research process as the interpreter of the participants’ experience in their own life world.

Participants

Six women between the ages of 18 and 25, all of whom lost a parent to cancer during their teenage years, discuss their experiences in connection with their parents’ deaths. The youngest was 13 years old when her parent died and the eldest was 17. Five of the women lost their mothers and one lost her father. The women are referred to using the following pseudonyms: Alva, Anna, Clara, Emilia, Jenny and Mira (Table 1). Jenny has had long lasting and recurring contact with treatment from child and adolescent psychiatry services and is currently in contact with adult psychiatry services. Emilia has received talking therapy from her local youth clinic and Mira has undergone psychotherapy for many years. Alva, Anna and Clara had not received professional talking therapies.

To recruit participants, we approached “Nära Cancer” (Close to Cancer), an online message board aimed at young people close to someone with cancer. We sent the message board an information letter about the study and were given permission to advertise for volunteers to participate. Of those who were in contact, three met the criteria; they had lost a parent to cancer during their teenage years and were now young adults (18-25 years old). A further three participants were recruited by colleagues from other workplaces who had become aware of the study.

Procedure

Their accounts were collected with help from in-depth interviews in order to obtain a clear image of the participants’ subjective life world. Six participants were chosen according to recommendations by Smith et al., [12]. We devised an interview guide containing six main question (see Appendix). The interview guide and its realization were tested in two trial interviews.

Before the interviews, participants were able to choose where they wanted the interview to take place. They were encouraged to choose somewhere they felt secure and where it was possible to speak without interruption. Two of the interviews were conducted in the home environment, two at the participant’s workplace and two on university premises. The interviews were recorded using digital voice recorders and then transcribed verbatim. The interviews lasted between 45 and 90 minutes. The transcribed material consists of 133 pages of text.

Data Analysis

We applied IPA to analyze the interviews. IPA describes each person’s unique experiences, as well as their common experiences; the aim is to examine experiences in a specific group. IPA rests on phenomenological and hermeneutical ideas [12-15]. The researcher’s active role in the research process as interpreter of the participants’ lived experiences and worldviews is emphasized in IPA. According to Smith et al. [12], and Reid, Flowers, & Larkin [16], IPA is linked to interpretative theory known as double hermeneutics. Here, the researcher tries to understand the participant as he or she tries to assign meaning to the world. The method is idiographic in that it carefully examines every individual on a case-by-case basis before providing statements of a more general nature. IPA is useful when the topic being researched is subjective, relatively new and process-oriented and when questions about identity, the self, and meaning are important [17-19]. The analysis of the interview statements followed the rules and steps outlined by Smith et al. [12] : Handling of the first interview; reading and re-reading eventually listening to the interview once again, writing commentaries, looking for themes, gathering themes into clusters, handling the other interviews in the same way and finally looking for patterns. The procedure resulted in a list comprising overarching themes and subthemes that reflected the participants’ experiences. The analysis was presented in a continuous text supported by carefully selected excerpts from each participant’s statement. The analysis took place first and foremost on a descriptive level and then on a second, interpretative level.

Ethical considerations

To ensure that the study maintained high ethical standards, we have followed the appropriate ethical regulations devised by the Swedish Research Council and Uppsala University in the CODEX rules and guidelines for research [20].

Each participant has been given a pseudonym for the study

We decided that at least two years were to have passed since the death of the parent to avoid the subject matter being too sensitive for discussion. Many of the participants expressed in their interviews the need to talk about their deceased parent. Legerski & Bunnell [21], have examined trauma research, weighing the benefits against the risks of participation. They found that only a few experienced brief, passing discomfort upon participation, whereas the majority felt positive about their participation.

Results

Loneliness is the common theme linking the accounts of the six women. Into loneliness and out of loneliness were the two main themes that became apparent from the young women’s accounts reflecting upon the process they went through when their parents became ill and later died of cancer. Each main theme contained sub-themes that reflect the process of losing a significant person to cancer and how to move on and find inner and external support (Table 2).

Into loneliness

When the parent first becomes ill and then dies, the young woman is left in a changed life situation. Her surroundings quieted, and talk about the deceased person is avoided. Despite the fact that the remaining parent is viewed as an important support, few seem to talk openly about the grief within the family.

Cancer comes along

As soon as cancer joins the family, loneliness creeps into the teenager’s life whilst the dying parent gradually disappears. The teenager takes less space in the family when she adapts – her needs can wait behind those of the parent. The women often feel estranged from their peers due to the fact they live under different circumstances and have different levels of responsibility, and that others do not share their experiences. The women explain how the home environment changed as the parent’s health deteriorated. Aid facilities, re-furnishing, room changes, hospital personnel coming and going – the cancer moved into their homes in many different ways. The constant presence of the illness influenced the perception of having a normal life and was an emotional strain.

The women talk of a need to be able to get away from home during the course of the illness. They sought refuge among friends, boyfriends and adults that could offer them security and breathing space from the cancer. Alva describes how the hospital moved into their home during the final stages of her father’s life. School became her refuge, where everything was normal.

Each of the women can recall the physical course of the illness in detail. They know exactly where and when the cancer first appeared, when the parent’s condition improved for a while, if at all, how the cancer returned, to which parts of the body it then spread, the treatments that were used and how they affected the parent. Clara says the following about her mother’s illness:

[the] first time was when I was five or six and she got ovarian cancer and was sick for a few years, then she was given the all-clear. Then just after 2002 it came back. She got breast cancer, which the doctors said was a new cancer, it had nothing to do with the other one. After that she got the all-clear again and then, the last time, when she got it for the third time, she developed a tumor in her neck that had spread from her lymphatic system it had spread from the breast cancer.

The women talk of their experiences of great considerations for their ill parent. This meant that as teenagers they had to adapt, and there were many times they let the needs of their parent take priority over their own needs and the emancipation process of teenage years. Both Emilia and Jenny explain how during the final stages of their parents’ illnesses, they stopped their extracurricular activities.

Floor ball, but most of all football, that was like, my life, and I went away to lots of training camps and matches, cups. Then eventually you just start to feel really guilty. My mum’s on borrowed time and here I am, playing sports. And it felt... and sometimes it’d feel like, wrong that I was sitting and laughing and having fun with my mates when really I should’ve been with my mum.

Clara talks about a fight she had with her mother when her father and grandparents took her mother’s side – not because her mother was right and Clara was wrong – but because her mother was ill. This is something she has since discussed with her relatives.

There were many discussions where I was totally in my right to put my foot down [but didn’t], and if it had been a normal situation it wouldn’t have been like that. I’ve since talked to dad and grandma about this and they’ve actually apologized for some of the things that happened then.

Mira describes how she kept herself in check whilst her mother was ill by not starting smoking and not becoming too drunk when she was out at parties; she knew that her father had to be ready and waiting if her mother suddenly deteriorated or suffered an attack. There was no time for him to have to leave and pick up a daughter that could not take care of herself. Mira did not want to be the reason for her mother needing to be alone. The teenage revolt arrived later and with more force after her mother’s death. Mira explains how her father was forced to put up with a lot when both she and her older brother became very disruptive.

Silence

Despite the fact that almost all the women felt that their families had been an important support, many of them talk about how their grief became something incredibly private and it is not always possible to be supported by family members. Twins Anna and Clara say how they both turned to each other with their grief. However, neither of them felt any great need to talk about their mother and grief and so it was difficult that others in the family did. Clara explains that she escaped to her boyfriend’s family to avoid managing her own grief and that of others. She wanted to be there for her father and sisters, but lacked the strength. Anna felt exactly the same as her sister; she needed her own time but it was difficult to find it.

Mira shares this experience of not being able to talk about her grief with her family members, although not to the same extent. She explains that this is partly for not wanting to upset the others, but also because everybody was in deep mourning and found it difficult to talk about the dead.

It’s also partly that, with my family, it’s really difficult for them too, maybe they’re not so good at bringing up the grief and talking about it or they don’t want to talk about it, because they don’t want to get sad. We still haven’t really talked about it as a family.

Both Mira and Jenny bore witness to poor understanding and ignorance about grief from their schools. They both found that when they returned, many of their teachers had not been informed about their losses. Mira also explained how she suddenly lost a lot of weight and whilst her classmates bluntly asked “are you an anorexic or what?” not one teacher asked how she was and the school nurse was easily reassured when Mira lied and said that she had started eating healthily.

Nobody wanted to follow up on it and I remember I had classmates that were like ‘but you only had carrots for lunch’, I mean it was really... because it’s like, when you can’t control what’s going on in your life, you take control over your food. It’s so (...) yeah, it’s so typical! And nobody was like ‘we can see you’re not eating properly’, y’know?

Mira talks a lot about how she needed help to understand the grief process, how it works. She believes that the lack of professional help really made her grieving process last longer. She needed someone who could help her understand what she was going through, someone that could help her understand that her reactions and feelings of anger and distress were natural and it was perfectly fine to feel such a way. And a process is exactly what it is – a grieving process that takes time.

Nobody ever talked to me about grief and I know that many years later I’ve thought about it – why didn’t anyone explain this mourning process to me? I mean that there actually is something that’s called the grieving process, it’s a process.

Just like the others, Anna and Clara had a good idea of the course that cancer takes. However they lacked information from the health care services about how the illness and medicines could affect the parent emotionally in relation to the other family members. Both of them believe that with better understanding and information, it would have been easier to deal with the argument with their mother, even now, in hindsight. Anna says:

They could have given us some form of information; that it was like, hmm (...) how it would affect her and maybe our situation at home. It might have been easier to deal with these clashes when they came up.

Mira explains that when other people find out that she no longer has a mother, this often results in silence; a misdirected thoughtfulness that many of the other women also provide examples of. Mira has reacted to the number of times she has had to take the reactions of others into consideration when they find out her mother is dead. They become self-conscious, ashamed, awkward and do not know how to behave around her. This made Mira feel responsible for making them feel more comfortable and handling their feelings, instead of her own.

Yeah you would think that they would be the ones to understand me, but I was the one that had to understand them. And it’s pretty tough when you’re so young, dealing with people around you. Both family and relatives, but also... people you don’t know.

Jenny thought it felt like those around her became wary of her – they were afraid to say something wrong or upset her.

Out of the loneliness

Despite the feeling of loneliness – or perhaps thanks to it – strength is evident in each interview; a strength which carries them forward. It is clear how the mother was the person who brought the family together and when she disappeared, so did a basic feeling of security.

Hold on to and miss

Both Jenny and Emilia describe that they expected the grief to pass; that you should become used to it, but this has not been the case. Emilia feels that what many people say – that things will get better – is a lie. What happens is that you learn to live with the pain and sometimes place it to one side. Nevertheless, it is still there and on certain occasions such as family celebrations, it intensifies.

I had a friend who had lost her dad some time ago, and I remember when, when she wrote something about it having been three years ago. Back then I thought ‘yeah, but three years, that’s a really long time! How can it still be so super sensitive?’ But then... you have no idea, because now I know exactly that you don’t measure it in years, that doesn’t matter, it doesn’t matter how much time has passed.

They all speak longingly about their deceased parents and how they miss their voices and words. There is a pronounced mourning for not being able to share their everyday life and the loss becomes even more apparent for the women during their major life events. Mira for example talks about how unfair it feels that her mother never saw her first exam grades, did not see her finish secondary school, never saw her career successes or meet her first boyfriend.

Yeah, there’s so many times that you miss just being able to tell them things and like, listen to what she would say about stuff... or what she would think.

The five women that lost their mothers describe them in very positive ways. The deceased mother is described as confident, strong, composed, caring, and with her death, a basic sense of security is lost, making the family more unstable. Alva, who is the only one to have lost her father, thinks of him and misses him, but does not describe him the same way as a central point of the family.

For Jenny and Mira, the loss of their mother is more than just the loss of a parent. For them, the “family” as a whole is greater than the sum of its parts, the family members. They both express that:

Now, in hindsight, it... it was more than just losing a parent because it felt like she had kept the whole family together. And then everything changed.

Each of the women pictures a good, close relationship to the parent if they had still been alive today. Their accounts bear witness to the fact that they have carried their deceased parent with them as a positive inner object that they continue to relate to. All of the women also believe that their mother or father would have been proud of their daughter, proud of her achievements and the person she has become.

Those closest

All of the women except one describe how they felt supported by the remaining parent and how their relationship with the parent has developed and become closer than it was before the other parent died.

This thing about the maternal role, sure, I can talk to my sister about... boy troubles and such, I can do that. But dad’s still the one that like, has the most experience, so sometimes I end up having this... typical ‘girl talk’ with dad. And he, he listens but he just thinks it’s a typical teenager thing, yeah, he probably doesn’t take it that seriously. But he doesn’t think... it doesn’t seem like he thinks it’s difficult. He’s just happy that I can tell him about it, about everything, and be open.

Mira is clear in saying that prior to her mother’s death, she did not really know her father so well. She was closer to her mother so it felt natural to turn to her. Since her mother’s death, her relationship with her father has deepened and he has taken a supporting role in Mira’s career. He has taken care of the practical side of things at home and given her lifts to and from her extracurricular activities. Anna discusses how her father and his daughters unavoidably became closer to each other after having gone through the loss together. She describes that the pain they went through has strengthened her ties to those closest. Clara also feels her father has been a great support and believes that his previous experience of having lost a parent has helped him to be a support to his daughters and to be able to talk about what has happened.

And like I said, we’ve had dad, who’s been a great support to us. He lost his mum when he was 17 and she was 46, so at exactly the same age, so he... yeah, even though he reacted differently well... It wasn’t the same illness, but we have still been able to openly talk about it.

Jenny describes her relationship to her father as somewhat inadequate, both when it comes to practical parental support and emotional support. She has never been able to talk to her father about the loss of her mother; they have been unable as a family to share the memory of the mother.

Before I thought it was really horrible that our relationship was so bad, because I thought ‘family is family’ and so you must have a good relationship. (...) But then I finally realized that he isn’t going to change, he can’t do any better, y’know? It takes more energy away from me than I get back in return. And so I know now that there are other people you can find to fill these roles. If you need help with something, you can... there are others that can help you, even if it would normally be your parents that would help with it. I was given a contact person by social services.

The supporters

Support from friends was important after the death of the parent. One of Jenny’s friends that she had not been in contact with for several years contacted her shortly after her mother died. Jenny was happy that this friend dared to make contact again and she explained how nice it felt to know that she was there. For Emilia, it was particularly nice to have understanding friends whilst she was grieving. Her old floor ball team contacted her and invited her to come and play with them if she wanted. She did this on occasion to get away from the loneliness and emptiness in the house and to not have to be home alone, where the sensation that someone was missing was very evident. She also often spent time with her grandparents until her father came home from work, to avoid having to be at home alone. The friends who had been with her throughout the illness, and that knew her mother, became even more important. They knew all about what had happened with Clara, which made her feel that she could speak frankly with them.

Going through this together has been a development and it feels like the bond has become much. Much stronger than what it was before. Anna and me have always had a strong relationship. We were in the same class, had the same friends; it’s still like that, so it couldn’t really get much stronger than that. But I think it’s got better with my dad and my older sister, we’ve really developed a much stronger bond actually!

Mira appreciated having adults around her that offered help and that she could talk to, or spend time with when she needed it. She talked about support from a teacher at school and a recreation leader from one of her previous schools from when she was younger. Clara found great support from her the parents of her boyfriend at the time. During her teenage years, Jenny had a female contact person who became an important adult in her life. Over time, this woman and her family have become Jenny’s contact family, with whom she has a good relationship and whom she perceives as positive supporting adults. Over the years, Jenny has developed a close relationship with her best friend’s parents and explains that in many ways, they have treated her as a member of their family.

I lived with this friend over the winter and her parents really helped out. Then I went to Paris with them last summer, so it’s a little bit like an extra family: I feel that I can also tag along when they have these family moments.

Emilia, Mira and Jenny have all had contact with either a counselor or psychologist. Each of them says how important these contacts have been for them. For Mira, who first began talking therapy after several years had gone by, it was an experience to finally listen to herself and focus on her own grief and needs, instead of constantly having to take other’s feelings and experiences into consideration. Emilia approached the youth clinic approximately one year after her mother’s death to seek help for the eating disorder she had developed.

But then after a while, she started to put the two together, sort of bring up this about mum and stuff. So then we could also start talking about other things that were pretty related to my eating disorder. These things going on that could have an effect. So it was like I was a tangled up mess and she sort of... undid the knots.

Both Mira and Jenny wish that they had been able to share their grief during their teenage years with others who had experienced the same. They both explain how they finally learnt about someone else’s experience of losing a parent when they read Johanna Thydell’s novel, In the Ceiling the Stars are Shining [22]. The book deals with a teenage girl whose mother dies of cancer, something that the author also experienced. Both women commented that this reading experience was extremely important for them, as they were able to relate to so much of what the author wrote about different situations and feelings. As a consequence, their own feelings became normalized.

Independence

Mira believes she would have been more “comfortable” and not as resourceful if her mother had not died. She does not think it would have been such an obvious choice to leave home so early and that perhaps she would have made more decisions within her comfort zone, for example she would have chosen a broader range of subjects at secondary school instead of the more specialized program she studied. Her strong feeling that life is fragile and can change in the blink of an eye means that she wants to make the most of life and she has taken many chances.

Well I’ve really been like this, just gone for it. Jumped on board and taken the chance. I think this has happened because, because I’ve seen that life can really change so quickly, it can end so suddenly and even if you are alive, you can’t always do what you want.

The period of the parent’s illness had already paved the way for more independence. All of those interviewed were made to grow up quickly and learn how to take care of themselves since one parent was ill and the other parent spent a lot of time with their ill partner.

We had to be independent really quickly. We had been living without our mum for quite a long time because she was in hospital in a different town and we were at school here. Sure we went to visit, but we were also on our own a lot and we had to learn how to take care of ourselves. Yeah, you just had to grow up.

When her mother later died, Mira explains how it became a wakeup call for her. She realized that life does not go on forever. This has led to Mira trying to make the most of life and realize her dreams. When she started upper secondary school, she left home and moved to a different town as the course that best fit her career goals was taught there.

Alva recounts how the powerlessness she felt when her father was ill has now transformed into a driving force in her education. She has moved abroad to study at university and she believes that she has become more motivated to study and master the profession as she has a drive to influence and help others.

I feel like I have become more motivated to study, because I have; I’m studying to become [profession] and I feel that there was perhaps a motivation there, that I want to make a difference and help with like... it has become a driving force. I’ve known I wanted to be [profession] for a really long time, even before, but I feel that this has pushed me forward more.

Closeness and distance

A common theme in the interviews was how it is difficult to let go of those close to you. Jenny describes this as a fear of creating new important relationships when there is a risk that they can vanish again after having made a mark on her life. For Jenny, this has resulted in it taking a long time for her to allow someone to become important to her, forming a protection from new painful losses.

It’s become really scary and difficult to like, let someone get close. And trust people, and it feels really unsafe, when you don’t know if people are going to stay or if they’ll go... So I have a few people who I’m really close to and the rest are... quite, like, a little bit more distanced.

Mira’s fear of loss has taken a different form. She also describes how she takes time and waits before she lets anyone get close, but then she tests the other person to see if they will stay.

So when I meet someone, I want it to be like... I test them all the time, really hard, maybe too much, and maybe in a sort of childish way that you want to be, you want to do stupid things, and then be like ‘Okay, are you angry at me now? Do you still like me?’.

Clara has many friends with whom she is very close and that she feels that she can share the most things. These friends have also been around since her mother was ill. On the other hand, it has been difficult to create new friendships since the loss of her mother:

Because maybe, maybe it would’ve been easier to start new relationships in my life if this hadn’t happened? But I think it has affected me, I’m not as open to new friends that I meet, the process has affected it.

Conclusion

A feeling of loneliness and estrangement is described by the women. It has partially to do with the aforementioned silence from others, when they were supposed to show consideration to the person mourning. However, the feeling was also connected to a more existential loneliness. Nobody can completely understand this pain that struck and has been a burden ever since. A feeling of loneliness that is always there has been described in a former case study [5].The women describe how the loss is something they will never overcome, rather it is something that they will have to learn to live with.

The fact that the parent was ill was something that constantly affected the women in their everyday life, both in thought and in feelings. This, for example, led to concern for the parent’s feelings, difficulty in concentrating at school and feelings of guilt that influenced the desire to continue with extra-curricular activities. The women describe their teenage years as a time that instead of being characterized by breaking away from their parents became permeated by the need to take responsibility and adapt to the needs of the ill parent.

Different studies show that a teenager who loses a parent is often more mature than their peers and risks being forced into an adult role far too young. This can result in a disruption of their processing of loss and sorrow and can also lead to a feeling of exclusion and of being different. The hardship has accelerated maturity and they have been forced to make decisions and take responsibility that they otherwise would not have needed to take [3,2,23].

The deceased parent remains very important to the lives of the women interviewed. Despite the fact that their mother or father are no longer alive, they still play an important role as inner objects in their daughter’s life. For many who are grieving, it is important to them to create an internal image of the deceased. When we lose somebody close, they go from being a person in our external reality to becoming internalized and then can serve as an inner adviser or aid [24,25]. Many of the women in the study express how they could imagine an inner dialogue with their deceased parent, in which it becomes possible to be forgiven for unresolved disputes and to receive support and encouragement, but they can also form a kind of moral compass.

In a large longitudinal study carried out by Massachusetts General Hospital, The Child Bereavement Study, it was evident that the children in the study appeared to maintain their relationship with their deceased parent, rather than let them go (26-28). This contradicts the more traditional theories of grief, which suggest that the child must relieve the relationship to the deceased parent of emotional energy [29,30]. It is thought that the internal construction of the parent provides the child with support and facilitates how they manage grief. The grief does not pass – many of the interviewed women express this. The natural recovery and adaptation to the individual’s new situation after a loss can continue for several years [31].

The interviewed women speak of a silence that followed the death of their parent. It sometimes feels as though the deceased parent was never there, as you are not able to share your memories of him or her with anyone. Talking to others about grief facilitates both the grieving person’s understanding for what has happened and a conscious cognitive assimilation [32,33].

Amongst the protecting factors for a child who has lost a parent is once more finding good parenting abilities from the remaining parent. These may, for example, be the ability to communicate, to offer warmth and support and to set boundaries, as well as being in good mental health [34]. In this present study, the majority of the women have become much closer to their remaining parent after their death and describe how them as an important support. One of the women, Jenny, describes her relationship with her father as inadequate. Jenny is the woman who has had contact with child and adolescent psychiatry services.

The interviewed were witness to how those around them had expectations for how they were to grieve at a set time beginning directly in conjunction with the parent’s death. When first offered talking therapy, the majority of the women were not ready for such help. Instead they wished that the offer had been made at a later date. The person who has been affected often lacks sufficient energy to summon the strength to initiate this contact themselves [35]. It is important to offer the grieving help and tune in to their needs on various occasions, not just once [36]. Everybody must find their own way to grieve and all people grieve at their own pace [37].

The young women express how they have developed by placing a higher value on life and increased independence. For many, the passage through loss and sorrow signifies many positive life experiences. However, it is not the loss itself that has been positive; it is the subsequent experiences made from looking back at what has been learnt about the darker side of life. Establishing new relationships, seeing that other people are dependable, is only possible in the long term [31,38].

The results from this study can also be understood based on research and theories about Post Traumatic Growth (PTG) and the processes assumed to lead to this. PTG is defined as a psychological change and process based on experiences of a very stressful event or crisis in life leading to an increased appreciation for life, a feeling of personal strength, greater emotional closeness and improved and deepened personal relationships [39]. Tedeschi and Belvins ([40], also discuss the possible processes they believe to precede PTG and what can be referred to as ruminations about what has happened and where reflecting over what has happened is important something which also seemed to be there among the young women in this study.

A limitation of this study but also a task for future research is that this study mirrors young females’ experiences and we do not know anything about how young males would have felt under the same circumstances. Another essential task for future research is to investigate the mourning process if it was the father, or the mother, who died in cancer, and the family constellation in other respects.

However this study has revealed a process that leads to getting back on track, in which an opportunity to move on after having lost a parent to cancer and finding supporting objects in both the internal and external worlds goes from feelings of enormous loneliness to finding paths out of loneliness by retaining the deceased person as an internal object and forming new relationships in the remaining parent and other important individuals, present and future. Conceptual paths found in this study in the mourning process, the object triad (self, internal and external objects) is an interwoven system, in an ever changing context, and how close or distance the objects are vary through time, in an ongoing maturing process for young people. The results of this study in and out of loneliness can be described as an adolescent‘s mourning process but also a possible process to resilience. The process to be back on track seems diverse and continues for a long time and outside help needs to tune in with this. A clincal implication is that when meeting an adolescent who have lost a parent to cancer it is important to be aware of and to validate all the upcoming feelings of sorrow and loneliness, but also to help the adolescent to take advantage of the remaining parent and to have knowledge about that the need for emotional help can be there for a long time, but also to carry hope for the future. Time is on their side. People can be there for help and development. A resilience process that is highly individual and contextual.

Appendix 1

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