Perinatal Loss: What Therapists Need to Know MODULE 2

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Perinatal loss: What therapists need to know MODULE 2

The nature of grief

Lesson 1 Consequences of perinatal loss.

Lesson 2 What is grief?

Lesson 3 Attachment theory and grief.

Lesson 4 Models and theories of grief.

Lesson 5 Gender, culture, sexual orientation and single by choice.

Consequences of perinatal loss

• Utter disbelief, shock.

• Shattered dreams, devastation and heartbreak.

• Violation of plans, expectations, reproductive stories.

• Existential anomaly (not the natural order of things).

• Mother has given up aspects of self for pregnancy & baby.

• Mother is primed in pregnancy to nurture & protect.

• Parent’s relationship has evolved to become invested in this baby.

• Other people excited about baby’s arrival and meaning in the family.

Davis (2016)

• Traumatic bereavement (separation distress + traumatic distress). (Neria & Litz, 2004) • Overwhelmed, shocked, devastated. • Profound sorrow. • “Suspended in time” “stuck in brokenness”. (Davis, 2016, p8) • The birth and death of a baby all at the same time. • In some cases, no explanation. • Guilt, self-blame. • Loss of innocence. • Loss of self. • Loss of future. • Isolated (“no one really understands”). • Life changing (“how will I ever be happy again?”).

Davis (2016)

Mental symptoms of grief

• Numbness, detachment.

• Yearning, preoccupation, thinking about baby or what happened.

• Confusion, disorientation, disorganized thought, difficulty concentrating.

• Anger, irritability, envy, guilt, regret..

• Fear, anxiety, worry, helplessness

• Sadness, hopelessness, despair.

• Experiences of seeing, hearing, or feeling presence of baby.

Davis (2016)

• Shortness of breath.

• Tightness in the throat.

• Heavy or aching arms.

• Empty feeling in the abdomen.

• Fatigue.

• Sighing.

• Crying spells, tearfulness.

• Sleeplessness, restlessness.

Davis (2016)

Physical symptoms of pregnancy

• Fertility medications affect hormones.

• Hormonal fluctuations.

• Bleeding, cramping.

• Possible infection.

• Body has delivered and recovering.

• Medical intervention.

• Lactation.

• Body changes.

Wenzel, 2014

• Loneliness.

• Withdrawal.

• Feeling marginalized, isolated, avoided, misunderstood.

• Feeling hurt by insensitivity of others.

• Feeling annoyed by others trying to fix it.

• Resenting that others expect you to be over it.

• Feeling like the only person who feels this way.

Davis (2016)

Spiritual / Existential symptoms of grief

• Why did this happen to me / to my baby?

• How could this happen? I did all the right things.

• Am I being punished?

• How could God let this happen?

• What’s the point?

• Everything seems so trivial.

• What’s the meaning of life?

• What’s my purpose? What do I do now?

Davis (2016)

Grief is “the intense and painful pining for and preoccupation with somebody or something, now lost, to whom or to which one was attached” (Parkes, 2006, p. 23)

From a psychodynamic perspective

• Developmental: perinatal loss represents an interference within the normal developmental process of adulthood.

• Conflictual: perinatal loss intensifies intrapsychic conflicts (related to the female drive to reproduce).

• Object oriented: the detachment process of grief that involves a re-conceptualization of self.

• Narcissistic: perinatal loss is a loss of a part of the self which may elicit narcissistic injury and rage. Not only has a woman lost her baby, she has lost herself as a mother.

(Leon, 1992, 1996, cited in Black, Wright & Limbo, 2016)

When you’re I spent years trying ready to have a not to fall baby you have pregnant. Now it’s one my time

Pregnancy is a I’ve done Everyone is having time of joyful everything babies expectation right

Children don’t die before their parents

• Cognitive adaptation to stressful life events.

• Pregnancy can be a stressful life event – biologically and psychologically.

• Losing a baby is a stressful life event (a stress within a stress).

• Subsequent pregnancies are likely to be affected by new schemas following loss.

Pregnancy Babies die means fear

(Black, Wright & Limbo, 2016)

What clients bring

• The way in which they experienced the loss.

• Brain’s arousal tendencies.

• Personality and temperament (e.g., sensitivity, intensity).

• Cultural, family, religious influences/pressures.

• Prior experiences with trauma, loss and grief.

• Emotional and cognitive strengths and deficits.

• Coping strategies.

• Support or lack of support.

• Attachment histories / attachment style.

Davis (2016)

• Grief is not one emotion • Grief is more than an emotional response • Grief affects how we think, feel and act • There is no right or wrong way to grieve • The grieving process is highly diverse and variable among individuals • Like pregnancy, grief involves cognitive and somatic changes • Grief exists within a broader socio-cultural context • Grief involves changes to social relationships • Social attitudes and patterns can dominate the grieving process • The loss of a baby carries a deep existential anguish (not the natural order of things) • Gestation is less important than the attachment the parent had to the baby • Parents’ attachment styles contribute to their experiences of grief

Attachment theory

“Attachment theory (Bowlby, 1980) emphasizes the interrelationships between attachment, affectional bonds, separation, and loss in human relationships”. (Black, Wright, & Limbo, 2016, p. 17).

Attachment theory applies to multiple relationship contexts

Ø Spouses and intimate relationship partners Ø With children Ø With parents (Black, Wright, & Limbo, 2016)

• The extent to which a relationship has been formed with the baby contributes to the parent’s experience of grief and loss.

• Parents’ attachments styles influence the nature of this relationship. (Wayment & Vierthaler, 2002)

Parents’ attachment styles

• Responses to loss vary (intensity and pain).

• Capacity to process the experience and integrate the loss vary.

• Attempts to remember or memorialize the baby vary.

• Parents’ attachment styles influence the nature of available support systems.

• Availability of social support plays an important role in processing trauma. (Dan Siegel, NICABM Trauma Series)

Future attachments

• The way in which couples grieve and support each other affects their relationship.

• Grieving and meaning making is important for future attachments.

• Unresolved grief can contribute to disorganized attachment patterns with subsequent children. (O’Leary, 2004)

Attachment to Adult attachment the baby

LOSS Attachment to subsequent baby & other children

Social support

Secure attachment style

Balanced

Ø Positive mental models of being valued and worthy of the concern and support of others.

Ø Greater capacity for tolerating distress without becoming dysregulated.

Ø More likely to have mutually supportive relationships available to assist in dealing with difficulties.

Ø More likely to ask for support when they need it. Ø More likely to adapt to grief over time.

Wayment & Vierthaler (2002)

Anxious Ø Fearful of being misunderstood, lack of confidence, sees others as undependable.

Ø Heightened expression of affect (under-regulation).

Ø “I cannot depend on you to be there for me when I need you”, “I cannot depend on myself to be able to elicit the help I need”.

Ø More difficult to feel soothed / calmed in relationships – despite constantly asking for support.

Ø More chronic grief patterns with high levels of distress.

Collins & Feeney (2000); Stroebe, Schut, & Boerner, (2010); Wayment & Vierthaler (2002)

Dismissing attachment style Avoidant

Ø Aloof, emotionally distant, sees others as unreliable or desiring too much closeness.

Ø Tend to shut down emotionally. Avoids or minimizes negative affect.

Ø More likely to lack emotionally supportive relationships resulting in having to deal with the loss by themselves. This confirms that others are not available / interested to support them.

Ø Struggle to ask for help.

Ø ‘Delayed’ or ‘absent’ forms of grief, heightened somatic complaints.

Maccallum & Bryant (2018); Stroebe, Schut, & Boerner (2010); Wayment & Vierthaler (2002)

Ø Experiences of unbearable distress in the absence of another to help regulate emotional states or provide effective support.

Ø “I have to manage this by myself. “I can’t do it” – fear without a solution.

Ø History of attachment disorganization results in being easily dysregulated by stress resulting in impaired integration / processing of trauma or loss.

Ø Unhelpful strategies for asking for help. Less likely to have support.

Ø Greater risk for dissociation and PTSD.

Carlson (1998), Stroebe, Schut, & Boerner (2010)

• Stages

• Phases

• Tasks

Stage models of grief Kubler-Ross 5 stages of grief 1. Shock and denial 2. Anger, resentment and guilt 3. Bargaining 4. Depression 5. Acceptance

Too rigid. No single set of stages associated with loss.

Unable to capture the complexity, diversity and individual grieving experience.

Grief not sequential. (Arizmendi & O’Connor, 2015) See Hall (2014)

Shock, numbness Searching and yearning Disorganization Reorganization

See Black, Wright & Limbo (2016)

Task model of grief

Worden 2009: A series of adjustments to the loss (tasks of mourning).

Finding an Accepting the Processing the Adjusting to life enduring reality of the loss pain of grief without the baby connection while moving forward

(Hall, 2014; Walter & McCoyd, 2015)

Seven determining factors (applied to perinatal loss)

1. Who was this baby / what did this baby mean?

2. What was the nature of the attachment to the baby?

3. What were the circumstances of the baby’s death?

4. What are the historical antecedents?

5. Personality factors relating to the grievers.

6. Social mediators (social context, social support)?

7. Concurrent stressors (what else is/was going on?)

The dual-process model of grief Stroebe and Schut (1999)

• Based on a cognitive-stress perspective (including coping).

• Draws from Bowlby’s ideas about disorganization and re-organization.

• Simple theory.

• Bears out in clinical practice.

• Not prescriptive.

• No discreet stages.

• Based on the oscillation between two orientations…

Loss Restoration Orientation Orientation

Summary

• Grieving does not happen in stages – it is unpredictable • Grieving typically begins with a period of high /acute distress progressing to lower distress over time (Arizmendi & O’Connor, 2015) • There is no ‘normal’ way to grieve • Models help us to organize information in ways that fit with the client’s experience and our understanding of where the client is at in their grief • Use models to frame or understand grief, not as formulas for grief • Grieving does not come to an end – grieving and healing co-occur (Davis, 2016)

© The Perinatal Loss Centre Module 2 17 Gender differences • Women typically experience higher levels of grief than men (Lin & Lasker, 1996), with threats to their identities (Wenzel, 2014) • Men do grieve, and can grieve intensely at times. • Fathers have been found to experience loneliness, anger, guilt and helplessness. (Murphy, Shevlin, & Elklit, 2012) • Men may deny their grief and internalize feelings of loss rather than openly express them. • Cultural norms and ‘being there’ for the woman can result in male inexpressiveness of grief or delayed grief. (Stinson, et al., 1992) • Substance abuse has been found in men post-loss. (Jaffe & Diamond, 2011)

Intuitive vs instrumental grieving

Intuitive griever Instrumental griever

• Expression of feelings. • Displays less intense feelings.

• Outward displays of crying and lamenting • Thinking the dominant characteristic. reflecting internal experience. • Feel that it’s important to have ability to • May have difficulty concentrating. master the situation.

• May feel disorganized and confused. • Rely on problem-solving strategies to regain a sense of control, rather than • Feels physically exhausted as a result. talking about feelings .

Martin & Doka (2000)

• There are differences in how one expresses grief based on the the way in which death is handled, or the practices of one’s cultural heritage.

• The therapist needs to be aware of the cultural expectations and interpretations of the loss.

• It’s ok to ask.

• Do not make assumptions about a client’s belief system based solely on race or ethnic background.

LGBT+ creating rainbow families

A Rainbow Family is a same-sex or LGBTQI parented family. At Rainbow Families, we define a Rainbow Family as: any lesbian, gay, bisexual, transgender or intersex person who has a child or children; or is planning on having a child or children by way of donor insemination (known or unknown), surrogacy (altruistic or commercial), foster care, foster to adoption, adoption (domestic or international), opposite- sex relationship, co-parenting or other means.

http://www.rainbowfamilies.com.au

• “Children need a mother”.

• “The child will be emotionally damaged”.

• “The child won’t be socially accepted”.

• “The child will become gay”.

• “The child will be teased or bullied”.

Ø Research has debunked all of these prejudices

LGBT+ people facing loss

• Loss can reinforce these unconscious schemas

• Layers of pain

• Loss of self-identity

• Long and difficult process before they can achieve a possible pregnancy. • Complexities of donor conception (e.g. known or unknown donor, involvement with donor?). • Men require surrogate. • Conception journey in hetero-normative even hetero-sexist environments. • Histories of marginalization in our hetero-normative culture. • Transgender couples face stigma and judgement (watch “I Was the Pregnant Man”). • Attachment to the baby begins very early. • Biological mothers typically grieve the loss more openly than the non-biological mothers. (Wojnar, 2007) • Who is the biological mother? • When one has had pregnancy loss or is infertile, the pregnancy and/or further losses in partner can be triggering. • Lack of social and/or legal recognition of being a grieving parent (e.g. male same sex couples experiencing surrogacy loss). • May feel isolated in grief. • May be lack of support from family and friends. • Discrimination or fear of discrimination by medical professionals. • Financial pressures around future conception. © The Perinatal Loss Centre

Loss for single parents by choice

• Reproductive stories likely to have involved a partner, but they feel that time is running out.

• When there is loss, there is a double loss of the reproductive story (loss of the baby and loss of the hoped-for relationship).

• Loss of time, and future options if financial constraints or fertility difficulties.

• May be facing childlessness (deep existential loss).

Module 2 References

Arizmendi, B. J., & O’Connor, M. F. (2015). What is “normal” in grief? Australian Critical Care, 28(2), 58-62. Black, B. P., Wright, P. M., & Limbo, R. (2016). Perinatal and paediatric bereavement in nursing and other health professions. Springer Publishing Company. Bowlby, J. (1969). Attachment and loss: Attachment (Vol. I). New York: Basic Books. Bowlby, J. (1977). The making and breaking of affectional bonds: Etiology and psychopathology in the light of attachment theory. The British Journal of Psychiatry, 130, 202-210. Bowlby, J. (1982). Attachment and loss: Attachment (Vol. I). New York: Basic Books. Bowlby, J. (1980). Attachment and loss: Vol. 3: Loss. New York: Basic Books. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books. Carlson, E. A. (1998). A prospective longitudinal study of attachment disorganization/disorientation. Child development, 69(4), 1107-1128. Collins, N. L., & Feeney, B. C. (2000). A safe haven: An attachment theory perspective on support seeking and caregiving in intimate relationships. Journal of personality and social psychology, 78(6), 1053. Davis, D. (2016). Empty cradle, broken heart: Surviving the death of your baby. Fulcrum Publishing. Doka, K. J. (Ed.). (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Research PressPub Hall, C. (2014). Bereavement and depression in the DSM-5. InPsych, 36, 22-23. Jaffe, J., & Diamond, M. O. (2011). Reproductive trauma: Psychotherapy with infertility and pregnancy loss clients. American Psychological Association. Johnson, O. P., & Langford, R. W. (2015). A randomized trial of a bereavement intervention for pregnancy loss. Journal of Obstetric, Gynaecologic & Neonatal Nursing, 44(4), 492-499. Kersting, A., & Wagner, B. (2012). Complicated grief after perinatal loss. Dialogues in clinical neuroscience, 14(2), 187. Klass, D., Silverman, P. R., & Nickman, S. L. (Eds.). (1996). Continuing bonds: New understandings of grief. Taylor & Francis. Kubler- Ross, E. (1969) On Death and Dying. New York: MacMillian.

Lang, C. G., Aita, M., Giguère, V., Lamarre, H., & Perreault, P. A. (2001). Weathering the storm of perinatal bereavement via hardiness. Death Studies, 25(6), 497-512. Lin, S. X., & Lasker, J. N. (1996). Patterns of grief reaction after pregnancy loss. American journal of orthopsychiatry, 66(2), 262-271. Maccallum, F., & Bryant, R. A. (2018). Prolonged grief and attachment security: A latent class analysis. Psychiatry research, 268, 297-302. Martin, T. L., Doka, K. J., & Martin, T. R. (2000). Men don't cry-women do: transcending gender stereotypes of grief. Psychology Press. Murphy, S., Shevlin, M., & Elklit, A. (2014). Psychological consequences of pregnancy loss and infant death in a sample of bereaved parents. Journal of Loss and Trauma, 19(1), 56-69. Neimeyer, R. A., & Sands, D. C. (2011). Meaning reconstruction in bereavement: From principles to practice. In R. A. Neimeyer, D. L. Harris, H. R. Winokuer, & G. F. Thornton (Eds.), Series in death, dying and bereavement. Grief and bereavement in contemporary society: Bridging research and practice (pp. 9-22). New York, NY, US: Routledge/Taylor & Francis Group Neria, Y., & Litz, B. T. (2004). Bereavement by traumatic means: The complex synergy of trauma and grief. Journal of Loss and Trauma, 9(1), 73-87. O’Leary, J. (2004). Grief and its impact on prenatal attachment in the subsequent pregnancy. Archives of Women’s Mental health, 7(1), 7-18. Parkes, C. M. (2001). A historical overview of the scientific study of bereavement. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research (pp. 25-45). Washington DC: American Psychological Association. Parkes, C. M. (2006). Dangerous Words. Bereavement Care, 26(2), 23-25. Rich, D. (2018). Psychological Impact of Pregnancy Loss: Best Practice for Obstetric Providers. Clinical obstetrics and gynaecology, 61(3), 628-636. Schut, M. S. H. (1999). The dual process model of coping with bereavement: Rationale and description. Death studies, 23(3), 197-224. Shear, M.K. (2015). Complicated grief treatment: Instruction manual used in NIHM grants. New York: Columbia Centre for Complicated Grief, Columbia University. Stinson, K. M., Lasker, J. N., Lohmann, J., & Toedter, L. J. (1992). Parents' grief following pregnancy loss: A comparison of mothers and fathers. Family Relations, 218-223.

Stroebe, M. S., & Schut, H. (2001). Models of coping with bereavement: A review. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 375-403). Washington, DC, US: American Psychological Association. Stroebe, M., & Schut, H. (2010). The dual process model of coping with bereavement: A decade on. OMEGA-Journal of Death and Dying, 61(4), 273-289. Stroebe, M., Schut, H., & Boerner, K. (2010). Continuing bonds in adaptation to bereavement: Toward theoretical integration. Clinical psychology review, 30(2), 259- 268. Walter, C. A., & Mc Coyd, J. L. (2015). Grief and loss across the lifespan: A biopsychosocial perspective. Springer publishing company. Wayment, H. A., & Vierthaler, J. (2002). Attachment style and bereavement reactions. Journal of Loss &Trauma, 7(2), 129-149 Wenzel, A. (2014). Coping with infertility, miscarriage, and neonatal loss: Finding perspective and creating meaning. American Psychological Association. Wenzel, A. (Ed.). (2016). The Oxford handbook of perinatal psychology. Oxford University Press. Winnicott, D. W. (1960). The theory of the parent-infant relationship. International Journal of Psycho-Analysis, 41, 585-595. Wojnar, D. (2007). Miscarriage experiences of lesbian couples. Journal of midwifery & women's health, 52(5), 479-485. Websites National Institute for the Clinical Application of Behavioural Medicine; Treating Trauma Masters Series https://www.nicabm.com/program/treating-trauma-master/ Rainbow Families. https://www.rainbowfamilies.com.au/