Perinatal loss: What therapists need to know MODULE 2 The nature of grief © The Perinatal Loss Centre theperinatallosscentre.com.au facebook.com/theperinatallosscentre 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. © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 1 Consequences of perinatal loss • 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) © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 2 Physical symptoms of grief • 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) © The Perinatal Loss Centre 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 © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 3 Social-emotional symptoms of grief • 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) © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 4 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) © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 5 Common schemas 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 © The Perinatal Loss Centre Children don’t die before their parents © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 6 From a cognitive stress theory perspective • 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) © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 7 About grief • 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 © The Perinatal Loss Centre 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 Perinatal Loss Centre © The Perinatal Loss Centre Module 2 8 Attachment to baby • 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) © The Perinatal Loss Centre 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. © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 9 Eliciting support • 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) © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 10 Early attachment Attachment to Adult attachment the baby LOSS Attachment to subsequent baby & other children Social support © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 11 Preoccupied attachment style 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) © The Perinatal Loss Centre 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) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 2 12 Disorganized attachment Ø Experiences of unbearable distress