Fathers and Perinatal Loss Pt. 26: Implications for Clinical Theory

Tracy Schaperow, Psy.D.

Tracy Schaperow

Licensed Clinical Psychologist

This article is part of a larger work.

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Implications for Clinical Theory

This section of the dissertation will discuss the clinical implications of this study. Salient common themes that have clinical implications will be highlighted and discussed in the context of a therapeutic situation.

A common theme among these participants was the need to take a managerial role after the loss. That is, they focused on their wives’ well-being, hid their feelings about the loss from their wives, and tried to be “strong” for their wives. These findings have several implications. First, the fact that they hid their emotions about the loss from their wives has implications for the treatment modality used for these men. For such men, couples counseling may be contraindicated. Couples counseling as a therapeutic modality requires men and women to express feelings and communicate in one another’s presence. Due to men’s proclivity to remain stoic and not express their true feelings in their wives’ presence, individual psychotherapy might be the modality of choice.

As taking a managerial role after a perinatal loss appears to be a unique defense among men, this behavior might be confusing, and, at times, frustrating to their female counterparts. Therefore, it would be helpful for clinicians to educate wives about their husband’s coping style. This education may help women understand their husband’s behavior more so that they do not assume that their spouses are not in distress. Furthermore, by understanding their husbands’ behavior, these women might better empathize with them, bringing the couple closer together. Since women present more often for psychotherapy than men, providing psychoeducation to female clients seems appropriate.

An important finding of this study is that many of these fathers’ psychological experiences after perinatal loss were unconscious. Because their sense of loss was primarily unconscious, and they displayed emotional stoicism, these fathers projected the illusion that they were doing better than they actually were. Clinicians should be careful not to collude with this image. Furthermore, clinicians respect fathers’ defenses, working slowly and carefully toward warded off feelings, since these feelings may be especially frightening for men. In showing feelings, fathers may show their weakness at a time when they feel they need to be strong.

Most of the participants in this study described having one perinatal loss; however, one participant reported two losses, both within the same year. Using a metaphor, he described being able to put his feelings with the first loss in a “box, and put the box aside;” however, with the second loss, he reported that “it’s a lot bigger box and doesn’t close well.” Given that he was the only father who did not hide his emotions from his wife, it is possible that when a father has two losses, he is more expressive with his emotions. Although he might be more expressive with his feelings, he may also feel overwhelmed by these emotions. Therefore, clinicians should also work slowly and carefully with fathers who have had multiple losses.

Essentially, challenging defenses does not come without its share of risks. It is essential that clinicians recognize that underlying these defenses there might be an enormous amount of pain. If a therapist uncovers or challenges defenses either too quickly or too intensely, the distress underlying the defenses may be overwhelming to the client.

It is necessary for clinicians to monitor their countertransference when working with these men. This investigator found that she often had reactions to these participants and their losses that could have interfered with doing therapy (or interviews) if she had not carefully monitored them. For example, she felt a sense of helplessness as she listened to these fathers’ tragic stories about their babies’ deaths. To cope with her helplessness, she often had the urge to interrupt their stories, do therapy, and provide comfort, rather than just letting them tell their story. This technique, however, would have been counter-therapeutic, as it is essential to let a parent tell their story after a loss. Because therapists who are less knowledgeable about working with parents after a perinatal loss might impede the therapeutic process by reacting to their own countertransference, it would behoove clinicians to carefully monitor their own feelings so that they do not prevent these men from discussing their losses.

Because each participant in this study varied in terms of the way he experienced the loss, therapists must keep in mind that the degree and type of defenses among men vary widely. Therefore, an ideographic assessment should be made for each man, thereby illustrating the treatment of choice for each individual.

Limitations of the Current Study

  1. The nature of the sample of the men in this study limits the generalizability of this study. The sample size was relatively small; hence, it is not likely that it is an accurate representation of the whole population of men who have endured a perinatal loss. Their demographics, such as age and education, varied. The type, circumstance, and time elapsed since the loss also varied. For these reasons, they are considered to be a heterogeneous population. Furthermore, the results need to be interpreted with caution, since men with different ages, education, types of losses, or time elapsed since their loss may be in distinct groups.
  2. The way that these fathers grieved may be reflective of gender socialization. All of them were raised with Western cultural traditions, which may have impacted their experience or expression of grief. Therefore, these results may not generalize to men from other cultures.
  3. An additional and obvious limit to the generalizability of this sample is that all participants were recruited through a support group network. Accordingly, this sample may have only represented a sub-section of the population that recognizes perinatal loss as a real and genuine loss, even if only for their wives.
  4. The interviews were retrospective, requiring participants to recall memories about a loss that occurred three months to three years prior to the interview. As such, the participants’ memory of past events may be distorted or inaccurate.
  5. This researcher’s involvement in the interview process leaves room for subjective bias. The relationship that develops between the researcher and participants can influence the content of the interview, as this relationship can alter what the participants choose to tell, and what questions the researcher asks.
  6. Similarly, the researcher’s involvement in the T.A.T. and C.A.T.-H administration may also have biased the results. Although the investigator used the standard administration as recommended by Bellak and Abrams (1997), these procedures involved the use of prompts when deemed necessary. The researcher’s use of those prompts may have been influenced by her relationship with the participants, and by her investment in this study.
  7. As the T.A.T. and the C.A.T.-H were used as experimental methods, issues of reliability and validity were not of central relevance; hence, these issues were not taken into consideration. Despite the advantages of using these instruments to gain indirect or unconscious information that the participants’ were attempting to defend against, the information gained from these tests must be interpreted with caution.
  8. Themes of loss were found in all but one participant’s T.A.T. and C.A.T.-H; however, these themes may have been present before their perinatal loss. The present research did not use any measures or controls that would ascertain if participants had themes of loss previous to their perinatal loss.
  9. The PGS was limited in its use in this study as it has not been validated on men. The norms used to compare these participants’ scores were developed on samples of women, and may be dated, as they were from eleven years ago. Furthermore, the PGS was used for a participant who had lost a baby to SIDS, and had not been validated on parents who endured the same type of loss.
  10. Despite the advantages of the researcher’s knowledge about perinatal loss in analyzing the data, this knowledge may have influenced her identification of themes. Furthermore, her relationship with the participants may have also influenced the analysis of the data.

Suggestions for Future Research

  1. As the results of the present study reflect the experiences of five fathers who had a perinatal loss and may not represent the experiences of other fathers who have had a perinatal loss, future research could replicate this study using a larger sample size. By using this larger sample size, the researchers could determine if the same themes arose. Then, once replicated, a quantitative study could be conducted to see how strongly these themes are associated with fathers after perinatal loss.
  2. This study included various types of perinatal loss, including SIDS, stillbirth, miscarriage, and neonatal death. Although both unique and similar themes arose among the participants with different types of losses, future research could compare fathers with different types of losses in the way that they grieve, and in the intensity of their grief. For instance, research might determine if fathers with later losses grieve more than fathers with earlier losses. Further research might also look to see if fathers are less aware or less conscious of their grief with earlier losses as they have less clear memories of those babies.
  3. The amount of time elapsed since the loss varied among participants in this study; therefore, future research could compare fathers’ reactions given the different amounts of time elapsed since the loss. For instance, a study could look to see if fathers focus on taking care of their wives during the first year of the loss, and then focus more on their own grief during the second year following the loss.
  4. Future studies may also look at the influence of a diagnosis of a handicap of the baby in-utero on grief before a perinatal loss occurs, as it did for one participant in this study. In this case, the diagnosis of Down’s Syndrome before the loss appeared to have had a strong influence on his experience.
  5. The participant in this study who had multiple losses reported that his reaction to his first loss was very different than his reaction to his second loss. Therefore, it might behoove researchers to compare the differences between the experience of one loss versus multiple losses in men.
  6. The results of the present study suggested that fathers might respond better to individual therapy than to couples therapy, because fathers may tend to hide their emotions in front of their wives. Future research should examine this phenomenon, as this research did not measure the usefulness of the different therapy modalities on these men.


Summary and Conclusion

The present investigation examined fathers’ conscious and unconscious reactions to perinatal loss. Five men who had experienced a perinatal loss in the form of a miscarriage, stillbirth, neonatal death, and/or Sudden Infant Death Syndrome (SIDS) participated in the study. Each participant was interviewed two times, and administered the Thematic Apperception Test (T.A.T.), the human form of the Children’s Apperception Test (C.A.T.-H), and the Perinatal Grief Scale (PGS).

Although each participant had unique reactions to the loss, common themes were found across participants. For instance, similarities among the participants before the loss included: a strong desire for children, excitement about the pregnancy, and the experience of bonding with the baby before its death. Furthermore, there were similarities in the participants' accounts after the loss. The emotional consequences of shock, numbness, guilt, anger, anxiety, and sadness are examples. Also, the participants took on "managerial roles" (Mandell, McAnulty, and Reece, 1980) by focusing on their wives' well-being, hiding their true feelings about the loss, and trying to be strong for their wives. All participants described changes in their relationships with their wives after the loss (e.g. stronger relationship), further illustrating commonalties among the men.

Finally, four (of the five) participants reported attending a support group after the loss. Although the participants were similar in many ways, there were also some differences between them. For instance, the amount of conscious grief and feelings about the loss varied among the men.

This investigation yielded interesting results, yet, there were some limitations. A small sample size, a retrospective design, and possible researcher bias are examples. Another limitation was the administration of the Perinatal Grief Scale (PGS), as this measure did not appear to adequately capture the men’s conscious and unconscious grief. In terms of application, the present study's results suggest that men may respond better to individual psychotherapy than couples psychotherapy following a perinatal loss, and that men may project the false illusion of adjusting to the loss. Future lines of research could use quantitative methodology to further elucidate the range of reactions in fathers experiencing reproductive trauma.

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