Fathers and Perinatal Loss Pt. 3: Models of Grief

Tracy Schaperow, Psy.D.

Tracy Schaperow

Licensed Clinical Psychologist

This article is part of a larger work.

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Models and Theories of Grief


Definition of Terms.

Various definitions of grief, loss, mourning, and bereavement exist in the psychological literature. Although these terms are slightly different in their meanings, the literature commonly uses them interchangeably.

Grief generally refers to the feelings and behaviors precipitated by a death (Biondi & Picardi, 1996).

Loss has been defined as the deprivation through death (Random House Webster’s College Dictionary, 1992). This dissertation, however, will expand the definition of loss to not only refer to the concrete death of a loved one, but to also refer to other losses, tangible and intangible.

Mourning often applies to the social expressions of grief, such as the funeral and wake (Biondi & Picardi, 1996).

Bereavement is often understood to be the reaction to the loss of a loved person by death (Clayton, 1990). To be consistent with the literature, this dissertation will use these terms interchangeably.

Models and Theories.

The psychological literature describes many models of grief. Most of these models involve two to five stages to the grief process. Sigmund Freud created the first psychoanalytic model of grief in his article Mourning and Melancholia (1917). He conceptualized the process of grief in two steps: shock and denial followed by working through . Freud believed that during the latter stage, working through, the individual frees up the energy invested in the lost object. This process is further illustrated in Freud s own words:

People never willingly abandon the libidinal position, not even, indeed, when a substitute is already beckoning to them. This opposition can be so intense that a turning away from reality takes place and a clinging to the object through a medium of a hallucinatory wishful psychosis. (Freud, 1917, p. 52)

Freud believed that once the individual has freed himself from his investment in the lost object, he has worked through the loss; only then is his ego available to invest libidinal energy in new objects. Unfortunately, cathexis (e.g. mental energy), is difficult to operationalize and measure. Therefore, no systematic research yet exists to support Freud s model of grief (Glick, Weiss, & Parkes, 1974).

Melanie Klein, another contributor to psychoanalytic theory, believed that individuals regress to the age of weaning during the grief process. When the child is weaning, he does not yet have a strong enough ego to integrate both the good and bad aspects of his mother. Therefore, when his mother does not meet his needs and he is frustrated, he grieves over the loss of the good parts of his mother. Klein believed that adults, when experiencing a loss, regress to the time when they were weaning and are not able to integrate both the good and bad aspects of the lost object. As a result, mourners can often be observed to engage in splitting by idealizing the deceased object and devaluing a living object (Burch, 1989).

Erich Lindemann (1944), in one of the first empirical studies of grief, discovered five components of the grief process: somatic distress, preoccupation with the image of the deceased, hostile reactions, guilt, and loss of organized patterns of conduct. He postulated that a mourner could recover from grief in four to six weeks by participating in therapy that focuses on grief-related issues. His work is influential in that it described how grief could be worked through with therapy and how it conceptualized grief as a syndrome with both somatic and psychological symptoms. However, it is believed that Lindemann underestimated the duration of the grief process (Glick, Weiss, & Parkes, 1974).

In her highly influential book, On Death and Dying, Elizabeth Kubler-Ross (1970) presented a five-stage model of grief based on anticipated loss. Her model was originally developed for those coming to terms with their own premature death; however, it is commonly applied to those who lose a loved one, whether expected or unexpected. These stages include: denial and isolation, anger, bargaining, depression, and acceptance. The first stage, denial and isolation, is characterized by feelings of shock and numbness, and functions as a buffer to the shocking news. Once one has worked through denial, he or she enters the next stage: anger. The anger often appears as irrational and is projected onto doctors and nurses. Following anger, the bargaining stage begins. This stage is briefer than the previous stages and the focus is on making bargains with a higher power in order to postpone death. Fourth, depression occurs when the feelings of anger, rage, and numbness die down. Finally, when no longer depressed or angry, the mourner goes through acceptance. Once the acceptance stage has begun, the individual is ready for his own death. That is, he has accepted the fact that it is time for him to die. Unfortunately, there is no quantitative research that exists to support Kubler-Ross’s ideas that there are only five ways or stages to grieve, that these stages are linear, or that all individuals must grieve in any one particular way (Corr, 1993).

Bowlby (1980) introduced a four-stage model of grief based on psychodynamic theory and attachment studies. These stages are generally considered to occur in a succession, although, they may appear in any order. They include: numbing, yearning and searching, disorganization and despair, and reorganization. Numbing, which lasts from three hours to one week, takes place when the individual first learns of the loss. Yearning and searching, which lasts from a few months to several years, occurs when the reality of the loss registers. It is characterized by intense pining and preoccupation with the lost object, followed by anger because of one’s inability to find the object. The next stage, disorganization and despair, is characterized by no longer trying to find the lost object. Instead, the mourner works at finding new patterns of thinking that does not include the lost object. Finally, reorganization occurs, and the mourner has accepted the loss and is ready to begin new relationships.

Many researchers argue that stage models are too rigid. Schuchter and Zisook (1993) held that stage models need to be understood as fluid. In other words, stages can happen in any order and are flexible. More than one stage can occur at any given time, and not everyone will go through all of the stages. In addition, the intensity and duration of different stages varies from individual to individual (Bugen, 1977).

Bugen (1977) believed that grief involved a combination of emotional states rather than fixed stages. These emotional states could be predicted by using his 2x2- matrix model with two axes: centrality and preventability. Centrality refers to the degree of closeness to the deceased person. For instance, high centrality is characterized by a person whom we feel we would have no life without, whose love we feel we cannot live without, and whom we did daily activities with. Preventability is the perception that the death could have been prevented. Bugen believed that high centrality and high preventability created an intense and prolonged grief reaction, while low centrality and low preventability resulted in a mild and short grief reaction.

Whortman and Silver (1989) disputed several common assumptions that underlie most grief models. The majority of grief models suggest that: distress is inevitable following a loss; lack of distress is pathological; grief work is necessary; recovery will occur; and resolution will be achieved. Whortman and Silver (1989) argued that quantitative research exists to support these assumptions and that these are all myths of how individuals cope with loss. Furthermore, these assumptions of how people cope can be harmful in that individuals may be pathologized if they do not appear distressed, work through the loss, recover from the loss, or resolve the loss. Although these authors bring up some important points of caution about the assumptions that mental health professionals make, there are also some drawbacks to their conclusions. Much of the grief literature on which they base their theories is from spinal-cord-injury research. Although spinal cord injury often involves grief, it is a qualitatively different type of loss than object loss. Furthermore, measurement problems in the grief literature may prevent researchers from accurately demonstrating both the distress that people feel after a loss, and the possible benefits of working through the loss with grief work.

Measurement problems in grief research create challenges in obtaining valid quantitative research (Hannson, Carpenter, & Fairchild, 1993). Few valid scales exist because it is difficult to test and retest the reliability of the instrument due to the fact that grief reactions change over time. Furthermore, these instruments measure a snapshot of the person rather than the entire process of the grief. Lastly, grief instruments only measure overt symptomatology, which is not a complete picture of the reaction. The present study, however, will take a more open-ended in depth approach instead of just using one instrument that takes just a “snapshot” of one point in time at an individual’s conscious experiences.

The Uniqueness of Perinatal Loss

Because few studies examine fathers’ experiences of perinatal loss, this portion of the literature review is primarily based on research and theories involving populations of mothers experiencing perinatal loss. The literature on fathers will be reviewed in a later section of this document.

Definition of Terms.Although the term perinatal loss originally referred to all reproductive losses happening between the twentieth week of pregnancy and the first month of life (Leon, 1992), more recent trends have been more inclusive and tended to include a wider range of losses. Hence, this dissertation has used the broader definition of perinatal loss and includes losses that occur before the twentieth week of pregnancy as well as ones that occur up to six months after birth. Therefore, in addition to stillbirth, ectopic pregnancy, and miscarriage; neonatal death and Sudden Infant Death Syndrome will also be included in the definition of perinatal loss.

Miscarriage is defined as the premature expulsion of a nonviable fetus from the uterus (American Heritage Dictionary, 1994).

Stillbirth is known as the birth of a dead infant who was carried for at least twenty weeks or weighed one thousand grams (Stringham, Riley, and Ross, 1982).

Sudden Infant Death Syndrome (SIDS) refers to the death from the cessation of breathing in a seemingly healthy infant, almost always during sleep (Random House

Webster's College Dictionary, 1992).

Ectopic pregnancy is the implantation and subsequent development of a fertilized ovum outside of the uterus, as in a fallopian tube. These types of pregnancies are not only deadly to the unborn child, but can also be lethal to the mother (Mikel & Stohner, 1995).

Complications in Mourning Perinatal Loss.

Mourning a perinatal loss is complicated for a number of reasons. For example, in Bowlby’s model of grief, one of the stages is “searching and yearning”. As such, the model requires the mourner to think about or “search and yearn” for characteristics of the lost object (Kirkley-Best & Kellner, 1982). However, in the case of stillbirth, miscarriage, and ectopic pregnancy, it is very challenging to search and yearn for the lost baby because there are no memories of past interactions with the baby, and no memories of the baby s appearance, voice, and odor (Leon, 1990). Without a clear perception of the baby, the searching and yearning can go on endlessly (Kirkley-Best & Kellner, 1982).

Because medical professionals are now aware of how difficult it is for parents to mourn without a clear image of the baby, some are now encouraging parents to hold, name, and have a burial for their stillborn child (Leon, 1992). Psychologically, this procedure makes the baby more concrete, gives the parents memories with the baby, and validates their loss as a real and genuine loss. Lewis (1979) illustrates one mother s experience of holding her stillborn son:

The mother was encouraged first to touch and then to hold him. She became frenzied, clutching her baby, and then stripping the clothes off. She kissed his navel and his penis. She forcibly opened his mouth and said, That's where his teeth would have been . Then she 'walked' her baby on the floor. Soon the mother calmed down and gave the baby back to the sister. The sister was distressed but when later the parents came to see her, her impression was that this mother was coping better than many bereaved mothers (p. 304).

Later, the benefits of holding her child were described:

She was attempting to come to terms with the baby's lost future. In her mind she maintained the continuity of the cycle of life. By kissing the umbilicus she was remembering her creative link with the baby in utero; kissing the mouth may be linked to the kiss of life, to the resuscitation. The mother longed for her son to grow teeth and learn to walk, and kissing his penis could be considered a wish to restore her dead son's potential capacity to create life. Creating memories about her baby in this way facilitated mourning (Lewis, 1979, p. 304).

Therefore, by creating positive memories with the baby, the parents are given a clearer perception of their child, and mourning is facilitated. Unfortunately, this procedure can only be used for stillbirth.

In addition to its invisible nature, reproductive loss has other challenges. Usually, the process of grieving a loved one is retrospective: focusing on past experiences with the lost individual. However, in the case of perinatal loss, mourning is prospective, involving, [the] relinquishing [of] wishes, hopes, and fantasies about what could have been but never was (Leon, 1990, p. 35). With perinatal loss, parents lose future experiences they would have had with the child. Often, on the anniversary of the death, parents think about their child’s age as well as what the child might have been doing at that time (Leon, 1990).

Because the fetus is part of the woman s body, losing the fetus is experienced as losing a part of herself (Frost & Condon, 1996; Leon, 1990). Thus, perinatal loss is a narcissistic wound that threatens her sense of identity, femininity, and self esteem (Leon, 1990). Often, the baby represents the mother s idealized fantasy of how she would like to be; therefore the loss leads her to feel insufficient and incomplete (Frost & Condon, 1996).

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