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Grief and the Marital Relationship.
There is debate on how a perinatal loss impacts the marital relationship. The controversy is over whether the loss causes marital strain (Mekosh-Rosenbaum & Lasker, 1995), whether it deepens the marital bond (Leon, 1995), or whether it has no effect on the relationship (Mekosh-Rosenbaum & Lasker, 1995).
Gilbert (1989) believes that parents often disagree on both the "correct" way to grieve and on how long they “should” grieve. This phenomenon is referred to as “incongruent grieving” (Gilbert, 1989). The baby may have a different meaning for each parent because one parent may have planned more for the baby's future than the other parent. The father may not be actively expressing grief over the loss (Frost & Condon, 1996). Instead, he may use a manic defense and keep busy to avoid feeling the loss (Phipps, 1981). Simultaneously, the mother may have more depressive reactions and constantly think about the loss (Phipps, 1981 & Suarez & Gallup, 1985). These differences in coping styles can lead to communication problems in the relationship (Phipps, 1981). Furthermore, the parents’ overwhelming guilt often causes them to blame each other for the loss (Frost and Condon, 1996). In addition, it is beneficial for the parents to be able to support each other (Mekosh-Rosenbaum & Lasker, 1995); if they are not able to, it can lead to conflict (Gilbert, 1989).
Perinatal loss can have an impact on sexual intimacy between partners. According to Phipps (1981), parents often associate sexual intimacy with producing a child that has died. In addition, the guilt that they may feel after the loss may cause them to deprive themselves of many pleasures, such as sexual intimacy.
Another factor that influences the marital relationship after perinatal loss is the fact that it is common for men to take the role of “supporter” to their wives. This role generally occurs for four reasons. First, grieving mothers often turn to their spouses for support following perinatal loss because they are more vulnerable than their husbands because of hormonal changes (Willner, Deckardt, Von Rad, & Weiner, 1996). Second, men feel the duty to "stay strong" and to be supportive of their mourning wives. Third, fathers often fear that expressing their sorrow about the loss will increase their wives’ grief (Dyregrove & Mattiesen, 1987). Finally, fathers’ nurturing instincts become awakened during their wives’ pregnancy (Pruett, 1995), adding to the need to take care of their wives.
Men and Perinatal Loss
General Review of the Literature.
A great deal of controversy exists regarding the degree, the duration, and the way fathers grieve following reproductive loss. Upon examining the intensity and duration of fathers’ grief, many studies have reported that fathers grieve little, and typically less than mothers do after these losses. For example, Theut et al. (1990) examined the differences between mothers’ and fathers’ grief reactions to miscarriage, stillbirth, and neonatal death 16 months after the birth of a subsequent child. Losses were divided into two groups: late loss, which included those parents who had experienced either a stillbirth or neonatal death, and early loss, which was comprised of parents who had undergone a miscarriage. Using the Perinatal Bereavement Scale (PBS), they found that the mothers’ grief reactions exceeded the fathers grief reactions in both the late-loss group and the early-loss group. This study is useful in that it demonstrated that parents’ grief can be long lasting, and that it continues following the birth of a subsequent child. However, it is possible that the Perinatal Bereavement Scale (PBS) did not accurately measure the father’s grief. The PBS was developed after interviewing only three fathers (and seven mothers); thus, it may not be a valid measure for grief in men. Furthermore, it measures overt symptoms of grief, such as dreaming and thinking of the baby, guilt about the loss, and preoccupation with the baby. The PBS fails to measure feelings that may have been displaced from the baby or the loss itself. For example, anger at the baby for dying may be displaced onto doctors. Because it is possible that fathers demonstrate less overt grief and displace their feelings more than mothers do, their grief may have been underestimated with the PBS.
Vance et al. (1991) studied the parental responses to Sudden Infant Death Syndrome (SIDS), stillbirth, and neonatal death two months after the loss. The researchers developed questionnaires, based on the Foulds and Bedford Delusions- Symptoms-State Inventory, that measured symptoms of anxiety and depression. Fathers scored lower on both measures, indicating they have less grief responses than mothers do to SIDS, stillbirth, and neonatal death. However, the participation rate for fathers was lower than for mothers. Perhaps those fathers who chose not to participate were in more distress or were more defended against their distress. Thus, the results of this study may have been skewed toward maternal reactions.
Beutal et al. (1996) conducted a longitudinal study comparing mothers’ and fathers grief reactions following a miscarriage. They gave questionnaires to 56 couples, measuring: depression, bodily complaints, anxiety, sadness, fear of loss, guilt, anger, and the search for meaning. Fathers scored significantly lower than mothers on all of these measures, suggesting that they grieve less intensely after a miscarriage than mothers.
The problem with all of these studies is that they used the same variables on fathers as they used for mothers, such as: depression, anxiety, sadness, guilt, thoughts about the loss, and feelings about the loss. It is speculated that the same construct used to measure mothers grief is not valid for measuring fathers grief (Vance et al., 1995). Some theorists believe that men do not directly express feelings about the loss, but instead repress the loss (Phipps, 1981), keep busy so they cannot think about the loss, suppress their feelings about the loss (Zeanah, 1989), or express their grief vicariously through their wives (Leon, 1990). Therefore, in many cases, fathers may underreport their symptomatology and appear to be grieving less than they really are.
Additionally, all of these studies compare the inte nsity and duration of mothers’and fathers’ grief, as if to see if fathers are worth acknowledging as grievers. In concluding that fathers do not grieve as much as mothers, researchers continue to put fathers on the “back burner” without acknowledging their experiences. An unfortunate consequence for fathers is that their grief may not be properly addressed.
Dyregrove and Mattiesen (1987) conducted a quantitative study looking at the similarities and differences between mothers’ and fathers’ grief one to four years following a stillbirth or a neonatal death. Measuring both short-term and long-term adjustment, the study found that mothers scored higher than fathers on: anxiety, depression, restlessness, somatic symptoms, avoidance of stimuli associated with loss, and intrusive thoughts, while scoring similarly on anger and work involvement. Overall, mothers experienced more intense and longer-lasting reactions to reproductive loss than fathers did. However, the investigators generated several hypotheses about why fathers scored lower on grief than mothers: 1) fathers have less of an attachment to the unborn child, 2) men have different coping mechanisms for stress than women, and 3) men underreport or suppress their emotions, leading to lower scores on the tests measuring emotions. If men do underreport or suppress their emotions, the authors concluded that “it is difficult to interpret conclusively the reported gender differences” (p. 12).
In a longitudinal study of perinatal loss, Zeanah, Danis, Hirshberg, and Dietz (1995) looked at the adaptation of mothers and fathers at two months, and then at one year after the loss. Overall, mothers’ grief exceeded fathers grief. However, 32% of the fathers in their study were found to be "Minimizers." In other words, these fathers were more defensive and may not have been consciously grieving. Instead, they may have been repressing their feelings about the loss. Thus, the fathers in this study scored lower on grief than the mothers, but may have been grieving just as much as the mothers.
The results of these studies bring up several questions: First, do men grieve after reproductive loss? Second, if men do grieve, what is the quality of their grief? Lastly, how do researchers assess the amount and quality of grief among fathers and measure the differences between men and women?
Some investigations have demonstrated that fathers do grieve after perinatal loss and that their grief is qualitatively different than the grief in mothers. Hunfield and Mourik (1996) compared the intensity of grief in men and women within a couple whom had experienced neonatal death six months previously. Using the Perinatal Grief Scale, the study found that there were no significant differences in the intensity of grief reactions among mothers and fathers. However, they did endorse different items on the test, suggesting that mothers and fathers grief may differ in quality from each other. Unfortunately, the investigators did not specify which items these fathers endorsed on the PGS.
Johnson and Puddifoot (1996) investigated the psychological impact of miscarriage on men. Using the Perinatal Grief Scale (PGS) and the Impact of Events Scale, this study demonstrated that men do have high levels of grief following a miscarriage. In fact, their grief levels were as high as the norms for women. Interestingly, fathers exceeded mothers on the "difficulty in coping" measure, which is typically endorsed by those who are not openly expressing grief, but are having difficulty coping with the loss in their day-to-day lives. Therefore, these results suggest that grief in men following a miscarriage is not only significant, but is qualitatively different than for women. Subsequently, the authors decided to further explore fathers’ reactions to miscarriage.
In 1997, Puddifoot and Johnson conducted a qualitative study looking at the grief experienced among fathers following a miscarriage. After interviewing twenty men and doing a thematic analysis, they found that many men expressed some similar emotions to females following a miscarriage, such as grief, confusion, blame, anger, and disgust.
However, the authors also found that many of the men in their study had reactions that were not seen as much in their female cohorts. First, many of the men in their study had difficulty expressing their emotions about the loss. For some men this struggle rooted from the feeling that others would not understand how they felt, while other men felt that it would be “self-indulgent” to express their feelings. Second, many men denied experiencing any negative emotions about the loss. However, those participants who were more active with the pregnancy, expressed more emotions about the loss. Third, many participants used “avoidance” as a defense. For example, they would “try not to think” about the loss in order to cope with it. Based these findings, the investigators believe that men struggle to acknowledge their grief, and that this struggle has several roots, including: (a) men's limited ability to endure emotional pain; (b) the threat to the men's gender identity if they were to acknowledge emotional pain; (c) the perception that if they talk about their own pain of the miscarriage, they will trigger their wives’ pain; (d) and the lack of recognition and support that men receive after a miscarriage (Puddifoot
& Johnson, 1997). Although the investigators of this study highlight some interesting issues about fathers and their perception of the origin of their grief reactions, the authors fail to elaborate on their findings and on their proposed sources of grief.
Mandel, McAnulty, and Reece (1980) conducted a qualitative study that looked at the paternal responses to Sudden Infant Death Syndrome (SIDS). Results indicated that the men in their study denied their loss through: taking the managerial role (i.e. arranging the funeral), intellectualizing their grief and blame, increasing their involvement outside the home, expressing a strong desire to have subsequent children, and avoiding professional support. Furthermore, the men in this study tended to be angry and aggressive, while the women in this study were depressed and withdrawn. It is possible that by denying their grief, these men were attempting to stave off their own depression. Therefore, these results suggest that men do grieve, and that their grief is manifested in a different manner than in women.
Vance et al. (1995) looked at parents who experienced Sudden Infant Death Syndrome or Perinatal Death at 2, 8, 15, and 30 months following the loss. These investigators not only used anxiety and depression scales, but also a measure of alcohol ingestion. More specifically, this study used a fourteen-question symptom complex subscale from the Fould’s delusions-symptoms-states inventory to measure anxiety and depression. Alcohol ingestion was considered to be heavy if the participants drank five or more drinks per day, or drank seven or more drinks a few days a week. Unfortunately, the authors of this study did not discuss or provide any information on the reliability of validity of these measures.
The results of this study indicated that when the prevalence of heavy alcohol ingestion was measured along with anxiety and depression, the difference between the psychological responses of men and women were low and nonexistent. More specifically, results indicated that at both two and thirty months following the loss, men were seen to be under more distress than the control group (non-bereaved fathers). At two months, fathers were primarily anxious, depressed, and consuming alcohol. At thirty months, men were less anxious and depressed, but they reported more alcohol consumption. This study is valuable in that it was one of the first studies which used different measures for men and women to measure distress following a perinatal loss. Furthermore, it demonstrated that many men might use alcohol to “numb” their feelings about their loss. Clearly, more studies are needed that will broaden our way of measuring distress in fathers following perinatal loss.
It is interesting to note that although the studies reviewed above suggested that they looked solely at fathers, all of them made comparisons of mothers and fathers. In contrast, most of the literature on mothers looks at only mothers. This phenomenon supports the idea that fathers are considered to be secondary to mothers as grievers after perinatal loss. This researcher has found only one study that examines fathers as a group, with no comparisons to mothers. Because this study is closely related to the topic of this dissertation, it will be thoroughly reviewed in the next section.
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