Short-term psychotherapy for perinatal loss.

Psychotherapy

Volume 24/Summer 1987/Number 2

SHORT-TERM PSYCHOTHERAPY FOR PERINATAL LOSS

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IRVING G. LEON Ann Arbor, Michigan Psychotherapy with victims of perinatal loss provides an opportunity to facilitate the mourning process (or complete unresolved grieving) as well as the further resolution of longstanding conflicts revived in pregnancy and its tragic aftermath. While a psychodynamic orientation is used, interpersonal resources and family styles of coping with loss are considered important factors in the outcome of perinatal bereavement. The emotional needs of mothers who have suffered a perinatal1 loss have long been unacknowledged and unmet by both the medical and mental health professions. Not too many years ago it was common practice for the caretaking physician of a mother who just had a stillbirth to deny her physical contact with the dead baby's body, prescribe tranquilizers to minimize her grief, and recommend forgetting about the sad event as soon as possible, perhaps by quickly attempting another pregnancy (Berezin, 1982; Cullberg, 1972; Giles, 1970; Klaus & Kennell, 1976; Peppers & Knapp, 1980). Within the past five to ten years many of these practices have changed due to the growing awareness that a miscarriage, stillbirth, or neonatal death can be a devastating loss to the parent, especially the mother (Berezin, 1982; Borg & Lasker, 1981; Friedman & Gladstein, 1982; Pep1 While perinatal death, as generally defined in the United States, "encompasses all losses occurring between the twentieth week of gestation and the twenty-eighth day of human life" (Berezin, 1982, p. 20), I will also include earlier miscarriages as perinatal losses. Due to the very different circumstances of an abortion, it is not expected that this loss will follow the bereavement pattern outlined here and, for that reason, will not be considered here. Reprints may be ordered from Irving G. Leon, 1289 King George Blvd., Ann Arbor, MI 48108.

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pers & Knapp, 1980). It is now recognized as appropriate for bereaved mothers to mourn pregnancy loss through grieving with such typical reactions as shock, disbelief, sleeplessness, crying, sadness, rage, anxiety, somatic distress, and both yearning and hallucinatory experience of the dead baby (Dunlop, 1979; Kennell et al., 1970, KirkleyBest & Kellner, 1982). Guided by a greater appreciation of maternal grief, hospital and medical practices now more effectively facilitate rather than impede the mourning process. In order to help the bereaved mother accept the reality of her loss, she is encouraged to view and, if she wishes, to interact with the dead baby by touching and holding if that is possible. Concrete reminders of the baby's birth and death may be rendered through naming the child, a funeral service and burial, photographs, and keepsakes from the hospital (Cohen et al., 1978; Jolly, 1978; Klaus & Kennell, 1976; Lewis, 1976, 1979; Raphael, 1983; Seitz & Warrick, 1974; Speck, 1978). Klaus & Kennell (1976) recommend a series of three meetings with the bereaved parents to assist their mourning. Immediately after the death, as well as during the first week, they review with the parents the appropriateness of their grief and the various forms that may take, and the benefit of mutual support. Any questions about the death are then answered. Within six months a followup meeting is scheduled to ensure that mourning is proceeding and, if necessary, provide a referral in the event of unresolved grief. Even a single fifteen to forty-minute phone call to the bereaved parents within ten days after the death, in which the grieving process is reviewed and parental concerns addressed, has been found to significantly reduce parental guilt and depression several months later (Schreiner et al., 1979). A burgeoning body of research advises physicians to deal with the immediate aftermath of perinatal death by providing crisis intervention which facilitates the parental mourning process. Virtually nothing has been written, however, on

Perinatal Loss Therapy


the role of psychotherapy in dealing with perinatal death. This article explores the technical issues involved in the psychotherapy of perinatal loss. In order to highlight the different possible outcomes and manifestations of perinatal loss, recent perinatal death is distinguished from unresolved grief of earlier perinatal loss. Treatment issues are discussed and a case illustrated for each instance. The Immediate Grief: Psychotherapy for Recent Perinatal Loss As already reviewed, the affective and behavioral responses to perinatal loss are becoming increasingly understood. Many of the unusual, if not unique, features of perinatal loss may serve as obstacles to mourning this death. Leon (1986a) highlights six reasons which may make perinatal death potentially more difficult to resolve than other losses: 1) the narcissistic nature of the loss; 2) the overwhelming self-blame experienced by the bereaved mother; 3) the lack of concrete memories and objects which would make both the child and the loss more real; 4) the inability to anticipate the death; 5) the prospective nature of the grief in which fantasies of future interactions must be mourned; 6) the stunning lack of social support and understanding by the medical profession and community at large. The combined impact of these factors may present a formidable challenge to the bereaved parents' attempt to cope with their grief. Self-help groups composed of bereaved parents may facilitate parental grieving by providing a safe haven to express one's sadness, loss, anger, and bitterness, free from the discouragement and criticism of perinatal mourning so often given by friends and family (Wilson & Soule, 1981). By observing other parents grieve their losses, the bereaved parent may be more likely to accept the normalcy of perinatal mourning, rather than retreat from the powerful expression of grief due to the fear of "going crazy." Psychotherapy may also help to resolve perinatal loss. In addition to facilitating the mourning process, psychotherapy may provide an opportunity to work on latent conflicts which have been revived in response to both the pregnancy and its tragic outcome. Leon (1986c) discusses how the aftermath of perinatal loss will depend on not only the mourning of the lost child but also the fate of the maternal and infantile identifications intensified during the mother's pregnancy. Since pregnancy signifies a developmental crisis whose outcome may have enduring consequences for the mother

(Benedek, 1970; Bibring et al., 1961; Deutsch, 1945), the unforseen and devastating conclusion of pregnancy with death rather than life may be a particular threat to the bereaved mother's emotional well-being. When the crisis of pregnancy is followed by the crisis of perinatal loss, there may be an opportunity to work on latent, longstanding issues that have now become paramount. Psychotherapy with recent perinatal loss demands the difficult balancing act of recognizing the appropriateness of at times unrestrained mourning (behavior and affects that might in another context be viewed as pathological), while being cognizant of the danger of a truly pathological outcome. Lewis (1979) offers the poignant example of how a newly bereaved mother's seemingly mad behavior of trying to "walk" her dead baby, along with frantically kissing his navel, mouth, and penis enabled her to more effectively mourn her child "by 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" (p. 304). The therapist needs to be able to accept the often dramatic expression of maternal grief as both a normal and necessary aspect of mourning. The newly bereaved mother may be reluctant to reveal typical reactions such as transient hallucinatory experiences of a baby crying or the powerful urge to steal another mother's infant for fear that she would be considered insane. She may consciously suppress her tendency to cry in response to any reminders of babies fearing that if she is not able to control her grief, it will overwhelm her and never end. The therapist may need to reassure her that such perceptions, wishes, and feelings are a natural expression of grief, mindful of the greater likelihood of the bereaved mother to pathologize her grieving based on the fact that she is in psychotherapy. At the same time, the potentially valuable role the therapist may serve as an interpreter of unconscious conflicts should not be overlooked in facilitating the bereaved mother's mourning. The unique way she grieves for her child with its particular blend of self-blame, narcissistic mortifi-

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Irving G. Leon cation, rage, and denial should be illuminated to prevent the beginning or deepening of emotional disturbance. It is particularly important to uncover her often distorted and potentially pathogenic explanation for the child's death in order for a more accurate and realistic understanding to be acquired. Case Illustration


Mrs. A Mrs. A2 is a 33-year-old married woman studying to be a medical technician who was seen weekly for twelve sessions in short-term psychotherapy. She contacted the therapist on what would have been her delivery date had her child not died in utero seven weeks earlier. She presented herself in a demure, somewhat inhibited manner, more like a shy schoolgirl than a young woman. This was her second pregnancy. She has a four-year-old, healthy son who appears well-adjusted. She is happily married to a successful businessman. This pregnancy had been carefully planned and much wanted. Mrs. A's immediate response to her loss was to immerse herself completely in her studies. She believed at first that she should not be grieving and should be handling things better, especially since she is in the medical field. While her husband had been supportive, he seemed to be at a loss as to how to help her and how to respond to her grief. Her therapist invited her to share her feelings about her child's death. Her grieving dominated the first half of treatment. She mourned the loss of the child she desperately wanted. There was great bitterness and a terrible sense of injustice that she should lose her baby while other women have children. She felt that she had failed as a woman, exclaiming that "even cows can have babies." She felt that therapy was the only place she could express these feelings as the "unspeakable" and "unthinkable" had happened. She was on vacation during the summer when she first noticed that the baby had stopped moving, and she felt guilty over not going to a physician sooner instead of waiting several days until she returned home. She believed that she should have known something was wrong, and she was afraid that she may have done something to hurt her baby. She was angry with doctors who did not know how the baby died. It was particularly difficult for her not to know the cause of death. Unfortunately, the baby's remains were mistakenly destroyed and, not having seen the baby, she did not know if it was a boy or girl. At first, she felt enormous pressure to become pregnant again as soon as possible, but decided to postpone that decision, as she began to recognize that she had suffered an irreplaceable loss. Mrs. A was born and raised in rural Canada, the oldest child with two younger brothers. She reported an unremarkable childhood, feeling positively about her parents. Her relationship with her mother was warm, although designed, it appeared, to avoid conflict. She left Canada as an adult, not having had any serious romantic involvements there, and eventually married an American. As the therapy progressed, her competition with women intensified. She felt that a personal blow had been struck at her when she learned that a good female friend had just become pregnant. Adding insult to injury, this woman was married 2 The author thanks Dr. Carol Barbour for providing case material on this client.

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to a Canadian. Mrs. A's inhibitions seemed to have prevented her from finding a husband in her home country. It became clear that she was unable to share her grief with close female friends who were supportive because of her intense competition with them. Her transference was marked by both admiration and envy of her female therapist. She had the powerful conviction that everything desirable and valuable was in her therapist's domain. At this point in the treatment, an important fact emerged. Mrs. A recalled one wonderful night during her summer vacation when she felt that she had everything—the man she loved, the pregnancy she wanted and, rare for her, an orgasm during sexual intercourse with her husband. When she lost her baby soon after, she felt that she was being punished for having experienced total fulfillment that night. Mrs. A explained that because she had wanted and had received too much, it had been her fate to lose it. The therapist clarified how she experienced herself as being punished for those pleasures and satisfactions which she felt were forbidden to her. While Mrs. A could acknowledge long-standing sexual inhibitions in her marriage, describing her marriage as a "brother-sister" relationship at times, she was reluctant to explore this area in greater depth, protesting against having her therapist "in my bedroom." As the intensity of her sadness and anger subsided by the latter half of her treatment, Mrs. A was motivated to help others cope with death. She attended seminars on grief and organized discussion groups for medical technicians on death and dying. As the intensity of her own grief lessened, she was able to help another bereaved mother who suffered perinatal death understand and cope with her grief. As Mrs. A better understood her conflicts over competition with women and internal prohibitions against sexual satisfaction, her inhibitions decreased. She began to feel more attractive and present herself in a more feminine, womanly manner. There was a sense of greater self-confidence and self-assurance as an adult. At the same time, there was a conscious decision not to examine fully her conflicted sexual wishes. While emotionally satisfied with her husband, she was seldom orgasmic. She still seemed to believe that it would be asking too much to have everything. As Mrs. A prepared to terminate therapy, there was a renewed optimism and sense of a new beginning. She felt better able to cope by herself with her grief which had diminished considerably. Her "getting through" Christmas day on her own— the one-year anniversary of learning she was pregnant—felt like a milestone. While she still wanted to have another child, the need was not as urgent and she decided to wait awhile longer. She ended her treatment feeling warm and appreciative toward her therapist.

Discussion This case typifies many of the immediate responses to perinatal loss such as maternal selfblame for the death, anger over the injustice of the loss, a tremendous yearning to regain the dead child, and the woman's devaluation of her maternal competency. The resonance of grief with time is particularly noteworthy with perinatal death. Mrs. A seeks help when her sense of loss is most acute, on the day mat she would have been reunited with her baby by the child's birth. This underscores


Perinatal Loss Therapy the potency of denial in the mourning process of perinatal death as the full impact of the loss emerges only as the delivery date passes with no baby there. Conversely, the ending of treatment is bracketed by the anniversary of learning of the pregnancy one year before. An integral part of the mourning process is accepting the demise of the wishes and fantasies of the child-to-be which were powerfully nourished during the pregnancy. This case illustrates that it is possible to mourn a perinatal loss with a bare minimum of available reminders and evidence of the baby. The mother's revived infantile identifications during her pregnancy are resolved by mourning her loss (Leon, 1986c). Mourning the perinatal death accomplishes, therefore, the resolution of both the loss of an object tie as well as the intensified infantile identification with the baby's dependency. The lack of major unresolved dependency issues may explain the relative ease with which Mrs. A was able to mourn her child's death. This appears confirmed by her comfortable and appropriate expression of dependency on her therapist. More serious conflicts over dependency and separation/ individuation would probably have resulted in more withdrawal and counterdependent maneuvers in the therapy as she felt threatened by her need for the therapist. Instead, she could let herself feel and appreciate a sense of being mothered by a relationship with an empathic therapist. The sense of feeling nurtured by an empathic therapist who can help the bereaved mother better understand and accept her grief may also help to repair the maternal identification damaged by having had a perinatal loss. Her positive identification with her therapist may have enabled her to help others as she had felt helped. Once the intensity of her grieving had abated, she found alternative avenues of nurturing by helping others cope with grief. Her maternal identification revived in pregnancy which could not be fulfilled in caring for this child could now find some satisfaction by aiding others. By helping surviving siblings deal with their inevitably confused and probably ambivalent feelings over the loss, the bereaved mother may also find a valid means of fulfilling her maternal strivings. Psychotherapy with the bereaved mother also provides an opportunity to work on latent, longstanding conflicts which have been refueled during the pregnancy and its tragic conclusion. Both her psychological functioning during pregnancy and her distorted understanding of the cause of the

intrauterine death demonstrates her grappling with oedipal issues. Although not enough data are available to fully delineate the regressive elements of this pregnancy, the material suggests that during the final trimester she was more able to accept herself as a sexually responsive woman. An increasingly positive maternal identification and differentiation from her mother may have enabled her to experience sexual satisfaction at that time not as an "oedipal victory" over her mother but as an adaptive attempt to resolve oedipal conflicts. Her perinatal loss, occurring at a time when she was especially vulnerable to those revived oedipal conflicts, reevoked in full measure her oedipal struggles: This child's death was experienced by Mrs. A as the punishment for sexual enjoyment which now became forbidden to her once again. Competition with women and her sense of feminine inferiority intensified as the proscription against sexual satisfaction increased. In a sense, her distorted interpretation of her perinatal loss undid the adaptation which was being made during her pregnancy. Her increased sense of adequacy as a woman independent of her mother was replaced by proscriptions limiting the fulfillment that she could hope to attain as a woman due to her conflicted competition with mother. The resolution of her perinatal loss may be considered adaptive insofar as she was able to mourn her child's death and accomplish enough work on revived oedipal conflicts to allow a more positive and less inhibited feminine identity than existed prior to her pregnancy. The opportunity for an even more complete and adaptive resolution of oedipal conflicts, as began to take form during this pregnancy, was not attempted at this time. Unresolved Grief: The Timeless Aftermath of Perinatal Loss Many factors may prevent the resolution of mourning after the death of a loved one. Raphael (1983) cites dependency on the deceased, guilt over the death (typically due to ambivalence toward the deceased), and a fear of being overwhelmed by one's grief as three possible obstacles to completing the work of mourning. In addition to such intrapsychic factors, Volkan (1970, 1985) suggests that circumstances of the death such as its suddenness and association with violence and mutilation may complicate mourning. Both researchers advise similar interventions in treating unresolved grief. The circumstances of the death and relationship with the bereaved are carefully reviewed

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Irving G. Leon in an attempt to understand the issues inhibiting grief as well as to facilitate its full affective expression (Raphael, 1983). Volkan's (1971, 1985) "re-grief" therapy emphasizes distinguishing the mourner from the deceased and uncovering the "linking objects" which maintain the mourner's tie to the deceased before the dead person finally can be relinquished. There has been scant investigation of unresolved grief of perinatal loss. Cullberg (1971) and Jensen & Zahourek (1972) indicate that long-standing depressive and phobic conditions may result from perinatal loss. However, methodological problems with these studies reduce their reliability (Leon, 1986a). Unresolved mourning of a child's death may result in the unconscious selection of a subsequent child to be a replacement for the loss by being identified with the deceased. Although the dynamics of the "replacement child" have usually been elaborated for the loss of older children (Cain & Cain, 1964; Poznanski, 1972), it is applicable as well to the unresolved mourning of perinatal death (Lewis & Page, 1978). In both instances, an overprotective, anxious attitude may dominate parental interactions with the "replacement child," due to both a feared repetition of loss as well as underlying disappointment and anger that this child cannot undo the original loss. Seeking to replace a perinatal loss with a subsequent pregnancy may be fueled by factors unique to perinatal death. Having minimal or no interaction with the deceased may more readily allow the displacement of feelings from the lost child onto the subsequent pregnancy since concrete characteristics and memories which could distinguish the two are not available. Due to the sometimes devastating blow to maternal self-worth resulting from perinatal loss, the mother may have a great eagerness to become pregnant again as soon as possible to undo and repair the narcissistic damage to her femininity. Whether selecting a "replacement child" is designed to recover an older deceased child or a perinatal death, mourning for the original loss is incomplete as the subsequent child cannot be loved in his or her own right but as an ultimately unsatisfying substitute for one who has been lost. Case Illustration Mrs. O Mrs. O is a 45-year-old married white woman. She is attractive and dresses in a careful, feminine manner. The most striking aspect of her self-presentation is her depleted, un-

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emotional voice, talking at a barely audible volume. In her initial psychiatric evaluation, she presented as moderately depressed, primarily due, it appeared, to the recent upheaval in her life of being remarried and moving to Michigan from her home state of Montana within several months. She especially missed her adult sons, aged 19 and 24, who lived back in Montana. Hyperthyroidism (Graves' disease) was recently diagnosed and managed by medication. She was divorced eight years earlier, followed by two years of heavy alcohol use. Upon completing a 30-day residential treatment program for alcoholism, she became an active participant in Alcoholics Anonymous and had been abstinent for five years. Just prior to her referral, she returned to drinking heavily and made a suicide gesture by ingesting several Inderal. In her initial appointment with her psychotherapist, Mrs. O reviewed what she had discussed in the evaluation, going on to complain about marital difficulties due to her husband's angry, controlling, and demanding behavior. It seemed whatever she did was greeted with his criticism. Her current husband is a heavy drinker, as was her first spouse. She was trained as a physical therapist, especially enjoying her work with the elderly, and was in the process of finding a job. She struggled against her depression, observing how she would isolate herself and refuse to leave the house for weeks. It was not until her second appointment that the history of her perinatal losses emerged, after direct questioning. There were two surviving children from six pregnancies. Her first pregnancy was uneventful and successful, followed by the stillbirth delivery of a girl two years later. After suffering a miscarriage, there was a second completed, healthy pregnancy, about two years after her first stillbirth. This was followed by two additional stillborns, the final loss over fifteen years ago. None of the perinatal losses could be explained medically and there were no visible defects. All of the pregnancies were planned, except the final one, occurring after her husband's (apparently ineffective) vasectomy. She was in the process of adopting a child when she learned of this pregnancy. With considerable anxiety she went ahead with this pregnancy, regretting the loss of the adoptive baby. All three stillborns had been named and had full funeral services. With considerable emotion, Mrs. O described how horrible she felt about her dead children. While knowing that she took proper precautions during the pregnancies, she blamed herself. For many years she has tried not to think or talk about her losses fearing that would make matters worse. In the midst of expressing her profound sense of loss over these deaths, she vented her rage at women who purposely end their pregnancies by abortion. She felt enormous jealousy toward other mothers, and strove to be close to relatives of the same age as her dead children would have been. Several days after these powerful revelations and before her next scheduled appointment, she came in asking to be admitted to an alcohol treatment program. She had returned to drinking during the past two weeks, but stopped the day after the last therapy appointment. She agreed with her therapist's view that she needed to work on her unresolved grief and that seeking residential treatment at this point might be in the service of avoiding her mourning. She was able to follow the recommendation of actively resuming her AA meetings and was able to remain abstinent for the duration of psychotherapy. She believed that talking about her losses was important, something that was always in the background but never discussed. Her first husband had told her to forget about them, and she rarely brought up her losses at AA meetings. Mrs. O blandly described how there was "death in the


Perinatal Loss Therapy house" throughout her childhood. Her mother had suffered a heart attack when Mrs. O was five, followed by open-heart surgery when she was seven and multiple heart operations afterward until she finally died when Mrs. O was 22. She remembers her mother being sickly throughout her childhood, but felt particularly close to her, especially after her first heart attack. She did not at first believe that her childhood was particularly unhappy. As her mother's condition worsened during childhood, her father withdrew into stony silence and heavy alcohol use. In addition to her father, a paternal aunt and uncle as well as one sister were reportedly alcoholic. She was never close to her sisters who were five and seven years older, respectively. Time-limited psychotherapy was planned due to financial difficulties and her uncertainty about how long she would remain in the area, especially if there was a marital separation. She recognized that enduring difficulties related to her alcoholism and deprived childhood would require long-term treatment for more complete resolution. While the focus would be on her unresolved grief and terrible sense of failure from her perinatal losses, the themes of loss (over mother) and failure (as a wife and alcoholic) were considered lifelong struggles for her to overcome. She was seen for 17 sessions in weekly psychotherapy with a planned termination date. Her grief over her perinatal losses, particularly the last child, James, dominated the first half of the therapy. Soon after the treatment plan was established, she presented with a recurrent dream. There was a dead baby with blood at the back of her head. She recalled an accident on swings when she was a young girl resulting in stitches in the back of her head. She was increasingly anxious about her 17-month-old granddaughter dying. The dream was initially understood as her wish to sacrifice her life so that her dead child might live in an attempt to preserve some measure of maternal selfworth. She recalled the last loss as the most difficult. Totally unexpected (and seemingly impossible due to her husband's vasectomy), she believed that the pregnancy was a gift from God. When she learned of the baby's intrauterine death (in the final trimester), she thought she was being punished and was enraged at God. For her own health, it was recommended that labor not be induced, resulting in her carrying the dead baby for about five weeks before delivery. Unlike her other dead children whom she clearly remembered, she could recall nothing of James—neither his face which she knows she saw, nor the funeral which she knows she attended. She could not cry for weeks after his death, but began to drink heavily. A friend's accusation of her being selfish for abandoning her responsibility toward her two surviving children helped to revive her. She began to understand more clearly how her ambivalence toward this pregnancy contributed to the difficulty in accepting his death and mourning the loss. The joy of learning of this pregnancy was mixed with the disappointment of losing a soon-to-be-adopted child and the dreaded repetition of another perinatal loss. She could not help but want and not want this child. She said that her carrying the dead baby made her feel like a casket, and that she felt too ashamed to be seen in public. At this time a part of her denied the reality of her child's intrauterine death, while another part desperately wanted to be rid of the burden of carrying death. She began to understand how the simultaneous denial of his death and wish to be rid of him compounded the terrible sense of having murdered her son. She did not want to hear the physician's explanation, convinced that she would be blamed. Likewise her guilt was

externalized in anticipating that her husband would accuse her of this death. Her inability to recall this child was understood as a need to deny his death in order to alleviate the overwhelming burden of guilt. When death cannot be acknowledged, mourning is unable to proceed. To facilitate the completion of grieving for James, she planned to return eventually to the hospital in Montana to clarify several questions about his death. Mrs. O began to recognize that her anxiety and sadness over leaving her adult children represented, in part, a repetition of the loss she felt over her stillborns as well as the dread that she could not protect them from harm. When her youngest son was to leave Montana to go to an out-of-state college, she fretted over his going to a strange city and having to make decisions on his own. She sensed that she was abandoning him, as if he were a helpless child. Mrs. O recalled how frightened she was of losing this son to Sudden Infant Death Syndrome when he was an infant, although he had no health problems. Just having had a stillborn and miscarriage, she was terrified that he would die if she left him alone. In the latter half of her treatment, Mrs. O began to tentatively approach her unresolved childhood issues. The topic of death had been avoided by her family at all costs. A family secret which was never openly discussed was the stillbirth of a son one year prior to her birth. This was the much-wanted and unplanned boy in the family. In her youth, Mrs. O became a tomboy who could "lick" any guy in the neighborhood. She began to recall the constant dread of her mother dying when she was growing up. When Mrs. O was eight, she was frightened of her mother bleeding to death, due to a blood thinner, should she get a small cut. Memories of being lonely and sad as a child returned. She resented how much the household changed due to her mother's condition, how quiet and well-behaved she had to be, lest she jeopardize mother's precarious health. She began to appreciate how her anger with her mother needed to be totally buried, lest it harm or kill her. When she was a teenager, she once angrily shouted that she hated her mother; she then returned to be sure her mother was safe. Mrs. O was unable to more fully resolve her guilt over rage with her mother, especially the deprivation she experienced in an emotionally neglectful household. Warm memories of her mother could be reported with ease, but expressing anger over her mother's unavailability was carefully censored. Her sisters were viewed as bitter and selfishly demanding, especially the eldest, whose anger with their mother, Mrs. O was convinced, worsened her condition. She recognized that powerful prohibitions against her anger continued, and she began to realize that her choosing and provoking angry, critical husbands both vicariously expressed and directly punished her anger. Rather than more directly express her need for her mother in therapy, she sought and found comfort in dependent attachments to a stepdaughter and a female "sponsor" at AA whom she would call if in crisis. Similarly, as the termination date approached, she could express her gratitude over how therapy had helped her to resolve her children's deaths, but she was unable to more fully explore her rage and hurt about ending. She recognized the treatment meant a great deal to her and worried about how she would cope without the meetings. She made tentative plans to join a grief group to continue her perinatal mourning, and the therapist suggested that formulating this idea at this time may be more designed to avoid the loss she was experiencing in terminating. Mrs. O realized that she wanted to put off thinking about ending therapy and would discuss the matter only when directly questioned. During her final session, Mrs. O described how her anxiety

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Irving G. Leon about her children considerably lessened with a much greater awareness of its association with her perinatal losses. Both she and her therapist began to appreciate that this overprotectiveness represented an attempt not only to undo the tragedy of perinatal loss, but also to vicariously satisfy her own unmet dependency needs that she suffered as a child. She reported that as she was more able to express her anger with her husband and not flee from it, he seemed less angry and the relationship was more stable. She reported a nightmare in which children were being shot and were falling into a river. It reminded her of a movie she had seen the previous day in which Jews were shot; she recalled that she had fallen into a river when she was four. Her continuing need to punish herself over feeling responsible for her children's deaths was reviewed. The association of this issue with her sense of responsibility for her mother's death became clear as she concluded the session and therapy by describing her guilt over causing her mother's "heartache," implying the physical damage wrought by her anger.

Discussion Many factors contributed to Mrs. O's unresolved grief over perinatal loss. The family style of avoiding the ever-present topic of death complemented her own reluctance to introduce her perinatal losses for several sessions. She seemed to learn and share her family's fear of the overwhelming affects which would accompany any discussion of death and mourning. The revival of maternal and infantile identifications in her pregnancies effected a powerful dependency on her children, making them difficult to relinquish in mourning. Identification with a frail, sickly mother, who herself experienced pregnancy failure as well as having her mothering compromised by a debilitating cardiac condition, could not provide a solid foundation of maternal self-confidence which could readily withstand the assault of multiple perinatal losses. Her infantile identification with her child-to-be reawakened the powerful deprivation of a little girl who could not regularly depend on a sick, inaccessible mother. Pregnancy's revival of the mother's oral conflicts (Benedek, 1956) was particularly threatening to Mrs. O due to her history of deprivation. Although unable to be fully elaborated in this brief treatment, it appeared that another source of deprivation and feminine insult in her childhood was her being in some measure a "replacement child" for an earlier stillbirth. Not accepted for herself, she became the "tomboy" to win her parents' affection. In this context, it is possible to understand her identification with the dead baby in her dreams as the wish to both sacrifice and punish herself not only for her own dead children but also for the stillborn brother she could not

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replace. At the same time, her identification with the dead baby is the expression of her own unmet neediness. She becomes the dead, unprotected baby. Her maternal self-worth, shaken by her perinatal losses, was nourished by caring for her surviving children. The perhaps tactless accusation by her friend of her selfishness in forsaking her responsibility to her living children was an effective confrontation because it possessed an element of truth. To the degree that her total preoccupation with her loss represented the revived experience of unresolved dependency, this was a self-involvement which prevented the mothering of her surviving children. Perhaps the paramount factor inhibiting her perinatal mourning was her long-standing inability to tolerate her rage due to her unconscious conviction that it harmed and ultimately destroyed her mother. The unfortunate emergence of mother's cardiac condition in the midst of her oedipal development probably reinforced the magical thought process in which her rage (fueled by both deprivation and competitiveness) could be held accountable for physical harm. It is not surprising to discover that rage and resulting guilt were externalized onto the selfish oldest sister (who was old enough to serve as a maternal substitute). This woman was both hated as well as held responsible for their mother's worsening condition. Her unresolved guilt over her mother's illness and death due to anger with her mother can be understood as an important root in the unresolved grief of her last child, James, due to her ambivalence about this pregnancy. In a manner analogous to her externalization of her anger and guilt onto her eldest sister, her rage and guilt was externalized in her fury at mothers who purposely kill (i.e., abort) an unwanted child. Mrs. O began to mourn her perinatal losses with surprisingly little reluctance. The span of over fifteen years did not diminish the immediacy and vividness of the deaths. Just as an anniversary may unconsciously revive earlier, unresolved losses (Hilgard, 1969), Mrs. O's physical separation from her home state may have precipitated the surfacing of her perinatal losses, enabling the resumption of mourning. Her alcoholism appears overdetermined as: 1) a genetic predisposition with a high loading in her family; 2) social learning of a family style of coping with stress; 3) her own defense against dealing with depression and loss; 4) an expression of neediness and deprivation ("oral


Perinatal Loss Therapy yearnings")- In relationship to her perinatal grieving, it was impressive to observe how readily her drinking ceased once she began to mourn. Coping with her perinatal grief seemed to remove one important motivation for her alcohol abuse. In the process of working on unresolved perinatal grief, Mrs. O's long-standing issues of depression, rage, and deprivation were exposed. While shortterm psychotherapy is unable to successfully resolve these lifelong difficulties, it clarified how unresolved perinatal grief may be a product of, and actively reinforced by, enduring psychopathology. Barry (1981) reports a similar finding with unresolved grief in general where he discovered that the successsful resolution of prolonged grief "uncovered much more severe personality problems upon whose substrate the pathologic or prolonged grief reaction was built" (p. 746). Psychotherapy for Perinatal Loss A careful evaluation is necessary to make the differential diagnosis between perinatal grief as a bereavement reaction (e.g., Mrs. A) and perinatal grief as a precipitant of a long-standing depressive condition (e.g., Mrs. O). Focal psychotherapy (Raphael, 1983) and "re-grief" therapy (Volkan, 1971, 1985) are realistically designed as shortterm interventions focusing on a specific loss accompanied by a generally adequate level of functioning prior to the death. The absence of underlying depressive problems enabled Mrs. A to resolve her immediate loss with few obstacles. A very different situation exists when perinatal grief is complicated by a prior depressive constellation of earlier losses, history of deprivation, difficulties in maintaining positive self-esteem, and/or unresolved rage. Perinatal grief may then become the proverbial "tip of the iceberg" of a more pervasive depressive, borderline, or narcissistic personality disorder. While Mrs. O was able to derive therapeutic benefit from grieving her perinatal losses in short-term treatment, it is unrealistic to expect that her long-standing depressive vulnerability, addictive potential, and self-defeating pattern of relationships would be successfully resolved without more intensive therapy. When short-term therapy is appropriate, the formal structure of time-limited treatment may address some of the central features of perinatal loss. Establishing the termination date early in treatment highlights the finality of separation and challenges the tendency to unconsciously adhere to magical, limitless expectations (Mann, 1973).

This provides an excellent context for resolving the bereaved mother's denial of the finality of her child's death. Moreover, by preparing for the termination date in advance, the bereaved mother is better able to tolerate loss. The traumatizing impact of a totally unexpected death, inducing a debilitating sense of helplessness, may be healed by anticipatory grieving. This affords a paradoxically greater measure of control and mastery over the dreaded inevitability of death (symbolized in termination). The bereaved mother's refusal to accept and cope with her child's death may be acted-out in the premature, abrupt decision to terminate her psychotherapy. This action both prevents the completion of mourning and repeats the suddenness of her earlier traumatic loss. "Bolting" therapy may be a desperate attempt to undo the helplessness experienced during perinatal loss by "turning passive into active": Instead of being left by her dead baby, the bereaved mother is now the one who leaves. In the rush to end treatment, there is no time to say goodbye, repeating the earlier circumstances of perinatal loss. As a defense against remembering and resolving the trauma, the abrupt termination may be an unconscious attempt by the mother to provoke in the therapist the feelings of loss, confusion, anger, and guilt associated with her perinatal loss. The first and foremost task in the psychotherapy of perinatal loss is facilitating the full expression of the mother's grief. When a mother, such as Mrs. A, is capable of enduring the guilt, anger, sadness, loss, and shame which generally comprise perinatal mourning, the therapist's empathic encouragement to share her grief may be all that is necessary for its natural expression. The commonplace unwillingness of friends and family to tolerate perinatal mourning (Berezin, 1982; Borg & Lasker, 1981; Helmrath & Steinitz, 1978) may be in stark contrast with the therapist who is able to empathicaUy witness, and not impede, maternal grief. Of course, when resistance to grieving occurs, a central task of the psychotherapy will be the removal of obstacles to mourning. While Mrs. O was able to resume mourning her multiple perinatal losses with relative ease, it later became clear that long-standing difficulties with ambivalent feelings toward her mother and childhood deprivation had impeded her mourning. As already indicated, the lack of both actual interactions with the baby and concrete reminders of the loss deprive the bereaved mother of the

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Irving G. Leon cherished memories which are the very essence of mourning. The therapist can encourage the mother's concrete description of the events around the time of loss in order to make both the child's existence and death as real as possible. What needs to be mourned by the mother is not a relationship with a person which never came to be, but the wishes, fantasies, and hopes of someone who will never become. Just as memories of the beloved must be mourned at the end of a long-standing relationship, wishes andfantasies of the child who will never be must be mourned in perinatal loss. It is the loss of one who will never be rather than the loss of one who once was. Thus, perinatal grieving requires remembering the emotionally laden, fantasized interactions with one's child-tobe in the painful recognition that they will never come to pass. Furthermore, the bereaved mother must concretely link the unfulfilled fantasies of the child-to-be with the physical remains of the dead child. Otherwise, the painful acknowledgment of the impossibility of those fantasies being realized someday may be forestalled, perhaps by an attempt to realize those fantasies in a subsequent pregnancy. The new "replacement child" prevents both the resolution of mourning for the child who has died as well as the unique, special attachment to this new child as an individual in his or her own right. The therapist needs to be alert to the dangers inherent in engaging the desperate defenses supporting unresolved grief. When a mother was gently questioned about any guilt she may have felt over a stillbirth twelve years earlier, she abruptly terminated that session and future meetings, convinced she was being accused by her therapist of causing her baby's death. A limited capacity to tolerate guilt, anger, and depression may result in a paranoid externalization of guilt experienced as an attack from outside. Interruptions in the therapy, such as those due to a therapist's vacation, may traumatically revive the loss and abandonment felt years earlier over a perinatal death. Even with careful preparation and planning, such an interruption may precipitate a defensive retreat from grieving, resulting in the abrupt ending of therapy. (For case examples of the above dynamics, see Leon, 1985a.) Termination will invariably be a crucial part of the psychotherapy. This phase of the treatment will highlight how completely the death has been resolved while allowing additional opportunity "in the transference" to directly work on loss issues. Even when significant work has been accomplished, a patient ending therapy before the planned

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termination usually indicates an unwillingness to complete mourning, perhaps resorting to another attempt to deny the final separation. Maintaining an unpaid balance months after the treatment has ended may signify unresolved anger and dependency as well as express the wish to preserve a connection with the therapist, another refusal to acknowledge the finality of loss. Although the focus of this article has been on maternal bereavement, it needs to be emphasized that perinatal loss is a family issue. While paternal grief over perinatal loss may not be as intense or as long as maternal mourning, fathers grieve the loss of their unborn children (Benfield et al., 1978; Helmrath & Steinitz, 1978). The divergent styles of perinatal grieving by mothers and fathers may cause marital tensions, creating an additional burden in an already stressful situation (Berezin, 1982; Peppers & Knapp, 1980). Surviving and subsequent children in a family with perinatal loss often struggle with confusion, guilt, anger, and hurt over what has happened, compounded by parental failure to directly inform them of the facts and address their concerns (Cain & Cain, 1964; Hardgrove & Warrick, 1974; Leon, 1986a,b; Moriarty, 1978). In cases where a child's psychological functioning has been compromised, there is usually unresolved parental, especially maternal, grief. While the theoretical framework applied in this article has been psychodynamic, other perspectives need to be utilized in assessing the impact of perinatal loss. The interpersonal environment in which the loss occurs may dramatically affect the outcome and expression of grief. The support or discouragement of parental mourning by spouse, extended family, friends, and medical personnel may facilitate or impede the grieving process. The availability of other avenues of expression of parental nurturance may influence the degree of resolution of parental identifications revived during the pregnancy. Family styles of avoiding and resolving loss with the possible adoption of such maladaptive mechanisms as denial and scapegoating may exert a powerful effect on the eventual outcome. Even within a psychodynamic approach, a broad perspective is needed to embrace the interpretation of unresolved, unconscious conflicts and the support of the mourning process. Fostering insight into long-term conflicts revived by perinatal loss must be balanced with facilitating the resolution of mourning by a careful reviewing of the facts and feelings pertaining to the death. In doing short-


Perinatal Loss Therapy term psychotherapy, both patient and therapist must realize that long-standing issues which may be activated by pregnancy and perinatal loss or which are usually involved in unresolved grief may require longer, more intensive treatment. The psychotherapy of perinatal loss demands considerable flexibility in understanding the principal issues, formulating a plan of intervention, and interacting in treatment. In evaluating the case, intrapsychic factors need to be considered in the context of family dynamics. Depending upon the assessment of what and where the primary issues are, individual adult, child, family, marital, or parental guidance are all potentially viable modalities for intervention. While the therapeutic mode chosen will affect the therapist's manner of intervening, within any mode there will probably need to be a balancing of interpretation in the service of insight with empathic support to help endure the rigors of mourning. References BARRY, M. (1981). Therapeutic experience with patients referred for "prolonged grief reaction." Mayo Clinic Proceedings, 56, 744-748. BENEDEK, T. (1956). Toward the biology of the depressive constellation. Journal of the American Psychoanalytic Association, 4, 389-427. BENEDEK, T. (1970). The psychobiology of pregnancy. In E. J. Anthony and T. Benedek (Eds.), Parenthood: Its Psychology and Psychopathology (pp. 137-151). Boston: Little, Brown. BENFIELD, D. G., LEIB, S. & VOLLMAN, J. (1978). Grief

response of parents to neonatal death and parent participation in deciding care. Pediatrics, 62, 171-177. BEREZIN, N. (1982). After a Loss in Pregnancy. New York: Simon & Schuster. BlBRING, G . , DWYER, T . , HUNTINGTON, D . & VALENSTEIN,

A. (1961). A study of the psychological processes in pregnancy and of the earliest mother-child relationship. The Psychoanalytic Study of the Child, 16, 9-24. BORG, S. & LASKER, J. (1981). When Pregnancies Fail. New York: Beacon Press. CAIN, A. & CAIN, B. (1964). On replacing a child. Journal of the American Academy of Child Psychiatry, 3, 443-456. CAIN, A., ERICKSON, M., FAST, I. & VAUGHAN, R. (1964).

Children's disturbed reactions to their mother's miscarriage. Psychosomatic Medicine, 26, 58-66. COHEN, L., ZILKHA, A., MIDDLETON, J. & O'DONNOHUE, N.

(1978). Perinatal mortality: Assisting parental affirmation. American Journal of Orthopsychiatry, 48, 727-731. CULLBERG, J. (1971). Mental reactions of women to perinatal death. In N. Moriss (Ed.), Psychosomatic Medicine in Obstetrics and Gynecology (3rdInt. Congress) (pp. 326-329). London: Karger-Basel. DEUTSCH, H. (1945). The Psychology of Women, Vol. 2: Motherhood. New York: Grune & Stratton. DUNLOP, J. (1979). Bereavement reaction following stillbirth. Practitioner, 222, 115-118. FRIEDMAN, R. & GLADSTEIN, B. (1982). Surviving Pregnancy Loss. Boston: Little, Brown.

GILES, P. F. H. (1970). Reactions of women to perinatal death. Australia and New Zealand Journal of Obstetrics and Gynecology, 10, 207-210. HARDGROVE, C. & WARRICK, L. (1974). How shall we tell the children? American Journal of Nursing, 74, 448-450. HELMRATH, T. A. & STEINITZ, E. (1978). Death of an infant: Parental grieving and the failure of social support. Journal of Family Practice, 6, 785-790. HILGARD, J. (1969). Depressive and psychotic states as anniversaries to sibling death in childhood. International Psychiatric Clinics, 6, 197-211. JENSEN, J. & ZAHOUREK, R. (1972). Depression in mothers who have lost a newborn. Rocky Mountain Medical Journal, 69, 61-63. JOLLY, H. (1978). Loss of a baby. Australian Paediatric Journal, 14, 3-5. KENNELL, J., SLYTER, H. & KLAUS, M. (1970). The mourning

response of parents to the death of a newborn infant. New England Journal of Medicine, 283, 344-349. KIRKLEY-BEST, E. & KELLNER, K. (1982). The forgotten grief: A review of the psychology of stillbirth. American Journal of Orthopsychiatry, 52, 420-429. KLAUS, M. & KENNELL, J. (1976). Maternal-Infant Bonding. St. Louis: C. V. Mosby. LEON, I. (1986a). The invisible loss: The impact of perinatal death on siblings. Journal of Psychosomatic Obstetrics and Gynecology, 5, 1-14. LEON, I. (1986Z>). Intrapsychic and family dynamics in perinatal sibling loss. Infant Mental Health Journal, 7, 200213. LEON, I. (1986c). Psychodynamics of perinatal loss. Psychiatry, 49, 312-324. LEWIS, E. (1976). The management of stillbirth: Coping with an unreality. Lancet, 2, 619-620. LEWIS, E. (1979). Mourning by the family after a stillbirth or neonatal death. Archives of Disease in Childhood, 54, 303-306. LEWIS, E. & PAGE, A. (1978). Failure to mourn a stillbirth: An overlooked catastrophe. British Journal ofMedical Psychology, 51, 237-241. MANN, J. (1973). Time-Limited Psychotherapy. Cambridge, Mass.: Harvard University Press. MORIARTY, I. (1978). Mourning the death of an infant: The sibling's story. Journal of Pastoral Care, 32, 22-33. PEPPERS, L. & KNAPP, R. (1980). Motherhood and Mourning. New York: Praeger. POZNANSKI, E. (1972). The "replacement child": A saga of unresolved parental grief. Journal of Pediatrics, 81, 11901193. RAPHAEL, B. (1983). The Anatomy of Bereavement. New York: Basic Books. SCHREINER, R., GRESHAM, E. & GREEN, M. (1979). Physician's

responsibility to parents after death of an infant. American Journal of Diseases of Children, 133, 723-726. SETTZ, P. & WARRICK, L. (1974). Perinatal death: The grieving mother. American Journal of Nursing, 74, 2028-2033. SPECK, W. (1978). Commentary: The tragedy of stillbirth. Journal of Pediatrics, 93, 869-870. VOLKAN, V. (1970). Typical findings in pathological grief. Psychiatric Quarterly, 44, 231-250. VOLKAN, V. (1971). A study of a patient's re-grief work through dreams, psychological tests, and psychoanalysis. Psychiatric Quarterly, 45, 255-273. VOLKAN, V. (1985). Psychotherapy of complicated mourning. In V. Volkan (Ed.), Depressive States and Their Treatment (pp. 271-295). Northvale, N.J.: Jason Aronson. WILSON, A. & SOULE, D. (1981). The role of a self-help group in working with parents of a stillborn baby. Death Education, 5, 175-186.

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