Complex Grief: How to Help Through Pregnancy and Child Loss Allena Barbato, JD, MACP

1. Complex Grief: How to Help Through Pregnancy and Child Loss Allena Barbato, JD, MACP

2. The bedrock of the Orthodox Faith is the home and family life. Home and family life is the bedrock of our Greek Orthodox life-style. The spirit that binds us together as a people finds its deepest roots in the home where the tenderest values of human existence, love, compassion, forbearance and mutual helpfulness thrive in abundance. Archbishop Iakovos 1972

3. Tremors in the family bedrock how to help: a mental health perspective • Pregnancy issues • Childbirth complications • Miscarriage & Abortion • Infant/child loss

4. Grief Process • Elisabeth Kubler-Ross wrote a pivotal book in 1969 called On Death and Dying, identifying 5 stages of grief. • Denial Stage: Everything is just fine. • Anger: This is YOUR fault! • Bargaining: I will do anything to change. • Depression: Why should I even bother? • Acceptance: I can deal with this.

5. Varying Levels of Grief • Issues that occur in Pregnancy, Childbirth, Miscarriages and the Loss of an Infant can contain all stages of grief • They will occur at varying levels, depending on which of the above.

6. Pregnancy Icon of the Annunciation. The Theotokos, model for mother, threading together God and man.

7. Pregnancy • Orthodox church’s official stance on pregnancy: life starts at conception. • “Marriage is holy. The home is sacred. Birth is a miracle. In these we find the very meaning of life itself.”-Rev Dr. Stanley S. Harakas • All life is holy and precious and must be protected and cared for. • Inherent on the mother to take the very best care of herself; physically, emotionally, and spiritually

8. Pregnancy • Challenges to a healthy pregnancy are often times unforseen; a woman and her family just assume all will go smoothly. • Physical Challenges • Exhaustion, loss of vim and vigor • Appetite changes • Body getting bigger, skin stretching • Hair composition, skin tone • Bedrest, gestational diabetes

9. Pregnancy • Emotional Challenges • Hormone levels changing • Is my baby going to be “healthy” • Feeling less of a “woman” • After the second trimester, can not hide pregnancy • Suffered sexual abuse, not comfortable with pregnancy • Unwanted child, giving up for adoption • In vitro testing shows a deformity • Worried about Father of child

10. Pregnancy • Spiritual Challenges • Knowing should be thankful for God’s Gift • Asking God to take back the child • Praying for a healthy child • Asking God why she has been given a deformed child

11. Guidelines for helping a pregnant woman • Ask how she’s feeling • Listen and comfort • If having difficulty or conflicted, do not try to palliate with “it is the will of God” or “it is a blessing”. • Remind that this is a temporary state • Hormone levels will eventually return to normal • Walk through birthing scenarios • Empower with positive thoughts on motherhood • If physical, refer to obstetrician. If spiritual, refer to spiritual father

12. Childbirth • Planning a childbirth • Fear can be a guiding factor in choosing • Completely medicalized to completely natural • The Orthodox church is supportive of either choice, as long as the guiding principle of protecting life is adhered to. • Painkillers are considered ok as long as they do not become addiction.

13. Childbirth • Negative birth experiences • What constitutes? • Cesarean vs. natural • Negative reactions to Cesareans are more likely if under general anesthesia, an emergency, and if no support person was present. • Quality of mother-child bonding does not appear to be effected by caesarean vs. natural. (One study) • Women who had cesareans were more likely to have negative moods and lower self esteem. • Case study: Client D-not good enough mother

14. Childbirth • Some studies showed the cesarean childbirth carried “significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to post-traumatic distress and depression.” The Handbook of Women, Stress and Trauma; Kendall-Tackett, K. 2005 • Interpretation of events: • Sudden-how quickly did events change, was anything explained? • Overwhelming-swept away by hospital routine, disconnected from experience? • Danger-was baby’s or mother’s life threatened?

15. Childbirth • Factors: level of care and decision-making. • All this can add up to “birth trauma” • Result: overwhelming fear, helplessness, loss of control, and horror. • Effect of birth trauma • Fear/anxiety can last for a number of months or longer • Replaying of events-daytime flashbacks, nightmares • Anger-at doctor, hospital, husband, self • Denial of negative experience • Depression compounded by history of abuse/PTSD

16. Childbirth • How effects of birth trauma can effect relationships • With Baby • Bonding • View of baby as being “not as good” • View of children as being “out of control” or “nasty” • With Husband • Other children

17. Guidelines for helping a woman through negative birth experience • Do not try to talk the mother out of a negative birth experience by telling her that “it wasn’t so bad” or that the important thing is that she had a healthy baby. • Encourage the mother to talk with someone she trusts who can listen and not minimize the experience. Also, there are support organizations and groups that can assist the mother while she talks about her experience. • Learning as much as possible about the experience helps the mother to understand the birth in a cognitive way, this can reduce anxiety. Getting the birth records to review and reading books on the subject takes the issue “out of the dark”. • The husband or other family members may also have been traumatized. He may have felt powerless while he watched events unfold around him. Because of this, he may not be emotionally available to provide the support the new mother needs. • Gently remind the mother that as bad as the birth experience was, it is the beginning of this little person’s new life and the rest of his/her life is the positive thing to focus on. This can bring perspective to the traumatized mother. • If the mother is talking immediately about having another baby, in order to “get it right” help her to understand that the important thing right now is to process what happened and to get to know your new little one, giving him/her all the attention they need and deserve. • Similarly, if the mother talks about never having another pregnancy due to the experience, help her to understand that taking drastic steps could cause further trauma. • Finally, suggest that the mother forgive herself if she is blaming herself for the negative experience. The “if onlys” can be very damaging to the mother’s psyche. This would be a good opportunity for her to go to her spiritual father and talk about forgiveness in general.

18. Miscarriages and Abortion • The official stance of the Orthodox church on Abortion is: this is the taking of a life, and therefore a sin unless the mother’s life is endangered and then it is considered an involuntary sin. • If there is an abortion as the result of mother’s life being endangered, help the mother to process the death, as she and family grieve. • Abortion as a choice • This choice can very negatively affect a woman’s psyche • One study found 82% of women had PTSD symptoms(Russia) • Primary form of birth control abortion

19. Abortion • Another study found that women who aborted their first pregnancy were four to five times more likely to abuse drugs and alcohol. (U.S.) • Women seeking early abortions were more likely to have been abused as children and have insecure attachments with partners.(Australia) • Multiple abortions can be indicator of past or present abuse. • Counsel the woman with grief counseling and refer to priest about sin.

20. Miscarriages • Orthodox church’s stance on miscarriages: it is the death of a living being; a baby. • Each year approximately one million births end in miscarriage in U.S. October is Pregnancy and Infant Loss Awareness Month. • Complexity: • The baby is often not visible (as most miscarriages occur before the second trimester) and therefore not real. • Many families are still quiet about the pregnancy at outset, in case something goes wrong. • Is not a child that has touched others’ hearts.

21. Miscarriages • Complexity (cont) • Where parents were once anticipating a birth, they are now facing death. • Millions of grieving parents • Case studies • Client A; the miscarried babies counted in family • Client M; bi-polar characteristics compounded by miscarriage • Fr John Breck writes of the mother who has miscarried, “Her pain needs to be acknowledged, accepted, and palliated through words and gestures of understanding, sympathy and love, offered by her family and the parish community.” –oca.or

22. Empathy and John 11:33-36 “When Jesus saw her weeping, and the Jews who had come along with her also weeping, he was deeply moved c in spirit and troubled.“Where have you laid him?” he asked. “Come and see, Lord,” they replied. Jesus wept.Then the Jews said, “See how he loved him!”. (John 11:33-36) • Jesus wept when He visited Martha and Mary after the death of Lazarus. Those who stood near Him on that day were quick to interpret His behavior, for they said, "See how he loved him" John 11: 35, 36! Grief was rightly seen as an expression of love. • Jesus knew that He would soon raise Lazarus from the dead, so why was He so disturbed by the events of that day? Probably for several reasons. First, there was His great sense of compassion. He hurt to see others hurt. His emotions were pushed to the limit by witnessing the sorrow of Mary. Those with compassion are able to "weep with them that weep" and all Christians ought to have this ability (Romans 12:15). • He has entered into all of our experiences and knows how we feel. In fact, being the perfect God-Man, Jesus experienced these things in a deeper way than we do. His tears assure us of His empathy.

23. Death of a newborn • Thy departure from this earthly life is a cause of grief and sorrow for your parents and all who love you, O little child; but in truth you have been saved by the Lord from sufferings and snares of many kinds. • O Savior and Master of our life: comfort the faithful parents of this departed child with the knowledge that to innocent children, who have done no deeds worthy of tears, are granted the righteousness, peace and joy of Thy kingdom. • —Canon Ode 9, The Service of Burial of an Infant

24. Death of a Newborn • Stillbirth • 1% of births, can be due to cord or placenta accident, infection or toxemia. • Baby could die before term • Baby could die during birth • Allow women to donate breastmilk. • Prematurity and Neonatal Death • Birth weight and gestational age-factors for survival • Teen pregnancy, poverty lack of natal care • Women can blame self

25. Death of a Newborn • Sudden Infant Death Syndrome (SIDS) • 1 in 700 babies in U.S., but lower in other countries • 90% of SIDS deaths occur within first 6 months • 3rd most common form of death for babies in U.S. Risk Factors Cigarette smoke, prematurity, sleeping on stomach, formula fed at highest risk. None risk factors present can still succomb to SIDS

26. Death of a Newborn • This loss is perhaps the most difficult of all losses discussed thus far. One author described it thus: • There are no shortcuts or quick fixes in these phases of healing for grief is relentless, and it will not be shortchanged. We cannot completely evade its presence in our lives no matter how desperately we may try. Yet, peace is possible in the mind and the heart when grief and pain are embraced, released and openly expressed.-Ended Beginnings, Panuthos and Romeo

27. Death of a Newborn • Common Reactions: • Overwhelming Sorrow • Numbness and Denial • Feeling of Unreality • Anger and Rage • Isolation • Guilt • Fear • Powerlessness and Loss of Identity • Depression

28. Emotional Factors of Grief • Grief involves complex emotional factors which are all related to the crisis of bereavement. We grieve because of self-pity, "What will become of me now that he's gone?" Or anger, "After all I've done for her during her illness, how could she just leave me?" Or guilt, "If I had only known, I would have " Or simply. because we will miss the departed individual. "How am I ever going to get along without you?" or a variety of other feelings which the loss of someone we love evokes in us. All these emotions are important and permissible. It is pointless and even harmful to argue that one should not feel anger or guilt, or self pity or a sense of loss. The feelings, even some very negative feelings must be accepted, expressed, and worked through before healing can begin.

29. Grieving death • To lack some feeling of grief at the time of death would be to lack love itself. Love binds us to other people. When death comes those bonds are severed, at least in a temporal, physical bodily sense. In a time of such separation, grief is evidence of love, itself a divine gift. • Sometimes as we fight back the tears and heroically suppress our feelings of grief, in the name of our Christian faith, it is almost as if we are trying to be more Christian than Christ Himself! • Lately, some have come to the erroneous conclusion that death should not be an occasion for grief. Some think death should be viewed as something natural and acceptable. Orthodox Christians know death is not acceptable even though inevitable. Amid Resurrection celebration, there is a definite place for tears and sorrow. While we cannot advise a joyous funeral, our living ought to point in that direction even though human reality will be pained and afflicted with our loss in death. While it is true we should look at death in view of Christ's triumph, as a process we rejoice in rather than mourn over, the human response to death is more complex than a simple smiling affirmation of the glory of the afterlife.

30. Greiving Death • Grief is a process of working out and living through some very painful feelings, coming to some tough decisions, and performing some difficult actions. But it must be done. Suppressing grief is tragic. When we drug or rationalize our feelings away, or cover our pain with a sugar coating or religious platitudes, we fail to face up to something that must be faced. Namely, someone we love has died and is now- gone from us. We are going to feel` the pain of their absence and we are going to miss their presence. Our life is going to be affected by their absence.

31. Guidelines for Helping Someone Grieve A Miscarriage or Death of an Infant • The first and one of the most important things you can do is to acknowledge that a baby has died and this death is just as “real” as the death of an older child. The parents’ grief and healing process will be painful and take time, lots of time. They will not have stopped “grieving about their baby” after a month or even a year. In fact, the parents will hold that child in their hearts and memories for the rest of their entire lives. Realize that the parents are sad because they miss their baby, and that he or she can never be replaced by anyone else, including future children or children they may already have. • Contact spiritual father or parish priest to notify him of the situation and ask for assistance with prayers and grief counseling. • Let the parents know that they and their family and the baby are in your prayers. Call or send a sympathy card. You don’t have to write a lot inside, a simple “You and your baby are in my thoughts and prayers” is enough. • What the parents need most now is a good listener and a firm shoulder, not a lecture or advice. Listen when they talk about the death of their baby. Don’t be afraid, and try not to be uncomfortable when talking about the loss. Talk about the baby by name, if they have named the child. Ask what the baby looked like, if the parents saw the baby. Most parents need and want to talk about their baby, their hopes and dreams for their lost child. • Give a hug. This is a sign of love and concern. Even if this is all you do, it’s a nonverbal way of saying “I’m sorry” or that “I’m praying for you.” • Offer to baby-sit their other children. Often there are follow-up doctor’s visits and the parents need a chance to be together as a couple as well. • Offer to bring over meals; often mothers have no energy to do even basic things. Organize parishoners to put together a meal calendar so the family has regular meals.

32. Guidelines for Helping Someone Grieve A Miscarriage or Death of an Infant • Offer to go food shopping, help clean the house, do laundry; anything that lightens the burden of daily chores that need to be done. This is especially helpful if the mother is still waiting to miscarry the baby. That process may take days and is physically and emotionally draining. • Be careful not to forget the father of the baby. Men’s feelings are very often overlooked because they seem to cope more easily. The truth is that they are quite often just as devastated as their partner. Encourage other men in the parish to reach out to the father so he has a chance to unburden his heart. • Give special attention to the baby’s brothers and sisters. They too are hurt and confused and in need of attention which their parents may not be able to give at this time. • If the children want to talk about the death, don’t be afraid to engage them in conversation. Children have a natural relationship to death and they are open and direct with adults with whom they feel comfortable. When children are allowed to share their dreams and thoughts openly, the difficulty of their grief can be reduced. • It may be hard for the bereaved parents (especially the mother) to see or even talk to a pregnant woman, small children and especially babies, they are all reminders of what she has lost. This is a very difficult situation as the bereaved mother can be jealous and then get angry at herself for feeling that way. • Remember that any subsequent pregnancies can be a roller-coaster ride of joy, fear and bittersweet memories. • Try to remember the anniversary of the death and due date with a card, call, or visit. Anniversaries can trigger grief reactions as strong as when the loss first happened. Months down the road a simple “How have you been doing since you lost your baby?” can give much comfort. • Remember also that mourning puts a tremendous strain on relationships between family and friends. • It is okay to admit that you don’t know how they feel. A good thing to say is, “I can’t imagine how you feel. I just wanted you to know that I am here for you and am very sorry.” Excerpted from “Comforting those Who Have Lost a Baby During Pregnancy or Shortly Thereafter” By Dennise Kraus

33. Further Research • “Comforting those Who Have Lost a Baby During Pregnancy or Shortly Thereafter” By Dennise Kraus, Diocesan Journal, Jacob’s Well • The Hidden Feelings of Motherhood by Kathleen A. Kendall-Tackett, PH.D. • Empty Cradle, Broken Heart: Surviving the Death of Your Baby by D.L. Davis • On Death and Dying, by Elisabeth Kubler-Ross • Breastfeeding Made Simple by Nancy Mohrbacher and Kathleen Kendall-Tackett • Ended Beginnings, Panuthos and Romeo • goarch.org • oca.org Allena Barbato, JD MACP

34. Thank you and God Bless!