II.         LITERATURE REVIEW……………………………………………………......13

Expectant Fatherhood……………………………………………………………13

The Development of Paternal Identity………………….………………..13

                        Parenthood as a Developmental Phase…………………………………..15

                        Psychological Experiences of Expectant Fathers…………….………….18

Physical Changes in Expectant Fathers………………………………….22

Models and Theories of Grief…………..…………………………………….….23

Definition of Terms….…………………………………………….….….23

            Models and Theories……………………………………………………..23

Uniqueness of Perinatal Loss…………………………………….………………28

                        Definition of Terms ……………………………………………………...28

Complications in Mourning of Perinatal Loss…………………………...29

Perinatal Loss and Adult Development………………………………….31

Psychological Reactions to Perinatal Loss ……………………………...32

Differences Among Various Types of Perinatal Loss…………………...36

Grief and the Marital Relationship………………………………………………39

Men and Perinatal Loss…………………………………………………………..41

General Review of the Literature………………………………………...41

A Qualitative Study Examining Fathers Experiencing Perinatal Loss.….48

Mitigating Factors That Influence Men’s Experiences of Perinatal Loss………..51

Ultrasound Scans and Grief……………………………………………...51

Men and Their Role as Supporters. ……………………………………...53

            Summary and Conclusions………………………………………………………54


III.  METHODS ………………………………………………………………….….…..57


                        Inclusion Criteria………………………………………………………...57

                        Exclusion Criteria………………………………………………………..58


            Semi-structured Interview………………………………………………..59

                        Perinatal Grief Scale……………………………………………………..60

                        T.A.T. and C.A.T.-H……………………………………………….…….62


            Analysis of the Data……………………………………………………….……..70

            Rationale for the Use of Qualitative Research…………………………………...73

            Protection of Human Subjects…………………………………………………...74


IV.  RESULTS………………………………….………………………….…………….76

            Description of Sample……………………………………………………………76


            Individual Analysis………………………………………………………………80

                        Participant One:  Dennis…………………………………………………82

            Background Information…………………………………………82

                        Demographic Information………………………………..82

                        Recruitment Process……………………………………...82

                        Description of the Loss…………………………………..82

            The Interview…………………………………………………….83

                        Desire for Children………………………………………84

                        Dennis’s Experiences During the Pregnancy……………84

                        Initial Responses to Susan’s Death………………………85

                        The First Year After the Loss……………………………88

                        Beyond One Year………………………………………...90

            The Perinatal Grief Scale………………………………………...94

            Dennis’s T.A.T. Results………………………………………….97

            Dennis’s C.A.T.-H Results………………………………………99

            Brief Commentary on Dennis’s Results………………………..101

                        Participant Two:  Karl…………………………………………………..102

Background Information………………………………………..102

                        Demographic Information………………………………102

                        Recruitment Process…………………………………….102

                        Description of the Loss…………………………………102  

The Interview…………………………………………………...103

                        Desire for Children……………………………………..103

                        Karl’s Experiences During the Pregnancy……………...103

                        Initial Responses to Dana’s Death……………………...105

                        The First Year After the Loss…………………………..107

                        One Year and Beyond…………………………………..108

            The Perinatal Grief Scale……………………………………….111

            Karl’s T.A.T. Results…………………………………………...114

            Karl’s C.A.T.-H Results………………………………………...115

                                    Brief Commentary on Karl’s Results…………………………...116

                        Participant Three:  Raymond…………………………………………...117

Background Information………………………………………..117

                        Demographic Information………………………………117

                        Recruitment Process…………………………………….117

                        Description of the Loss…………………………………117

            The Interview…………………………………………………...118

                        Desire for Children……………………………………..118

                        Raymond’s Experiences During the Pregnancy………..119

                        Initial Responses to Bryan’s Death……………………..120

                        The First Thirteen Months After the Loss……………...121

            The Perinatal Grief Scale……………………………………….123

            Raymond’s T.A.T. Results……………………………………...127

            Raymond’s C.A.T.-H Results…………………………………..128

                                    Brief Commentary on Raymond’s Results……………………..129

                        Participant Four:  Peter…………………………………………………130

Background Information………………………………………..130

                        Demographic Information………………………………130

                        Recruitment Process…………………………………….130

                        Description of the Loss…………………………………130

            The Interview…………………………………………………...130

                        Desire for Children……………………………………..131

                        Peter’s Experiences During the Pregnancy……………..131

                        Initial Responses to Tabitha’s Death…………………...132

                        The First Four Months After the Loss to the Present…...133

            The Perinatal Grief Scale……………………………………….135

            Peter’s T.A.T. Results…………………………………………..139

            Peter’s C.A.T.-H Results……………………………………….140

                                    Brief Commentary on Peter’s Results…………………………..141

                        Participant Five:  Ryan………………………………………………….142

Background Information………………………………………..142

                        Demographic Information………………………………142

                        Recruitment Process…………………………………….142

                        Description of the First Loss:  Miscarriage……………..142

                        Description of the Second Loss: Stillbirth……………...143

            The Interview…………………………………………………...143

                        Desire for Children……………………………………..144

                        Ryan’s Experiences During the First Pregnancy……….144

                        Reactions to the Miscarriage……………………………144

                        Ryan’s Experiences During the Second Pregnancy…….145

                        Initial Responses to Belinda’s Death…………………...147

                        The First Three Months After the Loss to the Present….149

                        Difference Between the Two Losses…………………...156

            The Perinatal Grief Scale……………………………………….157

            Ryan’s T.A.T. Results…………………………………………..160

            Ryan’s C.A.T.-H Results……………………………………….161

            Brief Commentary on Ryan’s Results………………………….162


V.  DISCUSSION………………………………………………………………………167

            Individual Analysis……………………………………………………………..168

                        Participant One:  Dennis………………………………………………..168

                        Participant Two:  Karl…………………………………………………..172

                        Participant Three:  Raymond…………………………………………...175

                        Participant Four:  Peter…………………………………………………179

                        Participant Five:  Ryan………………………………………………….181

            Common Themes……………………………………………………………….187

                        Similarities Among Participants Before the Loss………………………187

                        Emotional Consequences to the Loss…………………………………..189

                                    Shock and Numbness…………………………………………...189

                                    Guilt and Sense of Responsibility………………………………190




                        Fathers as Managers…………………………………………………….197

                        Relationship Changes With Spouse…………………………………….201

                        Using Support as a Way of Coping With the Loss……………………..203

            Conscious Versus Unconscious Grief…………………………………………..205


            Implications for Clinical Theory………………………………………………..211

            Limitations of the Current Study……………………………………………….214

            Suggestions for Future Research……………………………………………….216

            Summary and Conclusions …………………………………………………….217



            I.  Demographic Information…………………………………………………….78

II.  Dennis’s PGS Scores…………………………………………………………95

            III. Dennis’s T.A.T. Results……………………………………………………...[T1] 97

            IV.  Dennis’s C.A.T.-H Results………………………………………………….99

V.  Karl’s PGS Scores…………………………………………………………..112

            VI.  Karl’s T.A.T. Results………………………………………………………114

            VII.  Karl’s C.A.T.-H Results…………………………………………………..115

            VIII.  Raymond’s PGS Scores………………………………………………….125

            IX.  Raymond’s T.A.T. Results………………………………………………...127

            X.  Raymond’s C.A.T.-H Results………………………………………….…...128

            XI.  Peter’s PGS Scores………………………………………………………...137

            XII.  Peter’s T.A.T. Results…………………………………………………….139

            XIII.  Peter’s C.A.T.-H Results…………………………………………………140

            XIV.  Ryan’s PGS Scores………………………………………………………158

            XV.  Ryan’s T.A.T. Results ……………………………………………………160

            XVI.  Ryan’s C.A.T.-H Results……………………………………………...…161

            XVII.  Summary of PGS Scores……………………………………...………...166




            I.  Type of Loss…………………………………………………………...……...79

            II.  Time Elapsed Since Loss…………………………………………………….79

            III.  Frequency Tables of Themes……………..………………………..………149

            IV.  Frequency Table of Idiographic Themes…………………………..………150


Appendices…………(actual text excluded from this copy)…………………………...233

Appendix A: Interview Questions……………………………………………...233

Appendix B:  Perinatal Grief Scale……………………………………………..238

.           Appendix C:  Dissertation Flyer………………………………………………..243

Appendix D:  Advertisement……………………………………………….…..245

Appendix E:  Consent Form (Main Study)……………………………………..247

Appendix F:  Consent to Audiotape (Main Study)……………………………..250

Appendix G:  Subject Bill of Rights…………………………………………....252

Appendix H:  Consent Form (Clinical Work Sample)….………………………254


Chapter I


Just as the baby was coming out, it wrapped the cord around its neck and strangled itself.  Himself.  A boy —Anthony Jr.  As my father talked, tears dripped down the side of his face like candle wax.  The sight shocked me; until that moment, I had assumed that men were as incapable of crying as they were of having babies (Lamb,1992,  p. 12 ).


The above quote is a strong illustration of the emotional vicissitudes that fathers experience in response to perinatal loss.  More specifically, this quote depicts the unexpected and traumatic nature of this type of loss, as well as the significant impact it can have on fathers.  Although thousands of fathers undergo perinatal losses each year, there are relatively few studies that examine how these men respond to and cope with such an event.  Furthermore, there are no studies that examine how perinatal loss impacts the conscious and unconscious experiences of such men.  Without this research, the understanding of how fathers grieve after these losses is limited.  Therefore, this dissertation will seek to explore fathers' conscious experiences and the underlying unconscious processes following perinatal loss.

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. 

Unfortunately, perinatal losses occur frequently.  Recent statistics document that 20% of pregnancies end in miscarriage and ectopic pregnancy, 1.5% of pregnancies end in stillbirth (Mikel and Stohner, 1995), and .04% of live births end in SIDS (National Center for Health Statistics [NCHS], 1996).

There are several variables that complicate the process of grieving perinatal losses.  For instance, parents have few memories of the lost child.  Without many memories of the baby, parents may be unclear for whom they are grieving, and feel confused about what they are experiencing.  In addition, mourning a perinatal loss primarily involves prospective mourning, which is  “the relinquishing of wishes, hopes, and fantasies of what could have been but never was” (Leon, 1990 p. 35).  This type of mourning differs from the mourning required in later losses (i.e., the lost of a friend or spouse), in that later losses primarily require the mourner to focus on past experiences with the lost individual.

There are also various psychodynamic issues associated with perinatal loss that complicate the mourning process.  For instance, there is some evidence that parents regress during pregnancy; therefore, they lose a baby when they are already in a vulnerable state (Leon, 1990).  Furthermore, parents often feel ambivalent about the pregnancy, having a baby, and about becoming a parent.  Hence, they may think the loss is a result of their own forbidden wish not to have a child (Condon, 1986).  In addition, because parents commonly see their child as narcissistic extensions of themselves, losing their baby or fetus can feel like losing a part of themselves. 

            Perinatal loss may also interfere with some adult developmental tasks.  During each “critical period” of a child’s development, parents re-experience their own childhood phases and have the opportunity to rework them and achieve a new level of organization (Parens, 1975).  Because with a perinatal loss adults are losing the chance of having a child, it can delay or interfere with further adult development. 

Statement of the Problem

While it takes both a mother and a father to create a baby, the mother is the one who primarily receives support and empathy when a perinatal loss occurs.  Yet these losses can be significant for fathers, too.  An expectant father, like his wife, has often had fantasies of his baby, imagined what he, himself, would be like as a father, and thought about what his relationship might be like with his child (Zayas, 1987). Therefore, when he loses the baby, he is not only mourning the loss of his child, but also grieving the loss of the opportunity to be a father.  These issues bring up a salient question:  Why is it that when a perinatal loss occurs, fathers are put on the “back burner,” or given the job of arranging the funeral instead of being viewed as a griever?  This phenomenon probably stems from several sources, including the difficulty that men have in expressing emotions (Puddifoot & Johnson, 1997), the fact that men do not have a biological connection to the pregnancy, and society’s expectation that this loss is not theirs to grieve.

Although the psychological impact of perinatal loss has become more widely recognized and examined in the past twenty years, the existing literature primarily focuses on the mothers’ reactions to the loss.  Historically, few studies have examined the fathers’ responses to perinatal loss.  Furthermore, most of the existing perinatal loss research on fathers has compared the degree and duration of fathers’ and mothers’ grief to each other, concluding that fathers grieve less than mothers (Beutal et al., 1996; Theut et al., 1990; Vance et al., 1991).  The bulk of those studies, however, measure variables that are more suited to assess mothers’ distress, such as conscious manifestations of anxiety, depression, sadness, guilt, thoughts about the loss, and feelings about the loss. Because fathers may not directly express their feelings about or consciously grieve the loss, these variables may not fully capture the complete grief experience in fathers.

Many theorists believe fathers have unique, indirect ways of grieving perinatal losses (Leon, 1990; Phipps, 1981; Zeanah, 1989; Zeanah, Danis, Hirshberg, & Dietz, 1995).  Rather than directly expressing their feelings about the loss, they:  (a) keep busy so they do not think about the loss; (b) repress their feelings about the loss (Phipps, 1981); (c) suppress their feelings about the loss (Zeanah, 1989); (d) express grief vicariously through their wives (Leon, 1990); (e) or fail to consciously grieve (Zeanah, Danis, Hirshberg, & Dietz, 1995).  Therefore, to fully capture the grief reactions of fathers after perinatal loss, it would be useful to examine their unconscious experiences after the loss, or the feelings they may defend against and express only indirectly.  Hence, the present study will examine fathers’ conscious and unconscious experiences after perinatal loss through an interview, a grief scale, and two projective tests. 

In essence, much of the literature has failed to take into account the unique ways that fathers have of grieving after a perinatal loss.  Often, studies tap into conscious manifestations of depression, anxiety, and grief, missing the underlying feelings that may be expressed in other ways.  Thus, more research is needed that taps into fathers’ own unique ways of grieving and examines their unconscious experiences. In order to fully capture the grief experiences of fathers, this dissertation will use a psychodynamic lens, seeking to explore fathers’ conscious and unconscious experiences of perinatal loss.     

Statement of Purpose 

The rationale for studying the fathers’ experiences following perinatal loss is based on several factors.  To begin, little is known about how men experience this type of loss.  As mentioned above, much of the literature assumes that fathers= reactions to this loss are qualitatively similar to mothers’ reactions (Beutal, 1996; Theut, 1990; Vance, et al., 1991).  In addition, these methodological limitations may have some implications for clinical theory and practice.  The four main clinical implications are as follows.  First, mental health professionals may inadvertently underestimate men=s distress because they do not exhibit the same symptoms as mothers.  Additionally, these men may also underestimate their own levels of distress or attribute this distress to other factors in their life (e.g. stressful work environment).  Consequently, fathers may not adequately mourn their losses.  Second, the recognition that fathers do experience significant distress, despite their differing symptomatology from mothers, can help to normalize and validate their experience.  Thus, they will have the opportunity to effectively mourn their loss, and safely cathart their feelings and vulnerabilities.  Third, the awareness of perinatal loss as a significant loss for fathers can guide mental health professionals in re-conceptualizing the construct of fathers= grief following perinatal loss, facilitating the development of appropriate treatment approaches. For instance, mental health professionals could take note that unrelated symptoms, such as increased alcohol use, may occur in men as a disguised expression of feelings about the loss.  Lastly, an understanding of fathers' reactions following perinatal loss can help couples understand the process of how each individual grieves.  This understanding could decrease the possibility of interpersonal strife and conflict between the mother and father, protecting against the threat of separation and divorce.

The rationale for looking at the individual’s conscious and unconscious experience is that little is known about what really happens with men intrapsychically following perinatal loss. To date, no studies have looked at both the conscious and unconscious experience of fathers after a perinatal loss.  However, there is some evidence that fathers experience a lot of distress after perinatal loss.  For example, to address whether men experience distress after perinatal loss, Vance et al. (1995), looked at gender differences in distress following perinatal loss and Sudden Infant Death Syndrome. Not only did Vance et al. (1995) measure grief, anxiety, and depression, but they also measured alcohol ingestion.  Results indicated that when factoring in alcohol ingestion, men did experience just as much distress as women did at fifteen and thirty months following the loss.  Thus, we may hypothesize that fathers do experience distress following perinatal loss, but their distress manifests itself in different ways than that of mothers.  Because the current literature on perinatal loss lacks an accurate construct for understanding fathers’ experiences after perinatal loss, this dissertation has used a qualitative, rather than a quantitative method of research.

In the present study, an attempt has been made to examine fathers’ conscious experiences via an interview and the Perinatal Grief Scale (PGS), and to examine the unconscious, defended, or indirectly expressed aspects of their experiences via the use of two projective tests: the Thematic Apperception Test (T.A.T.) and the human form of the Children’s Apperception Test (C.A.T.-H).  This dissertation provides a more detailed explanation of these tests in Chapter three. 

This researcher believes that the meaning of an event to an individual is a crucial factor in determining its impact.  Therefore, the present study has adopted a psychodynamic framework for approaching fathers and perinatal loss.  To illustrate the full scope of fathers’ experiences of perinatal loss, this dissertation will critically review several important topic areas. First, perinatal loss occurs at the time that fathers are transitioning to fatherhood, so a section on expectant fatherhood will be included. Second, this dissertation will review literature on models and theories of grief to illustrate the “typical” phases of grief.  Third, a section describing unique aspects of perinatal loss will be included. Due to the limited literature on the topic of fathers and perinatal loss, this section will review the literature on mothers’ experiences of perinatal loss and attempt to apply this information to fathers.  Finally, this literature review will discuss and critique the existing literature on fathers and perinatal loss.

Following the literature review, a chapter describing the specific methodology of this dissertation will be included, as well as the results and the discussion of this study.  This investigator has used a parallel model, meaning that the clinical work sample is a separate component to this dissertation and is not in this copy of the document. 

Chapter II

 Literature Review

Expectant Fatherhood

            The intent of this section of the literature review is to illustrate three points: (a) the desire to be a father stems from early in life, (b) fatherhood has been considered a developmental phase that promotes growth, (c) and fathers may feel vulnerable during the transition to parenthood. 

The Development of Paternal Identity. Several theorists believe that the wish for a child among men is complex desire that is deeply rooted from early in life (Diamond, 1995; Ross, 1975; Tyson & Tyson, 1990).  Tyson and Tyson (1990) maintain that the wish for boys to bear children is particularly prominent during their anal stage of development (ages one to three).  Boys are primarily exposed to their mothers during this phase, resulting in the identification with and imitation of her through assisting in household tasks and engaging in fantasies of bearing a child. Simultaneously, boys experience anal and genital sensations during their anal phase, which accentuates fantasies of giving birth to a child.

Michael Diamond (1995) speculated that boys have their earliest wish for a baby during their oral and anal psychosexual phases of development.  He believed that during those phases, boys fantasize about the oral incorporation and the anal rebirth of their mothers.  For instance, a boy might fantasize about eating his mother=s breasts (oral incorporation) and later restoring her through his anus (anal rebirth).  Gradually, while still in their preoedipal phases, their fantasies include both parents, and they imagine their fathers impregnating their mothers, often by defecating or urinating on them.  Eventually, boys focus primarily on their fathers.   For example, the boy might wish to incorporate his father=s penis and restore him as a baby boy so that he can reverse the father-son relationship.

Similarly, Ross (1975) reported that young boys, in the preoedipal phases, identify with and desire to be like their mother by giving birth to a baby.  However, once the phallic stage (ages three to five) of development begins, most boys shift their main identifications to their father and begin to fantasize about getting an infant from their mothers, rather than wishing to be like their mothers and growing a baby inside of themselves.  Ross also believed that the wish for children stems from boys= desires to overcome their feelings of rage and helplessness toward their mothers because of her authority and omnipotence.  By wishing for children, boys are competing with and attempting to achieve power over their mothers.

It has been reported that later in development, boys begin to give up their wish of giving birth to a baby.  In his review of Freud=s ideas, Michael Diamond (1995) reported that once reaching their Oedipal phase of development, boys discover the female genitalia and believe that girls have lost their penises.  This discovery leads boys to fear that they themselves will be castrated, thus prompting their decision to further identify with their fathers, because they believe that their fathers have not been castrated.  As boys develop these masculine identifications, they begin to fantasize about impregnating their mothers, and they relinquish or repress their wish to grow babies inside of themselves. 

In conclusion, some theorists believe that the wish for a child among men is  deeply rooted from early in life.  Although these ideas appear to be widely accepted among theorists, they are primarily based upon clinical cases, and no systematic quantitative evidence exists to support them.

Parenthood as a Developmental Phase.  Some theorists believe that parenthood can be conceptualized as a developmental phase or task in adulthood  (Colarusso, 1990; Leon, 1990; Parens, 1975).  Therese Benedek was the first person to term parenthood a developmental phase, as she did so in her presentation to the American Psychoanalytic Association in 1958. She speculated that during each Acritical period@ in their child’s development, parents re-experience their own childhood phases, thus having the opportunity to rework them, and achieve a new level of intrapsychic organization (Parens, 1975).

In an annual meeting of the American Psychoanalytic Association in 1974, a panel debated the question of whether biological parenthood was a developmental phase (Parens, 1975).  During the conference, Kestenberg, for example, suggested that parenthood is a phase of adult development because it entails anxiety, conflicts, and defense mechanisms that lead to a change in psychic structure in each subphase.  In contrast, panel member Sylvia Brody argued that biological parenthood is not necessarily a developmental phase because the biological aspects of becoming a parent, such as pregnancy and nursing, have a psychological impact that lasts sometimes for just a short time.  Brody suggested that those biological parents who do not have the ability to rear a child may not undergo the structural changes in their ego and superego that characterizes a new developmental phase.  Therefore, each parent’s ability to rear a child must be considered before calling parenthood a developmental stage.  Similar to Brody=s view, William Thomas Moore suggested that, unlike most developmental phases, biological parenthood does not necessarily involve structural changes in the superego and the ego.  He believed that any of the changes in the ego and superego that do occur are the recycling or rejuvenation of earlier conflicts and defenses, not the structural change of developmental issues. Although this panel of speakers did not agree on whether parenthood is a developmental phase, the chairman, Irwin Marcus, concluded that parenthood evokes anxiety and conflict, which may or may not induce personality growth.

Other theorists do not label parenthood a “developmental phase,” but believe parenthood can fulfill some adult developmental tasks.  Erik Erikson suggested that parenthood could fulfill an adult phase of development (Davison & Neale, 1996; Erikson, 1964). In his eight-stage model of the psychosocial stages of development, he proposed that the seventh stage, Generativity versus Stagnation, was a major phase of adulthood.  Generativity refers to the production, creation, and caring for the next generation.  It is achieved by giving to the next generation through having children, working, or engaging in creative endeavors, and represents the successful resolution of this phase of development.  Conversely, Astagnation@ is the lack of productive endeavors, and can lead to boredom and a lack of a sense of caring. Therefore, someone who has not had children and has not found a way to give to the next generation in another way may suffer through Astagnation.@ Erikson speculated that the successful resolution of earlier psychosocial stages helps to facilitate the resolution of later stages.  For example, in Erikson=s first stage, Atrust versus mistrust,@ the infant learns (or does not learn) about consistency, predictability, and reliability in the caregiver=s behavior.  However, without experiencing consistent care giving as an infant, an individual may struggle to Agive@ to the next generation as a parent in the generativity phase of development.  Consequently, this individual may have difficulty successfully achieving generativity (Davison & Neale, 1996).

 Expanding upon Margaret Mahler=s theory of the separation-individuation process, Colarusso (1990), conceptualized biological parenthood as the beginning of what he called the third individuation. He defined the third individuation as a, "continuous process of elaboration of the self and differentiation from objects which occurs in the developmental phase of early (20 to 40 years) and middle (40 to 60 years) adulthood" (Colarusso, 1990, p. 181). He believes that this individuation involves separating from one's own parents and creating a family by procreation. Because the new or expectant parent often feel guilty for separating, they have a child as a "gift" for their parents (Colarusso, 1990; Diamond, 1986).

The third individuation is facilitated Aby producing a situation in which infantile themes and relationships can be reworked in relation to phase-specific, adult, developmental tasks and conflicts" (Colarusso, 1990, p. 184). In other words, each phase of the child’s development produces a different “situation” that challenges parents to further develop.  For instance, at the time of pregnancy and birth, the parents’ sexual identity is enhanced because they realize that their sexual apparatus can perform their primary functions.  When their child is in their preoedipal phases, the parents work through their early relationships with their own mothers as they reverse roles and become the all-powerful omnipotent caretakers. During the oedipal phase, the parents rework fantasies and impulses through interacting with their spouse, parents, and children.  In the latency phase, the parents must relinquish control of their child’s bodily functions, thoughts, time, and relationships; and therefore, mourn the loss of the pleasure obtained from being in control over a dependent child. When the child becomes an adolescent, the parents work through the separation, and accept their child’s preparation for replacing them as the most significant person in life.

Psychological Experiences of Expectant Fathers.  There is some speculation that men regress and rework their object relations during their wives= pregnancies (Bortz, 1994; Leon, 1990; Osofsky, 1982; Zayas, 1987).  Osofsky (1982) believes that expectant fathers, when they first learn of their wives= pregnancies, experience excitement, pride, and relief about their virility.  However, these feelings are soon followed by experiences of stress and upheaval, which stem from regressive pulls, unresolved conflicts, and earlier life experiences.

In his doctoral dissertation, Bortz (1994) attempted to demonstrate empirically that men, in their transition to fatherhood, regress and rework object relations.  Using the Early Memories Test, the Blacky Picture Test, and the MAACL-R, the study found that husbands with pregnant wives did not regress and rework object relations any more than husbands whose wives were not pregnant.  However, husbands who had wives who were in their first pregnancy spent more time thinking about their relationship with their fathers than did the other husbands.  Bortz (1994) noted that his recruitment strategy might have led to a self-selection bias in his study, in favor of healthier, less-regressed men.  In other words, the men who were psychologically healthy were willing to participate in the study and were not as prone to demonstrable regression and the reworking of object relations during their wives= pregnancies.  Conversely, men who were not psychologically healthy and who were experiencing more distress, possibly due to regression induced by the pregnancy, did not volunteer for the study because they were undergoing an abundance of turmoil: regressing and reworking their object relations. D. J. Diamond (personal communication, April 3, 2000) also suggested that any regression occurring for men might be delayed until after the actual arrival of the baby, whereas for women, with the physical stimulus of the pregnancy itself, regress may occur earlier.

            Pregnancy and new fatherhood are also believed to trigger unresolved Oedipal issues (Jarvis, 1962; Zayas, 1987).  Generally, the successful resolution of the Oedipus Complex is known to occur when Athe child relinquishes the desire for the parent of the opposite sex, identifies with the parent of the same sex, and seeks a partner of the opposite sex outside the family@ (Zayas, 1987, p. 15).  However, in many males, the Oedipus Complex is not fully resolved in childhood, and is triggered again during expectant fatherhood.  Thus, during his wife=s pregnancy, the expectant father may struggle to identify with his own father, while trying to remain close to his wife, who represents his mother (Zayas, 1987).

 In a case study of an expectant father, Jarvis (1962) illustrated one man=s struggle to resolve his Oedipal Complex.  He described a man who engaged in behaviors during his wife=s pregnancy that were uncharacteristic of him.  In the beginning of her pregnancy, he was jealous of her social activities, had tantrums when she upset him, and could not stand to be separated from her.  Later into the pregnancy, the father labeled his wife as physically sick, and took care of her.  He did all of the cooking and cleaning in the house.  Furthermore, he fantasized about giving birth to a baby, and decided to leave his career to become a food caterer. 

This case illustrates several Oedipal issues that were triggered for this man during his wife=s pregnancy.  When his wife was first pregnant, he remembered how he could not Apossess@ his mother, even though he was attracted to her, because she chose his father.  As a result, he became angry with his wife, who represented his mother.  To retreat from his anxiety about being angry at her, he identified with his mother by cleaning the house, fantasizing about having a baby, and desiring a more nurturing career as a food caterer (Jarvis, 1962).

It has been postulated that dependency needs are also intensified during expectant fatherhood (Zayas, 1987).  Often, a man who has a strong attachment to his own parents during childhood, transfers these attachments to his wife.  When his wife becomes pregnant, she becomes more involved with herself and the developing fetus, and provides less physical and emotional attention to him.   As a result, the man feels unloved and abandoned.  He feels ashamed of his feelings of abandonment and dependency. These unfulfilled needs trigger anxious feelings of separation related to past experiences with his mother as a young boy, causing great discomfort.

Some theorists have speculated that issues surrounding childhood sibling rivalry are activated in the male during his wife=s pregnancy (Gurwitt, 1976; Zayas, 1987).  Pregnancy can cause stress and upheaval in the expectant father, so he may desire to be emotionally closer to his wife than usual.  Simultaneously, he may fear losing his wife=s attention to the baby.  As a result, the expectant father may feel rivalrious and hostile toward the fetus, triggering earlier conflicts of sibling rivalry.  These issues may derive from unresolved Oedipal conflicts, whereby the jealousy is displaced from the parent to the sibling/baby, or from earlier preoedipal themes related to dependency and fear of loss.  It has also been postulated that pregnancy causes the expectant father to feel a sense of omnipotence and power (Diamond, 1995; Leon, 1990).  Feelings of omnipotence, which begin in pregnancy and further develop as children grow older, serve to deny his aging and ultimate death.  A narcissistic injury is also associated with aging and death; therefore having a child may counter this injury by enhancing a man’s self-esteem (Diamond, 1995; Leon, 1990).  In writing about the need for omnipotence through having children, Leon (1990) stated:

If facing one's inevitable end is the ultimate narcissistic blow (for what could be more humbling to a sense of personal power and efficacy), pregnancy may normally serve as a vital narcissistic defense, preserving a sense of self-worth and permanence.  (p. 15)         

            The experience of pregnancy for expectant fathers can be greatly influenced by the medical condition of both his wife and fetus.  High-risk pregnancies often lead fathers to feeling frightened and out of control because there are so many "unknowns" associated with the pregnancy.  These “unknowns” include the mortality of his wife and baby as well as concerns regarding the possibility of taking care of a sick baby (May, 1995).  Therefore, fear and anxiety may be heightened for fathers who are dealing with high-risk pregnancies.

Physical Changes in Expectant Fathers.  Many expectant fathers undergo physical changes during their wives= pregnancies.  Some men engage in dietary and behavioral restrictions mimicking their wife, which is called “ritual couvade” (May & Perrin, 1985).  Others develop physical symptoms characteristic of pregnancy, known as “couvade syndrome” (May & Perrin, 1985; Shapiro, 1985).  Couvade syndrome is characterized by gastrointestinal disturbances, colds, and aches and pains (Conner & Denson, 1990).  It was first discovered by anthropologists who found that in many preindustrial countries, males were engaging in dietary and behavioral restrictions mimicking their wives during pregnancy (May & Perrin, 1985).  

Various hypotheses exist regarding the etiology of these syndromes.  Couvade syndrome and ritual couvade have been explained as: (a) the man’s attempt to be "more connected" to the pregnancy (Shapiro, 1995); (b) as a way to identify with his wife (Conner & Denson, 1990); (c) as a way to empathize with her (May & Perrin, 1985); (d) a reflection of his envy of his wife's ability to bear children, (e) as representing feelings of anxiety, anger, and ambivalence about the pregnancy (Conner & Denson, 1990); and  (f) as a way to take away the wife's pain in her pregnancy (May & Perrin, 1985).  

In sum, becoming a father is a complex process, stemming from early in development.  Transitioning to this phase of life, however, can promote growth and further psychological development. 

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  Athe 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 AMourning and Melancholia@ (1917).  He conceptualized the process of grief in two steps: shock and denial followed by Aworking through@. Freud believed that during the latter stage,  Aworking 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 Aloss@ 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 Abuffer@ 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 Afind@ the object.  The next stage, disorganization and despair, is characterized by no longer trying to Afind@ 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 Amyths@ 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 Asnapshot@ 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, AThat'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, A[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).

Perinatal Loss and Adult Development.  Another factor that complicates mourning perinatal loss is that it is a developmental  “crisis within a crisis” for parents (Leon, 1990). Pregnancy itself is the first crisis, involving regression and changes in self-concept.  This crisis is resolved through the birth of a viable child.  When a perinatal loss occurs, however, there is no longer a child.  Then, a second crisis unfolds:  the loss itself.  Without the child, the adult is not able to enter parenthood, an adult developmental phase that pregnancy has facilitated.  Thus, in many cases, when there is a perinatal loss, adults lose the opportunity to actualize their parental identity and further develop their own adult identity (Leon, 1990).

The birth of a baby also facilitates the third-separation individuation (Colarusso, 1990).  The third separation-individuation is a phase of adulthood where adults further separate from their own parents in part by creating a family of procreation.  Perinatal loss can interfere with the entrance to parenthood, preventing further separation from one=s own parents and the consolidating of one=s own adult identity (Colarusso, 1990).

 Psychological Reactions to Perinatal Loss.  A variety of psychological reactions to perinatal loss among mothers have been described in the literature (Frost & Condon, 1996; Klock, Chang, Hiley, & Hill, 1997; Lee & Slade, 1996; Madden, 1994). Commonly, they have symptoms of shock, disbelief, somatic distress, insomnia, anhedonia, sexual dysfunction, anorexia, time confusion, emotional lability, weakness, dreams of the baby, preoccupation with the lost baby, and an inability to return to normal activities.  Simultaneously, feelings of inadequacy, sadness, guilt, anger, and irritability are experienced (Frost & Condon, 1996; Peppers & Knapp, 1980).

To date, there are many studies that report that depression is a significant reaction to perinatal loss in women (Condon, 1986; Dyregrove & Mattieson, 1987; Lee & Slade, 1996; Madden, 1994; Vance et al., 1995).  Although the majority of these studies report only depressive symptomatology, there is some evidence that many women actually develop depressive disorders.  For instance, Neugebauer et al. (1997) assessed the risk for major depressive disorder among women six months following a miscarriage.  The study found that Major Depressive Disorder, as measured by the Diagnostic Interview Scale (DIS), occurred in 10% of the women who miscarried, which was two times as much as the general population of women.  Furthermore, they found that women who miscarried and did not have previous children were at a higher risk for depression. 

            In an attempt to look at depression, Klock et al. (1997) gave questionnaires that assessed psychological distress to 57 women who had experienced recurrent miscarriages (average of 3 miscarriages).  Clinical depression, as measured by the Beck Depression Inventory (BDI), was found in 32% of the women in the study. 

Indeed, these studies demonstrate that clinical depression often occurs after perinatal loss, although, they ignore other emotions or behaviors that women experience (Madden, 1994).  These emotions include anxiety, guilt, increased substance use, and/or pathological grief, which will be discussed in the following paragraphs.

Anxiety is a common reaction women have to reproductive loss (Dyregrove & Mattieson, 1987; Lee & Slade, 1996; Vance et al., 1991).  In fact, in a study of early responses to Sudden Infant Death Syndrome (SIDS), stillbirth, and neonatal death, Vance et al. (1991) found that symptoms of anxiety were reported more frequently than symptoms of depression.   In another study, the psychological responses of women who had experienced multiple miscarriages were examined.  Using the State-Trait Anxiety Scale, they found that these women had overall high levels of anxiety (Klock et al., 1997).  Although studies have found that anxiety is very high among mothers after perinatal loss, the majority of research merely examines depression.  Clearly, more research is needed to assess anxiety in mothers after perinatal loss.

Guilt is another common emotion seen in mothers following reproductive loss (Condon, 1986; Frost & Condon, 1996; Lewis, 1979, Phipps, 1981).  Although there is controversy over where it stems from, two main sources are typically identified in the literature.  First, the mother is extremely aware that the fetus is entirely dependent on her. Therefore, when the baby is lost, the mother feels entirely responsible.  Second, the mother often may have mixed feelings about the pregnancy.  She may feel like she is giving up her physical well-being, figure, social activity, career, and concept of self as a child.  She may also worry about injury or death at delivery, coping with parenthood, and eventual loss of two-person marital relationship. Therefore, the mother may conclude that the loss was a result of her own forbidden wishes to not have a child (Condon, 1986).  These feelings of guilt may still be present despite the fact that she is cognitively aware that she did not cause the death (Phipps, 1981).

There is evidence that drug usage increases in women following perinatal loss.  Vance et al. (1994) examined pain medicine, prescription tranquilizer, and alcohol use two months after the loss of an infant through stillbirth, neonatal death, and SIDS.  Using a self-made questionnaire and an interview, this study had several findings.  First, no increase in the use of pain medicine was found.  Second, more prescribed tranquilizers were taken among all bereaved mothers, and were four times likely to be taken among. mothers who lost infants to SIDS than by the control group.  Third, bereaved mothers were not found to ingest more alcohol than non-bereaved mothers.  However, it is possible that these participants underreported their alcohol use because it is not socially desirable for women to drink, while accurately reporting prescription drug use because it is more socially acceptable to take medicine that is prescribed by doctors.    

The above study is useful in that it illustrates the degree that substances are used to numb the emotional pain of perinatal loss.  Indeed, this knowledge is essential  because it is likely that substance use suppresses grief, causing individuals to appear as if they are not grieving.  Therefore, it is possible that grief has been under reported in previous research. However, the results of the above study should be interpreted cautiously because it was conducted in Australia, and there are cultural differences in  style, acceptability, and traditions in both and alcohol and prescription drug use. 

Some women have extreme difficulty coping with reproductive loss and develop pathological grief.  According to Condon (1986), pathological grief can take two forms: absence of grief or prolonged grief.  The absence of grief occurs when there is no evidence of grief in the first two weeks following the loss.  Later, as a result of unresolved grief, other neurotic symptoms may be present, including: phobias, compulsive behaviors, somatiform disorders, psychosexual dysfunction, depression, and difficulty in bonding to a subsequent child.  Conversely, prolonged grief is a reaction that initially appears to be normal grief, but continues for longer than typical or does not abate over time. 

Similarly, Lin and Lasker (1996) divide pathological grief into two categories: chronic grief and delayed grief.  Chronic grief, as in prolonged grief, is when grief is Aprotracted or excessively intense@ (Lin & Lasker, 1996, p. 263).  Symptoms of chronic grief include: excessive anger, guilt, self-blame, or ongoing depression.  Delayed grief is when there is no obvious grief immediately following the loss.  Instead, the grief manifests itself later as over-activity, hostility against others, alienation, or severe depression. Because  these depressive symptoms are quite common in grief following perinatal loss, they make it difficult to differentiate from pathological mourning (Condon, 1986). 

Although these theories of pathological grief are useful in that they help to identify when women are struggling with grief, it is difficult to classify individuals into two categories.  Wide individual variations are to be expected in the grief experience.

 Indeed more research is needed on the psychological reactions to reproductive loss.  Many of the studies are retrospective in design, and participants may not accurately remember their reactions during the study.  Another weakness in this research is the high attrition rate in grief studies.  Moreover, participants in these studies may be at a different stage of grief, thus reporting different symptomatology.

Differences Among Various Types of Perinatal Loss.  Very few studies have explored the variations in psychological reactions to stillbirth, miscarriage, and Sudden Infant Death Syndrome (SIDS).  There is some existing debate on the differences in intensity among the losses.  Peppers and Knapp (1980) compared the impact that neonatal death, stillbirth, and miscarriage had on 65 mothers.  Because, at the time, no scale had been developed to measure grief responses to perinatal loss, the researchers developed their own scale.  This Likert-Type scale measured sadness, loss of appetite, inability to sleep, irritability, preoccupation, inability to return to normal activities, difficulty in concentration, anger, guilt, failure to accept reality, time confusion, exhaustion, lack of strength, depression, and repetitive dreams of the lost child. The results indicated that there were no differences in the intensity of grief between the three losses.  The findings from this study provide solid support, that the length of the maternal/infant bond is not necessarily proportionate to the intensity of the experienced grief.  However, the study was weakened by several factors.  First, the sample size was small, consisting of only 65 individuals.  Second, the participants included volunteers, which suggests a self-selection bias, where more distressed individuals may not have volunteered for the study, lowering one or more of the scores in the groups. Third, the investigator’s grief instrument had never been validated.  It is possible that their measure did not capture the type of grief reactions that occur after perinatal loss. 

Vance et al. (1991) examined the early responses to SIDS, stillbirth, and neonatal death.  Measuring both anxiety and depressive symptoms, this study found that parents who had a baby die from SIDS had the strongest grief reaction.  However, this study only measured anxiety and depression. Perhaps symptoms of anxiety and depression do not adequately measure the complete reactions to these three losses, causing parents who lost a child to neonatal death and stillbirth to appear as if they are grieving less than parents who lost a baby to SIDS.

Although little quantitative research has examined the differences in the experience among the various types of perinatal loss, speculations could be made based on the unique situation that surrounds each loss.   For instance, miscarriage has been considered a traumatic event because it happens very suddenly, and often involves considerable pain, loss of blood, and an invasive medical procedure.  Frequently, at the time of the miscarriage, women are alone without anyone to help them.  In addition, a miscarriage entails losing a pregnancy, requiring the mother to mourn both the loss of a baby and the loss of her pregnancy (Lee & Slade, 1996). Furthermore, the mother cannot see or hold the deceased infant.  Without this tangible evidence of the baby, the facilitation of mourning is difficult (Condon, 1986; Frost & Condon, 1996).   

On the other hand, stillbirth occurs in the hospital when the birth of a viable baby is expected.  Parents have had a longer time to attach to the baby as well as have had more time to fantasize about what the baby will be like.  Unlike miscarriage, by the time a stillbirth occurs, friends, family, and acquaintances are aware that a baby is expected, so parents must face many people who ask about the baby.  Mourning in parents is generally easier to facilitate after a stillbirth than after a miscarriage, because the loss is more tangible, allowing for the mother to hold the baby and have a burial for it.

In both Sudden Infant Death Syndrome and neonatal death, parents have had time to get to know the baby before the death.   They have attached to the baby, who is already born, as well as had a chance to say Agoodbye@ to the baby after he dies.  Although the opportunity to say “goodbye” often works to facilitate mourning, the more intense attachment associated with the longer life of the baby can make it difficult to mourn the loss.  In addition, unlike with stillbirth and miscarriage, this loss involves both prospective and retrospective mourning.  In other words, the parents must mourn both past experiences and future fantasies associated with the baby.  Furthermore, the situation of Sudden Infant Death Syndrome involves putting an apparently healthy baby to sleep in a crib and later finding him dead, creating another trauma.  Unfortunately, physicians usually do not have an explanation for the death even after an autopsy, leaving many parents confused about the loss (Defrain, 1991).

Because fathers’ experiences are somewhat different from those of mothers, the perinatal loss literature based on mothers does not necessarily apply to fathers in all aspects.  First, mothers have a biological component to pregnancy, while fathers do not. Second, fathers may experience attachment to babies a little later than mothers do, therefore, this loss may affect fathers in a different way.  Third, fathers are often coping with their wives’ reactions, which may be physical illness, psychological grief reactions, or hormonal changes after the loss.

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 Ashould@ 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 intensity 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 Ait 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 Anumb@ 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. 

A Qualitative Study Examining Fathers Experiencing a Perinatal Loss.  Hughes and Page-Lieberman (1989) conducted a qualitative study on the experience of bereavement in fathers following a perinatal loss.  Given that their study is very similar to this dissertation, a thorough review of the article will be covered in this literature review.  The purpose of this study was to thoroughly interpret fathers’ perceptions of their experiences of perinatal loss.  More specifically, the researchers focused on three areas of study:  the fathers’ perceptions of the losses, their closeness to the fetus prenatally, their experiences with others during the grieving period, and their intensity, nature, and duration of bereavement. 

The study used a retrospective, exploratory design, which took place six months to two years after the loss, and included an interview and the Grief Experience Inventory (GEI).  An interview guide was created and included both open-ended and close-ended questions.  A panel of experts piloted, reviewed, and modified this guide.  The questions focused on the father’s description of the events, their feelings, and the people involved with the death event.  Three individuals were trained to conduct the interviews. 

For analysis, all of the interview data was taped and transcribed.  Two independent raters coded both the manifest and the latent level of content of the interviews.  Fourteen coding categories were created.  They were developed from the interview data, the pilot, and the literature.  These categories included:  pregnancy health, centrality, death even, death preventable, shock feelings, sadness, anger, family’s involvement, men-women differences, OB physician relationships, nurse relationships, effect on marital dyad, guilt, and job performance. The fourteen items had 90% interrater reliability. 

This study used the Grief Experience Inventory (GEI) as an objective measure of the intensity and nature of their grief process.  This instrument has 135 true-false questions and takes thirty minutes to complete.  The authors reported that the GEI has a “satisfactory” level of interrater reliability and test-retest reliability, as well as having criterion and construct validity. Unfortunately, the investigators did not provide specific levels of reliability and validity.

            The sample included 51 fathers who were recruited from support groups and hospital lists of individuals who experienced a perinatal loss.  To be included in the study, the fathers had to experience the loss of an infant from twenty-eight weeks gestation of the neonatal period, have lost the infant six months to two years prior to the interview, and to be married at the time of birth.

To analyze the data, the researchers compared the scales to a normed bereavement group.  They used a t-test to measure the intensity and the nature of the fathers’ grief.

Several themes emerged.  The fathers in this study described the event of the death as a very active time.  They spent their time managing the mother's emotional condition while notifying their friends and family.  Simultaneously, they had to deal with their own feelings about the death.  When asked about how close they felt to the fetus, almost one-half (45%) reported that they felt close, but not as close as their wife did to the fetus.  Despite the fact that fathers are understood to attach less to the unborn fetus than mothers are, most of the fathers (80%) reported that they felt attached to the baby. 

The results of this study indicated that the way an individual perceived the preventability of a death often led to either self-scrutiny or anger toward another. Forty-one percent of the fathers did not think that the death was preventable, 39% had mixed feelings on whether the death was preventable, and 18% believed that the death was preventable.  If the father thought that the death was preventable, he often criticized himself.  In addition, 50% of the time he also blamed the physician or medical management for the loss.

Other findings of this study indicate that 78% of the fathers described sadness, but reported that this sadness was not "intensely overpowering or debilitating".  Twenty percent viewed their sadness as "more intense, enduring, or debilitating."  Although, the fathers acknowledged anger less often than sadness,  51% of them expressed this emotion.  Over one-half (57%) of the fathers expressed guilt over the loss.  Additionally, an important finding, especially to this dissertation was that only 37% of the fathers reported typical grief symptoms (fatigue, decreased appetite, and change of sleep pattern). This finding leads one to speculate that other factors in grieving may be at work.  

This study also documented some changes in work habits of the fathers.  Thirty-one percent of the men decreased their hours of work, and 14% increased the hours they worked.  One-fourth of the fathers reported that they used their work to "heal" or as a "diversionary" factor. Furthermore, fathers reported a short duration of grief.  However, other data indicated that there was a decrease in family functioning over time related to the loss.  Unfortunately, the researchers did not elaborate on how the family’s functioning decreased. 

Although this study was rich in data, it is based on a father=s memory of what happened.  Furthermore, the study may also have a self-selection bias.  Fathers who were less able to talk about their feelings or who had more severe reactions to the loss may not have volunteered for the study.  Additionally, this study only looked at the conscious experiences of these fathers.  Those fathers who were more defended against or who were not ready to talk about the loss may not have expressed their feelings about it.  Therefore, it would behoove of researchers to look at the unconscious experiences of fathers after perinatal loss.  Instead of using instruments that takes just a snapshot of one point in time of their conscious experiences, the present study will take a more open-ended, in-depth approach. 

Clearly, more research is needed on men=s grief following a perinatal loss.  Currently, there is a lack of validated instruments to measure the men=s grief.   Before valid instruments can be created, more research is necessary to understand men’s grief reactions following perinatal loss. 

Mitigating Factors that Influence Men’s Experiences of Perinatal Loss

The Influence of Ultrasound Scans on Grief.  Many theorists believe the use of ultrasound scans during pregnancy accelerates a father=s attachment to a fetus, and may increase his level of grief following a perinatal loss.  In a study of fathers= grief responses to miscarriage, Johnson and Puddifoot (1996) found that fathers who have seen an ultrasound scan of their baby experienced higher levels of grief than those fathers who did not see an ultrasound.  In a subsequent exploratory study, Puddifoot and Johnson (1997) interviewed 20 fathers following a miscarriage, discovering three effects of ultrasound scans: (1) they increase the reality of the existence of the baby; (2) they allowed fathers to become more involved with the pregnancy; and (3) they increased the levels of grief when a miscarriage occurred.  Although this study is useful in that it gathered first-hand experience reported by the fathers, it had a small sample size.  Therefore, the generalizability of these results is limited.  Beutal et al. (1996) conducted a study looking at the similarities and differences between couples= grief reactions following ultrasounds.  He found that while mothers were more attached to babies, fathers were not as strongly influenced by seeing an ultrasound. 

Aiming to further explore the influence of ultrasound scans, Johnson and Puddifoot (1998) conducted another study to see if the vividness of visual imagery is a mediating factor in fathers’grief responses.  In other words, they wanted to find out if seeing an ultrasound scan of their baby during pregnancy influenced the vividness of the visual imagery of their baby.  Did men who had more vivid visual images of their baby had higher grief reactions to miscarriage? The rationale behind looking at the visual imagery of the fathers is that previous research has documented that more vivid images of the baby after an ultrasound scan is associated with a stronger bond with the baby (Puddifoot & Johnson, 1997). Using the Baby Vividness of Visual Imagery Questionnaire and the Perinatal Grief Scale, the results of this study supported the authors’ hypotheses that the men who had seen an in utero ultrasound scan of their baby were more likely to have more vivid visual images of their baby, and those men with more vivid visual images exhibited significantly higher levels of grief.

This study is useful in that it emphasizes the influence that ultrasound scans have on the visual images men have of their baby, and how these visual images impact the degree of grief after a miscarriage.  However, this study took place in the United Kingdom; thus the cultural uniqueness of these men, as well as the different health care systems must be considered in terms of being able to generalize these findings.  Additionally, it could be speculated that the types of men who are willing to see an ultrasound scan are men who are more interested in their babies, and therefore  might have higher grief reactions to their miscarriages even if they did not see the ultrasound scan.  Finally, the majority of studies that look at the influence of seeing ultrasound scans on grief only look at miscarriages. The influence of ultrasound scans on grief of stillbirths, and Sudden Infant Death Syndrome are largely ignored.  One might speculate that these losses might be even more devastating for fathers if they began to attach earlier through ultrasound scans.  More research is needed on the influence of seeing ultrasound scans on grief following perinatal loss.

Men and Their Role as Supporters.  It has been reported that support networks are beneficial in facilitating grief subsequent to perinatal loss (Cordell & Thomas, 1990; Dyregrove & Mattieson, 1987; Mandel, McAnulty, & Reece, 1980).  Parents have a greater need for support following perinatal loss as such experiences increase their vulnerability and decrease their coping resources (Leon, 1992).  Without support, they have higher psychological morbidity (Lee & Slade, 1996) and higher levels of grief (Zeanah, 1995).  

The literature on perinatal loss has emphasized the impact that perinatal loss has on mothers and the need for husbands to support their wives.   Fathers have not been seen as individuals who mourn the loss, but as supporters to their wives following the loss (Johnson & Puddifoot, 1996).

This lack of recognition of fathers begins long before a perinatal loss occurs.  From the beginning of pregnancy, fathers are not considered a significant part of the childbirth process. The father is often given subtle messages from his peers and family that he is not as credible as his wife as a parent (Shapiro, 1995).  An ongoing message to men is that their role is to protect and support their wives (Jordan, 1990).  While men often turn to their wives for support during pregnancy  (Shapiro, 1995), their wives may be preoccupied with their own needs, such as a changing body and new emotions about becoming a parent.   Even at the birth of their child, fathers often take a passive role as a protector and supporter  (May & Perrin, 1985).  In a study looking at the experience of expectant and new fathers, many fathers felt unrecognized as a parent, felt that health care workers only considered their wife and baby, and felt excluded from parenting their child (Jordan, 1990).

Summary and Conclusions       

Within the literature, there is debate about how fathers grieve after a perinatal loss. Some researchers believe that fathers grieve little and less than mothers do, because they have less of an attachment to the fetus.  Other researchers believe that they have different ways of coping and expressing their emotions about the loss.  For instance, they may fail to express their emotions, underreport their symptoms, struggle to acknowledge that they have any grief, or be “Minimizers” and not be consciously grieving.  Furthermore, fathers may also intellectualize their grief, increase their alcohol consumption to numb their grief, or take a managerial role to avoid their own feelings about the loss (i.e. take care of wife=s needs). 

Much of the existing literature has failed to take into account the unique ways fathers have of coping with reproductive loss.  The measures used tap into overt grief,  anxiety, and depression.  However, they may not be capturing the full experience of grief for fathers. Thus, it is possible that fathers have more intense grief reactions to perinatal loss than is documented in the literature.     

To understand how fathers grieve a perinatal loss, several issues must be considered.  First, because the construct used to measure fathers= grief may be inaccurate, new ways of measurement need to be applied to the research.  Second, perinatal loss is a unique type of loss because it involves losing someone who is the part of oneself, and requires the parents to grieve for someone who they have no or few clear memories of. Thus, grieving can be difficult. Third, perinatal loss often occurs in the context of new or expectant fatherhood, which has been documented to be a time when men regress and rework object relations.  Hence, the loss of their baby occurs in an already regressed state, causing a Acrisis within a crisis@.

The problems with the current research as well as the complicated nature of perinatal loss suggests the need to explore this phenomenon more fully. This study will use a broad approach in examining fathers= grief, focusing on their conscious and unconscious experiences.  By using a qualitative design, this dissertation will attempt to create a more accurate construct of fathers= grief in the hope of laying the foundation for future quantitative research.


Chapter III

Method and Procedure



            This study used a qualitative approach to examine five fathers after they had lost a baby through a neonatal death, stillbirth, or Sudden Infant Death Syndrome (SIDS). While this is a relatively small sample even for a qualitative study, it is important to keep in mind that the goal was not primarily of generalization.  Rather, this researcher had decided in advance to use a limited number of participants in order to investigate and illustrate in maximum detail the themes that were discussed in the literature.  The following inclusion and exclusion criteria were implemented to specify the focus and parameters of this study.  Any individual who did not meet these criteria was given appropriate referrals (i.e., Psychotherapists in the community; support group).

Inclusion Criteria.

1.  Any married or single male who, within the last four years, had lost a baby less than

one year old through Sudden Infant Death Syndrome (SIDS), ectopic pregnancy,

miscarriage, neonatal death, or stillbirth was included in the study.

2.  Because this researcher is aware that the expression of grief depends upon one’s

cultural traditions and practices, this study used participants from the same cultural and

ethnic background (i.e., men of European decent born in the United States).  Therefore,

these findings do not generalize to men in other cultures.

Exclusion Criteria.

1.  Those individuals meeting the criteria for a Substance Abuse or Dependence

diagnosis, not in sustained full remission (over one year sobriety), based on the American

Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth

edition, 1994 criteria, was excluded.  All individuals were given a phone screen that

assessed for substance abuse and dependence.  If they met the criteria for either substance

abuse or dependence, they were excluded from the study.

2.  Any individual showing evidence of a psychotic process (i.e.,  flight of ideas,

ideas of reference, delusional thinking, hallucinations) in the initial screening or during

the interviews, were excluded.  Participants were asked about psychiatric hospitalizations

and medications.  If any of the potential participants exhibited any of the above signs or

symptoms and are not stabilized on medication, they were excluded.

3.  Any individual at risk for suicide as determined by this evaluator by assessing the

history of past suicide attempts and/or current suicidal ideation was excluded.

4.  Any individual who lost a child, who was at least one year old, was excluded from the



            In the present study, an attempt was made to examine fathers’ conscious experiences and unconscious, defended, and indirectly expressed aspects of their experiences.  Conscious experiences were obtained through semi-structured interviews and the Perinatal Grief Scale.  This study investigated each participant’s unconscious experiences through the Thematic Apperception Test (T.A.T.), the human form of the Children’s Apperception Test (C.A.T.-H), and a semi-structured interview.  The following sections provide a more thorough explanation of each instrument.

            Semi-structured Interview.  The interview had a semi-structured format, meaning that some of the questions were predetermined, and some of the questions were dependent on the direction of the interview. An interview guide (Appendix A) was created through the following process.  First, the researcher decided on the main areas central to this study.  These areas were determined by reviewing the literature on perinatal loss and through consulting with dissertation committee members.  Second, this researcher wrote out questions.  Third, the committee members read the questions and made suggestions for revisions.  Then this researcher modified the questions.  This process was repeated about four times.  Last, a final interview guide was solidified.

            In the interview, this researcher began by asking an open-ended question, and gradually moved toward more specific questions.  The rationale for beginning with an open-ended question is that it allowed each participant to engage in conversation with the interviewer, and limited the use of Ayes or no@ responses (Maykut & Morehouse, 1994).  By gradually working toward more specific questions, the researcher provided an opportunity for those men who had difficulty with open-ended questions to answer in a more comfortable manner.  Furthermore, this procedure ensured that all of the pertinent questions about fathers and perinatal loss were addressed.  The four main open-ended questions that were created for the interview are as follows: (a) “Tell me about the loss,” (b) “Tell me what you thought about having children before your partner was pregnant,” (c) “Tell me what you thought having a baby would be like when you were growing up,” and (d) “Tell me about the pregnancy.” Each of these questions had at least two or three levels of more specific questions that followed.  For example, after asking the individual to ATell me what you thought of having children before your wife was pregnant,@ the researcher asked a slightly more specific question, such as, AWhat were your thoughts and attitudes about having a baby,@ and then asked an even more specific question, ASome men feel excited, some feel unhappy, some feel afraid, and some men feel ambivalent about having a baby. What about with you?@  The interviewer was aware that some subjects require more prompting than others do; therefore, the interview guide was designed to adapt to the subjects’ needs for more or less questioning.

Essentially, the semi-structured interview aimed to gain information about the following topics:  (a) the experience/circumstances of the perinatal loss, (b) the experience of the pregnancy for the father, (c) the desires and fantasies about having children, (d) the way life has changed/not changed following the loss, and (e) future plans.

Perinatal Grief Scale.  The short version of the PGS, (Appendix B), used in the current study, was created by Toedter and Lasker in 1988.  The PGS is a 33-item Likert-type scale that is used specifically for pregnancy-related loss.  It has items that vary from strongly agree (1) to strongly disagree (5).  The original version of the PGS originally had 104 items.  However, the final version had reduced the number of items to 84, thereby increasing the psychometric properties of the measure (Potvin, Lasker, & Toedter, 1989).

There were no clear criteria or closely related existing instruments with which to compare the PGS, so it was validated through a method created by Cronbach and Meehl in 1959 (Toedter Lasker, & Alhadeff, 1988). The Cronbach and Meehl method used constructs created in previous literature that were thought to be important in predicting perinatal grief and combined key constructs, resulting in a new instrument. As an 84-item scale, the PGS was shown to be reliable with a .97 alpha coefficient. Because the authors of the scale felt that it was still too long to be utilized by researchers and clinicians, they dropped items that were not highly correlated with most of the other items. This change resulted in the short version of the PGS, which has three subscales, each consisting of 11 items. Each subscale of the short version of the PGS has at least a .85 reliability alpha coefficient, suggesting that each subscale is internally consistent. Although the long version has been validated on men, the short version of the scale has not. (Potvin, Lasker, & Toedter, 1989).  Moreover, only three men were willing to participate in the validation study of the long version of the PGS.  Perhaps the men who did not participate in the study had reactions that were different from those of the men who were willing to participate. Thus, this instrument may not have accurately assessed the grief experiences among the fathers in this study. Due to these limitations of the PGS and the exploratory nature of this dissertation, the PGS was supplemented by other sources of information.  That is, the semi-structured interview, the T.A.T., and the C.A.T.-H were also used.

The short version of the PGS contains three subscales entitled active grief, difficulty coping, and despair. These subscales were created to differentiate milder grief reactions from more debilitating and longer-lasting reactions from perinatal loss (Potvin, Lasker, & Toedter, 1989). AActive grief,@ which is not considered to be severe, is also

known as Anormal grief.@  This subscale includes questions regarding sadness, missing the infant, and crying for the baby.  ADifficulty coping@ suggests a hard time dealing with people and with activities. It is believed to indicate a more severe depression because the individual is withdrawing from others, and having trouble functioning with daily life.  ADespair@ indicates more serious and long-lasting detrimental effects of the loss. It is believed that the severity of an individual’s grief can be assessed based on his or her highest subscale score.  Therefore, the three subscales can be seen to reflect a continuum of grief that ranges from active grief to despair, reflecting the particular view of grief of the PGS authors. Because Potvin, Lasker, and Toedter’s model of grief is not the only one in the literature, this dissertation used the PGS in an exploratory way to see if it is a useful dimension in capturing grief in men. 

The T.A.T. and the C.A.T.- H.  The interview and the Perinatal Grief Scale were supplemented by selected cards of two projective instruments:   the Thematic Apperception Test (T.A.T.) and the human form of the Children=s Apperception Test (C.A.T.-H).

 Bellak and Abrams (1997) described the evolution of the T.A.T. and the C.A.T-H.  According to these authors, Henry Murray created the T.A.T. in 1943.   His instrument, still used today, consists of thirty black and white drawings that suggest various emotional themes (Bellak & Abrams, 1997).  In 1948, Leopold Bellak and Sonya Sorel developed the C.A.T. for children because they thought that children might identify more with pictures of animals than with pictures of people.  Because some children responded better to human figures than to animal figures, Bellak and Bellak modified the C.A.T. to human form (C.A.T.-H) in 1965.

            The T.A.T. is based on the assumption that an individual=s unconscious thoughts and feelings may be revealed in disguised ways through the stories told about these pictures.  Numerous studies have used the T.A.T., however only a few of those studies have had topics that were similar to this dissertation.  For instance, Ballou (1978) examined the significance of reconciliative themes during pregnancy in women.  By using a projective device, such as the T.A.T., the study was able to look at the internal experiences of women during pregnancy.  Similarly, Klatskin and Eron (1970) compared the projective content of pregnant women to their adjustment during the postpartum period.  The T.A.T. enabled the researchers to examine the women=s feminine identification as well as their acceptance of their pregnancy by looking for stories with positive female role themes. While most of this research has looked at women, the T.A.T. has been used in numerous studies on both men and women (Bellak & Abrams, 1997).

The C.A.T.-H, a descendent of the T.A.T., is an apperceptive test that was created by Bellak and Bellak in 1965 for children (Abrams & Bellak, 1997).  In its original form, the C.A.T. included ten black and white plates depicting animals in diverse situations that elicited various emotional themes.  The C.A.T.-H is the human modification of the C.A.T.  It has pictures that suggest similar emotional themes to the C.A.T., however they have humans instead of animals in them.  Analogous to the T.A.T., the C.A.T.-H is based on the assumption that an individual=s unconscious thoughts and feelings may be revealed in disguised ways through the stories told to these pictures.   The rationale for using this instrument as a supplement for the T.A.T. is that this researcher believes that the pictures of young children on the cards may evoke themes related to perinatal loss.  Although this projective test was designed for children, there has been some speculation that it can also be useful for adults (Kitron & Benziman as cited in Bellak & Abrams, 1997). Because there is no research supporting the use of the C.A.T.- H for fathers after a perinatal loss, this researcher used this instrument as an experimental method.

Questions [T2] [T3] of reliability and validity depend heavily on the context and purpose for which they are being used.  A variety of different coding scoring systems of satisfactory inter-rater reliability has been developed for the T.A.T. (Bellak & Abrams, 1997).  Validity of various constructs measured by this test has also been examined in a variety of ways.  Prior research on reliability and validity of these tests in not of central relevance in the present study, however, because this dissertation did not primarily aim to measure predetermined variables.  Rather, this study used these instruments in a qualitative fashion to gain indirect information about participants’ feelings and reactions that they may be attempting to deny or defend against in the interview and the direct self-report measure.  In this study, these instruments were used in the same fashion as any clinical evaluation. 

The following section describes the specific parts of the instruments that were used in the present study. Three cards from both the T.A.T. and the C.A.T.-H were administered.  The cards were chosen based on emotional themes related to this topic (i.e., children, loss, etc.). The primary investigator and the dissertation committee identified these emotional themes, which are largely based on the literature.  Pictures 2, 3BM, and 7GF of the T.A.T. were used, and  pictures 3, 5, and 9 of the C.A.T.-H were used.  Picture 2 on the T.A.T. is a country scene in which a young woman holds books in the foreground.  In the background of this picture, a man is working in the fields, and an older woman (who looks pregnant to some people) is looking at him.  This card elicits themes concerning identity, family relations and possibly pregnancy (Bellak & Abrams, 1997).  Picture 3BM has a boy huddled against a couch with his head leaning on his arm.  There is a revolver next to him on the floor.  This image typically elicits themes of anger, denial, and depression (Bellak & Abrams, 1997).  Card 7GF has an older woman sitting beside a young girl on a sofa.  The woman is reading or talking to the girl.  The young girl is holding a doll on her lap and looking away.  This picture evokes feelings about becoming a parent (Bellak & Abrams, 1997).

On the C.A.T.-H, card 3 has a picture of a man sitting in a chair with a pipe and a cane.  On his right side, there is a little boy sitting on the floor looking up at him.  This card aims to elicit themes about male identity.  Card 5 has a picture of a dark room with two babies sitting in a crib.  This card may elicit themes directly related to the loss of a baby.  Card 9 has a picture of a dark room with a child in his bed/crib facing toward the door.  This illustration pulls for themes of deserting a child or being deserted. The rationale for using these two projective devices is that they assess thematic content and interpersonal themes. Although systematic, far-reaching conclusions cannot be made from these projective instruments, these tests were used as another source of data and as an attempt to approximate more information than may be obtained from a clinical interview.  Because these projective instruments have not previously been used to assess feelings surrounding perinatal loss in males, the use of them in this study was an experimental procedure. This study aimed to obtain information that future studies can test more systematically.


            The five men used in this study were given a semi-structured interview, the short version of the Perinatal Grief Scale (PGS), and selected cards from the human form of the Children=s Apperception Test (C.A.T.-H) and from the Thematic Apperception Test (T.A.T).  This process required a telephone screen, which lasted between ten and twenty minutes, and two visits, which lasted approximately one to one and a half-hours each. All of the visits were conducted at the Center for Applied Behavioral Services at the California School of Professional Psychology at the San Diego Campus (CSPP-SD).

            This researcher recruited participants in the following ways: 1) by contacting local perinatal loss and SIDS support groups for referrals; 2) by attending a perinatal loss support group and giving out dissertation flyers (Appendix C); and 3) by placing an advertisement (Appendix D) in a newsletter for a perinatal loss support group network.

            The telephone screen was implemented to ensure that all of the potential participants met the criteria for the study. The potential participants were asked about the type of loss they experienced (to ensure they meet the criteria), past and current medications, history of psychological treatment, and history of psychiatric treatment. They were also assessed for past and/or current suicidal ideation and attempts, substance abuse and dependence, and psychotic symptoms.  If the participant met the criteria for the study, he was given information about the purpose of the study, and he was educated about the basic tenants of the informed consent form and the audiotape consent form. Once the individual was accepted into the study, his first interview was scheduled.

            The researcher monitored each participant’s distress level, emotional state, and diagnostic status during the first meeting.  If it was obvious that a person was extremely distressed or unstable, the interview or testing would have been discontinued and an attempt would have been made to get the participant what he needs.  However, no participants displayed this level of distress.

The first meeting began with an explanation of the purpose of the study:  A I am currently doing research on fathers and perinatal loss.  I would like to understand more about what it is like for fathers to lose their baby through Sudden Infant Death Syndrome, stillbirth, miscarriage, and ectopic pregnancy.@  The process of the two visits was described with the following statements: AToday, for about two hours, we will briefly go over some paperwork, fill out a questionnaire, and then begin the interview. During our next visit, which will also be about two hours, I will show you some pictures for you to tell me a story about and then we will finish the interview.@  After discussing the study, the researcher gave the participant a full explanation of both the informed consent form (Appendix E) and the audiotape consent form  (Appendix F).  In addition, the participant was given a copy of the ASubject Bill of Rights@ (Appendix G).  After signing the forms, the participant filled out the PGS. 

            The initial phase of the interview focused on building rapport.  The purpose of building rapport was to increase the level of comfort between the participant and the researcher, and to acknowledge the difficulties and pain of telling a stranger about the loss of his baby.  Once rapport had been established, the participant was asked an open-ended question, ATell me about the loss.@  This question allowed the participant to talk about memories of the loss.  Once the participant disclosed some memories, he was asked the question, ATell me how your baby died.@  Because the content of the discussion was distressing at that point, the remainder of the interview proceeded slowly.  Follow-up questions that address how life has changed since the loss, how thoughts and feelings have changed since the loss, how feelings have been expressed about the loss, and how relationships have changed since the loss were also asked. 

On the second visit the participants were given three cards from the T.A.T., three cards from the C.A.T.-H, and then completed the semi-structured interview.  The standard administration recommended by Bellak and Abrams (1997) was utilized.  That is, the participants were given the following directions: 

This is a test of imagination, one form of intelligence.  I am going to show you some pictures, one at a time; and your task will be to make up as dramatic a story as you can for each.  Tell what has led up to the event shown in the picture, describe what is happening at the moment, what the characters are feeling and thinking, and then give the outcome.  Speak your thoughts as they come to your mind.  Do you understand?  Since you have 30 [number has been changed] minutes for 6 [number changed] pictures, you can devote about five minutes to make up a story (Bellak & Abrams, 1997, p. 54).

Because the number of cards administered in this study was less than those in Bellak and Abram’s directions, the number of cards and minutes in the above directions were changed. 

The sequence of the card administration was as follows.  First, cards 2, 3BM, and 7GF of the T.A.T. were administered. Then, cards 3, 5, and 9 of the C.A.T.-H were administered.

Once the testing was finished, the remainder of the interview began.  This portion of the interview focused on the experience of the father before and after the pregnancy. By focusing on these experiences, the researcher was able to assess how the fathers= experience of pregnancy related to his experience of the loss.  For example, this researcher found that one father was extremely ambivalent about his wife becoming pregnant, and was somewhat relieved about the loss.

As with the first meeting, the second interview began by establishing rapport.  Once rapport was established, the researcher asked an open-ended question.  The researcher said, ATell me about the pregnancy.@  This statement allowed the participant to disclose memories about his partner’s pregnancy.  The researcher then followed-up with a more specific question, AWhat went through your mind when you first found out she was pregnant?@  Questions that followed addressed the participant=s attitudes as a child about having a baby, his thoughts just prior to his wife=s pregnancy, and how his thoughts and attitudes changed when she started to show.  In addition, the researcher inquired about the participant’s future plans of having children.

At the conclusion of the interview, the participant was asked about his reactions to the study, AWhat was it like to discuss this difficult life event with a stranger?@  All participants were given a list of referrals to therapists (sliding scale if necessary) that specialize in reproductive loss. Data from the interviews were used to identify themes in these individuals' experiences of their perinatal loss.

Analysis of Data

            Interview Data.  This study used Maykut and Morehouse’s (1994) constant comparative method to qualitatively analyze the interview data.  The goal of the data analysis was to identify common themes in the experience of fathers who have lost a child through SIDS, a stillbirth, or a neonatal death. The following paragraphs provide a step-by-step description of how this researcher utilized Maykut and Morehouse’s (1994) constant comparative method to extract common themes from the interview data on these fathers’ experiences of perinatal loss.

            The researcher began the data analysis by carefully transcribing the audiotapes to create interview transcripts.  Every effort was made to ensure that the tapes were transcribed accurately. Each page was numbered and labeled with the participant’s first initial (of his fictitious name) in the upper right hand corner. 

            The investigator then carefully read the data to extract themes.  The first reading aimed to gain a general idea of the themes. The second reading focused on identifying “units of meaning,” which are words, phrases, or groups of phrases that appeared relevant to the focus of study (Maykut and Morehouse, 1994).  For instance, Karl’s statement, “It’s a sunny day,” was not coded as a unit of meaning because it did not appear relevant to this study.  However, Karl’s statement, “I feel some guilt,” was coded as a unit of meaning because it was relevant to the focus of inquiry.  Units of meaning not only come from actual statements, but can also be inferred from a statement (Maykut and Morehouse, 1994).  For example, from Dennis’s statement, “My mother told me Susan [deceased daughter] didn’t matter.  Yeah, she told me that she didn’t matter and get on with life.  This is right after we had her,” this researcher inferred that Dennis felt angry toward his mother. 

            This researcher carefully read each transcript, looking for units of meaning.  All units of meaning were bracketed, and  the “essence” of the unit, as well as the participant’s first initial, and the page number, was written to the left of the bracket in the margin.  Each unit was then cut apart and taped onto separate 5” x 8” index cards.  Approximately 95% of the interview data was identified as a unit of meaning and placed on these cards. 

            A “discovery sheet,” or a “list of potentially important ideas, concepts, or themes” (Maykut and Morehouse, 1994) was then created.  The researcher listed her general impressions from the interview, the general themes extracted from the first transcript reading, and more specific themes identified from the second transcript reading on the sheet. 

            The researcher then began to create categories from the data.  The discovery sheet was reviewed, and one theme from the list was chosen.  That theme was written in large letters on a blank index card, and taped to the wall as the first provisional category.  The researcher then carefully reviewed each index card, choosing the cards that “looked alike” or “felt like” the first category, and taped them under the provisional category on the wall of the investigator’s office.  The investigator repeated this process, creating categories from both the discovery sheet and from the cards themselves, until all of the cards were taped onto the walls, totaling approximately 400 categorized cards. Occasionally, a card did not fit any category.  In this case, the researcher either created either a new category or expanded the parameter of an existing category.  Several cards neither fit any category, nor did they have enough information to create a new one.  Those cards were placed in the “miscellaneous” category for later review.  The researcher then reviewed all of the cards, combining or splitting up categories as necessary. 

            The cards were then removed from the wall. The cards were put in a separate pile for each category and held together with an elastic band.  A top card was created for each category, with the name or “essence” of the cards written on it, as well as the number of cards and first initial of each participant whose card was in the that particular category.

            Lastly, the researcher reviewed each transcript again, searching for any themes that may have been missed the first two times, and noting the order in which each participant experienced his reactions.

PGS Scoring. This researcher scored the PGS by using the standard method created for this instrument (Potvin, Lasker, & Toedter, 1988). The total PGS score was determined by first reversing thirty-one of the thirty-three items, and then adding the scores together.  To determine the subscale scores, the items in each factor (active grief, difficulty in coping, and despair) were added together. Because official norms have not yet been created for this scale, each participant’s scores were compared to the means and standard deviations in Potvin, Lasker, and Toedter’s (1989) validation study.

The T.A.T. and C.A.T.-H Data Analysis. This researcher administered the T.A.T and the C.A.T-H.  All responses were audiotaped and carefully transcribed. To establish some degree of inter-rater reliability of the tests, three judges were used to identify themes.  All three clinical judges were male, and chosen based on their extensive knowledge and numerous years of experience with these tests.  These raters were given a copy of the directions used for administration, along with the following instructions for rating: “Rate each story to identify the three most salient themes, the degree of distress, and the amount and nature of the defenses.” Each judge was blind to the topic of study, and rated the stories independently of the other judges.

Rationale for the Use of Qualitative Research

The rationale for applying the qualitative, rather than the quantitative, method of research on fathers’ experience of perinatal loss was that few studies have thoroughly studied this topic.  In fact, an abundance of the literature has focused on the mother's grief following perinatal loss.  When studies have looked at fathers, they have used the same measures for mothers as they have used for the fathers.  There is some evidence that fathers may have a qualitatively different grief response to this loss than mothers.  For instance, Vance, et al. (1995) found that when adding a measure of alcohol ingestion to the more typical measures of grief, depression and anxiety, men had just as much distress as their female counterparts.  Thus, we can conclude the indices typically used to measure grief reactions of mothers following perinatal loss may not fully capture the grief in fathers.  It is possible that men have some unique reactions to perinatal loss that quantitative studies are not yet measuring, so this dissertation aimed to gain a more thorough understanding of the fathers' experience of perinatal loss and identify pertinent psychological themes in these men.  An interview, projective instruments, and the Perinatal Grief Scale allowed the researcher to explore the issues surrounding perinatal loss and fathers in more depth than if a single hypothesis was tested in a quantitative study. This dissertation aimed to identify themes in men that can later be used to quantitatively measure grief in men. 

Protection of Human Subjects

The informed consent forms included all regulations relevant to psychotherapy and testing, such as the limits of confidentiality, Tarasoff, and mandated child and elder abuse reporting.  Confidentiality was protected by omitting names and by altering identifying information (such as profession, age, and family constellation). Audiotapes were held in strict confidence in a locked file and only supervising faculty and doctoral students involved with the project were allowed to hear the tapes.  Tapes and written notes were destroyed when they were no longer needed.

            As with psychotherapy and psychological testing, risks associated with this study were moderate. The semi-structured interview and the projective instruments may have triggered painful issues.   The information that was discussed was naturally emotionally laden.  If any participant had displayed moderate signs of distress, this researcher would have ended the interview, provided the opportunity for discussion, and given appropriate referrals. No participants, however, displayed this level of distress. In fact, four out of the five participants reported that they had benefited from participating in this study because it validated their experience, giving them a chance to process the loss.


Chapter IV



Description of the Sample


Participants consisted of five men who had lost an infant/s due to a miscarriage, stillbirth, neonatal death, and/or Sudden Infant Death Syndrome within the last three years.   Four of these men were recruited from a perinatal loss support group network, while the other man was recruited from a SIDS support group network.


Participants reported the following demographic information during their first meeting (See Table I).  All of these men were born in the United States.  Three reported that they identified as “Caucasian,” one reported that he identified as “Irish/Swedish,” and one reported that he identified as “Italian/Slavic.”  Four out of the five participants identified their religious affiliation, which included Christian, Episcopalian, Protestant, and Catholic.  Education levels varied:  two had master’s degrees, two had bachelor’s degrees, and one had a high school diploma.  Ages ranged from late twenties to middle forties.  All participants were married and were employed.  Socioeconomic status ranged from lower middle class to middle class.  

The types of losses incurred by these men varied (see Figure 1).  Four of the five men lost a baby to a stillbirth, neonatal death, or SIDS.  One man had two losses:  a miscarriage and a stillbirth. The age of these babies at their time of death ranged from eleven weeks into the pregnancy to four months after the birth.  Two of the participants had previous children at the time of the loss, and two participants have had a subsequent child since the loss.  The amount of time elapsed since the loss occurred ranged from three to thirty-six months (see Figure 2).




Table I.

Demographic Information


Religious Affiliation





High School Diploma





Bachelor’s Degree





Master’s Degree




Not Specified

Master’s Degree





Bachelor’s Degree


Figure I.  Type of loss





Neonatal Death































Figure II.  Time elapsed since loss


Number of months

Individual Analysis

Each participant’s loss experience was unique in nature; therefore, this section provides an individual analysis of every participant based on the interviews, the PGS, the T.A.T., and the C.A.T.-H.  A later section will summarize common themes among all of these men. 

            To fully illustrate the context of each man’s loss, these sections begin with a background that includes demographic information, the recruitment process, and a description of how the baby died. These sections then summarize the interviews, describing each participant’s experiences in chronological order.  Each interview is broken down into subsections, specifying the time frame in which particular reactions occurred.  The subsections for each participant vary slightly to accommodate each participant’s particular time frame.  For example, it had been three years since Dennis’s (participant one’s) loss, so his interview section was separated to include his initial responses to his baby’s death, the first year of her death, and beyond the first year of her death.  In contrast, Peter’s (participant four’s) baby had died only four months before the interview, so his interview description was separated into initial reactions to the loss and the first four months after her death.  Ryan (participant five) had two losses; therefore, his individual analysis has separate subsections for each of his losses.

Each interview description is written in as much detail as told by the participant; therefore, the length of these sections vary.  To fully illustrate each individual’s experiences, quotes have been used generously in the individual analysis.

            Following the description of each participant’s interview, the scores of the PGS and a table presenting all three raters’ analyses of the T.AT. and the C.A.T.-H have been presented.  An integration of all four sources of data will be discussed in Chapter five.



Participant One:  Dennis
Background Information

Demographic Information.  Dennis, a thirty-six year-old[1], Euro-American, Christian male, participated in the present investigation because he had a stillborn daughter, Susan, three years ago.  He identifies as a Christian and works as a truck driver for a construction company.  He has been married to his wife, Tammy, for twelve years.  They have four living children, ages ten, eight, five, and one and a half.  Tammy is currently six months pregnant. 

Recruitment Process.  Dennis was recruited from a perinatal loss support group in San Diego.  When Dennis was “on call” for the group’s hotline, this investigator called to find out how to advertise for participants in their newsletter.  After being informed of the research topic, Dennis expressed interest in participating in the study himself.  During this phone conversation, he explained how he continued to miss his stillborn baby, Susan, and how her birthday was coming up.  Dennis expressed excitement over the study, stating, “This is really great that you are doing this because dads are often ignored after a stillbirth.” After conducting a telephone screen to ensure that Dennis met the requirements for the study, the investigator scheduled the first meeting.

Description of the  Loss.   Dennis’s daughter, Susan, was stillborn three years ago.  Dennis first learned that Susan had physical problems and might die when he and his wife, Tammy, attended a routine doctor’s appointment during the pregnancy (he did not specify how far along she was into the pregnancy).  After doing a “high level” ultrasound, the doctor told Dennis and Tammy that Susan had several physical problems, such as Hydrocephalus as well as an inability to swallow because she did not have an esophagus.  Although Susan was still alive, she was not going to live for long.

            To find out if Susan’s physical problems were genetic, Tammy underwent an amniocentesis.  This common procedure, which consists of drawing a sample of amniotic fluid, tests for a genetic etiology for fetal abnormalities (Dennis never reported the results of this procedure).  After Dennis and Tammy got home from the procedure, Tammy felt Susan kicking and turning around a lot.  The next day she did not feel her move.  One week later, on Dennis’s birthday, Dennis and Tammy went to a sonogram appointment to “confirm that Susan was still alive.”  However, Dennis and Tammy learned that Susan had died.

            The next day, Dennis and Tammy went to the hospital to deliver Susan.  Tammy had an epidural.  She then “got sick” and started vomiting.  Because he has a “weak stomach,” Dennis left the room.  As Tammy vomited, she gave birth to Susan and yelled, “Susan’s here.”  Dennis ran into the room and saw Susan lying face-down on the hospital bed.

The Interview

The interview occurred in two sessions, one week apart.  The first meeting lasted one and one-half hours while the second meeting lasted one hour.  Dennis was articulate and answered questions enthusiastically throughout both interviews.  When he described the loss, he was tearful and provided great detail.  He repeatedly stated that he missed Susan “a whole lot.”

The following several paragraphs summarize Dennis’s interview, describing his desire for children, feelings about his wife’s pregnancy, his initial responses to Susan’s death, his responses for the first year after her death, and his responses three years after her death. Later, sections that summarize his PGS scores and his projective test results will be presented.

            Desire for Children.  One of Dennis’s most apparent themes was his strong desire to have children.  As early as age ten, he wanted “six or more” children.  Illustrating Dennis’s desire is a memory that he described from when he was twelve.  He stated, “I remember looking at the baby bottle going down the aisles shopping.  And I said to my mom, ‘You know, I can’t wait until I have a baby.’  So I always wanted kids.”  In addition to thinking about having children, Dennis also imagined what he would be like as a father.  He fantasized about being a “cool dad” as well as being like his own father (he did not describe his own father).  

            Dennis’s Experiences During the Pregnancy.  Dennis experienced a variety of strong feelings about his wife’s pregnancy.  He was glad that she was pregnant, stating repeatedly, “I think it’s cool and love when she is pregnant.”  He enjoyed hugging her when she was pregnant because “I hold her and she just feels sturdier . . . like there’s something to hold on to.” Another emotion that Dennis described was anxiety.  He was scared that his wife might become sick or die from medical complications.  In addition, he described a sense of responsibility for his wife’s welfare during her pregnancy, stating, “When she get’s morning sickness I feel like it’s my fault because it’s my baby.”    Dennis felt that if his wife was injured or died during the pregnancy, he would feel guilty because it was his “fault” that she was pregnant. 

            An important experience for Dennis during the pregnancy was being able to bond with his baby while she was still alive.  He was excited to be able to see her move (in utero) before she died.  The following statements further illustrate this bonding experience:

The times I felt Susan – my wife would put a cereal bowl on her, cereal bowl on her in the evening when she had cereal.  I remember putting the bowl on her tummy and she’s kicking.  The bowl would move.  And that was the only time I got to see her . . .do something.  You know, like move.  You know . . .move.

            Initial Responses to Susan’s Death.  When Dennis first learned that Susan had died, he used denial to postpone facing her death. To illustrate, he described his thoughts when he first found out: “They were wrong.  They had to be wrong.  Even though it was a doctor looking at our baby right there, I was in denial up until I held her in my arms.”

            Another one of Dennis’s early thoughts upon learning that Susan had died was that he had to be “strong” for his wife because he was afraid that his wife was going to “break down at any minute.”    Once Dennis began facing the reality of Susan’s death, he became anxious about her upcoming delivery.  Although his wife had given birth to three babies before Susan, he felt scared about what the delivery of a dead baby would be like.  Dennis also expressed anxiety over not knowing what Susan would look like when she was born.

            Immediately after his daughter, Susan, was delivered, Dennis felt numb.  This reaction  is best illustrated with his words:

All I could do was . . .there was a chair by the window like that one, and I took the chair and turned it around and I just, my wife said that I wept.  I didn’t cry or bawl, I wept.  When I was holding her I felt like I wanted to scream.  But I couldn’t.  It wasn’t a scream.  It didn’t come out.  I don’t know what.  I can’t describe the feeling.  But it was something in me that needed to come out.  And I couldn’t let it all out at once.  I can’t describe it.  It was a feeling that I hope I never experience again.  I couldn’t let it out.  It was like I wanted to scream, but that wasn’t it.  I wanted to scream, but I couldn’t.  And so, I just cried.

Another predominant emotion for Dennis was helplessness.  When he was holding Susan and she “didn’t look good,” he wanted to “do anything to make her feel better.”  However, he knew that “there was not anything I could do to help her.”

Dennis also expressed anger.  He felt angry with the doctor who delivered Susan because he referred to her as “the fetus,” rather than as a baby.  Dennis’s anger is reflected by him stating, “The doctor said, ‘Oh the fetus, there’s the fetus.’  And she wasn’t.  She was my baby.  She was my daughter.  And that was just lame of him to say.”   

After Susan’s birth, it was very important to Dennis that he spent as much time as he could with her.  It is likely that spending time with Susan enabled Dennis to bond and create clear memories with her, facilitating the mourning process.  Although he spent six hours with Susan, holding and cleaning her, Dennis felt that he did not have enough time with her.  Dennis said, “I wanted to stay as long as I could with her.” Dennis noted that the hardest part of that day with Susan was when it was time for him to leave the hospital because he did not want to leave Susan alone.  When describing how hard it was for him to leave Susan alone, Dennis explained, “I wouldn’t just lay her in the bassinet and just leave. Because she would be alone and I wouldn’t leave my other children alone.”

After leaving her at the hospital, Dennis continued to want to spend time with Susan.  One way that he felt that he would be able to “be with her” was to build her a casket. Dennis felt that by building Susan’s casket, he “would always be with her.”  Dennis’s strong feelings about building his daughter’s casket is best illustrated by the following statements:

I can’t ever hold her.  I mean, I can’t hold her anymore, and I wanted to do something for her.  I wanted to build her a casket because it was like the last, it is hard to explain, it was like the last thing I could do for her.  I can’t ever hold her in my arms again.  I held her for six hours and that was way too short.  But I can never hold her in my arms.  But if I build, I build her a casket and that was holding her, and that is what she’s in right now.  And so a part of me is in there with her.  You know, all the time.

Dennis’s strong desire to build Susan’s casket also reflected his need to protect and “to do something for her.” 

            Interestingly, Dennis described the casket with pride and great detail, as if it was his “baby.”  With tears, he provided the following description:

We put it together in the garage, my garage.  And we put a little cross on the top of it.  And some other friends, some friends of my wife’s, took it home and lacquered it, to seal it.  And they took it from there and had it upholstered.  And had it upholstered in pink satin and white lace, and on all the seams, on all of the corners, there was white lace going across.  And pink satin between it, and it was really beautiful, really beautiful.  We’ve got pictures of it and it was really beautiful.  Really beautiful.

Dennis’s desire to spend time with Susan continued through her funeral. He was very active, requesting to carry her from the car to the gravesite because “She’s my baby and I didn’t want someone else taking her without me.”

Dennis expressed sadness over burying Susan as it felt “unnatural” to bury his own child.  He had always expected that his children would be burying him, rather than that he would be burying his own child.  Dennis described his experience by stating, “You don’t expect to bury your kids.  I expect my kids to bury me and I expect to bury my parents.  And it’s so unnatural for you to bury you own kids.”

The First Year After the Loss.  Dennis primarily focused on taking care of his immediate family’s needs during the first year after Susan’s death.  He believed that focusing on their needs was a necessity because his wife was having difficulty coping with the loss:  She was not getting out of bed and not taking care of their young children.  Dennis grew concerned about his family’s welfare.  While he was at work, he constantly worried about his wife and children, frequently calling his house to see if they were okay.  Often, he left work early to check on his family, or asked his mother to go to his house and get Tammy out of  bed.

At this point, Dennis incurred “multiple losses” because he felt like he had not only lost Susan, but had also lost his wife and the mother of his children. He was concerned that his wife would never get better.  Additionally, Dennis continued to feel like he had to be the "strong” partner in his relationship because “if she was having a bad day, I couldn’t go home and have a bad day because the kids have to be taken care of.”

To be emotionally available to his family when he was home, Dennis hid his feelings about Susan’s death, and grieved primarily alone in his car.  While he was in the car, he listened to music and engaged in prospective mourning.  The following narrative illustrate Dennis’s prospective mourning:

Being alone in a truck for eight to nine hours a day, especially with a radio . . . and it played these sappy songs.  Butterfly Kisses. I can still listen to that one.  I don’t know if you know that song.  It’s about a guy, a song about a guy’s daughter who’s growing up and it goes from when she was a little girl until she’s a teenager.  And there’s other ones.  It was hard listening to that too.  And oh gosh, it was hard to be alone in a truck.

Dennis’s  most prominent emotions during the first year of grieving were anger and guilt.  When Dennis was asked who he felt the most angry at, he denied feeling angry at anyone in particular, “like God or my wife,” however, he later stated that he believed that his anger came from his “situation at home.”  Dennis also felt “ripped off” because “we went through the whole pregnancy and now we don’t get the baby.”

Although Dennis denied feeling guilty about his loss when he was directly asked, his guilt about Susan’s death became apparent when he described his friend’s stillbirth.  Two years after Dennis lost Susan, a friend of his had a stillbirth.  Dennis talked at length about how he felt that he, himself, had somehow caused his friend’s stillbirth, even though logically he knew that he could not have done so.  He felt extremely guilty for his friend’s loss, suggesting that he displaced his guilt about Susan’s death onto his friend’s stillborn baby’s death.  The following statements illustrate Dennis’s guilt over his friend’s stillbirth:

I felt like it was my fault, that I lost the baby because when you hear about it, normally, the average person, it’s well, a friend of mine’s brother, a buddy he works with had a loss, or a guy I went to high school with.  The way I felt about it was that we lost Susan so all our circle of friends were safe.  They’re safe because we lost ours.  And I felt like it was my fault because they knew me.  I felt like if I would have never met her, they would never lost their baby.  I felt guilty about that.  I felt like it was my fault, even though I knew rationally, that no it’s not my fault.

Dennis’s guilt also came in the form of regret about what he “didn’t do” for Susan.  He expressed regret over not diapering her after her birth, and not dressing her for the funeral.

            Beyond One Year.  Although it has been three years since Susan died, her death continues to affect Dennis’s life.  One way that it still affects his life is that he still engages in prospective mourning.  For example, when he sees his niece, who was born four months before Susan, he is reminded of Susan and thinks, “Well, Susan would be doing that too, and Susan would be doing that.  That’s what she would be doing right now.  They’d be playing there, they’d be friends and playing together and fighting.”  Another way that Susan’s death continues to affect Dennis’s life is that he has had more anxiety during his wife’s pregnancies that are subsequent to Susan’s death.  He described Tammy’s pregnancies after Susan’s death as “sheer nine months of terror.”  Because of Susan’s death, he feels like he lost his “innocence” during subsequent pregnancies because now he knows that “anything could happen.”

            Dennis’s relationships with his wife, children and parents have significantly changed since Susan’s death.  He believes that his marriage has strengthened and that he and Tammy are closer than they ever have been.  Dennis’s attitude toward parenting has also changed.  He now prefers to spend more time with his children and does not “like doing things that will take me away from my family.”  Dennis repeatedly explained how he “cherishes” the time he has with his children more than before because “anything could happen to them at any time.”  The following narrative reflects how Dennis “cherishes” his children more:

I cherish the time I have with my kids now.  Instead of watching the news, I read them a book.  Before, I put off reading them a book and now I try not to because now I know that anything could happen at any time.  My son could fall down and break his neck, or the kids could get run over by a car.

A central theme for Dennis was how his relationship with his own parents has

suffered since the loss.  He repeatedly expressed anger toward them, especially his mother, for how they handled the death.  Dennis feels that they did not validate Susan’s existence or her death.  For example, Dennis told a story about how his mother had planted a garden in honor of Susan.  However, a year after planting it, she told him that she was putting in a pool and that a tractor was going to go over the garden.  She told Dennis that she would replant it if he wanted her too, however, she did not express any interest in replanting it herself.  Then, instead of replanting the garden, she built a sidewalk over it.  Dennis felt very angry and believed that his mother did not originally plant the garden “from her heart.”  Instead, she planted it so that she could show it to her friends as a “poor me kinda thing.”

Throughout the interview, Dennis also talked about how his mother did not validate Susan’s existence or his feelings about her death.  She would often say to him, “You need to get on with your life,” or “What does she [Susan] matter.  She’s not here.  She doesn’t matter.  She’s not here and she’s not your child.”

            Dennis described another incident about how when his father made wood cutouts of all of the grandchildren’s names, he did not cut out Susan’s name. Dennis felt upset about that incidence, stating, “That hurt.  That hurt a lot.”

Dennis’s anger at his parents is best illustrated with following narrative:

I am sitting here talking to you, and I don’t like my mother at all.  I mean I love my mom and my dad, but I don’t like my mom at all.  Because she can be a real jerk.  She was last night.  Just the way she handled this whole thing.  My dad is just like, it never happened.  She was never born.  He never talked about it.  He didn’t cut out her name, didn’t make her name out of wood.

            Besides his family, Dennis has found two other sources of comfort: religion and a support group.  Although he did not talk about the support group during the interview, he did talk a lot about it during the phone screen.  He continues to go to the support group once per month and is often a group “leader,” or “on call” for those who had a loss.  In addition, he has done some public speaking at hospitals, advocating for fathers who have experienced a perinatal loss. 

            Dennis’s religious beliefs have also provided him with comfort.  He finds comfort in believing that he will see her again as he stated, “I have faith in Christ that I will be with her again one day.”  He also finds comfort because “I know she’s better off where she is.”  Dennis also reported that he has gotten more religious since losing Susan, and that his “relationship with God has gotten a lot stronger.”

The Perinatal Grief Scale

            Dennis completed the PGS in the beginning of the first meeting.  His scores were then computed and compared to the means and standard deviations of both the total score and the subscale scores of the PGS.  These means and standard deviations were found in the validation study of this instrument (Potvin, Lasker, and Toedter,1989).  Dennis’s total score was 60 (see Table II), indicating that his total grief score was approximately one standard deviation below the mean.  His score for the Active Grief subscale was 23, which was approximately 2 standard deviations below the mean.  His Difficulty Coping score was 21, .7 of a standard deviation below the mean.  On the Despair subscale, he scored a 16, which is approximately one standard deviation below the mean.


Table II. 

Dennis’s Perinatal Grief Scale Scores (compared with reference group[2])

        Active Grief               Difficulty Coping                Despair                      Total Score

Dennis      Mean    SD         Dennis    Mean      SD       Dennis    Mean   SD        Dennis     Mean      SD





39.92     8.25







8.53     16






 7.70       60










The following pages contain two tables of the results of the rater’s responses to the T.A.T. and the C.A.T.-H.  Table Three illustrates the results of the T.A.T.; Table Four, the C.A.T.-H.  These tables list each rater’s description of the themes, distress level, and defenses of Dennis’s stories to each of the cards used in the study. 

Table III.

Dennis’s T.A.T. Results


Card    Rater                Themes                                    Distress Level      Defenses

2                 1               Affiliation,                                 None                   Severe

                                    Achievement                                                        Repression,



       2               Emotional                                 Mild -                  Poorly Developed     

Guardedness and                      Moderate            Defenses, Denial,

Resistance, Lack of                                             Suppression,

Emotional Connectedness                                    Emotional     

Interpersonally,                                        Withdrawal

Limited or Underdeveloped                             

Fantasy Resources


                    3              Girl Goes to School, Mother

Watches, Brother Plows           None                   Wishes to Please

                                                                           Reveals Little            


3BM            1              Affiliation,

                                    Nurturance                               Moderate            Moderate



                    2              Emotional Guardedness            Moderate            Fragile Defenses:                                           and Resistance, Helplessness,                                     Emotional

                                    Need for Support, Limited or                               Withdrawal,

                                    Underdeveloped Fantasy                                     Denial, Suppression



                    3              Girl Has Bad News, Car           High                    Introjection,

                                    Will Not Start, Talks it Out                                  Attachment

                                    With Friends






Table IV.

Dennis’s T.A.T. Results (continued)


Card        Rater            Themes                                    Distress Level      Defenses


7GF                 1          Affiliation,                                 None                   Mild


                                    Nurturance                                                          Denial

                        2          Emotional Guardedness            Mild -                  Fragile Defenses:

                                    and Resistance, Extreme           Moderate            Repression,

                                    Emotional Resistance with                                    Suppression, Denial

                                    Maternal Figures, Attempts

                                    at Pseudo Self-sufficiency


                        3          Woman Reads Bible to Girl      Mild                    Sublimation

                                    Who Goes to Bed



Table III.


Dennis’s C.A.T.-H Results



Card    Rater                Themes                                    Distress Level      Defenses

3          1                      Affiliation,                                 None                   Moderate

                                    Nurturance                                                          Repression of



            2                      Emotional Guardedness            Moderate            Rigid, but Fragile

                                    and Resistance, Passive-                                      Defenses: Denial,

                                    Dependent Emotional                                           Suppression,

                                    Orientation, Strong,                                          Compartmentalization

                                    Unresolved Need for



            3                      Father “Should Be”                   Low -                  Isolation

                                    Playing with Boy, “Trying          Moderate

                                    to Relax,” Goes Down

                                    and Has Dinner



Dennis’s C.A.T.-H Results (continued)


Card    Rater                Themes                                    Distress Level      Defenses

5          1                      Affiliation,                                 None                   Severe                                                           Nurturance                                                          Denial and



            2                      Abandonment by Maternal        Moderate            Fragile Defenses:

                                    Figure, Fears of Loneliness                                 Denial, Suppression,

And Isolation, Tendencies                                    Distortion

to Distort Reality


            3                      Little Boys Take Naps, Mild                    Suppression

                                    Mother Does Housework, She

                                    Will Take Care of Them


9          1                      Affiliation,

Nurturance                               None                   Moderate Denial

   and Repression


            2                      Fears of Abandonment (None Given)      Less Adequate

                                    and Rejection, Very Strong                                  Defenses: Denial,

                                    Need for Nurturance, Fairly                                 Isolation, Retreat

                                    Strong Regressive                                                Into Fantasy



            3                      Father Will Pick Up Lonely       Mild                    Attachment

                                    Child and Carry Him Around

                                    Until He Goes to Work


Brief Commentary on Dennis’s Results

            Dennis’s interview, PGS, T.A.T., and C.A.T.-H had conflicting results.  During his interview he described having great difficulty with his loss; however, his PGS scores, T.A.T., and C.A.T.-H did not indicate a sense of grief and loss.  Because it is beyond the scope of this chapter to further discuss this discrepancy, these results will be discussed in greater detail in Chapter five.


Participant Two:  Karl

Background Information

            Demographic Information.  Karl, a thirty-four-year old, Irish-Swedish-American, Episcopalian male, participated in the present investigation.  He has been married to his wife, Vicki, for five years and manages a computer programming business.  Karl’s and Vicki’s daughter, Dana, died when she was four months old from Sudden Infant Death Syndrome (SIDS), one and a half years ago. They currently have one living daughter, Melissa, who was born eleven months after Dana died.  

            Recruitment Process.  Karl was recruited from a SIDS support group after the group leader gave his name to this investigator as a potential participant.   When the researcher contacted Karl to explain the study, he immediately expressed interest in participating.  After ensuring that he met the requirements for the study, this investigator scheduled him for the first meeting.  

            Description of the Loss.  Karl lost his daughter, Dana, to SIDS one and a half years ago.  At the time, Vicki was on a business trip, he was at home, and Dana was at daycare.  The daycare worker called Karl in panic, stating, “Dana’s not breathing!  Come over!  Come over quick.”  When he arrived at the daycare, the paramedics were doing CPR on Dana, and Karl “could see it in their eyes that their wasn’t much that they were going to be able to do.”  After a few minutes, the paramedics told him that Dana had passed away.  The crisis response team coordinated a crisis team in Oregon for Vicki so that they were available when Karl told her the news.  Karl then phoned Vicki and told her that Dana had died, and to open her hotel door so that the crisis team could help her.

The Interview. 
The interview occurred in two sessions, each one week apart.  The first meeting lasted about one and half-hours, while the second meeting lasted one-hour.  Throughout the interview, Karl was cooperative and answered questions readily.  At times he was tearful, especially when he talked about how he had to tell Vicki about Dana’s death. 

            The following paragraphs summarize Karl’s interview, describing his desire for children, his feelings about his wife’s pregnancy, his initial reactions to the loss, his responses for the first year after her death, and his reactions one-year and beyond the loss. Later, sections that summarize his PGS scores and his projective test results will be presented.

            Desire for Children.  Karl always wanted to be a father. As a child, he fantasized about becoming a father and “playing soccer and ball with my kids in the back yard.”  He felt that his own father “had a great life” as a parent because he “took summers off and played with all the kids.”  Karl’s feelings about having several children were evident when he stated, “I came from a big family and was always in the mindset of having a big family.”

            Karl’s Experiences During the Pregnancy.  Karl expressed a variety of conflicting thoughts and feelings about Vicki’s pregnancy with Dana.  When he first learned that she was pregnant, he was shocked because this happened sooner than he expected.  Karl also felt excited when he found out she was pregnant because he had always wanted children.  Although his primary feeling about the pregnancy was one of excitement, he had “a couple moments of anxiety.”  The following narrative illustrates Karl’s anxiety: 

And so, you get a couple of, “Do we have enough money to cover all this?  How is this going to change our lives?”  I definitely had a little anxiety about this whole issue.

Karl described himself as being “very involved” with Vicki’s pregnancy.  He

went to most of her ultrasound appointments, which he described as “amazing.”  For Karl, seeing the ultrasounds made him feel “a little more a part of it, too.”

            When Vicki started to “show,” her pregnancy became real for Karl.  The following narrative reflects how his thoughts and feelings about the pregnancy changed at this time:                  

I think just the reality of it [set in].  Just because it’s physically there.  It’s not just a concept, it’s a visual concept now.  So it kinda reinforced it.  You know this is really happening; this is gonna be reality. I think that’s the biggest level. It’s a major thing.  It’s like someone put a basketball right under her.

Karl made a variety of behavioral preparations for Dana during the pregnancy. 

For instance, he bought a crib, painted a bureau, purchased insurance, made financial preparations, and purchased some baby clothes.  One of Karl’s most predominant preparations for Dana was childproofing his home, which is illustrated in the following narrative:

I think I childproofed the house when she was like three to four months pregnant [he laughs].  My friends were like, “Oh you’re already childproofing the house. You know, and she isn’t going to have the kid for six months.  You know she’s not going into drawers and stuff for a year. 

Unlike the other participants’ infants in this study, Karl’s baby was born both

healthy and alive.  With excitement, he described her birth by stating, “Dana was born three days after my birthday, so that was a really, really cool time. And the Padres were in the World Series, so that was kind of memorable, too.  It was great.  I was excited about it!”

            Initial Responses to Dana’s Death.  When Karl first learned that Dana had died, he felt numb and was in denial.  On the day of the loss; however, he started to gradually accept the “new reality” that she had died.  Karl’s numbness, denial, and eventual acceptance are further illustrated in the following narrative:

I mean it was really, really surreal.  You know, the situation.  I just couldn’t believe she was gone.  And it was a very, very difficult moment, you know.  I don’t know if one specific thought came to mind, but just the disbelief that at that point, you know, it’s not real and I’m dreaming and things were going to change.  And I think over time it began to set in.  You know. . . a dream, which is real, and this is your new reality.  And so I had to come to terms with that.  The reality does set in.

Once the reality of the loss began to set in, Karl was primarily concerned about how he would have to tell his wife over the telephone, as she was out of the state.  Also, Karl wondered how she would react being so far from home. He described his feelings in the following narrative:

And obviously I had an awful time thinking of my wife who was out of town.  So that was . . . that was a major issue.  That was a really traumatic portion of it for me.  You know.  I had to tell her over the phone and getting her back into town and, you know, starting to grieve together at that point [he started to cry].

            For Karl, telling his wife was the most difficult part of the loss.  Karl felt helpless over not being able to comfort Vicki when he told her the news.  Throughout the interview he emphasized how difficult it was for him not to be able to take her pain away, even after she came home.  The following narrative reflects his feelings of helplessness:

And then to see my wife. . . you know you just have to deal with that, and you know, you can’t take that away.  You know, you just . . . you just gotta let them get through it and comfort them through it.  You can’t take their pain away.

Karl also felt helpless over being “in the situation and really not being able to do anything and really not having any clear answers.”  He described these feelings as “deeply affecting” him.

            In addition to feeling helpless, Karl felt angry.  He explained that he had “some flashes of anger,” but that he “wasn’t as angry as some people.”  Karl’s anger was primarily directed toward the child abuse team who, because of Dana’s death, were required by law to interview him immediately after the incident. Karl explains this interview in the following narrative:

He [the detective] was very aggressive in asking, you know, questions, almost in a confrontational-type manner.  And obviously, I had just been presented with the loss of my child and having to deal with that in that manner made me very angry. . . at that time I was very angry.

Karl also felt angry toward his acquaintances, who made what he felt were invalidating statements, such as, “You’re young.  You can have other kids.” 

            The First Year After the Loss.  During the first year after Dana’s death, Karl felt guilty, empty, and sad.  He felt guilty that he was not able to do anything to help Dana the day she stopped breathing and died.  Karl’s guilt was expressed in the form of “disappointment” in himself, and is reflected in his stating, “You know, I was taking care of the baby.  The disappointment, you know, the feeling of letdown that this occurred on my watch.”  Karl also described feeling empty, stating, “It’s like you’ve lost a piece of yourself and your family.” 

During this first year after her loss, he felt extremely sad.  When asked what made him the most sad, he stated, “I didn’t do anything wrong.  You know, there’s no rhyme or reason why. . . why this could happen to her.”  

Rather than openly expressing his feelings about the loss, Karl “kept things inside” because he felt a need to be “the strong one” for his wife.  He illustrated this need when he stated, “I needed to keep my emotions in check.  I needed to be this stoic and strong rock.”

Karl hid his feelings about the loss from his wife and grieved alone, primarily in his car.  He explained this process in the following narrative:

I grieved mostly in my car, and mostly alone.  That is pretty much where, where I did it.  I would go, and go on a drive or a walk.  Mostly it seemed to be in the car, when I felt most of my grief.  Sometimes I would yell on the top of my lungs driving. . . if I felt frustrated.

Similar to Dennis, Karl found that he “grieved to music” while he was in his car.  In the following narrative, he described how he related the loss to music.

A lot of what I relate, to music . . . there are certain songs that I hear that are kinda “Dana songs” and I am also hearing them in my car, mostly when I am driving I listen to them.  So that’s how I channeled my grief feelings.

Karl eventually went through a period of depression.  He suddenly felt “indifferent” about his new business, whereas prior to Dana’s death, he had been “gung ho” about it.  Thus, he began attending a SIDS support group and grief counseling sessions along with Vicki to help them cope with the loss.  He believes that these sessions, along with the group, helped them express their feelings about the loss to each other.

One Year and Beyond.  Although it has been one and a half years since Dana’s death, her loss continues to affect Karl’s life.  He reported that he views life differently now, stating, “You cherish life a lot more.  Before, it was somewhat taken for granted.  But now, we realize it is a fleeting thing and we cherish it a bit more.”  Similarly, Karl explained that he sees the “here and now” as more important than before, and takes time to appreciate it, rather than focusing on the future.

Similar to Dennis, Karl also believes that losing Dana has changed his parenting style.  He now “cherishes” and wants to spend more time with his new daughter.  The following narrative illustrates these changes:

When five o’clock comes, I want to get home and play with my kid.  Whereas before, I might pay more attention to my work.  So, in a roundabout way, it may have given me a better appreciation for things.

As a further illustration, Karl is more “cautious” with his new child.  He described watching after and taking more precautions with her because he does not “want to experience that type of pain again [of losing a child].”  Karl thinks that having to take “extra precautions” with his current child is a “downer” and wished that he “didn’t have to do that.”

            Karl now feels closer to his father and his siblings and communicates with them more.  In the following narrative, he describes how he feels closer to his family since Dana’s death:

I talk to most of them more now than I did.  I wasn’t very communicative, like calling them and things like that.  And I do that on a more personal basis now. I mean, it helps. My relationship with my Dad has improved tremendously in terms of lines of communication and frequency, and saying “I love you” and things like that.  In a weird way, I think we all make a little bit more effort.

Karl is also more apt to state his feelings toward his family.  Learning to express his feelings about Dana’s loss may have led to his being able to express his feelings about other parts of his life.

            Currently, Karl has many of the same feelings of guilt, emptiness, and sadness as he had during the first year after the loss. However, these current emotions are less intense than in the past.  To illustrate how these feelings have abated over time, he stated, “I think as you get a little bit further removed from it, it hurts a bit less. Or, you know, there’s something to be said about time.  But it doesn’t take away everything.”

            Although it has been one and a half years since the loss, Karl still thinks a lot about Dana’s death.  He struggles with not knowing the cause of her death.   Karl often asks himself, “Why me?  Why do I have to deal with this?”  Furthermore, he feels that Dana’s death diverted his path in life, illustrated by the statement “It’s like you’re going on one path and then an event occurs, and it diverts your path a little bit.  And some of that may be for the better, and some may be for the worse.”

            To this day, Karl engages in prospective mourning.  As he sees his new daughter growing up, he thinks about what Dana would be like at that age.  He engages in activities with his new daughter, activities that he could never share with Dana because of her early death. 

            Karl has found that both the SIDS support group and the couple’s counseling have helped him cope with the loss.  Both therapy modalities have aided him in expressing his feelings, especially to his wife.  He stated, “When we got in more of a group situation, whether it was with other families or with a counselor, I would say things that she didn’t realize I was feeling.”  He continues to be involved with the support group and does some public speaking about his experience to paramedics and firemen, to advocate for how to treat parents after they lose a baby to SIDS.  In the following narrative, Karl describes how talking about the loss has helped him.

It helps me.  I think I have the tendency to kinda put it [feelings] in a basket and I really need the help.  Talking about it helps me.  And I have some feeling that doing your research will help.  And so, in a way, I am not only helping myself, but also helping others.

The Perinatal Grief Scale

            Karl completed the PGS in the beginning of the first meeting.  His scores were then computed and compared to the means and standard deviations of the PGS. These means and standard deviations were found in the validation study of this instrument (Potvin, Lasker, and Toedter’s,1989). Karl’s total score was 80, indicating that his total amount of grief was approximately .55 standard deviations below the mean (see Table V).  His score for the Active Grief subscale was 31, indicating that his “active” or “normal” grief is 1.5 standard deviations below the mean.  On the Difficulty Coping subscale, Karl scored 24, which is approximately .3 standard deviation below the mean.  For the Despair subscale, Karl scored 25, which is .01 standard deviation above the mean.  Essentially, Karl scored slightly below the mean on his total score, and on his Active Grief and Difficulty coping subscale, and scored slightly above the mean on the Despair subscale.


Table V.

Karl’s Perinatal Grief Scale Scores (compared to reference scores[3])

      Active Grief                                Difficulty Coping               Despair                     Total Score

Karl      Mean     SD           Karl         Mean     SD          Karl    Mean     SD            Karl       Mean    SD



42.17   7.70


27.22     10.34


23.94    9.01







            The following pages contain two tables of the results of the rater’s responses to the T.A.T. and the C.A.T.-H.  Table six illustrates the results of the T.A.T.; table seven, the C.A.T.-H.  These tables list each rater’s description of the themes, distress level, and defenses of Karl’s stories to each of the cards used in the study.


Table VI.


Karl’s T.A.T. Results


Card   Rater   Themes                                       Distress Level    Defenses

2        1        Achievement, Affiliation,          None            Mild Denial                         



          2        Lack of Interpersonal                           Mild             Adequate Defenses: 

                    Connectedness, Separation                                       Emotional Distancing,

                    and Loss                                                                  Denial, Repression


          3        Girl Thinking Seriously, has                  Moderate      Intellectualization

                    Boyfriend, Father Working                 


3BM  1        Confusion, Anxiety, Denial                    Mild            Mild Isolation,

                    Abasement                                                               Moderate Denial


          2        Significant Depression -    Possibly      Severe           Fragile Defenses:                         

                    Chronic, Strong    Possibility of                                 Denial, Suppression,

                    Serious Problems with Alcohol,                     Oral Dependency



          3        Drunk Woman Sleeping on Hard       Moderately  Denial, Regression

        Bench, Getting Drunk and Sleeping    Severe            

        it off, Gender and Identity Confusion


7GF   1       Affiliation, Passivity, Autonomy        Mild              Moderate Repression


          2        Lack of Interpersonal                            Mild-             Less Adequate Defenses:

                    Connectedness, Potential for              Moderate         Emotional Distancing

                    Problems or Conflicts With

                    Maternal Figures, Potential for

        Excess Use of Fantasy                 


          3        Girl Holding Doll, Companion Maid  Moderate     Isolation

                    Not Mother, No Relationship, Girl



Table VII.


Karl’s C.A.T.-H Results


Card   Rater   Themes                                       Distress Level    Defenses

3        1        Affiliation, Achievement,          None             Moderate Isolation



          2        Lack of Interpersonal Connection,   Mild     Adequate Defenses: 

                    Tendency to Emotionally                               Repression, Suppression,

        Withdraw, Latent Exhibitionistic                    Retreat into Fantasy



         3         Father From Theater, Father Plays    Mild     Intellectualization

                    With Son Who Goes to Sleep,

                     Father Leaves Them


5        1        Affiliation, Affliction, Autonomy    None              Moderate Denial


          2        Fear of Abandonment, Unresolved  Mild -                Slightly Impaired:

                    Needs for Attention, Fears or           Moderate         Denial, Suppression,

                    Conflicts with Authority Figures                     Repression          


          3       Close, Playful Association of                Mild               Repression, Sublimation

                   Brothers, Parents Living for

       Children Or Watch Them Too Close,

                    Mischievous Children Awaken



9        1        Affliction, Non-Support                       Mild              Moderate Isolation



          2        Fears of Emotional and Physical       Mild -               Slightly Impaired:  Denial,

                    Vulnerability, Fears of                          Moderate     Suppression, Reaction

                    Abandonment and Rejection,                                    Formation

                    Strong Feelings of Loneliness

                    and Isolation


          3        Child in Crib Without Protection,    Moderate       Active Dependence

                    Not Safe, Not Much Emotion,

        Child Wants Attention

Brief Commentary on Karl’s Results

            Karl=s T.A.T. and PGS were consistent with his interview, both suggesting that he was struggling with his loss.  More specifically, his T.A.T. revealed that he was experiencing separation and loss (card two, rater two), while his elevated Despair subscale score on the PGS indicated that he might be having more serious and long-lasting detrimental effects of the loss.  Because it is beyond the scope of this chapter to further discuss these findings, these results will be discussed in greater detail in Chapter five.

Participant Three:  Raymond

Background Information

            Demographic Information.  Raymond, a forty-four year old, Euro-American, Protestant male, participated in the present investigation.  He currently works as a computer programmer, and has been married to his wife, Barbara, for seven years.  Raymond’s son, Bryan, was stillborn thirteen months ago.

            Recruitment Process.  Raymond was recruited into this investigation after he responded to an ad in a perinatal loss support group newsletter that his wife had showed him.  He called this researcher, explaining that he would like to be in the study for the purpose of “improving the knowledge” of fathers’ experiences after incurring a perinatal loss. After ensuring that he met the requirements for the study, this investigator scheduled the first meeting. 

            Description of the Loss.  Raymond’s son, Bryan, was stillborn thirteen months ago when his wife, Barbara, was thirty-six weeks pregnant.  Raymond and Barbara learned that Bryan most likely had Down’s Syndrome during a routine ultrasound test approximately two and a half months into the pregnancy.  They decided that they would keep their baby, whether or not he was born with Down’s Syndrome. They were then sent to a perinatologist so that the pregnancy could be better monitored with more frequent ultrasounds. Thirty-six weeks into the pregnancy, when they were at the doctor’s office, Barbara and Raymond learned that Bryan had died.  Planning to deliver the next day, they went home and tried to rest.  The next morning, Raymond took Barbara to the hospital to deliver.  With some of their friends, family, and two pastors there for support, the doctors induced labor, and Barbara delivered Bryan.

The Interview

            The interview occurred in two sessions, each two weeks apart.  The first meeting lasted about an hour and a half, while the second meeting lasted one hour.  Raymond was articulate and thought through his responses carefully.  Often, he gave intellectual descriptions of the loss and how he felt, rather than displaying affect.

            The following several sections describe Raymond’s desire for children, feelings about Barbara’s pregnancy, initial responses to Bryan’s death, and reactions for the first thirteen months after his death. Later, sections that summarize his PGS scores and his projective test results will be presented.

            Desire for Children.  Raymond talked at length about his conflicting thoughts and feelings about having children.  He reported that as a child, he thought about his future career in science, rather than about his future as a father. He did not think about having children until a few years ago when his wife began talking to him about it.  Raymond described feeling “in the middle” about whether he wanted to have any children.  In the following narrative, he describes his ambivalence about having a baby:

When we first talked about even having children at all, I was sorta ambivalent.  And, you know, my approach to it was, if we had a child or children, that was fine.  Several of our friends of course have them, and they are obviously happy with it and I know that I would be as well.  But, on the other hand, the independence that a couple has, in quotes, “not being tied down” you know, with children, also kind of appealed to me.  So my feeling was that if we never had children, I wouldn’t be overly upset.  So I was kind of right on the fence there. 

Raymond’s decision to have a child was largely influenced by his wife.  As Barbara’s desire to be a mother grew, Raymond began “leaning toward wanting children, as he described by stating, “What kind of pushed me over into the direction of having children was that my wife decided that she wanted children.”

Raymond’s Experiences During the Pregnancy.  When Raymond first learned that

Barbara was pregnant, he had “mixed feelings.”  He felt happy because he knew that she “very badly” wanted to have a child as she had waited a long time because of some bouts of infertility (he did not elaborate on this process).  However, a part of him still did not want a child.  He had concerns about the lifestyle changes and about the financial strains associated with becoming a parent. 

            As Barbara’s pregnancy progressed, Raymond gradually became more excited.  He carefully began to plan for Bryan’s arrival in a variety of ways.  To psychologically prepare himself, he talked with Barbara about how they would handle the lifestyle changes.  He also made a nursery for Bryan, decorating it and painting the furniture, and buying a variety of baby equipment. Raymond and Barbara named their baby after Raymond, using his middle name, Bryan, for the baby’s first name.  Furthermore, because education was always important to Raymond, he contemplated moving to a place with a better school system so that Bryan could have a high quality education. 

            Raymond described himself as being very involved with the pregnancy, attending most of the ultrasound scan appointments and often feeling Bryan kick.  On a daily basis, he listened to his wife’s “blow by blow” description of how Bryan was moving around in her womb. 

            When Raymond learned that Bryan might have Down’s Syndrome, his excitement about becoming a father dissipated.  He grew extremely concerned about having a special needs child, especially because of the “social ramifications” of the mental retardation associated with Down’s Syndrome.  He talked at length about how having a child with mental retardation was a “blow to my pride and my ego” because the child would never go to college or “measure up to the standards I knew I would set for my children.”  Raymond was extremely disappointed about the possibility that Bryan might have Down’s Syndrome, stating “We’ve worked so hard for this and now we finally got pregnant and now look what happened.”  Raymond perceived Barbara as “stronger” than he, and felt that she would have “risen” to the occasion of having a Down’s Syndrome baby; however, he did not know if he would have been able to do the same. 

            Initial Responses to Bryan’s Death.  When Raymond first learned that Bryan had died in-utero, he experienced shock and numbness, which is illustrated by his stating,  “I guess the only real feelings that I recall from that particular point was just sort of a numbing and shock.  You know, it’s the last thing of course you expect to hear.”

            Once the reality of Bryan’s death began to set in, Raymond primarily focused on Barbara’s well-being, rather than on his own thoughts and feelings.  He was extremely concerned about how she was going to get through the delivery, and about how she was going to cope with this loss over an extended period. Raymond reported that, after learning about Bryan’s death, they went home to rest for the upcoming delivery (scheduled for the next morning) and his “protective instinct” set in.  Specifically, he focused primarily on her needs, inviting one of her friends to stay over to provide support. 

During the interview, Raymond did not talk much about Bryan’s actual delivery, stating only, “Except for the fact that the baby was dead, it was like a regular delivery.”

            First Thirteen Months After the Loss.    One of Raymond’s most prominent reactions to Bryan’s death was that of relief, as he was extremely concerned about his own ability to cope with a child that has Downs Syndrome.  He reported having no “deep feelings of loss” because his feelings of relief were greater.  He was not “particularly proud to admit” these feelings, and had occasionally thought that if Bryan had been a “completely healthy, normal child, ” he would have been more devastated.

            Raymond expressed a variety of emotions in response to Bryan’s death.  His most central feeling was that of guilt.  He described feeling most guilty over his sense of relief, rather than about the fact that Bryan died.  Although Raymond repeatedly denied feeling guilty about the actual death, throughout the interview he talked about how Bryan’s life was entrusted to him and how responsible he felt for his life.

            Raymond also reported that he felt sad about Bryan’s death; however, when he was asked about what made him feel the most sad, he described his guilt and sense of responsibility for its occurrence.

            Raymond denied feeling angry when directly asked about this emotion; however, he later described feelings of anger toward his wife’s friend on the night they found out about Bryan’s death, because the friend was not supportive of his wife.  He also talked about how he felt angry with himself, like a “failure,” because he was not able to “finish the task” of having a baby. 

Rather than expressing all of these emotions, Raymond hid his feelings and reported that he has no desire to talk about the loss.  For the most part, he grieved alone in his car. He described himself as an “internalizer,” which he further defined as someone who has no inclination to talk about his feelings.  Rather, he is “. . . one of those people who resolves it myself.”  His feelings, therefore, often “manifest” when he is alone, in a car.  Unfortunately, Raymond would not elaborate about how he grieved in his car.           

            Along with hiding his feelings, Raymond focused on being “strong” for his wife, like a “. . . rock to which she can cling when she has felt like she was drowning.”  He often encouraged her to talk about her feelings about the loss with him so that she could be supported.

            Raymond does not have any children; therefore, losing Bryan triggered thoughts about his own mortality.  In his own words, he explained that it has “slightly brought up the notion of my mortality and the fact that I haven’t yet continued my family line.”

            Although Raymond reports that he has no “deep sense of loss,” he has often engaged in prospective mourning, reflected in the following narrative:

[We think about how] Bryan would be a year old now, you know.  He’d probably be doing this or you know, we’ll think about, we’ll see a child who is about that age, and this had happened all the way through, see it and think about uhm, “Gee, what would we be doing with Bryan now?”


Raymond reported that the biggest change in his life has been the change in his

relationship with Barbara.  He believes that the loss has brought them closer because Barbara has become “. . . less accommodating to her high-maintenance friends.” 

            Raymond believes that his strong social support system and some grieving rituals have helped him cope with the loss.  He belongs to a church where he has a “. . . wide circle of friends and acquaintances that have been supportive.”  Raymond believes that “any negative reaction that we may have had as a result of this has probably been cushioned somewhat by that [the support].”  As a ritual, he and Barbara go to the cemetery and bring Bryan flowers every other week.

            Barbara is currently trying to get pregnant again; however, Raymond feels extremely anxious and ambivalent over becoming a father in the future.  The following narrative further illustrates his concerns:

We are trying to get pregnant again.  She is back to the fertility doctor and is back on Clomid [a fertility medication].  And we’re back on the whole cycle.  Trying to do it again.  I still have the same concerns.  They may be amplified again a little bit by the fact that neither one of us is exactly spring chickens anymore.  I mean she celebrated her fortieth birthday last week and I am forty-four and you know . . . I’m concerned about if someone in their upper forties has the same ability to have patience as someone in their upper twenties does . . . That concerns me.

The Perinatal Grief Scale

            Raymond completed the PGS in the beginning of the first meeting.  His scores were then computed and compared to the means and standard deviations in Potvin, Lasker, and Toedter’s (1989)-validation study.  Raymond’s total score was 66, indicating that his total level of grief was approximately 1.5 standard deviations below the mean.  His score for the Active Grief subscale was 20, indicating that his “active” or “normal” grief was approximately 2.4 standard deviations below the mean (see Table VIII).  On the Difficulty Coping subscale, Raymond scored 23, which is an about .5 standard deviation below the mean.  On the Despair subscale, he scored 23, which is approximately .2 standard deviation below the mean. 

Table VIII. 

Raymond’s Perinatal Grief Scale Scores (compared with reference scores[4])

      Active Grief                             Difficulty Coping                  Despair                         Total Score

Raymond   Mean   SD      Raymond    Mean      SD       Raymond    Mean     SD    Raymond    Mean      SD



8.25       23

26.97    8.25


24.41  7.70




The following pages contain two tables of the results of the rater’s responses to the T.A.T. and the C.A.T.-H.  Table Nine illustrates the results of the T.A.T.; Table Ten, the C.A.T.-H.  These tables list each rater’s description of the themes, distress level, and defenses of Raymond’s stories to each of the cards used in the study.





Table IX.


Raymond’s T.A.T. Results


Card   Rater   Themes                                       Distress Level    Defenses

2        1       Affiliation, Achievement            None           Severe Repression, Denial


          2       Potential Separation Conflicts,           Mild           Fair Defenses:  Denial,

                   Emotional Distance Among Family                      Isolation, Rationalization

                   Members, Avoidance of Feelings


          3       Girl Goes to School, Father Plows     High           Moderate

                   Field, There Stands Mother


3BM  1       Affiliation, Nurturance                       Moderate    Moderate Denial


          2       Ambivalence with Expressing            Moderate   Relatively Poor Defenses:

                   Feelings, Potential Difficulty in                            Denial, Isolation,

                   Resolving Feelings Re. Losses,                             Suppression

                   Emotional Isolation           


          3       Woman Received Bad News,              High          Denial

                   Maybe of Death. Divorce


7GF   1       Affiliation, Nurturance                           None          Mild Denial


          2       Ambivalence About Emotional              Moderate   Fair Defenses:  Repression,

                   Commitment, Avoidance of Feelings,           Suppression, Denial,

                   Potential Conflict Around Maternal                          Emotional Distancing



          3       Mother Reading to Daughter Who

                   Isn’t Interested, Emotional Distance   Moderate   None Observed


Table X.


Raymond’s C.A.T.-H Results


Card   Rater   Themes                                       Distress Level    Defenses

3        1         Affiliation, Responsibility                None            Moderate Repression,



          2         Potential Conflict With Paternal      Moderate      Fair Defenses:  Repression,

                     Figures, Potential Conflict as a                                Denial

                     Paternal Figure, Potential Marital



          3         Father “Well to Do” or Like to         Moderate     Isolation

                     Give That Impression, Superior or

                     False Superior, “Turns Away From

                     Son,” Rejection



5        1         Nurturance, Affiliation                     None             Severe Denial, Repression


          2         Very Sensitive to Losses,                   Moderate      Relatively Poor Defenses:

                     Possibility of Early Parental Loss,                             Denial, Repression,

                     Tendency to Deny the Emotional                  Suppression

                     Impact of Losses


           3        One Put in Bed, Children Asleep    Absent          Repression

                     (Which They Obviously Are Not)


9        1         Affiliation, Nurturance                    None              Moderate Denial,



          2         Denial of Abandonment Fears,        Mild -            Rigid, Relatively Poor

                     Emotional Isolation, Ambivalence  Moderate       Defenses:  Denial,

About Expressing Feelings                                       Suppression,  



          3        Child Alone But “Cared For,”            Mild            Absent

Brief Commentary of Raymond’s Results

            Raymond’s interview, PGS, T.A.T., and C.A.T.-H had some conflicting results.  His PGS and interview were consistent with each other, indicating that he is not experiencing much grief or a sense of loss.  His projective tests, however, revealed that he might be struggling with a sense of loss.  On card 3BM of the T.A.T., rater two noted that Raymond might have potential difficulty in resolving feelings about losses.  On card five of the C.A.T.-H, rater two noted that he was very sensitive to losses, and that he had the tendency to deny the emotional impact of losses. Because it is beyond the scope of this chapter to further discuss this discrepancy, these results will be discussed in greater detail in Chapter five.    

Participant Four:  Peter

Background Information

Demographic Information.  Peter, a thirty-three year old, Euro-American male, participated in the present investigation.  He works as an advertising researcher and has been married to his wife, Laura, for six years.  Peter and Laura lost their daughter, Tabitha, four months ago, when she was three days old.  They have one living daughter, Meredith, who is three years old. 

Recruitment Process.  Peter was recruited into this study after this investigator approached him at a perinatal loss support group meeting.  During the telephone screen, he expressed interest in participating in this investigation, and asked several questions about this researcher’s graduate school program.  After ensuring that he met the criteria for this study, the researcher scheduled the first meeting.  

Description of the Loss.  Peter’s daughter, Tabitha, died when she was three days old after having been born premature.  When his wife was twenty-six weeks pregnant, she developed a life-threatening condition that could only be cured by delivering Tabitha.  Although Peter knew that Tabitha might not survive after being born at such a young age, his first priority was to “get my wife healthy.”  Laura delivered Tabitha by having an emergency C-section.  Three days later, Tabitha developed bleeding on the brain, and she died.

The Interview 

            Peter’s interview occurred in two sessions, each six days apart.  His first meeting lasted one hour, while his second lasted forty-five minutes. Peter was cooperative, yet reserved throughout both interviews. When he was asked more open-ended questions, he became uncomfortable, requesting that the interviewer be more specific.  Often, when he did give answers, he gave only brief descriptions of events and feelings, resulting in interviews that were significantly shorter than those with other participants.  Due to this briefness, his interview summary is shorter than that of the other participants.

            The following several sections summarize Peter’s interview, describing his desire for children, his experience of Laura’s pregnancy, his initial reactions to the loss, and his reactions for the first four months to the present.  Later, sections that summarize his PGS scores and his projective test results will be presented.

            Desire for Children. Unlike the other participants, Peter gave only a very brief description about his desire for children.  He stated that he had always wanted to have children, and that as a child, he “. . . knew that I would have children some day.”  In addition, he talked about how he and Laura had planned for a long time to have their second child, Tabitha. 

            Peter’s Experiences During the Pregnancy. Peter described Laura’s pregnancy with Tabitha as a positive experience.  He felt extremely excited when he first found out about her pregnancy, as it had taken several months for her to conceive.  Peter enjoyed bonding with Tabitha during this time.  He attended all of her ultrasound scan appointments, and often felt her heartbeat.  He described these bonding experiences as “pretty phenomenal and amazing.”

            When Peter first learned that Laura had a life-threatening condition and that she had to deliver Tabitha early to get healthy, he became extremely concerned, and focused primarily on Laura’s well-being.  He stated, “It was more like the baby came second to make sure that my wife was healthy.” Although his primary concern was about Laura’s health, he was also worried about whether Tabitha would survive because she was born so premature.  Peter describes his experience in the following narrative:

At that point, what they told us was that chances are slim, but not impossible.  And then from there, it was day by day, minute by minute, made it another hour, made it another two hours, made it a day.  And then after three days, she developed bleeding.  At that point, the chance of survival was nothing.

Initial Responses to Tabitha’s Death.  When Peter first learned that Tabitha had

died, he felt extremely “disappointed” because he had been planning for this baby for a long time, had been through the pregnancy, and now did not have a baby.  He repeatedly intellectually described this initial feeling as “disappointment,” rather than expressing emotions. In the following narrative, Peter elaborates: 

It was, you know, more disappointing because of the time it takes to get pregnant, and the time we had to wait, and then twenty-six weeks later, which is six months or something like that, you go through a pretty extended process to get to that point, and then, you don’t get the result.  And that’s probably the hardest part of it.  Wait for a long time and then you don’t get what you’re expecting.  You know, if it was like a two-week process, I’d be like, “Well okay, we’ll start again and in two weeks later we’ll get to that point.”  But not with this process.  You know, it’s like a nine-month process.  The difficult part is you wait a long time and that it doesn’t happen.

To further illustrate, he stated:

A year ago or so we decided that we were going to have another child and then we went through the process.  The long ride up the hill and a quick ride down.  I think looking forward to it, anticipation is building, and you know it’s a quick ride down the hill and so I think that, you know, it happened after all this waiting and anticipation, and all of the planning, then it didn’t happen.

            Peter believes that knowing that Tabitha’s chance of survival at twenty-six weeks was slim may have buffered his reaction to her death.  During the interview, he stated that losing her “maybe wasn’t quite as difficult” as it could have been if he had not been forewarned.    

            First Four Months After the Loss to the Present.  Since Tabitha’s death, Peter’s most prominent emotions have been guilt, anger, and sadness.  He talked at length about his guilt, which came in the form of regret over not investigating Laura’s medical condition more thoroughly to learn if there was any other cure besides early delivery.   During the interview, he mentioned repeatedly that he regretted “not doing more” to learn about her medical condition.  Interestingly, each time he discussed his regrets, he added a qualifying statement about how he could not be accountable for Tabitha’s death.  Peter’s anger was directed primarily at the doctors, who he felt may have been able to do something sooner or quicker to prevent Laura from having to deliver Tabitha so early.  He also reported that he felt angry at “the fact” that Tabitha had died.  Peter reported feeling little sadness.  Furthermore, this emotion came in the form of disappointment that he was expecting and planning for a baby, and did not receive one.

            One of Peter’s most prominent themes was that he hid his feelings and avoided thinking about Tabitha’s death, despite all of his emotional reactions described above.  During the interview, he stated repeatedly, “I’m not going to sit and think about it again and again and again.  That doesn’t help me - just to sit there and think about it.”  Similar to the other participants, Peter described hiding his feelings from others, frequently saying, “I feel no need to display my emotions.” 

            Another one of Peter’s most central themes was that of prevention.  He reported that he chose to focus on educating himself about Laura’s medical condition to prevent another loss from occurring, rather than thinking about Tabitha’s death.  The following narrative illustrates this focus: 

I’m more concerned with possibly how to prevent it rather than on dwelling on that it happened.  I mean, still, as I put it, it sucks that it happened.  But you know, we’re analyzing it from the standpoint, “Okay, what could we have done different?”  You know, you can go through the shoulda, coulda, woulda, and beat yourself up for doing that, but, you know, we can’t change anything.  All we can say is, “Okay, well, we can look at this or monitor this, or, you know, be more in tuned to this, or be even more in tune about the process” and try to work something out there.

            Peter asserted that, since his loss, he reflects on his values more and appreciates what he has more.  He feels that knowing that he already has a child, and that he has another opportunity to have one, has given him some perspective on Tabitha’s death.

            Peter and Laura plan on trying to have another baby.  Although he finds comfort in the hope that he may have another child, he also feels anxious about Laura’s being pregnant again. Peter expressed anxiety over future pregnancies.  To illustrate, he stated:

You know, you never know what is going to happen again.  I mean we have had both sides of them.  I mean we have had a successful pregnancy and an unsuccessful pregnancy.  And, to an extent, there is no real middle ground.  You can’t be partially pregnant.  You know, I guess there’s some nervousness that this isn’t going to be successful.

Peter reported that little has changed in his relationship with Laura since Tabitha’s death.  He said that she is now slightly less emotionally and physically available, often feeling tired and just wanting to “hang out” on the couch.  She has mood fluctuations, and Peter chooses to “. . . go along with the mood she creates.”

One of Peter’s greatest sources of comfort is in receiving quite a bit of support

from his friends and family, which he has found helpful in coping with the loss.  He reported that he felt fortunate to have “a good supportive family” that lives close by. 

The Perinatal Grief Scale

            Peter completed the PGS during the beginning of the first meeting.  His scores were then computed and compared to the means and standard deviations of the PGS. These means and standard deviations were found in the validation study of this instrument (Potvin, Lasker, and Toedter’s,1989).  Peter’s total score was 66, indicating that his grief was approximately one standard deviation below the mean (see Table XI).  His score for the Active Grief subscale was 22, indicating that his “active” or “normal” grief is approximately 2.6 standard deviations below the mean.  On the Difficulty Coping subscale, Peter scored a 21, which is approximately .6 standard deviation below the mean.  On the Despair subscale, he scored a 23, which is about .01 standard deviation below the mean.  Essentially, Peter scored below the mean on all of the subscales, suggesting that his grief scores were below average.      


Table XI.

Peter’s Perinatal Grief Scale Scores  (compared to reference scores[5])

   Active Grief                      Difficulty Coping             Despair                         Total Score

Peter     Mean     SD           Peter      Mean     SD         Peter       Mean      SD      Peter      Mean       SD  


42.17   7.70


27.22   10.34


 23.94  9.01


93.33    24.16







The following pages contain two tables of the results of the rater’s responses to the T.A.T. and the C.A.T.-H.  Table twelve illustrates the results of the T.A.T.; table thirteen, the C.A.T.-H.  These tables list each rater’s description of the themes, distress level, and defenses of Peter’s stories to each of the cards used in the study.


Table XII.


Peter’s T.A.T. Results


Card   Rater   Themes                                        Distress Level   Defenses

2        1         Achievement, Affiliation               Very Mild      Mild Denial



          2         Ambivalence About Committing    Mild             Adequate and Rigid

                     His Feelings, Problems in Making                       Defenses:  Suppression,

                     More Than Superficial Interpersonal                        Emotional Distancing,

                     Contact, Avoidance of Situation                  Denial

                     When Emotions Are Expressed


          3         Planting (Generativity, Industry),    Moderate    Withdrawal, Suppression             

                     Friendship, Insecurity, Relaxation

                     (Passive Gratification)


3BM  1         Confusion, Altruism,                     Very Mild      Intellectualization,

                     Nurturance, Loss                                        Extreme Denial


          2         Avoidance of His Deeper Feelings,  Mild -          Less Adequate Defenses:

                     Particularly Depressive Ones,          Moderate     Denial, Suppression,

                     Ambivalence About Committing                  Repression

                     His Feelings, Interpersonal Isolation

                     And Detachment


          3         Curiosity, Responsibility,                Mild             Superego

                     Turn Over To Police,

                     Gender Confusion


7GF   1         Autonomy vs. Compliance             Very Mild      Mild Undoing


          2         Significant Unresolved Conflicts    Mild              Fairly Adequate Defenses:

                     With Maternal Figures, Maternal                  Suppression, Denial

                     Figures Seen as Demanding or

                     Punitive, Unresolved Issues of

                     Adolescent Rebelliousness


          3        Generativity, Industry, Mother-        Mild              Submission

                    Daughter Conflict, Mother Prevails



Table XIII.


Peter’s C.A.T.-H Results


Card   Rater   Themes                                       Distress Level    Defenses

3        1         Passivity, Affiliation                      None              None Noted


          2         Possible Conflicts With        Mild               Adequate Defenses: 

                     Paternal Figures, Inability to                                    Emotional Distancing,

                     Commit Feelings, Unresolved                                  Suppression, Denial,

                     Oral, Dependent Needs.                                         Repression 


          3         Parallel, Intergenerational              Very Mild      Sublimation

                     Interaction, Passive,

                     Internal Conflict


5        1        Affiliation                                          None              Moderate Degree of Denial


          2        Denial of More Negative                Moderate           Less Than Adequate

                    Emotions, Avoidance of Feelings                         Defenses:  Suppression,

                    Regarding Parental Figures,                                      Denial, Rationalization,

                    Reaction Formation Tendencies                               Compartmentalization

                    With Upsetting/Threatening



          3         Brotherly Association, Going to   Very Mild       Repression, Isolation

                    Sleep, Having Fun


9        1        Autonomy, Affiliation                    None              None Noted


          2        Denial of Stronger, Negative             Mild                Adequate Defenses:

                    Feelings, Tends to Stay With                                    Denial, Suppression,

                    Known and Comfortable,                            Compartmentalization

                    Experiencing Some Conflict in

                    His Role as a Father


          3        Child Resists Going to Sleep,         (None Given) Sublimation

                    Parents Attend to Child, Child

                    Sleeps, Generativity, Resistance

                    to Passivity, Independence

        Parents Attend to Child

Brief Commentary on Peter’s Results

            Peter’s interview, PGS, T.A.T., and C.A.T.-H had some conflicting results.  While he scored low on his PGS, his sense of loss was apparent in his T.A.T.  Rater one noted that card 3BM revealed a theme of loss.  It was not clear during his interview, however,  how much of a sense of loss he was experiencing as he seemed to minimize his feelings. Because it is beyond the scope of this chapter to further discuss these findings, these results will be discussed in greater detail in Chapter five.


Participant Five:   Ryan

Background Information

Demographic Information.  Ryan, a twenty-eight year-old, Italian-Slavic-American, Catholic male, participated in the present investigation.  He works as a computer programmer and has been married to his wife, Megan, for three years.  Ryan and Megan incurred two losses within the past year. Their baby, Pat (gender unknown), miscarried eight months ago, and their daughter, Belinda, was stillborn three months ago.

Recruitment Process.  Ryan was recruited into this investigation after he responded to an ad in a perinatal loss support group newsletter.  During the telephone screen, he explained that he had recently incurred two losses and that he would very much like to participate in the study.  After ensuring that he met the requirements for the study, this investigator scheduled the first meeting. 

            Description of the First Loss:  Miscarriage.  Ryan’s wife, Megan, had a miscarriage eight months ago when she was eleven weeks pregnant. Megan first thought that something might be wrong with the baby when she started bleeding on Thanksgiving weekend.  On her doctor’s recommendation, she stayed on bed rest the entire weekend.   The following Monday, Ryan and Megan went to see the doctor.  The ultrasound scan told them that “nothing was right.”  Essentially, the amniotic sac was collapsing, and their baby had died.  Megan had a Dilation and Curettage procedure, which removes the remains of the baby from the uterus.  Megan and Ryan named their baby Pat, a name that can be used either for males or females, as they did not know the gender of the baby. 

Description of the Second Loss:  Stillbirth.  Megan became pregnant with Belinda one month after the miscarriage. Ryan did not think that he had a “good idea of what was happening throughout the process” when Megan was pregnant with Pat; therefore, they had frequent ultrasounds with this second pregnancy.  During the first few months of her pregnancy (exact time unknown), Megan started bleeding slightly.  When she and Ryan went to the ultrasound, they learned that there was a problem with the amniotic sac.  Megan was put on bed rest and began going to a perinatologist for more ultrasound monitoring.  Twenty weeks into the pregnancy Megan and Ryan went to an ultrasound appointment to “make sure everything was okay.” When Ryan saw the ultrasound scan this time he saw that their baby’s shoulders were hunched over and “knew exactly what happened.”   Belinda had died. The doctor told Ryan and Megan that they had to deliver that day; therefore, they went directly to the hospital.  Their friends and family came to the delivery.  Twenty-nine hours later, the nurse told them that Megan would deliver between ten minutes and one hour.  The nurse left the room to tell their friends and family.  With only Megan, Ryan, and the anesthesiologist in the room, Belinda was born, “sliding right out.”

The Interview. 
The interview occurred in two sessions, each six days apart.  The first meeting lasted one and a half hours, while the second lasted one hour.  Ryan was cooperative and answered questions enthusiastically throughout both meetings.  In the beginning of the first interview, Ryan asked the investigator to move some toys that were in the office because seeing them was “upsetting” for him. He had difficulty staying focused during the first half of the interview, often providing lengthy answers and forgetting the questions that were asked.  As the interview progressed, however, he stayed more focused on the topic of discussion, especially when asked specifically about his feelings.

            The following several paragraphs summarize Ryan’s interview, including his desire for children, his experiences of both pregnancies, his reactions to the miscarriage, his reactions to the stillbirth, and how his reactions to both losses differed from each other. Later, sections that summarize his PGS scores and his projective test results will be presented.

            Desire for Children.  Ryan has “almost always” wanted children.  As a child, he wanted to be a father.  When he was a teenager, however, he decided that he did not want children because “I didn’t want them growing up in this world.”  In his twenties, he worked as a nanny and decided that he wanted to have children because “they were cool.”  Ryan began his relationship with Megan in his late twenties and, when he learned that she wanted four children, he told her, “I’m good for it.”

            Ryan’s Experiences During the First Pregnancy.  When Ryan first learned that Megan was pregnant with Pat, he felt very excited.  He told a number of his family and friends.  Ryan, however, did not feel very attached to Pat.  He explained that he never heard her heartbeat, “wasn’t bonded,” and had “no idea what was going on” during the pregnancy.

            Reactions to the Miscarriage.  Although Ryan felt shocked when he first learned that Megan had miscarried, he did not think the loss was “a big deal.”  He justified the loss, telling himself, “it was meant to be” because maybe if she survived, something “really bad” would have happened to her.  The following narrative illustrates Ryan’s justification of Pat’s death:

For me, I had realized that it was better that way, that it happened.  I had justified in my mind that there may have been something drastically wrong with the child because maybe the child would go through murder, there’s killers, there’s some sort of pain.  I had justified in my mind that it was going to be okay.

Although at the time of the miscarriage, Ryan had no idea that “it was a big event in my life,” he reported that he now views the miscarriage as a major loss. 

            Ryan’s Experiences During the Second Pregnancy.  Ryan had mixed feelings about Megan’s second pregnancy, especially because it was so soon after the miscarriage. That is, he was excited that he was going to have a baby, and feared the “impending doom of not being able to carry to term.”  For Ryan, it was essential that he “put on a happy face” for Megan, never mentioning his fears to her.  Ryan continued to justify Pat’s death during the second pregnancy, thinking that she was “meant” to die so that this second child could be born.  

Early in the pregnancy, when Ryan learned about the separation of the amniotic sac, he became more scared.  Simultaneously, he told himself that nothing bad could happen to this baby.  Rather than “considering bad things as possible options of what could happen,” he focused on being excited about the baby.

            Unlike with the first pregnancy, Ryan described being very involved with the second one.  He helped with much of the housework because he “would try to have her relax as much as possible because if stress caused the first one, I didn’t want her to do laundry and have a second mishap.”  Essentially, he tried to be “generally supportive  and try to make her life easier.”

            Because Ryan had not felt “bonded” with Pat, he wanted to get to know Belinda and “have a good idea of what is happening throughout the pregnancy.”  Megan had earlier and more frequent ultrasounds scans, allowing Ryan to watch Belinda grow.  Ryan described the first day he saw her arms moving as “the coolest day of my life.”  Ryan elaborated on this experience by stating, “It was just amazing, that this little life form was already getting features that, you know, I didn’t know she had.”  He was glad that he saw the ultrasound scans because “I needed that time that I was able to bond, that I didn’t have with the first one.”

            To further facilitate bonding, Ryan engaged in several activities.  First, he took several pictures at the ultrasound.  Second, he built a website to share those pictures with his friends and family.  Third, he bought a home heart monitor, which he was excited about because “you could hear things happening.”  Fourth, Ryan read to Belinda while she was still in-utero.

            Another way Ryan felt that he was able to “get to know” Belinda is through his wife’s morning sickness.  Although he felt “bad” that she vomited at least once a day, he also felt that he was “getting to know her personality – like she hated pasta and salad.”

            Ryan described making several preparations for Belinda’s arrival.  He bought a mini-van, rebuilt his wife’s old crib, and spent his money more carefully (on items for Belinda rather than luxury items for his wife and himself).  Ryan expressed excitement about building the crib, reporting that he “sanded, painted it nice and white, and put TLC into it.”  Ryan and Megan also began planning the nursery; however, they did not go into “depth” because they were still thinking of their previous loss and had some doubt whether the baby would survive. 

            Initial Responses to Belinda’s Death.  When Ryan first learned that Belinda had died in-utero, he responded with shock, sadness, and helplessness.  He described his shock by stating, “I was so surprised that I didn’t know whether to sit or to stand.”  Ryan explained that he felt extremely sad when he noticed that Belinda’s shoulders were hunched over, noting, “It was just the saddest day.”  Ryan felt helpless over not being able to do anything to make Belinda better.  He stated, “All we could do was wait for the hospital to open up and that was it.”

            Ryan talked at length about Belinda’s delivery.  Although he knew that her death was negative, he tried to “turn the day [of delivery] around and not let it be a bad day.” Throughout the interview, he explained that he focused on the “good” and on the “present” because he knew he only had a limited amount of time with Belinda.  The following narrative illustrates how Ryan stayed focused on the “present” and on the “positive” the day of delivery: 

It was a really good experience because we were focusing on the good, instead of focusing on the path of, what we could have done to avoid it.  We were in the present, and it was actually the most in the present I have ever had.  We were there for that moment and I have never felt like that before.  It’s just we knew that we didn’t have much time with her.  And I think that helped us because if you concentrate on the good part of her life, you will remember them better.  What we did was concentrate on that, and that we knew we only had a limited time with her. . . Being there, in the present, was really, really helpful because we were able to remember more.

            When Belinda was born, Ryan was excited. He ran out of the delivery room, and shouted, “Oh, It’s a girl!.”  He felt proud of Belinda, and described her as if she were alive:

She delivered and came out perfect in every way.  She actually couldn’t close her mouth.  Her mouth was propped open and every time we tried to take a picture, we tried to close her mouth.  And she’d open it up.  So, we realized that she was trying to say something.

With his friends and family, Ryan both bonded with Belinda and celebrated her

birth.  He dressed her, covered her with a blanket, and took pictures of her with everyone at the delivery.  Ryan made handprints and footprints of Belinda, which he described as “really cool because with just pictures, you can’t really feel and touch.”  He was proud of making the molds because he learned that he was the first father that the nurse saw make them.

            After celebrating Belinda’s birth, Ryan learned that his wife, Megan, was bleeding internally.  The doctors had punctured her uterus when they did a Dilation and Curettage procedure (not all of the placenta came out when Belinda was born).  Ryan became anxious, fearing that he not only had lost Belinda, but that he would also lose Megan:

For about thirty-two hours, she was bleeding internally.  And that was pretty drastic for me because I thought I would lose her too.  It really scared me.  We couldn’t move her . . .at all.  We had to cut her open.  It was really scary for me.

Fortunately, the doctor was able to drain the blood and allow Megan’s uterus to heal.  Ryan felt relieved.

            Ryan received a lot of support from friends and family, both on the day of Belinda’s delivery and at her funeral.  Between four and twenty people were at the hospital for delivery, while over one hundred attended the funeral.  He reported that this support “. . . validated the fact that what we had to go through was real.”  Ryan felt that having friends and family at the delivery and funeral extended their support because “. . . they [friends and family] were able to understand what’s going on a little bit more.”

            The First Three Months After the Loss to the Present.  During the interview, Ryan talked at length about how he feels disorganized and in a state of “disarray” since Belinda’s death.  He has had a great deal of trouble concentrating, prioritizing, completing projects, and being on time for appointments.  The following narrative illustrates Ryan’s struggle in completing tasks and prioritizing:

One of the hard parts for me is there’s like a thousand things to get accomplished and I can’t accomplish anything.  It’s like I can’t finish a task.  I can’t find the time to finish a task.  I would rather start a new task than finish an old task.  And then I have other things on my list because I am creating a bigger list by not finishing anything.  I mean, if you had to put your finger on the hardest thing, that being in a state of disorganization constantly and then just not being able to prioritize things.  That’s my biggest problem.

Ryan’s state of disorganization has led to difficulty at work.  He described

feeling “scatter-brained” and feeling as if his thoughts were “mushpot” when he works.  He feels frustrated over this feeling: “It is the most foreign thing to me I have ever had.”  To illustrate, Ryan provided the following example:

Like yesterday I went to the office to go print.  I had to print like five things and do some other stuff.  It took me all day because everyone was asking me questions and we got a new machine at the office, and it’s just so compounded with things like that.

Ryan described time as passing “really, really slow” since Belinda’s death. He

reported that every day seems extremely long, and that it is hard for him to believe that it has only been three months since the loss.

            Ryan expressed a variety of strong emotions in response to Belinda’s death.  One of his most notable experiences was his sense of guilt and self-blame.  Although he reported that he “knew” that he did not cause her death, he still felt that it was his fault.  In one instance, he blamed himself after having painted her crib, when he noticed that the paint can said that it could cause a reproductive trauma.  Ryan further explained this incident in the following narrative:

Even though it was only really harmful if you’re a painter, it [her death] happened around the same time.  So, in the back of my mind, I said, “You kind of created this problem.”  I feel that it [her death] is partly my fault.

On another occasion, Ryan found some mold on his bathroom wallpaper, and thought that it caused her death.  He immediately stripped the wallpaper and scrubbed the walls.

            Ryan’s guilt and self-blame also came in the form of wondering whether or not he could have done something to prevent her death.  The following narrative further illustrates these feelings: 

What if I, what if she could have been on complete bedrest?  Then would this have happened?  What if that time I made her go to the store and she didn’t do it?  Of what if that one time we had sex we wouldn’t have done that?

Ryan also described feeling guilty about having any “good” feelings, which he explained by stating, “Even if you have a good minute, it’s a bad minute because you feel guilty for being in a good minute.”

            In addition to feeling guilty, Ryan felt angry. Since Belinda’s death, Ryan found himself easily agitated.  Although he was not angry at “anyone in particular,” he found himself directing his anger toward his coworkers by yelling at them.  To further illustrate his anger, Ryan provided the following description:

It’s like you’re holding an automatic rifle and just spinning around trying to hit anything.  You’re angry at your parents.  You’re angry at your spouse.  You’re angry at yourself.  You’re angry at the people.  You’re angry at everyone and everything because you happen to be the one going through it.

Ryan continues to feel sad about Belinda’s death.  He was somewhat

confused by this emotion, describing it as being “tied up” with other emotions, such as fear and regret. 

            Ryan has spent a great deal of time worrying about his wife’s well-being.  He described “. . . constantly worrying about how she is doing,” especially while he is at work.

            Ryan experiences his emotions as a “roller coaster.”  That is, their intensity goes up and down.  As time has passed, the intensity of these emotions has dissipated, and he has experienced them less often.  To illustrate his “roller coaster” of feelings, Ryan provided the following description:

The way I try to describe it is when it first happened, it was every feeling that you have, whether it was good or bad, turned on at all times.  And then some of them turned off.  Like I had anger, I had regret, I had guilt, I had pain, I had happiness.  I had everything you can think of. I was dead tired at the end of the day because I had all of these emotions turned on. Then slowly, the happiness turned off, and slowly the sadness turned off, and then the happiness turned back on and then sooner or later, you go from having everything on to like some of them on.

            One of the biggest changes for Ryan since Belinda’s death is that he plans his life less than he did before. He is now more present-focused.  He feels that he is tired of planning his entire life and having  it not “work out.”  To further illustrate why he plans his life less, Ryan stated, “It’s like I can’t plan anymore.  I mean I planned my whole life for all these things and when we wanted to get pregnant, we started this month because we wanted to have a baby this month.”  He now buys items more impulsively and enjoys not saving his money for the future.  Ryan also engages in prospective mourning, reporting that he often imagines “. . . what could have been and what was.”

            Ryan believes that Belinda’s death has “intensified” his relationship with Megan, describing every event and emotion in their relationship, whether positive or negative, as more powerful than before.  To illustrate these changes in his relationship with her, Ryan provided the following description:

Everything is more intensified than it was before.  Loving feelings are more intensified.  Anger feelings are more intensified.  Everything is just one notch up.  And it’s not always easy being one notch up.  It’s not always bad either.  It’s a weird mix.  I don’t know how to describe it, but like everything is just a little bit more important, even if it’s stupid little things like taking out the trash.  Now that issue is more important.  Spending more time together is more important than finishing a project.

Ryan also described Megan’s moods as “inconsistent” since the loss.  That is, her

moods fluctuate and are not predictable.  He finds that coping with a partner who is “inconsistent” is difficult because he can not predict what will be important to her when he sees her.  To exemplify, he stated, “Small things, like her cleaning, are either completely irrelevant or paramount [to Megan], and I never know when it is which.  It’s not as consistent as it was before.  I never know what it’s going to be.”  This inconsistency had led Ryan to a state of feeling helpless.

            Another challenge in Ryan’s relationship with Megan is that their moods are often incongruent.  He stated, “ A lot of times she’s up and I’d be down or vice versa.”   Ryan further explains how difficult        it is for him to be in a different mood than Megan in the following narrative:

And like, if I was in a happy mood, that I had put myself into, dealing with her being down is a little bit harder but it was even harder to be supportive when I was down as well.

In addition, he often fears bringing up Belinda’s death to Megan because, if she is “feeling good,” he does not want to make her “feel bad.”

            Ryan has coped with Belinda’s death in a variety of ways.  He talked at length about how he started a fund to create packages of baby items for parents after they have a miscarriage, a stillbirth, or a neonatal death.  He was enthusiastic about this project, and proudly explained how he created “a huge following” of people who donated money, totaling about $3,000.00.  These donations made Ryan feel excited, as he stated, “Wow!  People really care.”  Ryan described his project in the following narrative: 

Inside these packages we had some stuff for when the baby died.  They have baby blankets, baby clothes, and a camera so people could take pictures.  It was just the personal touch that we wanted.  We are also creating cards for people, if they want them, for every year – to show that someone is thinking of them.  We gave birth certificates because if you have a stillbirth, you can’t get a birth certificate because it is a certificate of a live birth.

Similar to when Dennis described the casket he made, Ryan described these

packages with pride and great detail:

Like the boxes.  I just sit there and go “Wow!”  You know, not to pat ourselves on the back, I was like “Wow.” I mean everyone chipped in and they made this beautiful thing that someone can take home.  We bought wedding cameras too.  I mean those packages are really complete because we bought wedding cameras because that’s what we could get at Party City. . . We took all the cases off the cameras so we just have a plain camera.  That’s not good enough for us.  So we actually made new jackets for all the cameras.  They have a little pink and blue and have all the directions for the camera.  We cut out all the holes. It allowed us to do some really cool things.

Ryan felt that creating these packages helped him “channel my grief” and was a

“real outlet.”

            Another way that Ryan has coped with the pain he experienced after Belinda’s death was to attend a perinatal loss support group.  He feels that this group has given him an opportunity to talk about her death, which he has thought that he has needed to do.  In the following narrative, Ryan described how the support group has helped him cope with the loss:

Right now, I mean we’re in need of support right now.  And it’s actually very helpful and we went last night.  We were able to meet with people on this.  It was very good.  It’s always good to sit down and talk about the story.  We kind of feel the need to talk about it.  We could talk about it between ourselves, but it’s also nice to talk to other people who understand what is going on.  Because not everyone does.

For Ryan, it has been important to share his story about his loss.  Moreover, he

built a web site that described how she died.

Ryan has also coped with the loss by educating himself about the physical causes

of her death.  He stated that he wanted to  “. . . gather as much objective information as possible.”

            Difference Between the Two Losses.  This additional section has been added to Ryan’s results because he repeatedly discussed how he experienced the loss of Pat and Belinda differently.  He explained how losing Pat was not as difficult for him as compared to the loss of Belinda, because he was not as bonded with Pat.  He was much more involved in Megan’s pregnancy with Belinda, seeing her image in many ultrasounds.  He felt that in the pregnancy with Belinda, he was “. . . more a part of the process of what was going on.”

            Ryan rated his grief after Pat’s death as much less severe than his grief after Belinda’s death.  To illustrate, he stated:

Let’s just say that one to ten, ten being the worse possible situation, I’d probably rate it [Pat’s death] one to two.  Not super important, not super painful, but not something you can just “sluff” off in two days. . . [for Belinda’s death] I’d probably say with myself that it would probably be somewhere around eight or nine.

He also compared his reactions to each of their losses with the following


[with feelings about Pat’s death] I could just put it in its own little box and put it

aside.  But having it happen like it happened with Belinda, it’s a lot bigger box and you know, it doesn’t close well.  And that’s part of the reason I’ve been so, just a mess.  The box doesn’t close. 

The Perinatal Grief Scale

            Ryan completed the PGS in the beginning of the first meeting.  His scores were then computed and compared to the means and standard deviations of the PGS. These means and standard deviations were found in the validation study of this instrument (Potvin, Lasker, and Toedter’s,1989).  Ryan’s total score was 98, indicating that his total amount of grief was .3 standard deviations above the mean (see Table XIV).  His score for the Active Grief (also known as normal grief) subscale was 38, which is .23 standard deviation below the mean.  On Ryan’s Difficulty Coping subscale he scored a 34, which is .82 standard deviations above the mean.  On his Despair subscale, he scored 26, which is .21 standard deviation above the mean.  Essentially, Ryan scored above the mean in his total score, Difficulty Coping score, and Despair score, while scoring below the mean in his Active Grief score. 

Table XIV.

Ryan’s Perinatal Grief Scale Scores (compared to reference scores[6])

      Active Grief                           Difficulty Coping          Despair                          Total Score

Ryan     Mean       SD        Ryan      Mean       SD       Ryan      Mean    SD       Ryan    Mean     SD        


 39.92     8.25


26.97      8.53


 24.41  7.70


91.31  21.16



The following pages contain two tables of the results of the rater’s responses to the T.A.T. and the C.A.T.-H.  Table fifteen illustrates the results of the T.A.T.; table sixteen, the C.A.T.-H.  These tables list each rater’s description of the themes, distress level, and defenses of Ryan’s stories to each of the cards used in the study.


Table XV.


Ryan’s T.A.T. Results


Card   Rater   Themes                                       Distress Level    Defenses

2        1         Autonomy, Achievement                  Mild            Mild Repression, Denial


          2         Ambivalence Re. Separation                Mild            Fairly Adequate Defenses:

                     From Parents, Problems in                                      Denial, Rationalization,

                     Separation In General, Significant                Regression

                     Potential for Problems With



          3         Daughter Deciding Whether to         High             Intellectualization

                     Leave Farm and Follow                    Moderate

                     Mother’s Life, Son Stays Home

                     and Works on Farm, Daughter is

                     Unclear About Independence

                     Passive Acceptance


3BM  1         Achievement, Dejection, Loss          Moderate     Moderate Denial


          2         Potential for Serious Substance         Severe         Relatively Poor Defenses:

                     Abuse Problems, Passive-Dependent                    Denial, Regression,

                     Emotional Outlook, Major Difficulty                         Rationalization

                     In Resolving Conflict


          3         Drunk Young Man Caught By Law,  High           Alcohol Abuse,

                     Is Sad, Passes Out, Will Learn From                     Suppression



7GF   1         Nurturance, Autonomy,                      Mild           None Noted



          2         Child-Like Emotional Outlook,            Moderate     Relatively Weak Defenses:

                     Dependency and Emotional                                      Denial, Regression

                     Neediness, Ambivalence About



          3         Girl is Deciding to Give Up               Moderate      Sublimation

                     Attachment to doll, Mother

                     Sensibly Supports Her,

                     She Puts Away Childish Things


Table XVI.


Ryan’s C.A.T.-H Results


Card   Rater   Themes                                       Distress Level    Defenses

3        1          Role Confusion, Loss,                    Mild              Mild Regression



          2          Significant Problems With                Moderate       Relatively Poor Defenses:

                      Dependency, Unresolved Anger                 Denial, Somatization

                      Toward Self, Self Image as Weak

                      and Damaged


          3         Crippled Man, Overcomes               Mild -          Compensation

                     Trauma, Help of Mate,                     Moderate

                     Undertones of Sadness


5        1          Sibling Rivalry, Affiliation,            Mild             Mild Denial



          2          Perceived Lack of Parental               Severe          Relatively Poor Defenses: 

                      Attention and Nurturance, Strong                        Denial, Regression

                      Fears About Abandonment


          3          Thunder/Lightening Frightened      High             Phobias, Attachment

                      Boys, Comfort Each Other                                  Distraction


9        1           Affiliation, Autonomy,                       Mild            None Noted



          2           Fantasies of Abandonment,               Severe          Relatively Poor Defenses:

                       Fantasies of Rejection,                              Denial, Regression

                       Child-like Emotional Outlook


         3            Thunder/Lightening, Fun,               High            Attachment  


                       Boy Seeks Brother for Comfort

Brief Commentary on Ryan’s Results

            Ryan’s interview, PGS, T.A.T., and C.A.T.-H results were consistent with each other, all indicating that he was struggling with his losses.  As noted earlier, during his interview, he talked at length about how he was struggling since his stillbirth.  Rater one noted that card 3BM of his T.A.T. and card 3 of his C.A.T.-H revealed that he was experiencing a sense of loss.  Similarly, his elevated Difficulty Coping and Despair subscale scores on his PGS suggests that he was having difficulty dealing with both people and activities, and had the potential for serious and long-lasting effects of the loss.  Because it is beyond the scope of this chapter to further discuss these findings, these results will be discussed in greater detail in Chapter five.



Five men who experienced perinatal loss participated in this investigation.  Each of these men was interviewed twice, and administered three psychological tests:  the PGS, the T.A.T., and the C.A.T.-H.

Each participant’s interview was unique; however, there were general themes threaded throughout them. Twenty-three themes were extracted from these interviews (see Figure III).  These themes were broken down into two main categories, and four subcategories.  These categories are as follows:  (1) Before loss; (2) After loss: (a) General themes; (b) Emotions; (c) Relationship Changes; and (d) Coping strategies.

To be considered a theme, two or 40% of the participants must have endorsed it.

Because some individuals had themes that were not endorsed by any other participants, but appear essential to understanding their experiences, Figure IV reflects those idiographic themes that were endorsed by only one participant.

Each participant’s scores varied on the PGS, so Table XVII presents these scores in a format that allows for comparison across individuals.

The results of the T.A.T. and the C.A.T.-H have already been thoroughly presented in table format; therefore, these will not be shown again in this section.  Themes from the interview, the PGS and the projective tests will be integrated and discussed in more detail in Chapter five.


Figure III.  Frequency table of themes extracted from the interviews








Before Loss






   Strong Desire for Children






   Excited About Pregnancy






   Extremely Ambivalent About







   Bonding Before Death






After Loss






General Themes












   Focusing on Wife’s Needs*






   Hiding Feelings About Loss*






   Being “Strong” for Wife*






   Increased Awareness of Own







   Increased Focus On Present






   “Cherish” Life and/or   

   Current Children More
















































Relationship Changes






   With Spouse






   With Parents






   Attitude Toward and Style of

   Parenting Changed






Coping Strategies






   Spent Time With Deceased








   Seeking/Learning About

   Cause of Death






   Built/Created Concrete

   Object for or Symbolizing  

   Own Deceased Baby






   Advocacy/Public Speaking






   Family and/or Friend Support






   Support Group







* These themes can fit under more than one of the categories.



Figure IV. Frequency table of idiographic themes extracted from the interviews


























Perceiving Self as “Failure”












Increased Reflection on Values






Avoid Thinking About Loss






Time Passing Slowly












Fluctuating Emotions








Table XVII.  Summary of Perinatal Grief Scale (PGS) Scores[7]

                  Active Grief                           Difficulty Coping               Despair                    Total Score

                participant   reference   participant       reference     participant  reference   participant    reference

                                     mean                                mean                               mean                               mean

















































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[1] All identifying information has been changed in order to protect their confidentiality and anonymity.

[2] The reference group scores were taken from Potvin, Lasker, and Toedter’s (1989) validation study.

[3] The reference group scores were taken from Potvin, Lasker, and Toedter’s (1989) validation study.

[4] The reference group scores were taken from Potvin, Lasker, and Toedter’s (1989) validation study.

[5] The reference group scores were taken from Potvin, Lasker, and Toedter’s (1989) validation study.

[6] The reference group scores were taken from Potvin, Lasker, and Toedter’s (1989) validation study.

[7] The reference mean scores varied depending on the type of loss.