Sangeeta Singg. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 2. Thousand Oaks, CA: Sage Reference, 2003.
Experiencing intense emotional distress following the death of a loved one is a normal human reaction. When a child dies, however, the unique dynamics of parent-child relationship further intensify bereavement reactions of parents. In the modern Western world, children are expected to outlive their parents. Parents not only expect to see their children grown and settled, they even expect to see their grandchildren growing and settling. A child’s death disrupts the normal life cycle expectations of parents, and the loss creates the havoc of emotional and familial crises. Because children provide parents a sense of purpose and hope for the future, parents envision their immortality and life continuation through their children’s lives. This sense of self-continuity through progeny leads to parents’ denial of their own death (Rando 1986d). Consequently, when a child dies, it leads to an overwhelming and enduring loss that may drastically affect the well-being of parents. Some researchers suggest that the trauma of experiencing a child’s death may lead to posttraumatic stress symptoms and a complicated mourning (Wheeler 2001). And if the death occurs suddenly, violently, or due to genetic factors, some additional issues of unpreparedness, preventability, and helplessness compound the grief process.
Compared with other losses, the death of a child is a more devastating experience for most people because they are confronted with many secondary losses as well (Rando 1986d). Beverly Raphael (1994) enumerates the many losses parents experience when a child dies:
A child is many things: a part of the self and of the loved partner; a representation of generations past; the genes of the forebears; the hope of the future; a source of love, pleasure, even narcissistic delight; a tie or burden; and sometimes a symbol of the worst part of the self and others. (P. 229)
A child’s death changes the family forever. In addition to the loss of dreams and future expectations of life with the child, a sense of failure as parents and survival guilt compound the grief process, making it a “bereavement overload” (Rando 1986c:51). Parental grief often escalates to a pathological level, turning into some form of unresolved grief, which is often considered abnormal in other types of bereavements. The traditional symptoms of unresolved grief seem normal components of parental bereavement, however (Rando 1986b). Diseases, accidents, suicide, and homicide victimize many lives, leaving many bereaved parents of all ages. In Western society, with increasing life expectancy, the number of elderly people who experience the death of a middle-aged child has also increased (Osterweis, Solomon, and Green 1984).
Reactions to losing a child are perhaps as varied as the number of parents. However, researchers have found some dynamics and reactions that are common among bereaved parents. A variety of bereavement reactions emerge at different grief stages. Therese A. Rando (1986d) describes various grief reactions occurring in three phases: avoidance, confrontation, and reestablishment (accommodation). The avoidance phase is the first stage of parental grief. This phase begins with the event of the child’s death, leaving parents in shock and denial. Feelings of bewilderment and numbness are initial reactions along with the disbelief about the news of the child’s death. At this stage, parents may be perceived by some people as strong or pretentious. What they may not know, however, is that these early reactions of shock, denial, and numbness act as buffers against grief until parents can collect their resources to face reality. According to Bernstein (1997:10), these brief periods of denial act as “shock absorbers” with a protective effect. Confusion and disorganization are also common reactions during the first phase.
The second phase described by Rando is the confrontation phase, which begins with the recognition of the loss and progresses to the most intense suffering and pain. It is also called the period of “angry sadness” (Rando 1986d:14). Extreme emotions such as fear, anxiety, anger, guilt, longing, despair, depression, obsession, and search for meaning are common reactions during this stage. Some individuals may have difficulty sharing their feelings, whereas others may cry and talk incessantly. Bereaved parents may even experience “grief attacks” involving waves of painful emotional and physical symptoms. These grief attacks can cause accidents if parents do not stop their activities and deal with their disabling feelings until they subside. Some of the common physiological reactions are gastrointestinal disturbances, weight loss, insomnia, physical exhaustion, heart palpitations, shortness of breath, weakness, and sighing. These symptoms tend to persist during the early stages. However, 5 years past the death, these physical symptoms may not persist, with the exception of insomnia (Bernstein 1997:14).
The final phase is the reestablishment phase in which finality of the child’s death sets in and the grief gradually declines. The parent resumes the normal routine of daily activities and learns to live with the loss. The emotional energy is reinvested in other relationships and pursuits. This phase often overlaps with the confrontation phase, taking the parent gradually to the final stage of grief. Because the parent begins living again, guilt is often experienced in the initial stages of this phase. As time passes, however, intensely painful days begin to be less frequent. Although the anniversary of the child’s death, child’s birthday, holidays, and other special days bring back memories and intense pain, crossing each milestone takes the parent closer to accommodation or adaptation. These terms are preferred to recovery in reference to parental bereavement, because recovery means returning to normal, and bereaved parents never completely return to normal; they mourn, integrate, and adapt (Bernstein 1997:xvi).
According to Rando (1986c), traditional grief models are inadequate to explain parental bereavement. An example is the popular model developed by Worden (2002) that consists of four tasks of mourning. Unlike other types of mourners, bereaved parents have trouble meeting all four tasks: (a) accepting the reality of the loss, (b) experiencing the pain of grief, (c) adjusting to the environment in which the deceased is missing, and (d) emotionally relocating the deceased and moving on with life. The failure to meet these four tasks has to do with the unique nature of the parent-child relationship, characterizing the loss to be multifaceted and enduring. Therefore, what is a normal process in parental bereavement is considered pathological in other types of bereavement. Four types of unresolved grief that may constitute normal facets of parental grief are (a) inhibited, suppressed, or absent grief when a parent does not accept the loss; (b) distorted/conflicted grief, consisting of feelings of extreme guilt and anger; (c) chronic grief, involving the grief process that continues; and (d) unanticipated grief syndrome, characterized by complicated “recovery.”
Feelings of being robbed, incomplete, inadequate, unsuccessful, and guilty are common feelings of bereaved parents reported in the literature. Most devastating, and a prominent feature of parental bereavement, are feelings of extreme guilt, especially in the early stages. Margaret Shandor Miles and Alice Sterner Demi (1986) identify six possible sources of parental guilt:
- Death causation guilt, results from parents’ perception that they may have contributed to the child’s death or that they failed to protect the child from the death.
- Illness-related guilt, involves their belief that they did not behave in optimal ways in relation to the sick or dead child.
- Parental role guilt, originally labeled as cultural role guilt, is related to the parent-child relationship before and at the time of child’s death. Parents believe that they failed to fulfill the socially prescribed overall parental role, and now they have no opportunity to rectify their mistakes because the child is dead.
- Moral guilts, tems from having an overly strict conscience or religious belief system that stresses guilt and punishment. The child’s death is perceived as the punishment for parents’ wrong deeds.
- Survival guilt, may result because a child’s death does not fit in the expected normal life cycle events.
- Grief guilt, relates to parents’ perception of their actions at or after the time of child’s death. This guilt may progress through three phases: (a) in relation to parents’ emotional reactions at the time of death, (b) in relation to grief reactions during bereavement, and (c) in relation to the “recovery phase” when the grief intensity begins to decline.
Different parents may experience grief differently. There is no set sequence of stages of grief and no really predictable pattern for all bereaved parents (Bernstein 1997). A bereaved mother and a health professional, Pamela Elder (1998) states, “I did not experience emotions in serial stages. … I dipped in and out of grief, sometimes coping, sometimes not. I did not feel that I ‘worked’ through my grief, rather that ‘it’ worked through me” (p. 121).
The nature and intensity of grief that a parent experiences are influenced by many factors, such as the nature of the death, ambivalence in parent-child relationship, age of the deceased child, sex of parents, marriage of parents, search for meaning, duration of grief, and social support. Some of these factors have been identified as risk factors for adverse outcomes for parents, whereas the others may be growth producing.
Nature of Death
People die either suddenly or with forewarning due to some terminal illness. The sudden death of a child is a tragedy that prompts intense emotional reactions in parents. Accidents, acute diseases, suicide, and homicide are often the causes of sudden death. Although suddenness of death is defined differently by experts, a common criterion in all definitions is the death without warning that catches survivors unprepared (Osterweis et al. 1984). Also, sudden deaths are more likely to result in more intense bereavement of longer duration (Raphael 1994).
In a study of 134 Caucasian married parents experiencing death of one child, Cole and Singg (1998) examined the bereavement reactions (despair, panic behavior, blame and anger, detachment, disorganization, and personal growth measured by the Hogan Grief Reaction Checklist) in relation to duration of grief and several psychosocial variables. The results show that regardless of the length of time since death, the parents whose children died suddenly experienced more panic and disorganization than those whose children’s deaths were anticipated. With sudden death, there is no time to collect one’s resources to cope with the loss. Parents feel an overwhelming need to search for answers. Feelings of lack of control over events create panic in the newly and suddenly bereaved parent (Bernstein 1997). According to Knapp (1986), “Parents who suffer the shock of sudden death pay their dues all at once rather than a little at a time!”(p. 79). These parents have a hard time returning to the level of functioning prior to death. Ronald J. Knapp (1986) calls this state the “shadow grief” marked by a dull “ache” that always lingers on (p. 67). On the other hand, parents who experience an anticipated death of a child move through the grief process more quickly and arrive at a level of functioning that is sometimes higher than before the tragedy.
Two major predictors of the intensity and duration of grief reported in the previous research are quality of the relationship and the mourner’s perception of preventability of the death, the latter being the most crucial factor (Bugen 1977). A child’s death presents both factors. Because deaths of children and young adults are more likely to be sudden and accidental, they are often perceived as “preventable” by bereaved parents, resulting in extreme guilt. Inability to prevent the death often creates a sense of failure in the parent. Even when a child dies as a result of genetic factors unknown to parents before the child’s diagnosis, they feel responsible for the child’s condition. If the cause of death was a disease, parents wonder if they had taken the child to the doctor sooner or noticed the symptoms sooner, the death could have been prevented (Rando 1986c). This kind of thinking refers more to what “should have been,” than to actual preventability of death (Bugen 1977:202). Pamela Elder (1998) aptly depicts the pattern of feelings that emerges with a child’s death that the parent feels could have been prevented:
At times, I was suspended with shock, then raging with anger, at the injustice of it all, followed by periods of great calm. There were days when I felt perfectly normal, as if nothing had really changed, but then I worried about whether I was a cold, uncaring mother. Kate had been so vital, so filled with joy and confidence in living. Yet she was dead, and I had had no power to save her. And so began the everyday business of living with grief. (P. 120)
Although not less painful, the death after prolonged illness, frequent hospitalizations, and expensive unsuccessful treatments may be a gradual and quieter experience as opposed to the experience of utter devastation with a sudden death. The parents whose children are diagnosed with a terminal illness have some time to prepare, a state called “anticipatory grief.” They begin the grief work at the time of diagnosis. Their journey after death is shorter and less volatile than for the parents with sudden loss (Bernstein 1997). Also, when a death is anticipated, the parents may nurture the child with more affection and help the child fulfill his or her wishes. As a result, they may have fewer regrets.
Ambivalence in the Parent-Child Relationship
Another factor involved in the intensity of parental grief is the degree of ambivalence in the parent-child relationship. This may result from unrealistic expectations of roles of parent and child in our society. Parents are expected to be all sacrificing and loving, and children are expected to be obedient, respectful, and lovable (Raphael 1994). Such idealistic expectations create ambivalence in the parent-child relationship. Although all relationships are subject to some degree of ambivalence, difficult reactions result when strong conflicting feelings are experienced by some parents toward their children. They love their children, but at times they feel angry or burdened when children behave in a rebellious manner or become terminally ill. A terminally ill child may require expensive treatments and may be noncompliant, and parents may feel angry and wish at times for the child to die (Miles and Demi 1986). These feelings lead to extreme guilt after a child’s death. Also, rebellious behaviors of children may cause embarrassment, undue financial expense, or significant distress to parents. Some parents may at times wish they did not have such a difficult or demanding child. Self-blame and feeling guilty are common reactions when a high degree of ambivalence exists in a parent-child relationship. A sense of relief may be experienced by some parents when a child dies after a prolonged illness or a problematic life. This may further compound the guilt reaction of a parent (Rando 1986d).
Age of the Deceased Child
Although many similar feelings and issues are experienced by all bereaved parents, different grief patterns emerge because of different developmental stages at the time of loss. Because of the nature of parent-child relationship, the tasks of mourning for an infant or an adult take different courses (Rando 1993). As a result, researchers have examined death of children ranging from the fetal stage to middle age.
Fetal and Infant Deaths
Fetal deaths are known as miscarriages and stillbirths, which occur either during gestation or birth. In the United States, the fetal (20 weeks or more gestation) mortality rate reported for 1998 was 6.7 per 1,000 registered live births plus fetal deaths (National Center for Health Statistics 2002). These deaths are differentiated from elected abortions. Miscarriage, also called spontaneous abortion, refers to a pregnancy loss that occurs before the 20th week. Different statistical estimates are available for miscarriages since classification is fraught with uncertainty. A conservative estimate is that 1 in 6 pregnancies ends in miscarriage (Daiter 1998). Miscarriages leave grieving parents with shattered dreams and hopes, especially the mother. A predominant feeling of sadness prevails. The attachment of a mother to the unborn child may form very early during the pregnancy. She may feel like a failure for not being able to deliver a live, healthy baby. Also, previous feelings of ambivalence about the pregnancy may compound feelings of guilt and anger. Fathers also attach to the unborn child by fantasizing what it will be like and how they will do various fatherly things with the child, but their sadness is often less intense (Raphael 1994).
A child under 1 year of age is called an infant. The infant mortality rate reported for 1999 was 7.1 per 1,000 registered live births excluding fetal deaths (National Center for Health Statistics 2002). Contrary to common belief, Cole and Singg (1998) found that the parents of infants tend to experience more despair than the parents of older children, regardless of the time since death. Parents experiencing the death of an infant are more likely to be younger and may not have any previous experience of losing a loved one. Although losing a child is the worst kind of loss, successful coping with the previous losses has beneficial effect on the bereavement process (Bernstein 1997). Also, the great dependency of an infant on parents, especially mothers, creates a strong bond that may leave them in greater despair. I will examine infant deaths in the following three categories: stillbirths, neonatal deaths, and sudden infant deaths.
Stillbirths. One in every 80 deliveries results in a stillbirth. In most cases, the baby dies just before or during delivery. In some cases, however, mothers have a forewarning prior to the delivery about the death of the fetus in utero (Osterweis et al. 1984:76). Emotional reactions to both an anticipated and a sudden stillbirth are reported to be similar, because bonding with the baby, especially by mothers, has already been established by the time stillbirth occurs. The modern technology of ultrasound often creates this bonding for parents very early when they observe the fetus on the monitor in a doctor’s office and obtain an image of their child. Fathers’ feelings are often ignored at these times, because they are expected to take on the role of protector. Mothers often feel anger, loneliness, and shame for not being able to bear a healthy baby, and these feelings can become exacerbated if there is insufficient support or “conspiracy of silence” (Osterweis et al. 1984:77). Often, the lack of social support when a woman goes home empty-handed complicates her mourning. In the past, parents were spared the sight of their stillborn babies due to a mistaken belief that not seeing the baby would be less traumatic. But now it is believed that seeing and even holding the dead infant may be therapeutic. Parents in hospitals are allowed to name the infant and collect mementos such as locks of hair and a picture of the baby (Osterweis et al. 1984; Raphael 1994).
Neonatal Death. The neonatal (under 28 days) mortality rate reported for 1999 was 4.7 per 1,000 registered live births excluding fetal deaths (National Center for Health Statistics 2002). Modern medicine has dramatically changed the survival rate of premature babies and babies with birth defects. However, sometimes in spite of the modern medical interventions, some babies survive for only a short period of time. In these situations, parents have some opportunity to bond with the baby, and they hope for a cure or miracle. When the infant dies, mothers often blame themselves more than fathers do and feel responsible for causing the death. Their behaviors such as smoking, drinking, and not taking better care of themselves are considered possible reasons for death. Anxiety and anger for the child’s not having had a chance compound the feelings of guilt in these mothers. Nevertheless, more emotional support is available to parents of these babies compared with parents of stillborn babies (Osterweis et al. 1984; Raphael 1994).
Sudden Infant Death. In 1999, a total of 2,648 infant deaths were attributed to sudden infant death syndrome, or SIDS. This total is equivalent to about 1 in 10 infant deaths for this particular year (National Center for Health Statistics 2002). SIDS is the leading cause of deaths in infants 1 to 12 months of age, an occurrence that usually happens during the first 2 to 4 months. For an infant’s sudden death to be diagnosed as SIDS, the infant has to be less than 1 year of age, with death investigation resulting in no causal explanation. Besides strong feelings of guilt and anger, overprotection of surviving children and fear of losing future children are common reactions of parents. Also, because a SIDS death often remains unexplained, the parental grief may become complicated with additional factors. For example, involvement of law enforcement officers may pose additional stress for parents who might be suspected of child abuse. Efforts have been made to educate homicide officers about SIDS so that innocent parents are spared the undue stress. Nonetheless, extreme guilt is often experienced by the parents due to the unexplainable nature of the child’s death, which leads to their relentless searching for the cause (Osterweis et al. 1984; Raphael 1994).
Death of an Older Child
Fewer older children die than infants. In 1999 in the United States, 12,844 children between 1 and 14 years of age died compared with 27,337 infants less than 1 year of age (National Center for Health Statistics 2002). Accidents are the major cause of death (45% of the deaths), especially in adolescence. Other major causes at this age are leukemia and other types of cancers. As in the case of the death of an infant, anger is a common emotion, accompanied by despair experienced by bereaved parents of an older child. Death of an adolescent is often more traumatic because parent-child relationship ambivalence is very high during this stage, possibly due to the child’s rebellion. Parents who can understand the cause of their child’s death and those who provide home care instead of hospital care, however, tend to have better bereavement outcomes (Osterweis et al. 1984; Raphael 1994).
Death of an Adult Child
When a younger adult child dies, grief reactions and family dynamics are similar to those that emerge when an adolescent child dies. When a middle-aged child dies, however, the parental bereavement takes on a little different form, with different grief dynamics for the elderly parent. It is estimated that at age 60, 10% of parents deal with death of an adult child. The untimeliness of the death of a child seems even more pronounced to elderly parents because of their age and expectation to die first. In some cases, the loss becomes more devastating because the child was the primary caregiver of the elderly parents. Also, because they suffer from many “normative-age graded losses,” such as their health, spouse, home, income, identity, and status, the multiplicity of losses complicates depression, a common problem among the elderly (Moss, Lesher, and Moss 1986-87).
According to Rando (1986a), the death of an adult child poses five special bereavement problems in parents:
- Successful accommodation of the loss is compromised. They have extreme difficulty in meeting the four tasks of grief work prescribed by Worden (2002), especially the first task of accepting the reality of the loss.
- They are excluded from the concern of others. Attention is usually given to the adult child’s spouse and children, and elderly parentsare often overlooked. This leaves them feeling invalidated and without much social support.
- Their grief and mourning are complicated with multiple factors, such as bereavement overload from other losses and health problems.
- As children become adults, parentshave less control and involvement in their lives. This further complicates the bereavement process. For example, parents may have no say about the funeral or funerary rituals.
- Their grief is further complicated with additional secondary losses, such as losing contact with the grandchildren because of the family’s moving away or losing financial and other support provided by the adult child.
Because of these problems, older parents seem less resilient, and the death of their adult child remains one of the most dominant issues of their later life. There is a sharp beginning of the tasks of grief work “but literally no end as long as life is lived and experienced” (Rubin and Malkinson 2001:232).
Sex of Parents
Another factor involved in dynamics of bereavement is the sex of parents. Generally, mothers experience more intense and more prolonged grief reactions than fathers. They also show different grieving patterns. For example, Cole and Singg (1998) found that bereaved mothers experience more intense symptoms of despair, panic, and disorganization than fathers do, regardless of the length of time since death. Fathers on the other hand experience higher levels of anger and loss of control (Osterweis et al. 1984). After some years, however, they function more like nonbereaved fathers, whereas mothers continue to resemble the recently bereaved mothers, showing greater affective, somatic, social, and psychological distress (Bernstein 1997).
Mothers of younger children exhibit more intense symptoms of grief than fathers do. This may be because mothers are more involved in the day-to-day tasks associated with child care, especially if they do not work outside the home (Rando 1986d). Many daily reminders become part of the mother-child interaction because of the more involved relationship. When a child dies, every environmental and sensory cue associated with the child elicits memories and adds to mothers’ grief. It will be interesting to see, however, if the styles of grieving will change for mothers and fathers in the future because more fathers are now sharing the parenting role in our society (Bernstein 1997).
Sex role socialization also contributes to sex differences in parental grief. Whereas women are socialized to accept help and express their emotions, men are expected to be self-sufficient and show emotional control (Rando 1986d). As a result, mothers tend to openly express their grief, whereas fathers deal with it more privately. Mothers may perceive fathers’ emotional restraint as a lack of love for the child, whereas mothers’ open expression of grief may leave fathers feeling helpless because they cannot control the situation. Each experiences a very solitary grief as noted by Knapp (1986), “I talk about ‘parents’ suffering, but it should be noted that this was an individual hell, containing only one person. Even one’s spouse became ‘out of reach’ during this stage” (p. 145). Because of this lack of emotional connection, the marriage often provides little support for the couple.
Fathers often immerse themselves in work after the child’s death. This leaves the mother feeling even more alone. The cultural conditioning further adds to this dilemma. Fathers normally assume the role of a family protector and provider who is in control. When a child dies, however, the father is presented with a situation he cannot control. Feelings of failure coupled with the social image of strong man exacerbate his grief. Nevertheless, work may provide social support and good distraction for some parents (often fathers); therefore, returning to work may be beneficial. A grieving parent may feel useful and valuable at work. The death of a child often lowers the self-esteem of parents, reminding them that they have failed to prevent the tragedy; work may provide opportunities for them to feel productive and useful, which may improve their feelings of self-worth (Bernstein 1997; Rando 1986d).
Marriage of Parents
Losing a child can place enormous stress on a marriage. Some marriages may deteriorate or dissolve after dealing with a child’s illness and death, whereas other marriages may be strengthened depending on the quality of interpersonal communication the couple had before the tragedy. One reason for marital discord may have to do with different styles of grieving for fathers and mothers (Osterweis et al. 1984). This lack of synchrony may result in communication problems and feelings of lack of support (Rando 1993). Also, because fathers adjust to the loss more quickly than mothers, mothers may perceive this reaction as a lack of love for the child or themselves.
Another area of marital stress after a child’s death is the sexual relationship. A frequent problem in this area is the lack of desire in one or both parents. The incongruency of needs for sexual intimacy of the couple can cause misunderstandings and a major secondary loss for some couples. However, grief can suppress the sexual desire for 2 or more years (a common symptom) after a child’s death (Rando 1986d:29). In a study by Hagemeister and Rosenblatt (1997) of the sexual relationship of bereaved parents, 67% of the couples reported a break or decline in sexual intercourse after their child’s death. Problems in this area of marriage were related to meanings they attached to the continuation or resumption of the intercourse. Meanings most often associated to sexual intercourse had to do with how the child was made, pleasure, and making another baby that one or both partners may not want.
All these dynamics add to the overwhelming grief experience of parents. Until recently, an erroneous belief has prevailed among many professionals and laypeople who assume that a high divorce rate exists among bereaved parents. Rando (1986d) argues that early research with methodological problems fostered this belief. Recently, the Compassionate Friends commissioned NFO Research (2002) to assess the impact of a child’s death on the American family. The survey results showed that of those parents who were married at the time of their child’s death, only 12% divorced. Furthermore, of that 12%, only 25% reported that the death of their child contributed to their divorce. In a recently conducted literature review to determine the incidence of divorce among bereaved parents, Schwab (1998) concluded that “the often-heard claim that there is an unusually high rate of divorce among bereaved parents is a myth” (p. 465). Instead, most marriages survive the stress presented by a child’s death.
Duration of Grief
A general consensus is that an average period of time for grief lasts approximately 12 to 18 months. However, duration of grief is much longer when a child dies (Rosen 1988-89). Some symptoms may take 3 or more years to be resolved, whereas the more intense symptoms may subside within 6 to 12 months.
The bereavement process does not follow a prescribed pattern; rather, it has many ups and downs. Symptoms may subside, then return with full force long after the child’s death. Brief upsurges may also occur during certain special times of the year, such as anniversaries and birthdays (Rando 1986b). A dull ache always lurks in the background; triggered by the appropriate stimulus, the pain comes bubbling to the surface (Knapp 1986). The pain may lessen and change, but there are some aspects of the loss that stay with parents as long as they live (Rando 1986b).
Bereaved parents often expect grief to be much improved after 1 year, but then they realize that life will never be the same again (Bernstein 1997). After several years of experiencing intense grief, the pain may lessen and personal growth may follow. As the finality of the child’s death becomes a reality for parents, accommodation occurs. Parents begin to take a more active part in their own lives, which begin to have meaning once again. The pain of their child’s death becomes less intense but is not forgotten. In time, however, the impact of loss of a child reaches a relatively steady state, but the meaning of the loss stays in constant flux throughout one’s life (Rubin and Malkinson 2001). Elder (1998) summarizes it well:
Kate died on 15 June 1988. Over the intervening nine years this subjective view of her death, always uncertain, has shifted and changed. There has been a continuing process of reassessment and reconstruction of the experience in order to enlarge the understanding of it. We have, as a family, reached the point when the concentration on the past, on Kate’s death, has moved so that we all feel able to live in the present and invest in the future. The intensity of feelings has lessened. Tears are no longer so upsetting. However, the past is always there and we are always working with it, but it no longer dominates every waking moment. A part of our life has gone, a part that won’t ever come back….We have reached an accommodation with it, by accepting that we won’t “recover” from it. For this implies we can go back to being the family we were before Kate’s death. Losing her changed everything. (Pp. 122-23)
Search for Meaning
A child is an extension of parents’ hopes, dreams, needs, and wishes for immortality and holds multiple meanings for parents. Therefore, a child’s death shatters the meaning and purpose of parents’ lives, leaving behind painful confusion (Rando 1986b). According to Wheeler (2001), the death of a child becomes a crisis of meaning for parents. This process involves both seeking understanding (cognitive mastery) and finding reasons to continue living (finding purpose in life). Because the death of a child violates previous assumptions and meanings, bereaved parents tend to lose both cognitive mastery and previously held goals and purpose. In a study of 176 bereaved parents, Wheeler asked open-ended questions about the experience of child’s death and the meaning of parents’ lives since the death to assess the crisis of meaning in parental bereavement. Responses of most parents suggested that the search for meaning was a major factor in their journey to gain cognitive mastery of the traumatic event. Finding the meaning of the death leads to a renewed purpose of their lives. The renewed meaning and cognitive understanding come from involvement with people and activities and their memory of the child. Wheeler considered the search for meaning to be the most important factor in the readjustment process after losing a child. Findings from another study by Hogan, Greenfield, and Schmidt (2001) support this contention. The parents who had lost their children 3 years ago had significantly lower scores on the Personal Growth subscale of the Hogan Grief Reaction Checklist than those who had grieved longer than 3 years. Rather than returning to an earlier level of functioning, parents had become different than they had been before the death. They viewed themselves as more tolerant, forgiving, compassionate, resilient, and loving after dealing with the child’s death.
Cole and Singg (1998) also used the Hogan Grief Reaction Checklist and found that recently bereaved mothers and fathers experience more detachment and less growth than parents bereaved for 2 or more years. These findings make sense because withdrawal from others is a normal bereavement symptom during the early grief stages. It is also logical that growth would have an inverse relationship with time since death.
To elicit more spontaneous responses, Cole and Singg (1998) asked the following questions in their study: “Have your views about life changed since the death of your child? If so, what are some of these changes?” Bereaved parents provided a multitude of meaningful information. Of the 134 bereaved parents, 79% showed increased altruism by reaching out to others in memory of the deceased child—for example, setting up scholarships or memorials, planting trees, revamping parks, writing books, collecting food for the poor, establishing program to facilitate the writing of caring/sharing/supporting notes to other parents who have lost children in a hospital, and getting involved in awareness programs such as those for drinking and driving. Parents attempted to give meaning and purpose to the child’s life and death (the main reason stated) by these endeavors. Altruism helps mitigate guilt, which is a common and pervasive emotional response by bereaved parents (Miles and Demi 1986).
After the tragedy, bereaved parents often feel that they had spent too much time doing things for the family rather than with the family (Knapp 1986). This was supported by Cole and Singg (1998). Of the parents in their study, 38% reported having a deeper appreciation for family and friends after dealing with the child’s death. Furthermore, an increased awareness of the fragility and preciousness of life was expressed by 31% of the parents, and 21% reported being more compassionate and caring toward others after experiencing their loss.
Several writers contend that suffering is a prerequisite to growth. For example, Frankl (1959) considered the suffering following a loss as the motivating force that gives one a chance to actualize to the highest value. Although suffering promotes change, this process does not always result in growth. Depending on several factors, but mainly on their attitude, some bereaved parents never recover their trust and remain chronically angry without finding any meaning in their child’s death (Rando 1986d). Of the parents in Cole and Singg’s (1998) study, 10% reported an increased feeling that life is meaningless. Knapp (1986) summarizes it best by saying that bereaved parents have two choices:
(1) They can die themselves, emotionally or physically—virtually following their child to the grave. In reality this isn’t a choice at all, although some parents do have a strong desire to do just that. Or (2), after floundering about aimlessly for a time, they can begin the long, hard struggle forward…. These are not easy choices but they are all that is available! (P. 19)
Bereaved parents often lack social support compared with other types of mourners. They are avoided by other parents because of the “anxiety-provoking nature of the loss” (Rando 1986c:53). When an infant or an older adult child dies, a lack of social validation of loss is experienced by bereaved parents. In cases of murder or suicide, parents feel additional isolation because of the sensitive nature of the death. Some parents feel judged because they are taking too long to get over the tragedy. Also, other people do not know what to say and they “hide behind the canned phrases” (Bernstein 1997:170). To adapt, however, parents need social support during the entire grief process. Social support may come from many sources, such as family, friends, neighbors, coworkers, and support groups (Rando 1986b).
Cole and Singg (1998) found that parents who share their grief with others tend to have less anger and despair than parents who do not share. Asynchronicity of grieving styles between couples, discussed earlier, is often perceived as an impediment for spousal support. In the national survey by NFO Research (1999), however, most bereaved parents found support through their family and community. They reported family members and clergy to be the most helpful sources and friends, coworkers, and funeral homes to be the least helpful sources.
According to Bernstein (1997), although friends and other caring persons want to help, they often feel frustrated and inadequate when bereaved parents do not respond quickly. They feel anxious about saying the wrong thing, and they often do just that because of tension they feel during face-to-face interactions with bereaved parents. Often, bereaved parents hear clichés such as “time heals,” “he’s in better place,” or “you still have two other children,” which add to their grief and may send the message that they are not grieving correctly. Honest comments such as, “I can’t imagine what it must be like for you,” are more helpful because it shows one’s willingness to listen. Silence and a comforting gesture or posture are also helpful. All that is needed is the validation of parents’ feelings about the child’s death as an unfair and dreadful tragedy.
Many parents consult mental health professionals or join support groups, because they believe they cannot cope with their grief without some additional support. Although many of these parents benefit from counselors, many feel worse, “additionally criticized and isolated” (Bernstein 1997:171). Those who are helped through professional counseling have usually moved out of the initial grief stages. From the beginning of the bereavement process, however, support groups can be very helpful. They allow bereaved parents to associate with other bereaved parents who can empathize with their pain. While emphasizing the value of support groups, Stearns (1988) states, “It has been my experience in more than twenty years of helping people that support groups offer a healing balm which often is more curative than any other type of support, including professional counseling” (p. 151).
Joining a support group can be very therapeutic, especially for those who lack support from families or friends. Through mutual sharing and support of group members, bereaved parents learn that their reactions are normal (Rando 1986b). Many local churches and hospitals have lists of such groups. One well-known group is The Compassionate Friends. There are other groups devoted to specific causes of bereaved parents, such as Mothers Against Drunk Driving, National Sudden Infant Death Syndrome Foundation, Parents of Murdered Children, Survivors of Suicide, and SHARE Pregnancy and Infant Loss. Many Web sites are now available that provide information, support, and opportunities for bereaved parents to talk to other bereaved parents.
However, although support groups are usually very therapeutic, Bernstein (1997) elaborates on another aspect. A support group is as helpful as its members make it at any given moment. Because these groups are open groups, continual entry of new members can be disruptive, and the functioning of the group may remain superficial. Leaders are self-selected and usually have no formal training in group work; they may also not be able to provide adequate safety for members. In addition, for some bereaved parents, a group may become a place to hide and hold on to the past.
Although we all cope with grief in our own unique ways, an understanding of some common denominators helps and acts as a road map. Knowing how most parents feel and cope when a child dies gives a newly bereaved parent hope that there may be an end to torture and hopelessness and that there is a life after the child’s death. A parent never completely gets over the child’s death, but in time and with adequate support, the parent learns to live with the pain. Some important issues a professional or a caregiver needs to be aware of are reiterated below.
Because of the severity and lengthy duration of parental grief, bereaved parents may be at a greater risk for physical health problems, the excessive use of pain avoidance techniques (e.g., radical changes in lifestyle, overinvolvement with work, chemical abuse, etc.), and marital problems. Also, because fathers in our society are less expressive of their grief and they maintain a strong front, they may need more help by professionals. Professionals should be especially cognizant of the alternative practices for dealing with grief by persons from ethnic minority groups. Sometimes being a member of an ethnic minority group, especially with social marginality and low income, can intensify feelings of social alienation, helplessness, and hopelessness when adequate support and understanding are lacking during bereavement (Osterweis et al. 1984; Rando 1993).
Because of the solitary nature of grief and high intensity of pain involved, communication problems may arise within the family. Parents may be too self-engrossed in their own pain and suffering to adequately support the other family members, especially the remaining children. Therefore, other sources of support, such as extended family, friends, clergy, and support groups, can be very helpful for both parents and siblings.
In the past, many professionals and laypersons did not realize the intensity of pain felt by parents who miscarried or lost an infant. This may be due to the belief that parents experience less pain when the child is not born or the child lives only for a brief period. Also, young parents may need help from many sources. Lack of grieving experience with past losses, limited financial resources, lack of social support, and limited time because of work and family demands may exacerbate the trauma experienced by young bereaved parents.
Some parents may take extreme measures to compensate and ameliorate the loss due to the death of a child. They may get pregnant right away or decide never to have another child. Having another child soon after the death of one child may interrupt grieving. This may have negative effects on both the replacement child and the grieving parent who may actually be extending the denial stage of grief. On the other hand, as also pointed out by Osterweis et al. (1984), waiting to get pregnant until the bereavement process completes may not be realistic, because grieving for a lost child never ends.