Flexibility

A cornerstone in working with pregnancy loss is flexibility. As Covington [6, p. 204] describes her practice, “I advise, analyze, educate, advocate, console, and support while employing a variety of treatment modalities.” Ideological purity should take a far back seat to therapeutic efficacy. How directive and structured one is should be determined by the need for crisis intervention (if the loss is very recent) and not a pre-set, one-size-fits-all treatment plan. Similarly, the length of therapy should be customized. Three or four sessions may be sufficient for a more normative counseling: A mother with a young child was initially shocked and dismayed by her miscarriage at nine weeks. Given a license to grieve by her therapist that had been derailed by family and friends, she readily obtained closure once she decided to honor her loss by constructing a life lesson session on pregnancy loss for her middle school health students. Grief counseling (not specifically applied to reproductive loss here) may do more harm than good when universally administered to those with normal bereavement [11].

However, when earlier, especially depressive, problems associated with emotional neglect and insecure attachment intervene, a longer therapy is usually necessary to more painstakingly establish a safer tie. A chronically depressed 35-year-old woman entered therapy in the midst of losing her preterm twins. Intertwined with the deep grief and despair of losing them and a subsequent pregnancy, she mourned the absence of emotionally available parents, frequently moving from country to country during her childhood to support her father’s successful business career. Now, as in the past, her relentlessly upbeat and grief-avoiding parents would hear none of her sadness. Over the course of five years of weekly therapy, she was able to grieve the loss of her three children, forge on to give birth to a healthy child whose pregnancy she was understandably convinced would never successfully conclude, and with much less anxiety and despair have a relatively calm fourth healthy pregnancy. The therapist’s consistently empathic and emotionally available stance provided a solid chamber to contain her at times seemingly bottomless despair. Very fulfilled over having the relationship with her sons that she never had with her parents, her depression has subsided considerably.

Many such extended treatments involve incipient prolonged or complicated grief, which while having elements of depression and PTSD can be clearly distinguished from those conditions [12], even if that diagnosis is only provisionally accepted in DSM-5 [13]. As many as 25% of bereaved women go on to have more chronic difficulties [2] with the majority not in fact following the “normal” model of a steady decline in grief, but instead some variant [14]. Because in the midst of such a recent loss, it often is not possible, clinically, to know how quickly emotional problems are likely to be resolved, it can be critical to be flexibly attuned to new issues as they arise and not be rigidly harnessed to a standardized treatment manual for all clients. An initial consultation of three to five sessions enables getting to know the woman as a whole person, including her childhood, adolescence and young adulthood, not simply as a victim of a traumatic loss. Discussing extended feedback and recommendations at that point may provide a clearer sense of direction as well as establishing a collaborative relationship, which is indispensable for change.

Boundary and confidentiality concerns often mitigate against concurrent individual and conjoint work by the same therapist in general psychotherapy. However, with reproductive loss absent earlier significant individual and marital problems, such multi-modal work is often effective. Typically (though not inevitably) the mother’s more enduring, deeper and self-blaming grief than her partner’s is given additional time individually, while tensions created by those differences may be worked through in conjoint sessions. It is neither necessary nor natural to expect men and women to grieve equivalently for these losses, particularly because the loss is so much more personal and immediate for the woman, it being within her body. It is crucial, however, that those differences be acknowledged and respected. Men especially need to be able to support, not reject, and join in – when honestly felt – their partner’s grief. He may need to be told by his partner that sharing his grief will not burden her, but bring them closer, as often happens following this loss. A bereaved father will rarely come to therapy for pregnancy loss of his own accord, but is quite willing to participate to help his partner. Usually that motivation is sufficient for him to meaningfully engage in the therapy. Conjoint sessions are usually not as critical for pregnancy loss as they are for infertility because the course of treatments, multiple stressors and marital decisions that need to be made are so much greater for the latter.

Rarely do I feel it is helpful to directly include children in the therapeutic work. That may inadvertently reinforce a parent’s sense of failure after such a loss by usurping a parenting function. It is better to empower parents by coaching them on addressing a child’s concerns based on their own intimate knowledge of their children. (For a more thorough discussion of dealing with sibling issues see reference [37].)

Strengths

In her very first session, Alice highlighted her ability to focus on the positives in her life – her being pregnant with twins, her high school days as an athlete and the survival of her daughter – even before she describes the loss of her son. Her resilience in being able to transcend adversity with an active sense of personal control is a critical asset in effectively coping with pregnancy loss [15]. A dual-process model of coping with bereavement [16] depicts how effective grief resolution balances the painful reckoning of grieving with an orientation to distraction and avoidance of grief in the service of establishing new identities and a changed reality without the deceased. Compartmentalizing grieving can be adaptive so long as grief is not wholly denied. Alice’s ability to parent by day, while grieving by night (as do many bereaved parents with another live child to parent), similarly demonstrates such a dual track in which self-regulation enables grieving which is modulated, oscillating with unimpaired functioning. Clinically, the therapist needs to echo her strengths, respect and sometimes encourage the legitimate need to have breaks from grieving and “come up for air.” Using humor during therapy – when it is not being used by the therapist to avoid his own discomfort with grieving – can offer needed relief, sense of normalcy and some occasional distancing from grief.

Empathy

Empathizing with the client’s experience in general and grief in particular engenders healing. In a meta-study of all psychotherapy, empathy is a moderately strong predictor of therapeutic success [17]. The utter sense of feeling abandoned among all kinds of bereavement may make empathy critical in facilitating grief. Grieving pregnancy loss may make therapeutic empathy even more indispensable due to the usual minimization, avoidance, and pat solutions others often apply to this loss if not personally familiar with it. Empathy is a key ingredient appreciated in medical care after miscarriage [18] and perinatal loss [19]. If we understand one form of empathy as being intuitively attuned to what kinds of statements or emotional expressions would be hurtful (i.e., how would I feel if that was said to me, taking the “I” to include what one knows about the client), empathy can occupy a helpful self-censoring function.

Empathy embodies three arenas [17]. By taking the other’s perspective, it fosters a cognitive sense of what the client is experiencing, promoting feeling understood. There is an emotional resonance felt within the therapist for the client, enabling the client to feel less alone. Finally, authentic caring actions including tears and providing realistic reassurance help the client to be genuinely cared for, aiding in the regulation of distress. The load lifted off of Alice’s shoulders could be traced to feeling understood by the therapist’s words, not feeling so alone and burdened due to his emotionally sharing her loss and providing a realistic basis for a happier future once her grief had subsided.

Ironically, while empathy is often belittled for its soft, soggy, unscientific connotations, its neurological credentials are quite impressive. Empathy is a mammalian trait rooted in the brain’s mirror neurons, which are activated by another’s actions and emotions [17]. The three different empathic processes described above have been associated with different areas of brain function, including, respectively, temporal cortex, limbic system and orbitofrontal cortex [17]. Different areas of brain activation can similarly distinguish between empathy, which preserves a distinction between self and other, versus a merging of self and other [20] (termed identification in psychoanalytic nomenclature). The client’s affective experience of feeling understood, appreciated and cared for takes precedence over the cognitive aspects of insight and interpretation, whether defined as an “implicit relational knowing” [21] or a neurological re-coding of more secure attachment paradigms via emotional engagement [22].

Empathy is at the crossroads of several overlapping clinical models: the client-centered approach of Carl Rogers [17], Kohut’s self-psychology using empathy as the crucial tool to accessing the client’s experience [23], and an attachment model of psychotherapy which, in part, through empathic attunement can provide a form of a secure attachment [24] from which many of the therapeutic tasks of integrating trauma, grieving the loss and repairing self-esteem may be resolved. This work proceeds at a much quicker and direct pace with the majority of clients who can readily draw upon the prevalence of earlier secure attachments. More characterologically disturbed clients often require longer treatments due to their heightened sensitivity to narcissistic slights, resulting in more therapist empathic failures re-enacting earlier hurts [23,25].

Even without re-enactments of earlier paradigms, our empathic failures are inevitable and potentially therapeutic. It enables the therapy to be truly collaborative with the therapist’s willingness to acknowledge mistaken understandings (without being willy-nilly or pleading mea culpa about it) and the client to feel more empowered in defining her own experience. It may promote resilience by fostering adaptation to an empathically imperfect world, perhaps akin to Kohut’s reference to therapeutic progress occurring following the reparation of empathic errors [23]. Alice was able to confront and readily forgive her doctor’s empathic failure of not expressing condolences over her son’s death once he more openly demonstrated by tears how much the loss meant to him. It was a powerful lesson to both, demonstrating to her that she could help effect the support she needed in her medical environment and it made clear to him that completely avoiding his own sadness and grief does no good for his patients.

In our initial session, Alice corrected my empathic misunderstanding of her deferring adoption due to preferring genetic parenthood (which she reminds me, she did not have) when she longed for the nurturance experienced in gestational parenthood. At the outset, clients may be encouraged to share when inevitable misunderstandings occur. We may be more susceptible to empathic errors when we expect clients to follow our prior clinical experience and/or what “the literature” suggests, rather than their own path. Our own personal (especially pregnancy) losses may facilitate empathy while ironically encourage empathic mistakes when we expectantly project our personal loss experience onto our clients. As wisely noted, “Empathy should always be offered with humility and held lightly, ready to be corrected” [18, p. 48]. It is an ongoing, evolving inter-subjective feedback loop, not a static, one-way expression of therapeutic sensitivity.

Processing trauma

After briefly reviewing the consultation process, I typically begin the first session by asking, “Where would you like to begin?” This is an invitation to tell the story of usually traumatic losses. For many (as with Alice) it began years back with the diagnosis and treatment of infertility, telling you the other crucial issues and events leading up to the specific loss. Typically, the details become more painstakingly specific, indicating the tell-tale imprinting of trauma on the mind, leading up to the shock and tears at the moment of loss. More traumatized and less trusting clients may not initially be able to tell their story with full intensity. Constructing a narrative, done over time with many repetitions, becomes an important, active way of processing a traumatic loss, that in one’s utter helplessness and initial shock felt beyond assimilation. Re-living the loss makes it more real. As Alice noted, even three months later, she still can’t believe it happened.

Therapeutic empathy and responsiveness leads to the client feeling less isolated and more supported, allowing the traumatic emotions and memories to be processed. It offers a “holding” environment in which the client feels safe with the therapist, solidifying the bond felt between them. This explains why the psychologically healthy client (as was Alice) almost always reports feeling much better after the first session. The emotionally overwhelming residues of the traumatic experience may be primed in later sessions by asking what continues to be the most difficult, painful or unforgettable aspects. Inquiring into what has helped the most may reveal what sources of strength and resilience can be mobilized, whether internal (e.g., fortitude, sense of humor), interpersonal (e.g., connection with others, emotional intelligence) or spiritual (e.g., faith in God, hope).

Cognitive-behavioral therapy similarly emphasizes the importance of exposure to the most traumatizing stimuli in order to extinguish the anxiety response [8,26]. However, if the CB therapist is not empathically attuned to what might re-traumatize the client, certain exposure practices (e.g., going to the baby section at Target) [8] may be exactly what is recommended to be avoided in the early work because it is just too painful. Interestingly, qualitative results from a CBT study indicated that one of the most helpful aspects of the intervention was “having an empathic, nonjudgmental person to talk to about their emotions and experiences around the loss” [8, p. 172].

These losses may be traumatizing not only due to anxiety producing, affective overstimulation, but because of “shattered assumptions” [27] of the world being viewed as safe, just and predictable. Schemas defining our security in the world undergo massive cognitive disruption, sometimes uprooting the foundations of religious beliefs. Reassuring cornerstones, often of one’s religious faith (e.g.,“If I am good and work hard, my just rewards will follow”), are now replaced by disorganizing, confusing questions of “What did I do to deserve this?” A crucial task of resolving these traumatic losses is making meaning and sense of what happened, assimilating what one can to one’s existing beliefs, and gradually modifying those schemas accommodating to the new harsh reality [11,28]. Multiple schemas are often simultaneously violated. Not only is one’s basic safety in the world eradicated by this loss, but the prior confidence in modern medicine and dependability of friends being sources of support and understanding may be casualties as well.

It is not the therapist’s job to prophetically resurrect the client’s infrastructure of meaning. But by articulating the areas of disrepair, encouraging a process of making sense of this loss and, crucially, offering an emotional climate of respect, patience, understanding and confidence in her finding, not alone, her way through this, usually allows the client to adaptively integrate past and current good in her life with the current tragedy. A new, more realistic and sober view of the world can co-exist with a renewed, though wary, confidence.

Both forms of trauma may besiege the bereaved, singly or in combination, and sometimes reviving earlier traumatic events. A 32-year-old woman expressed muted grief at her son’s premature birth and death, avoiding his name and thinking about him. It soon became evident that she was emotionally repeating the secrecy of a rape at 14 about which she never told her neglectful parents. Once this earlier trauma could be processed in re-telling what happened, reducing her shame and self-blame, she was better able to more emotionally grieve her son’s death, with less dissociative-like detachment. An understandable, lingering sense of vulnerability from the earlier rape could be challenged and modified by appreciating her capacity for assertiveness as an attorney.

The decision to end a pregnancy due to fetal anomaly may be especially traumatizing. One never imagined oneself getting such news or making such a decision. With the window of having a choice ever narrowing, a woman needed to decide within a week whether to terminate her Down’s pregnancy. What initially appeared to be a pathologic self-punitive paralysis of spending weeks obsessively reviewing her choice after the termination, later became understood as a necessary process of validating a decision that had to be made too soon for her psyche to absorb.

Traumatic residues are normal and to be expected in the pregnancy following a prior loss. Anticipating another shocking death, re-living cues of the last pregnancy, and detaching oneself from the much wanted child as one lives in a state of low-level hypervigilant anxiety, keeps her “one step in and one step out” of that difficult pregnancy [29]. One woman who endured multiple pregnancy losses was so convinced she would lose another one that she guiltily acknowledged wishing it would happen already, finding it intolerable to endure the wracking helplessness defining how traumatic those losses were. Her husband was troubled by her seeming indifference to the pregnancy, defined as “it.” Yet, once she gave birth to a healthy girl, her attachment quickly blossomed. In this situation, support figures – medical, mental health, family and friends – need to empathically and patiently accept her anxiety and responses as understandable based on her earlier loss(es), not trying to minimize or “talk her out of it,” encouraging additional ultrasounds if that relieves anxiety and maintaining an air of quiet hopefulness.

Husbands are very susceptible to these traumatic repercussions, often feeling as helpless bystanders to their wives’ bodily injuries. One man was always able to comfort and reassure his anxious wife, until his firm guarantee that their baby would be OK was shattered by a stillbirth. No longer could he maintain the aura of being her protector, requiring a slow process of accepting the limitations of his sense of power. Too often the man is left out of the grieving process, asked by family and friends how his wife is doing, with no acknowledgment of his own sadness and hurt. Cultural prohibitions against men expressing grief (i.e., viewed as weakness) may make it more acceptable for him to show anger rather than loss. Often he may show more grief by vicariously sharing with his wife’s tears.