Grief and Loss

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Psychological Effects
Validity of Studies
Reviews
Risk Factors
PTSD
Grief and Loss
Guilt
Ambivalence or Inner Conflict
Anxiety
Intrusion / Avoidance / Nightmares
Denial
Dissociation
Narcissism
Self-Image
Self Punishment
Depression
Psychiatric Treatment
Self-Destructive Behavior
Substance Abuse
Long-Terms Effects of Abortion
Replacement Pregnancies
Sterilization
Impact of Abortion On Others
Violence
Rape, Incest, Sexual Assault
After Late Term Abortion

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General Background Studies (Grief and Loss)

Living Through Personal Crisis, Ann Kaiser Stearns, (New York: Ballantine Books, 1984).

Ed Note: Inexpensive paperback available in local bookstore; the author states that "grief is profoundly misunderstood in American society." She attempts to deal with grief and loss in theoretical terms as well as practical examples, including abortion. The author states that the failure to understand grief, has distorted the literature on the effects of induced abortion.

Attachment and Loss, J. Bowlby, (London: Hogarth Press, 1980)

Ed Note: This work as well as other writings on the subject by John Bowlby, are considered to be the classic works on the subject.

"Absence of Grief," Helene Deutsch, Psychoanalytic Quarterly 6:12-22 (1937)

Comments by the author:

The work of mourning does not always follow a normal course. It may be excessively intense, even violent, or the process may be unduly prolonged to the point of chronicity when the clinical picture suggests melancholia.

If the work of mourning is excessive or delayed, one might expect to find that the binding force of the positive ties to the lost object had been very great. My experience corroborates Freud's finding that the degree of persisting ambivalence is a more important factor than the intensity of the positive ties, (emphasis added)

Guilt feelings toward the lost object, as well as ambivalence, may disturb the normal course of mourning. In such cases, the reaction to death is greatly intensified, assuming a brooding, neurotically compulsive, even melancholic character. Indeed, the reaction may be so extreme as to culminate in suicide. Every unresolved grief is given expression in some form or another.

"Typical Findings in Pathological Grief," Varnik Volkan, Psychiatric Quarterly 44: 231-250 (1970). Comments by the author:

People who suffer from pathological grief reactions are either caught in this struggle of loss and restitution without coming to a solution or have achieved restitution which is symptomatic.

Funeral rites and religious rituals are attempts to deal with common psychological components of grief-aggression for one. Therefore the mourner should be allowed to fully indulge in mourning rituals.

(Delayed Grief) Often the patients' first reaction to the death of the lost one is not enough to be prophylactic, and the grief must be delayed until a future time. These patients are symptomatic prior to the appearance of these symptoms on a clinical level, but the symptoms are hidden. The turning point in acknowledging the symptoms is often an anniversary of the death. Sometimes the factor which produces acute symptoms in relation to the important loss, is another real or fantasized loss.

The patient suffering from pathological grief reactions has a history of repeating dreams in which the dead person is alive, and usually appears undisguised.

The persistent seeking of reunion with the lost object appears to be the main motivation present in pathological mourning although it appears in forms which, because of repression and splitting, have become disguised and distorted.

"Traumatic Grief as a Risk Factor for Mental and Physical Morbidity," G Prigerson et al, Am J Psychiatry 154(5): 616-623, May, 1997

Symptoms of traumatic grief are predictors of future physical and mental health problems.

"Symptomatology and Management of Acute Grief, Erich," Lindemann, American Journal of Psychiatry, 101:141-148(1944)

Discusses normal grief, morbid grief reactions, anticipatory grief reactions. (Ed Note: This is considered to be an important foundational article.)

"Loss and Restitution," G. Rochlin, Psychoanalytic Study of the Child 8:288. (1953).

Humans cannot be without an object, and when loss occurs the object must be restored, although they may be forced to modify it.

"Mourning and the Prevention of Melancholia," Beverley Raphael, British Journal Medical Psychology 51: 303-310 (1978).

Freud considered the disturbance of self-regard which occurred in melancholia to be absent in mourning; in melancholia the relation to the object is no simple one; it is complicated by the conflict due to ambivalence...hate and love contend with each other. Preventive support at the time of the crisis may be helpful in lessening pathological effects. In some bereavements ambivalence may predispose the mourning to melancholia. Crisis support which facilitates the working through of this ambivalence may prevent or lessen the melancholia.

"Delinquency as a Manifestation of the Mourning Process," M. Shoor and M. Speed, Psychiatric Quarterly, 37: 540-558. (1963).

Delinquent behavior in a previously conforming adolescent may be a manifestation of a mourning process-a substitute pathologic grief reaction. Recognition of this etiologic factor may be crucial to proper management in such cases. Sexual promiscuity and mourning complicated by guilt are included as examples.

"Normal Adolescent Mourning," Max Sugar, American Journal of Psychotherapy 32: 258- 269 (1968)

Cites examples of normal and abnormal behavior of adolescents. The author states, "One of the tasks of adolescence is to learn the control of impulses."

"Treatment of the Adolescent with Borderline Syndrome," James Masterson, Bulletin of the Menninger Clinic 35: 5-18 (1971)

The adolescent with a Borderline Syndrome is defending himself against an abandonment depression...he or she wants reunion, not consolation for the loss. Their first unspoken question (to the therapist) will be: "How do I know you are any different? Prove to me that you have the capacity to understand me. Nobody else ever has. Prove to me you will not abandon me.") (Ed. Note: Families with this dynamic appear to be at risk for adolescent pregnancy and pressure for abortion by the mother of the adolescent.

"The mother of a patient with Borderline Syndrome often suffers form a Borderline Syndrome herself. The mother's pathologic needs impel her not to support and encourage the patient's separation and individuation, but rather cling to the child to prevent separation, discouraging moves toward individuation by withdrawing her support... Parents never having been mothered cannot mother, and never having been fathered cannot father. They perceive their children as parents, objects or peers.... They cling to the children to defend themselves against their own feelings of abandonment and cannot respond to the child's unfolding individuality. The child is subjected to scapegoating of the most extreme sort. Fathers, passive, inadequate men, dominated by and dependent upon their wives, play little parental role. The mothers are controlling women who need and vigorously battle to maintain the symbiotic tie with the child. These families communicate mostly by acts not words. Consequently, the adolescent expresses their need for help by an act-a plea for help- expresses as exactly and poignantly as any words, the blind, helpless, trapped crying out for succor and aid."

"On the Process of Mourning," Jeanne Lampl-De Groot, Psychanalytic Study of the Child, 38:9-13(1983)

Latency children, adolescents, and adults know intellectually that a dead person never returns; emotionally they all more or less deny this fact. In pathological cases, the denial cannot be corrected. Various inner and outer factors determine whether a mourning process will lead to a "normal" or to a "disturbed" mental life: a person's ability to master his unconscious guilt feelings and his need for punishment due to repressed infantile death wishes toward the deceased parent or sibling; the overcoming of his unconscious triumph over the deceased: "You are dead, I am alive-the survivor guilt; the capability to sublimated destructive impulses into constructive activities.

"The "Replacement Child": A Saga of Unresolved Parental Grief," Elva Orlow Poznanski, The Journal of Pediatrics, 81(6): 1190-1193, Dee, 1972.

Replacing a child with another allows the parents partially to deny the first child's death. The replacement child then acts as a barrier to the parental acknowledgment of death, since a real child exists who is a substitute. Thus the first stages of bereavement are prematurely arrested and the process of mourning continues indefinitely with the replacement child acting as the continuing vehicle of parental grief.

"The Management of Stillbirth - Coping With an Unreality," Emanuel Lewis, The Lancet, September 18, 1976, pp. 619-620.

Mourning stillbirth is difficult because although there is a sense of loss, there is little sense of having lost somebody. The difficulty of grieving someone "missing believed killed" is well known; a death without a body seen by anyone seems unreal. There is an added sense of unreality with stillbirth as there are no experiences with the baby to remember. Looking at and holding the dead baby, giving the baby a name, arranging the certification, attending the funeral, and seeing the baby's grave help make stillbirth a reality to the family. With these activities, memories are created which aid the recovery processes of mourning.

"On Replacing a Child," A. Cain and B. Cain, Journal of the American Academy of Child Psychiatry, 3: 443-456 (1964).

Discusses the cases of disturbed children who were conceived shortly after the death of another child. Mothers had suffered a surprising number of family losses in their own childhood. The parents had an intense narcissistic investment in the child who had died. The authors state: "We hope our conservative application of these findings will serve as a counterbalance to the stunning casualness found in some pediatric quarters in recommending the 'replacement' of dead children to grieving parents."

"The Effects of Sibling Death on the Surviving Child: A Family Perspective," R. Krell and L. Rabkin, Family Process, 18: 471-477 (1979)

Surviving siblings frequently become the focus of maneuvers unconsciously designed to alleviate guilt and control fate through silence and efforts to maintain silence, through substitution for the lost child and through endowing the survivor-child with qualities of the deceased. In a young family of childbearing age, a decision may be taken to produce a replacement-in the face of an earlier painful resolve to remain barren, whether out of fear or in payment of some guilt-ridden debt to the lost child. The new offspring is intended to fill the family void. The newcomer is perceived as a replacement, dealt with as a reincarnation, and hemmed in by diffuse conscious and unconscious expectations.

"The Inhibition of Mourning by Pregnancy," E. Lewis, Bulletin British Psychoanal. Soc. 10:24-26 (1977)

Grief and Loss Following Abortion

Many people will experience grief and loss both before and after abortion. Others may not experience grief or loss. These articles demonstrate some of the situations where grief and loss are manifested.

Psychological sequelae following second-trimester termination of pregnancy: A longitudinal study. Dawood Y, de Vries JM, van Leeuwen E, van Eekelen R, de Bakker BS, Boelen PA, Pajkrt E. Acta Obstet Gynecol Scand. 2024 Jul 8. doi: 10.1111/aogs.14848. Epub ahead of print. PMID: 38978342.

• Introduction: The decision to terminate a pregnancy due to fetal anomalies can have a significant emotional impact, especially in second-trimester terminations. Previous studies on the psychological consequences of pregnancy termination have had limitations, and little is known about the outcomes for partners and the impact of fetal donation. Therefore, we aimed to investigate the psychological effects of second-trimester pregnancy termination and identify factors associated with outcomes in both women and men, including donation of fetal remains to science. Material and methods: A longitudinal cohort study was conducted at the Amsterdam UMC in the Netherlands, involving women and partners who underwent termination at or before 23 weeks and 6 days of gestation. Questionnaires were administered at termination, 6 weeks, and 4 months after. We utilized validated questionnaires to assess psychological morbidity (grief, post-traumatic stress and postnatal depression and quality of life [QoL]), and factors that could potentially influence outcomes. Results: Of 241 participants, women displayed more pronounced psychological distress than men, though both groups improved over time. Four months after termination, 27.4% of women and 9.1% of men showed signs of pathological grief. Scores indicative for postnatal depression occurred in 19.8% women and 4.1% of men. A prior psychiatric history was a consistent predictor of poorer outcomes. Fetal donation to the Dutch Fetal Biobank was associated with reduced likelihood of symptoms of complicated grief four months after termination. Conclusions: Second-trimester termination of pregnancy for fetal anomalies can lead to psychological morbidity, particularly in women. However, there is a notable improvement over time for both groups. Individuals with prior psychiatric history appear more vulnerable post-termination. Also, fetal donation to science did not have a negative impact on psychological well-being.

"Neural Activation Underlying Acute Grief in Women After the Loss of an Unborn Child" Kersting A., et al. Am J Psychiatry. 2009 Dec;166(12):1402-10. Epub 2009 Nov 2.

OBJECTIVE: The traumatic loss of an unborn child by induced termination of pregnancy because of fetal malformation is a major life event that causes intense maternal grief. Increasing evidence supports the hypothesis that the same neural structures involved in the experience of physical pain are involved in the experience of social pain and loss. METHOD: To investigate neural activation patterns related to acute grief, the authors conducted a functional MRI study of 12 post-termination women and 12 noninduced women who delivered a healthy child. Brain activation was measured while participants viewed pictures of happy baby, happy adult, and neutral adult faces. RESULTS: Relative to comparison women, post-termination women showed greater activation in the middle and posterior cingulate gyrus, the inferior frontal gyrus, the middle temporal gyrus, the thalamus, and the brainstem in response to viewing happy baby faces. Functional connectivity between the cingulate gyrus and the thalamus during the processing of happy baby faces was significantly stronger in post-termination women. CONCLUSIONS: Overall, acute grief after the loss of an unborn child was closely related to the activation of the physical pain network encompassing the cingulate gyrus, the inferior frontal gyrus, the thalamus, and the brainstem. To the authors’ knowledge, the stronger functional thalamocingulate connectivity in post-termination women is the first in vivo demonstration of an involvement of the neural maternal attachment network in grief after the loss of an unborn child.

"Induced Abortion," Betty Glenn Harris in Parental Loss of a Child, Ed Therese A Rando (Champaign, IL: Research Press Co., 1986)

"I Killed My Baby- The Emotional Aftermath of Abortion" in Helping People Through Grief,When a Friend Needs You, Delores Kuenning (Minneapolis: Bethany House Publishers, 1987)

"The Hidden Grief of Abortion," Julia Upton, Pastoral Psychology 31(1): 19-25, 1982

"Grief and Elective Abortion: Implications for the Counselor," Larry G Peppers in Disenfranchised Grief. Recognizing Hidden Sorrow, Ed. Kenneth J Doka (1989)135-146 see also "Grief and Elective Abortion:Breaking the Emotional Bond", Larry G Peppers, Omega 18(1): 1-12 ,1987-88

Anticipatory grief prior to the abortion was found. High pre-abortion grief scores were found among women having a D&E abortion, those indicating frequent church attendance, indicated infrequent sexual activity, had discussed their decision with a minister, had a family member who opposed the abortion, the relationship with their partner had ended, sought abortion for financial reasons, had several weeks to consider the abortion, black women, and those with less than a high school education.

High grief reactions 6 weeks post-abortion included Catholic women, those with less than a high school education, women with a prior live birth, women with multiple abortions, women with previous miscarriages, those seeking abortion because of financial reasons or age, and those with no one to talk to prior to the abortion. The author concluded that grief associated with elective abortion is symptomatically similar to that following involuntary infant/fetal loss. (Ed Note: An important finding in the Peppers study was that substantially different groups of women had high pre-abortion grief scores as compared to the groups with high post-abortion grief scores. This demonstrates the wide range and diversity of grief responses.)

"Induced Elective Abortion and Perinatal Grief," Gail B Williams, Dissertation Abstracts Int'l 53(3): 1296-B, 1992.

A wide range of long term grief responses on the Grief Experience Inventory was found among women with only one induced abortion and no other self-reported prenatal losses within five years, or previous psychiatric history. The author concluded that some women will have grief responses for many years following their abortion.

"Psychological Aspects of Abortion," Edna Ortof in Psychological Aspects of Pregnancy, Birthing and Bonding ed. Barbara L. Blum, (New York: Human Science Press, 1980).

Describes post-abortion dreams in several women. For example, one woman dreamt two months after her abortion, "I was passing shops with an urgency to get somewhere. I walked down steps into a grocery. I came to a shelf of small jars of baby food. I put loads in the basket. Someone said. You can't have those. I left them and had a feeling of panic and ran out of the store." The therapist stated in response: "women who abort after having children seem to suffer greater discomfort than women who have not borne children. The sense of loss, when present, frequently is related to whatever hopes and fantasies the pregnancy represents, i.e., the loss of possibility of a child, the loss of a lover, the loss of hope of a marriage and motherhood, the loss of fantasy of one's importance to a lover."

"Ritual Mourning for Unresolved Grief After Abortion," K McAll and W Wilson, Southern Medical Journal 80(7): 817-821, July, 1987

Case studies taken from over 400 spontaneous or induced abortion experiences described a woman of strong religious belief who developed anorexia nervosa as a reaction to accompanying her friend who obtained an abortion; depression in a woman following abortion; repressed grief at a mother's miscarriage; sexual promiscuity in a 26 year old woman traceable to her mother's abortion; adverse reaction of children to abortion. Spiritual intervention was successfully utilized to resolve the grief.

"Psychological Adjustment to First Trimester Abortion," Janice Muhr, Dissertation Abstracts Int'l, Psychology, Clinical 4054-B ,1979

Pre and post abortion interviews found that among women who experienced abortion as a loss, mourning processes were blocked because of the volitional and moral nature of the decision. An affective cycle of guilt and loss was identified which did not resolve itself over time.

"Emotional Responses of Women Following Therapeutic Abortion," Nancy Adler, American Journal Orthopsychiatry 45(3): 446-454, April, 1975

Post-abortion women may feel a sense of loss precipitated by either internally based emotions or socially based emotions.

Grief and Loss Following Spontaneous Abortion

Depressive disorder and grief following spontaneous abortion. Kulathilaka S, Hanwella R, de Silva VA. BMC Psychiatry. 2016 Apr 12;16:100. doi: 10.1186/s12888-016-0812-y.

Background: Abortion is associated with moderate to high risk of psychological problems such as depression, use of alcohol or marijuana, anxiety, depression and suicidal behaviours. The increased risk of depression after spontaneous abortion in Asian populations has not been clearly established. Only a few studies have explored the relationship between grief and depression after abortion.

Methods: A study was conducted to assess the prevalence and risk factors of depressive disorder and complicated grief among women 6–10 weeks after spontaneous abortion and compare the risk of depression with pregnant women attending an antenatal clinic. Spontaneous abortion group consisted of women diagnosed with spontaneous abortion by a Consultant Obstetrician. Women with confirmed or suspected induced abortion were excluded. The comparison group consisted of randomly selected pregnant, females attending the antenatal clinics of the two hospitals. Diagnosis of depressive disorder was made according to ICD-10 clinical criteria based on a structured clinical interview. This assessment was conducted in both groups. The severity of depressive symptoms were assessed using the Patients Health Questionnaire (PHQ-9). Grief was assessed using the Perinatal Grief Scale which was administered to the women who had experienced spontaneous abortion.

Results: The sample consisted of 137 women in each group. The spontaneous abortion group (mean age 30.39 years (SD = 6.38) were significantly older than the comparison group (mean age 28.79 years (SD = 6.26)). There were more females with ≥10 years of education in the spontaneous abortion group (n = 54; SD = 39.4) compared to the comparison group (n = 37; SD = 27.0). The prevalence of depression in the spontaneous abortion group was 18.6 % (95 CI, 11.51–25.77). The prevalence of depression in the comparison group was 9.5 % (95 CI, 4.52–14.46). Of the 64 women fulfilling criteria for grief, 17 (26.6 %) also fulfilled criteria for a depressive episode. The relative risk of developing a depressive episode after spontaneous abortion was significantly higher than in females with a viable pregnancy (RR = 2.19, 95 % CI, 1.05 to 4.56). After adjustment for age and period of amenorrhoea, the difference was not significant. Prevalence of complicated grief was 54.74 % (95 % CI, 46.3–63.18).

Conclusion: The relative risk of developing a depressive episode after spontaneous abortion was not significantly higher compared to pregnant women after taking into account age and period of amenorrhoea (POA). Almost half the women developed complicated grief after spontaneous abortion. Of these, a significant proportion also had features of depressive disorder.