Webinar: Life after Pregnancy and Infant Loss

This Focus On Wellness event helps parents or individuals who have endured a perinatal loss, loss during pregnancy or the first two years of life understand their grief and their response to loss, know when to reach out for help, and that restoration and living their new lives after the loss does not mean forgetting or even not hurting.

This webinar is presented by Erica Billings, LPC Associate. Erica is under the supervision of Diana Cabrera-Stewart, LPC-S.

Watch a replay of the presentation here.

Learn more about Grief Counseling and Trauma, Grief and Loss.

Here is a transcript of the webinar:

Hello, everyone. Thank you for joining me this evening. My name is Erika Billings, and I’m a licensed professional counselor associate with Eddins Counseling Group. 

So a little bit about me. Two of my main interests are grief and loss, and I work with everything under that grief umbrella, including regret and missed opportunities. I also work with people on how sometimes grief and trauma coexist at the same time. I also like to help people realize where their grief is and where they didn’t even know that it was. 

We suffer many losses and grief along the way that are not related to the loss of a loved one, yet they are real losses. Sometimes we’re unaware that we’re even grieving. I’m especially interested in perinatal grief and loss. The perinatal time period and the perinatal community is near and dear to my heart. It was a pivotal time for me, and I think it is one of the most tender and fragile places that we can be in.

Most of us don’t get enough of the support that we need. 

I work with moms and dads, men and women, couples and singles, couples who have used ART, same-sex couples, couples who have adopted, and anyone who falls under that perinatal umbrella. I also like to work with people about how perinatal loss has affected their family unit as a whole. So if there are other living children or even grandparents in the picture. 

I imagine that you are here today because either you or someone close to you has experienced perinatal loss. My intention for this webinar is that you will gain a greater understanding of that experience. And with that greater understanding, walk away with some more clarity, direction, and even hope. 

Agenda

• Grief
• Perinatal Grief
• Maternal/Paternal Preoccupations
• Complicated Grief
• How does one grieve well?

Today, we will talk about grief in general. We will talk about specifically what perinatal grief is. We will discuss maternal and paternal preoccupations. I like to refer to them as parental preoccupations because they can be either mom or dad. We’ll talk about what complicated grief is, and we’ll talk about how does one grieve well, how does one move through the grief, and build a bridge to this new life after the loss.

Defining Grief

• Grief is not only an emotion; it includes all of the ways one adjusts.
• Grief is the shape love takes after someone you love dies.
• A natural process that is unique to each person, shared by many, and is shaped by the nature of the loss.
• Each person’s grief is like all others: each person’s grief is like some others; each person’s grief is like no others.
• Spiritual concerns often arise.
• Can feel like a physical illness.
• Affects psychological well-being, as well as social functioning
• Will I ever feel ok or love again? And then feeling ok can feel confusing.

Many of us do have trauma in one pregnancy and then grief in another or birth trauma in one pregnancy and loss in another. Those things are very real and they intersect in important ways. This presentation today won’t cover that, but maybe in the next one. 

Grief is not only an emotion or a feeling it includes all of the ways that one adjusts to their new life after the loss of a loved one. 

Grief is the shape love takes after someone you love dies. It is a natural process that is unique to each person, yet shared by many and is shaped by the nature of the loss. So the loss of a child is going to be very different than the loss of a grandparent. 

Each person’s grief is like all others’ grief; each person’s grief is like some others’ grief; each person’s grief is like no others’ grief. At first, these three statements seem to be in contrast to each other. But when you think about it, somehow all of these exist at the same time.

Each of us is utterly alone in our own personal, unique grief, and no one can fully understand that. Yet somehow we have a grief that is shared by many who have gone before us and who will come after us. 

Spiritual concerns often arise and are a major part of the grief process. When we’re grieving, we often wonder things like: “How could God have let this happen? If this could happen, how could there be a God who is compassionate?” And more specifically to perinatal loss: “What is the meaning of life? Why are we trying to create life and make babies if this is going to happen? What does death really mean?” If a parent doesn’t believe in an afterlife, they might wonder: “Does my baby have a soul? And where is my baby now?” 

Grief can feel like a physical illness. It affects our psychological well-being as well as our social functioning. We often ask ourselves questions like: “Will I ever feel okay again? Will I ever love again?” And then feeling okay again or feeling love again can feel very confusing. 

How Does Grief Show Up in Our Lives?

• Feelings
• Physical sensations
• Thoughts
• Behaviors

Grief shows up in our feelings, our physical sensations, our thoughts, and our behaviors. Common feelings are sadness and yearning, anger, guilt, and statements like “if only” or “what if”, anxiety, fatigue, helplessness, shock, and numbness. 

Physical sensations often include hollowness, tightness in the chest or throat, high sensitivity to noises, a sense of depersonalization (which is the experience of feeling like you’re not in your body and you’re observing yourself from outside your body, or a sense of nothing being real around you), breathlessness and extreme weakness. 

Thoughts tend to center around disbelief, confusion, and preoccupation with the loss, being engrossed and consumed by the loss. Behaviors include sleep and appetite disturbances, social withdrawal, crying, and restless hyperactivity. 

In perinatal loss, it’s very common for parents not to want to be around their friends. Their friends probably have little ones or are pregnant themselves, and being around other people at that time can feel simply unbearable. Another common behavior in grief is avoiding reminders of the loss or avoiding people, places, and situations that remind you of the loss. So in perinatal loss, a woman might avoid the last place she got an ultrasound, or she might avoid going to her doctor’s office, things like that.

We often suggest to women that when they call their OB or their midwife to make their next appointment, let them know that they’ve had a loss so that when they show up for the appointment, they aren’t getting statements like: “How is the baby doing? How are you and the baby doing?” We also suggest that it might be a good idea to take something to read or listen to so that she has something else to pay attention to besides just looking at other pregnant women. 

Adapting and Coping with Grief

• Intuitive
• Blended
• Instrumental

What does adapting to grief and coping with grief look like? Well, there tend to be three main styles that we fall into, and one is not better than the other. 

The intuitive style is when people feel and express intense emotions and they will say things like: “I feel so sad”. They vent their feelings, they cry, and they seek emotional connectedness with others. Most women tend to use this style of grieving. 

An instrumental style is where people express grief by taking action and figuring out logistics. It is more cognitively and behaviorally based. That is, it is centered around thoughts and actions, and feelings and emotions are not central.

It’s really important to know that both ways of expressing grief and moving through grief are equally valid and legitimate. Men typically fall into the instrumental style. So in the case of perinatal loss, it’s often fathers who are making arrangements for the bereaved mother’s care after the loss and who are doing other things like picking up the baby’s ashes from the funeral home and taking care of all of the many household tasks. 

Those who use a blended style of grieving use a little bit of intuitive and instrumental. So there are those who fall into the blended category, but most of us tend to lean toward one or the other. 

How is Perinatal Loss Defined? 

Perinatal loss is a death. It can be a miscarriage, a stillbirth, or a neonatal death. An early miscarriage is defined up to 10 weeks. A late miscarriage is 10 to 20 weeks. A stillbirth is after 20 weeks. And a neonatal death is less than 28 days old. 

The most important thing to know about all of these different losses is that for the vast majority of them, there is no known cause. There is no clear red flag and the loss is very hard to detect. 

Death of a Child

• Out of time experience.
• Parents are at risk of ongoing stress.
• There is the possibility of complicated grief developing.
• Family functioning is disrupted.
• Risk for siblings or subsequent children to bear the burden of being a “replacement child”.

The death of a child is an out of time experience. It’s what we consider out of the natural order of things. It is not the way life should be, and it is deeply disturbing and upsetting. Because of the intensity, anguish, and gravity of losing a child, parents are at risk of ongoing stress. And there is the possibility of complicated grief developing if the grief isn’t resolved. 

Family functioning is deeply disrupted. Parents and families and couples often feel unhinged by this loss. And there is a huge loss of innocence. The loss of innocence about the way life works, about the way the world is, about what you can expect and count on, about what things might be next time. There’s a huge loss of innocence, and the lens through which people view the world is forever changed. And there is the risk for siblings or subsequent children to bear the burden of being a replacement child.

What Do We Know About Perinatal Grief and Loss? 

Not much. We live in a death-denying society. We don’t have clearly defined rituals around how to go about moving through grief. Death is not a part of our usual experience. We often associate death with violence, old age, or even cartoon characters. 

In 1900, the average lifespan was 47 years old. By the mid-1970s, life expectancy was 74 years old in the developed world. This was the largest increase in human lifespan ever recorded. In the early 1900s, death was an ordinary part of life. Women had many pregnancies and many losses. Miscarriages, stillbirths, and neonatal deaths were expected. Now, they are shocking. This is in large part because of the astounding advances in medical care that we’ve had since then. 

The Reality of Perinatal Loss

The reality of a perinatal loss is that it is often not recognized as a real loss. This is evidenced by things like women being forced to take sick leave instead of having a maternity leave option. There’s often deep silence around perinatal loss, and perinatally bereaved parents are often referred to as silent grievers or disenfranchised grievers because their grief is not socially sanctioned. They are not given permission by society to grieve. Their grief is not acknowledged, it’s not recognized.

And they will hear statements like: “You’re young, you can have more children. You have lots more time to try. At least you already have two children.” And those statements are never helpful. They just throw salt on the wound. 

Parents who have suffered a perinatal loss are at a higher risk of developing a perinatal mood and anxiety disorder in subsequent pregnancies if the grief goes unresolved. 

Assisted Reproductive Technology (ART)

I want to give special mention to people who have used Assisted Reproductive Technology to have a baby. There are many complex issues around ART, and there is the increased risk of unresolved grief and a possible perinatal mood and anxiety disorder (PMAD), and subsequent pregnancies. 

If you’ve used ART and you’ve suffered the loss of a baby, not only have you suffered the loss of a baby, but you’ve suffered the loss of naturally conceiving a baby. You’ve suffered the loss of your identity as a fertile human being. There have been many losses along the way, and there is often a sense of deep failure or inadequate scene. The experience of losing many pregnancies and going through IVF is often not recognized as a true loss, especially early miscarriage with IVF.

What Are Maternal and Paternal Preoccupations, and Are They Normal? 

I like to refer to them as parental preoccupations, but in most of the literature, you’ll see maternal preoccupations. These preoccupations are essentially the concerns parents are engrossed with about taking care of the baby and protecting the baby. Some people describe this “altered mental state” almost like an OCD illness because the focus is almost entirely on the baby and it represents a huge psychological shift to meet the intense demands of physically caring for, protecting, and bonding with the baby. And yes, they’re normal! 

They’re part of a normative experience through pregnancy and postpartum. They essentially represent the beginning of a dyadic relationship. A dyadic relationship is a one-on-one relationship between parent and child. This is when attachment begins to form. 

These maternal and paternal preoccupations prepare parents to be open and create and sustain a relationship that fosters a bond attachment and love. It creates a willingness in the parents to care for the baby through a long period of dependency, which is absolutely necessary for the baby’s survival. 

Parental preoccupations often include distressing and intrusive thoughts centered on worry that harm will come to the baby.

So distressing thoughts are worrisome, upsetting thoughts, and intrusive thoughts are thoughts that are not wanted (we don’t want them to be there). But these preoccupations often include these things, and they’re centered on worry that harm will come to the baby. 

This is when internal representations begin to develop more fully. Internal representations are all of the hopes, dreams, fantasies, ideas, and images that we have about the future with life with this baby. They’re all of the hopes, dreams, and fantasies that we have about what this baby will be like, who he or she will be, what they will grow up to be, what we will be like as a mother or a father, and what life will be like with them. 

In Perinatal Loss, MP Are Complicated By:

• Deep interface between biological and psychological
• Still look pregnant
• Lactation starts
• Heighten levels of oxytocin
• Brain is literally resetting

In perinatal loss, these preoccupations are complicated by several things. We know that there is a deep interface between the biological and the psychological. There is a deep interface between what’s going on inside our bodies and what’s happening in our minds and in our hearts and our feelings and in our thoughts. 

In the case of perinatal loss, a woman may still look pregnant, but there is no baby. Because the hormonal shifts in the body after a loss represent the same hormonal shifts that happen after childbirth, she may begin to lactate. And this is just experienced as injury upon injury. 

Also, she likely has heightened levels of oxytocin, which again, is what happens after childbirth. Oxytocin facilitates maternal behavior and bonding. So this oxytocin is driving this woman to have these preoccupations about caring for and loving the baby, but there is no baby. It intensifies the suffering because the maternal behavior is stimulated, but there is no baby to care for. 

During this time, the brain is literally resetting. All of these hopes and dreams, these internal representations, these images are being altered over and over again. 

What Do Maternal Preoccupations Look Like in Perinatal Loss?

In perinatal loss, there is a physical and psychological rupture. We know that, as humans, we seek to form and maintain close attachment relationships throughout the entirety of our lives, and we resist separation. 

In perinatal loss, there is an acute, intense separation. It’s a deep disruption of biological and psychological processes, a deep disruption of fantasies, hopes, and dreams. These fantasies are in the woman’s stories, in the father’s stories, and in her internal representations about who the baby would have been. 

Many women remember the last time they were with their living baby. They remember the last time that they felt their baby move. They may recall that moment and realize that at the moment they thought: “Oh, the baby is being especially active right now”. And they may have had these internal representations, these images about the future of: “Oh, this baby is going to be an active one”. And after a loss, they go back to this time and now they wonder: “Was the baby struggling? Was the baby struggling to survive? Was that why the baby was being so active?” 

It is normal to have these internal representations that express deep concerns or anguish about not having been able to keep the baby safe. Unfortunately, these doubts and worries are often suffered in silence.

Maternal Preoccupations Center Around:

• • Emptiness: empty arms, empty uterus, empty house, IR are filled with empty images.
  • Guilt: cognitive distortion around responsibility, medical language and terminology can compound feeling like a failure.
  • Shame: socially the face of loss, downer, being around friends can feel unbearable.

These maternal preoccupations after a loss tend to center around emptiness, guilt, and shame. 

Emptiness 

Women have these images swirling through their minds and their bodies of empty arms. And a lot of women will say that their arms literally ache and long to hold the baby. They have images of an empty uterus and an empty house. 

Guilt

Around guilt, there are cognitive distortions around responsibility. Cognitive distortions are inaccurate beliefs around responsibility for the baby’s death. Women often attribute the loss to some failure on their part, even a mean thought or doubt about becoming a parent. And a mean thought and a doubt are a part of normal maternal ambivalence. It is very normal for us to have mixed feelings and emotions about becoming a parent and devoting so much of our lives to caring for this little baby. These are a part of normal maternal ambivalence and the fault and the responsibility is misplaced. 

Also, there’s a sense of failure and medical language and terminology can compound feeling like a failure. Phrases like “incompetent cervix” or “incompetent uterus” or “failed pregnancy” can compound this feeling of feeling like a failure. 

Shame

Many women now feel that they are socially the face of loss and they don’t want to be around their friends. It feels unbearable and they feel like they’re a downer. 

Maternal Preoccupations Can Become Maladaptive

These maternal preoccupations, while they are very normal in pregnancy and in perinatal loss, can become maladaptive. So that means they can become harmful and unhelpful. They are no longer helping a person move through the grief and rediscover meaning for life after this loss. 

These distressing, intrusive thoughts center around the baby who died, self-blame, and the body failing. This is a sign of these preoccupations becoming maladaptive. They can shift into ruminations. Ruminations are dwelling on the negative thoughts and feelings, the inaccurate beliefs, the causes and consequences of what happened, and trying to dissect all of that. 

These internalized representations of the self as inadequate or at fault can negatively affect attachment in current relationships and in subsequent pregnancies. They are also a risk factor for developing a perinatal mood and anxiety disorder and for developing complicated grief. 

In subsequent pregnancies, we expect to see anxiety because uncertainty is heightened. And one of the most difficult things for anyone to tolerate is uncertainty. Worry and uncertainty can influence life in profound ways, and they can live in the nursery in an unconscious way and become like a ghost in the nursery. This is when it becomes maladaptive and it is not helping the parents move through the grief.

Defining Complicated Grief 

Complicated grief is fresh and raw, long after the loss. It is when someone is stuck in ruminative and negative cognitive distortions. Again, the rumination is the dwelling, and the negative cognitive distortions are the inaccurate beliefs. It is when there’s a persistent preoccupation with the loss, a persistent sense of being engrossed and consumed with the death. 

Complicated grief is grief that blocks adapting to the loss. It blocks embracing life and it doesn’t resolve. A person experiencing complicated grief has difficulty regulating their emotions and is unable to face emotional pain. And there is difficulty acknowledging the loss. There is both a yearning and an avoidance that interfere with adapting to the loss. 

Complicated grief is essentially a grief that wrecks the quality of a life. It obstructs the reconstruction of meaning and purpose in one’s life. There is a chance for intergenerational transmission, which is when this grief is unspoken and implicitly present in the story of families. 

This intergenerational transmission, this grief that is passed down from one generation to the next can happen over multiple generations if the grief does not become resolved. And it becomes woven into the family story, into the very fabric and DNA of the family. 

Complicated Grief Can Occur When:

• Cognitive distortions
• Ineffective emotion regulation
• Lack of social support
• Lack of recognition of legitimate grief process

Complicated grief can occur when there are cognitive distortions (inaccurate beliefs), ineffective emotional regulation, a lack of support from others, and when there is a lack of recognition of this being a legitimate grief process. 

Grief Is Not Depression

There are some overlapping symptoms like sadness, guilt, sleep, and appetite disturbances. But grief is when there’s an intense preoccupation with the loss. One of the best ways to sum it up is that in depression, the self is empty. In grief, the world and everything around you is empty. 

What Are Some of the Most Recent Ways We Have of Understanding Grief? 

Elizabeth Kubler Ross was a psychiatrist and she worked with terminally ill patients. She worked with patients near the end of their life. Her work opened the door for a sea change in understanding the normative process of grief. 

In 1969, she published a book called “On Death and Dying”, in which she first discussed the five stages of grief that she noticed in these terminally ill patients. There were these five common stages that they tended to move through. 

In 1970, that book sold more copies than the Bible. As I said, her work opened the door for a sea change in understanding grief and led to all kinds of new interests and research in the area of grief. What we now know is that those five stages of grief that she noted in terminally ill patients don’t translate to every experience of grief. Those five stages are particular to people who are terminally ill. 

These five stages of grief have interwoven themselves into all fabrics of our society. They’re very, very very well known. And like I said, Elizabeth Kubler Ross did groundbreaking work and opened the door for so much more work. But unfortunately, those stages got translated to all these other different situations of grief, and they’re not accurate for the other situations of grief.

What we now know about grief as a whole in broad strokes is that it is more like phases rather than stages.

Phases that move from acute grief, which is this intense, fresh, raw grief to assimilated grief, which is a grief that you begin to fully take in and understand, to a grief that is integrated into an individual’s life. Attachment, the way we love and form relationships shapes the way we grieve. We now have this idea of continuing bonds, and we know that this old message of “accept and let go and move on” is not the only way to grieve. 

Many parents who have suffered a perinatal loss continue their bonds with their babies. They love their baby in their absence, and they often do this in secrecy and silence. Continuing bonds with a loved one who is dead can be a healthy way to move through grief. This can be done throughout the entirety of an individual’s life. This is different than fixating on the grief or being consumed by the grief.

Continuing bonds is a way of loving the person who died in a way that gives meaning to your life after death. 

And we now know that there is an oscillation between a loss orientation and a restoration orientation. That we naturally oscillate between these two orientations after someone we love has died. The loss orientation is simply these times, these moments when we feel the sadness, the yearning, the deep hole. And the restoration orientation is when we begin to focus on goals again or remaking a life with new meaning in a new way. 

There is a significant societal emphasis on restoration, which places parents at risk of getting stuck in tasks of recreating their lives without experiencing the pain of the loss. This does lead to an increased risk for PMAD in subsequent pregnancies. However, getting stuck in loss also leads to the risk of PMAD and complicated grief. So we know that oscillating back and forth between these two things is the way that we move through grief. 

We also know that grief is essentially the story of a life being disrupted and that the next chapters need to be written and the person grieving needs to find new meaning. 

How Do We Move Toward an Integrated Grief? 

How do we get to a place where the loved one can rest comfortably in our hearts and the death, the loss is acknowledged, it’s considered and it’s integrated and recognized? 

This healing is a process of addressing complicated problems. We know that intentionally oscillating between loss and restoration is how we move toward the grief. But what does that look like? Well, that looks like observing with an open mind what is coming up for you moment to moment. Observing with an open mind, an open heart and curiosity, and a non-judgmental attitude, what is coming up for you moment to moment? 

What are you feeling in your body right now? And where do you feel it? What does it feel like? On a scale of 1 to 10, how intense does it feel? Is it in the loss orientation or is it in the restoration orientation? 

It’s about observing and letting these things come up and allowing yourself to naturally go back and forth between the two.

We know that developing a coherent narrative of the loss is essential. That means developing a story with meaning around the loss that is free of cognitive distortions, that is free of inaccurate beliefs about blame and responsibility around the death of the baby. 

We know that finding meaningful emotional connections is vital. Identifying strengths and hopes for the future while also identifying positive emotions and memories about the baby who died because not all memories are about the loss or the final days. When curiosity re returns and when the desire for exploration returns, building on the restoration focus, building hope, confidence, and joy in life that includes remembering without emotional flooding and includes building on a sense of mastery in life. Mastery in life means how effective you feel in your life and how in control you feel of your life.

There are so many things in life that we have absolutely no control over, but this mastery in life is referring to controlling the things that we can that are within our grasp to control and that will give our life meaning. 

What Might Work with a Therapist Look Like? 

Working with a therapist, you would likely use intentional self-observation and reflection in the context of a supportive, helping relationship. You would likely explore avoidance behaviors. An example of avoidance behavior (besides avoiding people, places, things, and situations that remind you of the loss), is that you might feel safe expressing the sadness, the grief, the loss, and the yearning, but much less willing to evaluate beliefs around your own responsibility or your own failure. And that is another example of an avoidance behavior. 

You would address emotional flooding, and you would primarily do this by telling the story in small doses until there is enough emotional regulation to be able to tell the story as a whole without feeling like you’re being consumed by it or overwhelmed by it.

Also, you would learn how to go to the yearning and sadness and then set it aside, but not avoid it. So this “going to it and setting aside” is very different than avoiding it or becoming overwhelmed by it. Essentially you’d be learning how to flexibly oscillate in tandem between the loss orientation and the restoration orientation. 

You would find ways to experience positive emotions along with painful ones.

We know that experiencing these positive emotions is physically healthy and healing for us. You would work with a therapist to build a bridge. To build a bridge from your life before the loss to your life after the loss. Your therapist would help you name the proud moments that you had during your pregnancy or in the few days that you had with your baby. 

Again, these internal representations that you once had about holding life and preparing life and about the future of life with this baby, all these hopes and dreams and fantasies, can be a bridge to recovering and remaking your life after the loss. You might use imagery exercises to engage implicit memory, these unconscious memories that have been stored. 

You might use something called a grief monitoring diary, which is a simple way to note the intensity of the grief on a daily basis.

So you would note on a scale of 1 through 10 how intense the grief was throughout the day. For the most intense moment, you would rate that on a scale of 1 through 10 and then describe what was happening in the situation (like seeing a pregnant mom or something to that effect). Then you would note the moment throughout the day when the grief was at its lowest. You would note the intensity and what was going on around that time. This can really help you distinguish between what is grief and what is not grief. 

Your therapist might ask you questions like: 

• Has anyone been supportive? 
• How have your relationships been affected? 
• Has anyone been actively unsupportive? 
• Do you feel estranged from other people you care about? 
• Do you feel reluctant or afraid to be okay? 
• Do you feel reluctant to be happy? 
• And is it okay to be okay? 

These are all things that you would dive into and explore more fully in therapy. There are a few slides left that give you a little bit more information about me and how to get in touch with me and how to get in touch with the other therapist at Eddins Counseling Group.

I also want to leave you with a quote that I recently came across. I recently reread “Charlotte’s Web”, and on the back cover of the 60th-anniversary edition, there’s a quote from an author, Kate DiCamillo. She’s speaking of the book and she says: 

“Every word of the book shows us how we can bear the triumphs and despair, the wonders and the heartbreaks, the small and large glories and tragedies of being here. We can bear it all by loving it all.” 

I can’t think of a better quote, to sum up what we’ve been talking about here today. 

About the Facilitator

Erica Billings, LPC Associate

• Seleni Institute Training Intensive in Perinatal Mood & Anxiety Disorders and Perinatal Grief & Loss
• Brainspotting Trained
• Member of Houston Group Psychotherapy Society, Membership Committee Chair

For more information:

Call: (832) 559-2622 or

Text: (832) 699-2001

I thank you all for being here with me this evening. I send you all light and love and peace and comfort. Thank you for your time. Thank you for being here.