Under certain circumstances, some individuals may fail to grieve or their grieving process may be interrupted or obstructed (Worden, 2002). Factors that influence the way an individual grieves include the relationship they had with the deceased, the circumstances around the loss, previous losses, personality traits in coping with distress and social circumstances (Worden, 2002). Disenfranchised grief can lead or contribute to complicated grief and encompasses many of the same conditions as complicated grief. Complicated grief involves prolonged unresolved feelings, a sense of feeling overwhelmed, symptoms of traumatic distress, maladaptive behaviour and persistent disbelief about the loss (Lobb et al., 2010). This type of grief may also reveal exaggerated reactions, such as clinical depression, anxiety disorder, substance abuse and Post-Traumatic Stress Disorder (Worden, 2002). Examining the factors relevant to complicated and disenfranchised grief in the context of reproductive loss will help therapists and clinicians support their clients in the most appropriate ways and contribute to the development of an art therapy intervention.
Disenfranchised grief occurs when the loss does not receive normal social support, is not openly acknowledged or cannot be mourned publicly (Doka, 1989). Grief can be disenfranchised when the relationship with the deceased is not recognized, when the loss is not acknowledged or socially acceptable and when the griever is thought to be incapable of mourning or the loss did not impact them (Doka, 1989). The circumstances of the death and the way the bereaved chooses to mourn are additional factors that can result in disenfranchised grief (Doka, 2002, as cited by Attig, 2004).
These circumstances are defined by the culture and society in which they occur and imply “grieving rules” that determine who, how, when, for how long, where and for whom the individual grieves (Doka, 1989, p. 4). These “grieving rules” do not allow the bereaved to adequately express their feelings in a way that others can and do under different circumstances (Doka, 1989).
Attig (2004) notes the disenfranchisement of grief as a societal failure to empathize. Denying empathy to the bereaved undermines their suffering, the meaning of their loss and the pain or agony they may be experiencing; this in turn does not support their needs and if anything, contributes unnecessarily to their suffering. Disenfranchising messages from society, culture and family “actively discount, dismiss, disapprove, discourage, invalidate, and delegitimize the experiences and efforts of grieving” (Attig, 2004, p. 198). These types of behaviours interfere with the needs and rights of the bereaved by hindering, disapproving or even prohibiting their grief (Attig, 2004).
The type of relationship the individual had with the deceased is a factor that can contribute to complicated or disenfranchised grief (Doka, 1989). Ambivalent feelings about the death and the relationship with the deceased can make the process of grieving more difficult and lead to complicated mourning (Stephenson, 1985). It is possible to feel glad and sad about a loss. This ambivalence can bring about exaggerated feelings of anger and guilt, prolonging the process of grieving (Stephenson, 1985). In the context of abortions, feeling ambivalent towards the pregnancy has been identified as a significant reaction (Lemkau, 1988). A woman may feel relieved and happy she has proceeded with the abortion, yet still feel sadness from her loss and its meaning. This would suggest that women going through the experience of abortion are at risk for complicated mourning.
Another type of relationship relevant to complicated grief is a notably narcissistic relationship (Worden, 2002). In this case the deceased has been representational as an extension of the individual suffering the loss. Acknowledging this loss implies confronting and accepting the loss of oneself (Worden, 2002). Reflecting on the research discussed earlier, the first trimester of a pregnancy is referred to as the narcissistic stage, as the woman experiences her developing fetus as a part of herself, as opposed to a separate entity (Gray & Lassance, 2003). In the case of a miscarriage, this particular dynamic can influence the way a woman grieves her loss. The intensity of this loss can be explained by the “affectional bond” a term developed by Kennell, Slyter and Klaus (1970, as cited by Peppers & Knapp, 1980). The affectional bond or prenatal bond is the developing emotional attachment between the mother and infant during the first months of pregnancy (Peppers & Knapp, 1980). Fetal death abruptly severs this bond and results in heightened anguish and grief (Peppers & Knapp, 1980). In addition to this complicated ‘loss of oneself’, a miscarriage denotes a loss of hopes and wishes which will not be realized (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). Grieving for the loss of anticipated wishes and desires can also contribute to complicated mourning (Worden, 2002).
Type of attachment to the deceased and level of dependency associated with them are additional determining factors for complicated grief (Lobb et al., 2010). Insecure attachments stemming from childhood can affect the way an individual will respond and manage grief. People with a higher dependency on their partners or family are also at risk for complicated grief and difficulty managing their loss (Lobb et al., 2010).
The suddenness of a miscarriage is primary in how the parents will grieve and feel their loss (Peppers & Knapp, 1980). Having no indication or warning of their loss, the unforeseen death can be shocking and parents may respond with intense anger, frustration, bewilderment and guilt (Peppers & Knapp, 1980).
Worden (2002) notes that grief is a social process and highlights the importance of support systems such as family and friends. Lazare (1979, as cited by Worden, 2002) outlines three conditions which apply to the social aspect of grieving and can contribute to complicated mourning and disenfranchised grief. A socially unspeakable loss refers to circumstances where the individual and/or their family feels a need to keep the cause of death in secrecy (Worden, 2002). How the infant is defined and perceived by the culture can influence the response of the parents (Peppers & Knapp, 1980). In the instance of miscarriage the relationship with the deceased may have never been publicly recognized or even known to family and friends. Parents are deprived of validation through clichés such as “You’re young; you can have another”; “He would have been a vegetable”; “It happens in life” and “You’re lucky it happened now; she would have been such a burden” (Doka, 1989, p. 117). This disregard for the relationship disenfranchises the loss and leaves the bereaved without any normal cultural and societal supports in place for coping with this type of loss.
The community surrounding the parents will not perceive or respond to the death the same way they would to that of an older person. In this case they will dissociate normal grief from the situation and perhaps see the circumstances as “unfortunate” not “tragic” (Peppers & Knapp, 1980, p. 28). Not having had any social presence or recognition, the loss of a developing baby can be disenfranchised and will be difficult to mourn, as the support from family and friends may not be as strong or immediate. Additionally, pregnancy is often kept in secret until a specific stage, and the cause of death is sometimes unclear which may compel some families to keep their loss private. In a culture that idealizes motherhood, the experience of miscarrying can feel isolating (Worden, 2002).
Grief is disenfranchised when a loss is socially negated. In this dimension of social factors and complicated grief, the loss is not recognized, and the individual and the people close to them behave as though the loss did not occur (Lazare, 1979, as cited by Worden, 2002). This circumstance is particularly relevant to the experience of abortion. The ideologies and stigma around abortion does not make for a supportive or understanding social response and can put the bereaved in stressful or difficult situation (Doka, 1989). Women who chose to hold their unplanned pregnancy in secrecy often follow through with an abortion in isolation, suppressing the incident and creating a greater risk for complicated grieving (Worden, 2002).
The lack of a social support system or group is the third social factor that can contribute to complicated grief (Lazare, 1979, as cited by Worden, 2002). This support network includes family and friends, support groups and individuals who knew the deceased (Worden, 2002). In the instance of reproductive loss, abortions are often experienced in isolation and the counselling interventions around the procedure are insufficient. The aforementioned research has identified that coping after an abortion is affected by the support from family and friends, thus emphasizing the risk for complicated and disenfranchised grief in the experience of abortion.