Pregnancy loss support groups were first established in the United States in the mid-1970s (Layne, 2003). By the 1980s these groups had spread throughout the country, and by 1993 had reached approximately 900 groups (Layne, 2003). Around this time support groups were also showing up in Canada, Australia, Israel, Italy, England, West Germany, South Africa and the Virgin Islands (Layne, 2003). These groups offer support from women and couples who have had similar experiences and are described as “a story telling population” (Irvine, 1999, as cited by Layne, 2003, p. 47). Goals of the groups involve promoting and aiding parents in the positive resolutions throughout their grief experience and encouraging physical and emotional health of the bereaved (Peppers & Knapp, 1980). By bringing individuals with this shared experience together, support groups build a network of peers and friendships that can be relied on for support, comfort, compassion and telephoning at any time (Peppers & Knapp, 1980). It is not uncommon for support groups to publish newsletters featuring poetry, narratives, excerpts from journals, and letters from bereaved parents. Articles written by professionals on related topics are also a part of the newsletters (Layne, 2003).
Other resources for healing include therapy models designed specifically for reproductive loss. The Healing Process model is a program specific to reproductive loss and was developed by Gray and Lassance in Grieving Reproductive Loss (2003). This body of work intends to educate and train professionals and volunteers working with individuals grieving reproductive loss. In consideration of the diverse backgrounds of their workshop participants, the HPM accommodates individuals who may have little or no bereavement counselling training through a holistic way of looking at grieving and healing (Gray & Lassance, 2003).
The HPM (2003) does not follow any sequential order; it takes cues from the bereaved individual much like the tasks of mourning and the dual-process bereavement models. Components include acknowledgement, story telling, outlining the individuals history with reproductive loss and other losses, describing and normalizing grief reactions, establishing, reconnecting and continuing the bonds of the relationship with the deceased, addressing the questions around the loss, distinguishing ‘grief work’ from ‘guilt work’, expressing forgiveness and anger, letting go of the pain and encouraging self-care (Gray & Lasance, 2003).
Acknowledging the loss is an initial healthy response in the grieving process, as it gives the bereaved permission from themselves to grieve and accept the reality of their situation (Gray & Lassance, 2003). Acceptance of the loss may require repeated reviews of the relationship with the deceased, the events which surrounded the loss, its meaning and its implications (Rando, 1986).
Acknowledgement from family, friends and health professionals is also important in supporting the bereaved; dismissing reproductive loss minimizes and disenfranchises the grief of the bereaved. Women may hear phrases like, “You’re young, you can have another baby” or “It’s natures way” (Gray & Lassance, 2003, p. 37). The initial acknowledgement and acceptance of the event, whether it be an abortion or a miscarriage, can be the most helpful intervention for the grieving woman or parent (Gray & Lassance, 2003). Explaining normal grief reactions and responses will help the bereaved understand and validate what they are going through (Rando, 1986).
Identifying, expressing and accepting the variety of emotions present in the grieving process encourages grief resolution and is critical to the process (Rando, 1986). Societal, cultural, ethnic or religious influences can influence the expression of these emotions. In some cases, symptoms of grief may not be viewed as tolerable or normal (Rando, 1986). Identifying and working through these influential factors will facilitate free expression throughout the grieving process (Rando, 1986).
Secondary losses as a result of a death are often overlooked in the case of reproductive loss (Rando, 1986). A woman and/or parents will endure symbolic losses regarding their pregnancy that are related to the future; their hopes and expectations, their wishes for a family, their roles as mother and father and their fantasies about their child will be lost (Rando, 1986). Identifying secondary losses is an equally important step in the acknowledgement of the primary loss (Rando, 1986).
Telling a story to someone who will listen without judgment and offer compassion is integral to healing (Gray & Lassance, 2003). The story around the loss helps in processing the grief and gives the bereaved an outlet to express their own experience of the loss. Writing the story is an ideal way to record, develop and share the bereaved individual’s experience. Writing can also be useful in communication exercises between a couple coping with loss; it offers clarity and distance in the wake of confusing and painful feelings (Rando, 1986). Journalling is another writing activity that can be used as an outlet for the bereaved to express their experience and emotions. The process of writing provides the bereaved with an opportunity to organize and control their thoughts; journals can also be reviewed and reread to give the writer feedback on where they are at in their process of mourning (Rando, 1986). Helping the client remember even the smallest of details and sensations will help in re-creating their story (Gray & Lassance, 2003).
Noting the history of reproductive loss and other losses is necessary on behalf of the facilitator. This history will inform them of any unfinished mourning and of their coping abilities (Gray & Lassance, 2003). Recovering this history should be done at the pace of the client, for recalling more than they are prepared to remember too fast may cause additional distress (Gray & Lassance, 2003). Other significant losses and the time at which they occurred can give further insight to the needs of the client and their ability to cope (Gray & Lassance, 2003). Identifying significant stressors will also impact the way a woman grieves and manages her loss; these peripheral losses may contribute to complicated grief or maladaptive coping behaviours (Gray & Lassane, 2003).
Explaining how grief affects the body, mind and spirit can give the bereaved a sense that what they are going through is normal, and that others have experienced the similar reactions (Gray & Lassance, 2003). At this time the facilitator may underline that although grief reactions are similar among bereaved women and couples it does not take away from the individuality and uniqueness of their loss and ways of responding (Gray & Lassance, 2003).
The relationship or bond between the parent(s) and the deceased baby is important to establish, reconnect and maintain throughout and beyond the grieving process (Rando, 1986; Gray & Lassance, 2003). As the bereaved experiences some form of reorganization and restructuring in their life, they must form a new relationship with their deceased infant and establish a healthy way to remember and relate to them (Rando, 1986). Nurturing this relationship is a comforting and effective way to promote healing. Naming the baby will validate the baby’s uniqueness and individuality (Gray & Lassance, 2003). At a time when the mother may see or feel the baby as a part of herself, baby naming can help the mother separate her identity from the infant’s (Gray & Lassance, 2003). Parental attachment grows when a mother can hold, gaze upon or interact with her baby (Savage, 1989). These acts are inherent in giving the child a soul and identity, which are necessary for the comprehension of a loss (Savage, 1989). Many women will not have had a chance to experience these acts, therefore naming and giving the unborn baby an identity helps the bereaved to acknowledge and grasp the loss (Savage, 1989). Writing a letter or a poem to the baby may be an ideal way to reconnect and establish a bond with the baby.
Bereaved individuals or parents can often get stuck on the question of “Why?” (Gray & Lassance, 2003). Blaming is not uncommon and can be directed towards the self, the partner or the health care professionals; thus naming the reason for their loss may make sense, or give order to the stress and pain the individual is experiencing. The question of “Why?” can bring up beliefs about spirituality and the meaning of the pregnancy. This question may come at a time of intense grief and heightened emotion. Validating their question and letting them know meaning will ultimately find them, is one way to support the mother or couple (Savage, 1989). Bereaved individuals may identify a purpose or reasoning for their loss. At this time, and only then, should the therapist explore this notion with the client to support healthy grieving (Gray & Lassance, 2003).
Feelings of guilt are inherent in grieving reproductive loss (Gray & Lassance, 2003). Mothers and parents reprimand themselves for not taking better care of themselves, or for doing an activity that may have compromised the health of the developing infant; ultimately the mother feels like she was not able to protect her baby from death (Gray & Lassance, 2003). Confronting these feelings and identifying their source can be helpful in coping with guilt (Rando, 1986). Irrational beliefs can be the source of guilt and some individuals may need assistance identifying these and better understanding them (Rando, 1986). When phrases such as “should have”, “must” and “ought to” occur over and over they become irrational beliefs (Rando, 1986, p. 114). Transforming these thoughts into something more realistic can help the bereaved manage their guilt (Rando, 1986). Bereaved parents can get stuck feeling guilty and experience difficulty moving forward. In these cases, working on seeking and granting forgiveness from the self can encourage mothers and partners to continue their mourning process (Gray & Lassance, 2003). Focusing on forgiveness can be necessary when the bereaved are dealing with intense feelings of anger as well. Mothers and their partners may feel anger towards themselves or each other; they may be angry with family, friends or health care professionals for minimizing or dismissing their loss. To avoid obstructing the healing process, the therapist must be sure to adequately acknowledge any feelings of guilt or anger before focusing on forgiveness (Gray & Lassance, 2003).
Healthy closure from the experience of reproductive loss can start by having clients preserve memories, keepsakes and mementos from the loss (Gray & Lassance, 2003). Rituals are a specific behaviour or activity representational for feelings, thoughts, memories and meaning of an individual, group or event (Rando, 1986). They can signify transition, healing, connection and progression through powerful therapeutic experiences (Rando, 1986). Daily rituals can help with the initial coping after the loss; lighting a candle, journalling, or sending an internal message to the deceased can bring a sense of peace to the bereaved (Luebbermann, 1996). In Japan, parents hold a candle ceremony, sending out small candles on paper boats down a river (Luebbermann, 1996). Having the parents create their own memorial service or basic ritual can enrich a meaningful closure and provide a framework for the parent(s) to recall their loss and express their feelings in the future (Gray & Lassance, 2003; Rando, 1986). Planning a memorial service with the possibility of inviting family and friends or creating a ritual to commemorate the loss are ways to respect and accept the infant’s death (Luebbermann, 1996).
The therapist may assist the client in exploring options for self-care, as this is an important practice to highlight for the bereaved. Bringing awareness to the importance of caring for the self in a holistic manner is critical in a time of emotional distress; clients should be encouraged to create a self-care plan to be mindful of the mind, body and spirit (Gray & Lassance, 2003). The hormone fluctuation that takes place after a pregnancy loss can make a woman feel out of control, hypersenitive and moody (Luebbermann, 1996). It is important to be aware of these changes taking place and nourish the body with proper foods and liquids (Luebbermann, 1996). Coping with grief requires a great amount of energy and can deplete the bereaved in many ways (Rando, 1986). Adequate rest and nutrition should be encouraged and maintained to support proper health and immune function during a stressful and overwhelming time (Rando, 1986). Connecting with support groups, learning about grief and encouraging the bereaved to be gentle with themselves are suggestions the therapist may address (Gray & Lassance, 2003).
Rituals can be especially therapeutic in coping with loss. They offer a sense of meaning and structure to transitional times in people’s lives and symbolically, they bring individuals together to acknowledge, celebrate or honour an event (van Gennep, 1960, as cited by, Kobler, Limbo, & Kavanaugh, 2007). Rituals around transition often focus on past and future, holding on and letting go or life and afterlife (Anderson & Foley, 1998, as cited by, Kobler, Limbo, & Kavanaugh, 2007). They offer an opportunity to maintain a healthy connection to the deceased and create space for them in creative ways (Kobler, Limbo, & Kavanaugh, 2007). Practicing, establishing or developing rituals has been a means for coping with loss across cultures. Through the gathering of relatives and friends, social supports are put into place and made available to the bereaved (Rando, 1984). Messages of care and support are expressed to bring comfort to the bereaved (Rando, 1984).
Reproductive losses do not receive significant social acknowledgement, nor do the bereaved have any traditional ritual in place to honour the deceased in the same sense we would hold a funeral for an child or adult (Kobler, Limbo, & Kavanaugh, 2007). For bereaved parents the extent of a ritual involves meaning-making and participation (Kobler, Limbo, & Kavanaugh, 2007). Rituals provide an opportunity to give new meaning to the loss and therefore whatever activity is chosen must be meaningful to the individual (Kobler, Limbo, & Kavanaugh, 2007). The process of ritual requires active participation on behalf of the bereaved. Developing and deciding on the ritual activity can be facilitated by the therapist and led by the mother or parents, with options to participate in the ritual at a level they are comfortable (Kobler, Limbo, & Kavanaugh, 2007).
Practical grief and loss counselling techniques, rituals and meaning-making are significant to coping with reproductive loss. These suggestions and directives for supporting individuals dealing with reproductive loss can be integrated into a intervention that capitalizes on the individual’s positive coping skills (Rando, 1986).