Multiple miscarriage: Psychosocial implications

1. Multiple miscarriage:Psychosocial implications Uschi Van den Broeck Master in Psychology University Hospital of Leuven, Belgium Department of Gynaecology/Fertility Center

2. About me… • Clinical psychologist • University Hospital of Leuven, Belgium • Fertility Center: fertility counsellor • Department of Gynaecology • Phd-research • Psychosocial determinants of continuing or discontinuing fertility treatment: a psychological analysis • Funded by Leuven University Fertility Center and Department of Gynaecology

3. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

4. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

5. 1. Psychology of pregnancy • ‘Pregnancy begins psychologically, long before it occurs physically.’ • Growing towards motherhood fatherhood • Fantasies and dreams about life with future child • ‘New goal’

6. Psychology of pregnancy • Pregnancy = unique experience • Influenced by: • Cultural factors • Personal history: family of origin • Personality • Relationship • Expectations and beliefs • Social environment

7. 1. Psychology of pregnancy PREGNANCY = POINT OF NO RETURN = CRISIS

8. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

9. 2. Psychology of pregnancy loss • ‘A crisis within a crisis’(Leon, 1990) • Conflicting emotions: • Sometimes first experience with death for couples • Elation of pregnancy followed by despair of pregnancy loss

10. 2. Psychology of pregnancy loss • Sense of loss in different areas • Loss of a baby • Loss of self-esteem as a parent • Feelings of failure as a women • Loss of ‘pregnant status’ • Fear of loss of reproductive capacity • Fear of loss of health • Fear of loss of control • … MULTIDIMENSIONAL LOSS

11. ‘Christmas has always been a special time in our family. I miscarried on December 23rd and I didn’t feel like my family was there for me. I devoted all my time and energy into the Christmas preparations… but I felt like I had lost something that was ‘mine’… and nobody acknowledged that. I had a hard time saying goodbye to the feeling of being pregnant. I couldn’t get myself to eat red meat at the Christmas dinner. To them, it was nothing but to me…it was already my baby.’ ~ N.C., 35

12. 2. Psychology of pregnancy loss Loss is multi-layered • Individual loss • Family loss (parents, siblings, grandparents, etc.) • Impact on relationships • Impact on life conditions • Impact on future plans, goals

13. ‘After the second miscarriage, it got harder for me. I realized that I was going to be an ‘older parent’, and even more, that my own parents, might never get to be grandparents. I feel pressured into trying again…because the clock is ticking, but I can see that my wife can’t take it anymore right now. It’s getting harder on both of us.’ ~ J.E., 42, husband of N.C.

14. ‘Between something …and nothing’

15. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

16. 3. Common feelings when confronted with multiple miscarriage Multiple miscarriage? • World Health Organization (WHO) • At least 3 or more consecutive pregnancy losses before the 22nd gestational week • 1% of couples (Bagchi & Friedman, 1999)

17. Video Clip 1: Tori Amos

18. 3. Common feelings when confronted with multiple miscarriage Miscarriage and multiple miscarriage ‘unrecognized loss’ GRIEVING • Normal, healthy, dynamic, universal and individual response to loss • Healing process: surviving and continuing to live

19. 3. Common feelings when confronted with multiple miscarriage Major life-event: individual differences Tidal Wave G S R H I A E D F O w Longing Despair Out of control Sadness Regret Shocked Confused Angry Guilty Responsible Emptiness Panicky Loneliness Stressed Lack of self-confidence Unpredictable and repetitive pattern

20. 3. Common feelings when confronted with multiple miscarriage PHYSICAL SYMPTOMS Headache Stomach achees Shortness of breath constipated Tightness in the chest Problems with sleeping Lack of appetite ……. TRIGGERS SOCIAL SYMPTOMS Isolation Withdrawal ….. COGNITIVE SYMTOPMS Dreams Worrying Decision making …… Expressions of grief

21. 3. Common feelings when confronted with multiple miscarriage Unique aspects of perinatal grief in MM • ‘Psychological videotape’ • Possibly traumatic event • At risk for post-traumatic stress disorder, anxiety, depression, etc….

22. 3. Common feelings when confronted with multiple miscarriage • ‘Injustice’: ‘Why is this happening to me?’ • Feelings of helplessness • Need to blame someone • Desire to bring a sense of control to the event • Hope that if a cause can be identified, a recurrence can be prevented SEARCHING FOR A CAUSE  ‘premonitions’  little anticipatory grieving: ‘thief in the night’

23. 3. Common feelings when confronted with multiple miscarriage • Self-blaming possibilities: • Feeling that they’ve disappointed themselves, their partners, their family • Doubts about reproductive competence • Anger towards their own body • Each loss magnifies the pain: every loss is followed by a new period of grieving • Impact on self-image • Body becomes ambivalent object • Uncertainty rules: increasing ambivalence about each consecutive pregnancy

24. 3. Common feelings when confronted with multiple miscarriage • No or little public acknowledgement • Absence of visible ‘object’ to mourn, no rituals: prospective grieving  few memories • Few socially acceptable avenues for mourning • Lack of social support • Reassurance resulting in minimalizing the loss • ‘It was for the best’; ‘It’ll work next time’ … • ‘Conspiracy of silence’ • Designed to protect loved ones • Has the effect of further isolation Not a reality to anybody else Social environment: ‘taboo’

25. 3. Common feelings when confronted with multiple miscarriage • Accepting the reality of the loss and experiencing the pain and loss • ‘When you are in the trenches…’ • Adjusting to life without your babies • Time (gestational age) alone is not necessarily an indicator of the level or degree of attachment, nor is the physical presence of the baby after birth. (Moulder, 1994) • Trying to make sense of it • Give life meaning again • ‘Choose the wisdom out of the wound’

26. 3. Common feelings when confronted with multiple miscarriage Gender differences: mothers and fathers • Loss is equally important but different ways of experiencing feelings + at different times • “It’s a journey, not a destination.” • “Dance of closeness and distance” (Rosenblatt, 2006) • Fathers are often overlooked, feel ignored or excluded: have to deal with organisational tasks • Sexual relationship can be difficult for a while  physical reminder of the pregnancy

27. ‘It hurt me so much when people called or ran into J. on the street and they always asked how I was doing… it never occured to them that J. had lost a baby too. I was so angry at everyone for not realising we were both in this thing, we’d both lost our baby. It made it so much harder on J.’ ~ E.T., 25

28. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

29. 4. Coping with grief and loss • ‘There is no right or wrong.’ • No typical response to loss, there is no typical loss : it’s individual • ‘There are no rules.’ • No single pathway through grief: it comes and goes… “There is only one way, and that is your way.”

30. 4. Coping with grief and loss • ‘How long will I feel like this?’ • Expectations from environment • Bad times even when you feel better (process of grief!!) • ‘Shadow’ grief: special events and dates will remain triggers

31. 4. Coping with grief and loss • Risk of more intense or longer lasting distress: • Pregnancy strongly desired • Waited a long time to conceive • No living children • Elective abortions • Other losses in history • Few warning signs that a loss might occur • Experienced the loss relatively late in pregnancy • Little social support • History of coping poorly

32. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

33. 5. Infertility and recurrent pregnancy loss • Infertility and miscarriage are both devastating experiences • Together: larger impact, which can complicate grieving • Infertility:can create a life of its own • A lot of focus on pregnancy and childwish • Repeated cycles of hope and sadness etc. • Time consuming and emotionally consuming • Impact on a couple’s relationship and marriage can be considerable

34. ‘I just kept thinking: why is this happening to me? A miscarriage is horrible to happen to anyone but we had been trying to get pregnant for so long. That made it so much worse… I kept lying awake at night not knowing wether I’d be able to conceive ever again…’ ~ B.C., 32

35. 5. Infertility and recurrent pregnancy loss • Impact on partner relationship  vulnerable • Couples sometimes ‘balance’ grieving • Men and women experience infertility differently, inevitably pregnancy loss is experienced differently • Important to take time to build the relationship again, remember why you are together: both on an emotional level as well as on a sexual level

36. ‘We dealt with it very differently. T. doesn’t talk much at all and I felt so alone. Like I was the only person this had ever happened to. He didn’t understand or he didn’t want to…it came close to splitting us up.’ ~ A.V., 31

37. 5. Infertility and recurrent pregnancy loss • ‘Invisible loss’ is doubled • Physical component of treatment can become more invasive and traumatic with each repeated reproductive failure

38. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

39. 6. Trying again… • Timing? :too soon versus not soon enough • Importance of grieving each previous loss before trying for a new pregnancy • Focus on pregnancy increases: ‘obsession’ • Belief that it will make everything better • Sometimes it does • Sometimes it doesn’t: delayed grief reactions In general, no rules… Each couple has a unique experience and situation Informing them about the risks Honest communication: defenses have a function!!!

40. 6. Trying again… • Sexual relationship can become pressured • ‘Careless’ pregnancy is gone: dealing with uncertainty • Rituals and superstition: having a sense of control • Sharing the ‘good news’ with friends and family: when is the right time? • Extra check-up and honest reassurance from the medical team can help reduce anxieties  information and communication

41. Overview • The psychology of pregnancy • The psychology of pregnancy loss • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

42. 7. Helpful interventions • Decision making is up to the couple but ‘informed’ choice • ‘Joining’ the couple • Creating a safe ‘holding environment’ • Listening without judging • Stimulating creative outlets

43. ‘The hours, the days afterwards I had to decide if I wanted to see you, hold you. The biggest dilemma in my life. I felt so weak and sad, felt like I couldn’t deal with it all. I’m so terribly sorry I left you there, in the cold, with strangers, without keeping you safe and warm. I would give everything to keep you in my arms, keep you safe with me, talk to you, give you an everlasting and warming kiss… So quickly you left me, no longer a part of my life, taken away and never returned. You and me, without one another. I let the chance slip away to cherish you for the first and last time, to see you, feel you, smell you …’ ~ L.R., 29

44. 7. Helpful interventions • Creating mementos: pictures, clothes, teddy bear • Memorial activities • Keeping a journal: writing things down  taking control • Reaching out: talking with friends, joining support groups, etc. • Providing information: both medical and psychosocial • If possible: seeing, holding, touching, baby naming Reality reinforcing interventions Couple approach: don’t forget the husband!!!

45. References • Bagchi, D., & Friedman, T. (1999). Psychological aspects of spontaneous and recurrent abortion. Current Obstetrics & Gynaecology, 9, 19-22. • Burns, L.H. & Covington, S.N. (2000). Infertility counseling: a comprehensive handbook for clinicians. Parthenon Publishing, N.Y. • Leon, IG. When a baby dies: psychotherapy for pregnancy and newborn loss. New Haven: Yale University Press, 1990. • Spitz, B., Keirse, M., Vandermeulen, A. (2004). Omgaan met een miskraam. Uitgeverij Lanno, Tielt, 2004.

46. Multiple miscarriage:Psychosocial implications Thank you for listening Uschi Van den Broeck Master in Psychology University Hospital of Leuven, Belgium Department of Gynaecology/Fertility Center Contact: +32 16 34 28 60 Uschi.vandenbroeck@uz.kuleuven.ac.be