It was a privilege to present on an excellent webinar panel convened by the Mental Health Practitioners’ Network on the topic of supporting families grieving perinatal loss. I was moved by the stories told, especially by our lived experience representative Bonnie Carter OAM, but also the lived experience represented by the rest of the panel – Dr Nicole Hall, Eliza Strauss and Prof Steve Trumble – with their decades of clinical experience.
I am posting my written notes from the slides I presented here, as I wrote them out as I would a MDH blog post as part of my preparation. Writing word for word what I actually want to say beforehand helps me be more succinct when presenting from slides – I hope the notes below are useful, whether you watch the video linked above (intended for clinicians and professionals) or not.
Perinatal Loss and Grief
I think of grief as converting news of a major loss into felt reality. Spinal unit patients at the Austin Hospital in Melbourne Victoria taught me about this in my training. Many would not dream of themselves in a wheelchair until 3-6 months after their injury. 3-6 months was also the figure we psychiatry trainees were taught for how long the most acute phase of grief takes.
It seems to take at least that long – and often longer – for a painful new reality to find its way into the deepest, least verbal parts of us. Until we have learned at that level of procedural memory how to be with what has changed about our world, those deep parts err on the side of caution, break glass in case of emergency, and we can feel like the whole world is upside down, blown apart, a darker, more dangerous place.
That first 3-6 months is a steep learning curve that often doesn’t ever quite flatten out.
When asked to assess the mental health of someone who is grieving, I’m asking: how is their particular grief process being supported, both within them and around them? How are they going with their ‘why’? Because meaningful pain is so much more doable than meaningless pain: if you know ‘why’ enough, you can deal with the ‘how’ so much better.
A major difficulty with perinatal loss and grief is that while the birth of a child can be one of life’s peaks in terms of social visibility, excitement and expectation, falling from that height can terrible – it’s such a painfully long way down.
We are perhaps also less guarded as a society than we were when infant and maternal mortality rates were higher. We are certainly more isolated and secular; I am aware of other cultures with spiritual customs around perinatal loss, perhaps developed to help their communities cope with the awfulness of a baby dying. For so many of us now, there’s not only a lack of ‘why’, there’s a shortage of ‘who’ as well. Grief is a deeply personal but also relational process.
Doing it alone is so much harder.
Mental Health in the context of Perinatal Loss and Grief
There’s a tricky balance to strike between not pathologising a natural if sometimes unspeakably painful process, and not missing mental illness we need to identify.
There are venn-diagram overlaps between grief, adjustment disorder, major depression and post traumatic stress disorder for example, and a careful systematic check including risk factors and risk assessment is often needed.
It can feel insensitive to bombard a grieving person with checklists of symptom clusters, so I have learned to let myself muddle through, apologising for the clunky DSM interrogation and feeling my way for that tricky balance.
I’ve not gone into too much detail about psychiatric assessment in the context of perinatal loss and grief here, as there’s a lot of detail and nuance beyond the scope of this presentation. If you’re worried about yourself or someone you care about or for, speak with your GP or you can find a psychiatrist at
https://www.yourhealthinmind.org/find-a-psychiatrist
Working with Bereaved Parents
I tend to muddle through at my best if my patient feels safe with me, which is most likely to happen if I’m not in a hurry. I find it takes 30 minutes or so for my nervous system to find someone else’s nervous system, to feel like we have connected, like I can best imagine what my patient is going through. It’s why I think people meet for coffee for more than half an hour, or meet to sort out a thorny work issue, for more than half an hour.
Comedies can be 22 minutes, but most drama needs more than half an hour. Of course that’s me talking as a therapist fortunate to get 50 minutes a session, but you’ve got to work with how long you get; also some people prefer shorter contact, it might be all they can tolerate at the time.
However long you get, prioritise their experience: Much though I love to share what I’ve learned about perinatal grief, I check in regularly that we are focusing on what my patient wants to focus on, and addressing the questions and concerns they have.
I think that perinatal grief is particularly complex, so I work organically, with who and what turns up, be it a mum, a dad, a non-binary parent, a couple, a parent-child dyad or a family. And I expect to feel there’s so much still unaddressed by the end of the session. In fact that is a good sign, because it means we connected enough to feel around the edges of the unaddressed, to know a bit about what we don’t know.
Professional Teamwork around Perinatal Loss and Grief
Working perinatally, but especially around loss, needs a good team to thrive. The most awful cases of trauma and loss in my career have taught me consistently that you need a team, and it has to be good, but together you can do a lot of good.
This area of loss and grief can feel imposing to approach, as if only people with a certain training or existing experience can help. Specialised training can definitely help, but having a clinical frame, a human heart and a gentle curiosity about grief can make you available enough to someone suffering a loss, a presence they can deeply value.
When considering the team you need, don’t forget the ripple effects for all involved around a loss like this. Get a sense of the family setup, who’s who, and who might need more help than they’re getting.
Dads and grief
I was trained in mother-baby psychiatry and took some time to work out that I needed to call myself a Fatherhood Clinician as I worked out how to reach dads in my perinatal practice. I wanted to be fair to both parents and their baby – where two parents have undertaken pregnancy together I say it’s 50-50, that a baby is born in Dad’s mind as much as in Mum’s, or in the non-birthing parent’s mind as much as in the birthing parent’s mind.
It follows then, that the psychological loss is 50-50 too.
I’m gender inclusive wherever possible, but it’s also important to be specific about men and grief. Boys have long been raised to be incurious about their inner lives, and sometimes to be utterly shut down internally.
But as we now know here in the age of trauma-informed practice, the body keeps the score. Of course we don’t know how much of his 50% a dad took up – even the body may not seem that affected.
To be fair, we should wonder – where’s his half of this?
It might well be a body thing – grieving fathers may present with unexplained physical symptoms, anger, overuse of alcohol or pain medication, overeating, overexercise, overwork or over-tiredness and may not have joined the dots to their loss, or may just not want to seek help.
I tend to find though, that once they feel safe enough, most blokes now, boys of the 80s, 90s and 2000s, can move me with their words for their feelings.
Too often the problem is not a dad’s ability to talk, it’s that nobody asked.
We’re getting better at asking, and the more we listen, the more we find out that dads’ emotional lives are as rich as anyone’s, and a key to healing around perinatal loss.
Finally, here are some links to people and organisations doing great work in this area.
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