Who Knew?

Six times a year, I find myself in a stuffy, overcrowded hospital room, speaking to young, enthusiastic student doctors about to be let loose on the obstetrics and gynaecology ward. I’m not a doctor. I manage a counselling service in Brighton for clients seeking help following pregnancy loss, whether through miscarriage, stillbirth or termination. We also see clients who are deciding whether to continue with a pregnancy, sometimes because abnormalities have been detected in the foetus, or simply because they’re unsure, for various reasons, whether they can bring a child into the world. We work with women, men and couples. It is a totally non-judgmental, unbiased, client-centred service. 

Most of our clients are referred from the hospital. The invitation to speak to the medical students during their induction programme came after I contacted the consultant in charge of the unit. Some of our clients had reported worrying interactions with medical staff. For instance, a client was attending the unit for her 18-week scan. Other than some very light spotting, there had been no cause for concern; the scan felt like a sensible check on the progress of a much-wanted pregnancy. The junior doctor’s opening words have stayed with my client ever since: ‘No tears if there’s no heartbeat.’ The next thing he told her was that her baby had died.

Clients will recall in minute and vivid detail the words and attitudes of the medical team attending them. I have, of course, heard stories of huge compassion and empathy shown by medical staff; I have also heard tales about the insensitive use of cold, medical terminology – a longed-for and lost child described as ‘evacuated products’.

I assess all clients coming into the service, to gauge their physical and mental health, and find out about their self-care and support systems. It’s an opportunity to acknowledge the client’s loss and trauma, consider possible hormonal effects and look at processes of bereavement. I am constantly struck by the way our culture of avoidance and scant ritual around loss and death fails to acknowledge and silences the intensity of hidden loss and pain in miscarriage, termination and infertility.

Carl Rogers’ model of person-centred counselling allows the counsellor to put humanity before professionalism. Over the years, I’ve consistently trusted these deeply relational conditions to bring healing and counteract a medical system that often has no time or resources for unguarded listening, compassion or simple kindness. By providing traumatised clients with a place of safety, we can help them find their voice. For those who struggle with words, we use music, artwork, fabric or objects such as stones to represent the loss or enable release of buried emotions. Having something to hold, touch, feel or hear can connect with inexpressible, stuck or overwhelming feelings of loss and act as a focus for the pain. Separating ourselves from our loss in this way can release healing comfort.

When a client struggles to tell their story, I may ask what is going on in their body – if they notice any feelings or sensations and can find a colour, shape or word to describe their feelings, giving opportunity for it to shift. Much of the work is about communicating pain, finding expression and trusting that healing will come from being heard, accepted and received wholeheartedly by another. As counsellors, we offer and model what the client can potentially offer themselves – a mindful attitude of self-love and self-forgiveness.

Natasha, slight in frame, crept into the counselling room for an assessment. She had wanted her partner to come, but he changed his mind that morning. After marrying and moving into their first home, she and Dave were delighted to find out they were expecting a child. ‘We announced our news to family and close friends after the 12-week scan and began to renovate our house.’ At the next scan, no heartbeat was found, and Natasha was told her baby had probably died two weeks earlier. ‘The hardest challenge was questions at work and facing my pregnant sister. They tried to say the right things, but it was awkward and painful or people simply avoided us. Dave just stopped talking about it altogether, and the hospital simply told me to try again. After a year I was pregnant again, but this one didn’t get past 11 weeks. By the time I was pregnant for the third time, the fear was so great in me about carrying a baby that we didn’t tell a soul. No one knew I was pregnant so no one knew when I lost yet another life.’

Mourning the loss of something so deeply loved and desired is profound and life-changing. It can also be an incredibly lonely journey – one that many women and men travel unbeknown to close family and friends. I often wonder why there is such silencing shame around miscarriage. By encouraging clients to share as much of their story and feelings around it as they are able, we honour their loss and offer reassurance that moving forward doesn’t mean leaving the memory of the lost one behind. An explanation of the concept of continuing bonds can help the client hold a healthy connection with their dead baby while moving into the future.

I am constantly struck by the way our culture of avoidance and scant ritual around loss and death fails to acknowledge and silences the intensity of hidden loss and pain in miscarriage, termination and infertility.

Working with couples

Men often provide a solid source of support and comfort to their partner while she endures a painful labour and delivers a child that never draws breath. These men very rarely have a space outside the relationship to process such strongly imprinted grief.

Ross followed his wife into the counselling room like her shadow. He made little eye contact and continued to look extremely uncomfortable throughout the assessment. His pain was evident, but he seemed unable to find the words to talk about it. When he finally began to talk, it was with his eyes fixed on his wife and, as her tears came, he shut down, immobilised. How do you carry another’s pain when your own loss is so deep and so unprocessed? It wasn’t just the early loss of twins; it was the years of IVF treatment that had dwindled their finances and emotional resources. The air in the room felt thick with despair.

It can be challenging for a therapist to hold two people simultaneously in connected pain and ensure both experiences are fully heard and understood with compassion and tenderness. For me, it is about offering a safe-enough relationship, to which they can return to process the loss. Some couples’ relationships are strengthened by the journey; they take turns to hear one another and bring comfort to each other in the room. Being part of this process can feel almost like an intrusion on intimate grieving as the couple tenderly recount the hours with their dead infant, bathing, clothing and kissing their perfect stillborn. Even though the journey is difficult, given a safe, non-judgmental space in which to find their way, these couples are able to recognise their needs and accompany each other out of the maze of grief.

There are clients who feel so damaged by their experience that they retreat from a world that has become a hostile environment peopled by babies, pregnant women and proud fathers with their children. Social media are full of announcements about new births; families and close friends awkwardly share news of other pregnancies. There are adverts for nappies everywhere; a favourite TV soap, once a source of distraction, starts a lost pregnancy storyline; cars warn ‘Baby on board’. The world feels unsafe, full of painful triggers and reminders.

I encourage couples to understand and vocalise their attachment needs. This can help them navigate the powerful emotional world of loss and strengthen emotional connection and safety.

When Susan and Victoria came to the counselling service, they had lost a baby girl at 20 weeks and a baby boy at 22 weeks. Becoming pregnant had been an expensive, laborious and complicated journey, accompanied by the anxiety that they would lose another pregnancy. Victoria was pregnant for a third time, and the tension they brought into the room was palpable. Every movement, or lack of movement, of the baby prompted alarm, quiet panic and the expense of private scans. They retreated to the safety of each other, but at times the intense emotions spilled over into arguments, and then there was nowhere to turn. Thwarted desire to create a family, for motherhood, is one of the most severe pains I have ever encountered as a therapist.

In this work, we don’t have the luxury of building a relationship over time – the slow exploration of details of the client’s life as they emerge. These clients have only just managed to make it to counselling; most have never encountered a therapist before; the counselling room is somewhere they never wanted to be. Many clients are already on maternity leave, milk coming into their breasts and no baby to feed, suspended in their grief in a chasm of time. Clients will often want to show photos of the baby they lost at birth. I still remember the first time I was asked if I wanted to see a photo, and my mixed feelings of curiosity and fear – fear about how the baby would look and that my expression might reveal revulsion or pity. It can feel surreal and desperately sad to be looking at the face of a dead baby. It can also feel sacred and a privilege. I have now seen many such pictures, and it’s not scary. It can be beautiful; they look like they’re asleep. It is wonderfully accepting, simply to look at and be with them with their child, who is so present in every session. When my own tears have come, I’ve let them fall.

I use the client’s words to describe their lost baby, whether they talk about a ‘bunch of cells’, a ‘foetus’ or a ‘baby’. This is especially important with clients who are unsure if they can continue with the pregnancy. Women and men who have experienced such significant loss deserve to be heard unconditionally, without judgment. Rogers’ core conditions have to be enough, although sometimes it is difficult not to want to offer more – to try to rescue, to reassure a woman who has miscarried five times that the baby she is carrying will be okay. It can be difficult to hold strong boundaries: asked to accompany a client to a scan or a post-mortem, or change a day off to offer a session after a funeral, it’s very hard to say no. I set strict time limits on home visits after a complicated loss. I know all too well how easy it is for a grief counsellor to experience secondary or vicarious traumatisation.

I use the client’s words to describe their lost baby, whether they talk about a ‘bunch of cells’, a ‘foetus’ or a ‘baby’. This is especially important with clients who are unsure if they can continue with the pregnancy.

Trauma and self-blame

Many women arrive traumatised. Recent research into early miscarriages reveals that 40% of women experience symptoms of post-traumatic stress disorder three months after the pregnancy loss. Prenatal classes have only prepared these parents for the practicalities of pregnancy, birth and early childcare. No one ever warned them about the trauma and physical and emotional pain that a miscarriage can bring, or about the possible ending of a pregnancy or the death of a perfectly formed child, sometimes with no explanation for the death. Those seeking to comfort and encourage them rarely understand that they have lost not only a child but also their dreams. These clients can end up terribly isolated and misunderstood in their mourning, prey to unwanted but fierce jealousies when close friends conceive.

Becoming pregnant again after a loss can be a very different experience. Women can become vulnerable to anxieties and obsessive-compulsive behaviours as they question their body’s ability to carry another child fullterm. Their carefree trust in the safety of the womb and instinctive nurturing has evaporated following the violent, physical and visual shock of the previous pregnancy loss.

Alice had miscarried four times and, while preparing to embark on IVF, became pregnant again. Her anxieties had set in after the second loss. ‘I realised I couldn’t trust my body any more – the signs, the symptoms; even with the hospital staff reassuring me, I didn’t trust anyone.’ Alice had concluded that the last loss was due to attending a fireworks display: ‘The explosions were so loud and we were so close; we never should have gone. I miscarried the next day.’

Anxiety accompanies each stage of a subsequent pregnancy. Women can blame themselves entirely for previous losses, berating themselves harshly for failing in the task of being a protective, nurturing mother. Consistent unconditional positive regard from the therapist must be allowed to do its work.

The night before Sally, at 39 years old, was due to be induced, her baby stopped moving. She called the hospital, and staff reassured her all would be well and that some slowing of activity was normal. The next day, at the scan, Sally was told the baby’s heartbeat had stopped. Her partner was with her when she gave birth to their stillborn child, but the relationship dissolved a few months later. We worked together in therapy to reconcile her guilt over ‘not doing more when he stopped moving’, revisiting the ‘what ifs’ and attempting to bring loving kindness into the tortured thoughts with which she punished herself.

Post-termination

Post-abortion work can be more complex. Here the grief for a lost pregnancy is strong and often accompanied by unrelenting self-punishment and a lack of forgiveness. Once again, hearing stories without judgment in a gentle, accepting space can lead to healing.

Georgia thought she was going through the menopause when, at 43, she became pregnant. She had two teenage children. Her husband, Simon, was strongly opposed to bringing another child into the world, and they argued endlessly. Georgia was unsure herself, recalling the sleepless nights and exhaustion of toddlers. Simon went with her to the clinic, held her hand before the procedure, and even cried when Georgia said, minutes before she went in: ‘I don’t know if I want to do this.’ She didn’t want to hold his hand afterwards. When she came to counselling, she wasn’t sure if she loved him any more. She grieved alone. She couldn’t tell her best friend, who was on her third treatment of IVF. She couldn’t tell her family, who were strictly religious. She feared they would judge her. She cried herself to sleep at night and longed to be pregnant again, to turn back the clock, to be given another chance.

Men can also suffer in silence and alone with decisions to terminate a pregnancy. Couples ending a pregnancy after a foetus is discovered to have abnormalities are left with the sense that they had no choice but to make the choice, and painful, unanswered questions. In our work with these clients, our focus is often on lifting the deep sense of shame by empathising with the loss and reasons for the decision to terminate. This can give clients space to explore why they have created a protective shield by shutting down their feelings about the loss, and, through this, to acknowledge their pain and grieve well. It is now widely accepted that expressing grief and getting it to work for us is an important part of the grieving process.

Dora was 81 and had suffered from depression all her life. It began soon after she had an abortion at age 17, and it had never fully lifted. She went on to marry and have a family with a loving husband, but she never forgot the birthdays and age of her first, lost child. It felt a privilege to witness this wonderful lady’s tears of pain and, perhaps, relief, as she poured out her story for the first time. With this came an awareness of how much of her life had been stolen by this one secret.

Stories such as Dora’s reinforce the importance of our work. We are here to provide a space where bereaved parents and couples feel safe enough to feel their loss, talk about their grief, forgive themselves and each other, and, we hope, look to a future where they can remember their lost baby with love and sadness, and not with such overwhelming pain.

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