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Journal of Family Social Work
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Stillbirth and the Couple: A Gender-Based Exploration
Joanne Cacciatore a; John DeFrain b; Kara L. C. Jones c; Hawk Jones c
a
College of Human Services, Arizona State University, b Department of Child, Youth and Family Studies,
University of Nebraska, c Kota Press,
Online Publication Date: 24 November 2008

To cite this Article Cacciatore, Joanne, DeFrain, John, Jones, Kara L. C. and Jones, Hawk(2008)'Stillbirth and the Couple: A Gender-

Based Exploration',Journal of Family Social Work,11:4,351 — 372
To link to this Article: DOI: 10.1080/10522150802451667
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Stillbirth and the Couple: A
Gender-Based Exploration
Joanne Cacciatore
John DeFrain
Kara L. C. Jones
Hawk Jones

ABSTRACT. The stillbirth of a baby occurs in about 1 in 110 families
yearly. Yet, little is understood about the ways in which grieving
mothers and fathers experience the baby’s death. This study is intended
to explore the ways in which bereaved parents perceive and cope with
the death of their baby and how the baby’s death affects them both
individually and as a couple. Respondents answered open-ended questions about their experiences. Results suggest that mothers and fathers
grieve individually and collectively, struggling to find meaning in their
losses. Responses to a baby’s death may depend, in part, on the parent’s gender, as well as on the individual’s locus of control, couple
and family cohesion, the degree of attachment to the baby, and social
support. The death of a baby may create conflict in a marital dyad,
yet many couples also experience a greater sense of closeness. A
therapeutic relationship that is nonhierarchical and egalitarian,
focusing on ‘‘keeping the therapist close to the experience of each

Joanne Cacciatore is Assistant Professor, College of Human Services,
Arizona State University.
John DeFrain is Professor, Department of Child, Youth and Family
Studies, University of Nebraska.
Kara L. C. Jones and Hawk Jones are grief facilitators for Kota Press.
Address correspondence to Joanne Cacciatore, Arizona State University,
College of Human Services, 4701 W. Thunderbird, Glendale, AZ 85306.
E-mail: joanne.cacciatore@asu.edu
Journal of Family Social Work, Vol. 11(4) 2008
# 2008 by The Haworth Press. All rights reserved.
doi: 10.1080/10522150802451667

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partner’’ (Vatcher & Bogo, 2001, p. 76) may offer a place where the
marital relationship can flourish after such a tragic experience.

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KEYWORDS. Death of a child, gender, marital relationship, stillbirth

The death of a child precipitates a cascade of existential emotions for
families and thus multiple layers of loss within the family system.
Approximately 30,000 babies are stillborn in the United States each
year. Calculating from an assumption that each baby is survived by
both parents, two to four grandparents, and one sibling, about
150,000 family members are directly affected by stillbirth during the
course of one year; the effects of those losses are often cumulative
and intergenerational (Peterson, 1994). ‘‘At the individual level, parents
and siblings are left to cope with their own emotional angst’’ as each
member of the family struggles for equilibrium, leaving little energy
to devote to the emotional nurturance of others (Fletcher, 2002, p. 59).

REVIEW OF LITERATURE
A review of the literature reveals very little investigation into the
effects of a stillbirth on the couple relationship. The American
Psychological Association’s PsycINFO, with more than 2,000,000
sources, has very few sources linking infant death and marital=couple
couple dynamics in even a most cursory fashion. Similarly, Family
and Society Studies Worldwide database, a joint project of the
National Information Services Corporation and the National Council on Family Relations, lists more than 600,000 sources; again, little
research looks specifically at stillbirth and couples. Additionally, the
effects of a baby’s death on fathers have been ‘‘largely overlooked in
academic research’’ (McCreight, 2004, p. 326).
Fletcher (2002) found complex challenges facing families after a
child’s death. This is due to ‘‘(a) the unnaturalness of the death, (b)
parents’ feelings of failure as protectors, (c) need for reorganization
of the family, (d) the need to adjust roles, and (e) communication
issues’’ (p. 67). During the acute crisis, the family faces difficult decisions about ritualizing the baby, autopsies, and final disposition plans.
Later, they confront the unfamiliar territory of grief, while often

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caring for surviving children, restructuring roles, and adjusting back
to so-called normal life. Intimacy and sexual relations also decline
for at least a period after the death of a baby (Lang, Goulet, & Amsel,
2001). Both bereaved mothers and fathers demonstrate significantly
higher levels of depression than a control group, with these effects
being longer lasting in mothers at a point up to 30 months after the
death (Boyle, Vance, Najman, & Thearle, 1996; Vance & Najman,
1995). Stressors present many challenges for grieving couples
(DeFrain, Martens, Stork, & Stork, 1986).
Research indicates definitive differences between maternal and
paternal grieving styles, roles, and the emotional expressions of loss
directed toward others. Versalle and McDowell (2005) found that
those who were ‘‘feminine sex-typed . . . gave more sympathy’’ to
those grieving loss than did the masculine sex-typed’’ (p. 53). Mothers
typically experienced higher levels of and more enduring depression,
yearning, anxiety, guilt, shame, and trauma symptomatology (Barr,
2004; Samuellson, Radestad, & Segesten, 2001; Lang et al., 2001;
Varney Sidmore, 2000; Vance & Najman, 1995; Bohannon, 1990).
Bohannon (1990) found that bereaved fathers experience more anger
while bereaved mothers struggle more with guilt.
The mere physiological state of pregnancy may contribute to such
differences because the baby and mother share the same body, and
she often recognizes the baby as an extension of herself:
Perhaps the mother’s attachment to her child is the strongest
bond in the human. This relationship has two unique characteristics: Before birth, the infant gestates within the mother’s body
. . . and after birth, she ensures his survival while he is utterly
dependent on her. (Klaus & Kennel, 1976, p. 1)
The process of giving birth may also explain some of the differences between mothers and fathers. A number of women suffer from
post-traumatic stress disorder even after a normal pregnancy and live
birth (Brewin, Andrews, & Valentine, 2000; Astbury, Brown, Lumley, &
Small, 1994; Rowe-Murray & Fisher, 2001; Beck, 2004; Spies
Sorenson, 2003). A stillbirth, therefore, would likely intensify any
deleterious effects. Some women reported a sense of unreality, depersonalization, and being treated inhumanely during the diagnosis of
the baby’s death, contributing to negative psychological outcomes
(Trulsson & Radestad, 2004). Goldbach, Dunn, Toedter, and Lasker

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(1991) found both mothers and fathers experienced high levels of
despair, active grief, and difficulty coping. Yet, the mothers in this
study experienced significantly higher levels of those measures during
the first six to eight weeks following the baby’s death.
Socioculturally, fathers face many challenges after a stillbirth, as
men ‘‘have simply been disenfranchised from mourning practice’’
(Kanter, 2002, p. 1). In addition, ‘‘a father’s attachment to the
unborn child varies’’ (O’Neill, 1998, p. 33; McCreight, 2004).
‘‘Fathers are in a difficult position for a number of reasons: they
are expected to take care of the wife emotionally; they are expected
to continue to work and pay the bills; and they need to grieve for
their lost baby themselves’’ (DeFrain, Martens, Stork, & Stork,
1990, p. 97). While the mother’s loss may be more physical and less
abstract, ‘‘bereaved fathers struggle with their multiple roles feeling
powerless to support and protect their loved ones’’ (Armstrong,
2002, p. 344 ; Samuelsson et al., 2001). They express a desire to be
‘‘strong for their partner’’ and perceive their role to be as a supporter
(McCreight, 2004, p. 345). Barr (2004) suggested that, while women
may benefit from ‘‘the prosocial communal nature of functional
guilt’’ by seeking support in the aftermath of the loss, fathers’ guilt
proneness may be related to their ‘‘apparent inability to alleviate their
partner’s distress’’ (Barr, 2004, p. 506). One father said, ‘‘I had to be
strong . . . I was told not to show any emotion because it would upset
her. It’s funny: I was hurting, too, but I was not expected to show it’’
(as cited in Peppers & Knapp, 1980, p. 53). DeFrain et al. (1986)
found that 28% of mothers and 17% of fathers ‘‘seriously considered
suicide’’ after the death of their babies to stillbirth, and another 62%
of the mothers and 50% of the fathers reported that they wanted to
‘‘go to sleep and wake up only after the pain was gone’’ (pp. 96–98).
Differences in communication style account for some of the dissimilarities in the expression of grief and this may be a source of conflict
(Layne, 2003). Kamm and Vandenberg (2001) found significant
disparity between genders about grief communication, with mothers
placing more value on open communication than their partners.
Martin and Doka (2000) isolated two schemas: intuitive—the more
feminine style that focuses on seeking social support, narration,
and open expression; and instrumental—the more masculine style
that involves cognitive processes, refocusing of grief on tasks and
activities, and is often more solitary, structured, and bounded
(Zinner, 2000). Mothers tended to have a greater need to talk about

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the loss, reviewing details repeatedly. Fathers sometimes blamed their
partners for ‘‘clinging to grief,’’ while mothers accused their partners
of ‘‘seeking refuge in work,’’ sometimes causing alienation in couple
relationships (Laasko & Paunonen-Ilmonen, 2002, p. 180). Layne
(2003) noted that ‘‘most men are socialized not to discuss their feelings and to avoid emotionally charged situations’’ (p. 131). However,
a more feminine style of grieving may be the primary mode of
expression for some fathers, as the more masculine style may be for
some women. These differences can easily be overemphasized and
become stereotypes rather than representations of reality.
In one study, mental distress and low social support, including the
lack of support provided by family and friends, were negatively associated with marital satisfaction in both the loss and the control group,
and ‘‘those who perceive that they were well supported reported
having a more positive relationship with their partners’’ (MekoshRosenbaum & Lasker, 1995, p. 140). Hazzard, Weston, and Gutierrez
(1992) found that parents’ grief was mitigated by a supportive
environment. ‘‘The key elements in facilitating’’ healing after stillbirth are the mother’s acknowledgement of both the life and the
death of the baby as well as an ‘‘ongoing, informed, and sympathetic
social support network’’ (Ney, 2006, p. 3). The lack of social support,
including that stemming from marital dissatisfaction, intensified grief
responses (LaRoche et al., 1984; Clyman, Green, Rowe, Mikkelsen,
& Ataide, 1980). In a study of 82 mothers and 47 fathers experiencing
perinatal death, Zeanah et al. (1995) found that the quality of a marital relationship and social support were more important predictors of
adaptation than demographics such as age, education, or socioeconomic status. Similarly, another study found that the most important
predictor of maternal anxiety and depression after stillbirth was the
level of support from her partner and family (Cacciatore, Schnelby, &
Froen, 2008). DeFrain (1991) noted that, in families experiencing
the death of a baby, grieving parents ‘‘most often turned to’’ spouses
first, then to other family members and friends (p. 227).
While relationship stress may intensify after the death of a baby, the
divorce rate does not increase. Mekosh-Rosenbaum and Lasker (1995)
found that 5.77% of marriages ended in divorce after the death of a
baby (loss group) versus 3.67% after a live birth (control group).
DeFrain et al. (1986) found similar results with 1.5% of mothers and
3% of fathers citing their child’s death as the reason for their divorce.
Bohannon (1990) found that the conflict between mothers and fathers

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often resolved with the passage of time and that most parents reported
greater marital satisfaction after the death of their child. Despite the
recognized differences in mourning, most parents do not divorce after
a child’s death. Instead, ‘‘the crisis can [draw] many couples closer’’
(DeFrain et al., 1990, p. 91). This study will explore the experiences
of bereaved parents as individuals and as a couple in the wake of stillbirth and provide a therapeutic framework within which a clinician can
approach sessions for marital and family therapy.

RESEARCH METHODS
This was a retrospective analysis of anonymous data collected by
two nonprofit organizations that provide care and support to grieving families after child death. One organization, an international
group offering aid to families experiencing the death of a child, holds
an annual international conference for bereaved families and professionals. Another is a smaller, arts-based organization that mentors
grieving families.

Participants
Bereaved couples, invited to participate in this study in person and
online, were recruited through two Internet-based parental support
organizations and at a parental grief conference. Sixteen cohabitating
or married heterosexual couples responded to either all or some of the
exploratory questions.

Data Collection
Quotations from 74 bereaved family members provided in response
to the following questions were compiled. The responses of bereaved
couples were analyzed, and questions were targeted to parents who
had experienced stillbirth. Locations of data collection included a discussion group with 55 participants at a bereavement conference and
an online discussion group with 19 participants. The 23 open-ended
questions posed by the nonprofit organizations were informed by
empirical research led by Dr. John DeFrain on infant death over
the past 30 years across nine distinct studies and involving more than
1,000 participants and findings from an earlier study involving 304

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bereaved parents. Some families experienced the very recent death of
their child, while others’ experiences occurred several years earlier.
They were encouraged to tell their stories using their most comfortable format and language. A questionnaire was provided in person
or by e-mail. Narrative responses were collected over the course of
three months, submitted in writing by participants to the research
team by e-mail or in person.

Analysis
Our approach to the theoretical understanding of these data was a
priori (Ryan & Bernard, 2003; Strauss, 1987), grounded in earlier studies of stillbirth within family systems (DeFrain et al., 1986; 1990)
and on the couple and family strengths perspective (DeFrain & Asay,
2007; DeFrain and the University of Nebraska Extension Writing
Team, 2007; Sittner, DeFrain, & Brage, 2007; Sittner, Brage, &
DeFrain, 2007). The team reviewed each transcript carefully, extracting themes and examining similarities and differences using the constant comparison method (Glaser & Strauss, 1967). This comparative
method generates common themes, illuminates differences in these
data, and helps researchers stay ‘‘focused on the data rather than
on theoretical flights of fancy’’ (Ryan & Bernard, 2003, p. 91).
During this process, themes emerged that were common to many
respondents. There were also significant differences in the experiences
of parents. Women conveyed many of the responses about the couple
relationship. Fathers’ responses tended to be briefer and they
responded to fewer questions. While every couple responded differently, it was clear that the death of a child affected almost every
aspect of partnership.

FINDINGS
Theme 1: Cohesion
Consistent with previous research, couple=family cohesion,
including emotional bonding, mutual respect for the other’s grieving style, and sexual intimacy, appeared to be affected by the death
of a baby. For many, this tragedy seemed to bring couples closer,
increasing cohesion, despite the high degree of relational stress.
While the effects of the baby’s death relative to the quality of

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the relationship varied for each couple, those effects were, nonetheless, profound for each of them. Mothers and fathers experienced
an increase in emotional bonding and intimacy as well as interdependency, which are essential for cohesion (Olsen, Russell, &
Sprengkle, 1984), often relying primarily upon one another for support. They discussed the ways in which their relationships changed
after the death of the baby:
The death of our daughter brought us closer together . . . [Her]
death was overwhelming for both of us, but to have [my
husband] there with me for all those hours talking with me
or just watching me in silence and holding me made all the
difference . . . Our relationship as a couple has changed in that
there’s an unspoken bond, as if I know him on a different level
than I did before.
It has strengthened [our partnership]. Our relationship
before the loss of our daughter was strong, but our relationship
seems stronger now that it has weathered the ‘‘storm’’.
It has made me less critical and more affectionate to my husband. I used to care about the little messes around the house,
and what we were spending on ‘‘this or that’’, now I know that
none of those things are as important as I once thought they
were. We are stronger—more patient with each other
I think I am still dealing with how to incorporate the loss
into my life on a personal level. Whereas, my husband seems less
affected. There is a degree of disconnect between us. Emotionally we are working to find each other again.
Initially, [my] husband ‘‘shielded’’ me from everything and
everyone. After a very short time he began refusing to acknowledge baby had existed and this put a great strain on us both. We
eventually divorced.
Families struggled to balance the degree of cohesion, ranging
from strengthening and recommitment in the partnership to conflict
over differing styles of grieving and communication. From a
strengths-based perspective, the death of a baby appeared to incite
what Rosenblatt & Budd (1975) refer to as the consummate balance
between ‘‘togetherness’’ and ‘‘apartness’’ for many grieving couples.
Another important piece of cohesion included mutual respect
for the uniqueness of individual grieving styles. Those who felt their

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relationships grew stronger identified their strengths in grieving
together as a couple:
We recognize and respect that we grieve VERY differently. We
have not grieved together much at all.
Listening, no matter how many times I wanted to rehash the
events of the night that my daughter was stillborn, my husband
was there with a gentle, calm, and understanding spirit.
We allow each other to grieve in our own way.
We support each other more, and we each have given each
other a ‘‘longer leash’’ to do more.
Most mothers and fathers felt their strength came from giving each
other permission to mourn in the way most comfortable for them;
others identified communication, being able to talk together at any
time, as a source of strength in the relationship. Still others described
their strength in shared spiritual values.
Sexual intimacy changed for many couples after a baby’s death.
For an important minority, the death of their baby negatively affected cohesion. These struggling couples found this aspect of the
relationship collapsing, along with other types of communication:
[There was a] major decrease [of sexual drive] on my end. Didn’t
want to have sex unless we were going to [try to conceive]
again . . . [My husband] was very understanding.
[His return to work] seemed better for our day-to-day
relationship, but over time he slowly became less loving . . .
Within a few days [of returning to work] . . . he refused to discuss
our child, saying it was in the past . . . He was less loving and just
wanted sex instead of an act of love. I felt less attractive to him
and withdrew as sex became more violent . . . I later found out he
was having affairs.

Theme 2: Sense of Control: Internal and External Loci
Feeling powerless and the lack of control were common to
many parents in this cohort. In particular, faith in a higher power,
role ambiguity and identity, in addition to challenges related to
social relationships such as normalcy and social interaction are

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relevant to locus of control, adaptation, and coping. Bereaved
mothers and fathers seemed to struggle with faith. In exploring
spirituality, both bereaved mothers and fathers described some
degree of rethinking and reorganization of their religious=spiritual
ritual beliefs. For some, the result of their journey was that faith
became stronger. For others, it did not. This may be problematic
for some parents as they question the existence of control in their
lives:
[Our child’s death] has made it harder for me to pray—I feel like
God can’t or won’t take care of us now.
I feel like things are much less certain and controllable now.
I couldn’t save my baby.
At first I hated god—I had very little faith to hang on to
anyway and what was there was shattered. The minister from
our local church (where our son was buried) came to our house,
and my dad swears he saw him sprinkle holy water on himself
after he left. I have unconventional beliefs to begin with—but
I believe that I will see my sweet one again. I believe that in
his previous time here on earth that when he passed over his
mommy didn’t cry for him. And he needed for that to happen
before he could go on to where he was meant to be. I believe that
was why I was chosen, even though it was for such a short time,
to be his mommy—to love him and to cry for him for the rest of
my life and to help him go to that next level. I am so honored
that he chose me, and I hope that he waits for me.
My husband is no longer an atheist . . . and believes that
there is something after you pass.
I feel my church family is more than just a group of people.
My husband has become less spiritual and focuses on his career.
Their role as parents may be conflicted and some expressed a distinct identity crisis; others experienced solidarity in their roles as
parents. Couples were asked, if they had no other living children,
did they still think of themselves as parents? If they did have other
living children, how did their roles as parents change in the family?
Unknowingly we seemed to have changed our roles a little bit,
my husband seems to help out more with the day-to-day chores
at home (spending time with the other kids).

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I have gained so much patience that I never knew I could
ever be this way. . .We both still talk about our daughter and
go to her grave to have birthday parties . . . allow the children
to let go of balloons for holidays at church. . . .
We have two other living children—we have to carry on for
them. They deserve as normal a life as possible. . .our [living children] are why we had to try hard to keep ourselves together. We
do take our [living children] to the cemetery to care for the flowers, and we celebrate our [deceased] son’s birthday. . ..
Returning to normalcy may be different for mothers and fathers, and
the struggle for equilibrium may affect the quality of interpersonal
relationships. We asked couples to explore how it felt as they each
moved back into the world at large in their social lives and their
careers after the death of their child. Partners had very different
experiences, some feeling more in control than others. Still, such
experiences have profound effects on their relationships:
I didn’t go out socially for six [months]. My husband went to
one get-together three [months] after our son’s death and came
home within half an hour. I still cannot be around our friends’
daughter who was born on our son’s due date.
[My] husband went back to work quickly—after about a week
and a half. I had freedom to ease back into work at my own pace—
started back after a month and still not back to full schedule. After
returning to work my husband was unable to devote much
emotional energy to grieving, so I have largely grieved without him.
[My] husband returned to work . . . and seemed happy to do
so . . . and I was left on my own as his job took him out of town a
lot . . . We have since divorced . . . He has moved on with his
career and has separated himself from his entire family . . . I
work in the community and . . . feared returning to work and
being overwhelmed.

Theme 3: Attachment
Recent studies suggest some disparity between paternal and
maternal antenatal attachment (Righetti, Dell’Avanzo, Grigio, &
Nicolini, 2005; O’Neill, 1998; McCreight, 2004). Some of those

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differences are explained by biological factors such as fetal movement
and childbirth (Muller, 1993), as well as the more intimate nature of
the relationship between the mother and unborn baby (Mercer,
Ferketich, May, DeJoseph, & Sollid, 1988). Nevertheless, bereaved
mothers often wished their partners would be more openly expressive
with their grief, while fathers tended to be more hope focused and
future oriented. We asked the bereaved parents if there was any
way in which they would change the way they or their partner
responded to the death of their child. Intonations of the discrepancy
between mothers and fathers in their expressions and perhaps feelings
of grief following stillbirth emerged:
I wish my husband would have made a more permanent place
for our child in our family. For example, counting him in the
[number] of children we have.
I wish that he would mention her name more, initiate the
anniversary date activities, and tell me more about his feelings
surrounding that night=day and how he feels now.
The only thing I would change would be: [H]e only cried for
about five minutes then was the ‘‘strong one’’ after that.
I wish that [my wife] had not lost her sense of hope or
optimism.

Theme 4: Social Support
Social support was important for both mothers and fathers,
though the type of support needed and from whom the support came,
differed. Couples were asked to comment on grief support they may
have found individually and as a couple and if their support system
proved helpful to their relationship:
We have the support of a good friend . . . We have had pastoral
care, though I have taken much more advantage of it. I have
reached out to other mothers who’ve endured a loss through
the Internet and my social circle. My church and MOPS
[Mothers of Preschoolers] group has provided a lot of emotional
and practical support (mainly in bringing meals).
My family and some of our friends [provide support]. My
wife lost some friends who just couldn’t or wouldn’t ‘‘get it.’’

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Our last question for individuals focused on how their outlook on life
might have changed and any other thoughts that they thought might
be important for others to know about how the death of a child
affects the lives of families. These often reflect a deeper appreciation
for their children and for life in general:
I am much more likely to do things like go to the park, etc.
[I] take pictures of the kids more often because you never know
when they’ll be taken from you.
I am so much more aware of other people’s pain. I cannot
stand to watch the news and hear what other people do to their
children. I have a very low tolerance for stupid people and bad
parents. I [do] have a deep-seated fear of something happening
to one of our [living children] . . . [but] try harder not to sweat
the small stuff . . . we try to just really appreciate each other
more . . . appreciate life more.
Sometimes the little things don’t really matter.

DISCUSSION
Couples experiencing a stillbirth incur both risk and great opportunity to their relationship. Some risks are inherent when a couple’s
grieving style differs, and establishing boundaries around the very
personal process of grieving may create conflict. Spiritual struggles
and sexual intimacy, for some, may also create interpersonal conflicts. Yet, there are great opportunities for strengthening the marital
dyad. For example, couples in this study developed a degree of tolerance and respect for the style of the other, increasing their sense of
cohesion. They also shared many similar experiences such as the
desire to achieve familial equilibrium and their struggle around role
identity in the aftermath of loss.
Rando (1985) identified ‘‘unique factors of parental bereavement’’
as unnatural, ‘‘a death out of turn’’ that can result in survivor guilt;
social reactions that include emotional and social abandonment and
stigma; and ‘‘loss of primary support’’ as a result of stress on the
marital dyad (p. 21). Both bereaved mothers and fathers expressed
concern about the marital relationship and experienced many stressors within the family system following the sudden death of a baby.

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The word normal has an entirely new meaning as ‘‘the individual, the
marriage and the family are sorely tested by the death, and all is
permanently changed’’ (DeFrain, 1986, p. 171). The couple struggles
to create a new normal for their life.
The will to return to some degree of normalcy was present in all the
themes. For some, normalcy meant restructuring important aspects
of life, including relationships (both within the marital system and
beyond), role identify, and faith. The themes also demonstrated that
the experiences of bereaved families are both similar and different.
Many couples reported a feeling of renewed closeness, while a few
others struggled to connect emotionally with their partner. This
may have something to do with the second theme, the uniqueness
of grieving styles. Both mothers and fathers acknowledged the importance of allowing one another to grieve in their own way. While
mothers tended to want their partners to be more emotionally
expressive, fathers wanted to imbue hope for the future. Fathers
tended to return to work sooner and with fewer challenges than did
the mothers. They also sought support from within their families
more often, while mothers tended to seek support outside the family
circle. Many mothers and fathers grappled with faith, an often shared
struggle.
The process of grief is complex and evolving and, of course, there
are multiple dimensions to every individual. Thus, there will be
many ways of processing, understanding, and integrating the experience of child death within the family system. Intrapersonal histories,
such as preexisting mental illnesses or depressive disorders, individual and couple coping styles (Carver, Scheier, & Weintraub, 1989),
and individual resiliency can also affect the reactions of bereaved
mothers and fathers. The manner in which a person views and
responds to death will depend on the individual’s locus of control,
family cohesion, personal resiliency and strengths, degree of attachment to the baby, and culture. Social factors such as gender roles
(Cacciatore, 2007b) and the degree of perceived and actual social
support also affect individual grief.
After reviewing all the responses, it is clear that every person and
every couple experiences grief in a different way. While some mothers
and fathers may find similarities in grieving styles, the expression of
that grief may also vary, and the effects are profound and unique
from person to person. Ultimately, many expressed that the death
of their baby strengthened their relationship.

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Implications for Practice
The stillbirth of a baby can provoke stress and sometimes conflict
within the marital relationship, and this may affect their marital
satisfaction. Grieving mothers and fathers tend to look toward one
another for comfort first after the death of a baby (Cacciatore,
2007a; DeFrain, 1991). While mothers tend to experience longer lasting despair and grief after stillbirth, fathers also demonstrate high
levels of angst (Schwab, 2001; Goldbach et al., 1991; DeFrain et al.,
1990). Some bereaved parents, mothers in particular, will also seek
support from their external support systems. Such support may come
from community support groups, friends, coworkers, and marital and
family therapists. Working with families after a baby’s death can be
one of the most challenging experiences for a family therapist. For
many caregivers, there is a ‘‘struggle to balance the intense emotional
feelings’’ when a child dies (Kaplan, 2000, p. 87). One place to start
building the relationship may be with the four themes uncovered in
the narratives: cohesion, control, attachment, and support. Marital
and family therapists may consider including an exploration of these
factors while counseling couples after the death of a baby.
While the impact of family therapy ‘‘has been severely limited by
the strikingly low number of couples who seek help,’’ women, overall,
are more active in both identifying marital distress and seeking
therapy (Doss, Atkins, & Christensen, 2003, p. 165). Thus, therapists
may need to ‘‘make a special effort’’ to allow fathers a safe place to
express grief in a nonjudgmental milieu (DeFrain, 1991, p. 229). A
therapeutic relationship using feminist-focused therapy to explore
the above four themes is more nonhierarchical and egalitarian, focusing on ‘‘keeping the therapist close to the experience of each partner’’
(Vatcher & Bogo, 2001, p. 76). This model also ‘‘provides a language
and approach for framing and intervening in men’s systemic patterns
of withdrawal and distancing’’ if and when it occurs in the therapeutic relationship (p. 81). This integrative approach respects the
style continuum based on the individual and is also sensitive to gender differences rooted in the socialization of role identity. Under this
model, neither fathers nor mothers in the therapeutic relationship
would be coerced into expressing their emotions. Rather, if their
coping style is more suppressive, the therapist would respect these
differences and work within the context of their strengths. This may
be done by utilizing task-focused interventions and more action

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oriented and less expressive techniques. If their locus of control is
external, they may help the mourner regain some control using therapeutic techniques. Therapists should consider these themes—cohesion,
control, attachment, and social support—when counseling couples.
Bordin (1979) suggests three key themes in the formation of the
therapeutic relationship: (a) an agreement on the objectives of therapy,
(b) an understanding of the means to achieve those objectives, and
(c) the development of the interpersonal relationship between the therapist and the clients. Under this model, the therapist would first meet
with the grieving couple, allow them time to tell their story, listen
intently, express empathy, and build trust and rapport with the couple
(Cacciatore, 2007b). Some therapists use family photos, when appropriate, as a way to ‘‘elicit past experiences or bring the members of a family
into touch with feelings’’ (Kaslow & Friedman, 1977, p. 19). Godel
(2007) suggests that ‘‘for the parents of stillborn babies, photographs
are precious material’’ (p. 262). Gently encouraging the parents to share
photographs of the baby who died may be extremely useful in family
therapy. Kaslow and Friedman (1977) suggest that this technique provides a framework of ‘‘factual, historical significance’’ (p. 22) as well as
facilitating interaction and an awareness of the other person. These are
means by which grieving parents can recognize the stillborn
baby, ‘‘repair the disrupted biography of the family, and incorporate
the baby’’ into their new lives within the context of the therapeutic
alliance (Godel, 2007, p. 263). This process of interpersonal bonding
may take several sessions, allowing plenty of time for both the mother
and father to tell their own story of their child’s death and explore
togetherness and apartness as it relates to the mourning processes.
Once the interpersonal relationship is well established, the therapist
may want to discuss the objectives of the alliance and agree on individual and couple goals for therapy. They can also co-create a plan for
achieving those goals; a set of tasks, practical or psychological, to help
them from one session to the next. One tool, in addition to the discussion questions posited in the appendix, is the Grief Experience
Inventory (GEI). This standardized scale provides objective measures
of grief using 135 subjective questions. Schwab (2001) found that using
the GEI may facilitate respectful and necessary discussion between
bereaved parents, enhancing understanding of each other’s pain:
A father stated that after having completed the inventory, he
looked at his wife’s responses and realized how much more

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difficulty she was having . . . he had not been able to appreciate the
depth of her grief until he saw her GEI responses. ‘‘She marked
so many items true. It made me cry,’’ said the father. ‘‘Now I
am trying to be more understanding.’’ (Schwab, 2001, p. 112)
An early axiom of psychotherapy is that ‘‘all behavior is carried on in
terms of some system’’ and that ‘‘roles are partial social systems’’
(Kargman, 1957, p. 264). The death of a child is a loss that is ‘‘felt
deeply by all members of the family’’ (DeFrain, 1991, p. 229). Thus,
it is also imperative that the therapist recognize the role of the social
system, including peripheral family and friends and the interaction
between them and the grieving couple. Using a systems approach
offers the therapist a ‘‘detailed, explicit system of related categories,’’
a tool through which the client’s worldview is more readily understood (Kargman, 1957, p. 269). The death of a child affects everything from the definition of parenthood to parenting styles with
living children, from the sense of self as sexual beings to the view
of what it means to have a career. In the final comments of the survey, one parent offered advice that could be applied in the lives of
many of on this journey: ‘‘No expectation . . . is key. Grief changes
from minute to minute, month to month and year to year. You just
have to let it take you where it will.’’

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APPENDIX 1

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Qualitative discussion questions for MFTs:
1. What are the similarities and differences in regard to how you
explain the death of your child to yourselves, individually, and
as a couple?
2. Did caregivers give support to both of you? In what ways? Did
they treat the parent who gave physical birth differently than
the supporting parent? If so, how?
3. When your child first died, how did you react individually? How
did you interact as a couple? What are the similarities and differences in how each of you grieves?
4. How did your child’s death affect your outlook on spirituality—
individually and as a couple?
5. How has your outlook on life changed?
6. Are there similarities and differences in how each of you looks to
the future now?
7. How do you, individually and as a couple, try to carry on in life
in spite of your child’s death? How do you deal with differences
(if there are any) in how you have endured this loss?
8. As individuals, we all (hopefully) find support after the death of a
child. What are the supports you found? Did your individual supports also support you as a couple? If not, what additional supports did you have to find as a couple?
9. Are there similarities and differences in the roles each of you play
in life now and how they have changed since the death?
10. How do you continue to find ways to love each other in spite of
the loss?
11. Did your intimate relationship change after the death of your
child? If so, how? Did your feelings of sexuality about yourself
change? Did your interest in sex increase, decrease, or remain
the same? If so, can you describe the change?
12. After your child died—if you have no other living children—did
you still consider each other to be ‘‘parents"? If so, how did that
express itself? If not, why not?
13. After your child died—if you have older surviving children—did
you find you had to blend the parenting of your living children
with the grief? How did you do that?

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15. Again, if you had older surviving children, did you emerge to find
ways of being parents to both living children and to the child who
died, too? How did that blend happen in your family?
16. Did the death of your child change the way you communicated
with each other as parents? How?
17. How did grief change your perceptions of family and day-to-day
responsibilities?
18. Was your ability to do things socially as a couple affected? If
so, how? Did you feel differently about going out with friends?
On ‘‘dates’’ with each other? To social gatherings with extended
family?
19. Are there similarities and differences in how you approach going
back to work, dealing with bosses, coworkers, and clients?
20. When you and=or your partner first went back to work or other
everyday life activities after your child died, how did that affect
your interaction and communication with each other? How did
this re-immersion into everyday life activities affect your grief?
21. Did grief after the death of your child affect the way you communicated as a couple about finances? About career decisions?
About life path goals?
22. How has your relationship been strengthened and challenged by
grief and loss?
23. If there was one thing you could change about the way you interacted as a couple after your child died, what would that be? Why
would you change this one thing? How would you change it?
24. Please feel free to share any other thoughts you might have that
would help us better understand how couples endure the death of
a baby.