Perinatal Loss - An Exposure Based Approach To Alleviating Feeling

Western Michigan University
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Dissertations Graduate College
4-1996
Perinatal Loss: An Exposure Based Approach to

Alleviating Feelings of Grief in Bereaved Parents
Michele Lee Rosa
Western Michigan University
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Rosa, Michele Lee, "Perinatal Loss: An Exposure Based Approach to Alleviating Feelings of Grief in Bereaved Parents" (1996).
Dissertations. Paper 1704.
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PERINATA L LOSS: AN EX PO SU RE BASED A PPRO A CH
TO ALLEVIATING FEELINGS O F G R IE F
IN BEREA V ED PARENTS
by
Michele Lee Rosa
A Dissertation
Submitted to the
Faculty of The Graduate College
in partial fulfillment of the
requirements for the
D egree of D octor of Philosophy
D epartm ent of Psychology
W estern Michigan University

Kalamazoo, Michigan
April 1996
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
PERIN A TA L LOSS: AN EX PO SU RE BASED APPRO A CH
TO ALLEVIATING FEELINGS O F G R IEF
IN BER EA V ED PARENTS
Michele Lee Rosa, Ph.D.
W estern Michigan University, 1996
The efficacy of exposing bereaved parents to stimuli associated with their
deceased child as a means of alleviating their grief reaction was explored. Three
parents who had suffered a perinatal loss participated. Pre, post, and follow-up
measures of depression, hopelessness, anxiety, marital functioning, daily stress,
psychopathology, bereavem ent and grief were gathered.
Results showed clinically significant improvement for two of the three sub
jects on measures of depression and psychopathology. All subjects showed im
proved marital functioning. Negative change was seen on a measure of hopeless
ness for two of the three subjects. The treatm ent effects for symptoms of stress,
anxiety, bereavem ent and grief were mixed. Subjective reports from the parents
provided support for the utility of the intervention. Implications for medical and
mental health care providers involved in the care of parents following a perinatal
loss are discussed.
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Copyright 1996 by
Rosa, Michele Lee
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Copyright by
Michele Lee Rosa
1996
DED ICA TIO N
In loving memory of
Anthony J. Giacomo
(1902-1996)
ACKNOWLEDGEMENTS
I would like to thank the many who contributed to the completion of this
dissertation. First, to the members of my committee, Drs. M. Michele Burnette,
Galen Alessi, Patricia Meinhold, and Kevin Armstrong. I extend my sincere
appreciation for their guidance and support.
Second, to my immediate family members who continuously provided both
emotional and monetary support, as well as encouragement: my father, Charles
M. Rosa; my m other, D olores A. Rosa (Giacomo); and my younger sister, Gina
M. Rosa. I thank my entire extended family for their willingness to share in my
educational experiences.
Third, to the faculty members at the Childrens Hospital of Michigan
(especially, Drs. M arcia Gilroy, A rthur Robin and Joseph Fischoff), The
University of Oklahoma H ealth Sciences Center (especially, Dr. C. Eugene
W alker) and The Childrens Hospital of Oklahoma (especially, Drs. H eather
Huszti and R uphert Nitschke), I thank you for your encouragement and
permission to collect dissertation data while also completing my internship and
fellowship requirements.
Finally, I thank my high school English teacher, Ms. M aureen Carney
(Sauber). Because of her dedication to teaching and her insistence that students
write properly, with organization and with style, I have had to endure minimal
criticism of my writing abilities.
Michele Lee Rosa

ii
TABLE OF CONTENTS
ACKNOW LEDGM ENTS .................................................................................... ii
LIST O F T A B L E S .......................................................................................................v
LIST O F F IG U R E S ................................................................................................... vi
CH APTER
I. IN T R O D U C T IO N .........................................................................................1
Causes of Perinatal L o s s ..................................................................... 1
The Impact of Perinatal Loss ............................................................3
Treatm ent Is s u e s ..................................................................................10
II. M E T H O D ..................................................................................................... 19
Subjects ........................................................... 19
Characteristics and History ....................................................... 19
Recruitment ................................................................................. 20
Setting .................................................................................................. 20
M ate ria ls.........................................................................................21
P ro c e d u re ..............................................................................................25
Design ........................................................................................... 25
Experimental S e ssio n s.................................................................25
F o llo w -u p ...................................................................................... 27
Scoring and A n a ly sis.......................................................................... 27
III. R E S U L T S ..................................................................................................... 30
iii
Table of Contents-Continued
CHAPTER
D e p re s s io n ........................................................................................... 30
H opelessness.........................................................................................31
Psychopathology ..................................................................................32
Daily S tre ss .............................................................................33
M aternal Bereavement ......................................................................33
Grief ..................................................................................................... 36
A n x ie ty ...................................................................................................37
M arital Relations ............................................................................... 38
S U D S -L e v el....................................................... . ....................... . . . 4 0
Participant R eport .............................................................................42
IV. D IS C U S S IO N ............................................................................................45
APPENDICES
A. Self-Experiences Questionnaire .............................................................. 49
B. Structured In terv iew .................................................................................... 53
C. H um an Subjects Institutional Review Board Approval ..................... 55
B IB L IO G R A P H Y ..................................................................................................... 59
iv
LIST O F TABLES
1. Summary of Subjective D ata ........................ 43
LIST O F FIGU RES
1. Scores on Beck Depression Inventory ...................................................... 30
2. Scores on Beck Hopelessness S c a l e ........................................................... 31
3. Scores on SCL-90-R ...................................................................................... 32
4. Scores on Daily Stress Inventory ................................................................ 34
5. Scores on Perinatal Bereavement Scale(M others O n ly ) .......................... 35
6. Scores on Perinatal G rief S c a l e .................................................................. 36
7. Scores on Self-Evaluation Questionnaire - Form Y -l ............................. 37
8. Scores on Dyadic Adjustment S c a l e ........................................................... 39
9. Scores on Dyadic Adjustment Subscales - Subject # 1 ................... 39
10. Scores on Dyadic Adjustment Subscales - Subject # 2 ................... 40
11. Subjective Units of Disturbance - Subject # 1 .................................. 41
12. Subjective U nits of Disturbance - Subject # 2 .................................. 41
13. Subjective Units of Disturbance - Subject # 3 .................................. 42
vi
CHAPTER I
INTRODUCTION
Numerous scientists have written about attachment, loss and grief pro
cesses (Bowlby, 1977,1980; Kubler-Ross, 1970; Lindeman, 1944). M ore specific,
the literature has been growing with respect to the psychological adjustment of
individuals experiencing loss and grief subsequent to fetal and neonatal demise.
As defined by the National C enter for H ealth Statistics (1993), a fetal death is the
death of a fetus between 20 and 40 weeks gestation or the death of a fetus weigh
ing over 500 grams; a neonatal death is the death of any infant bom alive who
survives less than one month. The National Center for H ealth Statistics (1993)
reported over 30,000 fetal deaths and over 23,000 neonatal deaths p er 4,111,000
live births. Within the research arena, fetal deaths, miscarriages, stillbirths and
neonatal deaths have been grouped and term ed "perinatal losses" (Callahan,
Brasted & Granados, 1983; Hopkins-Hutti, 1988). Hence, the term "perinatal"
will be used throughout the rem ainder of this paper.
Causes of Perinatal Loss
Correlational research has shed some light on the potential causes of peri
natal demise. Hamilton (1984) interviewed women who had suffered an infant
death regarding their exposure to radiation. The results indicated a higher rate
of stillbirths in women reporting exposure to radiation. Savitz (1989) also inter
viewed parents who had experienced the death of an infant (generally stillbirths)
about their exposure to pesticides and radiation. The results, like those of
H am iltons indicated that women who had reported exposure to some form of
radiation (e.g., X-ray) during their pregnancy had higher rates of stillbirth than
did those women who did not report any exposure to radiation. In addition,
although maternal exposure to pesticides did not indicate a trend, paternal expo
sure to pesticides was associated with higher rates of stillbirth.
Prager (1984) investigated maternal report of smoking and drinking (i.e.,
alcohol) behavior during pregnancy. Results of this study indicated higher rates
of stillbirth and infants who w ere small-for-gestational-age associated with smok
ing behaviors during pregnancy while no increase in stillbirth was associated with
alcohol use. Noteworthy is the fact that women who smoked prior to pregnancy
w ere less likely to decrease or quit the behavior during pregnancy than were
women who drank during pregnancy. In other words, the mothers in this study
reported abstaining from alcohol use or greatly reducing their intake during preg
nancy while their reported engagement in smoking behaviors remained relatively
unchanged; such occurrences may help to account for the lack of incidence of
stillbirth related to alcohol use alone.
A 1986 study by P orter found no correlation between stillbirth and m ater
nal use of oral contraception, spermicide, Bendectin or antibiotics prior to (within
2 months) and during pregnancy. Again, data was collected via interviewing
women, retrospectively, regarding their use of such products. In order to increase
validity, the author did include pharmacy records with regards to when prescrip
tions for Bendectin, oral contraception, and antibiotics were filled; however, the
researchers did not confirm whether or not the prescribed medication was actually
taken. Interestingly, Bendectin has since been taken off the m arket due to causal
trends associated with its use and birth defects.
In general, causes of perinatal death have been attributed to toxic envi
ronmental factors occurring during pregnancy or attributed to "unknown" causes.
Perinatal deaths preceded by entanglements in the umbilical cord, asphyxia, low
birth weight, intrauterine growth retardation (IU G R ) and the like are explained
as having occurred due to toxic environmental factors, yet no explanation is avail
able of the mechanisms by which such factors lead to these complications in the
pregnancy. Education, proper prenatal care and proper feeding of preterm and
low birth weight infants has been the primary mode of attempts to reduce the
occurrences of perinatal loss.
The Impact of Perinatal Loss
The impact of perinatal loss on the mother, father, marital dyad and sib
lings has been best articulated and most thoroughly formulated within the
behavioral and traditional psychoanalytical orientations. Condon (1986) asserts
that perinatal loss may be m ore traumatic than, for example, the loss of an elderly
relative due to the unique psychobiological environment in which it occurs, the
complex psychological characteristics of the identity of the lost object, and the
sociocultural definition and meaning of the loss. Individuals experiencing the
death of an elderly relative do not have the psychobiological entanglements of
pregnancy to complicate their grief process. In addition, a deceased elderly rela
tive is "alive in memory" as real and as experienced; individuals are able to vividly
rem em ber activities with their relative, and the feel and smell of their relative.
The survivor is able to realize and account for a fulfilled life (i.e., the relative
lived, married, had children, worked, saw grandchildren, etc.) whereas the family
experiencing a perinatal loss is grieving the loss of fantasized wishes, hopes and
dreams; with the exception o f the fetal movements, the m other has nothing con
crete by which to characterize her childs identity. Lastly, many, if not all
researchers (e.g., Cullberg, 1972; Giles, 1970; Kellner, 1981; Kennell, 1970;
Kirkley-Best, 1982; Leon, 1992; Theut, 1988) point to the need for prolonged
social support from families and friends as aiding the grief process for individuals
experiencing a perinatal loss. Unfortunately, society has very different expecta
tions of how or if grief should be displayed and for how long a duration when the
loss is an elderly relative versus a fetus or newborn.
Leon (1992) presents a multi-model conceptualization of the impact of per
inatal loss as it differs from other losses. Steeped heavily in traditional psycho
analytical theory, Leon asserts an objects-relations model, a developmental
model, a narcissistic model and a drive-theory model explaining such differences.
Pregnancy as a new developmental stage creates an arena in which
individuals must prepare for parenthood. In doing so, individuals identify with
earlier conflicts and develop a new organization of their personality. Leon (1992)
parallels the developmental process which occurs during pregnancy to that which
occurs during adolescence. Perinatal loss creates an additional crisis in an already
vulnerable developmental phase. Further, perinatal loss disrupts the developmen
tal phase and may cause one to withdraw from the activities usually associated
with childbearing peers. Hence, a unique sense of isolation plagues the grief sub
sequent to a perinatal loss.
Leons (1992) drive model defines the grief of perinatal loss as unique to
other deaths in that it creates psychosexual conflicts. Powerful m aternal needs
to hold, feed, and care for the child are left unfulfilled. Hence, bereavem ent may
be confounded by previously unresolved Oedipal conflicts and separation-
individuation issues.
From an object-relations model, Leon (1992) defines pregnancy not only
as the creation o f a new child, but also as the revitalization of all parental rela
tionships. Hence, resolution o f grief subsequent to a perinatal loss requires griev
ing the child who had died as well as reexperiencing and/or resolving any previous
conflicts within the relationship with ones own parents.
Leons (1992) narcissism model defines the fetus much m ore as a physical
part of the m others self than as an individual. Additionally, through pregnancy,
females fulfill narcissistic ambitions (e.g., creation, power, sense of immortality).
H ence, resolution of the perinatal loss is complicated by increased narcissism
associated with pregnancy. According to Leon, underlying shame, inferiority and
helplessness replace the sense of infallibility pregnancy typically secures.
Brasted and Callahan (1984) and Callahan, Brasted and Grandos (1983)
articulate the behavioral theory regarding the impact of perinatal death versus the
death of an elderly relative as a non-normative life event which sensitizes the indi
vidual to death rather than promoting adaptation to death, which normative life
events function to do. Generally, individuals experience expected, distant deaths
throughout their life. For example, people experience the death of a great-aunt,
then a grandparent, then the death of their parent, etc. These deaths are de
scribed as normative and function to prom ote adaptation to the death experience.
Perinatal death is unexpected and out of the sequence of normative life events.
Perinatal death is described as non-normative and serves to sensitize the indi
vidual rather than prom ote adaptation. Events which serve sensitization functions
present as more traumatic in symptomatology.
The psychological adjustment of individuals experiencing a perinatal loss
can be greatly affected by not only its unique grief process but also by premorbid
personality characteristics and previous experiences with loss. Although the re
search regarding personal historical factors and their effects upon ones response
to perinatal loss are scant, Lindemann (1944) asserted that individuals with obses
sive personalities and histories of depression are m ore likely to experience
chronic, morbid grief. Additionally, case studies presented by Jureidini (1993)
suggest that obstetric complications can contribute to the genesis of Munchausen
Syndrome By Proxy (MSBP) through unresolved grief, secondary to perinatal
bereavement. In a study by Hunfeld, Wladimiroff, Verhage and Passchier (1995),
41 women who had suffered a perinatal loss secondary to a prenatal lethal
anomaly were interviewed at two to six weeks after the diagnosis and again at
three months after the perinatal loss. The researchers were interested in the
womens level of previous stress (defined by history of m ajor life events, receipt
of professional mental health treatm ent, and disposition for feelings of inadequacy
and anxiety) and acute psychological defense reactions to the diagnosis. Hunfeld
et al. (1995) found that inadequacy was the most strongly positive predictor of
perinatal grief at both the time of diagnosis and at three months post loss.
Additionally, having received mental health service in the past predicted signif
icantly m ore intense grief shortly after diagnosis. With regards to previous exper
iences with loss, the research is mixed. Giles (1970) and Dyregrov & Matthiesen
(1987) did not find any correlation between maternal functioning and previous
miscarriages, while Theut (1989, 1990) found correlates between early and late
losses with respect to increased dysfunction in the former.
The experience of perinatal demise and the subsequent bereavem ent reac
tion is nearly universally acknowledged to be associated with somatic distress,
guilt, hostility, preoccupations, depression and fatigue (Cullberg, 1972; Dyregrov
& Matthiesen, 1987; Giles, 1970; Hughes & Page-Leiberman, 1989; Kennell et al.,
1970; Peppers & Knapp, 1980; Raphael-Leff, 1991). However, research indicates
that paternal, maternal and even sibling reactions to perinatal loss may differ with
regard to severity, duration and the placem ent of blame.
Dyregrov & M atthiesen (1987) found that within a nonclinical sample
fathers reported their feelings at the time of the loss to be "sad" and to last for,
"a month or so" while mothers reported intense loneliness and feelings of empti
ness for up to a year. Similarly, Vance, Najman, Thearle, Embelton, Foster and
Boyle (1995) found that while maternal levels of anxiety and depression remained
significantly higher than that of controls at two and eight months following an
infant death from Sudden Infant D eath Syndrome (SIDS), a neonatal death, or
a stillbirth, the levels of paternal symptoms were far less evident eight months
post-loss. Hughes and Page-Leiberman (1989) queried fathers regarding the exis
tence of m other-father grief process differences and found that 69% of the sub
jects were able to identify that differences between their and their spouses grief
process did exist. Fathers indicated that their wives wanted to continually talk
about the loss while they preferred to focus on other issues. Others indicated that
they perceived the death as having not been preventable and viewing the hospital
as least supportive while their wives felt responsible for the death and viewed
family and friends as least supportive. Instruments such as the Beck Depression
Inventory (BDI), the Perinatal Grief Scale (PGS), the Perinatal Bereavement
Scale (PBS), the State-Trait Anxiety Scale (STAT) and the Impact of Events
Scale (IES) have shown elevated scores for mothers yet elevated scores for fathers
is not common (Cullberg, 1972; Lasker and Toeder, 1981; Theut, 1989, 1990).
Lastly, Miron and Chapman (1994) investigated m ens experiences with
miscarriage and identified four sequential phases of adjustment which differed
from a six phase process pu t forth by Swanson-Kaufmann (1986) regarding
womens experiences with miscarriage.
Hypotheses as to why the aforementioned gender differences exist focus
on the differences which occur after the couple leaves the hospital as well as upon
societal factors. Traditionally, fathers return to their place of employment and
have very little time to brood upon the event while m others remain at home,
indefinitely or for an extended period to recover, both physically and emotionally
and have extended periods of "free time" to think, process and brood upon the
details of the loss. In addition, maternal feelings of guilt surrounding feelings of
responsibility for the loss have no parallel within the paternal grief process -
mothers feel responsible because the child was inside their physical person. Alter
natively and in accordance with societal norms, men may block the deep emo
tional feelings associated with grief and loss and substitute a "take-charge" attitude
in efforts to make everything alright for their wives. Notably, the men in Miron
and Chapmans (1994) study identified their primary role as that of supporter to
their partner.
Sibling reactions to perinatal loss have been virtually unexplored and no
systematic, qualitative research exists (Leon, 1986). Sibling reactions are often
that of confusion, fear, anxiety (generally of the separation type), somatic com
plaints and sadness. Leon (1986) presents four constellations of sibling reaction
to perinatal death: "I killed the baby", "Mommy killed the baby", "I could die,
too" and "I will replace the baby". Siblings dealing with the loss as typified by the
first constellation generally believe that their ambivalence and/or jealousy towards
a new sister/brother caused the death. Typical symptoms include anxiety, somatic
complaints and sadness. Siblings dealing with the loss as typified by the second
constellation are usually the youngest of siblings and they generally believe that
their m other must have killed the baby because their world and everything which
happens in it is controlled by their parents. Typical symptoms include fear of the
parents and confusion. Siblings dealing with the loss as typified by the third con
stellation generally experience nightmares, separation anxiety and regression (e.g.,
failure to use toilet skills, thum b sucking). Siblings dealing with the loss as
typified by the last constellation generally want to relieve parental grief; in doing
so, these children experience anxiety and fear.
Treatm ent Issues
Several researchers have described treatm ent models for grief work from
behavioral (Callahan & Burnette, 1989; Ramsey, 1979), psychoanalytic (Condon,
1986; Leon, 1987), and supportive (Kellner et al., 1981; Kirkley-Best, 1982;
LaRoche, 1982) perspectives. In addition, H arr and Thistlethwaite (1990) de
scribed various creative therapies (e.g., stoiytelling, journaling, bibliotherapy, color
inventory, clay-modeling, posturing, and storyboarding) for the resolution of com
plicated and uncomplicated bereavement. Although no one treatm ent m ethod has
been systematically found to be of greater efficacy than another in the treatm ent
of bereavem ent (Condon, 1986), each has its strengths and weaknesses. The
behavioral therapies (e.g., flooding, exposure, systematic desensitization) require
fewer sessions than the psychoanalytic therapies (even short-term psychoanalytic
therapy). The behavioral therapies, however, may initially cause the individual
m ore intense feelings of discomfort than would psychoanalytic therapies. The cre
ative therapies provide greater insight into potential areas of conflict rather than
providing actual resolution o f the conflict issues.
It has been found that psychological recovery is not as good in individuals
whose grief is denied display, especially if they do not belong to a united family,
feel that they have nothing left to live for, or can not fit their loss into a secure
"* religious or philosophical background (Covill, 1968, cited in Giles, 1970; Editorial,
1967; Maddison & Walker, 1967). Related, LaRoche, Lalinec-Michaud, Engels-
mann, Fuller, Copp, McQuade-Soldatos and Azima (1984) found that Beck
Depression Inventory (BDI) scores were significantly correlated with seeing and
touching the baby after death whereas the Mourning Scale scores did not show
such a correlation. LaRoche et al. (1984) indicate that such a phenomenon sug
gests that women grieve w hether or not they see and hold the baby but that
depression is m ore likely to occur in women who do not have physical contact
with the baby. Hence, exposure to stimuli associated with a loss is thought to be
the critical ingredient in overcoming pathological grieving (Callahan & Burnette,
1989). However, two controlled attempts (Mawson, Marks, Ramm & Stern, 1981;
Sireling, Cohen & Marks, 1988) to prove the importance of exposure to grief
stimuli have not conclusively demonstrated that importance.
Sireling et al. (1988) replicated the 1981 study by Mawson et al. In both
studies, patients with morbid grief reactions subsequent to the loss of an attach
m ent figure (e.g., parent, spouse, adult child) were randomly assigned to either
guided mourning or antiexposure treatm ent groups with corresponding between-
session homework. Patients in the guided mourning group were encouraged to
expose themselves repeatedly to avoided cognitive, affective and behavioral cues
concerning bereavement (e.g., writing a letter to the deceased and reading it
aloud at the grave site; ventilation of negative feelings; facing avoided and/or dis
tressing situations, objects, or people reminding them of the deceased). With the
antiexposure group, the approach taken with the bereaved by many medical and
lay persons was formalized for evaluation by encouraging patients to get on with
living, not to think about the loss, to avoid anything painful connected with the
loss, and to think about the future rather than dwell on the past.
Sireling et al. (1988) modified the Mawson et al. (1981) design in the
following ways:
1. Instead of six sessions over two weeks, the replication study had 10 ses
sions over 14 weeks.
2. Both the exposure and antiexposure groups had m ore systematic ad
vice, support, and help concerning relationships, work and leisure activities than
in the original study.
3. To the avoided bereavem ent cues used in the original study, Sireling
et al. added affective and cognitive cues such as anger, guilt, and painful
memories and ruminations.
4. To self-assessments, Sireling et al. added a blind assessor and a
broader range of measures.
5. Follow-up in the replication was nine months rather than five months
post treatment.
6. The replication m ade use of cue cards to monitor and rate homework
together with ratings of compliance between and within sessions.
Both studies showed improvement posttreatm ent and follow-up, but avoid
ance and distress to bereavement cues improved m ore in guided mourning than
in antiexposure cases. On other measures, guided mourning yielded only margin
ally m ore benefit, gains in these areas being partly independent of reduced avoid
ance of bereavement cues (Sireling et al., 1988). However, the outcome of the
two aforementioned studies were confounded with procedural flaws. There was
subject violation of researcher instructions, differences in pre- versus post
treatm ent assessment methods and the unintentional and uncontrolled phenom ena
of the "antiexposure" instructions serving a paradoxical function whereby the sub
je c ts ) actually increase their contact with the stimuli associated with the loss
(Callahan & Burnette, 1989).
According to Giles (1970), who interviewed 40 women who had just lost
babies in the perinatal period, although doctors treated the womens physical
symptoms and prescribed sedatives liberally, in about half the cases the physicians
avoided discussing the death o f the baby. Giles (1970) asserted that the women
needed a sympathetic listener and reassuring explanations to remove misconcep
tions and guilt and to provide confidence for future pregnancies.
Although the role of exposure to grief stimuli remains unclear, experienc
ing perinatal death and the subsequent grief reaction remains a crisis for many
individuals. LaRoche et al. (1984) offered 30 mothers who had experienced a
perinatal death crisis intervention aimed at facilitating their grief process at a few
days, three weeks and three months after the loss. The mothers participated in
three one-hour interview sessions and completed various self-rating scales (i.e.,
Life Events Schedule, Beck Depression Inventory and a Mourning Scale); assess
ments of grief reactions were based on the criteria of Parks and Lindemann.
Following the three assessment sessions, the mothers grieving behavior was classi
fied as either an "Appropriate Grief Reaction" (A G R) or an "Inappropriate Grief
Reaction" (IG R ); an IG R was overly intense, shallow or absent as compared to
an AG R. O ne to two years following the perinatal loss, the m others were again
interviewed to assess for functioning as related to psychological adaptation, rela
tionships to spouses, family and friends as well as the degree of satisfaction with
hospital services and care, and attitudes toward future pregnancies. LaRoche and
colleagues found that six of the 30 mothers showed IGRs at the three week and
three m onth assessment. By the long term follow up, only one of those six dis
played depression or another psychiatric disorder. Three other mothers not iden
tified as high risk candidates by the three month evaluation developed high BDI
scores and clinical depressions at the one to two year assessment. Assessment of
the presence of mourning in all the subjects as measured by the Mourning Scale
confirms the findings of other studies and implies that a substantial degree of
bonding precedes tactile contact between m other and child (LaRoche et al.,
1984). In addition, the relatively low BDI scores and low incidence of
pathological variants of grief may indicate the usefulness of therapeutic interven
tion with this population (LaRoche et al., 1984).
The current trend in the mental health care system is to successfully treat
individuals using the least num ber of sessions while expending the least amount
of dollars. In addition, systematic examinations of the clinical treatm ent interven
tions employed to reduce and eliminate the symptoms of a grief reaction have
been inconclusive. Given the current demand for the availability of psychological
treatm ent services for couples/individuals experiencing a perinatal loss and the
m ental health care system trend, the behaviorally oriented treatm ent methods,
with their tradem ark of therapeutic success within a limited number o f sessions,
appear to be best suited for investigation.
Historically, exposure treatm ent strategies have warranted a basis of solid
empirical research regarding their efficacy. According to Masters, Burish, Hollon
and Rimm (1987), in the 1970s there was an increase in reports of exposure pro
cedures and their effectiveness in treating a variety of disorders, such as phobias
(Yule, Sacks, & Hersov, 1974), anxiety neurosis (Girado, 1974), Post Traumatic
Stress D isorder (PTSD) (Black & Keane, 1982), obsessive-compulsive behavior
(Hackman & McLean, 1975), agitated depression (Hannie & Adams, 1974), psy
chogenic urinary retention (Glasgow, 1975), somatic complaints (Stambaugh,
1977) and social withdrawal in children (Kandel, Ayllon & Rosenbaum, 1977).
Throughout the perinatal loss literature, many of the above stated symptoms (e.g.,
depression, anxiety and fear) are repeatedly reported by individuals experiencing
such a loss.
According to Marks (1987), the exposure principle is the process by which
continued exposure to stimuli that evoke distress results in habituation and extinc
tion of innate and acquired fear, anxiety or distress. The exact mechanisms by
which exposure reduces distress may differ across diagnoses depending on what
type of stimuli are being avoided. The mechanisms at work in resolving grief sub
sequent to perinatal loss are hypothesized to be as follows. Bereaved individuals
avoid talking about the death, perhaps for years, because of the subjective and/or
objective distress produced by such verbal exchanges and/or because family and
friends avoid listening to them because of the distressful nature of the content.
Hence, bereaved individuals and potential listeners learn to escape the distress by
withdrawing or changing the conversation topic and the verbal content thus re
tains its conditioned emotional response values. With exposure-based treatment,
the individual is instructed to speak of the death, the deceased, etc. to a therapist
trained to listen whenever the individual is ready to talk and who continually redi
rects the verbal exchange on the topic until the patient becomes calm. Hence,
escape (Sr-: negative reinforcement or relief) is contingent upon being able to talk
about the relevant issues with decreasing distress, rather than avoiding the topic
as in the past. Alessi (1992) describes "analog verbal conditioning" whereby ver
bal behavior conditions neutral verbal stimuli as conditioned emotional stimuli.
Therefore, the mechanisms at play which allow the bereaved individual to experi
ence decreased distress while engaged in verbal dialogue may include "analog ver
bal conditioning" (e.g., reframing), habituation to the conditioned emotional re
sponses associated with key verbal stimuli as well as learned coping responses
(e.g., relaxation); all such mechanisms help the patient stay with the topic, m oder
ate the distress level, and not withdraw from the conversation.
The current study assessed both individual and marital adjustment to and
resolution of the grief reaction subsequent to a perinatal death. D ata was col
lected prior to, during, and following an exposure based treatm ent intervention.
It was hypothesized that the clinical procedure of exposing bereaved individuals
to imaginal, in vivo, and verbal stimuli associated with a loss would serve multiple
functions. First, an exposure based treatm ent protocol may serve to validate a
loss often construed by society not to be "real". Second, the treatm ent sessions
may provide an opportunity for the bereaved to "work through" issues yet unre
solved and/or denied. Overall, it was hypothesized that post- and follow-up
assessment scores of depression, marital discord, daily stress, and bereavement
would be lower as compared to baseline measures. Given that the systematic
study of treatm ent methodologies aimed at reducing the symptoms of bereave
m ent in individuals subsequent to a perinatal loss is limited, this study may benefit
the literature not only by clarifying the importance of exposure to stimuli associ
ated with the loss, but also by serving to advance the literature regarding an
appropriate, effective and brief treatm ent intervention specific for grief reactions
subsequent to a perinatal loss.
CHAPTER II
M ETHOD
Subjects
Characteristics and History
T hree individuals (1 m ale and 2 females) served as volunteer subjects. The
m ean subject age was 39 years (range 36 years and 6 months - 43 years and 8
months). Subjects num ber one and two were married to each other and had a
m arked history of infertility. The couples loss of interest for purposes of this
study was a stillborn male (35 weeks gestation); the loss occurred two years and
eight months prior to their participation. Following the stillbirth, the couple also
suffered a miscarriage (nine weeks gestation). The couple had no living children.
Subject num ber three was married; however, her spouse was not eligible for par
ticipation in the study because he was not the father of the deceased child. Sub
ject num ber three did not have a history of conception complications and the loss
of interest for purpose of this study was a male child born at 28 weeks gestation;
the loss occurred 16 years and three months prior to her participation. The sub
ject had not been told of the cause of death, nor did she know if the child had
been bom alive. The subject had two subsequent pregnancies which produced
two living male children (8 years, 6 years); no further perinatal losses occurred.
19
Both female subjects were pharmacologically treated for a period of one week
with Valium or Tylenol-3 following their loss. All subjects had participated in a
local perinatal loss support group and subjects one and two received individual
psychotherapy for six to eight months following their loss.
Recruitment
Subjects were recruited via a mass mailing of an informational invitation
to local OB/GYN physicians, advertisement in local newspapers, and a mass mail
ing of an informational invitation to local perinatal loss support groups. Volun
teers who evidenced psychotic features and/or those who used antidepressant and/
or antianxiety medication did not qualify for participation. The second exclusion
criterion was included based upon the theory that antianxiety and antidepressant
medications may interfere with the individuals abilities to fully experience the
exposure-based treatm ent approach. One volunteer was excluded due to this cri
terion.
Setting
The initial interview, three subsequent experimental sessions, and the post
assessment session (one-week follow-up) were held in the outpatient clinic of
Childrens Hospital of Michigan D epartm ent of Child Psychiatry and Psychology
within the D etroit Medical Center. During sessions, only the researcher and one
subject was present. Baseline and follow-up questionnaires were completed in the
21
subjects homes.
Materials
The areas of interest in this study were individual and marital adjustment
to and resolution of the grief reaction subsequent to a perinatal loss. Question
naires used during this study included the Beck Depression Inventory (BDI), the
Daily Stress Inventory (DSI), the Dyadic Adjustment Scale (DAS), the Self-
Evaluation Questionnaire (Form Y -l), the Symptom Checklist 90-Revised (SCL-
90-R), the Perinatal Bereavement Scale (PBS), The Perinatal G rief Scale - short
version (PGS), the Beck Hopelessness Scale (BHS), and the Self-Experiences
Questionnaire (Appendix A). Additionally, subjects participated in a structured
interview (Appendix B).
The BDI is a 21-item instrument designed to assess the severity of de
pressed moods in adolescents and adults. Internal consistency estimates based
upon Cronbachs coefficient alpha for the mixed, single-episode major depression,
recurrent-episode major depression, and dysthymic patients were .86, .80, .86, and
.79 respectively. The range of Pearson product-moment correlations between pre
test and posttest administrations of the BDI for varying time intervals for psychi
atric patients ranged from .48 to .86, whereas the test-retest correlations of non
psychiatric patients ranged from .60 to .90 (Beck & Steer, 1987).
The DSI (Brantley & Jones, 1989) is a 58-item instrument which measures
the num ber and relative impact (7-point scale) of common minor stressors
frequently experienced in everyday life. The DSI provides a current measure of
stress over a 24-hour period and can be administered serially over several days or
weeks. The DSI yields three basic scores: (1) the Event score - the num ber of
items rated as having occurred that day; (2) the Impact score - the sum of the
impact rating values assigned to each item; and (3) the I/E Ratio - the average
impact rating for the day, calculated by dividing the Im pact score by the Event
score. The I/E Ratio score was used for purposes of this study. Alpha coeffi
cients of internal consistency w ere calculated for the Event and Impact measures
but not for the I/E Ratio because it is a composite of the Event and Impact
scores. Coefficients were .83 and .87 for Event and Im pact scores, respectively.
Evidence for the concurrent validity of the DSI has been shown in studies of
three independent samples (Brantley, 1987a, 1987b; Brantley, Dietz, McKnight,
Jones, and Tully, 1988).
The DAS is a 36-item questionnaire designed to assess marital functioning
with regard to finances, recreation, religion, affection, goals, household tasks,
career, communication, and commitment. Items are rated on a 6-point scale from
"always agree" to "always disagree" or a 5-point scale from "every day" to "never".
O ther items are "yes/no" questions.
The Self-Evaluation Questionnaire (Form Y -l) is a 20-item questionnaire
designed to assess anxiety. Each item is rated on a 4-point scale from "not at all"
to "very much so" with regard to how anxious the individual feels at the moment
they are completing the questionnaire.
T he SCL-90-R is a 90-item, self-report symptom inventory developed by
Leonard Degrogatis of Clinical Psychometric Research; it is designed primarily
to reflect the psychological symptom patterns of psychiatric and medical patients.
Each item is rated on a 5-point scale of distress (0-4). The instrument is scored
and interpreted in terms of nine primary symptom dimensions and three global
indices of distress. M easures of internal consistency for the nine dimensions
range betw een a low of .77 to a high of .90. Test-retest reliability measures hover
between .80 and .90 (Degrogatis, 1977).
The PBS is a 26-item instrument designed especially for the cited research
to m easure the bereavem ent of parents who have experienced a perinatal loss.
The PBS focuses on the thoughts and feelings (including sadness, guilt, anger, and
preoccupation with the loss) experienced by parents after a perinatal loss. Each
item is scored on a 4-point Likert scale. Although the items appear to have face
validity, no data have been reported on the validity and reliability of this
instrum ent (Theut, Zaslow, Rabinovich, Bartko and, Morihisa, 1990).
The PGS - short version is a 33-item scale developed to measure grief for
research on pregnancy loss (spontaneous abortion, ectopic pregnancy, fetal death,
and neonatal death) based upon the original 84-item 5-point Likert-type Perinatal
Grief Scale. The standardized alpha coefficient of the long versions is .97. Relia
bility analysis for each of the three subscales and the total scale of the short ver
sion is higher than .85. Test-retest reliability correlations between the first and
the second rounds for each of the three factors and for the total scale range from
.59 to .66, all at a significance level of .001 (Potvin, Lasker, Toedter, 1989).
The BHS is a 20-item scale for measuring the extent o f negative attitudes
about the future (pessimism) as perceived by adolescents and adults. The BHS
maintains high internal consistency across seven clinical samples (suicide ideators,
suicide attempters, alcoholics, heroin addicts, single-episode M ajor Depression
Disorders, recurrent-episode Major Depression Disorders, and Dysthymic Dis
orders); the corresponding Kuder-Richardson reliabilities were .92, .93, .91, .82,
.92, .92, and .87, respectively. Pearson product-mom ent correlation between test-
retest scores ranged from .69 to .66 (p < .001). The BHS also maintains respec
table integrity across six aspects of validity: content, concurrent, discriminant,
construct, predictive and factorial (Beck & Steer, 1988).
The Self-Experiences Questionnaire was designed specifically for the pur
poses of this study. The questionnaire was used to gather subjective reports from
the subjects regarding somatic symptoms, social support and the utility of partici
pating in the study.
The structured interview was designed specifically for the purposes of this
study and was used to obtain information regarding subject characteristics, type
of pregnancy loss, history of conception complications, receipt of medical and psy
chological services and the characteristics of any living children.
25
Procedure
Design
A single-case research design was used. Subjects provided baseline data
for a duration of two weeks prior to entering the one-week treatm ent phase. Sub
jective Units of Disturbance (SUDS) were taken at 15-minute intervals during the
three experimental sessions in an attem pt to assess "contact" with exposed stimuli.
Experimental Sessions
Subjects attend an initial interview and pre-assessment session, three exper
imental sessions, and a post-assessment session (one-week follow-up). Addition
ally, one-month follow-up data were collected through the mail. Each of the
three experimental sessions was time-limited to one hour; the other sessions
ended upon completion of the interview and questionnaires. All experimental
(i.e., exposure) sessions were conducted by the author under the supervision of
a fully licensed, Ph.D. level Clinical Psychologist with prior clinical experience
working with couples who have experienced a perinatal loss.
A fter the general purpose of the study was explained ("We are interested
in knowing how to better aid and support individuals who have experienced a per
inatal loss"), subjects signed an informed consent form and had the option of sign
ing a release of medical records form for their and/or their childs medical
records. Subjects then participated in the structured interview and completed the
questionnaires. Subjects num ber two and three were also instructed to complete
their questionnaires in privacy and to avoid sharing and/or discussing their
responses. Subjects completed the Self-Experience Checklist and the BHS at the
initial interview, following the last treatm ent session and at follow-up only; the
Self-Experience Checklist and the BHS were not completed weekly.
Following a baseline period of two weeks, the subjects presented at the
clinic for the first of three experimental sessions. During the one-hour sessions,
the subjects were asked to engage in verbal dialogue with the researcher regarding
their experiences. Subjects discussed details surrounding their attempts to con
ceive, the pregnancy, the labor/delivery, the child, the funeral and their hopes,
dreams, expectations, and loss. Two subjects brought in articles of clothing, pic
tures and mementoes of the pregnancy and child. The third subject chose to sign
the release for medical records; however, relevant information and pictures were
not able to be used during experimental sessions because the subjects medical
records were never located by hospital personnel. In essence, the researcher
organized each of the exposure sessions so as to maximize verbal, imaginal and
in vivo exposure to stimuli associated with the loss. The three experimental ses
sions occurred within a one week span, with each session being at least one day
apart.
Within a week following the last experimental session, the subjects re
turned to the clinic for the post-assessment session. During this session, subjects
again completed the questionnaires. The researcher answered any questions the
subject may have had and a list of community referrals for further mental health
services was provided. All subjects completed the experimental sessions and par
ticipated in a one-week follow-up.
Follow-up
O ne month following the last session, subjects were mailed a questionnaire
packet and asked to return the materials in an enclosed, confidential, self-
addressed, and stamped envelope. Subjects who failed to return the materials
within two weeks were contacted by phone on three separate occasions to prom pt
the return of the materials. Two subjects returned completed questionnaire
packets at the one-month follow-up. Despite having received the questionnaire
packet on three occasions and in contrast to her verbal report, subject num ber
three failed to return her one-month follow-up data.
Scoring and Analysis
The BD I is scored by summing the ratings for each o f the 21 items. The
final summation is then compared to a preestablished cut-off score (e.g., 0-9
normal/asymptomatic; 10-18 mild-moderate depression; 19-29 moderate-severe
depression; 30-63 extremely severe depression).
The DSI is scored by counting the number of items that received a rating
and entering this number in the "Event" space. An additional summation score
is calculated by summing the item ratings and entering that num ber in the
"Impact" space. The "I/E Ratio" score is calculated by dividing the Impact score
by the Event score. The score(s) is then compared to a normative table in order
to determine the corresponding T-score and percentile. One-day administration,
one-week administration and multiweek administration methods are scored in the
same manner.
The SCL-90-R is scored by first transferring the 90 items scores from the
test paper to the profile sheet. Second, summed distress scores for each of the
nine symptom dimensions and the "additional" items of the instrument are calcu
lated by adding together all the non-zero distress scores from each item compris
ing the dimension. Third, each summed distress score is divided by its respective
num ber of items. Fourth, in order to calculate the three global indices one must
take a grand total of the summed distress scores for the nine dimensions and the
additional items. Dividing that score by 90 provides one with the Global Severity
Index (GSI). The next step involves counting the number of positive symptom re
sponses to arrive at the Positive Symptom Total (PST). By dividing the grand
total calculated in step four by the PST, the Positive Symptom Distress Index
(PSDI) is achieved. Once the raw dimension scores and globals are calculated,
they are referred to the appropriate norm table for conversion to standard T-
scores.
The PBS and the PGS are both scored by totaling the num ber of items en
dorsed and summing the rating level of each individual response.
The DAS is first scored according to the scoring key. There are separate
weighted values for the DAS scoring and for the original Locke-Wallace scoring.
The obtained scores for items one through 32 are transferred to the DAS scoring
sheet for each partner. The points are then summed to obtain a subscale score.
The sum total of the four subscales gives the total DAS score.
The Self-Evaluation Questionnaire (form Y -l) is scored by simply adding
the weighted scores for the 20 items that make up each scale. Scores for both
forms can vary from a minimum of 20 to a maximum of 80. The raw score totals
for each form are then compared to normative data and the corresponding per
centile rank is determined.
The BHS is scored by summing the keyed responses of hopelessness for
each of the 20 items. Responses which indicate nonhopelessness receive a score
of zero and responses indicating hopelessness receive a score of one. The number
of hopelessness responses are totaled and the sum is indicated on the line
provided at the bottom of the questionnaire. The maximum score is 20. The
total is then compared to general guidelines for interpretation (0-3, normal range
or asymptomatic; 4-8 is mild; 9-14 is moderate; greater than 14 is severe).
The resulting data (i.e., changes in assessment scores) were graphed and
visually inspected for clinically significant change. The results are presented in
the following section.
CH A PTER III
RESULTS
Depression
M easures of depressed mood, as assessed by the BDI, are shown in Figure
1. Subject one consistently reported a m oderate-severe level of depression during
the baseline, treatm ent and one-week follow-up phases. However, at the one-
m onth follow-up phase subject ones depression level had improved to within the
mild-moderate range.
Subject twos reported depression level was within normal limits at
20 - -
S 15 -- Subject 1
Subject 2
10 --
Subject 3
5 -
Baseline Treatment 1 Week F/U 1 Month F/U
Figure 1. Scores on Beck Depression Inventory.
30
baseline, yet increased to within the mild-moderate range prior to the treatm ent
phase. However, subject twos level of depression improved and returned to
within normal limits during the treatm ent phase and remained within normal
limits throughout both follow-up phases.
Subject three reported a mild-moderate level of depression at baseline
which improved to within norm al limits prior to the treatm ent phase. Subject
threes depression rating rem ained within normal limits throughout the rem ainder
of the treatm ent and follow-up phases.
Hopelessness
Fre and post measures of hopelessness, as measured by the BHS are shown
in Figure 2. Subject one reported a m oderate level of hopelessness at baseline.
25 t
20 |
15
o
o Subject 1
CO A ~m ~
n Subject 2
10
Subject 3
o J 1----- 1--------1-------------- 1--------------1--------------1-------

Baseline 1 Week F/U 1 Month F/U
Figure 2. Scores on Beck Hopelessness Scale.
32
Subject ones level of hopelessness worsened to within the severe range at both
follow-up phase ratings.
Subject two also reported a m oderate level of hopelessness at baseline.
However, in contrast to subject one, subject twos level of hopelessness signifi
cantly improved to within normal limits at the one-week follow-up phase and rose
slightly to within the mild range at the one-month follow-up.
Subject three reported a mild level of hopelessness at baseline which rose
to within the m oderate range at the one-week follow-up.
Psychopathology
M easures of psychological symptomatology, as assessed by the SCL-90-R,
are shown in Figure 3. Throughout all phases of the research, subject one
175 x
-80
150 -
125
100-
Subject 2
75--
50- - --60
25-- --50
--40
Figure 3. Scores on SCL-90-R.
reported symptoms which w ere sufficient in frequency and severity to be indica
tive of clinically significant psychopathology. Subject ones T-scores were greater
than 80 at baseline, treatm ent and the one-week follow-up phases; his T-score was
75 at the one-month follow-up phase.
During the baseline phase, subject two reported symptoms which were at
or near the border of clinical significance (T=60; T =56). During the treatm ent
phase, subject twos reported symptomatology fell to within normal limits (T=40)
and continued to decline through the 1-week follow-up phase (T=37). Although
subject two reported an increase in symptomatology at the one-month follow-up
(T=51), her symptoms were still within normal limits and lower than baseline.
Subject three reported symptoms which were borderline significant (T=60)
at baseline and fell to within normal limits prior to and during the treatm ent
phase (T=50). However, subject threes symptomatology returned to a borderline
significant level (T =63) at the one-week follow-up.
Daily Stress
Measures of common and minor daily stressors, as assessed by the DSI are
shown in Figure 4. Throughout the baseline, treatm ent and one-week follow-up
phases, subject one experienced daily stressors which were sufficient in frequency
and impact to be clinically significant (T=74). A t the one-month follow-up,
subject one reported decreased experiences with daily stressors (T=65).
Throughout all phases of the research, subject twos experiences with daily
34
80 T
70--
60- -
Subject 1
Subject 2
Subjects
20 --
10--
Baseline
Figure 4. Scores on Daily Stress Inventory.
stressors remained within norm al limits. Subject twos T-scores for baseline,
treatm ent, one-week follow-up and one-month follow-up phases were 51, 56,47,
48, and 46, respectively.
Subject three reported experiences with daily stressors which were
sufficient in frequency and impact to b e clinically significant at baseline (T = 74),
yet which fell to within norm al limits prior to the treatm ent phase (T =47) and
remained as such throughout the rem ainder of the research. Subject threes
T=scores for treatm ent and one-week follow-up phases were 45 and 50,
respectively.
35
M aternal Bereavem ent
M easures of maternal bereavem ent, as assessed by the PBS are shown in
Figure 5. The PBS does n o t have preestablished cut-off scores with which to
define levels of bereavement. Both fem ale subjects evidenced elevated levels of
bereavement; however, subject three m aintained the same level of bereavem ent
throughout baseline, treatm ent and follow-up phases while subject two evidenced
a decrease in reported bereavem ent symptomatology during the treatm ent phase.
Subject twos improved bereavem ent status maintained throughout both follow-up
phases.
SO-
SO--
P 30 --
Subject 1(N/A)
20 -
Subject 2
10-- Subject 3
1 Month FAJ
Figure 5. Scores on Perinatal Bereavem ent Scale (M others Only).
36
G rief
M easures of grief subsequent to a pregnancy loss and assessed by the PGS
are shown in Figure 6. Like th e PBS, the PGS does not have preestablished cut
off scores with which to define levels of grief. Subject one consistently endorsed
a majority of the items on th e PGS. Subject ones active grief process remained
elevated in symptomatology throughout baseline, treatm ent and follow-up phases.
Subject twos responses showed a mildly elevated grief process at baseline
which subsequently decreased in symptomatology during treatm ent and follow-up
phases.
Subject three reported virtually no symptoms representative of an active
grief process at baseline. Although the return of an incomplete questionnaire
25 T
20--
15 - -
Subject 1
Subject 2
Subject 3
5 --
1 Month F/U
Figure 6. Scores on Perinatal G rief Scale.
37
prevented a measure of grief at the treatm ent phase, subject threes follow-up
m easure of grief is consistent w ith baseline measures.
Anxiety
M easures of state anxiety, as assessed by the Self-Evaluation Questionnaire
(Form Y -l) are shown in Figure 7. Subject ones state anxiety scores remained
high throughout all phases of th e research and ranged from the 91st to the 100th
percentile.
Subject two reported clinically significant levels of state anxiety at baseline
(87th percentile, 82nd percentile). H e r anxiety then decreased to within normal
limits during the treatm ent and one-week follow-up phases (50th percentile, 19th
80 T
60-
S 50 -
Subject 1
Subject 2
Subject 3
2 0 -
1 0 -
1 Month FAJ
Figure 7. Scores on Self-Evaluation Questionnaire - Form Y -l.
percentile); however, the decrease in anxiety was not maintained at the one-
m onth follow-up phase (72nd percentile).
Subject threes data shows the most fluctuation. Ginically significant state
anxiety at baseline (89th percentile) fell to within normal limits prior to the treat
m ent phase (44th percentile). However, subject threes decreased anxiety was of
a brief duration; although not returning to the baseline level, measures of state
anxiety increased at treatm ent and one-week follow-up phases (68th percentile,
73rd percentile).
Marital Relations
M easures of dyadic adjustment, as assessed by the DAS are shown in
Figure 8. Four subscales comprise the DAS: Dyadic Consensus, Dyadic
Satisfaction, Affectional Expression and Dyadic Cohesion. High total scores on
the DAS are indicative of b etter dyadic adjustment; the maximum score is 151.
DAS scores from subject numbers one and two, who were m arried to each other
indicate a positive marital relationship. Additionally, both subjects reported
improved dyadic adjustment at the treatm ent and one-month follow-up phases.
Subjects one and two w ere married to each other during their participation
in the research; hence, a comparison of their subscale responses was possible.
The subscale profile for subjects one and two is shown in Figure 9 and Figure 10.
Subject ones response set shows virtually no change across all phases. However,
there is improved dyadic satisfaction at the one-month follow-up phase. Subject
39
iso T
130 -
m
120 -
110 - -
100
2 90
o Subject 1
u 80
to
3 70" Subject 2
* SO
Subject 3
SO"
30
2 0 -
10 --
Treatment 1 WeekF/U
Figure 8. Scores on Dyadic Adjustm ent Scale.
50 -r
Dyadlc Consensus
Dyadic Satisfaction
20--
ANtetional Expression
Dyadic Cohesion
Figure 9. Scores on Dyadic A djustm ent Subscales - Subject # 1 .
40
00 t
50- -
40
Dyadle Coniontua
Dyadic Satisfaction
30--
Affactkmat Btpranlon
-o -
Dyadie Cohesion
10- -
Figure 10. Scores on Dyadic Adjustm ent Subscales - Subject #2.
twos response set shows virtually no change across all phases.
Although the DAS scores from subject three indicate a troubled marital
relationship throughout all phases of the research, dyadic adjustment was
improved from that assessed a t baseline at all subsequent phases. Subject threes
spouse was not eligible for participation in the research; hence, a comparison of
subscale scores is not applicable.
SUDS-Level
Subjective Units of Disturbance, as reported by each subject at 15 minute
intervals are shown in Figure 11, Figure 12 and Figure 13. Subject one reported
an absence of emotional distress throughout the first and second treatm ent
41
Subject #1
Session 1 Session 2 Session 3

In Vitro Exposure Treatment
Figure 11. Subjective Units of Disturbance - Subject # 1 .
Subject #2

Figure 12. Subjective Units of Disturbance - Subject # 2 .
42
Subject #3
0:15
0:30
:45
0 :6 0

Figure 13. Subjective Units o f Disturbance - Subject # 3 .
sessions. N ot until the third treatm ent session did subject one come into contact
with emotion-laden issues. Subjects two and three each reported emotional dis
tress throughout each of the three treatm ent sessions.
Participant R eport
Subjective reports of somatic symptoms and the utility of participation in
this project, as collected from the Self-Experience Questionnaire, are shown in
Table 1. All three subjects initially presented with multiple somatic symptoms.
A t follow-up, only subject one had maintained the multitude of somatic symp
toms; both subjects two and three reported significantly less somatic distress at
follow-up. Common to all subjects was the consistent presence of feelings of
Table 1
Summary of Subjective D ata
Initial Interview 1 W eek Follow-up 1 M onth Follow-up
Subject # 1 hopelessness hopelessness hopelessness

anxiety anxiety
marital distress marital distress
sadness sadness sadness
anger anger anger
poor concentration poor concentration poor concentration
no social support no social support no social support
stomach distress
Subject # 2 guilt
hopelessness
fear
anxiety
marital distress
sadness sadness sadness
anger anger
poor concentration
no social support
headaches
stomach distress
Subject # 3 guilt N/A
hopelessness
sadness sadness
anger anger
poor concentration
no social support headaches
Did participation in the research project help you?

Subject # 1 no yes
Subject # 2 yes yes
Subject # 3 yes n/a
Did your spouses participation in the research project help you?
Subject # 1 yes yes
Subject # 2 yes yes
Subject # 3 n/a n/a
Did your spouses participation in the research project help him/her?
Subject # 1 yes yes
Subject # 2 yes yes
Subject # 3 n/a n/a
sadness and anger. Although subject one had not viewed his participation in the
research as helpful to himself at the conclusion of his participation, by the one-
m onth follow-up, he had changed his position and viewed his participation as
beneficial. Both female subjects consistently reported their participation in the
research to have been helpful not only to themselves, but also to their spouses.
CHAPTER IV
DISCUSSION
This study explored the efficacy of exposing bereaved parents to stimuli
associated with their deceased child as a means of alleviating their grief reaction.
Clinically significant improvement occurred on measures of depressed mood and
psychopathology for two subjects. All subjects showed improved marital relations.
Two subjects showed an increased level of hopelessness following the treatm ent
intervention. Treatm ent effects were mixed for symptoms of stress, anxiety,
bereavem ent and grief.
Previous attempts to assess the efficacy of an exposure-based treatm ent
intervention for grief reactions (Mawson, Marks, Ramm, & Stem , 1981; Sireling,
Cohen, & Marks, 1988) were not directed toward grief subsequent to perinatal
death. Hence, this study serves to advance the clinical research on perinatal loss
by providing data on the efficacy of a short term, exposure based treatm ent inter
vention for grief subsequent to perinatal death.
Early researchers in the field identified marital relations, social support,
mental health and coping responses as the best predictors o f and areas of focus
for promoting uncomplicated bereavem ent and avoiding complicated bereavement
(Hughes & Page-Leibermann, 1989; LaRoche, 1984; Lasker & Toeder, 1981;
Moscarrello, 1989; Peppers and Knapp, 1980; Seitz, 1974). Hence, the results of
45
this study, which detected m ore treatm ent effects on general dependent measures
o f depression, marital functioning and psychopathology than on specific depen
dent measures of bereavem ent and grief subsequent to a perinatal loss are consis
tent with previous research. Further, results of this study expand the previous
research by providing support for subjective reports by parents experiencing a per
inatal loss that the death of their child had global and long lasting effects upon
themselves, their spouse, their marital, familial and social relationships.
Systematic examinations of the clinical treatm ent interventions employed
to reduce and eliminate the symptoms of a grief reaction have been limited and
inconclusive. Unfortunately, the conclusions which can be drawn from this study
are also limited by a small num ber of subjects and the absence of a control group,
as well as being inconclusive. Despite recruiting subjects by multiple means (e.g.,
newspaper ads, personal contact with and presentations to support groups, letters
to medical personnel) and within multiple locations (e.g., southwest Michigan,
suburban Michigan, central Oklahoma), response was too limited to implement
a controlled, group design. The limits of this study (e.g., small sample, no control
group), as well as previous research within the literature prevent one from making
experimentally sound decisions about the role of exposure to stimuli associated
with a loss. This study does, however, provide some clinically relevant evidence
to support future investigations of the use of exposure paradigms in treating peri
natal loss induced grief reactions. Continued recruitment is planned in order to
expand the number of bereaved individuals clinically treated with this exposure-
based approach. Additionally, the findings of this study should serve to alert
medical and mental health professionals to the need for thoroughly assessing the
multifaceted aspects of parental adjustment to perinatal death.
Further research is needed to determine w hether or not the parents who
endure the hardship of the death of their child may be better served if hospital
personnel give permission to and encourage family members to hold the baby,
take pictures, name the baby, organize funeral services, communicate with the
physicians, nursing staff and amongst themselves, and grieve as would be done in
response to the death of any other family member. Second, future research to
determine the benefit derived from educating parents about the grief reaction
(e.g., incongruent bonding, incongruent grieving among spouses, familial reactions
to perinatal death) is needed. Additionally, future research is needed to deter
mine the benefit derived from educating family members and friends with regard
to the fact that perinatal death is a real loss for parents and that the grief is likely
to be as long and m ore intense as that expressed over the death of an older child
or spouse. Family and friends may need to be advised to support their loved ones
for at least six months to a year and perhaps up to two years after the death and
to encourage maternal discussions about the child and the death, her subsequent
fears, anxieties, anger and sadness without excluding or minimizing the effect of
perinatal loss on the father.
Small sample sizes and the absence of well controlled, group design re
search plagues perinatal loss research. Ideally, future research would replicate
treatm ent intervention studies within controlled, group design contexts. However,
the difficulties incurred in attempting to design and implement such research may
not be easily overcome. Researchers may find it difficult to recruit parents who
have suffered a perinatal loss for various reasons. First, parents may be resistant
to engage in a research project shortly after experiencing such a traumatic event.
Second, parents may be lost to direct recruitment contacts (e.g., medical staff, psy
chologists, chaplains) after leaving the hospital. Third, parents may deny the
extent or degree of their grief reaction and hence fail to seek further professional
contact. Lastly, the current m anner in which health care professionals prepare
and support parents enduring a perinatal loss may be sufficient to diminish the
occurrence of complicated bereavement; however, professional experience sheds
grave doubt on such a hypothesis.
The establishment of multidisciplinary teams consisting of OB/GYN physi
cians, clinical psychologists, nurses and social workers who provide comprehensive
care to expectant parents may provided an arena through which to overcome the
difficulties inherent in perinatal loss research. Parents may be m ore inclined to
participate in research shortly after the death of their child if they had preexisting
relationships with members o f the multidisciplinary team. Second, increased in
terdisciplinary collaboration may serve to gather recruitm ent resources and subject
pools thereby increasing the likelihood of implementing group design research.
Appendix A
Self-Experiences Questionnaire
49
Self-Experience Checklist
(Initial Interview)
Please complete the following checklist as it applies to your

experiences since the time of the loss of your pregnancy/child.
As a result of mv loss. I have experienced the following (check all

that a p p l y ) :
guilt
hopelessness
fear
anxiety
marital distress
sadness
anger
difficulty concentrating
a lack of social support
headaches
stomach distress
interactions with a support group (please describe)
support from family, friends, etc. (please describe)
fr
other (please explain):
51
Self-Experience checklist
(End of Treatment)

experiences since the time you began participation in the research
project.
As a result of mv loss. I have experienced the following (check all

that a p ply):
guilt _____ sadness
hopelessness _____ anger
fear _____ difficulty concentrating
anxiety _____ a lack of social support
marital distress _____ headaches
stomach distress
support from friends, family, etc. (please describe)
Do you feel that vour participation in the research project helped

you? _____ yes no
If applicable, do you feel that your spouses1 participation in the

research project
helped you? _____ yes _____ no
If applicable, do you feel that your spouses' participation in the

research project helped
her/him? _____ yes no
Self-Experience Checklist
52
(Follow-up)

experiences since the time your participation in the research
project ended.
As a result of mv l o s s . I have experienced the following (check all

that apply):
guilt _____ sadness
hopelessness _____ anger
fear _____ difficulty concentrating
anxiety _____ a lack of social support
marital distress _____ headaches
stomach distress
social support from family, friends, etc. (please describe)
Do you feel that vour participation in the research project helped

you? _____ yes no
If applicable, do you feel that your spouses1 participation in the

research project
helped you? _____ yes no
If applicable, do you feel that your spouses' participation in the

research project helped
her/him? _____ yes no
Appendix 6
Structured Interview
53
54
Structured Interview
Code Number: ________________________________

DOB: _______
Marital Status:
Gender:
Type of loss:
a. pregnancy related -
explain: gestational age, cause (if known), gender (if
known), number of previous losses
b. child (must have been born alive) -
explain: age, cause, gender, number of previous losses
c. date of occurrence
Explain any history of conception complications:
Explain any involvement with medical and or mental health agencies

regarding the loss:
Explain the type and use of any medication prescribed during the
pregnancy and/or following the loss:
Explain any involvement with support groups:
Number of living children:

age:
gender:
health status:
Appendix C
H um an Subjects Institutional Review Board Approval
55
Human S u b jects Institutional Review Board
616 387-8293
56
W e s te r n M ic h ig a n U n iv e r s it y
Date: June 27, 1994
To: Michelle Rosa
From: Kevin Hollenbeck, C hair 'fsf'f k-
Re: HSIRB Project N um ber 94-04-04
This letter will serve as confirmation that your research project entitled "Perinatal loss: An
exposure-based approach for alleviating feelings of grief in bereaved parents" has been approved
under the full category of review by the Human Subjects Institutional Review Board. The
conditions and duration of this approval are specified in the Policies of W estern Michigan
University. You m ay now begin to implement the research as described in the application.
You m ust seek reapproval for any changes in this design. You m ust also seek reapproval if the
project extends beyond th e term ination date.
The Board wishes you success in the pursuit of your research goals.
Approval Termination: June 27, 1995
xc: Burnette, Psych.
SEP-28-1995 09:53 FROM UMU U P RESEARCH TO 914052713265 P .02
Human Subjects institutional Review Board Kalamazoo. M ichij^ 49008-3899

616387-8293
t t .' s
W es te r n M ic h ig a n U n iv e r s it y
Date: June 21. 1995 ^
To: Rosa, Michele L.
From: Richard Wright. Interim Chair
Re: Old HSIRB Project Num ber 94-04-04

New HSRIB Project Number 95-06-17
This letter will serve as confirmation that an extension to your research project entitled "Perinatal
loss: An exposure-based approach for alleviating feelings of grief in bereaved parents" has been
granted by the Human Subjects Institutional Review Board. The conditions and duration of this
approval are specified in the Policies of Western Michigan University. You may now continue to
implement the research as described in the original application.
You must seek reapproval for any changes in this design. You m ust also seek reapproval if the
project extends beyond the termination date. In addition if there are any unanticipated adverse or
unanticipated events associated with the conduct of this research, you should immediately suspend
the project and contact the Chair of the HSIRB for consultation.
The Board wishes you success in the continued pursuit of your research goals.
Approval Termination: June 21, 1996
xc: Michele Burnette, Psych.
T rn rai P.
The University of Oklahoma ESfS5; IV/tUs
Health Sciences Center a p p ro v a l d a te : 11/ 02/95
O FF IC E O F R ESEA R C H ADMINISTRATION
D r. H e a t h e r H u s z t i
P e d ia tric s /H e m a to lo g y - O n c o lo g y
CHO 2B265
SUBJ: An E x p o s u r e - b a s e d A p p ro a c h t o A l l e v i a t i n g F e e l i n g s o f G r i e f i n B e r e a v e d P a r e n t s ' .
D ear D r. H u s z t i :
T h e U n i v e r s i t y o f O k la h o m a H e a l t h S c i e n c e s C e n t e r 's I n s t i t u t i o n a l R e v ie w B o a rd r e v i e w e d
t h e a b o v e - r e f e r e n c e d p r o t o c o l a t i t s r e g u l a r l y s c h e d u le d m e e tin g . T he in f o r m e d c o n s e n t
docum ent and th e p r o to c o l a r e h e re b y a p p ro v e d . You m ay b e g i n s u b j e c t e n r o l l m e n t . I t is
t h e B o a r d 's ju d g m e n t t h a t t h e r i g h t s a n d w e l f a r e o f t h e i n d i v i d u a l who m ay b e a s k e d t o
p a r t i c i p a t e in t h i s s tu d y w i l l b e r e s p e c te d ; t h a t th e p ro p o s e d r e s e a r c h , in c lu d in g th e
p r o c e s s o f o b t a i n i n g in f o r m e d c o n s e n t , w i l l b e c o n d u c te d i n a rr-'m ner c o n s i s t e n t w i t h t h e
r e q u i r e m e n t s o f 45 CFR 4 6 , a s a m e n d e d ; a n d t h a t t h e p o t e n t i a l b e n e f i t s t o s u b j e c t s a n d t o
o t h e r s w a r r a n t t h e r i s k s s u b j e c t s m ay c h o o s e t o i n c u r .
As p r i n c i p a l i n v e s t i g a t o r o f t h i s p r o t o c o l , i t i s y o u r r e s p o n s i b i l i t y t o i n s u r e t h a t t h i s
s t u d y i s c o n d u c te d a s a p p r o v e d b y t h e B o a r d . A ny m o d i f i c a t i o n s t o t h e p r o t o c o l o r c o n s e n t
fo r m , i n i t i a t e d b y y o u o r b y t h e s p o n s o r , w i l l r e q u i r e p r i o r a p p r o v a l , w h ic h y o u may
r e q u e s t i n a n a m en d m en t l e t t e r o r m em orandum t o m e. A l l s t u d y r e c o r d s , i n c l u d i n g c o p i e s
o f s i g n e d c o n s e n t f o r m s , m u s t b e r e t a i n e d f o r t h r e e (3) y e a r s a f t e r t e r m i n a t i o n o f t h e
stu d y .
I t i s a c o n d i t i o n o f t h i s a p p r o v a l t h a t y o u r e p o r t p r o m p t l y t o t h e B o a rd a n y s e r i o u s , u n
a n t i c i p a t e d a d v e rs e e f f e c t s e x p e rie n c e d b y s u b j e c ts i n th e c o u rs e o f t h i s r e s e a r c h ,
w h e th e r o r n o t t h e y a r e d i r e c t l y r e l a t e d t o t h e s t u d y p r o t o c o l . T hese a d v e rs e e f f e c t s
i n c l u d e , b u t m ay n o t b e l i m i t e d t o , a n y e x p e r i e n c e t h a t i s f a t a l o r im m e d i a te l y l i f e -
th r e a te n i n g , i s p e rm a n e n tly d i s a b l i n g , r e q u i r e s (o r p ro lo n g s ) i n p a t i e n t h o s p i t a l i z a t i o n ,
o r i s a c o n g e n i t a l a n o m a ly , c a n c e r o r o v e r d o s e . F o r m u l t i - s i t e p r o t o c o l s , t h e B o a rd m u s t
b e in f o r m e d o f s e r i o u s a d v e r s e e f f e c t s a t a l l s i t e s .
The a p p ro v a l g r a n t e d h e r e i s e f f e c t i v e f o r on e y e a r . S h o u ld y o u w is h t o m a i n t a i n t h i s
p r o t o c o l i n a n a c t i v e s t a t u s b e y o n d t h a t d a t e , y o u w i l l n e e d t o p r o v i d e t h e B o a rd w i t h
a p r o g r e s s r e p o r t s u m m a r iz in g s t u d y r e s u l t s t o d a t e . IRB s t a f f i n t h e O f f i c e o f R e s e a r c h
A d m i n i s t r a t i o n w i l l r e q u e s t t h a t p r o g r e s s r e p o r t fro m y o u a p p r o x i m a t e l y t e n w e e k s b e f o r e
th e a n n iv e r s a ry d a te o f y o u r c u r r e n t a p p ro v a l.
I f y o u h a v e q u e s t i o n s a b o u t t h e s e p r o c e d u r e s , o r n e e d a n y a d d i t i o n a l a s s i s t a n c e fro m t h e
B o a r d , p l e a s e c o n t a c t IRB s t a f f . F in a l ly , p le a s e re v ie w y o u r p r o f e s s i o n a l l i a b i l i t y
i n s u r a n c e t o m ake s u r e y o u r c o v e r a g e i n c l u d e s t h e a c t i v i t i e s i n t h i s s t u d y .
S in c e r e ly y o u rs,
L a u r a I . R a n k in , M.D.
C h a i r , I n s t i t u t i o n a l R e v ie w BoanSea Box 26901 1000 S.L. Young Blvd., Room 121
Oklahoma City, Oklahoma 73190 (405) 271-2090 FAX (405) 271-8651
BIBLIOGRAPHY
Alessi, G. (1992). Models o f proximate and ultimate causation in psychology.

American Psychologist. 4 7 . 1359-1370.
Beck, A., & Steer, R. (1987). Beck Depression Inventory M anual. The Psycho
logical Corporation. San Antonio: H arcourt Brace Jovanovich.
Beck, A., & Steer, R. (1988). Beck Hopelessness Scale M anual. The Psycho
logical Corporation. San Antonio: H arcourt Brace Jovanovich.
Bowlby, J. (1977). The making and breaking of affectional bonds, Parts I and II.
British Journal of Psychiatry. 130. 201-210, 421-431.
Bowlby, J. (1980). A ttachm ent and loss: Loss, sadness and depression. Vol. III.
New York: Basic Books.
Brasted, W., & Callahan, E. (1984). A behavioral analysis of the grief process.
Behavior Therapy. 15. 529-543.
Callahan, E. J., Brasted, W. S., & Grandos, J. L. (1983). Fetal loss and sudden
infant death: Grieving and adjustment for families. Life-span developmental
psychology: Nonnormative life events (pp. 145-166). Academic Press, Inc.
Callahan, E. J., & Burnette, M. M. (1989). Intervention for pathological grieving.

The Behavior Therapist. 12. 153-157.
Condon, J. T. (1986). M anagement of established pathological grief reaction

after stillbirth. American Journal of Psychiatry. 143:8.
Cullberg, J. (1972). M ental reactions of women in perinatal death. Psycho

somatic Medicine in Obstetrics and Gvnecologv. 326-9.
Degrogatis., L. (1975). Symptom Checklist-90-R. Minneapolis, MN: National

Computer Systems.
Dyregrov, A., & Matthiesen, S. (1987). Similarities and differences in mothers

and fathers grief following the death of an infant. Scandinavian Journal of
Psychology. 28. 1-15.
59
Editorial. (1987). Journal o f the Canadian Medical Association. 9 7 .1296.
Giles, P. F. (1970). Reactions of women to perinatal death. Australian New

Zealand Journal of Obstetrics and Gvnecologv. 10. 207-210.
Hamilton, P., Roney, P., Keppel, K., & Placek, P. (1984). Radiation procedures
perform ed on U.S. women during pregnancy. Public H ealth Reports. 99.
146-151.
H arr, B. D., & Thestlethwaite, J. E. (1990). Creative intervention strategies in

the management of perinatal loss. Maternal-Child Nursing Journal. 1 9 .135-
142.
Hopkins-Hutti, M. (1988). Perinatal loss: Assisting parents to cope. Journal of

Emergency Nursing. 14. 338-341.
Hughes, C., & Page-Lieberman, J. (1989). Fathers experiencing a perinatal loss.

D eath Studies. 13. 537-556.
Hunfeld, J., Wladimiroff, J., Verhage, F., & Passchier, J. (1995). Previous stress
and acute psychological defence as predictors of perinatal grief - An
exploratory study. Social Science and Medicine. 40. 829-835.
Jureidini, J. 11993). Obstetric Factitious D isorder and M unchausen Syndrome

by Proxy. Journal of Nervous and Mental Disease. 1 8 1 .135-137.
Kellner, K. R., Kirkley Best, E., Chesborough, S., Donnelly, W., & Green, M.
(1981). Perinatal mortality counseling program for families who experience
a stillbirth. D eath Education. 5, 29-35.
Kennell, J. H., Slyter, H., & Klaus, M. H. (1970). The mourning response of
parents to the death of a newborn infant. New England Journal of Medicine.
283. 344-348.
Kirkley-Best, E., & Kellner, K (1982). The forgotten grief: A review of the
psychology of stillbirth. American Journal of Orthopsychiatry. 53. 420-429.
Kubler-Ross, E. (1970). On D eath and Dying. London: Tavistock.
LaRoche, C., Lalinec-Michaud, M., Engelsmann, F., Fuller, N., Copp, M.,
McAuade-Soldatos, L., & Axima, R. (1984). G rief reactions to perinatal
death - A follow-up study. Canadian Journal of Psychiatry. 29. 14-19.
61
LaRoche, C., Lalinec-Michaud, M., Engelsmann, F., Fuller, N., Copp, M., &
Vasilevsky, K. (1982). G rief reactions to perinatal death: An exploratory
study. Psvchomatics. 23. 510-518.
Lasker, J., & Toedter, L. J. (1991). Acute versus chronic grief: The case of
pregnancy loss. American Journal of Orthopsychiatry. 61 (4).
Leon, I. (1986). The invisible loss: The impact of perinatal death on siblings.
Journal of Psychosomatic Obstetrics and Gvnecologv. 5>, 1-14.
Leon, I. (1987). Short-term psychotherapy for perinatal loss. Psychotherapy. 24.

186-195.
Leon, I. (1992). The psychoanalytic conceptualization of perinatal loss: A multi

dimensional model. American Journal of Psychiatry. 149(111. 1464-1472.
Lindemann, E. (1944). Symptomatology and management of acute grief.

American Journal of Psychiatry. 1 0 1 .141-148.
Maddison, D., & Walker, W. (1967). British Journal of Psychiatry. 1 1 3 .1057.
Marks, I. (1987). Fears. Phobias, and Rituals. New York: Oxford University
Press.
Masters, J., Burish, T., Hollon, S., & Rimm, D. (1987). Response elimination and
extinction procedures. In Behavior Therapy: Techniques and empirical
findings, third ed. H arcourt Brace Jovanovich.
Mawson, D., Marks, I. M., Ramm, L., & Stem, R. S. (1981). Guided mourning
for morbid grief: A controlled study. British Journal of Psychiatry. 138.185-
193.
Miron, J. & Chapman, J. S. (1994). Supporting: M ens experiences with the

event of their partners miscarraige. Canadian Journal of Nursing Research.
26, 61-72.
National Center for H ealth Statistics. (1993). Personal communication.
Peppers, L. G. & Knapp, R. J. (1980). M otherhood and mourning: Perinatal

death. New York: Praeger.
Porter, JfpHunter-Mitchell, J., Jick, H., & Walker, A. (1986). Drugs and
stillW fh. American Journal of Public Health. 7 6 .1428-1431.
62
Potuin, L., Lasker, J., & Toedter, L. (1989). Measuring grief: A short version of
the Perinatal G rief Scale. Journal of Psychopathology and Behavioral Assess
m e n t 11. 29-45.
Prager, K., Malin, H., Spiegler, D., Van Nattu, P., & Placek, P. (1984). Smoking
and drinking behavior before and during pregnancy of married mothers of
live-born infants and stillborn infants. Public H ealth Reports. 9 9 .117-127.
Ramsey, R. W. (1979). Bereavement: A behavioral treatm ent of pathological

grief. In P. O. Ssgoden, S. Bates, & W. S. Dockens (Eds.), Trends in
Behavior Therapy. New York: Academic Press. 214-248.
Raphel-Leff, J. (1991). Psychological Processes of Childbearing. New York:

Chapman & Hall.
Savitz, D., W helan, E., & Kleckner, R. (1989). Self-reported exposure to pesti
cides and radiation related to pregnancy outcome: Results from National
Natality and Fetal M ortality surveys. Public H ealth Reports. 104. 473-477.
Sireling, L., Cohen, D., & Marks, I. (1988). Guided mourning for morbid grief:
A controlled replication. Behavior Therapy. 19. 121-132.
Spielberger, C. (1983). Manual for the State-Trait Anxiety Inventory. Consult

ing Psychologists Press.
Swanson-Kaufmann, K. (1986). Caring in the instance of an unexpected early

pregnancy loss. Topics in Clinical Nursing. 8, 37-46.
Theut, S., Pedersen, F., Zaslow, M., Cain, R., Rabinovich, B., & Morihisa, J.
(1989). Perinatal loss and parental bereavement. American Journal of
Psychiatry. 146(5).
Theut, S., Pedersen, F., Zaslow, M., & Rabinovich, B. (1988). Pregnancy subse
quent to perinatal loss: Parental anxiety and depression. American Academy
of Child and Adolescent Psychiatry. 27. 289-292.
Theut, S., Zaslow, M., Rabinovich, B., Bartko, J., & Morihisu, J. (1990). Resolu
tion of parental bereavem ent after a perinatal loss. Journal of the American
Academy of Child and Adolescent Psychiatry. 29(4), 521-525.
Vance, J., Najman, J., Thearle, M., Embelton, G., Foster, W., Boyle, F. (1995).
Psychological changes in parents eight months after the loss of an infant from
stillbirth, neonatal death, or sudden infant death syndrome - A longitudinal
study. Pediatrics. 96. 933-938.

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Western Michigan University

Perinatal Loss: An Exposure Based Approach to

Follow this and additional works at: http://scholarworks.wmich.edu/dissertations

Michele Lee Rosa

W estern Michigan University

Michele Lee Rosa, Ph.D.

W estern Michigan University, 1996

The efficacy of exposing bereaved parents to stimuli associated with their

measures of depression, hopelessness, anxiety, marital functioning, daily stress,

psychopathology, bereavem ent and grief were gathered.

jects on measures of depression and psychopathology. All subjects showed im

proved marital functioning. Negative change was seen on a measure of hopeless

loss are discussed.

The quality of this reproduction is dependent upon th e quality of the

Oversize materials (e.g., maps, drawings, charts) are reproduced by

Photographs included in the original manuscript have been reproduced

All rights reserved.

UMI Microform 9623734

This microform edition is protected against unauthorized

dissertation. First, to the members of my committee, Drs. M. Michele Burnette,

Galen Alessi, Patricia Meinhold, and Kevin Armstrong. I extend my sincere

appreciation for their guidance and support.

Second, to my immediate family members who continuously provided both

emotional and monetary support, as well as encouragement: my father, Charles

M. Rosa; my m other, D olores A. Rosa (Giacomo); and my younger sister, Gina

M. Rosa. I thank my entire extended family for their willingness to share in my

Third, to the faculty members at the Childrens Hospital of Michigan

University of Oklahoma H ealth Sciences Center (especially, Dr. C. Eugene

W alker) and The Childrens Hospital of Oklahoma (especially, Drs. H eather

permission to collect dissertation data while also completing my internship and

Finally, I thank my high school English teacher, Ms. M aureen Carney

criticism of my writing abilities.

Michele Lee Rosa

ACKNOW LEDGM ENTS .................................................................................... ii

Causes of Perinatal L o s s ..................................................................... 1

The Impact of Perinatal Loss ............................................................3

Treatm ent Is s u e s ..................................................................................10

Characteristics and History ....................................................... 19

M ate ria ls.........................................................................................21

Experimental S e ssio n s.................................................................25

Scoring and A n a ly sis.......................................................................... 27

Daily S tre ss .............................................................................33

M aternal Bereavement ......................................................................33

M arital Relations ............................................................................... 38

Participant R eport .............................................................................42

A. Self-Experiences Questionnaire .............................................................. 49

B. Structured In terv iew .................................................................................... 53

C. H um an Subjects Institutional Review Board Approval ..................... 55

1. Summary of Subjective D ata ........................ 43

1. Scores on Beck Depression Inventory ...................................................... 30

2. Scores on Beck Hopelessness S c a l e ........................................................... 31

3. Scores on SCL-90-R ...................................................................................... 32

4. Scores on Daily Stress Inventory ................................................................ 34

5. Scores on Perinatal Bereavement Scale(M others O n ly ) .......................... 35

6. Scores on Perinatal G rief S c a l e .................................................................. 36

7. Scores on Self-Evaluation Questionnaire - Form Y -l ............................. 37

8. Scores on Dyadic Adjustment S c a l e ........................................................... 39

9. Scores on Dyadic Adjustment Subscales - Subject # 1 ................... 39

10. Scores on Dyadic Adjustment Subscales - Subject # 2 ................... 40

11. Subjective Units of Disturbance - Subject # 1 .................................. 41

12. Subjective U nits of Disturbance - Subject # 2 .................................. 41

13. Subjective Units of Disturbance - Subject # 3 .................................. 42

cesses (Bowlby, 1977,1980; Kubler-Ross, 1970; Lindeman, 1944). M ore specific,