Good Grief
When a first pregnancy is welcomed by parents, the mind and body become fully engaged. Beyond the physiological and perhaps lifestyle changes of women, the hearts and minds of potential parents become wrapped up in fantasies of caring for a baby, searching for baby clothes and furniture, or imagining taking their child to the zoo or on other fun outings. Pragmatic considerations such as whether a woman will continue working after the child is born, financial planning, and planning the baby’s room are also often thought out.
Unexpected pregnancy loss, however, can result in disenfranchised grief, loss of knowing what to do next, or how to carry on. Even in light of the support of well-meaning others, a woman and her partner are faced with negotiating grief and loss.
Morgan and Asher
I first met Morgan and her husband Asher in the hospital. Morgan had just given birth to stillborn twins. The couple were in shock and disbelief following a traumatic series of events owing to twin-to-twin transfusion syndrome (TTTS). TTTS is common in up to 90 percent of women carrying identical twins who share a single placenta. Loss of one or both twins is common in up to 90 percent of women expecting identical twins if TTTS occurs prior to 24 weeks’ gestation. In one third of cases, when one baby is lost, the other will also be lost.11
Emotionally vulnerable and physically weak, Morgan and Asher shared what happened in a series of events leading up to the birth. First, Morgan underwent surgery in the hope of correcting the TTTS. However, the smaller of the twins failed to thrive. Then, in the hope of saving the larger twin, Morgan required a second emergency surgical procedure. However, the second twin died and Morgan simultaneously fell seriously ill. A week later, Morgan gave birth to stillborn twins.
Although Morgan and Asher understood the situation, it was devastating to come to terms with. Trying to make any sense of it seemed futile and the efforts of well-meaning others brought little solace. Asher was at a loss of how to be with Morgan, and Morgan was experiencing the raw pain and disconnect between her mind and body that seemed to be crying out: “You’ve given birth, now where are your babies?” As her emotions deteriorated, Morgan felt she was moving “numbly on a journey without a road map.” Adding to their confusion were feelings of disenfranchised love and awe for their twins who they would never get to know. Morgan and Asher left the hospital filled with grief as their dreams of parenthood were shattered and replaced by the need to plan a funeral.
A breath at a time, a step at a time…
In the early sessions, I introduced mindfulness skills and particularly breath work to calm Morgan and Asher’s anxiety and help them begin to come to terms with the traumatic events in their lives. Breath work provided Morgan with a skill for calming an acute, overactive stress reaction to post-pregnancy hormones, as well as the loss. Our mantra for therapy became “one breath at a time, one step at a time,” and this set the stage for working toward a psychologically safe space in which to allow painful emotions to surface and be explored, expressed, and unpacked through art. The process was slow, moving at a pace that enabled Morgan to gradually come to terms with what had happened. On several occasions we just sat quietly together, Morgan, Asher and I, or just Morgan and I. There were several instances where, midway through her story, she stopped to take a few deep breaths to gain composure.
Morgan’s early artworks attest to a range of shock, panic, anger, and grief. But a short while later, these early drawings became almost transparent, faint in line and color, echoing the multifaceted feelings of disconnect that resulted from the stillbirth (loss of the babies, her identity as an expectant mother, knowing how to be in the world). Despite many supportive family members and friends, Morgan chose to distance herself, particularly as a number of her friends were expecting, including one who was pregnant with twins. By keeping with the slow and open pace of mindfulness, Morgan was able to just be present with whichever emotion she was swept up in at the time. With mindful attunement, we met each one, turning gently toward the emotion with breathing and guided meditation as our entry point to explore it further.
As the grief process gradually began to unfold over the next few months, Morgan explained: “It’s like more layers of shock peeling away…[in] a problem that can’t be solved.” She missed being pregnant as well as the anticipation of motherhood, and her artworks during this period were more organic, symbolizing various phases of pregnancy that she had been forced to bid farewell to. These works pertaining to herself were mingled with others highlighting Morgan’s ever present awareness of her friends’ advancing pregnancies. This was taking its toll on her, yet all the while Morgan never lost hope that she would fall pregnant again.
Over time, Morgan began to build her strength and functioning reasonably well by eating healthy food, exercising, and cultivating a mindful relaxation practice. At this point, she began to connect with a handful of close friends, though saying “When I leave them, I still go home to what happened.” She was never able to escape it, and as feelings of numbness gradually gave way to anger and feelings of betrayal, there was a shift in her style of art, which went from faint transparencies to bold, bellowing kinesthetic images. The verbal descriptions that accompanied these images were equally intense, highlighting the mind–body connection through her capacity to express her anger both visually and verbally through the method. Although the intensity of Morgan’s anger subsided at times, it remained like an undercurrent and would crescendo from time to time.
Morgan announced one day that the hospital auxiliary group had given her a box with “a lot of memorabilia” at the time of the stillbirth; knitted outfits, hats, photos, teddy bears, and the like. Although Morgan seemed on the one hand to want to search for it, she wasn’t ready. And even if she did find the box, she wasn’t quite sure what to do with it, now that the girls were gone. We agreed that if Morgan did find the box and wanted to bring it or any of the items to therapy, she was welcome to do so.
However, a few weeks later Morgan announced with a mixture of excitement and trepidation that she was pregnant again. When we began to explore what a healthy pregnancy might look like, Morgan was drawn back to the twins and felt torn between the two pregnancies. Although Morgan and Asher were delighted about the new pregnancy, Morgan did not want to become dismissive and “forget the girls,” nor did she want to announce her pregnancy to others in case something went wrong or “they might forget the girls, or what happened.” In light of her ambivalence, it was essential to devote time to both aspects, and so this phase of therapy was focused mindfully and artfully in part on remembrance of the girls and in part on assisting Morgan to be present with her current pregnancy.
A few weeks after announcing her pregnancy, Morgan arrived with a large plastic box filled with memorabilia for the twins. As Morgan fished through an assortment of footprints on paper, teddy bears and the like, she pulled out two outfits, one for each of the girls. As she did so, we lay them side by side in a collage of sorts, giving Morgan the opportunity to speak about each of the girls separately. When she was finished, Morgan produced a photograph of herself and Asher, holding the twins. This seemed to be the most confronting, but as she placed the photo behind the outfits, it was almost as though the whole picture became complete. Even so, there was a pivotal moment where Morgan seemed less hijacked by her emotions and more able just to talk about them. The collage seemed to dissolve anger and despair, and suspend us in the presence and fullness of the crisis as Morgan shared the details of it in greater depth than before. She recalled moments of joy in her retelling of giving birth, followed by the shock and heartbreak of the twins’ deaths. She also recalled what others said and did, their concern for Morgan’s health, and the heart-rending aftermath of the funeral.
As remnants of grief mingled with a semblance of peace for the twins, Morgan found her way back to her advancing pregnancy, and the prospect of a healthy pregnancy and motherhood. But this was not to be; despite an apparently healthy pregnancy, and for unexplained medical reasons, Morgan gave birth to another stillborn baby girl. The shock and disbelief sent Morgan and Asher back to the raw grief that was already too familiar to them. Another stillbirth, another funeral: when I visited them in hospital, they were both operating from a state of survival and coping.
When Morgan returned to therapy, her anguish was palpable. She said she was “just surviving. It all feels like part of a single experience [the loss of the twins, the loss of the recent baby]…it’s all too familiar…like a recurring nightmare…it’s like the new grief is eclipsing the inner peace that I began to feel for the twins.” In an effort to sort things out in her mind, she announced that she needed cognitive behavioral therapy (CBT). However, in keeping with our therapeutic approach to take things “a breath at a time, a step at a time,” we began with a short period of guided relaxation, in which Morgan could stop and draw at any point in time if she chose to do so. We used this process for approximately ten minutes, in which Morgan went from moments of calm to audible bursts of magic marker on paper that culminated in 25 words strewn randomly across the page.
As we worked through the words that stood out most to Morgan, she began to see how her anguish and resilience were competing for headspace. Morgan reflected:
I recognize the negative self-speak now…and how I begin to spiral downwards…I saw it yesterday…I recognized the difference. Then I had to rebuild myself with things like, “you are worth it…you need to drop the fear and anger.” I was trying to pull myself out of it with positive self-talk.
But having already tried to make sense logically of traumatic events in her mind, Morgan found CBT ineffective in helping her change how she felt. Even in light of these conventional attempts to bolster resilience logically through positive self-talk, fear and anger continued to bubble under the surface. As such, we moved on to an ACT protocol, which Morgan was already familiar with. This was not going to make her fear and anger go away, but it provided Morgan with an opportunity to change her relationship to her feelings. Using the ACT hexaflex (Harris, 2009), we found a mindful way forward to address the reality gap (Harris, 2012) without Morgan feeling bogged down by painful thoughts or emotions. We continued with this protocol for the next few months.
Understanding the importance of Morgan’s readiness to confront emotional pain necessitated moving through therapy “a breath at a time, a step at a time.” This is not to say that we do not attempt to do this with all clients, but the phrase has been repeated throughout the case study to illustrate that in the face of repeated trauma, there was a need to proceed slowly and compassionately to avoid being swept up by the drama.
In Morgan and Asher’s case, emotional trauma continued to unfold throughout the course of therapy. In light of this, it was necessary to shape therapy as we proceeded in order to maintain a psychologically safe environment in which Morgan could allow for her emotional frailty. With the mindfulness tools of breathing and guided meditations providing a calm entry point in which to explore painful emotions openly, compassionately and non-judgmentally (Hanh, 1999), art provided opportunities to shape experience (Levine, 2005), and mindfully appraise it with compassion (Kashdin and Ciarrochi, 2013). As difficult as it was for Morgan not to get emotionally hijacked by her feelings, she cultivated a daily mindfulness practice outside of therapy. She listened regularly to guided meditations or apps for relaxation, and she introduced them as best she could in real time, when caught up in the reactive phase of her emotions.
Reflecting on the trajectory of her art tasks, we can see how the nature of Morgan’s emotions directly related to how and what she drew, wrote or created in the fullness and immediacy of moment. In the vein of needing to “shift gears” (Wadeson, 1987) with appropriate therapeutic art tasks, we were able to meet the traumatic burdens of shock and anguish along the way. In addition, because emotional memory functions well in helping clients shape their experience through art (Levine, 2005), both contemplative and cognitive mindfulness methods helped to facilitate the inward focus and remain open in the reflexive dialogue. Furthermore, the interface of creating a therapeutic space of psychological safety proved to be a significant element in shaping therapy through the core conditions of empathy, congruence, and positive regard.
Whereas drawing initially provided Morgan with a cathartic release for overwhelming emotions, it also brought order to chaos through form, color, and shape in her artworks (McNiff, 2004). Metaphorically, these were played out in transparent images when feeling “lost,” and bold visual outbursts when experiencing intense periods of anger. As constructions of re-experiencing what she was feeling at the time, the tangible nature of these images enabled Morgan to stop and reflect, even if only momentarily, on the course of her grief.
The immediacy and openness of writing out her thoughts after the second stillbirth served a similar purpose in helping Morgan authentically confront both her emotional frailties and inner strengths (Pennebaker, 2004). In keeping with Morgan’s propensity to “think things through” however, the CBT protocol fell short in helping her appraise the emotional memories that vied for her attention. But in this instance, the ability to reflect on her cognitions, emotions, perceptions, and sensations simultaneously (metacognition) through mindfulness (Kashdin and Ciarrochi, 2013) enabled Morgan to contextualize the crises within her resilience and hope.
The rich, corrective experience of the memorabilia collage added a further layer of integrative power to both the existence and the loss of the twins. It was during this art task that Morgan could begin to address the mind and body disconnect she had been grappling with (Frost, 2010). The box in some ways seemed to mirror the womb, and served as a tangible context for beginning to make peace with what happened.
On the whole, mindful art therapy provided Morgan with an anchor and signpost for being with the unpredictable nature of her trauma and grief. As a therapist, it was a privilege to provide a safe psychological space and, in keeping with the sentiments of Coryell (2007), “It is…a great honour to sit with people and share the burden of grief we all must carry at certain moments of our lives and so often alone (p.108).” Morgan chose to have her case study shared here in the hope that it would guide therapists or other parents of stillborn children, and perhaps help normalize their experience.
Morgan has since given birth to a healthy baby boy.
1See http://www.tttsfoundation.org for more information.
