Journal of Substance Abuse Treatment, Printed in the USA. All rights reserved.
Vol. 9, pp. 149-152,
1992 Copyright
0
0740-5472/92 $5.00 + .OO 1992 Pergamon Press Ltd.
BRIEF REPORT
Maternal Bereavement in the Perinatal Substance Abuser
VALERIE D. RASKIN,
MD ’
University of Illinois at Chicago
Abstract--Maternal bereavement has been reported in involuntary perinatal loss and voluntary custody relinquishment. Since child custody loss is common among childbearing chemically dependent women, maternal bereavement was investigated in a small pilot sample of obstetric substance abusers. Findings suggest that grief in anticipation of possible postnatal custody loss is common. Unresolved grief from previous custody loss was also common. Clinical features, treatment considerations, and public health concerns are discussed. Keywords-maternal
bereavement;
perinatal
substance
INTRODUCTION
abuser.
BACKGROUND:
MATERNAL BEREAVEMENT
Mourning may result from the loss of a loved person or from an ideal or abstraction (Freud, 1917). The involuntary loss of custody and/or caretaking responsibility for one’s children due to child abuse or neglect is common among pregnant chemically dependent women (Mackie-Ramos, & Rice, 1988). The loss of custody of one’s children is at once both the loss of a loved person and the loss of an abstraction. One loses one’s baby or child(ren) and one’s ideal image of oneself as a competent mother. Mothers who lose babies due to miscarriage, stillbirth or neonatal death show characteristic signs of what has been termed “maternal bereavement.” Involuntary perinatal loss often results in persistent preoccupation with the lost baby, guilt, anger, selfrecrimination, sadness, and fantasies about how life would be were the baby alive (Kirkley-Best, & Kellner, 1982; Kennel, Slyter, & Klaus, 1970). Late perinatal loss is associated with more intense maternal bereavement relative to early loss (Theut et al., 1989), and previous perinatal loss often has a profound impact on the psychological experience of subsequent pregnancy (Cohen, 1988). Perhaps not surprisingly, mothers who have given up infants for adoption also describe psychological distress which can be recognized as maternal bereavement. Persistent grief-up to 35 years without satisfac-
THE NEGLECT OF GENDER SPECIFIC IWJES for chemically dependent women has been well described (Blume, 1990; Griffin, Weiss, Mirin, & Lange, 1989). The very great stigma associated with women’s chemical dependence, the high prevalence of prior sexual victimization, physiologic differences, and unique patterns of psychopathology have all been identified as important areas requiring further investigation. Issues of gender specific consequences of substance abuse, in particular, how such consequences relate to the course of women’s chemical dependence, have received even less attention (Nichols, 1985). This paper will describe one such phenomenon seen in pregnant chemically dependent women: anticipated and past loss of child custody as a consequence of substance abuse.
Requests for reprints should be addressed to Valerie D. Raskin, MD, Department of Psychiatry (mc 913), University of Illinois at Chicago, P.O. Box 6998, Chicago, IL 60680. Presented in part at the Annual Meeting of the American Psychiatric Association, May, 1991, New Orleans. This research was supported by the National Institute of Drug Abuse grant #5R18 DA 06378-02. The author thanks Karen Sobieraj, Nada Stotland and Anne Seiden for helpful advice, and Queenie Mendonca for secretarial assistance. ‘Dr. Raskin was formerly with Cook County Hospital, Chicago, Illinois.
149
IS0
KD. Raskin
tory resolution-has been reported in women who voluntarily relinquished babies for adoption (Condon, 1986a). The lack of social validation of the loss or customary mourning rituals seen after perinatal death is even greater for relinquishing mothers, who keep the loss “shrouded in secrecy and shame” (Millen and Roll, 1985). Since involuntary custody loss is also a source of shame, maternal bereavement in the substance abuser may be underrecognized and its impact underestimated. To investigate whether maternal bereavement due to custody loss is of significance clinically in the perinatal substance abuser, pilot data were collected from clinical interview and chart review of a small sample at a large urban hospital. Demographic data, clinical findings and case vignettes will be described.
METHOD The author interviewed 15 pregnant (n = 10) or newly delivered (n = 5) women referred for substance abuse consultation from the obstetric service of Chicago’s only public hospital. Such patients are routinely referred for psychiatric consultation at this hospital, when identified. Aspects of maternal bereavement were discussed with each patient as part of an overall psychiatric assessment and intervention. In addition to patient interviews, charts were consulted for collateral or confirmatory data about obstetric history and social history including contact between hospital staff and the state child protective agency. RESULTS Demographics The patients were all low socioeconomic status residents of Chicago’s inner city. Two were in post-secondary school training (one university, one for-profit technical school); none were employed outside of homemaking and/or illegal activities. One patient was 22 weeks pregnant at the time of admission. The remaining 9 pregnant patients were in the third trimester. The postpartum patients were interviewed between 1 day and 3 weeks postpartum. The women were primarily multiparous (average gravidity = 4.2, range 1 to 7). Two patients were primiparous. Findings Of the mothers, 93.3% (14/15) reported being worried that their baby/fetus might be taken from their custody because of maternal substance abuse. All (15/l 5) had heard about (through media coverage and/or street talk) legal sanctions for substance abusing pregnant women including custody loss of newborns, but none were able to accurately describe the legal basis for a mandatory state child protective service report (positive newborn toxicology).
Of the 13 multiparous chemically dependent women, 92.3% (12113) had lost custody or caretaking responsibility for one or more children for some period of time. These included permanent involuntary custody loss with custody assumed by the state (n = 6), temporary custody loss with the mothers currently retaining custody but remaining actively monitored by the state agency (n = 3), caretaking relinquished to a family member (n = 2), and no prior loss but temporary loss of the newborn pending further agency investigation and judicial review (n = 1). Among the women who had lost custody to the state, the average number of children lost was 3 (range 2-5). Of the 5 postpartum women, 4 (80%) had mandatory reports made to state protective service for positive newborn toxicologies with custody hearings pending. Clinical Features All 15 patients had clinical symptoms of grief related to past or anticipated custody loss. These included preoccupation with the lost child(ren), sadness, rumination, and yearning for reunion. Many features of maternal bereavement in the special circumstance of custody loss were typical. The patients in this sample generally felt that the loss of custody of their children (whether to the state or to a family member) was a great personal tragedy. Several carried photographs of their child(ren) taken prior to custody loss. Ongoing fantasies about the child’s activities and development and fantasies about parenting the lost child were described. Several reported anniversary reactions including private observation of the child’s birthday. The dynamic relationship between maternal bereavement and subsequent pregnancy described in other instances of maternal bereavement was also seen here. Parents who have experienced perinatal loss often report holding back emotional attachment to the subsequent fetus until the perceived period of threatened loss has passed (i.e., first trimester following miscarriage). A related example is described. Ms. A., an intranasal heroin abuser, delivered an apparently healthy fourth child, 18 months after her third baby was temporarily removed from her custody as a neonate when he tested positive for heroin. She described the several weeks when she lost custody of that child as “terrible,” and attributed “postpartum blues” and an increase in her heroin use to her distress during the custody investigation. She predicted that she and this new baby would test negative, yet she did not name her new daughter and knew that “the judge is harder second time around.” At 36 hours postpartum, the author was present in the patient’s room meeting with another patient when Ms. A was informed by the obstetrics social worker that this baby also tested positive for heroin, and that the state child welfare had temporarily taken custody pending investigation. The mother, who had been noticeably affectionate and responsive to her infant, immediately left the room leaving the child unattended in a bassinet. She sub-
Maternal Bereavement in the Perinatal Substance Abuser sequently refused to pick her up or name her until the judicial hearing and custody determination was made.
Several mothers also noted that the experience of subsequent childbearing reactivates unresolved maternal bereavement. Ms. B, in her late 30’s, was an intravenous heroin- and cocaine-abusing woman who had presented herself to the police requesting treatment after being refused at two treatment programs. The month prior to delivery she was placed on methadone and apparently remained otherwise drug-free. She had permanently lost custody of her 3 other children and wished to keep this baby, in part to “make up” her losses. She reported being “happy but confused” about holding her newborn, often finding herself feeling sad remembering her other babies at this age and missing them “even more than before.”
One key difference in grief symptomatology in maternal bereavement between mothers who suffer perinatal loss and those who lose custody is the nature of guilt and self-recrimination. While guilt and anger are virtually always seen in maternal bereavement, the presence of shame following perinatal death, or persistent rage or blame of others may signify an especially problematic grief reaction in the instance in which the mother has taken ordinary prenatal precautions. For the woman whose substance abuse has led to the loss of custody of her children, the absence of guilt and even shame may signify extreme denial of either her substance abuse or her loss. Unlike perinatal loss, where blame usually cannot be assigned to any one person, custody loss can readily be attributed to a malicious judge, vindictive relative, meddling state child protective caseworker, and so on. The absence of self-recrimination following custody loss in this sample appeared to be associated with one of two pathologic conditions: denial of the loss (e.g., the arbitrary and unfair judge will soon be replaced by a reasonable judge who will immediately return my child), or denial of the consequences of her substance abuse (e.g., since it was someone else’s fault I do not need to change my behavior). DISCUSSION Although this is a small sample, these findings suggest that past and anticipatory grief are both common and worthy of clinical attention in the perinatal substance abuser. Certain treatment and public health considerations are raised and will be discussed further. The findings provide support for more extensive study of the phenomenon of maternal bereavement in the pregnant substance abuser. The principles of the treatment of maternal bereavement in the circumstance of pregnancy and substance abuse is somewhat different than conventional grief therapy. In traditional grief therapy, patients are
I51
supported while encouraged to ventilate the strong affects of anger, sadness, jealousy, and guilt precipitated by the loss (Mawson, Marks, Ramm, 8c Stern, 1981; Condon, 1986b). However, treatment of substance abuse, especially initially, typically avoids interventions which arouse very strong affects until the recovering addicted woman develops alternative means of coping with extremes of emotional distress. The clinician must walk a tightrope, acknowledging the bereaved substance abuser’s loss while monitoring closely for overwhelming affects. The clinician who overemphasizes the addicted woman’s loss risks inadvertently supporting her rationalization of substance use. However, the presence of addiction should not be used to collude with minimization or denial of the painful affect precipitated by custody loss. Ideally, support around the loss can be coupled with confrontation about patterns of coping with distress by substance use, and the specific risks of doing so at this time of vulnerability. A common maladaptive response seen in perinatal loss and voluntary custody loss is rapid subsequent pregnancy in an effort to replace the lost baby (Condon, 1986a; Cain & Cain, 1964). Although this study does not specifically address this phenomenon, the similarities to other features of maternal bereavement suggest that the so-called “replacement baby” phenomenon should be considered in the circumstance of custody loss. The postpartum substance-dependent woman who has recently lost custody of her baby (or who is court ordered to undergo treatment as a condition of maintaining or regaining custody) is at especially high risk. Hopelessness about the possibility of successful treatment may be expressed through rapid pregnancy, if success in treatment is understood to be necessary for reunion. At a minimum, the clinician treating a recently bereaved addicted woman should inquire about the woman’s active or passive intent to become pregnant again, empathically acknowledge the temptation to do so, and offer the suggestion that postponing subsequent pregnancy is likely to help her in her own recovery as well as in coping with her grief. Treatment of the bereaved perinatal substance abuser presents a countertransference minefield. Countertransference attitudes and feelings have a pronounced impact on treatment outcome (Imhof, 1991), and conscious and unconscious hostile or stereotyped attitudes to the “bad mother” are especially common in the treatment of the perinatal chemically dependent woman (Mackie-Ramos & Rice, 1988). With regard to maternal bereavement, countertransference reactions may include overt blame (“she doesn’t deserve to raise such an adorable baby”) and disregard (“how could such a terrible mother have any feelings about losing her baby”). A common countertransference problem is overidentification with or overemphasis on the fetus or baby at the expense of the mother. This manifests as “get clean so that you can get your baby back.”
152 This may be more readily recognized as countertransference if compared to the loss of a driver’s license after driving under the influence of alcohol. A statement such as “get sober so that you can get your license back” would be immediately seen as naive, or, worse, colluding with the patient’s minimization of the addiction. Preferably, the clinician would state something like “of course you want to stop using drugs to get your baby back, but recovery is so difficult that it’s got to be something you want for yourself, to make life better for you.” Recognizing such countertransference attitudes allows the clinician to detect instances in which the patient’s similarly stereotyped ideas about being a good mother are used to bolster resistance. Likewise, the clinician who can recognize his or her own negative attitudes can better empathize with the world in which the patient lives - one which is notably antagonistic to the drug-abusing mother. Addicted mothers not uncommonly have exhausted their avenues of social and family support. In many states, the presence of illicit substances in a neonate’s urine toxicology often results in mandatory reporting by the hospital to the child protective agency. Although it may seem to the clinician or the family member that a particular substance-abusing mother is ill-equipped to care for her baby, such a report and its associated threat of loss of custody is likely to precipitate a crisis for the mother. Paradoxically, she may have only the obstetric social worker to turn to for emotional support at the same time that the social worker is responsible for reporting to the state protective agency. The possible link between substance abuse and bereavement is of public health concern, if confirmed. Grief has been associated with increased substance use in widows (Zisook, Shuchter, & Mulvihill, 1990) and in relinquishing mothers (Condon, 1986a). It is almost a tautology to state that maladaptive coping with past and anticipated losses by substance use and abuse will be especially common in substance abusers. The “replacement baby” phenomenon has public health implications for the postpartum substance-dependent woman who attempts to cope with custody loss by subsequent pregnancy. A painfully futile cycle of attempted self-healing through repeated pregnancies might be mistaken for indifference to contraception or the risks of fetal drug exposure. A related public health concern is the possible negative effects of custody loss on the chemically dependent mother’s ability to bond with subsequent fetuses. Especially poignant is the irony that such a woman is expected to exhibit maternalfetal emotional attachment by abstaining from alcohol and drugs (a regard for her fetus which by definition she lacks for herself) while often experiencing anticipatory mourning and its associated detachment.
V.D. Raskin
CONCLUSION In summary, bereavement following the loss of custody due to prenatal substance abuse or child abuse or neglect secondary to substance abuse has many features typical of maternal bereavement following perinatal death. It is extremely persistent and generally experienced as a very significant event in the woman’s life. Substance abuse, maternal bereavement due to custody loss, and subsequent pregnancy interact to create a very vulnerable period for increased substance abuse or relapse at the same time that the woman’s recovery is especially urgent.
REFERENCES Blume, S.B. (1990). Chemical dependency in women: Important issues. American Journal of Drug andAlcoholAbuse, 16,241-307. Cain, A., & Cain, B. (1964). On replacing a child. American Acad-
emy of Child Psychiatry, 3, 443-455. Cohen, R.L. (1988). Developmental tasks of pregnancy and transition to parenthood. In R.L. Cohen (Ed.), Psychiatric consultation in childbirth settings (pp. 51-70). New York: Plenum Medical Press. Condon, J.T. (1986a). Psychological disability in women who relinquish a baby for adoption. Medical Journal of Australia, 144, 117-119. Condon, J.T. (1986b). Management of established pathological grief reaction after stillbirth. American Journal of Psychiatry, 143,
987-992. Freud, S. (1917/1959). Mourningandmelancholia. In E. Jones (Ed.), Collected papers (Vol. 4, pp. 152-170). New York: Basic Books. Griffin, M.L., Weiss, R.D., Mirin, SM., & Langell. (1989). A comparison of male and female cocaine abusers. Archives of Gen-
eral Psychiatry, 46, 122-126. Imhof, J.E. (1991). Countertransference issues in alcoholism and drug addiction. Psychiatric annals, 21, 292-306. Kennel, 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, 344349. Kirkley-Best, E., & Kellner, K.R. (1982). The forgotten grief: A review of the psychology of stillbirth. American Journal of Ortho-
psychiatry, 52, 420-429. Mackie-Ramos, A.-L., & Rice, J.-M. (1988). Group psychotherapy with methadone-maintained pregnant women. Journal of Sub-
stance Abuse Treatment, 5, 151-161. Mawson, D., Marks, I.M., Ramm, L., &Stern, R.S. (1981). Guided mourning for morbid grief. British Journal of Psychiatry, 138,
185-193. Millen, L., & Roll, S. (1989). Solomon’s mothers. A special case of pathological bereavement. American Journal of Orthopsychia-
try 55, 411-418. Nichols, M. (1985). Theoretical concerns in the clinical treatment of substance-abusing women: A feminist analysis. In D. Cook, S.L.A. Straussner, & C.G. Fewell (Eds.), Psychosocial Issues in the Treatment of Alcoholism. New York: Haworth Press. Theut, SK., Pederson, EA., Zaslow, M.S., Cain, R.L., Rabinovich, B.A., & Morihsisa, J.M. (1989). Perinatal loss and parental bereavement. American Journal of Psychiatry, 146,635-639. Zisook, S., Shuchter, S.R., & Mulvihill, M. (1990). Alcohol, cigarette, and medication use during the first year of widowhood.
Psychiatric Annals, 20, 3 18-326.
Vol. 9, pp. 149-152,
1992 Copyright
0
0740-5472/92 $5.00 + .OO 1992 Pergamon Press Ltd.
BRIEF REPORT
Maternal Bereavement in the Perinatal Substance Abuser
VALERIE D. RASKIN,
MD ’
University of Illinois at Chicago
Abstract--Maternal bereavement has been reported in involuntary perinatal loss and voluntary custody relinquishment. Since child custody loss is common among childbearing chemically dependent women, maternal bereavement was investigated in a small pilot sample of obstetric substance abusers. Findings suggest that grief in anticipation of possible postnatal custody loss is common. Unresolved grief from previous custody loss was also common. Clinical features, treatment considerations, and public health concerns are discussed. Keywords-maternal
bereavement;
perinatal
substance
INTRODUCTION
abuser.
BACKGROUND:
MATERNAL BEREAVEMENT
Mourning may result from the loss of a loved person or from an ideal or abstraction (Freud, 1917). The involuntary loss of custody and/or caretaking responsibility for one’s children due to child abuse or neglect is common among pregnant chemically dependent women (Mackie-Ramos, & Rice, 1988). The loss of custody of one’s children is at once both the loss of a loved person and the loss of an abstraction. One loses one’s baby or child(ren) and one’s ideal image of oneself as a competent mother. Mothers who lose babies due to miscarriage, stillbirth or neonatal death show characteristic signs of what has been termed “maternal bereavement.” Involuntary perinatal loss often results in persistent preoccupation with the lost baby, guilt, anger, selfrecrimination, sadness, and fantasies about how life would be were the baby alive (Kirkley-Best, & Kellner, 1982; Kennel, Slyter, & Klaus, 1970). Late perinatal loss is associated with more intense maternal bereavement relative to early loss (Theut et al., 1989), and previous perinatal loss often has a profound impact on the psychological experience of subsequent pregnancy (Cohen, 1988). Perhaps not surprisingly, mothers who have given up infants for adoption also describe psychological distress which can be recognized as maternal bereavement. Persistent grief-up to 35 years without satisfac-
THE NEGLECT OF GENDER SPECIFIC IWJES for chemically dependent women has been well described (Blume, 1990; Griffin, Weiss, Mirin, & Lange, 1989). The very great stigma associated with women’s chemical dependence, the high prevalence of prior sexual victimization, physiologic differences, and unique patterns of psychopathology have all been identified as important areas requiring further investigation. Issues of gender specific consequences of substance abuse, in particular, how such consequences relate to the course of women’s chemical dependence, have received even less attention (Nichols, 1985). This paper will describe one such phenomenon seen in pregnant chemically dependent women: anticipated and past loss of child custody as a consequence of substance abuse.
Requests for reprints should be addressed to Valerie D. Raskin, MD, Department of Psychiatry (mc 913), University of Illinois at Chicago, P.O. Box 6998, Chicago, IL 60680. Presented in part at the Annual Meeting of the American Psychiatric Association, May, 1991, New Orleans. This research was supported by the National Institute of Drug Abuse grant #5R18 DA 06378-02. The author thanks Karen Sobieraj, Nada Stotland and Anne Seiden for helpful advice, and Queenie Mendonca for secretarial assistance. ‘Dr. Raskin was formerly with Cook County Hospital, Chicago, Illinois.
149
IS0
KD. Raskin
tory resolution-has been reported in women who voluntarily relinquished babies for adoption (Condon, 1986a). The lack of social validation of the loss or customary mourning rituals seen after perinatal death is even greater for relinquishing mothers, who keep the loss “shrouded in secrecy and shame” (Millen and Roll, 1985). Since involuntary custody loss is also a source of shame, maternal bereavement in the substance abuser may be underrecognized and its impact underestimated. To investigate whether maternal bereavement due to custody loss is of significance clinically in the perinatal substance abuser, pilot data were collected from clinical interview and chart review of a small sample at a large urban hospital. Demographic data, clinical findings and case vignettes will be described.
METHOD The author interviewed 15 pregnant (n = 10) or newly delivered (n = 5) women referred for substance abuse consultation from the obstetric service of Chicago’s only public hospital. Such patients are routinely referred for psychiatric consultation at this hospital, when identified. Aspects of maternal bereavement were discussed with each patient as part of an overall psychiatric assessment and intervention. In addition to patient interviews, charts were consulted for collateral or confirmatory data about obstetric history and social history including contact between hospital staff and the state child protective agency. RESULTS Demographics The patients were all low socioeconomic status residents of Chicago’s inner city. Two were in post-secondary school training (one university, one for-profit technical school); none were employed outside of homemaking and/or illegal activities. One patient was 22 weeks pregnant at the time of admission. The remaining 9 pregnant patients were in the third trimester. The postpartum patients were interviewed between 1 day and 3 weeks postpartum. The women were primarily multiparous (average gravidity = 4.2, range 1 to 7). Two patients were primiparous. Findings Of the mothers, 93.3% (14/15) reported being worried that their baby/fetus might be taken from their custody because of maternal substance abuse. All (15/l 5) had heard about (through media coverage and/or street talk) legal sanctions for substance abusing pregnant women including custody loss of newborns, but none were able to accurately describe the legal basis for a mandatory state child protective service report (positive newborn toxicology).
Of the 13 multiparous chemically dependent women, 92.3% (12113) had lost custody or caretaking responsibility for one or more children for some period of time. These included permanent involuntary custody loss with custody assumed by the state (n = 6), temporary custody loss with the mothers currently retaining custody but remaining actively monitored by the state agency (n = 3), caretaking relinquished to a family member (n = 2), and no prior loss but temporary loss of the newborn pending further agency investigation and judicial review (n = 1). Among the women who had lost custody to the state, the average number of children lost was 3 (range 2-5). Of the 5 postpartum women, 4 (80%) had mandatory reports made to state protective service for positive newborn toxicologies with custody hearings pending. Clinical Features All 15 patients had clinical symptoms of grief related to past or anticipated custody loss. These included preoccupation with the lost child(ren), sadness, rumination, and yearning for reunion. Many features of maternal bereavement in the special circumstance of custody loss were typical. The patients in this sample generally felt that the loss of custody of their children (whether to the state or to a family member) was a great personal tragedy. Several carried photographs of their child(ren) taken prior to custody loss. Ongoing fantasies about the child’s activities and development and fantasies about parenting the lost child were described. Several reported anniversary reactions including private observation of the child’s birthday. The dynamic relationship between maternal bereavement and subsequent pregnancy described in other instances of maternal bereavement was also seen here. Parents who have experienced perinatal loss often report holding back emotional attachment to the subsequent fetus until the perceived period of threatened loss has passed (i.e., first trimester following miscarriage). A related example is described. Ms. A., an intranasal heroin abuser, delivered an apparently healthy fourth child, 18 months after her third baby was temporarily removed from her custody as a neonate when he tested positive for heroin. She described the several weeks when she lost custody of that child as “terrible,” and attributed “postpartum blues” and an increase in her heroin use to her distress during the custody investigation. She predicted that she and this new baby would test negative, yet she did not name her new daughter and knew that “the judge is harder second time around.” At 36 hours postpartum, the author was present in the patient’s room meeting with another patient when Ms. A was informed by the obstetrics social worker that this baby also tested positive for heroin, and that the state child welfare had temporarily taken custody pending investigation. The mother, who had been noticeably affectionate and responsive to her infant, immediately left the room leaving the child unattended in a bassinet. She sub-
Maternal Bereavement in the Perinatal Substance Abuser sequently refused to pick her up or name her until the judicial hearing and custody determination was made.
Several mothers also noted that the experience of subsequent childbearing reactivates unresolved maternal bereavement. Ms. B, in her late 30’s, was an intravenous heroin- and cocaine-abusing woman who had presented herself to the police requesting treatment after being refused at two treatment programs. The month prior to delivery she was placed on methadone and apparently remained otherwise drug-free. She had permanently lost custody of her 3 other children and wished to keep this baby, in part to “make up” her losses. She reported being “happy but confused” about holding her newborn, often finding herself feeling sad remembering her other babies at this age and missing them “even more than before.”
One key difference in grief symptomatology in maternal bereavement between mothers who suffer perinatal loss and those who lose custody is the nature of guilt and self-recrimination. While guilt and anger are virtually always seen in maternal bereavement, the presence of shame following perinatal death, or persistent rage or blame of others may signify an especially problematic grief reaction in the instance in which the mother has taken ordinary prenatal precautions. For the woman whose substance abuse has led to the loss of custody of her children, the absence of guilt and even shame may signify extreme denial of either her substance abuse or her loss. Unlike perinatal loss, where blame usually cannot be assigned to any one person, custody loss can readily be attributed to a malicious judge, vindictive relative, meddling state child protective caseworker, and so on. The absence of self-recrimination following custody loss in this sample appeared to be associated with one of two pathologic conditions: denial of the loss (e.g., the arbitrary and unfair judge will soon be replaced by a reasonable judge who will immediately return my child), or denial of the consequences of her substance abuse (e.g., since it was someone else’s fault I do not need to change my behavior). DISCUSSION Although this is a small sample, these findings suggest that past and anticipatory grief are both common and worthy of clinical attention in the perinatal substance abuser. Certain treatment and public health considerations are raised and will be discussed further. The findings provide support for more extensive study of the phenomenon of maternal bereavement in the pregnant substance abuser. The principles of the treatment of maternal bereavement in the circumstance of pregnancy and substance abuse is somewhat different than conventional grief therapy. In traditional grief therapy, patients are
I51
supported while encouraged to ventilate the strong affects of anger, sadness, jealousy, and guilt precipitated by the loss (Mawson, Marks, Ramm, 8c Stern, 1981; Condon, 1986b). However, treatment of substance abuse, especially initially, typically avoids interventions which arouse very strong affects until the recovering addicted woman develops alternative means of coping with extremes of emotional distress. The clinician must walk a tightrope, acknowledging the bereaved substance abuser’s loss while monitoring closely for overwhelming affects. The clinician who overemphasizes the addicted woman’s loss risks inadvertently supporting her rationalization of substance use. However, the presence of addiction should not be used to collude with minimization or denial of the painful affect precipitated by custody loss. Ideally, support around the loss can be coupled with confrontation about patterns of coping with distress by substance use, and the specific risks of doing so at this time of vulnerability. A common maladaptive response seen in perinatal loss and voluntary custody loss is rapid subsequent pregnancy in an effort to replace the lost baby (Condon, 1986a; Cain & Cain, 1964). Although this study does not specifically address this phenomenon, the similarities to other features of maternal bereavement suggest that the so-called “replacement baby” phenomenon should be considered in the circumstance of custody loss. The postpartum substance-dependent woman who has recently lost custody of her baby (or who is court ordered to undergo treatment as a condition of maintaining or regaining custody) is at especially high risk. Hopelessness about the possibility of successful treatment may be expressed through rapid pregnancy, if success in treatment is understood to be necessary for reunion. At a minimum, the clinician treating a recently bereaved addicted woman should inquire about the woman’s active or passive intent to become pregnant again, empathically acknowledge the temptation to do so, and offer the suggestion that postponing subsequent pregnancy is likely to help her in her own recovery as well as in coping with her grief. Treatment of the bereaved perinatal substance abuser presents a countertransference minefield. Countertransference attitudes and feelings have a pronounced impact on treatment outcome (Imhof, 1991), and conscious and unconscious hostile or stereotyped attitudes to the “bad mother” are especially common in the treatment of the perinatal chemically dependent woman (Mackie-Ramos & Rice, 1988). With regard to maternal bereavement, countertransference reactions may include overt blame (“she doesn’t deserve to raise such an adorable baby”) and disregard (“how could such a terrible mother have any feelings about losing her baby”). A common countertransference problem is overidentification with or overemphasis on the fetus or baby at the expense of the mother. This manifests as “get clean so that you can get your baby back.”
152 This may be more readily recognized as countertransference if compared to the loss of a driver’s license after driving under the influence of alcohol. A statement such as “get sober so that you can get your license back” would be immediately seen as naive, or, worse, colluding with the patient’s minimization of the addiction. Preferably, the clinician would state something like “of course you want to stop using drugs to get your baby back, but recovery is so difficult that it’s got to be something you want for yourself, to make life better for you.” Recognizing such countertransference attitudes allows the clinician to detect instances in which the patient’s similarly stereotyped ideas about being a good mother are used to bolster resistance. Likewise, the clinician who can recognize his or her own negative attitudes can better empathize with the world in which the patient lives - one which is notably antagonistic to the drug-abusing mother. Addicted mothers not uncommonly have exhausted their avenues of social and family support. In many states, the presence of illicit substances in a neonate’s urine toxicology often results in mandatory reporting by the hospital to the child protective agency. Although it may seem to the clinician or the family member that a particular substance-abusing mother is ill-equipped to care for her baby, such a report and its associated threat of loss of custody is likely to precipitate a crisis for the mother. Paradoxically, she may have only the obstetric social worker to turn to for emotional support at the same time that the social worker is responsible for reporting to the state protective agency. The possible link between substance abuse and bereavement is of public health concern, if confirmed. Grief has been associated with increased substance use in widows (Zisook, Shuchter, & Mulvihill, 1990) and in relinquishing mothers (Condon, 1986a). It is almost a tautology to state that maladaptive coping with past and anticipated losses by substance use and abuse will be especially common in substance abusers. The “replacement baby” phenomenon has public health implications for the postpartum substance-dependent woman who attempts to cope with custody loss by subsequent pregnancy. A painfully futile cycle of attempted self-healing through repeated pregnancies might be mistaken for indifference to contraception or the risks of fetal drug exposure. A related public health concern is the possible negative effects of custody loss on the chemically dependent mother’s ability to bond with subsequent fetuses. Especially poignant is the irony that such a woman is expected to exhibit maternalfetal emotional attachment by abstaining from alcohol and drugs (a regard for her fetus which by definition she lacks for herself) while often experiencing anticipatory mourning and its associated detachment.
V.D. Raskin
CONCLUSION In summary, bereavement following the loss of custody due to prenatal substance abuse or child abuse or neglect secondary to substance abuse has many features typical of maternal bereavement following perinatal death. It is extremely persistent and generally experienced as a very significant event in the woman’s life. Substance abuse, maternal bereavement due to custody loss, and subsequent pregnancy interact to create a very vulnerable period for increased substance abuse or relapse at the same time that the woman’s recovery is especially urgent.
REFERENCES Blume, S.B. (1990). Chemical dependency in women: Important issues. American Journal of Drug andAlcoholAbuse, 16,241-307. Cain, A., & Cain, B. (1964). On replacing a child. American Acad-
emy of Child Psychiatry, 3, 443-455. Cohen, R.L. (1988). Developmental tasks of pregnancy and transition to parenthood. In R.L. Cohen (Ed.), Psychiatric consultation in childbirth settings (pp. 51-70). New York: Plenum Medical Press. Condon, J.T. (1986a). Psychological disability in women who relinquish a baby for adoption. Medical Journal of Australia, 144, 117-119. Condon, J.T. (1986b). Management of established pathological grief reaction after stillbirth. American Journal of Psychiatry, 143,
987-992. Freud, S. (1917/1959). Mourningandmelancholia. In E. Jones (Ed.), Collected papers (Vol. 4, pp. 152-170). New York: Basic Books. Griffin, M.L., Weiss, R.D., Mirin, SM., & Langell. (1989). A comparison of male and female cocaine abusers. Archives of Gen-
eral Psychiatry, 46, 122-126. Imhof, J.E. (1991). Countertransference issues in alcoholism and drug addiction. Psychiatric annals, 21, 292-306. Kennel, 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, 344349. Kirkley-Best, E., & Kellner, K.R. (1982). The forgotten grief: A review of the psychology of stillbirth. American Journal of Ortho-
psychiatry, 52, 420-429. Mackie-Ramos, A.-L., & Rice, J.-M. (1988). Group psychotherapy with methadone-maintained pregnant women. Journal of Sub-
stance Abuse Treatment, 5, 151-161. Mawson, D., Marks, I.M., Ramm, L., &Stern, R.S. (1981). Guided mourning for morbid grief. British Journal of Psychiatry, 138,
185-193. Millen, L., & Roll, S. (1989). Solomon’s mothers. A special case of pathological bereavement. American Journal of Orthopsychia-
try 55, 411-418. Nichols, M. (1985). Theoretical concerns in the clinical treatment of substance-abusing women: A feminist analysis. In D. Cook, S.L.A. Straussner, & C.G. Fewell (Eds.), Psychosocial Issues in the Treatment of Alcoholism. New York: Haworth Press. Theut, SK., Pederson, EA., Zaslow, M.S., Cain, R.L., Rabinovich, B.A., & Morihsisa, J.M. (1989). Perinatal loss and parental bereavement. American Journal of Psychiatry, 146,635-639. Zisook, S., Shuchter, S.R., & Mulvihill, M. (1990). Alcohol, cigarette, and medication use during the first year of widowhood.
Psychiatric Annals, 20, 3 18-326.
