“It was worse than my son passing away.” The experience of grief in recovering crack cocaine addicted mothers who lose custody of their children
Citation
Janzen, K. & Melrose, S. (2016) “It was worse than my son passing away.” The experience of grief in recovering crack cocaine addicted mothers who lose custody of their children. Illness, Crisis and Loss. 25(3), 232-261 DOI: https://doi.org/10.1177/1054137316637188
Abstract
Grief could be considered to be the universal experience notwithstanding the cause. For addicted mothers, grief is a constant companion after losing custody of their children often leading them to attempt suicide and engage in self-destructive behaviors. Little is known about the processes and symptoms of grief in these mothers. This hermeneutic study explores the grief of four crack cocaine recovering mothers who lost custody of their children. Thematically, three nonlinear stages were identified that the mothers passed through in an iterative manner: betrayal, soul-ache, and reclamation. Posttraumatic growth was identified as an outcome once the mothers entered recovery. It is imperative that clinicians from all disciplines recognize and respond to the grief that addicted mothers who lose custody of their children experience, through the offering of grief support and grief counseling.
Keywords
crisis, grief, loss, trauma, comparative death, bereavement workers, counseling
Grief could be considered to be the universal human experience. All human beings have or will experience grief at one or multiple points in their lives through death or loss (Simon, 2013). For crack cocaine-addicted mothers who lose custody of their children, grief can be a constant companion (Janzen, 2010). This can cause extensive pain and distress spiritually, emotionally, and physically (Janzen & Melrose, 2013) and may have features of pathological grief (He et al., 2014). Losing custody could be likened unto the worst possible imaginable thing that could happen to a mother (Janzen & Melrose, 2013).
In our research exploring the lived experiences of four mothers recovering from addictions (Janzen & Melrose, 2013), we were struck by the profound and persistent grief that impacted our participants. In this article, we extend our work to examine the experience of grief in the context of child custody loss in four recovering crack cocaine-addicted mothers. We do this by linking our findings to the constructs of grief and bereavement, categories of grief, disenfranchised grief, grief in the context of child custody loss, and hope. Methodology is delineated. Results of the research are outlined. A discussion is presented and limitations are explored. We issue a call for the provision of grief support/counseling for addicted and recovering mothers who lose custody of their children.
Literature Review
Grief and Bereavement: Theoretical Foundations
Theoretical foundations related to grieving have evolved considerably since the time of Freud in 1917 who felt that the ultimate task of grieving was emotional detachment (Rothaupt & Beckner, 2007). Neimeyer and Currier (2009) see the goal of bereavement as one of adaptation or meaning making where “adaptation after death of a loved one oscillates between orientation to the loss . . . and restoration of contact with a changed world” (p. 355). There are two tracks that are associated with bereavement, the first being a biopsychosocial track which focuses on overt symptomatology and a relational track which looks at predeath and postdeath relationships with the deceased (Neimeyer and Currier, 2009). Neimeyer sees that working through a constructivist framework, grieving is attended to as an active, effort-bound process in order to reconfirm or reconstruct meaning which has been threatened by loss.
Moules, Simonson, Fleiszer, Prins, and Glascow (2007) note that grief itself is ambiguous: “grief is universal and individual; benign and malignant; life giving and life requiring, active and passive, heart and head; inarticulate and poetic; celebration and bereavement” (p. 122). As Niemeyer (2005) and Moules et al. note, grief is a lifelong experience—using the metaphor of a healing wound to better understand grieving.
With a physical wound, it is cleansed, sutured, and bound up and usually heals within a prescribed period of time. Instead, Moules et al. (2007) note that bereavement wounds remain open and jagged. Further, they cite that these wounds are painful and problematic as healing time is delayed, often resulting in considerable scarring. In essence, bereavement wounds heal from the inside out instead of the outside in (Moules et al., 2007). Shear et al. (2011) also use this metaphor to describe grief as being complicated in that symptoms interact and duration is prolonged.
Considering the work of Niemeyer (2005), Moules et al. (2007) look at this adaptation as “not the ground that changes but it is our location on the ground, our appreciation of it” (p. 133). The bereaved “live with the dead” where they struggle to construct a coherent account of their bereavement that pursues a sense of continuing with how they have been while also integrating the reality of a changed world into their conception of who they must be now (Neimeyer, Prigerson, & Davies, 2002, pp. 236–237). This is supported by Florczak (2008) who sees that the process of bereavement is in finding healthy, symbolic relationships and roles with the deceased.
Acute Grief
Acute grief is a normal human response to loss or death as death is considered as a common life event (Shear et al., 2011; Wittouck, Van Autreves, De Jaegere, Portzky, & van Heenden, 2011). Mourning and grief are considered to be natural responses to loss (Simon, 2013). While the acute grief process usually results in a life that is changed and restorative, acute grief processes do not normally need intervention (Shear et al., 2011, p., 103). Shear et al. note that psychiatrists emphasize that acute grief should not be treated as being pathological in nature. Acute grief is grief that occurs shortly after learning of a loss or death and involves a separation response as well as a response to stress (Shear, 2015). Most individuals move through the mourning process without the presence of severe mental or physical problems (Wiltouck et al., 2011). However, bereavement can trigger mental or physical disorders (Shear et al., 2011). The early bereavement period can exacerbate a risk for myocardial infarction, cardiomyopathy, or both (Shear, 2015). Further, Shear outlines that the risk is increased for the development of mood disorders, anxiety, or substance abuse as bereavement can trigger physical or mental disorders (see Table 1 for symptomatology of acute grief).
Table 1. Symptomatology of Grief and Loss
(Baum & Negbi, 2013; Boss & Yeats, 2014; Currier et al., 2012; Davidson, 2010; Gilbert, 2007; He et al., 2014; Holland & Neimeyer, 2011; Horowitz, Siegel, Holen, Bonaano, Milbrath & Stinson, 1997; Prigerson et al., 1997; Shear, 2015; Shear et al., 2011; Simon, 2013; Wittouck et al., 2011; Zisook & Shear, 2009)
| Symptomatology of grief and loss | |
| Acute grief | -Shock or disbelief, intense separation distress, longing and sadness, preoccupation with thoughts, memories and images of deceased, focusing on loss; Shock, anguish, loss, anger, guilt, regret, anxiety, fear, loneliness, unhappiness, depression, intrusive images, depersonalization, overwhelmed; decrease in usual activities |
| Prolonged grief/complicated grief/traumatic grief | -Sleep disturbances, substance abuse, suicidal ideation, and behavior, immune function alterations, nonadherence to therapeutic regimes for disease, mood, anxiety, or substance abuse disorders, emotional trauma/traumatic distress, headache, flu, eating changes, numbness, bitterness, anxiety, isolation, personal emptiness, avoidance of others, sleep interference, loss of interest of activities of daily living, intense yearning/longing, pain, impairment in social and personal functioning, activity restriction, insomnia, cardiac dysfunction, cancer, meaninglessness, hopelessness about future, anger, disconnection from others, depression, hypertension, cardiac problems, social impairment, psychotropic drug use, reduced quality of life |
| Disenfranchised grief | -Hidden sorrow, difficulty in mourning, anger, guilt, powerlessness, loneliness, generalized isolation, embarrassment, secrecy, restrained or stifled emotions, frustration, delayed grief reactions, chest pain, isolation, shame, disbelief, shock, numbness, guilt, regret, anger, sadness, anxiety, and depression; insomnia, chest pain, shortness of breath, fatigue, sleeplessness, nervousness, stomach problems, intensely emotional, tearfulness, depression, relief, loneliness, guilt, anxiety, and sense of disbelief; increased use of drugs and alcohol |
| Ambiguous loss | -Feelings of ambiguity, confusion, and ambivalence, immobilization, frozen grief, wounded or lost self-esteem, rupture of close relationships, sadness, doubt, anxiety, while at the same time preserving hope for return of lost person; increased conflict, relational rifts and alienation, depression, trauma, anxiety, helplessness, identity issues, stressrelated illnesses, substance abuse, interpersonal violence to self or others; dialectical thinking |
Abnormal Grief: Traumatic, Complicated, Prolonged, and Disenfranchised Grief
For the past 20 years, there have been various definitions of abnormal grief (Lobb et al., 2012; Rosner, Pfoh, & Kotoučová, 2011). The term abnormal grief or pathological grief has evolved over time and is now termed as prolonged grief disorder (Lobb et al., 2012). Prolonged grief disorder encapsulates traumatic grief, complicated grief, and prolonged grief. Rosner et al. (2011) note that the terms complicated grief and prolonged grief have been, and still are, used interchangeably. The term complicated grief is more prevalent in the overall literature (Bryant, 2014; Rosner et al., 2011; Seirmarco et al., 2011; Shear, Ghesquiere, & Glickman, 2013; Simon, 2013; Zetumer et al., 2015).
Armed with the outcomes of robust randomized controlled trials (RCTs), prolonged grief has been widely studied (Rosner et al., 2011). Despite intensive lobbying and research presented to the American Psychological Association, the term prolonged grief disorder was rejected and is not currently found within the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychological Association, 2013) nor the World Health Organization’s (2015) International Classification of Diseases Revision 10 (ICD-10; Bryant, 2014; Prigerson et al., 2009, 2008; Rosner et al., 2011). We now explore traumatic grief, complicated grief, and prolonged grief.
Traumatic Grief
Traumatic grief has its roots in the work of Prigerson et al. (1997) and Shear et al. (2011). The term traumatic grief is associated with loss that occurs through a traumatic event such as a car accident, domestic violence, homicide, or suicide (Neimeyer et al., 2002). Traumatic grief is now encompassed within the sequlae of prolonged grief disorder and termed as traumatic distress (Holland & Neimeyer, 2011; Rosner et al., 2011). Traumatic distress is differentiated between separation distress (which is relational in nature) as it is “influenced by more situational factors surrounding death” or the cause of death (Holland and Neimeyer, 2011, p. 254).
Complicated Grief
Complicated grief was first identified by Horowitz and colleagues (Horowitz et al., 1997, 2003; Prigerson et al., 1995; Rosner et al., 2011). Complicated grief refers to an abnormal grief process lasting greater than 12 months (Rosner et al., 2011) and encompasses two clusters of symptoms (Rosner et al., 2011; Wittouck et al., 2011). The first cluster is seen in terms of a “strong yearning” for the individual who has died (Rosner et al., 2011, p. 79). Rosner et al. and Wittouck et al. describe the second cluster as being composed of a number of factors related to cognition, emotion, and behavior (see Figure 1 for symptomatology of complicated grief).
The incidence of complicated grief is estimated by country to be between 2.4% in Japan, 3.7% in Germany, and 4.2% in Switzerland (Rosner et al., 2011). The estimations of those who have acute grief that will go on to develop complicated grief vary. Shear et al. (Shear, 2005; Shear et al., 2011) indicate that 10% of those who have acute grief go on to develop complicated grief. Overall complicated grief is approximated to be anywhere from 5 to 10% (Zetumer et al., 2015) to 20% of the bereaved population (Rosner et al., 2011). Shear et al. (2013) cite that approximately 7% of the bereaved older adult population develop complicated grief.
Prolonged Grief
The term prolonged grief was coined by Prigerson et al. in 2009. Prolonged grief occurs when traumatic grief and complicated grief are both present with features of separation distress (from main attachment figure) and traumatic distress (situational factors around death/cause of death; Currier, Holland, & Neimeyer, 2012). The incidence of those bereaved who are likely to develop prolonged grief is 10 to 15%. Worldwide, the incidence of complicated grief leading to prolonged grief disorder is 2 to 3% of the population (Shear, 2015). Shear notes a rise in incidence with the death of a romantic partner from 10 to 20%.
Disenfranchised Grief
Disenfranchised grief, as a concept, is identified to be effectively established within literature, research, and practice (Robson & Walker, 2013). Disenfranchised grief was first identified by Doka (1989). It is defined as a “grief that people experience when they incur a loss that is not or cannot be openly acknowledged, physically mourned or socially supported” (Boss & Yeats, 2014, p. 86) or a type of grief “where there is no social acknowledgement of the mourner’s relationship to the deceased, or the mourner’s loss, or the mourner’s ability to grieve” (Doka, 1989, pp. 98–99). Noting there are differences within and between cultures, ethnicities, religions, and society (Gilbert, 2007; Robson & Walker, 2013), Doka (2002) cites that there are many expectations on how bereaved are expected to mourn or grieve. The rules of grieving result in a wide range of accepted behaviors which may be met with apprehension, annoyance, or even censure (Gilbert, 2007).
Disenfranchisement has ties to subjugation as well as the political (Robson & Walker, 2013). Robson and Walker suggest that disenfranchised grief is not linear, but rather pyramidal in nature, suggesting a hierarchy of loss which differs from the normative notions of loss. The pyramidal nature of disenfranchised grief is felt to expansively affect primary attachment figures such as spouses and parents as they represent the top stratification of the pyramid (Robson & Walker, 2013). Primary attachment figures are felt to suffer the most in terms of disenfranchised grief (p. 103) (see Table 1 for symptomatology of disenfranchised grief).
Ambiguous Loss
An additional grief experience that is referenced in the literature is known as an ambiguous loss (Betz & Thorngren, 2006; Boss, 2004). Ambiguous loss is defined as an “unclear loss that continues without resolution or closure” and considered to be relational in nature (Boss & Yeats, 2014, p. 63). Ambiguous loss is a loss that does not fit within the traditional notion of death (Betz & Thorngren, 2006).
Boss and Yeats (2014) define two classifications of ambiguous loss: physical and psychological. Ambiguous loss is typologized to be either loss where there is physical presence but psychological absence or physical absence but psychological presence (Betz & Thorngren, 2006; Boss & Yeats, 2014). Examples of ambiguous loss are child custody loss, foster care, adoption, a significant other experiencing dementia, lost at sea, a significant other leaving without saying goodbye, loss of a pet, perinatal death, infertility, murder, and so on (Betz & Thorngren, 2006; Boss & Yeats, 2014; Gilbert, 2007).
Ambiguous loss presents itself as a situation where there are no rituals for meaning and that the loss is socially stigmatized (Betz & Thorngren, 2006). In our North American culture, Betz and Thorngren describe talking about or dealing with death as a process to be largely avoided, restrained, and denied or at the very least involve a quick turnaround. Boss and Yeats (2014) describe the perils of ambiguous loss as “living with someone who is both here and gone—or gone and not for sure—[as being] a bizarre human experience” (p. 63) which leads to significant symptomatology. The effects of ambiguous loss are considered to be trifold: immobilization, relational, and individual (see Table 1 for symptomatology of ambiguous loss).
Boss and Yeats (2014) cite that those who experience ambiguous losses are at higher risk of developing complicated grief. This is due to there being little possibility of resolution of the loss or bereavement. In essence, grief is frozen through the spaces of time (Boss & Yeats, 2014). Further, ambiguous loss is considered to be a type of disenfranchised grief and especially seen as negated by media, legal, and religious institutions that are intolerant of that ambiguity.
Grief in the Context of Child Custody Loss
There is very little literature related to grief in the context of child custody loss. A search of Google Scholar, Academic Search Complete, Research Library JSTOR, Omnifile Full Text Select, SAGE, and Scopus using the search term, “grief in child custody loss,” revealed only five studies. Four of these studies involved mothers (Askren & Bloom, 1999; McKegney, 2003; Novac, Pardis, Brown, & Norton, 2006; Wells, 2010) and one involved fathers who had lost custody of their children (Baum & Negbi, 2013).
Askren and Bloom’s (1999) study of 12 mothers who had relinquished custody of their children revealed that mothers experience initial acute grief reactions which often lead to pathological grief. Pathological grief is more particularly noted in mothers who involuntarily give up custody.
Novac et al.’s (2006) research centered on young, homeless mothers and custody loss of their children from the perspectives of 18 health and social service providers who engaged with this population. The outcomes of this study were primarily seen in recommendations for counseling related to bereavement and child custody loss.
The study of Wells (2010) focused on narrative analysis of custody loss and reunification with one participant. Wells did not center on grief but rather the associated rage and gendered shame that come from a motherhood ideology that is prevalent in America. The conclusions of this study note that motherhood identity is reconstructed through the processes of loss and regaining custody.
McKegney (2003) interviewed four mothers who had their children removed from them at birth and highlighted their loss of self-worth, isolation, and stigmatization. She noted the suffering (most often silently) that these mothers endured and the disenfranchised grief that they experienced. There is no known literature to date that explores grief through the lens of addicted mothers who lose custody of their children.
Grief and Hope
While grief and hope may be seen as opposite ends of a continuum, there is a relationship between them that Attig (2004) emphasizes cannot be discounted. Attig describes that at the very heart of grieving, constructive labors of love and hope are omnipresent through both soul work (related to motivation), spirit work (related to challenging with the unfamiliar or unexpected), and resilience. Moore (2005) contends that it is possible to choose hope, even in bereavement and loss. Hope is felt to effect healing both emotionally, physically, and spiritually (Fuedtner, 2005; Snyder, 2000).
Moore (2005) describes hope as an elusive concept—one which is not easily defined. Feudtner (2005) concurs stating that a plethora of definitions exist. Much of the seminal literature, however, is related to hope is found in the work of Feudtner (2005; 2010) and Snyder (2000). Theories related to hope arose in the 1960s and 1970s and generally defined hope as “having positive expectations” (Snyder, 2000, p. 12) According to Synder, hope is conceptualized as the triad of goals, agency, and pathways (thoughts and motivations) which culminates in hopeful thought. Further, Snyder (2002) defines hope as “the perceived capability to derive pathways to desired goals, and motivate oneself via agency thinking to use those pathways” (p. 249).
Hope is felt to be a combination of thoughts, feelings, decisions, and actions by individuals within a wider social and cultural milieu (Feudtner, 2005). Hope relates to positive performance, adjustment, and health (Snyder, 2000). Additionally, hope is believed to extenuate positive affect and decrease negative affect and has positive effects on goal setting (Feudtner et al., 2010). In the context of child custody loss, hope is felt to be a mainstay in recovering mothers with addictions who have lost custody of their children (Janzen, 2010; Janzen & Melrose, 2013).
Methodology
Our research utilized an interpretive theoretical framework and phenomenological hermeneutic approach based upon the work of van Manen (1997). The research question was, “What is the lived experience of mothers in recovery who have lost custody of their children?” The purposive sample included four recovering crack cocaine-addicted mothers who had lost custody of their children. Ethical approval was obtained by the university’s Research Ethics Board and the facility of origin where the sample was drawn. The mother’s age ranged from 18 to 30 years. Two had lost custody permanently and two were in the midst of court proceedings, attempting to regain custody. All of the mothers had coexisting mental health disorders and a history of abuse or interpersonal violence. Participants were recruited through advertisements which were placed in a longterm residential addictions treatment center. Pseudonyms were chosen by the mothers for themselves and their children. Digitally recorded, semistructured interviews lasted between 45 minutes and 1g hours. Interviews were transcribed verbatim. Nvivo8 (QRS International Dupuy Ltd., 2009) software assisted the researcher by maintaining and organizing the data.
The 68 pages of single-spaced data were analyzed for themes (Cresswell, 2013; Denzin & Lincoln, 2011; Ritchie, Lewis, Nicholls, & Ormston, 2013; Silverman, 2013). Specifically, a three-layered analysis based on the work by Perry (2009) was undertaken which included analysis of stories/researcher perspectives, member checking, and the reader of the research being invited to engage in their own analysis. Three themes and nine subthemes were identified: betrayal (substances, self and other betrayal; child welfare) soul-ache (the moment of loss, accountability; living with loss), and reclamation (learning to live again, a perfect day; reaching toward the future).
Throughout our analysis, our participants’ experiences with overwhelming grief stood out. In reviewing and reflecting further on the experiences of the addicted mothers who lost custody of their children, grief was identified as a major finding in our research. In response, themes and subthemes were subsequently recoded for references to and descriptions of grief and symptomatology. Therefore, in this article, we present a further explanation of the study of grief within the context of the three themes originally identified. Symptomatology is derived from the participants’ descriptions of grief.
Results
Betrayal
The multifaceted sources of feelings of betrayal that each of the women felt after custody loss led them quickly down a spiral of entering an ever-deepening relationship with their addiction that they saw no reprieve from. Charolotte painfully recounted:
And because I believed my life was going to revolve around my addiction and my drugs and the lifestyle that I had, that’s my thought to myself and I even said, I tried convincing myself for so many years, that’s the way I wanted to die [silence] [crying] That’s the way I wanted to die.
This resulted in “giving up on life” and actively seeking to “just sit aside and kill [themselves] slowly.” Their grief was played out through their addictions. Hannah related: “I’m going to kill myself. I push the envelope and I push it.” Each woman recognized that their addictions and the pain they felt from the loss of their children were destroying them—not only physically, but mentally and spiritually. Cristal sadly recounted, “I was destroying that out there. Destroying my soul.”
Each of the women experienced intense pain, hurt, and depression. Cristine related that her drug use abated that pain even if just for a little while. “I was feeling depressed. I just wanted the pain to go away. I didn’t want to hurt. I wanted to be okay and I guess I felt I was okay when I was high.”
Crack cocaine became their way of coping with loss, grief, and extreme loneliness.
Charolette expressed that loneliness. “I thought they understood. They didn’t understand. I felt so alone at those times. Although my family was there for me, I still felt so alone.”
Cocaine became the only friend they felt they had and giving up cocaine would be like losing a best friend. Hannah explained,
Ultimately that’s our coping skill. That’s our friend. Because, yeah I lost my best friend. When anything was going wrong, who was there for me? By continuing [with cocaine], by going down the road after my kids [were] gone, like with Clara being apprehended, I didn’t pick up the phone and call my treatment centre. I picked up the phone and called my drug dealer.
The judgment they felt from others was severe. Hannah related
I find society views mothers that use as write offs, that there’s no going back or coming back from it . . . society is so judgemental when it comes to . . . even if they find out you’ve been clean for 10 years. It doesn’t matter. You still have, you’re tainted or something.
The loss of their children combined with the judgment of others affected their self-esteem.
Cristine noted, “I just felt that I wasn’t good enough.”
Soul Ache
Soul ache for the mothers was a space where they were not living nor dead . . . they were just existing. Intense grief was their constant companion. It was not only their hearts that were broken, but it was also their very souls.
The moment of loss for the mothers was something that haunted them for many years and broke their hearts. They could vividly describe the events of that moment. Charolette talked about when she gave up custody voluntarily as a result of her cocaine use.
I walked into the courthouse and I still remember the look on my mom’s face. I didn’t even tell my mom and I share a lot with my mom. A lot. I didn’t even share with her that morning when I made the decision to give up on my kids. And then, the thought of my mom’s face. I think about it. How she looked at me. It still haunts me. It broke my heart. I didn’t want to face the reality [long silence] that I was part of the problem of giving them up.
Feelings of violence and hate toward child welfare workers involved in apprehending their children surfaced followed by a sense of powerlessness and hopelessness. “I wanted to get violent,” recalled Cristine. “I really felt I guess betrayed a little bit, misled for sure, and . . . but at the end of the day there was nothing I could do.” Hannah angrily expressed,
I hate them so much, and I don’t like using that word hate. [crying] It’s such a strong word. I know I had a part in it, I know I had a part in what I did. I know. But it—what they said to me, I will never, I will never, I will never forget it. Never.
Grief was expressed through the mother’s tears and at times panic-stricken crying. “I’ve never cried so hard in my life. Like nothing breaks my heart more. I went home and cried and I cried.” Hannah described her tears as “hysterical.” Relational difficulties were frequent especially with partners or family members were involved in the loss of custody.
Feelings of failure were predominant in each of the women to the point where one mother tried to bring solace to herself through denial by thinking “they’re not really my children. I just brought them into the world.” Cristine related, “I had failed. To a certain extent I had failed. If anything I felt sorry for myself for you know, being allowed to bring children into the world that I couldn’t keep.” Regret was commonplace. Cristal recounted,
But yeah, it’s been—it’s been like, I have a lot of regrets. I do, but you know, I know that there’s a way that I could always have made, and I think about it now there’s things I would have been able to change if I would have, I mean I know it’s not possible . . .
Self-blame, denial, shame, guilt, and anger were also experienced. Charolotte explained her feelings in continuing to live with loss.
“I blamed myself. I was in denial with it. I had so much shame, guilt, anger. I had all of it. It’s what kept me stuck in my addiction because I didn’t want to face the reality of it; I had to give up my boys.”
Mothers yearned for their children. Their children were omnipresent in their thoughts and hearts. One mother talked to the pictures of her children every night. For Hannah, the loss of custody of her son was worse than if he had died. She recounted . . .
Like especially when I lost my first son, like he passed away when he was a month old in my arms. That’s all I could think and it was worse than my son passing away because at least I knew he was gone. Knowing Jason was out there and I couldn’t be with him was horrible [crying] Sorry . . .
The loss of hope was perhaps one of the worst things the mothers experienced.
I felt that all hope was gone. What did it matter? I might as well just go and die and that’s what I tried to do. Like honestly, that’s why I ended up in the hospital because I tried to kill myself. My mom took me to the hospital and told them, “You don’t put her somewhere; she’s going to be dead.
Feelings of loss permeated their lives. “Just that loss . . . for me was the hardest thing in my life I’ve had to cope with. I’ve lived through hell, you know. I’ve lived through hell and been there and back many times, more than I can count.”
Reclamation
Despite the grief and struggle that these mothers still felt after many years of losing custody, there came a point where they chose to reclaim their lives. This reclamation was centered on recovery and the hope that their ongoing recovery gave them. In essence, they were learning to live again. This learning to live again was centered within the residential recovery center and its staff, an increase in spirituality and dependence upon God as their higher power, the return of hope of reunification at some point in time with their children, and the desire to give back.
The recovery center was instrumental in regaining hope. Charolotte explained the impact of the staff at the recovery center.
When I came into [Recovery Center] and as I started breaking down my walls,breaking down my guard, and started believing in the staff, starting to trust the staff, and knowing the staff wasn’t going to hurt me or tell me things that weren’t right I started to believe in that. Let us love you until you can love yourself. For me, they gave me that love. I didn’t believe it, you know, when I heard in rooms, let us love you until you can love yourself, I didn’t believe it because I had such low selfesteem. I was so down on myself. I was so negative about who I was. I didn’t believe it because it was too good to be true, right? But when I came to [Recovery Centre] they gave me that love. They gave me that part of me I didn’t know I still had because I buried it; I hid it away from myself.
Cristal recounted her dependence upon God as her higher power in her life. “I depend on God for everything today. I do have hope.” Charolotte expressed, “I know God hears me. He sees the tears I cry for them, but I have to meet him half way in order to see them.” Hannah made sense of losing custody of her children through her belief in God.
How do I make sense of it? Like, God is really big in my life now. That’s my higher power, that’s how I choose to define it and everything happens for a reason. There’s not one thing I don’t think, that goes on in anybody’s life that isn’t meant to happen. These are ultimate lessons for me.
Even when custody loss was permanent, the women held onto the hope that one day they would be able to be reunited with their children. Some of them were cognizant that reunification would happen when their children were adults. Others hoped that time would come sooner. They each could visualize an ideal or perfect day with their children. The greatest wish of all the mothers was to just hold their children and be alone with them. Cristine said, “Yeah. I’d go and I’d touch the face of my kids and feel their energy and their love.” Charolotte lovingly related:
What would I do? I’d cook for them. I would hold them [crying] I would do anything they wanted. Anything! If they wanted one day with me, I would do anything. Anything! I would be reasonable. I would cook for them, like I said. If they wanted to watch a movie, I’d watch a movie with them. The one thing I would want to do is just hold them. That would be one big thing for me, just to hold them. The rest would be up to them, anything they wanted to do. Anything. We’d do it.
Each of the women expressed a desire to give back—to help other women who found themselves in similar circumstances or give back to society. Cristal recounted,
I’m going to be like this person that helps other people. Not only my children, my family, but just, people, you know? And I will continue to work with homeless people and addicts and that’s one of the reasons why I want to go into social work. I want to specialize in something like that.
Charolotte wanted just to make a difference. At the time of the interview, she was painting rooms in the recovery center.
I belong in life and I can, I can make a difference, even if it’s just little. The painting I’m doing right now, it’s like I think about it. Who knows, if they’re going out in that room for a girl who’s going to be part of here, who needs that room. She’s probably still suffering right? She’s still hurting. What keeps me going is knowing that I gave to that girl, just something little like that. The painting in her room. Because I was hurting too, and helping that, for another lady that probably is going to come in here needing the room that I paint, she can use it. Little things like that with my recovery that keep me going, for another person, to help them out, that is much more.
Cristine summarized the hope that all the mothers had . . .
For a long time I thought I was powerless, but you know what? For the first time in forever I finally feel like I can do this because before I became overpowered by crack, I was an amazing person. I worked two jobs. I had my own place. I took care of my friend. Like I could do it, you know? I could function and I could make it happen because I was that person that was strong and able. Well, I finally feel that way again, so I can do it and I will, you know? I will, for me and for my kids because without my kids I don’t have me and without my me, I don’t have my kids.
Discussion
Grief in the Context of Child Custody Loss
There is a paucity of literature related to grief in child custody loss. The loss of child custody creates an ambiguous loss. This is especially true for mothers due to the “lost person [being] in fact alive and difficult to mourn” (Baum & Negbi, 2013, p. 1684; Boss, 1988, 2004). The loss of child custody also results in disenfranchised grief in mothers (McKegney, 2003).
McKegney (2003) notes that mothers suffer intense and often silent grief over the loss of their children despite the reason the children were apprehended. Weiss (1998) echoes this, describing the grief as “so intense and painful” (p. 1012) that child custody loss creates feelings of desperation. This desperation enacted itself out in an ever deepening spiral with each of the women’s addictions as well as feelings of violence toward those who apprehended their children.
Recovering mothers who lose custody of their children appear to fit into the latter category of ambiguous loss where the child is psychologically present but not physically absent (Boss, 2004; Boss & Yeats, 2014). This type of loss can be compared with a child that has been abducted, but in this case, the child is apprehended. When a child is abducted, the child often is taken against his or her will despite the mother–child relationship (Spilman, 2006). As in nonfamily abduction, apprehension or the taking or detaining of a child without parental consent is felt to be one of the most disturbing and emotionally distressing parental experiences that a parent can encounter in their entire lives (p. 150). Spilman describes vicarious trauma of both child and parent.
With this trauma, apprehension could be considered an emotionally violent loss and more so if the child is taken unexpectedly. Lichtenthal, Niemeyer, Currier, Roberts, and Jordan (2013) note that in situations where the loss has been violent in nature that traumatic grief is an outcome. Although in abduction there is much support in terms of family, friends, police, and attorney (Spilman, 2006), there seems to be little support for mothers who lose custody of their children. Mothers could be considered to live through the trauma of losing custody largely on their own. Price, Jordan, Prior, and Parkes (2011) refer the loss of a child as “living through [a] nightmare” (p. 1391).
Grief Reactions
Askren and Bloom’s (1999) analysis of 12 studies of mothers who resigned custody of their children reveals that initially mothers experience acute grief reactions. Acute grief gives way to chronic, unresolved grief and often results in pathological grief. When custody is lost involuntarily, mothers experience enduring psychological distress (Novac et al., 2006; Wiley & Baden, 2005). Comparing and contrasting the symptomatology of acute grief, the mothers in the study appear to initially experience acute grief reactions which give way to long-term psychological distress.
When mothers experience concurrent mental illness, their grief is described as extremely distressing (Seeman, 2012) which leaves them bewildered and confused (Sands, Koppelman, & Solomon, 2004). All of the women in this research experienced co-occurring mental health disorders, addiction, and a history of abuse/domestic violence. This could be considered to complicate the loss of custody of their children as mothers have to deal with mental health, addictions, and interpersonal violence as well as the loss of their children.
Rostila, Saarela, and Kawachi (2011) found that the probability of a mother’s mortality after the death of a child to be 31%. This increased mortality is supported by an earlier study by Winngaards-deMeij et al. (2007). The active attempts of suicide in which death did not result are consistent with the increased probability of mortality.
Parental loss of a child is considered to have the greatest risk for and prevalence of complicated grief (Kersting & Wagner, 2012). Shear (2015) estimates the prevalence of complicated grief in child loss to be greater than 20%. The mothers in this study exhibited many of the symptoms of complicated grief/prolonged grief.
Prolonged Grief
Prolonged grief does not singularly occur in bereavement but also can occur with other psychological conditions that are related to loss (Currier et al., 2012). Prolonged grief disorder is “characterised by intense, severe, and functionally impairing grief symptoms which have been shown to be distinct from bereavement related depression and anxiety” lasting for “at least 6 months to several years” (Litchtenthal et al., 2013, p. 7). For the mothers in this study, their grief was still present at the time of the interview—from 1 to 10 years after losing custody. This speaks to the long-term effects of child custody loss.
Mothers exhibited much emotion during the interviews, often crying as they spoke of their loss and grief. The impact of losing custody of their children can be understood as occurring long after the acute phase of grieving and could be considered as prolonged grief with characteristics of prolonged grief disorder (He et al., 2014; see Table 2 for symptoms of prolonged grief disorder vs. grief in child custody loss).
Table 2. Symptomatology of Prolonged Grief Disorder/Pathological Grief Versus Grief in Child Custody Loss in the Literature and Study.
| Symptomatology of prolonged grief disorder versus grief in child custody loss | ||
| Prolonged grief disorder= Pathological grief + traumatic grief + complicated grief (He et al., 2014) |
-Longing or intense yearning, pain, sorrow, or grief, avoidance of reminders, shock, dazed, confusion regarding role in life, trouble accepting the loss, difficulty in moving on, numbness, emptiness, meaninglessness, depression, PTSD, anxiety (Horowitz et al., 1997) | |
| It is noted that separation distress as well as traumatic distress can cause symptoms of prolonged grief disorder (Holland & Niemeyer, 2011) | -Separation distress, traumatic distress, major depression, generalized anxiety disorder, PTSD, invasive thoughts about lost relationship, meaninglessness, functional impairment in activities of daily living, trauma like symptoms (Holland & Neimeyer, 2011) -Problems accepting loss, unable to trust others, excessive anger, disconnection from others, hopelessness regarding the future, life becomes meaningless (Currier et al., 2012) -Cognitive, emotional, and behavioral symptoms (Wittouck et al., 2011) |
|
| Grief in child custody loss (Literature) | -Initial acute grief response of anger, guilt, and depression. -Denial, despair, atypical responses, headaches, sleep disturbances, appetite disturbances, lack of energy, fantasies, searching behavior, relational problems in family, long-term physical, social, and psychological problems. -Symptoms of chronic, pathological grief. (Askren & Bloom, 1999) -Magnification of previous trauma, despair, disempowerment, numbness, loss of self-esteem, loss of desire to live (Novac et al., 2006) -Substance abuse, psychiatric problems (Hoffman & Rosenheck, 2001) -Shame and rage (Wells, 2010) -Guilt, feelings of betrayal, humiliation, anger, worry, and grief (McKegney, 2003) -Difficulty sleeping, weight loss, diminished appetite, nightmares, explicit dreams related to child apprehension, or searching for lost child (Chalton, Crank, Kansara, & Oliver, 1998) |
|
| Grief in child custody loss (study) | -Intense grief and pain, desire to numb pain through addictions, substance abuse, anger, denial, self-blame, shame, guilt, negative self-talk, bitterness, hurt, feelings of failure, loss of hope, feelings of acting violent toward those apprehending child(ren), cutting everyone out of life, loss of self-esteem, betrayal, feelings of being misled, hysterical crying, suicidal ideation, active attempts of suicide, loss of self, self-neglect, relational difficulties especially with family members who have been involved with custody loss, extreme longing, giving up, frustration, discouragement, powerlessness, hate, feeling alone, separation distress, traumatic distress, depression, intense yearning | |
Note. PTSD = posttraumatic stress disorder.
Posttraumatic Growth
In ambiguous loss, the loss of role is mourned and creates a situation where a redefinition of relationship, roles, and responsibilities presents itself to the bereaved. Benkel, Wijk, and Molander (2009) also support this finding in that roles and relationships change with bereavement. Moules (1998) notes that “grief is . . . a journey of relationship. It is a relationship that searches for meaning” (p. 152). Lichtenthal et al. (2013) note that bereaved parents who experience prolonged grief disorder often report posttraumatic growth. The evolution of meanings surfaces over a period of months and years. This is consistent with the findings in this study.
The women in this study experienced meaning of their loss in their efforts to learn to live again despite the loss and symptoms of prolonged grief disorder. This occurred as they worked to reclaim their lives. One of the findings of this study was that the women moved through three nonlinear phases, in which the themes of betrayal, soul ache, and reclamation represent. Meaning was found once the mothers accepted accountability for their part in the loss of their children which often took years to occur after custody loss (see Table 3 for comparison and contrast of bereavement and associated themes in study).
Table 3. Contrast and Comparison of Bereavement Literature and Themes in Study.
| Comparison and contrast of bereavement literature and themes in study | ||
| Concept | Literature | Study |
| The experience of loss Traditional loss or ambiguous losses (Betz & Thorngren, 2006; Boss & Yeats, 2014; Douglas, 2004) |
– Emotional pain, physical pain, suicidal ideation, loss of control, feelings of being lost and without purpose, loss of identity (Boss & Yeats, 2014; Douglas, 2004) – Anguished suffering within a devastating emptiness (Florczak, 2008; Lichtenthal et al., 2013) – Loss of heart and soul – ”soul-stirring, soul-changing, and soul-calling” (Moules et , 2007, p. 137) – Loss of identity (Moules et al., 2007; Meert et al., 2015) |
– Emotional, physical, and spiritual pain, suicidal ideation, loss of control, loss of self-identity, and loss of purpose – Sense of self as mother remains, sense of self being separate from addictions – Place of soul ache is a place of this anguished suffering in what could be considered to be a devastating void – The nature of custody loss is where one loses their soul and then finds it again in a process of moving through soul ache to reclamation. Their soul is called back from the space of soul ache – Identity as mother intact, loss of child disrupts self-role concept |
| Complicated grief Struggle to adapt to loss over a period of months or years by 10 to 15% of bereaved population (Neimeyer & Currie, 2009) |
– Intense and persistent yearnings for the deceased – Intrusive thoughts regarding the death – Sense of inner emptiness – Hopelessness about the future – Difficulty acknowledging the reality of the loss – Vulnerability, functional impairment, substance abuse (Neimeyer & Currier, 2009; Shear et al., 2011) – Increased risk of mortality (Rostila et al., 2011; Winngaards-deMeij et al., 2007) |
-Intense and persistent yearnings for the child who has been lost – Troubling thoughts about the apprehension – Sense of inner emptiness (living and yet dead) – Hopelessness about the future – Trouble accepting the reality of the loss – Functional impairment, going deeper into addiction – Self-destructive path post custody loss (substance abuse) -suicidal ideation/suicide attempts |
| Traumatic grief Loss of an individual through death by trauma (Neimeyer et al., 2002; Neimeyer, 2011). |
-Traumatic death interrupts natural order in families – High arousal – Unintegrated sensations, perceptions persisting for years – Altered sense of security, predictableness, trust, and optimism overpoweringly and perhaps forever undercut by traumatic experience – Compelling struggle for explanation (Currier et , 2012; Holland & Neimeyer, 2011; Neimeyer et al., 2002). – Haunted by images and thoughts of death (Neimeyer, 2012; Tedeschi & Calhoun, 2008). |
-Loss of custody traumatic for mothers – Violates natural order of motherhood – High arousal – Loss/sensations/perceptions persist for years – Altered sense of security, predictability, trust, and optimism (betrayal) – Explanation becomes apparent when mother comes to grips with her own accountability in custody loss – Haunted by images of moment of custody loss/apprehension |
| Posttraumatic growth Highest form of change associated with grief; distress may be still present (Tedeschi & Calhoon, 2008) |
-Making sense of the death; meaning making (Michael & Cooper, 2013) – Discovering existential benefit/life lesson in loss (Currier et al., 2012; Neimeyer et al., 2002) -Transformation, positive adaptation, meaning construction (Michael & Cooper, 2013; Niemeyer, 2005) – Transcendence, transformation (Currier et , 2012; Michael & Cooper, 2013; Moules, 1998) – Process of re-identification undertaken – New understandings about life and death, a deeper appreciation and understanding of others – A wish to help others who are suffering – A sense of being a better person – Solid identification with others who have undergone bereavement (Douglas, 2004; Meert et , 2015) – Enduring pain modulated with growth – Expansion of new possibilities, changes in relationships with others, augmented sense of personal strength, an increased appreciation for life; changes in existential and spiritual positioning (Currier et al., 2013; Tedeschi & Calhoon, 2007) – Nonlinear in nature (Currier et al., 2012) |
-Life lessons found in coming to terms with loss – Meaning found in relationship with higher power – Positive adaptation and transformation through recovery as well as progressing though the three places/spaces that mother finds herself in (betrayal, soul ache and reclamation) – Identity as mother stable – Sees role as mother differently – Desire to help others who are suffering – Sense of being a better person – Strong identification with other mothers who have lost custody – Pain still is present but able to move through despite the pain – Growth seen in moving into the space of reclamation where we can reach toward the future – Life is valued and appreciated in reclamation – Change in spiritual orientation with relationship with higher power – Increased sense of being in control of future/self – New possibilities emerge for life and living – Mothers move back and forth between and through spaces of betrayal, soul ache, and reclamation |
Currier et al. (2012) found a curvilinear relationship between prolonged grief and posttraumatic growth which resulted in both interpersonal and intrapersonal changes. With intermediate symptoms of prolonged grief, there is found the greatest probability of post traumatic growth (p. 68). With lower or higher symptoms of prolonged grief demonstrates less post-traumatic growth (p. 69). The symptoms of prolonged grief, although many, seemed to decrease in recovery. With the mothers’ commitment to their recovery, their desire to give back could be demonstrative of posttraumatic growth. Talbot (1998) supports this is in that when those who are bereaved make a mindful decision to live, they choose to assist others in the capacities of volunteering or employment in a helping profession.
A move toward religiosity has been found to be related to greater posttraumatic growth (Calhoun, Cann, Tedeschi, & McMillan, 2000; Currier, Mallot, Martinez, Sandy, & Neimeyer, 2013; Milam, Ritt-Olsen, & Unger, 2004). Each of the mothers exhibited a great reliance on their higher power and emphasized a move toward both increased spirituality and religiosity. This may explain their ability, in part, to start to reclaim their lives.
Rumination is also found to have ties to posttraumatic growth (Triplett, Tedeschi, Cann, Calhoune, & Reeve, 2011). Triplett and associates describe two kinds of rumination: that which is deliberate and that which is intrusive. Deliberate rumination is found to result in constructive results and is associated with managing the emotional distress associated with the loss (p. 2). For years, the mothers ruminated about custody loss. During this time, the mothers seem to experience intrusive rumination. Once in recovery, the rumination appears to be more deliberate in nature as the mothers try to make sense of the loss of their children.
Hope remains central to recovering mothers who lose custody of their children. Even despite permanent custody loss in two of the mothers, they still maintained hope that one day they would be reunified with their children. This speaks to the power of enduring hope and the power of the human spirit.
Implications
In the words of John Reynolds (2002),
Disenfranchised grief is as political as it is clinical. Enfranchisement is a political term meaning to . . . set free, to liberate . . . The utility and clinical efficacy for Doka’s invention of a political term such as disenfranchisement is that it suggests and action or mobilization. (pp. 352, 384)
This action and mobilization begins with those who have positions of power in society: judicial systems, social workers, psychologists, nurses, physicians, and addiction counselors. To set free or liberate mothers with addictions who have lost custody of their children from stigmatization, marginalization and disenfranchisement in relation to their experience of grief can be a first step in reducing the disenfranchised grief of child custody loss.
The findings of this research demonstrate that mothers who lose custody of their children experience profound grief which can extend up to 10 years past the apprehension of their child(ren). It becomes imperative that treatment interventions such as grief counseling or grief support be provided to these mothers at the time of custody loss and be ongoing in nature—even after posttraumatic growth has been observed. This may assist in the prevention of the development of prolonged grief and prolonged grief disorder. This can start with social work agencies who can refer these mother’s to grief support programs as part of mandated options.
While the mothers’ suicide attempts did not result in death, it is clear that the risk of mortality can be great. Almost one third of mothers who experience child loss through death lose their lives (Rostila et al., 2011). In the words of Hannah, if child custody loss can be seen as “worse than if [a child] had passed away,” then the risk of mortality could be considered to be substantial. Regular contact with mothers by social workers and mental health professionals postcustody loss and regular suicide risk assessments and subsequent treatment can become life-saving actions.
Mothers who have concurrent addictions are 8.4 times more likely to experience death particularly through suicide and overdose (Hser, Kagihara, Huang, Evans, & Messina, 2012). Early mandated referral through the judicial system to addiction treatment centers may be the difference for these mothers. It is emphasized that grief support and grief counseling also be made available to mothers within addiction recovery programming.
Strengths and Limitations
As this research is a qualitative study, the results are not meant to be generalizable but transferable (Glesne, 2015). The small sample is mediated by the assertion that even a sample of one can result in a rich source of data (Crouch & McKenzie, 2006). A sample of at least three participants is considered adequate in qualitative research (Cresswell, 2013). A limitation could be seen within the notion of cause and effect. While through previous research some aspects of grief in mothers who lose custody are known, the paucity of prior research represents a limitation in determining cause and effect which may have been more representative in a quantitative study rather than a qualitative study. Nevertheless, this qualitative study is felt to have resulted in rich data for consideration.
Figure 1. The child custody loss grief model.
Conclusion
In this article, we explored the constructs of grief, bereavement, and loss from the standpoint of the literature. Results of the research were presented. A discussion surrounded ambiguous loss, grief, and posttraumatic growth in recovering mothers who have lost custody of their children. Limitations were outlined.
To date, there has been no known research which has centered specifically on the experience of grief in recovering crack cocaine-addicted mothers who lose custody of their children. This research adds to the knowledge base surrounding not only a mother’s child custody loss but also their experience of grief. As a result of this research, more is known about the symptomatology of the grief that is experienced by mothers and the processes that the mothers progress through: betrayal, soul ache, and reclamation. Although posttraumatic growth has been identified as an outcome of the mothers’ loss of custody and the grief that they bear, grief can continue past observations of posttraumatic growth. Much more research is needed to further understand these processes.
Although the mothers in this study did not succumb to their suicide attempts post child custody loss, the risk of mortality is great in this population. If even one life can be saved from suicide due to the devastating effects of child custody loss through the provision of grief counseling, the voices of the mothers in this research will not have been spoken in vain. We leave a call for grief support/ counseling to become an ongoing and standardized practice within all disciplines that are involved with addicted and recovering mothers who lose custody of their children.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
References
American Psychological Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychological Association.
Askren, H. A., & Bloom, K. (1999). Postadoptive reactions of the relinquishing mother: A review. Journal of Obstetric, Gynecological and Neonatal Nursing, 28(4), 395–400.
Attig, T. (2004). Disenfranchised grief revisited: Discounting hope and love. OMEGA: Journal of Death and Dying, 49(3), 197–215.
Baum, N., & Negbi, I. (2013). Children removed from home by court order: Father’s disenfranchised grief and reclamation of paternal functions. Children and Youth Services Review, 35, 1679–1686.
Benkel, I., Wijk, H., & Molander, U. (2009). Managing grief and relationships roles influences which forms of social support the bereaved needs. American Journal of Hospice and Palliative Medicine, 26(4), 241–245.
Betz, G., & Thorngren, J. M. (2006). Ambiguous loss and the family grieving process. The Family Journal: Counselling and Therapy for Couples and Families, 14(4), 359–365.
Boss, P. (1988). Family stress management. Newbury Park, CA: Sage.
Boss, P. (2004). Ambiguous loss. In F. Wash & M. McGoldrick (Eds.) Living beyond loss: Death in the family (2nd ed., pp. 237–246). New York, NY: Norton.
Boss, P., & Yeats, J. R. (2014). Ambiguous loss: A complicated type of grief when loved ones disappear. Bereavement Care, 33(2), 63–69.
Bryant, R. A. (2014). Prolonged grief: Where to after diagnostic and statistical manual of mental disorders, 5th edition? Current Opinions in Psychiatry, 27(1), 21–26. Retrieved from http://www.medscape.com/viewarticle/818619
Calhoun, L. G., Cann, A., Tedeshci, R. G., & McMillan, J. (2000). A correlational test of the relationship between post-traumatic growth, religion and cognitive processing. Journal of Traumatic Stress, 13, 521–527.
Chalton, L., Crank, M., Kansara, K., & Oliver, C. (1998). Still screaming: Birth parents compulsorily separated from their children. Manchester, England: After Adoption.
Cresswell, J. W. (2013). Qualitative inquiry & research design: Choosing among five approaches. Los Angeles, CA: Sage.
Crouch, M., & McKenzie, H. (2006). The logic of small samples in interview based qualitative research. Social Science Information, 34(4), 483–499.
Currier, J. M., Holland, J. M., & Niemeyer, R. A. (2012). Prolonged grief symptoms and growth in the first 2 years of bereavement: Evidence for a nonlinear association. Traumatology, 18(4), 65–71.
Currier, J. M., Mallot, J., Martinez, T. E., Sandy, C., & Neimeyer, R. A. (2013). Bereavement, religion, and posttraumatic growth: A matched control group investigation. Psychology of Religion and Spirituality, 5(2), 69–77.
Davidson, H. (2010). A review of the literature on three types of disenfranchised grief: grandparent grief, grief of birthmothers following adoption, and the grief of exspouses. Retrieved from http://www2.uwstout.edu/content/lib/thesis/2010/2010davidsonh.pdf
Denzin, N. K., & Lincoln, Y. S. (2011). The SAGE handbook of qualitative research. Thousand Oaks, CA: Sage.
Doka, K. (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington, MA: Lexington Books.
Doka, K. J. (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Champaign, IL: Research Press.
Douglas, D. (2004). The lived experience of loss: A phenomenological study. Journal of the American Psychiatric Association, 10(1), 24–32.
Feudtner, C. (2005). Hope and the prospects of healing at the end of life. The Journal of Alternative and Complementary Medicine, 11(Supplement 1): S23–S30.
Feudtner, C. (2010). Taking care of hope. American Journal of Bioethics, 10(5), 26–27. Feudtner, C., Carroll, K. W., Hexem, K. R., Silberman, J., Kang, T. I., & Kazak, A. E.
(2010). Parental hopeful patterns of thinking, emotions, and pediatric palliative care decision making: A prospective cohort study. Archives of Pediatrics & Adolescent Medicine, 164(9), 831–839.
Florczak, K. L. (2008). The persistent and everchanging nature of grieving a loss. Nursing Science Quarterly, 21(1), 7–11.
Gilbert, K. (2007). Ambiguous loss and disenfranchised grief. Retrieved from http://www.indiana.edu/famlygrf/units/ambiguous.html
Glesne, C. (2015). Becoming qualitative researchers: An introduction (5th ed.). New York, NY: Pearson.
He, L., Tang, S., Yu, W., Xu, W., Xie, Q., & Wang, J. (2014). The prevalence, comorbidity and risk of prolonged grief disorder among bereaved Chinese adults. Psychiatry Research, 219, 342–352.
Hoffman, D., & Rosenheck, R. (2001). Homeless mothers with severe mental illnesses and their children: Predictors of family reunification. Psychiatric Rehabilitation Journal, 25(2), 163–169.
Holland, J. M., & Neimeyer, R. A. (2011). Separation and traumatic distress in prolonged grief: The role of the cause of death and relationship to the deceased. Journal of Psychopathological Behavior Assessment, 33, 254–263.
Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbreath, C., & Stinson, C. (1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry, 154(7), 904–910.
Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbrath, C., & Stinson, C. H. (2003). Diagnostic criteria for complicated grief disorder. Focus, 1, 290–298.
Hser, Y. I., Kagihara, J., Huang, D., Evans, E., & Messina, N. (2012). Mortality among substance-using mothers in California: A 10-year prospective study. Addiction, 107(1), 215–222.
Janzen, K. J. (2010). And then there were none: The lived experience of recovering mothers who lose custody of their children (Master’s Thesis). Athabasca University. Retrieved from https://dt.athabascau.ca/jspui/bitstream/10791/8/1/Thesis%20PDF%20Final.pdf
Janzen, K. J., & Melrose, S. (2013). When the worst imaginable becomes reality: The experience of child custody loss in mothers recovering from addictions. Janus Head, 13(1), 176–213.
Kersting, A., & Wagner, B. (2012). Complicated grief after perinatal loss. Dialogues in Clinical Neuroscience, 14(2), 187–194.
Lichtenthal, W. G., Neimeyer, R. A., Currier, J., Roberts, K., & Jordan, N. (2013). Cause of death and the quest for meaning after the loss of a child. Death Studies, 37(4), 311–342.
Lobb, E. A., Rando, T. A., Duka, K. J., Flemming, S., Franco, M. H., Murray Parks, C., & Steele, R. (2012). A call to the field: Complicated grief in the DSM-5. Journal of Death & Dying, 65(4), 251–255.
McKegney, S. (2003). Silenced suffering: The disenfranchised grief of birthmothers compulsory separated from their children. Master’s Thesis. School of Social Work. McGill.
Meert, K. L., Eggly, S., Kavanaugh, K., Berg, R. A., Wessel, D. L., Newth, C. J., … Park, C. L. (2015). Meaning making during parent–physician bereavement meetings after a child’s death. Health Psychology, 34(4), 453.
Michael, C., & Cooper, M. (2013). Post-traumatic growth following bereavement: A systematic review of the literature. Counselling Psychology Review, 28(4), 18–33. Retrieved from www.researchgate.net/publication/260244829
Milam, J. E., Ritt-Olsen, A., & Unger, J. B. (2004). Post-traumatic growth among adolescence. Journal of Adolescent Research, 19, 192–204.
Moore, S. L. (2005). Hope makes a difference. Journal of Psychiatric and Mental Health Nursing, 12, 100–105.
Moules, N. J. (1998). Legitimizing grief: Challenging beliefs that constrain. Journal of Family Nursing, 4(2), 142–166.
Moules, N. J., Simonson, L., Fleiszer, A. R., Prins, M., & Glascow, B. (2007). The soul of sorrow work: Grief and therapeutic interventions with families. The Journal of Family Nursing, 13(1), 117–141.
Niemeyer, R. A. (2005). Grief, loss and the quest for meaning. Bereavement Care Journal, 24(2), 27–30.
Neimeyer, R. A. (2012). Retelling the narrative of the death. In R. A. Neimeyer (Ed.), Techniques of grief therapy: Creative practices for counseling the bereaved (pp. 86–90). New York, NY: Lexington.
Neimeyer, R. A., & Currier, J. (2009). Grief therapy: Evidence of efficacy and emerging directions. Current Directions in Psychological Science, 18(6), 352–356.
Neimeyer, R. A., Prigerson, H. G., & Davies, B. (2002). Mourning and meaning.
American Behavioral Scientist, 46(2), 235–251.
Novac, S., Paradis, E., Brown, J., & Morton, H. (2006). A visceral grief: Young homeless mothers and loss of custody. Toronto, Canada: Center for Urban and Community Studies, University of Toronto. Retrieved from http://www.urbancentre.utoronto.ca/pdfs/elibrary/Novacet-al-206-VisceralGriefHLMothers.pdf
Perry, B. (2009). More moments in time: Images of exemplary nursing. Edmonton, Canada: AU Press.
Price, J., Jordan, J., Prior, L., & Parkes, J. (2011). Living through the death of a child: A qualitative study of bereaved parents’ experiences. International Journal of Nursing Studies, 48, 1384–1392.
Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., Shear, K., Day, N., … Jacobs, S. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154(5), 616–623.
Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., 3rd, Anderson, B., Zubenko, G. S., … Kupfer, D. J. (1995). Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry, 152, 22–30.
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., … Maeijewski, P. A. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121.
Prigerson, H. G., Vanderwerker, L. C., Maciejewski, P. K., & Stroebe, M. S. (2008). A case for inclusion of prolonged grief disorder in DSV-V. In R. O. Hansson, H. Schut & W. Stroebe (Eds.) Handbook of bereavement research and practice: Advances in theory and intervention (pp. 165–186). Washington, DC: American Psychological Association.
QRS International Dupuy Ltd (2009). Products. Retrieved from http://www.qrsinternational.com/products.aspx
Reynolds, J. J. (2002). Disenfranchised grief and the politics of helping: Social policy and its clinical implications. In K. J. Doka (Ed.), Disenfranchised grief: New directions, challenges, and strategies for practice (pp. 351–388). Champaign, IL: Research Press.
Ritchie, J., Lewis, J., Nicholls, C. M. & Ormston, R. (Eds.). (2013). Qualitative research practice: A guide for social science students and researchers. Thousand Oaks, CA: Sage. Robson, P., & Walker, T. (2013). Hierarchies of loss: A critique of disenfranchised grief. OMEGA: Journal of Death and Dying, 66(2), 97–119.
Rosner, R., Pfoh, G., & Kotoucˇ ova´ , M. (2011). Treatment of complicated grief. European Journal of Psychotraumatology, 2, 79–95.
Rostila, M., Saarela, J., & Kawachi, I. (2011). Mortality in parents following death of a child: A nationwide follow-up study from Sweden. Journal of Epidemiology and Community Health, 66, 927–933.
Rothaupt, J. W., & Beckner, K. (2007). A literature review of Western bereavement theory: From decathecting to continuing bonds. The Family Journal: Counselling and Therapy for Couples and Families, 15(1), 6–15.
Sands, R. G., Koppelman, N., & Solomon, P. (2004). Maternal custody status and living arrangements of children of women with severe mental illness. Health and Social Work, 29(4), 317–325.
Seeman, M. V. (2012). Intervention to prevent child custody loss in mothers with schizophrenia. Schizophrenia Research and Treatment, 2012, Article ID 796763, 1–6.
Shear, M. K. (2015). Complicated grief. New England Journal of Medicine, 372, 153–160.
Shear, M. K., Ghesquiere, A., & Glickman, K. (2013). Bereavement and complicated grief. Current Psychiatry Reports, 15(11), 1–13.
Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., … Keshenah, V. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28(2), 103–117.
Seirmarco, G., Neria, Y., Insel, B., Kiper, D., Doruk, A., Gross, R., & Litz, B. (2011). Religiosity and mental health: Changes in religious beliefs, complicated grief, posttraumatic stress disorder, and major depression following the September 11, 2001 attacks. Psychology of Religion and Spirituality, 4(1), 10–18.
Silverman, D. (2013). Doing qualitative research: A practical handbook. Thousand Oaks, CA: Sage.
Simon, N. (2013). Treating complicated grief. JAMA, 310(4), 416–423.
Snyder, C. R. (2000). The past and possible futures of hope. Journal of Social and Clinical Psychology, 19(1), 11–28.
Snyder, C. R. (2002). Hope theory: Rainbows in the mind. Psychological Inquiry, 13(4), 249–275.
Spilman, S. K. (2006). Child abduction, parents’ distress, and social support. Violence and Victims, 21(2), 149–165.
Talbot, K. (1998). Mothers now childless: Personal transformation after the death of an only child. OMEGA: Journal of Death and Dying, 38(3), 167–186.
Tedeschi, R. G., & Calhoun, L. G. (2007). Beyond the concept of recovery: Growth and the experience of loss. Death Studies, 32(1), 27–39.
Tedeschi, R. G., & Calhoun, L. G. (2008). Beyond the concept of recovery: Growth and the experience of loss. Death Studies, 32, 27–39.
Triplett, K. N., Tedeschi, R. G., Cann, A., Calhoune, L. G., & Reeve, C. L. (2011). Posttraumatic growth, meaning in life, and life satisfaction in response to trauma. Psychological Trauma: Theory, Research, Practice and Policy, 1–11. Retrieved from https://ptgi.uncc.edu/files/2015/01/Posttraumatic-growth-meaning-in-life-and-life-satisfaction-in-response-to-trauma.pdf
van Manen, M. (1997). Researching lived experience: Human science for an action sensitive pedagogy. Winnipeg, Canada: The Althouse Press.
Weiss, R. S. (1998). Coping with loss: Separation and other problems that threaten relationships. British Medical Journal, 316(136), 1011–1013.
Wells, K. (2010). A narrative analysis of one mother’s story of child custody loss and regain. Children and Youth Services Review, 33, 439–447.
Wiley, M. O., & Baden, A. (2005). Birth parents in adoption: Research, practice and counselling psychology. The Counselling Psychologist, 33(1), 13–50.
Wittouck, C., Van Autreves, S., De Jaegere, E., Portzky, G., & van Heengden, K. (2011). The prevention and treatment of complicated grief: A meta analysis. Clinical Psychology Review, 31, 69–78.
Winngaards-deMeij, L., Srtoebe, M., Schut, H., Strobe, W., van den Bout, J., van der Heijden, P. G. M., & Dijkstra, I. (2007). Patterns of attachment and parent’s adjustment to the death of their child. Personality and Social Psychology Bulletin, 33(4), 537–548.
World Health Organization (2015). International classification of disease and related health problems 10th Revision. Geneva: World Health Organization Retrieved from http://apps.who.int/classifications/icd10/browse/2015/en
Zetumer, S., Young, I., Shear, M. K., Skritskaya, N., Lebowitz, B., Simon, N., … Zisook, (2015). The impact of losing a child on the clinical presentation of complicated grief. Journal of Affective Disorders, 170, 15–21.
Zisook, S., & Shear, K. (2009). Grief and bereavement: What psychiatrists need to know. World Psychiatry, 8, 67–74. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160/.
