Having Therapeutic Conversations With Fathers Grieving the Death of a Child

Abstract

A child’s death is a traumatic life experience for parents. Health-care professionals (HCPs) have sought guidance on how to intervene with grieving parents, particularly with fathers. Having therapeutic conversations is an effective way for HCPs to support grieving fathers. In our previous study, fathers identified core beliefs that influenced their experience of grief and coping. In this article, the Illness Beliefs Model was integrated with the findings to provide a framework for interventions to create open conversations, ease fathers’ suffering, and thereby help their spouse and family suffering as well. This article will guide HCPs to engage in therapeutic conversations to support bereaved fathers.

Keywords

fathers grief children death interventions beliefs

Introduction

The death of a child can have significant effects on parents’ health and coping (Hunt & Greeff, 2011) and has been reported as one of the most difficult experiences that a parent can live through (Proulx, Martinez, Carnevale, & Legault, 2015; Youngblut, Brooten, Cantwell, del Moral, & Totapally, 2013). Parents, whose child had died, have expressed living with significant levels of psychological distress that includes mental and physical symptoms (Goodenough, Drew, Higgins, & Trethewie, 2004; Youngblut et al., 2013). However, in the current literature, there is limited understanding of experiences of men grieving the death of a child and even fewer studies of interventions to support them (K. Davies, Whitworth, & Murray, 2015). Health-care professionals (HCPs) are intrinsically involved in the course of a child’s life-threatening illness and subsequent death. Working with and supporting bereaved families can play an important role in facilitating the grieving process for fathers who have lost a child.

To better understand fathers’ grief, we previously conducted a phenomenological study to record the experience of fathers 1 to 7 years after the death of their child. In describing their suffering and experiences of grief, fathers voiced specific beliefs that had an effect on their coping strategies (Proulx et al., 2015). The understanding of fathers’ beliefs in clinical practice is particularly congruent with the premises of the Illness Beliefs Model (IBM), a model that guides HCP interventions through the exploration and recognition of individual and family beliefs (Wright & Bell, 2009). The model posits that individual and family beliefs can facilitate or constrain the coping experience and by intervening through the exploration of beliefs opens the communication and suffering may be softened (Bell & Wright, 2015).

The purpose of this article is to suggest interventions for bereaved fathers guided by the IBM and bearing in mind the findings of our earlier study. By integrating the IBM to the research findings, we have identified practical and useful interventions for HCPs to support coping and to ease bereavement. The IBM emphasizes the use of therapeutic conversations, which are deliberate and purposeful actions or interventions on the part of the HCPs to engage individuals and families in an open dialogue (Wright & Leahey, 2013). Such conversations are intended to facilitate a better understanding of each family member’s different beliefs and coping strategies. They invite individual reflection on personal grief as well as on other family members’ grief.

Background

Despite considerable research on the human experience of grief, there has been little exploration of interventions for bereaved families (Moules, Simonson, Fleiszer, Prins, & Glasgow, 2007; Thirsk & Moules, 2012) and even less for bereaved fathers (Davies et al., 2015). Nonetheless, there is a general inclination in the literature to assume that men have difficulty responding emotionally to loss and that they are inclined to be more comfortable dealing with grief cognitively (Doka & Martin, 2010; Rigby, 2012). Men are traditionally brought up to act, to solve problems, and to refrain from expressing sadness and grief; in short, they are brought up to be tough (Hunt & Greeff, 2011; Rando, 1993; Thompson, 2000). However, Doka and Martin (2010) suggested that grieving styles, though gender-related, are not gender-specific. They differentiated between instrumental and intuitive styles of coping, with most men tending to adopt an instrumental style, where energy is focused on thinking or doing to master their feelings of grief (Doka & Martin, 2010). Grieving fathers have accordingly been reported to busy themselves with work or chores (Alam, Barrera, D’Agostino, Nicholas, & Schneiderman, 2012; Proulx et al., 2015; Wood & Milo, 2001). On the other hand, the intuitive griever experiences and expresses grief in an affective way, and with more intensity. These grievers tend to spontaneously express their pain through crying and a wish to talk about their feelings. Intuitive grievers tend to be found more in women. Men may therefore grieve differently than women, but they do not grieve less (Doka & Martin, 2010; Foster et al., 2011; Goodenough et al., 2004).

Other studies support this notion of gender differences in coping with parental grief. Alam et al. (2012) examined the gender differences and adjustment of mothers and fathers of children who died of cancer after 6 and 18 months. Gender differences in bereavement and adaptation to life after the death of the child included areas related to employment attitudes, grief expression, coping with grief, relationship with their spouse, and relationship with extended family members. The study by Youngblut, Brooten, Glaze, Promise, and Yoo (2017) also supported gender differences in grief. They used a standardized questionnaire to measure the changes in grief and factors affecting grief of mothers and fathers up to 13 months following the death of their child. A difference was found between mothers and fathers in their experience of grief where mothers’ grief intensity decreased after 3 to 6 months and fathers’ grief remained consistent throughout 13 months. These findings indicated that fathers experience grief intensely and that their grief may be experienced long term. Doka and Martin (2010) suggest several reasons for gender differences in parental grieving including contemporary patterns of male and female socialization, individual traits, emotion regulation, and cognitive appraisal of stress. In addition, the prevailing culture can also influence gender difference in parental grieving (Doka & Martin, 2010). In our previous study, Proulx et al. (2015) found that grieving fathers were aware of the different coping styles within the couple and that respect for these differences was of major importance in maintaining and strengthening the relationship with their partner. The findings of our and other studies indicate a need for HCPs to acknowledge gender differences in grieving and adjustment (Cook, 1988; Doka & Martin, 2010; Thompson, 2000).

Parental experience of bereavement of a child is unique but is contextualized within a family that can manifest in multiple ways. Whether married, divorced, or reconstituted families, few studies give specific guidance for HCP interventions to support grieving fathers alone or in the context of a parental dyad. Rather, these studies suggested using a compassionate attitude with clear and open communication that families found useful (Brooten et al., 2012; Davies, Baird, & Gudmundsdottir, 2013). While important, this describes a general approach for all HCPs. What is lacking is specific direction on how to accomplish this when a father is grieving. One study determined whether a multicomponent, standardized intervention to support parents’ grief was feasible and effective (Aho, Tarkka, Åstedt-Kurki, Sorvari, & Kaunonen, 2011). The intervention included three complementary components: First, a support package which included reading material; second, peer contact with fathers (a telephone call 1 week following the death of the child and scheduled a home visit); and third, a meeting with both parents present 2 to 6 weeks after the death of a child. Some support for the intervention program was found where 45% of participants felt the support from HCPs was helpful to very helpful in coping by reducing father’s grief reaction. Although promising, this study does not provide HCPs with specific supportive strategies when interacting with fathers or the couple.

Summary of the Previous Study on Grieving Fathers

In 2013, we conducted a phenomenological study to understand how fathers lived following the death of their child. We met 13 fathers whose child aged 1 to 17 years had died either from a complex chronic condition or from a sudden illness in the pediatric intensive care unit at a university health center. They were Caucasian and reported being raised in the Roman Catholic tradition. Fathers were interviewed 1 year after the death of their child but no more than 7 years; for more information about the sociodemographic description of the participants, see Proulx et al. (2015).

Three major themes and subthemes were identified to understand the fathers’ experience of grief: (a) Needing to push forward in order to avoid breakdown. Fathers believed that they needed to keep going or else their well-being would be severely affected and their family would pay the price. They did this by finding motivation from their other children and keeping busy. Fathers felt that it was crucial for the parent–couple to understand each other and to feel supported by their partner. (b) Keeping the child present in everyday life: Fathers believed in the benefits of maintaining a relationship with the deceased child through performing rituals, talking about the child with others, and actively remembering her or him. (c) Finding meaning in the experience of grief. Fathers searched for meaning in order to adjust to the death of their child. They also reported learning many lessons that were helpful such as enjoying the present moment, changing priorities, relativizing everyday dramas (everyday stresses), developing a new sensitivity, and reconsidering spirituality. Fathers described their grief experience and shared their beliefs that determined their coping. This study enhanced our understanding of the experience of bereaved fathers and highlighted factors that must be considered in therapeutic conversations with grieving fathers and couples (when they are in a couple relationship). The study also validated the need to support HCPs in exploring beliefs when intervening with fathers and couples.

The IBM

The IBM is based on the exploration and the understanding of “beliefs” through therapeutic conversations. The concept of beliefs includes values, assumptions, perceptions, meaning, and premises (Wright & Bell, 2009). Beliefs guide feelings, behaviors, and actions of the individual and the family and therefore are the focus of several interventions (Wright & Bell, 2009). Beliefs may be facilitating or constraining in the way they influence lives, relationships, behavior, illness, suffering, healing, and coping strategies. Facilitating beliefs are defined as beliefs that open possibilities for change and growth, thereby softening illness suffering. Constraining beliefs are identified as thoughts, opinions, or assumptions that influence the understanding of a particular situation that inhibits problem-solving and increases suffering. Beliefs about health, suffering, healing, spirituality, as well as relationships are central to coping. The IBM stresses the importance of exploring and understanding these beliefs to make a clinical judgment and distinction between constraining and facilitating beliefs. The HCPs role will then be to create a context for change, to uncover and distinguish beliefs, to challenge constraining beliefs, and to strengthen facilitating beliefs (Bell & Wright, 2015).

There is evidence to support the need to better understand individuals and families’ grief beliefs (Moules, 1998, 2009; Moules, Simonson, Prins, Angus, & Bell, 2004). Thirsk and Moules (2013) used the IBM to enhance the understanding of families experiencing grief in order to promote hope to families that allowing suffering to diminish. Several studies have also described the application of the IBM in areas other than grief. Arestedt, Benzein, and Persson’s (2015) research study with families living with chronic illness revealed that individual and family beliefs can have an impact on daily life coping. Their results acknowledged the importance for HCPs to uncover individual and family beliefs during their therapeutic conversations, as beliefs are responsible for how individuals respond to situations. West, Bell, Woodgate, and Moules (2015) studied family systems interventions in childhood cancer based on the IBM. Their study provided evidence that families holding certain beliefs, especially constraining beliefs, can lead to intense experiences of suffering. They concluded that HCPs should explore and challenge constraining illness beliefs to promote hope. These studies support the core of the IBM, that is, to understand the experience of illness suffering and the interventions targeted to lessening suffering.

Interventions for Bereaved Fathers Guided by the IBM

The IBM includes four types of macromoves that serve as guidelines for engaging in therapeutic conversations. These macromoves are as follows: (a) creating a context for changing beliefs, (b) uncovering and distinguishing illness beliefs, (c) challenging, altering and modifying constraining beliefs, and (d) identifying and strengthening facilitating beliefs. Macromoves are operationalized by specific and discrete interventions. Here, we will present examples of interventions for fathers mourning the death of a child. They are meant to provide a practical application of our earlier work and study findings and inspire useful actions. We did not think it was appropriate to present interventions for each theme and subtheme from our research findings. Instead, we chose to suggest interventions for the themes and subthemes we felt are the most relevant for HCPs during therapeutic conversations with fathers or the couple. These interventions can be used with only one member present, just the father alone, but we encourage meeting the couple during all therapeutic conversations, whenever the parents are together.

When parents are divorced or separated, the presence of the ex-spouse should be openly discussed and their current relationship should be taken into consideration. HCPs should try not take for granted but evaluate the ability of the ex-spouse to provide support. HCPs can assess the pertinence of including the mother of the lost child by evaluating their relationship. When fathers are in a new long-term relationship, the presence of the new partner should be also discuss. HCPs can keep in mind that the therapeutic conversation will create an opportunity to better understand each other’s beliefs, needs, and coping strategies.

In the next sections, we will focus on several interventions. One intervention in particular identified as interventive questions is fundamental to therapeutic conversations. Interventive questions are inspired by the work of Karl Tomm (1987, 1988) and include circular questions, reflexive questions, and therapeutic questions. For example, asking “Who was the most affected by the situation?” is a circular question intended to reveal differences in coping. A reflexive question such as “How do your coping strategies impact your day to day living and your partner’s day to day living?” can open up new understanding of the situation. Finally, a therapeutic question can be “What helps you the most in coping with the lost of your child?” to bring about the awareness in coping and suffering. The use of interventive questions aims to open possibilities for new understanding of the situation. They are meant to effect change by bringing out different ways of perceiving the problem, situation, or context and open the dialogue. They are the cornerstone of any therapeutic conversation.

Creating a Context for Changing Beliefs

To create a context for changing beliefs, the primary intervention is to establish a trusting and collaborative relationship with fathers. Generating a genogram, asking interventive questions and providing information during the interview with father will initiate a therapeutic conversation and lay the groundwork for a trusting relationship. The construction of the genogram will also help build the narrative of the family’s history. Creating a genogram entails eliciting information about the family structure, family history, family relationships, and family patterns. It can be a nonthreatening way of initiating a conversation with fathers and couples (Wright & Leahey, 2013). While creating a genogram, there is an opportunity to highlight and strengthen relationships. Some examples of interventions including interventive question during the construction of a genogram include as follows: Tell me about your relationship with your other child. What does he do that helps you the most? Has your relationship with your other child changed and how? How do you explain that change? Fathers from our study reported shifting their focus following the death of their child and finding motivation in their other children by just appreciating more the day to day activities with him or her.

To promote and create a context for change, an important intervention is to remove possible obstacles to change (Wright & Bell, 2009). Meeting with both parents, in contexts where that is possible, may help to remove obstacles to change by helping them better understand each other’s experiences and beliefs. It gives the opportunity for both spouses to hear the narration of thoughts and helps to increase their understanding. In our previous study, all of the fathers reported experiencing grief very differently from their wives. Several fathers explained that their spouse was not “at the same place at the same time” and that their capacity to understand each other’s ways of coping was helpful (Proulx et al., 2015). In our experience, many HCPs have the constraining belief that grief is an individual process. Although one partner in a couple experiences grief very differently from the other, all the fathers interviewed had acknowledged that they needed their partner and their support. A man may feel helpless in the face of his wife’s distress and may believe he needs to act on her distress rather than to offer to listen to her concerns. A woman may be perplexed by her husband’s perceived failure to express emotion. She may therefore view his less expressive style of mourning as indicating a lack of love for their deceased child (Doka & Martin, 2010; Stroebe & Schut, 1999), and divisions between them may deepen in consequence.

HCPs can facilitate the creation of a context for changing beliefs by exploring the differences in the way fathers and mothers react to bereavement while acknowledging and legitimizing these differences. Acknowledging and legitimizing differences in coping are interventions that can help decrease feelings of isolation and increase connection (Wright & Leahey, 2013). The following example of a legitimizing statement and interventive questions brings forward and acknowledges differences in styles of mourning: Parents often grief differently in the way they cope, what differences are there between you and your partner in the way you cope, or act, or grieve? How does your partner react when you want to go for a walk and she or he just wants to talk about her or his feelings? How does your partner let you know that she or he is not doing well? Who appears to have more difficulty coping? What makes you believe she or he is having more difficulty coping?

Relationships can suffer if effective communication and understanding are lacking about the varied ways individuals grieve, particularly between men and women. Providing information about different coping patterns between parents is another intervention that can help recognize each partner’s strengths in coping with grief. This can be a useful strategy for creating a context for changing beliefs.

Distinguishing and Exploring Illness Beliefs

Fathers in our earlier study described having suffered profoundly after the loss of their child; in cases of both sudden and expected death, some even revealed they had had suicidal ideations. Even after several years, they all express their sadness. However, they believed that they needed to keep going or their well-being would be undermined, and their family would pay the price (Proulx et al., 2015). For these fathers, the experience of pushing forward and simultaneously maintaining a relationship with the dead child was marked by a search for meaning in life. Eliciting beliefs about religion and spirituality is an integral aspect of IBM’s macromove of distinguishing and exploring illness beliefs.

Most of the participants in our earlier study said that they were raised Roman Catholic; for many, though, their child’s death was a challenge to their belief in God. Fathers felt a need to seek answers in philosophy or in other spiritual practices they had not previously considered. Parents also reported that their faith or spirituality was a source of comfort to them and helped them cope as in A. L. Thompson et al. (2011). Bereaved parents who struggle to find meaning in their experience suffer more severe grief symptoms and adjustment difficulties than those who were able to find meaning (Keesee, Currier, & Neimeyer, 2008; Lichtenthal, Neimeyer, Currier, Roberts, & Jordan, 2013).

Spirituality and spiritual beliefs can and should be explored early in the therapeutic relationship. Spirituality may or may not include religious beliefs, but it is linked to meaning making by individuals and families and to their perceptions and beliefs. While spiritual beliefs are largely facilitating for most individuals and families, they may also be constraining and need to be distinguished and explored. HCPs can give spiritual care when they inquire about the meaning of life and the understanding of death or let them express their anger toward God. HCPs can explore the spiritual dimension of the mourning experience using a nondenominational approach to allow for fathers’ spontaneous expression of spiritual beliefs. The use of interventive questions through therapeutic conversation can invite new understandings of families’ stories of loss and gains. HCPs can create space for the narration of fathers’ and families’ spirituality by asking the following interventive questions: What spiritual beliefs help you and your family cope with your loss? What is your understanding of death? How have you explained death to your son or daughter? What do you think happens after death? How do you make sense of your child’s death? What have you learned from this difficult experience of losing your child?

Challenging, Altering, and Modifying Constraining Beliefs

In accordance with the IBM, HCPs must assess and make a clinical judgment whether a specific belief is constraining to patients and families (Thirsk & Moules, 2013). An example of a constraining belief in our society and within families is one where individuals should “get over” a loss; where individuals must come to terms with death and let go and also the notion that grief has a time limit. This societal belief was constraining for most fathers in our study. Fathers spoke of their need to maintain a connection with their son or daughter and described ways they continued to communicate with the child to keep up the relationship. Many spoke to him or her in their mind, while others wrote letters or in a private journal. The importance of maintaining a connection with the deceased has been previously described (Moules, 1998). A number of recent studies contend that bereavement does not necessarily break the ties between the living and the dead (Root & Exline, 2014). There may in fact be a continuation of the bonds, albeit necessitating a change in the way bereavement is understood.

The exploration of views on this matter addresses the macromove of challenging and modifying constraining beliefs. The belief for the need to “get over” grief can cause parents suffering. Maintaining a relationship, in whatever form, can be very helpful (Moules, 2009). Interventive questions can explore beliefs about keeping up the connection and about the expectation of overcoming grief: What helps your partner keep your child present? How does that help him and you? What do you do to keep your child present? How have you shared your connection with your child to your partner?

With respect to the couple differences, Doka and Martin (2010) encourage clinicians to challenge the belief that the death of a child causes more divorce, “almost making it inevitable.” As several fathers reported in the study, if partners are able to recognize that differences are not necessarily constraining but may provide them with a larger arsenal of coping strategies, the bond between them may actually become stronger (Proulx et al., 2015). The fathers in our study who recognized and acknowledged couple differences in grieving also said that they felt closer to their spouse. HCPs can open the dialogue and by doing so, increase their awareness that couple differences can contribute to strengthening their couple relationship.

Identifying and Strengthening Facilitating Beliefs

Facilitating beliefs around mourning the loss of a child can come from a search for meaning and lessons learned. The fathers we interviewed in the previous study said that their experience made them more empathetic, gave them new sensitivity, and helped them be more “in touch” with their feelings (Proulx et al., 2015).

Encouraging conversations about new learning can help bring facilitating beliefs to the fore and prompt reflection about them. One of the lessons most fathers in our earlier study learned was the value of the present moment, for the death of their child underscored just how uncertain the future is. This is understood as “benefit finding” where personal or social consequences of the loss result in enhanced empathy, reordered life priorities, and closer connections to others (Davis , Nolen-Hocksema, & Larson, 1998; Keesee et al., 2008). Therefore, HCPs can engage in interventive questions around lessons they learned from their experience: How has grief impacted your family and your life? Can you tell me what the biggest change since your child died? Is there anything you can identify that you are doing differently since your child died? Sometimes fathers and mothers talk about how grief has made them re-examine what they consider important in life. Have you ever found yourself thinking about that? HCPs can also explore beliefs regarding changes in the way fathers perceive the world by asking: Fathers have told me they do not see the world the same way anymore. Does this sound familiar to you?

All the fathers in our study spoke of the importance of keeping busy to avoid being overwhelmed by their suffering. Distraction through work was cited by most of them but so too were other activities such as sports, taking care of the home, and taking care of others (their own parents, other children, etc.). Some found it hard to strike a balance between work as a sane distraction and work as a way to avoid thoughts and feelings about the dead child. HCPs can strengthen facilitating beliefs by normalizing and legitimizing this need to keep busy. They can achieve this by eliciting parents’ beliefs and strategies through such interventive questions as follows: What helps you most to “keep going”? What helps or motivates your partner to get up in the morning? What do you find most helpful when you need to take your mind off of things? If I were to ask your wife how she thinks you keep your mind occupied, what would she say? How helpful is keeping busy for you and your partner? What do you believe pushes you forward? In what way does keeping busy help both of you in the same way?

The fathers in our study said that they liked talking about their lost child and reminiscing with their friends, family, partner, and colleagues and even, some said, strangers. They tried to avoid painful memories, such as the child’s suffering, and preferred recalling the “good times.” By asking parents for the narrative of their family’s history and good memories of their child, HCP can focus on the strengths and relationships within the family and between the father and child. Useful therapeutic questions may thus include: What is one of your memories you have of your child that is precious to you? What do you miss most about your child? What was your favorite vacation with your child? What did you and your child like doing most?

Conclusion

Our previous research helped us better understand how fathers live their grief. In this article, we consider interventions inspired by those findings and guided by the IBM to help HCP in their practice with fathers, couples, and families facing these circumstances. We know that individual and families’ realities draw on their beliefs. Within the IBM framework, HCP have to assess beliefs and make clinical judgments as to whether or not they are constraining for patients and families (Thirsk & Moules, 2013). We must bear in mind that multiple realities can and should coexist in couple and family relationship. The use of interventive questions during therapeutic conversations is discrete, gentle, and at times very powerful interventions that bring forward reflection and can start important therapeutic conversations on difficult experiences. The IBM helps us to keep in mind that by creating a context to change beliefs, distinguish illness beliefs, challenge constraining beliefs, and strengthen facilitating beliefs, HCP can soften suffering, which is the essence of caring (Wright & Bell, 2009).

Footnotes

Acknowledgments

The previous study was supported by a grant from the Small Grants in Nursing Research at the McGill University Health Centre (MUHC), funded by Richard and Satoko Ingram of the Newton Foundation. We would like to thank the fathers who generously agreed to meet with us and trust us with their stories of living with grief.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research study was supported by a grant form the Small Grants in Nursing Research at the McGill University Health Center, funded by Richard and Sotoko Ingram of the Newton Foundation.

Author Biographies

Anne-Marie Martinez, RN, MSc, MFT, psychotherapist, is a clinical full professor, at the Faculty of Nursing, University of Montreal, Canada and a clinical nurse specialist, at the Montreal Children's Hospital, McGill University Health Center, Canada. Her research and clinical interests focus on family nursing, adolescence, fathers' grief, and spirituality.

Sonia Castiglione, RN, MSc, is evidence-informed decision-making advisor, Nursing Department, McGill University Health Centre, Montreal. Part-time faculty lecturer, Ingram School of Nursing, McGill University, Montreal.

France Dupuis, RN, PhD, is a full professor at the Faculty of Nursing at University of Montreal, Canada. Her research interests focuses in part, on the development of systemic family nursing practice in relation to paediatric chronic illness and its impact on families, and on another part, in knowledge translation in family systems nursing. She presented her work at different national and international conferences.

Alain Legault, RN, PhD, is a full professor in Nursing at the University of Montreal. His research interests are palliative care, end of life ethics, and nurses' education.

Marie-Claude Proulx, RN, MSc, is the former clinical nurse specialist at the McGill University Health Center, now in charge of patient and Family Centered Care. She is interested in research on bereavement, communication, and end of life care.

Franco Carnevale, RN, PhD, is a nurse, psychologist, and clinical ethicist. He is the founder and principal investigator for VOICE (i.e., Views On Interdisciplinary Childhood Ethics ); an international initiative to advance knowledge and practices relating to ethical concerns in childhood. He is a full professor at the Ingram School of Nursing at McGill University.

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