Time-Elapsed Marital and Family Therapy

With Sudden Infant Death Syndrome Families

David A. Baptiste, Jr., Ph.D.
Sudden Infant Death Syndrome (SIDS) is currently one of the commonest
causes of death of children in the early months of life. Because families are
unprepared for the suddenness of the child's death, bereavement without
benefit of anticipatory grief predisposes them to greater post-traumatic
stress. Although some SIDS families do seek therapy immediately follow-
ing bereavement, most do not. This paper describes six cases involving
couples who sought therapy after an elapse of time following the death of
their infants; it presents some issues specific to therapy with such couples
and families and offers recommendations for effective treatment.
The loss of a child is likely to be the most distressing and long lasting of griefs.
Gorer(8).
Sudden Infant Death Syndrome (SIDS), also called "crib death" or "cot death," is the
largest single cause of postneonatal infant mortality, accounting for approximately
one-third of all deaths in children between one week and one year of age (1, 2, 4, 11) .
Currently, the etiology of SIDS remains obscure although many hypotheses and coun-
ter-hypotheses regarding cause have been offered (5).
The available clinical evidence indicates that SIDS cannot be prevented and is sud-
den and mysterious. Characteristically, affected children are said to have been healthy
or to have had only transient symptoms, e.g., a cold, preceding death. Because or the
suddenness and unexpectedness of SIDS deaths, families are always unprepared. For
such families, unlike families whose child(ren) died under nonmysterious circumstances,
e.g., leukemia, the mitigating factor of anticipatory grief is absent. As a result, be-
reavement stemming from an SIDS death tends to predispose surviving family members
to greater post-traumatic stress.
Given these circumstances, many writers (e.g., Bergman [3]) have acknowledged
the impact of an SIDS death on surviving members and emphasized their need for
some kind of intervention. In this regard, Bergman has noted that immediate thera-
David A. Baptiste, Jr., Ph.D., is a Counseling Psychologist, New Mexico State University, and in private
practice, Las Cruces, New Mexico.
This article is a revision of a paper presented to the National Council on Family Relations, Annual
Meeting, Washington, D.C., October 1982.
The author wishes to express appreciation to John DeFrain, Judith Landau-Stanton, and Kaye Zuengler
tor their helpful comments on an earlier draft of this paper.
47
48 Family Systems Medicine Vol. 1, No. 3
peutic intervention seems to provide the best opportunity for the primary prevention
of emotional disturbances. Unfortunately, since therapy is optional, only a few families
do seek therapeutic assistance immediately following the bereavement. Most, for a
number of reasons, do not. Because of the severe emotional trauma occasioned by an
SIDS death, all parents of SIDS victims frequently experience some adjustment diffi-
culties concomitant to the loss. However, for those families who fail to fully and/or
adequately confront the death and mourn the loss, either on their own or through
therapy, incomplete mourning can and often does lead to pathological grieving. Such
grieving is often manifested in indirect ways and may continue for many years post in-
fant death (8).
Characteristically, couples or families who seek therapy after an elapse of time fol-
lowing the bereavement (approximately one to two years or even later) tend not to see
any relationship between the child's death and their presenting problem(s), nor do
they "consciously" ascribe any importance to the event as having contributed to their
difficulties. Indeed, it is not uncommon for such families to withhold any mention of
the death during the first few interviews. Later, when the death is mentioned, it is usu-
ally parenthetic and is not shared as an intrinsic part of the information provided.
In this psychological atmosphere, families report many difficulties. These include
marital problems which sometimes lead to dissolution of the marriage, problems with
surviving and/or subsequent children, and problems related to moving soon after the
child's death (4). Additionally, feelings of guilt and self-condemnation, individual
psychosomatic complaints and depression, and the projecting of blame for the death
onto each "other or a surviving child(ren) are not uncommon.
The purpose of this paper is threefold: 1) to sensitize mental health professionals to
the needs of couples and families who seek therapy after an elapse of time following
the SIDS death of their child; 2) to present issues specific to therapy with such couples
and families; and 3) to offer recommendations for effective treatment. Six cases in-
volving such couples are presented.
CASE REPORTS
Family 1
Mr. and Mrs. B. had moved from the East coast eight months previously.
Mr. B. (age 26) initially sought therapy for impotence and related marital diffi-
culties for which he blamed himself: his wife (age 22) wanted to conceive a child
but could not because her husband was impotent. At least five genitourinary
consultations found no organic basis for his impotence. Since the problem seemed
not to be an individual one, marital therapy was begun. The first three conjoint in-
terviews focused on Mr. B.'s feelings that he was less than a man and that he did
not deserve to live. Also Mrs. B.'s complaints that Mr. B. was more interested in
sex than in parenthood and that he did not want her to become a parent were is-
sues of concern.
In the fourth session, while discussing an unrelated issue, Mrs. B. casually
remarked that Edward would have been two years old the next day. Mr. B. re-
acted angrily and chided her for not giving up that "damn kid." They then volun-
teered that their child, Edward, had died of SIDS at age six months, approxi-
mately 18 months earlier. The night Edward died, the couple were engaged in
sexual intercourse when they heard him cry. At Mr. B.'s insistence the crying
was ignored since Edward had recently been fed and changed. Later that night
Fall 1983 Time-Elapsed Therapy With SIDS Families 49
Mrs. B. discovered Edward dead. Although the B.'s were assured by their pedia-
trician that the crying was in all probability unrelated to the death since death
was due to SIDS, Mrs. B. and her relatives blamed Mr. B. Mr. B. accepted the
blame and attempted in every way to atone.
Immediately after Edward died, Mrs. B. withdrew emotionally and abstained
from sexual intimacy. During this period, Mr. B.'s requests for sexual intimacy
were greeted with verbal abuse and charges that he was a "sex maniac." Later,
Mrs. B would consent to coitus only when she thought she was ovulating and
was able to conceive. Mr. B.'s inability to impregnate Mrs. B. increased both her
anger and her verbal abuse toward him. From her perspective, her husband "owed
her a child"; however, she did not plan to continue the marriage subsequent to
her conception.
In subsequent sessions, the couple revealed for the first time their collective
and individual anger about the death and became aware that they had not mourned
the loss. Mr. B. expressed anger and resentment at Mrs. B. and her relatives for
chastising and blaming him for the death, while providing support, sympathy,
and understanding to his wife. From his perspective, no one seemed to care
about his feelings "They just want blood!" He felt guilty and irredeemable and
wished that he, instead of Edward, had died. He resented Mrs. B. for rejecting
him sexually and relegating him to the role of a stud. Moreover, he questioned
why he should impregnate Mrs. B. when she planned to leave him. Mrs. B. re-
vealed that she was angry with Mr. B. because he accepted total blame for the
death. In so doing, he denied her an opportunity to share the blame and to atone
since she also felt guilty for the death. She lamented, "If only I had resisted Ray
and checked Edward when he cried, maybe I could have saved him." Her verbal
abuse of Mr. B. as well as her sexual abstention were, in fact, vicarious self-
punishment. She said: "Everyone was so nice and no one was punishing me."
Family 2
Mr. and Mrs. G. were a Mexican-American couple whose primary pre-
senting problem pertained to their different attitudes regarding adoption. Mrs.
G. (age 24) wanted to adopt a child, but Mr. G. (age 28) was against doing so.
He was uncomfortable with the idea of raising another man's child. Mrs. G.
revealed that Mr. G. felt less than a man because he was the infertile spouse. Mr.
G. objected to that disclosure. He felt ashamed of being infertile and had led his
family to believe that Mrs. G. was the infertile spouse. In the fourth session, he
reiterated his objection to the adoption, and in an offhand manner commented
that he had tried adoption before but it did not work. He explained that the cou-
ple had adopted a male child while living in Arizona. That child died of SIDS ap-
proximately 13 months prior to the couple's beginning therapy.
Subsequent to the death, Mr. G. had withdrawn and immersed himself in his
work. He refused to talk about the death and demanded that his wife behave
likewise. Mrs. G. expressed feeling angry with Mr. G. because he would neither
talk with her nor consent to talk with their priest about the death. She accused
Mr. G. of not wanting to mourn the loss because the child was adopted. Mr. G.
acknowledged that she was partially correct, but emphasized that the proposed
adoption was scary since it was another opportunity for him to fail. He viewed
his infertility as a failing; among his seven sibs, he was the only nonparent. To
him, the death was also a failure. He said, "It is bad enough I can't have a child,
50 Family Systems Medicine Vol. 1, No. 3
but I can't even take care of the one I was given." Tearfully, he vented his anger
at the child for dying and denying him parenthood. His anger at Mrs. G. re-
sulted from his knowledge that she was fertile and he was not. He said, "Talking
with her would be like rubbing my face in the fact that I am half a man. I just
didn't want to talk about it, but I hurt too, even more than she did." He accused
Mrs. G. of condescension because she knew that he had lied to his family about
his infertility, but she said nothing to the family. From Mrs. G.'s perspective, she
was being magnanimous for "the sake of peace."
Since neither spouse had adequately dealt with the death, the first order of
therapy was to help them to deal with the event and to complete their mourning.
Other important goals for therapy were: 1) to help Mr. G. accept his infertility
and view himself more positively; 2) to help Mrs. G. understand Mr. G.'s objec-
tion to the proposed adoption; 3) to help the couple share the grief resulting
from the child's death; and 4) to help the couple prepare psychologically for the
child they planned to adopt.
Family #3
Mr. H. (age 21) and Mrs. H. (age 19) sought therapy because of Mrs. H.'s
complaints of boredom and dissatisfaction with living in what she perceived to
be a large city (approximately 50,000 population). Married for three years, they
were parents of a daughter three years old. They had recently moved from the
eastern to the southern part of the state so the Mr. H. could attend the vocation-
al college. She longed to return to the rural existence of their hometown, but Mr.
H. was committed to a two-year degree program. From Mr. H.'s reports, Mrs.
H. had withdrawn emotionally, had been neglectful of both him and their daugh-
ter, and was moderately depressed; an initial evaluation confirmed the depres-
sion. Mrs. H. felt that in moving to the "big city" she had lost rural serenity,
familiar people and places places where she could take leisurely walksand
most of the people she loved. Angrily, Mr. H. retorted, "What you mean is you
can't go to that damn graveyard every day." Responding, Mrs. H. accused Mr.
H. of not wanting her to remember her baby. "Her baby" was a son who had
died of SIDS approximately one year previously, at age six months. Mr. H. in-
terjected that since the death "she would hardly go out of the house or leave Tara,
except when she go to that damn grave."
At the time of the child's death, there was some question regarding cause.
That is, did death result from maternal negligence, since Mrs. H. was drinking
heavily at that time, or from paternal abuse, since it was no secret that Mr. H.
did not want a second child and had been known to physically abuse his wife?
The uncertainty about the cause of death added significantly to the trauma and
stress of the couple. An autopsy revealed that death was due to SIDS. In the in-
terval, relatives on both sides had begun to assign blame for the death. Subse-
quent to the death, Mrs. H. was a bundle of outward emotions wanting to talk
about the event. On the other hand, Mr. H. remained outwardly calm but re-
fused to talk about a death concerning which he still had questions. The move
from his hometown, then, was a deliberate attempt to escape unpleasant and
painful memories. Some immediate goals for therapy were to provide the couple
with information about SIDS, to help them deal with their feelings about the
death, and complete their mourning. This included giving support to one an-
other and allowing each to feel what he/she felt rather than to repress those feel-
ings and vent them inappropriately.
Fall 1983 Time-Elapsed Therapy With SIDS Families 51
Family #4
Mr. J. (age 42) and Mrs. J. (age 28) had been married for one and a half years;
this was the first marriage for each spouse. Six months earlier, they had moved
from California so that Mr. J., an engineer, could work at the military missile
base. The couple's primary presenting problem was Mrs. J.'s difficulty in be-
coming pregnant. She had experienced a number of miscarriages and was at that
point very pessimistic that she ever would conceive a child. Based upon medical
reports, Mrs. J. was gynecologically healthy. In a subsequent session, Mrs. J.
complained of feeling pressured by Mr. J. to provide him with a child. Mr. J. ac-
knowledged that his age and a late marriage were significant contributors to his
urgency for parenthood. He reminded Mrs. J. that parenthood was an explicit
expectation for the marriage, and was mutually agreed upon by the couple.
Mrs. J. angrily retorted that she only agreed to parenthood as a condition of
the marriage because she was three months pregnant; abortion was not an op-
tion. Inquiries regarding the whereabouts of that child revealed that she had
died at age two months due to SIDS.
Following that disclosure, Mrs. J. expressed concern that Mr. J. held her re-
sponsible for the death. Since the death, neither spouse had talked much about
the event or the child. Mrs. J. felt that Mr. J. was insensitive to her feelings. Her
attempts to initiate discussion about the event were greeted by Mr. J. with com-
ments such as, "What's done is done! We can't bring her back. We just have to
get another one." Mr. J. referred to his wife's outward show of grief as "crying
over spilt milk" and emphasized the need for her to conceive again. Given the
circumstances, Mrs. J. became extremely anxious about her ability to perform
adequately as a mother. And although she wanted a child, she was afraid that
should she indeed be inadequate as a mother and should the second child die, she
would have to face Mr. J.'s wrath. That was a risk she was not willing to take.
Although Mr. J. felt the loss of his daughter very deeply, he believed that the
best way to help his wife was to "refrain from rehashing the situation and con-
centrate on conceiving another child." He felt he had to be strong for his wife
since she was "taking it so hard." He emphasized that much of his anger resulted
from his fear that, given his age, he might not get another chance at parenthood.
For this couple, some goals for therapy were: 1) to help them individually
and collectively deal with the death and complete their mourning; 2) to help Mr.
J. confront and deal with his fear of dying without progeny; 3) to help Mrs. J.
overcome her feelings of inadequacy as a mother; and 4) to help each spouse to
feel what he/she felt about the death and to mutually support one another.
Family #5
Mr. R. (age 26) initially consulted the author only to seek advice about ways
of dealing with his wife's (age 28) drinking problem. He emphasized that he did
not believe in psychotherapy, but a relative, a former client of the author, in-
sisted that he talk with the author at least once. From his perspective, his five-
year-old marriage functioned well until a year previously when Mrs. R. began
drinking heavily. He did not want to end the marriage but said, "It may come to
that if she don't stop drinking." In a subsequent conjoint session, Mrs. R. ad-
mitted to feeling depressed and empty inside as if "something was missing." She,
however, did not know what was missing. She had a good husband, a good mar-
riage, and she loved her job. Two sessions later, Mr. R. volunteered that Mrs.
52 Family Systems Medicine Vol. 1, No. 3
R.'s drinking worsened about the time he changed to the graveyard shift. At that
juncture, Mrs. R. interjected, "It was about the same time in October that Ben
died. I went back home (approximately 200 miles) to see the grave and came
back feeling sad and empty." Queried about Ben, they volunteered that Ben (Jr.)
had died of SIDS four years previously, at age two months.
Following the death, Mrs. R. "pulled herself together" and returned to work
without any perceptible difficulties. Similarly, Mr. R. returned to work and to-
gether they "picked up their lives and carried on." Mr. R. reasoned that they did
not have Ben for too long a time, thus they had not become attached to him. Fur-
thermore, they still had some unanswered questions about the death. Independ-
ently of the other spouse, each searched for commissions or omissions in the
way the other cared for the child. As a result, neither one talked much about the
child nor the event for fear of discovering and/or revealing his or her responsi-
bility for the death. In the years following the death, they involved themselves as
a couple and decided to postpone further parenthood despite Mrs. R.'s desire
for a child and intense pressure from both sets of relatives. During one session,
Mrs. R. vented her anger for the first time since the death. She expressed feeling
angry with both sets of relatives for not being supportive. She said, "None of
them, especially my in-laws, seemed too concerned. Like Ben (Sr.), they all feel
that we hadn't had Ben (Jr.) long enough to be broken up about his death. Every-
body keeps saying, 'You're young. Just have another one.' They just keep push-
ing 'Get another one, get another one.' Maybe they and Ben (Sr.) only had Ben
(Jr.) for two months. I had him for nine months before that. They just don't
understand a piece of me died when he did. I feel empty."
For this couple, some goals of therapy were: 1) to provide additional infor-
mation about the nature of SIDS; 2) to help them to confront and accept the
reality of the death and complete their grieving; 3) to help them to understand
the relationship between Ben's death and Mrs. R.'s drinking; and 4) to help
them to be more supportive and reassuring towards one another.
Family #6
Mr. A. (age 35) and Mrs. A. (age 28) sought therapy in an attempt to avoid a
divorce they both perceived to be imminent. The couple's primary presenting
problem pertained to difficulties in the stepfather-stepchildren (a boy age 12 and
a girl age 11) relationship. Married for three years, they had moved to their pres-
ent location one year previously. In the first few sessions, Mrs. A. complained of
recent difficulties in the marital relationship: Mr. A. was continually angry,
surly, very demanding of her, jealous of her time with the children, and very
concerned about how much of his money was used for the children. Previously,
especially while dating and in the first year of marriage, he was great with the
children. From the inception of the relationship, he knew that her ex-husband
provided financial support on a variable schedule. He seemed to accept that fact
in requesting that she stay at home. Mr. A. accused Mrs. A. of being uncon-
cerned about his needs by reneging on a promise made prior to the marriage. He
expressed feeling duped into marriage. He stated, "All she really wanted was a
pocketbook for her children." From her perspective, she kept her promise to
bear a child. A male child born to the couple in their first year of marriage had
died of SIDS at age five months. Following the death, Mr. A. became more in-
volved with his stepchildren, especially the boy, but fully expected Mrs. A. to
Fall 1983 Time-Elapsed Therapy With SIDS Families 53
conceive again. She denied promising to do so, saying, "I said maybe." Mr. A.
admitted liking his stepchildren, but wanted a child of his own.
Married at age 16, Mrs. A. was at age 28 as emphatic in her desire not to bear
any more children as Mr. A. was in his desire for biological progeny. He said,
"The marriage is over if she does not want more children." He also expressed
feeling that Mrs. A. was not as good a mother to his son as she could have been,
primarily because she did not really want the child. Mrs. A. resented the innuen-
dos about the quality of her mothering skills; she felt competent as a mother.
From her perspective, the death was divine punishment. Although she was not
guilty of actually killing her son, prior to his birth she had prayed for either a
miscarriage or a still birth, primarily because she was premaritally pregnant and
sincerely did not want another child. She did not want to go through "the diaper
and running nose bit again." With two preteens, she perceived an infant as an
unwanted burden. However, after the birth, she grew fond of the child and felt
deeply about his death. In fact, her resistance to bearing another child following
her son's death was motivated more by her guilt than her wish to avoid the chores
of renascent motherhood. She said, "I cannot forget the feeling of picking up my
son and realizing that he was dead and knowing that I had killed him by wishing
him dead. I will never forget!" Because of that memory, she never again wanted
to experience pregnancy. Given the polarization, there seemed very little room
for negotiating a compromise. Each perceived his or her position to be incon-
testably valid. Consequently, after six sessions, they terminated therapy and the
divorce became a reality.
CASE REPORTS: SOME COMMON FEATURES
From the case reports presented it is clear that there is a variety of problems that can
be associated with and are experienced by families whose mourning has been pro-
tracted as a result of incomplete grieving following the SIDS death of a child. Although
it is impossible to generalize about such families, there are some common features that
differentiate SIDS families who confront and deal with the reality of the death immed-
iately following the event, from SIDS families who truncate the mourning process,
and achieve premature closure and limited reorganization of their lives only to experi-
ence dysfunction later:
1) None of the six couples cited had fully or adequately mourned the death immedi-
ately following the event.
2) Most of the couples had either aborted or diverted grieving by using new involve-
ments to keep their minds off the event. This resulted in a pseudo-resolution rather
than a complete and successful resolution of the mourning.
3) In all cases, the initial presenting problem(s) was perceived by the couple as unre-
lated to the death. "Substitute" issues were presented; the grief process was masked
by defense mechanisms such as blaming, denial, rationalization, projection, and a
host of others, many at the unconscious level.
4) In all cases each spouse maintained his or her idiosyncratic means of expressing and
managing the grief. Male spouses tended to suffer in silence, sought diversion in
work or school, and displaced their guilt and anger through either denial of the
death or covert blaming of their wives for some omission in caring for the child (the
exception was Mr. B. who blamed himself). On the other hand, possibly because
female spouses were more involved in caring for the children, they tended to be more
54 Family Systems Medicine Vol. 1, No. 3
vulnerable to the death than were their husbands. Thus, they were more likely to
question their culpability for the death. They seemed to experience harsher feelings
of guilt, and once in therapy, they were generally more willing to talk about the
death and their grief resulting from the loss.
5) In the absence of an acceptable and /or satisfactory explanation of their child's
mysterious death, the couples evinced a frightened concern with responsibility for
the death. As a result, the normal process of grieving was complicated by a sub-
conscious belief that some act of omission on their part was responsible for the
death.
6) All of the couples had moved from the locality in which the death had occurred.
Although two couples (#3 and #4) denied moving to escape memories of the event
(from their perspective the move was solely employment-related), the remaining
four freely acknowledged that while the move may indeed have been consciously
work- or school-related, it was also an attempt to escape the unpleasant and pain-
ful memories.
THERAPY ISSUES OF SIDS FAMILIES
As is the case with other families who experience the loss of a member, each SIDS
family presents its own unique circumstances and issues related to its long-term loss
and inability to mourn that loss. However, experiences with these families have shown
that there are some commonly encountered issues which can be expected in therapy.
These include insufficient and/or inaccurate information about SIDS; the incompre-
hensibleness of SIDS; parental guilt and unvented anger; parental questions about
their adequacy as parents; and the family members' overwhelming need for support
and reassurance that they can mourn the loss and minimize dysfunction.
Insufficient Information About SIDS
Today as in time past, there continues to be much ignorance about SIDS. Although
some families are provided accurate information about SIDS from reputable sources
(e.g., pediatricians, state offices for SIDS information and counseling, public health
nurses, and medical examiners), others receive inaccurate or no information. Inaccur-
ate information and lack of information are significant contributors to the aura of
mystery that continues to surround SIDS. This compounds and intensifies the stress
experienced by the surviving family members. Consequently, the SIDS family be-
comes confused, tends to withdraw and isolate itself, and thus is often denied or lacks
opportunities to assess the accuracy of the information which has been received from
disparate sources. Lack of reliable useful information increases the family's inability
to fully comprehend the nature of SIDS. The need for accurate and reliable informa-
tion, then, is one of the important issues which these families bring to therapy.
The Incomprehensibleness of SIDS
To many SIDS families, SIDS is incomprehensible as a disease entity and is instead
perceived as a magical entity, because of its suddenness and mysteriousness. In addi-
tion, SIDS precludes comprehension because families usually lack a base of experience
with which to cope with the death. The inability to fully comprehend SIDS contributes
significantly to the family's feelings of culpability. In this regard, SIDS families are sig-
nificantly different from other families whose child(ren) died from a known disease
Fall 1983 Time-Elapsed Therapy With SIDS Families 55
(e.g., hepatitis) or even an untimely death (e.g., playground or automobile accident,
or drowning). Such deaths are comprehensible in that families are better able to ex-
plain why the child died. And although parents may still feel guilty about the death,
they may feel less culpable since they can identify a cause for the death, are better able
to answer prying questions, and can concretely incorporate the event into the normal
rationalization for mourning (9). However, an SIDS death deprives parents of the ad-
vanced warnings and explanations that are needed if families are to come to terms
with the reality of the death, and overcome the psychological obstacles that hinder ef-
fective mourning and eventual recovery.
Parental Guilt and Unvented Anger
Whether or not they openly admit to feeling so, virtually all SIDS parents, especial-
ly mothers, feel some guilt and responsibility for their child's death. Given the uncer-
tainty about the cause of death, guilt is frequently accompanied by anger. Whereas
guilt is usually personal, anger is more often multifocused and unvented. Anger stem-
ming from bereavement may take quite irrational forms (10) and may be directed at
one or all of the following: self, the spouse, the pediatrician, God, the dead child, a
surviving child, or whomever may have been caring for the child at the time of death,
e.g., a relative or babysitter. Pincus (10) has suggested that the anger and hostility of
surviving family members may be an expression of their ambivalence towards all these
people, but most especially and most painfully towards the deceased who is causing
the mourners so much distress by his/her abandonment. Since guilt and anger are fre-
quently repressed, families often experience much difficulty in acknowledging these
feelings in therapy. More importantly, they often fail to see how such feelings may
contribute to their protracted grieving and presenting problem(s).
Parents who harbor anger towards the dead child face an additional burden. At a
conscious level, such parents are aware that their anger is unjustified. At an uncon-
scious level, however, these parents feel it is justified: In dying, the child not only robbed
them of a chance to be a parent, but also may have caused them to question their ade-
quacy as parents. In this regard Pincus (10) asserts that such ambivalence is insepara-
ble from guilt, which is always present at the death of an important person, even though
much of this guilt has no rational justification. She notes that it is this mixture of justi-
fied and unjustified feelings which makes it so difficult to live with guilt. Bowlby (6)
has noted that one of the main characteristics of pathological mourning is nothing less
then an inability to express overtly those urges to recover and scold the lost object,
with all the yearning for the anger at the deserting object that they entail. A basic issue
for these families is their inability to perceive guilt and anger as normal responses to
their situation. Their inability to express these feelings as a basic part of the mourning
experience prevents satisfactory adjustment.
Parental Questions About Their Adequacy as Parents
An SIDS death like any child's death can and often does shatter parents' confidence
in themselves since such a death may exacerbate and/ or reinforce any ambivalent feel-
ings and doubts parents may have about their adequacy as parents. In this country
parents expect to rear their child(ren) from birth to adulthood and take great pride in
the successful performance of that task. As a result, a sudden and unexplained death
of an apparently healthy child undermines such parents' pride and violates their ex-
pectations in at least two ways: 1) Parents experience a loss of gratification of the
56 Family Systems Medicine Vol. 1, No. 3
parental role and of caring for their child(ren); and 2) parents experience a loss of self-
esteem in successfully performing their parental tasks.
A shaken confidence in their adequacy as parents can and often does affect the par-
ents' relationship with both surviving and subsequent ("replacement") children. Par-
ents tend to behave towards such children in a variety of ways depending upon whether
or not the child(ren) is a surviving one or a "replacement" for a dead sibling. Replace-
ment children may be born into a funereal atmosphere and reared in an emotional en-
vironment characterized by incomplete mourning. In such an environment parents
may be depressed, apathetic, withdrawn, and focused on the past and the dead child,
who frequently lives on in a very concrete way and whose identity is often imposed
upon the "replacement" child (7).
Surviving children may experience new problems in addition to any existing emo-
tional and/or developmental problems. Such children may be overprotected and re-
stricted because parents fear that they may also die of SIDS. Often such fears result
from misinformation about SIDS and inadequate grief resolution. Parents may reject
or neglect these children, and may cast them in the role of the family's scapegoat upon
whom feelings of anger are vented and guilt and hostility displaced.
Parents' questions about their adequacy may also aggravate dormant or denied
marital or family problems that existed prior to the death. For example, of the six
cases reported four couples had experienced marital difficulties before the death of
their child. For these couples there were at least three presenting problems: 1) the
(conscious) "substitute" problem, e.g., Mrs. H.'s(#3) dislike of large cities; 2) incom-
plete grieving related to the death; and 3) the dormant or denied problem(s) that may
have existed prior to the child's death.
The Overwhelming Need for Reassurance
Because of the emotional devastation resulting from an SIDS death, the surviving
family members need support and reassurance in at least four areas:
1) They are not responsible for the death. Most difficult for these families is letting
go of the tremendous guilt that results from feeling responsible for their child's death.
That guilt is important, because often it is linked to the more obvious marital and fam-
ily problems experienced by these families.
2) They are adequate as parents. This need is intimately related to the parents' feel-
ing culpable for the death. Since parents may feel that the death resulted from either an
act of omission or commission on their part, they often "unconsciously" abdicate fur-
ther parental responsibilities for surviving as well as subsequent children. This may be
manifested through behaviors such as rejection or neglect of children or an uncon-
scious refusal to conceive (miscarriages or even stillbirths) or role reversal, e.g., a sur-
viving child is expected to grow up fast and take care of his/her parents' needs.
3) A surviving or subsequent child will not die of SIDS. For these families there is no
restitution; having another child will not bring back one lost, nor does it guarantee
that a subsequent child will not die of SIDS. While there is evidence that some families
have lost at least two children to SIDS, this is rare. Such families have been predomi-
nantly of the lower socioeconomic class (5).
4) Wives/mothers (especially those whose sons have died) are still loved by their
husbands. In therapy, wives subtly express the need for reassurance of their husbands'
love, post infant death. This need is directly related to: (a) some husbands' preference
for male children; (b) the importance some families, especially husbands, place upon
Fall 1983 Time-Elapsed Therapy With SIDS Families 57
male children; and (c) some husbands' perception of their wives as the primary care-
takers of children, and thus responsible for their well-being. Consequently, when a
child dies while in her care, the wife/mother tends to feel responsible despite assur-
ances to the contrary. As a result, she may come to believe that she has failed in the
performance of her caretaking task, and has also failed her husband (guilt tends to be
more pronounced if the son was the firstborn child). Need for reassurance that she is
still loved is, then, at another level a need to know that she is forgiven for her imagined
wrongdoing.
Paradoxically, although these families need support, professional reassurances are
not enough to stop their pain. Family members, especially spouses, need to learn to re-
assure and support each other.
RECOMMENDATIONS FOR THERAPY
Experience in treating SIDS survivor families of the type described here has resulted
in an appreciation of the tasks and an awareness of some of the difficulties that thera-
pists may encounter in treating such families. However, despite the challenge, these
families can be treated successfully. In this regard, Beckwith (1) asserts that although
there is currently no proven way to prevent SIDS, it is possible to deal effectively with
families who have lost a child as a result of SIDS (p. 29).
Over the years, this writer has found that a systems model that incorporates conjoint
therapy using behavioral techniques is successful in treating these families. Using this
approach, the initial focus is on the family and understanding that system. The second
phase of therapy incorporates the insights into the family system by means of a behav-
ioral approach. The primary goals of therapy are to help the couple and/ or family to
carefully assess both the degree and quality with which the dead child lives on, and
how this "presence" affects their ability to complete their mourning and contributes to
their current relationship difficulties. Other important goals of therapy are: 1) to clar-
ify the puzzling and mysterious nature of SIDS and the associated dynamics of guilt; 2)
to alleviate either the assignment or acceptance of blame for the death; 3) to foster the
completion of grief and mourning; and 4) to prevent further estrangement and dys-
function of the family or couple by improving their communication and thus their
ability to mutually support each other.
One key to effective therapy with these families is an understanding of the specific
point(s) around which their guilt feelings are centered (e.g., Mr. B.'s impotence and
Mrs. R.'s drinking). Equally important is an understanding of the importance of the
dead child for the family and the psychosocial impact of the death for the family both
as individuals and as a unit. For example, many parents unconsciously invest a child(ren)
with their expectations, hopes, and dreams. Consequently, when that child dies such
expectations are not fulfilled and the impact of the death may be more profound for
the family.
Effective treatment of these families requires that the therapist: 1) have the requi-
site experience and be clinically skilled in treating bereaved families and individuals;
2) be knowledgeable about SIDS; 3) be comfortable with his/her own feelings about
death; 4) be willing to be both comforter and therapist; and 5) be aware of ways in
which grief can be denied by the family system.
Because of the numbers of SIDS deaths in the United States, many family therapists
will at some time encounter a surviving family of an SIDS victim. The following guide-
lines are offered:
58 Family Systems Medicine Vol. 1, No. 3
1) The therapist must be willing to give the family members permission to talk free-
ly and at length about the child and the death, as well as their grief and related feelings.
For these families opportunities to ventilate their feelings and be heard are limited.
Following the death, friends, relatives and even a spouse will often show concern and
be willing to talk about the death for a while. After a few weeks these persons may be-
gin to give the family subtle messages that they are reluctant to talk about the event
any longer. As a result, the bereaved family or couple may cease to feel what they feel
and truncate their grieving because of a reluctance to upset relatives, especially par-
ents, or the other spouse. The inability to adequately mourn the death often contrib-
utes to the intensification of the grief and may extend it with negative results such as
dysfunctional marital and family behavior.
Since the therapeutic interviews are often the first time in a long while, subsequent
to the death, that the family or couple are afforded an opportunity to talk openly
about the death and their repressed feelings about it, permission should be given in a
warm, empathic way, such that the family members do not feel interrogated or re-
garded with suspicion either for the death or for not mentioning it earlier in therapy.
2) The therapist needs to resist the temptation to narrow the therapy focus exclu-
sively on the presenting problem, the death itself, the bereavement-related reactions,
or any problems that existed prior to the death. It is important to recognize that the
problems of these families are multifactorial. Consequently, attention must be paid to
the presenting problem(s), the grief work, and the non-death-related problems that
often hinder a family's acceptance of the death and eventual recovery. In this respect a
family systems approach is useful to capture the multitude of issues.
3) The therapist should make every effort to involve the spouses' family of origin in
therapy, if they are available. It is important to remember that a family is an interac-
tive social system; thus, the death of one of its members is felt by the entire system, not
only the affected parents. As a result, the grieving, the mourning, the support, and the
planning for the future should involve all subsystems, e.g., parents, sibs, grandpar-
ents, and anyone else who is affected by the death. Unfortunately, however, at inter-
view most SIDS couples do not live close to their families of origin because either they
never did or they moved from such localities soon after the death.
4) Beyond the initial interview (in many cases only one spouse initially presents for
therapy), spouses should be seen conjointly. Conjoint interviews can limit the amount
of distortion that occurs when only one spouse in present. It can also be helpful in clar-
ifying the spouses' reaction to each other. When spouses focus on the salient issues the
marital difficulties concomitant to the death can be eliminated. In such interviews one
goal should be to support each spouse's self-worth. Consequently, each spouse should
be afforded the opportunity to voice his or her concerns and be protected against the
other spouse's attempts to blame or coerce him or her in a specific direction. Maxi-
mum therapeutic effectiveness requires that the therapist resist temptation to become
the exclusive advocate for either spouse or a specific family member.
5) The therapist must make every effort to involve the husband/father beyond his
physical presence. Because most male spouses tend to be taciturn in therapy, their con-
cerns and feelings about the death often are perceived as secondary to the concerns
and feelings of the female spouse. Believing that they need to be strong for their wives
or whomever, many husbands may externally maintain a stoic acceptance, but inter-
nally hurt intensely. Often a husband's report that "all is well" is in actuality masked
anger since husbands are most likely not to be included by others in dealing with grief
resulting from the death. Consequently, should the therapist accept the statement at
face value and deemphasize the husband's concerns, the therapist may unwittingly be
contributing to the husband's anger since it is not allowed expression.
Fall 1983 Time-Elapsed Therapy With SIDS Families 59
6) The therapist must be flexible in his or her treatment approach to these families.
Although there are many features common to SIDS families, each family must be con-
sidered unique in its appreciation of the event. As a result, the therapist must be pre-
pared to vary the timing of specific interventions directed at the family in therapy, and
must also be willing to accept some unique attitudes that may not be compatible with
his or her personal attitudes or beliefs (e.g., the therapist punishing the couple be-
cause they haven't grieved).
7) The therapist must guard against being overwhelmed by the number and mag-
nitude of the problems that many of these families bring to therapy. As indicated ear-
lier in this paper the problems of SIDS families are multifactorial rather than unifac-
torial. Under such circumstances therapy should be direct, active, and highly focused
on specific issues. Either an attempt to cover too much ground or overabsorption with
a specific issue to the exclusion of others can result in the therapist losing sight of other
important issues, thereby rendering the couple and/or family a disservice.
8) Therapists who treat these families must become familiar with the relevant lo-
cal, state, and national organizations that serve SIDS survivor families. Although
these families often are some years removed from the death, they may still be able to
benefit from the contact and information provided by these organizations. All families
should routinely be informed of the existence of such organizations and be allowed the
freedom to decide regarding affiliation. For some families an SIDS parent support
group may be more effective than a professional therapist. For others such groups may
be a beneficial adjunct to therapy.
9) Finally, the therapist must be sensitive to and aware of the couple's or family's
concerns/objections based upon culture or religion. It is important to remember that
religious beliefs can and often do significantly affect a family's attitude towards the
death, as well as towards the children and their place in the family. Such attitudes may
contribute to the couple's or family's difficulty in accepting the death and their inabil-
ity to adequately mourn the loss. Furthermore, some therapists may be remote from
either the social class and/or culture of the family, thereby adding a significant hin-
drance to effective treatment.
SUMMARY
Sudden, unexplained infant death (SIDS) presents acute problems in adaptation for
the surviving family members. For those families who do not fully or adequately con-
front the death and mourn their loss, an SIDS death constitutes a special risk to psy-
chological and social adjustment. Such families often truncate their grieving and achieve
a temporary reorganization of their lives but experience dysfunction later. Effective
therapy with these families requires that they confront the death, complete their mourn-
ing, and achieve appropriate closure.
REFERENCES
1. Beckwith, B. The Sudden Infant Death Syndrome. U.S. Department of Health, Education,
and Welfare, Publication No. (HSA) 78-5251. Washington, D.C., 1978.
2. Bergman, A. Sudden infant death. Nursing Outlook, 1972, 20, 775-777'.
3. Bergman, A. Introduction. In M. Miles (Ed.), Mental health aspects of Sudden Infant Death
Syndrome: Report of a conference. New York: National Foundation for Sudden Infant
Death, Inc., July 1975.
4. Bergman, A., Pomeroy, M., & Beckwith, B. The psychiatric toll of the Sudden Infant Death
Syndrome. General Practice, December 1969, 40, 99-105.
5. Bluglass, K. Psychosocial aspects of the Sudden Infant Death Syndrome. Journal of Child
60 Family Systems Medicine Vol. 1, No. 3
Psychology and Psychiatry, October 1981, 22, All-All.
6. Bowlby, J. Separation anxiety: A critical review of the literature. Journal of Child Psychol-
ogy and Psychiatry, I960, 1,251-269.
7. Cain, A., &Cain,B. Onreplatingadnild. American Academy of Child Psychiatry, October
1964,3,443-456.
8. Gorer, G. Death, grief and mourning in contemporary Britain. New York: Doubleday,
1965.
9. Mandell, F., McAnulty, E., &c Reece, R. Observations of paternal responses to sudden un-
anticipated infant death. Pediatrics, February 1980, 65, 221-225.
10. Pincus, L. Death and the family. New York: Vintage Books, 191 A.
11. Valdez-Dapena, M. Sudden unexplained infant death: 1970-1975. U.S. Department of
Health, Education and Welfare. Publication No. (HSA) 78-5255. Washington, D.C.,
1978.
Requests for reprints should be sent to David A. Baptiste, Jr., Ph.D., The Counseling and Student De-
velopment Center, New Mexico State University, Box 3575, Las Cruces, N.M. 88003.