​All human beings have the capacity for resilience. We have the capacity to recover from extraordinary challenges, trauma, and losses.We have the capacity to return to some place within ourselves where we are OK once again.     

When faced with a lost pregnancy women will recover and even grow from the loss. A women taps into resilience to survive the loss and she draws upon her reserves as she plans to either try again or not. Yet during times of extreme stress, loss, and challenge (as is the case with pregnancy loss) it may be necessary to pay closer attention to our capacity for resilience. The demands will be high during this time and it may be important to consider ways of both gaining and maintaining resilience...our natural self-righting ability to recover.    

This piece begins a conversation about how we gain and maintain resilience in the face of pregnancy loss. It stems from the body of work developed by Pauline Boss, Ph.D. an educator and researcher who is widely recognized for her research on what is now known as the theory of ambiguous loss. Ambiguous loss simply refers to losses that occur without closure or understanding. Missing loved ones, loved ones who vanished on 9/11, and caring for a family member with Alzheimer’s Disease are all examples of ambiguous losses. In the case of miscarriage and pregnancy loss we often have little more than two lines on a pregnancy test or a single ultrasound image as physical evidence of the pregnancy. Yet, the psychological presence of a pregnancy can be extremely well developed.      

Ambiguous losses leave us searching for answers. Ambiguous losses can complicate and delay grieving. To survive these losses we build strength by fostering resilience. We heal our hearts and minds with new ways of thinking. In her book, “Loss, Trauma, and Resilience” Pauline Boss outlines six therapeutic goals for working with ambiguous loss. I discuss each of these six goals below from the perspective of those recovering from pregnancy loss. They are not listed in order of importance or an ordered set. Feel free to read them in the order you prefer. Let’s look at these six goals as some key building blocks to resilience.

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Finding Meaning
 

What does it all mean? Your first miscarriage? Your fifth miscarriage? Your purpose in life? The inevitability of human loss and suffering? The meaning of life?    

Geeeeze.

Yep. [sigh] It’s about tackling questions both big and small; scientific and spiritual; personal and relational. In the realm of pregnancy loss sometimes questions are answered . Meaning is found. For example, chromosomes can be counted and ultrasound images can reveal missing structures. We can find meaning by understanding a medical diagnosis. But just as commonly, our questions about miscarriage have few definitive answers.  And that’s OK.  Because following pregnancy loss women can find meaning in the loss even if the answers we so desperately search for cannot be found. We can develop tolerance for the unknown/unknowable and honour the loss simultaneously.           
So how do we do that? How do we find meaning in the murky dark waters of miscarriage? In addition to scientific knowledge, to make meaning out of pregnancy loss, we tap into other sources of knowledge and pursue other avenues of thought.

Naming the Problem 

Hint: it’s NOT you! You likely walked into this whole business of procreation and parenthood with love in your heart and courage in your soul. The problem here is miscarriage, loss, uncertainty, infertility, ambiguity, etc.  These are the things that are now happening “to you” and you are doing your best to survive. And survive you will. Despite heartbreak, and despite uncertainty you move forward each day. This IS resilience.      

Dialectical Thinking 

Translation: Holding two opposing ideas at the same time. Here are some examples:

My pregnancy has ended
AND
I feel as though my baby will always be with me  

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My baby wasn’t developing properly
AND
To me my baby was perfect and whole

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The pregnancy is physically gone
AND
The pregnancy is spiritually present 
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We grieve the physical loss of the pregnancy and we talk about the parts of the pregnancy that remain alive (the love, attachment, and hope you held for your baby). For many of us this is a new way of thinking. It can seem illogical if we are used to accepting only singular explanations or if we practice black and white thinking. It is developing a comfort for simultaneously accepting opposite truths. It can be a test of resilience.       

Religion, Faith, and Spirituality 

These deeply held beliefs may provide ways of finding meaning from loss. These beliefs may provide you with some understanding about death as well as beliefs that can promote resiliency and health. Women may wish to connect with their own faith communities (members, leaders) for conversations about miscarriage and pregnancy loss and recovery from loss.
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Positive Attribution  

An attribution that is viewed as positive for you and your partner may help as you live with pregnancy loss; it can fortify resilience over the long haul.  For example, for many couples the loss of a pregnancy does not extinguish their hope to have a baby it can actually strengthen resolve to create a family.  Although a pregnancy may have only lasted days or weeks its brief presence may have brought a couple closer together.  The pregnancy may have been instrumental in re-focussing goals and priorities.     

Perceiving Suffering as Inevitable

Finding meaning does not mean avoiding suffering. To that very point, the loss of a pregnancy highlights an important aspect of our human experience that is painfully and inextricably linked. To love is to agree to be deeply wounded by loss. To bring life into the world is to be vulnerable to the death and the loss of that very life. Some of the greatest experiences and most meaningful relationships in our lifetime will be tied together with inevitable suffering. To love and to “try again” in the face of inevitable suffering is a courageous act of resilience.                                            

 

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Tempering Mastery

“The inability to cure illness and resign to death has always been part of the human trauma from loss, but today both subjective and cultural attitudes influenced by vast technology tend to strengthen our beliefs in mastery without the caveat that we can’t always fix a problem.  Feelings of failure can immobilize.  If we are socialized and conditioned to value mastery dogmatically, without the caution of tempered moderation, we are poorly prepared to maintain resilience when things don’t go our way -- or problems have no solutions.

What I have learned from my own experience and from working with many kinds of ambiguous loss is this: The more highly people value being in charge and having things their way, the more distressed they become when a loss has no resolution or closure.  Although I value mastery and agree with researchers that it prevents depression and health problems, I also see a need for moderation.  We must learn to temper our need for mastery if we are to have resiliency, especially with ambiguous losses.”

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Pauline Boss from Trauma, Loss, and Resilience.   

Mastery can be thought of as having a sense of control over one’s  life. “I can do just about anything I set my mind to do”. Sounds good right? Maybe not. Or maybe not all of the time. It seems as though a robust sense of mastery over one's life is only part of the story. In fact, when we take a closer look at miscarriage, pregnancy loss, and infertility (gulp) tempering or re-adjusting our sense of mastery over our fertility may actually enhance resilience.  
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Sure, there is a lot you can do to prepare for a healthy pregnancy. You can take prenatal vitamins, avoid drugs and alcohol, eat a balanced diet, stay active, and get lots of rest. If you are a candidate for IVF you can follow your doctor’s instructions to the letter to ensure that hormone levels are optimal for implantation.  But after that (and even doing all of that) you probably have come to recognize that your actions alone are not enough to ensure conception or save a pregnancy that was on course to fail. In fact, the belief that you do have that level of control may lead to worse outcomes for your own mental health by way of guilt and self-blame.  Yet for many of us who were raised to believe we can “do anything we set our minds to” the devastating experience of  infertility and pregnancy loss can bring us to our knees.  Our mind was set to “baby” and instead we were met with pain, blood, and loss. No baby. We found a painful and humbling human experience in its place.   
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So it seems like the “sweet spot” for miscarriage recovery and resilience may lie somewhere between doing enough to ensure your health is sound (following recommendations from your family doctor or specialist) and accepting that the final outcome of a pregnancy always carries some degree of uncertainty and viability lies outside of your control.  You are responsible for egg and sperm introductions and doing what you can to give them a nice place to hang out for awhile.  Beyond that...it’s in the hands of the fertility gods.  This is one leg of the journey that even Google and Siri are rendered useless.   
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Reconstructing Identity

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When a pregnancy ends and there is no baby to take home we may struggle and feel confused about identity. For a woman who loses a pregnancy before having a child she may question if she is a mother (without her child) or a single woman. For many women the shift in identity to “mother” following a positive pregnancy test can be almost instantaneous and everlasting. Therefore even early first trimester losses may lead to a loss of identity for a mother-to-be. Further, the transformation from single women to mother may be a lasting shift despite the fact her identity as a mother may not be acknowledged by those around her until she has given birth to a live baby. She will live in a world of an invisible motherhood identity.   
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Identity struggles may also be part of the relationship.  Partners may question “are we spouses or parents?”. Partners and Grandparents may also question their identity following the loss of a pregnancy as they may be farther from the pregnancy and have even less relational acknowledgement of their own identity transformations and losses.
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The loss of a pregnancy to a family with children may also lead to struggles with identity. An older sibling may have been eager to become a “big brother” or “big sister” and feel confused about the loss of his or her new moniker in addition to the profound loss of his or her sibling-to-be. Parents may pause when asked “how many children are in the family?”. Although we commonly respond based on the number of living children; parents will often have an internal response that covers both children living and pregnancies lost.  
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Resilience grows when women, partners, and families are able to reconstruct and revise identity following the loss of a pregnancy. Ambiguity is often embedded in pregnancy loss.  Therefore women may have to work to develop the ability to tolerate an identity that is not quite clear and may never be. It is her ability to develop comfort assuming two identities at once; as though she has a foot solidly planted in two worlds. She is both a mother and a “mother unrecognized” at the same time. Or resilience can grow as a result of developing comfort with multiple identities of one’s self: woman, partner, mother of one, grieving mother, co-creator of 6 pregnancies, etc.  On any given day you may find yourself more or less connected to reconstructed and revised identities. Developing comfort with changing and evolving identities can foster resilience.      
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Flexibility with couple identity may also be a key to building resilience in your relationship. Following the loss of a pregnancy a couple’s identity may need to change.  For couples that were previously more private there may be a need for greater openness with friends and family to strengthen connections and receive additional support through the immediate loss and the months to follow. For couples that were previously more social and active there may be need for more time alone and time “away from the crowd” in order to grieve and work through feelings of loss. When identities harden rather than evolve resilience can be harder to find. When couples remain open to the possibility of revising who they now are as a couple resilience can grow.
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Normalizing Ambivalence

Ambivalence from ambiguous loss is normal and can be managed. Resilience grows and stabilizes as we develop comfort to hold ambivalent feelings towards a lost pregnancy. Ok, let’s first start by making sure we define and separate the definition of the two words. Ambiguity refers to a lack of clarity and ambivalence refers to holding mixed or conflicting ideas about someone or something. Following the loss of a pregnancy women and partners may experience some of the following ambivalent ideas:

I am devastated that our pregnancy ended
AND
I am at peace with knowing my body was reacting normally
to a pregnancy that was not viable  

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We are devastated by the loss of our pregnancy
AND
We are at peace with the decision to end a pregnancy that was not viable  

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I have deeply mourned each lost pregnancy I have had
AND
I am aware and thankful that if not for those losses I would not
have the exact two children I have today 
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​Battling infertility has been one of the most painful experiences of our life AND
It has solidified and fortified our dream to build a family
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We will forever grieve each of our lost pregnancies
AND
We feel entirely ready to build a family through a plan for adoption          

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So the goal is not to get rid of ambivalence rather it is to talk about, bring into the light, and understand it. Resilience continues to grow with the acceptance and understanding that pregnancy loss is an experience both steeped in a lack of clarity as well as an experience that will generate a multitude of feelings often conflicting or opposed in nature. ​
 

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Revising Attachment

When a pregnancy ends it is not the attachment to the baby-to-be that ends it is the physical loss of a tiny heartbeat, or the halt of cell proliferation. Nevertheless the relationship as it was originally hoped for (mother to child, father to child) must be revised.  Our ability to renew or revise this human connection in a way that reflects the uncertainty of absence and presence can build resilience.  

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Parents acknowledge and accept the physical ending of a pregnancy and may continue to honour a life-long spiritual connection to the lost pregnancy. Women may continue to think about who the child would have been across the lifespan as well as the place the child may have occupied between siblings. It is important to note that revised attachments may be shared between parents or each parent may renew attachment to a lost pregnancy in a way that looks different to his or her partner. Consensus between partners or among extended family members is not required.

 

Resilience grows with the ability to revise attachment to the lost pregnancy.

Resilience may also grow as a woman moves forward slowly and attends to new or additional attachments in her life. This could include renewing connections to existing children following a period of physical recovery and mourning; connecting with other women who have lost pregnancies; or taking time away with partner by way of a holiday.

 

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​Discovering Hope

In the aftermath of a miscarriage or lost pregnancy hope can feel decimated. In the case of recurrent loss it may feel like hope has been lost forever. The use of the term “hope” in this section may include but also goes beyond what most women and partners hope for following pregnancy loss: a viable, full-term pregnancy resulting in the birth of baby. In this section, “discovering hope” refers more broadly to a belief that suffering can stop and that comfort is possible in the future; that one has a belief in a future good; that we can work to become comfortable with uncertainty, mystery, doubt, and half-knowledge.  Through these methods of discovering hope resilience increases.

In order to foster resilience women and partners may also have to allow hope to transform over time. This ability to be flexible and discover hope in creative ways may assist with maintaining resilience. For example, a couple may have hoped to have a large family including 4 or 5 biological children of their own. Yet following years of infertility and pregnancy loss find peace with no formal medical diagnosis to explain the infertility/losses in addition to the joyful adoption of three siblings from foster care. Another example may include families that find strength to stop trying and discover hope through meaningful connections with the children around them (nieces, nephews, community groups serving children, etc.)  Finding hope does not mean the pain of loss has vanished and the skies are ever-clear.  Discovering hope following ambiguous loss can be a painful journey itself.  Letting go of deeply held dreams and goals to embrace new dreams and realities is no simple task.  Yet our willingness to re-write and to edit our futures in ways that include hope and meaning (as well as uncertainty and loss) is a clear demonstration of resilience.

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Final Thoughts

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Let’ put this all together… To survive the loss of a pregnancy you call upon your resiliency. Your recovery from pregnancy loss takes time; you will need to replenish your reserves.  You must look for ways to strengthen, and increase your capacity for resilience. You are trying to recover from heartbreak that often has no clear answers. You are mourning the loss of something that is both immense and (sometimes) barely visible. You will need to find the strength to make it through your next pregnancy.      

Building resilience after pregnancy loss is not about running from grief or minimizing the profound sadness that is experienced following miscarriage and pregnancy loss.  In fact, it is finding the courage to look closer at all sides of grief. It is having the courage to find meaning in the loss. It is accepting that to love , even the tiniest spark of life, your heart will shatter upon its loss.     
We increase resilience when we embrace the alarming messiness of life, the uncertainty of life, and the inherent pain of love and loss.  We get in tune and we get comfortable with life’s contradictions, injustices, and ambiguities.  
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You become stronger, wiser, and at peace with the sacrifice of love and loss. You find new pathways to hope. You become comfortable letting go of old dreams and brave enough to start having new ones. You are building resilience. Keep going.       
     

 

Shannon Golletz