When a child dies

SINGAPORE - One of the worst and most unimaginable things for any parent befell Mr Richard Martinez last Friday evening.

"Our son Christopher and six others are dead," he cried with anguish. His 20-year-old son was killed in the shooting rampage in California earlier that day.

"You don't think it'll happen to your child until it does."

I have before me a copy of the second edition of Farewell, My Child - which is a collection of short memoirs of bereavement from parents whose children had died. This was published by the Child Bereavement Support (Singapore), a voluntary group that renders support to parents who have lost a child.

The preface of the book issues this portentous warning: "Such stories can tear you apart. They can be exhausting, consuming and fill you with fear."

Together these 39 stories are a flood of laments; each a visceral account of the turmoil of emotions following a child's death (the image of the child that accompanies each piece gives it a haunting poignancy). One after another, they are as relentless and jarring as the onslaught of grief that the writers have experienced.

Similar, yet unique

IN MOST, there was that initial frantic involvement of medical specialists and other health-care professionals who seemed to withdraw just as abruptly following the death - leaving the grieving parents to cope as best as they can.

While some of these professionals were "wonderful in their compassionate understanding", as recalled by one grateful parent, others were found to be wincingly maladroit and even callous.

(Another aim of the Child Bereavement Support is to work with the medical and care professions to provide sensitive and compassionate care to bereaved families).

In the immediate aftermath of these deaths, there was "shock, grief, rage, horror, disbelief", as described by one mother who lost her 23-month-old son, and which was "heart-breaking, soul- wrenching, spirit-breaking".

Then there was that headlong plunge into a world for which there can be no preparation.

"Grief turns out to be a place none of us know until we reach it… We might expect if the death is sudden to feel shock. We do not expect the shock to be obliterative, dislocating to both body and mind," wrote the American novelist and essayist, Joan Didion, following the sudden death of her husband of 40 years in her book, The Year Of Magical Thinking.

Twenty months later, Didion's daughter died at the age of 39 after an extended illness.

In a subsequent book Blue Nights, she chronicled the events that led to this second blow which "cut loose any fixed idea I had ever had about death, about illness, about probability and luck, about good fortune and bad, about marriage and children and memory, about grief, about the ways in which people do and do not deal with the fact that life ends, about the shallowness of sanity, about life itself".

In this period of grieving, relationships with others are often tested; some may hold true, others may be found wanting, while others need recalibrating.

The bereaved survivors would have to put up with the awkwardness of friends and associates who may have difficulty finding the right words or else offer clumsy hackneyed expressions of condolences.

Often the bereaved might feel that they would be judged by others and held responsible in some ways for the tragedy or that it is something that no one else would like to talk about, so they suffer in silence.

Grief: Price we pay for love

"The pain of grief is as much part of life as the joy of love: it is perhaps the price we pay for love, the cost of commitment," wrote psychiatrist Colin Parkes in Bereavement: Studies Of Grief In Adult Life.

The manifestation of this sort of grief varies from person to person, and the intensity fluctuates from moment to moment.

The specific features and their trajectory over time are unique for each person. They may be overwhelming immediately after the loss; they may occur in searing pangs or come on as heart-aching bouts of grief - often evoked by some internal or external reminders of the deceased.

For most bereaved individuals, acute grief symptoms lessened as the reality of the loss is assimilated into their life. They are able to pick up the pieces and carry on with life and savour whatever good and opportunities it offers.

Complicated grief

But there is a small proportion of the population - studies indicate about 10 per cent of bereaved people overall - who can't seem to recover, and continue experiencing intense acute grief. Those who lost loved ones through disaster or violent death, and parents who had lost their children are particularly vulnerable.

In this situation, the bereaved person continues to have strong pining for the loved one. Sometimes the yearning is so profound that thoughts turn to finding ways to be closer to the deceased - even to the extent of contemplating suicide.

There are frequent thoughts or images of that person coupled with either an almost obsessive preoccupation with, or a phobic avoidance of, anything associated with the loss.

The bereaved is buffeted by bouts of disbelief or anger about the death, and consumed with feelings of emptiness and a nihilistic view of the world.

There might be this endless loop of rumination about the circumstances or consequences of the death. Mental health-care professionals call this "complicated grief" and view it as a form of disorder.

Without professional intervention and treatment, complicated grief can be chronic and persistently disabling. It can lead to severe depression, alcohol abuse, post-traumatic stress disorder and suicide.

Intriguingly, brain imaging studies reported in 2008 by Dr Mary-Frances O'Connor and her co-workers at the University of California at Los Angeles, showed that in those with complicated grief, a region of the brain called the nucleus accumbens is activated when shown images of the decreased.

On the other hand, those who adapted well to their loss showed no activation of the nucleus accumbens, even though they may continue to feel sad.

As the nucleus accumbens is the brain-reward processing centre, the researchers postulated that the "pleasure" - if it can be called that - that the individual gets from keeping the memories of the loved one alive and the craving reinforce the habits that prevent the resolution of the grief.

In Blue Nights, Didion wrote of wanting to cling on to some reminders of her daughter - hoping that these would evoke some cherished memories. But she abandoned them when she realised that it wasn't healthy.

"In fact, I no longer value this kind of memento. I no longer want reminders of what was, what got broken, what got lost, what got wasted. There was a period, a long period, dating from my childhood until quite recently, when I thought I did. A period during which I believed that I could keep people fully present, keep them with me, by preserving their mementos, their 'things,' their totems."

Grief and redemption

Suffering and loss are inevitable in life, and our brain seems wired to deal with these terrible events without incapacitating us so grievously or permanently.

Indeed for some, that painful loss could have some epiphanic or redemptive value.

Emerging from that dark nether territory, some transformative insight might be gleaned, wisdom might be acquired, unrecognised strengths discovered, and relationships redefined and deepened. And some would even be inspired to do something positive in the wake of suffering - like the five bereaved mothers who came together to start Child Bereavement Support.

stopinion@sph.com.sg

The writer is the vice-chairman, medical board (research), at the Institute of Mental Health.

For more information, please visit Child Bereavement Support (Singapore) at https://www.cbss.sg

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