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Procedures
The five men used in this study were given a semi-structured interview, the short version of the Perinatal Grief Scale (PGS), and selected cards from the human form of the Children s Apperception Test (C.A.T.-H) and from the Thematic Apperception Test (T.A.T). This process required a telephone screen, which lasted between ten and twenty minutes, and two visits, which lasted approximately one to one and a half-hours each. All of the visits were conducted at the Center for Applied Behavioral Services at the California School of Professional Psychology at the San Diego Campus (CSPP-SD).
This researcher recruited participants in the following ways: 1) by contacting local perinatal loss and SIDS support groups for referrals; 2) by attending a perinatal loss support group and giving out dissertation flyers (Appendix C); and 3) by placing an advertisement (Appendix D) in a newsletter for a perinatal loss support group network.
The telephone screen was implemented to ensure that all of the potential participants met the criteria for the study. The potential participants were asked about the type of loss they experienced (to ensure they meet the criteria), past and current medications, history of psychological treatment, and history of psychiatric treatment. They were also assessed for past and/or current suicidal ideation and attempts, substance abuse and dependence, and psychotic symptoms. If the participant met the criteria for the study, he was given information about the purpose of the study, and he was educated about the basic tenants of the informed consent form and the audiotape consent form. Once the individual was accepted into the study, his first interview was scheduled.
The researcher monitored each participant’s distress level, emotional state, and diagnostic status during the first meeting. If it was obvious that a person was extremely distressed or unstable, the interview or testing would have been discontinued and an attempt would have been made to get the participant what he needs. However, no participants displayed this level of distress.
The first meeting began with an explanation of the purpose of the study: I am currently doing research on fathers and perinatal loss. I would like to understand more about what it is like for fathers to lose their baby through Sudden Infant Death Syndrome, stillbirth, miscarriage, and ectopic pregnancy. The process of the two visits was described with the following statements: Today, for about two hours, we will briefly go over some paperwork, fill out a questionnaire, and then begin the interview. During our next visit, which will also be about two hours, I will show you some pictures for you to tell me a story about and then we will finish the interview. After discussing the study, the researcher gave the participant a full explanation of both the informed consent form (Appendix E) and the audiotape consent form (Appendix F). In addition, the participant was given a copy of the Subject Bill of Rights (Appendix G). After signing the forms, the participant filled out the PGS.
The initial phase of the interview focused on building rapport. The purpose of building rapport was to increase the level of comfort between the participant and the researcher, and to acknowledge the difficulties and pain of telling a stranger about the loss of his baby. Once rapport had been established, the participant was asked an open- ended question, Tell me about the loss. This question allowed the participant to talk about memories of the loss. Once the participant disclosed some memories, he was asked the question, Tell me how your baby died. Because the content of the discussion was distressing at that point, the remainder of the interview proceeded slowly. Follow-up questions that address how life has changed since the loss, how thoughts and feelings have changed since the loss, how feelings have been expressed about the loss, and how relationships have changed since the loss were also asked.
On the second visit the participants were given three cards from the T.A.T., three cards from the C.A.T.-H, and then completed the semi-structured interview. The standard administration recommended by Bellak and Abrams (1997) was utilized. That is, the participants were given the following directions:
This is a test of imagination, one form of intelligence. I am going to show you some pictures, one at a time; and your task will be to make up as dramatic a story as you can for each. Tell what has led up to the event shown in the picture, describe what is happening at the moment, what the characters are feeling and thinking, and then give the outcome. Speak your thoughts as they come to your mind. Do you understand? Since you have 30 [number has been changed] minutes for 6 [number changed] pictures, you can devote about five minutes to make up a story (Bellak & Abrams, 1997, p. 54).
Because the number of cards administered in this study was less than those in Bellak and Abram’s directions, the number of cards and minutes in the above directions were changed.
The sequence of the card administration was as follows. First, cards 2, 3BM, and 7GF of the T.A.T. were administered. Then, cards 3, 5, and 9 of the C.A.T.-H were administered.
Once the testing was finished, the remainder of the interview began. This portion of the interview focused on the experience of the father before and after the pregnancy. By focusing on these experiences, the researcher was able to assess how the fathers experience of pregnancy related to his experience of the loss. For example, this researcher found that one father was extremely ambivalent about his wife becoming pregnant, and was somewhat relieved about the loss.
As with the first meeting, the second interview began by establishing rapport. Once rapport was established, the researcher asked an open-ended question. The researcher said, Tell me about the pregnancy. This statement allowed the participant to disclose memories about his partner’s pregnancy. The researcher then followed-up with a more specific question, What went through your mind when you first found out she was pregnant? Questions that followed addressed the participant s attitudes as a child about having a baby, his thoughts just prior to his wife s pregnancy, and how his thoughts and attitudes changed when she started to show. In addition, the researcher inquired about the participant’s future plans of having children.
At the conclusion of the interview, the participant was asked about his reactions to the study, What was it like to discuss this difficult life event with a stranger? All participants were given a list of referrals to therapists (sliding scale if necessary) that specialize in reproductive loss. Data from the interviews were used to identify themes in these individuals' experiences of their perinatal loss.
Analysis of Data
Interview Data.
This study used Maykut and Morehouse’s (1994) constant comparative method to qualitatively analyze the interview data. The goal of the data analysis was to identify common themes in the experience of fathers who have lost a child through SIDS, a stillbirth, or a neonatal death. The following paragraphs provide a step-by-step description of how this researcher utilized Maykut and Morehouse’s (1994) constant comparative method to extract common themes from the interview data on these fathers’ experiences of perinatal loss.
The researcher began the data analysis by carefully transcribing the audiotapes to create interview transcripts. Every effort was made to ensure that the tapes were transcribed accurately. Each page was numbered and labeled with the participant’s first initial (of his fictitious name) in the upper right hand corner.
The investigator then carefully read the data to extract themes. The first reading aimed to gain a general idea of the themes. The second reading focused on identifying “units of meaning,” which are words, phrases, or groups of phrases that appeared relevant to the focus of study (Maykut and Morehouse, 1994). For instance, Karl’s statement, “It’s a sunny day,” was not coded as a unit of meaning because it did not appear relevant to this study. However, Karl’s statement, “I feel some guilt,” was coded as a unit of meaning because it was relevant to the focus of inquiry. Units of meaning not only come from actual statements, but can also be inferred from a statement (Maykut and Morehouse, 1994). For example, from Dennis’s statement, “My mother told me Susan [deceased daughter] didn’t matter. Yeah, she told me that she didn’t matter and get on with life. This is right after we had her,” this researcher inferred that Dennis felt angry toward his mother.
This researcher carefully read each transcript, looking for units of meaning. All units of meaning were bracketed, and the “essence” of the unit, as well as the participant’s first initial, and the page number, was written to the left of the bracket in the margin. Each unit was then cut apart and taped onto separate 5” x 8” index cards. Approximately 95% of the interview data was identified as a unit of meaning and placed on these cards.
A “discovery sheet,” or a “list of potentially important ideas, concepts, or themes” (Maykut and Morehouse, 1994) was then created. The researcher listed her general impressions from the interview, the general themes extracted from the first transcript reading, and more specific themes identified from the second transcript reading on the sheet.
The researcher then began to create categories from the data. The discovery sheet was reviewed, and one theme from the list was chosen. That theme was written in large letters on a blank index card, and taped to the wall as the first provisional category. The researcher then carefully reviewed each index card, choosing the cards that “looked alike” or “felt like” the first category, and taped them under the provisional category on the wall of the investigator’s office. The investigator repeated this process, creating categories from both the discovery sheet and from the cards themselves, until all of the cards were taped onto the walls, totaling approximately 400 categorized cards. Occasionally, a card did not fit any category. In this case, the researcher either created either a new category or expanded the parameter of an existing category. Several cards neither fit any category, nor did they have enough information to create a new one.
Those cards were placed in the “miscellaneous” category for later review. The researcher then reviewed all of the cards, combining or splitting up categories as necessary.
The cards were then removed from the wall. The cards were put in a separate pile for each category and held together with an elastic band. A top card was created for each category, with the name or “essence” of the cards written on it, as well as the number of cards and first initial of each participant whose card was in the that particular category.
Lastly, the researcher reviewed each transcript again, searching for any themes that may have been missed the first two times, and noting the order in which each participant experienced his reactions.
PGS Scoring.
This researcher scored the PGS by using the standard method created for this instrument (Potvin, Lasker, & Toedter, 1988). The total PGS score was determined by first reversing thirty-one of the thirty-three items, and then adding the scores together. To determine the subscale scores, the items in each factor (active grief, difficulty in coping, and despair) were added together. Because official norms have not yet been created for this scale, each participant’s scores were compared to the means and standard deviations in Potvin, Lasker, and Toedter’s (1989) validation study.
The T.A.T. and C.A.T.-H Data Analysis.
This researcher administered the T.A.T and the C.A.T-H. All responses were audiotaped and carefully transcribed. To establish some degree of inter-rater reliability of the tests, three judges were used to identify themes. All three clinical judges were male, and chosen based on their extensive knowledge and numerous years of experience with these tests. These raters were given a copy of the directions used for administration, along with the following instructions for rating: “Rate each story to identify the three most salient themes, the degree of distress, and the amount and nature of the defenses.” Each judge was blind to the topic of study, and rated the stories independently of the other judges.
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