Child loss is a tragedy for every membei of the family, but for each individual it takes on a different meaning. For the mother, it can give rise to guilt, severe melancholia, a lifelong bereavement. For the father, we may find similar though somewhat different responses. For the siblings, we again find varied reactions - some having lifelong significance and others where the impact is less- For grandparents, the response can vary from great despair to quite contemplative mourning. The focus of this article is on the sibling who "loses," but since the sibling does not relate in a vacuum, we must at the outset recognize how the surviving child or children are confronted by the reactions of the parents, other siblings, and their own responses when the death occurs.
It is difficult for parents to continue in their roles as mother and father to the surviving children. Parenthood carries with it an additional burden - having to deal with one's own pain and yet comfort the living children. Striking the balance between too much and too little communication is truly a task requiring herculean strength. Despite the loneliness, the emptiness, the void left by the child who shared games, television programs, toys, hopes, joys, and hurts, responsibility remains to the survivors. When parents cannot fulfill their responsibilities to the living children, and when the focus is too concentrated on the dead child, the effects on the surviving children can be lifelong. These survivors can feel unloved, alone, ignored during the bereavement period or they may become overprotected and over-invested with care and apprehension. The children may feel pushed aside, ignored, and abandoned at a crucial time. In the family upheaval created by the dead sibling, unless the parents are aware of the entire situation, the surviving children may be ignored.
The mourning process for a dead sibling, especially in childhood and adolescence, is similar to other mourning processes, eg, loss of a parent. And yet there are differences.
The crying mother and father, the at times devastated household, the lack of opportunity to talk about the dead, the feeling of helplessness and powerlessness, the guilt - these responses and behaviors can be seen in both childhood parent loss and childhood sibling loss situations. But the loss of a parent presents a potential pathogenic trauma that seemingly more often interferes with development than an appropriately handled childhood sibling loss.
Not all children and adolescents emerge from this family tragedy with psychopathology or distorted personalities. Some become very creative and these gifted individuals deal with their mourning for the dead siblings in their creative works. I have studied and am studying the impact of childhood and adolescent sibling loss through death on the creative processes of Gustav Mahler, Edvard Munch, Kaethe Kollwitz, Thomas De Quincey, Jack Kerouac, Bertha Pappenheim, Nietzsche, Goethe, Oscar Wilde, Lenin, Van Gogh, and Heinrich Schliemann, to mention a few of my research "subjects."
Clinically, I have worked with adults who were "replacement children," even to the extent of being named after the dead sibling. The comparison with the dead child, the idealization of the dead child, the inability to compete with a ghost - these can become insurmountable developmental tasks and can lead to identifications with the dead sibling, even to the point of expecting to have a similar death or to have one's future child die as did the sibling. Anniversaries, holidays, pilgrimages to the cemetery, and enshrined keepsakes can become the focus of uncompleted mourning. Healing cannot occur and at times one even seeks a sibling replacement.
Older adults who lose a sibling realize that their family of origin is following the expected course of life and they themselves are much closer to the end of their lives. They do not fear death, though they are saddened by its greater probability. Younger individuals are also threatened by death, but for different reasons, eg, they wish to be with their spouse and children and see the latter grow and develop. Young children fear the darkness and "permanent sleep" that death connotes, including the loss of parents before they are ready for this permanent and irretrievable separation.
In 1962, I published my first paper on childhood parent and sibling loss in adult patients.1 There was very little in the published literature on this subject then, although we have seen many studies and publications on this topic in the last two decades. My somewhat crude epidemiologie study concentrated on a total of 380 patients whom I had seen in my private practice in the 8 years preceding publication. 1 did find a gender difference in the population and I also found that certain ages at loss carried greater risk than other ages.
Morawetz had studied the impact on adolescents who lost an older sibling in the Israeli Vom Kippur War.2 Joanna Fanos is currently involved in major research on the developmental consequences of the death of a sibling following a chronic illness (Fanos, personal communication). She affirms that the death of a child is generally considered to be one of the most stressful events encountered by families in our society. When medical advances extend the life of a child stricken with such disorders as leukemia and cystic fibrosis, Fanos reports an additional dimension to the sibling loss problem. What are the effects on mothers, fathers, and siblings of living with a child who has a fatal illness? Dennis FarreII is studying the impact of childhood sibling loss on the life of Hermann Hesse (Farrett, personal communication).
There can be various kinds of sibling loss that include events other than death. These include hospitalization for a prolonged period of time, divorce with split custody, abandonment, separations during war and other disaster experiences, and migrations to other countries with family breakups. The multiple meanings of these complicated events and the influence of these sibling losses on later patterns of behavior, feelings, fantasies, and other object choices can be observed best when such individuals are in psychoanalytic treatment. By combining psychoanalytic work with children, adolescents, and adults throughout their life course, we can now have new researches. Serious and even catastrophic illness in a 70-year-old sibling does not evoke the same reactions in an 80year-old healthy sibling as compared to what might result if this occurred when both were children. More normative studies are needed and baseline data must be obtained that can then be compared to deviation data. Normative crises are traumatic without being pathogenic. Catastrophic crises are traumatic and possibly pathogenic for the individual and the other members of the family.
The augmentation of observations of childhood normative and catastrophic crises, from the analyses of children and from reported cases of others (by data derived from the psychoanalytic treatment of adults who suffered similar catastrophic crises due to serious illness or injury to younger siblings), can be useful in furthering clinical understanding and theoretical formulations. Data from the analysis of one such case follows.
Adam, married and a successful lawyer, is 3'/2 years older than his only sibling, Richard. Richard has had Hodgkin's disease since he was 10 years old (Adam was 13Vi). This disease, treated "successfully" with medication, had three "crises": the first when the disease was initially diagnosed and treated, the second episode several years later, and the third, in 1984, 6 years after the second exacerbation. Adam, reacting to his brother's current exacerbation, has been able to recall and re-enact much of what occurred in the two earlier periods of acute disease. When the brother currently becomes very despondent and threatens passive suicide by stopping his medical treatment, Adam is filled with guilt, rage, and then shame at his reaction to his brothers regressions and sense of hopelessness and despair. The brother received supportive treatment while undergoing the painful, debilitating medical regime and the most uncomfortable side effects.
Adam had no conscious recollection of Richard before Richard was 4 years of age. Two years ago, Richard broached the idea to Adam that he, Adam, must have had a severe sibling rivalry that was repressed. My patient explored this and concluded his brother was correct. Their mother had always fostered a "healthy competition" between her sons as she felt this would bring out the best in both of" them. Adam recalled how he would seek to control and have "power" over Richard. When asked if he ever wanted Richard "out of the way," Adam said, "I never wanted him dead - because then I'd be in trouble with my parents - they were the law. By the way, do you think this could have contributed to my becoming a lawyer?" Adam described how his brother was overweight, did poorly in school, and acted out in petty ways. When Richard's illness was first diagnosed, Adam was out of the city in an Eastern boarding school. His mother called him and asked him to return to Chicago; he refused. Adam felt unconcerned, denied that Richard had a serious illness, and felt confirmed in this belief when Richard had a remission. When the second attack came on, Adam understood for the first time his mother's anguish and the "devastating effects of the chemotherapy" on Richard, his mother, and on him. (His father was dead.) His mother suffered two heart attacks in quick succession and he no longer could deny what the medication was doing to Richard's body - "he looked awful." Adam became very depressed, had severa! financial crises, and suddenly felt the burden of his brother's care and life in a way he had never experienced previously. Adam thought of suicide but realized it might kill his mother and brother. "Richard, my mother, and I were sunk low in the morass of life. " Richard had another remission, his mother recovered, and Adam came out of his "blue state" and went on again to fulfill his life goals in a very successful way. He finished his education, began his practice, married, and even though his mother subsequently died, his life seemed in balance.
Last year, Richard had his third exacerbation and again chemotherapy was recommended. The course this time has not been smooth. Side effects, liver biopsies, and bone marrow studies were accompanied by anger on Richard's part. Finally, Richard told Adam that he, Richard, hated him and always did. Now Richard calls Adam, insists that Adam or his wife drive him to the hospital for his treatments, and needs money constantly as he cannot work and has little in savings. Adam has said, "I am his surrogate mother and rather. He borrows money from me, he is so profligate with friends, he upsets me !voice loud], I can't stand it any longer. I now realize he always bugged me. I hate him. 1 finally got so angry with him I blew up. He hates me, despises me, that's why he harasses me." Adam calmed down and then went on, "I am not rivalrous with him. I am not jealous of him. I am winning every battle - health, money, sex, marriage, the future." When asked if he always felt triumphant, Adam went on, "Mother understood his competition with me and so spent more time with him socially. She wanted me to do this, too. When I would not she said I had an obligation to him and to her. 1 had a responsibility that I was not filling. Since our father died when he was quite young, he had fewer years with him and I had to take over. Actually when Daddy died, she fell apart and I actually did care for Richard, we were close then. But I thought just now, why me? Care for him, why me? Care for him, care for her, 1 am so mad at Richard now and at you [pause] that's crazy. You make no demands of me. Are you Richard, or Mother, or Daddy? I get so terrified that something will happen to you, to him, I'll be alone !crying]."
In a later session he became involved in a tranferrence reaction and began to talk of his competition with me, how little he has accomplished when compared to me, that he is unimportant even though he is well to do, "If I left the world I would not be missed. If you died the world would be a bigger loser than if I died. I guess Richard's illness, my mother's death, my father's death - they all are related."
The loss of a significant object, the loss of a home (security, personal possessions, familiar space that has emotional meaning), the dislocation from one's home or land as occurs in wars or disasters, gives rise to stressstrain responses that may have short-term or long-term effects, eg, post- traumatic stress disorder. The hidden or neglected victims of such occurrences frequently are children - be they siblings or direct descendants. In childhood sibling loss, the effects of the loss are mediated through different members of the family. The acute Stressors can give rise to later adversity unless it is recognized that there is a social context in which life and death events occur. Recognizing these individual responses in the family can lead to interventions that may prevent later difficulty. Understanding the meaning of the events to the child, appreciating the fact that events are not just single occurrences, but interact with what existed before as well as with other concomitant events, helps in our therapeutic recommendations and interventions.
Sibling loss, though initially related to the death of a sibling, can now be expanded to include the loss of a sibling through chronic illness (emotional, medical, surgical, long-term hospitalization), birth injuries, disabled children (accidents or illness with body changes), chronic illness with visible as well as nonvisible changes that require special parental and nursing care, medication on an ongoing basis, and restrictions in diet and activities. The impacts of these losses without death can have devastating effects. Sibling loss, from whatevet cause, occurs throughout the life course. We have little data about these stressful events in the various age groups. Sibling loss takes various forms, has different précipitants, different outcomes, and relates to the meanings and fantasies of the loss events.
In sibling loss through death or holocaust events, we find many reactions that can be seen in holocaust survivors, eg, identifications, guilt, inability to mourn , the paralysis of the future because of the past , a sense of foreboding and expecting dire consequences, anger, envy, responsibility, shame and stigma, overcompensations, resentment, etc. Variables I have observed as they relate to causes of the death can be broken down into acute (eg, accidents, unexpected illness, sudden catastrophes) and chronic (eg, childhood diabetes, renal disease). Various coping-defensive measures are utilized, eg, mourning- liberation, projection, denial, splitting, transference, depression and withdrawal, delinquency, psychosomatic complaints including sleep disorders, and school failures or difficulty.
It is time to study sibling loss from various points of view and with different methodologies. Perhaps not all siblings suffer from parental inattention following loss. If we can identify those who are especially vulnerable and at high risk we will be able to successfully intervene and prevent later personality pathology.
1. Pollock GHt Childhood parent and Sibling loss m aduk paiicnrs: A comparai i ve study. Arc* um CiWfuutTV 1962; 7:296- W5.
2. Morawetz A: The impact on adolescents of the death in wat of an older sibling, in SpielbeiE« CD. Saiason IG, Milgram, NA (edsl: Sntu inni Anmtt» Washington. n.C. , Hemisphere Publishing Corp, , pp 267-274. vol 8.