Being A Child Born After Loss: A Qualitative Research

Abstract

[...]of the thematic analysis, the main themes of "about the lost child", "the effect of being born after loss on life", "being a child born after loss", and "grief" were determined. Another group of participants, who had the contrasting experience of being born after a loss, recounted negative memories, such as persistent feelings of disappointing their parents and being subject to comparisons with the deceased child. [...]this study aims to scrutinize the impact of the experience of being born after the loss on the lives of these children. Method In this study, which aims to examine the impact of the experience of being born after loss on the individual, the phenomenological design, one of the qualitative research methods, was used.

Headnote

ABSTRACT

The loss of a child is one of the most traumatic experiences a person can go through. Parents who have suffered the loss of a child may bring another child into the world after or before completing the grieving process. Children born after the loss are referred to as subsequent children. The reality of loss and the attitudes of the bereaved parent affect the identity and mental state of the child born after loss. This study used the qualitative research method to understand the life experiences of children born after loss in depth. In line with the determined research method, semi-structured individual interviews were conducted with ten participants born after loss. The data obtained in the study were analyzed by thematic analysis. As a result of the thematic analysis, the main themes of "about the lost child", "the effect of being born after loss on life", "being a child born after loss", and "grief" were determined. The main theme "about the lost child" included information about the deceased sibling, objects and photographs, the cause and manner of death, images and fantasies about the sibling, emotions, and contact needs. Under the main theme of "the impact of being born after the loss of life", both the identity and psychological development of individuals, the impact on their career choices and their parents' attitudes were found. Under the main theme, "being a child born after loss", participants talked about being a scapegoat, a comforting child, or a gifted child. In the last main theme, "grief", participants gave information about their parents' grief, their grief, and their experiences of coping with this grief. It has been shown that coming into the world after loss affects individuals' identity, mental state, and choice of profession, and they may face negative parental attitudes. It may be recommended to monitor the grief processes of parents with child loss and to guide the planning of new children.

Keywords: Children, grief, death, qualitative study

ÖZ

Çocuk kaybı insanın deneyimlenebileceği en ağır travmatik deneyimlerden biridir. Çocuk kaybı yaşayan ebeveynler yas süreçleri tamamladıktan sonra veya tamamlamadan dünyaya yeniden bir çocuk getirebilirler. Kaybın ardından dünyaya gelen çocuklar kayıptan sonraki çocuk olarak adlandırılmaktadır. Kayıp gerçeği ve yaslı ebeveynin tutumları kayıp sonrasında doğan çocuğun kimliğini ve ruhsal durumunu etkilemektedir. Bu araştırmada kayıp sonrasında doğan çocukların yaşam deneyimlerini derinlemesine anlamak üzere nitel araştırma yöntemi kullanıldı. Belirlenen araştırma yöntemi doğrultusunda kayıp sonrasında dünyaya gelen on katılımcı ile yarıyapılandırılmış bireysel görüşme gerçekleştirildi. Araştırmada elde edilen veriler tematik analiz ile incelendi. Tematik analizin sonucunda "kayıp çocuğa dair", "kayıptan sonra doğmanın yaşama etkisi", "kayıp sonrasında doğan çocuk olmak" ve "yas" ana temaları belirlendi. "Kayıp çocuğa dair" ana temasında ölen kardeş ile ilgili bilgiler, eşya ve fotoğraflar, ölüm nedeni ve şeklini öğrenme, kardeş ile ilgili imge ve fanteziler, duygular ve temas ihtiyaçları yer almaktadır. "Kayıptan sonra doğmanın yaşama etkisi" ana teması altında kayıp sonrasında doğmanın bireylerin hem kimlik ve ruhsal gelişimlerine hem de meslek seçimlerine etkisi ve ebeveynlerinin tutumları bulgulandı. "Kayıp sonrasında doğan çocuk olmak" ana temasında bireylerin günah keçisi, teselli çocuk ya da armağan çocuk ile ilgili ifadeleri yer aldı. Son ana tema olan "yas"ta ise, katılımcılar ebeveynlerinin yası, kendi yasları ve bu yas ile baş etme deneyimleri ile ilgili bilgiler verdiler. Kayıp sonrasında dünyaya gelmek bireylerin kimlik, ruhsal durum ve meslek seçimine etki etmekte; bireyleri olumsuz ebeveyn tutumları ile karşı karşıya bırakabilmektedir. Çocuk kaybı olan ebeveynlerin yas süreçlerinin izlenmesi ve yeni çocuk sahibi olma süreçlerine rehberlik edilmesi önerilebilir.

Anahtar sözcükler: Ölüm, yas, çocuk, nitel çalışma

Introduction

When individuals experience the loss of an object, they tend to recreate the loss in their fantasies (Ainslie and Solyom 1986). Parents in this situation may choose to have another child to keep their mental image of the deceased children alive and help themselves in their grieving process. The desire of parents to have another child in order to preserve the memories, mental image, and life of a deceased child forms the foundation of the concept known as the replacement child (Temizel and Hocaoǧlu 2022). The term "replacement child" was first introduced by Cain and Cain in 1964. A replacement child refers to a child born shortly after the loss of a previous child to fill the void left by the deceased child (Cain and Cain 1964). Vamik Volkan (2014) defines replacement children as those who are tasked with psychologically preserving and maintaining the mental image of a deceased individual for protection.

Cain and Cain (1964) asserted that replacement children are born into a world overshadowed by grief, where their parents' attention is fixated on the past, idealizing a deceased mental image. To perpetuate their departed children's narratives, parents may bestow upon the child born after losing the identical name, dress them in matching attire, and display similar behaviours. This parenting style is geared towards preserving the bond between the deceased child and the family, as the replacement child bridges the loss and the family (Temizel and Hocaoǧlu 2022). Being born to fill the void is considered a developmental disruption. In addition to being born in a grieving environment, children after loss may have to shape their own identities in the shadow of another identity projected on them (Legg and Sherick 1976). The child who takes the place of the unconscious child is tasked with preserving the mental image of the deceased child (Temizel and Hocaoǧlu 2022). Children whose parents attempt to turn them into replicas of the dead child are deprived of their sense of individuality. These children, who unconsciously adopt their parents' fantasies, may experience confusion about their identities (Schwab 2009). It is predicted that children will encounter difficulties in separation-individuation after loss, particularly during adolescence. In summary, research shows that being a child after loss poses risks in terms of identity development and may lead to psychological difficulties (Vollman 2014, Temizel and Hocaoǧlu 2022).

Efforts of parents to intentionally forget or avoid remembering the deceased child while attempting to compensate for the loss of another child may manifest as enduring symptoms of complicated grief. This situation places the child born after the loss at risk of not receiving the emotional care needed during the growth process (Üstündaǧ-Budak 2015). In a recent study conducted by Vollman (2014) on children after loss and replacement dynamics, some participants mentioned that they were embraced, adopted, and occasionally rewarded by their families, serving as a favourable substitute for the deceased sibling. These children, characterized by their parents as a blessing for reuniting the family through their birth, were commonly perceived to hold a privileged status within the family. Another group of participants, who had the contrasting experience of being born after a loss, recounted negative memories, such as persistent feelings of disappointing their parents and being subject to comparisons with the deceased child.

Several studies have explored this concept based on Cain and Cain's (1964) definition of the replacement child. Despite being labeled with various terms by researchers, these children are commonly recognized as "children after loss" (Testoni et al. 2020). Research in this field is primarily confined to case studies (Reid 1992, 2007) and studies conducted in clinical settings or pathology with limited sample sizes. Upon reviewing the literature, no studies have been identified in our country that investigate the impact or experiences of children born after a loss on their lives. Given the multicultural nature of our country, it becomes crucial to explore the adult life experiences of these children born loss, particularly in the context of infant and child deaths. Such insights could serve as valuable guidance for developing counselling programs tailored to the needs of children born after loss and their parents. Consequently, this study aims to scrutinize the impact of the experience of being born after the loss on the lives of these children. This research is anticipated to contribute valuable information to the literature on being a "child after loss," an area with limited existing knowledge in Türkiye.

Method

In this study, which aims to examine the impact of the experience of being born after loss on the individual, the phenomenological design, one of the qualitative research methods, was used.

Sample and Procedure

The study employed non-probability purposeful sampling methods. Inclusion criteria were established as having experienced the loss of a sibling before one's birth (with no intervening siblings between the loss and the birth), the birth of the deceased sibling (excluding cases of miscarriage or abortion), volunteering to participate in the study, and being above 18 years old. Given the distinct impact on parents of losing a newborn child versus death due to miscarriage or abortion (Zeanah 1989), the cases involving the loss of a sibling due to miscarriage or abortion were used as exclusion criteria.

Permission to conduct the study was received from the Ethics Committee of Istanbul Bilgi University, dated 02.02.2023, with project number 2023-20507-017. The participants gave written and verbal consent. The study complied with the Personal Data Protection Law (2016).

The study announcement was prepared into a poster and disseminated across the first author's social media platforms and through email groups of mental health professionals specializing in trauma. Individuals meeting the participation criteria and expressing voluntary interest were informed about the research. Interviews were scheduled with people whose signed informed consent was obtained via email and completed a sociodemographic form. A reminder email was sent to the participants a day before the interviews, containing the information required to connect to the interview. Participants were reminded of their right to end the interview at any point or not to answer questions they did not feel comfortable answering. Fourteen individuals reached out to participate in the research, and interviews were conducted with ten of them. One person cited that the loss was due to miscarriage, while three others expressed a decision not to partake in individual interviews. As the literature suggests, there is no standard number for qualitative research, with an expected range of 5-25 participants, and interviews can be concluded upon reaching data saturation. In this study, interviews were concluded once data saturation was achieved, following the methodology outlined by Braun and Clarke (2013).

Individual interviews were conducted through the Zoom platform to facilitate participation from individuals residing in different cities and to achieve the desired number of participants. At the beginning of each interview, confidentiality rules were verbally explained, and after obtaining verbal consent, the interviews were recorded as videos. Participants were consistently reminded of their right to terminate the interview at any point or decline to answer questions that made them uncomfortable. The interviews took place between March 25, 2023, and May 12, 2023, with durations ranging from 42 to 87 minutes. The recorded sessions were transcribed into written text to be used in the analysis phase. A semi-structured guide was utilized during the interviews, comprising questions regarding the participants' childhood experiences after the loss (Şahin 2022). Initially, two pilot interviews were conducted to test the prepared guide. Following feedback from the pilot interviews, no changes were made to the guide, and the pilot interviews were integrated into the study. The final version of the guide had nine primary sections and 38 questions (Table 1). The questions were designed to progress from general to specific, in line with the principles outlined by Braun and Clarke (2013). Within this guide, participants were queried about their family life, growth processes, the deceased sibling, the impact of loss on their lives, individualization processes, and identity development. The researcher conducting the interviews took notes to capture facial expressions, emotions, and notable trigger points during the sessions.

Statistical Analysis

In this study, thematic analysis was used to explore the common experiences of individuals in their experiences with being born after loss. The six-step analysis framework proposed by Braun and Clarke (2013) guided the process. (1) Initially, the interviews were transcribed, and a familiarization process with the data ensued. (2) First codes were established by aggregating notable data. Subsequently, the generated codes were organized under potential themes, and the content and alignment of the themes with the dataset were analyzed. (3) To enhance the validity and consistency of the findings, two researchers independently developed codes and themes and then made comparisons with each other's decisions. (4) The main theme and sub-themes were finalized and presented to another researcher involved in the study. Following this stage, the analysis progressed; themes were distinctly defined and labelled. (5) The coded content was reviewed and documented in the final stage of the analysis. (6) To assess whether the findings accurately reflected the participants' experiences, the identified themes were shared with the participants via email, and their feedback was sought (Lincoln and Guha 1985). Two of the nine participants responded, confirming that the themes reflected their experiences.

The study's data was gathered by a psychologist studying for a master's degree in disaster and trauma studies. The analysis was conducted by an academician with expertise in qualitative studies, a mental health and psychiatric nurse, and the first author responsible for data collection. Additionally, another researcher who was not directly involved in data collection and analysis provided feedback throughout the study.

Results

Nine women and one man participated in the study. The average age of the participants was 34.9 years. Nine of the participants resided in Türkiye, and one resided in France. Five of the participants reported receiving psychological support actively or at some point in their lives. Two of the participants had lost two siblings before birth (Table 2).

Thematic Analysis

As a result of the thematic analysis, four main themes were determined. These main themes were labelled as "about the lost Child," "the impact of being born after loss on life," "being a child born after loss," and "grief." The main theme of "about the lost child" included details about the deceased sibling, including their belongings and photographs, understanding the cause and manner of death, mental images, and fantasies about the sibling, as well as emotions and physical contact needs. Under the main theme of "the impact of being born after loss on life", findings were obtained on the influence of individuals' birth after loss on their identity, psychological development and career choices, and the attitudes of their parents. The main theme of "being a child born after loss" covered expressions from individuals about being perceived as a scapegoat, a consolation child, or a gifted child In the last main theme, "grief," participants provided information about their parents' grief, their grief, and their experiences in coping with this grief (Table 2).

About the Lost Child

Within this main theme, participants shared their experiences concerning the siblings they lost, from growing up to the present day. Participants' various narration, knowledge, traces, emotions, and rituals related to the lost child formed this main theme. In their narratives, the participants included the knowledge they had about their siblings, how they learned about this loss, mental images, dreams, fantasies, emotions and their need for contact with their deceased siblings. In line with the participants' narratives, "knowledge", "mental images and fantasies", and "emotions" were identified as sub-themes.

Knowledge

Under this theme, participants shared knowledge about the deceased child, including the name, presence, date of birth, appearance, manner of death, cause of death, the process of learning about the death, and photographs and belongings. Some participants reported having minimal information about the deceased sibling, while others provided detailed accounts. Alongside information about the deceased child, various materials and photographs of the sibling were preserved by some participants. They mentioned possessing a photograph, a box containing materials, or a suitcase with the belongings of the deceased sibling. Several participants noted that information about the deceased child often surfaced by comparing themselves. One participant highlighted that characteristics typically attributed as positive for them were perceived as unfavourable in comparison to their deceased sibling:

"The talk was that she was a charming child. For example, I was hideous when I was born. Somehow? Then my aunts would say, 'Oh, you were so ugly, we used to say how could we love you, but you became so beautiful.'(...) She was a lovely child. I mean, she was so white, so overweight, well... That is how they describe her. For example, I was skinny." K5

Some participants could not remember how and when they learned, while others said they learned this information from a family member other than their parents. One participant, who learned about their missing sibling from their grandmother, detailed how they received this information. They described the profound impact of learning about the sibling and shared feelings of guilt, particularly after their grandmother's cheerful recounting of the situation;

"I do not remember the first time I learned about it, buti know and remember what she said. I do not remember exactly how she said it, but my grandmother told me a story about К. He was a smart boy. One day, work happened when we travelled on the road in our village. He said, "Look, grandma, they are going to erect poles here, and there will be lights on those poles. He told me that there would be electricity in the village. My grandmother told me a memory of him when he was three. This memory is very... It has a very, very bigplace in me. Because it is like this... That brilliant and special person was not supposed to go, and I felt guilty. As if he left because I came. Alternatively, if he did not go, I would not go; if I did not come, he would not. No, it is the other way around. Quite the opposite. I remember it made me feel like I was trying to take his place like I had done something wrong, like he should have lived, I should not have lived, I should not have come into the world. Furthermore, I was angry about that." КЗ

Men tai Images

Participants detailed the mental images that surfaced when they thought of the deceased sibling, often acquired through family narratives. While some mentioned lacking vivid mental images, others described visualizations based on the sibling as a baby or an adult. One participant shared that when thinking about their deceased brother, a silhouette would appear before their eyes, prompting various descriptions;

"For some reason, I think she looks like my mother, someone like my mother, like my mother when she was young. (...) For example, I always have these things in my head, like, I do not know. She has gold bracelets; her head is covered. After that, I imagined her as close to tradition, like a peasant woman. Maybe I am confusing her with my mother. I confuse her with my mother's youth." K5

Some participants explained that they could not visualize their siblings in their minds. Two participants, however, portrayed their deceased siblings using superhuman terms. One participant recounted how her mother positioned the deceased sibling as an intercessor and herself as an angel. Another participant described the deceased sibling as a guardian angel. Participants seemed to hold mental images of a life where the deceased sibling had not passed away, imagining the possibilities of what that life might have been like. Expressing curiosity and a longing for the potential of their deceased sibling's life, some participants fantasized about the lost sibling serving as a bridge between them and other siblings. She is offering protection from difficulties and becoming a close friend. One participant wondered about the physical appearance and relationships of their deceased sibling, believing they would get along well due to a slight age difference. Another participant expressed the desire for a close relationship with a sibling of the same gender, expressing a wish for an older sister.

Participants emphasized the importance of establishing a connection and relationship with the deceased sibling. They shared that they try to fulfil this need through various methods and rituals, including visiting the grave, painting, roasting halva, praying, and even expressing a desire to have a tattoo in memory of the deceased brother. One participant expressed her desire to carry the brother she could not meet on her body as follows;

"For example, when I was little, I told you I used to draw pictures of him. Maybe in the future, I want to get a tattoo about him. I want to carry it on my body. I can talk about that. Being his brother has always stayed with me, something I have always wanted to meet because I have never met him. When I was little, I always believed that I was this age. How old would my brother be? He would be this age. I wish I knew him. I wish he were my brother. I think it is a nice feeling. It makes you feel special. Nevertheless, at the same time, what do you call it, being unable to meet him all the time inside? Sad..."K6

Emotions

Participants shared their feelings towards their deceased siblings during the interviews. It was noted that some participants faced difficulty in articulating their emotions. The loss of the deceased child evoked a range of emotions in the participants, with predominant feelings including sadness, guilt, incompleteness, and anger. One participant noted that emotions evolved, while another emphasized a feeling of lack. Three participants expressed feelings of guilt related to their siblings' deaths. One participant described the guilt of being alive in the following way:

"For many years, I felt, as I said, guilt towards my brother К. I felt guilty because he should have lived. I should not have lived. At some point, I started to feel longing for him. I felt like I wished he was alive, that he would have protected me, that we would have spent time together, etc. Then, there was anger for a while. Why did you leave, why did you choose this path, why did all this happen? In the meantime, it is pure love; I respect him and what happened. I guess you go through this mourning thing?" КЗ

Impact of Being Born After Loss on Life

Under this theme, participants shared how being born after loss affected their lives during the interviews. Three sub-themes emerged from their responses: "career choice", "impact on identity and psychological status", and "parenting attitudes".

Career Choice

This sub-theme delves into the impact of being born after the loss on an individual's choice of profession. Some participants preferred helping-oriented professions, emphasizing their desire to make sense of human existence and life while contributing to healing. Others chose professions where the acts of creation and art intertwine. For instance, a participant who initially entered the psychology department by chance discovered a desire to become a therapist, to connect with people, and to exhibit strength while pursuing further education. Another participant, a psychological counsellor, mentioned the motivation to touch different lives through her chosen profession. A participant acknowledged studying law and specializing in human rights. Two participants completed their undergraduate education in fields where creativity takes center stage. Participants explained that creation served as both a hobby and a profession that has accompanied them since childhood. One participant, currently a teacher, shared that she initially studied history to connect with her roots and later became a teacher to impact the lives of children.

Impact on Identity and Psychological Status

Participants' accounts of the experience of being born after loss and its effects on identity and mental status formed this sub-theme. Participants stated that being born after loss made them feel inadequate, that their families had expectations and that they felt a constant need for acceptance from their parents. Two participants opened up about the defence mechanisms they use to continue their lives. One of the participants stated that she did not remember what she experienced and felt. Another participant stated that she avoids experiences such as farewell, death and mourning;

"(....) Those are the addresses I have difficulty with regarding farewells and mourning. For example, lama very tearful person. I cry all the time. My tears are ready for everything. Sometimes, I think maybe that is what it is about. There is something transference there. There is a story. (...) For example, I did not go to her funeral. I lost my grandmother; I did not go to her funeral. That is why confronting loss scares me and frightens me on the one hand. (...) I guess tolerance for loss may trigger my fear of death. That is why, for example, when I lost one of my friends' parents, it was challenging at first to go to the funerals of my friends. In recent years, I have been going there only when I have to. I mean, I have been avoiding it." K9

Some participants shared the dilemmas they experienced when leaving the family home and establishing their own lives. One participant associated the difficulty of leaving home with the comfort zone, while another explained that she perceived staying at home as a role assigned to her. For her, leaving home felt like leaving, dying, or departing. One participant settled abroad, expressing a strong desire to find peace of mind, while another described enjoying being on the road constantly. She articulated the situation she defined as an escape as follows:

'Well, I do not think my brother R positively affected me, except for coming into the world. I do not know any positive things I said. I love the roads very much, maybe that is to run away from home. You know, I can turn it into hitting the road. Other than that, I love nature. Again, the things I said are about escaping. Escaping to nature, escaping to open space. Maybe it is that thing inside the house, the gloom I live in..." K2

One of the participants revealed that she thinks about suicide from time to time. Interestingly, the presence of a sibling who died before her birth is one of the factors that prevents her from taking such actions. Consequently, she is concerned about inflicting a second loss on her family. Several participants discussed the impact of being born after the loss on their mental state and mentioned receiving psychotherapy support. For example, the participant who lost her brother to cancer expressed grappling with various phobias and anxieties. Another participant expressed her fear of death in the following manner:

"Fear of death... I struggled with panic attacks and, well, anxiety for a very long time. It is under control now. I do not know ifit is connected to that. He is like this... On the other hand, I also think it is like a guardian angel that I do not know, that I do not know, but it is like a guardian angel standing somewhere simultaneously. That is all I can say." K5

Paren ting Attitudes

The sub-theme of different parenting attitudes experienced by the participants emerged. Some participants detailed inconsistent and overprotective parenting attitudes. One participant who experienced inconsistent parenting described her parents' frightening discourses, her father's behaviours, and negative messages that she could not comprehend:

T mean, my father was always a person with psychological problems. Moreover, he always had the last word at home. He would slap you, try to kiss you. He would come home at night drunk. There would be such a smell of alcohol in the house, blah blah blah. It was a smell I loathed. After that, there was, how can I put it? It was a loveless environment. I mean, it was a loveless environment for everyone. It was a more loveless environment for me as an older child."

One participant explained that her parents were protective but did not provide this protection when she needed it. The confusion she experienced as a child triggered various emotions and impacted how she built relationships. Another participant summarized that her mother was very anxious, constantly calling her and that this anxiety was transmitted to her:

"Let me say that being born after the death of a child changed my mother a lot. I mean, she pays more attention to me than the others. I think she has a small amount of fear of loss after losing her child. I mean, my mother and I have an obsessive relationship. She acts like she is obsessed with me more than she loves me. For example, she calls me every second, like Where are you or come home. Apart from that, she also has many fears. He has much fear. He reflects this to me, too. I also feel fear when I do something. It creates anxiety about the future." K10

While the participants experienced guilt, fear of loss, and empathy due to these attitudes of their parents, they reported that their parents approached each other with guilt and shame. One participant, who sensed that their parents blamed each other for their childhood experiences, stated the following:

"Two, one feeling has been vital for us. Maybe for other families, too. Feeling guilty and what happened... Because my father... For example, my mother blamed my father for many years. Sometimes, she would throw things like that, like your father did not take me once, but there was something huge in her relationship with my father. I mean, she blamed him and wanted to punish him. This also spread to us. He always acted like he wanted to punish me for something. So that was the feeling that he conveyed to us, to me, throughout my whole life. Crime and punishment and retribution. Soyes, the thing of unspent mourning... Thatisit."K3

Being a Child Born After Loss

This main theme encompasses how participants born after the loss make sense of their existence as children. The participants question the reasons and consequences of being born and alive under this theme. Some participants harbour positive perceptions of being born after loss, while others hold negative perceptions and experiences of it. Accordingly, three sub-themes were identified: "scapegoat," "replacement and consolation," and "gift child."

Scapegoat

The first sub-theme of the main theme of being a child born after loss is scapegoating. One participant described coming into life after loss as being a scapegoat. She stated that she was blamed by her parents and subjected to negative discourses, and this situation had a profound impact on her.

'Well, for example, I was always a very admired and loved child. Even when I was young. For example, the neighbours greatly loved me because I was a perfect kid. After that, I was like a scapegoat for my mother and father. For example, the neighbours would say, ay, B. is such a sweet girl. I remember my mother saying, no, she is not that sweet. She does something at home, you would not know her, and so forth. Stuff like that. I know that I cried many nights. I prayed and begged God to let me get out of this house as soon as possible..." K5

Replacement and Consolation

Under the second sub-theme of filling in and being consoled, participants explained that they perceived their reason for being born and being alive as a consolation, brought into existence to fill the absence of the deceased sibling. One participant mentioned that being born right after her deceased sibling had a soothing meaning, especially for her mother:

"What kind of life did my parents have when I was born? I mean, I did not ask them this question much, to be honest. Nevertheless, my mother says, "That year started very badly for me, but it ended very well." Because at the beginning of the year, my brother passed away. Furthermore, at the end of the year, I was born. So, of course, my mother's sad, sad state, of course, but on the other hand, maybe I was a small amount of a consolation for them. (...) It is filling the place of something like that. For example, there is a void that I feel like I was born to fill. Is that consolation? I do not know, maybe something like that." K6

One participant stated that she was born upon the suggestion of her aunt to her mother, that her parents were distracted with her after the loss, that the emotional burden of this experience was heavy, and that she labelled herself as a "giveaway child":

"Being born after a loss, as I said, when you are a child, you do not care much. Then, when you measure what you have experienced, look back and weigh what you could not experience, it becomes a bit of a thing. It touches you. On the one hand, it is like trying to ignore my existence. I wondered why my aunt said they immediately made me, etc. However, it would be nothing if I did not exist. I would not be. (...) How did they cope? I mean, I think they probably played around with me. I call myself, well, my wife says not to call me that, but I call myself the giveaway kid as a nickname. This is a nickname I came up with much later." K2

Gift Child

Under this main theme, some participants expressed that they had a positive experience of coming into the world after loss, valued by their parents, and considered the chance of a lifetime. One of the participants stated that she was at the forefront among her siblings and was positioned as her mother's most precious one, and therefore, she never made her mother sad:

"You arealways the most precious to me," she says, but she has different values for everyone. Ido not remember ever upsetting her in my life; I do not remember raising my voice. (...) Of course, she loves others a lot, too, but she is extra fond of me. She shows it, she says it. (...) Even my parents say that I am the most precious one to my mother. I attribute it to that because I have never upset my mother in any way, at any time." K4

Another participant who positively experienced coming into the world after loss stated that her parents described her as a chance and that her behaviour was in line with this characterization:

"For example, sometimes when my mother loves me, she uses adjectives such as 'you are my biggest chance,' 'you are the real beauty that comes after you.' It is also good that my parents position me this way. They could have thought the opposite. She could have seen me in a much more negative way; she could have resented me. Nevertheless, on the contrary, maybe she saw hope again. She found another son to devote herself to like this. So that is good. I have seen many pros and cons of this. I mean, is it because of that loss or something else?" K8

Grief

Under this main theme, participants' grief experiences, observations and perceptions related to both themselves and their parents were included. Three sub-themes related to grief were identified. These sub-themes are "grief of the parent", "grief of the participant", and "ways of coping with grief".

Parent's Grief

Parental grief reactions constitute this sub-theme. Participants described the grief reactions of their parents that they were able to observe. Some participants stated that they did not have reliable information about the period of this loss, others described the effects of these grief reactions on themselves, and some participants stated that their parents, especially their fathers, were unable to grieve.

A participant who witnessed her parents' bereavement also stated that her parents did not attend ceremonies such as weddings. She also explained the emotional burden she experienced with a memory. She described how she and her siblings used to take turns wearing the clothes of her deceased sibling during their growing-up process and an ironing scene that emerged in her mind. She stated that this was the most significant trauma she carries to this day and that her mother used to lament while ironing the clothes of the deceased child;

"She has hair at home. She has a lock of hair. I wore all her clothes, Mrs. A. Isn't that already a big problem? My mother cried every time she ironed. For example, when I go to my oldest memory of my mother, the image of an iron always catches my eye. She irons with a lament: Here were my son's clothes, this and that, with tears like that. For example, I would run to another room so she would not see me crying. (...) Yes, we all wore them in turn. Not just me. My brother N wore them. I wore them too. That is how we grew up." K2

Some participants stated that their parents did not confront grief, that the deceased sibling was never talked about at home, and was ignored. Denying and not facing death negatively affected the surviving children. One of the participants stated that she did not know the location of her deceased sibling's grave, that she had never witnessed a visit by her family, and that her parents did not perform any rituals to commemorate this sibling. Participants expressed that they did not receive adequate care and attention from their parents due to the grief their parents were going through. They also mentioned the difficulties they experienced during the growing-up process:

"It feels. It makes you feel many things. I mean, as I said, first guilt, then anger, but then acceptance and the way life is. It felt big... I always felt lonely because my parents were very distracted, and I felt a little bit without guidance as if he could have provided that to me, but she could not. She did not. Such a loss. I felt like I had lost something, not my parents but me." КЗ

Some of the participants reported experiencing an anniversary effect on the anniversary of the birth or death of their parents' deceased child. It was observed that the anniversary effect was experienced as a change in mood, written posts on social media, blogging, and commemorating the loss, such as roasting halva. Some participants stated that loss and grief also affected their roles within the family, and they experienced confusion. Two participants stated that they had to assume the role of caregiver, while one participant explained her struggle not to assume the role of caregiver. Another participant stated that her sister assumed the role of the parent and her sister took care of her. Explaining that the fact that their parents did not face the loss in the process of growing up had different consequences, the participant described her mother's depressive mood and her father's addiction and dependent personality as follows:

"It hurt me the most because they both did not face it. I think it hurt me the most. My father, because of addiction, became a dependent personality. My mother was depressed for a long time; she lived on depression medication for many years. Furthermore, I did not get what I needed. I did not get the attention and care from my family. However, of course, while it looked like the opposite-they looked very devoted and devoted to us from the outside like we do not divorce because of you, we do these things to raise you well, we do everything- it was the opposite in reality. You know, there is such a phrase as 'hunger amidst plenty,' it was something like that." КЗ

Participant's Grief

Participants' grief reactions formed this sub-theme. During the interviews, participants discussed the processes and emotions they experienced regarding this loss. While one participant stated that she experienced feelings of mourning about her deceased sister, another participant stated that she visited the cemetery of her deceased sister, and it made her feel good. Some participants stated that they thought that grief was transmitted to them in the womb. Another participant described her experience as taking the pain intravenously:

'Yes, that is what I can say. That is to say, I think that some of my mother's emotions were passed on to me when she was pregnant. I feel it. For example, when my mother was pregnant with me, she was sad and melancholic, or she would feel emotional when sad songs were played. She is in that mood right now, to be honest. I mean, most of the time, I feel a bit, well, I should say I feel bad, or I do not have peace of mind. We are working on this right now with my psychologist. Here... How else should I put it? My brother passed away due to cancer. A few years later, my mother had cancer. Apart from that, I also have cancer phobias. Let us say I was also affected..." KI 0

Coping Mechanisms

During the interviews, it became apparent that parents and participants employed various coping methods to navigate this loss. Parents utilized coping mechanisms such as alcohol consumption, a lack of religious faith, reliance on superstitious beliefs, political engagement, and the decision to have another child. In contrast, participants chose to create some distance from their parents and sought support from social networks to manage the impact of grief. For instance, one participant shared that their parents had opted to have a new child as a way of coping with their grief.

One participant, born immediately after the loss, shared that her parents gave her a different name as a means of managing their anxiety surrounding the death. Another participant highlighted that the bond between siblings served a protective function and contributed to reuniting the family. Several participants admitted to having fears of confronting the truth, avoiding discussions about the loss with their parents for an extended period, and refraining from actively exploring or addressing the topic. In some cases, participants revealed that there was an unspoken agreement with their parents to avoid discussing the loss. Notably, a participant with a mother experiencing intense anxiety and fears disclosed that she distanced herself from her parent as a coping mechanism for her fear of loss:

"Because she looks like her mother... My mom looks like her mom. So I thought something like she looked like her mom. I spent much time with her too, and when I saw that I was affected by her... For example, when I saw her things in myself, I wanted to stay away. I mean, I did not want to accept it. For example, there is some coding in my brain. H was saying that you are a mother's daughter and so on. After a while, I started to believe in these things. Then, I did not accept them. I withdrew myself more. (...) He should solve some problems, but I suffer because he does not want to solve them. So right now, for example, as a solution, I am trying to stay away more. For example, I am staying with my sisters a lot right now. I am affected every second I am with him because he injects certain things into my brain."K10

Discussion

This study aimed to investigate the unique experiences of individuals born after loss. Consistent with the literature, it was observed that the amount of information the participants had about the deceased child varied, and the information they possessed was primarily derived from family narratives. Previous research suggests that children born after loss often idealize the deceased sibling. In line with prior studies (Leon, 1986; Reid, 1992), participants in this study were found to have mental images of their deceased siblings, aligning with the fantasies that, if the deceased sibling were alive, he/she would fill a void in their lives and play a role as a helper, confidant, or friend. Participants described fantasies that, if the deceased sibling were alive, he/she would serve as a bridge within the family, protect them from difficulties, and be a friend with whom they could get along well.

Parents who are not prepared for the birth of a child after the death of another child may attempt to raise the newborn by idealizing the deceased child. The family might expect the new child to resemble the one they lost, depriving the child of the chance to form their own identity. This scenario can evoke anger and guilt in the individual. The sense of guilt in the child can intensify, particularly when the birth after the loss is connected to the death of the sibling, and the parents' attitudes contribute to the survivor's guilt. Constantly subjecting the child born after the loss to comparisons, as noted by Cain and Cain (1964), exacerbates feelings of guilt and leads to anger. In this study, participants expressed being exposed to comparisons with the deceased child as a situation that fuels inadequacy and anger rather than framing it as a form of competition.

The impact of being born after the loss on a person's life manifests in various ways. Limited research on children born after loss suggests a tendency for these individuals to choose caregiving-oriented occupations (Leon, 1986), a trend observed in most participants in this study. Similar to the findings in this study, the literature also highlights creative responses among individuals born after loss. Historical figures like Vincent van Gogh, characterized as a replacement child, incorporated death, rebirth, twinning fantasies, and their role as a replacement child into their art. Beethoven, born a year after his deceased brother, even adopted the name of his late sibling (Legg and Sherick, 1976). Another historical figure, Mustafa Kemal Atatürk, is considered a replacement child and responded to this circumstance with aspirations of becoming a saviour (Volkan, 2014). It is believed that Atatürk harboured unconscious fantasies of rescuing his mother from grief and achieving immortality, which translated into his role as the saviour of his country (Volkan and Itzkowitz, 2020). While not as overt as Atatürk's example, it is hypothesized that some participants in this study pursued careers in teaching to realize their dreams of becoming saviours.

The urge for parents to adopt overprotective and restrictive attitudes towards a child born after loss may stem from the perception that they made a mistake in safeguarding their previous children, contributing to their loss. Overprotective tendencies can adversely affect the child's socialization, individualization, and identity development (Temizel and Hocaoǧlu, 2023). Pantke and Slade's study (2010) found that adolescents born after loss were subjected to more protective, anxious, and sheltering attitudes. In line with these findings, the participants in this study experienced a desire to leave home, associating this desire with escaping and achieving liberation. This suggests that the participants may be motivated by a quest for individualization. Additionally, heightened anxiety and fears related to the prospect of leaving home were observed for some participants.

Participants described the experience of being a child born after the loss as being a scapegoat, a source of consolation, a replacement, and a gifted child. Vollman's study (2014) reported that some participants felt inadequate in filling the void left by the deceased child, facing constant comparisons, while others felt rewarded with love and attention, becoming the focal point for their parents. Vollman (2014) categorized these experiences into inadequate replacement child and gift child. Although the terminology of the themes varies between these findings and the present study, the participants' experiences demonstrate similarities.

Families of the participants underwent varied processes after the loss, resorting to different rituals to cope with the grief. Some participants mentioned that their parents engaged in mourning rituals like roasting halva, visiting the grave, and praying on the death and birthdays of the deceased child, frequently remembering them. In contrast, others expressed having fewer memories of the deceased child. This indicates the influence of cultural norms on the ways grief is experienced and expressed (Martin and Doka, 2000). Becoming pregnant after a loss is recognized as a coping method (Powell, 1995), but it has been noted to have negative consequences for both the parent and the child (Temizel and Hocaoǧlu, 2023).

Children born after loss may face disruptions in attachment styles due to their parents' prolonged, unresolved grief (Vollman, 2014). Parents may grapple with the fear of losing another child, potentially negatively impacting attachment. Many participants in this study described inconsistent parenting attitudes and the unpredictability of their parents. The apprehension of experiencing child loss again might prevent emotional bonding for parents, but it is acknowledged as profoundly affecting the child. Additionally, parents having children as a way to cope with the grief, anger, and feelings of inadequacy from the deceased child or seeking solace from the new child can be viewed as role reversal (Temizel and Hocaoǧlu, 2023), termed as "parentification" (Van Parys et al., 2014). Some participants expressed that they took on the role of parents because their parents did not fulfil this role, and in some cases, they even had to care for their siblings born later. One participant mentioned that her sister assumed a parental role after the loss, stepping into the position of a mother. This phenomenon is believed to be associated with birth order, which can lead to role differences among siblings (Mendelson and Gottlieb, 1994). The lack of adequate care for individuals undergoing such role changes may contribute to the development of mental symptoms in the future. Nevertheless, many participants in this study have sought psychotherapy in adulthood, suggesting a heightened awareness of these issues.

The complicated grief experienced by parents can be passed from one generation to the next. Some participants reported that grief was passed on to them in the womb, while others grieved as if they had experienced the loss themselves. Research has observed that children who inherit the effects of loss through intergenerational transmission make attempts to cope with and integrate it into their life stories; through photographs, stories and letters, they attempt to piece together and make sense of a past that they did not primarily experience (Schwab, 2009). Attempts to make sense of loss can be a healing factor for the child born after loss, and this attempt to make sense of loss is a logical and necessary response (Vollman, 2014).

In line with the participants' narratives, it was observed that information about the grief experience of the father figure was quite limited, and the participants had relatively weak relationships with their fathers. In many cultures, fathers are often depicted as forgotten or shadow parents (LaRossa, 1997). This study found that the participants had limited connections with their fathers and lacked substantial information about them. This aligns with existing literature indicating that fathers may tend to deny or conceal their grief (Aho et al., 2006), a pattern reflected in the participants' experiences. Moreover, the literature also suggests that individuals assuming the father role may resort to increased alcohol and substance consumption as a means to avoid grief and pain following the loss of a child (Aho et al., 2006). Some participants mentioned that their parents started to consume alcohol after the loss, showing how deeply this situation affected their mental well-being during their formative years, with the inconsistency in their parents' approaches adding to the confusion.

There is limited information regarding the impact of being born after a loss on mental well-being and identity development. Although studies on this topic exist in Western societies, the research is relatively narrow in Türkiye. Addressing the experiences of individuals born after loss in Türkiye comprehensively may not only enrich the existing literature but also have implications for the field of psychotherapy. The participants in this study ranged from 19 to 53 years old, representing a diverse range of life experiences and awareness levels. This diversity is considered a strength of the study, as it contributes to a more comprehensive understanding of the subject.

Besides its strengths, this study has some limitations. Firstly, reaching individuals born after loss posed a challenge. Two individuals born after a loss provided feedback indicating that participating in an interview on this subject would be challenging for them, and they chose not to participate in the study. The recruitment process, mainly through social media, may have biased the sample towards individuals who have undergone psychotherapy, are mental health specialists or candidates, or have a high level of awareness regarding this issue, approaching their mental processes with curiosity. Another limitation is that the majority of participants were undergraduate and graduate graduates.

Conclusion

The research revealed that participants openly shared information, mental imagery, and thoughts about the deceased child, expressing deep emotions toward them. This underscores the profound impact of being born after such a loss on individuals' sense of self, mental health, career paths, and exposure to negative parental sentiments. It is advisable to closely monitor the grieving journey of parents who have undergone the loss of a child and offer guidance when planning for a new child. While some individuals expressed positive experiences regarding being born after such a loss, others conveyed negative sentiments. Nearly all participants recalled witnessing their parents' grieving process while growing up. This underscores the significance of assisting parents through the grieving process after experiencing child loss and stresses the importance of transparent communication about the departed sibling to alleviate uncertainty for subsequent children. Offering psychosocial support during the developmental stages of children born after such a loss could be pivotal in averting potential psychological distress.

Sidebar

Address for Correspondence: Gül Dikeç, Fenerbahçe University, Faculty of Health Sciences, Department of Nursing, English Nursing Program, Istanbul, Türkiye E-mail: [email protected]

Received: 22.09.2023 | Accepted: 24.11.2023

Authors Contributions: The author (s) have declared that they have made a significant scientific contribution to the study and have assisted in the preparation or revision of the manuscript

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared.

Financial Disclosure: No financial support was declared for this study.

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