Twin loss: Implications For Counselors Working With Surviving Twins
(Practice & Theory)
Journal of Counseling and Development; Valerie L. Schwiebert (1/1/2005)
Fascination with the twin bond has gripped cultures all over the
world for millennia (Bryan, 1983). Although only approximately 3% of
the total general population are twins, those who are twins have imbued
twin relationships with expectations of extreme closeness, magical
understanding, private languages, individual's fantasies of having
another self(Bank & Kahn, 1982; Center for Disease Control [CDC],
2000). In 2000, the number of surviving individuals resulting from
multiple births was 125 million worldwide.
Equal fascination with the severing of this mystically strong bond
seems like a foregone conclusion. Yet, strangely, a paucity of research
has been conducted to investigate how twins cope with the death of a
co-twin. Because the number of multiple births continues to increase,
due to the use of fertility drugs and women waiting until later life to
give birth, the likelihood of counselors encountering surviving members
of a twin loss is growing. Women who wait until later life to conceive
are at higher risk for conceiving multiple fetuses due to the
irregularity of ovulation (i.e., as women age, the chances of both
ovaries developing a follicle and both releasing these follicles during
ovulation increases) as well as the increased need for fertility drugs
to assist in conception. Counselors working with the bereaved surviving
twin (or other surviving siblings in higher order births) need to
understand the unique aspects of the twin relationship and resulting
complicating factors for the grief process. Therefore, the focus of
this article will be on the unique bereavement experience of the
"twinless twin," the ways in which patterns of identity development
affect the severity and nature of this grief, and implications for
counseling the survivor.
Overview
Identical twins, more scientifically referred to as monozygotic (MZ)
twins, are formed when one fertilized egg, or zygote, splits into two
eggs, leading to the formation of two babies who share 100% of their
genetic material (Bryan, 1983). Fraternal, or dizygotic (DZ) twins
result when two separate eggs are released and fertilized by two
separate sperm. This process results in two babies who share as much
genetic material as singleton siblings, which is only about 50% of the
genetic material (Segal & Ream, 1998). In the United States, 3% of
all live births result in twins (CDC, 2000), making 6% of all babies
who are born alive, twins. Throughout the world, rates of MZ twins are
roughly the same (about 3 to 4 per 1,000 births), whereas rates of DZ
twins are highest in Nigeria and lowest in Japan (Bryan, 1983). It is
well known that MZ twins occur randomly, whereas DZ twins seem to run
in families (Bryan, 1983; CDC, 2000), although some research suggests
that these patterns may be more complicated than were initially thought
(Segreti, Winter, & Nance, 1978).
Stories, stereotypes, legends, and fantasies surround the mystery of
twinship, but the general public's understanding of twins often ends
with this fascination (Noble, 1983). Being a twin, and experiencing
what Schave and Ciriello (1983) termed the twinning bond, carries both
advantages and liabilities. For example, the intense closeness that
comes to play a central role in the lives of twins (Wilson, 1995) can
provide some protection against loneliness, easing the pains of
adolescence (Pector, 2002) and, according to one study, serving as a
deterrent to suicidal behaviors. A further example to illustrate the
potential negative impact of the twin bond could be that research finds
that the bond can also impair social relationships (Pector, 2002),
increase the risk of academic delays due to circumstances such as "twin
language" slowing development of appropriate communication skills
(Pector, 2001, 2002), lead to difficulties with inequality (Woodward,
1988, 1998), and result in delayed individuation (Engel, 1975; Schave
& Ciriello, 1983).
Perhaps the most interesting consequence of the twin bond, and the
most relevant to the issue of twin bereavement, is the fact that twins
tend to form their identities along patterns distinct from those of
singletons. The fact that MZ and DZ twins tend to be more alike when
raised apart than when raised together (Schave & Ciriello, 1983)
suggests that the presence of the co-twin affects identity formation.
So strong is the need to establish an identity that many twins
differentiate from each other to emphasize their separateness (Pector,
2002).
Schave and Ciriello (1983) identified six patterns of identity
development in twin pairs, which are very briefly summarized here. Each
pattern carries with it its own dynamics when twins are separated:
1. Unit identity. This pattern is characterized by a merged identity
where each twin thinks of him- or herself as half of a whole
personality. These twins find separation extremely painful and, if
possible, often end up living with one another later in life.
2. Interdependent identity. These twins consider each other best
friends, look to each other for their primary support, and develop
other relationships that mimic the twin bond. They are truly friends
and depend on each other, sharing a healthy symbiotic relationship.
3. Split identity. Twins who perceive inequalities between each
other and who always define themselves as polar opposites may be
bonded, but seldom trust one another. Usually one twin is considered
"good" and the other "bad." The overvalued twin experiences relief at
separation because that twin has lost the bad parts of his or her
identity. However, the surviving twin still needs the twinship to
highlight the surviving twin's good qualities. The undervalued twin
experiences anxiety and depression, because this twin has lost the good
parts of him- or herself. The surviving twin may feel inadequate
throughout life, unless he or she pursues an understanding of his or
her role in the family.
4. Idealized identity. Being twins is the most important aspect of
these twins' lives, and they take great pride in this unique
relationship. They may not share thoughts and feelings intimately, but
they face the world as a team. Separation from each other is not too
difficult, although they may always remain attached to being twins.
5. Competitive identity. These twins share a strong empathetic bond
with each other, encouraging each other in their achievements and
developing close, enduring bonds with others. The identity of each twin
develops in parallel with that of the other, but each retains an
appreciation for differences between them. "As a group the competitive
twins have the most potential for growth outside of twinship" (Schave
& Ciriello, 1983, p. 82). They develop intimacy with other people,
although they are always comforted by each other's presence.
6. Sibling attachment identity. These twins develop very separate
identities, and experience a relationship similar to that of very close
siblings, making separation similar to that between non-twin siblings.
As can be seen from this brief summary of attachment styles in twins,
the grief process may appear differently in the surviving twin
depending on the attachment style. However, it is important to remember
that regardless of attachment style, twins experience a different type
of loss than singleton individuals. Depending on the age of the twins
when death of one sibling occurs, this factor of attachment may have a
different degree of impact upon the process. For example, a case in
which the sibling dies at birth may not be influenced at all by
attachment but a sibling that experiences the loss of a twin at age 40
may be greatly influenced by the style of attachment.
Need for Study
Very few counselors understand the twin bond, and even fewer
understand the loss of that bond (Segal, 1998b). But why, with all the
intrigue that surrounds that mysterious connection, has so little
research been done on what happens when one twin dies? What do the
general public and the world of mental health assume happens? Do the
bereft survivors cease to be twins, becoming singletons like the
majority of the population? Do they mourn the loss of a co-twin as they
would the death of another brother or sister? Or do they feel like an
essential part of themselves is missing?
Although psychologists have long believed that the most stressful
events humans could experience are spousal and child loss, very little
research has been done on the bereavement impact of sibling loss (Balk,
1983; Segal, 1998b; Tomassini, Rosina, Billari, Skytthe, &
Christensen, 2002), and even less on twin loss (Bryan & Hallett,
1997; Wilson, 1995; Woodward, 1998). "Twins tend to be regarded as
exceptions and irrelevant to empirical research studies; they may even
be excluded as a complicating factor" (Macdonald, 2002, p. 219). The
lack of research is accompanied by a general lack of awareness on the
part of therapists as to the unique nature and severity of twin loss
(Woodward, 1998, 2002).
A more thorough understanding of the unique issues of twin loss
could prove very beneficial to bereft siblings in general, as well as
to bereft twins and their families. Kemp (1999) coined the term
forgotten mourner to refer to those whose particular types of loss have
not been well researched. Forgotten mourners are at increased risk for
complicated grief, because they attempt to do their grief work without
the institutional supports that help recognized mourners. According to
Kemp, bereft siblings fall into this category. For bereft twins and
their families, research may be even more crucial. Friends, families,
and professionals need to understand the uniqueness of twin loss in
order to better help the bereaved twin (Woodward, 1988). Mental health
workers need to better understand the differential psychological
development of children who have lost a twin (Wilson, 1995), whereas
parents need guidelines for helping their surviving twin children cope
with the loss (Pector, 2001).
Frequency of Twin Loss
Due to increased use of artificial reproductive technologies, the
rates of twins and higher order births are rapidly increasing (Bryan
& Higgins, 2002), making twins a more significant portion of the
general population. Although the purpose of this article is to explore
the impact of twin loss at various stages of life, the fact is that the
risks of mortality are especially high in the first 5 years. Women with
twin and triplet pregnancies are, in general, considered to be at high
risk of losing one or more babies; 20%-50% losing a fetus within the
first trimester, 4%-17% losing one in the second trimester. Stillbirth
rates are 3 times higher in twins than in singletons (Bryan &
Higgins, 2002), and, in infancy, the risk of SIDS is about twice as
high for twins (Pector, 2001). However, once twins reach childhood,
mortality rates begin to match those of singletons (Bryan &
Hallett, 1997; Bryan & Higgins, 2002). It is interesting to note
that, although in Western culture little research has been done on twin
loss, twin bereavement is given much attention in many tribal cultures
throughout the world (Pector, 2002).
Grief Intensity in Twin Loss
Comparisons between twin loss and other forms of familial loss have
consistently shown that twins, especially identical twins, dread and
grieve the loss of a co-twin more than almost any other loss (Segal
& Bouchard, 1993; Segal, Wilson, Bouchard, & Gitlin, 1995).
Segal (2002) found that grief intensity following twin loss was about
the same as grief intensity following spousal loss. However, when
analyzed for zygosity, her data revealed that MZ twins experienced more
stress over the loss of a co-twin than over that of a spouse, whereas
DZ twins experienced less stress under the same circumstances. It is
important to note that the overall research on grief has been based
largely on female respondents and has been faulted for biases in the
way in which grief is measured. The interested reader is referred to
the studies cited for further examination of the issues surrounding the
measurement and interpretation of grief because this discussion is
outside the scope of the article.
This difference in the severity between MZ and DZ twins' responses
to loss were reflected in Segal et al.'s (1995) study of anticipated
grief. When a group of high school-aged twins were asked to rate their
anticipated grief levels at the loss of different family members, twins
overall most dreaded the loss of their mothers, followed by the loss of
their co-twins, and then their fathers. However, again, when separated
for zygosity, nearly half (49%) of MZ twins said the loss of their
co-twin would be worse than any other loss. Only 25% of DZ twins (and
13% of opposite sex DZ twins) anticipated this loss as being the
hardest. In general, studies have shown that grief reactions among MZ
twins were more intense (Segal, Sussman, Marelich, Mearns, &
Blozis, 2002; Woodward, 1998) and longer lasting than those of DZ twins
(Segal & Ream, 1998). Perhaps this is due to MZ twins' tendency to
rate themselves as being closer to each other than do DZ twins (Segal
et al., 1995). In summary, both anticipated and actual grief have been
rated more highly among MZ than among DZ twins (Segal, 2002).
What to Expect When a Sibling Dies
In order to understand what to expect when a twin dies,
professionals must first examine typical reactions to sibling loss.
Because twins are closer to each other than other siblings, and central
to each other's existence, the dynamics of sibling loss are exacerbated
when that sibling happens to be a twin (Segal, 1998a, 1998b). Typical
grief reactions of siblings include sleep disturbance, guilt,
depression, anger, shock, confusion, numbness, and increased fears
(Balk, 1983; Wilson, 1995). However, developmental levels are key to
understanding how individuals react to the loss of a sibling (Kemp,
1999). Developmental levels and their impact on the grief process are
briefly discussed as follows.
Childhood
Sibling loss that occurs in childhood can be devastating, causing
problems in school work, personal relationships, and later in adult
development (Balk, 1983). It is important to remember that a child's
reaction to the death of a sibling depends on many factors, including
the particular stage of development, birth order of the siblings, the
nature of the twins' relationship before death, the impact of the death
on the family, and concurrent stresses on the child and the family
(Kemp, 1999). As stated previously, these factors may have a differing
impact depending on the age of the twins. Older siblings are more
likely to feel guilt, whereas younger siblings frequently take on the
burden of being the "replacement child." Even children who never had a
relationship with a younger sibling after birth grieve the loss of the
chance to be a big brother or sister, especially if they have been
preparing for the role (Kemp, 1999). The difference here for the bereft
twin is that he or she has lost a role that could never be regained.
Adolescence
Teens understand that death is irreversible but may have difficulty
verbalizing their feelings about it (Pector, 2001). Teens form their
identities in the presence of their peers. The loss of a sibling at
this stage interferes with identity formation, leaving some survivors
feeling marked and different. Seeing their friends' activities as
trivial, they may begin to withdraw from social activities. This can
hamper their identity development and prolong the grief process
(Davies, 1988; Kemp, 1999; Segal, 1998b). Adolescents may experience
isolation from peers, suicidal thoughts, feelings of being responsible
for the death, or being overprotected by their parents (Wilson, 1995).
However, many adolescents speak about the positive impact of going
through the grief process. Some teens report feeling more mature after
processing such a loss, developing early independence, an ability to
live in the present or to appreciate more deeply their loved ones who
are still alive, and report an increased compassion toward others
(Balk, 1983; Kemp, 1999).
Adulthood
Even though sibling relationships are the longest relationships
humans typically have, sibling loss in adulthood is not considered as
severe as spousal loss (Segal, 1997). The roles siblings fill for each
other, such as companionship, rivalry, loyalty, and solidarity, persist
into adulthood. Sometimes, joint parent care or empty nest syndrome
brings siblings especially close to each other in middle or later
adulthood. Many familial interaction patterns cease with the death of a
sibling in adulthood (Moss & Moss, 1986). Loss of a sibling in late
adulthood may inspire an awareness of personal mortality (Moss &
Moss, 1986). Due to the anxiety that may be caused by this awareness,
and because of the increased closeness among siblings in later stages
of life, the death of one sibling actually can negatively affect the
longevity of surviving siblings. This risk is heightened among twins
(Tomassini et al., 2002). Therefore, counselors working with adults in
later life who lose a twin need to be aware of signs of depression and
declining health and should provide preventive support through the
grief process for the surviving twin.
What to Expect When a Twin Dies
The dynamics of sibling loss are exacerbated when that sibling is a
co-twin because of twins' tendency to be closer than other siblings,
the interdependency of their identity formation, and the centrality of
the twin to the other's existence (Segal, 1998a, 1998b). According to
Davies (1988), the amount of stress experienced by bereft siblings
correlates to the amount of life space shared by the deceased and the
survivor. "The unique bond of twinship dates from conception and when
it is torn in half through death, profound repercussions can be
expected" (Noble, 1983, Foreword). According to Bryan (1983), overt
psychiatric morbidity is much higher for surviving twins than for any
one group of grieving individuals.
Psychiatrist George Engel (1975), who lost an identical twin in
adulthood, identifies three factors that qualitatively separate twin
loss from other sibling loss: blurred ego boundaries (including
confusion as to who died and who is still alive); loss of identity as
being part of a twinship (resulting in decreased pleasure in telling
"twin stories"); and a sense of fusion of the self and the twin, which
lengthens the time during which the survivor can continue to believe
the co-twin is still alive.
Many twins have expressed the sense that a part of themselves is
draining away when a co-twin dies (Case, 1991). This sense of
"halving," or suddenly losing one's identity, is especially marked
among twins who differentiated from each other in order to fulfill
complementary roles. Often, during the healing process, survivors take
on characteristics of the deceased. For example, if the twin who died
had been the talkative one, the bereaved twin might start talking more
after the death (Woodward, 1998).
Physical identity often proves difficult for twin survivors (Segal
et al., 1995). Some twins have reported confusion when watching a
co-twin die, feeling unsure about who was dying, or later, when looking
in the mirror, deciding who was dead and who was alive (Case, 1983,
1991; Engel, 1975). The sight of the surviving twin can serve as a
painful reminder for him- or herself (Case, 1983; Kemp, 1999) or to the
family (Noble, 1983) of the loss of the other twin. This can be
compounded if the survivor, as part of the healing process, adopts
habits or mannerisms of the deceased twin (Bryan, 1992). Being confused
by others for a dead twin can be especially painful (Case, 1983).
The loss of closeness affects bereft twins severely for three
reasons. First, twins tend to be closer than singleton siblings,
depending on each other more and forming their identities around each
other (Segal, 1998a, 1998b). For some twins, especially identical
twins, the twin relationship is closer even than that shared with their
mother (Noble, 1983). According to Case (1983), the severity of a twin
loss is proportional to the closeness that preceded it. Second, many
twins concentrate their relationships on each other, not spending as
much time with other siblings, neighborhood children, or even parents.
When they lose each other, they lose most of the social support they
had developed (Case, 1983). Third, most twins have very limited
experience of being alone, and the loneliness when one dies is often
unprecedented for them (Macdonald, 2002). The sense of isolation and
"being marked" that many bereft siblings feel is more severe for twins
because of the belief that others do not understand the twin bond and
therefore cannot possibly understand what has been lost (Woodward,
1998).
According to Woodward (1988), one of the worst aspects of the loss
of a twin was the sense of endless seeking for what cannot be found.
Many twins desire to replace the closeness and companionship they
shared with their co-twin. This can alienate some singletons, who may
not even comprehend the level of closeness shared by the twins.
In addition to these aspects that apply generally to twin loss, more
specific issues are raised when the twin is lost at birth, in
childhood, adolescence, or adulthood. When a close relative dies, the
developmental level of the bereft strongly influences the effects of
the grief (Case, 1983). In general, the younger the survivor, the
greater the grief (Segal et al., 1995).
Childhood
Psychologists are divided as to the significance of twin loss
immediately after birth (Pector, 2001), but the effects on a survivor
whose twin died in childhood are profound (Bryan, 1992; Bryan &
Hallett, 1997; Case, 1983). Several people in such a family have
simultaneously been hit with the most stressful forms of loss
experienced by humans. Parents have lost a child, a twin has lost a
co-twin, and other children have lost a sibling. To compound the
intensity of these losses, society often "forgets" the loss of a twin
(Bryan, 1983). For example, when parents lose an entire pregnancy of
multiples, their grief is fully acknowledged in the community, but when
one or more babies survive, they receive very little sympathy (Bryan,
2002). Bryan (1992) offered an explanation for this:
Because the babies are of the same age, many people seem to
imagine that, in some peculiar way, one of them should be dispensable
and the other a sufficient replacement. Yet each baby is, of course, a
complete and precious being in itself. For most of her pregnancy the
mother has been relating to both or all of her babies, however many
there may be. And a death is a death, even if the lost baby be one of
quads or more. (p. 87) People often point out that at least one child
survived, a small consolation to bereft families (Noble, 1983).
Studies concerning parental reactions to multiple loss have shown
that parents grieve every bit as intensely for the loss of a multiple
as for the loss of a singleton (Bryan & Hallett, 1997; Pector,
2001). Not only do these parents grieve as much, their mourning is
greatly complicated by the psychological contradiction of celebrating a
birth, the new life of the twin who survived, and mourning the loss of
a child (Bryan, 1991, 1992; Noble, 1983; Pector, 1998, 2001). This
simultaneous joy and devastation creates a pervasive confusion around
the grief process as parents try to raise a live child and grieve a
dead one at the same time or, as is often the case, simply suppress
their grief (Bryan, 1983). Parents often postpone their grief for
months or years, so preoccupied and focused are they with caring for
the surviving twin (Bryan & Hallett, 1997). However, in addition to
the intense pressure to "pull through" and to parent the surviving
child normally, parents frequently miss some key closure moments with
the dead child, due to the chaos and confusion surrounding multiple
births. Often, both parents have not had a chance to see or hold both
babies, and often mothers and fathers were separated immediately after
the birth (e.g., babies needing emergency care). Many find it hard to
say goodbye to children they never really got to greet at birth. In
some cases, especially when the mother's grief is stifled or
discouraged, she fixes on and idealizes the dead baby, rejecting the
living child (Bryan, 1992). The parents may react in opposite ways,
sustaining a great deal of stress in their relationship with each
other.
The unique challenges faced by parents of deceased twins manifest in
unique developmental contexts for the child survivors. Whether the
parents go through the grief process immediately after the death of a
twin child (Case, 1991) or whether they postpone mourning for months,
years, or indefinitely, the impact on newborns is intense (Bryan, 1991;
Bryan & Hallett, 1997). Common parental reactions that harm
surviving twin children include overprotecting or rejecting the
surviving twin (Pector, 1998, 2001; Woodward, 1988, 1998), blaming the
survivor for the death of the co-twin (Bryan & Hallett, 1997; Case,
1983; Woodward, 1988, 1998), idealizing the co-twin (Bryan, 1983; Bryan
& Hallett, 1997), comparing the survivor to the deceased, and
failing to tell the child he or she had a twin (Pector, 2001).
In Woodward's (1988) study of bereft twins, both overprotection and
rejection of surviving co-twins by parents correlated with loss-related
problems at school. Some parents, who lost one twin in infancy, so
feared the loss of the other that they were reluctant to let the
survivor stray far from their sight (Bryan & Hallett, 1997).
According to Case (1991), the parents' leading the surviving child to
believe that life is full of danger and developing a strong
interdependence could interfere with the twin's development of other
relationships, with peers for instance. In Woodward's (1988) study,
female twins were more often overprotected by parents than were male
twins and reported feeling as if they were held back, never allowed to
grow up, or kept sick and in bed throughout their childhoods. Other
parents, also fearing further loss, withdrew psychologically from the
surviving twin (Case, 1983; Pector, 1998). Some withdrew from the
surviving identical twins because they were painful reminders to
parents of the lost child (Bryan, 1983; Bryan & Hallett, 1997).
However, the feelings of rejection were reportedly the worst among
children who were blamed for killing their twins in utero (Bryan, 1983;
Woodward, 1988), for causing the death, or not doing enough to prevent
it (Case, 1983; Pector, 2002).
Parents who lose one twin have also lost their identity as the
parents of twins, an experience they cannot replace at will. When
parents' identity revolved around being parents of twins, they risked
making the survivor feel worthless as a singleton (Case, 1983).
Sometimes, parents made twins feel so special that when the pair was
separated in death, the survivor felt worthless as just one. Many of
these bereft twins tried to combat their parents' disappointment by
trying to live for both children (Case, 1991). Others have tried to
develop the talents of their deceased twin in order to meet parental
expectations of the lost twin or to fill a sense of emptiness in the
family (Case, 1983; Pector, 2001). This leads some twins to develop
life-long patterns of needing to please others (Woodward, 1998).
One of the strongest feelings reported by those whose twins died in
childhood was guilt. This was especially prevalent when the co-twin
committed suicide or was handicapped or when parents rejected or blamed
the survivor for the death of the co-twin (Woodward, 1988). As these
guilt-ridden children, especially the boys, grew into adulthood, they
engaged in more risk-taking behaviors (Woodward, 1998). In some cases,
children are faced with the fear of their own death. Children who know
they are afflicted with the same genetic disease that killed their
sibling have to face the possibility of their own death while going
through the grief (Kemp, 1999). Identical twins share 100% of their
genes, and, if a co-twin dies of a genetic disease, the presence of
death may be very real indeed for the survivor.
Adolescence
The loss of an important attachment figure is experienced as
severely in adolescence as it is in childhood. When the bonds of
attachment are either broken or threatened, our sense of self can be
undermined for a lifetime (Woodward, 1998). When that attachment figure
is a twin, the disruption of the incompletely developed relationship is
nothing less than tragic (Pector, 2002).
For MZ twins, the developmental stage of identity versus role
confusion can be difficult even under normal conditions (Segal, 1998a).
Many MZ twins see their identities as being strongly connected with
those of their co-twins. Ainslie (1985) called this "being two parts of
a whole," and Woodward (1988) termed it polarization. Often, MZ twins
will decide who they are in relation to the other, in order to
complement each other or differentiate from each other. For many twins,
this leads to their feeling like half a person, or part of a unit; when
the co-twin dies, they are therefore no longer whole (Macdonald, 2002;
Woodward, 1988). The death of a twin is not only the loss of a loved
one, it is also the loss of a way of identifying oneself, because many
twins define their identities in relation to their twins (Macdonald,
2002).
For twins, the loss in adolescence may be particularly devastating.
While the bereft sibling is developmentally trying to form his or her
own identity, part of that identity has been present since conception,
the twin identity. Suddenly, that part of the bereaved twin's identity
is ripped from him or her. Counselors working with the bereft twin need
to be extremely sensitive to the loss of identity that has always been
a part of the individual at a time when, ironically, the surviving twin
is asked to form his or her own identity.
Adulthood
Loss of a co-twin in adulthood profoundly disrupts the emotions and
functionality of survivors (Hays, Gold, & Pieper, 1997), suddenly
forcing the survivor to "deal with new situations alone without being
able to confirm with another person," a situation that "can be quite
intimidating" (Woodward, 2002, p. 150). Because many young adult twins
have not yet begun independent lives, this is an especially hard time
to lose a twin (Bryan, 1992). Twins tend to maintain closer contact
with each other into adulthood than other siblings do (Pector, 2002),
making the loss especially difficult. Among adult identical twins who
have experienced the loss of a twin as well as other family members,
73% reported the loss of the co-twin as being more severe than the loss
of others (Segal, 1998b).
Grief postponed and grief ignored are two of the salient themes for
adult survivors of twin loss. Grief ignored is "when an adult twin
dies, the myriad silken threads of twinship may be submerged by family
and friends supporting the parents while unintentionally overlooking
the twin" (Noble, 1983, Foreword). Tomassini et al. (2002) found that
mortality rates for surviving co-twins increase during the 2nd year
after the death of a twin, suggesting postponed grief. Perhaps this is,
in part, because surviving twins find themselves offering support to
the spouse and children of the deceased, and delaying their own grief.
Birthdays and Other Special Occasions at all Ages
For bereft twins at all life stages, shared birthdays are
bittersweet reminders (Segal et al., 1995), symbolically bringing
together the celebration of life and the sadness that the co-twin is no
longer here to share in it. In Balk's (1983) study of bereft siblings,
nearly all of the children missed their deceased sibling at certain key
times of the year, including holidays and birthdays. However, this loss
is not confined to childhood. George Engel (1975) stated, regarding the
loss of his own identical twin, that sadness around anniversaries, such
as shared birthdays and death anniversaries, is experienced by all
bereaved individuals; however, what makes it different for twins is
"the pronounced tendency toward persistent confusion of identities in
the unconscious" (p. 24).
Implications for Counseling
As can be seen from the previous review of the literature, there are
several important implications for counselors working with bereft
twins, surviving multiples, and parents who have lost one child in a
multiple birth. Although general counseling techniques and issues
related to loss and grief continue to be important when dealing with
this population, other factors are essential to consider. Counselors
need to be aware of the significance of the twin bond as both a
strength and a liability. In addition, awareness of normative
developmental issues, combined with the stress of losing a twin during
these developmental milestones, can complicate grief issues. Therefore,
it is important for counselors to understand some of the factors that
may influence the grief process for bereft twins losing their twin at
different life stages. Identity development models are especially
helpful in understanding the relationship between the twins and have
direct implications for the development of effective treatment plans
for surviving twins. Perhaps the most important consideration in
dealing with bereft twins is the need for the recognition of the
uniqueness of the grief process. Counselors who are aware of the
intensity of twin relationships and who understand the impact on loss
of identity for the surviving twin may best help these individuals cope
with their grief and identity crises. In addition, although more
research needs to be completed, the finding that surviving twins tend
to die within 2 years of the death of their twin if the loss occurs in
later life, has direct implications for counselors. This information
allows counselors to be proactive and to develop treatment plans
designed to help the surviving twin find meaning in his or her life as
well as a sense of wholeness.
Finally, counselors working with twin bereavement need to be aware
that the bereft twin may be experiencing some grief issues that are
very similar to those of his or her parents and other siblings;
however, he or she may also be experiencing a very unique loss. This
loss must be validated and appropriate interventions developed to
assist the entire family in understanding the grief process so that the
bereft twin may move toward healing this often tragically deep wound.
Validation of the uniqueness of the loss will be key in working with
each family member because the social support network for the family
may consider that the loss of one twin is balanced by the surviving
twin, although, in reality, the family is struggling to grieve their
loss and celebrate the surviving twin's life at the same time.
Family issues may also complicate the grief process for the bereft
twin. Parents and surviving siblings may turn to unhealthy coping
resources as a relief from this incredibly painful loss. For example,
substance abuse is found at a higher rate in families who have
experienced the loss of a child (Li, Laursen, Precht, Olsen, &
Mortensen, 2005). Also, poor coping strategies may cause families to
abuse the surviving twin as the stress and grief become too
overwhelming. Families and surviving twins need support in their grief,
not only because of the loss of the twin but because of their loss of
the uniqueness of the twin experience, thereby grieving the loss of the
special status accorded them as families with twins (Thorpe, Golding,
MacGillivray, & Greenwood, 1991).
In conclusion, counselors working with surviving twins and their
families need to be familiar with some of the unique issues surrounding
twins. Although the normal grief issues may be expected, other factors
must also be considered when working with this population. As
previously discussed, age at the time of the loss, bonding pattern,
family coping strategies, and other factors need to be taken into
account when developing effective treatment strategies for this often
overlooked population. We realize that this article is only a beginning
in the discussion of the needs of survivors of twin loss, and we call
for additional research to be done to investigate the growing
population of individuals affected by twin loss.
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Rebecca Withrow, Counseling Department, University of North Carolina
at Greensboro; Valerie L. Schwiebert, Department of Human Services,
Western Carolina University. Correspondence concerning this article
should be addressed to Valerie L. Schwiebert, Department of Human
Services, 213 Killian Building, Western Carolina University, Cullowhee,
NC 28723 (e-mail: vschwieb@wcu.edu). COPYRIGHT 2005 American Counseling
Association
Reprinted with permission from the American Counseling Association #5302-11-350