Education And Debate Coping with loss

Separation and other problems that threaten relationships

BMJ 1998; 316 doi: (Published 28 March 1998) Cite this as: BMJ 1998;316:1011
  1. Robert S Weiss, emeritus professor of sociology
  1. Gerontology Institute, University of Massachusetts, Boston, Boston, MA 02125, USA

    This is the third in a series of 10 articles dealing with the different types of loss that doctors will meet in their practice

    Series editors: Colin Murray Parkes and Andrew Markus

    The secure or insecure attachments made to parents in childhood often prefigure the attachments which we make in adult life and predict the pattern of grief to which they give rise after the death of a partner.1 This article examines the problems of change and loss that can arise within an established “pairbond” relationship and cause it to go wrong and, sometimes, to end. It focuses on the particular problems that may bring people into medical care.

    Although people rarely come to their doctors complaining of problems in living, many psychosomatic and psychiatric disorders are caused by marital stress, and doctors often become aware that a patient is struggling with an unhappy relationship, or dealing with its loss, in the course of a diagnostic inquiry or a discussion of treatment procedures. In such cases an understanding of the emotional causes and consequences of relational problems, and how they might best be responded to, will be useful to the practitioner. I have covered these issues in more detail elsewhere.24

    Summary points

    Relationships are an important source of security and are influenced, for good or ill, by the expectations arising out of secure or insecure attachments earlier in life

    Distrust undermines security and causes grief and anger which may further undermine trust

    Children are often at risk when parental relationships break down

    Relationships that are ending are a cause of grief in both parents and their children and may cause symptoms and requests for help

    Doctors can reassure people of the normality of their grief, provide a safe place for its expression, and assess the need for specialist help

    Relationships in adult life

    Marriages and similar relationships—all the strong pair bonds between adults, regardless of marital status—are not only partnerships in the management of personal and familial life but also adult attachments. They provide each of the partners with an emotional base with which is associated a sense of security.

    Relationships arise out of complex associations between the mutual perceptions of the two people and their earlier experiences of attachments, particularly those to parents. These complex associations are further modified, for good or ill, by events within the relationship.

    In the early days of the relationship, when the partners are together, each is likely to feel a sense of comfort or completion. They will be raptly attentive to the other. Each will have learned to associate the other's image and voice with feelings of security and wellbeing. If a marriage is reasonably happy, simply hearing the other's voice in a telephone call, or seeing the other's image in a photograph, can foster feelings of wellbeing.

    Problems in relationships

    Problems can arise for various reasons. Sometimes the attachment of one or both partners is a reflection of an earlier attachment that was insecure and gave rise to distrust. When problems arise, as they will in all our lives, the partners may make negative assumptions about each other that belong to these earlier relationships rather than to the present situation. Alternatively, a new partner may fail to live up to idealised expectations arising from an earlier relationship. Whatever the cause, marital problems are devastating in their effects because the relationship that should foster security becomes a source of threat instead. Conversation is defensive, each partner protecting himself or herself against an expected assault by the other. Even when anger explodes into blind rage, other elements are being expressed by words and actions; these include despair, fear, and a misguided belief that the other can be intimidated into becoming once again a loving figure.

    In many unhappy relationships, conflict is limited, and instead one or both partners withhold their love. At home, partners avoid each other. Each then feels utterly alone in the world: isolated within the relationship but unwilling to invite friends into an emotionally chilly household.

    A truly unhappy couple may not divulge just how bad things are without sensitive, sympathetic interviewing; each partner feels there is too much chance of being misunderstood. Yet it will be found that the couple no longer kiss, perhaps no longer eat together, and the spirit of cooperation necessary for working together is absent.

    Children and marital conflict

    Some unhappily married parents are able, at least to an extent, to conceal from the child their feelings about each other and to show interest in and affection for the child. However, the child of such a marriage is likely to be aware of the parents' distance from each other, and underlying anger.

    In general, children do not do well when their parents are unhappy with each other. Sometimes one of the parents establishes an alliance with the child from which the other parent is excluded. This imposes on the child impossible dilemmas of maintaining incompatible loyalties and unrealisable commitments.

    Children whose parents are preoccupied by their unhappy marriage are likely to feel isolated and alone. They may seek support from outside the family, from teachers or friends, or they may turn in on themselves or show other aberrant behaviour. Most children in unhappy homes make do, as best they can, with too little emotional and moral sustenance.

    Helping troubled marriages

    Couples whose relationship is troubled can seldom be helped in a single session in their doctor's office; they are likely to need marital counselling. The doctor may have to strongly support this in order to overcome the couple's fear that counselling will make things worse. At the same time the doctor must be careful not to push the idea too strongly, in case one of the partners feels further alienated and further mutual disappointment ensues.


    Should the couple separate, both partners are likely to be distressed. Unlike the grief which follows a loss by death, the grief of marital breakup is likely to be confused and mixed with intense anger, and to give rise to uncertainties about personal acceptability and worth.

    The ending of relationships gives rise to mixed urges to re-establish the relationship coexisting with distrust of the relationship. Persisting tension is likely to express itself in preoccupations and in sleep difficulties. For a time each partner may experience an anxious, driving preoccupation with regaining the other, a preoccupation that can coexist with intense anger and determination to be rid of the other. Friends may take sides or may back off, leaving one or both partners socially adrift.

    Children and separation

    Parents experiencing the separation distress that accompanies the end of the relationship are likely to have little energy for attending to the needs of their children. However, the children of a couple who are breaking up will inescapably be distressed and in need of parental attention. They are likely to grieve over one of their parents departing from the home, to worry about the wellbeing of both parents, and to worry about their own wellbeing. If they are 9 or 10 or older they may express anger with one or both of their parents, despite their continued need for both parents' caring support. Their schoolwork is likely to suffer as they become preoccupied with their familial situation. Most at risk of negative consequences are those children who are recruited as allies by one or both parents or used by one or both parents as messengers to the other parent. Children do badly when put in the middle.

    Custody of the children

    The parent who does not have custody of the children will have to deal with feelings of loss. Grief may be so intense and painful that it causes the parent to make unreasonable attempts to regain custody or to demand unreasonable access. Here the doctor can help by providing parents without custody an opportunity to express and work through their grief and by assuring them that their devotion to the children, despite its difficulties, will be recognised and appreciated by the children.

    Helping at times of breakup

    People going through separation, particularly those with children, have many important decisions to make. At the same time, the parents are apt to be confused and unsure of themselves. Hence the parents are, at this time, likely to be unusually amenable to advice.

    The doctor who becomes aware that a patient is going through separation from a partner can explore with the patient the extent to which help is needed. It may be enough to reassure a distressed patient that intermittent feelings of desolation are normal accompaniments of separation, and that such feelings will subside with time. The patient might also be cautioned that, although anger is natural in separations, it sometimes causes people to say and do things that they later regret.

    It may be useful for the doctor to schedule a further appointment with the patient for one or two months later, to be cancelled by the patient if things are going well. This demonstration of the doctor's continued concern and availability can in itself be helpful to the patient. If, in a second appointment, emotional problems seem to be becoming chronic, referral to a mental health professional may be justified.

    The single parent household

    Single parents are likely to find themselves close to overload. If this occurs they may give up and become depressed, or they may turn to their children for help, no matter how old the children are. They often become easily irritated with their children. Feelings of being overwhelmed may make them tearful and overly anxious.

    The doctor can help by giving reassurance, sympathetic understanding, and an appointment for a talk. There is, however, a limit to the degree of involvement that is appropriate, and the doctor should be prepared to refer patients needing more than occasional support to a mental health professional, social worker, or Relate counsellor.

    New relationships

    Children may be apprehensive of a parent's new relationships; they may resent the new figure's entrance into their family. They are also likely to worry about how they can reconcile their continued loyalty toward their biological parent with acceptance of the new figure.

    The parent's marriage to the new figure can make things worse, although it can also provide the parent with needed help and companionship. If the step-parent has children from a former marriage, the children may worry that they will have to compete with their step-siblings for their parent's attention. They will also feel themselves required to adapt to a strange and often unappealing new family organisation.

    The articles in this series are adapted from Coping with Loss, edited by Colin Murray Parkes and Andrew Markus, which will be published in July.

    The doctor can be helpful to the children—and to the parent—by encouraging the parent to listen sympathetically to the children's concerns. This will reassure the children that they have not been deserted by the parent.


    Funding: No additional funding.

    Conflict of interest: None.


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