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ABSTRACT
What it is like when a lifelong twin relationship
ends through death in later life is the focus of
this study. It draws on interview data from seven
twins who are part of a longitudinal Swedish
twin study (SATSA) and who lost their co-twins
in old age. Data were analyzed using qualitative
latent content analysis. The results showed that
the experience of loss of the co-twin was profound,
including an emotional as well as a behavioral
dimension. Loss and loneliness were
expressed as the dominant feelings related to
the quality of the missing relationship as well as
the loss of twin identity. However, the grief experiences
in this study were primarily related to
the closeness and quality of the twin relationship,
rather than identity. Behavioral adjustments
included the use of outside as well as
internal cognitive resources to cope with life
after the loss. Despite the devastating experience
of losing a co-twin after a lifelong relationship,
the participants engaged actively in
their own grief processes. It was concluded that
twin loss is unique, in the sense of losing the
relational twin identity, as well as it is characterized
by similar features as the loss of a close
relationship among non-twins.
INTRODUCTION
The loss of a co-twin through death is, according to
earlier studies on twin loss, that twin lose an equally devastating experience for the surviving twin, as the loss of a
child or a spouse [1,2]. This indicates something of the
magnitude of this kind of sibling relationship, which is the
focus of this study. According to earlier bereavement
studies, we grieve most of all for those who are most important
to us, such as a spouse or a child [3,4] or for twins;
it may be the co-twin [1]. The concept of bereavement
through death in this study is in line with Strobe, Hansson,
Stroebe and Schut, (2002) which is referred to as the objective
situation of having lost a loved one and which is
experienced within emotional, physical, cognitive, behavioural,
social and philosophical dimensions.
Grief refers to the emotional reactions, including feelings
such as dejection, despair, anxiety, guilt, anger, hostility
and loneliness, which are expressed in behaviours
such as agitation, fatigue, crying and social withdrawal [3].
In this kind of definition, it is assumed that grief is related
to negative feelings only. But more recent bereavement
researches have questioned this view as there has been
evidence that positive emotions also occur encountering
major losses [5,6]. Positive emotions do not have to be an
indication of denial of the loss or indicative of pathological
behaviour, but may have an adaptive function in
the grieving process [7-9]. Not only are the relationships
with a spouse, children or siblings important, but also they
share a special bond with one another, which is called an
attachment relationship.
1.1. Attachment
Attachment relationships are according to Bowlby
(1969; 1980) characterized by features such as proximity
seeking, separation distress, safe haven and a secure base.
Proximity seeking involves enjoying and actively seeking
out the presence of the other and the relationship represents
a safe haven when the person is distressed as well as
it is a secure base from which new environments can be explored. When the relationship is threatened or disrupted,
the individuals will experience separation distress. This
kind of attachment is called “secure attachment”. Depending
on the quality of care, other attachment styles can
develop, such as avoidant attachment, which is characterized
by little affection in play, little or no distress on
departure and as adults these individuals may develop
distant and superficial relationships. In contrast, the ambivalent-resistant
attachment style may be proximity
seeking to the extent of being dependent on the attachment
figure. The first attachment in life is between child
and parent, which is an asymmetric attachment as it is the
child who is attached to the parent. Adult attachment
relationships are more symmetric with giving and receiving
on a more equal basis [10,11]. Twins have a
symmetric attachment to one another from the beginning
and as such they establish a close relationship very early
on in contrast to non-twins.
Attachment figures change over the life course and in
adulthood the romantic partner is the preferred attachment
figure over the parent [12,13]. Siblings are also considered
as attachment figures, as they share a continuing
bond with each other throughout life [14-17]. The death of
a sibling may therefore be experienced as one major life
event for the surviving sibling [18]. Twin relationships, as
a kind of sibling relationship, are according to Tancredy &
Fraley, (2006) placed after the romantic partner and are
higher in the attachment hierarchy than non-twin siblings.
Older twins also have a stronger attachment to their
co-twins than older non-twins have to their siblings [19].
1.2. Twin Loss
According to the twin study conducted by Segal, Wilson,
Bouchard, & Gitlin, (1995) identical twins were
found to be most and deepest grieved by their co-twin as
compared to fraternal twins and loss of non-twin siblings.
The cause was suggested to be related to the genetic origin
of twins, as identical twins share 100% of their genes
while fraternal twins share approximately 50% of their
genes [1]. A twin study by Schave & Ciriello, (1983)
instead suggested that the depth of twin loss is related to
the closeness of the relationship which in turn is related
to identity and that twins in very dependent twin relationships
also defined themselves through their co-twin
[20]. A difference between twins and non-twins are that
twins are related to each other from the very beginning
and a twin instead may develop ambiguous identity
boundaries. As a consequence this may add to confusion
of identity and leave the surviving twin with vulnerability
when the co-twin dies [21-23]. Reactions to the loss
are also related to age. The death of younger individuals
are considered as more untimely and often experienced
as more intense than the death of older individuals. Instead
older individuals may devalue or neglect their grief and internalize their feelings [24-26].
Generally, studies on twin loss have focused on childhood
and adulthood [27-30], but experiences related to
twin loss in old age specifically have to our knowledge
been given less attention and need further exploring. This
study will give some insight into grief in sibling relationships
and particularly twin loss in later life. Additionally,
it will contribute to knowledge that is helpful to
those connected to bereaved twins, such as family,
friends or grief counselors. The aim of this study was to
explore and describe how twins experience the loss of a
co-twin in later life.
2. MATERIALS AND METHODS
2.1. Method
The complexity of life and the perspective of individuals
in a social context can be understood with quailtative
approaches and consequently this study design was
based on data consisting of narratives of loss and bereavement
by older twins. Qualitative latent content analysis
of the narratives focuses on personal experiences
within their social context and the including of a variety
of experiences with each individual’s experience adds to
a greater understanding of a studied phenomenon [31,32].
The life stories of older people in this study do not only
give information about the personal experiences, but also
about the context. The context includes a time perspective,
which in this study means that the participants had
experiences of a life-long twin relationship and were able
to see how it had changed over time, as well as how the
co-twin relationship ended through death.
2.2. Participants
The participants are part of a qualitative study, based on
the life stories of 35 older twins [33], which in turn is a
subsample of a longitudinal twin-study, SATSA (=
Swedish Adoption Twin Study of Ageing) [34,35]. Seven
participants had lost their co-twin when they were between
75-91years, mean age of 86 years. The participants
had lost their co-twin from 6 months to 9 years before the
interview were conducted. Six participants had lost the
co-twin unexpectedly, who had died within hours to a
couple of days and one co-twin had died after two months’
sickness. The participants were two male and five female
twins, three were identical and four were non-identical
twins and all were married with families. (Table 1)
2.3. Data Collection
The interviews were conducted in the participants’
homes and tape-recorded with an average recording time
of approximately one hour (40 - 90 minutes). The questions
of loss and bereavement were part of a life story
interview regarding life as a twin and a semi-structured
interview guide was at hand in case the participants
needed some guidance through the interview. The following
are examples of questions regarding the death of
the co-twin: What is life like without your co-twin? What
happened when your twin passed away? Accounts of the
death of the co-twin were told almost without interruption
from the interviewer, whereas, when focusing on the
participant’s own reactions and grief work regarding the
loss, the interviewer intervened with questions like: What
did you think about ...? What was it like ...?
2.4. Data Analysis
The purpose of the qualitative latent content analysis
is to identify the underlying meaning by categorizing and
abstracting the text on different levels in relation to the
research question of the study [31,32]. The interviews
were transcribed verbatim by the first author and the
texts were analyzed based on the analysis steps in qualitative
latent content analysis described by Graneheim, &
Lundman, (2004). To get an overall impression of the
content, each transcript was read several times. The text
was then re-read, line by line, to identify topics and domains
related to the study’s purpose and research questions.
Meaning units were identified and condensed into
smaller units without losing the meaning of the words.
The next step included abstracting the meaning units into
labeling codes.
Codes related to the content were grouped together
into subcategories and subcategories with similar content
were further abstracted to main categories (see Table 2).
This phase of the analysis refers to the manifest dimension,
which is close to the text [31]. The next step included
comparing commonalities and differences in the
categories, and the pattern which was running through all
categories was identified as the theme expressing the
latent or underlying meaning of the text. The interviews
were read and analyzed independently by the third author
and agreement was reached regarding analysis and interpretation
of the texts (Table 2).