During their marriage, Sam and Jenny Mitchell always shared the parenting duties. But they knew a time would come when Sam would manage their 7-year-old daughter on his own.
Just days before Jenny died of breast cancer in April, "She told me she knew I would raise Ranee well," Mitchell said.
Today, the widower and single dad is on a steep learning curve. He wishes he knew a little more about braiding hair and treating poison ivy. He plans to consult his sisters when his daughter reaches puberty. And he occasionally turns to his daughter for her opinion on adult matters, though what he really wants is Jenny's take.
"Each day is different," he said, after a particularly hard week. "I will extend my hand and pretend Jenny is holding it as we reminisce. On other days I will try my hardest to refrain from crying when a familiar tune is playing, which often happens in a crowded restaurant."
Every year, thousands of spouses grieve the loss of their partners to breast cancer while adjusting to their new role as single parents. Yet until recently, the survivors, primarily men, have been largely ignored, both in terms of community resources and research efforts.
While experts say women tend to utilize support groups and therapy, there's some truth to the popular notion that men aren't comfortable sharing their feelings. Get men with similar experiences together for an "informational lunch" with a guest speaker, and support will happen, said psychologist Dan Shapiro, who has had cancer and is married to a woman with breast cancer. "Just don't call it support or therapy."
Surviving husbands need more psychological support, experts say, particularly as some research suggests young women are experiencing rising rates of late-stage breast cancer.
Data shows that after a mother's death, a father's coping skills and emotional availability is closely tied to the mental health of their children. Support groups are traditionally geared toward women, an older population of widows or widowers, or single fathers who have gone through a divorce.
"Most of these men (who have lost partners to breast cancer) still have photographs of their wives by the bed," said psychiatrist Donald Rosenstein, co-founder of Single Fathers Due to Cancer, a support group for men at the University of North Carolina's Comprehensive Cancer Support Program.
The prolonged nature of cancer can also create challenges. Unlike a sudden death, such as a car accident, the emotional and physical toll can stretch for years. Men are generally the primary informal caregiver for their spouse. Some research has shown that caregiving spouses report more psychological distress, including depression and anxiety, than the person with cancer they're caring for.
"Caregiving isn't only going to appointments," said Mitchell, who helped care for Jenny for six years. "It's also being there to pick up the loose ends when our loved ones are at their worst."
Women with children opt for more aggressive treatment near the end of life, compared to women around the same age who don't have dependent children, research suggests. They hope to stay alive as long as possible for their kids, but they end up experiencing more debilitating symptoms and a poor quality of life, said Rosenstein.
"With cancer, you see a deterioration of health status and the gradual shifting of roles," Rosenstein said. "When death comes, you are already pretty damn depleted, and then it's 'Tag, you're it!' The spouse is exhausted but has to dig deep again and pick up his family."
After Jenny's death, Sam Mitchell returned to the Cancer Treatment Centers of America, where Jenny had been treated. He met with Wanda Sheber, a mind-body therapist who had also worked with Jenny. Over the years, Sheber made it clear that her door was always open for Sam. But at the time, Mitchell preferred going for long, solitary walks.
"I can see a lot of men just walking away, never addressing some things," Mitchell said. "We're not jumping into a private therapy session; something almost has to break us in a little bit. It wasn't until we were closer to the end that I let (Wanda) in a little."
Widowed spouses face enormous and often surprising challenges, said Shapiro, author of "And In Health, a Guide for Couples Facing Cancer Together." Here's a short list of some issues.
You will hear, see or even smell your spouse in a crowd or driving by. "It can come out of nowhere and it's intense," Shapiro said. "It's also normal. It's normal to talk as if they can hear you. It's also normal to feel nothing one minute, to be completely numb even for a long time, and then feel everything the next."
It may feel disloyal to throw away her yogurt. "Homes are typically filled with reminders, and it can feel disloyal to remove those reminders, even when they are absurd, like things in the refrigerator that only they consumed, pill bottles on that side of the bed or the stack of clothing that was on its way to the laundry but never made it," Shapiro said. In the North Carolina support groups, men talk about how long to keep the wedding band on, Rosenstein said. "What does it mean if you take it off too soon? Is that disrespectful?"
Men worry they are going to screw up their children. "They feel like they have to be both the disciplinarian and the nurturer, and it's somewhat relentless," Rosenstein said. "What do you do when a middle schooler whose mom just died doesn't want to go to school or isn't cleaning their room? A lot of men are reluctant to continue with limits and discipline, and then they get ticked off and overreact. Our line is they shouldn't be doing anything radically different than what was expected before."
You — and your children — are more resilient than you might imagine. It's OK to be the "good-enough parent" once your spouse passes, Rosenstein said. "You weren't the perfect caregiver before mom died, nor is it possible or desirable to get it exactly right afterward. The name of the game is staying engaged and tolerating the sadness that you and the kids are going to have. It does get better in the overwhelming majority of cases."
Have the difficult conversations. Anecdotally, it seems that some men who have more explicit conversations about what comes next are adjusting a little better, Rosenstein said. "They don't have to imagine what their wife would have wanted. At the very least, don't miss the opportunity. Having the conversation can't be worse than what is happening; the person is dying."
It takes time. "It's like pulling out of a really tight parallel parking spot: You go forward, then backward," Shapiro said. For surviving spouses, habits become important: eating, exercising or getting anchored in kid activities, he said. "Even if at first life seems meaningless, it has a way of creeping back."
Mitchell still has good and bad days but knows "the pain will not be unbearable forever." In an email he wrote, "If we are parents, we owe it to our children to reach them, even when bad things happen. Life goes on, and we don't know what wonderful things we have coming to us."