by Grace H. Christ, PhD

Often palliative care professionals ask, “What does 9/11 have to do with hospice and palliative care?” As many of you know, I directed an intervention with families of firefighters who were killed in the World Trade Center attacks, following many of these families over the past 10 years. We have published three book chapters on the topic and one article in a palliative care journal that describes the intervention and the knowledge we developed from the families’ experiences. See FDNY Crisis Counseling and Grief and Bereavement in Contemporary Culture.

Our 9/11 intervention with the FDNY was preceded by a clinical trial of a family-focused intervention at Memorial Sloan Kettering with families in which one parent was terminally ill with cancer. In this cancer related intervention, we provided parent guidance to help families prepare for the loss of a parent, following up afterward for one year. These two interventions have given us research and practice experience with both expected loss and sudden traumatic loss. In this blog I wanted to share with you a few of our “lessons learned” about the similarities and differences between the two.

A film I recently reviewed, “From the Ground Up,” made by five FDNY widows, beautifully illustrates three important features of the widows’ experiences after the WTC attacks. I recommend it for learning and for teaching. The film will be publicly release next week. See a description at the end of this post.

First, the widows describe how the chaos, confusion, and complexity of the early hours, days, and weeks following the tragedy lengthened the time required for them and their children to actualize and accept the loss. They provide helpful details about how difficult it was to acknowledge the loss, to admit that it had in fact occurred, though logically they understood what had happened. The inability to find remains for many, the gruesome circumstances when remains were found, the ambiguity of the situation, and the catastrophic totally unimaginable destruction and dimensions of the disaster (nearly 3,000 died) made that first step in mourning difficult and time consuming.

So, even though we began with the families at six months after the World Trade Center attacks, they were still experiencing great shock amidst their grief and horror. At the same time and in parallel with grief, they were getting about the business of being effective single parents to grieving children. The delay was caused by these external conditions that required much more time for internal adaptation. This evidence challenges some recent bereavement research that suggests timelines like six months for grief recovery. While researchers acknowledge they are not studying traumatic loss (e.g., one of the most widely received bereavement studies focuses on samples of spousal loss from illness in older adult widows and widowers), mental health practitioners can inappropriately apply such timelines to other ages and death circumstances.

The impact of concurrent and cumulative stresses are not to be underestimated in terms of the timing and complexity of the process required to adapt to them. We know that when a loss is expected from illness, much of the acceptance of the reality of loss can occur in family members before the death actually occurs, even in children and certainly adolescents. In fact, our cancer studies showed that family members experienced some relief after a long and arduous illness process. Although the death of a family member from illness can have traumatic aspects, the illness provides opportunities for families to prepare for the loss in their day-to-day lives by absorbing and integrating information in small doses over time. This encourages palliative social work to make use of the preparatory time in illness to foster communication and normalization of family members’ experiences as they may enter more fully into the grieving process long before the patient’s death.

Second, the perspective of the widows in the film 10 years after the attacks highlights the fact that some losses you never really get over, but you do learn to live with them. It was instructive and helpful that, although it has been 10 years since that catastrophic loss, they became tearful and experienced anew the sadness of that event and its impact on their family. I myself cried on seeing their pain and remembering their profound losses. Yet they spoke with remarkable conviction and strength about their determination not to live their lives in these “dark spaces” but to honor their husbands’ sacrifices by living a productive and generous life helping others as well as themselves. This challenges the notion that such emotion after 10 years is inappropriate or necessarily an example of pathology. It seemed rather an accommodation to the reality of a profound loss that was shared by so many people and had such an enormous impact on their families and indeed on all of us.

Third, the movie illustrates how a productive, full, generous, and joyous life can coexist with experiencing the pain of profound loss. It’s not either/or. One of the widows talks about how pleased she is that she can now feel sadness about the losses of others and share in their happiness as well. All described efforts to honor the loss of their husbands through helping others. These two processes can operate in tandem. In communicating with some of the FDNY families leading up to the 10th anniversary, I have been enormously impressed and gratified by their continuing ability to integrate this experience, inventively solve the problems it has created in their lives and develop a satisfying and productive way forward for themselves and their children. 

On this important anniversary we all experience sadness and many thoughts and emotions about that catastrophic event. It brings up different memories for each of us. But this film helps us to celebrate the resilience of the human spirit and appreciate the healing power of community of which we are an integral part. We help folks walk through these enormously challenging situations, experience and learn from them, and turn again to life. 

This is an excellent film that provides important insights into the grief process following sudden catastrophic loss.