The Analyst at the Morgue: Helping Families Deal with Traumatic Bereavement

The RECOVER Program in Washington, DC, provides no-cost support and counseling for families who arrive at the Office of the Chief Medical Examiner (the morgue) to identify their family members who have died suddenly—homicides, suicides, drug overdoses, accidental death, SIDS, and unattended death. This unique collaboration between the District of Columbia Office of the Chief Medical Examiner (OCME) and the Wendt Center for Loss and Healing was initiated in November 1999 and remains the only program in the United States that provides onsite crisis grief counseling to all families every day of the year.

RECOVER was initiated by my chance meeting in a sushi bar in the spring of 1998 with the newly-appointed chief medical examiner for the District of Columbia, Jonathan Arden. When Arden spoke of the 1500 families that come to the morgue every year because of sudden or traumatic deaths, I suggested a program in which specially trained therapists could provide expert and sensitive support for families at the morgue, as well as follow-up services and efforts to help bereaved children.

Trained grief therapists have assisted more than 7,000 families (13,000 people), accompanying them through the identification process and providing practical information, emotional support, and follow-up letters and phone calls offering continuing services. Next of kin are required to identify the deceased by viewing Polaroid photographs of stark, often bloated faces at the medical examiner's office before the body can be released.

Once a sufficient rapport in the intervention has developed, an OCME intake worker is called in with a photograph of the head of the deceased. To offer some control in this often overwhelming situation, family members decide when to turn over the photo. Some seem on the surface to be relatively matter-of-fact, using defenses such as denial, avoidance, and isolation of affect, or even joking. On the other extreme, some family members engage in a desperate state of grief—overwhelmed, enraged, screaming, and in need of nurturance and help to contain them. Reactions vary from running out of the room to signing the photo after a quick glance to viewing it for many minutes to asking for a copy, feeling calmed, stroking or kissing the photo and saying, “Thank God I only have to see a photo.”

The basic approach is to enhance a sense of safety and security among family members, thereby providing a Winnicottian holding environment. The bereavement work is more like psychological first aid than therapy with efforts to stabilize, meet basic needs, mitigate the stress, and facilitate problem solving. The approach is to respect and support the defenses and thus to prevent regression.

In addition to the risk of suicide to avoid depression that they cannot bear, others may act out with impulsive action including verbal attacks, violence, substance abuse, and premature sexual behavior. A suicidal 15-year-old, who within a year lost his great-grandfather, father, and a series of aunts, uncles, and cousins, explained that the “sadness comes out as anger. Anger makes the sadness go away. Feeling it [the anger] usually works; doing something like beating up someone always works.”

The bereavement workers are subjected to secondary trauma. They can overidentify with a survivor, become enmeshed, and have difficulty respecting boundaries. They endure other countertransference reactions, transference reactions, and projective identification. They are subject to intrusive violent images and thoughts and other symptoms of PTSD as well as the odor of the morgue.

In her fourth homicide of the day, one worker was suspicious of a husband whose wife had been shot in the head; she described her acute discomfort sitting with him, wondering if he was the murderer. Another worker felt strange tension in the room when a 16-year-old boy identified his father. The father had abused the boy during his first six years. Protective custody had intervened and they had not seen each other for 10 years. The son said he was particularly interested in doing the identification because he had the need to see his father dead. The father of a toddler killed by a truck asked to bring her teddy bear to the autopsy suite so she would not be alone.

This work highlights many aspects of traumatic bereavement. Traumatic loss-related feelings include depression, anxiety, fragile self-esteem, dysregulation, somatization, internalized aggression, emptiness, and hopelessness that may continue for many years, particularly at anniversaries, holidays, and special life cycle events.

The role of the socially engaged community analyst was begun by August Aichhorn, D. W. Winnicott, and John Bowlby with delinquents, Anna Freud with children separated from parents during World War II, as well as Erik Erikson, Karl Menninger, and Viola Bernard.

Bereavement workers exemplify that role. Multiple recent interventions and consultations in situations of war, terrorism, traumatic loss, soldier children, homelessness, and exposure to violence are described in a book that originated from APsaA's Committee on Psychoanalysis in the Community—Analysts in the Trenches: Streets, Schools, War Zones (Eds. Sklarew, Twemlow, and Wilkinson, Analytic Press).