Assessing loss reactions among older adults: strategies to evaluate the impact of September 11, 2001.

As a result of the events of September 11, 2001, older adults have experienced a multitude of death-related and non-death losses. Mental health counselors who interact with older adults have a crucial role in identifying individuals who may be at risk for experiencing a subsequent, temporary, upsurge of grief Following a review of basic concepts and underlying philosophies that can be utilized to inform work with bereaved older adults, interviewing strategies and standardized measures available for use with older adults experiencing trauma and grief are described. Then using Corr's (2003) task-based approach as a framework, strategies for identification of need and intervention are presented.

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During her 85 years, Sophia had experienced many losses and challenges, including the death of her husband, Bill, in France during World War II; raising a child alone until her remarriage; watching her second husband's health deteriorate as he battled cancer; and losing her independence in December, 2002, following a stroke that forced her into an assisted living community. When she woke up on Thursday, September 11, 2003, she knew that this would not be an ordinary day. Sophia vividly remembered the powerful feelings that she experienced 2 years ago upon hearing about the destruction and death that had resulted from the terrorist attacks. She had relived the agony of not knowing if Bill had survived the invasion of Normandy, particularly while watching media coverage of the families who were waiting to confirm that a loved one was safe or to receive confirmation of a loved one's death. However, on the second anniversary of the terrorist attacks, she suspected that her emotions would be more focused upon her friend Mary, whose grandson, Jeffrey, had died in one of the towers on that fateful day.

Because she had decided not to join her family on their pilgrimage to New York City for the memorial service at Ground Zero, Mary was planning to spend some time quietly reflecting upon her grandson's life rather than thinking about how and where he died. She had asked Sophia if she would be willing to accompany her on a trip to the local museum, a place that she and Jeffrey had visited frequently during his summer visits. This was a place where Mary hoped that she could focus upon the laughter and joy that she had shared with Jeffrey as a child rather than on the tears that had been shed over the past 2 years following his death. Perhaps, she told Sophia, they could help each other through what was likely to be a bittersweet day.

On September 11, 2001, many lives were changed in ways that will be difficult to fully comprehend for years to come. Within hours of the attack on the World Trade Center, the Pentagon, and the crash of United Flight 93 in Pennsylvania, the nation was forced to grapple with the reality that life as people knew it would never be the same. The older adults (ages 40-85) who worked and/or lived near ground zero experienced intense reactions that were understandable and natural, as was their concern about family and friends. However, many older adults who were not directly involved in or impacted by the events in New York City, Washington, D.C., or Pennsylvania have also experienced a multitude of loss-related reactions to this unprecedented series of events.

This article examines strategies for assessing the reactions of older adults to the death and non-death losses experienced as a result of the events of September 11, 2001. In addition to examining potential changes in adults' assumptive worlds (e.g., perceptions of safety and security), factors contributing to potential subsequent, temporary, upsurges of grief (STUG) reactions (Rando, 1993) are identified. Assessment and treatment strategies used for identification of older adults at risk of a normal resurgence of grief during the aftermath of this national tragedy are discussed.

BASIC CONCEPTS AND UNDERLYING PHILOSOPHIES

Within 6 months of the terrorist attacks, Figley (2002) noted that the collective struggle to understand the implications of this trauma had only begun. In understanding older adults' reactions, it is helpful to remember that people struggle both individually and collectively to interpret their experience. This experience is shaped by many factors. Therefore, prior to examining strategies for assessing older adults' reactions to September 11, basic concepts and underlying philosophies that are relevant to the current discussion are briefly summarized.

Defining Loss

Literature published early in the thanatology movement focused largely on the meaning of death (Feifel, 1959), the process of dying (Kubler-Ross, 1969), and reactions to the death of a loved-one (Kutscher, 1969; Lindemann, 1944). As the thanatology movement has progressed, other forms of losses have been acknowledged. These physical or tangible losses, such as the unexpected and inconceivable loss of the workplace as occurred on September 11, are referred to as symbolic or psychosocial losses (Rando, 1993) or nonfinite losses (Bruce & Schultz, 2001). Nonfinite losses, according to Bruce and Schultz, are defined as being "contingent on a lack of synchrony with hopes, wishes, ideals, and expectations" (p. 7). For example, plans for travel or other activities during retirement may have been altered due to concerns about the safety of air travel or travel to particular foreign countries. These authors also describe nonfinite losses as being continuous and invariably insidious, frequently preceded by a negative life event that retains a vivid psychological presence, for example, "the disappearance of a family member in an impossible-to-reconcile circumstance" (p. 8). Ambiguous loss (Boss, 1999) involves uncertainty and doubt about the reality of the loss due to the nature and circumstances of the loss event, such as the time period immediately following the terrorist attacks when many older adults could not ascertain whether friends/family were alive.

The Assumptive World

Parkes (2002) asserted that we begin to develop a set of assumptions about the world from the moment of our birth. These early assumptions tend to be core assumptions that shape the way in which people recognize the world and act within it. In addition to assumptions about the outside world, we also develop assumptions about the consequences of our own and others' actions. These core assumptions include (a) self-trust, one's ability to cope with daily experiences; (b) other-trust, when necessary, being able to count on others to maintain our safety; and (c) world-trust, "the assumption that the world is a reasonably safe place" (Parkes, p. 238). When individuals are confronted with new information or new experiences, they must refine the aspects of their assumptive world that are now obsolete.

Needless to say, the events and aftermath of September 11 challenged the core assumptions of many people to varying degrees. For some older adults, challenges to these core assumptions may have seemed all too familiar in light of their need to overcome the challenges previously experienced during large-scale historic events (e.g., the Depression, the Holocaust, World War II). However, exposure to terrorism on American soil and the resulting challenge to their sense of world-trust may have been a very new experience for some life-long American citizens. As Joe, 68 years old, said, "I always thought we were safe here ... but ... now, there is no safe place ... not anywhere in the world."

The struggle to revise one's assumptions, labeled by Parkes (2002) as a psychosocial transition, can be painful and protracted. Individuals are challenged to relearn their ways in the world in a range of dimensions: emotional, psychological, behavioral, physical, social, intellectual, and spiritual (Attig, 2002). Finding ways to understand an individual's assumptive world prior to a life-altering event as well as supporting an individual during the process of relearning the world from a holistic perspective are important tasks. As Landsman (2002) noted, the trauma and loss literatures have "only fairly recently, and somewhat tentatively" (p. 25) addressed the subject of good outcomes. Yet, reorganizing assumptions following loss is truly a process of reconstructing meaning (Neimeyer, 2001) and relearning the world (Attig, 1996). Concepts such as resilience (e.g., Bonanno et al., 2002; Nolen-Hoeksema, 2000; Reivich & Shatte, 2002) and transcendence (e.g., Landsman; Prend, 1997), rather than pathology, incorporate a strengths-based perspective (Saleebey, 1997) into the assessment and intervention process.

ASSESSING REACTIONS: PROCESS AND STRATEGIES

Although, ideally, a comprehensive loss history would be conducted with each and every individual with whom a mental health counselor interacts, there are many factors that influence the mental health professional's ability to gather this type of detailed information. Some specific factors include the mourner's state of mind, the mental health counselor's counseling orientation, and the specific situation during which an assessment is required (see Rando, 1993). For instance, if the individual is seeking assistance during a time of crisis, the mental health counselor must focus specifically on information that is required to help the person achieve a state of safety and stability. In addition, if the individual has limited coverage for mental health care, the mental health counselor will be able to focus only on the issue(s) that are immediately relevant. In using limited resources wisely, the mental health counselor must also evaluate the appropriateness of gathering loss history information. Has the mental health counselor successfully established the rapport that is required to facilitate this process, that is, allowed the individual to feel comfortable discussing his or her loss history? If an appropriate relationship has been formed, is the individual a reliable historian? With informed consent, are there others who should be involved in the data collection and assessment process? If additional information about an individual's loss history is required to fully understand the current situation and the individual is ready for that process to take place, the following strategies and tools are available and useful in conducting assessments with older adults.

Identifying Loss and Trauma

Several basic tools can be utilized to document loss and traumatic events in an individual's life. First, the Loss History Checklist (Sofka, 1997a; also see appendix) lists various kinds of losses in four categories: death losses; non-death relationship losses; other non-death losses, including physical and psychosocial/nonfinite losses; and significant historic events (Duke University, 1999; MultiEducator, 2000; Nothiger, n.d.). Individuals indicate the presence or absence of a particular loss by checking off which losses they have experienced during their life. Many older adults have multiple losses that are clearly evident on the checklist, and these losses may be linked to historical events, through which the mental health counselor may not have lived (for historical events, see Duke University; MultiEducator; Nothiger). Second, the Loss History Graph (James & Cherry, 1989; James & Friedman, 1998), which is similar to the timelines that are utilized in history textbooks to document significant dates and events, is a visual method of documenting clients' loss history. The client anchors a line with dates and then indicates losses. Individuals are encouraged to be creative in how they document the impact and current status of the losses. They can depict past and current coping efforts by using lines of various lengths, various emotions by selecting colors to represent them, and the presence or absence of a particular reaction by using symbols. Individuals can also create additional timelines to represent their reactions to loss at different points in their life and/or different points in counseling, thereby providing a visual method of evaluating change over time. Third, when detailed information about a death-related loss needs to be gathered, Rando's (1993) Grief and Mourning Status Interview and Inventory (GAMSII) provides a comprehensive assessment of grief and mourning. This structured interview schedule focuses on demographic information, provides guidance for gathering a comprehensive psychosocial assessment (e.g., evaluation of history, mental status, and selected premorbid characteristics), and includes questions in 10 loss-related topic areas. For example, questions inquire about the circumstances of the loss, participation in rituals following the loss, ways of coping, and changes in one's assumptive world. Although the GAMSII is designed specifically for assessing grief related to the loss of a person, the language can be modified to evaluate reactions following a nonfinite loss, and irrelevant questions can be omitted.

These tools are also useful for exploring losses and trauma in the person's life. As the assessment process unfolds, it is essential to gather additional information about the time frame of the losses as well as the impact of these events on the individual. In addition, it is important to guide clients into broadening their definition of loss to include non-death events and information about dates, as specifically as is possible. Dates facilitate identification of times when grief reactions may recur.

Grief Reactions

At any point in time following a significant loss, a variety of circumstances can cause a subsequent, temporary upsurge of grief (STUG) reaction (Rando, 1993). First, grief can be triggered by a cyclic precipitant such as a significant date or the anniversary of an event. Survivors may experience grief-related reactions on the anniversary of a death, a birthday, or the date when a loved one was discovered to be missing, particularly if a body was never recovered. Additional examples of cyclic precipitants include National Crime Victims Week, an annual conference that includes a commemorative event, or a regularly scheduled memorial ceremony. Holidays are often very challenging for the bereaved because traditional celebrations or rituals are forever altered by the absence of a loved one. Second, a resurgence of grief can accompany a single event that involves an element of ritual such as the anticipated dedication of a memorial to victims of a tragedy or a ceremony signing a bill into law that is named in honor of a victim. These one time events, labeled by Rando as linear precipitants for a STUG reaction, can also be connected with significant developmental events that would have occurred had a person lived (e.g., a graduation) or with the bereaved's achieving a milestone with the deceased's absence being strongly noticed. A poignant example involves the children whose fathers died on September 11 and will not be present for any significant school activity, wedding, or other celebratory event. The third type of trigger, a stimulus-cued precipitant, is sometimes difficult to predict and may go unrecognized as the source of a reaction. These precipitants include sensory-based cues (i.e., sight, sound, smell, taste), physical cues (i.e., objects), and memory-based cues. These triggers can be quite simple and easily identified such as when watching video footage of the terrorist attacks reminds the viewer of a different, previous loss with similar traits or characteristics. Or the trigger can be more subtle and therefore more difficult to identify, as when the individual does not openly acknowledge being exposed to auditory, visual, or olfactory stimuli that are affiliated with a loss. For example, a person whose loved one died in a plane crash may not be consciously aware of a steady increase in air traffic over his or her workplace but may be reacting to increased exposure to the sound of airplanes.

To illustrate, consider the following older clients, reacting to the events of September 11. Even if individuals could describe their STUG reactions in detail, many had difficulty with pinpointing the trigger and its related specific loss. "I didn't know anyone that died on September 11th. Why is this bothering me so much? I'm feeling out of sorts ... in a funk ... discombobulated." On the other hand, some individuals knew exactly why they were feeling distressed, "This is bringing back things I haven't thought about or felt for 5 years, since my mother died." This kind of statement is a clear indication that a STUG reaction was occurring. These clients were dealing with a natural reaction to past losses and were also struggling with the revision of their assumptive worlds, usually without any conscious awareness that this potentially exhausting task was taking place. The following strategies and questions which were useful for pinpointing clients' STUG reactions and their triggers may be useful to mental health counselors in other contexts.

1. Evaluation of the client's exposure to media coverage or displays of information: How much has the person been watching television or reading online or printed materials related to events that could trigger memories of his or her own loss? Has the individual visited an exhibit or a display of materials related to the events of September 11,2001? What were the prominent themes or issues that were being presented or discussed?

2. Assessment of the client's participation in or exposure to rituals that commemorate loss: Has the person attended or watched any events (e.g., candlelight vigils, memorial services) that are designed to facilitate the process of grieving the victims of September 11, 2001, or to commemorate subsequent anniversaries of the terrorist attacks? Has the person visited websites that memorialize the deceased?

3. Assessment of the client's identification with the bereaved and/or the victims: Has the person been relating his or her experiences of psychological trauma, physical injury or pain, or grief to the experience of individuals directly involved in the events or the aftermath of September 11? People often found themselves thinking or saying, "I remember that all too well" or "If I lived near Ground Zero, I would have had to worry about that." With these triggers, described as points of identification (Doka, 2003), there were similarities between September 11 and the client's loss in terms of (a) the event (e.g., the loss was sudden, unanticipated; the death involved violent or horrific circumstances such as a plane crash; the loss involved terrorism or war), (b) complicating factors (e.g., unable to verify the death due to the absence of physical remains), or (c) personal characteristics (e.g., a victim of the same age, same relationship to the deceased, or the same challenges following the terrorist attacks).

Once a mental health counselor is aware of these types of reactions, it may be important to further assess the specific components of these reactions as well as their intensity. There may be multiple triggers influencing an individual's reactions. Consider individuals who are Holocaust survivors or veterans involved in any capacity in a war or conflict. Information about the terrorist attacks may have evoked strong memories of the fears that they experienced as well as the numerous losses, both physical and psychosocial, that they experienced. Images of death and destruction are familiar for these individuals. If a survivor visited Ground Zero prior to the completion of the clean-up efforts, the sights and smells could easily transport them back to another place and time in history. The following scales and standardized instruments are available to explore and document an individual's responses.

ASSESSING REACTIONS: SCALES AND STANDARDIZED INSTRUMENTS

Throughout the process of empirical study of reactions to loss, a variety of scales and standardized instruments have been developed to study the impact of trauma, grief, and other potential reactions to an event such as September 11, 2001. Although brief descriptions of various assessment tools are presented in this article, readers are encouraged to consult the original sources for in-depth information.

In recent years, the literature has recognized interrelationships between the experience of loss and the potential development of posttraumatic stress disorder (PTSD). To assist with the clinical and empirical assessment of trauma and PTSD, Norris and Riad (1997) published a review of 20 standardized self-report measures of trauma and PTSD that are appropriate for use among civilians. Of these scales, 5 facilitate the evaluation of trauma histories, and 15 measure symptom histories. The reviewers note that these scales provide a wide variety of choices, varying in length as well as adherence to DSM criteria for diagnosing PTSD.

For example, the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) was one of the first and most widely utilized tools developed to explore the impact of a traumatic event. The scale consists of 15 questions that could be used to evaluate levels of intrusion and avoidance symptoms as they presented within the prior week. A mental health counselor has the flexibility to personalize the scale by inserting the particular event to which the individual is reacting, which allows the scale to be used in a variety of situations. Following use of this scale as a screening tool for many years, revisions were made to facilitate the measurement of hyperarousal symptoms that are an integral part of the psychological response to trauma (Weiss & Marmar, 1996). These authors also recommended that response categories be modified to assess degree of distress rather than frequency of symptoms.

Rather than repeating the description of the remaining resources in detail, I want to repeat the importance of Norris and Riad's (1997) reminder that any potential assessment tool must be reviewed for appropriateness based on a respondent's culture as well as the type of trauma the respondent has experienced. Adaptations of a tool must be culturally accurate and appropriate, and respondents who do not speak English as a primary language may have difficulty with concepts that have no equivalent when translating the questions into their native language.

It has also my experience in clinical work with older adults that some individuals may not be capable of understanding questions that contain clinical jargon or words that exceed a 3rd grade to 5th grade reading level. Consider the mental health counselor working on an inpatient psychiatry unit who utilized information from a patient's psychosocial history to demystify an invalid MMPI profile. The psychiatrist's bewilderment was eliminated by providing two significant pieces of information: First, the respondent had a 3rd grade reading level and could not comprehend the questions; second, his wife, who had protected him from embarrassment about his illiteracy, was not present during visiting hours on the day he was asked to complete the profile. Rather than failing to comply with the psychiatrist's request, the client simply colored in the circles. Recalling this scenario always reminds me of the importance of basic information when dealing with complex issues.

In addition to assessment strategies that focus on the impact of trauma, numerous tools have been developed that conceptualize reactions to loss in terms of components of the grief process and/or mourning, though there may be some difficulty locating a useful, empirically sound clinical tool. In addition to this brief summary of commonly utilized tools, Neimeyer and Hogan (2001) review a variety of tools available to guide the development of an informed opinion.

The Grief Experience Inventory, developed by Sanders, Mauger, and Strong (1985) and created for use in clinical work and research, was one of the earliest tools and is one of the most widely utilized. The availability of a non-death version is a strength, and the inventory includes questions about a wide range of responses to loss. However, limitations include the length (135 questions), partly due to repetition of content so as to evaluate consistency and social desirability, as well as the use of a true-false response category. In addition to the reality that some respondents will add their own response category of "sometimes" (Schmittler, 1985), T-F response categories hamper the evaluation of change over time. Although this problem can be easily remedied through the use of a Likert-type response scale, documentation of the measurement properties of a modified version are not available. Should readers wish to obtain access to these tools, both the death and non-death loss versions are available from Argus (2002).

Hogan, Greenfield, and Schmidt (2001) developed an instrument that measures the multidimensional nature of grief. The Hogan Grief Reaction Checklist (HGRC), which was developed empirically and has been determined to be reliable and valid, contains 61 items measured on a 5-point response scale that tap six aspects of the grief process: (a) despair, separation stress; (b) panic behavior, physiological and somatic characteristics; (c) blame and anger, emotions of bitterness and hostility; (d) detachment, avoidance and withdrawal as well as change in identity; (e) disorganization, cognitive processes:, and (f) personal growth, existential/spiritual growth. These authors believe the continued use of assessment tools such as the HGRC will assist with differentiation between typical and atypical bereavement trajectories and with continued development of theory that accurately reflects the complex nature of grief.

Prigerson and Jacobs (2001) have encouraged mental health counselors to consider the possibility that some reactions to loss may not fall within normative response ranges. Therefore, specific criteria are needed to identify what they refer to as traumatic grief as a distinct psychological disorder. In order to evaluate an individual's symptomology, these authors created the Inventory of Traumatic Grief (ITG), a 34-item self-report tool that is easy to comprehend and simple to administer. The ITG provides a symptom severity score measuring separation distress and traumatic distress. Readers are encouraged to seek out additional information about this tool due to its prior use with older adults (Prigerson et al., 1995; Prigerson et al., 1996) and its sound psychometric properties (Gillies & Neimeyer, 2003).

In light of the large number of deaths that occurred on September 11, 2001, either fear of one's own potential death or the fear of the death of others would be a logical reaction. Should this be an issue of concern, there are numerous tools available to assess death anxiety, with detailed discussion and review of the tools and their applications available in Neimeyer (1994).

IDENTIFICATION OF NEED AND SUBSEQUENT INTERVENTION WITH OLDER ADULTS

A large body of knowledge has developed regarding factors influencing an individual's reaction to loss as well as potential strategies to assist individuals during times of grief and trauma. Corr (2003) has provided a task-based approach that facilitates a proactive approach to coping and empowerment of individuals throughout the helping process. This model is a good fit with the need to incorporate strengths and factors influencing resiliency into identifying and intervening with the older adults who needed support and services in the aftermath of September 11. According to Corr, four dimensions in the life of a human being must be considered in response to public tragedies: the physical, the psychological, the social, and the spiritual.

Physical Needs

In the hours and days after the towers fell, access to buildings in the vicinity of Ground Zero was extremely limited. The media released news of individuals who were unable to leave their residences as well as service providers who were unable to deliver necessary medical services and other resources upon which these individuals were dependent (Strock-Lynskey & Sofka, 2001). Older adults with mobility impairments or physical conditions requiring in-home care were at varying levels of risk until the problem of access could be resolved. Volkman (2001), an individual with physical disabilities who is a vocal advocate for the needs of those with disabilities, noted that many people were expressing concern about their own safety and pondering their own situation should a similar tragedy befall them. Mental health counselors should review their caseloads and identify individuals who may have experienced distress due to fears that their basic needs may not be met should a tragedy with similar consequences occur in their own neighborhood.

In addition to a system for quick identification of individuals in need of assistance, it is recommended that agencies be prepared to respond in an expedient and efficient manner. Prior to the advent of a tragedy or natural disaster, mental health service providers should familiarize themselves with the range of organizations available to assist in their community. Penner (2003) provides guidance in identifying appropriate organizations to involve in collaborative planning efforts for disaster response.

Within the past few years, increased emphasis has been placed on screening for trauma among individuals who are seeking care for medical concerns (Green, Epstein, Krupnick, & Rowland, 1997), particularly when somatization occurs. These authors noted the association between prior exposure to traumatic events and subsequent negative health behaviors and reminded mental health counselors to inquire about past traumatic exposure and recent stressors in persons experiencing somatic symptoms. If no medical explanation can be identified for an older adult's physical distress, additional assessment of potential psychological, social, and spiritual needs is warranted.

Psychological Needs

Completion of a traditional psychosocial assessment, including a strategy for identifying losses, will assist with the identification of potential psychological needs following a public tragedy. As previously noted, when no direct connection to the current event is evident, the availability of a loss history provides a mental health professional with useful information with which to evaluate the presence of a STUG reaction.

When the Alfred P. Murrah Federal Building in Oklahoma City was bombed on April 15, 1995, little was known about the psychological reactions to a highly publicized act of terrorism in the United States. As news of the terrorist attacks reached mental health counselors in September of 2001, helping professionals could seek out knowledge from those who had assisted as mental health service providers in Oklahoma City. In the meantime, several studies have appeared that provide some insight into the impact, long-term for Oklahoma City and short-term for September 11, on individuals who were directly involved in these terrorist attacks.

Pfefferbaum, Vinekar, & Trautman. (2002) studied the impact of loss and trauma on substance use behavior among a group of individuals who sought supportive services after the 1995 bombing. Increased substance use was reported by those individuals whose subjective appraisal of danger at the time of the trauma and self-reported grief were higher. Therefore, awareness that an individual has a documented history of prior mental health or substance use issues necessitates an assessment of the individual's current reactions and coping responses. In light of the challenges inherent in recognizing late-life depression and the reality that the impact of a trauma history on the mental health of older adults is often not adequately assessed (Karel, Ogland-Hand, & Gatz, 2002), the careful evaluation of psychological reactions among these individuals is essential. Awareness of the challenge of prescribing psychotropic medications for older adults also merits attention due to potential interaction with other prescription drugs (Sadavoy, 2003) and alcohol (Kane, Ouslander, & Abrass, 1999).

Although it is beyond the scope of this article to fully describe intervention strategies for assisting older adults with psychological needs in relation to the events and aftermath of September 11, 2001, some strategies to facilitate coping with loss are summarized and resources available for further guidance are referenced.

Normalizing and validating through support and education. Some grievers, due to the nature of their losses, have not been allowed to express their feelings about events that may not be socially acceptable to discuss. There may also be generational or cultural factors that have influenced the degree of disenfranchisement following a significant loss (Gajdos, 2002). Therefore, it is important to validate the loss and provide permission for expression of reactions that may not have been acknowledged for many years. Structured opportunities to express emotions related to personally traumatic experiences have been shown to be effective among older adults grieving the death of a spouse (Segal, Chatman, Bogaards, & Becker, 2001).

Some older adults may be experiencing a new type of disenfranchisement in the wake of September 11, 2001 (Scurfield, 2002) such as harassment, racism, or displaced retribution toward immigrants or individuals who share commonalities with those identified as terrorists (e.g., Muslims, those with Arabic-sounding names). Providing support and information about resources to assist with safety, should there be a need, is an important part of providing assistance in such a circumstance.

Mental health professionals are reminded of the importance of viewing grief as a family process (Shapiro, 1994; Winchester-Nadeau, 2001). Winchester-Nadeau noted that family perceptions of the loss of a family member influence how individuals and families grieve and may also have multigenerational effects. Viewing grief as a family process becomes particularly relevant for older adults who may be dependent upon their adult children or grandchildren for emotional support and practical assistance. Providing assistance to family members in the form of education about an older adult's reactions to loss events can be extremely beneficial, particularly if the older adult reports limited social support while having a seemingly available social support network. Intergenerational family therapy may be useful in identifying family patterns that facilitate or inhibit the process of coping with loss.

Acknowledging resilience and fostering empowerment and hope. Empirical research has helped mental health counselors to realize that, while some individuals experience a complicated mourning reaction following a tragic loss, many proceed through the process of coping with loss without the need for therapeutic intervention. Boss (1999) points out that "ambiguous loss can, in spite of high stress, produce some good. In the confusion and lack of rigidity lie opportunities for creativity and new ways of being that have some purpose and a chance for growth" (p. 134), including positive outcomes such as being less dependent on stability and more comfortable with spontaneity and change. Electronic media reports and the popular press constantly highlight the efforts of bereaved individuals to change policy (e.g., advocacy efforts by the Webdale family to pass Kendra's Law following the violent death of Kendra Webdale in New York City) or to inspire others who are coping with tragedy (e.g., Lisa Beamer, who wrote a book within a year of the death of her husband in the crash of United Flight 93 on September 11, 2001). According to the Trauma Foundation (n.d.), some individuals who experienced traumatic loss "channel the force of their grief and shock into preventive action--they become 'survivor advocates,' working to save others from having to experience a similar loss and trauma" (p. 1). Mental health counselors can encourage bereaved individuals to visit the Trauma Foundation's website for information and resources to assist those who wish to consider this coping strategy.

One of the principles presented by Bruce and Schultz (2001) for facilitating the grieving process involves directing efforts toward "creating resilience, specifically, in fostering skills that control anxiety, fear, and the perception of unremitting emotional pain" (p. 193). Mental health counselors must help older adults find ways to enhance their ability to balance coping with the distress while building a new assumptive world that allows for times of growth and joy. Tedeschi and Calhoun (1996) created a tool, the posttraumatic growth inventory (PTGI), that may be useful in this process. The PTGI contains 21 self-report items that assess the following factors: new possibilities, relating to others, personal strength, spiritual change, and appreciation of life. The authors noted a hope that this tool "can further our understanding of the natural processes people use as they struggle with the aftermath of trauma to derive meaning, feel wiser, and face uncertain futures with more confidence" (p. 469). Mental health counselors are encouraged to use this tool in partnership with scales that measure grief reactions and symptomology to provide a more balanced picture of the experience.

For some older adults, there may be factors that compound their ability to cope with a loss event. Should an individual experience significant distress, in-depth therapy to address complicated mourning may be required. As noted by Gajdos (2002), "When grief and trauma are not attended to with awareness and compassion in one generation, the deleterious effects of that trauma and grief cascade through the family tree, creating a domino effect of dysfunction" (p. 304). Mental health professionals are encouraged to refer to Rando (1993) and Worden (2001) for guidance.

Facilitating continuing bonds. In the past, debates have involved the following question: What is the best way to describe the end of the grief process? Individuals in the general public commonly suggest that "time heals all wounds," a griever should "just get over it," or "perhaps it's time to move on." Scholars over the years have proposed many terms including closure, adaptation, accommodation, reorganization, and resolution (Parkes, 2001; Rando, 1993). More recently, scholars have revisited the assumptions that were being made about the finite nature of the relationship with the deceased and described numerous ways in which individuals maintain an ongoing connection to and relationship with the deceased (Klass, Silverman, & Nickman, 1996). Due to wide acceptance of this view, older adults should be encouraged to nurture continuing bonds with deceased loved ones and to share information about these ways of maintaining a connection with family and friends and with their mental health counselors throughout the helping process.

As the ways of maintaining connections with the living undergo change in an age of technology (e.g., corresponding through e-mail rather than driving over for a visit on Sunday after church), it is important to recognize that older adults may rely on more traditional means of staying connected with the deceased. For example, spending time at an actual gravesite "visiting" with a loved one may be more meaningful than developing a website at a virtual cemetery. Developing a sensitivity to generational differences is crucial as the ages of those considered to be older adults spans a wider range. Among older adults, particularly those who are immigrants from other countries, attention to cultural and spiritual influences on the definition and traditional practices of continuing bonds is crucial (Klass & Walter, 2001).

Reconstructing meaning and revising the assumptive world. As noted in this issue by Servaty-Seib (2004), recent publications have broadened the conceptualization of coping with loss beyond the stages that are so commonly perceived as the correct response to loss. In addition to emotional and physical reactions to loss, strategies to assist those dealing with loss place an equally important emphasis on the cognitive processes involved in adjusting to loss and the subsequent changes in one's daily life. It is important to consider ways in which this process may differ for older adults.

According to Neimeyer's (2001) conceptualization of meaning making, older adults are faced with the challenge of redefining the self following a significant loss or life-changing circumstance, while also revising the nature of their interactions with the world around them. Following the loss of a relationship or a significant change in one's health or the surrounding world that impacts one's ability to interact with others, older adults who have always possessed a style of fierce independence have fewer adjustments to make than someone who tends to be more dependent upon others to meet their basic or socialization needs. Important generational differences in the degree to which older adults possess all of the knowledge and skills that are required to complete the tasks of daily living must be recognized and addressed because one's assumptive world changes drastically when an individual is no longer present to carry out his or her assigned responsibilities and roles.

When attempting to identify the relevant changes in interactions with one's world following an event such as September 11, 2001, perhaps the most difficult to contemplate are those which are abstract and intangible. For example, how does one regain a sense of safety and security in a world where these things so often taken for granted are tenuous at best? Mental health counselors are encouraged to assist older adults in identifying and acknowledging the challenges they are facing during this thought-provoking and highly emotional process. The role of serving as a source of support and guidance during an older adult's journey of redevelopment and reinvestment is a significant one.

Social Needs

Social needs can be viewed on several levels: those of the individual and those of the society as a whole. Empirical studies of individuals dealing with loss have frequently noted the role of social support as a factor in coping with loss, with positive relationships within a social support system often being identified as a protective factor (Karel et al., 2002). In the aftermath of September 11, 2001, it would be important to assess the availability of family, friends, or members of a formal social support system to provide older adults with physical and psychological support as well as a connection with a broader social network. For instance, according to a website that was only available for a brief time after the terrorist attacks, one family service agency initiated an intervention to aid those living alone. They used a check-in system implemented through a phone tree and in-home visits by professionals and paraprofessionals and volunteers. The site reported positive reactions from those living in institutions or older adults wanting as little as holding hands or talking.

Although the provision of individual support can be an important outreach strategy, the literature also notes the value of connecting individuals with others who can relate to their experiences as well as their reactions. Providing opportunities to experience mutual aid, referred to as the "all in the same boat phenomenon" by Shulman (1999), can be accomplished in various ways. Formal support groups can be formed in settings where older adults naturally gather such as senior centers, meal sites, places of worship, or other organizations or programs in which older adults are involved (e.g., fraternal organizations, volunteer programs). Informal gatherings provide numerous opportunities for mutual aid. There is no substitute for social events (e.g., potlucks, dances) or other activities such as quilting sessions, bingo night, or card clubs. Many meaningful conversations occur when individuals have contact with someone who can truly relate to their experience(s).

Access to the Internet and World Wide Web provides numerous sources of virtual support, but readers are encouraged to consider the pros and cons inherent in the resources available online (Sofka, 1997b). Although some older adults have gained the skills required to utilize this technology, ease of access to computers is impacted by economic resources and one's degree of physical mobility.

Upon consideration of the broader needs of society as a whole, mental health counselors should consider their potential role as advocates on behalf of the individuals whose needs are being handled inadequately and inappropriately, or simply cannot be met within the current network of service providers. Advocacy efforts may be necessary within a variety of systems of care, including medical, mental health, the legal and criminal justice system, or the social service system. Gaining skills to advocate in the political area is also a wise investment of a mental health counselor's time (see Haynes & Mickelson, 2003).

One additional component of our society, the media, merits additional discussion in this section on social needs. Dolan (2003) noted that "every possible media source bombards us with news and noise" (p. 85). In a prior section of this article, exposure to sights and sounds of a current tragedy has been noted as a trigger for STUG reactions among individuals with a significant loss in their past. For the purpose of comparison, it is not uncommon for the media to resurrect footage from previous tragedies. Members of the press may also seek out individuals whose lives were impacted by a similar tragedy in the past. Because of having the honor and privilege of speaking with individuals impacted by the Pan Am 103 bombing and the TWA 800 disaster, I was educated about the role of the media and about the difficult balance between wanting privacy during times of grief and recognizing that the media are also important allies. Media coverage plays a crucial role in advocating for policy changes (e.g., airport security). As a result of collaboration between human service professionals and members of the media to promote a more accurate and positive portrayal of social issues, the media in my community have a network of professionals who can be reached quickly during a time of tragedy or when it is important to describe local tie-ins to highly publicized events of national significance. Some agencies and organizations now have access to reporters who can educate the public about the availability of services and the challenges facing human service agencies in our community. Taking time to become acquainted with members of the media in one's community, when the need to do so is not urgent, can be time very well spent. In addition to providing support and assistance to individuals whose loss event becomes newsworthy, mental health counselors can be a great resource to the media and to the public by providing accurate information about reactions to tragedy as well as resources and strategies for coping with the aftermath (Dolan). Seeking out additional information to learn about the impact and role of the media during times of tragedy (e.g., Deppa, 1994) is strongly encouraged.

Spiritual Needs

Lord, Hook, and English (2003) noted that "when our ability to control life and death fails, we tend to look at the spiritual aspects of suffering and death in an effort to make sense of a senseless act" (p. 91). Depending upon the circumstances of the loss and the presence or absence of spiritual beliefs, a multitude of questions arise when comparing the reality of the situation with the philosophical and existential issues engrained in one's belief system. Lord et al. encourage spiritual sensitivity among mental health counselors who interact with individuals impacted by loss. These authors also provide faith-relevant (i.e., Hinduism, Judaism, Christianity, Islam) information regarding beliefs about the body and spirit, justice, the impact of involvement or lack of involvement of a spiritual leader in the process of death notification, and the role of ritual among bereaved individuals.

Thomson and Holland (2003) grappled with the question "How do we make meaning, make sense, out of what seems to be such a meaningless and senseless tragedy?" (p. 165). This question identifies a common struggle for many older adults who have experienced prior loss as a result of an event that seemed preventable or involved violence. The authors discuss meaning-making in relation to a faith development perspective, providing a review of a framework by Fowler (1981) that can be used to learn about the faith structure of an individual. One's faith structure, Thomson and Holland propose, is intimately connected to the process of meaning-making following a tragedy. For additional guidance in exploring spirituality and death, readers are encouraged to consult Doka (1993).

Moseley & Deliberato (2000) stated that "while the grief journey is not one that most people would choose to take, it most likely will change one's perspective on the people and events that are a part of daily life" (p. 3). They suggest that through examining inner thoughts and feelings, the person's grief journey can result in new growth, wisdom, and meaning. These authors have created a journal that can be used to explore one's spirituality following a loss event and to assist in creating rituals that can be used on special events that occur throughout the year (e.g., holidays, dates of significance in the life of the deceased). Because older adults have a lifetime of experience with tradition and ritual, as defined by their individual and family histories and practices, mental health counselors are encouraged to consider facilitating the use of ritual as a strategy for coping with loss (e.g., Mayo, 2001; Rando, 1985).

CLOSING THOUGHTS

On April 30, 2003, the Hospice Foundation of America (HFA) presented a teleconference entitled, Living with grief: Coping with public tragedy. This article has been strengthened greatly as a result of access to the companion book (Lattanzi-Licht & Doka, 2003). Materials created as a result of this teleconference (i.e., a video of the teleconference, the book) are available (see HFA, 2003) and are recommended as resources for continued exploration about ways to assist older adults in response to a public tragedy such as September 11, 2001. During a discussion following the teleconference at a site in Troy, New York, it was obvious that the mental health counselors, funeral directors, helping professionals from a variety of disciplines, and volunteers who had been directly involved in response and recovery efforts have a great deal of experience and insight to offer. However, many questions arose to which there were no answers. It is a reality that there are many additional questions that will be asked and explored for years to come. I hope that all professionals and volunteers involved in caring for older adults who were impacted by the events of September 11, 2001 find interdisciplinary opportunities for dialogue, discussion, and the sharing of knowledge that will be gained as a result of our unique and shared roles in their lives.

APPENDIX

Loss History Checklist Revised

A. Losses through death of:

   Biological mother          Biological father
   Adopted mother             Adopted father
   Adopted father             Foster mother(s)
   Brother(s)                 Sister(s)
   Husband/wife               Companion/lover
   Pet(s)                     Counselor/therapist
   Other(s)? Describe:

B. Relationship losses that did not involve death include:

   My own divorce             My own separation
   Divorce of parents         Separation of parents
   Loss of friendship(s)      Loss of co-worker(s)
   Loss of support            Loss of
   person(s)                  counselor/therapist
   Loss of contact with       Inability to have children
   child(ren)                 (infertility or other reason)
   Loss of contact with       Other? Describe:
   friend(s)

C. Other losses such as:

   Loss of home/residence     Loss of support services
   Being homeless             Loss of identity
   Loss of job                Loss of a career
   Loss of independence       Loss of potential
   Loss of control            Loss of time/years
   Loss of physical health    Loss of mental health
   Loss of vision             Loss of hearing
   Loss of sexuality          Loss of personhood
   Loss of trust              Loss of neighborhood
   Loss of safety             Loss of security
   Loss of                    Loss of country (refugee/
   childhood/innocence        resettlement)
   Loss of self-esteem        Bad accident or fire
   Loss of life as it was     Loss of hope
   Other? Describe:

D. Significant impact of historical events (impact on self or
significant others):

   War or conflict (specify):

   Holocaust                  September 11, 2001
   Other? Describe:

Loss History Checklist Revised

A. Losses through death of:

   Biological mother          Child(ren)
   Adopted mother             Grandchild(ren)
   Adopted father             Grandparent(s)
   Brother(s)                 Other relative(s)
   Husband/wife               Friend(s)
   Pet(s)                     Support person(s)
   Other(s)? Describe:

B. Relationship losses that did not involve death include:

   My own divorce             Loss of boyfriend/girlfriend
   Divorce of parents         Loss of neighbor(s)
   Loss of friendship(s)      Loss of doctor(s)
   Loss of support            Loss of contact with
   person(s)                  parent(s)
   Loss of contact with       Loss of contact with
   child(ren)                 brother(s)/sister(s)
   Loss of contact with
   friend(s)

C. Other losses such as:

   Loss of home/residence     Loss of possessions
   Being homeless             Abuse (all types)
   Loss of job                Loss of ability to work
   Loss of independence       Loss of freedom
   Loss of control            Loss of dreams
   Loss of physical health    Loss of goals
   Loss of vision             Loss of physical functioning
   Loss of sexuality          Loss of spirituality/faith
   Loss of trust              Frequent moves
   Loss of safety             Loss of comfort
   Loss of                    Loss of confidence
   childhood/innocence
   Loss of self-esteem        Loss of respect
   Loss of life as it was     Loss of privacy
   Other? Describe:

D. Significant impact of historical events (impact on self or
significant others):

   War or conflict (specify):

   Holocaust                  Act(s) of terrorism
   Other? Describe:

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Carla J. Sofka, Ph.D., MSW, is an assistant professor, Social Work Department, Siena College, Loudonville, NY. E-mail: [e-mail]..