Helping the survivors, whom he met in the Pierre and Plaza hotels, was an incredible experience, he said at the annual meeting of the American Academy of Psychoanalysis in May in Philadelphia. The hotels’ plushness provided an ironic contrast to the survivors’ emotional pain.

One woman in a ballroom screamed at O’Brien, "I am not crazy. I don’t want to see you!" One surviving husband confessed to him, "I will never know the smell of my wife again." O’Brien knew exactly how the husband felt since his own wife had died several years earlier. At one point, O’Brien admitted, "It was so bad for me that I hid in the bathroom for 25 minutes. My son was also incredibly supportive of me at this time. I came to realize that he was doing psychotherapy with me."

But there are ways to lessen the pain of losing a loved one, and there are ways to promote a normal grieving process. And that is what O’Brien wanted to impart to the survivors of 9/11 and share with his analyst colleagues at the session, which was titled "Innovations in the Grieving Process."

When a parent dies, the other parent needs to know what children’s normal reactions to death are. With young children, some regressive behavior—say thumb sucking—is normal for a while. Children through the age of 7 generally do not view death as final, and this concept is reinforced by television programs they watch. Children aged 7 to 10 tend to view death more as a monster than as something to be denied. Children 10 and older may handle death by eating more or by not paying attention in school.

The surviving parent needs to remain physically close to the children at this time, because children feel so insecure. Youngsters may also need to be accompanied to school. Having physical contact with objects that belonged to the dead parent can comfort children. O’Brien told one mother that it was all right for her daughter to sleep next to her in bed for a while, just as the father had once done.

The surviving parent also needs to impress upon the children how much they were loved by the dead parent, and as O’Brien stressed, "reassure, reassure, reassure them." Children also need to understand that a sight, sound, or smell that reminds them of the dead parent may rekindle their sense of loss and that such rekindling may occur indefinitely.

It also helps children who have lost a parent to get back to a normal routine as soon as possible. "I hate cell phones," O’Brien said, "but they are wonderful at this time."

A funeral may assist the grieving process more than a memorial service in cases where people are religious or where the death of a loved one is not 100 percent certain. Take the case of a woman of Irish descent whose husband had presumably been killed in the terrorist attacks but whose body had not been found. She asked O’Brien whether she should hold a memorial service or a wake for him. O’Brien advised her that a wake might be better, not just because of her religious beliefs but also because it would help her and her daughter mourn with friends and accept the death of their husband and father.

In contrast, some people may use memorial services as a way to avoid facing up to the death of a loved one, Grace Bellotti, M.D., a New York University psychiatrist and psychoanalyst who helped families deal with 9/11 reported at the AAP session. She cited the case of "Stella" and "Jeff," an older couple whose daughter "Gloria," a bond trader, had disappeared in the 9/11 disaster. Stella and Jeff decided to hold a memorial service instead of a funeral for Gloria because they refused to accept that she had died.

Stella and Jeff, Bellotti indicated, also illustrate how refusing to let other people into your life at the time of the death of a loved one can impede rather than promote the grieving process. On the day after the terrorist attacks, Stella and Jeff refused to receive visitors and were angry at reporters who wanted to talk with them. They stood in stark contrast to "Helen," whose firefighter husband had also disappeared and who, on the day after the attacks, held an open house for sympathetic visitors.

There are normal grief, pathological grief, and ambiguous grief, Bellotti continued. Normal grief lasts one to two years. In pathological grief, healing does not occur, and the bereaved cannot move ahead with his or her life. Ambiguous grief is where one is not sure whether a person is dead or not. "The swings between hope and grief are tumultuous," she said. It has been reported that the survivors of missing victims are at high risk for anxiety, depression, and psychosomatic symptoms, and the longer the possibility that a loved one is still alive, the greater the risk for psychopathology. But tolerance for such uncertainty varies, she said.

Today, Bellotti indicated, Stella and Jeff are experiencing a mixture of pathological and ambiguous grief. They are still angry, they still refuse to accept that their daughter is dead, and "emotionally they are spent and seem to have aged rapidly."

Grief, Bellotti concluded, cannot be resolved unless there is an acceptance of death and unless one finds "a new ray of optimism in life." Yet such acceptance and optimism are indeed possible, O’Brien indicated. In the two weeks after September 11, he said, he "learned about courage and bravery in some wonderful people." ▪