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2002-01-20

Sunday, January 20, 2002 11:41 PM
Shortcomings in the September 11 Fund's Proposed Allocation for
Non-Economic Damages

January 18, 2002

Mr. Kenneth Zwick, Director
Office of Management Programs
Civil Division
U.S. Department of Justice
Main Building, Room 3140
950 Pennsylvania Avenue
Washington, DC 20530

Dear Mr. Zwick:

As psychologists whose main expertise concerns how family members are affected by the sudden, traumatic death of a loved one, we are writing to ask you to reconsider the DOJ's proposed awards for non-economic damages for those who lost loved ones in the September 11 catastrophe. As you know, Congress has mandated that survivors be compensated for a broad range of non-economic damages including physical and emotional pain, suffering, inconvenience, physical impairment, mental anguish, loss of enjoyment of life, loss of society and companionship, loss of consortium, hedonic
damages, and all other nonpecuniary losses of any kind or nature (Sec. 402,7)

The question regarding how to translate such losses into dollars and cents is of course not a simple one. According to the Interim Rule, the figures arrived at ($250,000 plus an additional $50,000 for a spouse and each dependent) were selected because they are "roughly equivalent to the amounts received under existing federal programs by public safety officers who are killed in the line of duty or members of our military who are killed in the line of duty while serving our nation." However, these programs were not intended to compensate victims' family for the range of non-economic losses identified by Congress in the statute establishing the Fund.

In our judgment, the award for non-economic losses should be based in
large part on the same kind of data that would be used if these cases were to be tried in a court of law. In such cases, it is typical to call on the expertise of psychologists who can inform the judge and jury about the psychological sequelae of losing a loved one in a sudden, traumatic incident. Each of us has been involved in research and publication
regarding the long-term impact of experiencing such a loss for the past three decades (see attached biographical sketches). Moreover, each of us has been called upon as an expert witness in many wrongful death cases in order to help the judge and jury understand how people are typically affected by such losses.

We feel strongly that the proposed awards for pain and suffering are woefully inadequate because they fail to consider the profound psychological ramifications of experiencing the traumatic loss of a loved one. Although each case is unique, there is a large body of scientific evidence indicating that in most cases, the impact on surviving family members is absolutely devastating. As we describe below, the allocated funds do not begin to compensate survivors for the wide range of difficulties they are likely to encounter, or the mental health and other support services that will be necessary to help alleviate these difficulties. We also believe that failure to acknowledge the current and future non-economic losses by providing a more just and fair award will cause additional psychological harm beyond that caused by the loss itself.

There is clear scientific evidence indicating that the loss of a family member typically produces painful and disturbing symptoms of grief, including anxiety, yearning, depression, hopelessness, despair, crying, fatigue, loneliness, and loss of interest in life (see Rando, 1993, for a review). Loss of a family member has also been liked to a host of long-term difficulties in both adults and children, such as subsequent vulnerability to psychiatric illness, physical health problems, and problems in relationships (Nader, 1997). It is also well-established in the psychological literature that sudden, traumatic losses pose more severe problems in both short-term and long-term adjustment among survivors than deaths that occur as part of the normal life span (e.g., the death of an elderly spouse see Wortman, Battle, & Lemkau, 1997).

The purpose of this letter is to summarize the scientific evidence regarding the short- and long-term impact of experiencing the sudden, traumatic loss of a parent or spouse. We have focused on these particular losses because they are compensable under the current ruling. However, it should be noted that the loss of a child or sibling is also associated with considerable pain and suffering and greatly impaired quality of life. We begin by describing the initial psychological impact of a sudden, traumatic loss. This is important, because it is the inability to accept and understand such losses that sets the stage for the development of life-long problems. We clarify how the symptoms accompanying such losses differ from those experienced following a normal, on time loss. People who are faced with the sudden, traumatic loss of a loved one endure both grief symptoms and traumatic stress symptoms, placing them at double jeopardy for the development of long-term difficulties. We also explain how the traumatic aspects of the loss interfere with the normal resolution of grief. We then discuss the characteristics of losses that make them more traumatic for survivors and that enhance the risk for subsequent problems.

Following this summary of information on the impact of losing a loved one in a sudden, traumatic incident like the September 11 catastrophe, we provide a review of our own and others studies on the long-term impact of the loss of a parent on surviving children. We cover young children, as well as adolescent and young adults who lose a parent. We describe why the surviving parents response to the traumatic death of his/her partner typically causes difficulties in parenting, which can contribute to long-term problems. In discussing the long-term impact of parental loss, we show how such a loss results in significant problems across many domains of life, including the development of depression, anxiety, low self-confidence and predisposition to suicide; physical health problems; difficulties with school performance; increased aggressiveness and anger; delinquency and substance abuse; insecurities about sexual identity; and problems sustaining intimacy in relationships. We then provide a review of our own and others studies on the long-term sequelae of losing a spouse. We demonstrate how the sudden, traumatic death of a spouse results in a myriad of problems, including the development of post-traumatic stress disorder, depression, anxiety disorders, elevated mortality, a greater frequency of physical health problems, difficulties in handling such roles as parenting, enduring feelings of loneliness, and greatly impaired quality of life.

Initial Reactions to a Sudden, Traumatic Loss

Sudden, traumatic losses typically present survivors with an assault to their system that is simply too overwhelming to be dealt with or assimilated. In one horrific moment, their world has been permanently altered. Lives are turned upside down as survivors attempt to cope with the tragedy and its aftermath. Powerful feelings of confusion, anger, and anxiety are usually unleashed, along with symptoms more typical of grief, such as depression, somatic problems and fatigue. As Rando (1993) has expressed it, They suffer extreme feelings of bewilderment, anxiety, self-reproach, depression and despair (p.149). Against the backdrop of these profound changes, survivors are also confronted with everyday life problems that are often brought on as a direct result of the trauma. For example, a surviving parent may be faced with problems concerning the children that have emerged as a result of the tragedy, such as a young childs insecurities about being out of the parents sight, or an older childs rage concerning his fathers death.

Because sudden, traumatic loss represents such a devastating assault on the mourners coping resources, they frequently result in the development of post-traumatic stress disorder, or PTSD, symptomology. PTSD has been defined as the most common and severe type of post-trauma mental health problem that can occur (Freedy & Donkervoet, 1995, p. 9). The three hallmark classes of post-traumatic stress symptoms are re-experiencing symptoms (e.g., flashbacks or intrusive thoughts); avoidance or numbing symptoms (e.g., avoiding reminders of the trauma); and arousal symptoms (e.g., difficulty falling or staying asleep; irritability; difficulties with concentration). These symptoms can undermine survivors coping capacity at a time when the demands are monumental.

Research evidence suggests that exposure to trauma brings about permanent neurobiological changes that cause persistent hyperarousal, resulting in many of the PTSD symptoms that are experienced (Everly & Lating, 1995; Nutt, 2000). Unfortunately, PTSD symptoms can become chronic and debilitating, often resulting in lasting changes in personality such as increased hostility, suspiciousness, feelings of emptiness or hopelessness, impulsiveness, and constant feelings of impending doom. Long-term problems with sleep and concentration can often result in feelings of incompetence and decreased self-esteem. Individuals' efforts to cope with this pattern of symptoms often create additional difficulties. Because the affect associated with the trauma is so painful, survivors often withdraw from others at the first sign of tension or conflict, limiting their capacity to become involved in encounters that could be healing (Wortman et al., 1997). Chronic irritability, combined with a tendency to withdraw from others, can lead to interpersonal conflict with coworkers, family members, and friends. Survivors may also turn to an increased use of alcohol or other depressants in an attempt to self-medicate or dampen the painful overarousal they are experiencing. However, particularly among male survivors, alcohol use often becomes chronic and excessive (Nutt, 2000).

It is generally well established that the presence of trauma symptoms, such as hyperarousal and intrusive distressing thoughts, interferes with the process of working through and successfully resolving the loss (Rando, 2000; Nader, 1997). An important part of successful grieving involves recollecting the loved one and contemplating enjoyable things that were done together. Gradually, the person is able to put his or her life with the deceased into perspective, and begin to enjoy other things. When a person has suffered a traumatic loss, attempts to recollect the loved one are often associated with distressing memories or images, such as what happened during the loved ones death. These thoughts and images are so disturbing that individuals tend to avoid thinking about their loved one, making it far more difficult to process the loss.

People continue to experience painful upsurges of grief for many years following a traumatic death. The periods of intense distress are often triggered by reminders of the deceased or his or her death (Rando, 1993). Occasions such as birthdays, anniversaries, weddings, or retirement parties may evoke a strong desire for the loved one's presence. Taken together, these results are consistent with Herman's (1992) conclusion that "the impact of a traumatic event continues to reverberate throughout the survivor's life cycle" (p. 211)

Another reason why traumatic deaths pose such great difficulties is because survivors not only have to contend with the death of their loved one, but with the shattering of their most basic assumptions about the world. These include assumptions that the world is predictable and controllable, that the world is meaningful and operates according to principles of fairness and justice, that one is safe and secure, that the world is benevolent, and that, generally speaking, other people can be
trusted (Janoff-Bulman, 1992). The shattering of these core assumptions can have a profound impact on subsequent behavior. As Davis, Wortman, Lehman, and Silver (2000) have noted, the traumatic loss of a loved one causes many people to question the value of working toward long-term goals because they know that everything important to them can be taken away in an instant.

For a child, the death of a parent has a devastating impact on the assumptions that were previously held. Particularly if they have been part of a loving family, children, like adults, see the world as a safe and orderly place. When a parent dies suddenly and traumatically, the world and everything in it seems more precarious. As Harris (1996) has explained, "Regrettably, it only takes one shattering event of sufficient magnitude to change one's core beliefs about life…when terrible things can happen without warning, a child is left feeling vulnerable and insecure."

Characteristics of Sudden, Traumatic Loss That Enhance
Subsequent Risk of Pain and Suffering

There is clear evidence to indicate that the circumstances under which a death occurs can greatly elevate risk for the development of subsequent problems. The following characteristics of the loss have been identified through our own research and that of others as highly significant risk factors (see Rando, 1993, 2000; Wortman, et al., 1997, or Davis, Wortman, Lehman, & Silver, 2000, for reviews): (1) deaths that occur suddenly and without warning; (2) deaths that are untimely; (3) deaths involving violence, mutilation, and /or destruction; (4) situations involving multiple deaths; (5) deaths perceived as random; (6) deaths that are accompanied by concomitant stressors in addition to the loss; and (7) deaths brought about deliberately-- that is, by a person with the specific intent of causing the death.

The scientific literature provides compelling evidence for the importance of each of these factors in determining how people are affected by the loss of a family member. Several studies have shown that sudden, unexpected losses are particularly debilitating (Parkes & Weiss, 1983; Zisook & Schuchter, 1993). Feelings of incomprehensibility and bewilderment are paramount. The mourner views the world as a frightening place where someone else he or she loves may die at any time. There is also no chance to say goodbye and finish unfinished business with the deceased, and this can complicate the mourning process. The majority of research studies that have studied timeliness of the death have found that untimely losses pose more difficulties in coping (see Archer, 1999, for a review). Untimely losses are believed to result in a more difficult mourning process because they are regarded as more unnatural and more unjust (Wortman et al., 1997).

Of the risk factors described above, there is particularly compelling evidence that violent deaths result in intense and prolonged PTSD grief symptomology (see, e.g., Zisook, Chentsova-Dutton & Schuchter, 1998; Kaltman & Bonanno, in press). The Kaltman and Bonanno study showed that in contrast to those whose spouses died of natural causes, those who experienced the violent death of their spouse manifested a significantly higher number of PTSD symptoms during the full 2-year duration of the study. Those who lost a loved one through natural means showed a decline in depressive symptoms, while those who lost a loved one through a violent death showed no drop whatsoever in depressive symptoms over the 2-year course of the study. There are also many studies demonstrating that, among violent deaths, those most likely to result in long-term difficulties are those that are intentionally inflicted (see, e.g., Parson, 1995). Individuals who lose their loved ones through murder suffer more PTSD symptomology and depression than those who lose their loved ones through other violent means, such as suicide (Murphy et al., 1999). Moreover, among those whose loved ones were intentionally killed, there is little evidence that these symptoms abate over time. In one study of 150 family members who lost a loved one as a result of homicide, respondents whose loved one died five years previously evidenced virtually the same levels of symptomology (anxiety, depression, PTSD) as those who lost a loved one 1.5 years previously (Thompson, Norris, & Ruback, 1998). The intentional killing of one's loved one also results in more negative views of the world among survivors than losing a loved one in an accident (Wickie & Marwit, 2000-2001). Those whose loved ones are intentionally killed are also known to experience more intense feelings of betrayal, alienation, and rage (Riches, & Dawson, 1998).

Available evidence indicates that the risk factors listed above are cumulative: the more of them that occur together, the greater likelihood of severe, long-lasting symptomology. A person who experiences the loss of a loved one due to suicide or an automobile accident may experience some of these risk factors. However, those who lost loved ones in the September 11 catastrophe are very likely to experience all of them. The catastrophe occurred without warning. The vast majority of those who died were young people in their 20', 30's, and 40's. All were exposed to the loss of their loved one through one of the most violent and horrific means possible. The vast majority of survivors were unable to learn how their loved one died. Consequently, considering the nature of the attack, it is likely that most respondents were flooded with traumatic images regarding their loved ones final moments and ultimate demise. Another factor contributing to survivors traumatic thoughts is that most witnessed the destruction of the towers repeatedly as these images were broadcast on the media dozens of times. The process of who died and who survived most likely seemed random and haphazard to many (e.g., some people were saved because they arrived for work late). All survivors were exposed to a catastrophe involving multiple deaths-- the largest number of American citizens to be killed in a single action since the Civil War. Moreover, because many firms lost large numbers of employees, survivors have often had to contend with the loss of important members of their social network in addition to the death of their spouse. For virtually all surviving adults, the loss has been associated with such concomitant stressors as inability to recover the body and the necessity of dealing with myriad financial issues such as filing for insurance and completing paperwork to obtain charitable assistance. Finally, all have been faced with clear evidence that the attacks that killed their loved ones were deliberate.

The Impact of the Sudden, Traumatic Death of a Parent on Surviving Children

In this section, we review the literature regarding how surviving children are impacted by the sudden, traumatic death of a parent. Here we focus exclusively on empirical studies, and do not include case study reports focusing on a few respondents. Over the past three decades, well over a hundred studies have examined the impact of losing a parent. While the results of these studies are not completely consistent, the findings of the most scientifically rigorous studies, considered together, provide compelling evidence that the impact of parental loss on subsequent child functioning is profound. We begin this review by listing six major reasons why the traumatic loss of a parent is likely to result in major problems in many areas of the child's life. We then provide a list of intermediate problems that are likely to occur. These problems, such as difficulties with peers, or poor school performance, are likely to emerge within the first 10 years or so following the loss. Finally, we provide a list of long-term effects. These problems, such as the development of major depression or health problems, problems with intimacy, or problems with parenting one's own children, typically emerge during adulthood.

Major reasons why subsequent psychological, physical, social and behavioral problems typically emerge among children following the sudden, traumatic death of a parent

As noted previously, the sudden, traumatic death of a parent shatters the child's basic assumptions that the world is a safe and secure place, and that adults are trustworthy. These shattered assumptions often result in behaviors that develop into problems. For example, failure to trust adults may result in subsequent problems with adult authority figures.

Because of their own emotional upheaval, surviving parents may not be able to provide sufficient comfort and support to their children. Indeed, children need their parents to be strong and competent, but this is often not possible following the sudden, traumatic death of a spouse. If the child feels that he or she cannot rely on the surviving parent, fear and uncertainty become paramount. Because the surviving parent is often extremely distraught and less emotionally available for many months following the tragedy, children may feel as though they have lost both of their parents (Wortman, et al., 1997).

Given their own intense anguish, parents who have lost a spouse in a sudden, traumatic incident are often unable to provide consistent discipline to the children. This can result in a variety of behavioral problems such as a decline in school performance, or "acting out" at home or at school.

When the parent shows extreme distress, as is typical following the sudden, traumatic loss of a spouse, children are often placed in the role of caring for the bereft parent. This is particularly the case for children who are adolescents or young adults. They may feel burdened by feelings of responsibility for their surviving parent's happiness. They may also feel that they cannot share their own distress with their parent, for fear of adding to the surviving parent's distress. This can contribute to feelings of isolation and estrangement from the surviving parent. Young adolescent males may feel pressured to take over the role of father in dealing with chores around the house as well as helping to parent younger siblings. They typically feel inadequate in trying to assume this role, feeling that whatever they do, they cannot fill the shoes of their father (Harris, 1996). This can contribute to subsequent feelings of low self-esteem.

As noted previously, bereaved parents now recognize that they can lose a loved one in an instant. This typically leads to considerable anxiety about the safety and security of other family members (Lehman, Wortman, & Williams, 1987). As a result, the surviving parent typically becomes overprotective, severely limiting the activities of surviving children and challenging them on where they are going, when they are coming home, etc. Such behavior, while understandable, often precipitates considerable conflict between parents and their surviving children. It can also hamper the development of adolescents, who at this stage in their lives, need to learn to separate from their surviving parent as they prepare to begin life as an adult.

Many investigators have emphasized that while the loss of a parent of either gender presents enormous coping challenges for surviving children, the loss of a father can be devastating particularly to young boys, who lose an important role model. As Archer (1999) has indicated, this sets in motion all sorts of other changes that can alter a person's life course. This is particularly the case for adolescent males or for females who had a particularly close relationship with their father. At this time, adolescents are required to make decisions about dating, employment and education, among other things, that will affect their lives for years to come. It is often extremely difficult to make good life decisions at this time without guidance and support from the father, especially since the sequelae of traumatic loss (sleep disturbance, concentration problems) often impair good decision-making.


Intermediate effects of early parental loss

Next, we discuss six classes of problems that frequently occur among children who experience the sudden, traumatic loss of a parent and summarize the evidence for each.


Interpersonal problems, problems with one's peer group, and problems with social withdrawal
Children surviving the traumatic death of a parent are at greatly enhanced risk of interpersonal problems. As Nader (1997) has indicated, such children often lose friends because they develop pessimistic attitudes, or become more irritable following the trauma. Perhaps for this reason, they often have more difficulty than nonbereaved children do in sustaining intimacy (Jacobson & Ryder, 1969). It is also common for children, particularly adolescents, to become alienated from their peers. A young man who has lost his father may lose patience with a friend who is engaging in normal, adolescent "parent-bashing" -- for example, emphasizing that his parents are too strict or are otherwise annoying. Silverman and Worden (1993) have reported that following the death of a parent, school-aged children became more socially withdrawn, most likely because of the reasons listed above.

Mental health problems, including the development of depression, anxiety,
low self-confidence, and predisposition to suicide

Numerous studies provide evidence that children who experience sudden, traumatic loss are at elevated risk for these problems. Worden and Silverman (1996) reported significantly elevated depression and anxiety among the school-age respondents they studied. Similar findings regarding depression have been obtained by Balk (1991), Gersten, Beals, & Kallgren (1991) and Harris (1991). In the latter study, approximately 50% of the bereaved sample evidenced depression and other behavioral problems, a far higher percentage than normal. A similarly high rate of depression, about 50%, was found by Black (1984), who reports that this is an extraordinarily high depression rate for children. Weller, Weller, Fristad and Bowes (1991) found that bereaved children developed major depression immediately following their parents death. Cheifetz, Stavrakakis and Lester (1989) report that children older than 12 are most likely to exhibit depressive symptomology, while younger children are more likely to display anxiety and negativism. Holman (1998) has reported that low self-esteem is typical among children who have lost a parent. He believes that the absence of a role model often results in feelings of personal insecurity that have a negative impact on the self-concept. Finally, several studies have linked early parental loss to subsequent suicide attempts (see, e.g., Goldney, 1981; Lehman et al., 1987).

Physical health problems

A number of studies have provided evidence that loss of a parent is associated with enhanced risk of the development of somatic complaints, such as headaches or abdominal pain, difficulties in sleeping and eating, and an elevated risk for the development of illnesses (see, e.g., Balk, 1991; Krupnick, 1984). As Raphael (1983) has emphasized, being faced with reminders of the tragedy often brings on waves of somatic distress. Given the scope of this tragedy, survivors are likely to be confronted with frequent reminders of the event for the rest of their lives.

School performance

Several studies have reported a decline in interest in schoolwork, as well as a significantly decline in school performance (see, e.g., Harris, 1991; Nader, 1997; van Eerdewegh, Bieri, Parrilla, & Clayton, 1982; van Eerdewegh, Clayton, & van Eerdewegh, 1985). This may stem in part from the sleep disturbance, which often accompanies traumatic loss, leading to fatigue and difficulties focusing on one's studies. Such difficulties may also stem from concentration problems, which are extremely prevalent following a sudden, traumatic loss. There is also evidence to indicate that children who have lost a parent are more likely to drop out of school (see Holman, 1998, for a review).

Increased aggressiveness, anger, problems with impulse control, delinquency, and substance abuse

Numerous studies have demonstrated that children who experience the sudden, traumatic death of a parent are at greatly enhanced risk for problems of this sort. For example, van Eerdewegh et al. (1982; 1985) have reported that youngsters who lost a parent were more likely to become more aggressive and to fight with siblings (see also Elizur & Kaffman, 1982). Such children are also at enhanced risk for problems with anger and impulse control, particularly if they are male and over the age of 8 when the incident occurs (see Krupnick, 1984, for a review). Thompson, Kaslow, Price, Williams, and Kingree (1998) have found that such problems are particularly likely in those cases where the parental death came about as a result of the wrongful act of another. In a critical review of this literature, Berlinsky and Biller (1982) also identify several studies demonstrating significantly greater delinquency and criminal activity among individuals who have experienced the loss of a parent (see also Nader, 1997). Evidence of high alcohol intake has also been reported by many investigators (see, e.g., Harris, 1991).

Insecurities about masculinity, and problems relating to members of the opposite sex

It is clear from the psychological literature that boys who have lost their fathers are at greatly enhanced vulnerability to develop insecurities about their masculinity. These insecurities can contribute to their problems in relating effectively with women, and often lead them to engage in other behaviors that are reckless and life-threatening (Holman, 1998; Beaty, 1995). In a review of this literature, Holman has argued that as a result of growing up without a role model, boys become insecure about their masculine sex-role identity. This leads to some of the symptoms discussed in the previous sections, such as greater interpersonal aggressiveness, and increased risk of delinquency. Unfortunately, it also often leads to a relatively exploitative attitude toward females, where sexual conquest can become a means of validating masculinity. Moreover, these attempts to "prove" their masculinity can lead boys to engage in a variety of reckless behaviors. As Holman (1998) has expressed it, "The bravado of this protest behavior can quickly lead boys into activities that can be dangerous, and sometimes fatal, for themselves and for others." (p. 103). It is important to note that daughters also seem to be adversely affected by the absence of a father. Unlike young men, who attempt to display signs of masculinity, young women turn to others for the love and comfort that is now missing in their lives. Consequently, the death of a father has been shown to result in more teen marriages and more pregnancies among young women who lose a father (Bereczkei & Csanaky, 1996).

Long-term effects of early parental loss

The previous section demonstrates that children experience profound difficulties in many major areas of their lives in the first 10 or so years following the death of a parent. Perhaps the most important question, however, is whether these profound changes follow them into adulthood. Below, we review evidence regarding the impact of the loss of a parent on several distinct categories of adult functioning.

Relationship problems

There is clear evidence in the literature that those who have encountered the early loss of a parent experience significant relationship problems as adults. One such problem is fear of commitment (Erickson, 1998). There is evidence to suggest that such individuals are reluctant to form close relationships with their spouse because of the fear that their spouse could die, subjecting them to a second traumatic loss (Wortman et al., 1997). Research has also shown that the early loss of a parent leads to impairment in the capacity for intimacy (see Krupnick, 1984, for a review). Perhaps because of difficulties in establishing intimacy, as well as problems in managing or modulating one's emotions, it has been found that generally speaking, individuals who lost a parent in childhood have less satisfying marriages, as a rule, than adults who have not (see Berlinsky & Biller, 1982, for a review). Moreover, those who have experienced the sudden, traumatic loss of a parent as a child are extremely vulnerable to the breakup of a marital relationship or the end of that relationship through death (Prigerson, Shear, Bierhals, Pikonis, Wolfson, Hall, Zonarich, & Reynolds, 1997; Fraley & Shaver, 1999). The breakup or spousal death is not only associated with distress in its own right, but it can activate unresolved feelings about the deceased parents death. Finally, there is a clear indication in the literature that people who experience early parental loss have more difficulties in parenting their own children than people who have not suffered such a loss (Altschul & Beiser, 1984; Terr, 1991). According to these investigators, those who have lost a parent at an early age often fear that they will die early as well. Consequently, they avoid emotional intimacy with their children so as to spare the children grief and suffering if they should die. As Erickson (1996) has emphasized, this means that a transgenerational pattern can develop from parental loss, with future generations of children being affected.

Depression and suicide attempts

Many studies have examined the relationship between early death of a parent and subsequent development of depression during adulthood. While these studies are not entirely consistent, the vast majority of methodologically rigorous studies provide strong support for the hypothesis that early childhood loss is a potent risk factor for subsequent depression (see Krupnick, 1984, for a review). In one particularly impressive study, Barnes and Prosen (1985) studied a representative sample of respondents who had come to their physicians waiting room. He found that the childhood death of a father was significantly associated with adult depression, even though the death had occurred, on average, over 30 years previously (see Roberts & Gotlib, 1997, for similar findings). There are also a number of studies that have shown a link between death of a parent and suicide attempts (see, e.g., Farberow & Simon, 1969; Levi, Fales, Stein, & Sharp, 1966; Birtchnell, 1970). For example, Birtchnell (1970) found that twice as many depressed suicide attempters were parentally bereaved, compared to nonsuicidal depressed individuals (66.7% vs. 33.3%).

Health problems

While few studies have examined the long-term health consequences of losing a parent during childhood, those studies that are available support a relationship between early parental loss and subsequent development of illness. For example, Luecken (1998) found that blood pressure was elevated and cortisol functioning was compromised when college students who lost a parent were shown a stressful videoclip. Bendiksen and Fulton (1975) conducted a prospective study of a large cohort of parentally bereaved ninth graders, who were observed again in their thirties. Those who had lost a parent were significantly more likely to have experienced a serious medical illness than controls.
Similar findings have been reported in other studies (see Nader, 1997, for a review).

Problems with delinquency and substance abuse

There is indeed evidence to suggest that adults who have lost a parent during
childhood are more likely to become involved in criminal activity, or get into trouble with the law. In a prospective study by Bendiksen and Fulton (1976), men who had been bereaved in childhood had more criminal offenses in their twenties than did controls. Similar findings have been obtained in several other studies (see Berlinsky & Biller, 1982 for a review). There are also several studies that demonstrate a heightened frequency of early parental death among alcoholics and drug addicts (see, e.g., Oltman & Friedman, 1967).

Conclusion regarding the impact of the early death of a parent

It is impossible to predict, with certainty, whether an individual child who lost a parent will develop a particular pattern of symptoms. The number and intensity of symptoms depends on a wide variety of factors, including the way the surviving parent responds to the child, whether the family is subjected to economic hardship and disrupted living conditions, the availability of social support, and subsequent circumstances (such as poor parental remarriage). Nonetheless, on the basis of the evidence provided above, it is possible to state, with a reasonable degree of scientific certainty, that children will experience at least two intermediate symptoms and at least two long-term symptoms. In our judgment, the estimates provided above are quite conservative. Many of the studies reported in the literature focus on losses from all causes rather than extensively on sudden, traumatic losses. As noted previously, it is well established that deaths resulting from a sudden, traumatic incident pose more long-term difficulties than deaths resulting from natural causes. Particularly when the loss was sudden and traumatic, surviving children are likely to experience numerous symptoms that are quite serious. For example, Lehman et al. (1987) asked surviving parents a number of questions about the symptoms experienced by children in the study who had lost a parent in a motor vehicle crash 4-7 years previously. Forty-seven percent of the sample indicated that their children had experienced "extremely negative effects," including depression, drug abuse, and suicide.

The Impact of the Sudden, Traumatic Death of a Spouse on the Surviving Spouse

Below, we review studies focusing on the long-term sequelae of the death of a spouse. In discussing psychological symptoms and problems in functioning, we focus on difficulties that exist from a minimum of four years after the death to a maximum of over 60 years. In reviewing health outcomes such as mortality or the development of life-threatening illness, we include studies focusing on the bereaved during the first three years following the loss, as outcomes of this sort obviously have a permanent impact on the family. As in the previous sections of this letter, we focus only on systematic research studies, excluding case reports.

In evaluating the data presented below, it is important to keep in mind that following the traumatic death of one's spouse, the surviving spouse has to cope with much more than learning to live without their spouse, and coming to terms with a loss that was untimely, senseless, and horrific. He or she is also required to deal with an additional set of losses, known as secondary losses, that coincide with or develop as a consequence of the original loss. Typically, loved ones play many roles in a person's life. For example, a spouse may be one's breadwinner, sexual partner, best friend, confident, coparent, house and auto repair person, and the person in charge of financial matters. In addition to role losses of this sort, the surviving spouse must contend with the profound threat to the survivor's basic identity that typically accompanies spousal loss. As Archer (1999) has noted, the bereaved frequently describe their loss in physical terms, making such statements as, "I feel as though a part of me has died." Neimeyer (1998) has emphasized that the loss of someone we love can cause profound shifts in our sense of who we are, as whole facets of our past that were shared with the deceased slip away from us forever, if only because no one else will occupy the unique position in relation to us to call them forth." (p. 90). Although these identity shifts can occur in any loss of a close relationship, including the parent-child relationship, they are paramount following the death of a spouse.

In addition, the surviving spouse must come to terms with hopes and dreams for the relationship, for the family, and for the future, that are lost following the death of a spouse. These include discussed or implicit plans regarding future family trips, or subsequent family celebrations, such as having a party for a child who is graduating. The couple may have had discussions about such issues as the career choice or marital plans of their children. They may be looking forward to grandchildren, or they may have generated special retirement plans, such a moving to a nicer climate. Of course, all of these hopes and dreams are irrevocably shattered at the time the death occurs.

In all likelihood, it is the stress of dealing with the absence of the loved one, coping with the many secondary losses that accompany a spouse's death, as well as dealing with the loss of one's hopes and dreams for the future, that contribute to the development of long-term mental and physical health problems among surviving spouses. Below, we summarize these problems in several discrete categories, including depression and other psychiatric symptoms; anxiety and worry that harm will befall other family members; quality of life; intrusive thoughts and distressing and painful recollections of the loss, inability to resolve the loss or make sense out of what has happened, mortality and morbidity, and role performance.

Depression and other psychiatric symptoms

There is clear evidence that the sudden, traumatic death of a spouse results in long-term psychiatric symptomology. In one study, Lehman et al. (1987) compared individuals who lost a spouse 4-7 years ago in a motor vehicle crash with a matched control group of respondents who did not suffer such a loss. Bereaved spouses scored significantly higher than controls on three different measures of depression. They also scored significantly higher that controls on a host of other psychiatric symptoms including paranoid ideation, which involves feelings of suspicion toward others, and the belief that they cannot be trusted, and psychoticism, which involves feeling estranged, isolated and alienated from other people.

Similar findings have emerged in other studies. In a study of response to widowhood conducted by Lichstenstein, Gatz, Peterson, Berg, and McClern (1996), 2000 people were followed longitudinally and participated in assessments of their functioning every five years. Depending on the length of time since the death of their spouse, respondents were classified as short-termed bereaved (lost a spouse within the last 5 years) or long-term bereaved (lost a spouse more than 5 years ago, with a mean of around 17 years ago for women. Rates of depression were quite high in both the short-term (51%) and long-term (37%) groups. Since the rate of depression among the nonbereaved is about 9-10% in any given year, it can be seen that these rates are extraordinarily high. As long as 13 years after the death, respondents were evidencing depression scores approximately 4 times higher than population norms.

In a cross-sectional study focusing on nearly 800 bereaved individuals who lost their spouse from 1 to 60 years previously, the data suggests that the loss was associated with significant long-term depression. The difference in depression scores between widowed respondents and married respondents remained significant as long as 15 years after the loss, and it took the widowed more than 30 years to reach the level of depression of the married respondents (see Wortman & Silver, 2001, for a more detailed discussion).
Interestingly, when bereaved individuals who had remarried were compared to those who had not, there were no significant differences in how soon their depression was resolved.
This suggests that remarriage is not a "quick fix" for depression and other mental health problems that typically accompany a traumatic loss.

Anxiety disorders

There is evidence to suggest that following the death of a spouse, anxiety disorders are even more prevalent than depressive disorders (see Jacobs, 1993, or Rando, 2000, for reviews). In the previously described study by Lehman et al. (1987), respondents who lost their spouse in a motor vehicle crash 4-7 years previously evidenced significantly more anxiety than controls. In particular, they endorsed feeling significantly more nervous, edgy, and worried about the possibility of another tragedy. They were also significantly more likely to be experiencing phobic anxiety than were controls. Phobic anxiety involves persistent fear responses to specific places or situations.

Quality of life

Although few studies have assessed quality of life following the death of a spouse, those that have included such measures provide persuasive evidence that quality of life is indeed adversely affected by the loss. In the Lehman et al. (1987) study, it was found that highly significant differences emerged on the Bradburn Affects Balance Scale, a well-known instrument to assess quality of life, between those who lost their spouse 4-7 years ago and control respondents. This scale included a variety of items concerning the extent to which respondents find their activities interesting and meaningful, experience feelings of pleasure and enjoyment, and feel proud about things they have done. Bereaved respondents in this study also scored significantly lower on a scale designed to measure respondents' ability to get pleasure out of the good things in their lives. Finally, to provide an open-ended assessment of how respondents' general state of life had been affected by the death of their spouse, they were asked, in an open-ended question, to describe how their life was going, in general, at the present time. Bereaved respondents described their life as significantly more negative than matched controls. Those who lost a spouse were also likely to experience pervasive feelings of loneliness which, according to the respondents, were not ameliorated by the presence of other people. Similar results were obtained in the previously described cross-sectional study of the conjugally bereaved (Wortman & Silver, 2001). Bereaved respondents scored significantly lower than control respondents on life satisfaction, and it took approximately 15 years for bereaved respondents to reach the level of life satisfaction of control respondents.

Intrusive thoughts and distressing painful recollections of the trauma

In the previously mentioned study by Lehman et al. (1987), respondents who had lost a spouse in a motor vehicle crash 4-7 years previously scored significantly higher than control respondents on obsessive-compulsiveness, which involves repeatedly experiencing unpleasant thoughts. Over half of the bereaved spouses indicated that memories of their loved one still made them feel hurt and upset. Moreover, nearly half of the bereaved spouses indicated that they had reviewed the events leading up to the crash during the past month.

Findings from a more recent study conducted by Wortman and her associates (see Wortman & Silver, 2001) indicate that painful thoughts and memories continue for decades. As noted above, this study focused on individuals who lost a spouse anywhere from 1 to 60 years previously. Individuals reported painful feelings when they thought or talked about their spouse, and these continued for many years. Although the frequency of such painful feelings appeared to decline over time, it took respondents nearly 40 years to reach a point where they experienced such negative feelings "rarely". For the vast majority of respondents, such negative thoughts and feelings never seemed to fade away completely.

Since intrusive thoughts are triggered by reminders of the tragedy, it is very likely that survivors who lost loved ones in the September 11 catastrophe will have more difficulties than those who lost loved ones in other ways. Indeed, it is virtually impossible to escape reminders of the event. Given the historical significance of this tragedy, such reminders are likely to be encountered regularly for many years to come.

Mortality and morbidity

Dozens of studies have been conducted to determine whether there is a relationship between death of a spouse and subsequent mortality of the surviving spouse (see Miller & Wortman, in press, or Stroebe, Stroebe, & Schut, in press, for reviews). These studies are remarkably consistent in showing that following the loss of a spouse, individuals are at greatly enhanced risk of mortality. While the rates of mortality are higher for males, the vast majority of studies have shown significantly higher rates of mortality for females who lose a spouse than for control females who have not suffered such a loss. Interestingly, most of these studies have found that the risk of mortality is particularly heightened among the young bereaved.

Numerous studies have also provided convincing evidence that the death of a spouse results in morbidity, or the presence of physical health problems, in the surviving spouse. Several studies have reported that as a result of losing a spouse, the surviving spouse has higher rates of health care utilization, and is more likely to take prescribed psychotropic medication, than control respondents who have not lost a spouse (see, e.g., Avis, Brambilla, Vass, & McKinlay, 1991). Researchers have found that serious health problems are particularly likely to occur in those cases where the respondent reacts initially to the loss with intense feelings of traumatic grief. In a study by Prigerson, Bierhals, Kasl, and Reynolds (1997), the presence of early symptoms of traumatic grief, such as yearning and longing for the deceased and feeling empty inside, predicted such negative health outcomes as cancer, heart trouble, and high blood pressure, as well as suicidal ideation.

Role performance, satisfaction, and strain

The previously described study by Lehman et al. (1987) suggests that following the traumatic death of a spouse, there are major deficits in the ability to function successfully in various life roles, such as parenting, taking care of the household, and getting along with friends and relatives. Regarding their parenting ability, parents who had experienced the death of their spouse 4-7 years previously reported significantly more stress in dealing with their surviving children (e.g., they felt more frustrated, tense, or emotionally worn out) than parents who had not lost a spouse. Parents who experienced the traumatic loss of a spouse also reported spending less time with their friends, having more open arguments with them, and feeling hurt and offended by them more often than did control parents. Those who lost a spouse also reported feeling significantly more lonely than did control respondents.

Those who lost a spouse also reported being less able to do their housework, more ashamed of how they did their housework, more likely to have had minor arguments with salespeople or neighbors, and more likely to have felt upset while doing their housework than did controls.

Wortman et al. (1997) have reported that in cases where a young man is killed in a sudden, traumatic incident, conflicts frequently emerge between the surviving spouse and the deceased husband's parents or siblings. The in-laws are often quite critical and judgmental about such issues as how the surviving children are being raised and whether the mother's behavioral choices are taking adequate consideration of the best interests of the children.

Conclusion regarding the impact of spousal loss

Taken together, available research studies provide compelling evidence that the sudden, traumatic death of a spouse results in long-term consequences that are extremely negative. These problems are not only likely to cause enduring distress for the surviving spouse, but will almost certainly have a very adverse impact on the entire family. For example, persistent depression and/or anxiety on the part of the surviving parent will obviously have a negative impact on their ability to be emotionally available to their surviving children. The inability of the surviving parent to maintain the household will add to the disruption in children's lives. The enhanced stress that typically emerges between surviving parents and their children may contribute to the child's feelings of being alone in the world and misunderstood.

As in the case of the death of a parent, it is impossible to predict, with complete certainty, whether any given individual will manifest the troubling symptoms detailed in this section of the report or if so, how many symptoms are likely to be experienced. Individual reactions are influenced by a wide variety of factors. Those who have remarkably resilient personalities, and who have a great deal of social support, may experience fewer symptoms. Those who have a history of mental disorder predating September 11, those who have suffered prior traumas, and those who are experiencing concurrent stressors such as serious illness or job loss, are at risk of experiencing more of the aforementioned symptoms.

However, it can be stated with a reasonable degree of scientific certainty that on average, a person who has suffered the sudden, traumatic death of a spouse will experience a minimum of two of these very debilitating symptoms. As in the literature review on impact of early parental loss, this figure is a very conservative one. This is the case because there is overwhelmingly clear evidence that in most cases, these symptoms co-occur together following a traumatic loss (a term called comorbidity by psychologists). For example, in reviews of this literature, both Jacobs (1993) and Rando (2000) have emphasized that there is about a 50% comorbidity rate between symptoms of depression and anxiety following bereavement. Moreover, the studies that have focused on a large number of outcomes have shown that most respondents who experienced a traumatic loss report a wide variety of specific problems. This was definitely the case in the Lehman et al. (1987) study, where it was typical for respondents to experience several different psychiatric symptoms in addition to depression and anxiety. Along with these psychiatric symptoms, the majority of respondents also experienced lowered quality of life, parental stress, difficulties getting along with their friends, pervasive feelings of loneliness, and difficulties completing their housework.

Conclusions and Implications

It is clear from this review that those who have lost parents and spouses as a result of the September 11 catastrophe are likely to experience intense mental anguish, emotional pain and suffering, physical and mental health problems, and loss of enjoyment of life, as well as loss of consortium, society, and companionship. Children who lost a parent will never again be able to have that parent provide encouragement and support for their endeavors, or share in the joy of their accomplishments. Those who lost a spouse will find it far more difficult to enjoy milestones in their children's lives, since these cannot be shared with their spouse. The loss is likely to be felt for decades in the future, when there is no co-parent to celebrate the child's graduation, or no father to walk one's daughter down the aisle. In this review, we have chosen to focus on the impact of loss of a parent or spouse, since the majority of people who died were young married adults with small children and since these losses are compensable under the current rule. We should also note, however, that there is an extensive psychological literature documenting the long-term deleterious effects of losing a child or a sibling (Rando, 1993; Cleiren, 1993).

It is our hope that you will give full consideration to the scientific evidence reviewed here in making a final decision about the amounts awarded for non-economic losses. There is clear evidence that problems stemming from the loss of a parent or spouse are more severe and prolonged in cases, like the Sept. 11 catastrophe, where the loss was violent and where it was brought about deliberately. Hence, the catastrophe is likely to result in profound mental anguish as well as a need for costly, long-term mental health services and supports. While we will refrain from recommending a particular figure, we feel strongly that the amounts currently recommended are seriously deficient. We also feel that ideally, the award for non-economic losses should not be reduced by such collateral payments as life insurance premiums.

There is a clear indication in the literature that a factor strongly influencing survivors' subsequent recovery and healing is strongly affected by whether they feel that they have been treated fairly by the judicial system (Amick-McMullan, Kilpatrick, Veronen, & Smith, 1989). Of course, no amount of money can fully compensate the full extent of non-economic losses that these survivors have suffered. However, the pain and suffering of survivors is likely to be at the extreme high end for those losing a loved one. In contrast, the compensation currently offered is on the extreme low end, amounting to only a fraction of what is typically awarded in civil courts for traumatic deaths. In our judgment, the modest sums currently scheduled to be awarded are likely to send a message to survivors that their loss has not truly been acknowledged. Such a lack of acknowledgement of their pain and suffering will, we believe, add significantly to the pain and distress survivors are experiencing. We believe that substantially raising the amounts for pain and suffering will greatly enhance the likelihood that survivors will perceive the allocation of funds as just and fair.

Sincerely,



Individual Comment
State University of New York at Stony Brook
Stony Brook, NY


Institute for the Study and Treatment of Loss
Warwick, RI

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