MR. KOJO NNAMDIWhen a person dies suddenly, there's a good chance he or she will end up in the city Medical Examiner's office, commonly known as the morgue. And often someone will have to go and identify the body. It's a process that involves more paperwork and less drama than you'd expect from watching television crime shows. One thing that is accurate from TV shows, it's a difficult and traumatic experience.

MR. KOJO NNAMDIIn most cities and counties, families deal with the identification without support. But in a few places, including the District of Columbia, the Medical Examiner's office has grief counselors who help families deal with the sudden loss of someone close to them. They'll also walk them through the bureaucracy and connect them with support services. Joining us to discuss how this is done is Bruce Sklarew. He is a psychiatrist and psychoanalyst. He helped found the Recover Program in D.C. and has been a consultant to the Wendt Center for Loss and Healing for 20 years. Bruce Sklarew, thank you for joining us.

MR. BRUCE SKLAREWHi, Kojo.

NNAMDIAlso with us is Stephanie Handel. She's a therapist with the Recover Program at the Wendt Center. She's a licensed graduate social worker. Stephanie Handel, thank you for joining us.

MS. STEPHANIE HANDELThank you, Kojo. It's an honor to be here.

NNAMDIThe Recover Program took shape more than ten years ago, Bruce. Tell us how it came about.

SKLAREWI was eating sushi, specifically Abalone at the (word?) Restaurant about three blocks from WAMU...

NNAMDICorrect.

SKLAREW...and I couldn't communicate with the sushi chef as to whether this was raw shellfish. A bearded man next to me in his late '40s piped up and he could've been a marine biologist because he was very conversant with the shell, the jewelry and the lifecycle. He turned out to be the newly appointed Chief Medical Examiner Jonathan Arden...

NNAMDIJonathan Arden.

SKLAREW...I'd just read about in the newspaper. And we became friends and Jonathan tells me that up to 1500 families come to the office of the Chief Medical Examiner and they were met by D.C. clerks who would kind of, you know, press, shove sometimes these bloated awful looking photographs -- they do not see the bodies, they see Polaroids -- and say, is this the person? Sign here, fill out the papers and get lost. This is a slight exaggeration as to what it was.

SKLAREWSo I simply became a catalyst and got Jonathan together with the head of the agency and they took it off (unintelligible) .

NNAMDIDid Jonathan, at the time, express to you that he had a concern about this or did you immediately figure out that there had to be a concern about this?

SKLAREWI guess some combination. I don't think it was at the fore of Jonathan's mind because he was taking over a very difficult situation there. But he was amazingly receptive and cooperative, as is Dr. Pierre-Louis who succeeded him five years later.

NNAMDIStephanie, in what circumstances does someone have to come to the office of the Chief Medical Examiner commonly known as the morgue to identify a body?

HANDELWell, firstly, the morgue is just one part of the Medical Examiner's office.

NNAMDICorrect.

HANDELAnd unfortunately, what we see on TV, it heightens the anxiety when people think they're just going to the morgue. But the OCME is charged with the task of investigating and certifying all deaths in the District of Columbia that occur as a result of violence, which could be motor vehicle collisions, suicide, homicides, are suspicious in nature, when they're not under the care of a doctor or a doctor will not sign, when they're sudden or unexpected and we often see that with children and infants specifically.

HANDELIf the death seems to be a threat to public health, that will -- those will be reasons why a decedent will have to come into the OCME. And sometimes it's pretty shocking to a family because it seems like there's been a long history of illness and then there's a fall that might happen. And that too could be a reason why a family would have to come in to identify their loved one.

NNAMDIIf you'd like to join this conversation, if you have questions or comments for us you can call us at 800-433--8850. One of the reasons people may have questions or comments, Stephanie, is because we think we know what to expect because we see it on television all the time. And what we see on television all the time is that somebody walks into a morgue, somebody pulls a slab out and the person looks at the body of the person and then they either say, no, that's not related to me or they go through some kind of trauma. But it's my understanding that that's not the way it happens in real life.

HANDELIt's actually not the process at the D.C. Medical Examiner's office, which sometimes leaves people a little bit disappointed, to be honest.

NNAMDIBecause they see something on television...

HANDELThey see some...

NNAMDI...they think that's what they're walking into.

HANDELExactly and that's what they want. What actually happens is it's a very inviting waiting area. There are two separate family rooms. We meet the family. There are three people allowed to be a part of an identification process. And right from the beginning we try and decrease anxiety and anger in an effort to put them much more in control of this process. And death can feel very powerless. So what the process actually entails is a very comforting room in which we describe that there will be two documents. One document that is specific for information for the death certificate and one document identifying surviving next of kin and survivors to the family.

HANDELAnd then we let them know about the identification itself, which is done by a Polaroid photograph from the neck to the top of the head. And we really try and share some details so that they best know what to expect from the photograph. After viewing the photograph they do some printing of the decedent's name and signing their name. And within that process though we provide education around grief and trauma reactions, what to expect, next steps, how to get death certificates, really a lot of empowering education to help them feel much more in control of this identification process.

NNAMDI800-433-8850. Have you had any experience with a Medical Examiner's office here or in another city? Did you get any support? Do you wish you had? 800-433-8850. Bruce Sklarew, the general -- oh, go ahead, please.

SKLAREWOne brief comment related to control, in that the photograph -- when the photograph is brought into the room it is always facedown. And the family members have time to get ready. And they actually turn over the photograph so they have a little bit of sense of control. And, you know, the range of reactions are complete stoicism to, you know, screaming and yelling to wanting to spend hours looking at the photograph. It's a huge range of expressiveness.

NNAMDIA couple of aspects of that I'd like to discuss because, again, the way we watch it on television, somebody seems to be shocked at what they see. Somebody puts their arm around them, leads them out of the room, maybe sits with them for a few minutes and then we move onto something else. What kinds of support services does a person who is in -- who is traumatized in that way need?

SKLAREWThey need what an analyst named Wynnecott (sp?) once called a holding environment, a sense of caring about them. We can spend up to an hour or longer with some families. And an initial experience of a caring person who can deal with the huge range of feelings that are expressed, that has great ramifications for the rest of their mourning so that the traumatic bereavement doesn't turn into bodily symptoms. You know, wishes for revenge 'cause they can't deal with the feelings, follow-up care at the Wendt Center through letters and many other community resources.

SKLAREWSo we see this as just an acute intervention that has -- it can have many ramifications when people are ready to know that there are places out there where they can go and to the Wendt Center at a very sliding scale with the three offices throughout the city.

NNAMDIWe're talking with Bruce Sklarew. He's a psychiatrist and psychoanalyst. He helped found the Recover Program in Washington and has been a consultant to the Wendt Center for Loss and Healing for 20 years. Stephanie Handel is a therapist with the Recover Program at the Wendt Center. She's a licensed graduate social worker. Stephanie, connecting families to other support services besides the hour or so that they can be -- that can be spent with them at the office of the Medical Examiner, how important is that?

HANDELIt's different for each family because there are some families that are in great need for an immediate connection to literally manage the crisis. And in some ways where our Vigil Program or our Candles of Hope Program comes in our crisis response team are helping families create vigils, community-based rituals to help them in the days after a homicide or other deaths. And that is -- that's a continuum of our Recover Program at the Medical Examiner's office.

HANDELThere's other resources that people need to be connected to right away, like the crime victim's compensation program or the Metropolitan Police Department Family Liaison Unit or burial assistance. And there are others that they just need to know that there's support available out there. Support also comes in the form of education and the support for some is really that they just want to talk about how to prepare their children for the funeral that's coming up.

HANDELBecause children are not allowed to come in to be a part of the identification, really exploring how we can best support children and adolescents in the community is a critical component of the identification process in -- when we talk about supportive services.

NNAMDIIs this kind of grief counseling unusual for Medical Examiner's offices? Are there other programs out there? It's my understanding that a lot of city and county coroner's offices are too small to support this kind of program.

HANDELWell, if we look at "Crossing Jordan" on TV, they actually have a grief counselor.

NNAMDIYep.

HANDELBut the Cuyahoga County in Ohio, they have a grief counseling program that started in '99 a little bit right after hours that meets with families. The Gap Program, which is a program that we did a little bit of training under in the initial years in Philadelphia, very focused just on homicide, funding has changed their programming. San Diego came out to observe the D.C. Medical Examiner's office and the Recover Program a couple of years ago and has a very successful program going on there, a very successful program.

HANDELNew Mexico very focused on going out into the community. Their funding has changed the number of people that can actually provide services and it's specific to SIDS. And New York has their Safe Horizon program, not operating within the Medical Examiner's office, but they collaborate with the Medical Examiner's office to be able to provide support and resources specifically to homicide families.

NNAMDIWe spoke yesterday to Maryland's Assistance Medical Examiner, Victor Weedn. Before coming to Maryland he was the acting State Medical Examiner for the State of New Jersey where he tried to start a grief counseling program.

MR. VICTOR WEEDNI believe that Medical Examiner's offices are one of the government agencies that sees the most trauma and families in the greatest state of grief. I thought it was important that we intervene with grief counselors. But also I was wanting to hook them in through the social services network. Funding was an issue so we went out and we got a grant to fund a pilot study so that we might prove the value of the system.

MR. VICTOR WEEDNBut it didn't end up happening because people wanted to look into the personnel backgrounds of these grief counselors. That delay occurred over a year and the grant money ran out so we never really got the system up and running. But there was great excitement within the ME office, as well as with the mental health workers, to start this program and to show the value to the systems.

MR. VICTOR WEEDNI'm now in Maryland which has a centralized state Medical Examiner. So we like other government agencies right now are facing severe financial hardships and cutting even basic services. We do not have grief counseling services in Maryland. A Medical Examiner -- medical legal death investigations period are often very poorly financed in almost every jurisdiction of the country. Policymakers tend not to want to spend money on dead bodies. They don't think that really everything we do are for the living. Our patients, if you will, don't vote.

MR. VICTOR WEEDNGrief counseling, even though I think it would be very important for our offices, it's not the basic service of determining cause and manner of death. And from that standpoint it's seen often as a luxury.

NNAMDIThat's Maryland's Assistance Medical Examiner, Victor Weedn. Here is James in Washington, D.C. James, you're on the air, go ahead, please.

JAMESHello. This is actually just a word of endorsement for the Recover Program. Stephanie and Bruce, I worked with you over ten years ago as an intern and then therapist for your program. I am delighted you are around and you are receiving the attention you deserve. The mental health of our citizens in response to what they have to endure should never be seen as a luxury. It is a necessity, it is a right and I'm just very happy that you are getting this attention.

NNAMDIJames, thank...

JAMESAnd I'll take any comments off the air.

NNAMDI...James, thank you so much for your call. Bruce Sklarew, what do people experience at the time of losing someone suddenly?

SKLAREWDependent on, you know, their personalities and what losses, what trauma, what's happened in their parental relationships, there's a very wide variety between those who are relatively resilient and those who are subject to great difficulty. Various bodily reactions are common, depression, anxiety, somatization, the feeling of blankness and numbness, wondering if what's going to -- if it's death that is going to happen to them. If there's a murder and they cooperate with the police, are they going to be victimized by the murderers?

SKLAREWAnd various forms of not being able to deal with the depth of the feeling and instead having to act out. In another Wendt Center project one boy said, well, I feel like crying 'cause my brother was shot but I'm not going to let myself cry. Instead I'm going to go out and beat someone up. They can't deal with the very primitive feelings. And some of the reactions are just so overwhelmingly (unintelligible)

NNAMDIIt's my understanding, Stephanie, that one reaction that is really surprising is when people in this situation make jokes.

HANDELHumor enters the room very often. It's -- for many people it's the way of coping with an extremely overwhelming situation. And by -- sometimes it's remembering the person and laughing about them. Other times it's an absolute way of distracting from the reality that's in front of them. And often what we see is the laughing and joking happens right up until the picture is about to enter the room. And once the photograph of their loved one is brought into the room there really is a shift in the emotional state of each of the individuals that were joking and laughing just a moment ago. And the photo is turned over and the reality is right there.

HANDELAnd the laughing helped get them to that moment. And you will see them shift again to going back to laughing and joking once the photograph is taken out of the room. And it's their way of really managing. It's a defense mechanism that we need to respect in those individuals.

NNAMDIStephanie Handel is a therapist with the Recover Program at the Wendt Center for Loss and Healing. She's a licensed graduate worker. Thank you very much for the important work that you do.

HANDELThank you.

NNAMDIAnd Bruce Sklarew is a psychiatrist and psychoanalyst. He helped found the Recover Program and has been a consultant to the Wendt Center for Loss and Healing for 20 years. Thank you so much for joining us and for what you do.

SKLAREWThanks for the opportunity, Kojo.

NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.