A Model for Supporting Grief Recovery Following Traumatic Loss: The Tragedy Assistance Program for Survivors (TAPS).

While grief is a normal response to death and loss in human beings, some individuals experience severe and debilitating grief. Complicated grief was recognized in the 1990s as a prolonging of the normal grief process that impairs the mental and physical health of its sufferers. While there is some disagreement as to diagnostic criteria, it was included in DSM-5[1] as “persistent complex bereavement disorder.” Prevalence estimates for complicated grief in the general population range from 2.4%[2] to 3.7%[3] to 4.8%.[4] Among the bereaved prevalence is higher, ranging from 10% to 40%.[4-8]

Those who experience the sudden death of a spouse or child are at higher risk for complicated grief, as are women in general.[2,3] While the prevalence of complicated grief among military personnel and their families is unknown, the risks are clearly substantial, especially during periods of conflict and high operational activity. For example, during the 10-year period from 2001 to 2011 a total of 15,938 active duty military personnel died, and 80% of these were from sudden and traumatic causes including combat (31.5%), accidents (34.0%) and suicide (14.5%). According to the same study, this group of deceased service members left behind a total of 10,020 bereaved spouses, and some 12,641 grieving children.[9] Military health care providers should thus be aware of signs and symptoms of complicated grief, and intervention strategies to facilitate healthy grief recovery in bereaved military and family members. The current paper outlines a model and program that have been used successfully to assist military family members who experience the sudden death of a military member.

TAPS – the Tragedy Assistance Program for Survivors – was founded by Major Bonnie Carroll, whose husband was killed in a 1992 military plane crash along with 7 other servicemen. Following the crash, Carroll found meager support for survivors of a military death. Professional mental health providers she encountered seemed to have no understanding of the military and little real empathy for her situation of loss. Eventually, she found effective support among the other widows whose husbands died in the crash. It was this personal experience that convinced Carroll of the therapeutic value of peer support for grieving survivors, and led her to establish the Tragedy Assistance Program for Survivors (TAPS) in 1994, with the goal to provide bereavement care and supportive resources for survivors of a military death.[10] TAPS was incorporated as a non-profit organization, and is funded entirely by private donations.

While the different US military branches do provide a variety of support services for survivors, these tend to be time limited, and largely educational in nature. Professional mental health support is also generally available in the military health care system for survivors who seek it out, but providers frequently have little understanding of the military and the unique aspects of military death and bereavement. The TAPS organization fills this gap with professional expertise and the ability to act quickly to provide needed support. Each military service branch now has in place a written MOU (Memorandum of Understanding) with TAPS to facilitate referral of survivors to the TAPS network.

Central to the TAPS approach is the use of volunteer peer support professionals, survivors who have experienced a military death in their own family, and have received special training to provide grief assistance.[11] A key assumption of the peer support approach is that due to shared life experiences and circumstances, peers are better able to establish relationships of trust and support with those in need of assistance.[12] Considerable research has shown that peer support programs are effective in facilitating recovery from a range of mental health problems.[12-14] Peer support based programs have also proven effective for people experiencing grief.[15] The use of peer support provides three main benefits over traditional mental health approaches: (1) an increased sense of hope through positive self-disclosure; (2) use of similar background and experience, “experiential knowledge,” to facilitate positive role modeling; and (3) greater trust, understanding and empathy between the peer supporter and the recipient.[14]

The TAPS model of care for bereaved individuals relies heavily on peer support in a variety of programs that aim to facilitate healthy grief recovery in survivors. Two main theoretical perspectives have helped to shape the TAPS approach. Worden[16] argues that in order to adapt to loss, survivors must address a series of tasks. First, accepting the reality of loss, requires the survivor to admit and accept that his/her loved one is in fact deceased and will never again be seen in this life. The second task, experiencing the pain of grief, is essential to allow survivors to express emotions of anger, sadness, and regret instead of distracting themselves to comply with societal norms. The third task, adjusting to a world without the deceased, includes external both and internal adjustments. External adjustments are dependent upon the relationship to the deceased, and involve the survivor taking on new roles such as managing finances, or other projects previously fulfilled by the deceased. Internal adjustments are also dependent upon the relationship to the deceased and describe how survivors adjust to their own sense of self. No longer is a woman able to call herself a wife; she is now a widow. The fourth task is to find an enduring connection with the deceased in the midst of embarking on a new life. This task requires survivors to move forward with their own lives, while finding an acceptable place of memory and honor for their deceased loved ones.

Rando[17] provides another useful theoretical perspective, characterizing the grief process in terms of three phases: avoidance, confrontation, and accommodation. These phases may encompass different reactions depending upon individual survivor characteristics and the relationship to the deceased. The avoidance phase begins when the news of the death is first received. Here, the survivor typically experiences a sense of numbness, disorientation and confusion, and may be unable to understand what has happened. The confrontation phase is when grief is experienced most intensely, to include emotions such as heightened arousal, protest, anger, separation anxiety, and a confrontation of the reality of their loss – their loved one is dead. The accommodation phase describes how survivors progress through a gradual reintegration into their social and emotional worlds. The survivor is reconstructing his/her world and learning to go on with life without the deceased. In this last phase, the goal for the survivor is to create some kind of positive integration of his/her past life experiences with the new present reality.

THE TAPS BEREAVEMENT CARE MODEL

Following these ideas, the TAPS model for providing care to the bereaved consists of three phases: stabilization, hopeful re-appraisal, and positive integration (Fig. 1). These will be discussed in turn, along with descriptions of TAPS programs addressing each phase of grief recovery.

FIGURE 1.

TAPS bereavement care model: 3 phases of grief recovery.

Stabilization

The key goal in the stabilization phase is to provide immediate care, comfort and practical support to survivors of unexpected death. During this phase, survivors need to feel a sense of safety and stability, which is offered by TAPS peer supporters through various programs and services. Initial contact often occurs via telephone self-referral. The TAPS National Military Survivor Helpline is staffed 24 hours a day, 7 days a week by fellow military survivors. Calling this helpline puts survivors in touch with care providers specifically focused on the unique circumstances that survivors face after a military death. Once identified as a military loss survivor, the survivor is connected to whatever programs, services, and resources are needed. All services are provided at no cost to the survivor.

In addition to the TAPS National Military Survivor Helpline, TAPS also makes referrals to local grief support groups and mental health professionals who can provide survivors with sources vetted by TAPS specific to their unique needs. Following initial contact and establishing trust, survivors are assessed for suicide risk, clinical treatment needs (i.e. trauma), and specific issues (i.e. grief-blocking emotions). Referrals to mental health professionals are made whenever appropriate or when requested by the survivor.

One of the primary TAPS program interventions is specialized grief seminars which are held in multiple locations across the country throughout the year. These seminars provide a venue where survivors can connect with other TAPS survivors and receive information on grief, bereavement, coping skills, peer-based emotional support and related resources. The TAPS Online Community creates text-based chat sessions, video chat sessions, blogs, and message boards where survivors can engage both with TAPS staff and other survivors to meet, share their questions and stories of their loved ones.

Another kind of support frequently needed by survivors involves financial and administrative issues, such as applying for insurance benefits. The TAPS Casework Advocacy team is able to provide emergency financial assistance for survivors when they experience hardships such as a gap in insurance coverages, emergency basic housing and utility bills, education benefits, and funeral costs. These services also aim to provide survivors with a sense of safety and stability, freeing them to address their grief related emotions.

Hopeful Reappraisal

The key goal in the Hopeful Reappraisal phase is to assist the survivor in confronting and accepting the loss, addressing emotions, and establishing a sense of hope for the future. As humans, there is a normal, understandable tendency for all of us to avoid what feels painful. For those experiencing grief, while there is some value in initial feelings of numbness, in order to move towards recovery it is critical that survivors begin to approach and confront their grief. This phase is in alignment with Worden’s period of experiencing the pain of grief.[16] Rando likewise identifies the main task at this stage as confrontation, wherein the survivor experiences intense emotions of grief.[17] TAPS programs aim to facilitate the open confrontation and acceptance of loss, while at the same time encouraging feelings of hope regarding the future. As survivors begin to adjust to their new ‘normal’, additional TAPS programs come into play to support survivors through the grief process.

The TAPS Peer Mentor program becomes especially important during this phase. All peer mentors are volunteers who are themselves military loss survivors and are at least 1½ years past their own loss.[18] Peer mentors receive extensive training in order to prepare them for the role. The TAPS Institute of Hope and Healing, in partnership with the Hospice Foundation of America, provides on-site professional training and certification in grief management to supplement TAPS internal training programs. Training includes the effective use of active listening skills, familiarity with all TAPS programs and resources, identifying suicide risk, maintaining professional and personal boundaries, confidentiality, self-care, and when to make referrals to professional mental health providers. Having lived through their own military loss experiences, TAPS peer mentors intimately understand military tragedies and survivors’ unique needs.[10,18] As “beacons of hope” to newly bereaved survivors, peer mentors form an integral part of the TAPS approach during this phase of recovery. The peer mentor strives to listen without judgment, empathizing with feelings of grief, and sharing similar experiences as appropriate in order to help survivors find validation, normalization and hope for the future. Through the help of peer mentors, the survivor is enabled to shift focus from the death of their loved one to the life that was lived, and do the hard work of reorganizing family systems and roles.

Hopeful reappraisal is also facilitated through several TAPS Health and Wellness programs. These activities take place over several days in attractive locations and are designed to bring together small groups of survivors to further build a sense of community. Each TAPS Health and Wellness event includes physical activities such as kayaking, hiking, skiing, mountain climbing and horseback riding. Time is also reserved for conversation and reflection throughout the program. The TAPS Health and Wellness activities are specifically designed to encourage survivors to get out of their comfort zones, face challenges in nature, share their experiences with other survivors of a similar loss, make connections with others, experience a sense of belonging, and learn new tools and strategies for coping with grief.

“TAPS Togethers” provide similar opportunities for survivors to get together and support each other by sharing common experiences. These are 1-day events held across the country that bring survivors together in an organized social setting guided by TAPS peer mentors. Examples of TAPS Togethers include coffees, museum trips, baseball games, horse camps, outdoor adventures, yoga, BBQs, potlucks, and community service projects.

For children, Phase II likewise includes opportunities to work through the trauma. Children have access through TAPS to a supportive and nurturing social environment, which can help them process the trauma they have experienced and work through the emotions they may not be able to express while at home. TAPS programming at Good Grief Camps matches children with members of the military who have volunteered to serve as a Military Mentor for the duration of the program. Engagement in TAPS Youth Programs facilitates a sense of community among child survivors, and an awareness that the military still honors the life and legacy of their fallen military loved one. Activities aim to promote healthy coping skills including age-appropriate ways of communicating and expressing their emotions around grief.

Positive Integration

The focus in Phase III is to help survivors derive a positive sense of meaning from the loss, and integrate it into their life patterns while looking ahead to a positive future. This is in line with Worden’s[14] task of adjusting to a new world without the deceased, and Rando’s[15] accommodation phase, describing how survivors must reintegrate into the social world without the deceased. Military survivors often differ from non-military ones in how they view and interact with the world, and may be uniquely situated to experience post-traumatic growth (PTG) following a traumatic loss. For example, they are more familiar with frequent major life disruptions such as military moves and deployment separations.[19] Post-traumatic growth (PTG) can be defined as positive personal changes that result from the survivor’s struggles to deal with trauma and its psychological consequences. Survivors will continue to experience grief, and will likely have times of escalated sensitivity around anniversaries of the loss, but the emotions surrounding the loss may be less severe.

Survivors in this phase have a need to transform the intense pain of grief into a personally meaningful, pro-social activity. For many, TAPS becomes like an extended family, a community that promotes and supports working toward lives filled with greater purpose and meaning. TAPS Peer Mentors and the TAPS community of survivors continue to serve as important peer support elements and role models facilitating healthy grief recovery. Survivors are also encouraged to take advantage of resources and educational materials available through the TAPS Institute of Hope & Healing.

For children, Phase III is primarily about reintegration – how to go on with life in which their father or mother is gone, while accepting the feelings of loss this entails. Eventually, survivors in this phase will shift away from the focus on grief and death, to honoring their loved one’s life while living their own to the fullest.

TAPS Sports & Entertainment programs provide additional opportunities to shift grief into a positive frame. These programs provide families and loved ones of the deceased opportunities to connect with their favorite sports teams to honor the life and legacy of their fallen military members. For example, several major sports teams have partnered with TAPS to bring grieving children to meet with their favorite players. Sports and Entertainment programs span multiple generations with special events for kids, and opportunities for grieving adults to share the stories of how their loved ones enjoyed their favorite sports teams and players. Survivors from all types of losses and all relationships to the fallen are able to come together in a positive environment where they can connect with other military survivors and learn they are not alone in their grief.

CONCLUSION

While empirical studies of TAPS programs are currently somewhat limited, there is now extensive evidence that peer support-based programs like TAPS are effective in facilitating healthy recovery for people experiencing a range of mental health challenges.[12-14] In a recent systematic review that focused specifically on studies of peer support programs for bereaved survivors, results indicated a series of benefits accrue to survivors, including reduced depression and anxiety, fewer complicated grief symptoms, and increased post-traumatic growth.[15] Another study that looked at a sub-group of military survivors who used TAPS programs found that survivors who had a greater number of contacts with TAPS showed higher levels of post-traumatic growth and resilience.[19] The same study also determined that those who had a higher number of engagements with TAPS tended to have lower levels of depression, anxiety and suicidal ideation. Interestingly, among the survey respondents, those who also had served as Peer Mentors showed even higher levels of PTG and resilience. These results suggest that survivors who go on to assist other survivors derive increased benefits and growth from their experiences.

All TAPS programs are structured around the model of peer-based emotional support, and follow recognized best practices that have been identified in this domain.[11] This peer-based approach provides accessible, non-threatening and free services that work to decrease the survivor’s sense of isolation, and build a feeling of hope for a positive future therby facilitating healthy adaptation to loss.

With twenty-five years of experience providing critical support for grieving survivors of a military death, TAPS is a valuable resource for military health care providers. Since its inception, TAPS has assisted over 85,000 survivors of a military death. In 2018 alone, over 19,000 phone calls were fielded by the TAPS 24/7 Military Survivor Hotline, and over 30,000 hours spent by TAPS peers talking with newly bereaved survivors. Over 6,000 new survivors made contact with TAPS in 2018 through some one of its programs, to include over 400 grief seminars or camps held across the country. Clearly, the need is strong for the kinds of support services offered by TAPS to survivors of traumatic loss.