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Bereavement REACTIONS, CONSEQUENCES, AND (MARE Manan Osterweis, Fredric Solomon, anC3 Morris Green, Editors Committee for the Study of Health Consequences of the Stress of Bereavement Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1984
National Academy Press · 2101 Constitution Ave., NW · Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the Committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal gov- ernment, and its own initiative in identifying issues of medical care, research, and edu cation. This volume Is the final report of a study conducted under Contract No. 278-82-0020 {OD} with The National Institute of Mental Health of the Alcohol, Drug Abuse, and Mental Health Administration, Department of Health and Human Services. The study also received support from the Kenworthy-Swift Foundation, New York. Library of Congress Cataloging in Publication Data Main entry under title: Bereavement: reactions, consequences, and care. Includes bibliographies and index. 1. Bereavement Psychological aspects. 2. Bereave- ment-Psychosomatic aspects. 3. Psychotherapy. 4. Medical care. I. Osterweis, Marian. II. Solomon, Fredric. III. Green, Morris. Medicine (U.S.J BF575.G7B475 1984 ISBN 0-309-03438-8 3. Psychotherapy IV. Institute of 155.9'37 84-14870 Copynght ~ 1984 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written per- mission from the publisher, except for the purposes of official use by the United States Government. First Pnnting, September 1984 Second Pnnting, February 1985 Bird Pnnting, November 1988 Fourth Pnnting, October 1989 Fifth Pnnting, April 1992 Printed in the United States of America. Cover Photograph: EDVARD MUNCH. Evening (Melancholy: On the Beach), 1896. Color woodcut, 16~/4 x 18". Collection, The Museum of Modern Art, New York. Abby Aldrich Rockefeller Fund. ~ The Museum of Modern Art, New York, 1985.
INSTITUTE OF MEDICINE Committee on Health Consequences of the Stress of Bereavement *MORRIS GREEN, M.D., Lesh Professor and Chairman, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, In- diana (Chairman) *ERIC CASSE[L, M.D., Clinical Professor of Public Health, Comell University Medical Center, New York, New York PAULA CLAYTON, M.D., Chairman, Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota *DAVID S. GREER, M.D., Dean of Medicine, Professor of Community Health, Brown University, Providence, Rhode IsI~nd JULES Hirsch, M.D., Professor and Senior Physician, Laboratory of Human Behavior and Metabolism, The Rockefeller University, New York, New York MYRON A. HOFER, M.D., formerly Professor of Psychiatry, Associate Professor of Neurosciences, Albert Einstein College of Medicine; currently Director, Department of Developmental Psychobiology, Columbia Presbyterian University Hospital, New York State Psychiatric Institute, New York, New York JIMMIE HOLLAND, M.D., Chief, Psychiatry Service, Memorial SIoan- Kettering Hospital, New York, New York MARD] HOROWITZ, M.D., Professor of Psychiatry, University of California, San Francisco, CaTifomia BERTON H. KAPLAN, PH.D., Professor, Department of Epidemiology, School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina MARIE KILLILEA, Assistant Professor, Department of Mental Hygiene, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland *ARTHUR KLEINMAN, M.D., Professor of Medical Anthropology, Department of Social Medicine, Harvard Medical School, Boston, Massachusetts *GERALD L. KLERMAN, M.D., Director of Psychiatric Research, Massachusetts General Hospital, Boston, Massachusetts *Member, Institute of Medicine . · -
Members (cont'dJ GERALD KOOCHER, PH.D., Director of Training In Psychology, Children's Hospital Medical Center, Boston, Massachusetts *IDA M. MARTINSON, R.N., PH.D., Professor, Department of Family Health Care, University of California, S~T} Francisco, California *TACK H. MEDALIE, M.D., M.P.H., Chairman and Dorothy Jones Weatherhead Professor of Family Medicine, Case Western Reserve University, Cleveland, Ohio TOAN W. MULLANEY, D.S.W., Dean, National Catholic School of Social Service, Catholic University of America, Washington, D.C. ROBERT F. MURRAY, TR., M.D., Professor of Pediatrics, Medicine once Oncology, Howard University College of Medicine, Washington, D.C. GEORGE H. POLLOCK, M.D., President, The Institute for Psychoanalysis, Chicago, Illinois THEODORE SHAP~Ro, M.D., Professor of Psychiatry in Pediatrics, Director of Child and Adolescent Psychiatry at Payne-Whitney Clinic, Comell University Medical College, New York, New York ROBERT S. WEISS, PH.D., Professor of Sociology, University of Massachusetts, and Lecturer in Sociology, Harvard Medical School, Boston, Massachusetts WILLIAM WENDT, S.T.D., Executive Director, St. Francis Center, Washington, D.C. Institute of Medicine President FREDERICK C. ROBBINS, M.D. Study Staff, Division of Men ta] Health and Behavioral Medicine MARIAN OSTERWETS, PH.D., Study Director VICTORIA SOLSBERRY, M.S.W., Research Associate JANICE L. KRUPNICK, M.S.W., Staff Consultant FREDRIC SOLOMON, M.D., Director, Division of Mental Health and Behavioral Medicine PATRICIA A.R. Wows, Study Secretary RACHEL HUGHES EDMUNDS, Division Secretary *Member, Institute of Medicine iv
Acknow~edgmen Is This study was initially requested and funded by the Office of Preven- tion of the National Institute of Mental Health, with additional support from the Kenworthy-Swift Foundation, New York, for the work on chil- dren's reactions to bereavement. Stephen Goldston, Ed.D., Director of the Office of Prevention, National Institute of Mental Health, lent enthu- siastic support to the project from its Inception to its completion. Two other NIMH staff members were especially helpful in various phases of this study: Morton Silverman, M.D., Chief, Center for Prevention Re- search, and Barbara Silver, Ph.D., Special Assistant, Office of the Direc- tor. The project was launched at the Institute of Medicine by Delores Par- ron, Ph.D., who served as project director from October 1982 to January 1983. Useful background papers or critical reviews of chapters were provided by the following people: lack Barchas, M.D., Stanford University Medi- cal School; Maurice Eisenbruch, M.D., Harvard Medical School; Glen El- liott, Ph.D., M.D., Stanford University Medical School; Barry Garfinkel, M.D., University of Minnesota Medical School; John Mason, M.D., Vet- erans Administration Medical Center and Yale University; Phyllis Silver- man, Ph.D., Massachusetts General Hospital, institute for Health Pro- fessions; Albert SoInit, M.D., Yale University School of Medicine; Marvin Stein, M.D., Mount Sinai Medical Center, New York. We especially wish to thank: Janice L. Krupoick, M.S.W., staff consultant, who not only prepared the chapter on children's reactions to bereavement, but also assisted in the drafting and revising of the chapters on adults' reactions to be- reavement and on interventions; Leonard Rosenblum, Ph.D., Downstate Medical Center, New York, who prepared the chapter on monkeys' responses to separation and contrib- uted to the biology chapter; Linda Starke, who provided major editorial assistance to the staff and the committee as the report was being written; and Pamela Steele, who designed this book and researched illustrations. v
Con ten Is Chapter ~Introduction PART I. BEREAVEMENT: REACTIONS AND CONSEQUENCES Chapter 2 Epidemiologic Perspectives on the Health Consequences of Bereavement .. ... 15 The Question of Outcomes / The Constellation of Distress and Chef / Adverse Health Consequences of Bereavement / Risk Factors / Conclusions and Recommendations / References Chapter 3 Adults' Reactions to Bereavement . . . . . . . . . . 47 The Phenomenology of Chef / The End of the Bereavement Pro cess / Explanatory Models of the Bereavement Process / Con clusions and Recommendations / References Chapter 4 Reactions to Particular Types of Bereavement . 71 Death of a Spouse / Death of a Child / Pennatal Death / Death of a Parent Dunng Adult Life / Death of a Sibling Dunng Adult Life / Bereavement Following Suicide / Conclusions / Refer ences · - V11
vm / Contents Chapter 5 Bereavement During Childhood and Adolescence Developmental Considerations / Methodological Issues / Out comes of Childhood Bereavement / The Grieving Process in Children / Variables Affecting Processes and Outcomes / Inter ven~on Strategies / Recommendations for Future Research / References PART II. PERSPECTIVES ON BEREAVEMENT Chapter 6 Toward a Biology of Grieving Animal Models / Biologic Studies of Bereaved Human Beings / Promising Research Approaches / Chef as an Adaptation in a "Psychoneuroimmunoendocnne System" / Conceptual Frameworks / Conclusions / References 99 145 Chapter 7 Monkeys' Responses to Separation and Loss . . 179 Vanations in the Response to Loss / Phases of Reaction to Loss / Presepara~on Influences / Effects of the Separation Environment / Research Recommendations / References Chapter ~Sociocultural Influences . . . . . . . . . . . . . . . . . . 199 The Societal Context / The Cultural Backdrop / Conclusions and Recommendations / References PART m. ASSISTING THE BEREAVED Chapter 9 Roles of Health Professionals and Institutions . 215 Roles During the Dying Penod / Practices Around the Time of Death / Continuing Responsibilities of Health Professionals and Institutions/ Enhancing the Work of Health Professionals / Conclusions and Recommendations / References Chapter 10 Bereavement Intervention Programs. . . . . . . . . 239 The Mutual Support Approach / Hospices / Psychotherapeutic Interventions for the Bereaved / The Role of Medications / Sun~- mary and Conclusions / References Chapter ~ ~ Conclusions and Recommendations Index 283 297
