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Bereavement: Reactions, Consequences, and Care (1984)

Chapter: 11 Conclusions and Recommendations

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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"11 Conclusions and Recommendations." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

CHAPTER 11 Conclusions and Recommendations In this chapter, the committee reca- pitulates its major conclusions and suggests directions for clinical prac- tice and future research. These conclusions and recommendations are organized around the three questions mandated for study. WHAT CAN BE CONCLUDED FROM AVAILABLE RESEARCH EVIDENCE ABOUT THE HEALTH CONSEQUENCES OF BEREAVEMENT? The evidence from clinical experience and several kinds of research- epidemiologic, case follow-up, clinical, and social science leads to several important conclusions. First, bereavement is associated with appreciable distress in virtually everyone. Second, the distress, which can vary greatly in intensity and in the extent of interference with func- tion, is Tong lasting. A survivor's way of life can be altered for as long as three years and commonly is disturbed for at least one year. Third, there is tremendous variation in individuals' reactions to bereavement. These reactions consist of a number of intertwined processes psychologic, social, and biologic. They cannot be neatly plotted in a series of well- defined stages, nor is movement from the impact of the death to the resolution of bereavement likely to be in a straight path. Individuals will vary in terms of speed of recovery and in the amount of laack-and- forth movement between phases. Fourth, as has been recorded in myth and literature over the centuries, and as suggested by individual clinical experience, some bereaved persons are at increased risk for illness and even death. 283

284 / Bereavement: Reactions, Consequences, and Care Most bereaved individuals do not become seriously ill or die follow- ing the loss of someone close, but there is good evidence linking be- reavement to a number of adverse health outcomes for some people. These health consequences include premature mortality, some medical and psychiatric morbidity, and health-damaging behaviors. Following conjugal bereavement, young and middle-aged widowers who do not re- marry are at increased risk of mortality for a number of years, especially during the first year. For women, there is some evidence suggesting in- creased mortality in the second year {but not the firstJ following be- reavement. Higher mortality rates in men are due to increases in the relative risk of death by suicide, accidents, cardiovascular disease, and some infectious diseases. In widows, the relative risk of death from cir- rhosis and perhaps suicide increases. The bereaved's increased alcohol consumption, smoking, and use of tranquilizers and other medicines are well documented, especially among people who used these sub- stances prior to the Toss. Thus, bereavement appears to exacerbate and precipitate health-compromising behaviors. During the early, "acute" phase of bereavement, most adults suffer a variety of symptoms, some of which also are characteristic of depres- sion. Yet the constant, painful awareness of Toss, together with the rela- tive absence of self-blame, makes it clear that ordinary grief is distinct from depression. Grief may, however, give way to depression; approxi- mately 10 to 20 percent of the widowed are still sufficiently sympto- matic a year or more after their loss to suggest real clinical depression. Although this proportion is relatively small, out of the approximately 800,000 people who are widowed each year, this means that 80,000 to ~ 60,000 people suffer serious depression in any given year. The number of depressed individuals following other types of bereavement death of a child, sibling, or parent-is not known. There are few good controlled studies linking bereavement to specific disorders. But the diagnosis-specific mortality rates, symptoms, and health behaviors just discussed suggest that bereavement may exacer- bate existing illnesses, precipitate depression leading to suicide, aggra- vate or lead to alcohol abuse that can result in cirrhosis of the liver, and leave people vulnerable to infectious diseases. Like adults, children exhibit a range of responses immediately follow- ing bereavement. Although some researchers have reported that chil- dren do not grieve in the same way as adults, a number of grief-like reac- tions have been noted, such as appetite and sleep disturbances and difficulty in concentrating. Like adults, bereaved children may com- plain of physical symptoms, especially abdominal pain. They may also

Conclusions and Recommendations / 285 withdraw and regress in their behavior. There is general agreement that school functioning both academic performance and social behavior- are adversely affected by bereavement. Not surprisingly, the way chil- dren react to death depends on their age and stage of development. Chum p~yeno~og~c symptoms or neurosis and depression have been observed in community and patient samples of children who have lost a parent or sibling. Several studies report a relationship between childhood bereavement and mental illness, especially depression, in adult life, as well as increased risk of suicide. There is evidence suggest- ing a link between this type of early Toss and adult impairment in sexual identity, capacity for intimacy, and development of autonomy. Thus, at least some bereaved children are at increased risk for a number of ad . ~ To 1 · ~ ~ . verse consequences. However, current data do not support the impres- sion that the negative results are as widespread or as inevitable as for- merly thought. Althouch the full impact of death on chilcTren mall nc`t v O ~ ~ '' ^^-by- ~ ~ 4 ~ ~ . , . be realized until many years later, many factors subsequent to the death-including the normal develonmentn1 ninth anal the ~r`7 ~i . · . . -a- a-- ---r-~ -~~ r~~~ ~1~ ~^ CaretaKerS WIl1 nave major effects on ultimate outcomes. Almost everyone adults and children is distressed when someone close dies, yet the nature of the distress and its manifestations depend on a host of factors relating to characteristics of the bereaved individual and of the deceased, the nature of the death, the nature and meaning of the relationship, and perceptions about the availability and adequacy of social support before and after the death. These factors also influence the outcomes of the bereavement process, including the health out- comes just discussed. Certain biologic, psychologic, social, and situa- tional factors that place individuals at risk or protect them from adver- sity are apparent prior to the loss, others are related to the death itself, and some become apparent in the early aftermath of bereavement. Although rigorous studies of these many risk factors have not heen ~ ~ . ~ , - , ~ conducted there are several that appear to be good predictors of certain outcomes of bereavement. Poor previous physical health is associated with poor physical health following bereavement. Mental illness, espe- cially depression, is likewise likely to be exacerbated following bereave- ment and to interfere with normal grieving. Perceived social support is the best replicated predictor of psychosocial adjustment. However, like marriage which appears to be a protective factor for men against poor health following a spouse's death it is not clear whether the mere pres- ence of social support leads to good outcomes, or whether people who were emotionally healthy to begin with are able to elicit social support to meet their needs following bereavement.

286 / Bereavement: Reactions, Consequences, and Care ARE THERE PREVENTIVE INTERVENTIONS THAT SHOULD BE MORE WIDELY ADOPTED IN THE HEALTH CARE SYSTEM? Viewed in its broadest sense, the term "preventive intervention" in- cludes education, assessment, and primary, secondary, and tertiary pre- vention. From that perspective, there are a number of informal and for- mal activities that the committee felt should be undertaken with the bereaved in the community and as a part of humane and professionally responsible practice. As discussed in Chapter 9, the committee's views in this area are based more on its own collective judgment and upon clinical case reports than on definitive research findings. The committee was struck by the large amount of advice in the litera- ture directed to the public and to health professionals, and by the enor- mous growth of lay and professional programs to assist the bereaved. Although much of the advice and many of the programs seem to rest on solid conceptual ground, very few studies have been conducted to deter- mine whether these concepts have been translated into appropriate in- tervention strategies or even to test their effects. Because of this lack of evidence on the efficacy of the many interven- tion strategies, the committee cannot recommend that as a matter of public policy any particular approach be more widely adopted at this time. However, the efforts to devise conceptually sound programs to as- sist the bereaved are to be commended and certainly should not be dis- continued. In fact, as discussed in Chapter 10 and in the final section of this chapter, the committee believes it is time to subject various inter- vention strategies to rigorous study so as to determine their benefit to particular groups of bereaved individuals. Practice Recommendations In the committee's view, the well-being of the family and others close to a dying patient is part of health professionals' responsibility in termi- nal illness. Furthermore, as indicated in Chapter 9, the committee be- lieves that health care professionals and institutions have a continuing responsibility to assist the bereaved. The education of health care pro- fessionals should prepare them to provide information, offer emotional support, recognize the red flags that may signal a need for professional mental health intervention, and be knowledgeable about both lay and professional community resources to which the bereaved can be re- ferred as appropriate and desired. Routine history taking in primary care settings should include questions about recent Tosses and attention to the individual's adjustment to them.

Conclusions end Recommendations / 287 This is not to suggest that health professionals must routinely engage in Tong-term counseling of the bereaved. The committee does suggest/ however, that within the context of ongoing medical care, professionals have some responsibility beyond simple human compassion to be- come knowledgeable about bereavement and skilled in dealing with it. Unfortunately, in most reimbursement schemes there is a strong disin- centive to provide the kind of follow-up activities described in this vol- ume as desirable. The committee hopes that, while progress is being made toward remedying this, institutions will recognize the impor- tance of such activities and will permit health professionals to spend time with the bereaved> even in the absence of direct reimbursement. That nursing and medical education should prepare health profession- als for this role is not a new proposal. It has been a matter of public and professional concern for a number of years. The committee thus en- dorses efforts to devise training methods that will better equip health professionals to deal with sensitive psychosocial issues, to be aware of their own limitations, and to have the necessary knowledge and skills to make appropriate referrals. In the committee's view, these skills must rest on the broader founda- tions that health and mental health education and preparation for the ministry provide in order to be effective. The committee cannot endorse the development and certification of a new profession for "grief coun- seling" that is separate from existing health and social services. Until better data are available on variations in grief responses among the members of ethnic and minority groups, health professionals should be aware that the phases, timing, and significance of grieving by individ- uals of different backgrounds may vary from those reported in studies of persons in the mainstream population. In particular, as discussed in Chapter 8, the likelihood of the distress following bereavement taking the form of physical symptoms, and the particular bodily complaints, may vary substantially by cultural group and social class. If they are un- aware of this possibility, health professionals might conduct needless and costly tests or prescribe unnecessary and potentially harmful treat- ment. Thus, the committee urges that caution be used in determining deviance from norms, almost all of which have been based on the main- stream Caucasian culture. It is readily apparent that most bereaved individuals do not need pro- fessional mental health treatment. Yet, there are certain symptoms and circumstances of bereavement that are likely to warrant professional in- tervention for people in all cultural groups. For both adults and chil- dren, a prior history of mental illness, especially depression, and the suicide of someone close are likely to render them especially vuIneralale

288 / Bereavement: Reactions, Consequences, and Care and therefore candidates for close professional monitoring following be- reavement. Persistent somatic complaints or depressive symptoms that do not lessen in intensity over time may also be signs of difficulty. In children, repeated aggressive or hostile behavior toward others, a pro- longed drop in school performance, or regressive and insecure behaviors that persist over time are additional signs that help may be needed. For adults, drug and alcohol abuse, other health-injurious behaviors, diffi- culty in maintaining social relationships, and an individual's own per- ception that he or she is not doing well should trigger a professional re- ferral for evaluation. Furthermore, if the occurrence of an individuals symptoms is associated with family dysfunction, it is logical to include family assessment and treatment when dealing with abnormal bereave- ment states. In the case of bereaved children, it seems clear there is a potential for long-term, enduring consequences. Whether the best way to handle this vulnerability is with routine, periodic "mental health check-ups" is not clear. Such check-ups might lead both parents and child to believe there will be problems potentially contributing to a self-fulfilling prophecy. Thus, in the committee's view, it would be better to educate those who interact with children {parents, teachers, pediatricians J to recognize the signs that indicate a need for professional mental health intervention than to have mental health workers routinely involved. As discussed in Chapters 2 and 10, a number of drugs are rather com- monly prescribed to help ease the pain of bereavement. Many physi- cians have been hesitant to prescribe medication, particularly tricyclic antidepressants, for patients experiencing grief reactions, even when these are intense, distressing, and disabling. The view is widely held that to suppress the grief experience will have later adverse conse- quences. Yet no controlled trials have been reported in the literature to assess the Tong-term or short-term, positive or negative effects of antide- pressants on grief. The absence of such trials is all the more striking in view of the fact that clinical reports indicate a substantial proportion of bereaved individuals are often prescribed sedatives and minor tranquil- izers, primarily for insomnia. Again, there are no controlled trials of the efficacy of such prescriptions. Quite clearly such studies are needed. In the absence of such data, the committee urges clinicians to exercise caution in prescribing medications for bereaved individuals. The committee noted with interest the various efforts of health care institutions to assist the bereaved and to support health professionals in their activities in settings made stressful by frequent death. Examples of institutional responses to the soon-to-be bereaved and recently bereaved that appear to be conceptually sound practices include the availability

Conclusions end Recommendations / 289 of well-trained social workers and chaplains to assist dying patients and their families, hospital-based support groups for parents who lose a newborn and for relatives surviving other kinds of deaths, liberal visit- ing hours to allow families to spend time with dying patients, efforts to work with families and patients who prefer to be at home, and sensitiv- ity to families' wishes regarding their presence at the time of death. Not only must health care institutions be concerned with the well- being of patients and their families. They must also pay attention to staff needs, especially in such stressful settings as intensive care units, emergency rooms, and cancer wards, and to the impact of management and organizational practices on staff functioning in such settings. Some mechanisms for monitoring staff emotional response to their work should be formalized. Regular meetings at which staff are encouraged to air their concerns, adequate back-up support from mental health profes- sionals, and clearly delineated roles on health care teams may help al- leviate the sense of isolation and overwhelming burden of individual re- sponsibility so commonly reported. Public Education Because of the fairly recent historical changes noted in this volume, including institutional care of the dying and geographic mobility of fam- ilies, most people have little direct contact with death and may not be prepared for its impact on their families. That the public wants informa- tion about bereavement is evidenced by the amount of attention paid to this topic in the mass media. In recent years there have been numerous articles, television shows, and radio programs dealing with people's re- actions to bereavement. Although there are no studies to document the effects of information on the bereavement process, the committee was struck by the widespread view that thorough information of several types can be beneficial and often seems to be lacking. As discussed in several chapters, people's reactions to bereavement often are so varied, intense, and unexpected that they and those around them may be caught off guard. People expect to fee! sad; they do not expect to be an- gry at the deceased. And yet anger is common. They may be surprised at how quickly their emotions swing from one feeling to another and at their inability to control their moods. Knowing how they are feeling, they may be surprised that others in the family seem to be reacting so differently. Numerous anecdotes are reported in the literature about the inappropriateness of well-meaning comments offered by friends of the bereaved.

290 / Bereavement: Reactions, Consequences, and Care These examples and many others discussed in this volume suggest that people need information to prepare themselves for the death of someone close and to respond sensitively to others in similar situations. As discussed in Chapter 10, this has been a major activity of many mu- tual support groups. Because bereavement is and should be handled largely by families and other informal social networks, public education about reactions to bereavement and how they might differ for adults and children, and for mothers and fathers, should be encouraged so that fam- ilies and friends can provide the best possible support for the bereaved. WHAT FURTHER RESEARCH WOULD BE ESPECIALLY PROMISING TO PURSUE? Throughout this volume, gaps in current understanding about the be- reavement process, its outcomes, and the methods to assist the be- reaved have been pointed out. Inadequacies in the data base, such as the narrow scope of research, lack of good multidisciplinary studies, and some pervasive methodologic problems, have hampered the develop- ment of definitive conclusions. In this section, the committee draws together its key recommendations regarding future research directions that seem especially promising. Research on the Processes and Outcomes of Bereavement Important health consequences of bereavement do exist, although they are not evenly distributed in the general population of bereaved people. As discussed in Chapters 2 through 5 and in Chapter 8, a large number of psychologic, social, situational, and biologic factors have been implicated as contributors to increased risk of adverse conse- quences. Few of these risk factors have been well studied. Their relative importance is not known, nor is much understood about which factors contribute to which outcomes. These influences are likely to interact in complex ways to place individuals at risk in some ways and protect them in others. In the committee's view, high priority should be given to research aimed at better documentation and refinement of those factors that place particular individuals or groups at high risk following the death of someone close. Current hypotheses about subpopulations that are at risk for particular adverse consequences should be tested, and prospec- tive studies should be designed to identify characteristics of new sub- groups. More definitive knowledge about individual risk factors and their interplay holds the promise of identification of high-risk individ

Conclusions and Recommendations / 291 uals and the design of interventions to prevent or mitigate specific nega- tive outcomes. To accomplish this goal, the scope of research must be broadened. Al- though there is a vast literature from many different disciplines, most of it is on conjugal bereavement in adults and parental bereavement in children. There are very few data on the nature and consequences of be- reavement following the death of a sibling at any age, of a child at any age, or of parents during adult life. Research on specific Tosses would clarify understanding of the special problems of each. Current under- standing of the relationship between bereavement and the nature of the death is also very limited. Second, the health consequences of bereavement, especially the med- ical ones, are less well researched for children than for adults who have lost a spouse. Most studies of children are retrospective and have not used control groups. Most are based on responses of children receiving mental health care or, in the case of very young children, are based on observations of institutionalized children. Controlled studies of com- munity samples of bereaved children should be conducted. Profession- als' current knowledge does not clearly indicate whether it is bereave- ment itself or the way a child is dealt with and cared for subsequently that has the most effect on Tong-term outcomes. Prospective longitudi- nal studies that follow children for many years could shed some light on . . i. llS lSSUe. Third, most of what is known about bereavement comes from obser- vations made in the United States, the United Kingdom, Australia, and Israel. The American literature, but for a few descriptive accounts, is limited almost exclusively to studies of white, usually middle-cIass, persons. How other socioeconomic, racial, and ethnic groups react psy- chologically, socially, and biologically to bereavement is not known. Thus, it is unclear how generalizable the current knowledge base is; this makes it difficult to develop intervention strategies that are appropriate to the needs of minority groups. Indeed, as pointed out in Chapter 8, there is reason to suspect that impoverished ethnic minority group members, recent refugees, and migrants may be at especially high risk for negative health outcomes of bereavement. This topic should be in- vestigated. Such research would benefit from interdisciplinary colIabo- ration of health researchers with anthropologists and with health pro- fessionals who share a cultural identity with the groups being studied. Research on these three groups individuals who have experienced vari- ous types of Tosses, children, and various sociocultural groups-would greatly expand the scope of current knowledge of the impact of bereave- ment upon specific subpopulations. 1

292 / Bereavement: Reactions, Consequences, and Care To refine this knowledge, research on the biology of grieving is also needed. As discussed in Chapter 6, grief produces ma jor perturbations in the respiratory, autonomic, and endocrine systems and may substan- tially alter cardiovascular and immune function as well. Much of the existing biologic research has been concerned simply with documenting these changes in animals and humans. In the committee's view, it is time now to focus on clinically relevant physiologic changes in humans in order to understand better the mechanisms by which reactions to be- reavement might result in actual illness. In particular, more information is needed on the long-term effects of Toss in order to understand how physiologic responses change over the course of grieving and how responses to loss compare with other re . . ~ . . - .. . .. spouses to stress. Actct~ona~ studies are needed on the basic neurophys- iologic parameters of grief responses in order to understand more fully the susceptibility of bereaved subjects to disease. The relationship be- tween the responses to Toss and responses to other life stresses and c1~- , , _ _ . . taller comparisons of neuroendocrine and other biologic changes ac companying Brief and depression are needed. Multidiscinlinan7 .~tllelie.~ rat ^ ~ v.~_- should be conducted of the relationships between the intertwined but not fully congruent behavioral, psychosocial, and biologic processes. This expanded knowledge of physiologic processes following bereave- ment and their relationship to other responses will contribute to the de- velopment of appropriate preventive interventions. Most studies, whether biologic or psychologic, focus on the first year of bereavement. But because most people now die of chronic illness with forewarning for their families the period of anticipatory grieving 1 r . ~ ~ ., ~ before the death deserves rigorous study. Furthermore, because it seems clear that for many people the grieving process continues beyond a year, studies should track bereaved individuals for a longer period of time. Thus, more prospective longitudinal studies that begin before and run for several years after bereavement are needed. Traditionally, health consequences have been studied in individuals, but there is a growing realization that the individual's reactions may be based partly on interactions with the individual's most intimate group, which usually is the family. The death of one member will affect each and every other member as well as the family system as a whole. Thus, following bereavement, the changes in roles, relationships, and func- tioning within the family could lead to symptoms or disease in one or more members. In order to fully understand this process, prospective studies of entire families are needed. Finally, all research in this field has suffered from certain method- ological shortcomings. It has been hampered by the lack of agreement

Conclusions end Recommendations / 293 concerning predictor variables and outcomes what things are appro- priate to measure, how to measure them, and what to consider as end- points. This problem is evident in the epidemiologic, psychosocial, and intervention studies. So long as researchers make idiosyncratic deci- sions about these issues, comparisons across studies can be made only tentatively. The committee therefore recommends that the National In- stitute of Mental Health jNIMH) sponsor a conference of scientists from the many professional disciplines involved in bereavement research to develop a consensus about predictors and outcomes so that future stud- ies will be more fully comparable. Although a great deal is known about various aspects of bereavement and its consequences, most of it is discipline-specific. Isolated findings from psychology and psychiatry and from the biologic, medical, and so- cial sciences each tell part of the story. But until more good multidisci- plinary studies are done, the bereavement process and the mechanisms that explain it cannot be fully understood. Without such studies, the interactions between risk factors will remain unclear and it will not be possible to confidently identify groups at high risk. Good cross-discipli- nary longitudinal studies also will provide the foundations for interven- tion strategies that are appropriate to the range of needs of bereaved in- dividuals. The committee recognizes the difficulties involved in Tong-term mul- tidisciplinary research. It is hard to get and keep a team of researchers together, and the research is expensive. There are special problems in- herent in studying people over time: the situation is not static, many intervening variables cannot be controlled, and there are practical diffi- culties involved in tracking people for years. Nonetheless, in the com- mittee's view, funding agencies should give high priority to such re- search because it is only through well-designed, Tong-term, prospective, multidisciplinary studies that the impact of bereavement will really be understood. Research on Intervention Strategies The committee strongly urges that a broad research initiative be un- dertaken to study the impact of various psychosocial and pharmacologic interventions on the course and consequences of bereavement. Such re- search should be conducted in the awareness of cultural diversity and individual variations in reaction to bereavement. It should be specific to age, sex, social class, ethnicity, nature of the loss, and phase of bereave- ment. The impact of interventions on the acute distress of bereave

294 / Bereavement: Reactions, Consequences, and Care meet, on social as well as biologic functioning, and on health are some of the outcomes that deserve study. Current knowledge about the four major types of interventions dis- cussed in Chapter 10 mutual support, hospices, psychotherapy, and drug therapy does not yield conclusions about the applicability and ef- fectiveness of specific interventions. There is a paucity of good outcome data regarding their efficacy, apparently for several reasons. In the case ~, . . . or one psycnornerapeut~c approaches, cont~dent~al~ty and small sample sizes have constrained research. In the case of mutual support groups and hospices, t: aere is typically no one associated with the programs who has research skills and there has sometimes been a reluctance to expose the programs to scrutiny. Although the committee does not wish to single out any one approach as more deserving of study than another, it notes that there is currently an opportunity to study hospice bereavement programs that should not be ignored. With the amendment of the Social Security Act in ~ 982, hos- pice patient care services will now be reimbursed by Medicare for a three-year period. Although bereavement services for families will not be directly reimbursed, hospice programs must include these services in order to qualify for Medicare. Increasingly large numbers of people are being served by hospices and standardized data collection requirements are being established. The diversity of programs should enable the study of various approaches to bereavement intervention in a naturally occur . . nng experiment. In the committee's view, the Health Care Financing Administration and other branches of the federal government should make bereavement studies one of the priority areas for research during this exnerimentn1 · ~, . ~. c, ~ - p~IlOU. 1 U IOCUS only on lermmal care and Its costs would be to ignore an integral part of the hospice program and to pass up a rare opportunity to conduct major studies of the preventive possibilities of bereavement support and its associated savings potential. In designing such studies, attention should be paid to possible distinguishing characteristics of families who choose the hospice option; those characteristics could have particular significance following bereavement and, if not identi- fied and controlled for, could confound the results of the efficacy of be- reavement interventions. Although each of the major forms of intervention has certain distinc- tive features, there is a great variation within each type as well as some similarities among the different approaches. This makes it difficult to draw conclusions about the applicability or efficacy of mutual support groups, hospices, or psychotherapy in general. In addition, the literature often does not specify enough details about the nature of a particular

Conclusions end Recommendations / 295 intervention or enough precision about its goals to permit valid compar- isons even within one of the broad approaches. Here, as elsewhere, the lack of agreement about which outcomes to measure, and when and how to measure them, has further limited the usefulness of the data that have been collected. Research initiatives in this area should encourage cooperation be- tween program administrators, clinicians, and researchers from several disciplines so that carefully controlled studies can be conducted. In the case of drug therapies, the lack of research is striking. There have been virtually no controlled trials on the efficacy of commonly prescribed hypnotics and minor tranquilizers or on the use of antidepressants with the bereaved. Neither the immediate nor Tong-term effects of using drug therapy alone or in conjunction with psychosocial intervention are known. Finally, the committee recommends that the NIMH establish a spe- cial ad hoc research review committee to deal with bereavement studies of all kinds. A broad research initiative in this area requires a review committee that understands the nature and complexity of bereavement; the state of the art in research on the process, outcomes, and interven- tions; the value of different methods of studying bereavement; and the problems involved in conducting good longitudinal, multidisciplinary research in this area. Although currently many specific gaps exist in our understanding of the bereavement process, it is time to begin to put the entire puzzle together to link research on mechanisms, processes, and outcomes to the identification of groups at high risk for adverse out- comes, and to determine the best way to help individuals who have lost someone with whom they had close emotional ties.

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"The book is well organized, well detailed, and well referenced; it is an invaluable sourcebook for researchers and clinicians working in the area of bereavement. For those with limited knowledge about bereavement, this volume provides an excellent introduction to the field and should be of use to students as well as to professionals," states Contemporary Psychology. The Lancet comments that this book "makes good and compelling reading....It was mandated to address three questions: what is known about the health consequences of bereavement; what further research would be important and promising; and whether there are preventive interventions that should either be widely adopted or further tested to evaluate their efficacy. The writers have fulfilled this mandate well."

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