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OCR for page R1
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
OCR for page R2
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.
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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
. · -
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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
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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
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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
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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
