A PERSPECTIVE ON THE CURRENT STATE

Death Studies. 28: 289-308 2004 BrunnerRoutledge heaths ciencies ISSN: 0748-1187 print/1091-7683 online DOl:0.108007481180490432315 A PERSPECTIVE ON THE CURRENT STATE OF DEATH EDUCATION ①①①①①①①①①①①①①①如①①①的①①①①①①①①①①①①的①①如①①①①如①如①①① ⊥ ANNELORE WASS Gainesville. Florida. USA The authoroffers some views on the current state of death education with focus on the spar- ing attention given the death education of health professionals and of grief counselors. There is need for improved integration of the knowledge accumulated in the study of death schools. Facilitation of personal engagement woith the issue of mortality is an important component of the educate Various assessment problems are outlined and some uggestions for improvements are offered. The death education needs of various group including school age children andolderadults, are noted. The article contains a list of r reer ences, many not cited in the text, recommended for an extensive review of developments in It is satisfying to see this special issue of Death Studies devoted to honoring d remembering Herman Feifel, philosopher, psychologist, research cientist, professor, and the pivotal force in the death awareness move- ment and the development of the study of death. His achievement as prime mover and contributor to thanatology has been recognized by is colleagues through numerous honors and awards. The latest in his life was the "Gold Medal Award for Life Achievement in the Application In paying tribute to Herman Feifel in a discussion of death education, it is fitting to note that he was the first modern death educator. The Received 25 August 2003; accepted 2 October 2003. Address correspondence to Hannelore Wass, 601x N.w.54th Way, Gainesville, FL $2653 E-mail: wass(@ nersp nerd ufl. edu By the American Psychological Foundation, 2001 289

???????????????????????????????????????????????????? A PERSPECTIVE ON THE CURRENT STATE OF DEATH EDUCATION ???????????????????????????????????????????????????? HANNELORE WASS Gainesville, Florida, USA The author offers some views on the current state ofdeath education with focus on the spar￾ing attention given the death education of health professionals and of grief counselors. There is need for improved integration ofthe knowledge accumulated in the study of death, dying, and bereavement into the basic curricula of the parent disciplines and professional schools. Facilitation of personal engagement with the issue of mortality is an important component of the educative process.Various assessment problems are outlined and some suggestions for improvements are offered.The death education needs of various groups, including school age children and olderadults, are noted.The article contains alist of refer￾ences, many not cited in the text, recommended for an extensive review of developments in death education. It is satisfying to see this special issue of Death Studies devoted to honoring and remembering Herman Feifel, philosopher, psychologist, research scientist, professor, and the pivotal force in the death awareness move￾ment and the development of the study of death. His achievement as prime mover and contributor to thanatology has been recognized by his colleagues through numerous honors and awards. The latest in his life was the‘‘Gold Medal Award for Life Achievement in the Application of Psychology.’’1 In paying tribute to Herman Feifel in a discussion of death education, it is fitting to note that he was the first modern death educator. The Received 25 August 2003; accepted 23 October 2003. Address correspondence to Hannelore Wass, 601X N.W. 54th Way, Gainesville, FL 32653. E-mail: wass@nersp.nerde.ufl.edu 1 By the American Psychological Foundation, 2001. 289 Death Studies, 28: 2897308, 2004 Copyright #Taylor & Francis Inc. ISSN: 0748-1187 print / 1091-7683 online DOI: 10.1080/07481180490432315

A. Wass scientific symposium on"Death and Behavior" he organized and pre sented to the 1956 Annual Meeting of the American Psychological Asso- ciation, was a powerful and consequential educational act. The fact that it took more than two years to locate a publisher for the Proceedings speaks not only to the prevailing silence on the subject of death in the 1950s. but also to Feifel's strength of conviction and determination to break the taboo. He agreed that the "death awareness movement "can be considered a synonym for"death education" in the broadest sense Beginning with the 1960s, considerable efforts have been expended to develop and refine death education programs. Attention has been paid to important aspects of death education. They include(a)articulation of goals,(b)consideration of content and perspectives, (c)teaching methods,(d)teacher competencies, and(e)evaluation. Compared to the pioneering days of thanatology, we have seen advances in death edu cation offered to a variety of stakeholders including college students, the general public, primary-and secondary-level students, health pro fessionals, and grief counselors. In a wide range of programs, such as full semester courses, teaching units for public school students, and short workshops for professionals, it is apparent that attention has been paid to planning, goal setting, execution, and evaluation. Herman Feifel's influence, as his emphasis on the multidisciplinary nature of death studies and his insistence that death education benefits all (including children),(Feifel, 1977) is apparent. Most particularly, the humanistic perspective-the philosophical foundation of the study of death he articulated--is reflected in the goals of death education, which stress both acquisition of knowledge and development of self- understanding and clarification of values, meanings, and attitudes toward death. The range of experiential activities designed to assist with such personal engagement illustrates the commitment to this goal. It is a tribute to his leadership that despite institutional pressures, the over- whelming amount of death literature available, and the temptation to intellectualize death, this humanistic goal is still pursued (e.g, Attig, 1992; Gould, 1994; Papadatou, 1997) Because of space limitations in this special issue, I have chosen to examine the current state of death education for health professionals he basis for his 1959 path breaking book, The Leaning of Death. Personal communication at the Conference on Death and Dying: Education, Counseling and Care. December 1-3. 1976. Orlando Florida

scientific symposium on ‘‘Death and Behavior’’ he organized and pre￾sented to the 1956 Annual Meeting of the American Psychological Asso￾ciation, was a powerful and consequential educational act.The fact that it took more than two years to locate a publisher for the Proceedings2 speaks not only to the prevailing silence on the subject of death in the 1950s, but also to Feifel’s strength of conviction and determination to break the taboo. He agreed that the ‘‘death awareness movement’’ can be considered a synonym for ‘‘death education’’ in the broadest sense.3 Beginning with the 1960s, considerable efforts have been expended to develop and refine death education programs. Attention has been paid to important aspects of death education. They include (a) articulation of goals, (b) consideration of content and perspectives, (c) teaching methods, (d) teacher competencies, and (e) evaluation. Compared to the pioneering days of thanatology, we have seen advances in death edu￾cation offered to a variety of stakeholders including college students, the general public, primary- and secondary-level students, health pro￾fessionals, and grief counselors. In a wide range of programs, such as full semester courses, teaching units for public school students, and short workshops for professionals, it is apparent that attention has been paid to planning, goal setting, execution, and evaluation. Herman Feifel’s influence, as his emphasis on the multidisciplinary nature of death studies and his insistence that death education benefits all (including children), (Feifel, 1977) is apparent. Most particularly, the humanistic perspective
the philosophical foundation of the study of death he articulated
is reflected in the goals of death education, which stress both acquisition of knowledge and development of self￾understanding and clarification of values, meanings, and attitudes toward death.The range of experiential activities designed to assist with such personal engagement illustrates the commitment to this goal. It is a tribute to his leadership that despite institutional pressures, the over￾whelming amount of death literature available, and the temptation to intellectualize death, this humanistic goal is still pursued (e.g., Attig, 1992; Gould, 1994; Papadatou, 1997). Because of space limitations in this special issue, I have chosen to examine the current state of death education for health professionals 2 The basis for his 1959 path breaking book,The Meaning of Death. 3 Personal communication at the Conference on Death and Dying: Education, Counseling, and Care, December 173, 1976, Orlando, Florida. 290 H. Wass

Perspective on Death Education and for grief counselors. I present some overall conclusions about the place and state of death education today, based in par rt on a review of aspects of death education not included in this article. However I have listed references not cited in this text that i recommend for an extensive review of death education. The conclusions I offer come from the van- tage point of a person who has lived as these developments occurred and who has, for better or worse, contributed in some part to this history There have been considerable advances in knowledge pertinent to care the end of life, contributing to the understanding of dying persons nd their loved ones. Application of this understanding in education has mproved the quality of care provided in a variety of health care settings, hospices in particular, but also including hospitals and homes. Promising developments are underway in education and program development focusing on care in neglected clinical settings(e.g, intensive care units nd for neglected populations (e.g, African Americans in urban and rural communities, and residents in prisons). They are important steps toward achieving equity in the care of dying persons The development and increasing use of counseling and ce services to organizations and agencies involved in emergency to terror attacks, plane crashes, multiple murders, and natural cata strophes is a substantial achievement in the area of grief counseling Likewise, crisis intervention programs in the public schools have been offered for public school students, including attempts to introduce long term suicide prevention(e.g, Leenaars Wenckstern, 1991; Stevenson, 1994) Nonetheless, death education for health professionals and death edu cation for grief counselors are of considerable concern. It is important however, to keep in mind Feifel's(1982)observation that we are embedded in our time and culture.. each generation contends with the presence of death--raging against it, embracing it, attempting to domesticate it. and. at the same time. his further observation that although we are more knowledgeable and realistic about death. there is a persisting avoidance. There are numerous indications of avoidance and ambivalence in our current death system as well. Breath-taking advances in medical and biological sciences, such as genetics, genomics, on"Death in Contemporary America"to the American sychological Association in 1981 and presented the proceedings in a special issue of Death Educa tion which he guest-edited in 1982, 6(2)

and for grief counselors. I present some overall conclusions about the place and state of death education today, based in part, on a review of aspects of death education not included in this article. However I have listed references not cited in this text that I recommend for an extensive review of death education. The conclusions I offer come from the van￾tage point of a person who has lived as these developments occurred and who has, for better or worse, contributed in some part to this history. There have been considerable advances in knowledge pertinent to care at the end of life, contributing to the understanding of dying persons and their loved ones. Application of this understanding in education has improved the quality of care provided in a variety of health care settings, hospices in particular, but also including hospitals and homes. Promising developments are underway in education and program development focusing on care in neglected clinical settings (e.g., intensive care units) and for neglected populations (e.g., African Americans in urban and rural communities, and residents in prisons). They are important steps toward achieving equity in the care of dying persons. The development and increasing use of counseling and consulting services to organizations and agencies involved in emergency response to terror attacks, plane crashes, multiple murders, and natural cata￾strophes is a substantial achievement in the area of grief counseling. Likewise, crisis intervention programs in the public schools have been offered for public school students, including attempts to introduce long￾term suicide prevention (e.g., Leenaars & Wenckstern, 1991; Stevenson, 1994). Nonetheless, death education for health professionals and death edu￾cation for grief counselors are of considerable concern. It is important, however, to keep in mind Feifel’s (1982)4 observation that ‘‘we are embedded in our time and culture ... each generation contends with the presence of death
raging against it, embracing it, attempting to domesticate it’’, and, at the same time, his further observation that although we are more knowledgeable and realistic about death, there is a persisting avoidance. There are numerous indications of avoidance and ambivalence in our current death system as well. Breath-taking advances in medical and biological sciences, such as genetics, genomics, 4 Feifel organized a symposium on ‘‘Death in Contemporary America’’ to the American Psychological Association in 1981 and presented the proceedings in a special issue of Death Educa￾tion which he guest-edited in 1982, 6(2). Perspective on Death Education 291

A. Wass proteonics, and in new technologies, such as nanotechnology and regen eration technology, raise expectations for further extending human lives and unrealistic hopes for physical immortality bolstered by a flourishing anti-aging industry. Thus, criticism of death education efforts must be mpered by consideration of the larger cultural context in which these efforts are made Death education for health Professionals Pioneers in the study of dying patients and their care during the 1960s called for reform and spent their careers working toward achieving it Leading educators in the health professions have been mindful of the humanistic component in death education, attempting to balance train- ing for practical skills with attention to personal understanding and attitudes(e. g, Bertman, 1991; Papadatou, 1997; Quint Benoliel, 1967, 1982). During the early years great advances were made in the study of pain control and symptom management for the terminally ill,even- ually leading to legislation in the United States that entitles patients to compassionate pain relief" including controlled substances. One might expect that those responsible for preparing health professionals would have been eager to revise their curricula based on the data accumulating since the 1960s. However, it was primarily nursing schools that devel oped courses in death education. The most visible effect of the new teach ng was the development of hospice programs as an alternate to traditional“care” Care for the Dying in Hospice and Hospitals In professional education, the ultimate test of quality education lies in the effectiveness of care or counseling. Even though successful, hos workers have been criticized for the paucity of empirical evidence(by traditional standards of scientific inquiry) documenting efficacy. This evidence of hospice success has come largely from qualitative studies, clinical reports, and a wealth of personal narratives and testimonials by patients and their families. Despite nearly 30 years of hospice care in the United States, the mainstream medical community failed to gener- ally adopt its principles and practices for caregiving in hospital Because one of the major findings in early studies(Quint, 1967)showed

proteonics, and in new technologies, such as nanotechnology and regen￾eration technology, raise expectations for further extending human lives and unrealistic hopes for physical immortality bolstered by a flourishing anti-aging industry. Thus, criticism of death education efforts must be tempered by consideration of the larger cultural context in which these efforts are made. Death Education for Health Professionals Pioneers in the study of dying patients and their care during the 1960s called for reform and spent their careers working toward achieving it. Leading educators in the health professions have been mindful of the humanistic component in death education, attempting to balance train￾ing for practical skills with attention to personal understanding and attitudes (e.g., Bertman, 1991; Papadatou, 1997; Quint Benoliel, 1967, 1982). During the early years great advances were made in the study of pain control and symptom management for the terminally ill, even￾tually leading to legislation in the United States that entitles patients to ‘‘compassionate pain relief’’ including controlled substances. One might expect that those responsible for preparing health professionals would have been eager to revise their curricula based on the data accumulating since the 1960s. However, it was primarily nursing schools that devel￾oped courses in death education.The most visible effect of the new teach￾ing was the development of hospice programs as an alternate to traditional‘‘care.’’ Care for the Dying in Hospice and Hospitals In professional education, the ultimate test of quality education lies in the effectiveness of care or counseling. Even though successful, hospice workers have been criticized for the paucity of empirical evidence (by traditional standards of scientific inquiry) documenting efficacy. This evidence of hospice success has come largely from qualitative studies, clinical reports, and a wealth of personal narratives and testimonials by patients and their families. Despite nearly 30 years of hospice care in the United States, the mainstream medical community failed to gener￾ally adopt its principles and practices for caregiving in hospitals. Because one of the major findings in early studies (Quint, 1967) showed 292 H. Wass

Perspective on Death Education the lack of communication between physicians and patients with subse quent adverse effects on patients, it is important to determine what changes have occurred since then Klenow and Young(1987) reviewed the literature on physicians'com- munication with terminally ill cancer patients from the 1960s to the 1980s. They reported a dramatic shift from withholding diagnosis and prognosis to telling patients the truth. However, they also pointed to shortcomings in this literature(e.g, sample selection, response rates that undermine these findings. With the establishment of advance direc tives, the communication issue has become more complex. Findings from the most extensive study of dying in hospitals (involving over 9,000 patients in five major medical centers) indicate that most physi- cians do not know about patients'end-of life wishes, and of those who know, only 15% talk with patients (SUPPORT/ Investigators, 1995) Similarly, a key concern of hospice pioneers was to achieve optimal pain/symptom control in order to allow patients to live their last days nd to die with dignity. Many more pain centers have been established in the United States and abroad since the early days of hospice care, enabling sophisticated pharmaceutical and other means to control pair Yet in the study cited above nearly half of the dying patients in hospitals endured moderate to severe pain, and nearly half spent their last 10 days in intensive care units Medical and nursing education Not surprisingly, there has been inadequate attention to death and dying in medical curricula at all levels. Dickinson is a long-time observer of death education in medical, nursing, and other health-related profes sional schools. In a 1975 survey of U.S. medical schools he found that only half of them offered something more than"a lecture or two"on the subject of death. Moreover, most course offerings listed were electives, d fewer than 10%o offered a full course(Dickinson, 1976). More recent surveys indicated improvement. By the 1990s nearly all medical, nur sing, pharmaceutical, and social work schools offered some education about death and dying, most of it integrated into the basic curricula. In most schools, that consisted of only a few lectures. Full course offerings were improved over the past but still inadequate(13% in schools of med- icine, 15% in nursing). Full-course electives were taken by a fourth of the students. When queried about future plans, half of the medical and

the lack of communication between physicians and patients with subse￾quent adverse effects on patients, it is important to determine what changes have occurred since then. Klenow andYoung (1987) reviewed the literature on physicians’ com￾munication with terminally ill cancer patients from the 1960s to the 1980s. They reported a dramatic shift from withholding diagnosis and prognosis to telling patients the truth. However, they also pointed to shortcomings in this literature (e.g., sample selection, response rates) that undermine these findings.With the establishment of advance direc￾tives, the communication issue has become more complex. Findings from the most extensive study of dying in hospitals (involving over 9,000 patients in five major medical centers) indicate that most physi￾cians do not know about patients’ end-of life wishes, and of those who know, only 15% talk with patients (SUPPORT/Investigators, 1995). Similarly, a key concern of hospice pioneers was to achieve optimal pain/symptom control in order to allow patients to live their last days and to die with dignity. Many more pain centers have been established in the United States and abroad since the early days of hospice care, enabling sophisticated pharmaceutical and other means to control pain. Yet in the study cited above nearly half of the dying patients in hospitals endured moderate to severe pain, and nearly half spent their last 10 days in intensive care units. Medical and Nursing Education Not surprisingly, there has been inadequate attention to death and dying in medical curricula at all levels. Dickinson is a long-time observer of death education in medical, nursing, and other health-related profes￾sional schools. In a 1975 survey of U.S. medical schools he found that only half of them offered something more than ‘‘a lecture or two’’on the subject of death. Moreover, most course offerings listed were electives, and fewer than 10% offered a full course (Dickinson, 1976). More recent surveys indicated improvement. By the 1990s nearly all medical, nur￾sing, pharmaceutical, and social work schools offered some education about death and dying, most of it integrated into the basic curricula. In most schools, that consisted of only a few lectures. Full course offerings were improved over the past but still inadequate (13% in schools of med￾icine, 15% in nursing). Full-course electives were taken by a fourth of the students.When queried about future plans, half of the medical and Perspective on Death Education 293

A. Wass nursing schools had no plans to offer or expand death education. Time constraints, no need, and limited faculty resources were the main expla nations given(Dickinson, Sumner, Frederick, 1992, Dickinson Mermann, 1996). Serious inadequacies in palliative care education in the United Kingdom have been reported as well. Surveys showed th average medical student received approximately 6 hours of death related instruction, and at best, 20 hours in a 5-year medical curriculum (Doyle, 1991 ). Surveying nursing and medical school faculties in Canada and the United Kingdom, Downe-Wambow Tamlyn(1997)reported results similar to those by Dickinson for the United States. Death educa- tion was included in most programs, mostly integrated into regular cur- ricular offerings or offered as an elective, and only a small minority required a full course. Nursing programs in both countries provided a broader range of topics and allocated a greater number of hours to class and clinical sessions than did programs in medicine which focused marily on pain control/hospice care and ethical/legal issues. In both countries. the theorist most often discussed in death education was Elizabeth Kubler-Ross. Death education content was taught primarily by faculty members of the respective disciplines, except for the United States medical programs in which half the teaching was provided by other disciplines, such as psychiatrists, social workers, and nurses (Dickinson et al., 1992) Content analysis of professional textbooks further indicated the se ous neglect of care for dying patients. An examination of 50 best-selling medical textbooks in multiple specialties in terms of content in 13 end- of-life domains, found that with few exceptions (e.g, family medicine, geriatrics), content in end-of-life care is minimal or absent(Rabow et al., 2000). Nursing textbooks have been found similarly deficient Examination of 50 major textbooks used in nursing schools on 9 essen- tial content areas in end-of-life care showed. overall. less than 2% of he content was devoted to end-of-life care(Ferrel, Virani,& Grant, 1999) Paramedics are among other professionals that routinely work in death-related situations and are often first-line respondents to families in distress and grief. The literature is scant on death education for this group. In a national survey of paramedic programs, Smith and walz (1995) reported that nearly all programs offered some death education that is integrated into their curricula and only a small fraction offered a separate course. The didactic method of instruction was most frequently

nursing schools had no plans to offer or expand death education. Time constraints, no need, and limited faculty resources were the main expla￾nations given (Dickinson, Sumner, & Frederick, 1992; Dickinson & Mermann, 1996). Serious inadequacies in palliative care education in the United Kingdom have been reported as well. Surveys showed the average medical student received approximately 6 hours of death￾related instruction, and at best, 20 hours in a 5-year medical curriculum (Doyle,1991). Surveying nursing and medical school faculties in Canada and the United Kingdom, Downe-Wambow & Tamlyn (1997) reported results similar to those by Dickinson for the United States. Death educa￾tion was included in most programs, mostly integrated into regular cur￾ricular offerings or offered as an elective, and only a small minority required a full course. Nursing programs in both countries provided a broader range of topics and allocated a greater number of hours to class and clinical sessions than did programs in medicine which focused pri￾marily on pain control/hospice care and ethical/legal issues. In both countries, the theorist most often discussed in death education was Elizabeth Kˇbler-Ross. Death education content was taught primarily by faculty members of the respective disciplines, except for the United States medical programs in which half the teaching was provided by other disciplines, such as psychiatrists, social workers, and nurses (Dickinson et al., 1992). Content analysis of professional textbooks further indicated the ser￾ious neglect of care for dying patients. An examination of 50 best-selling medical textbooks in multiple specialties in terms of content in 13 end￾of-life domains, found that with few exceptions (e.g., family medicine, geriatrics), content in end-of-life care is minimal or absent (Rabow et al., 2000). Nursing textbooks have been found similarly deficient. Examination of 50 major textbooks used in nursing schools on 9 essen￾tial content areas in end-of-life care showed, overall, less than 2% of the content was devoted to end-of-life care (Ferrel, Virani, & Grant, 1999). Paramedics are among other professionals that routinely work in death-related situations and are often first-line respondents to families in distress and grief. The literature is scant on death education for this group. In a national survey of paramedic programs, Smith and Walz (1995) reported that nearly all programs offered some death education that is integrated into their curricula and only a small fraction offered a separate course.The didactic method of instruction was most frequently 294 H. Wass

Perspective on Death Education used. Most textbooks practically ignore death and only a minority of respondents use supplemental material so that paramedic graduates may have read less than one page of death-related text. What death edu- cation is available is inadequate. It offers little opportunity for partici- pants to become knowledgeable about death and grief, to deal with their own feelings, or to develop empathy New Developments in End-of-Life Care education Since 1995, medical and associations have made recommen- dations for and developed end-of-life education programs. These programs have been designed to assist physician and nurse educators in self-directed study, to conduct continuing education programs, and to integrate end-of-life information into their basic curricula. For example the American Academy of Hospice and Palliative Medicine in 1996 developed Unipacs, a training program in hospice and palliative care for physicians, consisting of eight modules, with content including assessment and treatment of pain and other symptoms, alleviating psy chological and spiritual pain, ethical and legal decision making, com munication skills, hospice/palliative approach to caring for patients withHivaiDsandforpediatricpatients(www.aahpm.org/) In 1998 the American Medical Association developed the progran EducationforPhysiciansonEnd-of-lifeCare"(epec)(www.epec net/), consisting of 20 modules. In addition, programs were developed to fit into particular programs. For example, the American Academy of mily Physicians prepared guidelines for a curriculum for family prac- tice residents on end-of-life care. This organization added physicians personal attitudes toward death as a component of the program. Similar programs have been developed for nurses. The American Association of Colleges of Nursing recommended competencies and curricular guidelines for end-of-life nursing and in 2000, based on these guidelines, designed the"End of Life Nursing Education Curriculum"(ELNEC (www.aacn.nche.edu/elnec/curriculum.htm Death education for grief Counselors Most counseling models for bereaved people were derived from tradi- tional psychotherapeutic interventions and focused almost exclusively

used. Most textbooks practically ignore death and only a minority of respondents use supplemental material so that paramedic graduates may have read less than one page of death-related text.What death edu￾cation is available is inadequate. It offers little opportunity for partici￾pants to become knowledgeable about death and grief, to deal with their own feelings, or to develop empathy. New Developments in End-of-Life Care Education Since 1995, medical and nursing associations have made recommen￾dations for and developed end-of-life education programs. These programs have been designed to assist physician and nurse educators in self-directed study, to conduct continuing education programs, and to integrate end-of-life information into their basic curricula. For example, the American Academy of Hospice and Palliative Medicine in 1996 developed Unipacs, a training program in hospice and palliative care for physicians, consisting of eight modules, with content including assessment and treatment of pain and other symptoms, alleviating psy￾chological and spiritual pain, ethical and legal decision making, com￾munication skills, hospice/palliative approach to caring for patients with HIV/AIDS and for pediatric patients (www.aahpm.org/). In 1998 the American Medical Association developed the program ‘‘Education for Physicians on End-of-Life Care’’ (EPEC) (www.epec. net/), consisting of 20 modules. In addition, programs were developed to fit into particular programs. For example, the American Academy of Family Physicians prepared guidelines for a curriculum for family prac￾tice residents on end-of-life care. This organization added physicians’ personal attitudes toward death as a component of the program. Similar programs have been developed for nurses. The American Association of Colleges of Nursing recommended competencies and curricular guidelines for end-of-life nursing and in 2000, based on these guidelines, designed the ‘‘End of Life Nursing Education Curriculum’’ (ELNEC) (www.aacn.nche.edu/elnec/curriculum.htm). Death Education for Grief Counselors Most counseling models for bereaved people were derived from tradi￾tional psychotherapeutic interventions and focused almost exclusively Perspective on Death Education 295

A. Wass on traumatic bereavement and complicated grief reactions. Therapy for trauma and pathological grief traditionally have been the domain of psychiatrists or clinical psychologists, often affiliated with psychiatric hospitals, outpatient services, or in private practice (Raphael Middletoa, Martinek, Misso, 1993). Early studies in adult bereave ment led to the establishment of mutual and self-help services and orga nizations. As more data were generated grief counseling evolved into a professional specialty. Leading experts have questioned the need for such a specialty, suggesting that well-trained and experienced mental health professionals, such as clergy, funeral directors, and physicians, can learn with short-term training what is needed to counsel"normall bereaved people, whereas the issues in grief therapy require more in- depth preparation(Worden, 1991). However, others observed that this distinction is not being made in practice(e. g, Raphael et al., 1993) The preparation of grief counselors has consisted primarily of conti nuing education programs such as workshops, seminars, summer insti tutes, and the like and has been widely dispersed. The need for such further education is shown in studies. Less than 50% of graduate pro grams in clinical psychology and related professions cover death-related problems, such as suicide(mongar Harmatz, 1991). And there is evi- dence to suggest that beginning counselors feel intensely uncomfortable when faced with client issues concerning grief or impending death (Kirchberg Neimeyer, 1991). A follow-up study showed that high levels of discomfort were predictors of personal fear of death, suggesting that death and grief counselors with high death anxiety are vulnerable. In addition, an overall low level of empathy was found (Kirchberg, Neimeyer, &James 1998). Participants in death education programs for grief counselors may include graduates with beginning or advanced degrees in psychology, the health professions, or other areas. They may be offered by educational institutions, professional associations, and hey may be hospital-, community-, or agency-based and provided by private organizations. Because of their large numbers, they are difficult to track or to study to ascertain quality and consistency. The inadequacy of preparation of counseling practitioners revealed in the Kirchberg Neimeyer studies were also found in surveys. In a national survey of counselors and counselor educators, Rosenthal(1981)found more than 80% of the respondents recognized the need for grief education and Internet search engines provide thousands of links to training programs

on traumatic bereavement and complicated grief reactions.Therapy for trauma and pathological grief traditionally have been the domain of psychiatrists or clinical psychologists, often affiliated with psychiatric hospitals, outpatient services, or in private practice (Raphael, Middletoa, Martinek, & Misso, 1993). Early studies in adult bereave￾ment led to the establishment of mutual and self-help services and orga￾nizations. As more data were generated, grief counseling evolved into a professional specialty. Leading experts have questioned the need for such a specialty, suggesting that well-trained and experienced mental health professionals, such as clergy, funeral directors, and physicians, can learn with short-term training what is needed to counsel‘‘normally’’ bereaved people, whereas the issues in grief therapy require more in￾depth preparation (Worden, 1991). However, others observed that this distinction is not being made in practice (e.g., Raphael et al., 1993). The preparation of grief counselors has consisted primarily of conti￾nuing education programs such as workshops, seminars, summer insti￾tutes, and the like and has been widely dispersed. The need for such further education is shown in studies. Less than 50% of graduate pro￾grams in clinical psychology and related professions cover death-related problems, such as suicide (Bongar & Harmatz, 1991). And there is evi￾dence to suggest that beginning counselors feel intensely uncomfortable when faced with client issues concerning grief or impending death (Kirchberg & Neimeyer, 1991). A follow-up study showed that high levels of discomfort were predictors of personal fear of death, suggesting that death and grief counselors with high death anxiety are vulnerable. In addition, an overall low level of empathy was found (Kirchberg, Neimeyer, & James 1998). Participants in death education programs for grief counselors may include graduates with beginning or advanced degrees in psychology, the health professions, or other areas. They may be offered by educational institutions, professional associations, and they may be hospital-, community-, or agency-based and provided by private organizations. Because of their large numbers,5 they are difficult to track or to study to ascertain quality and consistency.The inadequacy of preparation of counseling practitioners revealed in the Kirchberg/ Neimeyer studies were also found in surveys. In a national survey of counselors and counselor educators, Rosenthal (1981) found more than 80% of the respondents recognized the need for grief education and 5 Internet search engines provide thousands of links to training programs. 296 H. Wass

Perspective on Death Education only slightly over half had any. In a national survey of the formal mental health training of paid hospice staff, more than half reported the need for further training(Garfield, Larson, Schuldberg, 1982). About half of the respondents were trained by social workers or physicians, a third by nurses, and a fourth by counselors. The training format was didactic, 90% lecture and 84% readings To further complicate the picture regarding the preparation of grie counselors, many of the agents that provide training have made certifi- cates available, of special importance in the United States and Canada here no state or provincial grief counseling or therapy certification is required(Wolfe, 2003). Reports of dubious and bogus credentials in mental health counseling(Woody, 1997)make this issue urgent. A few studies have begun to examine credentials of grief counselors(zinner, 1993 In recent years attempts have been made to avoid some of the frag- mentation and truncation in preparing grief counselors. Several univer sities and colleges have begun to offer an alternative to continuing education for preparing professionals. For example, Brooklyn College of New York City offers a 33 credit hour concentration in conjunction with an M.A. degree program in Community Health. Hood College in Frederick, Maryland offers a Masters Degree, and Kings College in London, Ontario offers undergraduate and graduate certificates in death-related counseling. Some Conclusions Less than a fifth of students in the health professions are offered a full ourse on death; the rest typically are provided death-related content in a few lectures. This lack of depth dissatisfies teaching faculties and leaves graduates entering their professions inadequately prepared to care for dying people and their families or to counsel bereaved or suici- dal people. Thus although the contemporary study of death, dying, d bereavement is remarkable in scope and range, the knowledge accumulated has not substantially affected the curricula of the health, And only a minority of primary and secondary school studen ntion/prevention, depriving too many of the potential benefit of these interven-

only slightly over half had any. In a national survey of the formal mental health training of paid hospice staff, more than half reported the need for further training (Garfield, Larson, & Schuldberg, 1982). About half of the respondents were trained by social workers or physicians, a third by nurses, and a fourth by counselors.The training format was didactic, 90% lecture, and 84% readings. To further complicate the picture regarding the preparation of grief counselors, many of the agents that provide training have made certifi￾cates available, of special importance in the United States and Canada where no state or provincial grief counseling or therapy certification is required (Wolfe, 2003). Reports of dubious and bogus credentials in mental health counseling (Woody, 1997) make this issue urgent. A few studies have begun to examine credentials of grief counselors (Zinner, 1993). In recent years attempts have been made to avoid some of the frag￾mentation and truncation in preparing grief counselors. Several univer￾sities and colleges have begun to offer an alternative to continuing education for preparing professionals. For example, Brooklyn College of New York City offers a 33 credit hour concentration in conjunction with an M.A. degree program in Community Health. Hood College in Frederick, Maryland offers a Masters Degree, and King’s College in London, Ontario offers undergraduate and graduate certificates in death-related counseling. Some Conclusions Need for Integration Less than a fifth of students in the health professions are offered a full course on death; the rest typically are provided death-related content in a few lectures. This lack of depth dissatisfies teaching faculties and leaves graduates entering their professions inadequately prepared to care for dying people and their families or to counsel bereaved or suici￾dal people.6 Thus although the contemporary study of death, dying, and bereavement is remarkable in scope and range, the knowledge accumulated has not substantially affected the curricula of the health, 6 And only a minority of primary and secondary school students are provided death education or suicide intervention/prevention, depriving too many of the potential benefit of these interven￾tions. Perspective on Death Education 297

A. Wass counseling, or teaching professions or related disciplines of psychology and sociology. What happens to this knowledge? Much of it will reside in the journal literature to be shared with other professionals in thanatology without benefit to the mainstream fields and parent disciplines and ultimat the general public whom it is intended to serve. Data suggest a pattern of resistance at the institutional level. The barriers essentially consist of the failure to acknowledge the need for death education and, closely related, a lack of commitment, primarily of resources. The pursuit of better integration should be the shared responsibility of thanatologists and professionals in the related fields. Fortunately, some of the barriers are starting to come down. Recent programs in education for end-of-life care for nurse/physician educators and practitioners are promising beginnings toward correcting existing deficiencies Attending to the personal dimension short exposure to death education invariably means that the knowl- edge transmitted is inadequate and that little or no attention is paid to the personal dimension, that is, encouraging students to confront, clar- ify, and share personal understandings and attitudes about death. The personal dimension is the component intended to help students to deal with their anxieties, to become comfortable interacting with people in crisis, and to develop empathy- -attributes that make caregiving a humane and compassionate task for professionals and non-professionals alike. It is also a reason why educators should be familiar with the basics of group dynamics and able to create psychologically"safe"environ ments for small group discussions, role-playing, and other experiential activitie Packaging and bundling death education into portable modules or packs may be efficient but discourages spontaneity in interactions between teachers and participants. Self-directed study may be econom- ical but it deprives the learner of the opportunity for face-to-face inter- actions with a live teacher and others in a group of participants- essential aspects of the learning experience. In self-directed study it is more difficult to become comfortable with the subject of death, to ease anxiety and worry, and to develop empathy. Self-directed and distance education are valuable and appropriate if the goal of death education is transmission of knowledge. It is far less appropriate for attending to the

counseling, or teaching professions or related disciplines of psychology and sociology. What happens to this knowledge? Much of it will reside in the journal literature to be shared with other professionals in thanatology without benefit to the mainstream fields and parent disciplines and ultimately the general public whom it is intended to serve. Data suggest a pattern of resistance at the institutional level. The barriers essentially consist of the failure to acknowledge the need for death education and, closely related, a lack of commitment, primarily of resources. The pursuit of better integration should be the shared responsibility of thanatologists and professionals in the related fields. Fortunately, some of the barriers are starting to come down. Recent programs in education for end-of-life care for nurse/physician educators and practitioners are promising beginnings toward correcting existing deficiencies. Attending to the Personal Dimension Short exposure to death education invariably means that the knowl￾edge transmitted is inadequate and that little or no attention is paid to the personal dimension, that is, encouraging students to confront, clar￾ify, and share personal understandings and attitudes about death. The personal dimension is the component intended to help students to deal with their anxieties, to become comfortable interacting with people in crisis, and to develop empathy
attributes that make caregiving a humane and compassionate task for professionals and non-professionals alike. It is also a reason why educators should be familiar with the basics of group dynamics and able to create psychologically ‘‘safe’’ environ￾ments for small group discussions, role-playing, and other experiential activities. Packaging and bundling death education into portable modules or packs may be efficient but discourages spontaneity in interactions between teachers and participants. Self-directed study may be econom￾ical but it deprives the learner of the opportunity for face-to-face inter￾actions with a live teacher and others in a group of participants
essential aspects of the learning experience. In self-directed study it is more difficult to become comfortable with the subject of death, to ease anxiety and worry, and to develop empathy. Self-directed and distance education are valuable and appropriate if the goal of death education is transmission of knowledge. It is far less appropriate for attending to the 298 H. Wass