Using narratives to express bereavement : An interview study on professional female writers experiences that in their middle age have lost their mothers

Objectives of the study were to increase the knowledge about women who in their middle age have lost their mothers and to investigate the therapeutic value of expressive writing in the grief process according to the women. Method: An interview was carried out with 18 professional female authors about their writings about death of a close relative, their mothers. They were asked to tell about the grief and what the writing meant to them. Results: All authors described in narratives. Some results were evident such as; feelings of relief by writing and their reflections and memories became clear. As authors of imaginative literature they were use to the process of writing. Conclusions: The evidence from this study offers useful information for nurses to plan and design programmes based on narrative structures in nursing care.


INTRODUCTION
During some decades there has been an ongoing interest in research on people who has lost a close relative.The historical perspective can be mirrored in the classic Trauer und Melancholie [1], it has been stressed that people in grief are at risk, facing a severe stress factor [2].The fact is that almost every human being is likely going to experience this kind of stress sometimes in life.In early research it was stated that reactions caused by death of a relative are similar in spite of differences like age, situation and other circumstances [3].There are somatic as well as psychological reactions.Antonovsky is perhaps today even more used in analyses of the process of grief in his work with Sense of Coherence [4].One way of working through the grief is to write about it.The writing may be in the shape of diary or letters and the most common is that nobody is supposed to read it.The writing goes on for a while in order to make some release, a way of coping [5].
Some of the writings are more public, made by authors in order to reach a group of readers.
In the present study 18 authors have expressed their feelings in different ways and they are aware of that people react differently towards their writing.Writing about trauma feelings and grief gives meaning and relief although the sorrow dominated in the initial stage [6].
The aim of the study was to increase the knowledge about women's experiences that in their middle age have lost their mothers.The present study will capture the experiences of their grief expressed in their written stories.In addition; to investigate the therapeutic value of expressive writing as a therapeutic approach in the grief process according to the authors.
The main question put forward to the participants was: What is your experience of writing about grief after a mother has died?

Writing about Emotional Experiences as a Therapeutic Process
Earlier research shows that for years practitioners have used different forms of writing to help people heal from stress and trauma.Research today suggests that expressive writing may offer physical benefits to people with life threatening diseases.Studies by those in front position of this research suggest that writing about emotions and stress can improve immune functioning in patients with different diseases [6][7][8].It has to be pointed out that writing does make a difference.It depends on the population being studied and the writing form.The key to the effectiveness of writing depends on an improved understanding of emotions.The power of writing lies not in pen and paper, but in the mind of the writer.Writing or talking is not enough to relieve stress and thereby improve health [9].In a controlled intervention study two groups were compared, one group wrote about the most stressful event of their lives and the control group wrote about a neutral subject in their daily life.The stressful-writing group showed improvement on objective and clinical evaluations compared to the control group [10].
Another study lifts forward the positive health outcomes of expressive writing [7], However there is still much to be done to answer the questions how and why expressive writing works.This might be attributed to the fact that expressive writing affects people on multiple levels, cognitive, emotional, social, psychological and biological.

Sense of Coherence and Recovery from Depression
More than 20 years have passed since the American-Israeli sociologist Antonovsky introduced his salutogenic theory Sense of Coherence, meaning the way people view their life influences their health.The theory claims that Sense of Coherence is universal and can be applicable to any culture.Later research has proved that this is the case [11,12].Sense of Coherence develops over the life span.Quality of life and Sense of Coherence proved to be the core of health promotion.This theoretical framework could be considered a way to health promotion.It focuses on finding solutions and it helps people to move in the direction of positive health [4].Sense of coherence is a way of viewing the world and one's life.Three dimensions are described; comprehensibility, manageability and meaningfulness [13].Comprehensibility meaning the extent to which an individual perceives the situation as cognitively meaningful, manageability meaning the degree to which an individual perceives her resources to meet internal and external demands, meaningfulness meaning the degree to which an individual feels that life is emotionally meaningful and her problems as a challenge rather than hindrance.There is also a connection between a positive evaluation of a person's life history and his or her sense of coherence.The theory described above captures important aspects on an existential level.Lindeman [3] was the psychiatrist who laid the ground for modern crisis theory.He found some common symptoms in people who had experienced severe grief.His investigation was carried through by interviewing relatives of those who died in a fire in USA, the known Coconut grove fire in Boston 1942.He formulated clinical features including somatic distress such as psychosomatic symptoms as sleeping problems, loss of appetite are understandable and common.In addition, the development of crisis interventions is built on chock, reaction, working through, and reorganisation [14].

Narratives and Storytelling in Coping with Grief
Much work on death, dying, grieving, and bereavement discusses the role of stories in coping with these fundamental human processes.The value of narratives has been suggested by several authors [15,16] As we care for patients, we listen to their stories.Narratives examples are embedded in research describing the levels of competency in clinical nursing practice.The essentials are outlined as a reflection in nursing as a way in which we bridge the theory-to-practice gap [17].
Story telling can provide nurses with a tool for motivating change."Telling the right story at the right time can help a patient understand the importance of adherence to a treatment plan" [18, p. 2] or decide to make critical lifestyle changes.Storytelling is not a new.For generations, we have relied on stories from our ancestors to teach us values and expectations.The role of storymaking in disclosure writing was fruitful although the story was not "good" [19].Stories can help people explore other ways of feeling [20].Forming a story about one's grief could improve physical and mental health.Storytelling can be regarded as one of the oldest healing arts; it has been used for centuries as a universal way for the grieving person to cope with loss [15].An experience of loss of a loved one's death can disrupt the person's world.Many have an inherent desire to understand and recover from a loss; this may be accomplished by creating an account or a story to find meaning in the loss.To assimilate a major loss the grieving person needs to create a private personal story and then confide that story to others [21].We are a society that in general denies grief, and avoids the emotion whenever possible.Many find support in writing and sharing their experiences with others, knowing they are not alone in their feelings of grief [20,22].

MATERIAL AND METHOD
The research method used in the present study was qualitative interviews, a method that capture the informant's view.Semi structured interviews were conducted with women authors (n = 18).The stories are based on the experiences of women authors' grief of a mother's dead.The women authors were in their middle age.
The procedure followed five steps: Step 1: Literature from Nordic countries written by women authors concerning their own grief were looked for.By using the librarian's databases was found 18 authors.The key-words were: Women, grief, Nordic Countries.
Step 2: The first contact was via media and publications companies in order to get mailing or post address.The second contact was to send a letter that contends a guide of questions.The third contact was contact by phone with each author.Place of interview was chosen by the interview-person.The interview was tape-recorded and transcribed verbatim.Eleven interviews lasted for 1 hour and one for 2 hours and one for 2.5 hours.One interview was a phone-interview.One answered by a written letter.
Step 3: The interviews were transcribed.
Step 4: The result of the interviews were analysed with qualitative content analysis [23].The design of the study is based on the three sub processes-data reduction, data display and conclusion drawing/verification [24].
Step 5: The analyses were carried out according to Antonowsky with the following themes; comprehensible, management and meaningfulness [13].And according to Lindemann [3] with following themes; reoccupation with image of the deceased, feelings of guilt, and finally according to Cullberg [14] with following themes: working through and reorganisation.
There can be no validity without reliability, a demonstration of validity is sufficient to establish the reliability.They use the term dependability in qualitative research which they argue closely corresponds to the notion of reliability in quantitative research [25].In the present study this aspect is considered meaning that reliability is a consequence of the validity.The criteria for establishing trustworthiness in the present study were credibility and dependability.Credibility was ensured by describing and identifying those participating accurately and dependability relied on credibility.A qualitative research study that establishes credibility will also be dependable [26].In the present study dependability was assured by following a clear research procedure, and discussing decisions taken about theoretical choices with a research colleague.The analyses were used to ensure that the meaning units in a category were not only derived from one interview.By doing this it was possible to get consistency of the categories.At this stage the informants were contacted so that they could validate what they were trying to convey in the material.
Although the categories were consistent and valid, all aspects of the material were not clearly displayed.Since the aim was to describe the meaning of the writing about the grief process was a complex procedure.
Validity was assured in three ways.The first level was feedback during the interviews to assure a correct understanding of the participants' comments.The second level constituted the participants stories.The third level was connection of the interpretation to previous research in the area.To give validation of the accuracy of findings, literature was referenced in appropriate places, and themes were validated with [23,27].Rigor was achieved when a clear decision trail was followed.This meant that any reader or another researcher could follow the progression of events in the study, and understand the logic and justification for what was actually done and why [28].
The rules were followed regarding the participants receiving the usual assurance about anonymity, confidentiality and the right to withdraw at any point without prejudice.Comments are directly quoted, while always ensuring that the speaker is not identified.From an ethical perspective, the qualities as judged by the Declaration of Helsinki are that the research design and the need in society for such a project are deemed to be of importance.Informed consent was conducted with each of the authors.
Analysis consists of women authors' perceptions of the writing process, and its effects on bereavement.The starting point for the analysis is qualitative.A qualitative analysis of the women authors' accounts was made in several steps using the analytical technique described in qualitative research [25,29].A close examination of data was conducted, and compared for similarities and differences.The first step was a content analysis of the tape-recorded and transcribed interviews.Each of the written accounts was read several times in order to grasp the content.Second, each account was studied to identify qualitatively different comments which together make up the total account.Each comment was considered a unit of analysis and is defined as an utterance that provides new information about the women authors' impressions and opinions [30].Questions were asked about the phenomena as reflected in the data and reviewed for emerging themes.These were categorised, coded, and counted.
Open coding of each interview classified the data and allowed identification of categories.However, the researcher's cultural and linguistic understanding of the phenomenon is the prerequisite for coming to an understanding of participant's accounts.

RESULTS AND DISCUSSION
Writing the story about one's experiences in life has beneficial effects on illness symptoms and is associated with improved physical and mental health.There are benefits in telling the story [18].To take away the pain and grief experienced following a loss might not be possible, however we can always listen.Listening to a patient's story of loss or of illness, if even for just a few moments, can be beneficial in healing and recovering from the loss.
In the present study associations were found between Sense of Coherence and subjective physical well-being, and a stable but dynamic feeling of confidence.The discussion follows the steps in Sense of Coherence: Comprehensible-a belief that things happen in an orderly and predictable way, you can understand events in your life and reasonable predict what will happen.Events are perceived as structured and predictable.
Management-a belief that you have the ability, help, support, recourses necessary to take care of this and that things are manageable within your control.Necessary resources are available to cope with internal and external demands-manageability.
Meaningful-a belief that things in life are interesting and a source of satisfaction, and that things are really worth it and that there is a good reason or purpose to care about what happens.Life is felt to be meaningful and demands perceived as challenges deserving investment dedication.

Comprehensible
All interview persons talked very much about the feeling of the writing process.It was a combination of good and bad feelings as in the following statements:

*Relieving but heavy … like to get rid of a heavy burden … a beginning of self healing *It was an absolute feeling … it is important to find your own way of writing, short or long … to find your own words … not think so much about quality … grammatical rules *To write down my feelings was difficult…. Much inside … as well as a good feeling ... work through and … I recommend reading about it
Some interview persons also talked about the therapeutic process: *A small therapeutic procedure … it is a natural thing for me to put feelings into words

*... of course it is healing in every kind of grieving process … I m convinced that is true for every person
*The writing process is self therapeutic … it is important to get it on paper in order to take one step at a time in the bereavement process *I used to write diary … I wrote because I wanted to … important to share with others my experiences step by step … in the important process … a way to keep the memory alive … I thought it could be important to write from the social point of view.… It should mean something to lift forward a picture of my mother who was a simple woman from the country This is in line with previous research about storytelling as a way to express feelings, and to cope with loss [15,[20][21][22].

Management
One way to manage was to isolate oneself in a sense of not being vulnerable.

*I didn't want that anyone felt sorry for me … it should be direct from my heart *It was a good feeling to write ... to think and lift forward thoughts. One other way of defence is to focus on the natural thing in life to lose your mother, trying not to feel all the feelings which occur... *I had a feeling that grown up women must not grieve an old mothers dead … the death of a mother is a natural thing in life, nothing unexpected …
The next was to identify unsolved feelings as in following quotations: *... but the relationship often has many unsolved feelings that make the bereavement special and difficult … therefore I thought it was important to put into words the grief *You write to understand.You write because your memory hunts you.You write because you have to... *I wrote in order to share my experiences of my mother's death with other persons … for myself it was therapy... *I am convinced that the writing process is self therapeutic, not only in bereavement … many write diary … you could see the writing process as an instrument to understand your feelings and yourself better ...

Meaningful
To make the situation meaningful to themselves different cognitive solutions were expressed: *I wrote because my mother was a central person in my life, as are all mothers, not at all kind … a lot was not said between us … a lot of misunderstanding from my point of view since teenage … hatred and long periods of silence.I felt a need to share my feelings with others how my life had been as well as for my self...

Life is felt to be meaningful and demands perceived as challenges deserving investment dedication ...
Another author said: *I thought I couldn't be sad … I was middle-aged and my mother was old … I couldn't grieve her because I was grown up when she died and she was old.
Still it becomes important to write: … it was important to write … it was purely therapeutic to write about my grief … all feelings … memories connected to what I have carried inside me ... she was surprised indeed about her feelings and made it all meaningful by writing ...
Previous research shows that storytelling was fruitful although the story was not "good" [19].
In the long run: *Bereavement as a process over time that leads to self healing.Looking back and reflecting … it develops into missing, a missing that you never leave since long existential … with death you never negotiates … you accept … while self therapy over time continue ...

*… makes it more clear … it is only later you realise that the words help you … a kind of conversation … closeness to the person who has died … a cry, guilt, a prayer about forgiveness … *I am convinced of the healing power … self therapy … at first I did hide behind everything else
Working through according to Lindemann and Cullberg a theory to use when it is about psychic trauma, grief and trying to cope with the situation.Due to Lindemann some important symptoms are: Preoccupation with the image of the deceased, guilt-feelings, hostile reactions and behavioural change.It was expressed by the participants in words like:

*Relieving but heavy … like to get rid of a heavy burden … a beginning of self healing *… makes it more clear … it is only later you realise that the words help you … a kind of conversation … closeness to the person who has died … a cry, guilt, a prayer about forgiveness
The psychosomatic symptoms as sleeping problems, loss of appetite are understandable and common.Still nobody focused on that.
The theory of crises is built on the psychological phases; chock, reaction, working through and reorganisation [14].In the present study it was obvious that those women who have written their books are beyond the phases of chock and reaction and are in the phases of working through and reorganisation.It is evident in the answer presented below; … it was important to write … it was purely therapeutic to write about my grief … all feelings … memories connected to what I have carried inside me ... It was also evident that they found support in their reorganisation as one author said: *I am convinced that the writing process is self therapeutic, not only in bereavement … many writes diary … you could see the writing process as an instrument to understand your feelings and yourself better ...

The dimension of time
The interviews were carried out some years after the participants had written their stories.
Time aspects are important in the interview situations.This is a question that always appears when doing research about psychological trauma.What meaning has the time according to the answers one get.We think that in this study it was of rather importance that it was women who were used to reflect on feelings perhaps with some other person after construction and intellectualization.The women writers formulated similar experience although the interviews were carried out with each individual, face to face.
The interview persons were very eager to tell the story of their own about the writing, and what kind of content and effect it had upon their working through the grief, and for the reorganisation of life.They were openminded in their telling and would share their own experience with other individuals.It would be possible to use the word narrative because of the time spend with the interview persons and their openness to the study although the result has been discussed only from selected citations.It was necessary because of the number of interview persons, (n18).One might have done a more narrow selection, one or two persons, and done a deep interview.
Narrative analysis has become widely used technique for understanding a person's accounts of their life.There is considerable variation in defining personal narratives.The founder of narrative theory is often said to be Aristotle.He studied the plan in drama, known as poetics telling stories play in the grief process for coping and healing?By what means has writing about a mother's death been part in the grieving process?
The results of the interviews in this study build upon valuable knowledge and experiences of women writers.The study indicates that telling a story about the death of an elderly mother stimulate the grief process in a positive direction.The findings could be connected to the theory of Antonovsky [4].He describes three dimensions; comprehensibility, manageability and meaningfulness which are to be found when analysing the results.Comprehensibility could be exemplified by an extract such as "Relieving but heavy … like to get rid of a heavy burden … a beginning of self healing".It shows whether an individual perceives the situation as cognitively meaningful.Manageability the degree to which the respondents perceive their resources to meet internal and external demands.It could be exemplified by the extract; "I realized that I had something to tell … I had a feeling that grown up women must not grieve an old mothers dead … the death of a mother is a natural thing in life, nothing unexpected … but the relationship often has many unsolved feelings that makes the bereavement special and difficult … therefore I thought it was important to put into words the grief".Meaningfulness, according to Antonovsky is most important.If a person believes there is no reason to persist and confront challenges, then she or he has no motivation to comprehend and manage events.Meaningfulness could be exemplified with an excerpt such as; "Bereavement as a process over time that leads to self healing.Looking back and reflecting … it develops into missing, a missing that you never leave.since long existential … with death you never negotiates … you accept … while self therapy over time continue".According to Antonovsky it is the degree to which an individual feels that life is emotionally meaningful and her problems as a challenge rather than hindrance.In the present study the excerpts expressed by the respondents follows the theory of Antonovsky which captures important aspects of an existential level.
One theory to use in order to explain the writing is the theory about grief and crisis formulated by Lindemann and Cullberg [3,14].In present study it was used only to explain the two phases of working through and reorganisation.The interview was very much focused on the writing as a way of cope with the grief and it become natural to save the two phases as Cullberg stated Working through and reorganisation.Lindeman had some impact on the interpretation of guilt feelings and grief.
In line with the results in the present study is research by Pennebaker [6,7].He suggests that writing about emotional experiences, although painful in the days of writing, produces long-term improvements in mood and indicators of well-being.Writing helps a person focus and organize the experience [20].Stories can help people explore other ways to express feelings [15].In the present study participants' writing was a desire to understand and recover from a loss; this may be accomplished by creating an account or a story to find meaning in the loss.To assimilate a major loss the grieving person needs to create a private personal story and then confide that story to others [21,31].
Many people find relief in writing and sharing their experiences with others, knowing they are not alone in their feelings of grief.Writing the story about one's experiences in life has been shown to have beneficial effects on illness symptoms and is associated with improved physical and mental health.

CONCLUSION
The results of this study suggest that nurses' experiences could be a potential means for promoting successful nursing care.The evidence from this study offers useful information for nurses to plan and design communication programs based on a narrative structure in nursing care.Communication programs should be built on the situation of the patient, offering a cognitive and emotional tool by which nurses can communicate with patents.There are benefits for health care providers and patients in telling a story.Physicians may be unable to take away the pain and grief experienced following a loss, however we can listen.Listening to a patient's story of loss or of illness, if even for just a few moments, can have beneficial effects for the patient.However, more data are needed in order to explore the means by which narrative communication can be successful.