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Original Research

A systematic writing program as a tool in the grief process: part 1

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Pages 425-431 | Published online: 06 Dec 2010

Abstract

Objective:

The basic aim of this paper is to suggest a flexible and individualized writing program as a tool for use during the grief process of bereaved adults.

Methods:

An open, qualitative approach following distinct steps was taken to gain a broad perspective on the grief and writing processes, as a platform for the writing program.

Results:

Following several systematic methodological steps, we arrived at suggestions for the initiation of a writing program and its structure and substance, with appropriate guidelines.

Discussion:

We believe that open and expressive writing, including free writing and focused writing, may have beneficial effects on a person experiencing grief. These writing forms may be undertaken and systematized through a writing program, with participation in a grief writing group and with diary writing, to achieve optimal results.

Conclusion:

A structured writing program might be helpful in promoting thought activities and as a tool to increase the coherence and understanding of individuals in the grief process. Our suggested program may also be a valuable guide to future program development and research.

Background

Interest in the therapeutic effects of writing has grown tremendously in the last few years. Comprehensive literature and research have indicated the effects of writing on an individual’s adjustment to challenging or traumatic experiences.Citation1Citation11 The benefits of writing are first and foremost associated with exploratory and expressive forms of communication. The results of several studies of writing and its effect on health indicate that a potential positive health gain is possible through writing about traumatic and challenging experiences.Citation3,Citation6Citation11 To write, narrate, and discuss thoughts and feelings may be a tool in the grief process as experienced by bereaved adults who have lost a close person in their lives.

According to process-oriented writing theory, language is related to thought. Writing is described as a creative process wherein the writer may experience new thoughts, increased awareness, and knowledge.Citation5,Citation12Citation14 The philosopher Lipps (referred to by Pahuus)Citation15 emphasizes that to experience is to be moved bodily by an impression, and that an articulation of the impression is a way to handle oneself. According to the philosopher Ricoeur,Citation16Citation18 to narrate is to reflect on events and, in the story, a pattern of understanding is formed based on one’s own experiences. This interweaving may yield new insights and new stories, and create coherence in life that allows the individual to adapt to an altered life situation.Citation16Citation18

Theoretical framework

Grief experience

Grief is a fundamental life experience, although it is difficult to explain or understand. The loss of a close relation and dealing with bereavement and grief are painful and demanding and may constrain life.Citation19,Citation20 The grief process can be understood as a movement between relearning the world and adaptation, dominated by multifaceted and overwhelming experiences.Citation21 Thoughts and feelings may vary in their nature and intensity throughout the grief process.Citation20,Citation21 Dealing with grief refers to the bereaved individual’s experience of handling grief and adjustment. Some central aspects of grief processing include being allowed to express the grief experience, gaining an awareness of the loss, and acknowledgment through new insights and organization. Moreover, the grief process involves retaining and sustaining some ties to the person who has died and adjusting to the new life situation.Citation5,Citation20 As grief and grief work are individual experiences, support must be directed specifically toward each distinct experience.

According to classic grief theory, grief and grief work are limited in time, and grief work is successful when the bereaved person is freed from his or her ties to the deceased.Citation19,Citation22,Citation23 More recent grief theory puts this understanding under question and emphasizes the positive value of the ties to the deceased as a source of further life enrichment.Citation5,Citation20,Citation24 The grief process refers to the bereaved individual’s experience of dealing with loss and adjusting to living with grief. It involves the whole life situation and is profound and overwhelming, and the bereaved person appears to be vulnerable.

Writing as a tool

Writing is an aid to reflection, a way to explore and discover one’s own thoughts and feelings.Citation2,Citation5,Citation12,Citation13 Writing down one’s own ideas opens a channel that allows a person to become acquainted with his or her own thinking potential.Citation5,Citation9,Citation12,Citation13,Citation25 Writing and forming a story involve reflection on events and contribute to self-understanding and new insight.Citation5,Citation9,Citation10 According to process-oriented writing theory, the active use of language stimulates and promotes thought activities and learning, and the practice of different forms of writing is suggested, such as free writing and focused writing.Citation5,Citation12

Writing yields new thoughts; ideas, images, and feelings can be put into words, leading to clarification, understanding, and structure.Citation5,Citation7,Citation26 Increased awareness, organization, new insights, and acknowledgment are factors that are essential in dealing with grief.Citation5 Therefore, there are several similarities between the writing process and the grief process. The creative element of the writing process may allow the bereaved to move on during the grief process because writing may become a tool for the expression of his or her thoughts and feelings, new insights, clarification, and reorganization.

Several expressive writing studies have involved participants writing about traumatic or emotional experiences in the laboratory for 3–5 sessions, often over consecutive days for 15–20 minutes per session. However, in more recent studies, writing has been performed at home and in clinical settings.Citation1,Citation2 Over the past 20 years, several studies have supported the notion that writing about traumatic and stressful events could bring about positive outcomes.Citation1 In these different studies, writing sessions, time between the sessions, and writing instructions have varied.

Writing in groups

Participation in groups may strengthen the power of writing. Writing in groups provides a major component of the rehabilitation process, and began to emerge in the 1950s. The group was seen as a social microcosm with important therapeutic properties of its own.Citation27 Group approaches have many advantages in the treatment of grief and loss caused by death. According to Keefe et al,Citation28 a group provides a setting in which patients can be in touch with others with similar problems. Group participation can help patients gain a better understanding of the grief situation and the role of their own behavior, thoughts, and feelings in their perception of the situation.Citation28 YalomCitation29 emphasized several important supportive factors that must be included in the group approach. These are the “self-revelation” and the “learning from others” factors.

Against this background, the basic aim of the current paper is to suggest a flexible and individualized writing program as a tool for use in the grief processes of bereaved adults.

Method

An open, qualitative approach, following distinct steps, was taken to gain a broad perspective on the grief and writing processes as a platform for establishing a writing program.

  1. A systematic literature search was undertaken.

  2. We identified some ways of writing as tools that can be related to grief experiences.

  3. We investigated how different forms of writing can support the grief process.

  4. We discussed and arrived at the basic key areas to be included: several topics for writing, writing forms, and writing situations.

  5. A writing program was developed based on these steps.

  6. Practical guidelines and keywords for initiating the writing process in the program were discussed and are suggested.

  7. Finally, we arrived at a suitable structure and participants for such a writing program.

Results

By following the methodological steps described above, we developed a comprehensive writing program for use as a tool in the grief process. This consists of the program structure, topics, writing situations, and writing forms, including guidelines and keywords.

For the structure of the writing program, we suggest that writing follows two parallel pathways, as illustrated in : writing in a grief writing group and writing at home in a diary. The number of group meetings and their duration are also described. “Bereaved adults” means people who have lost someone close to them as a result of death; the loss of a child is an exclusion criterion.

Table 1 Suggested structure of the writing program

The topics and writing situations of the writing program are described in . The central aspects of grief work are included, such as being allowed to express the feeling of grief, gaining an awareness of loss, retaining and sustaining some ties to the person who has died, acknowledgment through new insights, and adjustment to the new life situation.

Table 2 Topics for the writing program, including both writing situations: group and diary writing

The topics may be applicable to both free writing and focused writing. Some examples of the two writing forms are illustrated in .

Table 3 Examples of writing forms

Writing guidelines and keywords have been developed to make the writing process easy and to stimulate an open, exploratory, and direct form of writing (Appendix 1).

Discussion

The basic aim of this paper is to suggest a flexible and individualized writing program for use as a tool in the grief process of bereaved adults who have lost a close person as a result of death.

Our suggested writing program incorporates elements from several writing studies.Citation1,Citation2 Out of these studies some options are considered as particularly important, such as an expressive and explorative writing form, concentrated writing sessions, and writing several consecutive times. Several theories emphasize the benefits associated with writing, which support the development of our program. It is fundamental to process-oriented writing theory that language is related to thought. There is a dynamic relationship between thought and language.Citation12Citation14 Writing is a creative developmental process,Citation12,Citation13 and through this process thoughts emerge. The writer may experience increased awareness and gain knowledge.Citation12,Citation13,Citation26,Citation30 Writing theory also claims that this active use of language stimulates and promotes thought activity and learning, and that putting ideas, images, and feelings into words leads to clarification, understanding, and structure.Citation12,Citation26,Citation31 Based on writing theory, the topics in the writing program involve two forms of writing: free writing and focused writing. These are described in detail in the following section. We believe that by combining these writing forms, the grieving person can express his or her inner thoughts and feelings by both being close to and maintaining a distance from the grief process. We suggest that these forms of writing should be encouraged as processing tools in the writing program.

Benefits of free writing

Free writing is an informal, exploratory, and expressive form of writing. Several language and writing researchers stress that free writing is an introspective technique of discovery.Citation5,Citation26 This form of writing is personal; it is closest to an “inner speech” and the thought process itself.Citation12,Citation13 Free writing may open up for expressive writing, which is uncensored writing in which the writer is not concerned with whether the text appears presentable or is comprehensible to others. The writer may allow him or herself an undisguised and direct form of expression. Free writing is also described as a therapeutic tool because it leads to reflection and illuminates the writer’s life experiences.Citation5,Citation32,Citation33 Through this form of writing, a bereaved person can express his or her loss and painful thoughts. During a demanding grief process, this may empower the writer who cannot otherwise move on in the grief situation.

Therefore, this mode of writing may raise the writer’s awareness, which is another therapeutic effect of free writing.Citation5 Based on these assumptions and previous research,Citation1,Citation2 we believe that the participants should be encouraged to write in an expressive way. Therefore, assignments that encourage free writing must be formulated very openly, and for the program to succeed, some guidelines, inspired by Francis and Pennebaker,Citation6,Citation7 may be helpful (Appendix 1).

Benefits of focused writing

Assignments that encourage focused writing are more clearly defined because the writer must respond to a more specific challenge. By introducing limitations on the topic, by appealing to a more defined form of writing, writing of a more informative kind may result.Citation5,Citation30 Thus, the writer has a chance to move thoughts on the subject a little to the background. Therefore, a narrower assignment based on focused writing may be experienced as less burdensome.

When an individual is dealing with very difficult, unpleasant, and painful issues in the grief process, focused writing may be experienced as gentler than a direct, undisguised, free-writing form. However, because we all build on our own experiences and interpretation of the world when writing, what is created through writing and expressing will always be related to these personal experiences.Citation5,Citation16Citation18 In this way, practicing both free-writing and focused-writing forms may strengthen the effect of each and lead to new insights and extended perspectives.

Benefits of writing in a group

The literature concerning the benefits of group participation is essentially in accord, which includes interpersonal learning and active supervision.Citation5,Citation27,Citation28 The beneficial components of group participation have been shown to include a feeling of community with the other participants and the possibility of talking to others about difficult thoughts and feelings.Citation5 The bereaved person finds him or herself in a vulnerable situation, which requires individualized assistance. Participation in a writing program allows both individualized and group benefits. All types of people can benefit from writing about their emotions.Citation2 Traditionally, grief groups have been conducted for periods of 3–5 months, although the length and content may vary.Citation5 This writing program is proposed to last for 5 months, during which time group meetings are held every 2 weeks during the initial 3 months, with one meeting in each of the subsequent 2 months, resulting in a total of 10 meetings. We argue that during this period, the participants may have gained sufficient insight and self-help that they can more easily adapt to their new life situations. We emphasize that some assumptions must be made beforehand regarding the suitability of the grieving person for participation in the suggested writing program, considering factors such as motivation, open-mindedness, and basic writing ability.

It has been proposed that the writing program’s various assignments or subjects concretize various aspects of the grief process, in a movement that involves relearning the world and adaptation.Citation21 Our suggested program represents a flexible and individualized approach to the grief process. We also suggest that group members suffering similar types of loss should participate in the same group. However, the structure and assignments described may be the same in different contexts. The time between the loss experience and participation in the program may vary. What is of primary importance is that the people themselves admit that they require some sort of help and that they are sufficiently motivated to attend the program.

Implications for practice

This writing program is meant for bereaved adults who have lost a close person as a result of death, although not the loss of a child. We suggest that throughout this writing program, the writing should be performed along two parallel tracks: writing in a grief writing group and writing at home in a diary (). The leaders of the grief writing groups should be professional supervisors. We suggest that in each group meeting, the writing should be centered on a subject or an assignment ( and ). When writing at home in a diary, the participants should write according to their personal wishes or initiative. However, some keywords should be given to help each individual get started (Appendix 1). The participants must be informed that it is essential that they write openly and spontaneously, with no concern for punctuation or correct grammar (Appendix 1). This last point is relevant to both writing in the group and writing at home. In the writing group meetings, conversation should be introduced before the writing session commences to focus on the theme of the day. Conversation should also be encouraged within the group after the writing session, giving the participants the opportunity to converse about their thoughts and feelings related to their writing.

The writing of each participant should be based on his or her own grief experiences and where he or she finds him or herself in the grief process.Citation21,Citation34 When writing in the diary, it is up to the individual to choose the topic and write spontaneously. Our experience indicates that the initiation of writing is often difficult. The motivation to start writing in a diary at home may be especially difficult. Therefore, some keywords are suggested to stimulate the individual to begin and to improve the expressiveness of the writing (Appendix 1). Possible drawbacks related to the writing process should be considered, such as the provocation of painful and difficult feelings and thoughts that may be perceived as an additional burden. Moreover, the individual may not be familiar with writing or could experience difficulty getting started. Our guidelines (Appendix 1) represent a tool with which to overcome these barriers. We believe that these guidelines will be motivating and make writing easier.

Conclusion

A systematic writing program is suggested as a tool to facilitate the grief process. We believe that process-oriented writing within this program should be helpful in promoting thought activity and in gaining coherence and an understanding of the grief process. Expressive and explorative writing can be undertaken as an integral part of traditional grief groups for adults or performed and systematized through a writing program with participation in a grief writing group, as suggested here. We hope that our suggested program will be a valuable support in helping people experiencing grief, and a guide for future program development and research. Part 2 of this two-part article will highlight the results of an intervention program based on the fundamental elements established here.

Disclosure

The authors report no conflicts of interest in this work.

References

  • SloanDMMarxBPTaking pen to hand: evaluating theories underlying the written disclosure paradigmClin Psychol Sci Practice200411121137
  • BaikieKAWilhelmKEmotional and physical health benefits of expressive writingAdv Psychiatr Treat200511338346
  • LeporeSJGreenbergMABrunoMSmythJMExpressive writing and health: Self-regulation of emotion-related experience, physiology, and behaviourLeporeSJSmythJMThe Writing Cure How Expressive Writing Promotes Health and Emotional Well-BeingWashington DCAmerican Psychological Association200299117
  • DellasegaCHaagenBA different kind of caregiving support groupJ Psychosoc Nurs Ment Health Serv2004428465515354598
  • FurnesBÅ skrive sorgen – bearbeidelse av sorg. Prosessorientert skriving i møte med en fenomenologisk språkforståelse. En hermeneutisk fenomenologisk studie av skriving som sorgbearbeidelse hos etterlatte Doctoral thesis. University of Bergen, Norway;2008
  • FrancisMEPennebakerJWPutting stress into words: the impact of writing on physiological, absentee and self-reported emotional well-being measuresAm J Health Promot1992628028710146806
  • PennebakerJWWriting about emotional experiences as a therapeutic processPsychol Sci19978162166
  • SmythJWritten emotional expression: effect sizes, outcome types, and moderating variablesJ Consult Clin Psychol1998661741849489272
  • PennebakerJWTelling stories: the health benefits of narrativeLit Med20001931110824309
  • SmythJTrueNSoutoJEffects of writing about traumatic experiences: the necessity for narrative structuringJ Soc Clin Psychol200120161172
  • KoopmanCIsmailjiTHolmesDClassenCCPaleshOWalesTThe effects of expressive writing on pain, depression and posttraumatic stress disorder symptoms in survivors of intimate partner violenceJ Health Psychol200510221122115723891
  • ElbowPWriting without TeachersNew YorkOxford University Press1973
  • ElbowPWriting with Power Techniques for Mastering the Writing ProcessNew York/OxfordOxford University Press1981
  • VygotskyLTænkning og Sprog IIKøbenhavnH: Reizel1982
  • PahuusMHoldning og spontanitet. Pædagogik, menneskesyn og værdierÅrhusKvaN1997
  • RicoeurPTime and Narrative volume I The University of Chicago Press; 1984McLaughlinKathleenPellauerDavidTemps et Récit IParis1983
  • RicoeurPTime and Narrative volume II The University of Chicago Press; 1985.McLaughlinKathleenPellauerDavidTemps et Récit IIParis1984
  • RicoeurPTime and Narrative volume III The University of Chicago Press; 1988McLaughlinKathleenPellauerDavidTemps et Récit IIIParis1985
  • ParkesCMBereavement: Studies of Grief in Adult LifeLondonPenguin1986
  • AttigTRelearning the world: Making and finding meaningsNeimeyerRAMeaning Reconstruction and the Experience of LossWashington DCAmerican Psychological Association20023353
  • FurnesBDysvikEDealing with grief related to loss by death and chronic pain. An integrated theoretical framework IPatient Prefer Adherence2010413514020622913
  • FreudSMourning and melancholiaStracheyJThe Standard Edition of the Complete Psychological Works of Sigmund FreudLondonHogarth1917/1957
  • BowlbyJAttachment and LossNew YorkBooks1980
  • AttigTHow We Grieve Relearning the WorldNew York/OxfordOxford University Press1996
  • StenslandPApproaching the Locked Dialogues of the Body – Communicating Symptoms through Illness Diaries Doctoral thesis. Division for General Practice, Department of Public Health and Primary Health Care. University of Bergen, Norway;2003
  • DystheOHertzbergFHoelTLSkrive for å lære Skriving i høyere utdanningOsloAbstrakt forlag2000
  • MacKenzieKRTime-Limited Group PsychotherapyWashington DCAmerican Psychiatric Press1990
  • KeefeFJBeauprePMGilKMRumbleMEAspnesAKGroup therapy for patients with chronic painTurkDCGatchelRJPsychological Approaches to Pain Management A Practitioner’s Handbook2nd edNew YorkGuilford Press2002234255
  • YalomIDThe Theory and Practice of Group Psychotherapy5th edNew YorkBasic Books2005
  • BrittonJBurgessTMartinNMcLeodARosenHThe Development of Writing AbilitiesLondonMacmillan Education19751118
  • MurrayDIndre revisjon – en oppdagelsesprosessBjørkvoldEPenneSSkriveteoriOsloLNU/JW Cappelens Forlag A/S1991
  • RainerTDagboken ditt hemmelige rom (The New Diary).OsloHilt og Hansteen as1992
  • ZimmermanSWriting to Heal the Soul Transforming Grief and Loss through WritingPittsburg, PAThree Rivers Press2002
  • DysvikEFurnesBDealing with grief related to loss by death and chronic pain: suggestions for practice IIPatient Prefer Adherence2010416317020694178

Appendix 1:

Guidelines and keywords for writing

Guidelines

  • Be honest and open in the writing process.

  • Be patient. To get started, you may write about whatever you want to or about daily situations.

  • Do not consider grammar or punctuation.

  • Write about everything that occurs to you while writing.

  • Be open and spontaneous.

  • Ask yourself questions and try to talk to yourself during the writing process.

  • Emphasize your feelings and how you experience them.

  • You are the owner of the text, and no one else should have access to it.

Keywords

  • How are you today?

  • Yesterday

  • Good feelings

  • Bad feelings

  • Good memories

  • Friendship

  • Future plans

  • Difficulties

  • Love

  • Relationships