INTRODUCTION
Bereaved family members may experience physical or psychological problems as part of the grieving process (Burnell & Burnell, Reference Burnell and Burnell1989; Stroebe et al., Reference Stroebe, Schut and Stroebe2007). Hanson and Stroebe (Reference Hanson and Stroebe2007) proposed that grief comprises emotional reactions such as depression and anxiety, cognitive reactions such as suppression and helplessness, and physical reactions such as fatigue, sleep disturbance, and eating disorders. About 15% of bereaved persons experience a more problematic grieving process in terms of symptoms of depression or posttraumatic stress (Bonanno & Kaltman, Reference Bonanno and Kaltman1999). It has been demonstrated that depression is a serious psychological problem for bereaved family members (Shear, Reference Shear2009).
Bereaved family members experience both the positive and negative aspects of grief during the process of caring for family members (Kang et al., Reference Kang, Shin and Choi2013). The positive aspects, often referred to as “growth,” have been demonstrated in previous studies. Lehman and colleagues (Reference Lehman, Davis and Delongis1993) studied changes experienced by bereaved family members among 40 individuals who had lost a spouse and 54 who had lost a child via a motor vehicle accident 4–7 years prior to being interviewed. There were three open-ended questions related to positive and negative life changes, and they identified the following categories: “increased self-confidence,” “increased concern for others,” “increased emphasis on family,” “greater appreciation for life,” and “increased religiosity/faith.” Tedeschi & Calhoun (Reference Tedeschi and Calhoun1996) developed a posttraumatic growth inventory that included these domains: “relating with others,” “new possibilities,” “personal strength,” “spiritual change,” and “appreciation of life.” “Hope” may be of value in the future, and there is no denying its importance in protecting bereaved persons from feelings of helplessness (Milberg & Strang, Reference Milberg and Strang2011). However, the few studies that have examined this issue were conducted mainly in Western countries, not in Japan.
In our study, we investigated these issues using bereavement life review. This psychotherapeutic method is specifically aimed at elevating the quality of life of bereaved family members. “Life review” is based on the developmental theory of Errikson (Reference Erikson1950), according to which a person who confronts his own death can integrate his present life by reviewing his entire life. This approach has been shown to be effective for alleviation of depression and elevation of spiritual well-being in the bereaved families of patients who died in a palliative care unit where specialized care was offered to patients and families (Ando et al., Reference Ando, Morita and Miyashita2010, where the details of life review are explained comprehensively). Those participants were recruited in a survey using questionnaires. The Ministry of Health, Labour, and Welfare (2013) recently promoted the notion that all patients should enjoy support to elevate quality of life both in palliative care units and on normal hospital wards. We thus employed this therapeutic technique for the bereaved family members in the present study and showed that it can be effective for treating depression and enhancing spiritual well-being (Ando et al., Reference Ando, Sakaguchi and Shiihara2013). The present study is a secondary analysis of that investigation.
Upon offering this treatment, we found some questions very difficult to answer, including those dealing with “pride” and “important points in a person's life” (Ando et al., Reference Ando, Morita and Akechi2012), so we utilized a few select items for the current study. To promote finding meaning and reconstructing the lives of the bereaved, we added questions on “changes during the bereavement experience” and “activities to be valued in the future” (future values). There are few studies on these items with bereaved families in Japan, so the aim of the present study was to investigate the associated factors as derived from narratives from the bereavement life review. We also posited that “change” includes “growth” and “values” includes “hopes.”
METHODS
Participants
The support group leader chose participants who met the following inclusion criteria: (1) that they belong to a bereaved family whose relative died on an ordinary hospital ward and not in a palliative care unit; (2) that they be aged 20 years or older, and (3) that they be capable of replying to questionnaires. The following were excluded: (2) bereaved families who suffered serious psychological distress, as determined by a clinical psychologist, and (2) those with serious dementia. A total of 21 bereaved family members were contacted, all of whom agreed to participate. One subsequently declined participation because of mental problems, leaving us with a total of 20 bereaved (10 males, 10 females). The mean age was 68.8 ±11.7 years. The background of the participants is presented in Table 1.
Table 1. Background of bereaved family members
Procedure
The ethical and scientific validity of the study was approved by the institutional review board of St. Mary's College. Before each interview, the counselor explained the study to the participant and obtained a signed informed consent.
The bereavement life review was conducted over two interview sessions. Each session lasted 30–60 minutes and occurred two weeks apart. Bereaved family members reviewed their lives during session 1. The five questions and their order were changed from our previous study (Ando et al., Reference Ando, Morita and Miyashita2010) to provide for a better flow of the therapy: (1) What are your most vivid memories from when the deceased was well? (2) In taking care of the patient, what are your most vivid memories about them? (3) Have you gone through changes due to the death of the deceased? (4) What is the most important thing in your life, and why? and (5) What will you value in future? The therapist recorded and transcribed the interviews verbatim. The narratives were then compiled into an album, from which keywords were selected. Photos and drawings from books or magazines related to subjects' narratives were included to make the album more visually attractive and memory-provoking. During the second session, the two reviewed the album together and verified the contents. The bereavement life review was conducted by a certified therapist in a private room provided by the support group.
Data Analysis
We employed “qualitative analysis” (see Funashima, Reference Funashima2001), based on the work of Berelson (Reference Berelson1952), which involves creating codes, subcategories, and categories. Narratives were selected from each question related to “changes” and “values.” These narratives were edited into the shortest possible statement without losing meaning and coded into one subcategory along with similar statements. Similar subcategories were then integrated into one category. To maintain reliability, categorization and coding were validated independently by two coworkers, who also provided professional advice. Inconsistencies were discussed and negotiated until agreement was reached.
RESULTS
Categories Associated with “Changes”
The categories of “changes” perceived by bereaved family members are shown in Table 2. Most participants had learned many things through the death of their relatives: they began to pay more attention to their own health (including diet and exercise); they thought more about their own mortality, they felt an increased level of the sadness of loss; and they began to be kinder to others. We grouped these comments under “learning from the deceased's death and self-growth.”
Table 2. Changes in bereaved family members after patient's death
Some subjects felt they were trying to move forward with their lives, making an effort to change, recognizing the importance of the deceased, and feeling a sense of gratitude for having known the deceased. These comments were grouped under “healing process.”
Some participants had received help from others and realized the importance of relating with others. Others felt that members of a support group had understood their suffering. Still others discussed changes in their relationships with parents and children. We categorized these comments under “relating with others.”
One participant felt that being a single parent might be a problem for their children because of prejudice, and another felt a burden to obey rural customs. We grouped these thoughts under “relating with society.”
The following is a sample of comments from one subject on the changes in her life. A 50-year-old woman, her husband had died two years earlier:
After my husband's death, I had to do everything by myself. The most difficult issue was my son's marriage. I felt there was a difference for a son with two parents or one parent in society. I was very sorry for my sons. I had three sons, and the eldest son had married, but the other two had not. I wanted to treat them equally, but I felt it was difficult for me to raise them and treat them like my eldest son. However, I remembered my husband's desire that parents should raise children well, and I rethought my situation and tried to make an effort.
Some participants felt the burden of housework, and some recognized that they were alone and had to do everything by themselves. We grouped these issues under “performing new family roles.”
Categories Associated with “Values”
We then categorized the future values of bereaved family members (Table 3). Some participants went to a support group or attended lectures about grief to ease their anxiety, some talked with the deceased through prayer, and others worked on distributing the belongings of the deceased. We integrated these issues under “continuing grief work.”
Table 3. Valued activities for the future of bereaved family members
Some participants hoped to live healthy lives without regret, to live without causing problems for others, and to live independently and with hope for the future. We grouped these under “living with a philosophy.”
Some wanted to raise their children to become responsible people, which we categorized under “attaining life roles.”
Most recognized the importance of family and peer relationships, wanted to maintain relationships, and wanted to be helpful to others. These comments were grouped under “keeping good human relationships.”
Some were not depressed, wanted to enjoy travel and going out, and to pursue interests. These comments were included under “enjoying life.”
The following is a sample from the narrative of a 75-year-old woman related to “enjoying life”:
It is important for me to be healthy both physically and mentally. Although I was very lonely and sad after my husband's death, I thought that if I am not healthy, my husband would worry about me from Heaven. If I am healthy and enjoy my life, my husband's soul will be comforted. Therefore, I try to find enjoyment in my life and to be mentally healthy in the future.
DISCUSSION
Categories Associated with “Changes”
Bereaved family members experienced both positive and negative aspects related to “changes” and “values.” Previous studies have treated positive aspects as “hopes.” We included “hopes” within “changes” and compared Japanese and Western subjects. Table 4 presents the commonalities and differences between the results of our study and those of Lehman et al. (Reference Lehman, Davis and Delongis1993) and Tedeschi and Calhoun (Reference Tedeschi and Calhoun1996). We found that there are similarities between “learning from the deceased's death and self-growth” in our study and “increased self-confidence,” “personal strength,” and “new possibilities” in others. So across the two cultures, bereaved family members had a heightened recognition of their own mortality and felt more self-confidence and personal strength.
Table 4. Coomn and different factos about changes through family's death in Japan and Western countries
Participants mentioned “relating with others” in the present study, and this factor appeared in the Western studies as “increased concern for others,” “increased emphasis on family,” and “relating with others.”
One of the factors in the current study was “relating with society.” One participant said that her children started talking to her about how she wanted them to treat her belongings after she died. Another said that she felt sorry for her children because it is desirable for children to have two parents—a traditional Japanese prejudice. Mourning customs in rural areas are pervasive and difficult to avoid, and some indicated that they did not like such customs.
Regarding differences, “performing new family roles” originates from an old Japanese custom where women do the housework and men take on most other activities. This change was thus particularly significant for some participants. The category may be less common in Western studies, but it appeared in Higashimura et al. (Reference Higashimura, Sakaguchi and Kashiwagi2001) in a Japanese survey questionnaire as “change of lifestyle.”
With respect to the “healing process,” bereaved family members felt sad about their loss, cherished their memories, recognized the importance of the deceased, and were grateful for having known them. Thinking about relationships with the deceased or reflecting on their relationships may be unique for Japanese subjects; some made an effort to adjust to their new lives and sadness by engaging in such activities as joining a grief care study group.
There are some categories that did not appear in the present study that have appeared in other studies. “Appreciation for life” has emerged in many previous studies and demonstrates how bereaved families can appreciate their life through the loss of a family member (Lehman et al., Reference Lehman, Davis and Delongis1993; Tedeschi & Calhoun, Reference Tedeschi and Calhoun1996). However, our participants did not express a newfound “appreciation for life,” perhaps because they were pondering their own deaths, as they were mainly over the age of 55. They felt it was natural for old people to die, not inconsistent with natural processes. Similarly, “spirituality” did not show up in the present study, probably because most participants did not practice a particular religion. Many studies have demonstrated the ability of religiosity to promote posttraumatic growth and ameliorate the grieving process (Currier et al., Reference Currier, Mallot and Martinez2013).
Categories Associated with “Values”
There have not been many studies that have examined the future values of bereaved family members, so we compared such values expressed as in our study with hopes expressed in others. Some bereaved family members had partly completed the grieving process and wanted to heal themselves while remaining linked to the deceased, consistent with “bonding” in grief (Stroebe & Schut, Reference Stroebe and Schut2005). Some found new paths to follow and chose to move in those directions, while others wanted to enjoy traveling and going out more.
Some bereaved women have wanted to speak publicly about the death of their mother in the hope of helping others in similar situations (Tracey, Reference Tracey2011). One group of investigators (Dyregrov et al., Reference Dyregrov, Dieserud and Hjelmeland2011) showed that the bereaved are motivated by the hope of helping others. Our results suggest that the bereavement life review might be useful in allowing expression of these hopes and future wishes.
We suggest that “continuing grief work” and “living with a philosophy” following the death of a loved one may demonstrate strong bonding between the deceased and the bereaved, while “attaining life roles,” “keeping good human relationships,” and “enjoying life” suggest milder bonding. These categories suggest that the bereaved perform daily roles and look to the future. The concept of bonding is presented in the context of the attachment theory put forward by Bowlby (Reference Bowlby1980); however, these suggestions require confirmation by further studies.
Limitations
One limitation of the study is that all participants were members of a support group for grief care and were actively seeking to heal themselves, to study the grieving process, and to help people going through the grieving process. Some were making progress with the grieving process and others were not depressed. These characteristics may have had some influence on the results, so generalization of our findings will require inclusion of more participants.
ACKNOWLEDGMENTS
This study was supported by the Pfizer Health Research Foundation.
