In Dialogue: How Writing to the Dead and the Living Can Increase Self-Awareness in Those Bereaved by Addiction

Abstract

This article examines how writing can increase the self-awareness of a socially isolated and often stigmatized population: those bereaved by addiction. Writing about a traumatic event has been shown to increase self-awareness which can improve health and regulate negative behaviors. Using narrative analysis on the writing of individuals bereaved by addiction, this study found that participants were able to increase their self-awareness through writing to the dead, the living and themselves. Participants’ writing also demonstrated their attempts to make sense and make meaning out of their loss which are both strong predictors of positive health outcomes. All participants in this study demonstrated increased self-awareness as well as sense-making and/or meaning-making which can lead to improvements in behavior regulation, psychological health and physical heath. This suggests that writing may be a uniquely beneficial therapeutic intervention for those experiencing disenfranchised grief as a result of bereavement by addiction.

Keywords

self-awareness grief disenfranchised grief bereavement writing loss narrative addiction expressive writing creative writing

Self-awareness can be broadly defined as ‘the extent to which people are consciously aware of their internal states and their interactions or relationships with others’ (Sutton, 2016, p. 646). Sutton (2016) explains that self-awareness has long been seen by researchers as a useful tool for alleviating psychological distress. Increasing self-awareness can be particularly valuable for those experiencing disenfranchised grief (Fenigstein et al., 1975).

Disenfranchised grief is defined by Doka (1989) as ‘the grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported’ (p. 4). At the heart of disenfranchised grief, therefore, is the recognition that who, what and how one grieves is not socially acceptable. For those bereaved by addiction, the stigma associated with drug-taking impacts the way that friends, family and the public act towards them (Valentine et al., 2016). For instance, disenfranchised deaths, particularly substance-related deaths, are often linked to a deviant lifestyle and are perceived as self-inflicted (Feigelman et al., 2011; Guy, 2004; Seale & Van der Geest, 2004; Valentine & Walter, 2015). Even if at times the deceased was well and recovering, if their death was a result of their addiction then they are forever typecast in the role of ‘“the addict”, leaving the family to “carry the stigma” associated with this into future social interactions’ (Goffman, 1963, p. 164). Those with substance-misuse issues are still regarded by many as ‘low-down’ and, therefore, when a substance-misuser dies the bereaved may be expected to get over the death quickly and ‘move on’, leaving many bereaved individuals feeling disenfranchised and stigmatized (Dyregrov et al., 2019, p. 418).

According to Titlestad et al. (2019), family members of substance-misusers commonly face years of hopelessness, powerlessness, uncertainty, despair and stigma leading up to the death of their loved one. After the death, the bereaved often experience conflicting feelings of anger and shame as well as guilt, both for not being able to prevent the death and also for any feelings of relief that the death brings (da Silva et al., 2007; Dyregrov et al., 2019). These feelings can lead the bereaved to withdraw and become more socially isolated as well as lead them to engage in destructive behaviors. Baumeister and Finkel (2010) state that the bereaved can engage in negative behavior patterns or choices including drinking, binge eating and self-harm. They state that these negative behaviors are often an attempt to lose self-awareness ‘by submerging attention in low-level sensory experiences’ (Baumeister & Finkel, 2010, p. 144). Fenigstein et al. (1975) believe that increasing self-awareness can provide the first step to recognizing negative emotions and behaviors in order to make positive change. Thompson and Gauntlett-Gilbert (2008) also note that greater awareness of ‘one’s own impulses and thought patterns should result in a decreased emotional reactivity and vulnerability’ (p. 396).

Increased self-awareness can have many benefits and has been a key consideration in therapeutic writing studies (Frattaroli, 2006; Pennebaker & Francis, 1996; Sloan & Marx, 2004). Pennebaker and Francis (1996) used participants’ writing to determine their self-awareness and demonstrate participants’ search for self-understanding. In their study, the more ‘insight’ words (such as ‘realize’, ‘see’ and ‘understand’) participants used the more their health improved (Pennebaker & Francis, 1996, p. 620). Previous research has also indicated that improving self-awareness through writing can lead to changes in emotional responses, behavior and health outcomes (i.e. Baikie & Wilhelm, 2005; Dishon et al., 2017; Pennebaker, 1997; Smyth et al., 2001). Finally, increased self-awareness can lead to sense-making (i.e. searching for a reason or explanation for the loss) as well as meaning-making (i.e. experiencing personal growth as a result of the loss) (Neimeyer, 2006; Neimeyer et al., 2010; Wojtkowiak et al., 2019). When sense making and meaning making are successful, the bereaved may accept the reality of their loss and develop a more positive view of the future (Bonanno, 2013; Neimeyer, 2019; Titlestad et al., 2020).

Research has shown that writing about traumatic experiences can have long-term, positive effects on health and wellbeing. According to a meta-analysis conducted by Frattaroli (2006) these positive health outcomes could be physical (i.e. improved immune function), psychological (i.e. decreased depression) or behavioural (i.e. an increase in self-care behaviours). Although the use of writing therapy and its benefits are widely documented, there has been little research exploring how writing might benefit individuals bereaved by addiction. Therefore, this small case study asked whether or not writing can improve the self-awareness of individuals bereaved by addiction. Participants in this study were asked to respond to ten writing prompts which were based on emotions and experiences often associated with disenfranchised grievers according to academic literature. This inquiry aimed to discover whether the participants’ self-awareness about their grief and emotions, as well as their relationships with others, would increase through writing.

Methods

Recruitment

This case study included 13 participants who were bereaved by addiction within six years of the research taking place. Every participant was a family member of someone who died from substance-misuse; of the 13 individuals who took part in the study, nine had lost a child, two had lost a parent, one had lost a sibling and one had lost a spouse. In order to recruit these participants, emails were sent to 19 UK-based organizations which provided bereavement and/or family addiction support. These emails briefly explained the study, in both the body of the email and via an attached JPG poster, and asked if the organisation could send information about the study to their clients and contacts. Out of the 19 organizations contacted, 12 offered to circulate the posters and call for participants via their Facebook, Twitter, and/or organizational newsletter. Most of the participants were recruited through DrugFam and The Compassionate Friends. All 13 participants met the following study requirements: they were over 18; were bereaved for six years or less; and had accessed, or were accessing at the time of the research, bereavement services in England or Wales.

Potential participants were sent a ‘Participant Information Sheet’ which outlined the study and gave them the option to cut off contact if they no longer wanted to participate. Once each participant agreed, they were phoned or emailed to arrange a suitable time to meet. Participants were given the choice to meet at their homes, if this was where they felt most comfortable, or to meet in a neutral location like a library or university building.

To ensure the ethical integrity of this study, all participants were also asked to sign consent forms in their first meeting which thoroughly explained the research. Participants were informed that it was the researcher’s responsibility to report anything they said or wrote which suggested they may harm themselves or others. Participants’ consented that any such reports could be made to the organization they were currently accessing for bereavement support and/or to their next of kin. Participants were also told during their first meeting that they did not have to answer any questions they found difficult or uncomfortable and were assured that they could stop their writing at any time. All participants and their deceased loved ones were also given pseudonyms as part of this study.

Writing Task

During this first meeting, every participant was told more about the study and given a writing pack with a set of instructions, ten writing prompts, a notebook and a pen. Before asking participants to write on their own, they completed two practice writing exercises in the presence of the researcher. Once these were completed they were encouraged to ask questions or raise concerns before they began writing on their own. Participants were then given between two and four weeks to complete all ten prompts and were told to only write to one prompt per day. This meant that they could respond to all the prompts over ten days or they could spread them out. This allowed participants the flexibility to fit the writing task around their lifestyle and helped them manage their emotional responses to the prompts. Participants were asked to write to each prompt for 20 minutes and to write in whatever way felt most comfortable for them.

Participants were assured through the ‘Participant Information Sheet’ and during the first meeting that they could choose to keep their writing confidential. It is reasonable to assume that those bereaved by addiction, as well as other populations who struggle with ‘stigma’ (Goffman, 1963) and/or ‘stigma by association’ (Bos et al., 2013), find it more difficult to share their writing so it is important that participants knew that submitting their writing was entirely voluntary. Once participants completed their writing task, they were asked to contact the researcher to arrange a second meeting in order to talk about their experience and submit their notebook or writing samples (if they wanted to).

In the end, a total of 12 out of the 13 participants opted to submit either their entire notebooks, or a selection of their written responses, for analysis. Only one participant did not submit their notebook or some writing sample, which is in keeping with Frattaroli’s (2006) findings that more than 90% of participants will turn in their writing at the end of a study, even when it is voluntary (p. 830).

Writing Prompt Construction

The writing prompts themselves were born out of ten themes which regularly appear in disenfranchised grief and/or bereavement by addiction literature (Corr, 1999; Doka, 1989; Osterweis & Townsend, 1988; Valentine & Walter, 2015; Werner-Beland, 1980; Worden, 2009). These themes include: ‘addiction’, ‘anxiety’, ‘anger’, ‘behavior ’, ‘others’, ‘sadness’, ‘loneliness’, ‘regret’, ‘memory’, and ‘grief’. These ten themes represented a range of experiences that individuals bereaved by addiction are likely to face, including emotional experiences (i.e. ‘anger’), cognitive experiences (i.e. ‘memory’), physical experiences (i.e. ‘behavior’), and social experiences (i.e. ‘others’). Although traditionally expressive writing prompts are much broader than this — asking participants to simply write about a traumatic experience — an increasing number of studies over the last twenty years have experimented with more focused writing topics (Kacewicz et al., 2007; Lichtenthal & Cruess, 2010). The narrower, more tailored prompts in this study allowed participants to write about a specific topic — that is, their thoughts and feelings related to their bereavement as well as to addiction — while still giving space for them to write about related experiences. For instance, ‘Creative Writing Prompt #3: Anger’ asked participants to:

Write about a time you were angry with the person you lost. Either before or after they passed away. Describe this time, what made you angry, what did you do?

This prompt encouraged participants to write about anger — an emotion that comes up frequently in relation to disenfranchised grief. Participants were asked to choose any time that they were angry — before or after the person had died. The set of instructions given to participants with the writing pack also reminded them that they could write about any related thoughts or feelings which might come up. Lichtenthal and Cruess (2010) suggest that these kinds of direct prompts might be uniquely beneficial for bereaved individuals as they help to ‘focus their writing in ways that help resolve grief and facilitate adjustment’ (p. 2).

Five of the ten prompts also asked participants to read a poem before responding . The five poems chosen for these prompts were:

‘The Race’ by Sharon Olds for a prompt on ‘anxiety (Olds, 1992)

‘After Your Death’ by Natasha Trethewey for a prompt on ‘behavior’ (Tretheway, 2007)

‘Sadness’ by Kim Dower for a prompt on ‘sadness’(Dower, 2013)

‘Another Feeling’ by Ruth Stone for a prompt on ‘regret’ (Stone, 2007)

‘Gorillas’ by Shelley Wagner for a prompt on ‘memory’ (Wagner, 1994)

These poems were selected for their accessibility, relatability and how well they spoke to the themes which emerged from the disenfranchised grief literature. Their selection was also guided by Leery’s ‘isoprinciple’ theory (Leedy, 1969), which expresses the importance of participants relating to or resonating with the poems that are shared.

Narrative Analysis

Narrative analysis was used to analyze participants’ writing (Coffey & Atkinson, 1996; Hiles & Cermák, 2008; Phoenix et al., 2010; Riessman & Speedy, 2007). In particular, this analysis focused on the ‘content’ – that is what participants said about their emotions, grief and relationships. In an attempt to understand what participants were saying about their bereavement experience, the narrative analysis primarily considered the presence of ‘insight’ words (Pennebaker & Francis, 1996) as well as ‘I’-statements (i.e. I am lonely), personal pronouns and tense usage.

To do this every writing sample was read twice and all ‘insight words’ and ‘I-statements’ were color-coded. Previous research suggests that an increase in ‘insight words’ (Pennebaker & Francis, 1996) and/or an increase in ‘I-statements’ (Neysari et al., 2016) indicates an increase in self-awareness. Therefore,these were counted across the writing samples to assess whether there was an increase of one or both from prompt #1 to prompt #10. In the case of writing sample submissions, these were counted in order. For instance, if a participant only submitted their responses to prompts #2, #6 and #8 then ‘insight words’ and ‘I-statements’ were assessed from prompt #2 to prompt #6 and then from prompt #6 to prompt #8 to determine if there was an increase.

After assessing the ‘insight-words’ and ‘I-statements’, personal pronouns were also color-coded and counted – for instance, how many first person pronouns were in prompt #1 versus in prompt #10. Tense usage was then analysed within each prompt (i.e. how often does the tense change in the response to a single prompt) and across the sample (for example, does tense change from mostly present to mostly past across the sample). The use of personal pronouns and tenses can reflect self-awareness about participants’ relationships (Hedtke & Winslade, 2016; Neysari et al., 2016). In the case of this study, the changing use of personal pronouns and tenses across the samples served to highlight three key relationships that were written about by most participants—their relationship to the dead, to others and to themselves.

A Note on Terminology: Expressive Versus Creative Writing

Although there are clear distinctions between the purpose of expressive writing — which is designed to allow individuals to deeply explore their trauma — and creative writing — which is often used as a form of self-expression or is intended for publication and public consumption — most therapeutic writing studies conflate the two terms. With this in mind, I feel it is important to clarify the terms I intend to use here. For the purposes of this article, I will use the term ‘writing’ to describe the act of writing in general. It can be assumed that when one is engaged in the act of writing they may write expressively, creatively or in another way not described here. Therefore, the term ‘writing’ acknowledges the many ways in which an individual might engage in the act of writing and the many styles in which they might write.

For the purposes of this study, I use the term ‘expressive writing’ as defined by Lepore and Kliewer (2013):

Expressive writing is a form of therapy in which individuals write about their thoughts and feelings related to a personally stressful or traumatic life experience. Expressive writing is sometimes referred to as written disclosure, because writers are instructed to disclose personal information, thoughts, and feelings. Unlike communicative forms of writing, expressive writing is personal, free flowing, and informal, often without concern for style, spelling, punctuation, or grammar. (p.46)

This definition effectively sums up ‘expressive writing’ as introduced by Pennebaker and Beall (1986) and as used in many other expressive writing studies since then (Frattaroli, 2006).

Finally, I will define the term ‘creative writing’ as an act which ‘draws on the imagination to convey meaning through the use of imagery, narrative, and drama’ and can be written in the form of ‘poetry, fiction (novels, short stories), scripts, screenplays, and creative non-fiction’. (Duke University, Creative Writing: Writing Studio Handout, n.d.). All 12 participants who submitted writing samples for this study engaged in creative writing in response to at least two prompts, primarily in the form of poetry, short dialogues and/or narrative retellings.

In Dialogue: What Participants’ Writing Revealed About Their Self-Awareness

Perhaps the most significant indications of self-awareness in participants’ writing can be seen in the ways they engaged in some type of dialogue with the deceased, other people and even with themselves.

Talking to the Dead

Eight out of 12 participants in this study wrote directly to the deceased individual. Those who did tended to be bereaved for less than two and a half years which may suggest that they felt physically, emotionally, or spiritually closer to their lost loved one than those who had more time (and more emotional distance) following the death. For instance, Alice who had only lost her son Robert a few months before we met often wrote directly to her son through poetry:

I ache + yearn for you

Just one last conversation

Please don’t go

I need you

but I never said it

I did not want you

To feel obliged

To make me happy

at your own expense

Stay home – don’t go. (Alice)

Here Alice speaks directly to her son in the present tense, as though he might be able to listen and follow her request not to ‘go’. According to Hedtke and Winslade (2016), those who write to the dead know that the dead do not really ‘speak back’ and the language used often supports an ‘effective alternative to the linguistically binary choice of speaking in either the past or present tense through the use of indicative verbs’ (p. 96). This can be seen in Alice’s poem where she speaks mostly using present tense verbs like ‘ache’, ‘yearn’, and ‘need’ but switches back to the past (before her son died) when discussing her choices – ‘I never said it’ and ‘I did not want you/to feel obliged’. Within the context of the poem, these past tense lines could be read as her regrets and her present tense lines could be read as her wishes. This piece arguably demonstrates Alice’s self-awareness in relation to herself and her emotions (both in the past and present) as well as her desire to maintain a continuing relationship with her son.

Other mothers also wrote often to their children. For instance, in Charlotte’s poem ‘REMEMBERANCE’, she lets her daughter, Nora, know that she will be remembered:

REMEMBERANCE

In the lonely silence of your abandoned room

I sit and remember you

I remember your birth

Tiny, pink and mewling like an abandoned kitten

But you were not abandoned

You were loved

Even in the midst of a whirlwind

You were loved

I spray your perfume into the stillness

And suddenly, for an instant

You are here

Laughing and full of life, the scent invokes you

And then the smell goes stale

You are gone again

I hug your clothes

Your long-forgotten toys

Music never to be played again

And posters on the wall

All that is left of you

Your essence is not here, I cannot capture it

But my memory will never grow cold

I remember you. (Charlotte)

Although this piece employs the ‘you’ pronoun in a similar way to Alice’s piece — suggesting that Charlotte is speaking directly to her daughter — the physical distance between them is palpable. Charlotte uses words like ‘silence’, ‘abandoned’, and ‘gone’ to demonstrate that Nora is no longer there in her room, in her clothes, in her ‘long-forgotten toys’. Charlotte repeats the lines ‘You were loved’ and ‘I remember’ almost as a way to reassure Nora, and herself, that this distance won’t disrupt the relationship they had. Just as in Alice’s poem, we can see Charlotte’s desire here for a continuing bond with her child which extends from the present into the future in the line: ‘But my memory will never grow cold’. While Alice, Charlotte and other participants wrote pieces which exclusively spoke to the deceased, other participants seemed to slip in and out of addressing the dead within the same pieces of writing. This can be seen in Gerald’s prose piece where he begins speaking to himself and then, a few sentences in, begins speaking to his daughter Esther:

The world feels different … Sometimes I feel the urge to shout and scream but that’s no good, there’s no one to hear. And what will that achieve. I’m sad that your son will never know you, all we have is pictures and videos but what do we say when he asks how did you die. The pain he may feel and the loss we will share all over again. We question ourselves are we going against your wishes in everything we do with him but you’re not here to put things right. (Gerald)

Gerald’s pronouns progress throughout this piece starting with ‘I’ (himself), then moving to ‘you’ (his daughter), and then introducing ‘we’ (him and his wife) as well as ‘him’ (his grandson/his daughter’s child). We can see Gerald focusing on himself in the opening sentences of this sample where he explains his feelings around grief, his sense of isolation (i.e. 'no one to hear'), and his sadness. He then switches to say that his sad feelings are linked to how his daughter’s son will never know her. He begins using ‘you’ words here. According to Neysari et al. (2016) the ‘use of “You”-words ‘such as “you” and “yours” in couple and family conversations has been linked with the notion of separateness, distancing, arguing, and blaming’ (p. 7). This can be seen particularly at the end of this sample where he seems to be blaming Esther, saying ‘you’re not here to put things right’ with her son or, perhaps, even with the family. However, in Gerald’s case, any blaming or distancing that is occurring might be offset by his use of ‘we’ which tends to reflect togetherness and community (Neysari et al., 2016; Pennebaker & Lay, 2002; Rude et al., 2004). Gerald even notes that he and his wife ‘share’ the pain of this loss and are trying to present a united front when it comes to their grandson, wondering what to tell him together about the death and whether they are following their daughter’s wishes. This suggests a close family whose members care for each other. The use of various pronouns in such a short sample provide an insight into Gerald’s grief experience, painting a picture of someone who is struggling to come to terms with loss but wants to do what is best for his family, even though his daughter did not, in his view, do what was best for her or for them.

Talking to Others

All participants wrote about conversations they had with family members, friends and/or acquaintances. Like those who ‘talked to the dead’, this reflected their self-awareness when it comes to their relationships with the living. For instance, Grace wrote five short vignettes in response to the ‘Others’ prompt about talking to other people following her son Liam’s death. This is the first of the set:

Wandering through ASDA not long after Liam’s has left. I got to the pasta isle and had a meltdown. Liam loved pasta!

A lady I used to work with some years previously came up to me and said.

‘You ok?’

‘Yeah’

‘Sure you’re okay?’

‘No not really’

‘Why, what’s the matter?’

‘Oh, you don’t know that my Liam has died?’

‘Oh’ – she turned and walked away.

NOTHING!! Not a kind word, a hug, some pathetic condolence … (Grace)

Under normal circumstances, the recounting of trauma or grief ‘solicits validation of one’s experience and provision of social support, both of which can facilitate healing and growth’ (Neimeyer, 2006, p. 70). However, when losses are ‘disenfranchised’ they are often met with ‘empathetic failure on the part of intimate and non-intimate others in the family and broader community’ (Neimeyer, 2006, p. 70). Grace goes on to discuss in her vignettes the negative impact the media portrayals of Liam and his death had on the community’s willingness to support her grief. Here, we can see her frustration at not receiving the support she was hoping for in her time of need.

Gerald also expresses how his expectations were not met when faced with talking to others about his bereavement:

Others say you’ll be fine, she’s at peace now. Well I say I wish she was here. They then give the awkward look as if to say, I didn’t mean that. I say just say it as it is. They give the awkward look again. Some even avoid us as though we had some disease that was contagious and don’t speak or at worst cross the street. Some don’t even mention and avoid the subject when it surfaces and change it as soon as they can. It’s like the elephant in the room. They ask what have you done with her belongings as though she didn’t exist and expect that all has gone. When we say we’ve not done anything and that is all as it was they give a shocked look as though to say why. (Gerald)

In this piece, Gerald highlights the distance between the ‘others’ and himself. In the opening sentences the lines oscillate between the ‘others’, ‘they’ and ‘some’ who are responding to his grief and the ‘I’, indicating that their responses are not helpful. He emphasizes others’ discomfort with his grief, describing them as being ‘awkward’, ‘shocked’ and/or hoping to ‘avoid’ the subject of his daughter’s death that it is the ‘elephant in the room’. His discussion of others avoiding him and his wife as though they had some kind of contagious ‘disease’ speaks to the idea of stigma by association (Bos et al., 2013; Goffman, 1963). At the root of stigma is social interaction and here we can see others avoiding the topic and, in some cases, even crossing the road to avoid speaking to Gerald and his family. Like Grace, Gerald also experienced an inquest after his daughter Esther’s death and the news of her death was in national newspapers. This left him feeling particularly vulnerable to others’ negative reactions.

Often when a substance misuser is alive, family members may ‘encourage that member to hide his or her condition’ (Bos et al., 2013, p. 9). When this is the case, the stigma by association can be felt more keenly after the death as the addiction becomes known to others. This was certainly the case for Debbie who lost her father to alcoholism:

The dark secret was now an open book for everyone to read or given free license to comment. All the services, the police, the coroner, undertakers, registers, etc. All had words they had learnt to sum up for these occasions, such as: “he was obviously a character”. My translation in my head was “I feel sorry for you that your father lived and died like this.” (Debbie)

After her father died, Debbie knew that people would begin commenting on her father’s addiction and his life. However, unlike Gerald, she found the platitudes and ‘rehearsed statements’ people were saying comforting:

During the traumatic ordeal that played out after the death I was so thankful for these rehearsed statements, they were helpful beyond belief. It seemed people knew what to say and do when I felt so lost. (Debbie)

Every participant who wrote about others seemed to be in engaged in an act of translation – considering the differences between what someone said and what they meant. The real, or perceived, stigma they felt caused them to constantly assess what other people meant when they said things about the deceased, like ‘at least they are at peace’ and ‘at least they are no longer suffering’. However, many participants in this small cohort suggested that if these comforts were given to someone who lost their child to cancer they would ‘mean’ something different than if they were given to someone who lost their child to addiction, even though the words are the same. This leads to a constant translation happening where those bereaved by addiction filter others’ comments and actions through the lens of the stigma they feel by association with their loved one.

In their earlier article, ‘The Secret Life of Pronouns: Flexibility in Writing Style and Physical Health’, Campbell and Pennebaker (2003) ask and answer the question ‘why might changes in pronoun use ultimately be beneficial?’:

Translating a traumatic event into language calls on cognitive, emotional, and linguistic processes, among them introducing and describing main characters, contexts, and events (i.e., people, places, and things). Once these components are introduced, their interrelationships need to be described. Pronoun choice communicates this relational information, even though pronouns are generally seen only as placeholders in language, simply referring to components previously introduced (see Muhlhausler & Harre, 1990). Pronoun choice is based on perspective. For example, “us and them” betrays a very different perspective than “you and them” by highlighting whether the author is identified with a group, and which one (p. 65).

All participants spoke to others in their writing and, through this, seemed to demonstrate self-awareness about these relationships. However, for the most part, those who showed a more changeable pronoun pattern across their writing — as assessed in the nine full notebooks I had access to — had been bereaved for three or more years. This may suggest that the more distance participants had from the death the more likely they were to think and write differently about the people still in their life.

Talking to Self

According to Neysari et al. (2016), using ‘I’-words demonstrates self-focused thinking and often acts as the primary way of expressing emotions, thoughts or feelings. Perhaps unsurprisingly, ‘I’ was the primary pronoun used across all participants’ writing followed by other first-person singular variants such as ‘me’, ‘my’, ‘mine’, and — less frequently — ‘myself’. This is not unique to bereaved individuals as the ‘spontaneous use of first-person singular personal pronouns’ is common across nearly all populations (Carey et al., 2015, p. e2).

Participants in this study predominately used ‘I-statements' in their writing to either retell a narrative; write about their feelings, thoughts or experiences with their loved one or others; or to talk to themselves. In most cases when participants ‘talked to themselves’ they were stating or reassessing how they think or feel about themselves and their reactions to things. However, five participants specifically started asking themselves questions as they wrote. This can be seen in this extract from Sophie’s writing in response to the ‘Anger’ prompt:

… I wish I’d been less angry in my own life before I had him [my son], less angry when he was young at his father’s drinking. Anger – such a destructive thing. Yet I have always turned my anger out and Patrick and his Dad – not sure about his sister – potentially? They turned theirs in on themselves. Is addiction the manifestation of anger turned inwards? I think the people we show our true feelings to are the ones we love. I suppose anger is one of them. But, it has the effect of pushing our loved ones away. (Sophie)

Here Sophie makes ‘I-statements' throughout which she combines with 'insight words', including ‘I wish’, ‘I suppose’ and ‘I think’. According to Neimeyer et al. (2009) these ‘insight words’ are strong indicators of self-awareness which can lead to a reflective process. However, Sophie asks two questions as well. The first is about herself and whether she turned her anger towards her daughter as well as her son and her ex-husband. This could indicate a search for meaning which, if successful, could help her understand things about herself and her relationships with her family (Boals, 2012; Park, 2010; Park & Ai, 2006). Her second question – ‘Is addiction the manifestation of anger turned inwards?’ – seems to be an attempt to make sense of her son’s addiction to heroin and her ex-husband’s relationship to alcohol (which she mentions previously in her writing). Again this demonstrates a desire to learn and understand more about the nature of their addictions. According to Lichtenthal and Cruess (2010) this kind of sense-making activity (which asks individuals to consider the nature of something which was previously assumed) may help to alleviate any guilt Sophie might be feeling around her son’s addiction.

Another mother, Alice, used the most ‘I-statements' out of any participant. She was the most newly bereaved in this study which may suggest that increased self-focus is more prevalent in the early stages of bereavement. Here she writes about her grief experience:

I am like Alice [in Wonderland] running as fast as I can in order to stay in the same place. Can one ever really outrun it? What is the secret of those who recover? Is it not looking back? Is it having more hands holding you and dragging you forwards? … My son is gone. Addiction took him from me. When I leave this place I hope I will be more tolerant and less judgemental but I fear I will not leave. There is nowhere to return to, no one to take his place, no thing I wish to do. So for now I shall stay, looking into the blackness and challenging the malevolence to show itself. But addiction works alone and divides and conquers. I am sorry that it won. (Alice)

This piece includes a large variety of ‘I-statements’ — ‘I am’, ‘I can’, ‘I hope’, ‘I fear’, ‘I will not’, ‘I wish’, ‘I shall stay’ and ‘I am sorry’. These statements cover a lot of ground, speaking to who Alice is, her frame of mind and emotional state, where she does and does not want to be, as well as what she can and cannot do. Unlike Sophie who seems to be asking herself a question about what addiction means, the questions Alice poses seem to be addressed outward towards the universe – i.e. ‘what is the secret of those who recover?’. These, in a way, could also be read as rhetorical questions as she, herself, seems unsure if grief can ever really be ‘outrun’. According to Boals (2012), meaning making can happen on two levels: when one appraises the situation caused by a stressful event or when one reconsiders their global beliefs and world views (p. 395). Alice seems to be attempting to do both here by questioning what it takes to come to terms with the loss of her son (i.e. the stressful event) as well as what it means to live in the world as a bereaved person who she hopes will be ‘more tolerant and less judgmental’ in the future.

Unlike the questions posed by other participants, Jemma often questioned why she was writing and what benefit this might bring to her. This can be seen in her response to the ‘Memory’ prompt:

Good memories and thoughts break my heart and make me think what a waste – why? I don’t want to write them down as I torture myself and resent those who had good times. (Jemma)

This prompt represents the fourth (out of ten) that Jemma questioned why she was writing and chose not to respond to fully. Here she cuts herself off from pain, seeming to know herself and what writing about good memories would do to her – i.e. ‘break’ her heart, ‘torture’ her and make her ‘resent’ others. According to Park and Blumberg (2002), this suggests no desire to search for meaning which could be the result of low levels of self-awareness. However, Jemma is a counselor in her professional life and has had counseling about her son’s death. So, perhaps this question of ‘why?’ is more about knowing herself deeply, having achieved high levels of self-awareness already and understanding that writing more about this would not benefit her. There is a precedent for this according to Neimeyer et al. (2009) who state that those who have already created a coherent story about their trauma (i.e. made meaning from it) do not tend to benefit as much, if at all, from expressive writing.

Results

The findings suggest that all 12 participants improved their self-awareness through writing. The increase in ‘insight words’ used by participants throughout their notebooks — such as ‘learned’, ‘realized’ and ‘reflected’ — as well as ‘I-statements’ indicated that writing led them to new ways of thinking about their bereavement experience. These findings are consistent with other therapeutic writing studies (e.g. Frattaroli, 2006; Neimeyer et al., 2009; Pennebaker & Francis, 1996; Sloan & Marx, 2004) and demonstrate that those bereaved by addiction can also increase their self-awareness through writing.

Strength and Limitations

Participants in this study came from a wide range of socio-economic backgrounds; had lost their loved ones’ to a variety of addictions (i.e. alcohol, Butane, cocaine, heroin, etc); and had been bereaved for various lengths of time, between 4 months and six years. Several participants in this study also faced additional, potentially traumatic experiences including prolonged ‘anticipatory grief’ (Dyregrov et al., 2019); discovering a substance-misuse related suicide; experiencing an inquest; and/or reading and watching news reports which covered their child’s death. It is encouraging to see that self-awareness increased across all 12 participants who submitted writing samples regardless of their socio-economic background, their loved ones’ addiction, their bereavement length and any additional challenging circumstances.

However, there are some limitations when it comes to generalizing the findings of this case study. All participants were from the same ethic background and their religion was not determined. Only two of the participants in this study were male, meaning the majority of those who submitted writing samples (ten) were female. Although writing seemed effective in increasing self-awareness for this small group, it is difficult to generalzse findings to a wider population from different ethnicities and religions or to assume that a study with mostly male participants would have the same outcomes.

All participants were also accessing, or had accessed, bereavement and/or family addiction services as well so had at least some experience of discussing or reflecting on their grief. The participants in this study also self-selected and were recruited, primary, through their support groups. This may have influenced the language they used in their writing (i.e. perhaps using ‘insight words’ or ‘I-statements’ is something they had previously been encouraged to do during support sessions). It is difficult to know if these findings could be generalized to those who have never accessed these services.

According to Titlestad et al. (2019), every death attributed to substance misuse will leave behind ‘at least ten next of kin who are likely to suffer the effects of bereavement’ (p.1). This bereaved by addiction population tends to be socially isolated, stigmatized and remains, largely, under-researched. Further qualitative and quantitative studies are needed to fully understand this disenfranchised group and to develop appropriate therapeutic tools to support their unique needs. Future research should aim for a larger sample size and be conducted over a longer period of time. It would also be helpful for future research to consider if any increase in self-awareness does in fact lead to behavior-regulation and positive health outcomes for those bereaved by addiction, as previous research with other populations suggests.

Discussion

Becoming more self-aware is the first step to improving ‘self-control’ (Silvia & O’Brien, 2004) and ‘self-regulation’ (Baumeister & Finkel, 2010). Increased self-awareness is also needed to ‘make sense’ (Castelli Dransart, 2013) and ‘make meaning’ (Neimeyer et al., 2009) out of loss. Although not requested or required for this study, all 12 participants who submitted writing samples also engaged in the act of sense-making through their written responses. They did this by asking questions about the death and/or reconstructing the death of their loved one through narrative retellings. These attempts to ‘make sense’ of the death can enable bereaved individuals to ‘continue loving the person who died while avoiding blame’ (Castelli Dransart, 2013, p. 328). This suggests that those who were most rigorously engaged in the act of sense-making — those who were bereaved for less than three years and/or admitted to having difficulty coping with their grief — were still attempting to reconcile the events of the death and their feelings about it.

Out of the 12 participants who submitted writing samples, 11 also attempted to ‘make meaning’ out of their loss by considering the ways in which their bereavement experience led to personal growth (Neimeyer, et al., 2010). This could be seen in the evolving questions participants asked, as well as the realizations they shared. Those who were engaged in meaning-making progressed from asking questions about why and how the death had happened to asking questions about what the death meant for them and their lives. This meaning-making led participants, primarily, to an important outcome: a new view of the future (Gillies & Neimeyer, 2006). It is worth noting that meanings made by participants in this study were ‘practically absent’ in the grief narratives of participants in Wojtkowiak et al.’s (2019) study, which explored meaning making in the context of hard drug users who have lost a significant other associated with drug use (p. 130). Although both studies deal with a population bereaved by addiction, the outcomes of participants’ meaning-making are different and seem to be related to the participants’ relationship with drugs rather than their relationship to the deceased. None of the participants in my study identified as drug users and two participants were even surprised when their loved one died, having not realised the extent of their drug use. This may have allowed my participants to more readily make meaning out of their loss and imagine a future for themselves in a way that the hard drug users in Wojtkowiak et al.'s (2019) study did not.

Of the 12 participants who supplied writing samples, all of them engaged in creative writing in response to two or more prompts. Every participant in this study also employed metaphor to talk about their emotions. According to Neimeyer (1999), this step away from ‘literal language’ to ‘figurative language’ can allow for a more intuitive exploration of feeling and lead to more instances of meaning-making. Because most studies which use writing as a therapeutic intervention conflate the terms ‘expressive’ and ‘creative’, it is difficult to compare whether or not this study encouraged participants to write creatively more often than other studies. However, previous research does suggest that making creative choices can lead to a more ordered narrative and more opportunities to engage in meaning-making (Neimeyer et al., 2010; Pennebaker & Chung, 2011).

In others studies with bereaved participants, writing letters or poems directly to the deceased person is very common (Barak & Leichtentritt, 2016; Hunsaker Hawkins, 1999; Lander & Graham-Pole, 2009; Rosenblatt, 2000; Valentine & Walter, 2015). However, in this study, only eight of 12 participants spoke to the dead. However, all 12 participants talked to family members, friends, strangers or others in their writing. How those bereaved by addiction ‘talk to others’ is particularly important when considering health outcomes as previous expressive writing research has indicated that the way in which participants use and change pronouns seems to lead to the biggest health improvements (Bond & Pennebaker, 2012; Campbell & Pennebaker, 2003; Landauer et al., 1998). According to Bond and Pennebaker (2012), participants in previous experience writing studies who:

fluctuated in their use of first person singular pronouns (e.g., I, me, my) to other personal pronouns (e.g., you, he, she, they) from one writing essay to the next showed much greater health improvements than those who relied on a single pronoun orientation. The authors interpreted the findings as reflecting the ability to change perspectives in writing. That is, use of I-words typically involved writing about how the person felt or viewed themselves whereas essays with high rates of other-pronoun words suggested a more external focus. (p. 1013)

Bond and Pennebaker (2012) suggest the ‘improved heath benefits’ might arise from the fact that ‘word use patterns typically reflect changes in the ways people think about an emotional upheaval’ (p. 1018). According to Neysari et al. (2016) relational pronouns are:

supposed to mirror the relation of the self to the other, vary as a function of adapting perception about the relationships and reveal couple related psychological processes (Pennebaker et al., 2003). “I”-words such as “I”, “mine”, or “my” stand for expressing own thoughts and feelings and stand for self-focused way of thinking … When individuals are experiencing physical or emotional pain they use more “I”-words, which reflects a switch of attention towards themselves (p. 7).

Talking to others may be a particularly valuable tool for those bereaved by addiction since so much of their disenfranchisement has to do with the way others view them and/or the way they think others view them due to stigma and stigma by association.

Family members’ perceptions of stigma by association have been linked to psychological and emotional distress as well as lower self-esteem which can serve to further the effects of disenfranchised grief (Bos et al., 2013; Goffman, 1963; Mak & Kwok, 2010; Struening et al., 2001). According to Bos et al. (2013), people with ‘high self-esteem are less vulnerable to the psychological impact of stigma by association’ (p. 12). However, those who have experienced bereavement by addiction are often worn out from coping with their loved one’s addiction and, over time, this can erode their self-esteem and sense of self-worth (Valentine & Walter, 2015). Talking to others, particularly documenting wrongdoings or standing up to others in their writing, may have offered participants a way to regain some self-esteem and help them feel more in control.

Ultimately, findings from this small case study suggest that writing is an effective tool for increasing self-awareness in those bereaved by addiction. It also acts as a useful method for facilitating both sense-making and meaning-making, both of which can lead to an increased sense of well-being (Stein et al., 1997) as well as better physical health (Murphy et al., 2003) and immune system functioning (Bower et al., 2003). The particular challenges of disenfranchised grief, coupled with the stigma felt by those bereaved by addiction, make meaning-making difficult for this population (Adfam, 2014; Doka, 1989; Neimeyer et al., 2009). Since all participants in this study improved their self-awareness through writing, and improved self-awareness is the first step to meaning-making, then writing could be considered a uniquely valuable therapeutic intervention for individuals bereaved by addiction.

Footnotes

Authors’ Note

Thanks are owed to the ENCAP Research Ethics Committee at Cardiff University for approving this study. Gratitude is also owed to DrugFam and The Compassionate Friends for their help recruiting participants, to the participants themselves for sharing their experiences, and to Professor Richard Gwyn for supervising this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Christina Thatcher

Author Biography

Christina Thatcher completed her PhD in Creative and Critical Writing at Cardiff University where she studied how creative writing impacts individuals bereaved by addiction. She is now a Creative Writing Lecturer at Cardiff Metropolitan University where she continues to conduct interdisciplinary writing research within the social sciences and medical humanities. She has published two poetry collections with Parthian Books which explore family addiction: More than you were (2017) and How to Carry Fire (2020).

References

Adfam. (2014, October). Drug and alcohol related bereavement project: Scoping review. https://adfam.org.uk/files/docs/Adfam-Cruse_Drug_and_alcohol_related_bereavement_Scoping_review_-_October_2014.pdf

Baikie

Wilhelm

(2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11(5), 338–346.

Barak

Leichtentritt

R. D.

(2016). Creative writing after traumatic loss: Towards a generative writing approach. British Journal of Social Work, 47, 936–954. https://doi.org/10.1093/bjsw/bcw030

Baumeister

Finkel

(2010). Advanced social psychology the state of the science. Oxford University Press.

Boals

(2012). The use of meaning making in expressive writing: When meaning is beneficial. Journal of Social and Clinical Psychology, 31(4), 393–409.

Bonanno

G. A.

(2013). Meaning making, adversity, and regulatory flexibility. Memory (Hove, England), 21(1), 150–156. https://doi.org/10.1080/09658211.2012.745572

Bond

Pennebaker

(2012). Automated computer-based feedback in expressive writing. Computers in Human Behavior, 28(3), 1014–1018.

Bos

Pryor

Reeder

Stutterheim

(2013). Stigma: Advances in theory and research. Basic and Applied Social Psychology, 35(1), 1–9.

Bower

J. E.

Kemeny

M. E.

Taylor

S. E.

Fahey

J. L.

(2003). Finding positive meaning and its association with natural killer cell cytotoxicity among participants in a bereavement-related disclosure intervention. Annals of Behavioral Medicine, 25(2), 146–155.

10.

Campbell

R. S.

Pennebaker

J. W.

(2003). The secret life of pronouns: Flexibility in writing style and physical health. Psychological Science, 14(1), 60–65.

11.

Carey

Brucks

Küfner

Holtzman

Große Deters

Back

Donnellan

M. B.

Pennebaker

Mehl

M. R.

(2015). Narcissism and the use of personal pronouns revisited. Journal of Personality and Social Psychology, 109(3), E1–E15.

12.

Castelli Dransart

(2013). From sense-making to meaning-making: Understanding and supporting survivors of suicide. British Journal of Social Work, 43(2), 317–335.

13.

Coffey

Atkinson

(1996). Making sense of qualitative data. SAGE.

14.

Corr

(1999). Enhancing the concept of disenfranchised grief. OMEGA—Journal of Death and Dying, 38(1), 1–20. http://dx.doi.org/10.2190/ld26-42a6-1eav-3mdn

15.

da Silva

Noto

Formigoni

(2007). Death by drug overdose: Impact on families. Journal of Psychoactive Drugs, 39(3), 301–306.

16.

Dishon

N. A.

Oldmeadow

Kaufman

Critchley

(2017). The effect of trait self- awareness, self-reflection, and perceptions of choice meaningfulness on indicators of social identity within a decision-making context. Frontiers in Psychology, 8, 2034.

17.

Doka

(1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington Books.

18.

Dower

(2013). Slice of moon (p. 50). Red Hen Press.

19.

Duke University. (n.d.). Creative writing: Writing studio handout. https://twp.duke.edu/sites/twp.duke.edu/files/file-attachments/creative-writing-1.original.pdf

20.

Dyregrov

Møgster

Løseth

Lorås

Titlestad

K. B.

(2019). The special grief following drug related deaths. Addiction Research & Theory, 28(5), 1–10.

21.

Feigelman

Jordan

J. R.

Gorman

B. S.

(2011). Parental grief after a child’s drug death compared to other death causes: Investigating a greatly neglected bereavement population. Omega, 63(4), 291–316. http://www3.ncc.edu/faculty/soc/feigelb/ODdeathspaper.pdf

22.

Fenigstein

Scheier

M. F.

Buss

A. H.

(1975). Public and private self-consciousness: Assessment and theory. Journal of Consulting and Clinical Psychology, 43(4), 522–527. https://doi.org/10.1037/h0076760.

23.

Frattaroli

(2006). Experimental disclosure and its moderators: A meta-analysis. Psychological Bulletin, 132(6), 823–865.

24.

Gillies

Neimeyer

R. A.

(2006). Loss, grief and the search for significance: Toward a model of meaning reconstruction in bereavement. Journal of Constructivist Psychology, 19(1), 31–65. https://doi.org/10.1080/10720530500311182

25.

Goffman

(1963). Stigma: Notes on the management of spoiled identity. Penguin.

26.

Guy

(2004). Bereavement through drug use: Messages from research. Practice, 16(1), 43–54.

27.

Hedtke

Winslade

(2016). The crafting of grief: Constructing aesthetic responses to loss. Routledge.

28.

Hiles

Cermák

(2008). Narrative psychology. In Willig

Stainton-Rogers

(Eds.), The SAGE handbook of qualitative research psychology (pp. 147–164). SAGE.

29.

Hunsaker Hawkins

(1999). Reconstructing illness: Studies in pathography. Perdue Research Foundation.

30.

Kacewicz

Slatcher

R. B.

Pennebaker

J. W.

(2007). Expressive writing: An alternative to traditional methods. In L’Abate

(eds) Low-cost approaches to promote physical and mental health. Springer.

31.

Landauer

T. K.

Foltz

P. W.

Laham

(1998). An introduction to latent semantic analysis. Discourse Processes, 25(2–3), 259–284.

32.

Lander

D. A.

Graham-Pole

J. R.

(2009). Love letters to the dead: Resurrecting an epistolary art. Omega, 58(4), 313–333. https://doi.org/10.2190/OM.58.4.d

33.

Leedy

J. J.

(1969). Poetry therapy. J.B. Lippencott.

34.

Lepore

S. J.

Kliewer

(2013). Expressive writing and health. In Gellman

M. D.

Turner

J. R.

(Eds.), Encyclopedia of behavioral medicine (p. 46). Springer.

35.

Lichtenthal

Cruess

(2010). Effects of directed written disclosure on grief and distress symptoms among bereaved individuals. Death Studies, 34(6), 475–499. https://doi.org/10.1080/07481187.2010.483332

36.

Mak

W. W. S.

Kwok

Y. T. Y.

(2010). Internalization of stigma for parents of children with autism spectrum disorder in Hong Kong. Social Science & Medicine, 70, 2045–2051.

37.

Muhlhausler, P., & Harre, R. (1990). Pronouns and people: The linguistic construction of social and personal identity. Oxford, England: Basil Blackwell.

38.

Murphy

S. A.

Johnson

L. C.

Lohan

(2003). Finding meaning in a child’s violent death. Death Studies, 27(5), 381–404.

39.

Neimeyer, R. A. (1999). Narrative Strategies in Grief Therapy. Journal of Constructivist Psychology, 12(1), 65--85.

40.

Neimeyer

R. A.

(2006). Re-storying loss: Fostering growth in the posttraumatic narrative. In Calhoun

L. G.

Tedeschi

R. G.

(Eds.), Handbook of posttraumatic growth: Research & practice (pp. 68–80). Lawrence Erlbaum Associates Publishers.

41.

Neimeyer

R. A.

(2019). Meaning reconstruction in bereavement: Development of a research program. Death Studies, 43(2), 79–91. https://doi.org/10.1080/07481187.2018.1456620

42.

Neimeyer

R. A.

Burke

Mackay

Van Dyke Stringer

(2010). Grief therapy and the reconstruction of meaning: From principles to practice. Journal of Contemporary Psychotherapy, 40(2), 73–83.

43.

Neimeyer

Pennebaker

Van Dyke

(2009). Narrative medicine: Writing through bereavement. In: Breitbart

Chochinov

(Eds.), Handbook of psychiatry in palliative medicine (1st ed., pp. 454–468). Oxford University Press.

44.

Neysari

Bodenmann

Mehl

M. R.

Bernecker

Nussbeck

F. W.

Backes

Zemp

Martin

Horn

A. B.

(2016). Monitoring pronouns in conflicts: Temporal dynamics of verbal communication in couples across the lifespan. GeroPsych, 29(4), 201–213. https://doi.org/10.1024/1662-9647/a000158

45.

Olds

(1992). The father (p. 26). Knopf.

46.

Osterweis

Townsend

(1988). Mental health professionals and the bereaved. DHHS Publication No. ADM 88-1554. U.S. Department of Health and Human Services.

47.

Park

C. L.

(2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301.

48.

Park

C. L.

A. L.

(2006). Meaning making and growth: New directions for research on survivors of trauma. Journal of Loss and Trauma, 11(5), 389–407.

49.

Park

C. L.

Blumberg

C. J.

(2002). Disclosing trauma through writing: Testing the meaning-making hypothesis. Cognitive Therapy and Research, 26(5), 597–616.

50.

Pennebaker

J. W.

(1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8(3), 162–166.

51.

Pennebaker, J. W. & Beall, S. K. (1986) Confronting a traumatic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274--281.

52.

Pennebaker

J. W.

Chung

C. K.

(2011). Expressive writing: Connections to physical and mental health. In Friedman

H. S.

(Ed.), The Oxford handbook of health psychology (pp. 417–437). Oxford University Press.

53.

Pennebaker

J. W.

Francis

M. E.

(1996). Cognitive, emotional, and language processes in disclosure. Cognition & Emotion, 10, 601–626.

54.

Pennebaker

J. W.

Lay

T. C.

(2002). Language use and personality during crises: Analyses of Mayor Rudolph Giuliani’s press conferences. Journal of Research in Personality, 36(3), 271–282. https://doi.org/10.1006/jrpe.2002.2349

55.

Pennebaker, J.W., Mehl, M., & Niederhoffer, K. (2003). Psychological Aspects of Natural Language Use: Our Words, Our Selves. Annual Review of Psychology, 54(1), 547--577.

56.

Phoenix

Smith

Sparkes

A. C.

(2010). Narrative analysis in aging studies: A typology for consideration. Journal of Aging Studies, 24(1), 1–11.

57.

Riessman

Speedy

(2007). Narrative inquiry in the psychotherapy professions. In: Clandinin

D. J.

(Ed.), Handbook of narrative inquiry (pp. 426–456). SAGE.

58.

Rosenblatt

(2000). Parents talking in the present tense about their dead child. Bereavement Care, 19(3), 35–38.

59.

Rude

Gortner

Pennebaker

(2004). Language use of depressed and depression-vulnerable college students. Cognition & Emotion, 18(8), 1121–1133.

60.

Seale

Van der Geest

(2004). Good and bad death: Introduction. Social Science & Medicine (1982), 58(5), 883–885.

61.

Silvia

O’Brien

(2004). Self-Awareness and constructive functioning: Revisiting ‘the human dilemma’. Journal of Social and Clinical Psychology, 23(4), 475–489.

62.

Sloan

D. M.

Marx

B. P.

(2004). Taking pen to hand: Evaluating theories underlying the written disclosure paradigm. Clinical Psychology: Science and Practice, 11, 121–137.

63.

Smyth

J. M.

True

Souto

(2001). Effects of writing about traumatic experiences: The necessity for narrative structuring. Journal of Social and Clinical Psychology, 20(2), 161–172.

64.

Stein

Folkman

Trabasso

Richards

T. A.

(1997). Appraisal and goal processes as predictors of psychological wellbeing in bereaved caregivers. Journal of Personality and Social Psychology, 72(4), 872–884.

65.

Stone

(2007). In the dark (p. 5). Copper Canyon Press.

66.

Struening

E. L.

Perlick

D. A.

Link

B. G.

Hellman

Herman

Sirey

J. A.

(2001). Stigma as a barrier to recovery: The extent to which caregivers believe most people devalue consumers and their families. Psychiatric Services (Washington, D.C.), 52(12), 1633–1638.

67.

Sutton

(2016). Measuring the effects of self-awareness: Construction of the self-awareness outcomes questionnaire. Europe’s Journal of Psychology, 12(4), 645–658.

68.

Thompson

Gauntlett-Gilbert

(2008). Mindfulness with children and adolescents: Effective clinical application. Clinical Child Psychology and Psychiatry, 13(3), 395–408.

69.

Titlestad

Lindeman

S. K.

Lund

Dyregrov

(2019). How do family members experience drug death bereavement? A systematic review of the literature. Death Studies. Advance online publication.

70.

Titlestad

Mellingen

Stroebe

Dyregrov

(2020). Sounds of silence. The “special grief” of drug-death bereaved parents: A qualitative study. Addiction Research & Theory. Advance online publication. https://doi.org/10.1080/16066359.2020.1751827

71.

Trethewey

(2007). Native guard (p. 13). Houghton Mifflin.

72.

Valentine

Walter

(2015). Creative responses to a drug- or alcohol-related death: A sociocultural analysis. Illness, Crisis & Loss, 23(4), 310–322. https://doi.org/10.1177/1054137315590733

73.

Valentine

Bauld

Walter

(2016). Bereavement following substance misuse. OMEGA–Journal of Death and Dying, 72(4), 283–301. https://doi.org/10.1177/0030222815625174

74.

Wagner

(1994). The Andrew poems (p. 8). Texas Tech University Press.

75.

Werner-Beland

J. A.

(1980). Grief response to long-term illness & disability. Reston.

76.

Wojtkowiak

Vanherf

N. C.

Schuhmann

C. M.

(2019). Grief in a biography of losses: Meaning-making in hard drug users’ grief narratives on drug-related death. Death Studies, 43(2), 122–132. https://doi.org/10.1080/07481187.2018.1456708

77.

Worden

J. W.

(2009). Grief counseling and grief therapy: A handbook for the mental health practitioner (4th ed). Springer Publishing.