Effects of a Bereavement Intervention Program in Middle-Aged Widows in Korea

Effects of a Bereavement Intervention Program in Middle-Aged Widows in Korea Hee-Young Kang and Yang-Sook Yoo

Dan-jeon is a meditative practice composed of both breathing and stretching exercises causing life energies to circulate blood throughout the body. Following a bereavement intervention program composed of Dan-jeon breathing sessions, a self-help group activity, and a health check, an experimental group showed significantly greater decrements in grief levels and symptoms of stress over a control group who received only a health check. Among the participants, there were no significant differences in immune response, percentages of T lymphocytes, helper T lymphocytes (Th), suppressor T lymphocytes (Ts), B lymphocytes, natural killer cells, monocytes, and Th:Ts ratios. D 2007 Elsevier Inc. All rights reserved.

B

EREAVEMENT IS ONE of the most difficult experiences in a person’s life, causing significant stress levels on family members confronting the crisis (Morton, 2005). In Korea, the death rate of middle-aged men due to diseases, industrial accidents, car accidents, and fatigue from overwork is three times higher than that of women (Korea National Statistical Office, 2005), leading to an annual increase in the number of bereaved women. In middle-aged women, bereavement causes significant stress levels as well as health, financial, family, and social problems for the people they know. This requires women to readjust their lifestyles (Gilbar & Ben-Zur, 2002; Kang, 1997). The normal response to bereavement is grief, which is a total response influencing our thoughts, emotions, and actions (Chon, 1997). It could serve as a stressor that causes serious effects on health (Parkes, 1998). Physical responses that may occur

From the Christian College of Nursing, Gwangju, South Korea. College of Nursing, Catholic University of Korea Song-eui Campus, Seoul, South Korea. Address reprint requests to Hee-Young Kang, RN, PhD, Christian College of Nursing, 67 Yangnim-Dong, Nam-gu, Gwangju 503-711, South Korea. E-mail addresses: [email protected], [email protected] B 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi:10.1016/j.apnu.2006.12.007

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for widows in grief can include increases in adrenal cortex activities, damage to immune systems, anorexia, sleep disturbances, and psychosomatic diseases (Gerra et al., 2003; Kato & Mann, 1999). Psychological responses include depression, anxiety, low self-esteem, panic, mental diseases, and chronic grief (Aneshensel, Botticello, & Yamamoto-Mitani, 2004; Beem et al., 1999; Constantino, Sekula, & Rubinstein, 2001; Goodkin et al., 1999). Socially, bereavement alters relationships with others and creates barriers with them (Beem et al., 1999; Potocky, 1993). Those suffering bereavement show higher rates of morbidity and mortality (Williams, 2004). An integrated management program that takes into account the whole physical and psychosocial situation of a bereaved family is needed to reduce these effects and support families while they adapt to the critical situation of bereavement. Previous research conducted overseas identified self-help group activities to reduce the level of grief and stress (Caserta & Lund, 1993, 1996; Constantino et al., 2001). In addition, relaxation therapy was found to enhance immune function (Houldin, McCorkle, & Lowery, 1993). In Korea, however, there is no systematized management for assisting a bereaved family. Research, which includes surveys on stress levels, social support networks, and the psychological state of bereaved women, as well as qualitative research on bereaved women and their family’s

Archives of Psychiatric Nursing, Vol. 21, No. 3 (June), 2007: pp 132–140

BEREAVEMENT INTERVENTION PROGRAM EFFECTS IN KOREAN WIDOWS

experiences along with biblical approaches for bereaved families, has been done. Nonetheless, there is still no research done regarding practical intervention in South Korea. The bereavement program in this study was developed by integrating three components: first, a self-help group activity for increasing grief awareness and management; second, the Dan-jeon breathing technique, which is a Korean traditional regimen noted for reducing depression and anxiety levels and improving health in middle-aged women (Hyun, 2001; Kim, 2005); and lastly, a health examination. The aim of this program was to develop a practical system with positive effects such as reducing grief levels, symptoms of stress, and immune responses of bereaved middle-aged women. LITERATURE REVIEW: BEREAVEMENT INTERVENTION

Bereavement intervention is most effective when implemented at the time of immediate loss. The intensity of grief caused becomes strongest within a period of 6 months after bereavement and then subsides as a gradual process (Victoria Hospice Society, 1993). Therefore, it is necessary to carry out an assessment on the risk factors of the bereaved families and implement intervention within the first 6 months. Potocky (1993) stressed the need for continued management as it affects the grief process at three points: before a loss occurs (primary prevention); following a loss, before the grief process becomes dysfunctional (secondary prevention); and after symptoms of morbid grief appear (tertiary prevention). He commented that a short intervention of 7 weeks would be effective. After omitting the 1st week’s orientation session and the 10th week’s evaluation, which were initially included in this study’s timetable, this study ran for 8 weeks instead of 10 weeks as originally planned. Observations of previous reports on bereavement research reveal that both self-help group therapy and relaxation techniques are effective in treating bereavement. According to Houldin et al. (1993), immune functions were strengthened and appetite and sleep functions were enhanced when a relaxation-training program was given to a bereaved spouse for a period of 4 to 6 weeks. In this study, Dan-jeon breathing was applied as a form of relaxation therapy. Dan-jeon helped alleviate tension from the sympathetic nerve

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system, thereby relaxing participants. In addition, Dan-jeon is noted for promoting emotional stability (Ahn, 1996). Caserta and Lund (1993, 1996) maintained that, by putting an average number of six persons into bereavement self-help group intervention, symptoms of grief were reduced. In Caserta and Lund’s study, the bereaved spouses were able to mutually share their grief from bereavement and learn about coping styles while receiving emotional and social support. Eventually, levels of grief and depression were alleviated and coping became easier. Stewart, Craig, Macpherson, and Alexander (2001) claimed that, by implementing a self-help group activity for an hour every week for a maximum period of 20 weeks, the distress caused by bereavement and the need for support were diminished. In sum, both relaxation therapy and self-help group activity have been identified as having positive effects on bereaved spouses. TREATMENT

The bereavement intervention program consisted of the Dan-jeon breathing technique, a self-help group activity that was reportedly beneficial for bereaved spouses, and a health check. The program was conducted at the heath care room of C College in G City. The program ran 10 times from 10 a.m. to 12 p.m. for 2 hours every Tuesday. The 17 people in the experimental group were divided into five subgroups of 3 or 4 people each to facilitate interaction among group members. Dan-jeon Breathing The Dan-jeon breathing applied in this study is based on Pungryudo (Korean elegant arts) and is composed of both Dan-jeon breathing and stretching exercises. Dan-jeon means the bplace where energies gather together.Q Dan ( ) signifies life energy and Jeon ( ) means to gather. These energies help to circulate blood throughout the entire body, which is the principle of the regimen. The breathing technique is done by concentrating the mind and slowly taking deep breaths from 4 to 5 cm below the belly button in the lower abdomen (Hyun, 2001). The stretching exercise has 60 poses, extending the muscles and joints at the main positions of standing, sitting, or lying down. This exercise, usually done easily by middle-aged women, was instructed by one Dan-jeon breathing master with

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Table 1. Dan-jeon Breathing Week

1

2–10

Contents

Time (min)

Overview of Dan-jeon breathing Definition of Dan-jeon breathing Location in the lower abdomen best suited for Dan-jeon Method of Dan-jeon breathing Warm-up stretching exercise Dan-jeon breathing Cool-down stretching exercise

60

(n = 6) had osteoporosis prevention care explained to them. METHODS

Research Design 20 30 10

20 or more years of experience. Dan-jeon breathing runs for 60 minutes with 20 minutes of warm-up stretch exercises, 30 minutes of breathing, and 10 minutes of cool-down stretch exercises. In the first week, the master used figures to define Dan-jeon breathing, to determine the location in the lower abdominal region that is best suited for Dan-jeon, and to teach the method of Dan-jeon breathing. From the 2nd to the 10th week, participants, led by the master’s demonstration and verbal instructions, performed the warmup and stretch exercises, breathing, and cool-down stretch exercises (Table 1). The participants also received a free videotape of Dan-jeon breathing training so that they could practice at home at least once a week. The authors and the Dan-jeon breathing master made this videotape.

A quasi-experimental design with a nonequivalent control-group pretest–posttest design was used. The independent variable is 10 sessions of a bereavement intervention program where each session runs for 120 minutes once a week. The dependent variable consists of grief levels, symptoms of stress, and immune responses (Figure 1). Participants This study’s results are based on a bereavement intervention program for middle-aged women in G City and J Province, South Korea. The participants were between 35 and 64 years old; bereaved less than 6 months; did not drink, smoke, or exercise Table 2. Self-Help Group Activities Week

1

Self-Help Group Activity The self-help group activity, conducted by the authors, was done immediately after the end of Dan-jeon breathing program. The self-help group met once a week for 10 weeks; each session ran for 60 minutes. The activity helped participants solve individual problems, share common experiences, and work toward the same goals (Cha, 1997). The self-help group was created as a type of support group based on Worden’s (1991) four-task model (see Appendix A; Table 2).

2–3

4–5

6–7

Health Examination The experimental and control groups underwent a health examination (mammography, bone density and blood pressure measurements, complete blood count) to check their health status. Ten participants with suspicious mammographic findings were asked to take a follow-up check. Based on the bone density examination, those found with osteoporosis (n = 1) and osteopenia

8–9

10

Goals

Understanding of grief

Contents

Time

Program orientation Introduce oneself Sharing story of husband’s death Understanding of grief Grief process Grief response Setting concrete and feasible goals Facilitation of Storytelling 1 grief work Topic: Accepting the reality of the loss and arranging for articles left by the departed Storytelling 2 Topic: Working through the 60 mins pain of grief (recording a tape or writing a letter) Provision of Storytelling 3 emotional Topic: Adjusting to support an environment where the deceased is no longer around Enabling open Storytelling 4 Topic: Emotionally relocating discussion of the deceased and moving related concerns on with life Draw a diagram of significant others Visit graves together Resolution Evaluate goal setting and of grief talk about their changed lives

BEREAVEMENT INTERVENTION PROGRAM EFFECTS IN KOREAN WIDOWS

Fig 1.

regularly; and were not involved in social clubs. The participants had no mental illness and understood the information in the questionnaires and the objectives of the study. In the program’s early stages, there were 18 people in the experimental group and 13 in the control group. Individual circumstances led 1 participant from the experimental group and 3 from the control group to resign. The final number of participants was 17 for the experimental group and 10 for the control group. There were no significant differences in general characteristics such as grief levels, stress symptoms, and immune responses between the two groups at pretest (Table 3). Procedure The authors first received approval for the study from a general hospital in G City. Letters consoling widows and introducing the bereavement program were sent based on a list of decedents from the general hospital in G City. The authors and a hospice unit nurse then explained the study’s purpose over the telephone. There were also a number of calls from people who had read newspaper advertisements about the study. The purpose of the study was again explained and then written consents were received. Lastly, participants were assigned, at their preference, to either an experimental or a control group. During the first meeting, the participants’ level of grief, symptoms of stress, and immune

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Research design.

responses were measured, and an examination of their health was carried out (mammography, bone density and blood pressure measurements, complete blood count). The experimental group attended 10 sessions of a bereavement intervention program. Sessions were 120 minutes each, held once a week for 10 weeks. For both groups, the grief levels, symptoms of stress, and immune responses were measured again following the program’s conclusion. When the data collection for the control group was finished, the authors personally met with each participant in the control group and discussed the results and difficulties of bereavement. Instruments Level of Grief Sanders, Mauger, and Strong (1979) developed an instrument that measures the level of grief and Lev, Munro, and McCorkle (1993) modified it into the Revised Grief Experience Inventory. Chon (1997) further modified it. The instrument used to measure the level of grief in this study is based on Chon’s modified tool, consisting of 19 items on a five-point Likert-type scale. The items included existential concerns, depression, feelings of tension and guilt, and physical distress. Higher scores indicated higher levels of grief. Chon, using this reliability measure, had Cronbach’s a of .93; Cronbach’s a in this study was .95.

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Table 3. General Characteristics Between the Experimental Group (n = 17) and the Control Group (n = 10)

Characteristics

Experimental Group, n (%)

Age (years)4 35–49 2 (11.8) 50–59 9 (52.9) 60–64 6 (35.3) Educational level4 VElementary school 8 (47.1) zMiddle school 9 (52.9) Believes in religion4 Yes 15 (88.2) No 2 (11.8) Number of years married V30 6 (35.3) N30 11 (64.7) Bereavement period (months)4 V2 7 (25.9) 3–4 5 (18.5) 5–6 5 (18.5) Cause of husband’s death4 Cancer 11 (64.7) Other 6 (35.3) Number of children4 1 5 (29.4) z2 12 (70.6) Employment4 Employed 5 (29.4) Unemployed 12 (70.6) Monthly income (US$)4 b1,000 10 (58.8) z1,000 7 (41.2)

Control Group, n (%)

v 2/t

P

2 (20.0) 5 (50.0) 3 (30.0)

1.000

6 (60.0) 4 (40.0)

.695

9 (90.0) 1 (10.0)

1.000

5 (50.0) 5 (50.0)

0.56

.453

6 (22.2) 4 (14.8) 0

.209

8 (80.0) 2 (20.0)

.666

3 (30.0) 7 (70.0)

1.000

4 (40.0) 6 (60.0)

.683

7 (70.0) 3 (30.0)

.692

(Th), suppressor T lymphocytes (Ts), B lymphocytes, natural killer cells, monocytes, and Th:Ts ratios. For the sampled blood, 3 cc of peripheral blood was obtained from the health care center in the hospital. This blood was then mixed with ethylenediaminetetraacetic acid. Lastly, it was analyzed by the FACS Caliber machine (BectonDickinson, Franklin Lakes, NJ) using the following primary antibodies: CD3+, CD4+, CD8+, CD14+, CD19+, CD45+, and CD16+/56+. Data Analysis Data analysis was done using the SAS program. The homogeneity of the two groups was found by way of the chi-square test and Fisher’s Exact Test. Pretest research variables and effect test before and after the experiment were measured by t test, Wilcoxon rank sum test, and Wilcoxon signed rank sum test. RESULTS

4 Fisher’s Exact Test.

Symptoms of Stress The instrument used to measure symptoms of stress in this study consisted of 93 items, which were rated on a five-point Likert-type scale. This instrument was developed by Beaton, Egan, NakagawaKogan, and Morrison (1991) and used by Han (1997); in this study, all the sexual life categories were excluded. The measure in this study included 11 symptom areas: peripheral blood vessel, cardiopulmonary, upper respiratory, central nervous system, gastrointestinal, muscular tension, pattern of habitual action, depression, anxiety, emotional anger, and cognitional disturbance. Higher scores indicated higher levels of stress symptoms. Han, using this reliability measure, had Cronbach’s a of .96; Cronbach’s a in this study was .98. Immune Response The immune response was measured by percentages of T lymphocytes, helper T lymphocytes

Level of Grief The grief level of the experimental group was 68.59 before treatment; it dropped to 44.71 upon treatment conclusion ( P b .001). The level among the control group decreased from 66.40 to 61.10 ( P b .01). In reference to the experimental group’s decrement in grief level, the score of 23.88 was significantly greater than the control group’s score of 5.30 ( P b .001; Table 4). Symptoms of Stress The median of stress symptoms for the experimental group decreased from a score of 121.0 before treatment to a score of 69.0 after treatment ( P b .001). At the same time, the control group showed a decrease from 130.5 to 120.0 ( P b .01). After treatment was implemented, the decrement in stress symptoms in the experimental group was significantly greater than that in the control group ( P b .001; Table 5). Immune Responses There was a tendency for the participants in the experimental group to have an increase in percentage in their B lymphocyte, monocyte, and Th:Ts ratio after the treatment was implemented, whereas there was a tendency for the participants in the control group to have an increase in percentage in their T lymphocytes, Th, Ts, and natural killer

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Table 4. Changes in Grief Level and Immune Response Between the Experimental Group (n = 17) and the Control Group (n = 10) Variables

Pretest (M F SD)

Grief level Experimental Control Immune responses T lymphocyte Experimental Control Th Experimental Control Ts Experimental Control Th:Ts ratio Experimental Control B lymphocyte Experimental Control Natural killer cell Experimental Control Monocyte Experimental Control

Posttest (M F SD)

Paired t Test

P

Difference [Posttest (M F SD)

Pretest] t Test

P

68.59 F 12.35 66.40 F 7.73

44.71 F 8.79 61.10 F 6.30

12.17 4.98

b.001 b.01

23.88 F 8.09 5.30 F 3.37

8.32

b.001

67.72 F 4.38 69.67 F 6.39

68.50 F 6.60 71.10 F 8.95

0.52 0.64

.611 .539

0.78 F 6.21 1.43 F 7.09

0.25

.806

42.35 F 6.62 46.00 F 8.73

42.18 F 6.17 46.80 F 6.56

0.19 0.32

.850 .756

0.17 F 3.78 0.80 F 7.90

0.37

.720

25.12 F 11.13 20.20 F 6.56

22.41 F 9.62 20.40 F 6.48

1.30 0.25

.213 .808

2.71 F 8.61 0.20 F 2.53

1.30

.208

2.04 F 0.97 2.55 F 1.12

2.28 F 1.32 2.49 F 0.78

0.76 0.50

.457 .626

0.24 F 1.29 0.06 F 0.40

0.90

.380

13.94 F 4.37 14.00 F 3.68

14.18 F 4.89 13.40 F 4.72

0.24 0.44

.810 .673

0.24 F 3.98 0.60 F 4.35

0.51

.615

15.41 F 4.11 15.10 F 4.28

15.12 F 4.76 16.50 F 5.02

0.23 0.97

.821 .359

0.29 F 5.27 1.40 F 4.72

0.85

.406

5.24 F 2.05 5.90 F 1.97

5.53 F 1.46 5.30 F 1.89

0.68 0.97

.509 .357

0.29 F 1.79 0.60 F 1.96

1.21

.238

cells. However, there were no significant differences between the two groups (Table 4). FINDINGS

In this study, there was a significantly greater reduction in the level of grief alleviation in the experimental group as opposed to the control group. While this finding might be accounted for by reasons outside this intervention, it still has similarities to other studies. The results are similar to those of Constantino et al. (2001), which reported significantly decreased grief level as a result of applying the Bereavement Group Postvention and the Social Group Postvention for widowed survivors of suicide. This study found that the stress symptoms in the two groups subsided significantly after treatment, and the decrement in symptoms of stress in the

experimental group was significantly greater than that in the control group. The present findings are similar to other results (Beem et al., 1999; Constantino et al., 2001; Gerra et al., 2003; Goodkin et al., 1999; Stewart et al., 2001) in which physical symptoms, anxiety, and depression have been reduced after implementing grief counseling, self-help group interventions, or both. The immune responses of the two groups before treatment were within normal ranges. After treatment, findings indicated no differences between the two groups in terms of immune responses. There have been reported research findings in which B lymphocytes taken from widows within the 3-month period after bereavement were found to be significantly lower compared with those of nonwidows (Beem et al, 1999), and the functional activity of natural killer cells was markedly reduced at Day 40 after bereavement (Gerra et al., 2003).

Table 5. Changes in Symptoms of Stress Between the Experimental Group (n = 17) and the Control Group (n = 10)

Experimental Control

Pretest, Median (Range)

Posttest, Median (Range)

121.0 (98.0–185.0) 130.5 (108.0–173.0)

69.0 (2.0–131.0) 120.0 (105.0–157.0)

Wilcoxon Signed Rank Sum Test

76.5 18.0

P

Wilcoxon Rank Sum Test

P

b.001 b.01

3.52

b.001

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However, Beem et al. (1999) found no significant differences in numbers of white blood cells, lymphocyte subsets, and natural killer cell activity between an experimental group and a control group. In the study of Beem et al., participants in the experimental group received grief counseling intervention 7 months after their bereavement; the control group did not. Similar to Beem et al., the present findings show some differences from the findings of Goodkin et al. (1998). Goodkin et al.’s study of gay men with HIV-1 claimed significant increases in counts of Th, T lymphocytes, and total lymphocyte count among both seropositive and seronegative gay men after a 10-week bereavement intervention period and a 6-month follow-up period. Differences in immune response results in the present study and previous bereavement-related research may be accounted for by physiological differences in responses to stressors, which can vary from person to person. If participants in this study had diminished immune functions, responses to intervention might be suspect. However, because the participants in this study had normal immune functions, it is speculated that the intervention might not have significant effects on these aspects. However, the lack of statistical significance may be due to the small sample size. Thus, two follow-up studies seeking effects on immune responses of bereavement intervention specifically may be needed: the first, using a larger sample size, and the second, involving selected bereaved families having abnormal immune functions. DISCUSSION

This study shows that the bereavement intervention program could be effective in decreasing levels of grief and symptoms of stress in middleaged widows. Accordingly, this program, using Dan-jeon breathing, self-help group activity, and a health check, could be applied to help widows. The Dan-jeon breathing technique is a Korean traditional regimen noted for reducing depression and anxiety levels and enhancing health in middleaged women (Hyun, 2001; Kim, 2005). Nevertheless, if Dan-jeon breathing is to be put into practice without a prior warm-up exercise, side effects such as Ju-hwa ( ) and Ip-ma ( ) must be avoided. Ju-hwa is a phenomenon in which symptoms such as headache develop due to

failure of normal flow of the life energy; in Ip-ma ), the supposed influence of an evil spirit ( causes a failure in the ability to reason normally (Hyun, 2001). In this study, Dan-jeon breathing was done for 30 minutes after life energy ( ) and blood ( ) circulation enhancement had been adequately reached through warm-up stretching exercises that relaxed the mind and body and reduced joint rigidity. Dan-jeon breathing was effective, and the physical stretch exercises accompanying it had a positive simultaneous effect. After the Dan-jeon breathing session, cool-down stretch exercises were performed to redistribute life energy, concentrated during Danjeon, back to the entire body. Thus, the effectiveness of Dan-jeon breathing and the effects of physical stretch exercises were achieved at the same time. The objectives of the group meetings in the present study were primarily drawn from Worden’s (1991) weekly task in handling grief. The self-help group activity designed for this study aimed to strengthen the interrelationship and companionship among group members and also clear up negative emotions and alleviate stress among participants. Participants developed emotional support for each other and received information services from the authors. The significance of this study’s bereavement intervention program is found through several apparent benefits. First, the program helped participants attain physical health and peace of mind through Dan-jeon breathing as they learned to enhance their capacity to manage their own health. Participants were assisted through distribution of self-instruction tapes, through which they learned to follow steps in performing Dan-jeon breathing at home. In addition, participants showed gains in recovering emotional stability through the self-help group activities within a socialized support network. Moreover, they were helped in overcoming the isolation of being separated from their spouses by being able to make purposeful visits to others. The program also helped participants establish mutual trust and a sense of intimacy by visiting the graves of their husbands together to pay homage. Finally, participants were provided with the opportunity to manage assessment of disease risks through the health examination. In the evaluation session after completing the bereavement intervention programs, the following

BEREAVEMENT INTERVENTION PROGRAM EFFECTS IN KOREAN WIDOWS

were some of the remarks made by the participants in the experimental group: bIt was good since I was able to train my body and mind through practicing Dan-jeon breathing.Q bIt was most comforting since I was able to share heart-to-heart talks.Q bI experienced peace in my mind at this meeting.Q bIt was so nice because I was able to check my health condition.Q bI secured self-confidence.Q It is noted that many of the potential participants of this study, due to Korea’s patriarchal social system, may have had a culturally conditioned tendency to avoid interpersonal relationships during the period of severe grief following bereavement. In addition, potential participants often found themselves having to earn their own living. As a result, the authors experienced many difficulties in securing participants and in proceeding with the bereavement program. In Korea, many bereaved women neglect themselves and their health problems. Many are unable to effectively manage their grief, loneliness, and economic difficulties, as well as to raise their children as single parents. Hospice institutions and community organizations should take positive actions to carry out a practical program for bereaved families and to provide realistic, systematic assistance for bereaved families. Despite the seriousness of the physical, psychological, and social problems caused by bereavement, so far there have been, other than this one, no studies of practical interventions designed to benefit bereaved families in Korea. Consequently, it is hoped that this study will serve as a stimulus to initiate active studies of bereavement intervention from a variety of disciplinary fields including nursing science. Three additional procedures need to be conducted to confirm the validity of the effects of this program: (1) repeat the original pilot study using a larger group of participants, (2) conduct a longterm study of bereavement, and (3) apply the program to men in bereavement. APPENDIX A. SELF-HELP GROUP ACTIVITY

The experimental group received self-help group activity in issues tied to bereavement. During the first week, participants were introduced to the bereavement intervention program and underwent grief counseling. The progress of grief, including the physical, psychological, social, mental, and spiritual aspects of normal grief, was explained.

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Participants introduced themselves and talked about the circumstance of their husband’s death, how they began participating in this program, and goals or wishes they wanted to achieve. Weeks 2 and 3 of counseling focused on accepting the reality of loss and arranging articles left by the departed. The authors told participants that realizing and accepting the loss are not acts that deny the bereavement but are, instead, steps one needs to take to intellectually and emotionally accept the current situations and acknowledge that the deceased will not return. Participants were also told to share their experiences dealing with accepting the loss and articles left by the deceased. Weeks 4 and 5 were spent working through the pain of grief. To do this, the participants need to know the distressing emotional responses that accompany bereavement. The participants either wrote a letter or recorded experiences in a tape and then shared their distressing feelings with others. During Weeks 6 and 7, participants were counseled on how to adjust to an environment where their deceased husbands are no longer around. During this period, necessities in adjusting to the new environment were explained to the participants. They were told that this adjustment, in itself, is a long-term task that requires learning new skills that can only be accomplished by leaving a state of confusion, pain, grief, and powerlessness and by entering a state where they will have to bear responsibility. Participants were then told to discuss issues in adjusting by sharing their experiences and thoughts. Weeks 8 and 9 covered how to emotionally relocate the deceased and move on with their lives. Participants were encouraged to move on with their lives by emotionally relocating the deceased to a person, hobby, or other activities that would preoccupy them. To stop mourning about their husband does not mean to forget him but to mediate the relationship with the deceased from the bbeing dimensionQ to the bmemory dimension.Q The participants then discussed this matter and, with a diagram, talked about someone who is meaningful or helpful to them. During the program, each participant visited the grave of his husband with other participants and was given time to mourn. After the bereavement intervention program has ended, they held a selfhelp group meeting, which they (regularly) continue to do so up to the present time. The final

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