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This article focuses on the history of the use of therapeutic letters in the
clinical scholarship of the Family Nursing Unit at the University of Calgary
and offers examples of a variety of therapeutic letters written to families
experiencing illness suffering. A case study from the research of Moules
(2000, 2002) is offered to further illustrate the usefulness of therapeutic letters as a family nursing intervention.
Keywords: therapeutic letters; Family Nursing Unit; Family Systems Nursing;
family nursing intervention; illness suffering
and Janice Bell (Wright et al., 1996; Wright & Watson, 1988), Lorraine
Wright and Maureen Leahey (1994, 2000, 2005, 2009), and Family
Systems Nursing graduates who completed one or more practicums in the
FNU (Harper-Jaques & Masters, 1994; Marshall & Harper-Jaques, 2008;
Wright & Simpson, 1991). The history and use of therapeutic letters in the
advanced nursing practice of the FNU will be described in this article,
examples of a variety of therapeutic letters written in the FNU will be
offered, and a case exemplar from the research of Moules (2000, 2002) will
be used to illustrate the usefulness of this family nursing intervention with
families suffering in their experience of serious illness.
have beliefs that facilitate and those that constrain in the ways they influence
lives, relationships, behavior, and illness suffering. Beliefs that are constraining can be explored, challenged, and altered; those that are facilitating
can be acknowledged, reinforced, and amplified (Wright & Bell, in press;
Wright et al., 1996). The Trinity Model conceptualizes the intertwining of
beliefs, illness suffering, and spirituality (Wright, 2005) and offers interventions for witnessing and acknowledging illness suffering and inviting
spiritual conversations that may soften illness suffering.
Clinical sessions in the FNU were observed from behind a one-way mirror by a clinical team, composed of faculty members and graduate nursing
students, at masters and doctoral levels. The clinical team participated in
the interviews by telephoning to the interview room with ideas and questions, as well as in presession and postsession discussions. The belief of the
clinical team in the benefit of multiple minds combined with the belief
that we are all in this togetherin our desire to learn from and be helpful
to families created a synergistic collaboration for both the clinician conducting the session with the family and the team observing from behind the
one-way mirror (Flowers et al., 2008). The structure of clinical work was
based on the five-part session first suggested by the Milan family therapy
team (Tomm, 1984). The interpretation of this five-part session in the FNU
consisted of a presession conversation between the clinical team members;
the clinical therapeutic conversation with the family and clinician; an
intersession, in the form of offering a reflecting team (Andersen, 1991),
where the family observed the team members discuss their observations
and reflections amongst themselves; a concluding discussion with the family; and a postsession clinical team discussion. The clinicians for the family
were faculty members, doctoral students, or 2nd-year masters students;
and all sessions received live supervision by a faculty member. All clinical
sessions, as well as the clinical teams presession and postsession, were
videotaped after consents were obtained from family members and students. On average, families received an average of four to five sessions.
After celebrating 25 years of clinical scholarship and learning from
families, the FNU was closed in December 2007 (Bell, 2008). This
advanced practice knowledge continues to live on through the offering of
Family Systems Nursing specialization at the University of Calgary and the
University of Montreal; through ongoing research and case studies from the
archived clinical database of the FNU; and through the clinical practice,
research, and teaching of faculty members of the FNU and more than 100
masters and doctoral graduates in Family Systems Nursing as well as hundreds of international nurses who have participated in the annual Family
Nursing Unit Externship workshops.
A Conversation of History:
Letters in the Family Nursing Unit
In fact, history does not belong to us, we belong to it. (Gadamer, 1989,
p. 276)
NJM: And when you first started, was it something that you had read about in
other literature in other family therapy literature, is it something you had
heard about at all in other peoples practices, or was it something that you
just sort of stumbled onto?
LMW: At that time it was just something we stumbled onto. But it was later
after that that I became aware of David Epston, much later . . .
NJM: Oh, so you didnt use the word therapeutic letters?
LMW: No. You know I cant remember just how we came and . . . because it
certainly wasnt something that was a routine part of our practice, like it is
now. What I remember is we used to use the letter and what we did with this
particular family to offer a split opinion instead of just offering it in the session, we would offer them a split opinion in a letter.
NJM: Why did you choose that particular way to do that instead of offering it
in session?
LMW: Well, because we thought it would have more impactthat they could
think about it, especially for families where there was really entrenched
beliefs.
NJM: At that time did you use letters with things other than split opinions?
LMW: Yes, we did on occasion. Ive never gone back and done any kind of
historical review about therapeutic letters in the FNU, but then it was later
that we began to became aware of David Epston and Michael Whites work
and especially David Epston, his use of them every single session. And they
were using them in a bit of different way.
NJM: Whats your personal belief around what kind of contribution do you
think they make in the clinical work?
LMW: Well, when I look at our clinical work and when I hear back from families, verbally, or their reactions you know from session to session, or what
they say to us on the outcome study, Id have to say that the three interventions that really seem to stand out, that they seem to most readily comment
on are; if I had an order, it would reflecting teams and therapeutic letters are
tied for number one, and Id say the use of commendations.
NJM: But those [commendations] are woven into both of those.
LMW: And theyre woven in; theyre embedded within those interventions, but
those are the things that I hear family members commenting on the most and
then after that what they comment on the most is the kinds of questions that
we ask.
NJM: Which is another thing, like commendations, its more of a microanalysis
of what happens in the letters and the reflecting teams, isnt it?
LMW: I was thinking in the terms of therapeutic letters, I mean what is always
so interesting to me is with any of those three ideas is that all of those interventions are ways of challenging constraining beliefs, in a way that makes it
more palatable to the families instead of just confronting someone, or taking
them on directly or what not. Its like it lifts it into another medium.
NJM: Well youve written in the Beliefs book [Wright et al., 1996] and also, you
read the anecdotal type of reports about how families and clinicians report
the value of a therapeutic letter. Im not sure I find this particular measurement a really useful one for me, but Ive been asking it of everybody along,
in terms of a therapeutic letter being equivalent in value to 3 to 10 clinical
sessions. My guess is that its such an individual answer, it really depends on
each family, but if you could just slip into generalizing around it, in your
opinion, what would you say one therapeutic letter is worth?
LMW: I dont know that I could go so far as to say its worth 10; but Id certainly say, that it has the potential, that every therapeutic letter is equal to one
therapeutic conversation, to one clinical interview.
NJM: So it doubles the interview?
LMW: Depends on . . . theres the skill and the expertise of the person writing
the letter, the clinician whos writing them. Some just really recap the session, which sometimes, in and of itself, thats useful too, for family members
to really have that historical perspective, cause its impossible to really
remember all the things. And to me its another way of getting at what perturbed them in the session, because that question of what stood out for them,
I think can be answered more clearly when the sessions really recapped, for
them again in writing. Its like theyve had two opportunities to think about
the session, what they reflected on in that moment, and what they reflect on
again after theyve left, because to me thats one of the most significant
things about the letters. Its another invitation to another reflectionabout
their lives, about the session, about the problems they are concerned about.
NJM: Would you say that thats the biggest thing that therapeutic letters do is
offer that invitation then?
LMW: To another reflection? Yes. To another reflection to invite them to challenge their own beliefs that may be troubling, that theyre suffering around.
To see it in writing takes on a whole different flavor and a whole different
meaning.
NJM: Can you speculate why?
LMW: I think anything you read is more penetrating than the spoken word.
NJM: And how do you think you came to that belief?
LMW: I guess from my personal experiences with words on paper, as opposed
to words verbally. Theres always exception to the rule. . . . I think its more
lasting somehow when its written. That it stays with you longer . . . the
beauty of being able to go back to the written word. That you cant always
capture, and sometimes youre trying to remember, now how did that person
say that to me, and what was it that they said exactly, but if you have a letter,
its that wonderful thing of being able to go back to the way it was actually
said, rather than the way you think it was said, or the way you think you
remembered it. And I think in lots of relationships thats what gets us into a
lot of trouble with each other is what we retain. I mean thats usually what
people argue over you said; no I didnt; I said, no you didnt, you said. And
we go around and round about that, about what we think our memory of the
words that were spoken that were very meaningful to us or that were hurtful
to us, or that were disappointing, and we try to recapture a conversation . . .
with the written word you can go back. We do give such value to the written
word in our society, way more than the oral tradition, in our particular culture
anyway.
NJM: But its interesting to me about, just because you put something into writing though, doesnt protect it from being misinterpreted, does it?
LMW: Oh no, it doesnt protect it from that but theres something about the
ability to keep going back and back to it in the way it was sent. Cause I find
verbally, you can keep going back and back to what you thought was said,
what you thought the message was, what you thought you heard, but the
beauty here is I cant change that.
NJM: Both the beauty and the risk, the danger.
LMW: Yes, very much, cause we can always modify. I mean were always saying to each other, Well gee if I did say that I didnt quite mean it that way.
You cant do that in a letter. You cant deny you said it.
NJM: Or if I did I didnt mean it.
LMW: Well, you can do that in a letter, well Did I say that? Well, I didnt really
mean to word it that way. But it stays, its there, it cant be removed in the
same way.
received a closing letter, which follows a more structured format, describing to the family what the team learned from them over the course of the
clinical work and what the team believed they offered the family (see
Tables 4 and 5 for examples of a closing therapeutic letter). With the familys permission, a copy of the closing letter was usually sent to the referral
source.
Typically, an FNU therapeutic letter would include the following elements: distinguishing individual and family strengths through the offering
of commendations (Bohn, Wright, & Moules, 2003; Houger Limacher &
Wright, 2003, 2006; Wright & Bell, in press; Wright et al., 1996; Wright &
Leahey, 2005, 2009), highlighting significant conversational events, offering reflections of the clinician and the clinical team, posing additional questions offered either as outcomes of these reflections or with the intent to
challenge constraining beliefs and invite family members to a new reflection, and celebrating therapeutic change and distinguishing new facilitating beliefs (Wright et al., 1996). Rather than the letter simply being a
summary of the session, the challenge was to offer something different in
the lettersome news of difference (Bateson, 1979). The news of difference needed to be carefully calibratednot too slight a difference so that it
went unnoticed, but not too large a difference or too many different ideas
so that the family members could reflect without feeling like they were, in
the words of one overwhelmed father, drinking water from a fire hose!
The ideas and suggestions also needed to be offered tentatively and speculatively to honor the ideas of objectivity (in parentheses) and the legitimacy
of multiple realities (Maturana & Varela, 1992). Following the research by
Moules (2000), the clinical team became more mindful to also acknowledge illness suffering and hear the cries of the wounded (James, cited in
Amundson, 2001, p. 186).
Because of the nature of the educational context of the FNU, graduate
student clinicians or graduate observers of the clinical sessions most often
wrote letters as a means to develop conceptual and perceptual skills in
Family Systems Nursing (Wright et al., 1996). A faculty supervisor always
reviewed and edited the letter before it was sent to the family. The educational context of the FNU raises the issue of teaching students how to write
therapeutic letters, while still maintaining a responsibility to the family. The
FNU was a clinical setting, but it was primarily an educational one, and
there was a responsibility to immerse the students in learning the clinical
practice, a part of which was giving them experience in writing therapeutic
letters. With experience, we, as faculty supervisors, learned to find a balance
Table 1
Example of a Family Nursing Unit (FNU)
Between-Session Therapeutic Letter
Dear Doreen and Charlie,
Greetings from the Family Nursing Unit.We were pleased to meet with you on
November 21, and we wanted to share some of our thoughts with you.
We were very struck by the love and caring you showed for each other, and
were touched by the warm stories of how you met and what attracts you to
each other. You both openly shared your concerns about how the numerous
illnesses were affecting your lives and were clear when telling us what you
thought you needed from us and from each other.You seem to share our belief
that illness is a family affair! When one person in a family is ill, it affects everyone in the family.
Charlie, we were impressed that you came to the session even though you
are in hospital, and awaiting surgery. It speaks to how very committed you are
to Doreen and your family. The love and support you feel for Doreen shone
through in what you said and the loving way you complimented her on her
strength and abilities.
Doreen, we were impressed by your ability to pull out your strength in
order to be there for Charlie during his present illness. You have learned ways
to influence the seizures you have experienced and put them in their place so
you can be there for your family.You have been able to overcome years of people telling yourself that you are no good, and tell us so clearly I am strong.
We really saw your strength during the session, and wondered what kinds of
things you and Charlie can do to feed that strength and make it bigger?
We thought about how, in the past, you have connected as a couple to put
problems and illnesses in the back seat. It seemed that you are pulling together
as a couple once again in order to cope with the bowel surgery. We wondered
what things might help you to be even more connected?
Doreen, you talked about feeling connected when Charlie shows that he
cares for you by saying nice things and being appreciative. Charlie, we wondered what things Doreen does that makes you feel more connected to her?
We wondered if you felt more connected during the times when Doreens
strength shows, and she is able to put her seizures in the back seat so she can
be there for you during the times when you are ill? We also thought about the
way that illness has served to pull you together as a couple, and wondered how
you could make the together in illness smaller in comparison to the two of
you coming together outside of illness.Would your coming together outside of
illness maybe help you put illness in its place?
(continued)
Table 1 (continued)
Again, we are impressed with your strength and ability to tackle problems
and illnesses as a couple.You have a lot to teach us about how families can live
and love in the face of numerous health problems. We are confident in your
ability to pull together as a couple to cope with the new health problems you
are facing in the next few weeks. We look forward to meeting you again in the
New Year.
Sincerely,
Rose Schroeder, RN, Master of Nursing Student
Janice M. Bell, RN, PhD, Acting Director, Family Nursing Unit
and other members of the clinical nursing team
between teaching and creating the opportunity for learning and needing a
certain amount of vigilance and surveillance. What goes out of the FNU,
with the signature of the clinician and faculty supervisor and director, is
laden with the ethics of responsibility, professionalism, and personal commitment. The therapeutic letters that left the FNU were the end result of
acts of balancing between learning, teaching, commitment, and integrity.
Table 2
Example of a Family Nursing Unit (FNU) Therapeutic
Letter to an Absent Family Member
Dear Elizabeth:
Greetings from the Family Nursing Unit. We met once again with your
mother and sister last week. They shared with us that you have been admitted
to the hospital. We want to let you know that we were sorry to hear this news.
We have been deeply touched by the love and admiration that your mother and
sister express for you.
Although we have not had the opportunity to meet you in person, we
believe you have a powerful presence in our conversations. We hope that in
writing to you, you may feel more a part of these conversations. We wonder if
you might be willing to share your thoughts in a letter with us.When you think
back to reading the letter that we sent you a few weeks ago, what stands out
in your mind? Have you had thoughts about it since that time? Is there anything
we might have misunderstood about your familys experience? We have
learned a little about how you worry about your family, and found ourselves
wondering what worries you might have for yourself. Are there any questions
you keep asking yourself over and over?
Your mother and sister have shared with us the great strength you show in
facing the challenges that diabetes brings. We realize that this journey has been
a long and difficult one for you and your family. It is amazing how you each
have found different and unique ways to support each other on this journey.
We feel privileged to have the opportunity to further learn about your familys
experience of living with illness.
With warm regards,
Tina West, RN, Master of Nursing Student
Lorraine M. Wright, RN, PhD, Director, Family Nursing Unit
and other members of the clinical team
The research interview occurred 2 years and 3 months after the closing of
their clinical work in the FNU and the receipt of their last therapeutic letter.
Rose Schroeder, RN, BN, a masters student in Family Systems Nursing in
the FNU in her 2nd year of study, wrote the letters. She had previous experience as a staff nurse in mental health, a nurse clinician, and a nurse educator.
Supervision for the clinical work and in the writing of the therapeutic
Table 3
Example of a Family Nursing Unit (FNU)
Letter Admitting a Therapeutic Error
Dear Wilma and Tim:
Greetings from the Family Nursing Unit! Our clinical team learned a great
deal from both of you during our conversation in January and we wanted to
share our thoughts and impressions with you in a letter.
It was a pleasure to see both of you again during our second session. Once
again we were grateful for your willingness to talk openly about the ways that
the intruder of muscular dystrophy (MD) has impacted your lives. You two
have been through a great deal together! We learned that you believe this illness has changed your relationship as a mother and father but has not changed
your strong love for your children.We were impressed with the dedication you
have shown in raising two children who have, at times, had their own struggles.
We learned that because of the changes that MD has brought, you are finding
it challenging to work as a team in your parenting roles.
This session was an opportunity for us to learn more about your relationship as husband and wife and the meaning it has brought to your lives. Wilma
and Tim, you helped us understand that you are very proud to have created a
satisfying marriage by building a strong foundation for your marriage through
your love and commitment to each other and your shared hopes and dreams.
It seems that MD has not only broken into your marriage relationship but has
stolen away your hopes and dreams for the future and has robbed you of feeling intimate and connected as a husband and wife. In particular, we learned
that you believe that it is not the physical changes of the illness but the cognitive changes that are eating away at the strong foundation of your marriage.
This left us wondering whether it would be helpful for the two of you to create
small moments of connection as husband and wife every day as a way to interrupt the belief that you are becoming only a care giver and care receiver.
We made an assumption during our session that, because of the strong
foundation you had built for your marriage, you both wished for some ideas
about how to reclaim your special relationship as husband and wife from the
influence of MD. Upon reviewing the videotapes of the session, we realize that
we did not check with each of you directly about whether you agreed with
this goal of strengthening your marital connection in our work together. From
comments you made at the end of our session, Wilma, we wondered if perhaps
we made an error by not asking each of you if you believe that it is possible
to reclaim your marriage from illness. We believe there are many possible
ways that illness suffering can be reduced and perhaps we were too premature
to conclude that strengthening the good foundation of your marriage was the
(continued)
Table 3 (continued)
best way to reduce the suffering and isolation you are both experiencing. We
now wonder if we need to challenge our teams belief about the best way to
help your family heal.
Throughout our conversations, we have learned that your family believes
that the illness of MD has caused you, Wilma, the most suffering. We are very
impressed with the dedication, perseverance, and wisdom you have shown as
a wife and mother in caring for everyone in your family for many, many years.
We believe we need to understand more about your experience and where you
have found the energy and resources to endure this unexpected life where illness has been so present in your relationships and daily routines. How do you
make sense that your life has been one of caring for your ill family members
[husband and daughter]? Where do you find support and respite from this
responsibility? What are your hope and fears for the future?
We have learned from our work with families that family members are
affected by illness differently at different times and phases over the long haul
of chronic illness. Just as it was helpful to see you together as a couple, perhaps
it would now be useful to have an individual session with you, Wilma, to learn
more about how you find the energy to care so deeply for your family. If this
ideas fits for you, we would be pleased to meet with you alone at our next session. If you have other ideas about who should attend the session or what the
focus of our work should be, please let us know.
Kind regards,
Lorraine Thirsk, RN, MN, Doctoral student
Colleen Cuthbert, RN, 1st-year Master of Nursing student
Janice M. Bell, RN, PhD, Director, Family Nursing Unit
and other members of the clinical team
letters was provided by Janice Bell, RN, PhD, an FNU faculty member.
Ms. Schroeder will be referred to as RS and Dr. Nancy Moules as NJM.
Table 4
Example of a Family Nursing Unit (FNU) Closing Therapeutic Letter
Dear Connie, Samantha, and Jeremy:
Greetings from the Family Nursing Unit. As part of completing our clinical
work with families, we send a closing letter as a summary and record of our
time spent together. From February 24 to April 14 we had an opportunity to
meet with you on three occasions.
We would like to share what we learned from your family and what we
believe we offered to you in these sessions. We were very touched and privileged with your sharing of the tragic experience of losing William and Aaron
[husband/father and son/brother], and your continuing journey in finding your
own ways to live with your losses.
What we learned from your family:
1. You shared with us your powerful story of experiencing two traumatic and
unexpected losses in your family [through the deaths of William and Aaron].
We heard that living with loss and grief has been the most challenging and
difficult journey you have endured as individuals and as a family. You have
taught us about strength and courage in the face of loss and grief. Although
we believe that families have amazing resilience and resources in difficult
situations, you demonstrated an exceptional capacity to rise to this challenge
and emerge with courage and sensitivity.
2. We have been impressed with your ability to remain a very close family, one
that supports and respects each other and one that has been able to share so
openly about deeply painful issues. In choosing to remain united and committed to one another, we learned again of the power that families have when
they work together. The team witnessed an extension of this commitment
when you openly expressed your hopefulness ad optimism for an untainted
future.You taught us that even amidst sorrow, pain, and grief there can be joy,
as you shared the changes and blessings in your family that evolved as a result
of William and Aarons deaths.
3. We learned that you are a very spiritual family and your strong spiritual beliefs
invited the team into the privilege of experiencing William and Aarons spirit
in our sessions. Your belief that God loves you unconditionally and has a reason and purpose for this loss seems to have helped you make sense of this
experience. You reminded us how ones strong spiritual beliefs and faith in
God is sustaining and can diminish suffering and contribute to healing.
Table 4 (continued)
the well-being of your family. We offered our perceptions that some family
members seem to have been able say good-bye to parts of the relationship
with William and Aaron more easily, and other members have had an easier
experience with saying hello. The team offered our belief that grief is both
about saying good-bye and saying hello and we wondered if there could be a
way that you could teach and share your abilities with each other. We also
offered you our belief that we are most hopeful for your family because of
your strength and commitment to one another.
2. Our team has been very impressed with your insight into your experience.
We suggested our belief that you are a family who accepts where each person
is with respect to coping and experiencing loss, yet seems able to gently offer
individual thoughts and beliefs to help with one anothers healing.
3. Your family has shown us that it is not only acceptable to be sad but that is
acceptable to be mad at God and we appreciated your belief:God can handle
it. Because of your strong spiritual beliefs, your lack of bitterness, and your
ability to continue discovering the many ways you are blessed, you have
opened yourselves to the possibility of finding happiness and living a rich life
alongside your loss and grief. We suggested that your ability to feel joy, express
laughter, embrace hope, and discover a sense of meaning in this experience will
serve you well as your continue healing and move forward on your journey.
Table 5
Example of a Family Nursing Unit (FNU) Closing Therapeutic Letter
Dear George and Linda,
Greetings from the Family Nursing Unit! It was a pleasure to meet with you
in March for our final session. We wish to highlight what we have learned from
you during our work together, as well as what we believe we have been able
to offer you in our conversations together.
Linda and George, we appreciate the commitment you have shown to our
work together as we explored the experience of illness suffering in your lives.
Together you found the strength to enter into some difficult and painful conversations with us about your experience of suffering with both the loss of
loved ones and the uncertainty of pain and chronic illness. We have been
impressed with the perseverance you have demonstrated in pursuing creative
ways to influence the challenges that the presence of chronic illness has brought
into your lives and relationships.
What we have learned from you:
1. Linda, you taught us how women who live with chronic illness and pain face
distinct challenges. Learning to live alongside unrelenting illness, fatigue, and
pain while trying to maintain your role as a wife creates the unique challenge of finding balance between caring for self while also nurturing your
marriage relationship with George. You helped us realize how the invisible
and unpredictable nature of chronic illness invites physical pain and emotional isolation from the ones you love most. We have learned that this loss
of emotional connection may be harder to bear and invites more suffering
than the illness itself.
2. George, you offered us a new appreciation of the complexity of being both a
family caregiver and a husband in the presence of illness.We learned about the
tremendous impact that illness has had on your marriage and how the uncertainty around which role (nurse or husband) you believe you need to offer in
any given moment can invite confusion, anger, and suffering. George, you have
reaffirmed what we have learned in our work with other families: that giving
the illness a name and an identity can help a family shift the illness from
robbing your lives to viewing it as an external, manageable circumstance.
3. Together you have reminded us that remaining connected and aligned as a
couple improves and strengthens your ability to defeat the influence of
chronic illness. With your careful formulation of the No Illness and Fatigue
Talk (NIFT) Day we learned how a couple can use their creativity to negotiate
changed patterns of behavior one day per week. Furthermore, you helped us
to understand how persisting in changing this one day has the potential to
result in changing many beliefs about yourselves and the illness.You skillfully
(continued)
Table 5 (continued)
demonstrated to us the breadth and depth of your wisdom surrounding your
illness experience by offering an elaborate, beautifully crafted letter about
how you both experimented with new ways of behaving and thinking. Linda,
your eloquent reading of your and Georges letter in our sessions permitted
us further understanding of how much suffering you and George have experienced, and how much work you have done together to become masters
over the monster of chronic illness in your lives [for more information about
this letter, see NIFT Day at www.janicembell.com].
George and Linda, it has been delightful to come to know you as individuals
and as a couple.You are a family who has shown remarkable strength and courage in the face of illness suffering. It is often difficult for families to transition
into living well and living at peace with chronic illness. Your dedication to the
work with us at the Family Nursing Unit to soften your illness suffering is
inspiring. We want to express what a privilege it has been to work with you,
and we wish you the best in your continued success as you live with this difficult illness experience.The insights you have shared with us will undoubtedly
(continued)
Table 5 (continued)
enhance our work with other couples and families who are suffering in the
midst of chronic illness.
As part of our work together, a research assistant will contact you within six
months to learn whether you would be willing to evaluate what was helpful or
not so helpful in our work together so that we can continue to improve our
practice with families.
With warm regards,
Janice M. Bell, RN, PhD, Director, Family Nursing Unit
Amy Marshall, RN, BN, 2nd-year Master of Nursing Student
Marianne Boucher, RN, BN, 1st-year Master of Nursing Student
and other members of the clinical team
better feeling about yourself as to where you can move, put more, okay Ive
got to go, strive towards that. . . . Myself, I found, especially after hearing
back you know from you some of the positive aspects that you wrote up on
the letters.
RS: So, the letters . . .
Doreen: Sure gave me an awful lot more strength to turn around and not be as
more strength to deal with . . . give me that much more strength and therefore, it gave me that ability to understand that I could do it and then when I
read it, it gave me . . .
RS: So did you go back and read the letters?
Doreen: Oh, ya, Ive gone back and read them a few times.
RS: Wow!
Doreen: Cause it gives me just that much more strengthyou can do it.
RS: Sounds like the letters are kinda helpful as a reminder sometimes.
Charlie: Oh, very much so.
Doreen: Like I say, to myself, it made me feel much stronger in dealing with my
own personal feeling about myself.
In the reflecting team during the fourth clinical session, RS offered the
suggestion that the reason the family has been able to handle illnesses better than many is because of their commitment. Dr. Janice Bell responded,
The other piece of it that is connected to, maybe even fuels or increases the
commitment, is this new awareness that when they feel supported, theyre
able to give more support. I heard Charlie talk about that as a new kind of
understandingthat when he feels supported, affirmed, when he feels loved,
when he feels cared about, that hes able to show, you know, that its easier
to show that caring back and Doreen said similarly, that . . . there is some sort
of similar theme for her . . . like she said When I read the letters, I gained
strength, I rely on him less, that enables me to support him more . . . sort
of balancing out that supportiveness between them. I was quite taken with that.
This comment gives us a glimpse into why these letters might have been a fit
for this family, a family we might not have anticipated being one who would
value them. The therapeutic letters helped them feel supported, gave them
strength in a way that nurtured and fueled their capacities to offer support. The
letters have withstood the test of time, still continuing to invite reflection,
conversation, and a sense or measure of time to hold up against change.
Summary
In this article, we speak to the use and significance of therapeutic letters
within the context and legacy of the clinical scholarship of the FNU.
Whereas we have described the content and process of writing therapeutic
letters to families, we have not discussed the numerous letters received
from familiesmany of which were invited by the clinician and clinical
team as a way to mark and celebrate therapeutic change and invite the family to offer advice and suggestions to other families about how they were
able to shift from constraining to facilitating beliefs about their lives, relationships, and illnesses in ways that softened their illness suffering (an
example of a letter from George and Linda [the family mentioned in Figure 5],
who want to publicly share their letter about their healing journey, is available at www.janicembell.com; see NIFT Day).
Relational practice with families emphasizes the healing aspects of relationship between family members, between the family and the health care
provider(s), and the relationship of the family to their illness suffering.
Therapeutic letters happen in reciprocity and relationship; they are written
with care and received with heart. They have the potential to heal, to invite
reflection and change, and to make a difference in suffering. This relationship of family and health care provider that is extended through the medium
of the written word is a sacred relationship, and the words within it must be
carefully chosen, delicately presented, and intentionally positioned. As an
intervention, therapeutic letters evoke ussubtly, boldly, and ethicallyto
preserve the integrity of relationships in nursing through the enduring tradition of the written word.
References
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Janice M. Bell, RN, PhD, is a nurse educator and registered psychologist who joined the
Family Nursing Unit, University of Calgary, in 1986 and served as the director of the Family
Nursing Unit from 2002 to 2007. Her scholarly expertise focuses on illness suffering and family healing with a focus on therapeu]tic conversations with families, family interventions in
health care, and family intervention research. The focus of her career is on building capacity
in nurses and other health care professionals to care for families experiencing illness. Her Web
site is www.janicembell.com. Recent publications include The Family Nursing Unit,
University of Calgary: Reflections on 25 Years of Clinical Scholarship (1982-2007) and
Closure Announcement [Editorial] in Journal of Family Nursing (2008), The Role of the
Clinical Laboratory in Teaching and Learning Family Nursing Skills in Journal of Family
Nursing (2008, with K. Flowers and W. St. John), and Beliefs and Illness: A Model for Healing
(in press, with L. M. Wright).
Nancy J. Moules, RN, PhD, is an associate professor, Faculty of Nursing, University of
Calgary. Her clinical, teaching, and research interests include hermeneutics, family nursing,
Family Systems Nursing, grief, therapeutic conversations, and pediatric oncology. Recent
publications include Hermeneutic Musings on Learning: The Dialological Nature of Teaching
Interpretively in Journal of Educational Thought (2007, with L. Binding, D. M. Tapp, and
L. Rallison), The Soul of Sorrow Work: Grief and Therapeutic Interventions With Families
in Journal of Family Nursing (2007, with K. Simonson, A. Fleizer, M. Prins, and B. Glasgow),
and Following in Behind: An Interview With the Reverend Bob Glasgow on His Practice
With Grief Work in Illness, Crisis, & Loss (2009, with K. Simonson).
Lorraine M. Wright, RN, PhD, is a professor emeritus of nursing, University of Calgary.
She is also an author, international lecturer, and marriage and family therapist. Her clinical
practice, lectures, and research focus on (a) illness beliefs of couples, families, and health care
professionals; (b) spirituality, suffering, and illness; and (c) marriage and family interven
tions. Her Web site is www.lorrainewright.com. Recent publications include Exploring the
Therapeutic Family Intervention of Commendations: Insights From Research in Journal of
Family Nursing, 12, (2006, with L. H. Limacher), `Living the as-yet Unanswered:' Spiritual
Care Practices in Family Systems Nursing in Journal of Family Nursing (2008, with
D. L. McLeod), and Nurses and Families: A Guide to Family Assessment and Intervention
(5th ed., 2009, with M. Leahey).