اثربخشی روایت‌درمانی بر اضطراب مرگ و حس انسجام زنان سالمند

Aging is one of the most sensitive stages of human development, characterized by unique conditions and challenges. Among the most prevalent psychological health concerns in older adults are death anxiety (DA) and sense of coherence (SOC). Therefore, the present study aimed to investigate the effectiveness of narrative therapy in reducing DA and enhancing SOC in older women. This research employed a quasi-experimental method using a pretest-posttest design with a control group and a follow-up phase. The statistical population consisted of all older women (with an age range of 70 to 80 years) residing in nursing homes in Gorgan, Iran in 2024. A total of 30 participants were selected through convenience sampling and based on inclusion and exclusion criteria. Participants were randomly assigned to either the experimental group (n=15) or the control group (n=15). Data were collected using Antonovsky’s SOC Questionnaire and Templer’s DA Scale. The experimental group received Payne’s narrative therapy across eight 90-minute sessions, while the control group received no intervention during this period. Data were analyzed using ANCOVA in SPSS version 26. The results indicated that narrative therapy had a statistically significant effect on reducing DA and increasing SOC in older women. Furthermore, the positive effects of the intervention were maintained during the two-month follow-up phase. The findings suggest that narrative therapy can be considered as an effective therapeutic approach for enhancing well-being in aging populations.
EXTENDED ABSTRACT
Introduction
Aging is a natural process, a universal phenomenon, and a distinct phase in human development and growth. Numerous influential factors play critical roles during old age, among which the sense of coherence holds particular importance. This construct is closely associated with functional status, psychological well-being, and overall health. A stronger sense of coherence in older adults correlates with higher levels of psychological well-being and serves as a key predictor of their quality of life. However, studies indicate that as individuals age, their sense of coherence tends to decline. Moreover, in later life, death is perceived more prominently as the endpoint of existence, often accompanied by heightened tension. Death anxiety encompasses a range of thoughts, fears, and emotions about the end of life and is recognized as a multidimensional concept. Research findings suggest that death anxiety is one of the common psychological challenges among older adults. Despite the breadth of research on aging, few studies have explored the potential role of narrative therapy in addressing such concerns. Therefore, this study aimed to examine the effectiveness of narrative therapy in reducing death anxiety and enhancing the sense of coherence among older women.
Method
This study employed a quasi-experimental method using a pretest–posttest design with a control group and a two-month follow-up. The statistical population included older women residing in nursing homes in Gorgan, Iran, in 2024. A total of 30 eligible participants were selected through convenience sampling and randomly assigned to experimental and control groups (15 participants each). Inclusion criteria were as follows: (1) willingness to participate and provision of informed consent, (2) residency in a nursing home in Gorgan, (3) minimum education level of fifth grade, (4) a score higher than 7.5 on the Death Anxiety Scale, (5) a score below 52 on the Sense of Coherence Questionnaire, (6) age range between 70 and 80 years. Exclusion criteria included: (1) presence of physical, motor, or cognitive disabilities or Alzheimer’s disease; and (2) concurrent participation in any other educational program. Data were collected using Antonovsky’s Sense of Coherence Questionnaire (1993) and Templer’s Death Anxiety Scale (1970). The intervention consisted of Payne’s narrative therapy package (2006). Although 106 older women were initially screened and met the inclusion criteria, only 30 remained after further assessments and completed the intervention. Data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics, including Shapiro–Wilk test, Levene’s F-test, and ANCOVA in SPSS version 26.
Results
Prior to data analysis, the necessary assumptions, ncluding Levene’s test, homogeneity of regression slopes, and the Shapiro-Wilk test. Given that the assumptions for univariate analysis of covariance (ANCOVA) were met, this justified the use of ANCOVA. Descriptive findings indicated that the experimental group’s post-test scores for sense of coherence increased compared to their pre-test scores. In contrast, their post-test scores for death anxiety decreased relative to the pre-test scores. Meanwhile, the control group showed no significant difference between pre-test and post-test scores. These changes were maintained at the two-month follow-up. According to the results presented in Table 1, the F-value for sense of coherence at the post-test was 41.33, and for death anxiety, it was 66.73, both statistically significant (P<.01). These findings support the research hypothesis, indicating that narrative therapy leads to improvements in sense of coherence and a reduction in death anxiety among older adults. Furthermore, at the follow-up stage, the F-value for sense of coherence was 66.85, and for death anxiety, 56.51, both of which remained significant (P<.01). This consistency further supports the effectiveness of narrative therapy in enhancing psychological well-being in the older population.
Conclusion
The findings demonstrated that narrative therapy had a significant impact on reducing death anxiety and enhancing the sense of coherence among older women. This effect remained stable during the follow-up phase. Therefore, narrative therapy can be considered an effective intervention for improving sense of coherence and decreasing death anxiety in older women. In narrative therapy, human problems are viewed as emerging from painful life stories that influence individuals’ experiences. The therapeutic process involves exploring how individuals interpret and narrate their life stories, emphasizing the creation of new meanings. Clients are guided to reconsider and revise their internalized narratives, which in turn empowers older individuals to feel more capable of predicting and managing their lives. Moreover, narrative therapy teaches clients to accept responsibility for their behaviors, thereby enhancing motivation for action and effort. It helps them recognize that control and responsibility for their lives rest in their own hands, and that death anxiety does not need to dominate them. By promoting self-awareness and introspection, narrative therapy encourages positive transformation, which can enhance resilience and alleviate distress related to death. Based on the findings, the following practical recommendations are suggested: (1) Future studies should account for potential confounding variables such as intolerance of ambiguity, psychological resilience, and depression; (2) Given the significance of aging-related issues and the need to enrich the research literature, organizations such as the Welfare Organization is advised to prioritize such studies; (3) Similar research should be conducted with older women in other cities to broaden the applicability of the findings.
Ethical Consideration
Ethical Code
This study was approved by the Ethics Committee under the code IR.IAU.CHALUS.REC.1403.072.
Financial Support
No financial support was received for this study
Authors’ Contributions
F.Z.G: Data Curation, Conceptualization, Visualization; A.Kh.Kh: Formal analysis, Writing - Review & Editing; A.M: Writing - Review & Editing, Supervision; L.A.Z: Project administration, Writing - Review & Editing
Conflict of Interest
The authors declare no conflict of interest
Acknowledgments
The authors extend their heartfelt gratitude to the Research Deputy of Islamic Azad University, Gorgan Branch, for their administrative supports and collaboration in conducting this research. The authors also sincerely thank all older participants for their patience and enthusiasm throughout the study.
References
Alimohamad, F., Stodehasl, N.A., & Karami, A. (2020). Developing a quality-of-life model based on metacognitive beliefs mediated by perceived stress in the elderly. Journal of Aging Psychology, 4(6), 341-355. [Persian]
Antonovsky, A. (1993). The structure and properties of the sense of coherence scale. Social science & medicine, 36(6), 725-733. https://doi.org/10.1016/0277-9536(93)90033-Z
Ardelt, M., Gerlach, K.R. & Vaillant, G.E. (2018). Early and midlife predictors of wisdom and subjective well-being in old age. Journal of National Library of Medicine, 73, 1514–1525. https://doi.org/10.1093/geronb/gby017
Asgari, SH., & Shafei, H. (2017). Predicting the quality of life of the elderly based on internal coherence, mindfulness, and spiritual intelligence. Journal of Positive Psychology, 3(3), 61-74. [Persian]
Baradari, A., Sheykhalslami, A., Sadri, A., & Ghamari, H. (2024). The Effectiveness of narrative therapy on family cohesion and marital intimacy in conflicted couples. Journal of Psychology Development, 13(7), 41-50. [Persian]
Chang, A.Y., Skirbekk, V.F., Tyrovolas, S., Kassebaum, N.J., & Dieleman, J.L. (2019). Measuring population ageing: An Analysis of the global burden of disease study. Lancet Public Health, 4, 159-167. https://doi.org/10.1016/S2468-2667(19)30019-2
Delavar, A. (2022). Research Methods in Psychology and Educational Sciences. Tehran: Editorial Publications. [Persian]
El-Ashry, A., El-Fatah, N, K., & Abdelhamim, E.A. (2024). Harmony found: Serenity's crucial role in alleviating death anxiety through attachment styles among community-dwelling older adults. Geriatric Nursing, 58, 247-254. https://doi.org/10.1016/j.gerinurse.2024.05.035
Fazeli, N., Soleymani, S., Farmani, F., Vakili, Y., & Ilanloo, H. (2022). The Effectiveness of narrative therapy on psychological capital and sense of coherence in people recovering from addiction. Journal of Addiction Studies, 16(64), 197-218. [Persian]
Foong, H.F., Hamid, T.A., Ibrahim, R., Haron, S.A., & Shahar, S. (2018). Predicting cognitive function of the Malaysian elderly: A Structural equation modelling approach. Aging & Mental Health, 22(1), 109-120. https://doi.org/10.1080/13607863.2016.1231172
Firouzi. A., Lotfi, F., & Vaziri, SH. (2022). Effectiveness of narrative therapy and good enough sex model on sexual attitude and sexual satisfaction in married infertile men and women. Journal of the Iranian Institute for Health Sciences Research, 21(4), 385-398. [Persian]
Hajihasani, M., & Naderi, N. (1400). Death anxiety in the elderly: The Role of spiritual health and perceived social support. Journal of Aging Psychology, 6(4), 319-309. [Persian]
Han, A., Kim, Ju., & Kim, J. (2021). A Study of leisure walking intensity levels on mental health and health perception of older adults. Gerontology & Geriatric Medicine, 7, 1-8. https://doi.org/10.1177/2333721421999316
Hirsikangas, S., Kanste, O., Korpelainen, J., Bloigu, R., & Kyngäs, H. (2018). The Effects of intervention on the quality of life, sense of coherence and daily activities of frequent attenders. Journal of Nursing Education and Practice, 8, 63-71. https://doi.org/10.5430/jnep.v8n2p63
Hourzad, A., Pouladi, S., Ostovar, A., & Ravanipour, M. (2018). The Effects of an empowering self-management model on self-efficacy and sense of coherence among retired elderly with chronic diseases: a randomized controlled trial. Journal of Clinical Interventions in Aging, 13, 2215-2224. https://doi.org/10.2147/CIA.S183276
Jiang, D., Tang, V.F.Y., Kahlon, M., Chow, E.O.W., Yeung, D.Y.L., Aubrey, R., & Chou, K.L. (2025). Effects of wisdom-enhancementn narrative-therapy and empathy-focused interventions on loneliness over 4 weeks among older adults: A Randomized Controlled Trial. The American Journal of Geriatric Psychiatry, 33(1), 18-30. https://doi.org/10.1016/j.jagp.2024.07.003
Khalvati, M., Babakhanian, M., Khalvati, M., Nafei, A., Khalvati, M., & Gafouri, R. (2021). Death anxiety in Iranian elderly: A systematic review and meta-analysis. Journal of the Elderly, 16(2), 152-171. [Persian]
Kakabaraei, K., & Maazinezhad, M. (2016). The Relationship between age and finding meaning in life with death anxiety in elderly men and women. Journal of Aging Psychology, 2(1), 37-48. [Persian]
Karris, M.A., & Arger, M.A., (2019). Religious couples re-storying after infidelity: Using narrative therapy interventions with a focus on attachment. Counseling and Family Therapy Scholarship Review, 2, 1-16. https://doi.org/10.53309/JCDM6423
Lim, S.Y., & Chang, S.O. (2020). Ego-integrity management of residents in nursing homes: a concept analysis based on the method by Walker and Avant. Journal of Korean Gerontological Nursing, 20(2), 97-108. DOI:10.17079/jkgn.2018.20.2.97
Mahmoudpour, A., & Haggi, A. (2024). Predicting self-coherence in the elderly based on emotion regulation, self-compassion, and attitudes toward death. Journal of Psychology Development, 1(94), 254-243. [Persian]
Mohamadzade, A. (2011). Investigating the psychometric properties of the 13-question Antonovsky Sense of Coherence Test. Master's thesis in psychology, Payam Noor University, Tehran. [Persian]
Momeni, K., & Radmehr, F. (2019). The effect of mindfulness-based stress reduction therapy on marital adjustment, sense of coherence, and psychological resilience of veterans' spouses. Journal of Military Medicine, 21(1), 21-12. [Persian]
Muruthi, B., McCoy, M., Chou, J., & Farnham, A. (2018). Sexual scripts and narrative therapy with older couples. The American Journal of Family Therapy, 46, 81-95.  https://doi.org/10.1080/01926187.2018.1428129
Naghipour, M., Kazemiyan Moghadam, K., & Horounrashidi, H. (2020). The Effectiveness of positive psychology on suicidal ideation and death anxiety in the elderly. Journal of Aging Psychology, 4(6), 357-367. [Persian]
Payne, M. (2006). Narrative therapy: An Introduction for counsellors. 2th ed. New York: SAGE Publications Ltd. 2006; 116. DOI:10.4135/9781446213322
Ramazani, F., Leylabadi, L., & Emamipour, S. (2023). Comparing the effectiveness of mindfulness-based stress reduction therapy and narrative therapy on death anxiety in the elderly. Journal of Health Promotion Management, 12(4), 28-39. [Persian]
Razavinezhad, M., Ziyaie, M., & Tarkashvand, R. (2023). The Effect of group narrative therapy on psychological cohesion in patients with traumatic spinal cord injury. Journal of Psychiatric Nursing, 11(3), 23-14. [Persian]
Srivastava, M., & Ghosh, A. (2024). Societal impact of death anxiety and mental health among nurses in India. Societal Impacts, 4, 100095. https://doi.org/10.1016/j.socimp.2024.100095
Taghipour, R., Siyahpoush, S., Kazemi, F., Sadeghi, P., & Farjad, T. (2020). Comparing the effectiveness of cognitive-behavioral therapy and narrative therapy on improving death-related distress and psychological resilience in female patients with breast cancer. Journal of Mashhad Medical School, 63(4), 2501-1694. [Persian]
Templer, D. I. (1970). The construction and validation of a death anxiety scale. The Journal of general psychology, 82(2), 165-177. https://doi.org/10.1080/00221309.1970.9920634
Wu, J., Fu, D., Zhang, L., Xie, X., Wang, X., Shen, X., Liu, S., Xu, X., Cheng, H., Ma, X., & Lin, D. (2024). The Relationship between psychological vulnerability, aging attitudes and life meaning in elderly patients with comorbidities. Health Promotion, 26(11), 894-904. https://doi.org/10.32604/ijmhp.2024.056223