Studies of Grief: Narratives of Incarcerated Women Who Experienced the Death of a Significant Person While in Prison

One of the most important issues that an individual confronts during one's life is the death of a significant person. Given the contextual nature of grief, incarcerated women are faced with unique challenges when the death of a person occurs during their imprisonment. Yet, little is known about grief experiences under these circumstances. The research questions guiding this qualitative study were: What are the meanings of the grief experience of incarcerated women? How does their grieving process compare with images of grief depicted as a normal process? To what extent do the women perceive incarceration influencing their grief? In-depth interviews with three women in a medium security prison in New England were completed and analyzed with regard to self-understanding, critical commonsense understanding, and theoretical understanding based on Kvale's (1983, 1996) approach to the interpretation of interviews. In addition, narratives extrapolated from the interviews were analyzed using Gee's (1985, 1986, 1991) and Reissman's (1993) approach to narrative analysis. For all three women two events (the delivery of the news of the death and going to the funeral home) were particularly stressful. All the women exhibited an acute grief response which could be expected given the nature of their relationship with their loved one. However, their grief was "suspended." The women were unable to express their grief, participate in important public rituals, and access adequate resources to support their coping. The context of the prison complicated the grieving process resulting in disenfranchised grief. This finding raises critical questions regarding possible complicated berea vement, which can further impact the adjustment to the multiple challenges that women confront when they are released from prison . Implications for nursing knowledge development , nursing practice and education , and the criminal justice system were discussed . Recommendations included longitudinal research studies , education of nurses and nursing students about disenfranchised grief , and policy changes in the criminal justice system . ACKNOWLEDGMENTS The completion of a dissertation is not only a personal achievement. There are many people who contribute in countless ways . First of all I want to thank and honor the three women who participated in this research . It is hoped the sharing of their compelling stories will make a difference for other women in prison. I am truly indebted to my committee members who provided me with guidance and support during this long and arduous process. Hesook Suzie Kim, my major professor, was my beacon, guiding me with her wisdom and thoughtful responses. I admire her intellectual honesty and appreciate her genuine interest in my work . I will always be grateful to her for keeping me on track yet respecting and fostering my own ideas. Donna Schwartz -Barcott, my mentor and advisor, has given so generously of her time throughout the doctoral program . I will be forever grateful to her for walking the path of intellectual inquiry with me, challenging my ideas, and nurturing my development as a qualitative researcher. I am thankful to Gene Knott for his careful consideration of my work, his insightful suggestions, and sharing his expertise. Jean Miller has been an inspiration to me since my arrival at the University of Rhode Island . Her gentle spirit combined with a commitment to facilitate the development of others is truly to be admired. Thanks to Ann Varna -Garis for her astute and helpful suggestions. The completion of this doctorate would not have happened without the enormous support of my family, friends, and colleagues . Words cannot describe the appreciation I have for my husband Ed. His unfailing support, enduring love, and hours spent reading and critiquing my work made it possible for me to pursue

CHAPTER I Introduction As a therapist, I have had the privilege of listening to the stories of women and men in their journeys through grief. One of the richest vehicles for gaining knowledge about human experiences is to provide opportunities for individuals to tell their stories . Personal accounts of life experiences are embedded with texture and personal meaning that is not readily available through other means. My own knowledge of the range of human responses to significant losses has deepened through the listening of stories in my clinical practice , enabling me to challenge the pervasive and limited views of grief as well as to identify gaps in research related to loss and grief issues .
As I began to prepare to facilitate a group on loss and grief in a women's prison , I reviewed the literature specific to grief and incarceration. Although mental health and substance abuse issues are discussed , surprisingly, no studies or articles were found that specifically addressed the grief experience of incarcerated women. The lack of attention to such a critical issue suggests the marginalization of this population, and is consistent with current findings that women in prison continue to be underrepresented in health care research.
During the course of the grief group, I became poignantly aware of the depth of pain these women were experiencing. What was particularly striking, however, were the comments related to their unique difficulties: "I know that I relapse because of so many undealt with losses ... when I get out they just hit me and I just start using again;" "how can we deal with grief while we are in here .. . it is so unreal;" "I don't know what to do with my feelings ... I'm afraid that I will lose it ... there is no place to go with them;" "there is no one who can share my grief here ... maybe a few close friends here, but that's all;" "all I got was 2 5 minutes to see her at the wake, that was it . .. big deal." These comments raised critical questions in my own mind, identifying the need for further inquiry about this vulnerable population, particularly in the specific issues of coping with grief while incarcerated, following the death of a significant person.
Women in prison often enter the correctional system with significant mental health issues and an extensive history of losses: impoverished backgrounds, broken families, history of physical and/or sexual abuse, mental illness, and substance abuse. In light of this information, an assumption is made that women may be at greater risk for a difficult bereavement following a major loss incurred while they are incarcerated. Experiencing the death of a significant person is one more major problem that may not be adequately addressed. By nature of their incarceration, the grief of women in prison is decontextualized.
Opportunities to have loss recognized and validated, to participate in mourning rituals, and to receive the social support that seems to be so needed in the grieving process may be absent. Doka ( 1989), Schneider ( 1994 ), and Corr ( 1998Corr ( -1999, three contemporary writers in the area of loss and grief, assert that acknowledging and validating loss has important implications for the grief experience. When a person incurs a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported, it is often described as disenfranchised (Corr, 1998(Corr, -1999Doka, 1989).
"The very nature of disenfranchised grief creates additional problems for grief, while removing or minimizing sources of support" (Doka, 1989, p. 7). When the loss or the griever is not recognized, social support and societal validation is often lacking. Subsequently, a more complicated grief experience may result (Corr, 1998(Corr, -1999Doka, 1989). Additional problems may arise that go beyond the usual difficulties in grief because disenfranchised grief typically involves intensified emotional reactions, ambivalent relationships, and concurrent crisis (Doka, 1989). Corr (1998Corr ( -1999 states: in circumstances of disenfranchised grief there is an absence of customary sources of support because society's attitudes make unavailable factors that usually facilitate mourning (for instance, the existence of funeral rituals or possibilities for helping to take part in such rituals) and opportunities to obtain assistance from others (for example, by speaking about the loss, receiving expressions of sympathy, taking time off from work, or finding solace within a religious tradition. (p. 5) If one accepts the premise that a person must have the opportunity to grieve in order to achieve an adequate adjustment to a significant loss, it seems to follow that there may be unique aspects of the incarcerated woman's experience that inhibits this process. Incarceration may interfere with opportunities to have a major significant loss recognized, validated, and supported. Although it is acknowledged that women in prison may have a number of significant losses, this study will focus on loss related to the death of a significant person.
The purpose of this study was to describe and understand the grief experience of women who experienced the death of a significant person during imprisonment. The specific research questions were: 1. What are the meanings of the grief experience of incarcerated women?
2. How does their grieving process compare with images of grief depicted as a normal process?
3. To what extent do the women perceive incarceration influencing their grieving process? 4 To examine issues of loss and grief of incarcerated women, a descriptive approach to inquiry was used consisting of two phases. In Phase One, which was carried out during the summer of 1999, a convenience sample of three women was recruited by the Warden and clinical staff at a State Women's Correctional Facility of medium security in New England. All of these women had experienced the death of a significant person during their incarceration. In-depth interviews were conducted to explore the personal experiences of these women. The interviews unfolded as a type of dialogue or conversation, in which I listened, showing interest, and asking questions for clarification. The interviews were tape recorded and transcribed verbatim. In Phase Two the data collected in Phase One was analyzed and interpreted using a combination of hermeneutic and narrative analysis. This analysis provided in-depth understanding of the grief experience of incarcerated women as well as how the women perceived their incarceration influencing their grieving process.
Psychiatric mental health nurses and nurse practitioners may encounter women who have been in prison after their release and can play a critical role in responding to the health care needs of this population . To increase our understanding of the needs of incarcerated women related to issues of loss and grief, and to contribute to the planning of effective intervention strategies, the grief experience of incarcerated women must first be explored. In-depth understanding of the grieving process and the influence of incarceration on the grieving process are critical in laying the groundwork for developing models of intervention and care for this vulnerable group.

Background
The Human Phenomena of Grief Kim ( 1987) developed a typology of four domains that "can be used to systematize research and ever-cumulating knowledge in nursing" (p. 99). This type of classification system serves as an organizing framework to categorize phenomena that are relevant to the discipline of nursing . The typology includes four domains: client , client-nurse , practice , and environment.
The emphasis of the client domain is on gaining knowledge about phenomena within a nursing perspective that pertains only to the client (Kim, 1987). According to Kim (1983), the focus of this domain is to gain knowledge about the client's problems, formulate ideas as to why problems exist, and deliver the most effective care to the client. Kim (1983Kim ( , 1987Kim ( , 2000 further delineates four classes of phenomena in the client domain : essentialialistic, developmental, problematic, and health care experiential. Essentialistic concepts refer to phenomena that are essential characteristics of human nature. Developmental concepts are related to phenomena in human growth and development. Problematic concepts refer to phenomena that are a deviation from the norm, and health care experiential concepts refer to phenomena that come from people ' s experiences in the health care system . Since grief is a universal human phenomenon, it can be classified as an essentialistic concept.

Loss and Grief
Loss is an integral part of human experience and can be defined as a "state of being deprived of or being without something one has had" (Peretz, 1970, p. 4).
Although loss is a universal experience , it is unique in the sense that "each individual has a distinct life history of contact with loss and develops a set of beliefs about loss reflective of that life experience" (Benoliel, 1985, p. 217).
Loss has been discussed in the literature as the primary antecedent preceding grief (Benoliel, 1985;Doka, 1989;Neimeyer , 1998;Peretz, 1970;Rando, 1984;Rodgers & Cowles, 1991;Schneider , 1994 ). Although the emphasis of the literature in the past has been predominantly on grief associated with the death of a significant person, the contemporary literature also discusses grief as a response to a wide variety of losses including physical illness or impairment, divorce, miscarriage, infertility, retirement, body image or identity , independence, rape, change in lifestyle, birth of a handicapped child, and the loss of one's home or homeland (Corr, 1998(Corr, -1999Doka, 1989;Neimeyer, 1998;Peretz, 1970;Rando, 1984;Schneider, 1994). Trolley (1993Trolley ( -1994 also draws similarities between the grieving process and traumatic life events. Based on the findings of their concept analysis, Rodgers and Cowles (1991) assert in general , it was found that the concept of grief is preceded by any situation in which there is a perceived loss, such as separation from any object of attachment whether it be person, pet or physical object of significance to the individual or changes in the satisfaction of an abstract personal need . (p. 449) In the course of one's life, numerous losses including the loss of important relationships will be experienced. However, the meaning of the loss varies significantly, and influences to a great extent the response to loss. The extent to which a given experience of loss is major for an individual depends on the unique nature and meaning of the loss, the individual's past experience with loss, the amount of social disruption produced by the loss, secondary losses, the vulnerability of the person at that point in time, the availability of supports, and the individual's adaptation or coping style (Benoliel, 1985;Rando, 1984;Schneider, 1994;Worden, 1991 ). In addition, patterns of responding to loss will also be influenced by sociocultural norms , religious beliefs, and customs (Benoliel, 1985;Neimeyer, 1998;Rando, 1984;Schneider, 1994).
Although this study focuses on grief experienced following the death of a significant person, it is not meant to imply that death is the most important loss for these women . It is acknowledged that there may be other losses that carry an even greater significance.

Conceptualizations of Grief
The concept of grief has been an area of interest in numerous disciplines for many years. Abundant literature can readily be found in anthropology, sociology, psychology, nursing, medicine , and epidemiology. Numerous theoretical formulations of grief have been developed which describe grief as a complex process. Typically , intervention with people in grief is informed by one or a combination of these theoretical perspectives .
Grief as A Crisis Lindemann's (1944) classic and widely quoted publication graphically described the symptomatology of normal grief. His work was based on psychiatric interviews with 101 patients . He analyzed the data in terms of reported symptoms and changes in mental status during a series of interviews. His subjects included psychoneurotic patients who lost a relative during treatment, relatives of deceased hospitalized patients, relatives of servicemen who died in World War II, and bereaved disaster victims of the Coconut Grove Fire. Lindemann (1944) defined gnef as "a definite syndrome with psychological and somatic symptomatology" (p. 101 ). He identified five predominant features of grief: somatic distress, preoccupation with the image of the deceased, guilt, feelings of hostility, and loss of usual patterns of behavior.
The duration of the grief reaction largely depends on the success of grief work which Lindemann describes as emancipation from the bondage of the deceased , readjustment to an environment in which the deceased is missing, and the formation of new relationships. According to Lindemann, a major obstacle to grief work is the tendency to avoid the intense distress connected with the grief experience as well as emotional expression. This was noted to occur particularly with men . Lindemann ( 1944) believed that the role of the psychiatrist was to assist patients in their readjustment stating "with eight to ten interviews in which the psychiatrist shares the grief work, and with a period of four to six weeks, it was ordinarily possible to settle an uncomplicated grief and distorted grief reaction" (p. 144). Lindemann (1944) also identified several morbid reactions to grief. He suggested that grief could be delayed or postponed for weeks or even years .
Expression of delayed grief may be precipitated by another loss or other circumstances in one's life. Distorted reactions, which may reflect unresolved grief could include an overactivity without a sense of loss, acquisition of symptoms belonging to the deceased, a medical disease such as ulcerative colitis, an alteration or progressive isolation in relationships with friends and family, furious hostility against specific persons such as physicians, absence of emotional display, lasting loss of patterns of social interaction, and agitated depression. Lindemann' s ( 1944) conceptualization of grief was based on his observations and psychotherapy with patients and not on research. In his publication, he did not provide information about the frequency of the interviews, the frequency of the syndrome described, or the time span following the death of the significant person in which he saw these individuals. In addition, Lindemann did not address the social context or the individual factors that may influence the grief experience .

Grief as A Life Transition
Colin Murray Parkes (1972Parkes ( , 1993Parkes & Weiss, 1983), a well-known English physician, is noted for his ongoing research and theory development particularly in the area of widowhood. Parkes' conceptualization of grief was influenced to a large extent by Bowlby's (1980) attachment theory, Lindemann's classic publication in 1944, andby Marris' (1974) work on loss and change.
Parkes challenges Lindemann's view that individuals recover from grief rapidly, stating that as a result of his own research with widows, grief was still prominent even after a year.

11
Initially, Parkes (1972) viewed grief as an acute stress response, but later d~scribed grief as a major life transition, or a period of challenge and readjustment. Parkes ( 1972) describes grief as a normal process in response to an overwhelming loss, and the "price we pay for love, or the cost of commitment" (p. 26). Although grief is highly individualized, common patterns of grief can be identified. However, grief may also be complicated by preexisting psychological circumstances so that it takes an abnormal course.
According to Parkes ( 1972), grief is a complex interweaving of psychological and social processes. Grief is a realization whereby the bereaved person struggles to revise her/his assumptive world, or the internal world that consists of all the expectations and assumptions that have been invalidated by change. The pain of change that accompanies grief is related to the need to revise assumptions that have become habits of thought and behavior. Since we rely on our assumptive world to keep us safe , a person feels very unsafe when this world is changed.
One of Parkes' (1972;Parkes & Weiss, 1983) most significant contributions is his systematic description of the physical , emotional, behavioral, and cognitive manifestations of grief. In his description of the pain of grief, he used the terms the "pangs of grief," or acute episodes of severe anxiety and psychological distress in which the person is strongly missed, and "pining ", a persistent and intrusive wish for the person who is gone, accompanied by preoccupation with thoughts of the deceased leading to intense searching behavior.
As attempts to recover the lost object fail, the berea ved experiences psychological pain, deep pervasive sadness, disorganization and numerous physical symptoms such as lethargy, restlessness and irritability, sleep and appetite problems .
As a result of his research with widows and widowers, Parkes (1972) identified four stages of grief: numbness , disbelief, and shock; yearning and protest; disorganization and despair; recovery and reorganization . The initial period of shock is most acute in the days immediately following a death . As shock subsides, an all-encompassing sorro w emerges followed by a period of disorganization. This disorganization frequently leads to anxiety and despair, as well as withdrawal from others. Multiple physical symptoms often exist such as sleeping and eating problems, anergia, decreased strength and stamina. During the period of intense grief , obsessional thinking of the illness or accident is present.
The period of disorganization lasts approximately 2 months , although for some people it may continue for a much longer period of time. Further recovery or reorganization seems to progress much more slowly. Evidence of the beginning of reco very is marked by feeling better , with a beginning interest in activities, and in being with other people. The person recognizes that change has taken place , accepts it, and examines how basic assumptions about themselves and the world have changed. Hallmarks of this last phase include freedom from emotional and physical symptoms, the development of new skills, interest in others, and an investment in the present. Parkes states that the four stages are not distinct and that features of one stage may persist into the next.
Clinical Models of Grief 13 William Worden, a well-known professor of psychology at the Harvard Medical School, has focused his work on developing a model for grief counseling. Worden's ( 1982Worden's ( , 1991 model is based on the belief that the resolution of grief can be influenced by intervention and that the grieving individual needs to take action. Worden (1982Worden ( , 1991 believes that the counselor's role is to facilitate the grieving process and help the client come to a resolution. Worden ( 1991) synthesizes the work of many other theorists and researchers, including Bowlby (1980), Lindemann (1944), Parkes (1972), and Engel (1961). Worden (1982) embraces Engel's (1961) view that grief is a departure from the state of health and well being, and compares the process of mourning to the process of physiological healing. He incorporates the works of Bowlby, Lindemann, and Parkes in his description of normal grief reactions. Worden (1991) asserts that mourning is necessary and that certain tasks must be accomplished for equilibrium to be reestablished . Incomplete tasks can impair further growth and development. Worden describes each task and provides a prescriptive guide for counselors to utilize in facilitating an individual's grief.
The four tasks are described as: accepting the reality of the loss, working through the pain of grief, adjusting to an environment in which the deceased is missing, and emotionally relocating the deceased and moving on with life.
In the first task, the person needs to come to terms with the reality of the loss, intellectually and emotionally. Belief and disbelief are intermittent as the individual struggles with this task. Working through the pain of grief is a necessary next step in order to successfully complete the grieving process .
Although individuals do manifest their grief differently , it is expected that the bereaved person will experience a combination of physical, emotional, behavioral, and cognitive distress . The clinician's role is to help the person identify and express feelings, particularly anger , anxiety , guilt, and helplessness . Worden ( 1991) believes that successful resolution requires the outward expression of feelings, stating "many feelings may not be recognized by the survivor or they might not be felt to the degree they need to be in order to bring about a successful resolution" (p. 43) .
In the third task, adj usting to an environment in which the deceased is missing , the bereaved struggles with the meaning of the loss . As fundamental beliefs and values are confronted , the bereaved often feel they have lost direction in their lives and may need to come to terms with major life changes such as living alone, raising children alone, facing an empty house, and managing finances alone .
The bereaved often is not aware of all the roles played by the deceased for some time after the loss occurs . During the third task , the counselor uses a problemsolving approach with the goal of helping people accommodate to loss by facilitating their ability to live without the deceased and to make decisions independently. Worden's ( 1991) description of the fourth task, which represents a modification of his earlier work in 1982, suggests the importance of the bereaved emotionally relocating the deceased such that the mourner no longer has a need to "reactivate the representation of the dead with exaggerated intensity in the course of daily living" (p. 16). The counselor's role is to help the deceased "find an appropriate place for the dead in their emotional lives-a place that will enable them to go on living effectively in the world" (p. 17).
According to Worden ( 1991) grieving is finished when the four tasks are completed. Some of the hallmarks include being more hopeful, adapting to new roles, experiencing pleasure again, thinking of the deceased without pain, and reinvesting emotionally back into living and in the living. Worden uses the four tasks as a guide for clinicians, outlining specific principles and procedures of grief counseling. In facilitating normal grief, the counselor interprets normal behavior, provides support and time for grieving, examines defenses and coping styles, and identifies pathology and refers when appropriate. Worden provides clues for diagnosing complicated grief and identifies factors that influence grief outcomes including the role of the deceased, nature of the attachment, mode of death, past history of losses, personality, and social variables. Worden also briefly addresses other types of losses including suicide, miscarriages, abortion, and AIDS. Worden's (1991) model is based on the belief that the resolution of grief can be influenced by intervention and that the grieving individual needs to take action. Although the model can serve as a guide for clinicians, caution must be used to not oversimplify the approach to grief counseling or ignore individual differences in coping style .

16
Therese Rando (1984), a clinical psychologist and well known presenter on the topic of normal and complicated grief, discusses the psychological reactions to normal grief as a guide for clinicians who are working with the bereaved. Her work is primarily based on the earlier works of Lindemann ( 1944 ), Parkes ( 1972), andWorden (1982). According to Rando ( 1984) "the reactions do not form rigid phases and the griever will probably move back and forth among them. All individuals will not experience all reactions presented; these are only some of the possible responses" (p. 29) . The reactions discussed by Rando (1984) are divided into three broad categories: avoidance, confrontation, and reestablishment. In avoidance the person attempts to avoid the acknowledgment of the loss, responding with shock, disbelief, and numbness . This "emotional anesthesia" serves as a protection or buffer from being overwhelmed by the impact of the loss.
Grief is experienced most intensely during confrontation . Anxiety, anger, guilt, depression, despair, inability to concentrate, irritability, tension, preoccupation with the deceased , and yearning are common experiences during this time . A gradual decline of the intense emotional reactions marks the beginning of reestablishment, whereby the person begins to reenter the everyday world . Rando ( 1984) underscores the importance of considering a variety of factors that may influence one's griefreaction. "Each person's grief will be idiosyncratic, determined by a unique combination of psychological, social, and physiological factors " (Rando , 1984, p. 43). Age, the meaning of the loss , individual personality style and coping beha viors, past experiences with loss , sociocultural and religious background, educational and socioeconomic status, secondary losses and/or concurrent ~risis, and physiological well being are critical in evaluating one's response to loss. Rando (1984 ) is also quite prescripti ve in the discussion of therapeutic interventions with grievers. Rando , like Worden, ( 1982 asserts that the expression of feelings of loss, anger and sadness is a "necessary part of the resolution of grief ' (p. 75) . Numerous strategies for interventions are outlined incorporating Worden's (1982Worden's ( , 1991 tasks. A strength of Rando's approach to intervention includes a thorough assessment of the person ' s grief and the significant factors influencing it.
A Transformative Model of Grief Schneider ( 1989Schneider ( , 1994 developed a model of grief that is cyclical , growth oriented and describes grief as a three-step disco very process: discovering what is lost, what is left and what is possible. Schneider's (1994) conceptualization of grief incorporates key concepts from other classic theories and descriptions of grief (Bowlby , 1980;Lindemann, 1944;Marris , 1974;Parkes, 1972). A significant difference , however, is that Schneider (1989Schneider ( , 1994 emphasizes the normative and growth potential of grief. Grief is described as an inherently dynamic and highly individualized process . Phases are used to illustrate the nonlinearity of the process. Throughout the model multiple dimensions are used to describe the complexity of the human response including physiological, emotional, behavioral, cognitive, and spiritual.

18
The first phase, discovering what is lost, often begins with shock followed by attempts to overcome or escape from the loss. Since the full significance of the loss cannot be fully absorbed at one time, a combination of coping strategies that conserve energy by escaping from the full impact of the loss, and holding on strategies that focus on trying to understand what happened and to problem solve, are called forth. Awareness is a turning point in the process of grief characterized by a challenge to physical stamina , the will to live, and the search for meaning.
The second phase, discovering what is left, proceeds to a more active discovery process of what remains and what can be restored. Grief enters a healing phase and an awareness of the outside world is regained through the senses. Sadness begins to sweeten, hopelessness is reduced, and loneliness is less frightening. The person is able to appreciate the meaning of the loss in a broader context with an acknowledgment that learning from the loss is also possible.
There is a movement away from focusing on the loss to being able to take risks.
During this process, the person is challenged to examine and possibly relinquish previously held beliefs, assumptions, roles, and basic values.
During the third phase, the person considers that the loss is growth producing. New potentials are discovered and the view of self is amplified . The person is at peace with her/his feelings, often re-ordering life's priorities. The ability to experience the fullness of life with an openness to hope, growth, freedom, and new choices are the hallmarks of this phase. Schneider ( 1994) discusses the significance of grief associated with other types of loss . This view is consistent with the contemporary literature and recommendations that a range of losses, not only death must be included in examining the nature of grief (Benoliel , 1985;Corr, 1998Corr, -1999Cowles & Rodgers, 1993;Doka, 1989;Littlewood, 1992;Marris, 1974;Neimeyer, 1998;Osterweis , Solomon, & Greene, 1984). 19 Schneider's (198919 Schneider's ( , 1994 model reflects a deep respect for the capacity of the human person to grow even in the midst of pain and suffering. This view is a welcomed departure from the traditional models that focus on negative individual outcomes . Schneider's (1989Schneider's ( , 1994 model also reflects a deep appreciation of the meaning of the person's experience evidenced in his discussion of validation which supports the genuine acceptance of the human condition, affirming the individuals' experience in the moment. Schneider (1994) believes that the primary goal of intervention is acknowledging and validating the loss and the griever.
According to Schneider (1994), validation fosters a deep appreciation of the moment, suspending judgment, incorporating genuine communication and respect for the uniqueness of the individual , without intention to change, manipulate, and control. Validation provides the safety necessary for the person to feel safe enough to discover what has changed.
The Dual Process Model Stroebe and Schut (1999) have identified shortcomings in the conventional grief theories and propose a revised model of coping with the loss of a close person. This model is not a phasal model, but "rather a waxing and waning, an ongoing flexibility, overtime" (Stroebe & Schut, 1999, p. 213) . The components of the model include the stressors associated with bereavement, the cognitive strategies involved in coming to terms with the life event, and the dynamic process of oscillation.
"This model identifies two types of stressors, loss and restoration-oriented, and a dynamic regulatory coping process of oscillation, whereby the individual at times confronts, at other times avoids , the different tasks of grieving" (Stroebe & Schut, 1999, p. 197). A basic assumption of this model is that coping is embedded in everyday life experience whereby people undertake in varying degrees, lossoriented and restoration-oriented coping. The process of confronting the reality of the loss takes place in dosages and allows for attending to other tasks that are concomitant with loss.
Loss orientation dominates early on in bereavement and refers to the concentration and dealing with processing of some aspect of the loss experience itself. It encompasses yearning for the deceased , rumination about the deceased, and the grief work concept of traditional theories. A range of emotional reactions are involved , from pleasurable reminiscing to painful longing.
Restoration orientation does not refer to an outcome variable, but to the secondary sources of and coping with stress. The focus is on the numerous adjustments and substantial changes that have to be made as secondary consequences of loss ( e.g., finances, development of a new identity from spouse to widow). The additional sources of stress can lead to further anxiety and distress.
A myriad of emotional reactions are also involved in coping with the tasks of restoration, including taking time off from the pain of grief. The individual is challenged to accept the reality of a changed world as well as accepting the reality of the loss.
A dynamic back-and-forth process, called oscillation, is a central component to this model. This refers to the alternation between loss-and restoration-oriented coping, the process of juxtaposition of confrontation and avoidance of different stressors associated with bereavement. At times the bereaved will be confronted by their loss, at other times they will avoid memories, be distracted, or seek relief by concentrating on other things. (Stroebe & Schut, 1999, pp. 215-216) In this model, it is postulated that oscillation is necessary for optimal adjustment over time.
A strength of this model is that it can account for cultural and gender differences. Some individuals and some cultures may be described as being more loss oriented or restoration oriented. In the discussion of this model, Stroebe and Schut ( 1999) assert "until further research has been done, caution must be observed in making assumptions, or in deriving practical applications from assumed regularities" (p. 220).

Summary
In the past, predominant models of grief have conceptualized grief as a sequential, predictable, linear process in which there is a progression of emotional and cognitive changes over time. This process has been organized in terms of phases and stages (Bowlby, 1980;Parkes, 1972) or tasks (Worden, 1982). With the growing awareness of the complexity of the nature and experience of grief, some contemporary writers assert that grief is not a linear process with concrete boundaries but rather a composite of overlapping fluid phases or spirals that vary from person to person (Arnold, 1995;Cowles & Rodgers, 1993;Rando, 1984;Rosenblatt, 1996;Shuchter & Zisook, 1993;Schneider , 1994;Stroebe, Hansson, & Stroebe, 1993). Recent authors have moved away from the focus on symptom resolution and suggest that grief may also be growth producing or transformative (Arnold, 1995;Benoliel, 1985;Schneider, 1994;Shuchter & Zisook, 1993). Neimeyer ( 1998) questions the adequacy of conventional grief theories, and presents an alternate view based on the fundamental assumption that meaning construction in response to a loss is the central process of grief. In this perspective , it is proposed that a profound loss can disrupt the very basic assumptions that we have constructed about the world and ourselves .
To date , there is little agreement regarding the course of normal grief. The expected course for what is considered nornrnl has increased over the years.
Although there is variation in the description of the phases of grief, and contemporary writers are beginning to challenge conventional theories, there continues to be some commonality in how this process is conceptualized. The process of grief can be described as having at least three partly overlapping phases: (a) an initial period of shock, disbelief, and denial; (b) an intermediate period of acute distress, and ( c) a period of integration, or assimilation.

23
The first phase may last from hours to weeks and is characterized by varying degrees of disbelief and denial. The mourner cannot believe that death is real and the person describes feeling numb and paralyzed. As recognition of the reality of the loss surfaces, denial often occurs serving as a buffer or protective mechanism, by allowing slow absorption of the reality of the loss.
The acute phase begins when death is acknowledged cognitively and emotionally. As the shock wears off, grief is intensely experienced frequently occurring in periodic waves. This distress is often accompanied by physical and emotional discomfort, social withdrawal, and painful preoccupation with the deceased. This acute period may last for several months before the person returns to a feeling of well being and the ability to go on living.
In the last phase, frequently referred to as restitution, integration, or assimilation, the bereaved shifts attention to the world around him or her and to the future. There is a gradual decline of grief and a beginning of the emotional reentry into everyday life and work. The hallmark of this phase is the ability for the bereaved to return to work, reexperience pleasure, and reinvest energy in new persons, ideas or things. The loss is put in a special place but frees the mourner to make new attachments.
The concept of "grief work" has been central in the major formulations of grief and has served as the blueprint for grief counseling. In fact, intervention models define the goal of grief counseling as facilitating "grief work" (Rando, 1984;Worden, 1982). The grief work hypothesis is based on the notion that one has to confront the experience of bereavement to come to terms with loss and avoid detrimental health outcomes (Stroebe & Schut, 1999). Most recently the concept of "grief work" has been called into question (Wortman & Silver, 1989;Wortman, Silver, & Kessler, 1993;Stroebe et al., 1994). According to Stroebe et al. (1994), "results from a few recent studies have provided empirical evidence in support that grief work may not be essential for adjustment as the majority of theoreticians and clinicians believed" (p. 194). The main points of criticism identified by Stroebe and Schut ( 1999) concern the lack of clarity in the definition of grief work, the poor quality of operationalizations in empirical studies, and the lack of application across cultures. In addition, the grief work hypothesis does not take into account gender differences and could be more representative of a female model of grieving (Stroebe & Schut, 1999).
The predominant grief models claim that the purpose of grief is to disengage or sever the bonds with the deceased, and to let go of the past so that the person is free to make new attachments. This belief has influenced the principles and goals of grief counseling. According to Silverman and Klass (1996) this belief is based on unexamined assumptions, inadequate empirical research, and has its roots in the modern Western world which focuses on individualism and separateness . Recent authors have challenged this view (Clark, 1993;Neimeyer, 1998;Silverman & Klass, 1996;Stroebe, Gergen, Gergen, & Stroebe, 1996;Vickio, 1999). Some authors have put forth the idea that resolution of grief may involve continuing bonds and that these bonds may be a healthy part of the ongoing life of the bereaved (Neimeyer, 1998;Silverman & Klass, 1996;Stroebe & Schut, 1999).
The major assumption in grief work is that persons experiencing the death of a significant person are able to engage in various social rituals such as wakes, funerals, and visits to the gravesites which may allow them to express and cope with grief within a context of social st:pport. Hence, the models of grief described in the literature contextualize grief in the possibility of involvement in such rituals.
However, incarcerated persons are often not able to engage in similar rituals in their loss of a significant person. This means that the grief experience of incarcerated persons may need to be understood from a model that specifically addresses disenfranchised grief.

Women in Prison
Approximately 82,716 women were incarcerated in Federal or State prisons in June 30, 1998. An additional 63,791 women were supervised in local jails (Bureau of Justice, 1999). The rate of incarceration for women is growing at a much faster rate than that of men (Bureau of Justice, 1994; Bureau of Justice Bulletin, 1999;Covington, 1998;Henderson, Schaeffer, & Brown, 1998;Phillips & Harm, 1998;Singer, Bussey, Song, & Lunghofer, 1995;Young, 1998). The number of women in prisons in 1998 increased 5.6% as compared to a 4.7% for men. "At midyear 1998 women accounted for 6.4% of all prisoners nationwide, up from 4.1 % in 1980and 5.7% in 1990" (Bureau of Justice, 1999.

26
Although the number of women entering prisons has continued to soar over the last two decades, there has been little attention paid to them in health care research (Coll, Miller, Fields, & Matthews, 1998;Jordan, Schlenger, Fairbank, & Caddell, 1996;Maeve, 1998;Singer et al., 1995). In fact "we know too little about women serving time" (Singer et al.,p. 103). "While the lack of representation of women in health research has become a national concern, health research regarding incarcerated women is particularly lacking" (Maeve, 1998, p .1). According to Singer and colleagues ( 1995), this paucity of research is related to three factors: women tend to commit nonviolent crimes; therefore, they are not considered a threat to society; they represent only a small proportion of inmates as compared to men; and they have unequal economic and political status.
Most women in State prisons are between the ages of 25-34, unmarried, members of a racial or ethnic minority, have at least a high school diploma or GED, and are unemployed at the time of arrest. Approximately 62% are single parents of one to three minor children, 60% have been welfare recipients (Singer et al., 1995). More than half of the women grew up in households without the presence of both parents (Bureau of Justice, 1994;Covington, 1998;Henderson et al., 1998;Maeve, 1998;Young, 1998). Histories of sexual and physical abuse, mental health problems, and significant substance abuse histories are reportedly high (Bureau of Justice, 1994;Fogel & Martin, 1992;Henderson et al., 1998;Jordan et al., 1996;Maeve, 1998). Most of the women come from impoverished backgrounds, and have lived chronically chaotic lives (Owen, 1998;Singer et al., 1995). "In short, crimes these women commit are often a reaction to negative life events, a response to a crisis or to prolonged disadvantage" (Singer et al., 1995, p. 103).

Life of Incarceration
Imprisonment is a stressful and painful life event which can have a negative impact on the physical and psychological well being of the person sentenced to prison (Burkhart, 1973;Fogel, 1993;Keaveny & Zauszniewski, 1999;Pang, 1989;Parisi, 1982;Toch, 1977Toch, , 1992. Imprisonment presents extraordinary obstacles to one's ability to cope and adapt, requiring the woman to struggle and survive conditions that most of us cannot even begin to comprehend (Owen, 1998). Although some people adapt to the challenges of the prison environment, there are many others who continue to struggle on a daily basis and never adjust (Owen, 1998;Toch, 1977Toch, , 1992. Some authors have used the term "pains of imprisonment" to describe the innumerable issues with which inmates must learn to cope (Giallombardo, 1966;Toch, 1977). Crowding, monotony, lack of privacy, loss of freedom, loss of relationships, the lack of heterosexual relationships, a decrease in autonomy, the absence of personal goods and services, and concerns about safety represent the critical challenges for people sentenced to prison (Giallombardo, 1966;Toch, 1977Toch, , 1992. These deficits often lead to feelings of inadequacy, powerlessness, decrease in self-esteem, and mental health issues. Security always takes priority in prison and overrides any issue or problem faced by the person in prison (Anderson, Bankson, & Zephirin -Atkins, 1998;Toch, 1992;Watterson, 1996).

28
"Prisons are established to contain, control, and punish those who have committed crimes . .. guards and treatment staff place a premium on maintaining security and safety. Gratifying an inmate's physical , emotional, or even therapeutic needs takes a necessary backseat" (Anderson et al., 1998, p. 251 ).
Although a variety of activities are offered throughout the day, inmates complain of feelings of boredom and an unending redundancy of daily routine. By nature of its imposed structure, daily life is governed by incessant rules.
Everything a woman does--sleeps, eats, bathes, and engages in recreation--is regulated or controlled. The loss of adult status leads to dependency, powerlessness, and infantilization (Anderson et al., 1998;Fox, 1982). The emphasis on uniformity undermines self-respect, as well as fostering apathy and dependence (Giallombardo , 1966;Toch , 1977Toch , , 1992. The lack of privacy and personal space as well as the pervasiveness of prison rules also interferes with adaptive strategies that people use when under stress, such as going for long walks and writing in journals . Subsequently, women are forced to return to previously learned dysfunctional strategies (Anderson et al., 1998).
According to Owen ( 1998) "interpersonal relationships are the anchor of prison culture" (p. 119). Incarcerated women try to maintain contact with their families on the outside . In fact, the primacy of relationships with children and families have a significant influence on the women. "Many women report that being separated from their children is the hardest part of doing time" (Owen, 1998, p. 127). Although many women maintain contact with their children through telephone, letters, and regular visitation, they experience a great deal of emotional pain as a result of the physical separation of imprisonment, emotional estrangement from their children, concerns about their well being, and fear of losing custody (Fox, 1982;Owen, 1998;Watterson, 1996).
Women in prison tend to develop kinship systems or informal social structures to ward off the deleterious effects of confinement, to develop a sense of belonging, and to ease their loneliness (Giallombardo, 1966;Owen, 1998;Toch, 1992;Watterson, 1996). These social structures are sometimes referred to as prison families or play families, with different women assuming the role of mother, father, sister, brother, or daughter (Burke, 1992;Owen, 1998;Watterson, 1996).
Prison families are much like friendships among people anywhere, like the kind of relationship where you guide and counsel a friend as though he or she were your own child, or relate to someone as if she were your sister or mother. (Watterson, 1996, p. 288) These families are often the basis for a woman's role or status within the prison culture (Owen, 1998). Same sex relationships, which may be sexual or nonsexual, are common in women's prisons (Giallombardo, 1966;Owen, 1998;Toch, 1992;Watterson, 1996). Some of these relationships are romantic, whereas others are based on a strong emotional attachment. In their yearning for companionship and intimacy, women often attempt to establish rapport with at least one other person who is usually an inmate (Owen, 1998;Toch , 1992). The search for a friend may Relationships with staff can range from cooperative to hostile. In some studies, relationships involve a recognition of common goals shared by the women and the officers: keeping peace, avoiding violence, sharing information, and accomplishing the routines of daily life (Owen, 1998). Relationships can also be highly conflicted, where the women experience many of the interactions with the correctional staff as demeaning and patronizing (Owen, 1998;Pang, 1989;Toch, 1977). Inconsistencies of rule interpretation and enforcement often result in frustration and increased tension (Fox, 1982;Owen, 1998;Pang, 1989).
Survival in prison largely depends on the woman being able to develop a productive routine or program within the prison as well as to develop relationships with other prisoners and staff (Owen, 1998). "Negotiating the prison world involves learning a unique set of strategies, behaviors, and meanings" (Owen, 1998, p. 168). Access to information about prison culture through past experience, knowing someone in prison, women's street culture, or a commitment to a deviant identity provides footprints as to what to expect. Interpersonal coping skills and learning how to deal with the prison bureaucracy influence to a large extent the adaptation of a woman who is doing time (Owen, 1998).

Contextualizing Grief oflncarcerated Women as Disenfranchised
The contemporary grief literature emphasizes that serious problems, such as masked or delayed grief, can occur when losses are not acknowledged or recognized and/or when the griever is not supported and validated (Doka, 1989;Schneider, 1994 ). When a person suffers a loss that cannot be openly acknowledged, publicly mourned, or sociall y supported , it is often described as disenfranchised, often resulting in a more complicated bereavement (Doka, 1989).
Grief can be disenfranchised in situations in which the relationship is not recognized or socially sanctioned, denying individuals the opportunity to publicly mourn the loss. Although close relationships may exist between friends, lovers, foster families, stepparents and stepchildren , neighbors , caregivers , and roommates such as in nursing homes or extended care facilities, an opportunity to publicly mourn the loss may not exist. Nontraditional relationships such as extramarital affairs and homosexual relationships often face negative reactions in the larger community, prohibiting the acknowledgment of the relationship.
There are numerous other situations in which the loss itself is not socially recognized as significant. Perinatal death, abortion, placing a child for adoption, infertility or the loss of the wished for child, loss of a foster child, and pet loss frequently lack acknowledgment, thereby leaving the griever emotionally isolated.
According to Schneider (1994) other losses which involve unpopular antisocial behaviors or the breaking of taboos can also be classified as disenfranchised.
Divorce , murder , mental illness, abuse , torture , incest, rape, suicide, and AIDS often lack the legitimization as significant losses .
There are other situations in which the griever is not recognized because the griever is not socially defined as capable of grief. The very young, the very old, and the mentally disabled may be excluded from important rituals because they are perceived as having little comprehension of the death of a significant person.

32
According to Doka (1989), Rando (1993), and Schneider (1994) the problem of disenfranchised grief can create additional problems for the griever .
Significant losses that are disenfranchised often lack acknowledgment and validation, thereby minimizing social support and the opportunity to participate in important healing rituals . The griever is often left grieving alone, in isolation.
If one accepts the premise that a person must have the opportunity to grieve and have the grief validated in order to achieve an adequate adjustment to a significant loss, it seems to follow that there may be unique aspects of the incarcerated woman's experience that inhibits this process.
According to Toch ( 1992) "confinement may amplify the processing of sorrow when a loved one is lost. Inmates may feel unable to manage both grief and their reaction to an (allegedly) unconcerned prison staff' (p. 247) . Prison resources are not always available when the women need them. Inmates may tend to reflect in the early morning or evening hours when the professional staff is absent (Toch, 1992). The woman then, may be forced to grieve alone, resulting in either emotional withdrawal, detachment, or acting out.
One of the inmates, who was in my grief group, discussed her experience following the death of her boyfriend and the father of her son, stating, There was no one for me to talk to. There was nothing I could do. In sharing her experience, several ke 1 issues were prominent. Since this woman's boyfriend had severe problems with substance abuse, her relationship with him was not recognized by her family. She was not able to attend the wake and funeral because he was not a family member. Since the relationship was not recognized, her loss was not recognized. She felt cheated and angry that she did not have the opportunity to say goodbye by not being able to attend the wake and funeral. In addition, she felt a great deal of emotional pain by not being able to be with and help her son with the death of his father. Incarceration prevented her from being "there for him." Guilt and sadness were expressed as she described this recent experience. She felt powerless and angry. However, since she had no avenue to express her anger, she feared losing control or "blowing" which would result in being placed in solitary confinement. This woman decided that the only way to deal with this loss was "to not deal with it, to try and not think about it." From her perspective, there was no opportunity to have her loss acknowledged or validated. Unfortunately, she had not been able to establish a trusting relationship with another inmate or staff person to whom she could tum for support . As a result, she felt isolated and alone in her grief.

34
The experience of this woman portrays some of the unique problems that women in prison face when dealing with the death of a significant person. This snapshot illustrates how it can be extremely difficult for grief to be expressed in a safe environment, for the loss to be acknowledge and validated, and for participation in healing rituals to take place.
Although disenfranchised grief has had little attention paid in the literature, it continues to remain a growing and significant issue (Corr, 1998(Corr, -1999Doka, 1989;Schneider, 1994 ). Even more lacking is research that explores the grief of women in prison. Given the increasing numbers of women in prison over the last decade and the problems that can result from grief that is disenfranchised, research in this unexplored area can provide a beginning understanding of their experience with the hope of influencing care in the future .

Research Design
Research Approach for the Study of Grief of Incarcerated Women

35
The grief experience of women in prison was the focus of this study. The specific research questions were: 1. What are the meanings of the grief experience of incarcerated women?
2. How does their grieving process compare with images of grief depicted as a normal process?
3. To what extent do the women perceive incarceration influencing their grieving process?
An interpretive perspective combined with in-depth qualitative interviewing was used in this study to examine the grief experience of incarcerated women. The data was collected through the interviews in the form of personal narratives and analyzed using narrative analysis, a common method for interpretive studies. "The ultimate aim of the narrative investigation of human life is the interpretation of experience" (Josselson & Lieblich , 1995, p. lX).
Acknowledging the philosophical underpinnings of any research method is a crucial first step in any research endeavor. "A scientist's coherence in articulating her or his positions or perspectives in terms of philosophy, theory and method is important not only for one's own work but also for the scientific disciplinary development" (Kim, 1996, p. 111 ). Understanding the philosophical underpinnings of a particular approach allows the researcher to make sound methodological choices.

36
The interpretive , or hermeneutic perspective, served to undergird this research study. This perspective conceives human science as the study of human beings in context (Freeman, 1997;Packer, 1985). "Hermeneutics involves an attempt to describe and study meaningful human phenomena in a careful detailed manner as free as possible from prior theoretical assumptions, based on practical understanding" (Packer , 1985(Packer , , p. 1082. The purpose of the hermeneutical method is to obtain a valid and common understanding of the meaning of a text through interpretation and reconstruction (Freeman, 1997(Freeman, , K vale, 1996. Since meanings are contextually grounded, they can emerge and be expressed in the process of indepth qualitative interviews . The word narrative comes from the Latin word "gnarus" which means knowing or telling a story (McCabe , 1991 ). The study of stories is not new, and has been the subject of scrutiny since the time of Aristotle (McCabe, 1991 ). The impetus to study narratives originated in the humanities and was influenced by the interpretive tum, the loss of faith in empiricism, as well as the struggles of the disenfranchised including women, minorities, and third world cultures (Riessman, 1993;Rosenwald & Ochberg , 1992). By the mid -1970s the social sciences moved away from the traditional positivist stance toward a more interpretive position whereby "meaning" became the central focus (Bruner , 1990). The last decade has witnessed a burgeoning interest in the study of narratives in the human and natural sciences, marked by diversity in methods and theoretical perspectives (Mishler, 1995). A proliferation of articles, books , and a journal dedicated to narratives is strong evidence of the increased recognition of the value to study stories .

37
The study of narratives is currently being used in theology, history, anthropology, sociology, psychology , nursing, social work, education, and occupational therapy. The particular experiences studied depend on the interest of the discipline. For example, in nursing , stories of interest are typically about health and illness . The knowledge gained from narrati ve studies is principally used to enhance the quality of care (Williams & Ferszt , 2000). Recent studies in nursing have examined the experience of women with breast cancer and the events leading to a diagnosis and treatment (Facione & Dodd , 1995), the experience of dealing with a life-threatening illness (Williams, 1995), values embedded in meaningful nursing practice (Fagermoen, 1997), and chemotherapy induced alopecia (Williams, Wood, & Cuningham-Warburton, 1999).

38
Analysis of personal narratives takes into account not simply what was told but why it was told in a particular way.
How individuals recount their histories--what they emphasize and omit, their stance as protagonists or victims, the relationship the story establishes between teller and audience--all shape what individuals claim of their own lives. Personal stories are not merely a way of telling someone ( or oneself) about ones life; they are the means by which identities are fashioned. (Rosenwald & Ochberg, 1992, p. 1) There is considerable disagreement about the precise definition of narrative (Riessman, 1993;Sandelowski, 1991;Sarbin, 1986). Many authors state that a narrative has a temporal dimension displaying movement through time, must have a plot or main story (Bell, 1988;Bruner, 1990;Mishler, 1986;Riessman, 1993) and must be coherent (Bell, 1988;Gergen & Gergen, 1983;Miller, 1990;Mishler, 1986Mishler, , 1991Polyani, 1985;Sarbin, 1986). Labov (1982) uses a more restrictive view, assuming that all narratives are stories about a specific past event, with a clear beginning, middle, and end. Others argue that although Western stories have a beginning, middle, and end, this linearity is not necessarily evidenced in other cultures (Riessman, 1993;Rosaldo, 1986;Sandelowski, 1991 ). Despite the range and diversity of definitions describing narratives, there is general consensus that the primary features of a narrative can best be described as a story that includes specific past events, moves through time, told to make a point, and is an effort to make sense of one's experience.
There are several basic assumptions inherent in narrative inquiry.

39
Numerous authors have identified that the impulse to narrate is natural and universal occurring across cultures and socioeconomic groups (Gee, 1985;Miller, 1990;Mishler, 1992;Polkinghome, 1988;Sarbin , 1986;White, 1980). Although telling stories is universal, narratives are culturally specific and must be read in context taking into account previous tellings and the relationship between the narrator and the interpreter (Gee, 1991;Miller, 1990;Mishler, 1986;Polkinghome, 1988;Personal Narratives Group, 1989;Polyani, 1985;Riessman, 1988Riessman, , 1993Rosaldo, 1986;Sandelowski, 1991;VanDijk, 1985). According to Sandelowski (1991) "narrators are socially positioned to tell stories at given biographical and historical moments and under the influences of prevailing conditions surrounding the storytelling, the social contact of narration, and the audience" (p. 162). Gender, socioeconomic class, and race may also shape the form of the narrative (Personal Narratives Group, 1989;Riessman, 1993).
Individuals actively engage in the creation of reality in their telling and retellings constructing their world through interpretation (Riessman, 1993). Narrative analysis is a logical and rich method of inquiry that produces meaningful knowledge about human experience. Since little is known about the grief experience of incarcerated women, this method is a viable research approach that can make a significant contribution to the understanding of the grief experience of these women.

Overview of Phases
This study was conducted in two phases. Phase One involved data collection from women in prison regarding their grief experience. Approval from the Institutional Review Board on Human Subjects was obtained on May 27, 1999.
Data collection, in the form of in-depth interviews, was completed in September 1999. Phase Two was a continuation of the project begun in Phase One. The data collected in Phase One was analyzed using hermeneutic and narrative analysis. Kvale's (1983Kvale's ( , 1996 approach to the interpretation of interviews combined with Gee's (1985Gee's ( , 1986Gee's ( , 1991 linguistically based model for the analysis of oral narratives and Riessman's (1993) recommendations for narrative analysis provided the framework for this analytic process.

Phase One
Setting Approximately 160-240 women are in the medium security prison in the State facility in which this study took place, at any given point in time, with a total of about 2,000 going through the system in 12 months. The majority of the crimes committed by these women are nonviolent (auto theft, fraud, breaking and entering, prostitution) or related to substance abuse. The length of sentence is typically 6 months or less for 50% of the women. In this facility, 61 % of the women are White, 26% are African American, and 12% are Hispanic. Although There are four wings or units in this facility. Each wing has a large day room or recreational room and a screened porch to the outside, which is the only location where the women are allowed to smoke. The majority of the rooms accommodate six women. The women are allowed to keep some personal items including radios and small televisions. Attempts to make the rooms attractive, given the constraints of institutionalization, are reflected in the availability of bulletin boards for cards or photos and floral wallpaper borders or stenciling . The building also houses the cafeteria, a chapel, a health room, a library, an exercise room, a visitation room for children, and several rooms for programs . A large yard, which the women access on a daily scheduled basis, offers recreational activities such as volleyball.
A variety of programs are offered in this women's medium security facility . The Warden has persevered in her efforts to bring a range ofresources for the women. A certified full-time teacher provides Adult Basic Education, High School Equivalency preparation and assistance with televised college courses.
Computer classes are also offered as well as instruction in English as a second language. A vocational life skills program has been developed which focuses on the development of basic skills such as the preparation of a resume and interviewing skills . Most of the educational programs are offered from September to June.
A voluntary substance abuse treatment program is also provided . This program includes individual and group counseling, anger management, relapse prevention, art therapy, aerobics, meditation, and cognitive restructuring.
Referrals for continued treatment are given to the women after they are released .
A chaplaincy team based on volunteer participation provides religious services and activities throughout the week. Additional programs offered in this facility include a counseling program for victims of sc.:xual and domestic violence, parenting education, and a peer suicide prevention program.
A mental health team provides care for women in crisis, psychopharmacology, and referrals for follow -up care after discharge.
Unfortunately, there is not enough staff to offer individual counseling to all of the women who need therapy. A mentoring program which assigns a volunteer as a support person during and after incarceration has been developed . This program is for women who have 6 months remaining on their sentence and exhibit high motivation for rehabilitation. Monthly support groups for the mentors and their mentees is provided. Case management and discharge planning have been developed to intervene in the cycle of recidivism. Discharge planners try to assist with housing, employment, treatment, family reunification and child contact plans.
Health care is provided by a part-time physician (20 hours) and a 24-hour nursing staff. The medical needs of the women far exceed the availability of services. A primary goal of the Warden and physician is to be able to provide an entrance physical examination and health education for all inmates. At this time, only inmates who present with medical problems can be seen by the physician .
Despite the amount of services offered in this prison, the rate of recidivism is quite high (50-60%). This is partially due to the relatively short sentences that prohibit the development of skills necessary to make significant changes in their abqity to deal with life on the outside. According to the Warden, the major gap in the system is the absence of transitional programs that would offer a full complement of services when the women are released from prison. The Warden also shares the view that most of these women do not belong in prison being that they are not a threat to society. The majority receive short sentences and upon discharge return to the same problematic environment. Although every attempt to provide continuity of care is made, the reality is that follow-up services are fragmented, unreliable, and hard to access.
A typical day in this medium security facility begins at 5:30 am and follows a highly regimented routine . If the women choose to be involved in work detail as well as take part in the variety of programs, the day is quite full with little free time. For some women, this type of routine makes prison time a little more tolerable, giving it some semblance of order and structure . However, separation from families and friends, the lack of privacy and personal space, and the absence of being able to make choices resonate as key issues with women in prison . The reality of prison life is just hard time! I became familiar with this setting in the spring of 1999 when I was asked to facilitate a grief group for the women. The Warden and clinical staff were aware that several women had experienced significant losses and believed they would greatly benefit from this type of group. Seven women participated in the group which met once a week for 6 weeks. The group was very well received by the women who all indicated the need for individual and/or group counseling that specifically addressed issues of loss and grief. During the summer of 1999, I continued my involvement in the prison by coordinating a community book drive for the prison library. I also provided education on the use of medications indicated for mental health problems.

Participants
The initial intent was to interview three to six women currently in the correctional facility who experienced the death of a significant person during their incarceration. Selection criteria included: the ability to read and speak English, no current psychotic disorder, some level of insight, and a willingness to participate in an 1 1/2-2-hour interview . Following the completion of three interviews, the data was sufficiently rich to indicate the appropriateness of this sample size. Samples in narrative studies are typically small, and often drawn from representative pools (Riessman, 1993 ). Purposeful samples are used because researchers want to identify good sources of information that will advance them toward their analytic goal (Sandelowski, 1995). This number of participants is a reasonable number to complete in light of the time required to obtain and interpret each participant's story or stories.
Potential research participants were identified by the Warden and/or the clinical staff. A list of potential participants was generated. Since race may shape the form of the narrative (Personal Narratives Group, 1989;Riessman, 1988), rigorous attempts were made to have an ethnically diverse population. This was not meant to be representative of the population of women in this prison, but to examine potential differences in their stories. The population included one Caucasian woman, one African American woman, and one of Native American descent.

45
The process of data collection proceeded by selecting, obtaining permission, and interviewing one participant at a time for a total of three cases.
Initially one woman, who met the criteria, was identified as a possible participant for this study by the Warden and/or member of the clinical staff. This woman had participated in a grief group that I facilitated several months prior to the beginning of this project. I met with this woman individually to describe the project in detail. She was very enthusiastic and agreed to participate. I obtained informed consent (Appendix A), collected demographic data (Appendix B), and then conducted the interview using an interview guide (Appendix C). The interview lasted 1 1/2 hours.
Once this interview was completed and the audiotape transcribed verbatim, I scheduled an appointment to meet with another potential participant on the list. I met with this woman and explained the project in detail. This woman felt that it would be too painful to revisit her issues of loss and declined to participate. I acknowledged her decision not to participate, demonstrating respect for her choice.
While I was waiting to meet another potential participant, the social worker asked if I would counsel a woman who was waiting to see the physician . Her grandfather had recently died and she was quite agitated and tearful. I met with her for approximately 30 minutes until the physician was available to see her. The woman who had been identified as a possible next participant was waiting for me in the administrative waiting area. I explained the study in detail and she readily agreed to participate in the study. We met for 40 minutes and scheduled to meet again the following week. When I returned the following week , she had been admitted to a local hospital for evaluation of her cardiac status.
The woman I had counseled had also been identified as a potential participant. We met to discuss the study and she willingly agreed to participate.
I returned the following week to interview the second participant who had been briefly hospitalized for observation . She agreed that this would be a good time to continue the interview. This participant was interviewed twice for a total of 2 1/4 hours. The interviews were transcribed verbatim. To ensure the privacy of the women, the interviews took place in a private meeting room in the administrative area.

Data Collection
In-depth guided interviews were used to elicit stories, encouraging the women to tell about their experiences in their own voices. The women were encouraged to take an active role in the interview process itself. It was my intent to allow the participants to determine the direction of the interview. However, at times, I intentionally guided the conversation in order to elicit stories that were related to the specific research questions .

47
According to Mishler (1986) and Riessman (1993 ), it is preferable to ask questions that open up topics , giving greater control to participants allowing them to construct answers in ways they find meaningful. An interview guide of several questions is recommended by Riessman beginning with questions about the topic of inquiry followed by probing questions to help the participant give further details as needed. The interview guide was used to help frame the focus of the themes that were of interest in this study (Appendix C).
The type of interview used in this study can be conceptualized as a form of discourse or conversation between two people about a theme of mutual interest (Kvale, 1983(Kvale, , 1996Mishler, 1986;Rubin & Rubin, 1995) . The interview is guided, neither a free conversation nor a highly structured questionnaire. As in an ordinary conversation, only a few topics are covered in depth, but in the case of the interview the researcher gently guides the discussion , encouraging the interviewee to answer in depth and in length (Chase, 1995;Rubin & Rubin, 1995).
The interview is typed and transcribed. The typed version along with the audiotape constitutes the material for the subsequent interpretation of meaning.
The interview proceeds much like a conversation but with a specific purpose. The interviews attempt to obtain open, precise, and rich descriptions of how people understand their world and how they create and share meanings about their lives (Kvale, 1996;Rubin & Rubin, 1995) .
The main goal of the interview is to understand the meaning of what the interviewees said, and then further expand the immediately experienced meaning in the interview through interpretation. According to K vale ( 1996) the research interview is a "construction site for knowledge" (p.14). The discovery of knowledge lies in the interaction between the research interviewer and the interviewee. The research interviewing involves "a deceptive simplicity" (Kvale, 1996, p. 12), yet at the same time requires expertise, skill, and craftsmanship on the part of the interview researcher. The interviewer needs to be knowledgeable about the theme but at the same time maintain deliberate openness to the phenomena and be critically aware of her/his own presuppositions. The interviewer must know what she/he is interviewing about as well as know how and why. Since it is the human interaction that produces knowledge, the interviewer must be acutely aware of the interpersonal relationship in the interview situation and take this into account during the interview situation and in the analysis of the data.
When using this type of method, the researcher uses her/himself as the research instrument and, therefore, must be aware of her/his own role in the entire process. "Who the researcher is, as a human being, and how well developed he or she is as an instrument for carrying out the inquiry process, greatly affects the outcome of research" (Salner, 1989, p. 66). The interviewer must have the ability to establish an atmosphere of trust so that the interviewee feels safe, comfortable, and able to freely share her/his experience. The interviewer must be able to empathetically, sensitively, critically, and actively listen in order to capture the many layers of meaning that are discovered during the interview process (K vale, 1996;Rubin & Rubin, 1995). In addition, the interviewer must be able to "interpret the multiple horizons of meaning implied in the interview situation with an attention to the possibilities of continued reinterpretation that lies within the hermeneutic circle" (Kvale,p. 135). The outcome of the interview is dependent on the knowledge, sensitivity, empathy and skill of the interviewer (K vale, 1996; Rubin & Rubin, 1995). The interviewer must be a gentle communicator, critically clear, and be able to consistently provide interpretations.
In each of the interviews I began with thanking the women for taking the time to meet with me. I discussed the study in detail, invited collaboration , and described my specific purpose. I made a sincere effort to provide an atmosphere of comfort and respect. Each participant was asked to tell about her experience of grief following the death of a significant person during her imprisonment. I began in a relatively open manner, clarifying responses, and guiding the women to answer in depth and in detail. I focused on the first three questions in the interview guide that specifically addressed the research questions . Depending on the timeframe and on the woman's level of energy, I proceeded to explore questions four through six which dealt with other losses.
First Participant (Mary--a pseudonym) The first woman I interviewed was a 35-year-old Caucasian widow with three children currently living with a family member. She identified herself as Baptist, announced with pride that she completed her GED while in prison, and enthusiastically described the college courses in which she is currently enrolled. This woman's sister, who served as a mother figure and major support person for many years, died 10 months prior to the interview.
This woman had participated in the grief group I facilitated several months prior to this study. Since I was aware that the death of her sister was a critical issue for her, I took an active role in facilitating stories related to this particular loss. If I had not had prior knowledge of this woman's history, I would have been less directive during the interview.
Specifically, I began the interview by saying "can you start by telling me how you found out about her illness, and then what happened; just tell me in your own words if you remember." This woman freely and spontaneously shared her thoughts and feelings. Rich stories of her grief experience were spontaneously created. The opportunity to tell her story seemed to have a therapeutic value for her. In fact, early in the interview she stated that "it helped to talk about it." The interview went smoothly. I felt that I had developed a trusting relationship with her during the grief group which fostered a high degree of comfort for her in this situation as well. She was consistently engaged, frequently smiling, and tearful at times. Episodically she became increasingly upset. At these times I consciously moved to less intense topics to give her a break from the intensity of the pain that she was obviously feeling. I was always acutely aware of not causing additional harm.
During parts of the interview, it was difficult for me to hold back my own tears. The stories were heart wrenching and difficult to hear. I was deeply aware of this woman's struggle and pain. I felt a deep admiration for her courage and tried to communicate that during the interview. Given my clinical background as a psychotherapist, empathic, sensitive, and active listening was easy for me .
However, I frequently found it difficu lt to remove myself from responding as a therapist and intervening . In addition, I had to be consciously aware of the rule in the prison that "touching is not allowed." This was very difficult for me and unnatural. We completed the interview in 1 1/2 hours with the understanding that I could return if needed.

Second Participant (Barbara--a pseudonym)
The second participant was a 40-year-old, single African American woman whose mother died 10 months prior to the interview . She also described herself as Baptist and proudly announced that she had completed 2 1/2 years of college prior to imprisonment. Describing herself as an educated woman was obviously very important to her as she emphasized it several times . This interview proceeded differently than the first one . As in the first interview, I began with a broad opening statement by saying, First I want to thank you for being willing to talk to me . As we were saying I am interested in understanding what it's like to experience a major loss, especially while in prison . Today I'd like to talk about your Mom's death . If you can start off by just using your own words, just tell me what happened to your Mom.
Unlike the first woman, this participant had a need to frame her story within a broader context. With a sense of command, she began by telling me about her life as a young girl. This was obviously important to her, so I assumed an active listening role and was less directive than I had been in the first interview.
There were long periods of monologue throughout the interview. This woman had little eye contact with me during the interview. She looked down almost the entire time, and was teary during most of the time. I maintained eye contact with her, frequently nodding and offering her Kleenex during tearful times. She looked at me episodically as if to see ifl was remaining attentive to her. She seemed sad, but obviously wanting to talk.
I found myself irritated with the noises in the hallway and the interruptions in the room by correctional officers. What I found interesting, however, is that this woman just kept talking. Perhaps the women become accustomed to the constant noise and intrusions. Since it was considerably more noisy that day, I experienced myself working harder to maintain a connection. I made a conscious effort to stay attentive and to be quiet. I was careful to check in with her as to her level of comfort in continuing the interview.
She seemed to have more eye contact with me when I returned a second time to continue the interview. At the end of the interview she commented on how helpful it was to have someone to speak to about the loss, about the pain, stating, It's a way to express me, and speak of the pain , that I feel .. . I feel as though it's a way to let go of some of the pain , and the built up grief and tears that I have not been able to voice and express to anyone.
Like the first interview, rich painful stories were spontaneously created during both of our meetings. Both interviews lasted a total of 2 l /4 hours.
Third Participant (Christine--a pseudonym) The third participant was a 28-year-old single woman of Native American descent, with three children in foster care, and was in the process of placing them for adoption. She comes from a Baptist and Catholic background, and completed 11th grade prior to imprisonment. This woman's grandfather, who had been her father figure and raised her for most of her life , died 1 month prior to the interview.
Briefly knowing this woman from having counseled her 2 weeks prior to the interview seemed to have established some level of trust. Even though our contact had been brief, she stated that she had found our time together helpful. I felt that we had made a good connection. She had also heard about me from some of the other women in the prison who had been in my grief group . . She appeared less anxious, tearful, and agitated, probably related to the medication that was prescribed.
The interview proceeded quite easily. She maintained good eye contact throughout the interview, was friendly , and frequently smiled at me. Like the two previous interviews, after I had discussed the study and obtained informed consent, I began with a broad opening sentence "first I'd like to thank you for being willing to talk to me. I'd like to hear about your grandfather today . Can you begin by telling me how you first heard about your grandfather's death?" She was very willing to talk but needed more direction than the first two interviews. As in the previous two interviews, rich stories were also easily created. I validated and shared some of my own experience related to adoption , acknowledging her love for her children, and the painful yet loving decision that she was making. I told her that I really admired her. "You know it's not easy to do that, you put their needs and their welfare first out of your love for them." She was so thankful for my validating and supportive comments, and shared, "Thank you. At least somebody said something like that. You know, my own mother didn't say anything ." Like with the other two women I was struck by the depth of her pain, privileged to hear her stories, and deeply saddened by how these women seem to expect so little from life. This interview lasted 1 1/2 hours .

54
Overall observations and impressions of the interview were recorded in memos following each interview, allowing me to immediately reflect on the interview situation and identify any issues or problems that occurred (Appendix D). Personal reflections were also documented in a journal immediately following each interview. The memos and journals enhanced reflection on the interview while the experience was fresh, and later added to the richness of the analysis .

Phase Two: Analytic Methodology
Analysis of the interview data, completed in Phase One, was carried out in Phase Two. Kvale's (1983Kvale's ( , 1996 method of analyzing interview data was used as the first step in the analysis, followed by narrative analysis of the text utilizing the processes recommended by Gee (1985Gee ( , 1986Gee ( , 1991 and Reissman (1993). Gee's linguistically based model for the analysis of oral narratives combined with Riessman 's ( 1993) recommendations for narrative analysis served as the guide for the analysis of narratives obtained from the three participants.

Holistic Analysis
In order to obtain a comprehensive understanding of the meanings of the grief experience of women in prison, the process of interpretive analysis consisted of three steps, each step having a specific purpose. During each step, the audiotapes, transcriptions, and researcher's memos were reviewed several times. Kvale's (1983Kvale's ( , 1996 approach to the hermeneutical interpretation of interviews addresses the meaning of the text in three different contexts: selfunderstanding, critical commonsense understanding, and theoretical understanding. The three steps in this study were guided by Kvale's approach for the interpretation of interviews. 1. Self-understanding . The interviews were read initially to obtain a sense of what the women themselves understood as the meanings of their statements. "This interpretation is more or less confined to the subjects' understanding: a rephrased condensation of the meaning of the interviewees' statement from their own viewpoints as these are understood by the researcher" (Kvale, 1996, p. 214).
This perspective addressed the first research question (What are the meanings of the grief experience of incarcerated women?) and the third research question (To what extent do the women perceive incarceration influencing their grieving process?).
2. Critical commonsense understanding. This second and broader perspective goes beyond reformulating the subjects' self-understanding. The researcher amplifies or enriches the interpretation of the statements themselves by focusing on either the content of the women's statements or on the women making the statements . "One here attempts to get at the spirit of what is said, extending its meaning, by reading between the lines and by drawing in broader contexts than the interviewee does" (Kvale, 1983, p. 181 In this step, the interview data was structured using the specific procedures for the narrative analysis based on the works of Gee (1985Gee ( , 1986Gee ( , 1991 and Riessman (1993) . Following Riessman's (1993) recommendations, initially the interviews, along with the audiotapes, were read and reread allowing me to immerse myself in the women's accounts. According to Riessman (1993): Narrators indicate the terms on which they request to be interpreted by the styles of telling they choose. Something said in a whisper, after a long pause, has a different import than the same words said loudly, without a pause . (pp. 19-20) Repeated listening allowed me to methodically focus on the features of speech as well as emotion that was critical to the interpretation of the accounts (Riessman, 1993).
The specific narratives were identified and analyzed using Gee's (1985Gee's ( , 1986Gee's ( , 1991 sociolinguistic approach to narrative analysis . The women's experience of grief was compared to theoretical definitions and descriptions of grief. Particular attention was paid to the similarities and differences of the women's experience of grief with the literature. The narratives were then closely reexamined again to identify the contextual factors influencing their accounts responding to the third research question (To what extent do the women perceive incarceration influencing their grieving process?) . More specifically, the examination of disenfranchised grief, and its applicability to the experience of these women was conducted.

Narrative Analysis
Since little is known about the grief experience of women in prison, the analysis of narratives provides an excellent vehicle for exploring this phenomenon. Narrative analysis as an analytical method is well represented in the literature (Gee, 1985(Gee, , 1986(Gee, , 1991Kvale, 1996;Mishler, 1986;Riessman, 1993;Sandelowski, 1991;Williams, 1995). It involves the systematic collection and analysis of stories people tell about their experiences . The analysis of narratives is more than an examination of stories . Narrative analysis takes as its object of investigation the story itself, with the purpose of producin g a written interpretation of the story, allowing for systematic study of individual experience and meaning (Riessman, 1993). Meaning -making events are interpreted by the teller, then the analyst.
The women's personal accounts of their grief experiences were systematically studied using the linguistic approach developed by Gee (1985Gee ( , 1986Gee ( , 1991 and elaborated by Riessman (1993) . Gee is frequently cited by researchers across disciplines as an important resource for analyzing narratives .
Riessman presents a comprehensive approach to the study of narratives in her thoughtful , concise book, Narrative Analysis . Riessman (1993) emphasizes the need to be cautious in analyzing narratives stating "the challenge is to find ways of working with texts so the original narrator is not effaced, so she does not lose control over her words" (p. 34). Gee's (1985Gee's ( , 1986Gee's ( , 1991 approach was selected for this study because it keeps the analysis close to the participants' narration. There is no reordering of the telling or fragmentation of the text. Although this method is complex and time consuming , it captures the full richness of the narratives . 58 Gee (1985Gee ( , 1986Gee ( , 1991 draws on the oral tradition in sociolinguistics, and applies key principles of the English prosodic system, a system of stress and pitch, in the analysis of narratives. This approach focuses on how narratives are constructed and how different resources of language are used to create a form that carries meaning (Mishler, 1995). Changes in pitch , pauses , and other features that punctuate speech are analyzed. Textual coherence and structure are critical components of the analysis. According to Gee (1985) "the structure gives us some insight into possible meanings or ways of understanding the text" (p. 12). Riessman (1993) suggests beginning with a full transcription, a first draft of the entire interview that includes all striking features such as crying , long pauses, and laughing . This initial transcription needs to be carefully scrutinized several times to pick up the features of discourse before going to the next level.
Riessman also recommends that the researcher personally transcribe the text rather than delegating to a transcriber. Although transcription of interviews is a tedious and painstaking process, I transcribed my own interviews. Transcriptions are more than a technical procedure, are a critical part of the research process, and are also essential to the interpretive process (Riessman, 1993;Silverman, 1993).
Locating narratives in research interviews is often a complex interpretive process. "Where one chooses to begin and end a narrative can profoundly affect its shape and meaning" (Riessman, 1993, p. 18). The narratives embedded in the women's accounts were located through careful listening of the audiotapes and reading of the transcripts. Gee's (1986) discussion of the linguistic nature of narrative discourse was used as the primary guide for identifying the boundaries of narratives. According to Gee (1986), "spontaneous oral language, in any culture, bears some overt markers of its structure" (p. 393). Long pauses, changes in voice pitch, an increase in false starts and hesitations are usually indicators of the beginning of a narrative.
Once the boundaries of the narrative segments were chosen, the text was divided into lines, stanzas, and strophes. Each line is about one central idea or topic, and is much like what one would see as a sentence in writing. Each line is numbered and is made up of one or more idea units. Material that is said with a prominent pitch is capitalized, and the "main line" parts of the plot are underlined.
An idea unit contains a piece of new information and is characterized by a single pitch glide (falling, rising, rising-falling, or falling-rising) with the pitch in the rest of the unit leading up to or away from this disruption. The start of each idea unit is often signaled by a pause or slight hesitation and a change in the voice pitch.
Idea units, focuses, and lines are part of the structure of a text which cues interpretation (meaning, sense). Of course, how a text is said sets up inferences about meaning that go well beyond the actual structure of the text. (Gee, 1991, p. 23) 60 Lines pattern into larger units called stanzas. According to Gee ( 1991) "stanzas are a universal part of the human language production system for extended pieces of language" (p. 23). Each stanza captures a single "vignette" that is quite narrow in theme or topic. The lines sound as if they go together by tending to what is said and with little hesitation between lines. "Stanzas will have a unitary perspective, not just in terms of larger segments like time, location and character, but also in terms of a quite narrow topic or theme" (Gee, 1986, p. 403).
Stanzas often take on the properties of stanzas in poetry in terms of structure and patterning (Gee, 1985). "Stanzas organize the lines of the text while at the same time they constitute the internal structure of the sections" (Gee, 1986, p. 401).
Stanzas can be further grouped as larger units called strophes and parts.
Stanzas sometimes fall into related pairs, called strophes, which then fall into larger units called parts. The parts are the larger units that make up the story as a whole. The use of stanzas and strophes allows the researcher to analyze the coherence of a story.

Ethical Considerations
Since incarcerated populations are a particularly vulnerable group, the researcher must be extremely sensitive to issues of coercion, informed consent, and confidentiality. In addition, issues of loss and grief are very sensitive topics, requiring the researcher to be particularly aware of not causing harm or emotional distress in the research process. Key risks of harm in sensitive research include invasion of privacy, breach of confidentiality, and embarrassment (Lee & Renzetti, 1993). Assessing the participant's distress and/or fatigue during a sensitive interview must always be in the researcher's mind (Cowles, 1988;Kavanaugh & Ayres, 1998). Allowing for taking breaks , being flexible in postponing portions of the interviews and using process consent are strategies that can be used to minimize psychological distress (Cowles , 1988;Kavanaugh & Ayres, 1998).
Sharing stories of loss and grief could potentially be painful for participants. This issue was discussed with the Warden and clinical staff at the prison. The interviews were timed in such a fashion as to be certain that counselors were available. Therefore the interviews were scheduled during the week and daytime hours. In her research, Cowles ( 1988) noted that some of the interviewees experienced more nightmares and insomnia when interviews were conducted in the evening. Therefore , Cowles ( 1988) recommends that interviews be conducted during the day. Each participant had access to a counselor who was available at the request of the participant or researcher following the interview, if needed.
Because of the tight confinement in prisons, knowledge of who is participating in research studies is easily obtained. To ensure confidentiality, all interviews took place in a private office. Informed consent procedures must be explicit in how the participants are chosen, and must appraise potential participants that they will receive no legal benefits or special consideration from the parole board by participating in research (Maeve, 1998).

62
A certificate of confidentiality was obtained from the U.S. Department of Health and Human Services to relieve the researcher from any compulsory legal demands regarding the research. Specific exceptions to the communication of information with the correctional staff, such as suicidal ideation, homicidal intent, plan to escape, or unreported child abuse were clearly stated in the informed consent.
Due to the sensitive nature of the study, all transcribed tapes, notes, consent forms, and demographic sheets were secured in a locked box at the investigator's office. The listing of first names with assigned code numbers were recorded on a separate sheet filed in a locked drawer to which only the investigator has access. The signed consent form and identifying demographic data are kept separate from the rest of the study data. The interview was identified by a code number. The study records including the audiotapes and written notes will only be shared with a small number of colleagues. At the end of the research, all audiotapes and written notes will be kept in a locked cabinet in the researcher's office and destroyed after a reasonable length of time.
The nature of prison life endorses distrust among the women and staff (Maeve, 1998). Before the stady began, I focused on building relationships with inmates over a 3-month period of time. I cofacilitated a loss and grief group, coordinated and provided educational programs on health and pharmacological issues for the women, and facilitated the provision of programs such as a concert by a church choir, and a community response to providing current books for the women ' s library . These activities involved consistent contact with inmates in the hope of establishing relationships that foster mutual respect and trust.
The literature notes that participants can benefit from in-depth interviews (Hutchinson, Wilson, & Wilson, 1994). Sometimes participants experience a sense of relief in being able to express personal feelings, thoughts and problems as well as having their experience validated and acknowledged (Hutchinson et al., 1994;Mishler, 1986;Riessman, 1993). This may prove to be particularly meaningful for the women in prison who are often ignored , infantilized or given few, if any, choices . In sharing information, participants may feel a sense of purpose in contributing to others. At times, participants may feel empowered by telling their story or may gain a new perspective about themselves or their situations . Healing can occur as a result of the interaction and the ability to express one's feelings and thoughts in a context of mutual respect (Cowles, 1988;Hutchinson et al., 1994).

Trustworthiness
The research interviewer must be aware of and address controversial issues regarding the value or trustworthiness of interpretive research findings (Bailey, 1996;Kahn, 1993;Kvale, 1996;Lincoln & Guba, 1985;Sandelowski, 1986;Taylor & Bogdan, 1984). Assurance of quality in narrative analysis is accomplished by making the research process visible and allowing for systematic investigation (Bailey, 1996;Riessman, 1993;Sandelowski, 1991). "The findings must be presented so that fellow researchers and consumers may participate in the evaluation of the researcher's analysis" (Bailey,p. 192). The researcher must be consciously aware of her role in the entire research process (Kahn, 1993).

64
Many researchers have taken the position that the issue of quality or authenticity in qualitative research must be reconceptualized and is determined by a process of validation (Bailey, 1996;Eisner, 1981;Kvale , 1996;Van Manen, 1990). Validity comes to depend on the quality of craftsmanship during investigation, continually checking, questioning, and theoretically interpreting the findings (Kvale, 1983(Kvale, , 1996. The research findings are justified to the extent that the text "rings true" in its richness and depth, as well as the degree to which the researcher discusses with clarity and precision how the data was collected, interpreted, and analyzed. The interpretations made by the researcher must be faithful descriptions of the human experience that people have and describe. In the reporting of the research, the interview researcher must be able to communicate her/his findings in a manner that is inviting and compelling to the reader (Eisner, 1981;Kvale, 1996;Salner, 1989;Van Manen, 1990). According to K vale ( 1996), "the quality of the craftsmanship results in the products with knowledge claims that are so powerful and convincing in their own right that they, so to say, carry the validation with them, like a strong piece of art" (p. 252) .
When using in-depth interviews as a research method , the researcher must be aware of the potential for errors and/or misinterpretations . Human beings get tired, may exhibit selective perception, rely on their memory, and may not be clear about her/his presuppositions. Since knowledge development is dependent on the researcher ' s ability to listen empathetically , establish trust, be an expert in interpersonal relationships, the researcher must be aware of and address how she/he can influence the interview . The researcher, in particular, must be able to encourage story telling, allowing participants to articulate their story without interruption.
Numerous problems that can occur in the transcriptions of the research interviews must be addressed. Transcriptions depend on the quality of the recording and the skill and precision of the person typing the transcriptions. Some investigators choose to do their own transcriptions in order to secure the many details that are relevant to their specific analysis. However, transcribing interviews is tiresome and stressful and can lead to errors or misinterpretations .
One of the greatest criticisms of this method is that it depends on subjective impressions . The deliberate use of the subjective impression need not be negative (Kvale, 1996;Mishler, 1986). "It is the personal perspective of the subjects and the interpreter that can provide a distinctive and sensitive understanding of the phenomena" (Kvale , 1996, p. 291). The researcher strives to show, describe and interpret the meanings of an experience while remaining faithful to it.
In considering the potential problems that can impact on the trustworthiness of the researcher's work , a variety of checks and balances were used in this study . Reflective journals displaying the researcher's basis for making decisions, memos, talking through research findings with colleagues , going back to the source for verification of interpretations, and an independent audit were carried out (Kvale, 1996;Lincoln & Guba, 1985;Taylor & Bogdan, 1984).
For this study the original audiotapes and their transcripts were made available to the members of the dissertation committee. In addition, a qualitative nurse researcher skilled in narrative analysis using Gee's (1985Gee's ( , 1986Gee's ( , 1991 analytical approach served as a consultant and reviewed the transcripts, the analytical process, and the interpretation of data. The raw data (partial transcripts) and the interpretive process are displayed in the research report.
The researcher's interpretations were shared verbally with the participants throughout the research process. The reactions of the participants are summarized and included in the research report. An anonymous follow-up short self-report questionnaire was given to each woman to complete once the interview process was accomplished, to obtain feedback regarding their response to this interview process (Appendix E). Finally, the doctoral committee served to establish a degree of consensus for this study.

Human Subjects
The Confidentiality Certificate from the Department of Health and Human Services was obtained on June 16, 1999. Approval from the Institutional Review Board on Human Subjects for Phase One was obtained on May 27, 1999. The Consent Form for Research approved on this date was the consent form used for data collection in Phase One.

Results
The results of this study are interpretations of the meanings of the grief experience of women in prison who experienced the death of a significant person during incarceration . The data were collected through in-depth interviews . The purpose of the analysis was to address the following research questions: 1. What are the meanings of the grief experience of incarcerated women? 2. How does the grieving process compare with images of grief depicted as a normal process?
3. To what extent do the women perceive incarceration influencing their grieving process?
The study sample was comprised of three participants, who have been given fictitious names. Each participant's interview was analyzed separately using a three-step analysis based on Kvale's (1996) approach to the interpretation of interviews. The complete transcription of each interview was initially treated as a whole and read several times to establish the meanings in three contexts: selfunderstanding , common sense understanding, and theoretical understanding . In addition, for a detailed account of theoretical understanding, narrative analysis was incorporated. The combination of these analytical approaches was used to provide a comprehensive understanding of the grief experience of these women.

First Participant-Mary
Mary is a 35-year-old Baptist, Caucasian widow who completed her general equivalency diploma while in prison. She has three children, ages 9, 11, and 15, currently living with her sister and her family . Mary has three other younger siblings who are living out of state and with whom she has minimal contact. She grew up in a difficult family situation. Her father had a serious machinist injury when she was 5 years old. He came home a changed man after 2 years of hospitalizations . Her father abused Mary when she was 7 or 8 years 68 old. When Mary was 11 years old, her mother abandoned the family. One day she went to work and never returned. She had no contact with her children until they became adults. Her father remarried, and Mary's stepmother also was abusive.
Like her two older sisters, Mary was anxious to leave home and married quite young . She was in an abusive marital relationship for 13 years and had three children. When Mary left her husband, he took their three children and disappeared. After a long and unsuccessful search, she became despondent, turned to alcohol and drugs to ease her torment, leading to her current and only incarceration . She has been in prison for nearly 3 ½ years. Her husband returned with the children after she was in prison and committed suicide 2 years ago. Ten months ago, Mary's oldest sister died of cancer at the age of 37. Mary participated in a grief group that I facilitated two months prior to my interview with her.

Self-understanding
The following statements have been extrapolated from the interview to reveal Mary's understanding of the meaning of her grief experience related to her sister's death.

Critical Commonsense Understanding
The following interpretation goes beyond Mary's self-understanding and includes a more critical interpretation by the researcher of either the content of what is said or of Mary.
The major impression gained from this interview is the strength and perseverance of Mary throughout a very difficult life, the importance of maintaining a strong connection with her deceased sister , and the change from a passive woman to a more assertive one. She is a woman who has tried to make the most of the resources of the prison to become educated , develop more positive parenting skills and, in essence, transform her life. To be with her is to be inspired by witnessing the ability of this woman to change in such a dramatic way despite an impoverished history .
Mary is very engaged throughout the interview , stating that she appreciates the opportunity to speak, particularly to someone who is not affiliated with the prison. She is an active participant and hopes that by telling her story, other women will be helped in the future. Mary began the interview by describing how she was told of her sister's death and her anger at her family for withholding information about her sister's decline in order to protect her. She was grateful to have her counselor with her when she received news of her sister's death on the telephone . Although she states that she did not realize that her sister was so ill, she also states that a part of her knew that something was wrong . Perhaps it was just too painful for her to accept the possibility that her primary support person was seriously ill.
When she went to the funeral home, she could not believe that this was her sister in the casket. Despite recognizable family photos around the casket, her sister's dramatic emaciated and aged physical state was striking. Mary was in a state of shock. She was alone, shackled and handcuffed when she went to the funeral home, without the support of her family. She describes the kindness of the two officers who accompanied her.
When she returned to the prison, Mary remained in acute distress for 3 days. The officers released her from her work detail for that period of time. The intensity of her response interfered with her daily routine. After 3 days, Mary convinced herself that she needed to become motivated . She used images of her children and "self talk" as a vehicle to help her cope and return to her routine schedule.
Mary takes pride in having accessed the resources that the prison has to offer. She appreciates and actively participates in groups and receives both individual and drug counseling. She uses prayer, yoga, meditation, reading, and other methods of distraction to help her cope with her grief and with being in pnson. She has contact with a religious sister weekly who supports her spiritual journey. She struggles with her faith, trying to rely on her God for strength yet also questioning God's hand in her painful losses. Maintaining a connection with her deceased sister is a source of great comfort for Mary . Almost on a daily basis she speaks to her sister, looking for the inner peace experienced by her sister. Her feelings of loss are particularly difficult when she feels sad or smothered by prison life. She yearns for the closeness , the support, and the encouragement that she once received from her sister.
Almost 1 year later, she continues to experience grief as an oscillating process, but now is able to remember the good times and feels less angry with God. Only when she is able to go to the gravesite will Mary be able to fully accept the reality of her sister's death . For her, being in prison forces a sense of unreality in this experience . Life is suspended , or as she states "put on hold ." Mary goes into great detail describing the difficulty of experiencing a major significant loss while in prison. Family support is minimally available. A fac;:ade of toughness needs to be maintained. Feelings of sadness and particularly anger cannot be expressed due to the fear of being disciplined. Although she describes some officers as supportive and compassionate , she graphically describes the personal degradation that often occurs by many officers who use their authority to ridicule the women, treating them without dignity or respect.
Their ruling hand is strongly felt as many officers use their power, adapting set rules for their convenience. Mary takes pride in now becoming an advocate for other women, in being a voice for others, and trying to make changes that will have a positive impact in the future.
As is often the case with grief, Mary visits other losses that she has experienced in the past. She describes at great length her life prior to her imprisonment: an abusive childhood, abandonment by her nfot}:ler, an abusive spouse, the disappearance of her children, and the death of her husband . Unlike the situation with her sister, Mary was informed of her husband's death in a factual, distant, and nonsupportive manner, which led to hysteria and shock. Her deep anger for her husband remains.

75
Mary recognizes that life following imprisonment will be a major adjustment. She has a limited support system and has lost contact with many of her friends . Although her father and mother are still alive, so much pain and unfinished business remains. Her anxiety and concerns about discharge are felt as she explores the challenges that will confront her. As is sometimes the case with women in prison, her children are a strong motivating force for her to make the most of her prison time.

Theoretical Understanding
This level of interpretation goes beyond self-understanding and also exceeds critical commonsense understanding. Statements are interpreted within a theoretical context. This level of analysis includes interpretations from reading the text as a whole followed by interpretations using narrative analysis Holistic analysis. The holistic reading of this interview indicates Mary's grieving experience (related to her sister) as moving from shock of the realization of her sister's death to the initial responses of sadness and withdrawal. These initial reactions were followed by attempts to return to some level of functioning, oscillating between feeling the pain of grief and focusing on her daily routine .
Almost a year later, she is still actively grieving, recognizing the full impact of her sister's death will not occur until she is released from prison. The first story , which is related to the death of her sister, has been extracted from the interview for narrative analysis . The analysis of poetic structures described by Gee ( 1986Gee ( , 1991  1 first of all/I didn't know THAT SHE WAS SICK 2 nobody was telling me 3 cause they wanted to protect me 4 cause I was in jail Stanza 2 (lack of preparation) 5 but it DIDN'T HELP 6 found out a week before she passed away that she was dying of cancer 7 so I didn't get time to/THEY ALL PREPARED THEMSELVES 8 they knew she was dying · Stanza 3 (finding out) 9 she was in the hospital the last 3 months and they told me 10 WHEN I FOUND OUT it was like 6 months 11 6 months before she passed away that she was really sick 12 but then THEY TOLD ME THREE MONTHS before she passed away that she was IN REMISSION 13 but she wasn't 14 she was in the hospital Stanza 4 (feeling cheated) 15 they thought they were protecting me 16 but it doesn't protect you 17 cause they had all the time TO PREPARE THEMSEL YES 18 and I DIDN'T HAVE NONE OF THAT TIME Stanza 5 (telephone conversation) 19 all of a sudden I talked to her on the phone Friday 20 and she was gone Monday This initial part of the story emphasizes the damage of concealing information from a family member. Even though her family thought that they were protecting Mary, in fact, concealment has only added to her emotional pain.
Therefore, her sister's death comes as an unexpected event. One year later, Mary continues to experience intense grief at times, but 96 also begins to remember the good times as well as the bad times. She tries to come to terms with her God and now takes responsibility for avoiding dealing with her sister's serious physical decline. As a result she is less angry with her family, viewing the concealment with a different lens. Her reconnection with her spirituality is a source of strength and comfort.

Summary
Based on this three-step analysis of Mary's interview, the acuity of her grief is still quite apparent although Mary's sister died almost I year ago. The freshness of grief is strongly felt as Mary tells her story . Since Mary's sister was the one person she turned to in times of need, it can be expected that her grief will be difficult given the meaning of this loss (Parkes, 1993). Mary's need to maintain a relationship with her sister rather than sever bonds brings her comfort and solace (Silverman & Klass, 1996).
Although she is able to remember good times from the past, the yearning for her sister's return is also present. Since Mary experienced her sister's death as sudden and unexpected, it is more difficult to prepare and absorb the reality of the loss gradually over time . This often leads to a more difficult bereavement (Rando, 1984;Schneider, 1994).
Mary's initial manifestations of grief are expected given the context of the relationship and the unexpected nature of the death (Rando, 1985;Schneider, 1994 ). She returns from the funeral home in shock, withdrawing from others, not eating and having difficulty focusing. The pangs of grief as described by Parkes (1972;Parkes & Weiss, 1983) are evident as Mary describes quite vividly her deep sorrow, restlessness, and persistent yearning for her sister. It takes her 3 weeks and a great deal of self talk before she can return to her prison routine. Her children are a strong motivating force for mobilizing herself. The waxing and waning discussed by Stroebe and Schut ( 1999) is described by Mary as she oscillates between being immersed in her sorrow and trying to get motivated. Her grief is easily triggered even 1 year later and she continues to experience manifestations of acute grief.

100
The context of the prison does not allow Mary to participate in important healing rituals within the context of what Mary believes to be a loving social support. Although Mary describes the prison officers as kind and supportive immediately after her sister's death, the portrayal of the correctional officers shifts . Mary readily verbalizes the constraints of prison life in being able to express sadness and anger. In fact, this part of her story is shared with much greater emphasis in voice and a contrasting change in affect than the beginning of the story. One senses the degradation of the women by many of the correctional officers with the pressure "to be tough" regardless of their internal suffering. This finding is consistent with the work ofToch (1992) who describes that inmates may have great difficulty managing both grief and the prison environment.
Mary's resourcefulness is a strength that she brings to this situation. Her spirituality, her ability to make use of mental health services including a counselor and groups provide important avenues for dealing with this major loss. Her increased sensitivity towards others and her determination to make a difference in the prison before she leaves resonates with Schneider's (1994) discussion of grief as having the potential to be a growth-producing experience.

Second Participant-Barbara
Barbara is a 40-year-old single , Baptist, African American woman who completed high school and 2 years of college education on a basketball scholarship. She has two sisters, one younger and one older, whom she has little contact with at this time. Her father died when she was quite young. Barbara's mother raised her three daughters by herself and never remarried. Barbara began using drugs when she was in college and struggled with substance abuse for years. This is her third incarceration. Barbara's mother died 10 months prior to this interview, 1 year and 5 months after she began this period of imprisonment.

Self-understanding
The following statements have been extrapolated from the interview to reveal Barbara's understanding of her grief experience related to her mother's death.

Critical Commonsense
The following interpretation goes beyond Barbara's self-understanding and includes a more critical interpretation by the researcher of either the content of what is said or of Barbara.
The major impression gained from this interview is the deep regret, guilt and loneliness that Barbara continues to feel 10 months after the death of her mother. During the interview Barbara began by intentionally going back to 1995 as the beginning point of her story . It is important to her that the context of the relationship with her mother be established before she begins to discuss her mother's death. She clearly wants to communicate how close she was with her mother and how her mother had continued to love and forgive her despite numerous incarcerations. It is also important to Barbara that her attempts at caring for her mother during her illness are acknowledged and that she be recognized as a caring and loving daughter. The feelings of deep regret and persistent guilt are major themes. Barbara has little eye contact throughout the interview until the very end, continually looking down with a thoughtful and sad affect. Periodically she looks at me as if to see ifl am really interested in what she has to say . She also makes the point of describing her mother's experience, both negative and positive, of being Black in White America and her own positi ve experiences with a White family . In so doing, she seemed to be trying to reassure me that race was not a barrier to our communication . At the end of the interview she expresses her appreciation for being able to tell her story, to share her pain . Barbara begins the interview by reviewing her past, how her mother raised three children on her own and how Barbara at the young age of 13 began to work to help her mother. She had the opportunity to go to college out of state on a basketball scholarship. This was a major event in the family's life, particularly for her mother who had great hopes that Barbara would succeed. However, her two sisters were envious and resented the closeness that existed between Barbara and her mother . During these college years, Barbara began using drugs and gambling which eventually led to numerous incarcerations and the destruction of everything for which she had worked. Barbara made several but failed attempts to become clean . Throughout it all her mother continued to love and forgive her. It appears that she was the only person in Barbara's life that did not abandon her despite her repeated failures .
Barbara describes in great length how well she tried to care for her mother when she became quite ill. The strain of caregiving and the anger at her two sisters for their lack of support during this difficult time comes through in her story. Barbara was also her mother's major support person when her own mother died .
Barbara recalls with detail the day that her sister came to the prison to tell her about her mother's death . She reacted with shock, numbness, and disbelief.
She was out of control, screaming and uncontrollably crying, looking up at the chapel ceiling asking God why . As she heard the details of her mother's death, the thought of her dying alone became a fixed image in her mind, an image, which continues to torment her.
Barbara goes on to describe her visit to the funeral home . The humiliation and degradation of having to go in handcuffs and shackles as well as the pain of being there alone without support is quite apparent. The inability to participate in planning the funeral or attending the funeral adds to the loneliness of grief that was felt by Barbara. Although there has been great tension in the family in the past, Barbara believes that sharing this major loss with them would be healing and brings her comfort .
The first 3 months following her mother's death were extremely difficult for Barbara. Through it all Barbara maintained a fac;ade, fearing that if she expressed her sadness or anger, she would be medicated or disciplined. The loneliness of her grief continues, as she feels unable to share her pain with anyone.
Although she describes herself as feeling more at peace with her mother's death she also acknowledges that the full impact of her mother's death will not occur until she is released and is able to go to the gravesite.

Theoretical Understanding
This level of interpretation goes beyond self-understanding and also exceeds critical commonsense understanding . Statements are interpreted within a theoretical context. This level of analysis includes interpretations from reading the text as a whole followed by interpretations using narrative analysis.
Holistic analysis. The holistic reading of this interview indicates Barbara's grief experience as moving from the shock of the realization of her mother's death when informed by her sister to the initial responses of withdrawal, loss of appetite, insomnia , rumination and guilt. Barbara intentionally maintains a fac;ade of toughness and feels totally alone in her grief. The freshness of her grief is still present. She acknowledges the full impact of this loss will not occur until she is released from prison and able to go to the gravesite . Narrative analysis . There is one very lengthy narrative in this interview.
The portion of the narrative which focuses on her grief experience and the influence of the prison on her experience has been extracted for narrative analysis.
The analysis of poetic structures reveals piercing accounts of Barbara's intense emotional struggle in attempting to deal with her mother's death. The prison as a barrier to grieving also comes through in great detail.

Part 1 Hearing The News
Strophe 1 The Telling Stanza 1 ( sister calling) 1 you know um well anyway the captain/WHOEVER MY SISTER SPOKE TO whatever 2 she came up around 9:30 3 so she might have called that morning 4 night whatever , fine Stanza 2 (sister coming) 5 but by the time she came up 6 they were in agreements 7 to not do it the way I know normally to be done 8 you know, uh, they THEY LET HER COME UP Stanza 3 ( off the job) 9 and they took me off MY JOB 10 and they um took me in THE CHAPEL 11 to um,um  Stanza 13 ( over it and over it) 55 and they let us stay and talk for a while 56 and then you know/I just went over it and over it and over it 57 the same thing in my head 58 and asked WHY WHY WHY In this part of the narrative Barbara describes how her sister told her about her mother's death and her initial responses of shock, disbelief, and out of control behavior. The intensity of her pain is felt in stanza 10, with Barbara crying and using long pauses, Barbara is obviously in acute distress.  Barbara's feeling of humiliation, degradation, and the pain of going to the funeral home alone is poignantly expressed. Barbara begins this part crying through stanza 22 as she sets the stage for her experience of going to the funeral home . The depth of her pain emerges. Stanza 27 is filled with sobbing, indicative of the humiliation she feels being dressed in prison garb with her mother watching over her. The changes in her voice repeatedly emphasize her distress in going to say her last good -byes to her mother in shackles and in handcuffs. Barbara's helplessness and powerlessness is particularly expressed in stanza 24 as she continues to describe her inability to help her mother.  In this part Barbara reviews her experience of returning to the prison following the visit to the funeral home. Although she acknowledges her sister in stanza 54, she is angry with her and feels abandoned by her. Her yearning for family support is emphasized. She once again struggles with the circumstances of her mother's death, how she let her mother down, and now how she is being let down by her family. The meaning and strength of the connection between Barbara and her mother is highlighted in this part of the narrative. She sobs throughout stanzas 58, 64 and 65. Her mother was the one person who was always there for Barbara, regardless of her failures. Barbara acknowledges her struggle in trying to let her mother go but returns to the harsh reality that her mother was her one and only support .
Stanza 66 (women's grief) 277 women lose a lot Part 6 Grieving in Prison 278 guys camouflage and they suffer/I'm not saying a woman's grief IS WORSE than a guys 279 a woman's grieving is more emotional because THEY'RE NOT AFRAID TO CRY 280 they're NOT AFRAID TO BE HELD AND HUGGED 281 they don't that think it's less than/in all actuality A TEAR IS COMFORTING 282 a shout, or a cr:y/OR to scream out your pain or anger IS EVEN BETTER Barbara begins to describe her grief experience following her return to prison: withdrawal, emptiness, crying, feeling like a zombie yet trying to be strong and deal with the routine of daily prison life. She tries to maintain control and acknowledges that she would readily be overwhelmed if she allowed the full impact of her mother's loss to surface. She shares the importance of maintaining a connection with her mother even now and describes the pain of being invalidated by the other women. She uses the metaphor of women needing comfort when she is really referring to her own need to be held and consoled. In this part the anger that she feels towards her sister is expressed . To some extent she blames her sister for not being home and also for her mother's death. It appears that her mother was trying to reconcile her relationship with her daughter. The intense sorrow that Barbara has for her mother , who died alone, is once again expressed. She is described as a woman who was always there for other people and so her dying alone particularly seems unjust. at God, rumination , difficulty accepting the reality of the death of her mother, and the need for others to push her in order for her to function. She tries to cope through prayer and meditation but her pain is easily triggered by how other women respond to their own mothers. The loneliness of grief is accentuated by the absence of support and validation from the other women and the officers . She employs the metaphors of sympathy cards and leaves of absences to illustrate the differences between grieving as an inmate and grieving as an officer. The fear of discipline poses another barrier for Barbara to express her grief . In addition, the women are constantly having to adjust to the different officers and how they choose to enforce the rules. There is a lack of consistency that adds to the stress of trying to cope . Barbara's helplessness and powerlessness is strongly felt . throughout this part of her narrative. She races through most of the stanzas and remarkably slows down when she speaks about wanting the death of her mother to be untrue. The change of pace in her voice is quite striking once again emphasizing the meaning of this relationship and the difficulty Barbara continues to have in accepting this death . wasn't home 539 and I said WHAT'S WRONG WITH YOU 540 why weren't you home with the kids for the week or Mother's day 541 well she had made an arrangement for her kids to be with her son and his children 542 because it WAS HARD FOR HER TOO Family holidays are significant marker events that become even more magnified in prison. For Barbara, they serve as reminders of the loss of family in her life, particularly her mother. Although she had a strained relationship with her family, Barbara continues to yearn for contact and support from them which is only minimally given by telephone.

Summary
Based on this three-step analysis of Barbara's interview, the acuity of her grief is still apparent. Since her mother was her main support person, her best friend, it can be expected that her grief will be more intensified (Parkes, 1993 ).
Barbara's need to maintain a strong connection with her mother, to feel her presence is essential to her (Silverman & Klass, 1996). Although she is struggling to make peace with the fact that her mother is no longer in pain, the circumstances of her death while Barbara was incarcerated continues to haunt her. Her persistent guilt may add to a more difficult bereavement (Rando, 1984;Schneider, 1994).
Barbara's initial manifestations of grief are expected given the relationship with her mother and the suddenness of her death (Rando, 1984;Schneider, 1994).
She reacts with shock, disbelief and becomes out of control. Although she is able to go to the funeral home, the humiliation, and degradation of going as a prisoner and being without family seems to erase the benefit of the viewing for her.
Barbara describes how difficult the first several months were for her or as she states "3 months of agony." She experienced what is normally seen in acute grief: sadness, disbelief, loss of appetite, difficulty sleeping , rumination, difficulty concentrating, anger at God and her family (Rando, 1984;Schneider, 1994 ). She also states that she is aware of the danger ofreally being in touch with her pain and works hard at disengaging from it when she can. She acknowledges that the full impact of the reality of the loss will not occur until she is released from prison and can go to the gravesite. She yearns for and lacks family support, experiencing the loneliness of grief intensely. The lack of validation from family, other inmates, and staff adds to the burden of her grief.

138
The context of the prison is another barrier to Barbara ' s grieving process.
She fears being disciplined if her true feelings are expressed. However, it is important to note that in Barbara's situation the threat of security is of concern due to her physical size and her apparent history of being out of control. Security is the priority in the prison environment and the mental health of the women is secondary (Toch , 1992).
Barbara ' s emphasis on the need to have a photograph of her mother and her belief that this would be a source of healing and support for her must be underscored . She returns to this issue numerous times in her narrative and, in fact, ends with that same theme. She expresses gratitude for having the opportunity to tell her story , to express her feelings, to be acknowledged , and hopes that she, in tum, can help another (Hutchinson et al., 1994;Mishler, 1986;Riessman , 1993 ).

Third Participant-Christine
Christine is a 28-year-old single woman of Native American descent with Baptist and Catholic religious backgrounds. She completed eleventh grade with special education. She had three children, one age 10 and twins age 9, whom she placed for adoption. She has an older brother and a younger sister with whom she has minimal contact. At the age of 2 her father died . Her mother was 19 at the time and left with three children. Subsequently, her grandparents raised her. At the age of 12, Christine returned to her mother's home for a short period of time and then returned once again to her grandparents following serious abuse by her stepfather, and after a series of placements in group homes. Christine had difficulty with school and describes poor impulse control and frequent truancy. At the age of 18 Christine had her first child followed by the birth of twins 2 years later. Christine has been incarcerated three times. Her grandfather died in a nursing home 1 month prior to this interview, and 1 year and 1 month after her imprisonment.

Self-understanding
The following statements have been extrapolated from the interview to reveal Christine's understanding of her grief experience related to the death of her grandfather.

Critical Commonsense Understanding
The following interpretation goes beyond Christine's self-understanding and includes a more critical interpretation by the researcher of either the content of what is said or of Christine.
The major impression gained from this interview is the acuity of Christine's grief, her fear of losing control, her aloneness, and longstanding issues of loss and abandonment. During the interview Christine begins by describing the way that she was told about her grandfather's death. He had been in a nursing home for 6 months, slowly deteriorating. His continued decline was kept from her and so the news of his death came as a shock. She was alone when the correctional officer informed her of his death. Although she was allowed to call her grandmother, her aloneness in this situation is once again striking .
When she went to the funeral home the following day, the reality of her grandfather's death was acutely felt and her fears of abandonment triggered . Like the other two women, Christine was shackled, handcuffed, and accompanied by two officers.
When she returned to the prison, Christine was in severe distress for several weeks, unable to function and needed to be medicated . Although she describes withdrawal from emotional pain as a familiar coping style, her inability to function is striking.
Christine speaks of her grief with emotional distance. It is as if she is telling a story about someone else. This presentation is markedly different from last week when I saw her prior to physician intervention. At that time she was sobbing, highly anxious, and extremely agitated. It is possible that the change in her presentation is a result of pharmacological intervention.
Like the other two women, Christine describes the fear of expressing anger or as she states "going off' because of the consequence, discipline, and isolation.
It is better not to feel, to maintain the routine than to be in touch with the pain that accompanies grief. Except for the safety net provided in individual counseling, there is no place that Christine feels safe enough to express her deepest sorrow or anger. She resorts to "sleeping" and staying in bed which had been allowed for her as the way to protect herself. The threat of isolation on the disciplinary wing is a strong motivator for staying in what appears to be self-control.
Christine takes pride in how she has handled this situation and in not losing control. Although she states many of the staff are supportive, she also identifies that access to mental health care is difficult. The process of accessing a counselor may take a week or more. The support that she has had from the counseling staff is in sharp contrast to the lack of support from her family. Telephone contact with her grandmother is painful and a visit with her impossible. Although she describes her grandmother as "her champ" she does not want her grandmother to visit her in prison "because of what they have to go through when they first come." As is often the case with grief, one significant loss may trigger past losses .
The death of her grandfather came as a crisis point, which triggered memories of the death of her father and the loss of her children . She has created a loving image of her father even though he died when she was quite young. Her story of her relationship with him is embellished with fond memoirs and closeness.
The loss associated with the placement of her three children to foster care and, subsequently, allowing them to be adopted is also revisited. She expresses pride in herself in making this difficult decision and belie ves that it was a good choice that she made on her children's behalf. She has hopes of seeing them when they are grown and fears that they will think that she abandoned them.
The context of Christine's past describes an emotionally fragile woman who has endured a great deal of emotional pain and struggle in her life . She is a survivor , a woman who has experienced an early childhood loss, chaotic family life, physical and sexual abuse, multiple arrests, and periods of incarceration .

Theoretical Understanding
This level of interpretation goes beyond self-understanding and also exceeds critical commonsense understanding. Statements are interpreted within a theoretical context. This level of analysis includes interpretations from reading the text as a whole followed by interpretations using narrative analysis.
Holistic analysis. The holistic reading indicates Christine ' s grieving experience as moving from shock of the painful realization of the death of her grandfather as encountered at the funeral home, to the initial responses of depression , withdrawal, loneliness, and fear of abandonment. These initial reactions were followed by a resolve to stay in control in order to avoid disciplinary action, and to maintain the minimal support that she was receiving on her wing. The current loss ignites her memories of the death of her father, the loss of her three children , and the fear of losing her only remaining source of support, her grandmother. Narrative analysis. Four narrati ves are embedded in this interview. It is interesting to note that all of the narrati ves are related to her relationships with her family. The first narrative is related to the death of her grandfather followed by narratives of her relationships with her father, her grandmother, and her children .  routine, she will be removed from the wing, from the minimal support that she is receiving from the staff and the other women. This threat is a strong motivator to be in control and push aside any feelings that normally accompany grief. The minimal support that she receives from friends is underscored as well as the importance of keeping in contact with family.

Summary
The grief experience based on this three step analysis indicates an expected initial response of shock and disbelief given the meaning of Christine's relationship with her grandfather and his sudden, unexpected death (Rando, 1984;Schneider, 1994). Her relationship with her grandfather and grandmother represented a safe place in her life. Since we rely on our assumptive world to keep us safe, a person feels very unsafe when this world is challenged (Neimeyer, 1998;Parkes, 1972).
Christine's manifestations of grief are an exaggeration of what would normally be expected . Insomnia, appetite disturbance, anergia , despair, and withdrawal from others are certainly seen in the very early period of acute grief (Parkes, 1972;Rando, 1984;Schneider , 1994). However , her total inability to function for a 2-week period, requiring pharmacological intervention is striking.
Given the meaning of the loss, her past coping style, and her long history of abandonment issues, it is not surprising that she is having such difficulty. The most significant meaning of the loss to Christine is abandonment which becomes associated with possible, impending abandonment.

Cross Case Analysis
Several similar issues emerged from the narratives of each of these women .
All three women shared their experiences of being given the news, going to the funeral home alone, an acute grief response upon return to the prison and the influence of their incarceration on their grief experience All of the women make reference to how the news is delivered and note the importance of having family contact around the delivery of the news . The experience and humiliation of going to the funeral home alone , in shackles and in handcuffs is noted by all three women but particularly captured in Barbara's piercing account. She vividly describes the humiliation and the degradation of going to view a loved one in prison attire . Barbara is the only woman who does not feel supported by the two officers who have accompanied her. All three women exhibit acute distress which is intensified by their experience of being without family support at the funeral home.
All three women describe the return to prison as stressful needing to stay in control and maintain prison routine . Christine needs medication to deal with her acute symptoms and Barbara is committed to avoiding being medicated, if at all possible. Although Mary and Christine have received some support by several of the other inmates and the correctional staff, it is short lived.
The three women present quite differently in telling their stories. Mary is very engaged from the beginning, which is most likely related to her feelings of comfort with me and trust based on her experience in the grief group that I facilitated. The process of meaning making quickly comes to the foreground in Mary's account. When she reaches the end of her story, she accepts responsibility for knowing about her sister's decline, but not wanting to accept it. In so doing, she can forgive her family for what she initially claimed to be concealment. The skunk becomes a metaphor for communication with her sister and her attempts to maintain a bond but to also let her go.
Barbara has a distinct need to tell her story within a broader life context.
She wants and needs to be seen as a loving and devoted daughter and continues to struggle throughout the interview with her failure to save her mother. She is haunted by the circumstances of her mother's death and is unable to move much beyond her guilt. Unlike Mary, she is disconnected emotionally from her family and basically grieves totally alone. Her fayade keeps her distant from the real pain that lies just below the surface . It is difficult to know how supportive her family really would be even if she were not imprisoned . Although she continues to yearn and express the need for family support, her family relationships have been strained over time . Even now, they have failed to support her minimal requests, for a picture of her mother and for a visit.
Christine's narrative is brief in comparison to those of Mary and Barbara .
She is also the only woman who tells her story with emotional detachment. This may be attributed to her medicated state in light of the extreme difficulties she had coping with this death.

CHAPTER V Summary and Conclusions
This study explored the grief experience of women who were incarcerated at the time the death of a significant person occurred. The focus of the study was to gain an understanding of this human experience through in-depth interviews encouraging the women to talk about their experiences from their own perspectives. Additionally, the study was to contribute to an understanding of the grief experience within the context of the prison environment.
A two-phase qualitative research study was undertaken to explore the grief experience of three Engl_ ish-speaking women in a medium security facility in New England. Phase One consisted of in-depth guided interviews, which lasted 1 1/2-2 1/4 hours. One woman was interviewed twice. This approach to interviewing encouraged the women to take an active role in the interview process and facilitated storytelling. I personally transcribed each interview, which is a critical part of the research process and also essential to the interpretive process.
The full transcriptions included all striking features such as crying, long pauses, and laughing. Each interview was completed and transcribed before proceeding to the next participant.
In Phase Two, the audiotaped and transcribed interviews were analyzed using K vale 's ( 1983; 1996) approach to the hermeneutical interpretation of interviews, combined with Gee's (1985Gee's ( , 1986Gee's ( , 1991 and Riessman's (1993) approaches to narrative analysis. The entire study spanned a period of 14 months. In the initial phase, the three women experienced shock and disbelief, but these responses were accentuated by the manner in which the news of the death was given to them, combined with their experience of going to the funeral homes.
In addition, it is interesting to note despite the fact that all three deceased relatives had serious illnesses, their deaths came as unexpected events followed by complete shock. Since imprisonment keeps the women from being in physical contact with their loved ones during their deterioration , they are often unable to anticipate their deaths. Therefore, the shock is heightened, raising the possbility for a more difficult bereavement (Rando, 1984;Schneider , 1994 ).
The following intermittent period of acute distress was rather unstable and complicated by imprisonment. All three women experienced acute grief upon return from the funeral home visit. The manifestations of their grief are consistent with conceptualizations of grief in the literature (Lindemann, 1944;Parkes, 1972Parkes, , 1983Rando, 1984;Schneider, 1989Schneider, , 1994Worden, 1982Worden, , 1991, but were contained within a 2-3 week period of time. Mary and Barbara forced themselves to return to their prison routine, while Christine needed pharmacological intervention to help her cope . It is important to note the freshness of Mary's and Barbara's grief during the interview, despite the length of time since the death of their loved ones . All three women discussed their need to maintain a bond, a connection with their deceased loved ones which brings comfort to them. This finding supports the work of Neimeyer (1998) , Silverman and Klass (1996), and Stroebe and Schut ( 1999) who assert that continuing bonds may be a healthy part of the ongoing life of the bereaved.
All three women described in detail the fear of expressing any of their feelings, particularly anger, because of the threat of disciplinary action . In fact, Barbara and Christine both state that it is better not to feel , to maintain control than to be in touch with the pain that accompanies grief , because of the constraints of prison life. All three highlighted their fear of discipline if any of their true feelings are expressed. The fear of isolation served as a strong motivator to stay in control. It is clear the context of the prison added to their pain and led to the suspension of their grieving process . Mary and Barbara graphically described their grieving process as being "suspended" stating the full reality of their loss will not be realized until they are out in the free world, when they can go to the gravesites, and express their deepest sadness and anger without fear of retaliation.
In each of these cases, the women did not have the opportunity to participate in the celebration of important public rituals . Participation in postdeath rituals provides a context within which the loss is shared. The lack of participation in rituals or rites of passage led to further isolation and disconnection from their communities. Although the women were able to go to the funeral homes and view their loved ones, it occurred alone without the presence of family, close friends, or a support person such as a counselor.
Mary and Christine note they received support from the correctional officers at the funeral home and immediately upon return to the prison from staff and other inmates. However, this support was short lived . Situationally available support, not necessarily from close family members and friends, seems to help individuals cope with the suffering that accompanies grief by affirming the individual, offering strength and nurturance, and providing a safe place to express emotions and have one's experience validated. When sufficient support is not available, detachment and suppression of feelings is often necessary, but the consequences may be so severe that complicated berea vement may result needing professional intervention (Rando, 1993;Schneider, 1994).
Women in prison are also unable to access other resources that are helpful to individuals in the grieving process. The opportunity to choose to be with individuals who are nurturing and to find creative outlets for dealing with painful feelings such as exercise, art, music, distraction, or even prayer groups are limited at best. Small gestures such as receiving flowers are not possible . An additional complicating factor is the lack of privacy. There is no place for the women to be alone with their thoughts and with their tears. Journaling, an important vehicle for expressing painful emotions, is prohibited because of the fear of raids that occur on the wings . A private place to cry or even the freedom to rest quietly and relax is unavailable.
Given the numerous constraints imposed by incarceration, the women appeared to suspend their grief. They were unable to express their feelings, have their grief experiences validated, or employ a variety of coping strategies that are available to people outside of the prison environment. Prison life is experienced as another world, a "temporary" life, which may be a barrier for processing and integrating grief.
In summary, grief can be described as a long, arduous process in which individuals move back and forth confronting the reality of the loss, processing the loss, and experiencing a range of emotional reactions. Grief in relation to the death of a loved one is experienced in the full context of one's life, past and present, not as a separate incident. It is interpreted by each person in the context of that life.
Women in prison have limited opportunity to grieve , have their grief openly acknowledged, publicly mourned , or socially supported. Therefore, it can be described as disenfranchised (Corr , 1998-99;Doka, 1989;Rando, 1993;Schneider, 1994). Disenfranchised grief can create additional problems for the griever, leading to a more complicated bereavement (Doka, 1989;Rando, 1993;Schneider, 1994). When a mourner's perceived needs for support are not met, a more difficult bereavement can be expected (Rando, 1993). Grieving in prison is suspended, felt in isolation and decontextualized . Although the women's grief is deeply felt, it is not connected to their everyday lives. They grieve in isolation, lacking the opportunity to be with others who also share their grief and share their memories. Therefore, these women are unable to integrate their grief in the fabric of their daily lives. The major issue in this context may be the suspension of grief.
The grieving process is constrained and becomes contained by self-control for fear of punishment. The tendency is to idealize what would have been if not incarcerated. In light of the numerous adjustments that these women need to make upon their release from prison, disenfranchised grief can have serious impact on their ability to cope and successfully adapt to the multiple challenges that confront them.

Methodological Implications
The methodological approach of this study provided a meaningful way to systematically study the grief experience of women in prison and begin to obtain a deeper understanding of the many layers of meanings of this experience . The richness of data obtained through the use of in-depth guided interviews confirms the benefit of using this method for the development of nursing knowledge. As a practice discipline, it is imperative that nurses build on their knowledge of how human beings understand their world in order to develop more effective clientcentered interventions, enhance the quality of care, and facilitate change in health care delivery systems.
The context of the prison presents unique challenges to the qualitative researcher. Accessibility to participants is dependent on the relationship the researcher has with prison authorities . The Warden and clinical staff, where this study took place, were supportive of this research and facilitated entry into the system . Since the issue of trust for the women is vital, the researcher needs to establish her or himself in the prison system prior to conducting research in this setting. Having instituted a positive reputation in a clinical capacity, prior to this study, had a positive impact on the women ' s receptivity to participation.
Interviewing in the prison system can be very difficult at times. Private office space is at a premium, which can impact on a scheduled interview. Patience and flexibility is key in dealing with the numerous frustrations and potential barriers that can occur. Although interviews were conducted in a private room in the central administrative area, the noise in the hallways was distracting and interruptions from correctional officers frustrating. It often took a great deal of energy to focus on the participant despite these distracters. It was obvious to me that the women were accustomed to the noise, as well as interruptions, and appeared oblivious to them.

Researcher's Qualifications
Given the vulnerability of this population and the sensitivity of this topic, I had to be particularly sensitive to the women and to the potential for causing harm.
Process consent throughout the interview was obtained as well as pacing the interview according to the women ' s needs. My expertise as a psychiatric mental health clinical nurse specialist was an asset in being comfortable with the intensity of feelings expressed, in being able to interview the women in nonthreatening and supportive fashion, listen empathetically, be attentive to the emotional state of each participant, and guide very difficult conversations. Feedback and comments on the reflection form (Appendix E) indicated the participants benefited from the interview process . All three women completed the optional form and mailed it to me within 2 weeks. Some of their comments ("Thank you for listening to my pain and sorrow; I am grateful to have talked to you about my sister;" "it helps me to deal with it more and stop stuffing my feelings;" "I like talking about loss and I need to talk about it because I feel so lost right now") indicated their appreciatiuon for the opportunity to tell their stories, express their pain, and have their grief experiences acknowledged and validated. All three women stated that they would suggest to other women that they participate if given the opportunity.
My background as a psychotherapist posed additional challenges in conducting this research. I had to be consciously mindful of my role as a researcher versus a counselor. The "no" touching rule of the prison felt quite unnatural and foreign to me. When participants were tearful or sobbing as they told their stories, it was difficult to withhold any kind of physical gesture, such as touching their arm. I had to rely on silence, eye contact, and my presence to communicate support and understanding. Another issue that needs to be addressed is the impact of conducting this type of research on the researcher. It was important for me to process the interview through person al reflective notes, memos , and dialogue with committee members and my consultant. I quickly learned the importance of planning quiet reflection time following each interview and an activity such as a walk to release the pain of hearing such compelling stories.

Data Analysis
The combined approach to analysis in this study required full immersion in and complete familiarity with the data. The study resulted in an understanding of the meanings of the grief experience from the women's perspective ( selfunderstanding), the researcher's perspecti ve (critical commonsense understanding), and allowed for comparison of the women's grief with the literature (theoretical understanding). Repeated analysis of interviews also led to insights as to the impact of imprisonment on the grieving process. Kvale's (1996) approach to the analysis of interviews provided for a plurality of extensive interpretations. Each level of interpretation further deepened the knowledge of the phenomena being studied . The process of narrative analysis added to the depth of interpretations and allowed me to confront the remarkable power of the stories . When the women told stories about their experience, they provided gripping descriptions of what happened as well as interpretations of how they felt when certain events transpired. Riessman's (1993) and Gee ' s (1986Gee ' s ( , 1991 approaches to narrative analysis are a tedious and time-consuming process. Gee ' s (1986Gee ' s ( , 1991 sociolinguistic approach focuses not only on what is said but how it is said, requiring repeated listening for linguistic syntax, and rewriting the interview segment in stanza format. However, this approach brought to the foreground the meaning of the loss to the women and the intensity of their responses, keeping me actively engaged in their compelling accounts . The analysis of narratives kept the interpretations close to the women's own voices, allowing for the discovery of the most significant meanings for them . The narratives emphasized what Mattingly ( 1991) describes as the "feltness" of the experience for the women. This type of depth and richness of detail might not have been disco vered through other analytic approaches for qualitative interviews such as content analysis or thematic analysis.
One of the issues in carrying out narrative analysis was the selection of narrati ves to be included in the analysis. Mary's and Christine's interviews contained several narratives, whereas Barbara's interview contained one lengthy narrative. The selection of narratives , or in Barbara's account , narrative segments was guided by the three research questions .
The narratives embedded in these three interviews confirm some of the basic assumptions about the importance of narrative in human experience. The struggle to make sense of one's experience , the process of meaning making, and the opportunity to review life events were clearly illustrated in this study, particularly in Mary's and Barbara's accounts. Each interview yielded different amounts of data . Christine's interview was the shortest , probably related to her degree of sedation from medication . Mary had been a member of a loss and grief group that I facilitated and had told her story to me before . Barbara's interview was by far the lengthiest requiring two separate interviews . According to Barbara this was the first time that she had the opportunity to tell her story to anyone .
Although the combination of these two analytical approaches provided indepth and abundant detail, redundanc y of the data did occur. The analysis of narratives overlapped to some degree with the three levels of interpretation .
Despite this redundancy , the narrati ves provided further confirmation of the interpretations made in self-understanding, critical commonsense understanding, and theoretical understanding. Presentation of the findings in the form of narratives displayed the researcher's basis for making decisions allowing for corroboration of research findings.
As a result of this study, it is clear that narrative analysis is particularly useful when the researcher approaches the interview without previous knowledge of the participants' stories . During Mary ' s interview I was more directive as compared to the other two women. I had heard Mary's story before in the grief group that I facilitated. Since I was particularly interested in the death of her sister , I was much more directive during the interview than is typical of the style of interviewing that promotes storytelling.

Future Directions for Nursing Knowledge Development
To my knowledge this is the first study that has explored the grief experience of incarcerated women . The results have shed light on the implications of disenfranchised grief. The findings support the need for future research in several areas. Many women who are incarcerated have a history of mental health problems and chaotic lives. Therefore , the question as to whether their grief experience would have been different if they were not incarcerated at the time of the death of loved one is a consideration. Longitudinal studies that continue to examine the grief of incarcerated women at 6 months and 1 year after release from prison will contribute to a more comprehensive understanding of their grief experience over time .
Given the limited number of women interviewed in this study, further exploration of the grief experience of incarcerated women is recommended. A broader collection of narratives is needed to achieve an understanding of a wider range of human experience. In addition, studies that explore grief related to significant losses other than death will contribute to the knowledge that is severely lacking.

Implications for Nursing Education and Nursing Practice
The number of women in local, state, and federal correctional facilities continues to rise every year. As a result, it is likely that more nurses will be in a position of providing care to this vulnerable population in hospitals, home care, community settings, primary care, private practices, and in prison. The personal accounts provided by these women are valuable tools for nursing students and practicing nurses in developing a broader appreciation of their mental health needs. When a woman is released from prison, the most urgent issues are to plan for transition back into the community and to address immediate health concerns.
This study points to the necessity for educating nursing students and practicing clinicians regarding the importance of incorporating a loss history and addressing issues of unresolved grief in clinical practice. It can be assumed that unresolved grief of incarcerated women may further complicate their adjustment following release from prison. Therefore, raising awareness of the potential problems of unresolved grief with this population could create more effective client-centered interventions during imprisonment and following release. Follow-up programs that assist women in their transition back into the community must include an avenue to explore potential issues of unresolved grief.
This study also confirms the benefits of narratives in nursing practice.
Storytelling gives clients the opportunity to express feelings, reflect on their experience, make sense of their experience, and discuss primary fears and concerns . Promoting an environment for storytelling can provide nurses with insight into the patients ' struggle with issues of health and illness that goes beyond what is obtained through structured assessment tools and nurse patient dialogue .
Given the current environment of managed care, nurses will need to be creative in incorporating time to encourage storytelling within their day-to-day patient care activities.

Implications for the Criminal Justice System
This study also has potential policy and educational implications for the criminal justice system . It adds support to the Warden's approach , as well as making specific suggestions . The importance of having a family member or counselor present at the time that news of death is given to an inmate must be underscored. The need for a policy allowing for a support person to accompany the inmate to the funeral home must also be examined . The humiliation and emotional pain captured in these three accounts begs for a change in policy that humanizes this heart -wrenching experience. Education of prison staff regarding grief and sensitizing staff to issues of loss and grief will be a formidable task given the retributive nature of our criminal justice system and the necessary priority for security . However , it is imperative that correctional authorities develop support systems to help women cope with grief during imprisonment and in their followup care.
You have been asked to take part in this research project by the University of Rhode Island, College of Nursing. Ginette Ferszt, the person mainly responsible for this study, has described the project to me in detail. You should feel free to ask questions . If you have more questions later Ginette Ferszt , PhD (c), RN, will discuss them with me.
Description of the Project: You have been asked to take part in this study which explores the grief experience of women in prison . This study is an effort to better understand the loss issues of women in prison and how being in prison affects their grief experience.
What Will be Done : You will be asked to describe your experience of grief during a 11/2 to 2 hr. interview. A second interview may be needed. The interview will be conducted in a private room, and will be audiotaped . During the interview you will tell about your losses, your grief experience and how being in prison has affected your grief.

Risks or Discomfort:
You may feel upset talking about some of the topics that may come up during the interview. If so, you have the option of being referred to a counselor. You may choose to stop any time you want to. Whether or not you participate in this study is up to you. You do not have to be in it. The researcher is not working for the prison or any court system. You understand that there will be no effect on your parole , classification status and/or inmate record whether or not you take part in this research.
Benefits of the Study: There may be some benefits to you participating in this study . These benefits may include some or all of the following : a sense of comfort from being able to talk about your feelings and thoughts; a sense of contributing to better care for other women in prison. You understand that taking part in this research will have no effect on your parole , classification status, and/or inmate record.
Reportable Child Abuse: If, while talking to the researcher , you tell her about some abuse of a child, and if you say that it has not been reported to DCYF, the researcher will inform you that (1) she is required by law to report the abuse to DCYF; (2) that we must terminate the interview; and (3) that DCYF does not, and will not have access to what you have said--they cannot request or subpoena the interview or any notes. However, you have been made aware that previously unreported information may be subject to investigation and subpoena by the attorney general. You understand that the purpose of the study is not to track reportable incidents of abuse.

Confidentiality:
Your part in this study is confidential. None of the information will identify you by name . All information provided by you during the study will be kept strictly confidential. Your name will not be used on any notes, reports or publications resulting from this study. Your signed consent form and identifying face sheet will be kept separate from the rest of the study data and will be placed in a locked room at the University of Rhode Island. The interview data will be identified by code number. No individual information collected by the researchers will be given to the RI Department of Corrections. The RIDOC will not subpoena: or otherwise request individual data which is collected by the researcher. The study records including audiotapes and written notes will be shared only with a small number of professional colleagues. The tapes, notes and transcriptions will be saved and may be made available to other qualified researchers at a later time.
You understand that a federal Certificate of Confidentiality has been obtained for this study which will help the investigator protect your privacy even if study records are subpoenaed.
If you tell the researcher at any time that you are planning to escape, plan to commit suicide, or plan to hurt or kill someone , the researcher will have to report the issues to prison staff.
Decision to Quit: The decision whether or not to take part in this study is up to you . You do not have to participate. If you decide to take part in the study, you may quit at any time. This will not affect your parole or inmate record. You can also ask to rest at any time if you get tired. Whatever you decide is okay. If you want to quit, you will simply tell the researcher.

Rights and Complaints:
If You have read the consent form and your questions have been answered. You are at least 18 years or older. Your signature on this form means that you understand the information, you agree to take part in this study, and agree to audiotaping. This consent form will be stored in a locked space at the University and will not be attached to any of your responses.
You have been given a copy of this consent form to keep.

Signature of Participant
Printed Name Personal Narratives of Incarcerated Women". We will assist you in accessing the population of women that you are interested in interviewing and will provide you with the privacy that you need for the interviewing process. The Department of Corrections will not subpoena or other.vise request individual data, which will be collected by you for this research. Use CAPS for material that is focused or said with a prominent pitch Underline the main line parts of the plot