The Effect of Person-Centered Narrative Therapy on Happiness and Death Anxiety of Elderly People

Introduction: This study was conducted with the aim of investigating the efficiency of Interventional person-centered narrative therapy on increasing happiness and reducing death anxiety in elderly people. This study, which is a single case study is in the form of multiple baselines. Methods: Of population of elderly people in nursing homes in Tehran, one person was selected using accessible sampling and participated this study. Research tool included Oxford happiness questionnaire (1989) and Templer Death Anxiety Scale. To analyze data, chart and graphical analysis were used. Results: Results showed that person-centered narrative therapy has a positive effect on increasing happiness and reducing death anxiety. Percentage change for happiness and anxiety was 42% and 53% respectively. Conclusion: The effects of these improvements largely remained during follow up period. Therefore, narrative therapy can be used that results in inner peace by having a positive theme toward events.


Introduction
Changes that will occur in later decades in age structure of the population, results in elderly age to become more tangible. Life expectancy has increased significantly among elderly people and the highest increase was observed in the age of 85 years and over. This raise is faster relative to other age groups and it is predicted that it will accelerate in the future (Shajari, 2009). In 2025, ten percent of the population of Asia will be people over 64 years of age. Percent of elderly people living in European countries will rise to 22.4%, i.e. about 4.1% of the population of Europe (Squire & Tindall, 2002). In 2021, people over 60 years of age will account for 10% of the population of Iran (Majd, Delavar, & Ta'ghoobi, 2002). The growing population of elderly people has attracted the health policy maker's attention, since they predict growing load of health and social care and population growth related to younger generations (Squire & Tindall, 2002).
Aging is an important phenomenon which takes place inhuman's life. Old people comprise a large number of populations in all societies. Therefore, any action taken to improve their lives conditions can reduce social problems and therefore family problems will be reduced (Ghasemi et al., 2009). Health and its relationship with increased lifelong has created a lot of challenges. Studies show that ageing is accompanied by hygienic problems and reduction in activities. When age increases, physical performance disorders will also increaseand its negative impacts on ability to remain independent increases need for help. This in part can reduce the elderly's life quality, happiness, optimism and hopefulness (Maghsoudnia & Akbarpour, 2006).
The amount of happiness and health status of the elderly people diminishes with age (Haller & Hadler, 2006). In addition, retirement and losing occupational and social status, losing their beloved ones, reduced health status, reduced sensational perceptions and changes in self-concept, will have a negative impact on psychological wellbeing and happiness of the elderly people (Sheybani, Tazraji, & Pakdaman, 2010). Considering the effects of happiness on various aspects of the elderly life, it seems necessary to investigate the effects of some joyful interventions on happiness of this age group. In terms of the outcomes of happiness, several studies have shown that feeling of happiness can be employed to treat mental illnesses, increase mental resistance and strengthen the defense force against stress (Saul & Saul, 1990;Lyumbormicsky & Ross, 1997). Argyle (2001) states that feeling of happiness can be used to promote mental health status. Seligman, Rashid and Parks (2006) have categorized the concept of happiness in three components: positive emotions (joyful life); commitment (involvement or good life) and meaningfulness (the meaningful life). Seligman believes that studies in recent years have confirmed that happiness creates benefits that value more than having good feeling. Happy people are healthier and more successful. They have more social commitment and involvement. Among psychological interventions, psychoanalysis (Woods, Spector, Jones, Orrell, & Davies, 2005), cognitive behavioral therapy (Richardson, & Stallardand Velleman, 2010), positive psychological interventions (Sin & Lyubomirsky, 2009) and narrative therapy (Hsieh & Wang, 2003) have been used to improve self-esteem, socialization, life satisfaction and happiness in elderly people.
As time passes, death will be more manifested in personal life. From past to present, relatively in all cultures and societies, facing this phenomenon has created anxiety and fear among people. Based on sample studies conducted in the society of the US, fear of death is known as the most common type of fear among Americans (Wong, 2009). This type of fear is apparently an unknown fear and it is the fear of death outcome, fear of life stopping, fear of losing loved ones and fear of pain and suffering (Belskey, 1999). Anxiety is the result of concerns of a stressful experience because of a potential fear. Jannette Belskey (1999), the psychologist, defines death anxiety as the thoughts, fears and emotions about the last event of life that we experience in normal life conditions.
Among various types of anxiety, based on its known origin, death anxiety is a major one. Death anxiety is one of the human's stresses that has been more pronounced than before by population growth and aging of the population. Death anxiety (thanatophobia) is defined as an unnatural and huge fear of death. This anxiety is defined as a feeling of fear of death, apprehension when thinking about dying process or events that happen after death (Naderi & Hosseini, 2011). Narrative therapy is one of the ways of treating this sort of anxiety. It has been used widely for treating depression, dementia, feeling of loneliness and quality of life (Woods et al., 2005;Chao et al., 2006, Chiang et al., 2010. However, it has rarely been used in positive psychology, happiness and anxieties related to the elderly especially death anxiety.
Narrative therapy initiated and developed during the 1970s and 1980s. A major part of this growth and development is beholden to the official founders of this approach, i.e. Michael White, the Australian family therapist and his friend and colleague David Epston from New Zealand. They planned for a narrative approach to therapy using a constructivist approach which has a long history and it has been stated as a therapeutic theory before by George Kelly. This approach remained unknown until 1990s in North America.
Narrative therapy is a form of psychotherapy that seeks to help people identify their values and the skills and knowledge they have to live these values, so they can effectively confront whatever problems they face. The therapist seeks to help the person co-author a new narrative about themselves by investigating the history of those qualities. Narrative therapy claims to be a social justice approach to therapeutic conversations, seeking to challenge dominant discourses that it claims shape people's lives in destructive ways. The approach was developed during the 1970s and 1980s, largely by Australian social worker Michael White and David Epston of New Zealand.
Narrative therapy is a highway with positive meaning and theme relative to events the result of which is nothing but inner peace. In general, by conducting this study, we conclude that this intervention can be used in nursing homes as a secondary treatment along with pharmacotherapy. So I think it has main contribution in research about this field.
The value of this paper is to deepen the understanding of older adults' distinctive reality and to help health care and medical professionals to better understand older adults' needs. As professionals adapt to the shifting demographic composition of reality, it should be of importance to comprehend what old age might mean to older adults, to whom we are attending. Interventions with older adults may benefit from clearly understanding PCT as an important approach for promoting successful aging and reducing health and medical disparities.
PCT is essentially based on the experiencing and communication of attitudes and these attitudes (congruence, unconditional positive regard and empathy) cannot be packaged up in techniques (Rogers, 1951(Rogers, , 1980Sanders, 2007). Moreover, PCT provides the opportunity for deeply negative or despairing experience to be expressed, fully felt and received empathically as a reality of experience (Barrett-Lennard, 2007). This is particularly true when working with older adults (Pörtner, 2008). In fact, PCT is based on the premise that people are free to express themselves and, hence, should assume responsibility for their decisions. Furthermore, PCT also emphasizes 'here-and-now', as opposed to a 'there-and-then' approach (Rogers, 1951(Rogers, , 1980. In this context, person-centered approach is a holistic, organismic theory that regards the individual as an integrated whole (Sanders, 2007). For Rogers (1951Rogers ( , 1961Rogers ( , 1977Rogers ( , 1980, human nature is positive and optimistic, which does not refute the ability for destructive, anti-social and depressive behaviour. Yet, PCT focuses on the potential for positive change and sustains that environmental factors are critical for determining both positive or negative self-concepts, and hence healthy or unhealthy functioning (Rogers, 1980). Sarakiins (2007, as quoted from Boustani et al., 2007) showed that the old people were happier after taking part in sessions. This research is important because old people's health is very important for any society. This can be used for improving old people's health and many important steps have been taken for this means.
The results of studies conducted by Neuner (2010), Katani (2009), Sarakinz (2007, as quoted from Boustani et al. (2007) verified the influence of narrative therapy in improving psychological problems. Lopez & Kerr (2006) showed that group therapy can influence development and increase of sense of optimism, happiness and hope in old people. Lopes et al. (2014) investigated and compared narrative therapy and cognitive-behavioral therapy influence on depression. The results of the research showed that impact size for both groups was higher in comparison with expectation and control group.
Narrative therapy is a kind of training which can be implemented on old people. It tries to change mental frameworks of people to which an individual refers most usual. This is done via critical thinking and affects mental premises. Narrative therapists work on individuals who either have problems told by them or by society. These are negative stories in which individuals think they have lost their control over their lives and cannot change them (Shapiro & Ross, 2002). The fact that the story is immersed in problems allows the individual to pay attention to good results, happenings and moments which indicate the values of the individual (Abedi, 2006).
Narrative therapy focuses on narrative-telling attitude of the client during the counseling process. The relation between the psychotherapist and the subject in this type of psychotherapy (counseling) is a level and cooperative relation, not like the relation between a specialist and the client. In this relation, the counselor attempts that the client has a stronger narration of themselves and their life. During this process, the narrative therapist asks special questions that events and happenings of one's life to be narrated from a fresh and clear perspective, which have never been part of problematic plan. With the motto of "The problem is not the person, but the problem itself". Narrative therapy tries to separate the nature of people from their problems. It attempts to separate people's problems for themselves, unlike many approaches in modernist era that consider people's characteristics and features as part of their nature. This technique is called externalization. Even the weak points and positive capabilities of the person are externalized to allow the person to achieve a better and clearer narration of their life and self (Carey & Russell, 2002).
Narrative therapy is a cost-effective and reliable method. Most studies conducted on narrative therapy are group-oriented and they are conducted in Western and East Asian countries. While person-centered narrative therapy studies are not of a long history in Iran. Unique narratives and memories of a person and cultural differences between Iran and other countries may affect the results of narrative therapy. Therefore, this study has investigated the effect of person-centered narrative therapy on increasing happiness and reducing death anxiety in elderly people.

Method
This was a single case pilot study of a multiple baseline design. In these types of designs, the experimental variable is applied only for a single person, behavior or situation after baseline. These designs can be used for a single person or a small group of people (Delavar, 2005). Case studies are in-depth investigations of a single person, group, event or community. Typically, data are gathered from a variety of sources and by using several different method. The research may also continue for an extended period of time, so processes and developments can be studied as they happen. Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of 'averaging'. The case study is not itself a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies. Strengths of case studies are: Provides detailed (rich qualitative) information; Provides insight for further research; Permitting investigation of otherwise impractical (or unethical) situations. Limitations of this method are: Can't generalize the results to the wider population; Researchers' own subjective feeling may influence the case study (researcher bias); Difficult to replicate and Time consuming (McLeod, 2008). Case study is a published report about a person, group, or situation that has been studied over time; also it is a situation in real life that can be looked at or studied to learn about something.
The Population of this study was elderly people who were living in Towhid Center of Rehabilitation and Nursing Home in Tehran in 2015. They were living in this center over a year. With regard to research design, just one client was used. The Sample in this study was selected using purposive sampling using accessible sampling. The subject was selected based on main criteria, i.e. Low score on happiness scale and high score in death anxiety and recognizing the inappropriateness of these factors. The client is 73 years old and he has got a high school diploma. He has three children and his wife passed away because of cancer. He is under physician's supervision because of physical problems related to old age.
To collect data, Oxford Happiness Questionnaire (OHQ) and Templer Death Anxiety Scale (DAS) were used. Oxford Happiness Questionnaire with a list of 21 items is of high reliability and validity, and it was first developed by Argyle and Lu (1990). After consulting Aaron Beek, Argyle decided to reverse sentences in Beck's depression list and consequently he provided 21 items. Then, he added 11 more items to include other aspects of happiness. Finally, he implemented the 32-item list of 8 students and asked them to judge about the formal validity of items after ordering them. Therefore, by creating changes in some items and eliminating 3 items, the final list reduced to 29 items. Argyle et al. (1989) reported alpha coefficient of 0.9 in 347 subjects. Various studies suggest acceptable test-retest reliability of the questionnaire. Each question of OHQ contains 6 codes: strongly disagree (1); moderately disagree (2); slightly disagree (3); slightly agree (4); moderately agree (5) and strongly agree (6). Participant must read the statements carefully and indicate how much he agree or disagree with each of questions. Some of the questions are phrased positively and others negatively. There are no "right" or "wrong" answers (and no trick questions). The first answer that comes into case head is probably the right one for him. Some of questions should be scored in reverse. The sum of the item scores is an overall measure of happiness, with high scores indicating greater happiness.
Another tool used in this study was Templer Death Anxiety Scale (1970) translated into Persian by Rajabi and Bahrani (2002). This questionnaire consists of 15 questions that express subject's attitudes toward death. Subjects answer each question using yes and no. Yes answer shows anxiety in person. Therefore, scores of this scale varies between 0 and 15 and a high score expresses high death anxiety in person. Studies conducted on reliability of death anxiety show that this scale is of acceptable reliability. Saggino and Kline (1996) reported Cronbach's alpha of 0.68, 0.49 and 0.60 for triple factors obtained using factor analysis, the Italian version. Templer obtained test-retest coefficient of DAS as 0.83. Conte, Weiner and Plytchik (1982) reported split-half reliability of DAS as 0.76 and the correlation between each question and a total score as 0.30 to 0.74 with an average of 0.51 for elderly people and 0.44 for students. In addition, Abdul-Khaligh (1991) obtained coefficients of 0.57 and 0.78 for males and females for split-half reliability of DAS, the Arabian version. They reported test-retest coefficient of 0.78 and 0.88 for two above-mentioned groups with an interval of one week. Kelly and Corriveau (1995) reported test-retest reliability of 0.85 for DAS and internal consistency coefficient of 0.73.
In this study, narrative therapy was used as individual therapy. Of benefits of the single case method relative to designs with a larger sample is its flexibility. The Flexibility of this method is the possibility to shape this new therapy in terms of happiness and death anxiety. In fact, because of frequent evaluations, more information is obtained through follow-up of disease during therapy and study of the ways that changes occur. The therapy was concluded in 6 sessions of 45min to 1 hour. Topics, themes, assignments and exercises were concluded, based on practical guideline of Witt and Cappeliez (2000). All sessions had a fixed pattern. Investigating reaction to previous session, examination of assignments, subject related to each session and presenting assignments related to provided themes in each session were all according to practical guideline. According to this guideline, the intervention includes 6 sessions on various subjects including main determining life events, family life, occupation, mostly working life and personal interests, experience of stress, love and hate, believing in life meaning and goals.
According to narrative therapy approach the client was encouraged to talk about himself using externalization language and to share his life story. In addition, he came to this insight that his problem is apart from himself. Separating people from their problems is a method to increase personal control and functionality. Then, using deconstructivism, the therapist asked questions from the subject that made the history of the problem more understandable for the therapist and client. In addition, using these questions, the effect of beliefs, customs and cultural, political, social and family values were also investigated. This resulted in the subject to test accuracy of these beliefs and values and deconstruct pre-prepared meanings in his mind and reconstruct them. Then, he was encouraged to adopt a position against his problems using his previous abilities and capabilities obtain in therapy sessions.
The general design used in this therapy includes the following sections: ass.ccsenet.org Asian Social Science Vol. 12, No. 10;  The subject explained his story full of problems.
 His problem was named with his help.
 Externalization language was used.
 Political, cultural and social issues were considered.
 The subject was invited to adopt a position relative to the problem and story.
 Medical documents were used.
 The subject was assisted to remember important and effective people in his life.
Narrative therapy sessions included 10 45-minute sessions as follows: (Some sessions combined and 6 meeting was conducted) First session: introduction and increasing trust and conduction of pretest Eighth session: helping him with changing the name of his narration and the fact that there is nothing called objective reality but his problem is usually his mental perceptions Ninth session: writing a letter to the respondent for improvement when the narrative therapist is absent and emphasis on his or her strengths against problems Tenth session: holding a meeting with one of his family members or a friend and review of the sessions and giving a reward for being successful at changing the name of the narrative Data from therapy sessions and tools were analyzed using the mean and standard deviation in SPSS11 software and they were descriptively and graphically reported. Based on the profile, effects of independent variable independent variable were examined. To calculate changes in improvement percent, the following formula was used.
∆A% AI AO AO AO is a target problem in the first session (happiness and death anxiety) and AI is a target problem in the last session (happiness and death anxiety). ΔA% is the different in recovery percent in cases under therapy using person-centered narrative techniques in sample under study.
Routine outcome data can be used to answer questions regarding the effectiveness of an intervention. It is necessary to collect this type of data on a large scale and, collate the data, which can then be analysed using statistical methods to provide what is known as an 'effect size' for how effective the therapy has been.

Results
Based on data from measurement tools of Oxford Happiness and Templer Anxiety Scale, whole data showed that this method of therapy increases the scores of happiness and decreases scores of death anxiety. These effects remained during follow up period. As could be seen in Table 1, subject's score has increased from baseline during therapy sessions and an increasing trend was observed in death anxiety. The general amount of improvement observed includes a 42% increase in happiness and 53% decrease in death anxiety.   Vol. 12, No. 10; narrative therapy is effective in increasing subject's score in happiness and decreasing their score in death anxiety.
Graph 3. Changes of subject's score in happiness in pretest, posttest and follow-up stages Graph 4. Changes of subject's score in death anxiety in the pretest, posttest and follow up stages

Discussion
The results of this study showed that using person-centered narrative therapy, happiness in elderly people can be increased and their death anxiety can be reduced. This result complies with the results of Yoosefi, Sharifi, Tagharrobi and Akbari (2015) as well as Jamalzad Azad, Kafi and Rafi'iyan (2015). In addition, these results comply with the results of Cappeliez, Guindon, and Robitaille (2008) as well as Gudex et al. (2010). They report that although narratives strengthen positive emotions in elderly people, emotions created by retelling memories seem to be transient. This method provides a limited insight relative to self and present time and it is the footstone to promote positive emotions and happiness (Bryant, Smart, & King, 2005). Another study investigated the effect of this therapy on depression signs in elderly people, showed that this therapeutic method can be effective (Zadeh, Shahi, & Khani, 2012) that confirms the efficiency of this therapy and complies with the results of this study. The main part of therapy in this study assisted the subject to understand the relation of his stories with others and his life. In fact, the important thing is to discover the style of story. Beck and Steer (1987) believes elderly people can think of therapeutic conversations in Narrative therapy consider their own lives through particular stories and narrations. Then they've been asked to explain their pessimistic stories which are overfilled with feelings of failure, unhappiness and severe disappointment.
Two key issues that can explain the effectiveness of narrative therapy are: a) the role of human interaction especially with peers and b) the role of catharsis and externalization of bitter/sweet memories, reorganizing them and clarification of previous blind spots. Payne (2006)  about what is important to them because of its focus on positive interactions and quality, and provides a supportive and comforting environment that enhances the communication and interaction between people.
The primary focus of narrative therapy presented in this study was on interpretations or meanings that the subject has attributed to events and happenings in his life. His interpretive understanding of events caused him to limit his actions or develop them. This therapy helped him to achieve a more comprehensive interpretation of his condition.
Therefore, narrative therapy is a highway with positive meaning and theme relative to events the result of which is nothing but inner peace. In general, by conducting this study, we conclude that this intervention can be used in nursing homes as a secondary treatment along with pharmacotherapy.
As there are a lot of cultural diversities in our country, it is consider that narrative therapy is highly dependent on culture. Therefore, it is recommended that psychologists, counselors and social workers who work with the elderly, utilize the theoretical principles and the therapeutic process of this approach since proverbs, poetry, metaphor, story and narrative is interwoven with the lives of people and can be used as a very important therapeutic technique especially for the elderly.
Of restrictions of this study, it can be pointed out that one-month follow-up period cannot be a proper interval for follow-up period. In addition, small sample size and improper location of holding therapeutic sessions are other limitations of this study. In fact, the limitations of this study are the small sample size and lack of a control group without any intervention and the strength is practical, operational and the easy solution way for increasing happiness of elderly people.
However, it is suggested to use stronger designs in later research and consider 3-month and 6-month follow-up periods. In addition, it is suggested to conduct later studies with larger sample size to investigate efficiency and effect of this method. Furthermore, it is suggested to compare the effect of this therapy with common individual therapies available for happiness and death anxiety. Holding training and briefing courses for managers and staffs of nursing homes, teaching properly dealing with elderly people and justifying them in terms of the importance of psychological therapies can have a major effect on later studies. Since issues, including social relations, gatherings of elderly people in public places and telling memories are of special importance in the history of our culture and civilization, it is suggested to teach this Interventional therapy to psychologists working in nursing homes as an effective and easy treatment to promote the mental health of elderly people in the society.
Overall, the current study indicates that Person-Centered Narrative Therapy is not only an opportunity for elderly to tell the others their meaningful aspects of life events but also help them to reappraise their emotional state. Given the simple, inexpensive, and harmless nature of this technique and its effect on happiness and death anxiety in elderly, it is suggested that reminiscence programs be used more extensively in elderly population.