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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Aging Stud. Author manuscript; available in PMC 2010 April 1.
Published in final edited form as:
J Aging Stud. 2009 April 1; 23(2): 97–102.
doi:  10.1016/j.jaging.2008.11.001
PMCID: PMC2701702
NIHMSID: NIHMS114956

Suffering and Generativity: Repairing Threats to Self in Old Age

Abstract

Suffering is a powerful experience that can be difficult to articulate. Suffering differs from pain alone and includes an individual’s awareness of a threat to self through death, loss of identity, or uncertaintly of the meaningfulness of one’s life. In response to this threat, generative acts, especially creative expressions imbued with the self, may act as a means to repair the self in crisis. The case of Mr. A., an 85-year old man in good health, illustrates how various artistic pieces he created – a wooden dog and several poems -- helps him to restore a “fading” self. For Mr. A, the idea of “fading away” or becoming weaker and less useful until eventually disappearing is a major source of personal suffering. Through his art, he creates unique, interactive and tangible entities that can outlive his physical body and help him reclaim or repair threats to selfhood.

Introduction

Suffering is a powerful experience which can be difficult to articulate (Black & Rubinstein, 2004). Although definitions of suffering include intense physical and/or emotional pain, suffering differs from pain alone (Black, 2007; Cassel, 1982; Kahn & Steeves, 1986) and includes an individual’s awareness of a threat to self through death, loss of identity, or uncertainty of the meaningfulness or effectiveness of one’s life (Cassel, 1982; Charmaz, 1983; Pennebaker & Keough, 1999). This “threat to self” may also be compounded by advanced old age, where physical or cognitive changes or changes in one’s social world may further challenge a person’s ability to maintain a long-held self concept (Charmaz, 1995).

In response to threats to self, generativity may offer a way to restore or repair a self in flux. Generativity describes the acts that one may undertake to ensure some continuation of self after death, such as having children, passing along traditions or skills, investing in one’s community, or creating artistic works that will survive the artist (McAdams, 1993; McAdams et al., 1997; McAdams, de St. Aubin & Mansfield, 1997). Although generativy has been examined as a “normative” stage in adult development, it has rarely been explored in the context of suffering (Black & Rubinstein, in press). Generative acts may well represent a means by which the threatened self can be reclaimed or repaired.

The goal of this paper is to explore generativity in the context of suffering and advanced old age. It will begin with a brief overview of suffering and selfhood, challenges to narrating the suffering self, and generativity as means to self repair. To illustrate how generative acts may be used to mitigate the experience of suffering in old age, the case of Mr. A (a pseudonym), an 85-year old informant, will be presented. Mr. A uses two forms of artistic expression -- woodworking and poetry – to narrate his suffering. In each form, he creates unique, interactive and tangible entities that can outlive his physical body and help him explore and validate his concept of self through conversations with others. For Mr. A, the most insidious form of suffering is the experience of “fading away,” of gradually becoming less until eventually ceasing to exist altogether. Mr. A therefore uses his artistic creations to help stave off threats to self and to create a sense of permanence in what he perceives to be a fading life.

Suffering and Old Age as Threats to Selfhood

As many have argued, suffering is subjectively defined, internally experienced, and culturally mitigated (Benedict, 1989; Black, 2002; Black & Rubinstein, 2004: Kahn & Steves, 1986). Shared cultural values help shape and influence what comprises an “acceptable” suffering, what types of suffering (if any) have value, and how the experience of suffering should be voiced or silenced (Black & Rubinstein, 2004; Charmaz, 1983; Das, 1994; Kahn & Steeves, 1986). Cassel (1982) defines suffering as “the state of severe distress associated with events that threaten the intactness of the person” (p. 650). Kahn and Steeves (1986) describe the experience of suffering as occurring not necessarily when one feels intense pain but instead when the meaning of pain threatens the self. According to Kahn and Steeves, the “self is the experience of being alive, embodied and unique. The self is embodied but is not the body, is conscious but is not the mind.” (p. 626). The self must be capable of perceiving a threat; suffering, therefore, occurs at the point of perception, not in the experience per se.

Charmaz (1983) specifically explored suffering as loss of self in people of various ages who were experiencing a chronic illness. She argues that it is through social relationships that the self is developed and maintained throughout a lifetime and that one’s self concept depends on outside validation. When a person’s internal self concept is in conflict with external validation, such as a chronically ill person who may see him or herself as active and capable but be treated by others as ill and in need of help, a threat to self can occur which can then lead to suffering. Anthropologist Robert Murphy, who wrote a personal account of his growing disabilities resulting from a malignant brain tumor, describes having an “embattled” identity. As he moves from an “able-bodied” man who hadn’t given much thought to the meaning of disability, to one who was increasingly dependant on assistive devices such as wheel chairs, he says that his sense of self was “no longer dominated by my past social attributes but rather on my physical defects” (p. 104.) As in many definitions and descriptions of suffering, suffering didn’t necessarily describe the painful event but rather the treatment of the individual by others as a result of that event which challenges the self concept (Black, 2001). Charmaz (1983) suggests that three reconstructive although not necessarily positive actions may result in reaction to threats to self: 1) living a restricted life, 2) social isolation or 3) discrediting definitions of self.

Like the experience and expression of “suffering,” old age is heavily reliant on cultural rules and physical realities but is uniquely experienced by the individual (Biggs, 2004; Black & Rubinstein, 2004; Hazan & Raz, 1997). For example, the point at which one is considered to be “old” and the roles, responsibilities, “appropriate” activities, and expectations for the “elderly” are shaped by one’s cultural group (de Medeiros, 2005; Raz, 1995). Physical and/or cognitive decline may further influence whether a person is identified as being “old” and may place additional limits on the ways in which he or she is viewed, reacted to, restricted, or encouraged in various levels of social participation (Charmaz, 1995).

Given the potential for losses and limits, cultural myths of old age have suggested that old age is a time of suffering. Work on the aging self, however, has suggested that rather than experiencing threats to the self as part of the normative experience of old age, many experience an “ageless” self, a self that is continually able to evolve and adapt and therefore remain ageless even in the face of great change (Kaufman, 1986). Although threats to selfhood, as in the suffering self, may not be an inevitable part of old age, they do occur. Ageist treatment in general or reaction to an age-related disability may lead to threats to selfhood and subsequently suffering. It is therefore important to better understand how self and suffering are experienced and narrated in the elderly who suffer.

Narrating the Suffering Self

If the experience of suffering is tied to a loss of self, then difficulty in expressing this experience may further challenge selfhood. Personal narratives are often described as a presentation of the self (Conway & Pleydell-Pearce, 2000; McAdams, 1993). However, personal narratives can be a particularly problematic form of expression for one who is suffering for several reasons. The ability to narrate the experience of suffering can be a challenge given the intensity of the experience; this intensity may transcend the limits of narrative alone. In short, a person in the midst of suffering may lack enough distance from the experience to be able to reflect upon and articulate it in a cohesive way (de Medeiros, 2005; Kirmayer, 2000; McAdams, 1993; McAdams et al., 1997; Scarry, 1985.)

Scarry (1985) writes about the “unsharability” of pain and suffering, its resistance to language, and the culturally shaped ways in which one learns how to express pain (e.g., vocalizing cries) or to suppress them. Rather than being able to place pain and suffering into words, Scarry suggests that a person may use metaphors, symbols or objects to express an otherwise ineffable experience. Reducing an intense experience to language alone runs the danger of lessening the experience for both for the teller who is forced to transcribe suffering into words and to the listener who benefits from the softening of the experience that language provides.

Kirmayer (2000), writing about the experience of illness, argues that although narratives help one construct a coherent identity and sense of self, other forms of expression may be equally effective and more apt to be applied in the context of suffering. Poetry, for example, allows a person to express intense emotions through metaphors and figurative language. No overarching narrative is needed so there is no need by the individual to “fit” his or her experiences into a story form. Kirmayer (2000) describes these poetry fragments as “the building blocks of narrative: moments of evocative and potential meaning that serve as turning points, narrative opportunities, irreducible feelings and intuitions that drive the story onward” (p. 155). Like Scarry, Kirmayer suggests that although telling a narrative of suffering may not be possible for an individual who suffers, other creative forms of expression may provide opportunities to make one’s suffering known, if not in a complete, coherent story then in smaller pieces which could be pieced together in a meaningful way.

Pennebaker and Keogh (1999) also stress the importance of expressing traumatic experience, although they rely more on written narratives in their studies than other forms of expression. In several studies, Pennebaker and colleagues have reported increased wellbeing and reduction of perception of trauma and stress on individuals who express their experiences through writing (Pennebaker, 1985; Pennebaker, Cohler & Sharp, 1990; Pennebaker & Keogh, 1999; Pennebaker & King, 1999; Pennebaker, Mayne & Francis, 1997). The authors do acknowledge, as have others, that it is often not possible and may even be detrimental for some people to verbally express their experiences with trauma because of the personal upheaval it may cause (e.g., too much personal disclosure, inability to gain sufficient emotional distance from the event) (Pennebaker & Keogh, 1999). They suggest that other forms of expression which can take on many forms outside of traditional talk or personal essay writing, can be beneficial in helping people to rebuild one’s self and identity.

Generativity as Self Repair

In the face of threats to self and amidst the challenges of making the experience known through narrative, generative acts of expression can be important in rebuilding or restoring the self. Generativity was originally described by Erickson (1963) as “an interest in establishing and guiding the next generation,” (p. 103) which he believed was primarily achieved through parenthood, but could be expanded to include productivity and creativity in other realms such as the community at large. He later expanded his definition of generativity to include challenges to prevent stagnation within the individual associated with lack of interest or initiative and resulting in a sense of giving up (Erickson, 1993). Although generativity is not the last stage of Erickson’s life cycle (it is the seventh out of nine in his revised schema and is generally associated with middle age), he stresses the importance of continued commitment to creativity and caring with and for others. To stop doing so, he argues, would be “worse than death” (p. 112).

Kotre (1984) redefined generativity as “a desire to invest one’s substance in forms of life and work that will outlive the self” (p. 10). For Kotre, four types of generativity exist: biological (e.g., having children); parental (e.g., raising children, passing down family traditions); technical (e.g., teaching skills); and cultural or creating something and passing it down to others. Kotre makes a distinction between creativity and generativity, however. For Kotre, creativity describes creating something new and applying novel yet appropriate solutions. Creativity ends when a product is made. Generativity, however, describes passing along something old in which the self is infused, and continuing to care for that product as it develops.

McAdams and de St. Aubin (1992) present a theory of generativity that draws from Erikson (1963) and Kotre’s (1984), but is based on the interaction of seven psychosocial features (cultural demand, inner desire, generative concern, belief in the species, commitment, generative behavior, and personal narration) with individual and societal concerns for the next generation. Of particular concern to the current article is the authors’ discussion of the last two psychosocial features, generative behavior and personal narration. Generative behavior includes “creating, maintaining, or offering” (p. 106). In addition, the creation or offering must be an extension of one’s self, a product or legacy, and is not the same as an act bourne from altruism alone, although a generative behavior can involve a “selfless” offering of an extension of self. Personal narration for McAdams and de St. Aubin (1992) refers to an individual’s inner narration of his or her plan to have some part of the self live on even after physical death. They describe an evolving personal myth that may change throughout a person’s lifetime but which always has an eye toward what of the self will live after them. The generative self is one who’s story, in part, lives on after the physical self is gone.

Methods

Mr. A is an 85-year old Jewish-American man who participated in a larger study on the meaning of suffering in old age. Participants in the study were community dwelling older adults, age 80 or over, who were willing to complete three face-to-face ethnographic interviews regarding their perceptions of and experiences with suffering. Interviews were based on a semi-structured questionnaire. Although each question was read to the informant at some point during the interviews, interviewers were encouraged to probe when the informant brought up a particularly salient topic or when an informant’s response seemed to require more explanation. [For additional details of the study and methods, please see Black (2007) and (Black et al., 2007)].

All interviews were tape recorded and transcribed verbatim. In addition, interviewers included field notes which included conversations held “off tape,” impressions of the informant, and other relevant details regarding setting, tone or other conditions relevant to the interview. Data were analyzed using standard methods for qualitative data analysis (Schensul et al., 1999.) These included inductive thematic coding of narrative data and team meetings to discuss findings (Charmaz, 2002; Glaser & Strauss, 1967.)

Mr. A was selected as a case study based on methods described by Yin (2003). Yin argues that an exploratory case study is effective when the broad goals of the study have been defined but when an observed social phenomenon is not clearly understood. The case of Mr. A. emerges from the larger study context of the meaning of suffering. Mr. A. is unique in his presentation of tangible, generative acts which he brought to the interview and through which he narrated his experience of suffering.

The Case of Mr. A

Mr. A described himself as being in good health. He was very physically fit, with muscular arms and a lean build, and said that he worked out regularly at several local health clubs where he had memberships. Mr. A completed high school but decided to pursue a career in radio repair rather than attend college, a decision which he still regretted. He was active in the local senior center where he taught a class each week, but said he wished he would have been a high school teacher by profession. All of the interviews with Mr. A took place in an empty classroom at the senior center.

At the time of the interview, Mr. A had been married for 55 years. He and his wife had two grown, successful daughters, one of whom owned a retail business that he said “catered to famous people.” Mr. A described his second daughter by saying, “She can make as much as $8,000 in one weekend. So how can I teach her anything?” Although the concept of generativity often includes transferring knowledge or traditions to children, Mr. A’s daughters did not figure strongly in his interview, perhaps because he felt he had no valuable knowledge to pass down or nothing to teach them. For a man who wanted to be a teacher and who valued sharing knowledge with others, this was personally disappointing for him. His perception that he had nothing to give his daughters also may speak to the type of knowledge he believed was worthwhile passing down—knowledge that can be translated into earnings.

Interestingly, after the tape recorder was turned off, Mr. A told me a story of a woman he knew before meeting his wife, a woman whom he loved deeply and wanted to marry. When he left for the war, he served in the navy, she ended the relationship. He later found out that she had become pregnant but decided on an abortion. He said he was told that the aborted child was a boy, and believed there was a “boy spirit” somewhere. He said the thought of the “boy spirit” brought him some degree of comfort despite his loss.

When we started the first interview, Mr. A handed me a wooden dog he had carved. It was about three inches long and two inches tall, with pointy ears, no tail, stubby legs and two ink dots for eyes. The dog was rather primitive in its simplicity; it was neither detailed nor particularly well crafted but its edges were rounded and so well-worn that even the pointy ears had a softness to them. When he handed me the dog, he told me that most people who held it did not want to give it back. He called it “a friendly little dog” and said that sometimes he would even let people borrow the dog for a few weeks as long as they agreed to return it, which they always did.

The wooden dog, along with poems he wrote, emerged as pieces of permanence – part generative and part restorative -- in the face of a life he described as “fading away.” Mr. A introduced the idea “fading away,” his idea of suffering, in the context of describing a job he once had writing binary code. He said, “I wrote 17 pages of ones and zeroes to translate what I wanted this machine to say… It had to be converted to binary, because binary, well, who knows. It all disappears and fades. After all, I am fading. I’m lucky in a sense to get to old age.” When I asked him to explain what he meant by “fading,” he said, “I’m fading because I’m approaching 85. I mean, I’m not going to get bigger and better at 85. I’m going to get less and less. So I say ‘fading’ because that’s how everything happens. You take a piece of steel and it’s been useful for many years and then it suddenly acquires a cover of rust and you say ‘why?’ Everything fades. Tell me something that doesn’t. You can’t think of anything that doesn’t fade. It gets weaker, it gets less useful.”

For Mr. A, the biggest threat to self was this gradual decline, the idea becoming less and less over time until ultimately disappearing. The wooden dog offered a piece of permanence in his fading world, a way to restore part of the fading self or at least hang onto the self as is, before it could fade any more. For example, early in the interview I asked Mr. A. whether he had any close friends who were still living. He explained, “I have one [friend], but he’s a relatively new friend. Not an old friend. My old friend moved to Florida. His wife passed away, who was a dear friend of my wife. She loved that little thing [referring to the wooden dog]. She really did. In fact, I let her have it for awhile. I look at that [dog] and I think of her. My wife won’t even touch it because she loved her [friend] so much.”

In addition to the dog, Mr. A showed me other creative and generative works, specifically some poems he had written. In one poem he writes, “My limbs are still/joints painfully bend./I guess I’m closer to the end.” Mr. A makes light of the changes in his body, which he feels signals his eventual death. Similar to his description of the piece of steel, he describes his joints as no longer bending with ease, almost like the Tinman character from The Wizard of Oz finds himself rusting into immobility. Mr. A told me there was no point to getting old since aging only led to uselessness. Like his wooden dog, the poem is a generative creation, infused with his sense of self and introduced not as a final and complete piece, but as an expression of an idea which he can continue to explore with himself or others. The poem also has the potential to live after him, even if only in the transcript of our interview.

Mr. A read another poem to me, “Anger,” which he had written about his wife:

She looked like she would explode
Her face livid
And her eyes became narrow slits
With little anger flashes
Lighting them.
He looked at her,
Calm at first,
But soon his anger began to parallel hers.
The distortion of his face told her
That she had gotten to him and his frustration
Caused little beads of perspiration to dot his
Forehead and run down his nose.
Anger, the psychologists say, is the secondary response.
First comes frustration or hurt.

He laughed after he finished reading it and said, “It’s a lot of fun to write this stuff and read it and sometimes you get somebody who really wants to listen and then it becomes important. If you have somebody to listen to it, and I thank you for listening, then you feel, you know you accomplished something. Somebody else enjoyed it besides yourself.” The dialogic interaction with teller and listener is a key part of his generative and restorative acts (Cohler & Cole, 1996). Mr. A. engages the outsider to listen to the aspects of his life he tells or shows through his creations and is validated when someone does.

As with his other short poem, Mr. A makes light of a very serious topic, an angry encounter between himself and his wife. He mentions in the poem that his wife knows she’s “gotten to him” and caused him to lose some control. However, in writing the poem, Mr. A is able to gain back a bit of this control by placing his emotions into crafted words and phrases and, in essence, bringing order to a very chaotic moment. As with his other pieces, he is able to use this poem as a means for talking about marriage, disappointment, anger, and other aspects of his life. Again, the pieces he creates are therefore generative works, as described by Kotre (1984), since they do not end when the product is completed (e.g., the poem is written, the animal is carved) but are works that he continues to care for as they develop.

When we returned to the subject of suffering, Mr. A., like many of the informants in the study, did not talk directly about his own suffering but instead described others who he thought had suffered. He said, “Guys in the infantry [during World War Two], they suffered. I wonder how they can be so brave to have to get up in the morning. I’m not relating myself to that kind of suffering. [Mine] was mild suffering. I wasn’t an infantry man. I was on a ship and what happened to one happened to us all.”

In talking about the war, he described an incident in which his ship shot down a Japanese plane. He said, “We were out there watching this kamikaze who is heading towards us and we hit it with a shell. It exploded and the pilot, the Japanese pilot, flew out of his plane. As he plummeted to the sea, I saw his scarf flap and I said, ‘Damn. I wonder who tied that around his neck. His mother? His wife? His girlfriend? They’ll never know what happened to him.’” The thought that someone close to the pilot tied the scarf that morning, not realizing that the pilot would never be seen again, that he would fade away into the sea, stayed with Mr. A as a powerful image of an outsider’s view of loss and a reminder of the importance of remembering.

Discussion

The purpose of this paper was to explore how generative acts may help to restore threats to selfhood associated with the experience of suffering in old age. The case of Mr. A., an informant who used a small wooden dog he had whittled and poems he had written illustrated how these generative acts helped him to combat the biggest threat to self, his gradual “fading away.” More than just pieces that he’s created for display or posterity, the wooden dog and poems become objects which he can introduce to others and, in doing so, work toward validating his self concept while narrating his suffering. Specifically, Mr. A. invites people to hold the wooden dog, giving him an opportunity to talk about others who have held it and what they have meant in his life. In such encounters, Mr. A. is also able to start new relationships, learn more about himself and others, and potentially passed along a bit of himself through the stories that he tells. In this way, Mr A achieves a sense of permanence in the face of his eventual disappearance.

In the exchange with Mr. A regarding how his wife’s friend loved the little wooden dog but later passed away, the dog represents loss for both Mr. and Mrs. A. It reminds them both of friends who are gone. Unlike his wife, who won’t look at the dog because she doesn’t want to be reminded of her friend, Mr. A uses the dog to remember lost friends and to share a small piece of himself with others through the stories he tells involving the dog. In this respect, the dog becomes a generative act that provides some continuity of selfhood for Mr. A. The wooden dog, which he gives to other people to hold, is a conduit for connecting, remembering, and preventing his ‘self’ from fading away.

Mr. A’s poems functions in a similar way. It is interesting that rather than produce a written copy of his poems, which would have been quicker and easier, Mr. A. chose to read them aloud to me, inviting me, the interviewer, to listen and to comment. This dialog between us helps make the distinction between Kotre’s view of creativity, which ends once the item has been produced, and generativity, which describes passing along something of the self that continues to develop over time. By reading and discussing his poems. Mr. A is able to “tend to” his product, watch the reaction it has on others, and possibly edit the poem a bit based on feedback while continuing to reflect on the meaning of his poem and life. Mr. A is engaged in generative acts that are creative yet include an important element of a continually evolving self.

The aspect of reflection and evolution found in the wooden dog and poems also speaks to repairs to the self through these generative acts. By presenting and discussing key moments from his life and his self concept through his art, he is able to validate his self concept and perhaps better understand other aspects of his ‘self’ through his interactions. He is able to examine threats to his concept of self and possibly to resolve them, which in turn leads to repair of the self.

Mr. A is also able to act as teacher of his own life through the wooden dog and poems. Teaching and passing along something of value to others are crucial to him. Not only does he teach classes at the senior center, he continually mentioned his regret at not having gone to college to become a high school teacher. He mentions, in reference to his daughters, that there is nothing he can teach them given their great success. On the one hand, it makes him happy that he has fulfilled his role as father. On the other hand, his inability to teach them points to his loss of value. Like the piece of steel, he risks becoming weaker (more rusty) and less useful.

Although he could have resorted to some of the reconstructive reactions to threats to self described by Charmaz (1983), specifically living a more restricted life, social isolation or discrediting definitions of self, Mr. A seems to do something very different. He proactively confronts threats to self hood and attempts to work through them, therefore not living more restrictively, not becoming socially isolated, and not discrediting definitions of self. Again, Mr. A’s generative acts seem to help him continue to move forward despite his suffering or despite his fears of fading away. His actions are a reassurance that he is still present and noticeable.

Overall, the case of Mr. A suggests that certain types of generative acts may help to repair selfhood, especially the aspect of selfhood which requires the validation of others, as suggested by Charmaz (1983). Although we cannot generalize as to whether encouraging people who are suffering to engage in projects aimed at self repair -- through artistic expression, writing, or some other outlet -- could help mediate the experience suffering in old age, it presents some encouraging avenues for future research. Whether the internal awareness of the need for self repair drives generative acts, or whether the type of suffering influences if and to what extent self repair can be achieved are questions worth pursuing.

Footnotes

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Works Cited

  • Benedict S. The suffering associated with lung cancer. Cancer Nursing. 1989;12(1):34–40. [PubMed]
  • Biggs S. Age, gender, narratives and masquerades. Journal of Aging Studies. 2004;18(1):45–58.
  • Black HK. Different ways to hurt: An elderly woman’s narrative of suffering. Journal of Aging and Identity. 2002;7(1):3–15.
  • Black HK. Is pain suffering? A case study. International Journal of Aging and Human Development. 2007;64(1):33–45. [PubMed]
  • Black HK. Jake’s story: A middle aged man’s physical and spiritual journey to death. Qualitative Health Research. 2001;11(3):293–307. [PubMed]
  • Black HK, Rubinstein RL. The effect of suffering on generativity in African American men. Journal of Gerontology in press. [PMC free article] [PubMed]
  • Black HK, Rubinstein RL. Themes of suffering in later life. Journal of Gerontology: Social Sciences. 2004;59B(1):S17–S24. [PubMed]
  • Black HK, White T, Hannum SH. The Lived Experience of Depression in Elderly African American Women. Journals of Geronotology: Psycholocial and Social Sciences. 2007;62:S392–S398. [PubMed]
  • Cassel E. The nature of suffering and the goals of medicine. New England Journal of Medicine. 1982;306:639–645. [PubMed]
  • Charmaz K. Loss of self: A fundamental form of suffering in the chronically ill. Sociology of Health and Illness. 1983;5(2):168–197. [PubMed]
  • Charmaz K. Stories of suffering: Subjective tales and research narratives. Qualitative Health Research. 1995;9:362–382.
  • Charmaz K. Qualitative interviewing and grounded theory analysis. In: Gubrium JF, Holstein JA, editors. Handbook of interview research: Context and methods. Thousand Oaks, CA: Sage; 2002. pp. 675–693.
  • Cohler BJ, Cole TR. Studying older lives: Reciprocal acts of telling and listening. In: Birren JE, Kenyon GM, Ruth J, Schroots JJF, Svennsson T, editors. Aging and biography: Explorations in adult development. New York: Springer; 1996. pp. 61–76.
  • Conway MA, Pleydell-Pearce CW. The construction of autobiographical memories in the self-memory system. Psychological Review. 2000;107:261–288. [PubMed]
  • Das V. Moral orientations to suffering: Legitimation, power and healing. In: Chen LC, Kleinman A, Ware NC, editors. Health and social change in international perspective. Boston: Harvard University Press; 1994. pp. 139–167.
  • de Medeiros K. The complementary self in old age: Multiple perspectives on the aging person. Journal of Aging Studies. 2005;19(1)
  • Erickson EH. Childhood and society. New York: Norton; 1963.
  • Erickson EH. The life cycle completed. New York: W.W. Norton; 1993.
  • Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967.
  • Hazan H, Raz AE. The authorized self: How middle age defines old age in the postmodern. Semiotica. 1997;113(34):257–276.
  • Kahn DL, Steeves RH. The experience of suffering: Conceptual clarification and theoretical definition. Journal of Advanced Nursing. 1986;11:623–631. [PubMed]
  • Kaufman S. The ageless self: Sources of meaning in late life. Madison, WI: The University of Wisconsin Press; 1986.
  • Kirmayer L. Broken narratives: Clinical encounters and the poetics of illness experience. 2000. pp. 153–180.
  • Kotre J. Outliving the self: Generativity and the interpretation of lives. Baltimore: The Johns Hopkins University Press; 1984.
  • McAdams DP. The stories we live by: Personal myths and the making of the self. New York: The Guildford Press; 1993.
  • McAdams DP, Diamond A, de StAubin E, Mansfield E. Stories of commitment: The psychosocial construction of generative lives. Journal of Personality and Social Psychology. 1997;72(3):678–694.
  • McAdams DP, de StAubin E. A theory of generativity and its assessment through self-report, behavioral acts and narrative themes in autobiography. Journal of Personality and Social Psychology. 1992;62(6):1003–1015.
  • Murphy RF. The body silent. New York: Norton; 1987.
  • Pennebaker JW. Traumatic experience and psychosomatic disease: Exploring the roles of behavior inhibition, obsession and confiding. Canadian Psychology. 1985;26:82–95.
  • Pennebaker JW, Cohler M, Sharp LK. Accelerating the coping process. Journal of Personality and Social Psychology. 1990;58(3):528–537. [PubMed]
  • Pennebaker JW, Keough KA. Revealing, organizing and reorganizing the self in response to stress and emotion. In: Contrada RJ, Ashmore RD, editors. Self, social identity and physical health. New York: Oxford University Press; 1999. pp. 101–121.
  • Pennebaker JW, King LA. Linguistic styles: Language use as an individual difference. Journal of Personality and Social Psychology. 1999;77(6):1296–1312. [PubMed]
  • Pennebaker JW, Mayne TJ, Francis ME. Linguistic predictors of adaptive bereavement. Journal of Personality and Social Psychology. 1997;72(4):863–871. [PubMed]
  • Raz AE. The discourse of aging and other age-related languages: How selves are authorized in the postmodern. Studies in Symbolic Interaction. 1995;18:23–57.
  • Scarry E. The Body in Pain: The Making and Unmaking of the World. New York: Oxford University Press; 1985.
  • Schensul JJ, LeCompte MD, Trotter RT, Cromley EK, Singer M. Enhanced Ethnographic Methods: Audiovisual techniques, focused group interviews, & elicitation. Walnut Creek, CA: AltaMira; 1999.
  • Yin RY. Case study research: Design and methods. New York: Sage Publications; 2003.