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Therapeutic Letters and

the Family Nursing Unit

Journal of Family Nursing


Volume 15 Number 1
February 2009 6-30
2009 Sage Publications
10.1177/1074840709331865
http://jfn.sagepub.com
hosted at
http://online.sagepub.com

A Legacy of Advanced Nursing Practice


Janice M. Bell
Nancy J. Moules
Lorraine M. Wright
University of Calgary, Alberta, Canada

This article focuses on the history of the use of therapeutic letters in the
clinical scholarship of the Family Nursing Unit at the University of Calgary
and offers examples of a variety of therapeutic letters written to families
experiencing illness suffering. A case study from the research of Moules
(2000, 2002) is offered to further illustrate the usefulness of therapeutic letters as a family nursing intervention.
Keywords: therapeutic letters; Family Nursing Unit; Family Systems Nursing;
family nursing intervention; illness suffering

n the Family Nursing Unit (FNU), University of Calgary, we have used


therapeutic letters as a Family Systems Nursing intervention for more
than 22 years and written hundreds of letters to families (Levac et al.,
1998; Moules, 2000, 2002, 2003, 2009b [this issue]; Moules, Thirsk, &
Bell, 2006; Wright & Bell, in press; Wright & Simpson, 1991; Wright &
Watson, 1988; Wright, Watson, & Bell, 1996). It has been noted in FNU
outcome studies and in-session comments that families report a valuing and
appreciation of the letters and, in many instances, attribute the letter with
substantial credit for therapeutic change and softening of illness suffering
in the context of their clinical work. Prior to the doctoral research by
Moules in 2000, therapeutic letters had not been studied in nursing,
although they have been presented in clinical and theoretical family nursing
literature surrounding the clinical work of Lorraine Wright, Wendy Watson,
Authors Note: Address all correspondence to Dr. Janice M. Bell, 12224 Okanagan Centre Rd.
West, Okanagan Centre, British Columbia, Canada V4V 2H5; e-mail: jmbell@ucalgary.ca;
Web site: www.janicembell.com.
6

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 7

and Janice Bell (Wright et al., 1996; Wright & Watson, 1988), Lorraine
Wright and Maureen Leahey (1994, 2000, 2005, 2009), and Family
Systems Nursing graduates who completed one or more practicums in the
FNU (Harper-Jaques & Masters, 1994; Marshall & Harper-Jaques, 2008;
Wright & Simpson, 1991). The history and use of therapeutic letters in the
advanced nursing practice of the FNU will be described in this article,
examples of a variety of therapeutic letters written in the FNU will be
offered, and a case exemplar from the research of Moules (2000, 2002) will
be used to illustrate the usefulness of this family nursing intervention with
families suffering in their experience of serious illness.

The Use of Therapeutic Letters in Clinical Work


The literature on therapeutic letters is primarily clinically based and
descriptive. The term and the specific practice of therapeutic letters are
generally attributed to the domain of narrative therapy and specifically to
the work of David Epston and the late Michael White (Epston, 1989; White,
1995; White & Epston, 1990). Epston first experienced using letters in 1977
in a psychiatric outpatient clinic. Epston (1994) offered that the purposes of
letters include offering summaries of clinical work that privilege clients
stories over medical documentation, creating opportunities for future
reflection and discussion, allowing for salvaging of bad sessions,
acknowledging of clinician mistakes, allowing for clarification of confusion and transparency of thinking, creating more possibilities for both client
and clinician reflection, and as vehicles to communicate difficult ideas that
might be more easily heard and absorbed when read privately.
Wojcik and Iverson (1989) wrote of letters as a means to provide emphasis and punctuation; to create a sense of drama; to provoke; to appease
families and decrease clinicians defensiveness by allowing opportunity for
explanation; to offer hypotheses, interpretation, or the ability to strategize
for solutions; and finally to terminate with clients. Although the authors
speculated on the power of the printed word (p. 77), they admitted to a
lack of understanding of the source of the power.
Shilts and Ray (1991) referred to their use of letters as a strategic intervention with a specific intent to engage clients in therapy, promote cooperation, and find solutions to their presenting problems (p. 98). Other
strategic uses of letters include attempts to change the rules of family systems (Elkaim, 1985); to engage nonattending spouses (Wilcoxen & Fenell,
1983); to increase the effect of therapy and serve as a record (Wood & Uhl,

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8 Journal of Family Nursing

1988); as a means to offer information prior to an initial session (Coles,


1995); as a vehicle to offer other mediums such as cartoons, which might
invoke questions and dilemmas that represent a clients own (Kennedy,
1995); as a way to provide teaching, information, and normalizing to clients
who have experienced sexual abuse (Harper-Jaques & Masters, 1994); or as
a means for the clinician to organize treatment and maintain a sense of
control (Lown & Britton, 1991).

Clinical Scholarship of the


Family Nursing Unit, 1982-2007
Advanced nursing practice in the FNU is focused on illness suffering
and family healing. The FNU was established in 1982 by Dr. Lorraine
Wright as a research and education unit for the purpose of creating and disseminating practice knowledge with families suffering with serious illness
(Bell, 2008; Flowers, St. John, & Bell, 2008; Gottlieb, 2007; Wright et al.,
1990; Wright, Watson, & Duhamel, 1985). Wright first coined the term
Family Systems Nursing and later published an article with Leahey in 1990
that offered distinctions between family nursing and Family Systems
Nursing, with the latter emphasizing the family system as the unit of assessment and intervention. Over time, an evolved understanding of Family
Systems Nursing asserts that it is an advanced practice with attention to the
reciprocity and interaction between multiple systems levels: illnesses, individual family members, family systems, and larger health care and societal
systems. The ability to think relationally or systemically and assess
multiple systems levels, while intervening at the systems level that offers
the greatest leverage for health and healing, is one of the hallmarks of
Family Systems Nursing. A preference for collaborative, strengths-based
relationships with families and a belief in the legitimacy of multiple realities (Maturana & Varela, 1992) also characterize this nursing practice.
Clinical scholarship in the FNU (Bell, 2003) resulted in the development
of two advanced nursing practice models known as the Illness Beliefs
Model (Wright & Bell, in press; Wright et al., 1996) and the Trinity Model
(Wright, 2005). The clinical practice of the FNU is also foundationally
grounded in two models for generalist family nursing practicethe Calgary
Family Assessment Model and the Calgary Family Intervention Model
(Wright & Leahey, 2005, 2009). Out of many domains of family functioning, this approach to clinical practice pulls to the foreground an emphasis on
beliefs, recognizing that family members as well as health care professionals

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 9

have beliefs that facilitate and those that constrain in the ways they influence
lives, relationships, behavior, and illness suffering. Beliefs that are constraining can be explored, challenged, and altered; those that are facilitating
can be acknowledged, reinforced, and amplified (Wright & Bell, in press;
Wright et al., 1996). The Trinity Model conceptualizes the intertwining of
beliefs, illness suffering, and spirituality (Wright, 2005) and offers interventions for witnessing and acknowledging illness suffering and inviting
spiritual conversations that may soften illness suffering.
Clinical sessions in the FNU were observed from behind a one-way mirror by a clinical team, composed of faculty members and graduate nursing
students, at masters and doctoral levels. The clinical team participated in
the interviews by telephoning to the interview room with ideas and questions, as well as in presession and postsession discussions. The belief of the
clinical team in the benefit of multiple minds combined with the belief
that we are all in this togetherin our desire to learn from and be helpful
to families created a synergistic collaboration for both the clinician conducting the session with the family and the team observing from behind the
one-way mirror (Flowers et al., 2008). The structure of clinical work was
based on the five-part session first suggested by the Milan family therapy
team (Tomm, 1984). The interpretation of this five-part session in the FNU
consisted of a presession conversation between the clinical team members;
the clinical therapeutic conversation with the family and clinician; an
intersession, in the form of offering a reflecting team (Andersen, 1991),
where the family observed the team members discuss their observations
and reflections amongst themselves; a concluding discussion with the family; and a postsession clinical team discussion. The clinicians for the family
were faculty members, doctoral students, or 2nd-year masters students;
and all sessions received live supervision by a faculty member. All clinical
sessions, as well as the clinical teams presession and postsession, were
videotaped after consents were obtained from family members and students. On average, families received an average of four to five sessions.
After celebrating 25 years of clinical scholarship and learning from
families, the FNU was closed in December 2007 (Bell, 2008). This
advanced practice knowledge continues to live on through the offering of
Family Systems Nursing specialization at the University of Calgary and the
University of Montreal; through ongoing research and case studies from the
archived clinical database of the FNU; and through the clinical practice,
research, and teaching of faculty members of the FNU and more than 100
masters and doctoral graduates in Family Systems Nursing as well as hundreds of international nurses who have participated in the annual Family
Nursing Unit Externship workshops.

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10 Journal of Family Nursing

The incorporation of therapeutic letters in clinical practice has existed in


the FNU for more than 22 years (Wright et al., 1996; Wright & Simpson,
1991; Wright & Watson, 1988). The FNU clinical team of graduate nursing
students and faculty members employed the influence of letters to create
opportunities for more collaborative and transparent therapeutic relationships with client families. Letters provided opportunity to offer commendations or acknowledgments of individual and family strengths, describe
what the family taught the nurse clinician, emphasize and punctuate in-session
ideas, offer new ideas and questions, distinguish and amplify change, challenge constraining beliefs and solidify facilitating beliefs, admit a therapeutic error, and actively challenge the clinicians own ideas and beliefs
(Wright et al., 1996).

A Conversation of History:
Letters in the Family Nursing Unit
In fact, history does not belong to us, we belong to it. (Gadamer, 1989,
p. 276)

A unique advantage and opportunity occurred in the research of Moules


(2000) by having Dr. Lorraine Wright, founder of the FNU and director of
the FNU (1982-2002), as a research participant. This allowed for a portion
of the interview to focus on the evolution and practice of letter writing in
the unique context of the FNU, as well as the extraordinary opportunity to
interview an accomplished and sophisticated clinician, who at the point of
Mouless doctoral thesis had more than 15 years of clinical experience in
writing therapeutic letters to families. In situating the context for letter writing in the FNU, it is important to remind ourselves that we are historical,
that how letters evolved in the FNU is important to how they are practiced
now. LMW refers to Dr. Lorraine Wright; and NJM refers to Dr. Nancy
Moules, who conducted this research interview.
LMW: I think the first time we ever published [Wright & Watson, 1988] about
the use of therapeutic letters was in 1988, so it would have been a couple of
years before that. I remember that family very well because of the letters.
Because that was really the most dramatic thing about the work with this
family. We wrote letters separately, one to the daughter and one to the mother
and they were justshe just came in holding this letter, like this, waving it
like this . . .

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 11

NJM: And when you first started, was it something that you had read about in
other literature in other family therapy literature, is it something you had
heard about at all in other peoples practices, or was it something that you
just sort of stumbled onto?
LMW: At that time it was just something we stumbled onto. But it was later
after that that I became aware of David Epston, much later . . .
NJM: Oh, so you didnt use the word therapeutic letters?
LMW: No. You know I cant remember just how we came and . . . because it
certainly wasnt something that was a routine part of our practice, like it is
now. What I remember is we used to use the letter and what we did with this
particular family to offer a split opinion instead of just offering it in the session, we would offer them a split opinion in a letter.
NJM: Why did you choose that particular way to do that instead of offering it
in session?
LMW: Well, because we thought it would have more impactthat they could
think about it, especially for families where there was really entrenched
beliefs.
NJM: At that time did you use letters with things other than split opinions?
LMW: Yes, we did on occasion. Ive never gone back and done any kind of
historical review about therapeutic letters in the FNU, but then it was later
that we began to became aware of David Epston and Michael Whites work
and especially David Epston, his use of them every single session. And they
were using them in a bit of different way.
NJM: Whats your personal belief around what kind of contribution do you
think they make in the clinical work?
LMW: Well, when I look at our clinical work and when I hear back from families, verbally, or their reactions you know from session to session, or what
they say to us on the outcome study, Id have to say that the three interventions that really seem to stand out, that they seem to most readily comment
on are; if I had an order, it would reflecting teams and therapeutic letters are
tied for number one, and Id say the use of commendations.
NJM: But those [commendations] are woven into both of those.
LMW: And theyre woven in; theyre embedded within those interventions, but
those are the things that I hear family members commenting on the most and
then after that what they comment on the most is the kinds of questions that
we ask.
NJM: Which is another thing, like commendations, its more of a microanalysis
of what happens in the letters and the reflecting teams, isnt it?
LMW: I was thinking in the terms of therapeutic letters, I mean what is always
so interesting to me is with any of those three ideas is that all of those interventions are ways of challenging constraining beliefs, in a way that makes it
more palatable to the families instead of just confronting someone, or taking
them on directly or what not. Its like it lifts it into another medium.

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12 Journal of Family Nursing

NJM: Well youve written in the Beliefs book [Wright et al., 1996] and also, you
read the anecdotal type of reports about how families and clinicians report
the value of a therapeutic letter. Im not sure I find this particular measurement a really useful one for me, but Ive been asking it of everybody along,
in terms of a therapeutic letter being equivalent in value to 3 to 10 clinical
sessions. My guess is that its such an individual answer, it really depends on
each family, but if you could just slip into generalizing around it, in your
opinion, what would you say one therapeutic letter is worth?
LMW: I dont know that I could go so far as to say its worth 10; but Id certainly say, that it has the potential, that every therapeutic letter is equal to one
therapeutic conversation, to one clinical interview.
NJM: So it doubles the interview?
LMW: Depends on . . . theres the skill and the expertise of the person writing
the letter, the clinician whos writing them. Some just really recap the session, which sometimes, in and of itself, thats useful too, for family members
to really have that historical perspective, cause its impossible to really
remember all the things. And to me its another way of getting at what perturbed them in the session, because that question of what stood out for them,
I think can be answered more clearly when the sessions really recapped, for
them again in writing. Its like theyve had two opportunities to think about
the session, what they reflected on in that moment, and what they reflect on
again after theyve left, because to me thats one of the most significant
things about the letters. Its another invitation to another reflectionabout
their lives, about the session, about the problems they are concerned about.
NJM: Would you say that thats the biggest thing that therapeutic letters do is
offer that invitation then?
LMW: To another reflection? Yes. To another reflection to invite them to challenge their own beliefs that may be troubling, that theyre suffering around.
To see it in writing takes on a whole different flavor and a whole different
meaning.
NJM: Can you speculate why?
LMW: I think anything you read is more penetrating than the spoken word.
NJM: And how do you think you came to that belief?
LMW: I guess from my personal experiences with words on paper, as opposed
to words verbally. Theres always exception to the rule. . . . I think its more
lasting somehow when its written. That it stays with you longer . . . the
beauty of being able to go back to the written word. That you cant always
capture, and sometimes youre trying to remember, now how did that person
say that to me, and what was it that they said exactly, but if you have a letter,
its that wonderful thing of being able to go back to the way it was actually
said, rather than the way you think it was said, or the way you think you
remembered it. And I think in lots of relationships thats what gets us into a
lot of trouble with each other is what we retain. I mean thats usually what

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 13

people argue over you said; no I didnt; I said, no you didnt, you said. And
we go around and round about that, about what we think our memory of the
words that were spoken that were very meaningful to us or that were hurtful
to us, or that were disappointing, and we try to recapture a conversation . . .
with the written word you can go back. We do give such value to the written
word in our society, way more than the oral tradition, in our particular culture
anyway.
NJM: But its interesting to me about, just because you put something into writing though, doesnt protect it from being misinterpreted, does it?
LMW: Oh no, it doesnt protect it from that but theres something about the
ability to keep going back and back to it in the way it was sent. Cause I find
verbally, you can keep going back and back to what you thought was said,
what you thought the message was, what you thought you heard, but the
beauty here is I cant change that.
NJM: Both the beauty and the risk, the danger.
LMW: Yes, very much, cause we can always modify. I mean were always saying to each other, Well gee if I did say that I didnt quite mean it that way.
You cant do that in a letter. You cant deny you said it.
NJM: Or if I did I didnt mean it.
LMW: Well, you can do that in a letter, well Did I say that? Well, I didnt really
mean to word it that way. But it stays, its there, it cant be removed in the
same way.

Types of Therapeutic Letters Written


in the Family Nursing Unit
With the exception of the closing letter, which denoted the end of the
clinical work with the family, not all families received therapeutic letters
during their clinical work at the FNU, or after every clinical session.
Generally, it was decided in the clinical teams postsession discussion to
send a family a letter, a decision at times initiated by the clinician, a team
member, or the faculty supervisor. This decision seems to be related to
some indication that the family might find a letter useful, the perception
that the family might benefit from clarification of the session (see Table 1
for an example of a between-session therapeutic letter), the intention to
invite nonattending family members (see Table 2 for an example of a therapeutic letter to an absent family member), the admission of a therapeutic
error (see Table 3 for an example of a letter admitting a therapeutic error),
the intention to summarize the multiple ideas offered in the reflecting team,
or creating an opportunity to offer further ideas that developed during the
postsession discussion. At the termination of the clinical work, all families

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14 Journal of Family Nursing

received a closing letter, which follows a more structured format, describing to the family what the team learned from them over the course of the
clinical work and what the team believed they offered the family (see
Tables 4 and 5 for examples of a closing therapeutic letter). With the familys permission, a copy of the closing letter was usually sent to the referral
source.
Typically, an FNU therapeutic letter would include the following elements: distinguishing individual and family strengths through the offering
of commendations (Bohn, Wright, & Moules, 2003; Houger Limacher &
Wright, 2003, 2006; Wright & Bell, in press; Wright et al., 1996; Wright &
Leahey, 2005, 2009), highlighting significant conversational events, offering reflections of the clinician and the clinical team, posing additional questions offered either as outcomes of these reflections or with the intent to
challenge constraining beliefs and invite family members to a new reflection, and celebrating therapeutic change and distinguishing new facilitating beliefs (Wright et al., 1996). Rather than the letter simply being a
summary of the session, the challenge was to offer something different in
the lettersome news of difference (Bateson, 1979). The news of difference needed to be carefully calibratednot too slight a difference so that it
went unnoticed, but not too large a difference or too many different ideas
so that the family members could reflect without feeling like they were, in
the words of one overwhelmed father, drinking water from a fire hose!
The ideas and suggestions also needed to be offered tentatively and speculatively to honor the ideas of objectivity (in parentheses) and the legitimacy
of multiple realities (Maturana & Varela, 1992). Following the research by
Moules (2000), the clinical team became more mindful to also acknowledge illness suffering and hear the cries of the wounded (James, cited in
Amundson, 2001, p. 186).
Because of the nature of the educational context of the FNU, graduate
student clinicians or graduate observers of the clinical sessions most often
wrote letters as a means to develop conceptual and perceptual skills in
Family Systems Nursing (Wright et al., 1996). A faculty supervisor always
reviewed and edited the letter before it was sent to the family. The educational context of the FNU raises the issue of teaching students how to write
therapeutic letters, while still maintaining a responsibility to the family. The
FNU was a clinical setting, but it was primarily an educational one, and
there was a responsibility to immerse the students in learning the clinical
practice, a part of which was giving them experience in writing therapeutic
letters. With experience, we, as faculty supervisors, learned to find a balance

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 15

Table 1
Example of a Family Nursing Unit (FNU)
Between-Session Therapeutic Letter
Dear Doreen and Charlie,
Greetings from the Family Nursing Unit.We were pleased to meet with you on
November 21, and we wanted to share some of our thoughts with you.
We were very struck by the love and caring you showed for each other, and
were touched by the warm stories of how you met and what attracts you to
each other. You both openly shared your concerns about how the numerous
illnesses were affecting your lives and were clear when telling us what you
thought you needed from us and from each other.You seem to share our belief
that illness is a family affair! When one person in a family is ill, it affects everyone in the family.
Charlie, we were impressed that you came to the session even though you
are in hospital, and awaiting surgery. It speaks to how very committed you are
to Doreen and your family. The love and support you feel for Doreen shone
through in what you said and the loving way you complimented her on her
strength and abilities.
Doreen, we were impressed by your ability to pull out your strength in
order to be there for Charlie during his present illness. You have learned ways
to influence the seizures you have experienced and put them in their place so
you can be there for your family.You have been able to overcome years of people telling yourself that you are no good, and tell us so clearly I am strong.
We really saw your strength during the session, and wondered what kinds of
things you and Charlie can do to feed that strength and make it bigger?
We thought about how, in the past, you have connected as a couple to put
problems and illnesses in the back seat. It seemed that you are pulling together
as a couple once again in order to cope with the bowel surgery. We wondered
what things might help you to be even more connected?
Doreen, you talked about feeling connected when Charlie shows that he
cares for you by saying nice things and being appreciative. Charlie, we wondered what things Doreen does that makes you feel more connected to her?
We wondered if you felt more connected during the times when Doreens
strength shows, and she is able to put her seizures in the back seat so she can
be there for you during the times when you are ill? We also thought about the
way that illness has served to pull you together as a couple, and wondered how
you could make the together in illness smaller in comparison to the two of
you coming together outside of illness.Would your coming together outside of
illness maybe help you put illness in its place?
(continued)

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16 Journal of Family Nursing

Table 1 (continued)
Again, we are impressed with your strength and ability to tackle problems
and illnesses as a couple.You have a lot to teach us about how families can live
and love in the face of numerous health problems. We are confident in your
ability to pull together as a couple to cope with the new health problems you
are facing in the next few weeks. We look forward to meeting you again in the
New Year.
Sincerely,
Rose Schroeder, RN, Master of Nursing Student
Janice M. Bell, RN, PhD, Acting Director, Family Nursing Unit
and other members of the clinical nursing team

between teaching and creating the opportunity for learning and needing a
certain amount of vigilance and surveillance. What goes out of the FNU,
with the signature of the clinician and faculty supervisor and director, is
laden with the ethics of responsibility, professionalism, and personal commitment. The therapeutic letters that left the FNU were the end result of
acts of balancing between learning, teaching, commitment, and integrity.

A Case Example of Therapeutic


Letters in the Family Nursing Unit
The first four letters from the FNU in Mouless research (2000, 2002)
were received by Doreen and Charlie. This couple was referred to the FNU
by their home care worker, because of concerns regarding Doreens uncontrolled epilepsy and Charlies bowel disease, diabetes, cardiac disease, and
depression. Doreen made the initial contact and came to the first session on
her own. Her concerns were her own health, the health of her husband, her
dependence on him, and the influence of all these issues on their relationships
with each other and their children. Doreen and Charlie both had a long history of involvement in the health care system and in the mental health system
and had been seen for marital therapy several times and for extensive periods
in the past. At the FNU, they were seen for four sessions over a period of 3
months and received four therapeutic letters (Letter 2 to Doreen and Charlie
is offered as an example of a between-session therapeutic letter in Figure 1).

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 17

Table 2
Example of a Family Nursing Unit (FNU) Therapeutic
Letter to an Absent Family Member
Dear Elizabeth:
Greetings from the Family Nursing Unit. We met once again with your
mother and sister last week. They shared with us that you have been admitted
to the hospital. We want to let you know that we were sorry to hear this news.
We have been deeply touched by the love and admiration that your mother and
sister express for you.
Although we have not had the opportunity to meet you in person, we
believe you have a powerful presence in our conversations. We hope that in
writing to you, you may feel more a part of these conversations. We wonder if
you might be willing to share your thoughts in a letter with us.When you think
back to reading the letter that we sent you a few weeks ago, what stands out
in your mind? Have you had thoughts about it since that time? Is there anything
we might have misunderstood about your familys experience? We have
learned a little about how you worry about your family, and found ourselves
wondering what worries you might have for yourself. Are there any questions
you keep asking yourself over and over?
Your mother and sister have shared with us the great strength you show in
facing the challenges that diabetes brings. We realize that this journey has been
a long and difficult one for you and your family. It is amazing how you each
have found different and unique ways to support each other on this journey.
We feel privileged to have the opportunity to further learn about your familys
experience of living with illness.
With warm regards,
Tina West, RN, Master of Nursing Student
Lorraine M. Wright, RN, PhD, Director, Family Nursing Unit
and other members of the clinical team

The research interview occurred 2 years and 3 months after the closing of
their clinical work in the FNU and the receipt of their last therapeutic letter.
Rose Schroeder, RN, BN, a masters student in Family Systems Nursing in
the FNU in her 2nd year of study, wrote the letters. She had previous experience as a staff nurse in mental health, a nurse clinician, and a nurse educator.
Supervision for the clinical work and in the writing of the therapeutic

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18 Journal of Family Nursing

Table 3
Example of a Family Nursing Unit (FNU)
Letter Admitting a Therapeutic Error
Dear Wilma and Tim:
Greetings from the Family Nursing Unit! Our clinical team learned a great
deal from both of you during our conversation in January and we wanted to
share our thoughts and impressions with you in a letter.
It was a pleasure to see both of you again during our second session. Once
again we were grateful for your willingness to talk openly about the ways that
the intruder of muscular dystrophy (MD) has impacted your lives. You two
have been through a great deal together! We learned that you believe this illness has changed your relationship as a mother and father but has not changed
your strong love for your children.We were impressed with the dedication you
have shown in raising two children who have, at times, had their own struggles.
We learned that because of the changes that MD has brought, you are finding
it challenging to work as a team in your parenting roles.
This session was an opportunity for us to learn more about your relationship as husband and wife and the meaning it has brought to your lives. Wilma
and Tim, you helped us understand that you are very proud to have created a
satisfying marriage by building a strong foundation for your marriage through
your love and commitment to each other and your shared hopes and dreams.
It seems that MD has not only broken into your marriage relationship but has
stolen away your hopes and dreams for the future and has robbed you of feeling intimate and connected as a husband and wife. In particular, we learned
that you believe that it is not the physical changes of the illness but the cognitive changes that are eating away at the strong foundation of your marriage.
This left us wondering whether it would be helpful for the two of you to create
small moments of connection as husband and wife every day as a way to interrupt the belief that you are becoming only a care giver and care receiver.
We made an assumption during our session that, because of the strong
foundation you had built for your marriage, you both wished for some ideas
about how to reclaim your special relationship as husband and wife from the
influence of MD. Upon reviewing the videotapes of the session, we realize that
we did not check with each of you directly about whether you agreed with
this goal of strengthening your marital connection in our work together. From
comments you made at the end of our session, Wilma, we wondered if perhaps
we made an error by not asking each of you if you believe that it is possible
to reclaim your marriage from illness. We believe there are many possible
ways that illness suffering can be reduced and perhaps we were too premature
to conclude that strengthening the good foundation of your marriage was the
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Bell et al. / Therapeutic Letters and the Family Nursing Unit 19

Table 3 (continued)
best way to reduce the suffering and isolation you are both experiencing. We
now wonder if we need to challenge our teams belief about the best way to
help your family heal.
Throughout our conversations, we have learned that your family believes
that the illness of MD has caused you, Wilma, the most suffering. We are very
impressed with the dedication, perseverance, and wisdom you have shown as
a wife and mother in caring for everyone in your family for many, many years.
We believe we need to understand more about your experience and where you
have found the energy and resources to endure this unexpected life where illness has been so present in your relationships and daily routines. How do you
make sense that your life has been one of caring for your ill family members
[husband and daughter]? Where do you find support and respite from this
responsibility? What are your hope and fears for the future?
We have learned from our work with families that family members are
affected by illness differently at different times and phases over the long haul
of chronic illness. Just as it was helpful to see you together as a couple, perhaps
it would now be useful to have an individual session with you, Wilma, to learn
more about how you find the energy to care so deeply for your family. If this
ideas fits for you, we would be pleased to meet with you alone at our next session. If you have other ideas about who should attend the session or what the
focus of our work should be, please let us know.
Kind regards,
Lorraine Thirsk, RN, MN, Doctoral student
Colleen Cuthbert, RN, 1st-year Master of Nursing student
Janice M. Bell, RN, PhD, Director, Family Nursing Unit
and other members of the clinical team

letters was provided by Janice Bell, RN, PhD, an FNU faculty member.
Ms. Schroeder will be referred to as RS and Dr. Nancy Moules as NJM.

Significance of the Letters to Doreen, Charlie, and Rose:


Withstanding the Test of Time
In the final clinical session with Doreen and Charlie, RS asked questions
designed to evaluate her own practice as well as gain some understanding
of the experience of the family regarding the clinical work. In the process
of this evaluative discussion, Charlie suggested that the letters were very
significant.

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20 Journal of Family Nursing

Table 4
Example of a Family Nursing Unit (FNU) Closing Therapeutic Letter
Dear Connie, Samantha, and Jeremy:
Greetings from the Family Nursing Unit. As part of completing our clinical
work with families, we send a closing letter as a summary and record of our
time spent together. From February 24 to April 14 we had an opportunity to
meet with you on three occasions.
We would like to share what we learned from your family and what we
believe we offered to you in these sessions. We were very touched and privileged with your sharing of the tragic experience of losing William and Aaron
[husband/father and son/brother], and your continuing journey in finding your
own ways to live with your losses.
What we learned from your family:
1. You shared with us your powerful story of experiencing two traumatic and
unexpected losses in your family [through the deaths of William and Aaron].
We heard that living with loss and grief has been the most challenging and
difficult journey you have endured as individuals and as a family. You have
taught us about strength and courage in the face of loss and grief. Although
we believe that families have amazing resilience and resources in difficult
situations, you demonstrated an exceptional capacity to rise to this challenge
and emerge with courage and sensitivity.
2. We have been impressed with your ability to remain a very close family, one
that supports and respects each other and one that has been able to share so
openly about deeply painful issues. In choosing to remain united and committed to one another, we learned again of the power that families have when
they work together. The team witnessed an extension of this commitment
when you openly expressed your hopefulness ad optimism for an untainted
future.You taught us that even amidst sorrow, pain, and grief there can be joy,
as you shared the changes and blessings in your family that evolved as a result
of William and Aarons deaths.
3. We learned that you are a very spiritual family and your strong spiritual beliefs
invited the team into the privilege of experiencing William and Aarons spirit
in our sessions. Your belief that God loves you unconditionally and has a reason and purpose for this loss seems to have helped you make sense of this
experience. You reminded us how ones strong spiritual beliefs and faith in
God is sustaining and can diminish suffering and contribute to healing.

What we believe we offered you:


1. Our team offered you our observation of your closeness as a family and we
witnessed the concern you have not only for your individual well-being but
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Bell et al. / Therapeutic Letters and the Family Nursing Unit 21

Table 4 (continued)

the well-being of your family. We offered our perceptions that some family
members seem to have been able say good-bye to parts of the relationship
with William and Aaron more easily, and other members have had an easier
experience with saying hello. The team offered our belief that grief is both
about saying good-bye and saying hello and we wondered if there could be a
way that you could teach and share your abilities with each other. We also
offered you our belief that we are most hopeful for your family because of
your strength and commitment to one another.
2. Our team has been very impressed with your insight into your experience.
We suggested our belief that you are a family who accepts where each person
is with respect to coping and experiencing loss, yet seems able to gently offer
individual thoughts and beliefs to help with one anothers healing.
3. Your family has shown us that it is not only acceptable to be sad but that is
acceptable to be mad at God and we appreciated your belief:God can handle
it. Because of your strong spiritual beliefs, your lack of bitterness, and your
ability to continue discovering the many ways you are blessed, you have
opened yourselves to the possibility of finding happiness and living a rich life
alongside your loss and grief. We suggested that your ability to feel joy, express
laughter, embrace hope, and discover a sense of meaning in this experience will
serve you well as your continue healing and move forward on your journey.

We would like to repeat that, as a result of meeting your family, we believe


we will be different with and have more to offer other families who are journeying with their own experiences of loss and grief. We thank you for this
immense gift and blessing.
We would like to remind you that you will be contacted in about six months
time to be invited to participate in a follow-up study, intended to improve our
clinical practice with families.
With warm regards,
Nancy L. Moules, RN, MN, Doctoral student
Lorraine M. Wright, RN, PhD, Director, Family Nursing Unit
RS: What do you think helped the most by coming here?
Charlie: Like Ive remarked about the comments that are said afterwards [the
letters] and how its picked . . . your picking out the positives and relaying
that back to us, maybe you know even if its a negative, then hearing it that
way, thats sort of what Im picking up, and its really encouraging.
Doreen: Ya, I was going to say something along the same line. Just reading the
letters, it gives you a positive attitude towards yourself where you pick up
anything that you know you feel good aboutyouve obviously picked up
from listening to what were saying and things like that and it gives you a

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22 Journal of Family Nursing

Table 5
Example of a Family Nursing Unit (FNU) Closing Therapeutic Letter
Dear George and Linda,
Greetings from the Family Nursing Unit! It was a pleasure to meet with you
in March for our final session. We wish to highlight what we have learned from
you during our work together, as well as what we believe we have been able
to offer you in our conversations together.
Linda and George, we appreciate the commitment you have shown to our
work together as we explored the experience of illness suffering in your lives.
Together you found the strength to enter into some difficult and painful conversations with us about your experience of suffering with both the loss of
loved ones and the uncertainty of pain and chronic illness. We have been
impressed with the perseverance you have demonstrated in pursuing creative
ways to influence the challenges that the presence of chronic illness has brought
into your lives and relationships.
What we have learned from you:
1. Linda, you taught us how women who live with chronic illness and pain face
distinct challenges. Learning to live alongside unrelenting illness, fatigue, and
pain while trying to maintain your role as a wife creates the unique challenge of finding balance between caring for self while also nurturing your
marriage relationship with George. You helped us realize how the invisible
and unpredictable nature of chronic illness invites physical pain and emotional isolation from the ones you love most. We have learned that this loss
of emotional connection may be harder to bear and invites more suffering
than the illness itself.
2. George, you offered us a new appreciation of the complexity of being both a
family caregiver and a husband in the presence of illness.We learned about the
tremendous impact that illness has had on your marriage and how the uncertainty around which role (nurse or husband) you believe you need to offer in
any given moment can invite confusion, anger, and suffering. George, you have
reaffirmed what we have learned in our work with other families: that giving
the illness a name and an identity can help a family shift the illness from
robbing your lives to viewing it as an external, manageable circumstance.
3. Together you have reminded us that remaining connected and aligned as a
couple improves and strengthens your ability to defeat the influence of
chronic illness. With your careful formulation of the No Illness and Fatigue
Talk (NIFT) Day we learned how a couple can use their creativity to negotiate
changed patterns of behavior one day per week. Furthermore, you helped us
to understand how persisting in changing this one day has the potential to
result in changing many beliefs about yourselves and the illness.You skillfully
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Bell et al. / Therapeutic Letters and the Family Nursing Unit 23

Table 5 (continued)
demonstrated to us the breadth and depth of your wisdom surrounding your
illness experience by offering an elaborate, beautifully crafted letter about
how you both experimented with new ways of behaving and thinking. Linda,
your eloquent reading of your and Georges letter in our sessions permitted
us further understanding of how much suffering you and George have experienced, and how much work you have done together to become masters
over the monster of chronic illness in your lives [for more information about
this letter, see NIFT Day at www.janicembell.com].

What we believe we offered you:


1. In our work together we witnessed and celebrated the tremendous strength
you have as a couple. It has been a privilege to observe the special connection of your relationship. In having your relationship witnessed and reverenced, we reminded you of what we believe you already knew: that you are
a spiritual couple who has a sacred relationship, worthy of nurturance and
nourishment. We wonder in what ways you will continue to nurture your
marital relationship as you live alongside of chronic illness.
2. We believe that we challenged your beliefs about your abilities to influence
and control the space that chronic illness occupies in your lives. We encouraged you to name the chronic illness as a way to invite you to view illness
as separate from Lindas being and outside of your marriage. You agreed to
call it the monster. In our efforts to support you to find ways to manage the
monster and keep your marriage strong we encouraged each of you to
experiment with ways in which to give your marriage more status than the
monster of chronic illness.
3. We offered you our belief that you are an empowered couple with the
resourcefulness and creativity to navigate challenges that will arise, including
the influence of the monster of illness. We offered you the idea that you can
use your skills at mastering illness to conquer anything! We spoke with you
about how chronic illness robs couples of the most intimate aspects of their
marriage and challenged you to rediscover the meaning and place of sexual
intimacy in your marital bond. How might you continue to reclaim a life of
creativity, strength, and joy?

George and Linda, it has been delightful to come to know you as individuals
and as a couple.You are a family who has shown remarkable strength and courage in the face of illness suffering. It is often difficult for families to transition
into living well and living at peace with chronic illness. Your dedication to the
work with us at the Family Nursing Unit to soften your illness suffering is
inspiring. We want to express what a privilege it has been to work with you,
and we wish you the best in your continued success as you live with this difficult illness experience.The insights you have shared with us will undoubtedly
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24 Journal of Family Nursing

Table 5 (continued)
enhance our work with other couples and families who are suffering in the
midst of chronic illness.
As part of our work together, a research assistant will contact you within six
months to learn whether you would be willing to evaluate what was helpful or
not so helpful in our work together so that we can continue to improve our
practice with families.
With warm regards,
Janice M. Bell, RN, PhD, Director, Family Nursing Unit
Amy Marshall, RN, BN, 2nd-year Master of Nursing Student
Marianne Boucher, RN, BN, 1st-year Master of Nursing Student
and other members of the clinical team
better feeling about yourself as to where you can move, put more, okay Ive
got to go, strive towards that. . . . Myself, I found, especially after hearing
back you know from you some of the positive aspects that you wrote up on
the letters.
RS: So, the letters . . .
Doreen: Sure gave me an awful lot more strength to turn around and not be as
more strength to deal with . . . give me that much more strength and therefore, it gave me that ability to understand that I could do it and then when I
read it, it gave me . . .
RS: So did you go back and read the letters?
Doreen: Oh, ya, Ive gone back and read them a few times.
RS: Wow!
Doreen: Cause it gives me just that much more strengthyou can do it.
RS: Sounds like the letters are kinda helpful as a reminder sometimes.
Charlie: Oh, very much so.

In the research interview, 2 years and 3 months later, Moules (NJM)


asked the family how they would value the letters in terms of worthiness
and how they might equate the value of the letters to the value of clinical
sessions:
Charlie: I would say, uhm, anywhere from three to five sessions, like somewhere in that area there; it uh, you know it could be more, like it wouldnt be
any less, thats for sure. I found it very invaluable, like it just you know its
just like you know what price do you put on a persons life? Thats the way
you look at that too. Its in the eye of the beholder. To me it was like, it did a
lot for me, it just built me up, it gave me some more self-esteem.

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 25

Doreen: Like I say, to myself, it made me feel much stronger in dealing with my
own personal feeling about myself.

In the research interview with the nurse clinician, RS reflected on the


impact the letters had on her as a clinician working with the family.
RS: I mean certainly the philosophy of the FNU and the work, clinical work, the
actual sessions, I mean we try to pull out unique outcomes, try and pull out
positives within the family, try and look at strengths, and develop strengths,
um, those kinds of things. But, and certainly I write them down in charting,
but kind of in writing a letter to the family, um, I have to pay meticulous
attention to those details, to those strengths. I think just their whole experience of the letters was very positive, so as a clinician, the letters became more
meaningful to me as well.
NJM: Do you think that the work you did with this family would have been as
good if you hadnt written the letters?
RS: No. No.
NJM: What would you say that these letters had been worth to this family in
terms of if you could equate it to a number of sessions?
RS: For this family I would say that the letters probably would be equivalent to
them continuing in therapy for the last [laughs] if I would have continued to
see them ongoing once a month from then until now.
NJM: So were talking almost 3 years?
[Laughter]
RS: I think so [still laughing]. Well, I dont know if I can equate it that way.
I would say a lot of sessions, maybe 5 to 10, but I think that the value of the
letters has been in the time, in how they have withstood the test of time.
I dont think Charlie would have came had we not had the letter, so I think
that probably I mean it was invaluable, that first letter, because if there was
just Doreen at the session, I dont think their marriage would have lasted. So
I think that it was invaluable in that way, so I dont know that you could
equate it to sessions, cause I could have a thousand sessions with Doreen
alone, and I dont think I would have gotten very far.
NJM: Would you have guessed, you know first impression, that this was a family where letters might be useful?
RS: When I first met Doreen . . . I didnt necessarily think she would be the
type that would just sit down and read a letter . . . like I wouldnt have
guessed that she would have spent the time to really go over it and keep it
and keep going over it.

In the reflecting team during the fourth clinical session, RS offered the
suggestion that the reason the family has been able to handle illnesses better than many is because of their commitment. Dr. Janice Bell responded,

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26 Journal of Family Nursing

The other piece of it that is connected to, maybe even fuels or increases the
commitment, is this new awareness that when they feel supported, theyre
able to give more support. I heard Charlie talk about that as a new kind of
understandingthat when he feels supported, affirmed, when he feels loved,
when he feels cared about, that hes able to show, you know, that its easier
to show that caring back and Doreen said similarly, that . . . there is some sort
of similar theme for her . . . like she said When I read the letters, I gained
strength, I rely on him less, that enables me to support him more . . . sort
of balancing out that supportiveness between them. I was quite taken with that.

This comment gives us a glimpse into why these letters might have been a fit
for this family, a family we might not have anticipated being one who would
value them. The therapeutic letters helped them feel supported, gave them
strength in a way that nurtured and fueled their capacities to offer support. The
letters have withstood the test of time, still continuing to invite reflection,
conversation, and a sense or measure of time to hold up against change.

Postscript: Doreen and Charlie


Approximately 6 months after the completion of clinical work, the FNU
routinely conducts an outcome study, designed to evaluate the clinical
work. The family indicated a high degree of satisfaction with the clinical
work and the subsequent changes they have experienced with themselves,
particularly as a couple in a marital relationship. Charlie responded when
asked, What did you find most helpful about the family sessions?
You know youre struggling, but you dont see the good things youre doing.
Therapeutic letters give you a real boost.

As a closing comment to the influence of these letters on this family,


transcripts from the research interviews follow. RS asked in the research
interview if the family had received any subsequent clinical work:
I was just curious if I mean Ive always kind of wondered about this family
because they have had so many issues in the past, have had therapy numerous
times of various sorts, Im just wondering because it was only four sessions
plus four letters whether they felt it still had impact on the, or whether . . .
cause four sessions isnt very long for a family dealing with these kind of
problems . . . that I would say that if this is a difference that has been longstanding that would mostly be attributed to the letters. Certainly the sessions
would have had an impact, but I think that a lot of the credit would have to
go to the letters.

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Bell et al. / Therapeutic Letters and the Family Nursing Unit 27

Summary
In this article, we speak to the use and significance of therapeutic letters
within the context and legacy of the clinical scholarship of the FNU.
Whereas we have described the content and process of writing therapeutic
letters to families, we have not discussed the numerous letters received
from familiesmany of which were invited by the clinician and clinical
team as a way to mark and celebrate therapeutic change and invite the family to offer advice and suggestions to other families about how they were
able to shift from constraining to facilitating beliefs about their lives, relationships, and illnesses in ways that softened their illness suffering (an
example of a letter from George and Linda [the family mentioned in Figure 5],
who want to publicly share their letter about their healing journey, is available at www.janicembell.com; see NIFT Day).
Relational practice with families emphasizes the healing aspects of relationship between family members, between the family and the health care
provider(s), and the relationship of the family to their illness suffering.
Therapeutic letters happen in reciprocity and relationship; they are written
with care and received with heart. They have the potential to heal, to invite
reflection and change, and to make a difference in suffering. This relationship of family and health care provider that is extended through the medium
of the written word is a sacred relationship, and the words within it must be
carefully chosen, delicately presented, and intentionally positioned. As an
intervention, therapeutic letters evoke ussubtly, boldly, and ethicallyto
preserve the integrity of relationships in nursing through the enduring tradition of the written word.

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C. J. Falicov (Ed.), Family transitions: Continuity and change over the life cycle (pp. 407430). New York: Guilford.

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Wright, L. M., Watson, W. L., & Bell, J. M. (1990). The Family Nursing Unit: A unique
integration of research, education and clinical practice. In J. M. Bell, W. L. Watson, &
L. M. Wright (Eds.), The cutting edge of family nursing (pp. 95-112). Calgary, Canada:
Family Nursing Unit Publications.
Wright, L. M., Watson, W. L., & Bell, J. M. (1996). Beliefs: The heart of healing in families
and illness. New York: Basic Books.
Wright, L. M., Watson, W. L., & Duhamel, F. (1985). The Family Nursing Unit: Clinical
preparation at the masters level. The Canadian Nurse, 81, 26-29.

Janice M. Bell, RN, PhD, is a nurse educator and registered psychologist who joined the
Family Nursing Unit, University of Calgary, in 1986 and served as the director of the Family
Nursing Unit from 2002 to 2007. Her scholarly expertise focuses on illness suffering and family healing with a focus on therapeu]tic conversations with families, family interventions in
health care, and family intervention research. The focus of her career is on building capacity
in nurses and other health care professionals to care for families experiencing illness. Her Web
site is www.janicembell.com. Recent publications include The Family Nursing Unit,
University of Calgary: Reflections on 25 Years of Clinical Scholarship (1982-2007) and
Closure Announcement [Editorial] in Journal of Family Nursing (2008), The Role of the
Clinical Laboratory in Teaching and Learning Family Nursing Skills in Journal of Family
Nursing (2008, with K. Flowers and W. St. John), and Beliefs and Illness: A Model for Healing
(in press, with L. M. Wright).
Nancy J. Moules, RN, PhD, is an associate professor, Faculty of Nursing, University of
Calgary. Her clinical, teaching, and research interests include hermeneutics, family nursing,
Family Systems Nursing, grief, therapeutic conversations, and pediatric oncology. Recent
publications include Hermeneutic Musings on Learning: The Dialological Nature of Teaching
Interpretively in Journal of Educational Thought (2007, with L. Binding, D. M. Tapp, and
L. Rallison), The Soul of Sorrow Work: Grief and Therapeutic Interventions With Families
in Journal of Family Nursing (2007, with K. Simonson, A. Fleizer, M. Prins, and B. Glasgow),
and Following in Behind: An Interview With the Reverend Bob Glasgow on His Practice
With Grief Work in Illness, Crisis, & Loss (2009, with K. Simonson).
Lorraine M. Wright, RN, PhD, is a professor emeritus of nursing, University of Calgary.
She is also an author, international lecturer, and marriage and family therapist. Her clinical
practice, lectures, and research focus on (a) illness beliefs of couples, families, and health care
professionals; (b) spirituality, suffering, and illness; and (c) marriage and family interven
tions. Her Web site is www.lorrainewright.com. Recent publications include Exploring the
Therapeutic Family Intervention of Commendations: Insights From Research in Journal of
Family Nursing, 12, (2006, with L. H. Limacher), `Living the as-yet Unanswered:' Spiritual
Care Practices in Family Systems Nursing in Journal of Family Nursing (2008, with
D. L. McLeod), and Nurses and Families: A Guide to Family Assessment and Intervention
(5th ed., 2009, with M. Leahey).

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