Finding Meaning in Later Life Janet Anderson Yang, Ph.D. Krista McGlynn, Breanna Wilhelmi, Heritage Clinic, a division of the Center for Aging Resources [email protected]
1 Helping Clients develop Meaning
• Meaningful roles in family & the community • Meaningful activities in the community and/or individually at home • Meaning as an attitude • Meaning & Hope intertwined
2 Later life’s losses can make it harder to find meaning:
• Can make it harder (physically & mentally) to follow past meaningful pursuits • Can make it harder to develop new meaningful activities/roles • Can make it harder to find hope
3 Existential Meaning in the face of loss
How can we help older clients build meaning and hope when faced with loss or decline?
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Existential Meaning in the face of loss How can we help clients improve their mental health and quality of life through development of altered perspectives, existential meaning, wisdom, integrity, spirituality?
5 Viktor Frankl (1980) stated that there are 3 avenues to meaning
6 Existential Meaning • Victor Frankl (1980) stated that there are 3 avenues to meaning: – Creating a work or doing a deed; – Experiencing something or encountering someone; – Attitudes: “Even if we are helpless victims of a hopeless situation, facing a fate that cannot be changed, we may rise above ourselves, grow beyond ourselves and by so doing change ourselves.” 7
Existential Meaning in the face of loss Developing meaning is one approach which may help.
8 Meaning
• Robert Neimeyer counsels helping bereaved clients develop and internalize sense of attachment security with newly constructed meaning. • Martin Horrowitz recommends following trauma, helping clients create new meaning in a world which allows/permits such trauma to occur.
9 • What types of meaning might older adults find?
10 Types of meaning • Facing & accepting death • Self discovery/Life • Creative expression Review • Appreciating beauty • Forgiving self & others • Honoring and sharing • Self transcendence wisdom, experience • Mindfulness, “Being” • Community • Contemplation • Enhanced relationships • Connecting with nature • Altruism, Charity • Spirituality / Religion • Guiding younger generations • Grappling with the finitude of life • Creating a legacy
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Self Discovery Forgiving Self & others
Erik Erikson
12 Stage (age) Psychosocial crisis
I (0-1) -- trust vs mistrust infant
II (2-3) -- autonomy vs shame and doubt toddler
III (3-6) -- initiative vs guilt preschooler
IV (7-12 or so) -- industry vs inferiority school-age child
V (12-18 or so) -- ego-identity vs role-confusion adolescence
VI (the 20’s) -- intimacy vs isolation young adult
VII (late 20’s to 50’s) -- middle adult generativity vs self-absorption
VIII (50’s and beyond) -- old adult integrity vs despair
13 Self Discovery Forgiving Self & others
• Erikson: the 8th stage, conflict between integrity and despair; the approach of death stimulates review of life to prepare for death.
14 Erikson’s Eighth Stage • The primary task in old age is to come to an: “acceptance of one’s one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions.”
15 16 Erikson’s Eighth Stage This involves: a consolidation of one’s understanding of the life one has lived, to be achieved through the struggle between integrity and despair, including “mourning for: – time forfeited and space depleted, – autonomy weakened, – Initiative lost, – generativity neglected, – identity potentials bypassed, – too limiting identity lived.” • E. Erikson: The Life Cycle Completed, 17 p.63. Life Review
• Robert Butler suggested that later life is a time for people to review their lives, allowing a return to consciousness of past experiences, especially unresolved conflicts; this can bring serenity and wisdom: “Life Review.” • The goal of life review is to expiate guilt, resolve internal conflicts, reconcile relationships, and renew one’s ideals.
18 James Birren
• The purpose of life review is to develop an acceptable image and leave behind an acceptable legacy. • Awareness of coming of death can stimulate a person to review one’s life to integrate the actuality of his/her life with what might have been and to reorganize attitudes towards one’s life
19 Life Review &/or Reminiscence Therapy • Structured activity to access and process thoughts about past experiences; • Done individually or in groups • May include writing assignments • Integrative reminiscence refers to reappraisal of losses, shortcomings and difficulties, reviewing values, and personal meaning • Instrumental reminiscence refers to recall of problem solving and positive adaptation, and reactivating positive self concept 20 Life Review Techniques • Time Line – Mark years and ages of the person – Ask person to recall important personal events, e.g., educational events, family events, work, accomplishments, loves, losses, hopes, regrets, pleasures – Use important world events as markers – Use aids to evoke memories (Photos, picture books, letters, diaries, scrap books, mementos, music, foods, smells, textures)
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Life Review Techniques
• Trace client’s experience based on a theme – E.g., pets, money, education, religion, family, love relationships, places of residence • Encourage client to take a pilgrimage to an old home, neighborhood, workplace, reunion • Family Life Review • Family Tree • Write an autobiography
22 Finishing Unfinished Business
• Family relationships • Terry Hargrave & William Anderson: Finishing Well: Aging and Reparation in the Intergenerational Family
23 Transcendence
• Transcendence: Within aging there may be an increased emphasis on internal processes or inner experiences facilitating expanding consciousness. Older adults may have more time to meditate, contemplate & reflect (Newman, 1987). Life satisfaction may increase as person shifts towards increased focus on the cosmic world versus the material world (Tornstam, 1994).
24 Transcendence:
• The ability to move beyond the immediate circumstances (Brennan, 2009). • Connection beyond the self; Transcending the gulf between people or between the person and the universe, or between the person and the creator of the universe (McFaddon, 2009).
25 Transcendence
• Lars Tornstam: Gerotranscendence is “cosmic communion with the spirit of the universe” • Ram Dass: “aging provides the greatest opportunity to develop inner wisdom, compassion, spiritual insight and balance.” – Perceiving illness as a blessing rather than a misfortune. – “heavy grace:” “the stroke was unbearable to the Ego, and so it pushed me into the Soul level also…and that’s grace.” 26 Contemplation/Meditation
• Mindfulness practices – E.g, Acceptance and Commitment Therapy (ACT) Hayes, S & Strosahl, K. – Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behavior Research and Therapy, 44(1), 1-25
27 Mindfulness
• Concentrating your awareness on moment to moment experience with a nonjudgmental attitude of acceptance. • Example
28 “An 86 year old woman once recounted to me how severe arthritis brought her kicking and screaming into the domain of her own soul: ‘One morning, I was sitting at my kitchen table, staring into space. It was one of those windy days when the sun keeps coming out and going in. All of a sudden, a sunbeam crossed my kitchen table and lit up my crystal salt shaker. There were all kinds of colors and sparkles. It was one of the most beautiful sights I’d ever seen. But you know, that very same salt
29 shaker had been on the kitchen table for over fifty years. Surely there must have been other mornings when the sun crossed the table like that, but I was just too busy getting things done. I wondered how much else I’d missed. This was it, this was grace. I needed crippled hands before I could sit still. Sometimes you have to be stopped right there in your tracks before you can see that all the beauty in life is right in front of you.’”
30 Connecting with nature
• Looking at the night sky • Listening to the birds • Looking at the clouds • Gardening • Caring for a plant • Watching birds
31 Spirituality
• Spirituality: Includes a set of beliefs which may include love, compassion, respect for life, existence, relationships with ourselves, others, the universe, the sacred; extends beyond the physical & material to a state called transcendence. • Religion: the practical expression of spirituality; the organization, ritual, practice of one’s beliefs. 32 Spirituality
• When is it appropriate for mental health professionals to initiate conversation about spirituality and/or religion? • When and how? • Necessity of not proselytizing
33 Spirituality Consider: • Assessing religious and spiritual coping on Initial Assessment. • Assessing childhood and younger adult history of client’s thoughts, feelings, experiences of God, religion, spirituality. • Encouraging previous positive spiritual / religious coping; gaining new spiritual or religious experiences, as desired by the client. • Exploring & diffusing negative experiences with spirituality / religion.
34 Joint Commissions on Accreditation of Healthcare Organizations (JCAHO) 1. I was wondering if spirituality or religion is important to you? 2. Are there certain spiritual beliefs and practices that you find particularly helpful in dealing with problems? 3. I was also wondering if you attend a church or some other type of spiritual community? 4. Are there any spiritual needs or concerns I can help you with? 35 Los Angeles County Department of Mental Health guidelines • 4.15 Assessment and integration of spiritual interests of clients in their wellness and recovery • http://file.lacounty.gov/dmh/cms1_178944.p df
36 • Grappling with the Finitude of Life
37 Facing and Accepting Death
• Jung: One of the tasks of later life is “to discover in death a goal towards which one can strive.” • What could that be? • Can the reality that life is ending be motivating? • Perhaps the reality that life is ending can be motivating for some older adults, to pursue some life goals or meaning. 38 Facing and Accepting Death
• Is there any reason to talk about death? • Does the fear of dying, or of death, or of the mystery of after-death seem to be part of the client’s mental illness/emotional distress?
39 How? • Start with practical issues, such as their desires as to how they want to be treated if they are unable to make such decisions themselves. / Use the Five Wishes Document. • Discuss what your client would want to occur after his/her death, e.g., funeral or memorial service, cremation or burial, etc. • How old were your parents or grandparents when they died? / What did they die of? • In what way do those facts affect your thoughts of your own death? 40
How? (cont.) • How do you feel about being ___ (client’s current age) years old? • What do you think about the end of your life? • What do you think will happen after you die? • What do you think about what will happen while you are dying? / • Assess your client’s answer for how it relates to their mental illness.
41 Facing and Accepting Death
• The preeminent coping task faced by a dying individual is dealing with loss. • Individuals and family members often try to shield each other from grief. Avoidance however may lead to increased isolation and disconnect for individuals and family members. • Grieving individuals generally benefit from the opportunity to express their emotions.
42 Facing and Accepting Death
Client views of a “good” death typically include: • Optimizing physical comfort • Maintaining a sense of continuity with one’s self • Maintaining and enhancing relationships • Making meaning of one’s life and death • Achieving a sense of control • Confronting and preparing for death
43 Maintaining and enhancing relationships • Often an enhanced appreciation of the importance of loved ones occurs in dying individuals along with a wish to connect more deeply. • Concerns central to the dying individual in relation to family include: – Wanting to feel like they have been appreciated – Opportunities to say goodbye to the people closest to them – Expressing feelings to family – Comfort in knowing the family will be all right without them
44 Eliciting relationship goals
• Clinician can facilitate eliciting relationship goals by asking the following questions: – Are there important relationships in your life, including relationships from the past, that need healing or strengthening? – Are there relationships in which you feel something important has been left unsaid? – Do the most important people in your life know what they mean to you?
45 Goals continued
• Are there stories, values, or ideas that you want to transmit to people as part of your legacy? • Are there ways that you can help your family now to prepare for and deal with your death? • How might you be able to continue to be a presence in the lives of people you love after your gone? • How would you like to say goodbye to the people who have been important to you?
46 Facing and Accepting Death
• Yalom – Existential Psychology – Staring at the Sun
47 Example KC 64 y.o. Cauc. woman; major stroke; severely limited; referred by APS. Spousal conflict/elder abuse; anger issues. With case management and mental health services, She moved out of home into assisted living; much anger & conflict with staff; explored the fear underlying her anger: fear of pain, Led to fear of dying with pain; reduced fear of pain; fear of dying continued; despite belief as an atheist, fear of hell; led to discussion of shame and guilt; treatment helped resolve some of these feelings; reduced fear & anger & anxiety; was able to gain more satisfaction from simple things, e.g., animals; interpersonal conflict decreased. 48 Wisdom • Wisdom – using knowledge, experience and understanding to confront circumstances, tolerate difficulties, make decisions • People can be encouraged to honor the wisdom they have developed from their life lie experience • People can be encouraged to share their wisdom
49 Creative Expression
• Drawing (KB) • Painting • Listening to music (BH) • Viewing art • Playing music – Books (GC) • Listening to music – Museums • Singing • Writing • Dancing
50 Pleasant Events
• Pleasant Events Schedule (320 items) • http://www.healthnetsolutions.com/dsp/Pleasan tEventsSchedule.pdf • Older Adult Pleasant Event Schedule (66 items) • http://oafc.stanford.edu/coppes.html • Pleasant Events Schedule – AD (for Alzheimer's’ patients) (20 items) • http://www.ncbi.nlm.nih.gov/pubmed/9046704
51 Relationships
• Opportunity for enhanced community • Deepened relationships, interdependence • Altruism, charity, volunteering – Telephone reassurance • Guiding younger generations – Audio recording
52 Relationships
• Caring for grandchildren • Enlist local faith communities to visit, telephone call, transport • Help re-establish dormant relationships • Use of technology – chat groups; skype; email • Opportunity for resolving past hurts, conflicts
53 • “A physical therapist tells how a stroke led to the reconciliation of a father and son who had not spoken in years: My patient was a large man, and the dead weight of his stroke made it impossible for his tiny wife to move him at all. His son agreed to come over and learn how to do a wheelchair transfer, but he came in looking so hostile I wanted to call off the whole thing. He didn’t even say hello. I explained that he had to grip his father in a bear hug and then use a rocking motion to pivot him from the bed to the wheelchair. The son went over to the bed where
his father 54 was sitting and put his arms around him, just like I said. He got the rocking motion going, but then all of a sudden I realized that both of them were crying. It was the most amazing thing. They stayed like that for a long time, rocking and crying. This son was moved to linger in his father’s arms for the first time since boyhood. Unexpected embraces, uncharacteristic expressions of feeling, these are only some of the ways that relationships grow through frailty’s demands.”
55 Leaving a legacy
• Irvin Yalom (2008) discusses approaches to make sense of death, including “rippling,” which refers to the ways in which influence others that can impact generations to com. • James Birren discusses the importance of leaving a legacy – helping others, raising children, writing a book, creating art, influencing others, political achievement, contributing to science,
56 Cultural Intersectionality and Finding Meaning in Later Life
57 What is intersectionality?
“We experience life – sometimes discrimination, sometimes benefits – based on a number of identities we have.” Kimberlé Crenshaw, J.D.
We find meaning in life through the sociocultural lenses through which we experience the world.
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What are some cultural identities?
• Age • Occupation • Mental Illness? • Race • Wealth Diagnosis? • Ethnicity • Family/Friends • Gender • Ability/Disabilit • Sexuality y • Religion • Health/Wellnes • Language s • Education • Appearance • Region/Locality • Others
59 SEXUALITY
LANGUAGE GENDER
ETHNICITYAGE ABILITY
RACE SPIRITUALITY
FAMILY
60 Some identities garner privilege and power, while others oppression and marginalization.
Each dimension of identity impacts how the client finds and makes meaning in their life.
It may be especially therapeutic and meaningful to examine intersecting cultural identities in later life.
61 Explore with client:
• Which cultural identities mean the most/have the most meaning? • Where has the client experienced the most/least privilege/power? • Where/when has the client felt oppressed/marginalized? • Which identities are most strong/rich/dense/dominant? • Which are most delicate/light/sparse/subdued?
62 “Alice”
67 year old, widowed, disabled, unemployed, African American heterosexual woman with 6th grade education, originally from the Southern US, with minimal family contacts. History of early childhood trauma, unemployment, poverty, depression. "I want to get involved in something to better myself“ "I don't want to be sitting at home watching life pass me by."
Considering client’s cultural intersectionality, how might we help her develop meaning and hope?
63 • Client and primary clinician collaboratively explored client’s personal goal of getting her GED. • Clinician to provide ongoing therapeutic support and encouragement in client’s goal-directed activities. • Therapeutic goal and intervention considered the client’s cultural intersectionality by targeting and empowering her racial, gender, age, educational, etc. identities, which were traditionally a source of marginalization and oppression.
64 References
Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64(3), 170-180. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 1241-1299. Lafayette College (2015, October 15). Kimberle Crenshaw discusses intersectional feminism [Video file]. Retrieved from https://youtu.be/ROwquxC_Gxc. US Census (2015, January). Educational attainment. Retrieved from https://www.census.gov/hhes/socdemo/education/data/cps/historical
65 Culture specific forms of meaning/hope and meaning development • Latino • African-American • Asian • Native American
66 Latino Elders
• Family relationships may be particularly important; meaning may be derived from reconnecting estranged family relationships, improving communication with family &/or mourning for unmet expectations. • Religious/spiritual issues may be very important; working through conflicts in elder’s spiritual perspective may increase existential satisfaction.
67 African American Elders • Relationships with family, including extended family & fictive kin may be highly important; facilitating improved or reconnected relationships may bring increased meaning. • Religion may be important; encouraging religious readings, listening to religious programs & prayer may increase satisfaction. • Church relationship may have been important, but lost with increased frailty; reconnection may bring sense of purpose. 68 Asian-American Elders
• Filial piety & family relationships may be seen as more important than the self. • Personal meaning may be intricately tied in with family; help reconnecting, decreasing conflict or mourning for what’s been lost or not had may be important. • Exploring feelings about death may take particular sensitivity; talking about death may be seen as “making it happen.” 69 Native American Elders
• Spirituality may be of great importance. • May hold Native, Christian, or both spiritual perspectives concurrently; exploration and enhancement of either or both may be beneficial. • Death perspective may include anticipation of the spirit crossing over to the other side, joining with ancestors; exploration of beliefs about death may be meaningful. 70 Client example 1
• A 64 year old African American woman is referred to you. She is widowed; she had 2 children; one son lives in town and the other lives in New York. She has Multiple Sclerosis, is significantly paralyzed and is bed bound. Although she was raised in a religious home, her husband was not religious and she
71 Client example 1 (cont.) • has not been attending religious services often in her adult life. She wishes her son and his children would visit her more often, but they come only about once or twice a month. She is very depressed, and complains that life is not worth living. • How could we help her develop meaning and hope? 72
Client example (2)
• Mr. B. is a 79 year old Asian-American man. He was a successful business man, as CEO of a large company. However, his investments did not work out well and he has little money now. He has 3 children with whom he has little contact. One lives in China; one in Los Angeles and one in Santa Barbara. His wife lives in China. Mr. B. lives in 73 Client example (2) cont.
• independent living in a senior apartment complex. He had a mild stroke, limiting his mobility, and he has early Alzheimer’s Disease. He demonstrates significant anxiety, including anxiety that he will be placed in a nursing home. • How might we help him develop meaning and hope?
74 • Mr. B. – Encouraged ADHC attendance – Attempted reconnection with family – Life Review – Mourning for loss of expected relationships with children
75 References & Readings • Bender, Bauckman & Norris, (1999). The Therapeutic Purposes of Reminiscence. Sage Publications. • Birren, J. & Cochran, K. Telling the Stories of Life Though Guided Autobiography Groups. Johns Hopkins Univ. Press. • Birren & Deutchman, (1991). Guiding Autobiography groups for older adults. Johns Hopkins Univ. Press • Bram, A., Bramsen, I., Tilburg, T., van der Ploeg, H. & D. Deeg (2006). Cosmic Transcendence & Framework of Meaning in Life. J. of Gerontology 61B (3), S121-128.
76 References & Readings • Bram, A., Bramsen, I., Tilburg, T., van der Ploeg, H. & D. Deeg (2006). Cosmic Transcendence & Framework of Meaning in Life. J. of Gerontology 61B (3), S121-128. • Butler, R. (1963). Life Review: an interpretation of reminiscence in the aged. Psychiatry, 26, 65-76. • Butler, Robert. 2002. Age, Death, and Life Review. Living With Grief: Loss in Later Life. Hospice Foundation of America. • Curriculum in Ethnogeriatrics http://www.stanford.edu/group/ethnoger/ • Dass, R. (2000). Still Here: Embracing Aging, change and Dying, Riverhead Books. 77 References • Erikson, E. (1985) The Life Cycle Completed. New York: WW Norton & Co., Inc • Frankl, V. (1980). Psychotherapy on its way to rehumanism. International Forum for Logotherapy, Fall, 3(2). • Haight, Barbara and Haight, Barrett. The Handbook of Structured Life Review. (Health Professions Press, 2007). • Hargrave, Terry D. and Anderson, William T. (1992) Finishing Well: Aging and the Reparation in the Intergenerational Family. Brunner/Mazel. New York
78 References & Readings • Hoffman, Nancy. (2005). When the Past Is Prologue Reminiscence in Clinical Practice. [Review of the book The Past in the Present: Using Reminiscence in Health and Social Care]. PsycCRITIQUES. Vol 50 (14). • Knight, Bob G.,McCallum,T.J., Psychotherapy with older adult families: The contextual, cohort-based maturity/specific challenge model in Nordhus, Inger Hilde (Ed); VandenBos, Gary R. (Ed); Berg, Stig (Ed); Fromholt, Pia (Ed).(1998).Clinical geropsychology. (pp. 313-328). Washington, DC, APA. • Kunz & Soltys, (2007). Transformational reminiscence: Life Story work. Springer.
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References • Newman, 1987, in Generations: 23(4), Winter, 1999-2000. Issue on Meaning • Rainer, T. (1979) The New Diary: How to Use a Journal for self- guidance & Expanded creativity. Tarcher/Penguin Group. • Rainer, T. (1997). Your life as Story: Writing the New Autobiography. Tarcher/Penguin Group. • Tornstam, 1994, in Generations: 23(4), Winter, 1999-2000. Issue on Meaning • Yalom, Irvin D. (2008). Staring at the Sun: Overcoming the Terror of death. San Francisco, CA: Jossey-Bass. • Yalom, Irvin D. (1980). Existential Psychotherapy. Basic Books.
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