“Learning is the discovery that something is possible”
-Fritz Pearl (1893-1970)
Formulation Objectives
The main objectives of this study were to develop, implement, and evaluate an intervention aimed at preventing and reducing loneliness to increase the well-being of older people. Specifically, the goal was to investigate the outcome of the intervention in terms of both impact and process, as experienced by participants.
In this study, the role of evaluation was considered as part of psychological research investigation, rather than a demarcated system of political and/or decision- making inquiry (Greene, 2000; Mertens, 2010). Evaluation in this context differs from standard evaluations in that the usefulness of the intervention is investigated in an all- encompassing way rather than focusing on the appropriateness of its individual elements, as seen in “dismantling” studies (Mertens, 2009; Patton, 1990; Routasalo et al., 2009). However this study is similar to standard evaluation programmes in that it takes place in “real-life”, in “the actual context where whatever we are interested in occurs” (Robson, 2002, p. 3). In effect, there was a concern for action or change, linked to the principle that practice can help to improve theory, and vice versa (Robson, 2002). There was also a dual concern for improved health outcomes and the advancement of knowledge of a largely under-researched area in psychology: loneliness and the well- being of older people.
Aims
This study had four aims. The first was to provide insight into the existing theory on the typology of loneliness proposed by Weiss (1973; social and emotional loneliness), and the subsequent operationalisation of emotional loneliness into family and romantic loneliness (DiTommaso & Spinner, 1997). The second was to investigate the usefulness of a group instrumental reminiscence intervention to increase older people’s ability to cope with challenges associated with aging, such as loneliness. A third aim of this study was to broaden the existing knowledge in this area of research by directly asking participants for their views on what successful aging and loneliness consist of, as well as possible useful strategies for its alleviation. The final aim was to
evaluate the intervention in a comprehensive way to shed some light on the above considerations and to illuminate the needs of older adults, in view of informing future interventions. Figure 1 shows the outline of the current investigation.
Figure 1. Outline of the current investigation.
Research Questions
1. What is the effect of the Self-Enrichment Course on the participants’ self-
reported levels of well-being and loneliness (social, romantic, and family) over time?
2. How is the Self-Enrichment Course experienced by participants? (Do they find
it acceptable and useful, and if so, in what ways?)
3. What are the participants’ understandings of well-being and loneliness in the context of the Self-Enrichment Course, as well as their life experience and wisdom?
4. In what ways do the participants’ experiences of the Self-Enrichment Course, understandings of loneliness and well-being, and quantitative scores
converge?
Development of an Intervention: The Self-Enrichment Course (SEC) The complete intervention developed in this study, the SEC, is provided in Appendix A. However, as outlined in Chapter Two, making the background and content of newly developed interventions explicit can facilitate future replication and the refinement of future interventions. To expand knowledge in this area, and
• Rationale for intervention • Assumptions Context • Detailed content • 5-week trial SEC • Impact • Process • Needs of older adults Outcome
ultimately to help prevent and alleviate loneliness among older people, this section outlines the rationale behind the SEC, as well as its essential elements.
Theoretical Framework
One crucial consideration highlighted in the literature review as well as in guidelines set out by researchers (e.g., Laidlaw & Baikie, 2007; Pachana et al., 2006) is the need for a clear theoretical framework when developing psychological interventions for older adults. The following model was selected as it is current, empirically-based, tailored to the needs of older adults, and offers the most complete framework for the transfer of existing knowledge in psychotherapy to clinical work with older people.
The contextual adult life span theory for adapting psychotherapy model. In response to the discrepancy between the loss-deficit model (Gitelson, 1948; prominent prior to 1980) and the life span developmental psychology of the 1970s, Knight (2004) proposed the Contextual, Cohort-Based, Maturity, Specific-Challenge Model
(CCMSC) as a framework for guiding psychotherapy with the aging population. The CCMSC emphasises that adaptations to psychotherapy are necessary to address not only the developmental views on aging, but the unique socio-cultural environment, cohort membership, and challenges associated with older age. From the CCMSC’s perspective, older adults are recognised as more mature than younger ones, but are also viewed as facing some distinct challenges, such as adjusting to illness, disability, and grief (Knight, 2004).
More recently, the work of Knight was adapted to integrate further views on aging, namely to make explicit the role of culture as a core constituent in the context of older adults. In 2008, Knight and Lee proposed the Contextual Adult Lifespan Theory for Adapting Psychotherapy (CALTAP). As with the CCMSC, problems associated with aging are framed in the CALTAP as challenges specific to older people, where adjustment can be achieved (e.g., through psychotherapeutic interventions). In addition, the many cognitive and emotional changes associated with aging are seen as an
indication of maturation rather than deficit (Knight & Lee, 2008). The model provides a broad conceptualisation and understanding of aging and context-specific influences on older people, in view of guiding an integrated psychotherapy approach for the aging population.
There are five main components to the CALTAP: cohort-based influences, culture, context, maturation, and age-related specific challenges. Each is briefly discussed, namely in terms of their guiding influence on the development of the SEC.
Cohort differences shape people’s developmental trajectories in later life (Knight & Lee, 2008; Knight & Poon, 2008). According to the particular cohort they belong to, people possess various personality and functional abilities, as well as beliefs and attitudes that remain stable with age. One’s historical context can be explored by adding 20 years to the person’s birth year (Knight, 2004). For participants in the current study (born on average around 1926), it is likely that their worldview has been shaped by the direct or indirect experience of World War II (WWII), for instance. In retrospect, the researcher recalls one participant’s comment as follows:
“There are three parts to life: Before the war, during the war, and after the war”.
In view of that, the researcher set out to gather information on this particular cohort through an open interaction with the participants. As suggested by Knight and Poon (2008); “the constructive use of the therapist’s ignorance can facilitate rapport building and greater openness” (p. 236). Accordingly, the first session of the SEC would include a brainstorming activity, where participants could discuss their views and experiences in regards to life in general. In addition, the therapist’s curious attitude towards individuals’ past experiences throughout the duration of the course would allow the fostering of a sense of trust, and a broader understanding of the challenges inherent to individuals in this cohort.
Next, culture plays an important role in promoting different developmental trajectories and corresponding experiences for people. That is, the values and beliefs of older people have a direct influence on their help-seeking behaviour, mental illness interpretation, and presentation in therapy (Knight & Poon, 2008). All participants in the current study were proficient in English, and identified as New Zealand European. The understanding of what it would mean to grow up in or to immigrate to New Zealand in those years would be explored throughout the course, and the participants’ own language when discussing feelings and emotions, privileged. The researcher also needed to acknowledge her own cultural background, as well as the participants’ perception of the researcher’s ethnicity in terms of possible transference/counter- transference (Knight, 2004; Yalom & Leszcz, 2005). As such, a few participants referred to the collegiality between New Zealand and Canadian soldiers during WWII.
The third component of the CALTAP consists of social context, which includes specific environments and rules for older adults. The current study took place in a retirement village which includes both full-care and independent living facilities. In both cases, leaving one’s home to transition and live in a shared facility comprises
major change in one’s life. The fact that the researcher spent a considerable amount of time in the participants’ residences prior to the beginning of the intervention (during the assessment phase) allowed for an initial understanding of the participants’ living
environment. During the intervention, participant-centred views of their living contexts would be considered and integrated in the content of the sessions. For example, the facility’s existing activity program would be discussed as a specific means to entertain social connections. In addition, the discussion of loneliness as a multidimensional phenomenon would allow for the consideration of the participants’ emotional, social, and interpersonal contexts (Knight & Poon, 2008). Finally, the participant-driven nature of the SEC meant that the individuals’ personal experiences of their social environment would be discussed.
Fourthly, developmental processes of maturation influence older people’s view of themselves in society, as well as age-related changes that can be addressed in therapy (Knight & Lee, 2008). Negative aspects of maturation include deterioration in physical and cognitive abilities, such as changes in memory (e.g., free recall) and fluid intelligence (e.g., abstract reasoning). Consequently, maturation calls for therapeutic adaptations such as reducing background noise and distractions in therapeutic settings, as well as the adoption of a more directive stance with simpler phrasing (Knight & Poon, 2008). In implementing the SEC, steps were also taken to compensate for decline in memory, such as the use of name badges, the provision of personal journals to take notes, and of handouts containing summaries of each session’s key points.
Notwithstanding this, the researcher wished to provide a context in which the positive aspects of maturation would be celebrated. In effect, research in scientific gerontology and life span developmental psychology has shifted from a focus on the pathology of aging towards a more optimistic perspective (e.g., Baltes & Smith, 1990; Birren & Scroots, 2006; Constança, 2007). The CALTAP highlights the role of
cognitive and emotional complexity pertaining to older adults as most relevant to psychological interventions (Knight & Poon, 2008). To illustrate, the expansion and preservation of crystallised intelligence and the continuous development of wisdom can help older adults adapt to life’s challenges. Therefore, it was crucial that the SEC would facilitate the participants’ ability to draw upon their own life experience and expertise. Cognitive complexity represents an asset in examining life events from others’ perspectives (Knight & Lee, 2008; Knight & Poon, 2008); and thus would guide the use of feedback in providing alternatives to dysfunctional thoughts and behaviours.
Finally, the specificity of challenges in late life was considered. Many older adults experience problems that threaten psychological homeostasis such as chronic illness, disability, grief, and prolonged care giving for other family members (Knight, 2004). Although these difficulties can arise at any point in the life span, the likelihood of their occurrence increases with age (Knight & Poon, 2008). Consequently, the SEC was tailored to facilitate the processing of such tasks, with an emphasis on emotional and thinking processes, as well as social support. The focus on loneliness and
associated experiences (e.g., loss, separations) was paired with an emphasis on well- being, namely the participants’ specific understandings of what is helpful to them.
To conclude, the CALTAP provided a meta-theoretical basis for the
development of the SEC, particularly in terms of social context, culture, maturation, cohort effects, and age-related specific challenges. The work of Knight (2004), Knight and Lee (2008), and Knight and Poon (2008) highlights the importance of considering the relationship between environmental and individual factors when working with older people in a therapeutic context. In line with this, cognitive-behavioural approaches to therapy can provide a good basis for interventions to address the needs of older people (Knight & Lee, 2008; Knight & Poon, 2008; Koder, 2007). CBT, for instance, places a dual emphasis on the individual and their context (Goncalves, Albuquerque, Byrne, & Pachana, 2009; Laidlaw et al., 2004; Laidlaw et al., 2003).
However, as pointed out by Knight and Poon (2008) and Laidlaw and McAlpine (2008), the problems faced by older people tend to be ongoing, persistent and
progressive, which can be a challenge for the typical short-term focus of CBT. In addition, older people typically have several decades of past life experience behind them, and the natural inclination to reminisce about the past (Birren & Scroots, 2006; Butler, 1974; Cappeliez & O’Rourke, 2002) can pose a challenge for the present- oriented nature of CBT (Knight & Poon, 2008).
Participants in the current study belong to the “old-old” population, also called “oldest old” or the “very old” (Constança, 2007, p. 137). Coming from the perspective that as age increases, one’s past (or accumulation of memories) increases, the question of how to employ the past in a therapeutic fashion was carefully considered. Although CBT acknowledges the role of childhood experiences in one’s current functioning (Beck, 1995), it was unclear whether this approach alone is sufficient in the context of 85 year olds. Since the very old have lived and coped with challenges through decades, there was a need to explore the possibility of using their past experiences directly.
Overall, the apparent importance of the past in older adults’ current lives called for the integration of different approaches in developing the SEC.
Consistent with Knight and Lee’s (2008) transtheoretical perspective to adapting psychotherapy with older adults, the following section examines in greater detail a positive aspect specific to maturation, or old age: the attainment of wisdom.
From wisdom to reminiscence. The theory of psychosocial development proposed by Erikson (1950, 1982) introduced the notion that people experience different psychological processes through different stages of life. This approach has been heavily criticised by researchers. For example, Franz and White (1985) have argued that due to his focus on issues of identity, Erikson’s theory ignores the
development of intimacy and other forms of interpersonal attachment. In addition, the validity of such categorisation of human behaviour during development has been questioned. In effect, “stage” theories assume or predict that the way in which certain variables combine to influence action is the same for everyone. As posed by Weinstein, Rothman, and Sutton (1998): “Is it reasonable to assume that behavior change can be described by a single prediction equation?” (p. 291).
A more useful way to consider this approach in the context of old age might be to think of people “travelling” though these stages in an idiosyncratic way. For
example, the eighth stage of life in Erickson’s model has an emphasis on the integration of life activities and on feeling worthwhile. In this phase, the psychosocial crisis is defined as “Integrity versus Despair” (Erikson, 1950). By reviewing one’s
accomplishments throughout life, one is able to develop a sense of integrity if life is perceived as successful, or a sense of despair from the perception of having failed to accomplish one’s life goals. Seeing life as unproductive can lead to dissatisfaction with life, which often leads to hopelessness and depression (Klausner, Snyder, & Cheavens, 2000). The basic virtue (or potential positive outcome from the psychosocial crisis) associated with this life cycle stage is the attainment of wisdom (Erikson, 1982). Although allegedly concerning people aged between 55 and 65 years old (Erikson, 1982), it is reasonable to assume that depending on life circumstances, people can experience integrity, despair, and wisdom at different ages in later life.
Drawing from Erikson’s theory, numerous theories and classification systems have been put forward as an attempt to encapsulate the particular role of wisdom in old age. Most of the early theorists (e.g., Kohlberg, 1973) have implicitly assumed a positive correlation between wisdom and advancing age (Bluck & Glück, 2005).
The ongoing and notable work of Baltes and colleagues (see, e.g., Baltes & Smith, 1990; Scheibe et al., 2007) has focused on understanding wisdom from a lifespan perspective: Life Span Contextualism. From this perspective, wisdom refers to a highly developed body of knowledge regarding the meaning and conduct of life, and
knowledge involves “an awareness of the strong interrelatedness of self and others” (Scheibe et al., 2007, p. 123). From this angle, wisdom refers to interpersonal relationships or to one’s sense of connectedness to others, which links the nature of wisdom to that of loneliness (Cacioppo & Patrick, 2008; Weiss, 1973).
Recently, Knight and Laidlaw (2009) proposed the translational theory, a wisdom-based model for psychological interventions aimed at enhancing the well- being of older people. The authors argued that instead of focusing on pathology in old age, there is value in asking what psychotherapy can do to facilitate the attainment of wisdom. They further suggested that, despite a recent growth in the literature for outcome research in psychotherapy with older people (e.g., CBT for depression and anxiety), “research has tended to evaluate outcomes with nonmodified therapies using models borrowed largely from adult mental health settings without consideration to conceptual input from life span developmental and gerontological theories” (Knight & Laidlaw, 2009, p. 694).
In defining wisdom as a goal for adult development, Knight and Laidlaw (2009) also emphasised the focus on Life Span Contextualism proposed by Baltes and Smith (1990), and Scheibe et al. (2007). This view supports the stance taken by the CALTAP model in applying psychological interventions with older populations.
Psychotherapeutic goals involving the promotion of better relationships with others and an improved ability to deal with one’s emotional life, are consistent with the attainment of wisdom (Knight & Laidlaw, 2009). In effect, wisdom enhancement can be
understood as a skill to be developed, namely by reminding older people of their long- standing coping skills, and promoting ways to apply these to the challenges inherent to aging.
In terms of integrating wisdom to psychotherapy, one widely used method is life review, or reminiscence (Bluck & Glück, 2005; Butler, 1974; Knight & Laidlaw, 2009). The interest for reminiscence in clinical work was revived with a seminal article by Butler (1963), which had a strong impact in the field of gerontology. Within the psychodynamic perspective shared by both Erikson and Butler, the attainment of wisdom can take place through reviewing one’s life.
Effectively, one aim of reminiscence therapy is to promote a sense of integrity (Butler, 1974). The general goals of reminiscence are to systematically review one’s life in order to resolve past conflicts, celebrate past successes, deal more effectively with changes and losses, and gain an overall sense of worth and accomplishment (Butler, 1963; Haight & Haight, 2007; Hendrix & Haight, 2002; Webster & Haight, 1995). The numerous benefits of reminiscence, including decreasing depression and anxiety, strengthening self-esteem, improving interpersonal relationships, and increasing psychological well-being, have been well documented (Bluck & Glück, 2005; Bohlmeijer et al., 2007; Cappeliez & Robitaille, 2010; Gibson, 2004; Kunz, 2007).
Cappeliez, Guindon, and Robitaille (2008) defined reminiscence in basic terms: “the recalling of personally relevant memories from the past” (p. 266). The authors further explained that reminiscence can arise spontaneously, as in response to a smell