Strategies for Therapy with the Elderly: Living With Hope and Meaning, 2nd Edition
Each section and each theme was divided in half so that there were T1 and T2 variables for each theme. In addition to the major themes described above, there were two final variables that were summed scores—total empowerment and total disempowerment. These categories were also divided in half so that there were empowerment T1 and T2 and disempowerment T1 and T2 totals. Several methods were used to increase the confirmability of the findings. The credibility of the first investigator was established by hundreds of hours spent in the field, as evidenced by the number of recorded sessions.
Persistent observation was thorough enough to produce in-depth information and to differentiate relevant from irrelevant observations. Some methods of establishing credibility such as triangulation, negative case analysis, and informant checking could not be used because this was a secondary data analysis. One judge was a doctorally prepared geropsychiatric nurse, and the other was a doctorally prepared counseling psychologist familiar with the data analysis method used.
Reproducibility, that is, intercoder reliability or intersubjective agreement, was established by having the two expert judges apply the coding instructions independently. When a disagreement occurred, an agreement was made after careful analysis and discussion. Confirmability was also established by maintaining complete records, including a trail of raw data, data reduction and analysis, and coding and counting decisions.
Stability was determined by coding and recoding the same data at different times and checking for intracoder reliability. The findings are presented in two sections, disempowerment and empowerment themes. Within-subject change was determined by computing the Wilcoxon signed-rank test on T1 and T2 theme data. To determine change over time, the themes were divided into empowerment—T1 and T2 and disempowerment—T1 and T2.
This involved counting the number of sessions for each subject and dividing them in half. Each subject then had four cells with scores that could be computed in the first and second halves of the therapy, permitting the Wilcoxon signed-rank test to be run. Although there were no differences in the total overall empowerment and disempowerment themes after completing the therapy, there were differences in the disempowerment themes over the course of the therapy sessions. There were no T1 or T2 differences in empowerment themes. This study is unique in that it provides insight into the process and outcome of life review psychotherapy with homebound depressed older adults.
All participants had been hospitalized in geropsychiatric treatment programs and had been evaluated by a psychiatrist in a face-to-face clinical interview using the DSM. All had follow-up home-based psychotherapy conducted by one geropsychiatric nurse who used the same consistent life review approach with each individual. One reason that in-home life review therapy was beneficial may be the result of the previous hospitalization in a specific treatment program in which the subjects participated in individual, family, and group therapies and were ready to continue this work after discharge.
Lasoski and Thelen found that although older adults selected outpatient services less often than younger adults, their attitudes toward mental health services were positively influenced by previous exposure to psychiatric services. Over the course of therapy, from T1 to T2, the participants showed significant decreases in the disempowerment themes of anxiety, denial, despair, and isolation. In a managed care environment, this has particular significance for preventing relapse and rehospitalization.
Other investigators have reported similar results.
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Fishman found that better health was related to fewer negative emotions about past events. Heidrich found that the elderly in poor physical health had higher depression but that they identified positive relations with others as an important dimension of their lives. It was recommended that interventions targeted for older women address the managing of health problems and depressive symptomatology together rather than individually. This study thus provides further evidence that psychosocial treatments developed specifically for older adults have a positive impact on their overall well-being and facilitate their ability to remain independent and live at home.
The significant decrease in disempowerment negative themes fits with theories of depression, which suggest that individuals with depression often have low self-esteem; with negative thoughts; and, in older adults in particular, with numerous somatic complaints, particularly memory problems and other physical manifestations Beck, ; Grotjahn, , ; Kaplan, In short-term, problem-focused psychotherapy, the goals must be specific and attainable.
In this study, the participants received 13 therapy sessions. Howard, Kopta, Krause, and Orlinsky use the term dose-effect to describe length of treatment and patient benefit. Crits-Christopher found in a meta-analysis that there must be at least 12 sessions for efficacious results. Knight studied elders receiving psychotherapy in their homes and found that those individuals with diagnoses of psychoses and anxiety showed the greatest changes, with depression and adjustment disorders showing more modest changes.
Given the serious nature of the depression in this sample, a decrease in negative themes was the best possible outcome for the cost of treatment. A decrease in negative thoughts may also have value in terms of positive health outcomes. However, this was not possible to ascertain in the current study. The results of this study suggest that life review therapy may be an effective therapy for many homebound elderly with depression. The authors thank Fredrick C.
Address reprint requests to Graham J. National Center for Biotechnology Information , U. Author manuscript; available in PMC Oct 7. The publisher's final edited version of this article is available at Nurs Res. See other articles in PMC that cite the published article. Abstract The purpose of this study was to examine the process and outcomes of life review therapy provided by an advanced practice geropsychiatric nurse to older adults discharged from psychiatric hospitals to home health care.
Related Literature A number of studies have examined the effectiveness of reminiscence or life review in community and nursing home samples, but the results have been inconsistent. Methodology Sample The study reported here was a retrospective analysis of the therapy notes and records from psychiatric home visits with patients 65 years of age and older who were discharged to homebound status from three freestanding psychiatric hospitals in the southern part of the United States. Procedures The elders received follow-up at home by an advanced practice geropsychiatric nurse for short-term therapy that was reimbursed under Medicare Part B for homecare.
Data Analysis Content analysis methods were used to analyze the data. Disempowerment Anxiety Anxiety was defined as a state of being uneasy, apprehensive, or worried about what may happen about a possible future event. Denial Denial was defined as a statement in opposition to another or a contradiction; the act of disowning or repudiation. Despair Despair was defined as being overcome by a sense of futility or defeat or having an utter lack of hope. Isolation Isolation was defined as being separated from a group or whole and set apart.
Loneliness Loneliness conveys a heightened sense of solitude and gloom. Loss Loss was defined as the harm or suffering caused by losing, being lost, or being deprived of something. Empowerment Connection Connection was defined as the relation between humans that depend on, involve, or follow each other. Coping Coping was defined as the ability to contend or strive especially on even terms or success; to contend with difficulties and act to overcome them.
Efficacy Efficacy was defined as effectiveness; or as the power or capacity to produce a desired effect. Hope Hope was defined as a feeling that what is wanted will happen; a desire accompanied by expectation. Trust Trust was defined as a firm belief or confidence in, for example, honesty, integrity, reliability, and justice of another person or thing—faith; reliance.
Confirmability Several methods were used to increase the confirmability of the findings. Open in a separate window. Discussion This study is unique in that it provides insight into the process and outcome of life review psychotherapy with homebound depressed older adults. Acknowledgments The authors thank Fredrick C. Medical and psychiatric determinants of outpatient medical utilization. The development of depression: Friedman R, Katz M, editors.
The psychology of depression. Reminiscence intervention in nursing homes: What and who changes?
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International Journal of Aging and Human Development. The effect of life review group on the reminiscence functions of geropsychiatric inpatients. Blazer DG, Busse E. The American psychiatric press textbook of geriatric psychiatry. American Psychiatric Press; Depression in an elderly clinic population: Findings from an ambulatory care setting. Assessing and managing depression in the older adult: Implications for advanced practice nurses. Dual diagnosis in elders discharged from a psychiatric hospital. International Journal of Geriatric Psychiatry.
Relations among social activity level, reminiscence, and morale. Themes in reminiscence groups with older women. An interpretation of reminiscence in the aged. The efficacy of brief dynamic psychotherapy. American Journal of Psychiatry.
Fogel B, Furino A, editors. Mental health policy for older Americans: Protecting minds at risk. Structured and unstructured reminiscence training and depression among the elderly. Some analytic observations about the process of growing old. Psychoanalysis and social science. International Universities Press; Analytic therapy with the elderly. The therapeutic role of structured life review process in homebound elderly subjects. Examining key variables in selected reminiscing modalities. The impact of reminiscence groups in two different settings.
The self, health, and depression in elderly women. Western Journal of Nursing Research. Content analysis for the social sciences and humanities. The dose-effect relationship in psychotherapy. Psychiatric Illnesses in the elderly: Journal of Geriatric Psychiatry and Neurology. Writings from the Stone Center. Factors influencing therapist-rated change in older adults. Psychotherapy with older adults. An introduction to its methodology. Attitudes of older and middle-aged persons toward mental health intervention. Definition, prevalence, and characteristics.
Strategies for Therapy with the Elderly
Purpose, Understanding, Responsibility, and Enjoyment — the four components that define meaning in life Wong, b; Wong, b. Numerous intervention skills can be used to achieve each of these components. Have you ever unfairly blamed your friend in order to get out of a difficult situation? Have you ever sacrificed your self-interest in order to help others or serve society?
Have you found something for which you are willing to work hard and sacrifice?
The following are some techniques to activate awareness of responsibility: It is interesting to note that the PURE strategy not only provides a conceptual framework for assessment and treatment, but also addresses the fundamental issues in meaningfulness, as proposed by Kauppinen in press , a philosopher specializing in meaning. His Fitting Attitudes Analysis of Meaningfulness states: Agential pride comes from personal responsibility, feelings of fulfilment come from a sense of understanding and enjoyment, confident hope in receiving admiration comes from pursuing a worthwhile and significant purpose in serving the greater good.
Each component represents an important existential theme and meaning-oriented intervention. MT recognizes different levels of acceptance, from cognitive acceptance and emotional acceptance to integrative acceptance which incorporates a negative event with positive aspects of life. This dual process approach effectively integrates the negatives and positives that are inevitable in life, and negotiates a dialectic balance between opposing life forces Wong, d.
This involves a variety of questions designed to encourage clients to reflect and find answers inside themselves. It often revolves around basic existential questions such as: What is the point of all my striving? How do I know my true calling?
What would make my life more meaningful and significant? What special mission or goal have all my experiences and gifts prepared me for? This method is ideal in drawing out what is innate and implicit within the human soul for what is right, noble, and significant. Viktor Frankl has used this method effectively in helping his patients to listen to their intuitive conscience, to discover enduring values, and to discover their new meaning in life.
According to Frankl, dereflection is based on the human capacities of self-distancing and self-transcendence. It involves asking questions such as: If everything went well, what would it look like? Is there anything in life that you would die for? In short, this technique helps clients see through their confusion and discover what really matters. Various questions are used to help clients see the consequences of their behaviour.
This is designed to develop a balanced view of maintaining mental health. Daily Self-Affirmation Mantras exercise. This is designed to cultivate and maintain a positive attitude. Gratitude Exercises serve as a spiritual exercise rather than an instrument for happiness:. In sum, MT is a positive, integrative, and evidence-based existential therapy.
It addresses all the traditional existential themes, but also makes full use of valid and reliable quantitative measures and the vast literature on meaning research. MT moves existential therapy closer to mainstream psychotherapy, without losing its existential philosophical roots. My answer is that it does not restrict the practice of free-flowing existential-phenomenological therapists.
What it does do is provide additional tools, both conceptual and technical, to assist existential therapists in their case conceptualization and assessment as advocated by Hoffman et al. As a result of the recent positive psychology movement, meaning in life has moved to the centre stage of mainstream psychology. The present MT approach makes it possible to integrate new discoveries in meaning research with existential therapy Wong, MT is also a value-based and spiritually-oriented therapy. It views each individual as an autonomous human being, seeking authenticity and personal significance against the backdrop of the bleak human condition.
It advocates a person-centered and holistic approach of working with all dimensions of the person, but emphasizing the spiritual core as the heart and soul of psychotherapy. Thus, MT has much to commend itself to address mental health issues related to the crisis of meaning at both individual and societal levels.
The Process and Outcome of Life Review Psychotherapy With Depressed Homebound Older Adults
MT differs from both the American version of existential-integrative therapy and the European version of phenomenological-existential therapy by virtue of its focus on meaning-seeking and meaning-making for a worthy life, rather than on existential anxieties. Existential Analysis, 26 1 , Introduction Meaning matters more than we realize. A Positive Approach In a family of different types of existential therapies, MT distinguishes itself as making meaning fulfillment the most important principle.
An Integrative Approach Meaning is all we have, because we are a meaning-seeking, meaning-making species, shaped by a culture of socially constructed symbols and moral norms. These assessments can also add a quantitative source of heuristics and verification The time for the idea of meaning has finally arrived in mainstream psychology. Meaning-Centered Assessments Tools This paper only lists a sample of measures developed by me to illustrate the connection between my meaning research and MT. One of the few meaning measures that unpacks different sources of meaning. Life Orientation Scale LOS; Wong, c was designed to determine the extent to which individuals hold a meaning mindset or global belief that life has intrinsic meaning.
This instrument was designed to assess where one stands at the present moment with respect to searching for the answers to eight important existential questions. It is useful as a springboard to start a dialogue on existential issues. The most widely used scale to measure five major death attitudes, from death fear to death acceptance. It can also be used to assess suicidal ideation. A scale that measures attitudes important to maintaining optimism in tragic or dire situations. Measuring effective stress appraisal and coping strategies.
This can be used to assess whether clients are able to see stress as a controllable challenge and to make more positive re-appraisals as a result of counselling. This is the only scale that measures internal locus of control and external locus of control as two separate dimensions Meaning-Centered Intervention Strategies The following 5 intervention strategies are based on major theoretical concepts in MT.
Other Techniques and Exercises Socratic dialogue. Looking back for lessons learned in life. Looking at present opportunities to learn and serve. Looking forward to fulfilling future life goals. Looking inward in mindful meditation. Looking downward to extend a helping hand to those who need it. My life has intrinsic meaning and value. I am pursuing my mission with passion.
I am more than enough for all the challenges that may come my way. I choose to stay positive throughout my day. Gratitude Exercises serve as a spiritual exercise rather than an instrument for happiness: Identify 3 things you are thankful for in a recent setback or difficulty. Identify 3 things good about a significant person with whom you have a conflict. Express daily gratitude for the blessings you received that day. Reflect on what you do have and express gratitude for these gifts.
Meaning Therapy: Assessments and Interventions
Conclusion In sum, MT is a positive, integrative, and evidence-based existential therapy. Evidence-based practice in psychology. American Psychologist, 61 , Meaning in positive and existential psychology. Telling the stories of life through guided autobiography groups. John Hopkins University Press. Individual meaning-centered psychotherapy for patients with advanced cancer: Meaning-centered group psychotherapy for patients with advanced cancer: The doctor and the soul: The feeling of meaninglessness: A challenge to psychotherapy and philosophy.
Death attitudes across the life span. Omega, 2 , Meaning in life and coping: Sense of meaning as a buffer against stress. A Very Short Introduction. The origins of meaning: Objective reality, the unconscious mind, and awareness. Classical perspectives, emerging themes, and controversies pp. The experience of meaning in life: Classical perspectives, emerging themes, and controversies. Emotion, relationship, and meaning as core existential practice: Journal of Contemporary Psychotherapy , Binding clinical, existential, and positive psychological perspectives. Meaning-in-life measures and development of a brief version of the Personal Meaning Profile.
Handbook of psychotherapy integration. Trauma and meaning making: Converging conceptualizations and emerging evidence. A multidimensional approach to cognitive appraisal. Stress Medicine, 6 , Character strengths and virtues: A handbook and classification. Optimizing human development across the life span. Its current practice, implications and theory. Existential well-being and health. The experiential liberation strategy of the existential-integrative model of therapy.
Meaning, mortality, and choice: The social psychology of existential concerns.