HN501 Unit 10 DBP

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CHAPTER15GainsandLossesinLateAdulthoodAspeoplemoveintooldage.docx
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CHAPTER 15 Gains and Losses in Late Adulthood As people move into old age, in their 60s and 70s, or into old-old age, in their 80s and 90s, both gains and losses continue. However, losses may considerably outweigh gains. “Even in young people’s lives, not everything goes well. Old age is a genuinely difficult situation with lots of sadness and frustration. Many things do not go well” (Pipher, 1999, p. 26). How can the elderly effectively manage the ever-increasing losses they experience? For example, can their developmental trajectory be a positive one when they experience multiple health problems or find themselves in chronic pain? An important focus of this chapter will be to identify the means by which elderly adults manage their lives and the extent to which they can grow, maintain themselves, and regulate their losses. Clearly, different people manage their late-life losses with varying degrees of success. But you may be surprised to learn that for a majority of us, successful development is what we can expect for much of our old age. At age 81, Helen still maintains her job in a bookstore. As one of the oldest siblings in a large working-class family, she learned early to value hard work and has always been active and productive. Her job provides her with opportunities to maintain her skills as well as the chance to learn new ones, such as the new computerized system her company uses to inventory material. Helen is fortunate in that her health is good, aside from some problems with arthritis that slow down her movement. She recognizes that she must regulate her activity now more than before, reducing extraneous activities so she can be well rested and prepared for work, thus optimizing her performance there. She is an avid crossword puzzle fan, her recipe for staying mentally active. When she noticed herself becoming more forgetful, she compensated by writing notes to herself and establishing and following set routines. She travels and volunteers less these days, compared to what she did years ago when her husband was alive. Now she chooses to spend more time with her family and has eliminated activities she considers unnecessary. She knows what she can do and what gives her a sense of satisfaction. Helen’s adaptation is a good example of how a person can cope successfully with the challenges of aging. In what follows, we will first review the nature of the losses and challenges that typically confront people in old age. Then we will look at the ways in which the elderly cope with these challenges, paying special attention to the processes that seem most important for the lifelong experience of psychological well-being. The fact that the world’s aging population is rapidly increasing adds a level of urgency to these issues if we are to support healthy development at all points in the lifespan (see Figure 15.1). FIGURE 15.1 The growing aging population across the world. The numbers of aged are predicted to rise sharply across the world in coming years. SOURCE: United Nations World Population Aging 2009; [no longer online] http://www.un.org/esa/population/publications/WPA2009/WPA2009-report.pdf. PHYSICAL, COGNITIVE, AND SOCIOEMOTIONAL CHANGE IN LATE LIFE Challenge and Loss in Late Adulthood Physical Change A gradual decline from peak functioning is characteristic of most physiological systems beginning as early as age 30. By late adulthood, the losses are usually noticeable and have required some adjustment in expectations or lifestyle. A lifelong runner who still entered marathons at age 62 remarked, “At 30, my goal was to win. At 50, I celebrated every race that I finished. Today, I’m delighted to be at the starting line.” Maintaining good physical and mental health becomes more challenging with age, as the immune system becomes progressively less effective in staving off cancer and infections and as the cardiovascular, respiratory, and organ systems function less adequately. Chronic illness and the need for more vigilant health maintenance increase dramatically with age. Age shifts in the leading causes of death illustrate these changing health concerns. In the United States, accidents are the leading cause of death in adults up to age 45. But at 45, heart disease and cancer take over as the leading causes of death, followed by cerebrovascular diseases and chronic respiratory illness (U.S. National Center for Health Statistics, Health, United States, 2010). People of any age can suffer from acute or chronic illnesses, such as cancer, heart problems, diabetes, and so on. But the risk of these illnesses climbs dramatically and steadily in our later years. Among the continuing declines of old age are two that are common and often especially debilitating. First are increasing sensory deficits (see Chapter 13). Changes in the visual system can be particularly important for one daily activity: driving. A number of aging changes make driving more difficult, including loss of visual acuity, loss of sensitivity to movement in the periphery, increased recovery time after exposure to glare, and reduced night vision. These changes do not contribute significantly to accident rates until people reach their mid-70s (Whitbourne, 2002; U.S. Bureau of the Census, 2012). A second important decline in older adults is the onset of pain, stiffness, and swelling of joints and surrounding tissues that we call arthritis. After 65, about half of women and about 40% of men experience the most common form, osteoarthritis, which involves the thinning, fraying, and cracking of cartilage at the ends of bones. Ordinarily, this cartilage helps protect our joints from the friction of bone to bone contact. As cartilage degenerates and other joint changes occur, such as the growth of bony spurs and modifications in connective tissues, joints may stiffen and swell. The upshot is often pain and reduced movement. Being overweight or overusing a particular joint (for example, the knees in sports like running and tennis) can contribute to susceptibility, but ordinary degeneration with age is part of the problem. Osteoarthritis can range from being a painful nuisance to being a source of major disability. It can affect the performance of simple tasks, such as opening a jar or walking, as well as more complex skills such as playing the piano or swinging a golf club (Whitbourne & Whitbourne, 2011). How older individuals respond to daily physical symptoms has a substantial impact on their overall health over time. Being proactive in seeking help when health problems begin and making a strong commitment to treatment, such as sticking to medical treatment plans or exercise regimens is important. In a longitudinal study of people above age 60, Wrosch and Schultz (2008) found that the use of such health management control strategies was directly related to health maintenance versus decline. We have repeatedly examined the role of stress in inflammatory and disease-related processes throughout the lifespan. In old age, stress-related allostatic load contributes to disease burden and lowered quality of life (see Prasad, Sung, & Aggarwal, 2012 for a review of inflammation’s role in chronic diseases of aging). Of particular significance are studies that implicate stress in telomere shortening. Telomeres are the protective ends of chromosomes that are shortened by physiological and psychological stress as well as age. When stress is chronic, accelerated cell aging has been observed both in children and adults. Shortness of telomeres is associated with earlier mortality (Lin, Epel, & Blackburn, 2011) but some shortening may be reversed with effective stress management strategies such as mindfulness meditation (Epel, Daubenmier, Moskowitz, Folkman, & Blackburn, 2009). Not all stress is bad, however. Exercise is a beneficial form of physical stress that provides abundant benefits for all age groups. Physical activity includes things like walking a pet or gardening. Remaining as active as possible in later life, both through structured exercise and physical activities, helps reduce stress and promotes health. Other mild stress, such as the stress of caloric restriction and exposure to cognitive stimulation, also appears to reduce deterioration in aging individuals (Mattson, Chan, & Duan, 2002). Attention to health maintenance is an important aspect of successful coping in late adulthood. Brain and Cognitive Change Cognition depends on a healthy and well-functioning brain. This means, among other things, that synaptic connections operate smoothly and the integrity of white matter is preserved. You have seen that healthy brain development proceeds in an organized fashion with the frontal lobes last to mature. As people age, those portions of the brain that matured last tend to be most vulnerable. Vascular problems and atrophy affect the frontal lobes first in late life, although this phenomenon does not account for all the cognitive changes of aging (Raz, 2000). Thus, executive functions, largely controlled via frontal lobe funtioning, are areas that generally show earliest age-related declines. Continuous decrements on many neurological measures related to cognition like brain volume, cortical thickness, neurotransmitter efficiency, and so forth extend from the decade of the twenties onward (see Salthouse, 2009). In this section we’ll take a look at these changes and provide a brief review of related material from Chapter 13. Alvin and his partner/caregiver describe the challenges of living with dementia. You probably recall that reserarchers make a distinction between fluid and crystallized intelligence as a way of describing two types of intellectual resources. In previous chapters we call these categories mechanics (fluid) and pragmatics (crystallized). Another way to think about this distinction is to consider fluid intelligence as the processing efficiency of the cognitive system and crystallized intelligence as the product of that processing (Salthouse, 2006). For many years, correlational studies of cognitive aging in adults have reported declines in both fluid and crystallized intelligence (Jones & Conrad, 1933; see Figure 15.2a . Longitudinal studies paint a different picture. They suggest that crystallized intelligence, as represented by measures of verbal ability and factual knowledge, does not decline until the mid-70s, and the declines are modest thereafter (Schaie, 1996). Many old individuals show no declines in some areas, and some who have maintained good health actually continue to improve on crystallized intelligence measures. For example, in one longitudinal study of 70- to 100-year-olds, vocabulary knowledge increased until age 90 and showed only slow declines thereafter (Singer, Verhaeghen, Ghisletta, Lindenberger, & Baltes, 2003). In contrast, gradual decrements in fluid intelligence, marked by slower processing speed and reduced inhibitory functions occur with age. Such declines may limit the efficiency of working memory operations, such as learning and problem solving, but these effects may be balanced by the maintenance or advancement of crystallized intelligence or pragmatics (see Figure 15.2b). Interestingly, even for people who perform well on cognitive tasks well into old age, there appear to be changes in the areas of the brain that are being activated. In brain imaging studies, older adults frequently show underactivation of some brain sites and overactivation of other sites, especially the prefrontal lobes, relative to younger adults. Also, older adults are more likely to involve both sides of the brain in performing a task when younger adults may only use one side. There could be many reasons for these differences in brain utilization, but some evidence indicates that compensation for loss is often involved, helping the older individual to maintain levels of performance. This is a little like using a back-up reserve and can be successful at moderate levels of task difficulty. When the demands exceed capacity, a resource ceiling is reached, which might explain age-related cognitive declines (see Reuter-Lorenz & Cappell, 2008). Despite the fact that longitudinal results have been the dominant paradigm for interpreting age changes in cognition, some researchers have questioned the accuracy of these results. Salthouse (2009) showed that reanalyzing the longitudinal data while extracting the effects of prior testing or “practice effects” changes the picture. After statistically removing the practice effects, results from longitudinal findings more closely mirror the declines observed in cross-sectional analyses. These findings, however, should not diminish the importance of longitudinal work. They do suggest, however, the need to more clearly identify true maturational change, devoid of practice effects, and to factor in the developmental stage at which the learning occurs relative to when it is lost. Craik and Bialystok (2006) offer a framework (see Figure 15.2c) for understanding age changes in cognition that integrates cross-sectional and longitudinal results. These authors use a different way of characterizing cognitive functions: representations and control. Representations are the kinds of schemas or sytems of schemas one develops over time to interact with the world. In previous chapters we described Piaget’s famous stage theory, a narrative of how representations develop from reflexes to abstract thought across the years of childhood and adolescence. Representational systems can involve declarative (language or world history) or procedural (playing chess or driving a car) knowledge. Representations are the foundation of crystallized intelligence. Control involves the ways one works with knowledge and includes attention, learning efficiency, flexibility of working memory, inhibitory control and processing speed. Both representations and control features interact. Consider how your attention is drawn to certain kinds of information which, in turn, results in the construction of new schemas or representations of the world. As your understanding grows in a particular domain, so does your expertise. FIGURE 15.2 Three models of cognitive change throughout the lifespan. Part a reflects an inverted u-shaped curve of cognitive development. Performance increases in childhood, is maintained in adulthood, and decreases thereafter. Part b illustrates differing trajectories for fluid and crystallized intelligence. Part c incorporates executive processes informed by neuroscientific findings that show more subtle patterns of maintenance and decline. SOURCE: Craik, F. J. M. & Bialystok, E. (2006). Cognition through the lifespan: Mechanisms of change. Trends in Cognitive Sciences, 10, 131–138. Used with permission from Elsevier. At older ages, the process of forming new representations is more challenging despite the retention of previously learned representational systems. It appears that using these systems contributes to their maintenance, supporting the proverbial “use it or lose it” advice. But even previously learned representations depend upon control funtions in order to be accessed and used. For example, the name of that elementary school classmate you’re trying to recall does you no good buried in your memory unless you can access it. Peak levels of cognitive control functions occur in young adulthood, and gradually decrease thereafter. Craik and Bialystok posit that research on cognition in childhood and late life are separated by differences in language and emphases. “In development, the primary emphasis is on the changes in representations as the child constructs a coherent interpretive basis for understanding the world; in cognitive aging, the primary emphasis is on decline in control processes as they produce impairments of access to existing knowledge, integration of new and existing information, and translation of knowledge into timely and adaptive action” (Craik & Bialystok, 2006, p. 136). But a more holistic approach to cognition and, in particular, to executive functions across the lifespan can help us map existing knowledge onto new findings in neuroscience. This approach also offers a potential paradigm for studying remediation efforts to increase cognitive reserve (Reuter-Lorenz & Mikels, 2006). Dementia. Dementia is a syndrome that affects multiple functional domains due to chronic and progressive disease processes in the brain. Cognitive and emotional skills like memory, judgement, language, self-regulation, and motivation are progressively diminished. Alzheimer’s disease (AD) is the most common type, accounting for 60% of all cases. Frontotemporal dementia (deterioration primarily in frontal and temporal lobes), vascular dementia (related to problems with blood flow to the brain), and dementia with Lewy bodies (or protein build-up) have also been identified. Among these four main types of dementia, there is a great deal of overlap and combined types are frequent (World Alzheimer Report, 2009). The World Health Organization estimates that 35.6 million people around the world were living with dementia in 2010 and rates are predicted to double every 20 years (Alzheimer’s Association, 2012). AD is diagnosed primarily by its clinical characteristics and by excluding other possible causes of dementia. Diagnostic procedures continue to be improved, and skilled clinicians can be quite accurate once a comprehensive evaluation is performed. At this point, however, only autopsy can definitively conclude the presence of AD. Typically dementia progresses in stages. There is a prodromal period, lasting for a year or two, when symptoms (e.g., memory loss) do not reach a clinical threshold but are more impaired than what would be normal for that age. In its early stages, it looks like absentmindedness: forgetting where you recently put something or forgetting something that happened in the last few days or the last few hours. Difficulties with decision making, word-finding, regulating moods, or completing complex tasks might be present. Some pharmaceutical treatments are currently being tested for symptom reduction at this stage, but, thus far, daily exercise and cognitive stimulation have shown the greatest benefit (see Morley, 2011; Cheng, Chow, Song, Yu, Chan, et al., 2012). More general confusion may follow in the middle stage (second to fourth or fifth year). Individuals might have difficulty remembering even very recent events, wander away from home and get lost, and become unable to prepare meals or perform other self-care tasks. People at this stage may be quite distressed by their memory loss, perhaps even paranoid if they frequently cannot remember what they have done or where they have put things. They may also conclude that others are responsible for these lapses. A relative of one of the authors, for example, would insist that people had entered her apartment and had turned on her TV when she wasn’t looking. Others may become hostile in their frustration and confusion. One elderly man, believing that an intruder had entered his home, assaulted his own son each time the latter visited. In later stages, memory and language problems get worse, disorientation is extreme, and physical coordination is affected. Eventually, in the last stage (fifth year and after), Alzheimer’s patients, often mute and bedridden, need full-time care and supervision, and death is the outcome (see Alzheimer’s Association, 2012). This is not the only course of the disease. Early-onset AD strikes 40- to 50-year-olds, ends in death after about 5 years, and clearly has a genetic contribution. In all forms of AD, extensive brain changes include the formation of plaques, clumps of insoluble protein that are damaging to neurons, and tangles, twisted filaments of another protein, which may interfere with communication between neurons and even cause cell death (Braak & Braak, 1991). Amyloid precursor protein (APP) and several enzymes that operate on it appear to play an initial role in development of plaque formation (Ballard, Gauthier, Corbett, Brayne, Aarsland, & Jones, 2011). Related inflammatory processes also appear to be important precursors of dementia. These inflammatory processes can start up to 10 to 20 years before actual symptoms appear (Friedrich, 2013). Early stage studies have also found noticeable brain changes in AD including thinning in several areas of the brain (Dickerson et al., 2008). The inability to remember things after an intervening distraction or period of time (either several minutes or longer), called delayed recall, is considered one of the best preclinical signs of approaching AD (Salmon & Bondi, 2009). Many of us have seen the ravages of dementia in a relative or friend, and we worry that extreme memory loss and disorientation are the inevitable consequences of aging. But they are not. Normal aging does not lead to dementia, although the frequency of illnesses and conditions that cause dementia does increase with age. Among these are cardiovascular problems that limit the oxygen supply to the brain for some period of time. These include cerebrovascular accidents, or strokes, in which an artery serving the brain is either clogged or bursts. A single stroke can lead to acute onset of dementia. More typically, many minor strokes (multi-infarct dementia) can gradually do sufficient damage to cause dementia. Hypertension (high blood pressure), or hypertension combined with diabetes, increases the risk of this type of dementia (Whitbourne & Whitbourne, 2011). Although AD and other forms of dementia are not characteristic of the majority of elderly, there is some suspicion that the formation of plaques and tangles may occur to some extent in all of us. Some environments seem to enhance or reduce AD rates. For example, lifelong education and intellectual stimulation seem to decrease the risk (Snowdon, 1997; Wilson et al, 2010). Terminal Drop and Terminal Decline.  Terminal drop and terminal decline describe the phenomena of deteriorating cognitive ability as adults approach the end of their lives. In the months and years prior to death, individuals may show a substantial decline in intellectual functioning as indicated by scores on intelligence tests (e.g., Berg, 1987; Wilson, Beck, Bienias, & Bennet, 2007). Figure 15.3 illustrates this finding from one set of longitudinal data. Once used synonymously, researchers are now distinguishing between the terms drop and decline. The former change is more precipitous while the latter suggests a gradual process. Researchers using a large-scale Canadian sample (MacDonald, Hultsch, & Dixon, 2011) found little support for the terminal drop trajectory for aggregated cognitive measures used in this study. Instead, the evidence showed greater support for the model of terminal decline. Abrupt declines in cognition may be observed in certain circumstances, and more research is needed to determine why they occur, given the clinical importance of such meaningful changes. Either way, patterns of cognitive deterioration appear to reflect the individual’s declining health status, although there also appear to be some individual differences in deterioration processes linked to genetic susceptibility (Wilson et al., 2007). Interestingly, people often seem to be able to detect in themselves whatever changes in health status are predictive of death. A number of studies have found that when older adults self-rate their health as “poor,” they are much more likely to die within the next few years than when they rate their health as “excellent” (e.g., Wolinsky & Johnson, 1992). Apparently, people often realize when they are going into decline. In Box 15.1, we examine the effect on caregivers when the elderly reach the end stage of their lives. FIGURE 15.3 The relationship between survival scores on an IQ test of verbal meaning in a longitudinal study. SOURCE: Berg, S. (1996). Aging, behavior, and terminal decline. In James E. Birrens, et al. (Eds.), Handbook of the psychology of aging (4th ed.). Burlington, MA: Elsevier Science (USA). Used with permission from Elsevier. Autobiographical Memory. One cognitive function that has particular significance for one’s sense of self as well as for social interactions throughout the life span is called autobiographical memory. This is the remembered self, “representations of who we have been at various points in the past” (Fitzgerald, 1999, p. 143). It draws from several long-term memory systems (see Chapter 6 for an introduction to these systems). When we recall specific experiences in our lives we are calling on episodic memory; when we remember that we know some fact we’re using our semantic memory; and when we remember how to do something we depend on our procedural memory. Autobiographical memory has often been treated as synonymous with episodic memory, which is a very important part of it, but our self-recollections are not episodic alone. Autobiographical memory is important in many ways. It provides us with a “sense of identity in narrative form” (Fitzgerald, 1999, p. 143). It also is a source of information about social interactions that have worked and that have not worked for us in the past. When we draw on autobiographical memory to tell stories about ourselves to others, it helps us reveal and share ourselves, get closer to others, create impressions, even teach lessons (Fitzgerald, 1999; Hyman & Faries, 1992). One stereotype that people often have about the aged is that they remember more about their early lives than about what has happened to them recently. Studies of autobiographical memory indicate that this belief is only partially true. Elderly people actually do remember their more recent experiences better than earlier experiences, although the stories that they tell about themselves are often well-rehearsed experiences from the distant past. There are two very salient characteristics of self-memories for adults of all ages. One is recency: The strength of a memory declines the more time has passed since the memory was formed. That is, we are more likely to remember something that has happened to us recently than something that happened in the more distant past. One way to study autobiographical memory is to say a word, like “dog,” and ask a person to report a specific experience in his life that the word calls to mind. Regardless of the age of the respondent, half of all such cue-prompted memories will be from the most recent 12 months of his life. Eighty percent are from the most recent decade. “The remembered self is largely a now-self, not a distant-self,” even for old people (Fitzgerald, 1999, p. 159). Box 15.1: The Burden of Care In the United States, most elderly people are in good enough health to take full responsibility for their own lives and well-being. But with advancing age the chance of chronic illness or disability increases and for many, there comes a time when full self-care is impossible. For approximately 80% of the frail elderly, family members provide the care that is needed, and often one person bears most of the responsibility (Martin, 2000). For these primary caregivers, there may be rewards, but there often are costs as well—psychological, physical, occupational, social and financial—that together are described as the care burden. This burden can bring with it serious consequences for caregivers and sometimes, for patients. For caregivers of patients with dementia, for example, quality of life often declines, and their physical and mental health is jeopardized. For patients, care burden sometimes contributes to the abuse or neglect of the patient or to generally poor standards of care (Papastavrou, Kalokerinou, Papacostas, Tsangari, & Sourtzi, 2007). Benefits and Burden A caregiver may reap emotional benefits from her role if her self worth is tied in part to “an ethic of responsibility and care” (Martin, 2000, p. 988). In Asian cultures, filial piety (xaio) provides an explicit cultural norm that guides caregiving behavior. Children are taught to care for aging parents as a form of gratitude and respect (Wang, 2004). But even in cultures without such explicit norms, children usually care for their parents in old age (Montgomery, Borgatta, & Borgatta, 2000). Good quality caregiving can promote feelings of competency and self-esteem. For some caregivers there may be financial benefits associated with caregiving as well, as when the primary caregiver anticipates having some priority in the patient’s will. In some circumstances, caregiving can be a satisfying aspect of a reciprocal relationship in which the patient continues to serve as a source of emotional and social support to the caregiver. Interestingly, the burden of care is not necessarily reduced by the positive elements of caregiving. For example, caregivers who report strong feelings of general mastery (vis a vis their caregiving) have often been found to experience more care burden than other caregivers, perhaps because those who are more effective tend to work harder (e.g., Greenberger & Litwin, 2003; Halm, Treat-Jacobson, Lindquist, & Savick, 2006). There are many sources of care burden, such as fatigue, uncertainty about the future, uncertainty about care procedures, discomfort with the tasks required, and so on. The role strain that caregivers experience, trying to balance the needs of the patient with other responsibilities such as work, parenting, and self-care is an important part of the problem. The time and energy consumed both by the physical needs of patients and by their psychological and behavioral difficulties contribute heavily. In one study of over 800 caregivers, researchers found that burden was largely predicted by the degree of physical and/or psychological disability of the patient (Martin, 2000). For caregivers, the psychological and physical consequences of care burden can be profound. The risk of depression and suicide is substantial. Health decline and increased risk of death are common. Emotional turmoil, including feelings of anger, helplessness, guilt, and loss, are typical (see Mace & Rabins, 1999). Primary caregivers often feel unfairly treated or misunderstood by other family members who are less involved in patient care. Their anger and resentment, and the chances of a long-term rift, are greater when more distant family members justify their lesser involvement by minimizing the needs of the patient or the sacrifice of primary caregivers (Ingersoll-Dayton, Neal, Ha, & Hammer, 2003). To appreciate the nature of care burden, consider the following excerpts from the diary of one woman who cared for her husband at home. Her spouse suffered from multi-infarct disease, which resulted from a series of minor strokes. Damage to the brain is progressive, much like Alzheimer’s disease. The changes in her husband’s interpersonal behavior, linked to his growing confusion and memory loss, clearly constitute the heaviest part of this caregiver’s burden. August 28th : (Charlie said) . . . “We don’t even have any water in the house.” Oh no, I thought, not again, but he went on. “And since we don’t have water in the house they’re going to condemn it for sure.” “They’re not going to condemn it,” I said. “I told you that before.” “That’s all you know about it. You’re just dumb and stupid, that’s all.” He was ranting like a maniac. “I never saw anybody so ignorant.” He kept going on and on, but . . . I managed to change the subject. It’s so hard to contend with something like this, to keep loving someone who calls you names and treats you like an enemy. I remember how nice it used to be to sit here in the evening and enjoy the TV together. And how Charlie used to laugh and joke around. I also remember how thoughtful he used to be. How warm, generous and loving, and how close we were. Now, he’s so wrapped up in his own mixed up world and in his own thoughts, he hardly pays any attention to what’s going on around him, or what I’m doing. He doesn’t seem to have a grasp on reality, and yet, his family thinks he’s just fine, that he’s just a little forgetful. September 15th : . . . It’s 8:30 P.M. He’s sitting on the sun porch and he’s been crying for over an hour and I don’t know what to do. I’ve tried everything I can think of to quiet him down, but he still just keeps right on crying. When I ask him why he’s crying he says, “I don’t know.” It hurts to see him like this. March 18th : . . . I heard loud weird noises coming from the kitchen . . . I hurried into the dinette area just in time to see Charlie raise his arm and throw a handful of ice cubes into one of my cooking pans . . . Water and ice cubes were everywhere. “What are you doing?” I yelled. “I have to,” he shouted. “We’re running out of water.” “We aren’t running out of water,” I yelled back. “Now, put everything down and leave it alone.” “Get away!” he threatened and he took a swing at me . . . . . . Every time I tried to stop him, he’d come at me with fury in his eyes, clenched fists, arms swinging, yelling that we were running out of water. (Shiplett, 1996) Primary Caregivers Most primary caregivers are either adult children or spouses of the patient. Among all racial and ethnic groups, women, especially daughters, are more likely to be primary caregivers. Aronson and Weiner (2007) claim that women today actually spend more total time caring for older parents than they do caring for children. When multiple family members contribute, there appear to be some differences in the tasks that female and male caregivers perform. Women are more likely to provide routine hands-on care, whereas men are more likely to provide help in specific situations. Men are more likely to use formal services than women, and they are less likely to feel a conflict with their employment responsibilities, perhaps because less is typically expected of men as caregivers. Many studies indicate that care burden tends to be greater for women than for men, although this gender difference can be moderated by ethnicity. Specifically, African American women report less care burden than White women, whereas African American men report more care burden than White men. Given that African American households are more likely to include extended family members than White households, it may be that African American women expect to care for frail, elderly relatives, whereas African American men may have less expectation of such responsibilities. African American families may also provide more support to women caregivers than White families. The aforementioned virtue of filial piety may affect the nature and quality of caregiving among Asian families. A study of Caucasian-Canadian, Chinese-Canadian, and Hong-Kong Chinese caregivers explored the strength of traditional cultural attitudes and caregiving quality (Chappell & Funk, 2012). Contrary to expectations, filial piety did not predict behaviors related to care of basic daily needs because children cared for parents across all cultures examined. However, both Chinese groups were more likely to provide greater emotional support to aging parents, possibly demonstrating one distinctive effect of cultural socialization. Further research into cultural differences seems especially important if it can help illuminate environmental factors that explain caregiving patterns and mitigate the burden of care (see Martin, 2000, for a review). Helping Caregivers Delehanty and Ginzler (2005), in their guide for caregivers, remind us of the lesson that airline safety instructions impart: “In the event the oxygen masks deploy due to loss of cabin pressure, put on your own mask first, then assist others.” The point is, of course, that a caregiver whose mental or physical resources are depleted can actually endanger herself and those who are dependent on her. Consider these quotes from Mace and Rabins (1999), one from a patient’s daughter and another from a patient’s husband, both primary caregivers: My mother would scratch at herself in one spot until it bled. The doctor said we had to stop it. I tried everything until one day I guess I snapped: I grabbed her and shook her and I screamed at her. She just looked at me and began to cry. (p. 218) Sometimes I couldn’t stand it. My wife would get to me so, always on about something, and the same thing over and over. Then I would tie her into her chair and go for a walk. I felt terrible about it, but I couldn’t stand it. (p. 217) Most guidelines for caregivers emphasize the critical importance of “timeouts,” regular daily or weekly respites from the constancy of caregiving tasks (e.g., Delehanty and Ginzler, 2005; Mace and Rabins, 1999). To make timeouts possible, caregivers need access to resources, such as adult day care programs, professional in-home aids, or regular substitutes among family and friends. Avoiding isolation and reserving time for socializing is critical. Many communities, especially through their medical facilities, offer either individual or group interventions to educate and support caregivers. These services teach caregivers what to expect, how to cope, and how to access resources, and help them to understand their own emotions and the behaviors of difficult patients. A meta-analysis of studies of treatment interventions for primary caregivers found significant benefits of both individual and group approaches (Yin, Zhou, & Bashford, 2002). Interestingly, although women caregivers reported more care burden than men before intervention, women tended to benefit more. Also, there were cultural moderators: Group interventions were more effective than individual interventions for non-White caregivers, but for White caregivers both forms were equally effective. The impact of the caregiver’s role, and the need for support, is poignantly expressed in the words of one husband caregiver as he tried to write a journal about his wife’s illness: “I realized that I was telling the story of my own deterioration. I gave up my job to take care of her, then I had no time for my hobbies, and gradually we stopped seeing our friends” (Mace & Rabins, 1999, p. 214). Clearly, helpers can play a role in reducing the costs of care burden, both by advocating for community resources for caregivers and by providing a range of interventions to meet caregivers’ needs. This may sound a bit confusing, given that adults learn new information less efficiently with age. As we saw in Chapter 13, information in working memory is not as easily transferred to long-term memory at later ages. However, older people nonetheless do continue to learn, and newer memories are more readily retrieved than older memories. FIGURE 15.4 Proportion of reported flashbulb memories by age and time of event for older adults. SOURCE: Based on Fitzgerald, J. M. (1999). Autobiographical memory and social cognition. Development of the remembered self-adulthood. In Thomas M. Hess (Ed.). Social cognition and aging. Elsevier Science. Burlington, MA: Elsevier Science (USA). However, a second salient feature of self-memories is a phenomenon that is ignominiously called “the bump” or the “reminiscence bump.” Regardless of age, adults’ cue-prompted memories of the self from the young adult period (from about ages 18 to 22) are slightly but reliably overproduced (see Berntsen & Rubin, 2002). That is, more memories are produced from this era than we would predict on the basis of recency (see Figure 15.4). If we explore autobiographical memory in a different way, by asking adults to tell us about their flashbulb memories, nearly all of what they tell us comes from the bump era (e.g., Fitzgerald, 1988). Flashbulb memories in these studies are defined as recollections that are especially vivid and personally relevant. It appears that when people talk about memories that are intense and important to them, they draw very heavily on experiences from young adulthood, even in their old age. If we ask people to tell stories that they would include in a book about themselves, again, a disproportionate number of the narratives come from the bump era (Fitzgerald, 1992). Similar results come from studies in which people are asked to name the most memorable books they have read (Larsen, 2000), the songs they find most desirable to listen to (Holbrook & Schindler, 1989), or the films that help describe their era (Schulster, 1996). That is, the elderly refer more often to items from their young adulthood than from any other time of their lives. Fitzgerald (1999) argues that the strength of the bump phenomenon for people’s most important memories and preferences reveals the significance of late adolescence and young adulthood as a period of intense self-development. This phenomenon might also be explained by the fact that these events tend to be positive in tone and reflect a bias toward remembering pleasant things (Thomsen, Pillemer, & Ivcevic, 2011). It’s also been proposed that these reminiscence events were encoded more strongly in memory in the first place, given their highly emotional charge (Dolcos, Labar, & Cabeza, 2005). However, the recency effect in cue-prompted memory research makes it very clear that people continue to add to their self-stories throughout their adulthood and that healthy older people have their recent past available to them despite some declines in learning efficiency. Stereotypes and Age Discrimination Among the challenges that elderly people face are stereotyped attitudes and responses from others based on age category rather than on actual characteristics. An age stereotype can be defined as a set of widely held beliefs about the characteristics of older people. These knowledge structures or schemas can lead to relatively uniform treatment of older people regardless of their own individual characteristics. They are thought to account for certain discriminatory or demeaning practices, such as mandatory retirement and patronizing talk (Hummert, 1999). TABLE 15.1 Traits Associated with Stereotypes of Older Adults STEREOTYPE TRAITS Negative   Severely impaired Slow-thinking, incompetent, feeble, inarticulate, incoherent, senile Despondent Depressed, sad, hopeless, afraid, neglected, lonely Shrew/curmudgeon Complaining, ill-tempered, demanding, stubborn, bitter, prejudiced Recluse Quiet, timid, naïve Positive   Golden ager Active, capable, sociable, independent, happy, interesting Perfect grandparent Loving, supportive, understanding, wise, generous, kind John Wayne conservative Patriotic, conservative, determined, proud, religious, nostalgic SOURCE: Hummert, M. L. (1999). A social cognitive perspective on age stereotypes. In Thomas M. Hess (Ed.), Social cognition and aging. Burlington, MA: Elsevier Science (USA). Used with permission from Elsevier. Research on the content of old-age schemas in Western cultures has identified seven common stereotypes. Four of these are negative, such as “severely impaired” or “shrew/curmudgeon,” but three are more positive, such as “perfect grandparent” (Hummert, Garstka, Shaner, & Strahm, 1994). A description of each is provided in Table 15.1. A recent study involving participants from 26 countries asked individuals to assess “typical” adolescents, adults and old people from their own country on Big 5 personality characteristics (Chan et al., 2012). Stereotypic views of older people tended to be very similar across all cultures included in this study. Old people were viewed as less active, extraverted, and impulsive compared to other age groups. They were also perceived as more agreeable and more apt to prefer to follow a routine in their daily lives. Facial features associated with aging play a significant role in activating these stereotypes. The older people look, the more likely they are to be described in ways that fit a negative stereotype. In one study, participants were asked to match the photographs of people perceived to be in their 60s, 70s, or 80s with trait sets describing either positive or negative stereotypes (Hummert, Garstka, & Shaner, 1997). The older the appearance of the person in the picture, the more likely participants were to match the picture with a negative stereotype. Gender of the pictured person played a role as well. For example, pictures of unsmiling women were more likely to be matched with a negative stereotype than pictures of unsmiling men. Many studies find that people are more likely to see men than women as losing more general competence or agentic ability with age, yet they are more likely to judge women as needing more help with age (Kite, Stockdale, Whitley, & Johnson, 2005). Because of age stereotypes, the very same behavior in younger versus older individuals is perceived differently. For example, the seriousness and the causes of a memory failure, such as forgetting the name of a new acquaintance, tend to be perceived quite differently depending on whether the failure is ascribed to a 30-year-old or to a 70-year-old. When younger adults forget, the cause is more likely to be seen as transient and external, such as “that’s a hard thing to remember.” When older people forget, the cause is more likely to be seen as something stable and internal, such as having a poor memory (see Erber & Prager, 1999; and Kite et al., 2005, for reviews). When age stereotypes are triggered, the quality of social interactions can be affected. For example, people, including clinicians, often use “patronizing talk” when speaking with an elderly person. This kind of conversation has many characteristics: simplified vocabulary and sentence structure, slower pace, careful articulation, an overly familiar or overbearing tone, and disapproving, controlling, or superficial content (e.g., Hummert & Ryan, 1996; Hummert, Shaner, Garstka, & Henry, 1998). Hummert (1999) has argued that such talk is probably grounded in stereotypic ideas about declining memory and hearing abilities in the aged. It appears, then, that aging brings with it stereotypic reactions and expectations from others, which seem likely to interfere with satisfying social interactions. Researchers have found that when older individuals perceive themselves as the target of age discrimination, their sense of well-being is negatively affected (Gartska, Schmitt, Branscombe, & Hummert, 2004). Also, the experience of stereotype threat may actually impair performance. For example, O’Brien and Hummert (2006) gave people in late middle age (48–62 years) a memory task, and either implied that they were in the “older” group by saying that their performance would be compared to younger adults, or implied that they were “younger” by saying they would be compared to older adults (over age 70). Participants performed significantly better when they saw themselves as the “younger” group than if they were characterized as the “older” group! Thus, even older people appear to have negative stereotypes about the elderly, having internalized these beliefs when they were younger. Harmful aging self-stereotypes, often operating below the level of awareness, can impact health and well-being, as Levy (2003) has shown in a series of experiments. When primed by negative stereotypes of aging, elderly participants showed reductions in cognitive performance, will-to-live, and cardiovascular functioning. Some research also indicates that the conversational styles of older people often include features that may cue stereotypes. For example, older people are sometimes prone to making “painful self-disclosures” to relative strangers about illnesses, loss of a loved one, and other personal problems (e.g., Coupland, Coupland, Giles, Henwood, & Wiemann, 1988). For the elderly, self-disclosures may serve self-presentational goals, such as indicating resilience, but for younger listeners they tend to strengthen stereotypes of the elderly as weak or lonely. Thus, misinterpretations of some characteristic behaviors of older adults probably contribute to stereotypic responses from others (Hummert, 1999). The Shrinking Social Convoy Aging brings with it the more and more frequent experience of social loss. Friends, partners, and relatives may die or suffer from debilitating disorders such as Alzheimer’s disease. In one study of 85-year-olds, 59% of the men and 42% of the women had lost a friend to death in the past year (Johnson & Troll, 1994). But illness and death are not the only sources of social loss. When people retire they lose daily contact with their colleagues at work. If the elderly person is constrained by limited finances or health problems, opportunities to visit others or to be part of club or other social activities may be reduced. Adult children may move to geographically distant locations. The elderly may leave behind neighbors and shopkeepers of long acquaintance if they move from a larger home to an apartment, an adult community, or an assisted-living facility. The shrinking of the social network and the pain of bereavement are problems that increase in late adulthood (Rook, 2000). In Chapter 10, we noted that adolescents are largely segregated into age-bound communities that share language, interests, and a dress code, among other things. Mary Pipher (1999) proposes that the physical, cognitive, and social changes of late life segregate older people as well, in ways that are important for helpers to understand. As we have noted, older people often live in circumstances that separate them from their families and their communities, often because poor health makes independent living impossible. Although these arrangements may provide the benefit of day-to-day care and companionship, they may also prevent older people from interacting with members of younger generations and deprive them of opportunities for service to others. Thus, some of their own developmental needs may be going unmet. “The old look for their existential place. They ask, ‘How did my life matter? Was my time well spent? What did I mean to others?’” (Pipher, 1999, p. 15). Social segregation creates islands of culture that discourage intergenerational bonding and may make older people feel less valued and useful to others. The elderly are restricted in other, less obvious ways. Older individuals may sometimes use language in ways that position them within a cultural group or cohort that is separate from younger generations (e.g., using “depression” primarily to mean a period of economic downturn rather than a mental health problem). Many elderly people also feel segregated from society because it simply moves too fast. Pipher (1999) recalls the adjustments she needed to make when interviewing her older clients: I learned to let the phone ring fifteen times. I learned to wait at doors five minutes after I rang the bell. I had to slow down to work with the old. Their conversation is less linear, and there are pauses and repetitions. Points are made via stories; memories lead to more memories. . . . When I walked the old, I walked slowly and held hands at intersections or when sidewalks were slick. . . . Because their bones break more easily, the old are afraid of falling . . . a broken hip can mean the end of independent living. (p. 27) In the next section, we will consider how older adults face these and many of the other losses and challenges that we have described. Later in this chapter, we will take a special look at bereavement across the life span, with particular attention to how the elderly cope with the deaths of those close to them and with their own dying process. Maintaining Well-Being in the Face of Loss: Successful Aging How do aging adults adapt to, or cope with, the increasing losses they face? Baltes and colleagues (e.g., Baltes & Baltes, 1990; Baltes, Lindenberger, & Staudinger, 2006) suggest that three processes are key to successful development at any age, and especially in the later years. The first is selection. This is a process of narrowing our goals and limiting the domains in which we expend effort. It is not difficult to see that selection is important at any time in the life cycle. For example, at 20, Len selected a career, limiting the possible directions his life could take but also enabling him to achieve high levels of expertise and productivity by focusing his training and practice on career-related skills. At 62, Len selected family life instead of career. Because he felt his stamina waning somewhat, and despite the many satisfactions he still gained from his work, he decided to retire earlier than originally planned so that he could give more energy to developing relationships with his young grandchildren. Thelma, at age 81, engages in all three processes that are key to successful development at this age. Can you identify examples of selection, optimization, and compensation? The second process is optimization, finding ways to enhance the achievement of remaining goals or finding environments that are enhancing. Len, for example, traded in his sporty two-door coupe for a larger sedan so that he could take the grandchildren on excursions to movies or museums. He also moved from a small apartment in the city to a place in the suburbs, closer to his children with amenities such as a yard where he could entertain his family. The final process that contributes to successful development is compensation. When a loss of some kind prevents the use of one means to an end, we can compensate by finding another means. For example, by age 76, as Len’s eyesight began to fail, chauffeuring his grandchildren was no longer possible. He now entertains the youngest ones at his home most of the time, planning special events such as “video marathons” and backyard camping “trips.” Baltes provides the following example of successful development in old age: When the concert pianist Arthur Rubinstein, as an 80-year-old, was asked in a television interview how he managed to maintain such a high level of expert piano playing, he hinted at the coordination of three strategies. First, Rubinstein said that he played fewer pieces (selection); second, he indicated that he now practiced these pieces more often (optimization); and third, he said that to counteract his loss in mechanical speed he now used a kind of impression management such as introducing slower play before fast segments, so to make the latter appear faster (compensation). (Baltes, Lindenberger, & Staudinger, 1998, p. 1055) The three combined processes of successful development are called selective optimization with compensation (e.g., Baltes et al., 2006). Table 15.2 summarizes some everyday sayings that seem to promote the three processes of selection, optimization, and compensation, and it provides examples of questionnaire items that have been used to assess these processes. As previously discussed, meeting basic needs for autonomy, competence, and relatedness substantially determines a person’s sense of well-being and life satisfaction, according to self-determination theory (see Chapter 14). Several theorists argue that whatever challenges we face in meeting our needs, there are two broad types of strategies that people use to control their destinies. Heckhausen (e.g., Heckhausen, 1999; Wrosch, Heckhausen, & Lachman, 2006) refers to primary and secondary control strategies. When our control efforts are attempts to affect the immediate environment beyond ourselves, we are exerting primary control. The growth of competencies of all kinds serves primary control functions and contributes to feelings of mastery and self-esteem. When we choose to develop some competencies and not others (that is, when we engage in selection, such as choosing a career) we are using a primary control strategy. When new retirees freely choose and plan their retirements, they are using primary control strategies (see Box 15.2). TABLE 15.2 Selection, Optimization, and Compensation: Brief Definitional Frames and Examples from Proverbs and Questionnaire Items STRATEGY ROLE IN DEVELOPMENT SAMPLE PROVERB SAMPLE QUESTIONNAIRE ITEM Selection Concerns directionality and focus of developmental outcomes such as goals. Jack-of-all-trades, master of none. Those who follow every path, never reach any destination. Between two stools you fall to the ground. I always focus on the most important goal at a given time. When I think about what I want in life, I commit myself to one or two important goals. To achieve a particular goal, I am willing to abandon other goals. Optimization Concerns the acquisition and refinement of means and their coordination to achieve goals/outcomes. Practice makes perfect. If at first you don’t succeed, try, try, and try again. Strike the iron when it’s hot. I keep working on what I have planned until I succeed. I keep trying until I succeed at a goal. When I want to achieve something, I can wait for the right moment. Compensation Concerns maintenance of functioning by substitution of means in situation of losses of means. There are many hands; what one cannot do, the other will. When there’s no wind, grab the oars. Those without a horse walk. When things don’t work the way they used to, I look for other ways to achieve them. When things aren’t going so well, I accept help from others. When things don’t go as well as they used to, I keep trying other ways until I can achieve the same result I used to. SOURCE: Baltes, P. B., Lindenberger, U., & Staudinger, U. (2006). Life span theory in developmental psychology. In W. Damon & R. M. Lerner (Eds.), Handbook of child psychology Vol. 1. Theoretical models of human development (6th ed., pp. 569–664). Hoboken NJ: Wiley. Reproduced with permission of John Wiley & Sons Inc. From the perspective of self-determination theory, exercising primary control could serve autonomy, competence, and/or relatedness needs. Secondary control generally refers to our attempts to modify our expectations in the face of things we can’t change. We are using secondary control strategies when, for example, we change our aspirations and goals because we cannot do everything we used to do or when we minimize the importance of specific needs after failing to achieve some end. Mary and George together made the transition into retirement. How would you classify their paths, according to Schlossberg’s theory? Box 15.2: Navigating the Transition to Retirement Beverly, a counseling psychologist and community activist, began to think about her retirement in earnest when she was 57 years old, after a bout with cancer. She recuperated well and her prognosis was good, but the sudden confrontation with ill health helped her to see that she might not always be able to work. Until then, she had vaguely assumed she would work until she dropped. Indeed, at first, she couldn’t imagine her life without the challenge of a full schedule of diverse clients and community speaking engagements. But her illness led her to examine her goals for the future more carefully. She decided that in time she would like to reduce her work commitments to have time for other interests. She had always wanted to explore her artistic talent, and when her long-time partner retired, they both hoped to have more time and energy to pursue the activities they enjoyed together, especially international travel. By the age of 65, Beverly felt she was ready to make the change. She stopped taking new clients and reduced her speaking engagements to one or fewer a month. She began thinking of herself as a retiree. Most modern adults, both men and women, have been part of the workforce for 30 or more years by the time they retire. How do they navigate the sometimes dramatic transition from being a worker to being a retiree? Not everyone who can retire chooses to do so. And when people retire (defined by Webster’s dictionary as “withdrawal from one’s position or occupation”) the strategies people devise for making the shift are quite diverse. Nancy Schlossberg, a retired counselor herself, identified multiple paths from an interview study of 100 retirees. Some were “continuers” who continued to use their work skills part time or in different settings. Beverly is a continuer; she maintains a small client roster and continues her community activities at a reduced level. “Involved spectators” keep a hand in their previous work but adopt some new role. Schlossberg herself is an example of this category. A former counseling professor, she became an author and consultant who applied her counseling knowledge to developing guidelines for retirees. “Adventurers” leave behind their old work skills and develop new talents or skills, sometimes taking on a new job. “Easy gliders” try to keep their time unscheduled. They seem especially comfortable with the flexibility they have without work or other regular commitments. “Searchers” in Schlossberg’s study have not yet found a path that works for them, but see themselves in a trial-and-error phase. “Retreaters” seem to give up on finding a satisfactory lifestyle and become depressed (Dittman, 2004; Schlossberg, 2004). Some of the diversity in Schlossberg’s findings may reflect not only different pathways of retirement but also different stages of retirement. Atchley (1976) argued that adjustment to retirement follows a typical progression for many people. Stage 1, honeymoon, is a time when people focus on the pleasures of being free from the constraints of old schedules, dress codes, and other work demands. In Stage 2, disenchantment occurs when people begin to experience an emotional “letdown” as they face the day-to-day realities of retirement, such as separation from work colleagues, uncertainties about how to feel competent and in control, a sense of diminished generativity and meaningfulness, new tensions that may arise with one’s partner, financial concerns, and perhaps, boredom. Stage 3, reorientation, can be a time of active trial and error. The retiree seeks solutions for the problems that retirement presents and tries strategies for building a satisfactory life. In Stage 4, stability is achieved. The retiree finds a functional path that seems to work. Life span theorists would say that selective optimization with compensation is achieved. Finally, Stage 5 is termination, the end-of-life transition, when the individual’s health declines and she becomes dependent on others for her care. There are certainly substantial individual differences in the retirement experience that depend on many factors, such as health, financial security, and marital status. For example, although research on the effects of marital status is limited, it suggests some complex processes at work. In one study, married and remarried women rated themselves as healthier and more satisfied with retirement than unmarried (divorced, widowed, never married) women; yet the two groups scored about the same on overall feelings of well-being (Price & Joo, 2005). Another study examined the retirement status of married partners, and found in general, that satisfaction was greater when both partners were retired. Also, if one partner were still working, satisfaction of the retired partners tended to be lower if they felt that their decision-making power in the relationship had diminished (Szinovacz & Davey, 2005). This was true for both genders. Despite the importance of individual circumstances, research suggests that Atchley’s stage descriptions do capture some predictable phases of retirement for many people. In addition, there may be several cycles of reorientation and stability, with the same individual renegotiating her retirement strategy several times as her life continues to change with the death of a partner, shifting health status, financial changes, and so on. The longer we live, the more cycles we are likely to experience. Reitzes and Mutran (2004) found general support for the idea that retirement is a dynamic, and to some degree, stagelike process. Satisfaction was high after 6 months (honeymoon), but had declined after a year (disenchantment) and had increased again after 2 years (reorientation and stability). They also identified a number of individual difference factors that impact how well people adjust to the retirement transition both in the honeymoon stage and thereafter. They assessed 800 men and women who were between the ages of 58 and 64 and who were employed full time (at least 35 hours per week) as the study began. The participants represented a random sample of people in this age range living in the Raleigh–Durham–Chapel Hill, North Carolina metropolitan area, so the sample was diverse with respect to race and socioeconomic status. The participants completed an initial screening, and they were tracked with follow-up phone calls until they retired. About 600 of the original sample had retired within 5 years. Those who were willing to continue the study were reassessed at 6 months, 1 year, and 2 years postretirement. In addition to providing information on income, pension eligibility, health status, marital status, and so on, at every assessment period the participants completed a questionnaire designed to measure their attitudes toward retirement. At the preretirement assessment, they also completed measures of their self-esteem, the social roles they filled in their current lives (e.g., parent, spouse, widow/widower, divorcee, etc.), and their “friend identity,” which captured how they viewed themselves in the friend role. The participant rated herself as a friend on a five-point scale, from (1) passive to (5) active, from (1) anxious to (5) confident, and from (1) unsuccessful to (5) successful. The researchers also collected information on the participants’ retirement experience, like how much retirement planning the participants had done preretirement, what reasons they had for retirement, whether they continued working in any capacity during retirement, and so on. Reitzes and Mutran found little difference between men and women or among different socioeconomic groups with regard to the basic ingredients of a successful retirement. Several factors at preretirement were strong predictors of positive attitudes toward retirement both early in retirement and later: pension eligibility, high self-esteem, and a positive friend identity. Not surprisingly, pension eligibility allows a degree of financial security that reduces some of the stress of the shift to retirement. As Reitzes and Mutran suggest, individuals with a strong sense of self-worth and who feel confident about their relationships with friends probably are better able to organize and structure new opportunities with confidence. High self-esteem helps people be optimistic that they will be successful in new activities and pursuits. A positive friend identity would seem to be especially valuable when release from work constraints provides more time for interactions with friends. Some other factors were very helpful for ensuring a happy honeymoon phase: being in control of the decision to retire (that is, doing so voluntarily), and approaching retirement with a plan of action. People who felt that they had no choice but to retire, because of the conditions of their employment or because of ill health, were not as happy as others in the 1st year of retirement. The same was true for people who had not carefully considered what they would do in retirement. These individuals were less satisfied at the start, but with time their situations tended to improve, and they were often doing as well as other retirees after 2 years. One retiree provides a good example of some of these factors at work, and of the typical stages that many retirees experience. Jack just plunged into retirement optimistically with no plan but his usual belief that he could “handle it.” For a while he enjoyed finishing some carpentry projects he had never had time for and some travel. But he wasdeep into disillusionment within a few months. He missed the opportunity to interact with colleagues and he missed the status he had achieved in his work life. With some help from a counselor, he identified the problems and mapped out some alternative solutions. He chose to begin consulting on a part-time basis (often voluntarily for nonprofit organizations), which brought him in touch with a wider range of people and helped him feel generative. At 72, Jack still enjoys good health, and after 4 years of retirement he believes that this is the best time of his life. Both primary and secondary control may involve cognition and action, although primary control is almost always characterized in terms of behavior engaging the external world, whereas secondary control is predominantly characterized in terms of cognitive processes localized within the individual. (Schultz & Heckhausen, 1996, p. 708) When primary control efforts fail or we suffer losses that we cannot overcome, secondary controls are likely to become important. Schultz and Heckhausen indicate that our repertoire of both primary and secondary control strategies will increase with age until late midlife but that the sheer weight of late-life declines will make primary control decline as well, so that people are likely to use more secondary control strategies in old age. Heckhausen (1997) found, for example, that adults in their 60s demonstrated more flexibility in adjusting their goals than adults in their 20s.When young, middle-aged, and elderly adults were asked to state their five most important goals and plans for the next 5 years, there was a clear shift in aspirations across age (Heckhausen, 1997). Elderly people had fewer aspirations regarding work, finances, and family and more aspirations related to health, community, and leisure pursuits than young adults. Heckhausen argues that these shifts reflect the fact that older people generally have less primary control potential over work, finances, and family. They therefore shift their goals in a compensatory way to those over which they may be able to take some primary control. On the whole, how well do people in old age adapt to the challenges of late life? There is a tendency for a terminal decline in well-being that is driven by changes associated with impending death such as health decline, cognitive and physical disability (Gerstorf et al., 2008). Yet, as we suggested earlier in this chapter, generally older people report high levels of well-being. Ryff and Keyes (1995) analyzed measures of six dimensions of well-being from interviews with 1,108 adults. The responses of young (25 to 29), middle-aged (30 to 64), and old (65 or over) adults were compared, and several measures were found to increase over age. Old adults scored higher on a measure of positive relationships than both younger groups. They scored as well as the middle-aged and higher than the young adults on measures of environmental mastery and autonomy, and they scored as well as both younger groups on self-acceptance. Older adults did score lower than the younger groups on two dimensions of well-being: purpose in life and personal growth. Perhaps as a person leaves behind the arenas in which generativity is most directly expressed—work, parenting, and community service—opportunities to feel useful or to grow seem diminished. This conclusion is consistent with findings that elderly women who continue to care for a disabled adult child report a much greater sense of purpose in life than elderly women who do not have such responsibilities (Kling, Seltzer, & Ryff, 1997). Generativity issues aside, results of these studies suggested that aging and a sense of well-being were often quite compatible and that some aspects of well-being actually improved in old age. More recent population-based longitudinal studies using Ryff’s dimensions, however, failed to find the expected increases in well-being into old age (Springer, Pudrovska, & Hauser, 2011). Some of these differences may be due to methodological problems; thus, more research is needed to clarify maturational trends across specific dimensions of well-being. Wisdom, Aging and Culture Wisdom is often perceived as going hand in hand with advanced age. If that is true, then the well-being elders do manifest may be related to the wisdom they accrue over the years. But what exactly is wisdom anyway? And does everyone achieve it in late life? The search for wisdom has been at the heart of religious and philosophical systems since ancient times. Its study as a Western scientific topic, however, began in earnest only in the 1970s. This may be due, in no small part, to the breadth of the topic and the difficulties posed in defining and measuring it. For some elderly people, wisdom may be a special asset in managing the problems of life. Wisdom has been called “expertise in the fundamental pragmatics of life” (Baltes et al., 1998, p. 1970). We have seen that the practical problems adults must face do not necessarily have one right answer. As young adults gain experience with the complexities of such ill-defined problems, the adolescent expectation that logical, absolute right answers always exist may give way to a more relativistic perspective. This perpective acknowledges that there are multiple, contextually embedded truth systems (e.g., Perry, 1970/1999). But wisdom encompasses more than cognitive skills. A wise person is an expert in the “psychological art of life” (Staudinger 1999, p. 343) that includes aspects of motivation, emotion regulation, other-directed versus self-involved orientation, tolerance for ambiguity, and insight. Wise people recognize and deal with the dialectics inherent in human existence (e.g., good and bad, strength and weakness, self-interest and altruism) in a balanced way. They often help guide others to do the same. “Mastery of such dialectics in the sense of wisdom does not mean that a decision for either one or the other side is taken but rather that both sides are essential for grasping human existence. Wisdom embraces these contradictions of life and draws insights from them. It further develops heuristics about when and under which circumstances to focus on which side of each of these opposites (Staudinger & Gluck, 2011, p. 217).” Messages about wise ways of navigating life’s challenges are embedded in culture. In fact, researchers often use folk theories of wisdom as a starting point for their work. Transmitted across generations in folk tales and proverbs, these insights have, according to Csikszentmihalyi and Rathunde (1990), universal evolutionary value. Table 15-3 contains proverbs from different cultures, each offering advice about anger and conflict. Do you notice any similar themes? Can you come up with proverbs that present an opposing message? If so, they may be examples of the dialectic we’ve described. TABLE 15.3 Wisdom Across Cultures: Wise Counsel About Anger. PROVERB ORIGIN He who is slow to anger is better than the mighty; and he who rules his spirit, than he who captures a city. Old Testament, Book of Proverbs 16:32 Life is short, but troubles make it longer. Roman proverb If you fear something, you give it power over you. African Proverb When anger and revenge get married, their daughter is called cruelty. Russian Proverb Force, no matter how concealed, begets resistance. Lakota (Sioux) Proverb The man who strikes first admits that his ideas have given out. Chinese Proverb A knife wound heals, but a tongue wound festers. Persian Proverb Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else; you are the one who gets burned. Indian Proverb (Buddhaghosa) For what cannot be cured, patience is best. Irish Proverb Don’t notice the tiny flea in the other person’s hair and overlook the lumbering yak on your own nose. Tibetan Proverb Two wrongs don’t make a right. English Proverb He who starts up in anger, sits down with a loss. Turkish Proverb Never do anything out of anger; would you hoist your sails during a storm? Arabic Proverb SOURCE: Mieder, W. (1993). The Prentice Hall encyclopedia of world proverbs. Upper Saddle River, NJ: Pearson Education, Inc. Used with permission from Pearson Education. So, is wisdom universal or culture-specific? Perhaps there are some distinctions in the way wisdom is defined that differentiate East and West (Takahashi & Overton, 2005). Western cultural views tend to emphasize the cognitive aspects of wisdom, such as breadth of knowledge and ability to analyze. Eastern cultures take a more expansive view, incorporating both cognition and affect into their understanding of wisdom. However, similarities across cultures are greater than these distinctions. Staudinger and Gluck (2011) make clear that the consensus across cultures is that wisdom represents the “perfect integration of mind and character for the greater good” (p. 221). Is wisdom more likely in old age in all cultures? In a program of research on wisdom by Staudinger, Baltes, and their colleagues, Western participants were told about people experiencing difficult real-life problems and were asked to describe and explain what the fictional people should do. One example of such a real-life problem, along with a response that received a low score for wisdom and one that received a high score, is presented in Table 15.4. Scores for wisdom were based on raters’ judgments of how rich the respondent’s factual and procedural knowledge seemed to be, whether the response took into account the developmental context, the degree to which the response reflected a relativistic view and a recognition of uncertainty, as well as attempts to manage uncertainty (e.g., Staudinger & Baltes, 1996). Findings from studies using this technique indicate that wisdom, as defined by Staudinger and Baltes (1996), does seem to require experience and thus is somewhat enhanced by age. The years from 15 to 25 appear to be very important for wisdom acquisition (Pasupathi, Staudinger, & Baltes, 1999, 2001), but after 25, the proportion of people whose wisdom scores are above average does not change substantially. After 75, fewer people continue to function at above-average levels on measures of wisdom (Baltes & Staudinger, 2000). Studies using somewhat different methods have found a tendency for wisdom to increase well into middle adulthood (e.g., Blanchard-Fields, 1986, 2007) but also to decline thereafter (e.g., Labouvie-Vief, Chiodo, Goguen, Diehl, & Orwoll, 1995). Grossman and colleagues (2010) reported that older Americans displayed wiser reasoning in relation to solving interpersonal conflicts than did younger or middle aged Americans. TABLE 15.4 Wisdom Problem and Abbreviated Responses Wisdom Problem A 15-year-old girl wants to get married right away. What should one/she consider and do? Low Wisdom-Related Score A 15-year-old girl wants to get married? No, no way, marrying at age 15 would be utterly wrong. One has to tell the girl that marriage is not possible. (After further probing) It would be irresponsible to support such an idea. No, this is just a crazy idea. High Wisdom-Related Score Well, on the surface, this seems like an easy problem. On average, marriage for 15-year-old girls is not a good thing. But there are situations where the average case does not fit. Perhaps in this instance, special life circumstances are involved, such that the girl has a terminal illness. Or the girl has just lost her parents. And also, this girl may live in another culture or historical period. Perhaps she was raised with a value system different from ours. In addition, one has to think about adequate ways of talking with the girl and to consider her emotional state. SOURCE: Baltes, P. B., & Staudinger, O. M. (2000). Wisdom: A metaheuristic (pragmatic) to orchestrate mind and virtue toward excellence. American Psychologist, 55, 122–136. Used with permission from the American Psychological Association. The developmental trajectory of wisdom aquisition, however, may not be the same for all cultural groups. Let’s consider the ways that people deal with conflict. Kunzmann and Baltes (2003) found that individuals scoring high on wisdom tend to prefer cooperative conflict management, as opposed to dominance strategies. They also score high on involvement with others, yet at the same time tend to moderate their emotional reactivity more than other people. They also seem more committed than others to pursuits that have the goal of enhancing the growth and potential of both themselves and other people. Consistent with themes presented in prior chapters, Some Eastern cultures tend to privilege harmony and cohesion in social relationships. Their conflict management strategies tend to be indirect and considerate of multiple points of view. Behaviors that assert automony and independence, leading to more direct conflict management strategies, are more characteristic of people in the United States. Grossman and his colleagues (2010) reasoned that the sensitivity to social cues young children learn in interdependent cultures may foster an earlier development of wise reasoning skills for solving conflict. Consistent with previous findings, older North Americans in this cross-cultural study gave wiser responses to questions about inter-group conflict than did younger and middle aged Americans. However, younger and middle-aged Japanese participants gave wiser answers when compared to younger U.S. groups, suggesting cultural differences in wisdom development. Elderly Americans reasoned more wisely about inter-group conflict whereas Japanese elderly were wiser with regard to interpersonal conflict. Let’s take a closer look at some ways of operationalizing wisdom. Theorists from the neo-Piagetian perspective argue that relativistic thinking represents a new, qualitatively more advanced form of logical thinking, called postformal thought. Others regard more relativistic thinking as a function of reflection and experience, perhaps benefited by advancing metacognitive understanding of the limits of one’s own thought processes. In the latter view, relativistic thought does not represent a qualitatively different level of functioning, but the outcome of accumulating knowledge. From either perspective, the result for some, though not all, adults is the achievement of wisdom. Researchers from the Max Plank Institute in Germany (The Berlin Wisdom Project; Baltes & Smith, 2008) have been at the forefront of this research agenda. This group posits five criteria for a wise person. The first is a deep fund of factual knowledge about life, human nature, and relationships with others. The second involves well-developed procedural knowledge about how to deal with life and its conflicts. The ability to consider life’s challenges from multiple perspectives and to work toward decisions that balance one’s own and others’ interests are the third and fourth criteria. Finally, understanding that true certainty is impossible for life’s ill-defined problems and coming to peaceful terms with uncertainty is the fifth criterion in this typology of wisdom. Identifying criteria makes it a little easier to assess the components of wisdom. One interesting research finding is that, in addition to age and culture, training and experience in occupations that involve managing and reviewing life’s problems seem to promote wisdom. Clinical psychologists, for example, receive higher wisdom scores than people with similar levels of education who are in fields that do not focus on “the fundamental pragmatics of life” (e.g., Smith, Staudinger, & Baltes, 1994). Clinical training itself seems to be important, because even when analyses controlled for the contribution of intelligence and personality differences across professions, clinicians had a wisdom advantage (e.g., Staudinger, Maciel, Smith, & Baltes, 1998). Social-Emotional Experience in Late Life FIGURE 15.5 Numbers of very close social partners are maintained in old age. SOURCE: Lang, F. R., & Carstensen, L. L. (1994). Close emotional relationships in late life: Further support for proactive aging in the social domain. Psychology and Aging, 9, 315–324. Used with permission from the American Psychological Association. Perhaps you are wondering how late-life increases in wisdom might co-exist with cognitive declines? Contemporary research paints a nuanced picture of gains and losses that appear in old age. Evidence supports growth in some areas of socioemotional functioning as long as certain conditions (such as relatively good health and social support) are present. The socioemotional domain seems to be enhanced and better regulated with age. One reason is that older adults become more selective about the social relationships in which they invest their time. They tend to selectively invest in fewer social relationships, keeping or replacing close, deeply satisfying relationships and eliminating more peripheral ties (Carstensen, 1998). Figure 15.5 demonstrates that in one study the number of very close social partners stayed about the same for people ranging in age from 69 to 104, but the numbers of less close social partners dropped dramatically (Lang & Carstensen, 1994). Laura Carstensen and her colleagues explain this socioemotional selectivity as a function of people’s expectations that the time remaining in their lives is limited (e.g., Carstensen & Mikels, 2005; Charles & Carstensen, 2008). In both Western and Eastern cultures, they have found that people of any age will become more selective about whom they spend time with if they perceive their remaining time in life to be constrained (e.g., Fredrickson & Carstensen, 1990; Fung, Carstensen, & Lutz, 1999). Because older people (and others who expect their lives to end soon) pay more attention to their feelings, their emotional experiences are more enhanced and complex (Carstensen, 1998). For older adults, emotional characteristics play a greater role than for younger adults in how they categorize potential social partners (Frederickson & Carstensen, 1990). Older adults also remember relatively more emotional information from descriptions of people than younger adults do (Carstensen & Turk-Charles, 1994). While this selectivity may benefit socioemotional satisfaction, what about cognition? A U.S. study of White and African American elderly living in the community points in a different direction. This study found that the number of social networks an older person had was related to less cognitive decline even after controlling for baseline differences in education, SES, health, depression, and intellectual ability (Barnes, de Leon, Wilson, Bienias, & Evans, 2004). The authors concluded that it may be important for older individuals to retain as many social connections and engage in as much social interaction as possible presumably to enhance cognitive reserve. Social relationships serve a strong protective function. Other studies suggest that they play a causal role in preventing onset of dementia (Fratiglioni,Wang, Ericsson, Maytan, & Winblad, 2000) and in promoting recovery after illness, such as stroke (Glymour, Weuve, Fay, Glass, & Berkman, 2008). Self-reported emotional well-being seems to increase over the years of adulthood, although some decrements after age 60 have been reported (Charles & Carstensen, 2008). Compared to younger adult cohorts, older individuals report more satisfying friendships, marriages, and family relationships. They also report less conflict with others, possibly because of improved emotion regulation over the years (Charles & Piazza, 2007). Older adults are more likely to remember positive experiences than negative ones when compared to younger adults (Charles, Mather, & Carstensen, 2003). Older adults’ neural processing of emotional information involves greater activation of the amygdala when viewing positive images as compared to negative images, whereas no such difference occurs for younger adults (Mather, 2004; see also, Kisley, Wood, & Burrows, 2007). When older adults think about emotion arousing experiences in their lives, they show less heart rate reactivity than younger adults, especially for negative emotions like anger and fear (Labouvie-Vief, Lumky, Jain, and Heinze, 2003). In one experience-sampling study (Carstensen, Pasupathi, Mayr, & Nesselroade, 2000), negative emotional states ended more quickly for older participants, but positive states lasted just as long as they did for the younger participants. In a variety of cultures, older adults describe themselves as having greater control over their emotions than younger adults do (Gross et al., 1997). When older and younger adults listened to taped conversations containing negative remarks, presumably about them, older adults tended to “emotionally disengage” more than younger adults, reporting less anger and less interest in the speakers (Charles & Carstensen, 2008). In direct observations of conflict management between spouses, older couples were more skillful than long-married middle-aged couples at interspersing positive, affectionate statements with negative ones and keeping negative expressions to a minimum (e.g., Levenson, Carstensen, & Gottman, 1993, 1994). It appears that older people may be wise in the ways they deal with emotions: Don’t dwell on sorrow, and make happiness last. Besides focusing on the positive, older people may be more accepting of things they cannot change. Shallcross and her colleagues (2013) explored connections between emotional well-being and acceptance, “the process of deliberately and nonjudgmentally engaging with negative emotions” (p. 734) in an effort to reconcile the inevitable declines of late life with increases in positive affect. Indeed, age-related trends were found for increased acceptance and decreased anger and anxiety among participants ranging from 21 to 73. Interestingly, and consistent with other research, sadness did not decrease with age despite the observed growth in positive affect. While well-being increases up to a point, depressive symptoms also increase in old age. Overall rates of major depressive disorder (MDD) are lower among older groups but minor depression and subclinical symptoms of depression increase from middle adulthood into very old age (Blazer, 2003; Buchteman, Luppa, & Heller, 2012). It is difficult to establish accurate prevalence estimates because different methodologies and assessments, developed on younger age cohorts, may not reliably capture the nature of late life depression (Edelstein, Drozdick, & Ciliberti, 2010). Co-occuring cognitive declines and physical illnesses also complicate diagnostic efforts. Rates of MDD among community-dwelling adults aged 65 and above range from 1% to 5% (Fiske et al,. 2009) and increase (12.4% to 14.4%) among long-term care residents (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). Rates of depressive symtpoms that are clinically relevant are much higher. Depressive symptoms have been reported by over a third of aged 65 and older adults living in the community (Sirey, Bruce, Carpenter, Booker, Reid, et al., 2008), although other estimates are lower. Those above 85 show very high rates (43.9%; see Luppa, Sikorski, Luck, Weyerer, Villringer et al., 2011). African Americans showed more severe symptoms than other groups in a recent study (Shellman, Granara, & Rosengarten, 2011) although more research is needed to clarify cultural differences. Symptom recognition is important because of the relationship of depressive symptoms to more serious physical and mental health problems. Depressive symptoms in late life are different from those that younger people are likely to report. The elderly are more likely to report loss of interest, hopelessness, and helplessness as well as somatic symptoms. Pain, insomnia, and loss of appetite are common. Older individuals are less likely than younger adults to report guilt, self-deprecation, dysphoric mood, or suicidal ideation (see Edelstein et al., 2010). Fortunately, despite the intractability of many health problems in old age, research on the effectiveness of treatment for depressive symptoms has been encouraging. As with younger clients, elderly people, including nursing home residents, respond positively to a variety of psychotherapeutic interventions, including cognitive behavioral, brief psychodynamic, interpersonal, life-review, and problem-solving therapies (Antognini & Liptzin, 2008; Pot et al., 2010). EXPERIENCING LOSS Death and Dying In the expectable rhythm of life, most people begin to take the prospect of their own mortality more seriously during middle adulthood. Illness, the deaths of parents, spouses, siblings, or friends, the experience of watching adult children struggle with problems, and many other bumps in the road grow more frequent, and they signal what has already been lost. At some point, we begin to think of time not as unlimited “time to live” but as “time left to live.” In old age, the reality of death and loss are inescapable. Even though advances in medicine have extended life and greatly improved its quality for many people, all of us face the certainty of death. And though death can occur at any point in the life cycle, the proportion of individuals who die in late adulthood is much greater than at any other time. Currently, close to 80% of the U.S. population live beyond age 65. Of this group, more than 75% will struggle with heart disease, cancer, stroke, lung disease, or dementia during their last 12 months of life (Lynn, 2000). Despite these statistics, elderly individuals report less anxiety about death and are more realistic about its inevitability than are middle-aged adults (Gesser, Wong, & Reker, 1988). Professional helpers will undoubtedly come face to face with the emotionally challenging issues of death and dying in their work. They may be called on to support children who experience a parent’s death, relatives or friends of a suicide victim, families struggling to cope with the aftermath of a fatal accident, or individuals facing their own deaths from illnesses such as cancer or HIV/AIDS. Or they may work with the elderly, for whom the prospect of death ever more insistently intrudes into daily life. Death in later life is generally expected. The experience of death for younger persons can be particularly traumatic. Although the older person and his family may have time to prepare themselves for the separation, death at earlier ages defies the natural order. Even though we present the issues of death and dying in the context of later life, many of the issues involved in dying and bereavement are similar across the life span. First we will consider the issues involved in dying. Then we will look at the psychological work of bereavement. Facing Death Dame Cicely Saunders, founder of the modern hospice movement, recounted a dying patient’s words to her: “I thought it so strange. Nobody wants to look at me” (Ewens & Herrington, 1983, p. 5). This remark captures many elements that describe the experience of dying: general reluctance to address the topic of death openly, anxiety about death that informs this reluctance, guilt that emanates from the lack of openness, and the loneliness and isolation of the dying person. If death is a part of every human life, why do many of us avoid discussing it? Death clearly represents unknown territory, and it is difficult to comprehend a more painful or stressful life event than the prospect of dying or of losing a loved one. According to some existential therapists, fear of death is the ultimate source of anxiety and the foundation of most depression and alienation (May, 1979). Some people have also pointed out that the advances of modern medicine, despite their obvious benefits, have encouraged us to think of dying in some of the same ways we conceptualize treatable illnesses (Kane, 1996). Fortunately, much progress has been made in understanding death and dying relatively recently. Modern U.S. culture is very gradually moving away from one that denies or sanitizes death to one that supports death with dignity. Courageous pioneers such as Elisabeth Kubler-Ross (1969) have directed our collective attention to the issues facing the dying and the bereaved and, in doing so, have shed much-needed light on their needs and concerns. Faced with a growing population of elderly and prompted by advances in research, the field of medicine has taken steps toward more compassionate care of the dying. An emerging consensus among medical specialties regarding end-of-life care is reflected in the development of a set of core principles for providers (see Table 15.5). These 11 principles list the responsibilities of end-of-life caregivers to patients and their patients’ families or support systems. Societies such as the American Medical Association and the Joint Commission on the Accreditation of Healthcare Organizations, to name a few, have adopted these principles (Cassel & Foley, 1999). In general, the principles support more humanistic approaches to end-of-life care, including better pain management, continuity of care, and attention to the psychological dimensions of death and dying. These principles are reflected at the practical level in state initiatives such as Oregon’s policies to improve end-of-life care (Wyden, 2000). TABLE 15.5 Core Principles for End-of-Life Care Respecting the dignity of both patients and caregivers; Being sensitive and respectful of the patient’s and family’s wishes; Using the most appropriate measures that are consistent with patient choices; Encompassing alleviation of pain and other physical symptoms; Assessing and managing psychological, social, and spiritual/religious problems; Offering continuity (the patient should be able to continue to be cared for, if so desired, by his/her primary care and specialist providers); Providing access to any therapy that may realistically be expected to improve the patient’s quality of life, including alternative and nontraditional treatments; Providing access to palliative care and hospice care; Respecting the right to refuse treatment; Respecting the physician’s professional right to discontinue some treatments when appropriate, with consideration for both patient and family preferences; Promoting clinical evidence–based research on providing care at end-of-life. SOURCE: Cassel, C. K., & Foley, K. M. (1999). Principles for care of patients at the end of life: An emerging consensus among the specialities of medicine. Used with permission from the Millbank Memorial Fund. Available at [no longer online] www.milbank.org. What Is a Good Death? Most people hope for a good death, but what does that really mean? As the poet Robert Frost observed, “Hope does not lie in a way out, but in a way through.” You might imagine that dying quickly without unnecessary suffering or dying at home surrounded by loved ones would provide good ways through this final passage. But preferences may be different for different people. Steinhauser and her colleagues (Steinhauser et al., 2000) investigated the relative importance of factors that signify a good death in a survey of 2,000 seriously ill patients, physicians, recently bereaved family members, and other care providers. There was general agreement among all respondents that certain attributes were highly important. These included elements of symptom management and care (freedom from pain and anxiety, freedom from shortness of breath, being touched, and kept clean), certain practical details (having financial affairs in order, knowing what to expect about one’s condition), and patient–professional relationship quality (having caring, trustworthy providers who listen). In addition, specific psychological attributes (maintaining dignity, not dying alone, having the opportunity to resolve unfinished business and saying good-bye) were also rated highly by all respondents. The entire patient group expressed concern about being burdensome to their families. Somewhat surprisingly, they also viewed being able to help others as an important contribution to their end-of-life quality, suggesting the significance of generativity across the life span. But some differences among respondents were noted as well. Though many people assume that patients prefer to die at home, this was not the overwhelming preference of this sample. In contrast to the value placed on autonomous decision making by many professionals, members of certain cultures prefer to share decision making with relatives because this is perceived as supportive (Searight & Gafford, 2005). Members of Chinese, Pakistani, and Hispanic communities may actively strive to protect their loved ones from knowledge of the full extent of their illness because it is deemed impolite, cruel, or deleterious to health (Talamantes, Lawler, & Espino, 1995). In some Asian communities, a family’s desire for extraordinary measures to preserve the life of a relative may reflect the deep reverence they have for their elders. African American patients were more likely than their White counterparts to want all available life-sustaining treatments. They were also less likely to utilize hospice services or to have prepared advanced directives (see below). Wicher and Meeker (2012) suggest that some of these preferences may be shaped by African American cultural and religious perspectives on death. It is important to recognize that there are many ways to define a good death. It is incumbent on caregivers not to make assumptions about their clients, but to ask for and listen to individuals’ needs. Despite the importance of these individual differences, many studies have demonstrated that palliative care (Hanson, Danis, & Garrett, 1997; Singer, Martin, & Merrijoy, 1999) and the ability to prepare for death (Christakis, 2000; Emanuel & Emanuel, 1998) are two of the most consistently wished-for aspects of end-of-life care reported by patients and families. Palliative care, or comfort care, involves services provided by caregivers from several disciplines. It embodies a comprehensive approach to care that addresses pain management, emotional and spiritual care, and psychological support for caregivers and survivors (Billings, 1998). The philosophy of care embodied in the modern hospice movement, which serves people suffering from terminal illness, is a good example of a palliative, patient-centered approach. Considered a hospitable respite for weary travelers in medieval times, hospice is now a place where people on another kind of journey, from life to death, can find peace and comfort. The hospice philosophy of end-of-life care says much about its philosophy of death, primarily about what the dying person needs in order to have a good death (Callanan & Kelley, 1992). Hospice emphasizes the importance of giving patients as much knowledge about their condition as possible so that they maintain some control over their care. The focus is not on curing disease but on managing symptoms and pain by means of palliative (pain-reducing) medicine. Perhaps more difficult to manage are other aspects of dying: the emotional, social, and spiritual sequelae of illness. In this approach to treatment, patients and their families are assisted in coping with the feelings of depression, anxiety, rejection, abandonment, and spiritual discomfort that may arise from the process of dying and losing a loved one. Some studies have found that hospice patients are more satisfied with their care than conventional hospital patients (Kane, Wales, Bernstein, Leibowitz, & Kaplan, 1984) and that provision of hospice care in nursing homes improves quality of care there (Baer & Hanson, 2000; Wilson, Kovach, & Stearns, 1996). As noted earlier, there are clear worldwide trends toward improving end-of-life care by incorporating palliative care for all patients, regardless of setting (Lynn, 2000). In some areas, coalitions of hospitals, hospices, medical practices, nursing associations, long-term care facilities, social workers, and pastoral and mental health counselors have been formed to provide high-quality, comprehensive services to seriously ill individuals and their families (Mitka, 2000). Having a good death appears to be related to the person’s ability to make informed decisions about treatment, a notion congruent with what has been said about the psychological benefits of control. However, even though the importance of this kind of control has generally been acknowledged by practitioners of palliative care, studies suggest that a significant number of patients, even the most highly educated ones, still misunderstand the treatment options available to them. Silveira and her associates (Silveira, DiPiero, Gerrity, & Feudtner, 2000) examined whether knowledge about end-of-life options such as refusal of treatment, physician-assisted suicide, active euthanasia, and double effect was improved among patients who had signed advance directives or living wills, who had experienced previous illness, or who had previously cared for a dying loved one. Refusal of treatment refers to patients’ refusal of any food, water, or medical treatment that prolongs life. Physician-assisted suicide involves prescribing medicine that enables patients to take their own lives. Active euthanasia refers to injection of a medication by someone else that causes immediate death. The double effect means giving medication intended to relieve pain even though there is a chance that death can result. Advance directives or living wills are statements, typically in writing, that describe a person’s wishes regarding medical treatment in the event of incurable illness. The results of the study showed that knowledge about end-of-life treatment options was generally poor. It was not improved for those who had signed advance directives or who were ill themselves. Knowledge was somewhat more accurate for those who had cared for dying loved ones. In general, caregivers often wait too long to discuss end-of-life preferences. Decisions may be made in haste, when the dying person is too ill or caregivers too distressed to make reflective choices (Gleeson & Wise, 1993). It is important, therefore, to initiate conversations about end-of-life decisions well in advance of the stresses of illness. The Process of Dying In the late 1950s, Elisabeth Kubler-Ross (Kubler-Ross, 1969), a Swiss-born psychiatrist, began to study the ways that people who were dying faced death. At that time, the dying were largely invisible among hospital patients, and she encountered a high degree of professional resistance to her work. When she asked her fellow physicians to recommend to her their dying patients so that she could talk to them, she was told that there were no dying patients in her 600-bed hospital (Ewens & Herrington, 1983). But after meeting people who realized that they were dying and after listening carefully to their stories, she described responses to death that appeared to characterize the process: denial, anger, bargaining, depression, and acceptance. Each of these responses represents a type of coping or defense mechanism for dealing with death. Perhaps it was unfortunate that she referred to these processes as “stages” and linked them together in sequence. Although Kubler-Ross herself (Kubler-Ross, 1974) emphasized that the stages do not always occur in order and that they can and often do occur simultaneously, the use of a stair-step approach is fraught with the kinds of problems we discussed in Chapter 1. Foremost, perhaps, is that a stage sequence can be irresistible to helpers who are looking for fixed, clear guidelines for understanding grief. Criticism of the model has centered on the overall lack of empirical evidence for the existence of stages (Kastenbaum, 1986; Klass, 1982) and the problems that arise when professionals and caregivers use the stages as a road map by which to evaluate functional versus dysfunctional adjustment to death and dying (Corr, 1993). The belief among some helping professionals that these five responses are the only appropriate ones for the dying represents another limitation of the model as it is applied to practice. Studies of individuals who have received terminal diagnoses do provide some support for the initial manifestation of shock or disbelief as well as for the presence of greater acceptance before death (Kalish, 1985). In general, however, helpers should remember that there is much greater variation in the process than is allowed for by a strict interpretation of these stages. Perhaps the reactions can be viewed as some important ways that people cope with impending loss, but by no means is the sequence fixed nor the range of coping mechanisms exhaustive. With these caveats in mind, let us consider each of these coping mechanisms in more detail. Denial may follow the initial shock that is associated with news of a terminal illness. At best, it temporarily protects the person from the reality of a terrifying situation. Denial is associated with feelings of numbness or disbelief and buffers the person from the full weight of the threat. Considered in this way, some measure of denial can be adaptive. It allows a person to temper the emotional impact, thus rendering it more manageable (Janoff-Bulman, 1993). Anger is a normal reaction to separation and loss. Anger may be directed toward God (“Why me?”), toward others (“Why didn’t you do something to help me?”), or toward the disease itself, which is viewed as an enemy to be battled. Often this is a very difficult response for family members to tolerate from loved ones who are dying. Resentment or hostility toward family members or caregivers who are healthy may reflect the depth of the dying person’s pain and cries out for caregivers’ compassion. Anger can ebb and flow throughout the course of illness, depending upon the individual and the specific circumstances (Rosenblatt, Walsh, & Jackson, 1972). The essence of bargaining is to try to postpone the inevitable by making promises, usually to a higher power. Sometimes individuals will try to delay death until some memorable event, such as an anniversary or a child’s marriage, takes place. The individual may offer some prize, such as “a life dedicated to God,” if the chance to live longer is granted. Depression as a reaction to impending death is characterized by sadness and feelings of hopelessness. Kubler-Ross distinguished between reactive depression, or depression that results from loss of functioning or other problems associated with the disease process, and preparatory depression, which is related to prospective loss and separation. Acceptance is characterized by a sense of peace and relative tranquility, which suggests that the person has come to terms with his impending death. We stress, however, that this peace is relative. No one should be evaluated on how quickly or completely she accepts death. Remember, too, that these reactions, although important, do not reflect all possible ways of managing the dying process. It is helpful for professionals to understand that the dying process may also be distinguished by the nature of illness. Figure 15.6 illustrates some trajectories of dying for patients suffering from three common diseases: cancer, heart disease, and dementia (Eti, 2011). Awareness of these patterns can enhance provision of palliative care. Professionals can better help families understand prognoses and make more informed decisions about treatment. Bereavement Life is death kept at an arm’s length. Love is grief dressed in its Sunday best. And sadness is the tax assessed on any happiness. —From St. James’ Park Epistle by Thomas Lynch FIGURE 15.6 Trajectories of illness in common diseases of aging. The trajectories of cancer, organ failure (heart failure) and dementia, show different pathways. SOURCE: Eti, S. (2011). Palliative care: An evolving field in medicine. Clinics in Office Practice, 38, 159–171. Used with permission from Elsevier. Sadness is not the sole province of the dying person. Those who suffer the loss of loved ones are themselves deeply grieved. Grief is a universal reaction to loss or separation, and, as you recall from the discussion of attachment theory, it takes a number of behavioral forms, such as active distress, protest, and searching for the lost attachment figure. Grief has been described with great poignancy from the earliest times by philosophers, poets, and religious leaders. It has been memorialized in song and codified in ritual. Grief is often so unsettling to observe that it elicits from others a desire to give comfort and solace. Many religious and secular customs have grown up around the grieving process in an attempt to help people survive the rigors of suffering and to give meaning to death. Culture also plays a role in determining how grief is expressed, for example, as an emotional versus a physical set of symptoms (Kleinman & Kleinman, 1985). Box 15.3 describes various rituals from different cultures that demonstrate some of the diversity in people’s beliefs about, and experiences with, death. Helping professionals are often called upon to offer support to people who have experienced the loss of loved ones. An extensive clinical folklore has developed, primarily about the ways that grief should be expressed and the best ways to help people express it. In the 1980s, a vibrant debate commenced when researchers began to question the lack of empirical support for many of these traditionally accepted assumptions about grief. A number of inconsistencies or “myths” about grieving were uncovered in the process (Wortman & Silver, 1989, 2001), and researchers and clinicians have since continued this important dialogue. What follows is a discussion of some classic approaches to grief, an examination of some of the major tenets of bereavement counseling, and a brief summary of evidence from recent studies. Classic Approaches to Bereavement Freud’s (1917/1957) theorizing about grief and mourning was very influential in shaping the legacy that came to be known as grief work. In simple terms, Freud believed that individuals who lose a loved one (or object) must withdraw their emotional attachments or energy (or libido) and detach (or decathect) from the lost object. Loss causes great pain, and bereaved people, Freud believed, inevitably need to struggle with the process of letting go. As manifestations of their mourning, they may lose interest in the world, prefer to isolate themselves from others, dwell on thoughts of the deceased, and suffer from depression. Gradually, the reality of loss is accepted. From Freud’s perspective, successful resolution involves decathecting, or detaching emotionally, from the former relationship and reinvesting psychic energy into the formation of new attachments. Bob, age 81, and his family describe their experience learning about and living with the deaths of family members. How do Bob and his children differ in their bereavement processes? Box 15.3: Funeral Rituals in Different Cultures In virtually every culture, distinct funeral rituals have evolved that are fascinating reflections of people’s beliefs about death. Social anthropologists suggest that these rituals serve to bind a culture together by expressing its “collective representations” about fundamental issues such as life, death, and spirituality (Metcalf & Huntington, 1991). To illustrate the diversity of beliefs and the many ways of demonstrating grief, we present a look at funeral practices in four cultures: the Chinese of San Francisco’s Chinatown (Crowder, 1999; Hill, 1992), the Luo of Kenya (Nyamongo, 1999), traditional Jewish families (Schindler, 1996), and the San Francisco gay community during the last decades of the 20th century (Richards, Wrubel, & Folkman, 1999–2000). For the Chinese, a funeral signifies the important transition from family member to ancestor, that beneficent spirit who will look out for the family’s well-being from the spirit world. The connection between living family members and their ancestors is so important that, prior to the mid-20th century, Chinese immigrants living in the United States routinely returned their dead to China to be buried next to other family members. The Chinese community in San Francisco practiced elaborate traditional rituals, complete with funeral processions and brass bands. Funerals drew large groups of family members and friends, and they provided an occasion to tell the world about the accomplishments of the deceased. So fundamentally important was this practice that funerals in the Chinese province of Gansu were held before the person dies, so that he could be present to hear about the good things he had accomplished in his lifetime (2001, N. Zhang, personal communication). Chinese funerals in San Francisco may incorporate Christian or Buddhist elements into a ceremony that traditionally consists of five parts: the visit, the service, the procession, the burial, and the dinner. The visit, or wake, allows visitors to view the body of the deceased. Near the body are placed a portrait of the dead person, usually framed with flowers, and items of food, such as chicken, vegetables, rice, and tea, intended to sustain the soul of the person through the journey to the afterlife. Various items such as jewelry, money, and clothing are placed in the coffin for his use as well. The funeral service, usually held the day after the visit, includes prayers and a eulogy. The funeral procession consists of a hearse, the funeral cortege, and a band, which plays hymns and other traditional music. On its way to the cemetery, the procession typically stops at the deceased’s home or place of business. The portrait of the dead person is then taken from the hearse and set up facing the building. The mourners bow to pay their respects and may toss “spirit money,” pieces of white paper in the shape of bills that are intended to placate malevolent spirits, into the air. Some relatives and friends await the procession at the house and greet the spirit of the ancestor with offerings of food, incense, and candles. At the gravesite, members of the funeral party, males first, followed by females, toss dirt, flowers, coins, or rice into the grave. The ritual is concluded with a formal seven-course meal, because seven is the number for death. At the center of each table is a cup of white rice liquor in honor of the departed. The Luo live in the western part of Kenya near Lake Victoria. They, like the Chinese, believe that a person who dies becomes transformed from an earthly member of the family into a spiritual one. The funeral ritual is a transformative rite of passage. Death among the Luo is marked by a funeral fire, which is kept burning for approximately one week. The body of a deceased male is prepared by the men of the same clan and lies in state for 4 days, while that of a deceased woman lies in state for 3. After the burial, animals are slaughtered at the site of the funeral fire. Their numbers and kind depend upon the socioeconomic status of the deceased. Relatives and neighbors might contribute some animals for slaughter, knowing that the same will be done for them in their time of bereavement. During the period of mourning, the sons of the deceased keep company around the fire. Their wives stay together in the house of the deceased, avoiding any sexual contact because of their belief that sexual relations will cause the death of their own sons. The widow of a deceased man is inherited by the dead man’s brother, thus transferring her care to another relative and giving him the benefit of an additional laborer. Traditional Jewish funeral practices emphasize honoring the deceased as well as giving the bereaved time and freedom to grieve. Jewish law is very sensitive to the emotional pain experienced by grieving persons and structures rituals to provide explicit comfort for them. During the funeral service, an emotional eulogy encourages mourners to vent their feelings by crying. A similarly cathartic release is elicited during the recitation of the Kaddish, or ritual prayer. Flowers are not customarily given in this cultural tradition because they signify happiness, an emotion that is discordant with the painfulness of death. Throughout the period of mourning, called Aninut, great care is taken to support the bereaved. Jewish law indicates that those who have experienced a loss should be exempt from normal religious obligations, such as studying the scriptures. Customs such as Kreiah, or the ritual tearing of garments and the breaking of a shard on the lintel of the deceased’s house, provide religious sanctions for outward displays of anger and sadness during the time of mourning. The period of Shiva, a 7-day mourning period, is dedicated to visiting and consoling the bereaved. Providing emotional comfort and social support for the survivors is viewed as an important religious obligation that helps to move people beyond the pain of their loss to a state of acceptance. Once the official 12-month grieving period is over, the Kaddish prayer is recited again, and excessive outward displays of mourning are expected to cease. A relatively new culture, that of the gay community in San Francisco, developed its own ways of dealing with bereavement due to the unfortunate increase in HIV/AIDS related deaths in that community. Because many members of this community died in hospice or home settings, their dying often took the form of a vigil. Family and friends attended the dying person, keeping him as comfortable as possible while saying their good-byes. After death, rituals such as bathing and dressing the body honored the wishes of the deceased and allowed the bereaved to feel connected to the loved one. Photos could be placed around the bedside, and valued objects, such as letters or items of religious significance, were placed near the body. Funeral services could combine elements of formal religious rites with those that signified some personal meaning. For example, planting trees in the loved one’s memory, burning incense, playing music, and so forth might be incorporated into the service. These examples, although certainly not exhaustive, emphasize the healing function of rituals, either traditional ones or those that are newly created. Whatever their type or origin, regardless of their religious or cultural underpinnings, rituals appear to draw people together in their encounter with death. They give voice to fears and to sadness, and they signify love and respect for the persons who have died. Freud presented these theoretical ideas on mourning well in advance of some important deaths that were to occur in his own personal life. The loss of his daughter at age 25 and of his grandson at age 4 affected him greatly. He wrote that his life was permanently altered by these enormous losses and that, although acute grief may subside, people “remain unconsolable and will never find a substitute” (Freud, 1929/1961, p. 239). These words suggest that Freud, in his later years, recognized that one does not necessarily recover from grief nor cut the cords of old attachments. However, his earlier notion that active grieving leads to recovery is one idea that he never formally revised and one that has permeated the canon of grief counseling. Other assumptions, that successful resolution of grief necessitates detachment from lost loved ones and reinvestment in other relationships and that abnormal mourning may follow from conflicted relationships, have also influenced clinical practice. Bowlby’s (1969/1982, 1980) highly influential construction of the bereavement process, based on attachment theory, depicts his view of typical human reactions to the experience of separation from or loss of attachment figures. The theory was initially developed to describe the responses of children temporarily separated from their caregivers (see Chapter 4, Box 4.2) and was later adapted to describe permanent separation, or bereavement, in adults. Bowlby’s description of various reactions to separation gave rise to popular stage conceptions of dying, such as those of Kubler-Ross (Archer, 1999). Bowlby’s description of the grieving process includes four phases. At first, the loss is met by disbelief, a phase Bowlby called shock. The grieving person may experience numbness or feelings of unreality. Emotions may be blunted, and some individuals may even appear unaffected by the loss. Others may display emotional outbursts or may experience dizziness or other physical symptoms. The sense of disbelief eventually subsides when the reality of loss sets in. A second phase, protest, follows. Bereaved individuals may experience periods of obsessive yearning or searching for the lost loved one as well as bouts of restlessness or irritability. Funeral traditions vary dramatically across cultures, reflecting fundamental beliefs about life, death, and spirituality. The subsequent period, called despair, may be characterized by great sadness; social withdrawal; sleeping, eating, or somatic disturbances; and other symptoms of depression or emotional upset. People may experience flashbacks or intrusive memories of the deceased. They may actively seek support from others by telling and retelling the story of their loss. Yet, as with a child whose attachment figure has left him, the comfort of others cannot replace the presence of the lost loved one. Gradually, the bereaved person begins to adjust to the loss. Bowlby used the term reorganization to describe the last phase of grieving a permanent separation. Taking a position in opposition to Freud’s, Bowlby believed that bereaved individuals do not decathect, or detach, from their lost loved ones. Instead, they discover ways to hold on to the memory of the deceased and integrate that memory into their current life and new attachments. They heal, in part, by drawing comfort from the sense of the deceased person’s presence (see Fraley & Shaver, 1999). Assumptions About Grief Work and Empirical Support As we have noted, a number of assumptions about bereavement, many derived from classic theories such as these, have been reexamined in the light of new evidence and cross-cultural information. One of the most prevalent myths is that people need to deal with their loss, by confronting the pain in an active way, for healing to occur. Avoiding the sadness, it is assumed, leads to later emotional problems. The tenets of grief work explicitly encourage bereaved individuals to confront and “work through” their feelings about loss for recovery to take place (Parkes & Weiss, 1983; Stroebe, 1992). This process, often facilitated by therapeutic intervention, might involve reflecting upon one’s relationship to the deceased, expressing anger and other negative emotions related to the death, questioning and trying to construct meaning from the death, and ultimately resigning oneself to the loss. Unexpressed grief and unexamined loss, which have not been integrated into one’s revised view of the world and the self, are thought to place the bereaved person’s long-term physical and psychological well-being at risk. Another assumption is that the normal grieving process evolves in a sequence of stages that take a usually brief but arbitrarily determined period of time, such as 6 months to a year, to complete. Those studies that have investigated the existence of stages in bereavement find little evidence to support the belief that people grieve in a linear, predictable fashion (van der Waal, 1989–1990; Wortman & Silver, 1987). Although many people do report initial shock and, later, some measure of reorganization, the intervening process does not necessarily follow in a clear sequence of compartmentalized, independent reactions. There is also a great deal of confusion over how long the manifestations of grief should persist before the grief is judged “abnormal.” Previous diagnostic criteria (American Psychiatric Association, DSM IV-TR, 2000, p. 740) indicated that a clinician may consider a diagnosis of major depression if the depressive symptoms attendant to bereavement persist beyond two months. However, it is common for people to show grief symptoms much longer than 2 months. Several studies report gradual declines in depressive symptoms within the first 2 years after loss (Middleton, Raphael, Burnett, & Martinek, 1997; Stroebe & Stroebe, 1993), but depression may persist even longer (Martinson, Davies, & McClowry, 1991), particularly if the circumstances surrounding the death have been especially traumatic. Such findings have led to criteria for use in the diagnosis of complicated or abnormal grief that allow for longer periods of normal grieving (see Horowitz et al., 1997). Controversy surrounds the recent decision to allow a diagnosis of depression two weeks after bereavement (DSM-V, 2013). At issue is the distinction between normal and complicated (also called chronic, unresolved, pathological) grieving and the decision to treat it as depression needing medication (see Francis, 2010). Abnormal grief was viewed by Bowlby (1980) as grief that is either excessive and protracted or absent. At one end of the continuum is chronic grief, which, like a preoccupied attachment, is marked by persistent yearning, anxiety, and unremitting distress. This type of mourning immobilizes bereaved individuals and prevents their return to normal functioning. Absence of grieving, on the other end of the continuum, was viewed by Bowlby and others (Deutch, 1937; Parkes, 1965) as a maladaptive defense against the trauma of loss. In this response, characteristic of a highly avoidant attachment pattern, bereaved individuals suppress grief and try to exclude frightening and painful feelings from consciousness. Despite the lack of consistency in empirical support, the concept of abnormal grief has been accepted in clinical practice (Rando, 1993). It is widely assumed that people should demonstrate great distress after a loss and that failure to do so is abnormal, a condition often called the “requirement of mourning” (Wright, 1983). In general, some recent research has failed to find support for the assumption that all people need to work through loss in the highly cathartic fashion advised by advocates of grief work to adjust successfully. Contrary to what helping professionals might expect, a certain amount of detachment during the grieving process predicts healthy recovery for some bereaved individuals. Bonanno and Keltner (1997; see also Bonanno & Kaltman, 1999 for a review) provide data demonstrating that minimizing expression of negative emotions can offer some benefit to the bereaved. In this study of individuals whose spouses had died, the remaining partners who manifested a high degree of emotional distress (fear, anger, disgust, and the like) at 6 months after their loss continued to report poorer outcomes after 2 years. Those individuals who had lower initial levels of distress had better health and lower levels of grief after 2 years. Similarly, in a study designed to explore the coping styles of bereaved individuals, Bonanno and his colleagues (Bonanno, Znoj, Siddique, & Horowitz, 1999) reported that some detachment or emotional dissociation was not related to the development of later adjustment problems but was, in fact, predictive of positive outcomes. Neimeyer (2000) concludes from an examination of research that the use of grief-focused interventions with individuals who are not highly distressed risks doing them harm. Other studies of bereaved individuals (Lund et al., 1985–1986; Vachon et al., 1982), of parents whose babies died from SIDS (Wortman & Silver, 1987), and of individuals who experienced spinal cord injuries (Dinardo, 1971) showed similar results. Those individuals who demonstrated the highest levels of distress initially were also most distressed and less effective in coping with the loss up to several years later. Individuals who showed lower levels of initial distress were generally better adjusted later and were not more likely to experience delayed grief reactions. One conceptual explanation for these findings draws on the framework of individual differences in attachment representations. Specifically, adjustment to loss may be less difficult for individuals whose emotional systems can be deactivated more easily (avoidant) than for those who have difficulty suppressing emotions (ambivalent) (see Fraley & Shaver, 1999). Another hypothesis is linked to gender. For example, one study demonstrated that females gave priority to sharing feelings after a loss, while males viewed problem-solving approaches as more important (Hopmeyer & Werk, 1994). Also, extreme levels of distress might indicate longstanding difficulties in emotion regulation or stress sytem activation. Certainly, much more research is needed to understand fully the significance of individual differences in grieving. Overall, the evidence presented above should not be interpreted to suggest that outward signs of distress are necessarily unhealthy. Either side of an either-or argument is problematic. Just as a prescription to demonstrate intense grief is not right for everyone, neither is the advice to remain stoic. What we need to understand are the mechanisms that might explain individual differences in grief reactions, in hopes of constructing a more comprehensive theory of grieving. For those who take the stoic approach, perhaps it is not simply detachment, or the temporary psychic space it provides, but also the restricted focus on loss that makes for better overall adjustment. The traditional advice of grief work, which is to confront pain head-on, may be problematic for some people because of the risk of chronically activating systems related to yearning or “pining” for the lost loved one. Rumination, an emotion-focused style of coping, is correlated with poor adjustment. Excessive preoccupation with the deceased or obsessive dwelling on thoughts of pain and sadness may qualify as rumination. In a longitudinal study of hundreds of bereaved individuals conducted over 18 months, Nolen-Hoeksema and Larson (1999) found that the use of rumination as a way to cope with loss was highly related to depression at each interview point. In addition, people who ruminated tended to have great difficulty finding meaning in the loss, despite the significant amount of time they spent trying to do so. These findings are consistent with the strong association between ruminative coping and depression in general (Nolen-Hoeksema, 1991). You might wonder how a bereaved person can make sense of his loss, another assumed measure of successful grieving, if he does not engage in some rumination. Yet, is it really necessary for people to make sense of the loss to adapt successfully? Davis, Lehman, and Wortman (1997) report that not all people who struggle to make sense of deaths, accidents, illnesses, and other tragedies are able to explain these events in satisfactory ways. Many people do not try to do so, preferring to move ahead with their lives without searching for existential or philosophical meaning. Davis and his associates (Davis, Wortman, Lehman, & Silver, 2000) reported very consistent findings from several studies that investigated the benefits of meaning-making for later adjustment. In general, individuals who were able to derive meaning from the event relatively early on were least distressed at follow-up interviews. Interestingly, those who were able to find something positive in the experience or who were able to reappraise the loss to extract some benefit from it were the best adjusted. Religious or spiritual beliefs often helped people find meaning in the loss. However, others found that loss precipitated a cascade of doubts about faith because it shattered their views of a just world. Those who did not initiate a search for meaning were also found to have relatively good adjustments. It was the group that struggled for meaning without finding it that suffered most in this study. Nolen-Hoeksema and Larson (1999) reported significant associations in their bereavement study between the tendency to ruminate and the inability to find meaning in the experience of loss. The highest level of distress at follow-up interviews was demonstrated by the group who struggled continually to make sense of the inexplicable. Certain contextual circumstances may make it more difficult for people to find meaning or benefits from the deaths of loved ones. Among these kinds of deaths are those that occur suddenly (Parkes & Weiss, 1983); deaths of children (Nolen-Hoeksema & Larson, 1999); deaths due to intentional, malicious causes such as homicide (Murphy, 1997); and deaths due to the negligence of others, such as those involving motor vehicle accidents (Wortman, Battle, & Lemkau, 1997). Some measure of restitution made by the perpetrators of these acts can be beneficial in reducing the bereaved families’ distress and promoting resolution of grief (Davis et al., 2000). An Integrated Perspective on Grief As research in this area increases, more sophisticated models of grieving have been developed (Cook & Oltjenbruns, 1998; Rubin, 1981). One such model that weaves together some of the theoretical and empirical threads described above is the dual-process model proposed by Stroebe and Schut (1999). This conceptualization depicts an interplay of stressors and coping strategies within a flexible, oscillating framework. Specifically, the authors propose that bereaved individuals simultaneously engage in two kinds of coping mechanisms, approach and avoidance, that wax and wane over the course of grieving. Approach tendencies are reflected in activities synonymous with grief work: confronting the painful reality of death, expressing sadness, and gradually desensitizing oneself to the reminders of loss. Approach tendencies can be tolerated for only so long. They are loss focused and can lead to rumination or excessive preoccupation and, often, great distress. According to the dual-process model, the loss-focused work of grieving is balanced by parallel activities that are restoration focused. This type of coping strategy is directed toward handling the practical tasks that need to be done to carry on with daily life. For example, a widow might experience intense periods of grief during which she focuses on memories of her life with her deceased spouse; however, she might also have dependent children who need care. Attending to their needs serves as a distraction, mitigating the periods of loss-related distress. Both loss and restoration coping strategies are part of the grieving process, and Stroebe and Schut view their dynamic oscillation as a healthy regulatory mechanism. Bereaved individuals go back and forth between emotion-focused (loss-oriented) and problem-focused (restoration-oriented) modes of coping. This approach-avoidance interplay protects bereaved individuals from the exacting extremes of unrelieved distress or rigid mental suppression. In general, there is more loss-oriented coping early in the grieving process and more restoration-oriented coping at later points. Traditional conceptions of abnormal grief can be viewed as “disturbances of oscillation” (Stroebe & Schut, 1999, p. 217), either overly loss oriented or excessively avoidant. Figure 15.7 presents a diagram of the dual-process model of coping. FIGURE 15.7 A dual-process model of coping with loss: pathways. SOURCE: Stroebe, M. S., & Schut, H. (2001). Model of coping with bereavement: A review. In M. S. Stroebe, R. O Hansson, W. Stroebe & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (p. 397). Used by permission of the authors. Applications This chapter presents information about some key ways people change in later life and how they adapt to or cope with those changes. Coping has been defined as a person’s “cognitive and behavioral efforts to manage (reduce, minimize, master, or tolerate) the internal and external demands of the person–environment transaction that is appraised as taxing or exceeding the resources of the person” (Folkman, Lazarus, Gruen, & DeLongis, 1986, p. 572). Adaptive coping, or managing the demands of life relatively well, is at the heart of achieving and maintaining optimal health and wellness. This is certainly true at any age, but perhaps even more so in old age, when the threat of overtaxed resources and the need to tolerate limitations becomes inevitable. Life involves gains and losses. It is naïve to assume that everyone can and will maintain a high quality of life right up to their death. But on the other hand, unnecessarily pessimistic views of old age, fueled by negative stereotypes of the elderly, restrict the ways people choose to adapt to aging and limit their sense of control over their lives. Helpers who are knowledgeable about and skilled in understanding coping mechanisms can promote healthy adaptation, regardless of client age (Ponzo, 1992). Sources of concrete information about how to cope with getting old (Skinner & Vaughan, 1983/1997), how to understand the perspective of elders (Pipher, 1999), and how to deal with dementia (Mace & Rabins, 1999) can help clinicians build their foundation of knowledge. Whitbourne (1989) summarizes the task: The main point that a clinician must keep foremost in mind when working with an aging client is the need to be flexible. The aging process involves multiple physical, psychological, and social demands that can all potentially impact on the individual’s ability to function. Clinicians may be called upon to perform advocacy services, environmental interventions, and interdisciplinary consultations, which they would not ordinarily regard as falling within the domain of “psychotherapy.” It is only by maintaining an open approach to the multiple needs of the aged client that the clinician can hope to bring about successful change. (p. 168) A Good Fit: Adaptations for Professionals Myers and Harper (2004) offer useful suggestions for clinicians who work with older clients. In general, helpers who work with this population may be younger than their clients. Consequently, more time and sensitivity are required to build rapport with individuals who may be less comfortable with sharing feelings or with asking questions of “authority” figures. Younger professionals also need to be prepared to deal nondefensively with older clients who might view them as unable to understand the lived experience of old age. Lengthening the sessions in individual counseling and increasing the number of sessions for support groups or other group therapy formats is more important in reducing relapse for older clients than is the case for younger ones. Psychological treatments should be modified as well. Many typical counseling approaches can be accommodated to meet the needs of older clients (Gellis & Kenaley, 2008; Kennedy, & Tanenbaum, 2000). Some of these modifications have been summarized in Table 15.6. The flexibility described by Whitbourne above should extend to the physical environment in which counseling is provided. For example, older clients may have physical limitations that affect their ability to sit for long periods or may need modifications to assessment procedures due to hearing or vision problems. Lyness (2004) advises medical and counseling professionals who work with an older population to screen routinely for depression and other mental health issues because mental health concerns can be the underlying cause of many other presenting problems. At the end of life, helping professionals can bring a real advantage to patient care: well-honed communication skills. Patient-centered communication that blends empathic listening with provision of information appears to offer patients the greatest support. What are the skills helpers need for delivering bad news when it is needed? It’s important to remember that delivering such life-altering news can be very stressful for professionals who are called upon to communicate it. So, awareness of one’s own response to dying and understanding of best practices in this area can be useful. Practicing compassion for oneself as well as for clients and their families is a powerful resource. Barclay, Blackhall, and Tulsky (2007) offer a very helpful review of key considerations for culturally appropriate communication of difficult information. It’s critical for helpers to understand that not everyone wants to hear the same amount of information about prognosis, symptoms, and so forth. Sometimes patients’ wishes for information are different from those of families. Carefully inquiring about how much information is desired as the dialogue unfolds is a good practice. Sometimes separate conversations are indicated, provided consistent information is delivered. When prognosis is poor, helpers can help support realistic expectations by discussing ways to manage symptoms, providing emotional support, and connecting the patient and family with resources rather than offering unrealistic promises. Cultures differ with respect to how directly bad news should be delivered, and it is essential for helpers to be sensitive to cultural norms in this regard. “Here the difference is not only about whether to tell the truth, but also about what it means to tell. Learning the truth in a more indirect way may be seen as preferable because the ambiguity allows the patient the possibility of hope” (Barclay et al., 2007, p. 963). In general, prior preparation of advance directives can provide an opportunity for discussing preferences for truth-telling while individuals are still healthy. Difficult information should be conveyed with language and pacing that supports patients’ understanding. Communication should be caring yet straightforward. The authors suggest pausing to check for comprehension after every three facts. Summarizing the conversation aids understanding as well. Planning for continuing care that includes that patient and/or family can help convey the reality of continuing support through the process. Healthy Aging and Prevention TABLE 15.6 Therapeutic Adaptations for Older Clients TYPE OF THERAPY EXAMPLES OF TARGET THERAPEUTIC OUTCOMES SOME ADAPTATIONS FOR OLDER CLIENTS Brief Psychodynamic Resolving survivor guilt; reducing negative attitudes toward self related to aging. Recognition and skillful handling of age-specific transference issues, (e.g., client’s view that younger therapist is inexperienced and unable to help). Cognitive Behavioral Changing dysfunctional thoughts; active problem solving. Understanding of older clients’ learning styles; recognition of cognitive and sensory impairments that might interfere with learning; use of concrete written material and practice. Behavioral Therapy for Depression Improving mood through increasing positive reinforcement. Provision of methodical and concrete approaches to identify and engage in positive, mood-enhancing experiences and systematically avoid unpleasant experiences. Interpersonal Therapy for Depression Improving interpersonal relationships through time-limited approach to problem-solving using therapist as supportive resource. Active therapeutic stance that focuses on solving real problems within the context of old age; provision of ample social support. Life Review or Reminiscence Therapy Finding meaning in life at present by reflecting on and integrating past conflicts. Empathic listening that provides a context for a review of the past; review of memorabilia like photographs, journals, and writing exercises. Problem-Solving Therapy Finding ways to view problems more realistically and solve them more effectively. Careful listening to client’s problems, empathy, encouragement and support for trying new solution in a personal context. Group Therapy Addressing multiple needs of older clients, particularly clients in institutionalized settings. Screening of participants to ensure a relatively high degree of homogeneity in cognitive and sensory functioning; provision of structured format; ample positive reinforcement of group members; timing of meeting in midmorning to early afternoon. Source: Based on Kennedy, G. J., & Tanenbaum, S. (2000). Psychotherapy with older adults. American Journal of Psychotherapy, 54, 386–407. The amount of research on aging continues to grow, due, at least in part, to the aging of the world’s population. One wave of research is focused on “successful aging,” a perspective that assumes that healthy functioning and even the achievement of certain gains is possible in late life. One such initiative is actually a series of studies called the MacArthur study because of the financial support provided by the John D. and Catherine T. MacArthur Foundation (Rowe & Kahn, 1998). The fruits of 10 years of intensive investigations involving thousands of participants, millions of dollars, and the combined expertise of biologists, neuropsychologists, sociologists, epidemiologists, geneticists, and gerontologists, among others, tell us a great deal about successful aging. Older people often meet their needs to feel competent and productive by engaging in part-time or volunteer work. To summarize briefly, enjoying a healthy and productive old age is possible. The more physically and mentally fit older individuals are, the more likely they will age successfully. Clearly, one’s lifestyle prior to old age can have a tremendous influence on the quality of later life. A healthy diet and regular exercise, including aerobics and weight training, confers a real physical advantage. Although maintaining healthy habits provides protection from disease and should, ideally, be maintained consistently, the MacArthur study revealed that positive changes in eating and exercise habits, even in old age, can help people live longer and healthier lives. Equally important to successful aging are social relationships. It turns out that older people benefit more from emotional than instrumental support in many cases. So while it can be very helpful to offer help with housecleaning, providing a patient listening ear may go a longer way toward promoting well-being. A sense of being productive also appears to be a benchmark of healthy aging as well. Healthy men and women are three times more likely than those with physical or mental health problems to be engaged in paid work or volunteer activities. However, as we have seen, even people with physical limitations often manage, with some creativity, to engage in activities that keep them in touch with the world. Productive engagement with others, in whatever form it takes, is linked to a sense of mastery or personal self-efficacy. A “can-do” attitude contributes enormously to well-being. Professionals can facilitate the development of self-efficacy by fashioning opportunities for older individuals that reflect their self-endorsed goals and that challenge their capacities without overwhelming them. Helpers also need to provide encouragement to older people to engage in these challenges, give confirming feedback for mastery, and help dispel negative stereotypes that lead to passivity and hopelessness. Through her volunteer work in the community, Marie, at age 92, feels productive and remains socially engaged. When Losses Occur What should we do to help when the losses of later life occur? Based on recent longitudinal studies, several principles appear to be important. Helping professionals should be aware that grief has many affective, behavioral, and physical manifestations and that there is wide variation in expressions of mourning at the level of the individual and culture. The oversimplified use of stage theories may suggest that there is one correct way to grieve and one circumscribed time frame in which to do so. One can only imagine how discouraging it must be for a bereaved person to be told that she is not grieving correctly. In our fast-paced world, it is often difficult to let people take the time they need to heal. Helpers should not hold prescriptive rules for how long grief should last, because many people continue to grieve well beyond the limits of several months or even years. Remember as well that the absence of overt, intense grief is not necessarily problematic. Not everyone who fails to demonstrate great distress or who does not search for meaning in a loss will suffer eventual emotional problems. Furthermore, we often expect people to “recover” from a loss by returning to an earlier level of functioning, despite evidence that this is often impossible. Difficulties in the grief process may be considered to be an imbalance between too much expression and too little, but even this is mediated by personality, gender, culture, and beliefs. Some interventions that have traditionally been favored by helping professionals, such as active grief work interventions, may not be useful and may actually be more distressing for individuals given to ruminative tendencies. Even support seeking, a style of coping that involves seeking help from other people, may be a source of stress unless those sought after for help are themselves compassionate and willing to listen (Nolen-Hoeksema & Larson, 1999). Efforts to personalize interventions depending upon needs and characteristics of clients are important. Several sets of tasks have been developed that describe the responsibilities of helpers or other caregivers in times of bereavement (Rando, 1993; Worden, 1982). The following is a brief description of Worden’s tasks with evidence-based recommendations derived from the bereavement coping project of Nolen-Hoeksema and Larson (1999). Keep in mind that bereaved individuals differ in their needs, so these recommendations should be considered general guidelines. Bereaved individuals may need support in order to accept the reality of loss. Providing assistance with funeral arrangements and helping to prepare meals or clean up are all useful ways to be of help. It is important not to “push” the person to accept the loss but to be respectful of the individual’s style of coping. Helpers and other loved ones should allow bereaved persons to identify and express feelings if they want to do so. Judicious use of open-ended questions and provisional language (“Sometimes people say that they occasionally feel anxious or impatient. I wonder if you ever feel that way?” Nolen-Hoeksema & Larson, 1999, p. 182) can promote feelings of safety and acceptance. Bereaved persons need to learn how to live without their lost loved ones. For example, they may need to learn restoration-focused tasks previously handled by the deceased, such as managing finances or cooking for children. The helper can scaffold the development of these skills by anticipating possible needs, helping to break them down into manageable tasks, and providing concrete assistance or information. Survivors may need help in finding a place in their lives for the deceased. This may take many forms, depending upon the individual, but generally entails finding a way to maintain some emotional connection. For some people, talking about the deceased is easier and more beneficial than talking about themselves. Silverman (2000) noticed in her work with bereaved children that they were much more articulate when asked to talk about the person who died than they were when asked to talk about their own feelings about the death. She called this process “constructing a relationship to the deceased.” The next task for helpers requires them to be patient and allow time and a nurturing context for grieving. It’s worth considering very carefully the risks and benefits of treating grief as an illness that needs medication. While this may surely be advisable in certain cases, it’s also possible to turn what is an expectable reaction to loss into a disorder. “Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short-circuits the expected existential processing of the loss, reduces reliance on the many well-established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment” (Francis, 2010, p. 46). Helpers may need to help normalize grief for the bereaved. Grieving people often report fears about “going crazy” because of symptoms such as visual or sensory hallucinations, panic attacks, and other signs of intense distress. Learning that these are common occurrences in bereavement that will go away in time is very reassuring. Helpers should provide continuing support, as needed, to help survivors weather the trials of grieving and to assist them in examining the effectiveness or ineffectiveness of their coping strategies. Taking notice of strategies that are effective is an empowering exercise because it allows people to recognize that they have some choice. Strategies that are less helpful can be identified, and more useful possibilities can be suggested. Finally, helpers need to identify and find other sources of support if they, for whatever reason, cannot provide for the range of needs described above. Integrity: The Life Cycle Completed From Erikson’s (1950/1963) perspective, people struggle continuously throughout the life cycle with the “hazards of existence” (p. 274) and should not expect to reach a level of achievement in any of the stages that is completely impervious to conflict. The negative pole of each developmental task represents its counterpoint, a reminder of each stage’s dynamic quality (see Chapter 1, Table 1.2). The period of old age is no exception. Facing old age and death are awesome challenges. Yet over a lifetime, the struggles of earlier stages ideally bear fruit. The resulting integrity, that sense of coherence or wholeness that comes from “acceptance of one’s own and only life cycle [italics added]” (p. 268) is the product of strengths accumulated from each earlier period: hope, self-control, direction, love, devotion, affiliation, and care. Renunciation, the outcome of the final stage according to Erikson, is consummate generativity. It embodies acceptance of the natural order, namely that wisdom which allows us to view death as a stage of life. “Healthy children will not fear life,” Erikson wrote, “if their elders have integrity enough not to fear death” (p. 269). Erikson’s view of the life span, then, is less of a straight line and more of a circle, with its final stage a gift of courage and caring for the generations that follow. In his psychosocial view of development, the quality of life from beginning to end is touched by its social intersections. As we are learning, positive relationships keep people well (Ryff & Singer, 2000); they offer long-term protective factors. Nurturing others, so necessary for survival of our species, returns on the investment at the end of life when we receive others’ care. As we age, some have suggested the need to reminisce or review life events as a way of integrating the features of one’s identity and achieving integrity (Butler, 1963). Part of the benefit of this process, undoubtedly, involves sharing the story with others. We have provided throughout this book descriptions of various aspects of human functioning: attachments, social networks, cognition, brain development, identity, marriage, adaptation, family ties and aging, among many others. There is much left to learn about these topics and about how that knowledge can be used to benefit individuals and societies. Research agendas continuing into the 21st century promise to improve even further our working knowledge of the life span and offer potential avenues for best practice. With this knowledge, helping professionals will be in a unique position to foster resilience, to cultivate compassion for themselves and others, and to create conditions that support well being for all members of the human family in the face of life’s challenges. Summary Physical, Cognitive, and Socioemotional Change in Late Life Despite the increasing number of losses older people experience as they move into old age (60s and 70s) or into old-old age (80s and 90s), most older individuals manage to adapt to old age successfully. As people age, they experience declines in many physical systems, including the immune and sensory systems. Arthritis, particularly osteoarthritis, is especially common. Cognitive change across the lifespan shows a nuanced pattern of change. Perspectives from longitudinal, cross-sectional and integrated models describe maintenance or even gains in some crystallized knowledge (representation) but declines in fluid processes (control) mediated by executive functions. Executive functions are typically the first to show decrements in the aging process. Cognitive functioning in old age is related to overall health, and substantial declines in cognitive functioning, known as dementia, are usually due to cardiovascular accidents or disease processes such as Alzheimer’s disease. Brain changes associated with dementia can start many years before symptoms become evident. Current thinking implicates both genetic and physiological influences (e.g., inflammation) on disease progression. Terminal drop or decline refers to a rapid decline in intellectual functioning shortly before death. Studies of autobiographical memory indicate that, contrary to stereotypic notions, older people remember their more recent experiences better than earlier experiences (recency), even though older adults learn new information less efficiently than younger adults. However, if adults are asked about flashbulb memories, especially vivid and personally relevant recollections, their reports are largely about events in their early adulthood, referred to as the bump period. That is probably why elderly people often tell stories about their early years. As people age, their network of friends and family members shrinks. Social loss is exacerbated by negative stereotypes about aging that assume all elderly people share certain negative characteristics. These stereotypes can lead to discriminatory or demeaning practices that interfere with positive social interactions. Stereotypes of aging are similar across cultures. Negative self-stereotypes of aging also affect performance and mood of older individuals. Three processes appear to be important for successful development in old age. Selection involves limiting activities to a few that are particularly rewarding. Optimization involves finding ways of enhancing achievement of remaining goals. Compensation involves finding new means to achieve our ends. Together these processes are called selective optimization with compensation. There are other, similar ways of describing adaptation processes. In self-determination theory, three needs are said to motivate adaptation at any age: autonomy, competence, and relatedness. Another description of techniques for facing challenges emphasizes two broad strategies. Primary-control strategies are attempts to affect the immediate environment and often increase feelings of mastery and self-esteem. Secondary-control strategies are attempts to change ourselves, such as changing goals. If the latter approach allows a person to then take primary control over some stressor, feelings of happiness and well-being are likely to be enhanced. On the whole, older people seem to cope well with the challenges of late life according to their self-reports. They compare positively with younger adults on some aspects of well-being, such as positive relationships and self-acceptance. Reported well-being does declines in later life. Does increased wisdom help the elderly to cope? Wisdom involves superior knowledge, judgment, emotion regulation, and advice-giving with regard to important questions about life. Research indicates that it is somewhat more likely to characterize older rather than younger adults, although wisdom seems to be as much a quality of the individual person as it is of age. Cross-cultural similarities and differences have been observed in wisdom acquisition and expression. As people age, they pay more attention to their feelings, and their emotions are more enhanced and complex. Positive emotions are as common among the old as the young. Negative emotions, except for sadness, occur less often. Emotion regulation seems to improve. Yet, rates of clinically important depressive symptoms and incidence of minor depression increase into old age. Experiencing Loss Elderly people report less anxiety about death than younger people. Dying adults often must deal with others’ reluctance to deal with death and may feel lonely and isolated. A good death for most people includes symptom management and care (such as freedom from pain, being clean), practical details (such as knowing what to expect), a good patient–professional relationship, and certain psychological attributes (such as maintaining dignity, not dying alone). But many people have very individual needs and desires as well. For example, some people prefer to die at home, but many do not. Palliative care, such as that promoted by the hospice movement, is important to most people. People who sign living wills or advance directives do not necessarily know more about their end-of-life options, although those who have recently cared for a dying patient are more aware. Kubler-Ross described several reactions to dying that are called stages but that do not necessarily occur for all dying adults and do not occur in any fixed sequence: These are denial, anger, bargaining, depression, and acceptance. The dying process is also influenced by the nature of the terminal illness. Knowledge of typical trajectories can improve effectiveness of palliative care. Both Freud and Bowlby proposed influential theories of the grief process. Freud originally believed that bereaved individuals needed to withdraw from the lost loved one and reinvest emotional energy into forming new attachments. Bowlby used attachment theory concepts to describe stages of the grief process: shock, protest, despair, and reorganization. Assumptions derived from these theories have been disputed by contemporary researchers. In particular, the existence of a stage sequence of grief reactions has not been validated. The concept of abnormal grief and the need for cathartic grief work have been called into question as well. Contemporary models of grieving include diverse ways of coping with loss. The dual-process model of Stroebe and Schut incorporates both loss-focused elements and restoration-focused elements within a flexible framework. Current controversies exist regarding whether to treat grief as a form of depression needing medication.

CHAPTER 15 Gains and Losses in Late Adulthood

As people move into old age, in their 60s and

70s, or into old

-

old age, in their 80s and 90s, both gains and losses continue. However, losses may

considerably outweigh gains. “Even in young people’s lives, not

everything goes well. Old age is a

genuinely difficult situation with lots of sadness and frustration. Many things do not go well” (Pipher,

1999, p. 26). How can the elderly effectively manage the ever

-

increasing losses they experience?

For example, can th

eir developmental trajectory be a positive one when they experience multiple

health problems or find themselves in chronic pain? An important focus of this chapter will be to

identify the means by which elderly adults manage their lives and the extent to w

hich they can grow,

maintain themselves, and regulate their losses. Clearly, different people manage their late

-

life losses

with varying degrees of success. But you may be surprised to learn that for a majority of us,

successful development is what we can

expect for much of our old age. At age 81, Helen still

maintains her job in a bookstore. As one of the oldest siblings in a large working

-

class family, she

learned early to value hard work and has always been active and productive. Her job provides her

wit

h opportunities to maintain her skills as well as the chance to learn new ones, such as the new

computerized system her company uses to inventory material. Helen is fortunate in that her health is

good, aside from some problems with arthritis that slow dow

n her movement. She recognizes that

she must regulate her activity now more than before, reducing extraneous activities so she can be

well rested and prepared for work, thus optimizing her performance there. She is an avid crossword

puzzle fan, her recipe

for staying mentally active. When she noticed herself becoming more forgetful,

she compensated by writing notes to herself and establishing and following set routines. She travels

and volunteers less these days, compared to what she did years ago when her

husband was alive.

Now she chooses to spend more time with her family and has eliminated activities she considers

unnecessary. She knows what she can do and what gives her a sense of satisfaction. Helen’s

adaptation is a good example of how a person can co

pe successfully with the challenges of aging. In

what follows, we will first review the nature of the losses and challenges that typically confront

people in old age. Then we will look at the ways in which the elderly cope with these challenges,

paying spe

cial attention to the processes that seem most important for the lifelong experience of

psychological well

-

being. The fact that the world’s aging population is rapidly increasing adds a level

of urgency to these issues if we are to support healthy developm

ent at all points in the lifespan (see

Figure 15.1). FIGURE 15.1 The growing aging population across the world. The numbers of aged

are predicted to rise sharply across the world in coming years. SOURCE: United Nations World

Population Aging 2009; [no long

er online]

http://www.un.org/esa/population/publications/WPA2009/WPA2009

-

report.pdf. PHYSICAL,

COGNITIVE, AND SOCIOEMOTIONAL CHANGE IN LATE LIFE Challenge and Loss in Late

Adulthood Physical Change A gradual decline from peak functioning is characteristic

of most

physiological systems beginning as early as age 30. By late adulthood, the losses are usually

noticeable and have required some adjustment in expectations or lifestyle. A lifelong runner who still

entered marathons at age 62 remarked, “At 30, my go

al was to win. At 50, I celebrated every race

that I finished. Today, I’m delighted to be at the starting line.” Maintaining good physical and mental

health becomes more challenging with age, as the immune system becomes progressively less

effective in sta

ving off cancer and infections and as the cardiovascular, respiratory, and organ

systems function less adequately. Chronic illness and the need for more vigilant health maintenance

increase dramatically with age. Age shifts in the leading causes of death i

llustrate these changing

health concerns. In the United States, accidents are the leading cause of death in adults up to age

45. But at 45, heart disease and cancer take over as the leading causes of death, followed by

cerebrovascular diseases and chronic

respiratory illness (U.S. National Center for Health Statistics,

Health, United States, 2010). People of any age can suffer from acute or chronic illnesses, such as

cancer, heart problems, diabetes, and so on. But the risk of these illnesses climbs dramati

cally and

steadily in our later years. Among the continuing declines of old age are two that are common and

CHAPTER 15 Gains and Losses in Late Adulthood As people move into old age, in their 60s and

70s, or into old-old age, in their 80s and 90s, both gains and losses continue. However, losses may

considerably outweigh gains. “Even in young people’s lives, not everything goes well. Old age is a

genuinely difficult situation with lots of sadness and frustration. Many things do not go well” (Pipher,

1999, p. 26). How can the elderly effectively manage the ever-increasing losses they experience?

For example, can their developmental trajectory be a positive one when they experience multiple

health problems or find themselves in chronic pain? An important focus of this chapter will be to

identify the means by which elderly adults manage their lives and the extent to which they can grow,

maintain themselves, and regulate their losses. Clearly, different people manage their late-life losses

with varying degrees of success. But you may be surprised to learn that for a majority of us,

successful development is what we can expect for much of our old age. At age 81, Helen still

maintains her job in a bookstore. As one of the oldest siblings in a large working-class family, she

learned early to value hard work and has always been active and productive. Her job provides her

with opportunities to maintain her skills as well as the chance to learn new ones, such as the new

computerized system her company uses to inventory material. Helen is fortunate in that her health is

good, aside from some problems with arthritis that slow down her movement. She recognizes that

she must regulate her activity now more than before, reducing extraneous activities so she can be

well rested and prepared for work, thus optimizing her performance there. She is an avid crossword

puzzle fan, her recipe for staying mentally active. When she noticed herself becoming more forgetful,

she compensated by writing notes to herself and establishing and following set routines. She travels

and volunteers less these days, compared to what she did years ago when her husband was alive.

Now she chooses to spend more time with her family and has eliminated activities she considers

unnecessary. She knows what she can do and what gives her a sense of satisfaction. Helen’s

adaptation is a good example of how a person can cope successfully with the challenges of aging. In

what follows, we will first review the nature of the losses and challenges that typically confront

people in old age. Then we will look at the ways in which the elderly cope with these challenges,

paying special attention to the processes that seem most important for the lifelong experience of

psychological well-being. The fact that the world’s aging population is rapidly increasing adds a level

of urgency to these issues if we are to support healthy development at all points in the lifespan (see

Figure 15.1). FIGURE 15.1 The growing aging population across the world. The numbers of aged

are predicted to rise sharply across the world in coming years. SOURCE: United Nations World

Population Aging 2009; [no longer online]

http://www.un.org/esa/population/publications/WPA2009/WPA2009-report.pdf. PHYSICAL,

COGNITIVE, AND SOCIOEMOTIONAL CHANGE IN LATE LIFE Challenge and Loss in Late

Adulthood Physical Change A gradual decline from peak functioning is characteristic of most

physiological systems beginning as early as age 30. By late adulthood, the losses are usually

noticeable and have required some adjustment in expectations or lifestyle. A lifelong runner who still

entered marathons at age 62 remarked, “At 30, my goal was to win. At 50, I celebrated every race

that I finished. Today, I’m delighted to be at the starting line.” Maintaining good physical and mental

health becomes more challenging with age, as the immune system becomes progressively less

effective in staving off cancer and infections and as the cardiovascular, respiratory, and organ

systems function less adequately. Chronic illness and the need for more vigilant health maintenance

increase dramatically with age. Age shifts in the leading causes of death illustrate these changing

health concerns. In the United States, accidents are the leading cause of death in adults up to age

45. But at 45, heart disease and cancer take over as the leading causes of death, followed by

cerebrovascular diseases and chronic respiratory illness (U.S. National Center for Health Statistics,

Health, United States, 2010). People of any age can suffer from acute or chronic illnesses, such as

cancer, heart problems, diabetes, and so on. But the risk of these illnesses climbs dramatically and

steadily in our later years. Among the continuing declines of old age are two that are common and