Enhancing Psychological Resiliency and Well-Being in Later Life:

The Role of Meaning in Life

Schulich Mini Medical School Presentation, November 7, 2013

Dr. Marnin J. Heisel, Ph.D., C.Psych.

Affiliations: Departments of Psychiatry and of Epidemiology & Biostatistics, The Schulich School of Medicine and Dentistry The University of Western Ontario; Lawson Health Research Institute Office: LHSC-Victoria Hospital 800 Commissioners Road East, Room A2-515 London, Ontario, N6A-5W9 Phone: (519) 685-8500 ext. 75981 E-Mail: Marnin.Heisel@lhsc.on.ca

Presenter Information

• American Foundation for Suicide Prevention

• Canadian Coalition for Seniors Mental Health

• Canadian Institutes for Health Research

• Lawson Health Research Institute (Sam Katz Fund)

• Movember Canada

• Ontario Mental Health Foundation

• Ontario Ministry of Research and Innovation

• Public Health Agency of Canada

• Social Sciences and Humanities Research Council of Canada

• UWO, Department of Psychiatry

Funding Acknowledgements

• By the end of this presentation, you will be able to:

• Demonstrate familiarity with theory and research on Meaning in Life (MIL) and other psychological resiliency factors as they contribute to psychological health and well-being among older adults

• Discuss findings of a longitudinal study of risk and resiliency factors to the development and/or exacerbation of late-life depression and suicide ideation

• Consider ways of incorporating a focus on Meaning in Life (and psychological resiliency more broadly) into routine healthcare with older adults

Learning Objectives

• The older adult population is growing and could exceed 70 million North Americans by 2030 (U.S. National Institute on Aging).

• The Canadian older adult (65+) population is expected to reach 20-25% of the population by 2030 (Statistics Canada).

• People are living longer than ever before, over the entire course of recorded human history.

Some Background

• Psychopathology is not inevitable with age

• Most middle-aged and older adults are emotionally well-adjusted

• However, as many as 20% of adults 55 years and older experience significant mental health problems (U.S. Surgeon General, 1998)

• These difficulties can impede healthy aging, and can confer risk for physical and mental health problems, and for suicide, necessitating focus on enhancing psychological resiliency

Mental Health and Aging: The Good News

What do we mean by “Health”?

• In 1948, the World Health Organization (WHO) proposed the following definition: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”

Health

• In 1986, the WHO issued this updated definition: “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities”

Health

Healthy Aging • So, by extension, healthy aging must mean more than just growing older without severe physical infirmities, maladies, or medical illnesses…although it’s nice not to have those.

• It may involve physical health, emotional well- being, having social supports or resources, and various capacities. Perhaps health is something to use, rather than merely something to have.

Healthy Aging • But what if we do have physical, mental, or social problems as we grow older…is it not possible to be healthy?

• Yes, of course it is…this is where the concept of resiliency figures in.

• What do we mean by “resiliency”?:

• Quality of life?

• Absence of illness?

• Resistance to illness?

• Protection from illness?

• Ability to rebound?

• Recovery?

re·sil·ience noun 1.the power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity. 2.ability to recover readily from illness, depression, adversity, or the like; buoyancy. Also, re·sil·ien·cy. [Origin: 1620–30; < L resili(éns), prp. of resilīre to spring back, rebound (see resilient) + -ence ] Dictionary.com Unabridged (v 1.1) Based on the Random House Unabridged Dictionary, © Random House, Inc. 2006.

• According to Alfieri and colleagues (JAGS, 2010): “In psychology, resilience is the positive capacity of people to cope with stress and catastrophe; in technology, resilience is the property of a material to absorb energy when it is deformed elastically and then, upon unloading, to have this energy recovered (the opposite of frailty). Encountering significant difficult circumstances, resilience can be described by viewing constant competence under stress, recovery from a dramatic event, favorable outcomes regardless of high-risk status, and ability to build and increase the capacity for learning and adaptation. All of these things work together to prevent debilitating behaviors.”

• Some would hold that truly resilient people are protected against developing mental disorders

• Others hold that resiliency becomes activated only in response to stressors, challenges, and difficulties, and may lead to growth in the aftermath of challenging life circumstances (e.g., “post-traumatic growth”)

• The literature supports both positions

• Resilience: • Hardiness/strength/gumption/stoicism • Coping/adaptation/compensation/stick-with-it-ness • Flexibility/elasticity/ability to bounce back/rebound • Equilibrium/balance/stability/equanimity • Optimism/hope/faith/belief • Religiosity • Spirituality • Transcendence/otherliness • Excellence/giftedness • Intelligence/wisdom/creativity/insight • Happiness/contentedness/acceptance/gratitude • Meaning in life • Purpose in life/fulfillment/direction • Coherence/integrity/wholeness/peacefulness • Salutogenesis/hygiene/thriving • Well-being/wellness/holism • Social support/connectedness/belonging/love

• Much of my research focuses on suicide and its prevention, particularly among older adults

• My work has focused on the detection, identification, and assessment of suicide risk and interventions to reduce risk

• It also includes efforts to enhance Meaning in Life in order to confer psychological resiliency, contribute to mental health and well-being, and prevent risk for suicide

“That which does not kill us makes us stronger” Friedrich Nietzsche

• Roughly 6000 seniors die by suicide annually • Older adults have high rates of suicide and employ lethal means of self-harm. • This is especially true among older men who have the highest rates of suicide of all demographics in Canada and worldwide. • The ratio of suicidal behaviour to death by suicide among older adults is as low as 1-4:1 (McIntosh et al., 1994). • “Baby boomers” have high rates of suicide.

The Epidemiology of Late-Life Suicide

Source: Statistics Canada “Portrait of Generations, Using the Age Pyramid, Canada, 2011”

• Treating mental health concerns is insufficient; we also need to focus on mental health promotion.

• These approaches should ideally be empowering, respectful of older adults’ values and dignity, and relevant to their lives and experiences.

• Research and interventions are needed focusing upon assessing and enhancing sources of well-being and of psychological resiliency.

• Gooding and colleagues (2012) compared psychological resilience among older (>65) and younger adults (18-25) in the U.K.

• Older adults reported greater psychological resilience

• Older adults’ resilience was associated with emotion regulation and problem-solving; younger adults’ resiliency was highly associated with social support.

• Resiliency was negatively associated with perceived health problems, lack of energy, and hopelessness in both groups.

• Greater resiliency was associated with higher levels of psychopathology and physical dysfunction, but only in older adults.

• Hildon et al. (2010) investigated factors associated with resilience (“flourishing despite adversity”) among 174 adults 68-82 • Compared with “vulnerable” participants, the “resilient” experienced fewer adversities, were younger, were somewhat more likely to be female, and had better quality relationships, larger families, more family support, several close confiding relationships, and better social integration • The resilient were more likely to use adaptive, and less likely to use avoidant, styles of coping • These factors tended to buffer the negative effects of adversity

“He who has a WHY to live for can bear with almost any HOW.” Quotation by Nietzsche found in Frankl’s Man’s Search for Meaning.

• The Viennese psychiatrist, Viktor Emil Frankl (1905-1997), developed Logotherapy (literally “therapy through meaning”), as a meaning-centered theory and system of existential psychotherapy focusing on enhancing Meaning in Life (MIL).

• His work “Man’s Search for Meaning” describes his survival of Auschwitz, and the role played by meaning recognition in enhancing his own survival (and that of others), and in deterring suicidality.

• Meaning-centered therapies have generally not been well studied, in an empirical fashion.

• Manualized approaches generally don’t exist, as existential interventions are typically tailored to the unique life experiences of the individual

• Frankl would say that the clinician who treats two clients in exactly the same way is mistreating at least one of them.

• The pendulum seems to be swinging back; Breitbart and colleagues at Memorial Sloan Kettering in N.Y. demonstrated efficacy of meaning-centered therapy groups for older adults living with cancer

What is Meant by “Meaning”?

Meaning • Not “semantics”

• Existential meaning (“what is meant”)

• A profound sense of coherence, purpose, or significance

• Has inherent worth and value

• Meaning exists objectively (trans-subjectively)

• Meaning is unique to each individual

• It is discovered, not created

• We can perceive meaning in our lives (or meaning possibilities), or not

• It may have properties of transcendence and intentionality

•Frankl’s approach to the study of meaning takes a dimensional view of human beings (termed a dimensional ontology).

•Specifically, this holistic view states that human beings can be understood as comprising 3 distinct, though inextricably interrelated, dimensions; the somatic (or physical), the psychic (or psychological), and the noetic (or existential, spiritual, or humanistic).

•NOUS = (Greek) psyche, soul, spirit, consciousness

•It is similar to 3 people touching an elephant while wearing blindfolds…one touches an ear, one the tail, and the other the animal’s side…all three come away with a different picture but all are touching the same thing

The Three Pillars of Logotherapy

Freedom of Will Will to Meaning Meaning of Life

Three Sources of Meaning/Value in Life

Creative Experiential Attitudinal

The Tragic Triad

Pain/Suffering Guilt Death

• Creative = what we contribute to the world

• Work/occupation

• Sports/exercise

• Volunteering/giving to others

• Community contributions

• Charity

• Artistic creation

• Art, music, poetry, prose, theatre, photography

• Experiential = what we receive from the world

• Pleasant experiences

• Friendship

• Love

• Security/safety

• Beauty

• Appreciation of art

• Art, music, poetry, prose, theatre, photography

• Attitudinal = attitudes towards successes and failures

• Happiness

• Acceptance

• Understanding

• Misery

• Despair

• Being both a gracious winner and a good loser

• Ultimate meaning refers to the perception that one’s life serves a greater purpose; it is the most existential or spiritual dimension of MIL.

• This approach to MIL fit developmental changes experienced when growing older.

• If physical health problems challenge our creativity, we can enjoy life’s experiences.

• If sensory problems challenge our experiential abilities, we can still strike a positive attitude.

• And we can still pursue spiritual aims.

“Dignity must not be confounded with usefulness”

(V. Frankl)

• Neugarten and others have shown that older adults tend to be more inward-focused than younger adults, supporting life review, reminiscence, and existential interventions with older adults.

• Lukas noted an increasing capacity for spirituality with age, supportive of work on gerotranscendence (note: spirituality ≠ religion)

Pleasure Power ensues Success Meaning Money Self-Actualization

Person

Family Friends Work Hobbies

Parallel System of Meaning

Sole Overarching Value (e.g., Work)

Pyramidal System of Meaning

Meaning

Despair

Success Failure

Research Findings

Meaning is Associated with Well-Being in Later Life

•Adjustment & longevity (O’Connor & Valerand, 1988) •Changes in physical health (Heidrich, 1998) •Autonomy, personal worth (Saul, 1993) •Alzheimer caregivers (Farran et al., 1991) •Seniors w/ dementia (Farran, 1997) •Creativity (Hickson & Housley, 1997) •Depression/optimism (Reker, 1997) •Illness appraisal (Nesbitt & Heidrich, 2000) •Successful aging (Wong, 1989) •Depression (Prager et al., 1997) •“grandparenting” program (Carney et al., 1987) •Suicide ideation (Heisel & Flett, 2007,2008)

• Nygren and colleagues (2005) reported associations among purpose in life (PIL), sense of coherence, resiliency, self-transcendence, physical and mental health among 125 adults 85+ years of age in Sweden

• Hedberg and colleagues (2010) reported associations between PIL, general health, having family to talk to, and attitudes toward aging in adults 85+ in Sweden

• Schneider and colleagues (2006) reported significant associations between subjective well-being and sense of coherence in adults 60+ years old, accounting for worsening physical health and increasing disability

• Krause (2003) reported “older adults who derive a sense of meaning in life from religion…have higher levels of life satisfaction, self-esteem, and optimism”

• Braam and colleagues (2006) reported an association between MIL-framework and cosmic transcendence among older Dutch adults

• Breitbart and colleagues (2010) found that terminally ill older participants in a meaning-centered psychotherapy group, based on Frankl’s tenets, experienced reduced desire to hasten death

• Perception of MIL has been shown to be positively associated with longevity among older adults; this finding appears to be mediated by physical health (Krause, 2009; O’Connor & Vallerand, 1998)

• Researchers have also shown that purpose in life confers greater longevity in later life, even controlling for physical health and well-being (Boyle et al., 2009)

• MIL partially buffers the association between coping style and suicide ideation and behaviour (Edwards & Holden, 2001). • MIL is associated with suicide ideation upon hospital admission among individuals who self-harmed (Petrie & Brook, 1992). • Reasons for Living are negatively associated with suicide ideation (Edelstein et al., 2009; Linehan et al., 1983).

Research on Meaning and Suicidality

• We have reported that mental health and well- being variables (e.g., MIL, PIL, and life satisfaction) are negatively associated with suicide ideation among clinical mental health and heterogeneous older adult samples (Heisel & Flett, 2004, 2007, 2008), in cross-sectional analyses.

Our Previous Research

• We studied suicide ideation and purpose in life among 49 mood and/or personality disordered mental health patients (M = 37.5 years; SD = 8.2) • Suicide ideation was associated positively with depression (r = .75), social hopelessness (r = .77), and neuroticism (r =.47), and negatively with purpose in life (r = -.69), and with life satisfaction (r = -.33).

Heisel & Flett, 2004

• The protective factors improved prediction of suicide ideation in a hierarchical regression analysis beyond the risk factors alone. • Depression interacted with purpose in life in predicting suicide ideation.

• We replicated this study with a heterogeneous sample of older adults (65+) recruited from nursing and retirement residences, medical and mental health services, community centres and health classes

Heisel & Flett, 2007, 2008

• Meaning in Life was negatively associated with:

• depression (GDS; r = -.46, p<0.01) • global hopelessness (BHS; r = -.53, p<0.01) • social hopelessness (SHQ; r = -.29, p<0.01) • suicide ideation (GSIS; r = -.62, p<0.01)

• Meaning in Life was positively associated with:

• life satisfaction (SWLS; r = .39, p<0.01) • purpose in life (PIL; r = .45, p<0.01) • physical health reports (r = .30, p<0.01)

• Consistent with Frankl’s theoretical approach, demonstrating the human capacity for discovering MIL in the face of suffering and adversity, we have shown that MIL interacts with depressive symptom severity in predicting late-life suicide ideation (Heisel & Flett, 2007).

• We have also found significant improvement in MIL among participants in our clinical trial of IPT adapted for older adults at-risk for suicide (Heisel, Duberstein, Talbot, King, & Tu, 2009)

• Cross-sectional findings support robust negative associations between suicide ideation and MIL • Yet, longitudinal methods are required in order to test whether MIL protects against the onset and/or exacerbation of suicide ideation. • We thus embarked on a longitudinal study intending to first replicate our cross-sectional findings of negative associations between late-life suicide ideation and MIL, and then attempt to extend those findings over a 6+ month follow-up period, accounting for intervening life stressors.

What Next?

Intervention

Prevention

Intervention

Postvention

• Public health initiatives (Universal) • Means restriction (UK gas ovens/meds packaging)

• GP depression assessment/tx (Gotland study)

• Suicide prevention strategies/practice guidelines

• Community initiatives (Selected) • Gatekeeper model (Spokane, Florio et al.)

• Outreach initiatives (Japan, Oyama et al.)

• Telehealth/Telecheck (Italy, DeLeo et al.)

• Clinical initiatives (Indicated)

What Works?

• Existing research generally supports community outreach and mental health intervention for at-risk older adults

• Most of these studies demonstrated a positive impact on the mental health and well-being of women

• And yet men have the highest rates of suicide and are far less likely to access healthcare and mental health services

• Moreover, mortality data indicate increasing suicide rates for men in post-retirement years

• With funding from Movember Canada, we will be delivering, testing, and disseminating 12-week meaning-centered men’s groups for men over 60 who are facing retirement and struggling to recognize MIL

• Groups will initially be run in community centres in London, with future groups planned in Alberta and in B.C.

• The groups will encourage camaraderie among men facing a common life transition

• We will evaluate the groups in terms of: • enhancing mental health and well-being, • promoting a smooth transition to retirement, • reducing or preventing the development or

worsening of symptoms of depression, hopelessness, and suicide ideation,

• cost-effectiveness and sustainability

• We hope that these groups will become part of work outplacement for men facing retirement

• Future research may include groups for higher-risk individuals, those with health limitations, and possibly with women

• The burgeoning older adult population is creating capacity concerns in our mental healthcare system.

• Research is needed addressing the promotion of psychological well-being in later life.

• MIL may be a key resiliency factor potentially protective against the onset and/or exacerbation of suicide risk.

Summary

• Preliminary findings are quite promising for our new measure of MIL.

• We will now assess its utility as a clinical outcome measure.

• Our work supports the contention that MIL is positively associated with mental health and well-being, and not only negatively associated with depression and suicide ideation, but may actually help to prevent its onset, even in the context of stressors, losses, and transitions.

Study findings were limited by relatively low levels of participant suicide ideation; we did not focus on prediction of suicidal behaviour.

Helping an individual seek out sources of meaning that resonate with one’s personal experiences, goals, talents, and/or values can increase one’s likelihood of discovering MIL, and can reduce risk for suicide, even in the face of stressors, transitions, and depression.

We will assess this in more detail in our upcoming study with men facing retirement.

Thank you