Providing spiritual care is about tapping into the concept of spirituality: core meaning, deepest life meaning, hope and connectedness.
The search for meaning, connectedness and hope becomes more significant as older people are faced with the possibilities of frailty, disability and dementia.
Spirituality, ageing and meaning in life can be discussed in the context of an alternative view of “successful ageing”.
A model of spiritual tasks in older age can help explain the spiritual dimension and provide a starting point for spiritual assessment.
Like many other developed countries, Australia has an ageing population. The proportion of people over the age of 65 is projected to increase from 12% in 1997 to 18% in 2021 and about 26% in 2051. The number of people over the age of 85 has also increased sharply — by 69% in the decade 1991–2001.1,2 Improvements in health care have led to increased longevity, but the extra years are wasted unless people can find hope and meaning in life.
Health care is not just caring for people’s physical needs. Spiritual care is a way of helping older people in their search for hope and meaning, especially as they face issues of grief, loss and uncertainty. Depression in older people, especially those in aged care facilities, is one aspect of loss of meaning and hope. This article presents an alternative view of ageing and a model of spiritual tasks in ageing. Spiritual reminiscence is proposed as one way to help provide spiritual care.
There are different views of ageing in our society. One view sees ageing as a period of physical decline that includes illness and disability, with an emphasis on the “burden” of an ageing population. Government policy has concentrated on the cost of this ageing population, exemplified by the Intergenerational Report.3 A second view is of “successful ageing”.4 This promotes continued engagement with the wider community and pursuit of physical and psychosocial activities as a means of ageing successfully. However, this view begs the question of what happens to people who are not “successful” — older people who live with multiple chronic health problems, who are depressed or live with dementia. The reality is that the later years in life may frequently be accompanied by chronic illness requiring special care.
Therefore, an alternative view is needed. We propose a third view that sees ageing as a “spiritual journey”, with challenges that continue across the later years of life. This is a journey that searches to find meaning in one’s life and, therefore, reason for continued life and hope. This view accepts the possibility of death, while living life to the full. Taking this third view allows people living with increasing disability to find hope and to flourish, even in the face of uncertainty.5
Elements of each of these views of ageing are true, and it is important to take account of each in considering the wellbeing of older people and their holistic care. By examining concepts of spirituality and transcendence in later life, we explore ageing as a spiritual journey.
The concept of spirituality is about core meaning and connectedness, and it is from this that we respond to all of life. Anger, hate, love, forgiveness and hope come from this core. For some older people, spirituality may be expressed in a relationship with God or a higher being, while for others it may be expressed through family and friends, nature, and/or the environment. When we talk about spirituality, we are not specifically talking of religiousness, although for people who have a religious faith, religiousness is part of their spirituality.6 A better way to think about spirituality is to imagine it as an umbrella. Religion, being one way to express spirituality, comes under this umbrella.
Describing the spiritual domain has always been difficult. It is deeply related to hope and is the spark that enlivens human beings. Essential elements of spirituality seem to revolve around a relationship with self, others and God, a sense of meaning and purpose, hope, connectedness and beliefs.7 Issues of spirituality appear more urgent when people face situational and developmental crises of life, such as coming to terms with a terminal illness and the rising awareness of one’s own mortality.8
That which lies at the core of each person’s being, an essential dimension which brings meaning to life. Constituted not only by religious practices, but understood more broadly, as relationship with God, however God or ultimate meaning is perceived by the person, and in relationship with other people.8
There has recently been an increasing interest in studying the spiritual dimension. US studies have often revolved around religiousness or religious practices.9 However, Australia is largely a secular country. Although 80% of Australians affirm a belief in God or a higher being, only 20% attend church at least monthly — well down on the 45% of attendees in the 1950s.10 A 1999 study by Hughes and Black11 found that two-thirds of Australians felt that a spiritual life was important. Respondents sought meaning and a sense of peace and wellbeing in their lives through their relationships, family, work, nature and music. As a consequence, in Australia, the term “spirituality” appears to elicit more useful information than the terms “religion” or “religiousness”. In spite of the widespread view that some form of spirituality is important, many people who care for older people do not see spiritual care as a priority because the person does not declare a religion or go to church.
As people grow older, especially from middle age onwards, they often become more introspective.12 Erikson et al13 have described a series of psychosocial developmental stages of ageing, the final stage being to move towards integrity or despair, the outcome of which is wisdom. The development of a model of spirituality in ageing described here came about from many hours of interviewing, listening to and analysing the stories of older people. One study explored and mapped the spiritual journeys of independent older people: Where did they find meaning in life? Were they conscious of being on a journey? What was it like? What were the possibilities? Was there still hope in growing older and frailer?8 Other studies have concentrated on frail elderly people6 and those with dementia.14 Each of these studies has sought to explore the spiritual dimension of ageing.
The model shown in the Box is based on qualitative analysis, using grounded theory, of data obtained from in-depth interviews with older people.8,15 It has been refined and affirmed in subsequent studies.6,15 In this model, the central core of spirituality is what the person perceives as ultimate meaning in life. The person responds to life from what lies at the heart or deepest core of their being, and this will vary with the individual. The model is dynamic, with interactions shown by arrows.
The model provides a framework for understanding spiritual processes in ageing. It centres on the human search for meaning and the associated responses to perceived meaning. Other tasks involve the development of transcendence (the ability to triumph over the psychosocial, physical and spiritual challenges of ageing), moving from provisional to final life meanings, finding intimacy, and finding hope. The model allows for continued spiritual growth and development until the end of life. It also suggests opportunities for spiritual assessment and intervention.
What brings greatest meaning to each individual is the starting point for that person; it is from this point that he or she responds to life. For example, if the person thinks of God as judgemental, then guilt may be a central feature of the person’s life, and he or she may not be able to feel hope. If core meaning comes through relationship with loved ones, it is important to know this, especially if there has been a loss of relationship through death or separation. Meaning is at the centre of what it is to be human, and loss of meaning can be an important factor in grief and depression.
The response to meaning is a reaching out from our depth to otherness and to others. If art, music or environment is a central source of meaning, then the person will respond to meaning through this. If God is central in meaning, then worship, prayer, reading of sacred scriptures or meditation may be the person’s means of response. People who are depressed may feel that life is meaningless and may find it difficult or impossible to respond to life unless the depression is first treated.
At developmental stages of our lives or during critical life experiences, we assign meanings to our experiences. These “provisional meanings” are subject to change at a later point. Changes later in life, such as the diagnosis of a terminal illness or an increasing awareness of one’s own mortality, may be triggers to examine provisional life meanings and move towards assigning “final meanings”. Reminiscence therapy (see below) has been used in such circumstances to help people resolve past issues, including traumatic experiences. Coleman has used reminiscence therapy effectively with older people traumatised by their experiences of World War II.16
A study of independent-living older people showed that all of them feared future vulnerability or losing control of their lives.8 In a similar study of frail elderly nursing home residents, 55% of participants said they had no fears.6 Yet, the latter group had many more disabling conditions than the independent-living group. The precarious balance between vulnerability and self-sufficiency was an important theme for these older people. As vulnerability increased, the move from “doing” (being active) to “being” (having little energy or ability to engage in activities) was more frequently observed. These changes, associated with self-transcendence (the move from self-centredness to other-centredness), are spiritual changes and were present regardless of religious and spiritual background. However, not all of the people studied had progressed along a continuum towards self-transcendence. While some very frail older people seemed at peace and expressed a deep sense of joy in their lives, others experienced despair. A sense of despair may lead to failure to thrive, a concept much studied recently in the broader context of frailty.17 It is contended that one aspect of failure to thrive may be a lack of nourishment of the soul, or lack of love and spiritual care, similar to the failure to thrive concept in paediatrics. My work of mapping the spiritual dimension with frail elderly nursing home residents indicated a possible link between frailty, failure to thrive and lack of hope.
In a review by Levers et al17 of the literature on frailty in older people, in which the multidimensional nature of frailty was acknowledged, only one study was found that included spirituality in a theoretical framework, and none considered it in a research framework. The authors of the review noted that, while the three most common factors contributing to frailty were physical activity, ageing and disease, confusion exists about the relationship between frailty and the multiple identified factors. Considering that only one study included spirituality at all, this is an area for further study.
Reminiscence work was presented first in the early 1960s by Butler as “life review”.18 In many cases, life review gives people an opportunity to reflect on their accomplishments and a chance to right old wrongs, reconcile with enemies and become ready to die.18 Butler felt that this process is not always encouraged. Older people have been told that this type of nostalgia is “living in the past and a preoccupation with self”.18 He counters this attitude with the proposition that life review should be considered as part of a natural healing process.
There has been much written about reminiscence and life story in relation to older people.16,18-20 Haight and Webster18 differentiate between the concepts of life review and reminiscence. They propose that reminiscence has little structure and may jump from event to event as memories are triggered, whereas life review is a more sequential telling of a life. However these concepts are defined, they are both ways of recalling the past.
Spiritual reminiscence6 differs from reminiscence in that it focuses on the meaning of life through the life story, including connectedness, and the faith context (where this is part of the person’s story), and on what has given joy or brought sadness. The process of spiritual reminiscence may identify events that caused anger, guilt or regret. Expressing some of these issues in later life may help people to reframe events and come to a new understanding of how their life was lived.21 Spiritual reminiscence helps people find meaning in life in the present and develop strategies to accept changes of later life, including losses of significant relationships and increasing disability. It offers people with dementia the chance to talk about their fears and hopes and where they find meaning. Outcomes of spiritual reminiscence work include facilitating transcendence and finding hope in the face of increasing vulnerability.8,14
Although we live in a largely secular society, spiritual care should not be seen as an “optional extra” for older people. The search for meaning in later life becomes more real for many older people, and this search is essentially a spiritual search, with questions of meaning, transcendence and hope becoming important. Thus, one important view of ageing is of a spiritual journey. The spiritual quest does not cease with the onset of frailty or with the diagnosis of dementia. Older people often need support and spiritual care that will include journeying with them in their search for meaning and grappling with the issues that arise when life itself seems threatened. Using spiritual reminiscence is one way of offering this care.
Spiritual tasks in later life: a continuing process*
* Reprinted with permission of Haworth Press from MacKinlay EB. The spiritual dimension of caring: applying a model for spiritual tasks of ageing. J Relig Gerontol 2001; 12: 157.14
- 1. Australian Institute of Health and Welfare. Australia’s health 2004. Canberra: AIHW, 2004. (AIHW Cat. No. AUS 44.)
- 2. Australian Institute of Health and Welfare. Older Australians at a glance 2002. 3rd ed. Canberra: AIHW and Australian Department of Health and Ageing, 2002. (AIHW Cat. No. AGE 25.)
- 3. Australian Government Treasury. Intergenerational report 2002–03. 2002–03 Budget Paper No. 5. Canberra: Commonwealth of Australia, 2002. http://www.budget.gov.au/2002-03/bp5/html/index.html (accessed Mar 2007).
- 4. Rowe J, Kahn R. Successful aging. New York: Random House, 1999.
- 5. Braxton D, Swindell R, MacKinlay E. A voice worth listening to: a U3A Online at Griffith Successful Ageing Study. Queensland: Griffith University Desktop Publishing, 2005.
- 6. MacKinlay EB. Spiritual growth and care in the fourth age of life. London: Jessica Kingsley Publishers, 2006.
- 7. Young C, Koopsen C. Spirituality, health and healing. Thorofare, New Jersey: Slack Inc, 2005.
- 8. MacKinlay EB. The spiritual dimension of ageing. London: Jessica Kingsley Publishers, 2001.
- 9. Koenig HG, Lawson DM. Faith in the future: healthcare, aging, and the role of religion. Philadelphia: Templeton Foundation Press, 2004.
- 10. Bellamy J, Black A, Castle K, et al. Why people don’t go to church. Adelaide: Openbook, 2002.
- 11. Hughes P, Black A. Managing the diversity of implicit religions in Australian society. In: Bouma G, editor. Managing religious diversity: from threat to promise. Sydney: Australian Association for the Study of Religions, 1999.
- 12. Neugarten B. Adult personality: toward a psychology of the life cycle. In: Neugarten B, editor. Middle age and aging: a reader in social psychology. Chicago: University of Chicago Press, 1968.
- 13. Erikson EH, Erikson JM, Kivnick HQ. Vital involvement in old age. New York: WW Norton and Co, 1986.
- 14. MacKinlay EB. The spiritual dimension of caring: applying a model for spiritual tasks of ageing. J Relig Gerontol 2001; 12: 151-166.
- 15. MacKinlay E, editor. Spirituality of later life: on humor and despair. New York: Haworth Pastoral Press, 2004: 43-58.
- 16. Coleman PG. Creating a life story: the task of reconciliation. Gerontologist 1999; 39: 133-139.
- 17. Levers M-J, Estabrooks CA, Kerr Ross JC. Factors contributing to frailty: literature review. J Adv Nurs 2006; 56: 282-291.
- 18. Haight BK, Webster JD, editors. The art and science of reminiscing. Washington: Taylor and Francis, 1995.
- 19. Gibson F. The past in the present: using reminiscence in health and social care. Baltimore, Md: Health Professions Press Ltd, 2004.
- 20. Haight BK, Gibson F. Burnside’s working with older adults: group processes and techniques. Sudbury, Mass: Jones and Bartlett, 2005.
- 21. Randall W, Kenyon G. Reminiscence as reading our lives: toward a wisdom environment. In: Webster J, Haight B, editors. Critical advances in reminiscence work. New York: Springer, 2002.
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