Janet Anderson Yang, PhD, ABPP, Krista McGlynn, MA and Breanna Wilhelmi, MS

Later life can be a time of troubling concerns, such as physical and cognitive decline, pain, loss, awareness of life ending, and approaching death.  Standard approaches to mental health treatment often require physical and cognitive abilities, focus, and energy.  Clinicians working with older adults may struggle in helping clients find satisfaction in the face of these declines and losses. 

A number of clinical approaches can help aging adults enhance meaning in their lives.  These approaches include interventions related to existential meaning, life review and reminiscence, leaving a legacy, transcendence, mindfulness, wisdom, spirituality and religion, grappling with the end of life, creativity, and enhancing relationships.  Clinical methods for helping aging clients enhance meaning and achieve the goals of later life within the context of co-existing challenges will be discussed within this article.

Existential Meaning
One approach to help aging clients is assisting them in developing altered perspectives and increasing existential meaning, wisdom, and integrity.  Renowned psychiatrist Victor Frankl (1986) considered three avenues of meaning, including creating a work or doing a deed, experiencing something or encountering someone, and changing one’s attitudes about situations.  Other authors also emphasize the importance of helping clients develop new forms of meaning after losses and trauma (Neimeyer, 2011; Horowitz, 1986).

Life Review and Reminiscence
Erik Erikson (1982) proposed that the developmental task of older adulthood is to resolve conflict between integrity and despair.  The approach of death stimulates review of life to prepare for death. This involves  consolidating an understanding of one's life, to be achieved through the “mourning for time forfeited and space depleted, autonomy weakened, initiative lost, generativity neglected, identity potentials bypassed, and too limiting an identity lived" (Erikson, 1982).

Robert Butler and James Birren also discussed the importance of life review.  Butler (1963) suggested that later life is a time for people to review their lives, allowing a return to consciousness of past experiences, especially unresolved conflicts.  By reviewing one’s life, one can expiate guilt, resolve internal conflicts, reconcile relationships, and renew ideals, thereby experiencing new peace and gaining wisdom (Butler, 1963).  Birren (2001) suggested that the purpose of life review is to develop an acceptable image of one's life and leave behind an acceptable legacy; that an awareness of coming death can stimulate a person to review one’s life to integrate the actuality of one’s life with what might have been and to reorganize attitudes toward one’s life in a more positive way.

The developmental process of life review has been adapted to become a form of psychotherapy, sometimes referred to as reminiscence therapy.  Life review or reminiscence therapy is a structured activity to access and process thoughts about past experiences.  It often involves marking down a timeline and writing in dates and major life events, then analyzing and discussing the meaning of the events.  Integrative reminiscence generally refers to reappraising losses and difficulties, reviewing values and personal meaning, and working toward a renewed understanding of the life lived.  Instrumental reminiscence refers to recalling past successes, achievements, and positive adaptations, in order to reactivate a positive self-concept.

Within life review or reminiscence therapy, techniques that can be used include marking the years and ages of the client, asking the client to recall important personal events (e.g., education, family events, work successes, loves, losses, hopes, regrets, and memorable experiences), using important world events as markers, using aids to evoke memories (e.g., photos, picture books, letters, diaries, music, and foods), encouraging the client to take a pilgrimage (e.g., to an old home or neighborhood), and writing an autobiography.  These activities then evoke therapeutic conversation.

Leaving a Legacy
Another aspect of understanding the meaning of one’s life is to consider what legacy the person has left.  Irvin Yalom (2008) stated that one may find meaning in life and come to terms with death through understanding “rippling,” or the ways in which the person has influenced others, which, in turn, consequently influence other people’s lives and can impact generations to come.  James Birren (Birren & Deutchman, 1991) discussed the importance of reviewing a person’s legacy, which might include acts of helping others, raising children, creating art, writing, professional successes, political achievement, influencing others, and contributing to science, among other things.  To this end, clinicians can help clients consider their legacies, including what they have done in their lives, these actions’ impact on others, and potential effects on the future.

Transcendence
Gerotranscendence represents the ability to move beyond the immediate circumstances to form connections beyond the self, transcending the gulf between people, between person and the universe, or between person and the creator of the universe (Brennan, 2009; McFaddon, 2009).  Within aging, there may be an increased emphasis on internal processes that facilitate expanded consciousness.  Older adults may have more time to meditate, contemplate, and reflect (Newman, 1987).  Life satisfaction may increase as a person shifts toward increased focus on the cosmic world rather than on the material world (Tornstam, 1994).  Clinicians may suggest contemplative practices to older adult clients and explore the idea of transcendence with them to improve their sense of meaning in life.

Mindfulness
Developing a mindfulness or meditation practice is another avenue to help older adults gain meaning and satisfaction in their lives (Hayes, Strosahl, & Wilson, 1999).  Mindfulness is the act of concentrating one’s attention on moment-to-moment experience with a nonjudgmental attitude.  Mindfulness is successful in treating anxiety and stress, as well as other disorders (Kabot-Zinn, 2003).  Acceptance and commitment therapy (Hayes et al., 1999) and Mindfulness-Based Stress Reduction (Kabot-Zinn, 2003), among other evidence-based practices, can be useful interventions to help clients experience their lives in meaningful new ways.  Mindfulness may also include encouraging the client to learn new breathing techniques, to listen to recorded meditation lessons, and/or to set up a space to meditate or connect with nature, among other possibilities.  Since mindfulness can be practiced anywhere, it may be a helpful intervention for those experiencing a lack of mobility and consequent boredom or depression. 

Wisdom
Due to their long lives and consequent extent of experience, older adults have undoubtedly developed substantial wisdom (Baltes & Staudinger, 1993).  They have used knowledge, experience, and understanding in many different ways to confront circumstances, tolerate difficulties, and make decisions.  Clients can be encouraged to discern, honor, appreciate, and share with others the significant wisdom they have developed from life experiences. 

Spirituality and Religion
Older adult clients may find meaning in their lives through developing or rediscovering spirituality and/or religion.  Spirituality includes a set of beliefs that may include love; compassion; and a respect for life, existence, and relationships with ourselves, others, the universe, and/or the sacred.  Spirituality can extend beyond the physical and material to transcendence and can be secular in nature.

Religion includes the practical expression of spirituality in the organization, ritual, and practice of one’s beliefs.  Many older adults indicate interest in religion and/or spirituality; addressing these issues may benefit the client’s mental health. 

Clinicians need to use careful clinical judgment as to if, when, and how to talk about spirituality or religion in order not to assert their own values or proselytize clients toward their own beliefs.   Encouraging a client’s positive spiritual and/or religious coping activities and exploring previous negative experiences may be good places to start.  Specific instruments, such as the HOPE Questionnaire (Anandarajah & Hight, 2001) or structured guidelines (“Parameter 4.15”, County of LA Department of Mental Health, 2012) may be used.

Grappling with the End of Life
Many older adults are troubled about being closer to death.  Discussing this topic may be difficult.  While health care providers have been encouraged to talk with patients about end-of-life wishes (Steinhauser et al., 2001), clients’ fears and concerns about dying and death are often not addressed.  Older adults may have concerns or fears related to pain and suffering during the dying process, what happens at the moment they die, whether they will be alone when it happens, what happens after death, and who all they will leave behind.  A related case example follows:

Carol was a 69-year-old client seen in therapy by the first author at Heritage Clinic in Pasadena, California.  Carol had had a stroke, was bed-bound, and fought with her husband considerably.  With some help, she moved out of Heritage Clinic to an assisted living facility.  Carol then began having conflict with the staff.  The therapist helped the client talk about her anger and then wondered if her anger might be related to underlying fear.  With enough trust established, the therapist asked the client if she was afraid of what was happening to her body.  The client identified that she was frightened of having another stroke and intolerable pain.  With consultation with her physician, Carol was reassured that if she were in pain, she would be offered enough medication to relieve her pain.  Carol then identified that she was afraid of dying and going to hell, which surprised her to realize, as she was a staunch atheist.  Her fear of going to hell was traced back to childhood messages at home and within early church lessons.  The therapist helped the client challenge and resolve her belief that she was bad and would go to hell.  Her fear, anxiety, and interpersonal conflict decreased, and her satisfaction in her life improved.

Clinicians may gently initiate discussions about these concerns through asking clients questions about their parents’ age at and cause of death, in what way the conditions of their parents’ death affect their thoughts of their own death, how they feel about being their current age, what they think about their end of life, and what they think will happen after they die.  Clinicians may then assess the client’s answers and link them to their mental health concerns.  In addition, clinicians may complete an advanced health care directive or a Five Wishes document (Aging with Dignity, 2011) to obtain more clinically-relevant information.

Creativity
Encouraging creativity can bring new or renewed meaning in later life.  Activities may include listening to music, playing music, singing, writing, dancing, drawing, coloring, painting, or viewing art or art books.  Clinicians may use a Pleasant Events Schedule to stimulate a structured discussion of creative or pleasant activities within clients’ lives (Lewinsohn, 1971).

Enhancing Relationships
Later life can be a time of losses of relationships, leading to isolation and loneliness.  Coping with these losses  may include developing new relationships, seeking to reconnect with prior relationships, and/or working to reconcile conflicted or estranged relationships.  Hargrave and Anderson (1992) describe a combination of life review therapy and family therapy in a way that can help promote healing in family relationships.  Volunteering, giving to others, caring for grandchildren, and mentoring younger persons may bring considerable meaning from an interpersonal approach for aging patients.
 
Later life can bring about frailties that cause dependence on others for personal needs. While the increased dependency can be troubling, it may be an opportunity for enhanced relationships.  Lustbader (1999) presents a beautiful example of the latter:

“A physical therapist tells how a stroke led to the reconciliation of a father and son who had not spoken in years: My patient was a large man, and the dead weight of his stroke made it impossible for his tiny wife to move him at all.  His son agreed to come over and learn how to do a wheelchair transfer, but he came in looking so hostile I wanted to call off the whole thing.  He didn’t even say hello.  I explained that he had to grip his father in a bear hug and then use a rocking motion to pivot him from the bed to the wheelchair.  The son went over to the bed where his father was sitting and put his arms around him, just like I said.  He got the rocking motion going, but then all of a sudden I realized that both of them were crying.  It was the most amazing thing.  They stayed like that for a long time, rocking and crying.  This son was moved to linger in his father’s arms for the first time since boyhood.  Unexpected embraces, uncharacteristic expressions of feeling, these are only some of the ways that relationships grow through frailty’s demands” (p.23).

Cultural Considerations
Clinicians may help older clients find meaning in their lives through collaborative exploration of clients’ cultural identities.  The intersectionality theory framework provides one such way to navigate this task.

Introduced by civil rights advocate Kimberlé Crenshaw (1991), intersectionality theory emphasizes the multidimensionality of cultural identities with specific attention to the roles of power, privilege, oppression, and marginalization.  From this perspective, clients find meaning in life through the sociocultural lenses through which they experience the world (Yang et al., 2016).  In clinical practice, this means working with clients to unravel the complexity, diversity, and connectedness of their co-existing identities.

Some identities tend to garner privilege and power, (e.g., being white, cisgender, heterosexual, educated, male, or wealthy) while others tend to yield oppression and marginalization (e.g., being of color, transgender, homosexual, bisexual, uneducated, female, or impoverished).  Due to the prevalence of ageism, old age may be associated with greater feelings of powerlessness and marginalization (Laws, 1995).  Younger adults often experience greater social capital while older adults may struggle with feeling “past their prime” and “put out to pasture” (North & Fiske, 2012).

The process of exploring one’s various identities may be challenging.  Clinicians can help aging clients explore questions concerning the importance of these identities; when, where, and how they experienced the most and least privilege and power in life; and which of the client’s identities are the most and least dominant and important to them. 

A patient's various identities can give clinicians an idea of themes to explore within the therapeutic setting, but the clinician should also be careful not to make assumptions.  Many people within certain groups do not subscribe to beliefs that may be associated with that group.  Therefore, it is important for clinicians to let the client lead these conversations and to be aware of their own biases. 

With that said, there may be certain issues that are more relevant and helpful to explore for members of specific groups of aging clients.  For example, family relationships may be particularly important for clients of certain ethnic or racial groups, so meaning may be derived from reconnecting or improving communication with family members or from mourning unmet expectations.  For others, spiritual or religious beliefs may be of particular significance, so it may be helpful for these clients to explore their spiritual understanding, read religious texts, listen to religious programs, visit a place of worship, or explore the meaning of death in the context of their spiritual or religious beliefs.

In conclusion, therapists working with older adults may benefit from considering ways to help their clients enhance satisfaction and a sense of meaning in their lives.  While some clients may directly indicate they want to work on developing meaning, others may not suggest that developing meaning could help them.  The therapeutic work may benefit from gently approaching one or more of these avenues toward increasing meaning in life, including reminiscing and reviewing the client’s life, considering what legacy the client has left, enhancing the client’s sense of spirituality, exploring transcendence, utilizing mindfulness, honoring the client’s developed wisdom, coming to terms with the end of life, enhancing existing relationships, and increasing creative endeavors.

Dr. Janet Anderson Yang, PhD, ABPP is a licensed clinical psychologist, board certified in geropsychology.  She has been working with older adults for over 35 years.  She is the Clinical Director and the Training Director at Heritage Clinic, a division of the Center for Aging Resources, a mental health clinic and adult day care center.  She provides services to older adults, supervises clinical staff, and trains mental health professionals.  This includes directing Heritage Clinic’s doctoral internship accredited by the American Psychological Association.  Dr. Yang has published articles and conducted trainings on psychotherapy with older adults, mental health outreach, reminiscence, and other topics related to mental health and older adults.
 
Breanna L. Wilhelmi, MS is a PhD Candidate at the Pacific Graduate School of Psychology at Palo Alto University (expected graduation 2016).  She specializes in trauma, geropsychology, and culturally-sensitive clinical practice and advocacy.  Her doctoral internship is with Heritage Clinic in Pasadena, California and her postdoctoral fellowship is with Wise and Healthy Aging in Santa Monica, California.  She currently provides in-home psychological services to community-dwelling older adults with serious mental illness.

Krista McGlynn, MA is currently a clinical psychology intern at Heritage Clinic, a community-based mental health clinic serving the older adult population.  Previously, Krista worked as a Registered Nurse in the areas of critical care and hospice.  Her future career goals include continuing her work with the older adult population and expanding her training in the area of palliative care psychology.  Krista recently began a fellowship position specializing in palliative care at the Audie L. Murphy Veterans Administration Hospital in San Antonio, Texas.

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