The Effectiveness of Mental Health Services with the Elderly in Retirement Facilities

Running Head: EFFECTIVENESS OF MENTAL HEALTH SERVICES

The Effectiveness of Mental Health Services with the Elderly in Retirement Facilities: A

Longitudinal Research Proposal

Megan E. Miller

Research and Program Evaluation

Spring 2015

Dr. Mustafa A. Moyenda

Chicago State University

EFFECTIVENESS OF MENTAL HEALTH SERVICES 2

Chapter 1:

Introduction

Elderly in the United States face many challenges as they age. Loss, physical and

mental changes, and environmental changes are just some of the challenges that the

elderly face. However, much can be done to combat negative effects of those changes,

such as utilizing counseling services, implementing new activities, and forming new

relationships through activities. This research proposal is aiming to target elderly

individuals who have reported a decrease in meaning towards the end of life. Through

individual and group counseling sessions elderly who participate in this research will be

able to set a foundation for further research to be completed. This research proposal is

also aiming to bring to light the areas of most concern when helping the elderly near the

end of life such as, depression, meaninglessness, global care concerns, and racial and

ethnic disparities. The problem is growing and deepening every day and the elderly

around the world are a growing concern when it comes to mental health, which is why

this research is aiming to aid in the combat against end of life meaninglessness.

Problem Statement

In 2010, the United States conducted a census that revealed 40,267,984 elderly

persons over the age of 65, living in the United States (Werner, 2011). This is an increase

of 5.3 million compared to the Census conducted in 2000, when this population

numbered only 35.0 million. By the year 2020, it is projected that there will be over 55

million elderly, and in 2030, 72.1 million (Administration on Aging, 2011). This

population will continue to grow, and with that growth, there is great need for mental

health services to grow with them. The challenges that face public health are: to identify


risk factors, increase awareness about mental disorders and the effectiveness of treatment,

remove the stigma associated with mental disorders and receiving treatment for them,

eliminate health disparities, and improve access to mental health services, particularly

among populations that are disproportionately affected (Williams, Chapman, & Lando,

2005).

Research estimates that 20% of people age 55+ have experienced a mental health

concern (American Association of Geriatric Psychiatry, 2008). It has been shown that the

highest rate of suicide in the United States is white men over the age of 85. These men

have a suicide rate of 45.23 per every 100,000, compared to an overall rate of 11.01 per

every 100,000 for all ages combined (Web-based Injury Statistics and Query Reporting

System, n.d). The stigma of being diagnosed or labeled as mentally ill is a barrier that

many people face and have a difficult time understanding. It is important that

professionals within the mental health community realize that the elderly are a population

falling off of the maps.

Due to the lack of services and knowledge among the elderly, many face

hardships that could have been avoidable. “Adults age 50–64 were more likely than

adults age 65 or older to report that they were ‘dissatisfied’ or ‘very dissatisfied’ with

their lives (5.8% compared to 3.5%, respectively)” (Center for Disease Control, 2008).

Dissatisfaction at the end of life is cause for therapeutic implications. This research is

relevant because of the lack of research with the elderly, lack of services provided to

retirement facilities, and lack of services for elderly with already previously diagnosed

mental illnesses.


Purpose of Study

The purpose of this research is to reduce end of life meaninglessness with the aid

of individual and group counseling (mental health services). This research is important

because it is known that as people age, the amount of life meaning decreases. Due to the

fact that life meaning decreases, the elderly face an increase of depression, low self-

esteem, and loss of satisfaction. This research will build on previous research used with

the elderly in group and individual counseling settings and it will allow for more research

to be done using the existential process. Existentialism is necessary with this type of

research because of self-exploration within the concept of meaninglessness. “Victor

Frankl maintained that a human being's most basic and primary motivation is not self-

actualization but finding as much meaning in existence as possible and realizing as much

value as possible” (Das, 1998). This meaning that there should be a greater concern for

one’s most basic and primary motivations, such as meaninglessness at the end of life.

This process will not only explore depression and anxiety, in terms of existentialism, but

it will also shed light on meaninglessness and how to better serve the elderly in the end of

life.

Hypothesis and Research Question(s)

Due to the lack of services for the elderly at the end of life, this research is

determined to answer the follow hypothesis and research questions.

(R1) Do mental health services decrease feelings of meaningless at the end of life?

(H1) Group therapy will decrease feelings of meaninglessness over a 12-week period of

time. (H2) The elderly in individual counseling and group counseling will report an

increase of satisfaction in already established relationships. (H3) The elderly who


participate in individual and group counseling will report an increase in their own sense

meaning of life.

Nature of Study

Existentialism is a counseling theoretical framework that has shown to be best

utilized with the aging population. Existentialism seeks to find meaning in one’s life, and

bring to light the importance of one’s purpose here on earth. “Personal meaning is a

complex achievement of the human spirit and is found in the individual’s confrontation

with the challenges of the world and one’s own being” (Längle, 2004). Understanding

that personal meaning is a complex and challenging part of the human spirit is important

when working with the elderly because of the loss, pain, and confusion that may occur at

the end of life. Embracing existentialism will be the best course of action for the elderly

participating in this research because it will allow for immense growth and personal

exploration, which will create deeper life meanings and will deepen already existing

relationships. “Meaning, from an Existential Analytic and Logotherapeutic context, is

understood as a correlation of two given facts: the demand of the situation; and one’s

understanding of oneself, i.e. what a person thinks and feels in terms of who they are or

should be” (Längle, 2004).

Längle (2004) states that phenomenological and empirical research have revealed

three existential motivations involved with idea of discovering meaning at the end of life.

The first motivation is framed using the following question: “How can one relate to the

fact of being in the world?” (Längle, 2004). This question is imperative to this research

because it addresses how one may have distorted beliefs about where they fit into society

as an elderly individual. The next question is, “How can one relate to the fact of having a


life?” (Längle, 2004). This question is also imperative because this determines what the

individual may deem as their purpose in whatever life may mean to them. Finally, the

third question is, “How can one relate to the fact of one’s own individual identity (self)?”

(Längle, 2004). This question identifies personal flaws one may admit to having about

how they view themselves (self-esteem) in regards to their individual identity. Overall, it

is important to keep these three questions in mind when it comes to using this theoretical

framework with the elderly. As a result, these individuals are seeking greater meaning

within their values and beliefs, and it is necessary to be aware of how they want to live

within these contexts.

“Frankl regarded the will to meaning as an authentic and genuine human

phenomenon and not as a neurotic symptom of unconscious conflicts” (Das, 1998).

“Rather than dismiss the will to meaning as a neurotic phenomenon, Frankl used it as an

important psychotherapeutic principle” (Das, 1998). This basic human need, as stated by

Frankl, is an important principle to understand when working with the elderly because it

is a fundamental foundation to their being at that stage in life. Research from a number of

different disciplines has shown that a sense of meaning or coherence in one’s life is an

important correlate of physical and mental health as well as longevity (Antonovsky,

1979; Borysenko, 1987; Paloutzian, 1996; Pelletier, 1979; Schumaker, 1992; Das, 1998).

This is especially critical when it comes to helping the elderly discover meaning towards

the end of life because of the potential losses and deficits that one individual may be

faced with. In Frankl’s view, the will to find meaning can not only preserve mental and

physical health, but it may be beneficial to an individuals survival of extreme conditions

such as pain, suffering, and grief. “Despite the important role that meaning plays in


people’s lives, few psychologists and counselors have dealt directly with the phenomena

of meaning” (Das, 1998). This has caused a deficit in existential meaning research, which

is why this research is necessary to conduct with the elderly.

Definitions

Elderly is defined as any individual over the age of 65 years old.

Existentialism is a philosophical theory or approach that emphasizes the existence of the

individual person as a free and responsible agent, determining his or her own

development through acts of the will (Existentialism, 2015).

Existential Meaning means finding structure and support in one’s life (Längle, 2004).

Existential Neurosis is a sense of emptiness, meaninglessness, and alienation (Das, 1998).

**It should be noted that if any of the participants do not understand the concepts, then

researchers will explain to them in detail what the definition or term means.

Scope and Delimitations

This study will not involve elderly individuals outside of the one retirement

facility of the researchers choice. What this research is not aiming to do is cause the

individuals who are participating existential neurosis, which is a sense of emptiness,

meaninglessness, and alienation (Das, 1998). This research is not to place less importance

on any other age group; however, these researchers believe that there is a lack of

knowledge and implications of existential therapy with the elderly regarding

meaninglessness. This research is not going to eliminate potential individuals based on

race, gender, sex, previously diagnosed mental illnesses, monetary limitations, or

religious affiliations. This research is not going to examine any potential mental illnesses

that may arise in any of the participating individuals; however, the researchers will


provide services and referrals on an individual basis. The limitations of this research are

that not every race of elderly may be represented within this study. This means that this

study may not be able to be applied to all races, however this study will aim to have as

much variation in race as allowed. The second limitation within this study is the reliance

on self-reporting among the individuals who participate. Without having any way to

verify the information the elderly report, the researchers must be confident in the

responses given to them. Finally, this research will be limited to one retirement facility

over a two-year period, and the research may face loss of participants due to medical

conditions or death.

Summary

Overall, there is an increasingly important need for the elderly to receive services

concerning end of life meaninglessness. With over 72.1 million elderly approaching the

year 2030 the need for such services will be desperate (Administration on Aging, 2011).

Existentialism provides basic fundamental human needs that benefit the elderly and their

journey to decrease end of life meaninglessness. This research will aim to provide

services to 12 men and women over a two-year period of time using Pre and Posttest

measures that will measure depression tendencies among other health related concerns.

This will allow researchers to measure how effective mental health services (Individual

and Group Therapy) are when working with the elderly. Another goal that researchers are

aiming to find is the ability to apply these services to other retirement facilities and how

purposeful these services are.


The next chapter will present a review of empirical and theoretical literature

related to meaninglessness at the end of life, as well as any other factors that may affect

meaninglessness.


Chapter II:

Literature Review

Introduction

The review of this literature is divided into six main sections: Geriatric Services,

Racial and Ethnic Disparities, Global Concerns, Depression, Effectiveness of Group

Counseling, and Meaning. The first section of the literature review will provide an

overview of the types of research that have been conducted around the issues of the

aforementioned sections of this chapter. The second section will discuss geriatric services

that are currently being offered to the elderly, and how effective they are to this

population. The third section will discuss racial and ethnic disparities among the elderly

in regards to mental health services. The fourth section will discuss how depression is a

significant factor in end of life meaningless. The fifth section will discuss the

effectiveness of group counseling with the elderly and why it is necessary when working

with this population, and the final section will discuss the necessity for meaning,

especially existential meaning, at the end of life.

This comprehensive review of literature was conducted using EBSCO:

Educational Research Complete. The key search terms included elderly, existentialism,

humanistic approach, group counseling, effectiveness, meaninglessness, existential

meaning, end of life depression, depression, mental health services, reminiscence,

effectiveness, and geriatric services. Additionally, statistical information was obtained

through government databases, such as the Center for Disease Control and the

Administration on Aging.


Theoretical Foundation

As mentioned in Chapter 1, existentialism is a counseling theoretical framework

that has shown to be best utilized with the elderly population. Existentialism seeks to find

meaning in one’s life, and brings to light the importance of one’s purpose here on earth.

Keeping existentialism in mind, this literature review aims to use existentialism as the

foundation for need. Understanding that personal meaning is a complex and challenging

part of the human spirit is important when working with the elderly because of the loss,

pain, and confusion that may occur at the end of life. This foundation will be important to

the understanding of how underserved the elderly are at the end of life. Embracing

existentialism as the foundation for this literature review will help the reader best

understand the course of action for the elderly participating in this research. This will

allow for immense growth and personal exploration, which will create deeper life

meanings and will deepen already existing relationships.

Empirical Literature Review

Overview

The lack of attention paid to the elderly in society today is astounding.

Researchers believe that elderly with proof of mental disorders are less likely to receive

mental health services, specifically that they are less likely to receive care from a licensed

mental health professional (Karel, Gatz & Smyer, 2012; Ginsberg, 2015). It has been

observed that elderly living in America underuse mental health services for a number of

reasons including, but not limited to, reduced insurance coverage, lack of geriatric

psychologists or geriatric mental health professions, lack of coordination in primary care,

lack of mental health and aging providers, stigma of receiving mental health care, denial


of mental health diagnosis, and access to transportation just to name a few (Bartels,

Blow, Brockmann & Van Citters 2004; Ginsberg, 2015). It is clear that there is a

diminished amount of resources, and agencies providing mental health services to the

elderly. One of the critical needs of the elderly is to bring to light the lack geriatric

services and need to have them.

Geriatric Services

According to Cowan & Cole (2014), the number of elders with mental and

physical health needs currently outweighs the number of professionals capable of caring

for them (Institute of Medicine, 2008; Substance Abuse and Mental Health Services

Administration, 2007). Increasing mental health issues, such as depression and substance

abuse are common amongst the elderly (Cowan & Cole, 2014). Therefore, as a result of

the rapid growth of the geriatric population and their mental health needs, there may be

more individuals within this age group seeking assistance from human service

professionals (therapists or counselors). It is important for human service practitioners to

be prepared to work within this diverse and rapidly growing population in need of

professional services. In preparation for treating the increasing elderly population, one

must develop the cultural knowledge, awareness, and skills to work within a multicultural

discipline. Not only should human service practitioners be trained to be more culturally

competent, but also in utilizing best practices for addressing the unique challenges faced

by this age group (Cowan & Cole, 2014). Having multicultural sensitivity allows for the

counselors to focus on the deeply seeded issues, such as meaning and end of life desires.

The need for geriatric services will increase as the year 2030 approaches, and with that

racial and ethnic disparities will grow too. As human service practitioners the need for


more culturally competent providers is more necessary than years prior.

Overall, to combat issues surrounding the elderly it is important to address the

foundations of care. The elderly are one of the most underserved populations and in

preparing for treating the elderly; therapists must grow and learn to be culturally

competent and aware individuals. Not only should individuals be trained more closely

with expansive worldviews, but they should also be aware of unique challenges that the

elderly face. These unique challenges may range from depression all the way to extreme

substance abuse. There is still much research needed to be completed in order for

researchers to understand the depth of care needed for the elderly.

Racial and Ethnic Disparities

Akincigil, Olfson, Seigel, Zurlo, Walkup & Crystal (2012) first investigated racial

and ethnic disparities in the diagnosis and treatment of depression among community-

dwelling elderly. Depression has become a significant concern for elderly Americans

(Akincigil et al., 2012). It has been estimated that 6.6% of elderly Americans experience

an episode of major depression during a one-year period (Akincigil et al., 2012). If

depression goes untreated or undertreated, especially amongst the elderly, this will

significantly affect quality of life and will increase death rates among this group of

individuals. According to Akincigil and colleagues (2012), several studies during the

1990s identified racial/ethnic differences in the diagnosis and treatment of depression,

both in the general adult population and among the elderly. They found that there was an

overall increase in rates of depression amongst the elderly; however, some of these

studies suggest that these increases cannot be applied to racial/ethnic subgroups

(Akincigil et al., 2012). In contrast, a recent national study suggested that even though


there are overall increases in treatment rates in the 2000s, there was a significant increase

that occurred amongst African Americans, hopefully narrowing the racial/ethnic gap

among elderly adults (Akincigil et al., 2012). Although their are differences, there is

much research still needed regarding racial and ethnic disparities which is an important

health concern for all elderly populations.

Akincigil et al. (2012) performed a secondary analysis of the Medicare Current

Beneficiary Survey data (n = 33,708) for the years 2001 through 2005. It was estimated

that logistic regression models assessed the association of race/ethnicity with the

probability of being diagnosed and treated for depression with either antidepressant

medication or psychotherapy. The results yielded that the depression diagnosis rates were

6.4% for non-Hispanic Whites, 4.2% for African Americans, 7.2% for Hispanics, and

3.8% for others (Akincigil et al., 2012). It is apparent that among the elderly, significant

racial/ethnic differences exist in the diagnosis and treatment of depression. The results

are consistent with the underrecognition and undertreatment of depression among

minority elders (Akincigil et al., 2012). Evidence suggests that stigma, patient attitudes,

and knowledge of care may vary by race and ethnicity, affecting how each patient accepts

or denies diagnosis and treatment. It is clear that there are many factors that play a role

for racial and ethnic disparities among the elderly; however, things such as monetary

factors and communication barriers should not be one of the issues the elderly are still

facing when it comes to receiving care.

However, there are some promising approaches in the near future that will

provide relief for the elderly. This includes providing universal depression screenings and

ensuring access to mental health services in low-income and minority neighborhoods


(Akincigil et al., 2012). It is necessary that researchers infiltrate retirement facilities,

especially in low-income neighborhoods, to implement therapy, which may contribute to

a decrease in depression, and therefore meaninglessness at the end of life. “Continued

surveillance and research documenting racial/ethnic differences in depression diagnosis

and treatment among the elderly is also necessary to evaluate whether progress in

eliminating any disparities continues” (Akincigil et al., 2012, p. 326).

Overall, racial and ethnic disparities are deepening the need for culturally

competent counselors. As the worldviews of counselors begin to change and adapt

towards a more embracing point of view, the help given to the elderly will deeply richen.

By infiltrating retirement facilities, especially in low income neighborhoods around the

world counselors will soon be able to target key concerns that effect the elderly the most.

The above researchers have found that there are promising approaches being developed

and implemented amongst the elderly, however there is still links that research has yet to

form. Meaninglessness at the end of life has become an increasing concern, due to high

suicide rates amongst the elderly, which is why there is a pressing need to complete and

implement this research with future generations. Vigorous clinical and public health

initiatives are needed to address this persisting disparity in care not only in the United

States, but globally as well.

Global Concern

Escolar-Chua & Guzman (2014) have found that with the growing number of

elderly becoming a global concern, many countries have focused on education as a means

of promoting successful aging. Many countries around the world have developed

programs that are aimed at protecting and promoting the elderly and their well being


when it comes to successfully aging (Escolar-Chua & Guzman, 2014). The overall intent

of Escolar-Chua and Guzman’s (2014) experimental study was to assess the effectiveness

of community-based third age learning programs on the life satisfaction, self-esteem, and

level of depression of a select group of Filipino elderly in a community setting. “These

studies further highlighted the health benefits of later-life learning, indicating that these

benefits have much to do with the psychosocial resources senior citizens gain through

third age learning programs, including increased life satisfaction, self-esteem and

confidence, and reduced depression” (Escolar-Chua & Guzman, 2014, p.78).

Sustaining commitment to the elderly and mental health services allows for

mentally stimulating activities, which in turn leads to increased life satisfaction and

successful aging (Escolar-Chua & Guzman, 2014). The results indicate that a variety of

community-based third age learning programs significantly improved the life satisfaction

and self-esteem of the Filipino elderly and reduced their level of depression. This shows

that not only is this an issues in the United States, this is rather a global concern for all

elderly. Similar studies in the Netherlands and Italy revealed similar results. It is

important to note that elderly may experience different levels of meaning at various

points during their aging process, but it is relatively similar to elderly at the same age as

those around the world. Although there is concern for lack of resources, there is also

concern that mental health professionals have yet to tackle the mounting challenges in

front of them.

According to Suri (2010), the 21st century may mark a societal period in which

the needs of the elderly are larger than the resources available (p. 176). One of the

greatest challenges to mental health professionals will be learning how to respond


effectively to the unique concerns and issues of aging (Penick, 2004; Suri, 2010). Suri

(2010) states that there is an importance to research presence and spiritualty when

studying existential meaning. Using three of her patients, Suri (2010) measured how

present, how spiritual, and assessed how much meaning each of these individuals report

having. “It is impossible to be fully present to those who are in the final stage of life,

those who are exploring their spirituality and the meaning of their lives, without

reflecting on one’s own life” (Suri, 2010, p. 183).

This is especially noteworthy for counselors and practitioners to recognize that

patients may cause for self-reflection and countertransference. In working with the

elderly, she has on many occasions been forced to look at her own mortality and her own

feelings of fear, loneliness, anxiety, despair, and joy. She has found that working with

elderly clients has helped her to cultivate her own courage so that she is more willing to

tap into her own humanness and come more fully into a relationship. Existential meaning

may be more important to the counselor client role than previously noted.

Overall, the above research has discovered that decreasing meaninglessness is an

important factor in increasing life satisfaction, however there are many other factors that

are needed in order to successfully decrease end of life meaninglessness. It is important

to note that including spirituality, sexuality, presence, and self-esteem as the key

components to decreasing end of life meaninglessness may have the best chance of

supporting the decrease. By including these four components this may open more doors

for the elderly to open up and accept services. It is important to not limit this research too

narrowly, because it may in fact by missing the largest group of elderly who may benefit

the most from services. It should also be noted that the counselors who aim to target this


population might benefit greatly from counseling services themselves due to the high

level of countertransference possible. Furthermore, elderly may face many challenges to

successfully aging, and finding meaning, which may include sexual and physical

downfalls.

Depression

According to Teixeira, Vasconcelos-Raposo, Fernandes & Brustad (2013), “it has

been suggested that individuals with higher levels of state-anxiety and trait-anxiety

towards the end of life tend to have a higher incidence of depression and anxiety

disorders in comparison to individuals in the normal population (McLean and Woody,

2001, p. 308). The aim of this study was to compare sex, physical activity, academic

qualifications, and the symptomatology of depression among elders. “Recent studies have

revealed a tendency to include physical activity into therapeutic interventions, because it

has beneficial effects in both depression and anxiety” (Teixeira et al., 2013, p. 308).

However, researchers should note that more research needs to be completed and shown to

be consistent, in order to be applied to the elderly population as a whole.

Depression among the elderly is one of the most serious public health problems

that modern societies face (Chapman and Perry, 2008; Teixeira et al., 2013, p. 308).

Within the elderly population, depression is associated with a marked reduction in

cognitive abilities, which, in turn, is commonly accompanied by a decrease in social and

physical activities (Fiske, Wetherell, & Gatz, 2009; Teixeira et al., 2013, p.308). Elderly

who have decreased their social interaction typically have decreased physical activity as a

result of isolation. “Physical activity contributes to the reduction of psychological

distress among the elderly because it promotes psychosocial interaction, improves self-


esteem, helps in the maintenance and improvement of cognitive functions, and serves to

reduce the frequency of relapses of depression and anxiety” (Stella, Gobbi, Corazza &

Costa 2002; Teixeira et al., 2013, p. 309). It is important to note that a link between

being physically active and decreasing end of life meaninglessness is one that has not

been empirically proven. However, it is the aim of this research to implement physical

activity in to group counseling sessions to decrease feelings of loneliness, depression, and

anxiety. A significant correlation was identified between physical activity, depression and

anxiety, and for trait anxiety, however this correlation was not statistically significant.

Group counseling has been shown to combat, and even lower, depression, anxiety and

end of life meaninglessness among elderly. Depression is one of the largest indicators of

end of life meaninglessness, which is why this research aims to identify a link between

the two. It is important to note that group counseling has been shown to decrease

depression amongst the elderly, as well as forging meaningful relationships between

other group members.

Overall, depression is a critical issue that must be addressed amongst the elderly.

Not only is depression one of the largest indicators of end of life meaninglessness, it is

also linked to isolation and loss of relationships amongst the elderly. It is key to combat

isolation and end of life meaninglessness due to the rising suicide rates amongst the

elderly. In order to combat depression among the elderly research seeks to implement

group counseling as a means of intervention. Using group counseling as a means of

intervention with the elderly has been shown to improve relationships, decrease isolation,

increase physical and mental abilities, and decrease end of life meaninglessness; this

revealing why it is crucial to implement group counseling amongst the elderly.


Effectiveness of Group Counseling

According to the American Counseling Association (2015) group counseling,

“allows one to find out that they are not alone in their type of life challenge” (p.1). This

means that group counseling not only increases one’s understanding of the struggles or

concerns one may be having around the topic, but it also provides a variety of possible

solutions available to the individuals who are participating (American Counseling

Association, 2015). Alma, Groothoff, Melis-Dankers, Suurmeijer, & Van der Mei (2013)

conducted a pilot study to determine the effectiveness of a multidisciplinary group

rehabilitation program, Visually Impaired Elderly Persons Participating (VIPP), on

psychosocial functioning. Declining visual function is a highly common problem within

the elderly population. Due to the fact that increasing vision loss has a profound impact

on the elderly, it is important to understand that because of this, the elderly face elevated

emotions and emotional distress, increased risk for depression, reduced mental health and

a decline in life satisfaction, and general well being (Alma et al., 2013).

Furthermore, social functioning might be impacted, due to vision loss, which may

lead to isolation and loneliness, decreasing end of life meaninglessness. However, Alma

et al., (2013) found that group-based programs offer the opportunity for social interaction

that allow the participants to share a range of experiences and coping strategies for both

functional and emotional issues (Rees, Saw, Lamoureux, & Keeffe, 2007; Alma et al.,

2013). It has been shown that elders who have contact with peers on a regular basis are

highly valued by persons who participate in group-based programs and this allows for the

fostering of social support, which seems to be an effective buffer against the negative


effects of vision loss and aging (Burmedi, Becker, Heyl, Wahl & Himmelsbach, 2002;

Alma et al., 2013).

Finally, Gaggioli, Morganti, Bonfiglio, Scaratti, Cipresso, Serino & Riva (2014)

explored the potential benefits of intergenerational reminiscence, involving groups of

seniors and children. According to VandenBos (2006), editor in chief of the American

Psychological Association dictionary, reminiscence therapy is defined as “the use of life

histories - written, oral, or both - to improve psychological well-being” (p.1).

Reminiscence therapy is commonly, and typically used with the elderly population to

combat end of life meaninglessness and depression. Previous research has yielded that

reminiscence may increase general wellbeing in the elderly population in both

spontaneous and structured therapy, such as an intervention (Gaggioli et al., 2014). In

particular, it has been shown that the biggest advantage of reminiscence is an increase in

self-esteem proving to be beneficial in decreasing meaninglessness at the end of life.

Overall, group counseling helps the individual realize that they are not alone in

their struggles. This forges new relationships, creating meaning in the individuals’ life.

The importance of having relationships, platonic or romantic, at the end of life is one of

the foundations in decreasing meaninglessness towards the end of life. Not only does

having relationships at the end of life combat meaninglessness, it also teaches the

individuals new ways to cope with loss or change. Group counseling is important when

dealing with the loss or change amongst the elderly because it links them to a support

system, revealing that they are not alone in their struggles. It is worth noting that the

positive effects of reminiscence group therapy have decreased loneliness and increased


self-esteem, however, there is still a lack of resources to combat end of life

meaninglessness alone.

Meaning

Memory is not just the imprint of the past time upon us; it is the keeper of what is meaningful for our deepest hopes and fears. – Rollo May

(Malette & Oliver, 2006).

Existential meaning is the foundation of one’s being, creating purpose and drive

in one’s life, as well as a basic human need. Existential meaning defined by Längle

(2006) is the ability to find structure and support in one’s life. “Frankl (1988) stated that

there are three sources of meaning, meaningful work or good deeds, authentic encounters

with others, and the attitude one chooses to adopt when faced with an uncontrollable

situation” (Malette & Oliver, 2006, p.33). Without these fundamental sources of meaning

it may be difficult for individuals to love themselves, and others. Malette & Oliver (2006)

suggested that existential meaning and personal growth are strongly and intimately linked

across the lifespan. As one ages, the individual is invited to shift his or her foundations of

meaning, causing one to analyze the pillars of their foundation, specifically around

meaning, when entering the end of life. The importance of end of life meaning cannot be

stressed enough, as this “redefines one’s being-in-the-world by attributing meanings to

the joys, accomplishments, and losses of one’s life” (Malette & Oliver, 2006, p. 31).

Malette & Oliver (2006) focused on three areas of research, retirement, aging, and

existential/personal meaning. The first area was retirement and Jonsson, Borell, and

Sadlo (2000) found that “most of the retirees they studied felt a need to commit

themselves to a regular activity such as sports, reading, volunteering or consulting”

(p.32). Activities that engage the elderly in regular routine-like behaviors provide

stability at the end of life. This is important due to many successes and failures that an


individual may have faced earlier in life. Creating structure and making sure stability and

order is involved in future research is key to best help the elderly.

The second area of research was ageing which, yielded Rowe and Kahn’s (1987)

theory of Successful Ageing (SA), which has generated a significant body of research as

well as much controversy. Malette & Oliver (2006) define SA as involving (a) “the

ability to maintain a low risk of disease and disease-related disability; (b) high mental and

physical functions; and (c) active engagement with life” (Rowe & Kahn, 1998, p.38;

p.32). They put forward that individuals are responsible for their own ageing process, and

that most physical and mental health problems can be avoided by using preventative

measures. Other researchers argued that SA should be all encompassing, including

spirituality, sexuality, and emotional openness. “Aguerre and Bouffard (2003) argued that

there are better means to promote SA: forgiveness towards oneself and the other,

mindfulness-based stress reduction programs and Life Review” (Malette & Oliver 2006,

p.33).

Finally, the study implies a deep knowledge of the self, which allows the

individual to transcend losses and hurts, and to be more fully in the present moment.

Existential meaning, or rather personal meaning, as stated before, is a basic human need.

It was found that personal meaning is a reliable source of happiness, as well as, perceived

well-being. This concept of personal meaning is contingent on how one chooses to live

out the end of their life. This also depends on how one lives, such as independently

living, or within a retirement facility. It is the goal of this research to prove whether

individuals living in a retirement facility experience higher rates perceived happiness

through the forging of relationships.


Sherman, Rybak, Randall, & Davidson, (2011), have previously studied older

adults and found that relationships between meaning in life and depression, anxiety,

hope, and life satisfaction have a major impact on end of life stress. The purpose of this

study was to examine the nature of relationships, specifically if physical and mental heath

and volunteerism can predict meaning in life in the elderly. Sherman et al., (2011)

hypothesized that physical and mental health would be positively associated with

meaning in life. The results yielded that “meaning in life was positively and significantly

associated with self-reported satisfaction with health” (Sherman et al., 2011, p.86). This

supports previous research that a positive relationship between physical health and

decreased meaninglessness.

Overall, meaning is the foundation of why purpose exists in one’s life. Every day

for 50 or 60 years one wakes up, goes to work or to school, has meaningful conversations

and relationships and as soon as one retires things seem to change. Why is it when

someone reaches the age of 65 they get tossed aside and assume that they are happy they

do not have to work any longer? What if that career was the only thing holding them

together? Meaninglessness should not be tossed aside, nor should the elderly be ignored.

Which is the one pattern that has stayed consistent with the elderly, neglect of services.

Not only has meaning shown to be linked to positive life satisfaction, but it has also been

linked to the longevity of happiness at the end of life.

Summary

The above review of the literature provides the framework for this proposal of

decreasing meaninglessness at the end of life with the use of mental health services

(individual and group counseling). The review of literature revealed that the limitations


of this research are that more research on existential meaning in the elderly and mental

health interventions amongst the elderly are needed. There is also a lack of research on

the global concern for the care of the elderly. This proposal will aim to provide a

framework that may be used across the globe to aid the elderly. Another limitation of

current research is that there is a severe lack of resources for the aging elderly population,

which may be a factor as to why Caucasian men over the age of 85 have the most

significant suicide rate here in the United States. Researchers know that depression is a

major factor during the end of life, however a shift is needed to encompass all aspects of

meaning towards the end of life. A key link to shift this research is focusing on all the

factors that one may face during the end of life, which includes meaninglessness, and

how to decrease it. Raising self-esteem and self-efficacy within the elderly is also an

important factor of this research.

Methodologically, despite facing the challenge of death, and other illnesses the

aim of this research is to track a group of willing and participating elderly for two years

on an individual and group-counseling basis. A longitudinal analysis on a small scale will

help the researchers determine whether or not this may be applied to all elderly, hopefully

globally, but first whether or not it may be applied to other cultures. This research builds

off of previous studies in factors being studied, however this study will be unique in its

own rights.


Chapter III:

Methodology

Rationale

This research proposal is aiming to target men and women over the age of 65 to

engage in a psychoeducational group counseling sessions, as well as individual

counseling sessions. As previously stated, by the year 2030 there will be over 70 million

elderly living in the United States alone (Administration on Aging, 2011). The need to

provide mental health services to the elderly is increasingly present in society today.

Specifically targeting retirement facilities and the elders who live among these facilities

is key for the layout of this research proposal.

Geriatric services are at an all time low, with much emphasis on depression

amongst the elderly being the focus; however, the need for further research regarding end

of life meaning is also crucial. Racial and ethnic disparities are also at the forefront of

need in this research, as much research has yet to be done regarding various cultural

populations. Which leads to the need for global care for the elderly as a primary service

versus care after the fact. As individuals age they face many challenges and losses. This

is where the need for mental health services is dire.

Depression is a key component of this research proposal due to the sheer number

of elderly who commit suicide and face depression in the end of their lives. Without

including this factor researchers of this proposal may miss opportunities to help

individuals of the underserved population. Finally, the last two components of this

research deal with effectiveness of group counseling and meaning. Group counseling has

been proven to aid in forging relationships and building continuity in one’s life. It may be


that group counseling is the one thing these individuals have to look forward to in their

week, causing them to find purpose and meaning at the end of life. End of life

meaninglessness is too common and yet nothing is being done on a global and culturally

concerned manner to combat this. In order to lead fulfilling and meaningful lives at the

end of life, it is important that researchers start implementing group counseling for the

elderly.

Demographics

The demographics of individuals who will participate in this research proposal are

any man or woman over the age of 65 living in the retirement facility of the researchers

choosing. Participants will not be selected to participate if living with terminal illness,

such as advanced cancer, or previously diagnosed with a mental illness with a dual

diagnosis. The aim of this research is to target those who may be experiencing depressive

symptoms linked to end of life meaninglessness, who have not been helped or sought

treatment for themselves. As stated previously, this targeted population is extremely

underserved when it comes to mental health services, and with the growing number of

elderly in the United States this research seeks to provide a potential solution to this

problem. The researchers of this proposal will not discriminate on race, religion, or age as

long as they are over the age of 65. Researchers of this proposal want to keep the range of

race and ethnicity in participants open in order to account for a racially and ethnically

diverse sample. Next, the researchers of this proposal will explain the research design and

methodology they plan on using to obtain information for this proposal.

Methodology/Research Design

The research design that will be used in this proposal is a qualitative longitudinal

design. First, by utilizing a longitudinal design there will be ways for the researchers of


this proposal to check for consistency, as well as continuously check for successes and

failures amongst the participants. Second, by utilizing a qualitative study design the

researchers will be able to see any phenomena or patterns that may be occurring among

this particular population. Eventually, this proposal will be implemented in retirement

facilities around the world. With the use of the longitudinal study design researchers of

this proposal will be able to rule whether or not it will be successfully applied to other

cultures effectively. If and only if a variety of cultures are represented in this research

proposal will the researchers be able to assume that the results of this group may be

applied to other cultures around the world. By creating a foundation for other cultures,

this research proposal is aiming to combat end of life meaninglessness for all elders of

different cultures and races. Next, the researchers of this proposal will explain how they

aim to collect their data as well as how they plan to sample the population of this

proposal.

Sampling Procedures & Data Collection

Researchers will conduct pre-group interviews with any participants that will

volunteer for this study. Researchers will use a systematic random sample technique. By

utilizing a systematic random sample researchers will be able to include all the

participants who want to participate in the group with being able to rule out those who

may not qualify. During the pre-group interview the researchers of this proposal will

conduct a mental status exam and gauge whether or not the volunteer would best fit this

research.

The data of this proposal will be collected utilizing a pretest and posttest measure.

This will allow the researchers of this proposal to gauge where the participant(s) may be


in accordance with depression, meaninglessness, and their mental health. Second, the

researchers will be able to rule out any individuals who may be requiring immediate

mental health attention. This will allow for researchers of this proposal to be able to refer

the participant to immediate mental health services, especially those who do not meet the

requirements of this proposal. It is the duty of the counselor to do no harm, and aid in

getting the participants help if needed. The following are research questions and

hypotheses’ that the researchers of this proposal aim to answer.

Research Questions

Due to the lack of services for the elderly at the end of life, this research is

intending to answer the follow hypothesis and research questions.

(R1) Do mental health services decrease feelings of meaningless at the end of life?

(H1) Group therapy will decrease feelings of meaninglessness over a 12-week period of

time. (H2) The elderly in individual counseling and group counseling will report an

increase of satisfaction in already established relationships. (H3) The elderly who

participate in individual and group counseling will report an increase in their own sense

meaning of life. Next, researchers of this proposal will explore ways in which they will

analyze data collected from the participants.

Data Analyses

Researchers plan to analyze the data by inputting the data into SPSS Version 23.

Researchers will assign trait variables to each characteristic being measured.

Meaninglessness will be variable 1, depression will be variable 2, meaningful

relationships will be variable 3, racial and ethnic disparities will be variable 4, geriatric

services satisfaction will be variable number 5, and awareness of global concern will be


variable 6. Once the pre and posttest measures are collected researchers of this proposal

will assign numbers to each participant and their variables, and run a one-way ANOVA

regression analysis of data. Once the data has been computed through SPSS the

researchers will then decide on whether or not the data is statistically viable or not. In the

case of if the data is revealed to not be reliable, researchers will decide whether or not to

run a different statistical analysis of the data. Using the Geriatric Depression Scale (GDS)

researchers will begin to collect data from each of the participating members.

Instruments

This proposal aims to analyze any data collected using the Geriatric Depression

Scale (GDS) created by Sheikh & Yesavage in 1986. While there are many instruments

available to assess depression, the GDS has been tested and used repeatedly with the

older population. Researchers of this proposal are utilizing the GDS short form “as it is

more easily used by physically ill and mildly to moderately demented patients who have

short attention spans and or feel easily fatigued as it takes only between five and seven

minutes to complete” (Greenberg, 2012, p.1). The GDS is not a substitute for other

mental health diagnostic instruments, however it is a useful screening tool in a clinical

setting to assess depression among the elderly when baseline measurements are compared

to subsequent scores (Greenberg, 2012). The GDS does not account for homicidal or

suicidal ideation. The GDS will provide the researchers of this proposal with a baseline

for whether or not the participant is experiencing depression or not.

Validity & Reliability

Overall, the GDS was found to have a 92% sensitivity rate and an 89% specificity

rate when evaluated between other diagnostic data (Greenberg, 2012). The validity and


reliability of the tool have been supported through both clinical practice and research. “In

a validation study comparing the Long and Short Forms of the GDS for self-rating of

symptoms of depression, both were successful in differentiating depressed from non-

depressed adults with a high correlation (r = .84, p < .001)” (Sheikh & Yesavage, 1986;

Greenberg, 2012, p.1). This research aims to utilize the GDS throughout the course of

this study to address depressive symptomology of the participants of this research to

combat any negative effects of individual and group counseling.

Human Subject Concerns/Ethical Procedures

Researchers have a few human subjects and ethical procedures. First, researchers

of this proposal will address ethical principals of the American Psychological Association

(APA). This research will embrace the five foundations of ethical principals, which are:

A. Beneficence and Nonmaleficence, B. Fidelity and Responsibility, C. Integrity, D.

Justice, and E. Respect for People’s rights and Dignity (Gall, Gall & Borg, 2007, p. 78).

Second, researchers of this proposal will follow ethical guidelines that have been listed

by the APA such as: “1. Resolving Ethical Issues, 2. Competence, 3, Human Relations, 4.

Privacy and Confidentiality, 5. Advertising and Other Public Statements, 6. Record

Keeping and Fees, 7. Education and Training, 8. Research and Publication, 9.

Assessment, and 10. Therapy” (Gall et al., 2007, p. 78).

First, researchers of this proposal will analyze potential risks to subjects, in which

these risks will be minimized by using procedures which are consistent with sound

research and which do not unnecessarily expose subjects to risk (Gall et al., 2007).

Whenever appropriate, researchers of this proposal will use procedures already being

performed on the subjects for diagnostic or treatment purposes (Gall et al., 2007). If there


are any risks to participating subjects the risks will be reasonable in relation to anticipated

benefits, if any, to subjects, and the importance of knowledge that may be reasonably be

expected to result (Gall et al., 2007). Researchers of this proposal will provide an

informed consent, which will be sought from each prospective subject or the subject’s

legally authorized representative, and appropriately documented (Gall et al., 2007). When

appropriate, the research plan of this research proposal will make adequate provisions for

monitoring the data collected to ensure safety of subjects, such as locking any data away

in a secure cabinet or computer (Gall et al., 2007).

By utilizing these ethical guidelines and procedures researchers of this proposal

will account for the safety, concern, and wellbeing for the participants of this research. In

the informed consent paperwork, researchers of this proposal will have listed the above

five ethical principals, in which they will follow while conducting this research. If any of

the above ethical procedures and principals are broken, the participants of this research

will have the ability to file a complaint with the Chicago State University Institutional

Review Board (IRB).

Summary

Overall, this research proposal will aim to analyze end of life meaninglessness

among 10 elderly men and women living in one retirement facility. Researchers will

analyze and collect data through the use of the Geriatric Depression Scale, in which the

data will be analyzed using SPSS version 23. A one-way ANOVA regression analysis

will be used when the data is computed into SPSS. Researchers will be aware, and

comply will all human subjects concerns and ethical guidelines. If any concerns or

guidelines are broken throughout this process, these individuals are volunteers and will


have the opportunity to file a complaint, or withdraw from the research without

consequences.


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The Effectiveness of Mental Health Services with the Elderly in Retirement Facilities

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