Psych 216 Unit Exam 4 Notes

Stages of Dying

Psychological process of dying

• Denial
• Anger
• Bargaining
• Depression
• acceptance

What is Palliative Care

History of Palliative Care

• United Kingdom: Cicely Saunders, St, Christopher's Hospice
• Canada: Balfour Mount, McGill University
• 1970: Elizabeth Kubler-Ross (Switzerland, USA) publishes "on Death & Dying)
• 1973: Balfour Mount (Canada) visits St. Christopher's Hospice in London (UK)
• 1974: Balfour Mount coins the term palliative care
• 1975: the first Canadian Palliative care services start as hospital and homecare services
• 1980s: Palliative care service spreads in Canada
• 2018: the government of Canada publishes palliative care framework

As Defined by Canada's Palliative care Framework

• An approach to care that aims to reduce suffering & improve quality of life for people with life-limiting illnesses through:
• Advance care planning
• Pain & symptom management
• Supporting psychological, social, emotional, spiritual and practical domains
• Supporting caregivers during illness & after death

What is Palliative Care

• Canada was a leader in the early development of a palliative approach to care. Canada’s new framework for palliative care is based on recent consultations with a range of stakeholders, including patients and care providers. It adopts the definition of palliative care used by World Health Organization (WHO).

According to WHO, palliative care:

• Provides relief from pain and other distressing symptoms;
• Affirms life and regards dying as a normal process;
• Intends neither to hasten or postpone death;
• Integrates the psychological and spiritual aspects of care;
• Offers a support system to help persons live as actively as possible until death;
• Offers a support system to help the family cope during the person's illness and in their own bereavement;
• Uses a team approach to address the needs of persons and their families, including bereavement counselling, if indicated;
• Will enhance quality of life, and may also positively influence the course of illness;

Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

New Approach: The bowtie Model

• The bowtie model of palliative care – also created in Canada – gives specific expression to this idea.

In the blue part of the model, you can see a strong focus on biomedical or disease management interventions.

In the orange part of the model, you can see that there is an increasing focus on life with or life beyond advanced illness.

Over the course of an advanced illness, you can see that at first, there is a strong focus on disease management, but as the balance shifts and physical function declines, the focus shifts beyond optimizing physical health toward optimizing relationships, addressing spiritual or existential concerns, and promoting quality of life.

Myths

• You must be dying to receive palliative care
• You must give up treatment to receive palliative care
• Your life will be shorter if you accept palliative care
• Palliative care is only available in hospices and palliative care units

Equity and Palliative Care

Where we can expect to die

• 50% hospital down from 80% in 1994
• 30% long term care
• 15% hospice or palliative care setting
• 10% home & other

Improving palliative care access and equity

• Hospice alone cannot meet the needs
• Better access to palliative care in Canada requires integration into more parts of our healthcare system
• In "a palliative approach" it is recognized that while not every aspect of the palliative care tradition can be integrated into every healthcare service, integrating the appropriate aspect will support access and equity

Palliative approach in long-term care

• Without adaptations to introduce a palliative approach in long-term care, there can be serious access and equity issues.
• For example, most long-term care residents do not receive palliative care even though for many people who move to long-term care, it is their last home, and the time they spend there may be brief, such as less than two years
• <2 years was the average length of stay in long-term care
• 28% of LTC residents had "receiving palliative care " as the reason for admission
• 66% of residents identified as having < 6 months to live did not receive palliative care
• 6,100 residents of long-term were transferred to hospital and died there
• Because many people who rely on long-term care have dementia, one way to improve a palliative approach in long-term care is to introduce new ways of caring that are very well suited to dementia care. One such approach is is Namaste Care.

Namaste care is a group day program tailored for residents who can no longer participate in traditional recreational programming. Joyce Simard, the American social worker who created the program, named it after the Hindu greeting, “namaste”; “I honor the spirit within you”. While today, we might be more cautious about borrowing terminology across cultures, this word summarized the goal of the program more concisely than any other word she knew.

Namaste Care

• is most frequently offered as a group program, intended to run seven days per week, twice per day, for two hours each time.

During Namaste Care, program participants visit a room with soft music or nature sounds, lowered lighting, and pleasant scents. Some aspects of personal care (washing face, hands, and feet; grooming; and nail care) are included to facilitate an experience of gentle, caring touch. Consentaneous hydration and soft, sweet foods are offered to stimulate appetite and raise caloric intake.

• These aspects of Namaste Care align well with recommendations for palliative dementia care, including patient-centred care, continuity of care, optimal symptom management, and psychosocial and spiritual support. Creator Joyce Simard suggests the program also promotes family involvement, communication, and assessment.
• The program has spread globally, and the first two Canadian implementations were in Saskatoon and Hamilton.

SPA-LTC Practice Model

• The “strengthening a palliative approach in long-term care” research team (SPA-LTC; spaltc.ca) has emphasized that a palliative approach includes end of life care, but can start much earlier – as soon as the time of diagnosis with a chronic health condition, such as those we have studied in this class (1). But many people feel a greater need for a palliative approach when their family and healthcare team begin to take more of a role in coordinating support (2). The majority of families who rely on long-term care find a palliative approach resonant with their experience (3), including at the end of life (4).

They discovered there are 4 main models:

1. Reliance on external palliative care specialist
2. Creating hospice care units within LTC
3. Capacity-building within LTC
4. A hybrid model: in house capacity building with external support from palliative care specialists

SPA-LTC’s model falls in the fourth category. It emphasizes continuous quality improvement and capacity building using these and other best practice approaches:

• Introducing an interdisciplinary palliative care champion team means that a palliative approach to care remains a focus of long-term care at every level.
• Implementation of comfort care rounds allows staff to learn from experience, and cope with repeated loss.
• Consultation with palliative care specialists allows long-term care staff to access information about pain and symptom management when they need it, and gradually increases knowledge and skill.

You can see the SPA-LTC practice model on the slide. Approaching it from the outside in:

• The outer pink ring speaks to continual effort to support team capacity building and continued growth.
• The middle white ring highlights the palliative philosophy of attending to body, mind, emotions, and spirit in our own way, by emphasizing pain and symptom management, knowledge and preparedness, good relationships, and quality of life.

In the inner wheel, there are seven elements, and those are the strong practices we emphasize in the practice model. These practices are typically adaptations to existing systems and practices to improve teamwork and communication related to changes in health.

Communicating about Change: Recognizing illness or dying trajectories

• It can be helpful to know that for different health conditions, the months and years leading up to death can feel different. If family and friends have a good understanding of this, it can help them know what to expect, and reduce conflict with each other or the medical system.
• An illness trajectory or dying trajectory graph describes variations in the dying process that vary by duration and shape.
• It is possible, of course, to die suddenly from an unexpected cause, such as an aneurysm or an accident, as shown in the first trajectory.
• It is also possible to experience a steady decline in the terminal phase of an illness such as cancer, as shown in the second trajectory.
• One further possibility is to have a period of advanced illness that is marked by a very slow decline with a series of crises, each one appearing as though it could be the end. This is a common pattern in heart disease (repeated heart attacks), kidney disease (repeated flare-ups), and COPD (repeated infections).

Another Illness Trajectory: Frailty

• Another trajectory has been recognized. The trajectory of frailty is associated with a very gradual decline from a pervious level of health. It can be difficult to know that death is coming because the change is so slow and gradual

Communicating about change

• Another way to understand change is to consider change by hearing people's stories
• In the SPA-LTC "cup of care" podcast series, you can hear 6 x 20 minutes family caregiver stories about how health trajectories and support needs unfold
• While no two families are alike, you may hear some common themes

Planning for changes

• Advance care planning- a way f articulating your values and preferences for future care, whether through conversation or documentation
• Advance directive- legal document that expresses your wishes for future care in the event you can no longer speak for yourself, and usually emphasizes specific types of interventions
• Do not resuscitate order- direct healthcare workers not to resuscitate after a cardiac or pulmonary arrest

A Palliative Approach in Saskatchewan

Prairies hospice

• A hospice-without-walls program in Saskatoon
• Developed by professionals as non-profit community service
• Relies on community volunteerism
• Supports volunteers with training and ongoing support
• Matches volunteers with community members who are dying and works by;
• Supporting individuals where they are located
• Providing a consistent relationship with the same volunteer

Threshold singers

• a compassionate community movement that began in one American State and has since spread elsewhere
• Relies on community volunteerism
• Engages volunteers in singing, with compassion, to people crossing threshold in life, and most particularly, the threshold of dying

How does culture shape death & dying

Death Ethos

• Death ethos refers to a culture's prevailing philosophy of or outlook on death, which can be inferred by:
• Funeral rituals
• Treatment of the dying
• Belief in presence of ghosts
• Belief in afterlife
• Treating death topics as taboo
• Representation of death in the arts

Death Ethos: Historical Perspective

Psychology of Death and Dying

• Death anxiety- worry or fear provoked by thinking about the possibility of death
• Occurs on a spectrum'
• Natural to have some death anxiety
• May ebb and flow
• May be a more common experiences because of the "invisible death" cultural ethos
• Can become severe or clinically significant (thanatophobia) includes:
• Avoidance of things connected with death (e.g., refusal to attend or discuss funerals)
• Preoccupation with preserving health (e.g., clean eating, hydration, exercise), or with testing death (adventure sports, competitions)

Coping with Death Anxiety:

• Living life to the fullest (Yalom)
• Personal reflection / articulating what hasn't yet been allowed
• Death education/ demystifying death

Suggest exercise (Koestenbaum, 1976):

• Write your own obituary
• Plan your death and funeral services

Over the lifespan:

• Young adults- sense of being cheated by death
• Middle-aged adults - begin to confront their own mortality
• Older adults- more accepting of death

Terror Management theory

• Proposes that when thoughts of death are activated, there are benefits
• Health-conscious behaviours
• A focus on living according to core values
• A focus on good relationship

Other theories that are related to terror management theory:

• Awareness of finitude (mortality) is the idea that people become very conscious of death once most same-age peers have died
• Erikson's concept of ego integrity (believing you have lived a good life) becomes increasingly important with age
• Legitimization of biography: thinking through or writing down the story of our life (e.g., memoir)

Bereavement from the biopsychosocial perspective

• Like many things we have studied, bereavement can also be considered from a biopsychosocial perspective.
• Biologically, stress can have effects on physical feelings, such as causing sleeplessness, increased pain, or longer recovery times from illness.
• Psychologically, constant thoughts and feelings about the loss can be associated with sadness and anger, and can also reduce available attention, compromising memory. Sometimes, when people are distracted by grief, they forget cherished moments, which renews grief. It can be important for people to understand that sadness compromises attention, which in turn compromises memory, and that they may very well remember better on a different day.
• Socially, bereavement has many effects socially. It can change your position in your family and community (example: spouse to widow). It can alter your support network (example: couples’ friends to “third wheel” in a group that doesn’t understand your experience). It can also change how much financial strain you have. Many Canadian households rely on a double income, and when that is not available, a change in residence or other kinds of changes may be necessary. This is stressful to navigate alongside grief.

Theories of Grief

• You may be familiar with the popular though unspoken idea that a loss should be ‘worked through’ and that after a year, it should be resolved.
• While the first year can be especially hard, because it is a year of the first time revisiting milestones such as birthdays, anniversaries, holidays, and the date of death, there is nothing else to suggest that 12 months is the magic number. Some cultures have rituals or ceremonies to help the bereaved person to mark grief milestones over time. Other cultures don’t.
• According to attachment theory, those who have the strongest bonds may have the most difficult adjustment, and there is no predictable window of time. Part of the adjustment is exploring how to maintain bonds. Speaking out loud to the deceased, writing letters to the deceased, keeping special objects and clothing, and visiting special places are ways to do this. Even people who were not very spiritual might find themselves doing these things to express their attachment bond. This is healthy and normal. But because few people talk about it, it might seem abnormal to the bereaved person, their friends, or their family members.

Dual Process Model of Grief

• The dual-process model proposes that another path to adjusting to loss is to balance the practical adaptations with the emotional response to the loss. For example, in addition to managing the funeral and burial, or considering what to do with the possessions of the person who has died, a bereaved spouse is called on to take on new household roles.
• Accepting these roles for the first time may increase stress and re-engage the feelings of loss. Yet, over time, as a person becomes more confident and efficacious, they can continue to rebalance their life. There is a balance to be struck between practical tasks, which can increase efficacy and help a person adjust to their “new normal” and allowing time for feelings such as sadness, anger, and stress. It can be a mistake to coach people to “get their feelings out” or have a strong expression of grief, because grief is not once-and-done, and the balance between practical and emotional work is something that helps the bereaved person cope and adjust.

Medical Assistance in Dying

Physician-assisted Suicide and Euthanasia

• Physician-assisted suicide: terminally ill patients make conscious decision to end their lives and receive tools from physicians to do this
• Euthanasia: physician takes action causing patient to die
• Controversial: opponents cite "do not harm" ethical code and potential to treat suicidal dying patients mental health. Advocates cite the importance of quality over quantity of life and personal control over outcomes

History of Medical Assistance in Dying in Canada (Maid)

• Carter v. Canada was a Supreme Court decision that upheld support for physician assisted suicide
• This led to new legislation in Quebec upholding the right to assistance in dying under limited circumstances
• It then also led to new federal legislation
• Bill C-14, legislation on medical assistance in dying, received royal assent on June 17, 2016.
• Gloria Taylor brought a claim before the British Columbia Supreme Court in 2009. Her case challenged the Criminal Code prohibition against euthanasia. Taylor had ALS, which is a fatal neurodegenerative disease that causes progressive muscle weakness. She would lose the ability to use their hands and feet, then the ability to walk, chew, swallow, speak and, eventually, breathe. She did not want to die slowly or painfully, but she knew she would lose the ability to control this as her condition progressed.
• The Supreme Court at the federal level ultimately agreed there were grounds for the claim and gave government a limited time to implement new law. What the law means is that there is now a loophole in which it is not illegal to help someone die under very limited circumstances, which I will show you on the next slide. This also means that it is still illegal to do this outside the allowed circumstances.

What is Medical Assistance in Dying (Maid)

• MAID is when either a physician or a nurse practitioner administers a substance to a person who is requesting this, and the substance causes their death
• OR it can also involve either of these health care professionals prescribing or providing the substance so that the person can self-administer. This is less common, because it is less controllable, and there can be adverse effects, such as poor communication with family or insufficient dose, resulting in significant distress to others.

What terms does MAID replace

• Because hastening death is not always legal (e.g., as in the case of homicide) we need to be as precise as possible in defining the ways that death may be hastened.
• Assisted suicide means intentionally ending one’s own life with the help of another person who provides the knowledge, the means, or both. For example, if a person is suffering a lot because of a terminal illness such as Lou Gehrig's disease or cancer, in some cases, that person may be interested in controlling the end of their life. In most cases, this is done by ingesting substances that cause death. Many people who request assisted suicide would like the help of a doctor to ensure access to the substances, appropriate doses of substances, appropriate substances, and someone to oversee the process. In the case of assisted suicide, the patient is conscious and capable of decision making, and they end their own life.
• Active euthanasia refers to the deliberate ending of someone else’s life. Sometimes, this is based on a clear statement of the person’s wishes and it is very much like assisted suicide, except that the patient is not the one that takes the final step to end his or her own life – they may request that someone else administers the substance that will ultimately cause death. In some cases, in countries where it is legal, a person other than the patient may have the legal authority to make the decision to end the patient’s life. To understand why someone might make this decision on behalf of another person, imagine that the patient has such a severe illness that they are delirious, in and out of consciousness, and in severe pain. Active euthanasia can also mean very directly taking the life of someone else for compassionate reasons.
• Passive euthanasia means allowing a person to die by withholding available treatment. For example, if a person is being provided with measures to support life, such as a respirator, passive euthanasia means withdrawing that support with the knowledge that this will most likely result in death. For example, if a person had been comatose for several months and was being kept alive by life support, his or her family might choose to allow that person to die by asking the hospital to remove life support.

Eligibility for Maid

• It is not a crime for a physician or nurse practitioner to provide medical assistance in dying to a person who is…
• Eligible for publically funded health services in Canada
• At least 18 years of age and independently capable of making health care decisions
• have a grievous and irremediable medical condition
• Made the decision independently, without outside pressure or influence and
• Gave informed consent to the procedure.
• What exactly classifies as a “grievous and irremediable medical condition”?
• It has to be serious and incurable
• In an advanced state of irreversible decline
• Their medical condition causes them enduring physical or psychological suffering
• Their death has to be reasonably foreseeable

Who's not Eligible

Emphasize who is NOT eligible to access MAID:

• People who are not dying (patients could have a grievous and irremediable condition but their death has to be reasonably foreseeable)
• People who are not competent to make the decision, which could be (not in all cases) terminally ill patients with a severe mental illness or cognitive impairment
• People looking to make advance directives (for example, if a patient in the early stages of dementia wishes to seek this service in the later stages and knows they may become unable to consent, they cannot request the service for a later time, since it is unclear if their values will change, and this could be very distressing for them).
• People with family members in control of their health decisions cannot request MAID on someone else’s behalf (Proxies directives are not accepted)
• People under the age of 18, including those who could be deemed a “mature minor”, currently cannot request MAID.
• Some of these situations are expected to be legally challenged. For example, although advance directives are a widely contested issue, proxy decision-makers and decisions made by mature minors are widely used in other healthcare situations.

Implications for Psychologists

• COMPETENCY ASSESSMENTS: Psychologists may be involved in conducting assessments for competency of terminally ill patients; that is, are they capable of making such a significant decision? However, practices may differ across provinces and health care settings.
• PSYCHOTHERAPY: In terms of psychotherapy, psychologists are asked about MAID in counselling and psychotherapy sessions This is especially likely in health and rehabilitation settings. One reason this inquiry is often brought to psychologists rather than other team members is because we typically have longer sessions with clients, and the sessions have a more personal focus. In the context of psychotherapy and counselling, psychologists will be involved in MAID through discussing end-of-life concerns with patients who may be considering a hastened death using these services.
• However, psychologists must be very careful about these conversations, since there is a law against counseling someone to commit suicide (in this case, we interpret “counsel” to mean advise or encourage rather than to have a counselling or psychotherapy session) as well as our ethical standards for respecting the autonomy of persons

To protect clients’ interests, psychologists:

1. Should not provide information about the option of MAID if the client hasn’t requested it.
2. Should not initiate a discussion with the patient about considering MAID.

• Nevertheless, if such a discussion is client-initiated, and done objectively (meaning, neither encourage MAID nor counsel against it), psychologists can participate in the discussion.

Why do People Choose MAID

• PSYCHOLOGISTS’ NEED FOR GUIDANCE IN IDENTIFYING WHERE TO INTERVENE IN SUICIDE INTERVENTION – WHICH FACTORS ARE MODIFIABLE?
• Many terminally ill clients experience a loss of control over their bodies and over their lives. As psychologists, we can try and work to restore their sense of autonomy and dignity as an alternative to MAID.
• Many clients witness the impact their illness has on their loved ones, which causes them great pain. In these cases, alternatives to MAID can include opening discussions with family and identifying social or financial supports that can reduce the sense of burden.
• Palliative care is not always adequate or available for clients. Yet, research shows that if pain and symptoms are treated, a patients’ wishes to hasten death can dissipate. Palliative care and MAID are increasingly valued alternatives in Canada, with citizens advocating for both approaches.
• One study looked at negative stereotypes around aging and found that when elderly people were faced with hypothetical situations of terminal illness and were primed with negative stereotypes, they were more likely to lose their will to live. This suggests that terminally ill clients could also be experiencing implicit coercion, in a sense, from society – to put it bluntly, they may sense that their lives are devalued by others and this may be associated with an increased inclination to hasten death.

Conscientious objection

• Moral Discomfort
• Health care professionals can refuse to provide MAID
• Likely to be the case for some healthcare institutions as a whole (e.g., health organizations operated by religious groups)
• We all have different values. Some professionals have values that align with MAID and others have values that don’t align with MAID. Health care providers have a right to choose to not be involved in these services, without penalty. However, they also have an ethical duty to not abandon a patient/client with different values or experiences than their own. Health providers must ensure that our patients have timely referrals to those better equipped to answer their questions.
• MAID is more likely to be challenging for some healthcare institutions, such as those with religious affiliations. To accommodate both the patient’s and the providers’ values, these settings may arrange timely referrals and transfers.

Theoretical Approaches to the study of optimal aging

• Healthy aging
• Successful aging
• Active aging
• Positive aging
• Narrative approach
• There are five main theoretical approaches to the study of optimal aging: healthy aging, successful aging, active aging, positive aging, and the narrative approach. These theories vary in terms of their emphasis on biology, psychology, and social or physical environment.

1. Healthy Aging

3 broad areas of emphasis:

• Prevention
• Risk management
• Treatment
• Research on healthy aging is just what it might seem to be – research aiming to understand why diseases occur, with the hope of preventing or delaying those diseases. This is thought to be one way to encourage optimal aging.
• For example, studies of dementia have suggested that we can prevent dementia by eating well, exercising, and challenging our minds. At mid-life, we can manage risk factors such as diabetes, high blood pressure, or high cholesterol to avoid dementia. Research continues to explore viable treatments, and we now have medications like Aricept that can prolong memory functioning for a short amount of time.

1. Successful Aging

Rowe & Kahn defined successful aging as

• Absence of disease and disability
• High cognitive and physical functioning
• Engagement with life
• In 1998, John Rowe & Robert Kahn worked on the MacArthur Foundation study of aging in America. Part of their goal was to identify people who were exceeding average outcomes, and so they defined successful aging as the absence of disease and disability, high cognitive and physical functioning, and engagement with life. This has become the most widely used model of optimal or successful aging.
• Although Rowe & Kahn captured some aspects of the essence of successful aging, inspiring a great deal of theory and research on the topic, over time, their definition has been criticized for being overly focused on health, failing to account for the ways that psychological traits (e.g., extraversion, neuroticism) seem to impact our experience of life, and failing to take social factors into account. For example, would it be fair to say an older adult has not been “successful” in aging if social stereotypes or other social factors are what most undermines their quality of life?
• Despite that Rowe & Kahn seem to be identifying meaningful differences among older adults, or things that captivate our curiosity, they have been criticized for being too focused on health or physical aspects of aging, and not enough on psychological or social aspects, much like the healthy aging perspective.

Successful cognitive aging:

• Cognitive performance that is objectively above average for an individual's age group
• " superagers"- individuals 80 and older with superior episodic memory. These adults had cognitive test performances that were not superior to younger adults but were superior to same-age peers. They had a thicker volume of cortex, which suggests both rich experiences and the absence of disease processes. They had unexpectedly high levels of of C-reactive protein. (This is a puzzle, since this is an biomarker of inflammation, and can be associated with heart conditions and other disease conditions at mid-life – in fact, some of these conditions are associated with the later development of dementia.) Another characteristic of cognitive superagers is that they remaining engaged with life, including being involved with family.
• Life expectancy
• Physical health, independence
• Mental health, cognition
• Personal growth/ learning
• Happiness/satisfaction
• Psychological resources ( e.g., autonomy, coping, self-esteem)
• Social participation
• Social support
• Bowling & Dieppe (2005) conducted a review of how the term successful aging was actually being used by researchers in 170 academic papers published before the year 2005.
• They found that researchers had modified the original Rowe & Kahn approach, collectively emphasizing a broad range of concepts including life expectancy, physical health, mental health, personal growth, happiness, and psychological resilience, as well as social support and social participation.
• This review enhanced attention to psychological and social contributors to successful aging but overall showed a continued emphasis on physical wellbeing and cognition.

Older adults:

• Enjoyment of diet
• Physical appearance
• Sense of humour
• Spirituality
• Accomplishments
• Sense of purpose
• Productivity and contribution to life
• Financial security
• neighbourhood

1. Active Aging

Active aging

• " the process of optimizing opportunities for health participation and security in order to enhance quality of life as people age" )World Health Organization)
• The active aging approach emphasizes approaches that encourage and enable people to participate actively in the social, political, and economic life of their communities. Whereas the idea of successful aging places the onus on the individual to have a good experience of aging, this approach calls for social systems to include older adults and thereby optimize the experience of aging.
• It encourages engagement in physical and social activities which are associated with health and wellbeing. It recognizes the advantages of older adults’ participation in communities, including the positive contributions to the economy of older adults who work, volunteer, or provide childcare, and of older adults who spend their pension money.
• You can see that the World Health Organization’s conception of Active Aging includes a heavy emphasis on the world around the individual, including the economy, society, the physical environment, and healthcare. However, personal factors and behavioral choices also play a role in determining active aging

1. Positive aging

• A response to a study of aging that has traditionally emphasized decline
• Emphasizes growth, generativity, and development in the older adult years
• The positive aging movement, which stems from the positive psychology movement, is a a response to a study of aging that has traditionally emphasized problems and decline. Instead, it emphasizes understanding growth, generativity, and development in the older adult years.
• Martin Seligman, the founder of positive psychology, defined it as sub-field of psychology that works to achieve “a scientific understanding and effective interventions to build thriving individuals, families, and communities”
• This figure shows that North American culture’s negative expectations about successful aging do not line up well with a more positive reality.
• We assume that more than half of older adults have any degree of memory impairment, when in fact less than 25% do.
• We assume the loss of driving skills, when in fact only a minority will lose their license.
• We assume living with serious illness is the norm, when in fact this is true for only 1 in 5.
• Many people assume that older adults will not be sexually active, but 4 in 5 are.
• Older adults are also less likely to be depressed, to be lonely, to not feel needed, to have financial difficulties, or to be a burden to others than we anticipate based on cultural stereotypes.
• The positive aging movement recognizes that older adulthood is good for most people and aims to make people more aware of this.

Some conclusion from positive psychology of aging

• Stress and anger decrease after 20
• Worry decreases after 50
• Enjoyment rises after 50
• Exercise make us happier at all ages
• Social support is associated with happiness at all ages
• Older people have more health problems, but fewer problems overall

1. Positive aging & the Paradox of Wellbeing

• The set point perspective maintains that personality determines happiness levels
• The social indicator model considers what social conditions (e.g., wealth/poverty, companionship/bereavement) are associated with better subjective wellbeing
• The paradox of wellbeing is that older adults stay positive despite objectively having more problems than younger adults ( contrary to the predictions of the social indicator model)
• It is well established that, as a group, older adults maintain high subjective wellbeing (high happiness, low sadness, and positive cognitive appraisals of life) despite facing circumstances that are objectively challenging. The paradox of well-being refers to the fact that older adults stay positive despite having more problems than younger adults.
• There is an ongoing effort to understand this phenomenon.
• One theory is that we develop a robust set of coping skills over a lifetime.
• Another theory is that the older adults who survive are better off than those who died earlier, leading to a survival effect.
• A third theory is that these changes are anchored in biology.
• In the ongoing effort to understand the survival effect, Baird and colleagues completed longitudinal research. Remember that this kind of research is the best way to see how individuals change over time.
• They found that life satisfaction increases from mid-life through to approximately age 70, and then begins to decrease, though usually not any more so than at early mid-life. This may mean that adverse circumstances (e.g. under supported health and disabilities, losses, low income) are more disruptive at this stage than earlier in older adulthood.
• The lifespan diamond encapsulates evidence that if people choose to enrich one aspect of life (physical, relational, mental, activity) they will also create positive changes in the others. For example, being psychologically well helps you engage in more relationships, be more active, and eat well. Investing in any one area may pay dividends in all.

1. Life story, Identity and Narratives

• Narratives can serve an adaptive function
• Older adults may embellish their life story to see themselves more favorably over time
• Identity assimilation in later life may protect self-esteem, at least up to a point
• Another theoretical approach to examining people’s experience of aging comes from the narrative tradition. Previously in our course, we discussed Dan McAdams’ and Jennifer Pals’ work on identity at midlife.
• One key question is, in the face of chronic health conditions, living on reduced pension income, and facing the losses of friends and family members over the lifetime, older adults still seem to thrive at exceptional levels, on average.
• According to McAdams, people construct their life story throughout their lifetime, and benefit from constructing a life story that emphasizes achievements and experiences that reflect favorably on their identity. Although not every older adult constructs their story this way, doing so might help them to maintain high levels of wellbeing even when their circumstances have changed in ways that are less desirable.