the effectiveness of mental health services with the elderly in retirement facilities
TRANSCRIPT
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 3
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.
EFFECTIVENESS OF MENTAL HEALTH SERVICES 4
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 5
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 6
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 7
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 8
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.
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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.
EFFECTIVENESS OF MENTAL HEALTH SERVICES 10
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.
EFFECTIVENESS OF MENTAL HEALTH SERVICES 11
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 12
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 13
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 14
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 15
(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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 16
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 17
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 18
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-
EFFECTIVENESS OF MENTAL HEALTH SERVICES 19
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 MENTAL HEALTH SERVICES 20
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 21
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 22
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 23
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.
EFFECTIVENESS OF MENTAL HEALTH SERVICES 24
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 25
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.
EFFECTIVENESS OF MENTAL HEALTH SERVICES 26
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 27
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 28
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 29
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 30
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 31
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 32
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
EFFECTIVENESS OF MENTAL HEALTH SERVICES 33
have the opportunity to file a complaint, or withdraw from the research without
consequences.
EFFECTIVENESS OF MENTAL HEALTH SERVICES 34
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