The efficacy of treatment reminders of life with emphasis on integrative reminiscence on self-esteem and anxiety in widowed old men.

OBJECTIVE: Loss of wife besides the phenomenon of aging could cause some psychological disorders and may shorten the duration of this stage of life. The aim of this study was to examine the efficacy of treatment reminders of life with emphasis on integrative reminiscence on self-esteem and anxiety in widowed old men.
METHOD: This was a clinical trial with pre-test and post-test design with a control group. The study population included All 60 to 80 year old men living in Meshginshahr; among whom, 34 participants were selected using convenience sampling method. They were randomly allocated into two equal groups (experimental and control). The experimental group participated in therapy sessions and the control group did not receive any intervention. The research instruments were Rosenberg Self-Esteem Scale and the General Anxiety Questionnaire. Data were analyzed using multivariable covariance analysis in SSPS-19. Statistical significance was set at P<0.05.
RESULTS: MANCOVA results showed that the treatment positively affected the variables of self-esteem and anxiety in old widowed men (p<0.001).
CONCLUSION: The reminders of life therapy with emphasis on integrative reminiscence may enhance self-esteem and reduce anxiety in widowed old men. This treatment gives better results compared to the traditional treatments and it is recommended to be implemented in nursing homes.

RCT Entities:   Population Interventions Outcomes

Aging is the accumulation of changes in a person over time. Aging in humans refers to a multidimensional process of physical, psychological and social changes. Depression and anxiety are the most important issues in aging; many factors are involved in the emergence and enhancement of aging, including loss of power, purpose in life, physical skills, painful diseases, low social status and financial strength and most importantly feeling lonely due to death of close people, friends or a spouse. Approaching the end of life and death imposes certain pressures on elderly people which most likely increase anxiety due to loneliness and depression in this population (1). According to the researches, death of a spouse incurs the highest trauma and stress to the other spouse (2). The elderly who have lost their spouse feel guilty and become depressed for blaming themselves, because their self-worth is dependent on the past achievements rather than on the future. An old man who has been experiencing management of life along with his spouse, finds himself alone when he losses his spouse. Loss of emotional support paves the way for mental disorders (3). Several studies have noted loneliness in the final years of life as the predisposing factor for contracting mental illness. Sleep disturbances, poor appetite, restlessness, exhaustion, preoccupation, anxiety, inability to meet the routine of life, loss of interest and motivation, irritability and aggression are psychological disorders seen in this group of seniors (4,5). The changes that the seniors are faced with in terms of role reversals, dependency on their children or loss of a spouse can be very difficult to cope with. According to the perceptions of the seniors, they are not useful to anyone in any way and this increases their feeling of worthlessness. Their pillars of existence and the ideas of life in general begin to disappear. Loss is always painful, loss of a spouse, of mobility, health or independence. In such situations, it is no wonder that the senior citizens suffer from low self esteem.

This is a precarious mental situation that may lead to depression and health problems that will prevent them from enjoying life. If there is no support system, the elderly may even turn to alcohol or drug abuse and in severe cases, suicide (2). Undoubtly, the combination of numerous aging issues with the big problem of death greatly boosts loneliness-induced depression and anxiety in the elderly. Medical therapy also reduces merely issues related to physical outcomes of depression and anxiety. Therefore, in recent years, more attention has been paid to cognitive approaches to treat and reduce the outcomes of aging (5,6). Reminisence with emphasis on integrative reminiscence is one of the psychological approaches. Butler (7) proposed life review for the first time. He considers life review as the natural action and general process in which individual calls past experiences, thinks about them and evaluates them and meditates on them with the goal of achieving greater self-knowledge. The therapeutic aspect of life review is to revive these experiences and conflicts, reassess them, resolve them and reach character integrity (8). The purpose of life review is to help people to integrate their life experiences and give a new meaning to their lives by modifing the adaptive property of this treatment. During the life review process, a person expands his own understanding of the history of private life with review of life experiences and re-formatting and cognitive restructurtion of life events that would directly affect his emotions. Thus review of life is essentially a treatment process which leads to the insight and understanding more of oneself with emotional, behavioral and cognitive changes (9). According to Butler, this treatment has two purposes: First, it will help the client to help reduce the cognitive inhibition and emotionally process annoying and unwanted thoughts and emotions related to negative past events (10). Another purpose for life review as Butler put it is to create a situation where the consultant and the client can give new meaning to past experiences so he can sum up his successful experiences of life and reduce his anxiety. In fact, the logic of treatment is that the depressed or anxious person is engaged in a progressing process of assessing the hardships and weaknesses in life and get rid of the anxiety and the constant rumination (11). Integrative reminiscence is also part of the process of life review therapy and in general includes statements that refer to acceptance of one’s past, looking at a person’s past life as a valuable and satisfying course, finding meaning in life, closinge up the distance between reality and ideal, accepting negative events in the past, solving conflicts, and recognizing a continuous pattern between past and present (12). Untreated anxiety can lead to cognitive impairment, disability, poor physical health and a poor quality of life. For older adults, depression often goes along with anxiety, and both can be debilitating, reducing overall health and quality of life. It is important to know the signs of both anxiety and depression and to talk to a physician about any concerns. Anxiety is also strongly linked to the memory. Anxiety can interfere with memory, and significant anxiety can contribute to amnesia or flashbacks of a traumatic event (10). Older adults report more feelings of anxiety than younger adults, but this does not always result in a clinical psychological problem but impacts the quality of life. Indeed, men and older adults may be confronted by a greater number of anxiety provoking events. Older individuals experience unique physical changes and life changing circumstances such as retirement and the death of others. Also, as males’ sexual function is in the high level until the end of life, so it is possible that loss of wife will be along with sexual dissatisfaction for them. This can finally lead to merging of psychological problems. There is a relationship between increasing age, physical activity and self-esteem. As the age increases, the amount of physical activity is reduced and this results in self-esteem reduction (2). This research intends to answer the question of whether reminders of life therapy with emphasis on integrative reminiscence are effective for self-esteem and anxiety of widowed old men.

Material and Methods

This clinical trial study was conducted with pre-test and post-test design and a control group. The study population included all 60 to 80 year old men living in Meshginshahr, Ardabil, Iran who had lost their wives for any reason. From this population, 38 participants were selected using convenience sampling method and were randomly allocated into two equal groups (19 persons in the experimental group and 19 persons in control group). Then the experimental group participated in therapy sessions, but the control group did not receive any intervention. The inclusion criteria were as follows: not having memory impairment; being in the target age range, being a widower and lack of physical and mental chronic diseases. The exclusion criteria were as follows: 3 sessions of absence, having a personal crisis during the intervention (e.g., loss of a significant member of the family), or suffering from a severe physical or psychological disorder. Two participants from the experimental group and 2 participants from the control group were excluded for various reasons, including the absenteeism of more than three sessions, lack of participating in the pre-test, disease and relocation to another city. There were not any nursing homes for old men in the city of Meshginshahr, so the researcher performed the sample selection by referring to the forest park in the city. We studied the medical and psychiatric records of the samples. After selecting the samples, the participants’ information was taken and after specifying a place for meetings, they were invited to attend the meetings.

Finally 17 patients in the experimental group and 17 patients in the control group were settled. The following tools were used for data collection:

Research Tools

1 Rosenberg Self-Esteem Scale: The scale consists of 10 items and is used to measure overall self-esteem. This is a ten-item scale, with items ranging from strongly agree to strongly disagree on a four-point scale. Higher scores on this scale indicate high self-esteem. Rosenberg research results showed that generally this scale has a high reliability. Test retest reliability ranges from 0.82 to 0.88 and its Cranach’s alpha ranges from 0.77 to 0.88 in different studies. Recent studies have shown that its Cronbach’s alpha internal consistency is 0.78. The correlation coefficient of this test with Eysenck self-esteem scale has been reported to be 0.61 (13).

2 Ahvaz General Anxiety: This questionnaire was developed using factor analysis by Najjarian, Attari and Makvandi (14). This questionnaire is a Pencil-paper tool with 27 items with four options of “never”, “rarely”, “sometimes”, “often”, and with the score of zero, one, two and three, respectively. A high score shows high general anxiety. Dabirinejad (15) found its validity to be 0.64 through the correlation of anxiety and aggression scores at the significance level of 0.001 which shows a good reliability. Najarian et al. (14) obtained a Cronbach’s alpha coefficient of 0.90 for the entire male and female participants. Mojtahedzade (16) calculated the reliability coefficient of the questionnaire with Cronbach’s alpha and split half method as 0.83 and 0.71. Dabirinejad (15) determined the reliability of the questionnaire using Cronbach’s alpha and split half methods as 0.93 and 0.90. This showed coefficients for this questionnaire.

Group sessions were conducted by a psychologist, who directed the entire intervention. The treatment program consisted of 6 sessions which was held once a week for an hour due to the physical circumstances of the participants and according to the handbook of interventions (12).

The topics for each session included: 1) Major turning points in life; 2) Family history; 3) Career; 4) History of loves and hates; 5) Stressful experiences; 6) Meaning and purpose of life. Participants were provided a summary of their memories before each session. Because of using integrative reminiscence, the participants interpreted and assessed the subjects with the help of the therapist at the end of each session and tried to find and give meaning to what they had experienced and accept negative past experiences and integrate them into the present life. Each session focused on a specific topic from childhood through old age (remembering where one lived; town/city; games from childhood and youth; popular songs; holidays and special days; the movies over time and remembering grandmothers).

After 6 sessions of intervention for the experimental group, the post-test was performed on both groups. Due to the illiteracy of some of the participants, data were collected orally from them. All assessments were conducted by a Master’s level psychologist who was not the therapist and who was blind to participants’ treatment group. While reminiscence sessions were held, the control group continued to participate in the activities normally imparted at their retirement home. The study was approved, and written informed consent was obtained from each participant prior to the study. We performed a descriptive study of the dependent variables of interest (means and standard deviations). MANCOVA analyses were carried out to determine group differences. Data analysis was performed with the SPSS statistical package (V.19.0) and a 5% a priori Type I error.

Results

The demographic characteristics of the participants are presented in Table 1.

Table 1:

Demographic Characteristics and Comparison of Participant Characteristics before Treatment processing

Characteristics	No. of Subjects	%	Group				P
			Experimental (n = 17)		Control (n = 17)
			N	M±SD	N	M±SD
Age (years)	34	100	17	69.41±5.72	17	70±5.42	0.76
Educational level	34	100					0.153
Illiterate	7	20.59	2		5
Primary school	9	26.48	5		4
Secondary school	6	17.64	3		3
Diploma and higher	12	35.29	7		5
Income per month (rials)	34	100					0.433
<1 million	16	47.05	8		8
1–2 million	13	38.23	7		6
≥ 2 million	5	14.72	2		3
Employment status	34	100					0.351
Retired	9	26.48	4		5
Employed	25	73.52	13		12

The participants were 34 widowers with a mean age of 69.71 (range 60–80) who were randomly allocated into two equal groups of 17. The mean age of the experimental group was 69.41±5.72 years and that of the control group was 70±5.42. Table 2 shows the mean and standard deviation of self-esteem and anxiety variables of the experimental and control groups To measure the equality of variances, data were evaluated with Levine’s Test of Homogeneity of Variance. The results showed that the variances of the experimental and control groups were equal for self-esteem (F = 2.19, p = 0.14) and anxiety (F = 1.79, P = 0.19) were equal. The results showed significant homogeneity using MANCOVA tests including Pillai’s Trace, Wilks’ Lambda, Hotelling’s Trace and Roy’s Largest Root (By controlling the age, education level, income level, employment status variables). Experimental and control groups differ from each other at least in two dependent variables, Therefore Covariance analysis method can be used to analyze the data. MANCOVA results on the variables of self-esteem and anxiety in both control and experimental groups after controlling for the pre-test and confounding variables are presented in Table 3.

Table 2:

Mean and Standard Deviation of Self-Esteem and Anxiety Variables of the Experimental and Control Groups

Variables	Statistical Indexes	Experimental Group		Control Group
		Pre-test	Post-test	Pre-test	Post-test
Self-esteem	Mean	11	22.53	10.24	9.59
	standard deviation	1.37	3.86	1.2	0.87
Anxiety	Mean	55.41	24.71	47.59	45.29
	standard deviation	4.40	3.86	6.67	5.80

Table 3:

MANCOVA Results on the Variables of Self-Esteem and Anxiety in Control and Experimental Groups after Controlling for the Pre-Test

Tests of Between-Subjects Effects
Source	Dependent Variable	Type III Sum of Squares	df	Mean Square	F	Sig.
Group	Post-test of anxiety	3300.748	1	3300.748	187.058	< 0.001
	Post-test of self-esteem	896.801	1	896.801	125.437	< 0.001
Error	Post-test of anxiety	529.368	30	17.646
	Post-test of self-esteem	214.482	30	7.149

As seen demonstrated in Table 3, group has a significant influence after controlling for the impact of pre-test on the post-test scores of self-esteem (F = 125.43, p<0.001) and anxiety (F = 187.05, p<0.001) variables. This analysis shows that the two groups are different in the two investigated variables according to the means presented in Table 2. Furthermore, an increase in self-esteem and a decrease in anxiety scores were observed in the experimental group as compared with the control group.

Discussion

The findings of this study revealed that a reminder of life therapy with emphasis on integrative reminiscence has a positive effect on self-esteem and anxiety in old widowed men.

Our results are consistent with findings of Fujiwara et al. (17), Stinson, Young, Kirk & Walker (18), Chiang et al. (19), Stinson (20), Zhou, He, Gao, Yuan, Feng & Zhang (21). Also, the result of the present study is consistent with that of Huber’s (22) study that reported only 7% of 100 life reviews had negative outputs.

The results of this study suggest that the reminders of life therapy with emphasis on integrative reminiscence have a positive effect on self-esteem in old widowed men. During the group sessions, the participants were stimulated to recall life events and to interact with others. The activity encouraged participants to share acquired life philosophy and earlier memories of historic and personal events which shaped their lives, and thus promoted a sense of identity and a positive contribution to the next generation, and reaffirmed the meaning of their lives. In addition, reminiscence group therapy provided the participants with an opportunity to enhance their interactions within and outside the group. By expressing emotions and feeling fully supported, participants experienced catharsis. At the end of the session, participants reflected on their contributions to the group and to their loved ones. The supportive atmosphere of this group created a sense of “togetherness”, of being accepted and being a valued group member. This cohesiveness may have contributed to the participants’ feelings of being significant to those around them, including their families and other participants. These factors are related to self-esteem and may have contributed to its improvement. The findings are in accordance with previous studies (23,24,25).

Reminders of life therapy with emphasis on integrative reminiscence focused on the uniqueness of the elderly life cycle. In this treatment, the clients are well aware of the content of their lives and they do not need to learn new skills. Also, inviting the elderly to talk about their past is an appealing activity. When they become aware of the positive point in their life and their inner strengths with the help of the consultant, the process of self-respect and personal and social values are shaped and their self-esteem increases. Aging will significantly reduce the influence of elders in the family or nurseries; thus, their self-esteem decreases. It increases their anxiety due to being left alone and inattention from family and the community day by day. Reminders of life and reminiscence give an opportunity to individual to feel they control the story of their life. The feeling of control leads to an increase in self-esteem and a decrease in depression. Bryant, Smart, and King (26) believe that the development of insight and the present and past mental imagery are factors that will cause positive emotions and reduce anxiety. They also suggest that reminiscence helps the elderly to put together scattered parts of their life that have been torn apart over time due to tolerance of ordeals and hardships of life and reach a unified understanding of self and their age conditions. Another purpose of life review as Butler notes, is to create a situation where the consultant and the client can give new meaning to past experiences so he can sum up his successful experiences of life and reduce anxiety. In fact, the logic of treatment is that the depressed or anxious person is engaged in a progressing process of assessing the hardships and weaknesses in life and get rid of anxiety and constant rumination. An appropriate treatment of the overall life review is considered when the client is faced with a problem because its purpose is to enhance the adjustment of individual with life changes and reduce anxiety as a result (11).

Korte et al (27) and Meléndez-Moral et al. (28) believe that recounting personal identity is very effective in raising self-esteem. It should be noted that the change in attitude and self-acceptance as a result of attention to past and present and raising awareness can lead to enhanced self-esteem. Reviewing many past events helps the person to put aside styles of thinking and behavior that leads to reduced social relations and low self-esteem during the time and achieve the ability to mitigate the negative feelings toward themselves and others (29). Cull (30) argues that people who listen to other people’s biography and memories are affected by this process, because they can communicate with those who have had similar experiences and can discover events and important relationships in their own life. Reminiscence, life review and recall are involved in enhancing individual’s self-confidence and cause a positive sense of self-identity in individuals. It can be valuable in resolving the unsolved problems and their negative memories. During the reminiscence, individuals evaluate positive and negative experiences in the past by restoration of their life story, and this reduces their anxiety and increases their self-esteem (31).

There were some limitations to the current study. The study was conducted in one geographical area of the city and the sample size was small. Therefore, the generalizability of the results to other elderly populations is limited.

Other limitations of this study can be mentioned as lack of generalization of this therapy to other communities, the convenient sampling method, small sample size, and including only men, lack of follow up for re-evaluation, and lack of information to control for other covariates (medication, co morbidities, other support system, etc.). This intervention is highly recommended as a cost effective, independent and convenient intervention at all the nursing homes and even in private houses. Furthermore, information regarding how to approach the elderly can be shared with the family as part of the intangible process of treatment in families. Another suggestion is that treatment be performed on other variables the elderly are involved with.