Special Articles / P. Udhayakumar, Ilango Ponnuswami, Abraham Francis / Scientific Writing and Publishing in Social Work
This paper presents a perspective on the development of knowledge in the spiritual dimension of aging, with particular emphasis on wellbeing. At present, the gerontological literature is drawing attention to the increasing influential role of spirituality in physical and psychological wellbeing of older adults.Spirituality has a significant positive relationship with physical and psychological wellbeing of the older adults. Further, spiritual intervention helps the individuals to recover from psychological distress and death anxiety, as well as from chronic illness.With the rapid growth of older populations worldwide, emerging issues regarding the physical and mental health of older adults requires greater research and clinical attention. The current trend of aging populations suggests the need for greater emphasis on the spiritual wellbeing of older populations. This article addresses the need for health care practitioners to acquire spiritual knowledge and skills in understanding the spiritual needs of older adults during therapeutic processes.
Keywords: Spirituality, Wellbeing and Older Persons
Proponents of holistic health believe that the time has come to give serious consideration to the spiritual dimension. Spiritual health in this context refers to that part of the individual which reaches out and strives for meaning and purpose in life (Park, 1970). Older individuals have spiritual needs to be met as well as spiritual wealthto give (Beran, 2009).Ageing, an issue of global concern, is a product of demographic transition. In 1950, only 8% of the world population was aged 60 years or older; however, by 2005, that proportion had risen to 10%. It is expected to more than double over the next 45 years, reaching 22% in 2050. That is, the number of older persons (aged 60 years or older) will nearly triple in size, increasing from 673 million in 2005 to almost 2 billion by 2050 (United Nations, 2005). Elderly people are regarded as one of the vulnerable populations in the field of nursing. Vulnerable populations are defined as being at risk of poor physical, psychological, and/or social health and thereby require special care and attention. Along with aging, older people experience declining functional status and are likely to have multiple chronic illnesses (Aday, 2000). India, a sub-continent that carries 15 per cent of the world’s population, is gradually undergoing a demographic change as a result of many factors including specific development programs. With decline in fertility and mortality rates accompanied by an improvement in child survival and increased life expectancy, a significant feature of demographic change is the progressive increase in the number of elderly persons (Shankardass, 1995).Ageing is an important part of the spiritual journey and offers opportunity for growth and discovery of self through suffering and loss which can be helped by attention to the creative self. The successful ager in this position is the ageing self who can both negotiate and retain meaning through discovery of self and who can than transcend self. Spirituality is viewed as basic human need which has the potential to promote the quality of life of elderly, whether ill or well. Religion and spirituality are playing an ever-increasing role in the lives of older adults and in their pursuit of physical and psychological wellbeing. Despite the recent growth in gerontological interest in the salutary and supportive benefits of religion and spirituality in the adaptation and coping with the challenges of aging and old age losses, very little of an empirical nature is known about the precise contribution of religion, spirituality and personal meaning to the lives of older adults (Ellison, 1994).The current trend of aging populations suggests the need for greater emphasis on spiritual wellbeing of older population. This paper focuses on spirituality and wellbeing of older persons. This article first introduces aging and chronic illness. Second, the concept of spirituality. Third, addresses spirituality in wellbeing. Forth, the salutary effects of spirituality on the health of the older persons. Finally, discusses about the therapeutic effects of spirituality.
Aging and Chronic Illness
Aging is a universal phenomenon of increasing importance to both developed and developing countries as their older populations increase. Under its impact, long-term care for the elderly has emerged as one of the most important issues throughout the world in the twenty-first century (Lee, 2005).Chronic illness is a frequent experience for older adults. Physical changes of aging do occur and it is how older people live with these changes that is often more important than the physical changes and decrements of aging (Mackinlay, 2008).As age advances, due to deteriorating physiological conditions, the body becomes more prone to illness. The illnesses of the elderly are multiple and chronic in nature. Arthritis, rheumatism, heart problems and high blood pressure are the most prevalent chronic diseases affecting them. Some of the health problems of the elderly can be attributed to social values also. The idea that old age is an age of ailments and physical infirmities is deeply rooted in the Indian mind and many of the sufferings and physical troubles which are curable are accepted as natural and inevitable by the elderly. Regarding the health problems of the elderly of different socioeconomic status, it was found that while the elderly poor largely describe their health problems, on the basis of easily identifiable symptoms, like chest pain, shortness of breath, prolonged cough, breathlessness/ asthma, eye problems, difficulty in movements, tiredness and teeth problems, the upper class elderly, in view of their greater knowledge of illnesses, mentioned blood pressure, heart attacks, and diabetes which are largely diagnosed through clinical examination (Raju, 2002).The leading cause of death in old age in India is cardiovascular disease (CVD). Earlier in life, infections are still the leading causes of death but among older people most deaths are due to non-communicable diseases (Roy, 1994).
Approximately 20% of older adults have a mental illness today, yet only half of older adults who acknowledge such problems receive treatment and only a fraction of those receive specialized mental health services (Dupree et.al., 2005; U.S. Department of Health and Human Services, 1999). Common psychiatric problems which prevail among elders are depression, anxiety, dementia and suicide. Depression is the most common mental health problem of later life, affecting 10–20 per cent of older people (NIMHE, 2005) and up to 40 per cent of care home residents, yet in older people depression is often under-diagnosed and under-treated. Studies suggest that among the elderly, anxiety disorders are more common than are depressive disorders, with prevalence rates of generalized anxiety disorder ranging from about four to twelve percent (Himmelfarb & Murrell, 1984). Acute confusional states, nowadays synonymously called delirium, are frequent and dangerous events in elderly hospitalized patients. Elderly people have a higher risk of completed suicide than any other age group worldwide (WHO, 2001). In an epidemiological study on dementia in India with 2145 randomly selected respondents, the prevalence of dementia in the community was found to be 4.1 per cent and the risk of dementia increases more than five-fold in the oldest old (Saldanha et al., 2010).
Your beliefs become your thoughts; your thoughts become your
words; your words become your actions; your actions become your habits;
your habits become your values; your values become your destiny.
- Mahatma Gandhi
Spirituality is conceptualized as one of the dimensions of a person in the reciprocal interaction worldview (Martsoft & Mickley, 1998). The Oxford English Dictionary defines spiritual as ‘the breath of life which gives life to physical organism’ and is therefore, understood to be a vital principle of human kind. Spirituality is a common human experience that forms an integral part of every person’s search for meaning and purpose in life, suffering and illness (Swinton, 2001; Tanyi, 2002). It is the search for existential meaning and/or for finding answers to life questions such as: Who am I?Why am I here?What does it all mean?andWhat I am supposed to do with my time on Earth? Thus, because of our desire to find meaning, we embark on a spiritual journey (Povilonis, 2001). Jesus described God as spirit (John 4:24). It follows that spirit (often interchangeable with soul in the Bible) is the whole person, the totality of one’s being.It is the outward expression about an intra, inter and transpersonal experience of the inner workings of the human spirit (Reed, 1992; Swinton, 2001). “The inner workings of the human spirit” is presented as an underlying assumption of spirituality. Spirituality is usually observed in individuals’, families,’ and communities’ thoughts, behaviours and languages that are assumed to emanate from their intra, inter and transpersonal experiences with spirit (Swinton, 2001). Spirituality strives to answer deep existential questions pertaining to the meaning of life, suffering, illness and so forth. It helps to recognize the need for human interconnectivity and the desire to transcend the self in meaningful ways and motivates us to choose meaningful relationships (Stoll, 1989; Swinton, 2001).
Aging and the search for meaning
Aging is part of the task of being human. It involves decline and loss. The spiritual journey is bound up with the search of meaning. Spirituality is about constructing meaning. The process of constructing meaning will be shaped by the person’s cultural background, experiences and social conditions in which they live. Spirituality, however, opens up and connects the person to the larger context of life, offers a bigger picture than her/his own personal existence, and as such connects and gives recognition to the individual as having a meaningful human existence in a particular cultural and social context in a particular time and place (Povilonis, 2001).Ageing is an important part of the spiritual journey and offers opportunity for growth and discourage of self through suffering and loss which can be helped by attention to the creative self. The successful ager in this position is the ageing self who can both negotiate and retain meaning through discovery of self and who can than transcend self (Mowat, 2005).The task of old age and its fundamental purpose is therefore to search for meaning through a search for spiritual self. This is what Jung called individuation, Antonovsky called a sense of coherence and Erikson called ego integrity. The search for and maintenance of self can take place through remembrance. The remembrance of self is part of the manifestation of attitude (Frankl, 1984). According to Jernigan (2001) studies on aging process has led to view that “spirituality” is important for older persons’ quality of life, and especially, for helping them live with the losses and limitations as well as the possibilities of their own particular situations. In this view, “spirituality” is important in the lives of older adults as they seek to:
Addressing Spirituality in Wellbeing
Proponents of holistic health believe that the time has come to give serious consideration to the spiritual dimension and to that role this plays in health and disease. Spiritual health in this context refers to that part of the individual which reaches out and strives for meaning and purpose in life. It is the intangible “something” that transcends physiology and psychology. As a relatively new concept, it includes integrity, principles and ethics, the purpose in life, commitment of some higher being and belief in concepts that are not subject to “State of the art” explanation (Park, 1970).
Ai (1999) proposed a new, working definition: “SWB lies at the very core of one’s life-an journey with respect to ultimate concern about the meaning of life and a need for wholeness, transcendence, or enlightenment. Achieving SWB implies a sense of harmony, inner freedom, and peace in relationship to such infinite entity as God, community, nature, the environment, or the cosmos.”Row and Elliott (2009) studied the role of religious activity and spirituality in the health and well-being of older adults and found that existential well-being was strongly related to all outcome health measures. Spiritual wellbeing and prayer contributed to the prediction of psychological wellbeing, subjective well-being, physical symptoms and depression, even when the contributions of age, gender, healthy behaviors and social support were included. Fryback and Reinert (1999)posit that spirituality was an essential component to sense of health and wellbeing. In their study subjects viewed spirituality as a bridge between hopelessness and meaningfulness in life. Spirituality was emphasized as a “core component” of the retreats, which included activities such as meditation, prayer, yoga, relaxation, breathing exercises, visualization, physical exercise, communication skills, social support, and various discussion groups (Kennedy et al., 2002). Fry’s (2000) found that variables of religion and spirituality such as personal meaning, religious involvement, spiritual practices, religious salience, inner peace and religious resources were significant predictors of wellbeing among community-living and institutionalized adults between the ages of 60 and 90. In addition, the effects of these religious and spiritual variables on wellbeing were stronger in the institutionalized sample than in the community sample. Moreover, these variables were better predictors of wellbeing than variables such as physical health, stressful life events and social support.Kirby, Coleman and Daley (2004) reported that spiritual beliefs was a significant predictor of psychological wellbeing among 233 frail and non-frail elders in Britain and moderated the negative effect of frailty on psychological wellbeing. Emery and Pargament (2004) reviewed the literature on links between religious coping and health and wellbeing for elders and found that most elders reported that spirituality/religion were potential resources to cope with the many challenges of late life. First, religion may offer elders a source of personal stability and a source of intimacy and belonging. Second, elders can draw on spiritual support from the Supreme Being of their religious traditions. Third, religious systems of belief can affirm the significance and indeed sacredness, of the individual and life, in spite of social, physical and psychological change and loss. Finally, religion represents a source of power and mastery at a time when elders may feel their own personal powers ebbing.
The conceptual model clearly depicts that spirituality is considered to be as a core component which influences the health status of the older persons. Research in the field of medical sciences have found that elders with physical and psychological discomfort have shown positive results like decrease in level anxiety, depression, stress and improvement in physical and psychological wellbeing after practicing spirituality. The major concern during the old age period is that, most of the elders consider themself that they have lost their meaning in life and their existence in this earth is no more going to be useful to the society and family as well. Hence, the above fact leads to physical and psychological discomfort during the old age period. Besides, regular spiritual practice or being highly spiritual gives the real sense and meaning of one’s life and in turn spirituality helps an individual to identify his inner potential or inner strength. Henceforth, spirituality is considered as a low cast intervention for promoting the wellbeing of the elders (Udhayakumar & Ilango, 2012).
Salutary Effects of Spirituality on Health of the Older Persons
Spirituality plays an important role across all ages. Spirituality has been found to have a positive effect on one’s self-acceptance, personal development, people skills and life goals (Hackney & Sanders, 2003). Tzeng and Yin (2006) discovered that most hospitals which offer hospice care have such services. Many patients have high spiritual needs once they are hospitalized. Spirituality not only affects mental and physical health but also the social wellbeing of an individual (O’Connell & Skevingston, 2005). Suhail and Chaudhry (2004) argue that spirituality gives meaning and purpose and acts as a barrier against negative emotions. However, sometimes medical care providers are unable to fulfill clients’ spiritual needs due to time constraints and workload. Social workers, specifically, must play a role in helping elderly patients deal with health issues, taking spiritual aspects into account. This can be achieved through proper health assessment and holistic intervention (Saad et al., 2010). Mounting evidence has revealed the relationship of spiritual or religious involvement and better mental and physical health in late life (Dwyer et al., 1990; Idler &Kasl, 1997).Religion and spirituality are among the most significant means for coping with the crises and problems of living and dying (Pargament, 1997). Recently researchers have shown mounting interest in the relationships between religious participation, physical and mental health status, and psychological well-being among older adults. Numerous studies have also documented a strong positive relationship between religious involvement and coping behaviors in response to stress and negative life circumstances (Koenig et al., 1989). Udermann (2000) asserted that there is strong scientific evidence that individuals who a) regularly participate in spiritual worship services or related activities and / or b) feel strongly that the presence of a higher being or power is a source of strength and comfort to them are healthier and possess greater healing capabilities than people who do not attend worship services and / or have a strong relationship with a higher being or power.Jang and Kim (2003)investigated the factors which influenced spiritual wellbeing among 382 elders over 65 in Gwangju and Kyungsang, Korea and found that religion, satisfaction of life and physical health significantly influenced spiritual wellbeing. The results showed that spiritual wellbeing was positively related in women; having religious beliefs, especially Protestants or Catholics; participating in religious services; being financially stable, satisfied with life, and having better function of daily life activities, less physical pain or discomfort, better perception of their physical condition, more opportunities for conversation, higher recreational activity and higher satisfaction with social interaction.Individuals who regularly participate in spiritual worship services or related activities and who feel strongly that spirituality or the presence of a higher being or power are sources of strength and comfort to them are healthier and possess greater healing capabilities. Numerous research investigations have reported positive correlations between spirituality and decreased rates of stroke, cancer, cardiovascular disease, hypertension, drug abuse, suicide, and general mortality. It has been suggested that faith is beneficial for health and healing because it helps people avoid unhealthy behaviors such as smoking and excessive drinking. However, studies designed to statistically control for such factors also report positive associations between spirituality and health in individuals with unhealthy behaviors (Udermann, 2000).
Spirituality and Mental Health
Mental health is defined as the capacity of individuals andgroups to interact with one another and the environment in ways thatpromote subjective wellbeing, optimal development, and use of cognitive,affective and relational abilities(Commonwealth Department of Health and Aged Care and Australian Institute ofHealth and Welfare, 1999).Cohen and Koeing (2004) define mental health as not only the freedom from mental disorders such as depression, bipolar disorder and schizophrenia, but also as frequent experiences of positive emotions such as joy, contentment, and peace. Miller and Thoresen (1999) believe that the study of the effect of spirituality on mental health represents a true frontier for psychology. Ellison (1994) provided a conceptual framework to help understand the mechanisms through which religious involvement and spirituality may influence mental health. He suggested that religiousness/ spirituality may (a) reduce the risk of a number of stressors (e.g., antisocial behavior); (b) provide a sense of meaning or coherence that counteracts stress and assists with coping; and (c) provide a network of like-minded persons who can serve as social resources and promote the development of psychological resources, including self-esteem and a sense of personal worth. Kirbyet al., (2004) reported that spiritual beliefs was a significant predictor of psychological well-being among 233 frail and non-frail elders in Britain and moderated the negative effect of frailty on psychological wellbeing. They suggested that spirituality was a resource in maintaining psychological wellbeing and that it was more significant for elders with greater levels of frailty. Blazer (2000) recognised that depression in older adults is a result of a complicated interaction of several factors. There may be biological reasons for this, such as structural changes and psychological reactions to stressors that may make older adults more vulnerable than younger adults to depression. Also, certain social and psychological stressors, such as the loss of a spouse, may also predispose older adults to depression. Conversely, older adults may be less susceptible to depression that younger adults for other reasons, such as greater wisdom and lesser tendency that younger adults exaggerate the impact of negative events. Spirituality might be a means through which stressors experienced by older adults are buffered. Spirituality provides a means to address existential issues and provide a context to form personal meaning. God images or other symbolic representations of the transcendent have the power to evoke emotions, which in turn, influence motivation and behavior (Shafranske, 2009).
Therapeutic Effects of Spirituality
Einstein stated that he could not conceive of a genuine scientist without profound faith (Einstein, 1956). Mehmet Oz, a cardiac transplant surgeon known for his use of complementary therapies in post-surgery, describes multiple case studies in which spirituality was a deciding factor in patient survival (Oz M, 1998). Herbert Benson, a cardiologist and founder of the Mind Body Medical Institute, in Boston, describes similar experiences (Bension, 1978). Robert Gerber, who has proposed a unifying theory for many complementary therapies, states that “A system of medicine which denies or ignores(thespirit) will be incomplete because it leaves out the most fundamental quality of human existence- the spiritual dimension” (Gerber, 2001). Religion and spirituality are among the most significant means for coping with the crises and problems of living and dying (Pargament, 1997; Kaye & Raghavan, 2002). In-depth interviews of older adults in nursing homes and independent living in Australia revealed six categories of spiritual need that provide a basis for assessing opportunities for spiritual growth. These were helping people clarify their centers of ultimate meanings, respond to those meanings through religious and spiritual actions and symbols, find and reframe memories and experiences linked with final meanings, transcend their losses and suffering, establish intimacy with God and others, and find hope (MacKinlay, 2001). Assessing the spirituality of clients may begin casually, but the process deserves to become more systematic. Fortunately, many steps toward such assessments already have been taken by professional people (Ellor, 2003). Whenever spiritual issues emerge as a part of the diagnostic process, appropriate interventions or referrals ought to be provided or brought to the attention of those who need them (Moody, 2005). Examples of this approach include:
Spirituality and Social Work Practice
The Social Work Code of Ethics states: “The primary mission of the social work profession is to enhance human wellbeing and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty”. The term “needs” may imply human needs at different levels or dimensions: material, physical, psychosocial, and spiritual (National Association of Social Workers, 1997).The inclusion of religion and spirituality in social work practice raises concerns about the profession’s ability to address these issues with competence, ethical integrity, and cultural sensitivity (Patel & Amin, 1998). The Council on Social Work Education (CSWE) now recognizes that religion and spirituality are vital parts of the cultural diversity of client and requires that social work curricula on diversity and populations at risk include some content on religion (CSWE, 1994).Suhail & Chaudhry (2004) found that spirituality gives meaning and purpose and acts as a barrier against negative emotions. However, sometimes medical care providers are unable to fulfill clients’ spiritual needs due to time constraints and workload. Hence, it is imperative for other healthcare providers such as nurses and social workers to realize the uniqueness of the spiritual needs of every individual and the ways in which spirituality impacts on behaviors and life style.
Spirituality as a resource for wellbeing is acknowledged by many scholars and clinicians, and numerous empirical findings about their positive influences on health have been found in the western literature. Spirituality, therefore, may become more important for people who approach the end of life. Additionally, as can be seen from the review of spirituality in the previous background section, scholars and clinicians in the field of health care have discussed spirituality, attempted to conceptualize it, and acknowledged that existential concerns will trigger spiritual pain. Thus, spiritual wellbeing is something related to contentment in their life. However, it can be said that the concept of spirituality in Indian literature is still in chaos compared to the literature about spirituality in western countries. Although nowadays, increased numbers of scholars try to conceptualize spirituality, there are no sound research findings and no theory regarding spirituality.It is important to emphasize that effective health care requires a team approach, and that spiritual care forms an important part of this approach, in both prevention and treatment.
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