Introduction
The largest growing section of the American population is the elderly. As a group, those aged 65 and older have increased by a factor of 11, from 3 million in the beginning of the 1900’s to 33 million in 1994 (Hobbs, 2001). In addition the oldest old (85+) are another small but rapidly expanding group making up just over 1% of the American population in 1994 (Hobbs, 2001). Between 1960 and 1994 the oldest old increased a staggering 274 percent making it the largest growing age group in the Nation. Indeed the future population projections see the oldest old age group as continuing to grow. This population group will have a tremendous impact on a number of national issues, including the economy, healthcare, geriatric related services, and will affect the way the American government decides its policies and programs. One simulation model has concluded that the interaction of current demographic, health, and income trends will mean a tripling of the number of elderly individuals needing of nursing home or other care between 1990 and 2030 (Hobbs & Damon, 1996).
The graying of America
One facet that needs further research is the area geriatric psychology. Developmentally, a number of changes take place in old age that directly affects the quality of life experienced by individuals in the later years of life. Recently, much more attention has been paid to the subdiscipline of geriatric psychology. A recent search on google.com displayed 103,000 hits for “geriatric psychology.”
A main feature associated with age and especially old age is that of impending biological decline and death. While a number of researchers disagree on the details of biological decline it is generally accepted that later life brings decreases in height and weight, mobility and muscle mass, bone mass, sensory acuity, cardiovascular and respiratory abilities, central nervous system (CNS) and autonomic nervous system (ANS) structures (Cavanaugh & Blanchard-Fields, 2002). Some changes are minor and unnoticeable, while other may be life changing.
Of particular interest to geriatric psychologists is the loss of neural material in the brain, especially the prefrontal cortex (PFC), and how this affects an individual’s psychological resiliency to other physical and environmental changes specific to aging populations. Changes to the PFC may or may not affect the quality of life of elderly individuals, but researchers have not specifically addressed this issue. One problem is how to determine the construct quality of life. A great deal of recent literature has focused on examining death attitudes/anxieties (Copp, 1998; Depaola, Griffin, Young, & Neimeyer, 2003; Fortner & Neimeyer, 1999; Fry, 1990; Hines, Babrow, Badzek, & Moss, 2001; Ingebretsen & Solem, 1998; Langs, 2003; Martinez de Pison Liebanas, 2002; Neimeyer & Fortner, 1995; Wass & Myers, 1982; Weiler, 2001) in order to determine variables and factors related to the experience of the inevitable final moment. Only one recent paper (Weiler, 2001) analyzes the relationship between perceived quality of life and death attitudes, accounting for personal meaning making as a significant factor. Because death is unavoidably a pan human experience, it may well serve as a point of research interest to determine what factors affect the resiliency of aging adults in experiencing death anxiety and hence be reflective of quality of life.
The future reality the geriatric population will be exposed to will more than likely impact, at least to some degree, the quality of life experienced in the last years of life. An examination of death attitudes and anxiety has already produced preliminary information on some factors that affect the development of anxiety vs. positive attitudes. These studies have invariably looked at age, gender, ethnicity, economics, psychological and physical health, religiosity, and other extravariables. Several studies (Bearon, 1996; Depner & Ingersoll-Dayton, 1988; Ryff & Singer, 1998; Smider, Essex, & Ryff, 1996) have noted the importance of the development and maintenance of close personal social relationships as a noteworthy factor in individuals with positive life evaluations. In addition, the prevalence of adult attachment literature in the psychological realm is truly overwhelming. Most psychologists would not disagree that attachment experiences (Ainsworth, 1989; Ainsworth & Bowlby, 1991; Bowlby, 1988) significantly affect the ability of an individual to make and maintain social relationships. Yet, the present author could find no studies directly linking attachment experiences to death anxieties. If positive attachment experiences tend to foster more stable and long term close supportive social relationships, and if social support structures in old age are negatively correlated with death anxiety, then it would seem that research focusing on attachment of adults and their experience of their own death would be beneficial in determining such a relationship.
This paper evaluates both death attitudes/anxiety studies concerned with the older populations and pertinent adult attachment literature in order to establish a worthwhile stream of inquiry for clinical geropsychologists. Implications for clinical changes and adaptations in other institutions will be offered as a way to improve the quality of life of the aging individuals who will make up a growing percentage of the American population, and face very unique obstacles to their successful aging and dying.
Components of Attachment
Bowlby first explored the relationship of parent-child dyad interactions based on ethological studies. He determined that the close social interactions that occur between children and caregivers have significant impact on the development of social expectations, attitudes and behaviors. This transactional relationship between offspring and caregiver functions on several levels: (1) there is an emotionally significant bond that has basic survival functions, (2) cybernetic systems that reside within the CNS of each partner act to maintain proximity or ready accessibility of the partner to the other, and (3) the systems can only operate if each individual has a “working model” of the others probable behaviors or responses based on past experiences (Bowlby, 1988). Attachments have four essential features, each of which is reflected in the behavioral patterns directed toward the primary attachment figure; proximity maintenance—the continual seeking of physical closeness; safe haven—seeking comfort or safety when needed;, separation distress—displaying overt grief or panic on unexpected or prolonged separations; and secure base— depending on the attachment figure as a base of security from which to explore the environment and other activities not related to attachment (Hazan & Diamond, 2000).
Attachment Development
The formation of attachment generally occurs between the 6th and 8th months of life and typically centers on one individual (Hazan & Diamond, 2000). During infancy and early childhood, children rely on their parents for protection, comfort, and assistance (Bowlby, 1988). They strive to remain in close physical contact, and the accumulation of their interactions helps both the mother and child to better approximate the other’s mental state. How parents respond to their children’s needs affects the specific nature of their attachment and consequently, their social learning about how future interactions will progress.
Infants are equipped with a number of species-characteristic signaling behaviors (i.e. crying) that serve to keep caregivers in very close proximity (Ainsworth, 1989). This proximity-keeping behavior has direct adaptive value since it ensures that parents will tend to the needs of the child. A frightening or stressful situation that produces crying, for instance, will signal the parent’s, and especially the mother’s, protective response mechanisms. Throughout the child’s experiences, gradually they build up “expectations of regularities in what happens to him or her” (Ainsworth, 1989). The consistency of the parent’s responsiveness acts to form the child’s comprehension of how they will be treated in a social environment.
Attachment behavior develops, in one of four ways, based on the consistency and responsiveness of the parents to a child’s needs. Secure attachment develops when parents are consistently available to their children, and are sensitive to their needs. A securely attached child develops a healthy trust that a parent will be around during a frightening or stressful situation (Bowlby, 1988). Because they are confident that their caretaker is protecting and available, they are more likely to explore the surrounding environment, aware that if they get into trouble, they have a safe haven to return to. Being more likely to explore, they will tend to interact with more developmentally appropriate stimulus.
Securely attached children are likely to be described by teachers as “cheerful and cooperative, popular with other children, resilient, and resourceful” (Bowlby, 1988). In addition, they are likely to be relatively indifferent to minimal separations from their mothers and happily greet them upon return (Hetherington & Parke, 1999). Their experience with the social nature of humans is positive and they develop confidence in their ability to navigate the social landscape.
Insecure attachment happens when primary caretakers are inconsistent in their responses to a child’s signals, who are indifferent or distant, who may respond to a child’s request in negative or frustrated ways, or who fails to soothe a child. Insecurely attached children suffer negative social experience and begin to form models that human society functions as they have experienced. Consequently, they are more likely to be described as “emotionally insulated, hostile, or antisocial and as unduly seeking of attention” (Bowlby, 1988). In addition, insecurely attached children may develop inadequate defense mechanisms that confound the relationship between themselves and parents because of their disadvantaged social experiences.
According to a now classic study by Ainsworth, The Strange Situation, children were exposed to a situation where their mothers left and returned twice. The degree of attachment relationship had considerable impacts on the child’s reaction to the situation of the “leavings” and upon the return of their mother. Securely attached children suffered the least amount of stress at being separated from their mothers, showing excitement and warmth upon their subsequent returns (Hetherington & Parke, 1999). In contrast, all the insecurely attached children maintained some degree of dissassociative behaviors directed at the mother for leaving them in strange environments.
Insecurely attached children can be further broken down into three distinct categories: Insecure-avoidant, insecure-resistant, and insecure-disorganized (Hetherington & Parke, 1999). Insecure-avoidant attachment children show little distress when their mothers are gone, and avoid them upon return, sometimes becoming visibly upset. Their past history has taught them that the mother is not concerned with their needs and so they are to be avoided. Insecure-resistant attached children show the opposite behavior, becoming extremely upset when mothers leave, but indifferent upon their return, as if to punish their mother’s for leaving them in the first place. The third type, insecure-disorganized attachment babies display random confusion and disorientation upon their mother’s return, often freezing or repeating their movements, such as rocking or tapping of an appendage (Hetherington & Parke, 1999).
The importance of bond formation between parent and child should not be underestimated because it sets the stage for neurological development in a number of social and cognitive domains. Personality aspects of children are heavily affected by their primary (parental) relationships. If children learn early that the social world is not stable, does not provide them safety, and is often cruel, they will tend to develop personality patterns that both represent this belief and adapt to survive in such a world. Bowlby (1988) believed that there is a strong emphasis of stability and continuity of how an individual’s existing internal experiences will affect the way in which they construe and respond to every new situation. While the extent of this truth has been both challenged and changed over the years, the impact of early social experiences has not been dismissed as a serious factor in the ability of children to develop species-normal behaviors. A child’s first experience of bond formation is not likely to be forgotten, in fact, how well the child forms bonds is a direct measure of how successful they will be as adults in a complex social landscape (Iwaniec & Sneddon, 2001).
Attachment in Adulthood
The ability to maintain and foster close healthy relationships is an integral part of adulthood. Attachment experiences in childhood have been shown to be predictive of the quality and nature of adult relationships in later life (Shaver & Mikulincer, 2002; Sperling & Berman, 1994). Sperling and Berman (1994) succinctly defined adult attachment as
“the stable tendency of an individual to make substantial efforts to seek and maintain proximity to and contact with one or a few specific individuals who provide the subjective potential for physical and/or psychological safety and security . . .[which is] regulated by internal working models of attachment, which are cognitive-affective-motivational schemata built from the individuals experience in his or her interpersonal world” (p.8).
Extant in this definition is the representational models that each individual uses with others in order to predict how they will act towards the individual. Past social relationship interactions build up a working model of how others tend to treat the individual. In addition, it is highly probable that these working models may be (somewhat) self-fulfilling as people tend to select environmental situations that are in line with their beliefs about self and process this information within their existing belief-system (Iwaniec & Sneddon, 2001). While adults may participate in a number of different types of relationships, attachment relationships are typically characterized between an adult and their parents, their children, and close love relationships which include security features (Sperling & Berman, 1994).
A wealth of research supports the existence of both secure and insecure attachment styles in adult romantic relationships (Ainsworth, 1989; Feeney, Noller, & Hanrahan, 1994; Hazan & Diamond, 2000; Hindy & Schwarz, 1994; Levitt, Coffman, Guacci-Franco, & Loveless, 1998; Mikulincer, 1998; Shaver & Mikulincer, 2002; Sperling & Berman, 1994). Other studies have directly linked the quality of attachment with psychological and physical health state (Ainsworth, 1989; Hazan & Diamond, 2000; Ryff & Singer, 1998; Shaver & Mikulincer, 2002). Insecure attachment in adults has been described as “undue jealousy, lack of self-disclosure, feelings of loneliness even during relationships, reluctance to commit in relationships, difficulty in making relationships in new settings, and tendencies to see partners as insufficiently attentive” (Iwaniec & Sneddon, 2001, p. 184). During stressful situations insecurely attached adults may suffer more depression, see their circumstances as deserved or insurmountable, and recoil from the support offered by social relationships.
Because social relationships make up such a significant part of adult life experience, and because individuals have participated in social relationships over the course of their life, the quality of their attachment directly affects the individual’s ability to maintain close, supportive, social relationships in adulthood and old age. In addition, it is hypothesized that adults who are securely attached and thus are able to maintain relationships and utilize their support systems in times of stress will be more likely to overcome obstacles in life and thus have more positive overall perspectives on their life course which will result in less anxiety about death in old age.
Death Anxiety
While death is statistically related to old age, thanatology literature has overwhelmingly centered on death at younger ages, primarily those related to cancer, aids, or traumatic occurrences (Ingebretsen & Solem, 1998). Older people are the most preoccupied with thoughts about death, though they tend to do so with little or no anxiety compared to adolescents or adults (Ingebretsen & Solem, 1998). Yet there is still considerable variance in the level of anxiety experienced by the heterogeneous group labeled elderly. Several researchers have attempted to describe the components of death anxiety in order to develop a basis for theory and ultimately to improve clinical practices with elderly patients.
Death anxiety has only recently been accented in psychological circles and especially so in geriatric focused research. Because of this deficit, Fortner and Neimeyer (1999) constructed a comprehensive quantitative review of death anxiety studies which allowed them to identify seven distinct psychological constructs specifically related to geriatric populations. Death anxiety was found to be related to age, ego integrity, gender, institutionalization, physical health, and religiosity. Higher levels of death anxiety in the elderly were found to be negatively related to ego integrity (r = -.30), and positively related to more physical problems (r = .28) and more psychological problems (r = .19) and may, to some extent, be related to institutionalization (Fortner & Neimeyer, 1999) though this may also be due to loss of self-efficacy and social relationships.
Death anxiety is higher in middle-aged people than in the elderly, but this does not suggest that all elderly have low levels of death anxiety (Depaola et al., 2003). Age comparisons of death anxiety do not seriously help to elucidate what causes death anxiety in older people.
Ego integrity refers to the psychosocial development of integrity versus despair in old age (Hetherington & Parke, 1999). Those individuals who have successfully developed levels of integrity are less prone to death anxiety according to Fortner and Neimeyer (1999). Developmentally, those who have shown greater satisfaction in overcoming life obstacles are naturally more able to deal with difficult situations. In addition, individuals who are satisfied with their life achievement may also be more resistant to death anxiety because they are buffered by positive feelings of meaningful accomplishment.
Differences in death anxiety between male and females have not been consistently shown. For example, some researchers have reasoned that death anxiety is higher in females than males (Neimeyer & Fortner, 1995), but others did not support this view (Fortner & Neimeyer, 1999). The mixed results may be attributed to differences in research design, or operationalization of anxiety, i.e. social experience—associated more with coping strategies of females, or overcoming obstacles—associated more with the coping strategies of males. In addition, different cultural experiences by women and men may significantly affect their access to resources and information, further complicating their experience of death. It seems likely that, globally, women might be more at risk of death anxiety because of the depressed state of freedoms and access to resources in many countries, yet no research conclusively rests this issue.
Being forcibly put into restrictive environments seriously undermines ones self-efficacy and autonomy. Therefore it comes as no surprise that some research studies
(Fortner & Neimeyer, 1999) have found a positive relationship between institutionalization and higher levels of death anxiety. However, the literature is still too vague to make any definitive argument on this issue. Past research has failed on many cases to discuss the difference between voluntary and involuntary commitment to an institution (such as a nursing home). Individuals with higher levels of physical and psychological problems are more often institutionalized which may compound the effects of death anxiety. Loss of bodily control, ability to control one’s environment, or care for one’s self adequately seriously affects autonomy and self-esteem or ego integrity negatively. Clearly, more research is needed before conclusions on these variables can be reached.
Religiosity has produced mixed results as a variable in death anxiety studies. Some researchers found those who are more religious to have lower levels of death anxiety (Neimeyer & Fortner, 1995), while other have not (Fortner & Neimeyer, 1999). The difference in results is most likely due to definitions of religiosity of belief or behaviors, and not to individual faiths. It may also be that the current geriatric cohort is relatively homogeneous in their faith as compared to younger cohorts which have also been included in the studies.
In general, elderly who are independent, have positive levels of ego integrity, and are sufficiently satisfied with their life’s path show lower levels death anxiety than elderly in different situations. On the whole, death anxiety is less in the elderly than other age groups. These results may reflect a closer death experience in the elderly, i.e.—lost loved ones. Socialization between elderly about their shared experiences probably naturally includes more death themed conversations than other age groups. Or, the decrease in overall death anxiety may be related to other personal factors such as difference in coping strategies, personality, or life-span experience. What seems clear though is that protective factors against death anxiety may be related to coping strategies.
Positive Health, Social Relationships, and Quality of Life
In the past, human health has been defined as a lack of physical or mental dysfunctions. This definition is clearly inadequate to account for the complexity of what makes up total human health. According to Ryff and Singer (1998), positive human health (PHH) is a complex philosophical, emotional, mental, and biological interaction of factors that are evaluated in social contexts and support “happiness”. Numerous studies on well-being (Bearon, 1996; Depner & Ingersoll-Dayton, 1988; Diener, Suh, Lucas, & Smith, 1999; Long & Martin, 2000; Shaver & Mikulincer, 2002; Shu, Huang, & Chen, 2003) have reached the same conclusions, namely, that one of the most important influences in the development of PHH, well-being, and life satisfaction is that of maintaining close personal relationships throughout the lifespan. The protective factor of social relationships is so fundamentally ingrained that it extends beyond the human experience, indeed, back into evolutionary history.
The history of life on the planet can only be written in terms of social interaction. Bacteria, the earliest forms of life, demonstrate incredibly complex social behaviors, including foraging for food, protecting resources, and mass communication (Bloom, 2000). When some bacteria colonies exhaust their immediate energy resources, they send out scouts in concentric circles in search of new environments to exploit. Those scouts that find food return to the center of the colony leaving behind a chemical trail that other bacteria will be able to follow. The bacteria who do not find anything of energy value to the colony do not come back, but instead undergo programmed cell death, excusing themselves, and their failure, from the rest of the colony (Bloom, 2000). The evolution of life is wrapped up in this social networking so much so that humans who do not form quality social relationships, those of love and support will not only tend to suffer health problems more often (Ryff & Singer, 1998), but also decrease their overall satisfaction with their own lives (Ainsworth, 1989; Depner & Ingersoll-Dayton, 1988).
Social relationships offer more than just support in times of stress. They have been shown to be affect the development of one’s self concept (Shu et al., 2003). Shu et al. (2003) demonstrated that elderly living in a retirement facility had more positive self concepts if they were more interactive with others. Social relationships also affect the biological functioning of individuals. Ryff and Singer (1998) discussed how a wide variety of stressors in animals (i.e. electric shocks, social defeat, maternal separation, etc.) can alter many different aspects of the immune system. However, the impact of stress on the immune system could not be fully explained in terms of biology, instead, there seems to be a strong correlation between positive social interaction and stressors as a protective function. Social interactions have been shown to affect emotional and personality stability as well (Diener et al., 1999).
The correlation between perceived quality of life and Intimacy (the ability to form close personal relationships) has been explored by Antonucci, Lansford, and Akiyama (2001, as cited in Weiler, 2001). Antonucci et al. found that women who did not have a friend in which to confide were less satisfied with life than those who did and more likely to report depressive symptomology. Weiler (2001) suggests that friendship may also constitute a facilitator of meaning, enabling people to formulate their belief systems and to find meaning in life’s challenges. In the absence of friends, finding meaning in life becomes complicated because the sharing process is non-existent. “Human flourishing, whether in the form of deeply engaged life purposes or richly experienced love relationships, likely affects multiple biological systems” (Ryff & Singer, 1998, p. 9).
Conclusions
Worry about death is perhaps the most universal and fundamental source of threat and anxiety humans may encounter. While younger individuals generally show more anxiety concerning death than older people, older people are closer to the final moment and therefore variables affecting their death anxiety levels may also affect their perceived quality of life. Social relationship competency is a necessary component in the development and maintenance of social support systems throughout life, and especially into old age. Attachment is a requisite for preventing loneliness because early social experiences form the individual’s perception and ability to use social relationships for protective functions (Long & Martin, 2000). Shaver and Mikulincer (2002) argue that attachment level in adulthood is highly correlated to an individual’s ability to use social relationships in times of stress. Considering that aging individuals are exposed to a number of age related stressors, i.e. biological decline, death of loved ones, it is no surprise that considerable attention is given to the role of social relationships in mediating these stressful events.
Death anxiety has been shown to be negatively correlated with close support systems as formed by past attachment experiences (Becker, 1992). Individuals classified as securely attached consistently rely on proximity seeking and social interaction to protect themselves from extreme distress (Shaver & Mikulincer, 2002). Elderly who have had inconsistent attachment experiences in childhood and therefore are insecurely attached, adopt and entirely different strategy for resolving of stressful situations. For example, Shaver and Mikulincer (2002) found that people who scored high on the avoidance-anxiety dimension tend to focus on their own distress, mull over on negative thoughts, and adopt emotion-avoiding coping strategies instead of diminishing the distress. This supports the idea that death anxiety in old age may well be negatively correlated with positive attachment experiences, and that insecurely attached individuals may show greater death anxiety because their coping mechanisms are not centered on the protective nature of social relationships.
A growing percentage of aging individuals will require some type of assisted living. Government and private agencies which develop retirement centers, assisted care facilities, or other elderly communities should consider the importance of social interactions in the design of such facilities so as to increase the opportunities to foster social interactions between their community members if they want to help increase the quality of life experienced by elderly in the last years of life. Currently, many elderly facilities may neglect to emphasize the socialness of their programs because of an insufficient understanding of the role that close personal relationships plays in protecting the elderly from the stresses of biological and social aging. Considering that elderly individuals are more likely to lose those close to them, it is suggested that further research be conducted on the best way to implement social programs in order to provide the elderly with access to a wide social matrix in the hopes of increasing their quality of life in the last years. In addition, increasing education programs for new parents in the formation of attachment may, in the future, increase the overall well being of the general population by increasing the quality and use of social relationships in order to overcome life stressors.
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