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RESEARCH THESIS IN SUBMISSION FOR THE AWARD OFDOCTOR OF PHILOSOPHY TITLE: WELL-BEING AND OLDER PEOPLE: A QUALITATIVE INVESTIGATION INTO THE CONCEPT OF WELL-BEING AS INFORMED BY THE PERSO

RESEARCH THESIS IN SUBMISSION FOR THE AWARD OF

DOCTOR OF PHILOSOPHY

TITLE:

WELL-BEING AND OLDER PEOPLE:

A QUALITATIVE INVESTIGATION INTO THE CONCEPT OF WELL-BEING

AS INFORMED BY THE PERSONAL PERSPECTIVES OF OLDER PEOPLE DRAWN FROM CLINICAL AND NON-CLINICAL POPULATIONS.

AUTHOR:

ANDREW PAPADOPOULOS BSc (HONS), MSc, C.Psychol.

INSTITUTE OF GERONTOLOGY KING’S COLLEGE LONDON UNIVERSITY OF LONDON.

SEPTEMBER 2008

TO: JENNY.

MY APPRECIATION FOR A SHARED JOURNEY

AND FOR YOUR SUPPORT, ENCOURAGEMENT AND GUIDANCE

THROUGHOUT, WITH LOVE

The term Well-Being is widely used in health and social care Yet there is

to-date, no consensual definition of well-being apparent in the literature

Theoretical formulations of well-being have been grounded within a wide variety of frameworks, models and perspectives of human existence with insufficient attention having been given towards the development of a model

or theory of well-being informed by the perspectives and opinions of older people themselves

In addition, research clearly shows that ethnicity and mental health have important contributions to our understanding of well-being, but have rarely been considered together in well-being research

Accordingly, the following research sought to investigate whether a concept ofwell-being is evident from the personal perspectives of older people drawn from clinical, non-clinical and ethnic minority populations

Grounded Theory was identified as the principal method for this investigation

and for reasons of Triangulation, three sources of data were chosen:

i) An analysis of ten clinical case files involving former patients who had

received psychological treatment for a range of psychological

difficulties

ii) A non-clinical population of older people drawn from the Thousand

Elders Project – University of Birmingham.

iii) A smaller non-clinical population of older people drawn from an

African-Caribbean Community Centre in Birmingham

Data was analysed using a Grounded Theory approach with respect to the interview samples with a purely thematic analysis to analyse the data from theclinical cases

Results:

Six overarching themes emerged namely: Integrity of Self, Integrity of

Other, Belonging, Agency, Enrichment and Security Each theme was

considered as reflecting a distinctive property of well-being and each having

three psychological dimensions: Subjective; Behavioural and Contextual

Each dimension was further divided in terms of reflecting either positive or

negative connotation (cc Table 26 p188 “A Proposed Structural Model of

Well-Being”)

A second level of analysis of all codes was undertaken in order to explore

whether operational relationships or meanings existed between codes This

level of analysis intended to reflect how the structural properties and

dimensions identified might work together in the day-to-day lives of

individuals Eight Themes or psychological Styles were identified which were

then aligned into four Typological dimensions namely: Self-assured vs Insecure, Something vs Nothing, Giver vs Martyr, Receiver vs

Dependant (cc Figure 4 p213 “A proposed operational model of

well-being”)

It is proposed that the psychological styles Self-assured vs Insecure and

Something vs Nothing reflect a single axis of psychological Self (one which

is congruous with several existing psychological models of the self) whilst

Giver vs Martyr and Receiver vs Dependant reflect a single axis of

Management of Self (that is, the way in which individuals manage challenges and threats to one’s core Self in terms of the nature of relationships people

form with each other)

It was concluded that firstly; the models taken together appear to offer a unique construct and understanding of well-being in terms of the current literature, but one which aligns itself more with Eco-systemic rather than Bio-medical, Eudemonic or Existential perspectives Secondly; that together, the models offer a framework for understanding both the structure and

operalisation of well-being in the context of older people Thirdly that the models offer a basis for integrating research on Psychological Well-Being and Quality of Life research in Older People

B) Jenny LaFontaine, Consultant Nurse; Dr Sarah Willott, Clinical

Psychologist; Dr Rachel Spector, Clinical Psychologist, Vercella Phillips and

my other colleagues at Birmingham and Solihull Mental Health NHS Trust for additional academic advice and support with independent script analysis.C) Teresa Morton, Birmingham and Solihull Mental Health NHS Trust; Valerie Madill, Age Concern, Kingstanding, Birmingham; Dr Laxman Nayak, Centre for Applied Gerontology, University of Birmingham; Deska Howe, African-Caribbean Resource Centre, West Bromwich, Birmingham, for their help, support and facilitation in enabling me to contact those older people who agreed to participate in the research

D) Professor David De La Horne and Martin Preston, Directors of Psychology,Birmingham and Solihull Mental Health NHS Trust, for their agreement for me

to have time and support towards the completion of the PhD

E) To all those older people with whom I have had the privilege and pleasure

to have known and worked with throughout my professional career and to whom I owe much by way of my knowledge and understanding of late- life psychology

F) To my family and friends for their encouragement and support In particular,

to my Wife Jenny, for her help and tolerance during some very difficult times.G) Finally, I owe particular gratitude to all those people who gave their

consent and time to participate in the research

The term Well-Being has been widely used to both inform and determine

health and social policy, care and treatment and the evaluation of intervention systems as applied to older people Yet there is to-date, no consensual

definition of well-being apparent in the literature

It is concluded, from the literature review, that theoretical formulations of being, have been grounded within a wide variety of theoretical models and perspectives of human existence with insufficient attention having been given towards the development of a model or theory of well-being informed by the perspectives and opinions of older people themselves

well-Where well-being indices have been used within the context of oriented research, such indices have varied widely (e.g across health,

outcome-psychological and existential dimensions) and have often been used

interchangeably with similar indices denoting Quality of Life and Life

Satisfaction

In addition, research clearly shows that ethnicity and mental health have important contributions to our understanding of well-being, but have rarely been considered together in well-being research

If the term is used both as a basis for informing policy and provision to older people and as a criteria for evaluating intervention outcomes, there is an ethical obligation to ensure that the term reflects a valid (evidence-base) foundation for defining and describing parameters of human existence

In addition, both the term itself and the way it has been used, has been largelyconstructed and informed from the perspectives of professionals and

academics

There is a methodological imperative, therefore, to investigate whether a concept of well-being can be identified from the perspectives of older people themselves In the absence of any evidence for such a construct then,

arguably, the term remains assumptive

Accordingly, the following research has sought to investigate whether a

concept of well-being is evident from the personal perspectives of older

people

Specifically, the research asks:

“Do the personal narratives of older people, as reflected in clinical, clinical and ethnic minority populations, provide a meaningful

non-framework for a construct of well-being specific to late life?

Principal Aims of the Research:

 To critically evaluate the available literature on well-being in relation to its use, definition and research methodology and to develop a

reasoned methodology for the current research

 To explore how older people, drawn from clinical, non-clinical and ethnic minority populations, construct well-being as derived from an analysis of the results

 To consider how this construction of well-being compares and

contrasts with those in the literature and to develop a theoretical model

of well-being based upon it

 To critically evaluate the methodology, results and theoretical

constructions developed within the current research with a view to providing reasoned directions for future research and to discuss the implications for policy and provision in the care of older people

Methodology:

Given the aims of the research and that it focuses upon the lived experiences

of participants, Grounded Theory was identified as the principal and most appropriate method for this investigation

Procedure:

For the purposes of Triangulation, three sources of data were chosen

The first, involved an analysis of the case notes of ten clinical cases involving patients with a range of psychological difficulties who had undergone a course

of psychological treatment but who had been discharged prior to the research

The third source of data, involved interviewing a smaller non-clinical

population of older people drawn from an African-Caribbean Community

Centre in Birmingham (Ethnic Minority Sample).

A series of open questions were developed and formulated as a

semi-structured interview procedure and piloted with a small sample of older

people

The data from these pilot interviews were analysed for content and richness ofinformation The interview procedure, together with the original questions, wasrevised accordingly

The revised protocol was then used to interview the Non-Clinical and Ethnic Minority Samples sample In addition, it was used to inform the analysis of theClinical Sample

Analysis:

Data drawn from the case files (Clinical Sample) was analysed using

Thematic Analysis This data was secondary and incorporated clinical terms and procedures within its content The analysis of each case was used to inform the analysis of each subsequent case

Data drawn directly from the interviews (Non-Clinical and Ethnic Minority Samples) was analysed using a Grounded Theory approach

Results:

Firstly:

Six overarching themes emerged and were defined in terms of their

relationship with the data, namely: Integrity of Self, Integrity of Other,

Belonging, Agency, Enrichment and Security (cc Table 26 p188 “A

Proposed Structural Model of Well-Being”)

Each theme was conceptualised as reflecting a distinctive property of

Well-Being and as consisting of three psychological dimensions: Subjective; Behavioural and Contextual Each dimension was further conceptualised as

having either positive or negative connotations according to the way in which respective codes were aligned

No specific themes differentiated the three data sources suggesting that the model is representative of the views of all older people in the sample

Discriminative characteristics were identified between the clinical and clinical samples only at a dimensional level.

non-Secondly:

A second level of analysis of all codes was undertaken in order to explore whether additional relationships or meanings existed between codes; i.e

those reflecting the way in which Well-Being is operationalised or applied in

the day-to-day lives of the research participants

Eight Themes or Psychological Styles were identified which were then aligned

into four Typological dimensions namely: Self-assured vs Insecure,

Something vs Nothing, Giver vs Martyr, and Receiver vs Dependant Identifying the structural source of codes for each dimension (from Table 26

p188) revealed that Self-assured vs Insecure and Something vs Nothing

reflected codes drawn primarily from the property Integrity of Self, whilst Giver

vs Martyr and Receiver vs Dependant, were drawn mainly from properties

Integrity of other and Belonging respectively It is proposed that the

psychological styles Self-assured vs Insecure and Something vs Nothing

reflect a single axis of psychological Self (one which is congruous with

several existing psychological models of the self) whilst Giver vs Martyr and

Receiver vs Dependant reflect a single axis of Management of Self (that is,

the way in which individuals manage challenges and threats to one’s core

Self in terms of the nature of relationships people form with each other cc

Figure 4 p213).

Identifying the percentage of codes denoted for each psychological style by

each data set, it can be shown that for the Clinical Sample, the greatest proportion of codes prioritise Insecure, Nothing, Martyr and Dependant, whilst for the Ethnic Minority Sample, the greatest proportion of codes prioritise Self-

assured, Something, Giver and Receiver The Non-Clinical Sample codes

prioritised Giver with the others falling between the Clinical and Ethnic

Minority, codes (cc Figure 4a p214) It is proposed that the Ethnic Minority

Sample experience the greatest level of well-being with the Clinical Sample experiencing the least and that well-being within the Ethnic Minority Sample ismainly drawn from their supportive and affirming relationships with family, friends and their faith, and the interests they pursue both individually and within their close community

Poor well-being as reflected within the Clinical Sample appears related to a history of difficult relationships and poor self-concept where managing threats

to one’s core self is mediated via relationships that involve either dependency

or martyrdom or a dynamic interplay between the two

The Non-Clinical Sample appear to comprise individuals who whilst neither having a strong sense of self nor being ontologically insecure manage their self by primarily giving to others

In terms of the principal aims of the study, it was concluded firstly; that the

models taken together appear to offer a unique construct and understanding

of Well-Being in terms of the current literature, but one that aligns itself more with an Eco-systemic perspective rather than Bio-medical, Eudemonic or

Existential perspectives as described in the literature review Secondly, that

together, the models offer a framework for understanding both the structure

and operalisation of well-being in the context of older people Thirdly; that the

models offer a basis for integrating research on Psychological Well-Being and Quality of Life research in Older People

The results are discussed in the light of the literature review and regarding directions for further research

INTRODUCTION 15

LITERATURE REVIEW 20

SECTION 1) THEORETICAL PERSPECTIVES ON WELL-BEING 23

i) BIO-MEDICAL PERSPECTIVES ON WELL-BEING 23

ii) PSYCHOLOGICAL PERSPECTIVES ON WELL-BEING 26 iii) EUDEMONIC PERSPECTIVES ON WELL-BEING 35 iv) EXISTENTIAL PERSPECTIVES ON WELL-BEING 39

SUMMARY AND REFLECTIONS 45

SECTION 2) FACTORS INFLUENCING THEORETICAL PERSPECTIVES ON WELL-BEING 48 i) WELL-BEING AND QUALITY OF LIFE 48 ii) WELL-BEING AND MENTAL HEALTH 53 iii) WELL-BEING AND ETHNICITY 56

SUMMARY AND REFLECTIONS 62

CONCLUSIONS 64 RATIONALE AND AIMS OF PRESENT STUDY 67

METHODOLOGY 69

 METHODOLOGICAL APPROACH 69  DESIGN 72  SOURCES OF DATA 76  PROCEDURE: 81 1 ETHICAL CONSIDERATIONS 81 2 PILOT PHASE 81 3 MAIN STUDY 84 A) Clinical Case Studies 84

B) Non-Clinical Sample 85

C) Ethnic Minority Sample 86

4 PROCEDURE FOR THE ANALYSIS OF DATA SETS 87 5 SOFTWARE 96 6 SELF IN ROLE 97 RESULTS AND ANALYSIS 102

 SUMMARY 103

 THE CLINICAL SAMPLE 113  THE NON-CLINICAL SAMPLE 130  THE ETHNIC MINORITY SAMPLE 152  INTEGRATING THEMES: A STRUCTURAL AND OPERATIONAL MODEL OF WELL-BEING 176

2 Prospective participant information sheet 284

3 Participant consent forms (I, ii, iii) 389

5 Letter of approval: King’s College Research Ethics Committee 398

6 A personal perspective on the research 399

7 Kings College Schedule for the assessment of Well-Being (first draft) 405

8 Well-Being intervention programme (first draft) 411

LIST of TABLES

1 CLINICAL SAMPLE Derived Codes vs Frequency of Occurrence in

Sample

Appendix 414

2 CLINICAL SAMPLE Convergent codes identified by independent

assessor (A01 to A03) denoted as “Y” Appendix 416

3 CLINICAL SAMPLE Description of Codes as Derived from the Case

4 CLINICAL SAMPLE Allocation of Meanings against Codes 121

5 CLINICAL SAMPLE Constructed Themes with Associated Codes 123

6 CLINICAL SAMPLE Description of Identified Themes with example

narrative segments drawn from associated Codes for each Theme

Appendix 280

7 CLINICAL SAMPLE Organisation of Identified Codes with

Associated Narratives Grouped within Subjective, Behavioural and Contextual Meanings for Respective Properties:

124

8 NON-CLINICAL SAMPLE Derived Codes vs Frequency of Occurrence in

Sample

Appendix 417 8a NON-CLINICAL SAMPLE Identified sub-codes for “Contented life”

Appendix 421

9 NON-CLINICAL SAMPLE Convergent codes identified by independent

assessor

Appendix 422

10 NON-CLINICAL SAMPLE Number of Scripts(Documents) Containing

Individual Codes

Appendix 424

11 NON-CLINICAL SAMPLE Identified Codes from Clinical (Case Study)

Sample Post-Treatment Compared with Codes from Non-Clinical Sample and Pre-Treatment

Appendix 426

12 NON-CLINICAL SAMPLE Description of Codes as Derived from the

Scripts (documents) quotations

136

13 NON-CLINICAL SAMPLE Allocation of Meanings against Code 139

14 NON-CLINICAL SAMPLE Identified Themes with Associated Codes 143

15 NON-CLINICAL SAMPLE Description of Identified Themes with example

narrative segments drawn from associated Codes for each Theme

Appendix 286

16 NON-CLINICAL SAMPLE Organisation of Identified Codes with

Associated Narratives Grouped within Subjective, Behavioural and Contextual Meanings for Respective Properties:

146

17 ETHNIC MINORITY SAMPLE Derived Codes vs Frequency in Sample Appendix

428 17a ETHNIC MINORITY SAMPLE Identified sub-codes for “Contented life” Appendix

431

18 ETHNIC MINORITY SAMPLE Convergent codes identified

by independent assessor

Appendix 433

19 ETHNIC MINORITY SAMPLE Number of scripts containing

Individual codes Appendix 436

20 ETHNIC MINORITY SAMPLE Description of codes as derived from

associated quotations across all scripts

158

21 ETHNIC MINORITY SAMPLE Allocation of Meanings against Codes 162

22 ETHNIC MINORITY SAMPLE Identified Themes with Associated Codes and

Frequency of Occurrence across all Scripts

166

23 ETHNIC MINORITY SAMPLE Description of identified Themes with example

narrative segments drawn from associated codes for each Theme

Appendix 339

24 ETHNIC MINORITY SAMPLE Organisation of Identified Codes with

Associated Narratives Grouped within Subjective, Behavioural and Contextual Meanings for Respective Properties:

170

25 INTEGRATING PERSPECTIVES Relationship between codes from Clinical

Sample with those from Non-Clinical and Ethnic-Minority Samples

182

26 INTEGRATING PERSPECTIVES Organisation of Identified Themes with

Associated Narratives and codes across Dimensions for Respective Properties:

PROPOSED STRUCTURAL MODEL of BEING

188

27 INTEGRATING PERSPECTIVES Organisation of Identified Themes with

Associated Narratives across Dimensions for Respective Properties: PROPOSED STRUCTURAL MODEL of WELL-BEING

194

28 INTEGRATING PERSPECTIVES Categorisation of all codes according to

Psychological Type

200

29 INTEGRATING PERSPECTIVES Psychological Types: Definitions constructed

from supporting codes

206

30 INTEGRATING PERSPECTIVES Frequency of Occurrence of Codes Located

Within Respective Well-Being Properties

208

31 INTEGRATING PERSPECTIVES Frequency of codes falling within each

Psychological Type for all data samples

210

32 INTEGRATING PERSPECTIVES Percentage of Codes Derived from Associated

Data Sets for Psychological Type

212

FIGURES

EXAMPLES DRAWN FROM DATA SAMPLES

214

In the series of Reith Lectures entitled “The end of Age” (BBC Radio 4, May 2001), Professor Thomas Kirkwood highlights a change in thinking amongst academics surrounding biological ageing The traditional construction that biological ageing was a programmed process facilitating eventual death has been abandoned for the contemporary notion that humans are biologically programmed for indefinite survival

He goes on to argue, that this contemporary view of ageing creates new challenges for both individuals and societies Firstly, the most notable

challenge concerns both the freedom to make choices and the nature of choices available in determining our futures Secondly, the need to draw uponand integrate wider disciplines in the field of gerontology Thirdly, to explicitly re-think our existing conceptions of healthy ageing from the traditional focus

on illness and functional ability alone, to include the broader perspective of

Well-Being where quality of life, life satisfaction and meaningful existence are

essential components

However, whilst the concept of well-being has attracted a wide range of

disciplines from philosophy (dating back to the early Greeks) to economics, it nevertheless remains an amorphous concept that lacks any agreed

theoretical framework (Bowling, 2001)

According to Honderich (1995), well-being embodies our ideas about what constitutes human happiness and the sort of life that it is good to live

Accordingly, well-being is considered to be both a condition of the good life and what the good life achieves However, the notion of a good life can be further delineated between that which relates to leading a moral life (reflectingAristotle’s notion of Eudemonia) and a life in which comfort and enjoyment reflect a large part (Hedonism)

In the context of psychological research on well-being, Ryan and Deci (2001) suggest that both Eudemonic and Hedonic approaches account for the

majority of research in this field:

A) Hedonic:

Within a Hedonic perspective, well-being consists of subjective happiness, pleasure and avoidance of pain as experienced within various life domains

Broadly constructed, a Hedonic approach is concerned with life satisfaction as

measured or considered in emotional terms (Diener and Suh, 2005)

Keyes, 1995) or that of Bright on Wholeness in later life (1997).

In a similar manner to the Hedonic approach, well-being from a Eudemonic perspective appears to have dimensional qualities but where such dimensionsreflect the extent to which one may have achieved a potential rather than the degree of emotional valence that is held surrounding a particular life domain.These perspectives, which may reflect several disciplines, tend primarily to becharacterized by attempts to unify both subjective (experiential) and objective (behavioural/observed) correlates of people’s lives under one or more

descriptive meta-construct

However, some authors have argued against the distinction between what is

essentially good and what is enjoyable suggesting that both are necessary

pre-requisites of being (Honderich, 1995) According to this view,

well-being is a concept that spans both the moral and non-moral aspects of life; reflecting a complex interplay of both In addition, this view suggests that given well-being cannot be enjoyed by individuals living in conditions of

poverty and oppression, it follows therefore that well-being has a political dimension

Accordingly, the challenge facing health and social policy in the context of older people is identifying both the conditions of well-being that are

meaningful to older people themselves and the political arrangements and mechanisms which will facilitate it The question of the distribution of well-being is, according to Honderich (1995), essentially a matter of social justice

In 2004, the Government of the United Kingdom produced a well-being

manifesto (Jackson, 2004) The manifesto itself is grounded within a model of well-being that consists of two psychological dimensions of well-being and a contextual dimension of well-being:

1) Life Satisfaction:

Diener et al (2005) suggests that life satisfaction encompasses a broad

category of phenomena including emotional responses, domain–specific satisfaction and more global judgments of life satisfaction The concept of life satisfaction has been widely used within the literature on well-being both as a

basis for defining well-being (Diener et al 1999) and as an index of

psychological well-being in itself (e.g Goff 1993; Chow & Chi 1999; McColl et

al 1999; Hillerås et al 2000; Lundgren et al 2000).

2) Personal development:

The concept of personal development encompasses the components of thosemultidimensional models of well-being that are arguably grounded within a Eudemonic perspective, which considers well-being as a set or

conglomeration of potentialities As denoted above, these may be identified ashierarchical needs e.g as denoted in Maslow’s Theory of Motivation (1970) or

as dimensions reflecting: autonomy, purpose in life, self-esteem and the notion that life has meaning e.g as denoted in Ryff’s multidimensional model

of well-being (1989) or that of Bright (1997)

3) Social well-being:

This contextual component is based on Keyes’s classification of social being that identifies a sense of belonging to community, social contribution, engagement in pro-social behaviour and a positive view of society (Keyes, 1998)

well-Reviewing the research in this area, Marks and Shah (2005) denote that whilst life satisfaction is inversely related to mental health difficulties including depression, personal development appears to be strongly linked to overall health, longevity, resilience and the ability to cope with adverse

circumstances

Many of the components of well-being encompassed by life satisfaction and Eudemonic perspectives parallel those identified as quality of life indicators within quality of life research For example, Gabriel and Bowling (2004)

explored quality of life indicators in older people as part of the Economic and Social Research Council (ESRC) Growing Older Programme The authors suggest that from the perspectives of older people themselves, quality of life isabout:

 Having good social relationships;

 Help and support when needed;

 Living in a home and neighbourhood which is perceived to give pleasure, security and access to local facilities and services;

 Engaging in hobbies/interests and leisure activities;

 Having a social role and maintaining social activities;

 Having a positive psychological outlook and being able to accept circumstances which cannot be changed;

 Having good health and mobility;

 Financial security and sufficiency to meet basic needs and enjoy life

 Retaining one’s independence and control over one’s life.

Not surprisingly some would suggest that quality of life and well-being appear

to be synonymous constructs relating to the physical, the material, the social, the emotional and the developmental (Felce and Perry 1995) Others would

argue that well-being reflects the subjective experience and evaluation of one’s life, whilst quality of life reflects the objective context or domain (and

way of living or relating within that context) from which well-being is derived

well-2 There is no agreement as to how well-being should be measured.

3 Objective indicators of well-being used in the research only allow for group and individual comparisons to be made Idiosyncratic variation and understanding of well-being cannot be made using objective indicators alone.

4 Similarly, subjective indicators of well-being will provide

measures of the level of well-being experienced by an individual but may not indicate why this level may be high or low.

5 Psychological well-being uses concepts and indicators in relation

to self-esteem, resilience, coping etc Such indicators also relate

to mental health and therefore could provide a strategic direction regarding what is needed and how, in order to facilitate positive mental health.

6 In the context of research, simply asking a single question about well-being is open to bias and prejudicial assumptions.

Given the issues raised by Hird, one might conclude that policies and services

to older people that are based upon an assumptive construct, is unethical

If a construct of well-being is to be used as a basis for informing policy and provision, then such a construct needs to be evidenced from the perspective

of older people themselves

Accordingly, the principal question that the current research will seek to

The following search engines were primarily used in this research:

Medline, ProQuest, PsyClic

Other sources of literature reviews included:

Centre for Policy on Ageing-New literature on old age

Ageing and Society

Ageing and Mental Health

The Gerontologist

British Journal of Clinical Psychology

LITERATURE REVIEW

Contemporary literature on well-being, in the context of older people, reflects

a broad spectrum of perspectives principally drawn from Philosophy,

Psychology, Medicine, Theology and Social Gerontology

The scope of the following literature review is to identify, consolidate and critique the ways in which well-being has been described and studied and to thereby provide a rationale for the current research

Critique of denoted perspectives is undertaken based on:

A) Their relevance in reflecting the experiences, views and circumstances of

older people

B) The adequacy of identified indices of well-being, drawn from these

perspectives, as predictors of the impact and adjustment of older people to the challenges they face

Section 1) explores the theoretical frameworks that have underpinned

research on well-being and older people

The first framework explores well-being from a bio-medical perspective and

evaluates its relevancy and ethical implications as applied to the

circumstances and experiences of older people

The second framework draws upon studies, informed from Psychological

perspectives, which investigate how the properties and dimensions (as

denoted indices) of well-being influence the challenges and adjustment to these challenges, faced by older people This section is further divided into two sub-sections The former, focuses upon studies deploying objective correlates of psychological functioning; informed from a predominantly

Positivist (physical science) perspective The latter, focuses upon studies

deploying subjective correlates; informed from a predominantly Humanistic

perspective

The third framework considers well-being from a Eudemonic perspective

Having its origins in Aristotle’s Nicomachean Ethics (Honderich 1995), this approach considers well-being as grounded in happiness and what it means

to live a good life Accordingly, descriptions and models of well-being

reflecting this perspective tend to identify and integrate subjective,

behavioural and/or contextual domains of human existence under one or more meta-constructs

The fourth framework investigates well-being from an Existential perspective

This approach, grounded in Existential Philosophy (Reker and Chamberlain 2000), also concerns itself with the wider perspective of human existence However, here well-being is considered under the central tenant of a

meaningful life, rather than as reflecting a happy life or a good life As a

theoretical framework, it defines both the dimensions and properties of

meaning and denotes the life domains from which individuals derive meaning.

Accordingly, this perspective is considered to be one which seeks to integrate and arguably unify perspectives two and three above It will also be discussed

as a basis for comparison in the light of the results from the current research

Section 2) explores well-being research and older people in the contexts of

quality of life, mental health and ethnicity, where these factors have been

shown to both influence theoretical perspectives on well-being and inform policy and service provision to older people

The first part explores the use of well-being in the context of Quality of Life

research and considers whether well-being and quality of life are

synonymous

The second part explores the research on ethnicity and well-being It suggests

that whilst racial identity per-se is not a factor in predicting subjective

well-being, ethnicity informs the meanings individuals may hold or construct

surrounding indices of subjective well-being No such relationship appears to

be particularly evident within the literature on gender and well-being in older people

The third part explores the research on mental health and well-being and

considers the importance of drawing upon the perspectives of older people who experience mental health problems

Accordingly, it is argued that both ethnicity and mental health requires

representation within well-being research

The concluding section provides an overview regarding the way in which being has been described and studied in the literature and seeks to

well-consolidate critical appraisals of the research as a basis for providing a

rationale to the present study

SECTION 1) THEORETICAL PERSPECTIVES ON WELL-BEING

i) Bio-Medical Perspectives on Well-Being

Well-being in the context of biomedicine is traditionally considered to reflect the presence or absence of illness symptoms or functional disability (Sidell 1995) in medical, psychiatric and neurological modalities Indeed, within this framework, the construction of successful ageing has been used as a basis for defining in part, well-being (Rowe & Kahn 1987, 1997)

One of several models of successful ageing, Rowe and Kahn define

successful ageing in the context of their model as the ability to maintain:

i) Low risk of disease and disease-related disability through

adopting a healthier lifestyle

ii) High mental and physical functioning

iii) Active engagement in life

Whilst having received much criticism in terms of not considering the many possible patterns of ageing that older people experience and that the model

can be seen as having a Eurocentric value base (Ouwenhand et al 2007), it

has been extensively used as an evaluation tool for exploring the effects of intervention systems and health promotion programmes on older people

What can be described as the health-related paradigm of well-being (Sidell

1995), has dominated and arguably continues to dominate Health Policy, practice and research in Western culture since post industrialization

Historically, this perspective developed prominence in the Western culture

during the Enlightenment at the end of the 18th century Often termed as

Modernism, this period was characterised by value and power given to three

major features:

 Reason over ignorance

 Order over disorder

 Science over superstition

Informed largely by positivist thinking and research, modernism arguably gave

birth to the pathologising of illness and disability (Tarnas 1996)

However, contemporary “Post-Modernist” conceptions of the bio-medical

perspective seek to broaden the scope of its definition and meaning from

simply one pertaining to illness and functional disability, to the inclusion of social adjustment, competency and quality of life (Katz and Peberdy 1997) Bury (1982) argues that a principal advantage of a health-centred formulation

of well-being is that it objectifies illness and disability and thus separates it from the self Bury goes on to suggest that this division has a social function

It enables the social legitimization of illness behaviour and abdicates

responsibility for the condition and often its remediation, from the individual.Yet this model has received much criticism during the past 20 years

particularly with respect to its legitimacy for informing the provision of health care to older people and those with chronic illnesses

As a facet of the care delivered to those with chronic illnesses, Bury (1982) asserts that by definition, since medicine cannot cure chronic illness, the ultimate responsibility for managing the condition is often placed upon the individual sufferer

In relation to older people specifically, a model of well-being that is solely grounded within the dimensions of illness, disability and competence, is

incongruous with the perspectives of older people themselves and arguably may serve as a basis for reinforcing ageist stereotypes, identities and care practices in some contexts (Bytheway, 2005; Biggs, 2004; Sidell, 1995)

Informed from a social constructionist perspective, Harding and Palfrey (1997)

argue that many chronic illnesses, such as the Dementias, are predominantly socially constructed in such a way as to provide society with a legitimate basisfor disempowering and controlling such individuals Care practices informed

from social constructions are thus considered as performative acts or simply

socially sanctioned modes of behaviour intended to establish conformity

In addition, a bio-medical perspective on well-being has a different

connotation for older people that younger people Several studies have shownthat older people per se, consider such health related indices of well-being as

a means to an end, in terms of accessibility to quality of life activities, rather

than an end in them selves (Nesbitt & Heidrich, 2000) As Asberg et al

(1990) point out, health can never be the ‘goal’ of life but it is an important means for achieving what one wants in life Similarly, Lawton (1991), and Sarvimáki and Steinbock-Hult (2000), argue within the context of older people,that the goal of healthcare cannot simply be freedom from disease or disability

but to enable people to live as good as a life as possible despite illness and decreasing capacity.

Freund (1982, 1988, 1990) identifies two key components of health related well-being: Firstly, that which pertains to physical processes and the mind and secondly, the relationships between body and mind and our social

existence He suggests that well-being is a product of the body’s capacity to regulate its biophysical processes with a more global ability for individuals to exert control over these processes in relation to one’s social existence and emotional functioning

In an attempt to link psychological correlates with health Antonovsky (1984)

postulates the concept of Sense of Coherence

Firstly, Antonovsky suggests that we need to think salutogenically about

health He argues that the traditional way of conceptualising health is to

consider people as being either healthy or diseased where being healthy reflects a state of homeostasis and being ill or diseased reflects a disruption

to homeostasis (“pathogenic paradigm”)

He claims that this form of dichotomous thinking not only supports ageist stereotypes of illness identity, but fails to account for those people who may have a chronic illness yet remain functionally active In addition, addressing ill health from this viewpoint is commonly about identifying and ameliorating pathogenic causes rather than recognising that

 Pathogens are endemic in people’s lives and eradicating them will notlead to health

 Psychological factors are intrinsic in predicting peoples response to illhealth

 We invest in studying high-risk groups rather than understanding the

“symptoms” of wellness

Thinking salutogenically therefore is seeing the normal state of individuals as

one of entropy, disorder and of disruption of homeostasis rather than of

balance and equilibrium Accordingly, he considers individuals to move back

and forth along a continuum of health-ease and dis-ease Where one is

located on this continuum, in terms of one’s ability to cope with adverse health

conditions, is largely mediated by a psychological mechanism (or personality

type as has been suggested) he calls Sense of Coherence.

“The sense of coherence is a global orientation that expresses the extent to

which one has a pervasive, enduring though dynamic feeling of confidence that one’s internal and external environments are predictable and that there is

a high probability that things will work out as well as can reasonably be

expected.” (Antonovsky 1979, p.123)

Antonovsky goes on to postulate three specific components that make up Sense of Coherence, namely:

 Comprehensibility: a way of understanding one’s world (schema) that

makes sense and has the potential to be influenced or predicted in a positive way

 Meaningfulness: the emotional concomitant of comprehensibility

based in a sense of optimism

 Manageability: the capacity or resources one has (mental, physical,

social and practical) to assist them overcome the challenges they may face

Finally, Fox (1999) drawing upon a post modernist perspective, suggests that the focus on health alone as defining a construct of well-being, is to return to away of being and thinking about being which is both constraining and limiting

He argues in his book ‘Beyond Health’ that health should be constructed in

the broad context of ‘being’ as affirmation of potential rather than as a narrow bio-psycho-social construct

This view, arguably grounded within an existential model of well-being, will be explored further

ii) Psychological Perspectives on Well- Being

Whereas health related well-being has been principally defined as pertaining

to the presence or absence of illness and disability, studies that have used theterm psychological well-being, have developed a range of indices within their

definitions In addition, the notion of emotional well-being has often been

used to specifically refer to the affective counterparts of psychological

psychological well-being is constructed in the context of the presence or absence of psychopathology and defined in accordance with various

diagnostic criteria including International Classification of Diseases (ICD) 10, Diagnostic and Statistical Manual of Mental Disorders (DSM) IV etc

For example, Komproe et al (1997) in their study exploring the relationship

between available support and psychological well-being in 109 older women deployed standardized assessments of depression as their index for

psychological well-being Similarly, Sharma et al (1996) exploring the

relationship between family integration and psychological well-being in retired army personnel, deployed statistical measures of depression and anxiety as their correlates for psychological well-being

Secondly, those indices derived from a Humanistic or “Positive Psychology”

perspective (Snyder and Lopez 2005), where constructs of self-esteem,

independence/mastery, purposeful activities, social engagements and life satisfaction, are considered duly as reflecting both indices and sources of

psychological well-being (Kemmler et al 1997)

A) Self-esteem:

According to Hewitt (2005), self-esteem is generally considered as the

evaluative dimension of the self-concept that is rooted within four concepts

namely, acceptance, evaluation, comparison, and efficacy

Demo (1992), following a review of the literature on this construct, suggests that self evaluation becomes more favourable through the life-span; is

represented by a moving baseline from which situational fluctuations emerge;

is characterised by both stability and change over the life course; and plays

an important role in the stability of the self-concept

Whilst some would argue that the concept of self-esteem is a Western

construct (Hewitt, 2005), self-esteem has nevertheless drawn a wide body of research in the field of gerontology, both as a predictor of health status and social adjustment, and in terms of identifying factors which influence it (Lupienand Wan, 2005)

In terms of the resilience of self-esteem in later life, Robins et al (2002)

undertook a large scale, cross-sectional internet study involving 326,641 individuals whose ages ranged from 9 to 90 years They found that self-

esteem levels were high in childhood, dropped during adolescence, rose gradually throughout adulthood then declined sharply in old age irrespective

of gender, socioeconomic status, ethnicity and nationality However, Twenge and Crocker (2002) compared self-esteem amongst American older people from a range of ethnic back-rounds They found that African Americans

scored highest on measures of self-esteem than White Americans who

themselves scored higher than the other ethnic groups in the study

Pinquart and Sörensen (2001), synthesised findings from 300 empirical

studies on gender differences in life satisfaction, self-esteem, happiness, loneliness, subjective health and subjective age They found that gender differences accounted for less than 1% of the variance with respect to

subjective well-being and self-esteem

With respect to those factors which have been associated with high or low

levels of self-esteem: McKevitt et al (2005) exploring quality of life in older

people who were housebound (ESRC Growing Older Programme, 2005) found that high levels of self-esteem were associated with high levels of familysupport and religious commitment

Similarly, Krause (1995) showed that self-esteem was highest in those older individuals with high levels of religious commitment, and that social support (both received and reciprocated) were considered as facilitating self-esteem

(Krause ,1987; Krause and Shaw, 2000; Ranzijn et al 1998; Wentowski,

1981)

Regarding the role of self-esteem in health and adjustment, Murrell et al

(1991) and Ben-Zur (2002) found that high levels of self-esteem were

associated with a decreased risk of depression in older people, whilst

McAuley et al (2000) found that changes in physical efficacy following

exercise related to the development of self-esteem in older adults

Similarly, Brandtstädter et al (1993) explored the relationship between loss of

control, depression and self-esteem using both cross-sectional and

longitudinal studies within the age range middle to late adulthood They found that older people are effective in maintaining a sense of control and a positive view of themselves in spite of age- related developmental losses

The authors suggest that the resiliency of the ageing-self is influenced by both

instrumental activities which either prevent or alleviate developmental losses

which are relevant for self-esteem, and accommodative processes by which

personal goals and frames of self-evaluation are adjusted to changes inresources and functional capacities

B) Independence/Mastery:

Fisk & Abbots (1998) argue that the professional view of independence is

grounded in the concept of dependency (Broe et al 1998), and measured on

such functional indices as activities of daily living Using a structured interviewapproach on 146 older adults (age range 74 to 105) and qualitative analysis, they identified 5 key themes developed from the responses of older people themselves concerning independence namely:

 The importance of deciding things for oneself.

 The importance of financial resources.

 Limitations brought about by illness and frailty.

 Desire to receive necessary help without becoming a burden to others.

 The development of strategies for mitigating against loss and functional decline associated with ageing

Central to all five dimensions of independence is the capacity to have control and mastery over one self, one’s environment and one’s resources (Perlin & Schooler, 1978; Kobasa et al 1981; Blaxter, 1990; Sidell, 1995).

Following a review of twenty papers published on perceived control in older adults between 1995 and 2005, Jacelon (2007) concludes that high-perceivedcontrol is an important factor for well-being in this group

Accordingly, Jang et al (2003), suggest that sense of mastery is an indicator

of psychological resilience that can facilitate adaptations to the changes and challenges associated with ageing in both white people and people from otherethnic groups Lack of mastery has also been shown to be a central

component to the aetiology of depression (Seligman 1973), and specifically in

older adults (Knipscher et al 2000).

A study by Kunzmann et al (2002) explored the specific and long-term

emotional implications of three different types of control beliefs associated

with mastery; personal control over desired outcomes, personal responsibility

for undesirable outcomes and perceived-others control Using both cross

sectional and a longitudinal samples from the Berlin Ageing Study, the

authors found that perceived control over desirable outcomes is associated with high emotional well-being whereas perceived others control is an

emotional risk factor

Interestingly, Wolinsky et al (2003), undertaking a longitudinal study of older

adults, concluded that the only major predictor of perceived control is mental well-being

Kasser & Ryan (1999) have also shown that lack of perceived autonomy is a predictor of mortality in older adults

Within the context of physical health, Sofaer et al (2005) investigated the

relationship between perceived control and chronic pain using a qualitative study They found that the desire for independence and control was linked to adaptation to a life with chronic pain Sub-themes included; acceptance and non-acceptance, pacing oneself, helping others, use of prayer, looking and feeling good

C) Purposeful Goals and Activities:

Clearly, the notion of personal activity and the pursuit of meaningful goals is

an issue, which expands philosophy, psychology, sociology, psychiatry, socialanthropology and religion and is integral to the practice of many professions Accordingly, it has many definitions and applications

However, within the context of psychological well-being, Frankena (1973) and

Baker et al (2005) suggest that purposeful activities are not only important to

the extent that one derives pleasure, but that they are an important

mechanism through which individuals develop mastery

Coleman (1999) supports this view by recommending the deployment of purposeful activities in maintaining self-identity in older people and those with

disabilities (Elliot et al 2000).

Specific activities, that have been shown to enhance health related indices, include active recreation, intellectual activities and spiritual/religious activities

(Lawton et al 2002, Warr et al 2004), with social activities having a direct

effect upon reducing mortality rates (Menel 2003)

Indeed the role of purposeful activities is central to Baltes and Baltes

Successful Ageing model (Baltes and Baltes 1993, Freund and Baltes 2002)

The model proposes that throughout the life course, individuals continually seek to achieve mastery in life through the implementation and coordination ofthree principal activities namely:

i) Selection (developing and choosing goals),

ii) Optimisation (applying and refining goal relevant means), and

iii) Compensation (substituting new ways or means to achieve a goal

when previous means are no longer available)

The authors locate the model within a perspective that considers life

management as essentially proactive and agentic According to this

perspective, setting clear goals and investing in the means to pursue these goals, even in the face of major challenges, is adaptive

However, the model appears to consider adaptability simply in the context of behaviour alone Little attention is given to broader motivational and socio-cultural influences which arguably direct and drive adaptive styles and which provide a basis for understanding why some coping strategies may be

considered adaptive by some but not by others

D) Social relationships:

The importance of social relationships within the context of psychological being has been argued extensively through the work of such authors as Bolby, (1969, 1973a) on Attachment Theory, and through studies which have explored the impact of loss (Strobe, 2002) and those investigating the value oftherapeutic alliances in the context of psychological therapies (Norcross 2002)

well-As a source of psychological well-being, Morrow-Howell et al (2003)

investigated the effects of volunteering on the well-being of older people who partook in the American Changing Lives Study They found that volunteering reduced the risk of depressive symptoms Similarly, Stevens (2001)

evaluating a friendship enrichment program for older women (age range 55 to 83) and using a structured interview approach, found that those individuals who were able to engage in new relationships at one year follow up reported significantly lower levels of loneliness than at the start of the program

Edmunds, (2003) found that social support and family support correlated with

life satisfaction in older people, whilst Thuen et al (1997), exploring the role of

widowhood on psychological well-being, found that both widows and

widowers reported lower levels of psychological well-being than their married counterparts but that this effect was moderated by social support

Similar results were obtained by Holicky & Charlifue (1999) who identified marital relationships as enhancing well being and life satisfaction following

spinal cord injury, and in the personal management of arthritis symptoms

Stevens-Rachford (2004)

Specific factors, inherent within social relationships which have been shown toaccount for the mediating influences on psychological well-being in older

people include: lineage with family relationships (Drew and Silverstein 2004),

the opportunity to reciprocate in relationships (Ramos and Wilmoth 2003), the range of social networks available (Friedman 1997; Heidrich 1996) and the perceived adequacy of social relationships (Stuckey and Smyth 1997;

Webster 1997; Newsom & Schulz 1996) particularly within parent-child

relationships (Cox, 2002)

Masse et al (1998) have supported the role of social engagement, as a

specific index of psychological well-being Their study involved the use of content analysis of narratives from individuals who had previous experiences

of trauma Two scales were produced namely; (a) ‘psychological distress manifestation scale’ and (b), psychological well-being manifestation scale” The “psychological distress manifestation scale” was based upon 23 items reflecting four factors (anxiety/depression, irritability, self-depreciation and social disengagements) ‘The psychological well-being manifestation scale’ was based upon 25 items reflecting six factors (self-esteem, social

involvement, mental balance, control of self and events, social ability and happiness)

The authors concluded that the four factor and six factor scales can be viewed

as components of two correlated dimensions namely, psychological distress and psychological well being, where the constructs of social involvement is inherent in both scales and reflected as ‘social disengagement’ in the former and ‘social ability’ in the latter

Interestingly, the ‘psychological distress manifestation scale’ denotes factors, which are all directly commensurate with DSM IV criteria for Post-Traumatic Stress Disorder, whilst the ‘psychological well being manifestation scale’

denotes several factors identified as reflecting the concern of a Positive

psychological framework

E) Life Satisfaction

The concept of life satisfaction has been widely used within the literature on well-being both as a basis for defining well-being (Diener et al 1999) and as

an index of psychological well-being in itself (e.g Goff 1993; Chow & Chi

1999; McColl et al 1999; Hilleras et al 2000; Lundgren et al 2000) It has

also been used in a similar way in the context of subjective well-being, quality

of life and existential well-being (which will be explored later in this section).Where it has been used as a single concept, life satisfaction has been shown

to be relatively stable over 15 year period in people from middle to late

adulthood (Schilling 2006), then either increasing in some individuals or

remaining stable with others after 60 years (Mastekaasa 1988) Where

compared with younger adults, older adults seem more satisfied with their

lives then their younger counterparts (Campbell et al 1976)

Subjective Components of psychological well-being:

Subjective components of psychological well-being, often termed as

subjective well-being are those that investigate an individual’s judgment of;

and feelings towards their lives and are accordingly, usually derived from studies that have used qualitative approaches in the analysis of personal narratives concerning well-being

Drawing upon a wide body of research, Schmitt & Júchtern (2001), argue that the concept is one of the most favoured indices of positive psychological functioning in much of the ageing literature for several reasons: Firstly, that positive psychological functioning based upon indices of subjective well-being

in early life seems to relate to successful ageing and longevity in later life For

example, Hybels et al (2004) found that depressive symptoms were less

important at predicting functional decline in older adults than subjective being indicators

well-Secondly, that the appraisal of one’s own well-being determines subsequent developmental outcomes (Davis, 2005)

In addition, with respect to the provision of services to older people, the

authors suggest that both objective variables and their subjective appraisals, denoting psychological well-being, can be considered as intervention targets for maintaining independent living and improving health

However, Diener et al (2005) raises concerns with the concept of subjective

well-being in that it encompasses a broad range of phenomena including emotional responses, domain–specific satisfaction and more global judgments

of life satisfaction

For example, Tanner (2001) studied the subjective experience of

psychological well-being on a group of older people (65+) living in the

community, following decisions made by social services departments

concerning eligibility for service provision Factors that were identified as being important in defining well-being included:

 Self-reliance,

 Maintaining control,

 Maintaining equilibrium in helping relationships (respecting

boundaries and reciprocity),

 Protecting the ‘core self’ (responding to threats to identity and

engaging with individual meanings),

 Creating a supportive social space (access to resources, changing

 Having a sense that one’s life expectations have been met and that a sense that few discrepancies exist between what was

wanted and what was received;

 Having a sense of not being lonely;

 Having a sense that life is both purposeful and meaningful;

 Emotional stability and relative sanctuary from depression and anxiety;

 Having fun and being kept busy

A similar study by Redman (1996), exploring variation in judgments

surrounding subjective well-being, investigated the effects of race as an important variable and concluded that racial identity was not a factor in

predicting subjective well-being Whilst Evans et al (2002) identified the

importance of home environment on influencing emotional well-being

Kraus (2003) explored the relationship between religious meaning and

subjective well-being in older people using life satisfaction, self-esteem and optimism as indices of subjective well-being and concluded that religious

meaning was a strong predictor of subjective well-being Similarly, Kirby et al

(2004) concluded that spirituality mediates psychological well-being in older people with increasing frailty

Whilst such studies exemplify structural components to subjective well-being, Schmitt & Júchtern (2001) investigated the question as to whether subjective well-being is a multi-dimensional or uni-dimensional construct The authors based their study from data collected as part of the Interdisciplinary

Longitudinal Study of Adult Development Their results suggest that

underlying the various indicators of subjective well-being is a single global factor that links components of well-being in a hierarchical structure

iii) Eudemonic perspectives on well-being

Eudemonic perspectives on well-being reflect those that can be considered as

having concern with the broad challenges of living (Ryff et al 2006) where

such challenges are mediated by the drive towards living a happy and

contented life

Such perspectives, which may reflect several disciplines, tend primarily to be

characterized by attempts to unify both subjective (experiential) and objective

(behavioural/observed) correlates of people’s lives under one or more

descriptive meta-construct It is arguable as to whether quality of life studies described in the following section, which have identified multi-dimensional indices, could also have relevance here (Gabriel and Bowling, 2004; Gwyther,

1997; Bamford, C and Bruce E, 2000; Grewal et al 2006; Betty, 2001;

Hillerás et al 2000)

Specifically, according to Ryan and Deci (2001), a Eudemonic perspective considers well-being as a set or conglomeration of potentialities These may

be identified as hierarchical needs (e.g as denoted in Maslow’s Theory of Motivation (1970)) or as dimensions reflecting: relatedness, self-perception, engagement, independent action and purpose (e.g as denoted below in Ryff’s multidimensional model of well-being (1989) or that of Bright (1997)).Well-Being from a Eudemonic perspective is dimensional but reflecting the extent to which one may have achieved their potential rather than the degree

of emotional valence that is held surrounding a life domain

In contrast, Existential perspectives have similar concerns but where the drive

towards living is held as reflecting meaning not necessarily happiness or

contentment

Tellkis Nayak (1982) draws upon the concept of ‘spiritual well-being’ where

well-being reflects subjective meanings to one’s life which both unify and

transcend biological, psychological and cultural dimensions, whilst

Antonovsky (1979) considers well-being as the unification of one’s mental, physical and spiritual health

Gray & Moberg (1977) describe well-being as the deepest requirement of self,which, if met, enables the person to function with meaningful identity and purpose

Marcoen (1987) broadens the concepts of self in relation to well-being and postulates six ‘reality domains’ in which people have elaborate relationships

with, namely: our inner world, our body, others ( i.e individuals and groups), the culture and material environments in which we live, the associated conditions and challenges we face and our broader

existence in an immense universe Marcoen (1987) suggests that a person

may experience well-being in each of these domains, manifested as either feelings of comfort or distress and that a lack of well-being in one domain may

be compensated for by increased well- being in another In addition, that such experience may also reinforce each other or provide a basis for

achieving greater insight into another

Ryff (1989), Ryff & Essex (1991), Ryff & Keyes (1995) integrate humanistic perspectives, life span developmental perspectives and clinical approaches tomental health in developing a multi-dimensional model of well-being in which she identifies six components:

 Self-acceptance: Having a positive attitude about one’s self and one’s life.

 Positive relations with others: Being able to make and maintain warm,

satisfying and trusting relations with others

 Autonomy: Being independent, self-determining and internally regulated.

 Environmental mastery: Being competent in managing the environment

and making use of surrounding opportunities and supports

 Purpose in life: Having goals and objectives for living, a sense of

directedness and feeling that there is meaning to life

 Personal growth: Having feelings of continued development, being open

to new experiences and having a sense of realising one’s potential

Further studies using this model suggested differential trajectories across age bands with older people considering Positive relations with others, Autonomy and Environmental mastery as being more important to them than their

younger counterparts Self-acceptance was rated as equally important across all age ranges (Ryff & Keyes, 1995) Regarding gender, women considered Positive relations with others and Personal growth more highly than men (Ryff

& Singer, 1998)

Lehman (1988) and Bright (1997) consider the experience of well-being as a product of personal characteristics, objective life conditions within various contexts or life domains and the extent to which the Self experiences

satisfaction and contentment in these various domains

Bright (1997) goes on to describe nine prerequisites in her construct of

‘wholeness’ namely:

 Independence and autonomy;

 The ability and right to make choices;

 Self esteem;

 Exceptional relationships;

 The capacity to give to others;

 To feel a sense of community;

“A dynamic state of physical, mental and social wellness; a way of life which equips the individual to realize the full potential of his/her capabilities and to overcome and compensate for weaknesses; a lifestyle which recognizes the importance of nutrition, physical fitness, stress reduction, and self

responsibility.” (WHO 2004).

Well-being is thus seen as the product of four key factors over which the

individual has varying degrees of control over namely: biology, social and

physical environment, healthcare organisation and lifestyle.

Emergent themes inherent in such eudemonic perspectives include the

subjective experience of satisfaction with life and the interrelationships

/unification between these and contextual life domains including health,

spirituality, relationships with others, functional ability, purpose and identity.Finally, whilst most eudemonic models and perspectives are drawn from non-clinical populations, Kitwood (1997) considers well-being in the context of critical social psychology In particular, he considers people who experience

dementia and who’s Personhood has been undermined.

Kitwood describes personhood as:

“a standing or status that is bestowed upon one human being by others, in the

context of a relationship and social being It implies recognition, respect and trust” (Kitwood 1997, p8)

He argues that traditionally, dementia sufferers have been victims of what he

describes as Malignant Social Psychology Specifically, he identifies such

individuals as having been intimidated, outpaced, ignored, infantilised,

labelled, blamed, manipulated, invalidated, disempowered, controlled,

objectified, marginalised and stigmatised

Rather than defining well-being per-se, Kitwood seems to consider well-being

as intrinsic to personhood He identifies the needs of people with dementia as reflecting

Thus, where an individual’s personhood is being supported through the

addressing of their needs, such individuals will indicate well-being through

play, holding, recognition and giving

iv) Existential Perspectives on Well-Being

Arguably, Physical, Psychological and Eudemonic perspectives on well-being,including well-being in relation to domain specific quality of life experiences, can be considered as being grounded within a construct of ‘wellness’ or in leading a happy and contented life Accordingly, such research is concerned with those factors that both predict and from which one derives wellness and contentment

Alternatively, Existential perspectives consider well-being in the context of

one’s broader experience of being or existing in the world where positive

meaning rather than life satisfaction, quality of life or absence of illness and disability constitute well-being (Lobchuk & Stymeist (1999), Reker &

Chamberlain (2000).)

Drawn from the Philosophical writings of Kierkegard, (1941); Sartre, (1948);

Heidegger, (1962), existential philosophy is underpinned by three principal

concerns: time, choice and meaningfulness.

Time:

From a phenomenological viewpoint, time refers to our ongoing experiences coupled with our ability to reflect on past events and envisage possibilities in the future Time becomes an existential issue because we cannot move it back Whilst we may understand our lives from a historical perspective, we are bound to live our lives forward in time and face the challenges time brings.

As noted extensively within the existential literature, one of our greatest

existential fears is that in time, we will have to face our own inevitable

annihilation, i.e that we are finite and that therefore we can become nothing

or that that which is now will never be the same again (Stevens, 1996)

However, the concept of nothingness is not restricted to death Both Satre (1948) and Yalom (1980) consider the concept of nothing more broadly as nothaving a sense of self/self-identity, or of becoming socially excluded or in

Laing’s terms becoming Inauthentic (Laing, 1960).

Laing suggests that our fear of becoming inauthentic creates a more chronic

state of Ontological Insecurity that we both manifest and have to manage in

different ways from an individual level to a socio-political level

Individual level:

At an individual level, anxieties surrounding non-being can be addressed

through either denial (often expressed via psychic defence mechanisms) or by

transcending our own mortality For example, through having children,

creating roles, products, processes or theories that will live on after our death

or affirm our existence to the world

Social level:

At a social level, society constructs conventions, identities, roles and

ideologies which can either foster a sense of being something within society

(Heidegger’s 1962 notion of mindfulness of being), assuming one is

considered as meeting the criterion, or create the conditions which give rise to

a sense of nothingness as can be argued from the point of ageism This dichotomy can be conceptualised as underpinning Erickson’s (1980) notion of

ego-integrity (acceptance of one’s life for what it has been) vs despair (that

one’s life has been meaningless/nothing)

Choice: