SOCW-6111-Discussions Wk 11

  

Discussion 1:
Biopsychosocial Holistic Approach

The assessment and incorporation of a client’s spirituality has become increasingly common in the field of social work. While historically social workers were trained to avoid discussions centered on religion, we now know that spirituality encompasses many ways of believing. “The Society for Spirituality and Social Work is a network of social workers and other helping professionals dedicated to spiritually sensitive practice and education” (Society for Spirituality and Social Work, n.d.). Addressing a client’s spirituality allows for a biopsychosocial holistic approach that can aid in the process of understanding illness, disability, and end-of-life issues.

For this Discussion, review the Monod et al. (2010) article and locate one scholarly article addressing spirituality with the elderly.

· Post your explanation of the significance of addressing spirituality with the elderly. 

· Identify a spiritually based intervention for this population. 

· Describe the effectiveness of the use of spirituality with the elderly as found in the literature. 

· Then, describe your own thoughts on the use of spirituality in an intervention.

Support your posts with specific references to the Learning Resources. Be sure to provide full APA citations for your references.

References (use 3 or more)

Browne, C. V. (1995). Empowerment in social work practice with older women. Social Work, 40(3), 358–364. 

Holosko, M. J., Skinner, J. F., Patterson, C. A., & Brisebois, K. (2013). Intervention with the elderly. In M. J. Holosko, C. N. Dulmus, & K. M. Sowers (Eds.), Social work practice with individuals and families: Evidence-informed assessments and interventions (pp. 197–235). Hoboken, NJ: Wiley.

Laidlaw, K. (2001). An empirical review of cognitive therapy for late life depression: Does research evidence suggest adaptations are necessary for cognitive therapy with older adults? Clinical Psychology and Psychotherapy, 8(1), 1–14. 

Monod, S. M., Rochat, E., Büla, C. J., Jobin, G., Martin, E., & Spencer, B. (2010). The spiritual distress assessment tool: An instrument to assess spiritual distress in hospitalised elderly persons. BMC Geriatrics, 10, 88.

Discussion 2: Life Review

While the use of reminiscing about one’s life may not seem a particularly therapeutic approach, the use of life reviews has been found to be correlated with life satisfaction (Haight, 1992) and positive mental health outcomes (Westerhof, Bohlmeijer, van Beljouw, & Pot, 2010). The spontaneous and informal sharing of one’s life story to provide younger generations insight into history is an age-old tradition that, according to Haber (2006), has diminished recently under the shadow of the technical age. In response, practitioners have “found” this tool in the therapeutic process. There have been several theories used to support the integration of this intervention. You will be asked to identify and assess a theory you believe best fits this approach to working with the elderly.

For this Discussion, review the Haber article.

· Post your choice of a theory that best aligns with the use of a life review and why. 

· Explain how you believe life review can be a useful intervention when working with elderly clients.

References (use 3 or more)
Browne, C. V. (1995). Empowerment in social work practice with older women. Social Work, 40(3), 358–364. 
Holosko, M. J., Skinner, J. F., Patterson, C. A., & Brisebois, K. (2013). Intervention with the elderly. In M. J. Holosko, C. N. Dulmus, & K. M. Sowers (Eds.), Social work practice with individuals and families: Evidence-informed assessments and interventions (pp. 197–235). Hoboken, NJ: Wiley.
Laidlaw, K. (2001). An empirical review of cognitive therapy for late life depression: Does research evidence suggest adaptations are necessary for cognitive therapy with older adults? Clinical Psychology and Psychotherapy, 8(1), 1–14. 

Haber, D. (2006). Life review: Implementation, theory, research, and therapy. The International Journal of Aging and Human Development, 63(2), 153–171. 

Monod, S. M., Rochat, E., Büla, C. J., Jobin, G., Martin, E., & Spencer, B. (2010). The spiritual distress assessment tool: An instrument to assess spiritual distress in hospitalised elderly persons. BMC Geriatrics, 10, 88.

INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 63(2) 153-171, 2006

LIFE REVIEW: IMPLEMENTATION, THEORY,

RESEARCH, AND THERAPY

DAVID HABER, PH.D.

Ball State University

ABSTRACT

A selective literature review of publications on life review generated ideas on

implementation, theory, research, and therapy. The review begins by

differentiating life review from reminiscence, and summarizing ways to

conduct a life review. A dozen theories that have been influenced by the life

review technique are presented, with a focus placed on Erikson’s Stages of

Psychosocial Development. Erikson’s theory has not only been influenced by

the life review, it has had a major impact on life review research. Three

research topics are discussed: Erikson’s ego integrity versus despair in old

age, demographical differences in the practice of life reviews, and the impact

of conducting life reviews on staff in institutional settings. Most practitioners

of life reviews are institutional staff, university students, and family members,

many of whom have had limited prior training. The prospect of a certified life

review training program is discussed.

Rather than seeing ones life as simply one damned thing after another, the

individual attempts to understand life events as systematically related . . . a life

story (Gergen & Gergen, 1983).

To understand life, people tell stories. Storytellers in traditional societies were

older adults, the ones who remembered the past and helped the young learn from it.

For many years, this storytelling tradition not only served as a means for passing

down information from one generation to the next, but enhanced the elder’s status

within the community.

153

� 2006, Baywood Publishing Co., Inc.

Along with many other changes associated with modernity, this storytelling role

among older citizens fell by the wayside. And, some argue, the prestige, status, and

self-esteem of older adults have been diminished as well. In contemporary society,

however, a growing number of community practitioners and educators are

attempting to revive the storytelling role and enhance the mental health of older

adults through a life review.

This selective literature review differentiates life review from reminiscence,

summarizes ways to conduct a life review, compares theoretical frameworks, and

examines research and therapeutic topics. The review was guided by four search

engines—Medline, AARP Ageline, CINAHL, and PsycINFO—using the terms

life review, reminiscence, life story, and oral history. About 600 abstracts were

identified, and 140 publications were selected for review.

LIFE REVIEW VERSUS REMINISCENCE

Though life review and reminiscence are by far the most commonly used terms

in the literature, there are many similar expressions in use, such as life story, life

history, oral history, guided autobiography, personal narrative, and narrative

gerontology. These terms are oftentimes uniquely defined by a particular author,

and other times used interchangeably. Standard definitions of these terms have not

been achieved, though progress has been made toward the important goal of

differentiating life review from reminiscence.

The simplest definition of reminiscence is the recall of memories. This is

usually characterized as simple daydreaming, storytelling, or nostalgia by oneself

or with others. Reminiscence is likely a universal experience from at least the age

of 10 (King, 1982). It is a passive and spontaneous process that may be part

of a life review but is not synonymous with it. Sometimes the terms reminis-

cence and reminiscence therapy are used as synonyms for life review. In these

instances, the terms do not refer to the simple and spontaneous recall of mem-

ories, but a structured and systematic process deliberately implemented with

willing participants.

A life review is typically structured around one or more life themes, most often

family themes—ranging from ones own childhood, to the experience of being a

parent, to being a grandparent; and work themes—from first job, to major life’s

work, to retirement. Other commonly used themes, but by no means the only ones,

are: major turning points; impact of major historical events; role of education,

health, holidays, music, literature, or art in ones life; experiences with aging, dying

and death; and meaning, values, and purpose.

Life review is also more likely than reminiscence to be an evaluative process, in

that participants examine how their memories contribute to the meaning of their

life, and they may work at coming to terms with more difficult

memories.

Individuals who engage in reminiscence or life history, in contrast, often detail the

events of their life in more of a descriptive fashion.

154 / HABER

While life review is similar to reminiscence in that people enjoy doing it, it

is also done for educational or therapeutic purposes. Life review con-

ducted for educational purposes can teach or inform others, pass on knowl-

edge and experience to a new generation, or enhance understanding of ones

own life or oneself. Life review conducted for therapeutic purposes can

help people cope with loss, guilt, conflict or defeat; or help someone find meaning

in ones accomplishments.

Robert Butler’s (1963) landmark article on life review and reminiscence, “The

Life Review: An Interpretation of Reminiscence in the Aged,” was the major

impetus in the field even though some contentions in his article have been

disputed. Several analysts, for instance, have disagreed with Butler that life

reviews are universal (Lieberman & Tobin, 1983; Merriam, 1995; Taft & Nehrke,

1990). Butler, however, makes a distinction between reminiscence and life review,

and the universality that he referred to in his article may have been exclusively

focused on reminiscence.

Another Butler contention that has not received unanimous support is that

reminiscence becomes more frequent with age. This has been confirmed by some

researchers (Lieberman & Falk, 1971; Revere & Tobin, 1980) but not others

(de Vries, Blando, & Walker, 1995; Romaniuk & Romaniuk, 1983; Webster,

1994). And Butler’s assertion that reminiscence appears to be precipitated by

approaching death is not supported by one research study (Merriam, 1995).

What is indisputable about Butler’s article, though, is that he began to

remove the stigma associated with reminiscence and life review among older

adults. Butler argued that these activities were not predominantly triggered by

pathological tendencies for the purpose of escaping the realities of the

present, but were normal processes that emerged from a desire to enjoy, grow,

cope, or change.

Birren and Cochran (2001) observe that life review is not therapy, but it often

can be therapeutic. Lewis and Butler (1974) go one step further and note that the

life review can be a very useful tool for therapists. “. . . the life review obviously is

not a process initiated by the therapist. Rather the therapist taps into an already

ongoing self-analysis and participates in it with the older person” (p. 166). The

authors then describe several techniques for using life review to enhance

individual and group psychotherapy.

CONDUCTING A LIFE REVIEW

Recognizing the universality and value of reminiscence, Butler encouraged

more formal life reviews that systematically elicit memories for educational and

therapeutic purposes. And increasingly over the four decades since Butler’s

seminal article was published, practitioners in the community have translated the

desire to reminisce among older adults into more formal life reviews.

LIFE REVIEW / 155

Activity directors in retirement communities and nursing homes, for example,

are providing an enjoyable or educational life review experience for older

residents. Students instructed by university professors or high school teachers

are initiating intergenerational life review experiences that benefit both

generations. And family members are recording life reviews for the benefit of

younger generations.

A life review requires few resources and modest training. It can be done by

oneself, but more often it is guided by a partner, or by a facilitator as part of a group

experience (Birren et al., 1996; Birren & Cochran, 2001). Haight (1995) surveyed

41 guided life reviews in the literature and reported that they were roughly equally

divided between paired and group interventions.

Paired life reviews tend to be of shorter duration, up to six meetings; group life

reviews tend to range from 1 to 11 months (Haight, 1995). Paired sessions allow

for easier access and less complicated confidentiality issues; group sessions add

the benefit of helping older adults establish new peer relationships or adjust better

to a new congregate housing site or institutional setting.

Based on considerable experience with conducting life reviews, Haight and

colleagues (2000) report that for a life review to have substantial impact on the

participants’ mental health it should involve a sufficient investment in time (6

weeks or longer), scope (birth to present), intimacy (listening by other), and

evaluation (analysis and synthesis). The ideal length of a single interview session

is unknown, but sessions often last between one and two hours, unless physical

frailty requires a shorter time period (Detzner, 1981).

Often a life review involves the use of memorabilia to inspire memories, such as

scrapbooks, family photo albums, letters, cherished possessions, and genealogies

(Sherman, 1995b). Music can be used to enhance memories, especially as they

relate to weddings, wars, holidays, religion, or popular songs of a particular era

(Kartman, 1991). In addition, some older adults take pilgrimages to significant

sites in their past in order to stimulate memories. Although a life review may be

just an oral experience, an additional written version is likely to add to its potential

impact on mental health (Sherman, 1991, 1995a). The interview sessions may

initially be recorded by tape recorder or by written notes, followed by repeat

editing and multiple drafts.

Conducting life reviews with college or high school students as interviewers

requires making sure that students have two skills: writing and interviewing

(Myerhoff & Tufte, 1975). Writing skills include not only knowledge of gram-

mar but editing skills to enhance the meaning of the content. Interviewing

skills include setting up meetings in a reliable fashion, avoiding interference

with the flow of memories, stimulating additional memories when necessary,

listening with great attention and openness, and focusing the interview if the older

adults’ memories wander. Facilitating group life reviews, however, requires

additional skills typically obtained through training and experience (Burnside &

Haight, 1994).

156 / HABER

There are an increasing number of persons who have gone into the business of

preserving life reviews through written materials, audio tapes, video tapes, and

CD-ROMS (Kunz, 1998). In 1994, the Association of Personal Historians was

founded, and in 1995, an international biannual conference was launched, called

The Reminiscence and Life Review Conference.

LIFE REVIEW THEORY

Erikson’s Stages of Psychosocial Development

Erik Erikson’s (1950) Stages of Psychosocial Development was focused pri-

marily on childhood development, due to the prevailing influence of Sigmund

Freud at that time. The last two of Erikson’s eight stages, though, were focused on

the second half of life, and this inclusion was particularly innovative for its time.

Erikson directly addressed the importance of conducting a life review during the

last stage of life.

Each of Erikson’s developmental stages embodies a fundamental issue that

challenges the individual who attempts to resolve it and move on to the next stage.

The issue in stage seven is external in focus and deals with generativity versus

stagnation. Generativity refers to whether the individual is able to help guide the

next generation in parenting, teaching, mentoring, and other behaviors that

contribute a positive legacy that will outlive the self.

Although this stage directly relates to life stories and the ability to transmit

culture to younger generations, no empirical study was found that uses gener-

ativity as its guiding theory. One contributing factor may be the lack of an opera-

tional definition for generativity. Erikson (1975) defines it as not just procreativity

and productivity, but any activity that contributes to the life of generations.

The issue in stage eight, however, has drawn considerable attention from

researchers, theoreticians, and therapists. Stage eight is aimed inward and deals

with the central issue of ego integrity versus despair. Ego integrity is defined as a

basic acceptance of ones life as having been inevitable, appropriate, and

meaningful. Despair, in contrast, is associated with resentment, guilt, and regret.

Erikson viewed life review or reminiscence as vital to the task of stage eight, the

stage associated with old age. Life review can help older individuals acquire ego

integrity and avoid despair. A life review, according to Erikson, can help create an

acceptance of one’s one and only life cycle with few or no regrets. It does this by

helping individuals integrate memories into a meaningful whole, and to provide a

harmonious view of past, present, and future (Clayton, 1975). Those who are

unable to accept and integrate their life experiences will be filled with despair.

If life review is vital for achieving ego integrity, Erikson does not address why

some individuals may achieve ego integrity without this intervention. Nor does

Erikson address why some individuals fail to make progress toward ego integrity

through a life review, and some may even experience a deeper despair.

LIFE REVIEW / 157

Erickson’s developmental theory has generated an enormous amount of

attention to psychosocial development in the second half of life. One study

reported that when older adults are cued to recall memories, content analyses of

the resulting memories shows them to be systematically related to Erikson’s

psychosocial stages (Conway & Holmes, 2004). Nonetheless, as with any theory,

there has been criticism generated as well. A substantial amount of this criticism

has been leveled at the way stage theory emphasizes developmental process at the

expense of cultural variability and cohort effects (Pietikainen & Ihanus, 2003;

Weiland, 1993). On a related note, Cole (1992) points out how stage- and

age-structured perspectives tend to reduce the historical role of religion and

spirituality in guiding the life course.

Wallace (1992) has argued that “growing old differs across settings and

contexts . . . and that developmental views are biased in assuming that aging is the

same for all people, at all times, and in all situations” (p. 120). Erikson’s

methodology, in fact, was based on personal constructs of identity that reflected

the moods of his own life (Kushner, 1993; Thorson, 2000), and he did not subject

his personal observations to systematic data collection and analysis in his own

country and time, much less cross-culturally or with cohorts from substantially

different eras (Pietikainen & Ihanus, 2003).

Erikson’s contention that individuals attempt to resolve the issue of ego

integrity once and for all in the eighth stage of life has been challenged by Melia

(1999). She argues that ego integrity is an issue that emerges repeatedly

throughout adulthood, and in any adult stage of life. She studied the lives of 39

older Catholic religious, and found that ego integrity was never established

definitively, but needed to be grappled with as each new loss—death of a

significant other, health problems, and so forth—was encountered throughout

adulthood. The author of this review refers to Melia’s contention as a “coming to

terms” perspective, and this will be addressed in the next section, after one final

criticism of Erikson’s stages, by Erikson himself.

Erikson, with an addendum by his wife (Erikson & Erikson, 1997), modified his

own eight stages by adding a ninth stage, in a work called: The Life Cycle

Completed: Extended Version. The ninth stage is when the individual truly enters a

life cycle; i.e., cycling back to the issues they were born with. This stage, typically

in one’s late 80s and 90s, is marked by loss of strength, control, and autonomy. The

key issue is to gain hope and trust, which mirrors the issue of the first stage,

infancy. The challenge in stage nine is to avoid giving up, and to be as fully alive as

possible until one is dead.

Coming to Terms

A “coming to terms” perspective provides an alternative to developmental

theory where ego integrity is or is not resolved once and for all in the eighth

stage of life. Coming to terms may instead be a repeated experience that

158 / HABER

arises with each loss in adulthood, and this psychological adjustment may

occur independently within each of several dimensions of life (e.g., family,

work). This perspective was applied by the author to life review projects

competed by students in his introductory gerontology classes over the years

(Haber, 1986). Adults come to terms, or fail to come to terms, with their past

in three ways:

1) Value the Good Things—Adults look back on their lives and recognize the

good things they have achieved in their family life, work career, personal

endeavors, religious orientation, and other domains of life. Older adults, in

comparison to younger adults, may be more oriented toward maximizing

emotional rewards through the life review process (Pasupathi & Carstensen,

2003). Students in the author’s classes, therefore, have been encouraged to

draw out positive experiences, emphasize them, and maximize the mental

health benefits that can be accrued by emphasizing and valuing positive

memories.

2) Come to Terms with the Difficult Things—Older adults come to terms with

most of the major challenges of life, such as adjusting to widowhood,

retirement, and diminished physical vigor. Students in the author’s classes

have been encouraged to support older adults when they choose to examine

these experiences, but not dwell on them when the older adult appears ready

to move on. This moving on process may involve a shift to a more neutral or

positive topic, with students being encouraged to end each interview session

on a positive note.

3) Not Come to Terms with the Difficult Things—Older adults may not be able

to come to terms with some aspects of their life. They may obsess on the

perceived good old days, or fixate on failures or conflicts in ones past or

present. A longstanding feud with a family member or the death of a child,

for instance, may become an obsessive and anxiety-producing memory

(LoGerfo, 1981). Depending on the setting, such as a nursing home or a

retirement community, students may need to terminate the interview as

gracefully as possible, and inform the staff at these facilities of a possible

need for a mental health referral.

Unlike Erikson’s developmental theory, which culminates with the issue of

resolving integrity versus despair in the last stage of life, coming to terms is an

ongoing process throughout adulthood. However, in comparison to Erikson’s

eighth stage of development which has inspired a substantial number of empirical

studies, a coming to terms perspective has not been subjected to many

investigations. Perhaps this is due to the subjective nature of analyzing a

coming to terms with ones life, and the smaller number of qualitative–versus

quantitative–studies that are being published in academic journals.

LIFE REVIEW / 159

Other Theories

There are many other theories that relate to the life review perspective that have

also received scant attention in the literature. In general, these theories note that

life stories are constructed and reconstructed through the telling of story after story

in order to maintain a positive identity (Gergen, 1980; Meacham, 1995; Molinari

& Reichlin, 1985; Randall & Kenyon, 2002; Tarman, 1988). One threat to an

individual’s identity is the increasingly rapid pace of social and cultural change

with each succeeding generation, combined with a negative stereotype of aging.

Thus, memories that may have once been positive tend to fade, and may need to

be retrieved, reaffirmed, and validated in the context of present day life. And

negative memories may need to be ignored or minimized in their emotional import

through selective reminiscing about positive experiences. There is evidence to

suggest that older adults who engage in life review do this more effectively in

comparison to younger adults (Pasupathi & Carstensen, 2003).

Another theory along these lines is Erving Goffman’s (1963) dramaturgical

presentation of self. “Older individuals attempt to present a positive impression of

themselves in order to combat the growing stigma of old age” (Tarman, 1988, p.

172). Goffman (1959) proposes that individuals continually manipulate the

impressions that others make of them in order to maintain their self-esteem.

Life review can also be interpreted in the context of several gerontology

theories. Continuity theory, for instance, suggests that as individuals transition

from one stage to the next over the life cycle, the primary need is to seek order and

meaning by linking past events with the present (Atchley, 1989). As stated by

Parker (1995) “Individuals build life stories as they age, and these stories

incorporate past events into an organized sequence, giving them a personal

meaning and a sense of continuity.”

Life review has also been associated with both the disengagement and activity

theories in the field of gerontology. Prior to Robert Butler’s reinterpretation of

reminiscence and life review, there was widespread speculation that this type of

activity is part of the disengagement process; i.e., living in the past versus seeking

new experience (Butler, 1963). Conversely, one can interpret the life review

process as part of activity theory (i.e., an active mental activity) that might sharpen

mental acuity and postpone dementia (Wilson et al., 2002).

Many theorists have posited that the life review enhances therapeutic

techniques. Butler (2002) proposes that the life review skill may be a valuable

component of family therapy, “facilitating consensus and clarification of specific

family issues” (p. 9). Puentes (2004) suggests that life review can be integrated

with, and strengthen, cognitive therapy through the review of major themes in ones

life and examining them for cognitive distortions.

Crose (1990) proposes that life review can be a valuable addition to gestalt

therapy by bringing significant past events into the here and now in order to

resolve a persistent issue and achieve closure. Ray (1998) examines life review in

160 / HABER

the context of feminist theory. Kralik and colleagues (2004) suggest that the life

review process may be an important component of self-efficacy theory, and can

fortify coping strategies with chronic illness.

Reker and Chamberlain (2000), in their edited book: Exploring Existential

Meaning, point out that the life review process may be interwoven with existential

theory. Both address the same questions: How do events in my life fit into a

larger context? What is the purpose of my life? Is there meaning in my life?

What is worth living for? Except for “fixed reminiscence,” when the story is

told repeatedly in the same way to affirm a particular value, most memories are

told through “dynamic reminiscence,” with feelings and meanings still evolving

(Chandler & Ray, 2002).

Merriam and Clark (1993) suggest that life review can bring together theorists

who tend to work in separate domains. The authors note that most, if not all,

important aspects of our lives are within the domains of work and love. Work is

task and achievement oriented, and tends to attract analysts from the fields of

sociology, organizational behavior, or management. Love, however, is focused on

feelings and relationships, and attracts psychologists and related therapists. Life

review practitioners, however, can bridge the theoretical divide by asking the

following questions: Does activity and energy devoted to one area stimulate or

deplete development in the other? Do men emphasize work and women love, to

the neglect of the other? If one area is neglected is there necessarily a diminution

of life satisfaction?

LIFE REVIEW RESEARCH TOPICS

Ego Integrity versus Despair

Given that Erikson’s eighth stage of psychosocial development is the most

widely cited component of a theory in the life review literature, it is not surprising

that the outcome variables drawing the most attention correlate with his two basic

concepts: ego integrity versus despair.

Many life review studies measure ego integrity, or related dependent vari-

ables such as life satisfaction, psychological well-being, and self-esteem (Haight

et al., 2000). One study of elderly nursing home residents reported that completing

a life review was positively correlated with high ego integrity scores (Taft &

Nehrke, 1990). In a carefully controlled study, a randomly selected group of 60

homebound elderly subjects increased life satisfaction and psychological

well-being in comparison to a friendly visit control group and a no-treatment

group (Haight, 1988).

A study of 36 female residents in three nursing homes noted that life review led

to increased life satisfaction (Cook, 1998). Another study reported that a life

review intervention was effective in improving the life satisfaction of 31 older

adults living in sheltered housing (Fielden, 1990).

LIFE REVIEW / 161

A substantial number of life review studies measure depression, which can be

viewed as an operational definition of Erikson’s despair. Depression is the most

common emotional disorder among older adults, and it is often overlooked and

under-treated by health professionals (Haber, 2003). When treated, the primary

modality has been medication which, while effective, can be expensive and may

have substantial side effects. Several studies, however, have demonstrated that an

inexpensive life review can be effective in treating depression without harmful

side effects.

Haight and colleagues reported that a life review intervention in comparison to a

friendly visit was not only an effective intervention for reducing depression among

residents in a nursing home (Haight, Michel, & Hendrix, 1998), but a 3-year

follow-up revealed lasting effects with some of the residents (Haight et al., 2000).

Similar—though shorter-term—positive results were obtained with older adults

who were: clients of a social service agency (Serrano, Latorre, Gatz, & Montanes,

2004); older women living in an assisted living facility (Jones, 2003); older

residents living in nursing homes (Ashida, 2000; Taft & Nehrke, 1990; Youssef,

1990); and clinically depressed hospital patients (Bacher et al. 1991; McDougall,

Blixen, & Suen, 1997).

Beecham and colleagues (1998) speculate that life reviews allow institution-

alized residents in particular an opportunity to gain a sense of control over their life

story, in contrast to a lack of control over independence, medical decisions, and

their institutional environment. In addition, high pretest depression scores in

institutional settings allow for a reduction to take place, in contrast to community

settings where low pretest depression scores make further reduction unlikely

(Haight, 1988; Stevens-Ratchford, 1993).

One study of older adults with moderate or severe depression reported that life

reviews led to significant improvements in depressive symptoms within a short

6-week time frame (Watt & Cappeliez, 2000). The researchers noted that this

psychosocial treatment appeared to work more quickly than traditional clinical

interventions, because it is more familiar to the client—the interviewee is already

an expert in the material (personal memories), and does not need to learn new

therapeutic skills or vocabulary.

As noted by Weiss (1995): “The life review process is often seen by older adults

as a more appealing and less threatening activity than most counseling

interventions, because it invites older adults to discuss their past and to uncover

positive life experiences and inner strengths” (p. 168).

Demographical Differences

The content of life reviews may be influenced by demographic variables, such

as gender, ethnicity, age, and so forth. The demographic variable that has received

more research attention than most is gender. Males appear to focus life reviews

162 / HABER

more on instrumental activities, personal achievements, and historical events,

while females focus more on relationships and emotional events (Davis, 1999;

DeGenova, 1995; Keller, 2002; Ray, 1998).

Sherman (1991) found men to relate memorabilia used in life reviews more

to personal values or ideals, while women relate them more to individuals.

David (1995) found men more attentive to their own selves, women more on

significant others. deVries and colleagues (1995) and Webster (2001) found men

reminisce less frequently, and when they did reminisce they remembered fewer

events, while women reminisce more frequently and reported more enriched,

interpersonal memories.

Ethnic differences with life reviews are only beginning to receive attention.

Blacks used reminiscence more than whites to understand life in general and their

own lives in particular, as well as to teach others about the past and their own

accomplishments (Merriam, 1993). Another study reported that both Chinese-

American and Mexican-American elders demonstrated as much willingness

to participate in life reviews as Anglo-Americans (Atkinson, Kim, Ruelas, &

Lin, 1999), though in another study the earliest memories of Chinese adults

occurred significantly later than the earliest memories of white Americans

(Han, Leichtman, & Wang, 1998).

These isolated studies do not begin to tap systematic differences among ethnic

groups. Even the most basic question has not been addressed: Do the oral

traditions of different ethnicities influence receptivity toward, or outcomes from,

life reviews?

Finally, life review and reminiscence are being studied more with children,

adolescents, and young adults. Though participants of all ages recall episodes of

wisdom through their autobiographical experiences, it seems that “. . . wisdom

itself manifests differently in different life phases, and full use of one’s wisdom

appears to be a developmental achievement. Adolescents may not yet have

developed the ability to take full advantage of their life experiences by embedding

them in a life story and learning lessons from them” (Bluck & Gluck, 2004, pp.

568-569). Autobiographical memory may be an emerging capacity, along with the

understanding of self (Fivush & Haden, 2003).

Staff Impact

Another area beginning to receive research attention is the impact that life

reviews have on the staff persons administering them. Three studies reported that

conducting life reviews had positive effects on staff perceptions toward older

persons (Goldwasser & Auerbach, 1996; Pietrukowicz & Johnson, 1991; Ross,

1990). One study reported that home health aides were enthusiastic about learning

life review techniques and applying them to older clients, but because of initially

strong attitudes toward aging these aides did not improve their attitudes (Haight &

LIFE REVIEW / 163

Olson, 1989). They did, however, express appreciation about having a therapeutic

tool to enhance their clinical practice.

Another study of nurse’s aides compared those who received a medical chart

along with life history information, with a control group of aides who only

received a medical chart. Aides who received additional life history information

and training demonstrated significantly improved attitudes toward nursing home

residents in comparison to control aides (Pietrukowicz & Johnson, 1991). These

findings are particularly significant given the huge problem of nursing home

personnel turnover.

Haight’s Review

Barbara Haight and colleagues have done three comprehensive summaries of

life review studies through annotated bibliographies. They report that life review

and reminiscence articles have increased to about 15 a year over the past decade,

up from just two or three a year immediately after Robert Butler’s seminal article

in 1963. The most recent annotated bibliography covered 80 life review publi-

cations between 1994 and 2000, and was organized by type: scholarly discussions,

research studies, applications, and methods (Hendrix & Haight, 2002). The

authors concluded that life review research interventions have become lengthier

and more likely to produce better outcomes, and that life review research

methodologies have become more sophisticated and varied.

THERAPEUTIC IMPLICATIONS

Most practitioners of life reviews are staff persons, students, and family

members with limited prior training. Oftentimes, life reviews are practiced with

the most vulnerable populations, not only with older adults in nursing homes, but

more recently with older persons grappling with serious disease (Overcash, 2004)

or terminal illness (LeFavi & Wessels, 2003).

The most pressing need, therefore, is to reduce the likelihood that practitioners

harm the mental health of older adults. Researchers, in fact, have warned against

allowing well-meaning but inadequately trained practitioners to break down the

use of purposeful denial or non-reflection as a primary defense mechanism

(Hewett, Asamen, Hedgespeth, & Dietch, 1991; Shute, 1986). Denial, in fact, may

be adaptive in early bereavement and some health setbacks, and the encourage-

ment of individuals to review their past or current situation may distress them

(Luborsky, 1993).

The development of a brief training program may help practitioners adequately

screen older adults and identify those who might not benefit from a life review.

Even more ambitious would be a training program for practitioners to help their

clients come to terms with difficult memories from the past, as well as to identify

164 / HABER

additional sources of self-worth from the past. One way to accomplish this may be

to emphasize the themes (e.g., work or family) that are associated with higher

levels of life satisfaction, and to assist them with crafting a more balanced inter-

pretation of past events (Watt & Cappeliez, 2000).

Haight (1995) reviewed nearly 100 life reviews and reported that only 7% were

associated with negative outcomes. Although this finding is promising, it must be

assessed in the context that negative outcomes may be more difficult to get

published in research journals than studies that report positive outcomes.

Even if this small percentage of negative outcomes is representative of the

larger practice of conducting life reviews, a considerable minority of persons

may be ill-served by educators, practitioners, students, and family members

who are not trained to provide therapeutic assistance. This danger may be

enhanced in institutional settings where depression is widespread and where, in

one sample, 30% reported that the retrieval of memories was undesirable

(Tobin, 1972). Thus, greater caution and supervision may be needed in certain

settings or situations.

An expanding group of life review practitioners are college and high school

students who implement them as part of their educational curriculum. To

enhance the safety and efficacy of student efforts, more in-depth analyses of

educational programs, similar to McGowan’s (1994) mentoring-reminiscence

program with college students interviewing homebound older adults, need to be

made available to faculty and teachers. McGowan encourages students to focus

more on the historical dimension of life reviews rather than the evaluative

aspects. He notes, however, that when older adults want to evaluate an aspect of

their life review, and student interviewers are willing, the evaluation is likely to

have a good outcome.

A long term goal of life review practice, therefore, may be the develop-

ment of a certified training program that enhances the likelihood of safe and

effective interventions.

CONCLUSION

Progress is being made toward a consensus definition of life review, though

standard definitions in this field have proven elusive. There is less consensus,

however, on how to conduct a life review, including what type of questions to ask,

the frequency and duration of interviews, and the content of the training of

interviewers or group facilitators.

A dozen theoretical frameworks are noted as having been influenced by the life

review technique. Erikson’s Stages of Psychosocial Development is examined in

more depth because it has not only been influenced by the life review practice, but

it has had a major impact on life review theory and research. Most of the research

attention has been focused on Erikson’s eighth developmental stage: ego integrity

LIFE REVIEW / 165

versus despair, while the seventh stage: generativity versus stagnation, has been

largely ignored.

Three research topics are examined. Erikson’s concepts of ego integrity versus

despair is a primary focus of life review research. Another area of research interest

is the demographical differences in the practice of life review, particularly on how

gender influences the content of life reviews. Studies also suggest that life reviews

can impact favorably on staff, with the potential for reducing high rates of

personnel turnover among nursing home staff and home health aides.

There has been inadequate research attention on the qualitative process of

coming to terms with ones past, to reaffirm positive events and to reinterpret

difficult memories in the quest to enhance mental health. This neglect raises the

question of whether the growing numbers of staff persons, students, and family

members conducting life reviews are adequately trained to assist others. A goal

with therapeutic implications, therefore, is the development of a certified training

program that enhances the likelihood of safe and effective interventions.

The future direction of the field of life review may best be served by the

advancement of a greater number of coordinated sessions at professional

conferences, so that researchers, practitioners, and educators can systematically

address issues of high priority.

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LIFE REVIEW / 171

RESEARCH ARTICLE Open Access

The spiritual distress assessment tool: an
instrument to assess spiritual distress in
hospitalised elderly persons
Stefanie M Monod1*, Etienne Rochat1,2, Christophe J Büla1, Guy Jobin3, Estelle Martin1, Brenda Spencer4

Abstract

Background

: Although spirituality is usually considered a positive resource for coping with illness, spiritual distress
may have a negative influence on health outcomes. Tools are needed to identify spiritual distress in clinical
practice and subsequently address identified needs. This study describes the first steps in the development of a
clinically acceptable instrument to assess spiritual distress in hospitalized elderly patients.

Methods

: A three-step process was used to develop the Spiritual Distress Assessment Tool (SDAT): 1)
Conceptualisation by a multidisciplinary group of a model (Spiritual Needs Model) to define the different
dimensions characterizing a patient’s spirituality and their corresponding needs; 2) Operationalisation of the
Spiritual Needs Model within geriatric hospital care leading to a set of questions (SDAT) investigating needs related
to each of the defined dimensions; 3) Qualitative assessment of the instrument’s acceptability and face validity in
hospital chaplains.

Results

: Four dimensions of spirituality (Meaning, Transcendence, Values, and Psychosocial Identity) and their
corresponding needs were defined. A formalised assessment procedure to both identify and subsequently score
unmet spiritual needs and spiritual distress was developed. Face validity and acceptability in clinical practice were
confirmed by chaplains involved in the focus groups.

Conclusions

: The SDAT appears to be a clinically acceptable instrument to assess spiritual distress in elderly
hospitalised persons. Studies are ongoing to investigate the psychometric properties of the instrument and to
assess its potential to serve as a basis for integrating the spiritual dimension in the patient’s plan of care.

Background
The relationship between spirituality and medicine is a
field of growing interest [1-3]. In palliative care, the
spiritual dimension is considered as an important com-
ponent of care along with physical, psychological, and
social or existential support [4]. Spirituality is also con-
sidered an essential component of the multidimensional
approach used in geriatric care of elderly patients who
face illness, disability, and potentially life-threatening
events [5].
Spirituality has been shown to influence, usually in a

positive way, coping with illness, disability, or life-threa-
tening events [6-10]. Many studies have documented

significant associations between spirituality and better
mental, physical, and functional health, especially in
cancer, HIV, and hospice patients [11,12]. Some studies
have, however, shown that negative manifestations of
spirituality may be associated with poorer health out-
comes. Religious struggle, defined as negative feelings
towards God, feeling punished by God, or believing
that « the devil is at work in the illness », has been
associated with increased mortality in elderly patients
[13]. Spiritual distress, that can be defined as “a state in
which the individual is at risk of experiencing a distur-
bance in his/her system of belief or value that provides
strength, hope, and meaning to life” [14], seems also
associated with more severe depression and desire for
hastened death in end-of-life patients [15,16]. Spiritual
distress might have a potentially harmful effect on
patients’ prognosis and quality of life [17-20].

* Correspondence: stefanie.monod-zorzi@chuv.ch
1Service of Geriatric Medicine & Geriatric Rehabilitation, University of
Lausanne Medical Center (CHUV), 1011 Lausanne, Switzerland
Full list of author information is available at the end of the article

Monod et al. BMC Geriatrics 2010, 10:88
http://www.biomedcentral.com/1471-2318/10/88

© 2010 Monod et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

mailto:stefanie.monod-zorzi@chuv.ch

http://creativecommons.org/licenses/by/2.0

Despite evidence suggesting an association between
spiritual distress and worse health outcome, very few
intervention studies have been conducted to improve
patients’ spiritual health [21,22]. This may be explained
by the lack of consensus on the definition of spirituality,
and, as a consequence, of spiritual distress, within health
care research [23-25]. Numerous instruments have been
developed to assess spirituality. Most currently available
describe behaviours, beliefs or attitudes towards spiri-
tuality [26-28]. Although some instruments measuring
spiritual well-being or spiritual needs might equally
reflect spiritual distress [29-31], none of these instru-
ments has been designed for this specific purpose.
Moreover, conceptual models on which to base spiritual
assessment, spiritual distress recognition and spiritual
intervention in hospital settings are essentially lacking,
and are called for in order to improve patient care
[25,32]. These conceptual models should also be con-
gruent with other Bio-Psycho-Social processes of care in
order to promote integrative models of care in hospital
settings. These shortcomings need to be addressed as a
prerequisite to conducting intervention studies.
The present paper describes work to address this issue

and presents: a) an operational definition of spiritual
distress; b) the successive steps in the development of
an instrument to assess spiritual distress in hospitalized
elderly patients; c) the subsequent assessment of this
instrument’s face validity and acceptability in clinical
practice.

Methods
Basic concepts
There are different ways to assess spirituality; this
research focuses on assessment of the patient’s spiritual
state. Spiritual state is here defined as the patient’s feel-
ings regarding his or her spirituality. Spiritual state is
dynamic: it fluctuates according to a hypothesised spec-
trum of spiritual wellness, ranging from spiritual well-
being to spiritual distress. A spiritual state might be
worse because of external stressors such as illness or
bereavement; it may also be improved by spiritual inter-
vention. This concept of spiritual state appeared as the
most appropriate way to assess spirituality within the
hospital setting. The intention is that assessment of a
patient’s spiritual state should serve to determine the
need for specific interventions.
Based on this definition of a spiritual state, an opera-

tional definition of spiritual distress was hypothesised.
The hypothesis was made that spiritual distress arises
from unmet spiritual needs and that the greater the
degree to which a spiritual need remains unmet, the
greater the disturbance in spiritual state and the greater
the level of spiritual distress experienced by the patient.

Development of the Spiritual Distress Assessment Tool
(Figure 1)
The development of The Spiritual Distress Assessment
Tool (SDAT) was based on a conceptual model of spiri-
tual needs assessment previously published under the
name of the Spiritual

Needs Model [33].

Development of the Spiritual Distress Assessment

Tool was yet carried out in three stages.

a) Conceptualisation of spirituality and spiritual needs in
hospitalised persons: definition of the Spiritual Needs
Model [33]
An interdisciplinary group of health professionals (one
physician, four nurses, and three chaplains), working in
five different geriatric hospitals in Switzerland, met on
fourteen occasions over a two-year period to define and
conceptualise spirituality in the hospitalised person. The
group was directed by one of the co-authors (ER).
A literature search and review in PubMed and Google,

using “spirituality” and “religiosity” as search terms, was
performed to select and define candidate dimensions
that could characterize spirituality in hospitalised per-
sons. Candidate dimensions were discussed and consen-
sus was achieved through the sharing of spiritual care
experiences, role play and case analysis. Finally, using
the same process, the working party further defined the
spiritual needs corresponding to each selected dimen-
sion of spirituality.
The work of the interdisciplinary group resulted in a

definition of spirituality in hospitalised persons, of the
dimensions that characterize a patient’ spirituality and
of the needs corresponding to each of these dimensions.
The overall concept was defined as The Spiritual

Needs Model [33].

b) Definition of the Spiritual Distress Assessment Tool
(SDAT) and guidelines for administration
Two of the authors (SM and ER) decided to integrate
the Spiritual Needs Model into hospital geriatric care
over a six month period in order to assess its practic-
ability in clinical care.
This phase of the research was conducted in the post-

acute care unit of the Department of Geriatric Medicine,
University of Lausanne Medical Center. This 66-bed
unit admits patients aged 65 years and older and pro-
vides interdisciplinary care to restore the highest possi-
ble level of functional independence and quality of life.
Eighty percent of patients report a Judaeo-Christian reli-
gious background.
During this phase, the leader of the working party

(ER) was integrated into the interdisciplinary team. He
performed systematic bedside assessments of patients’
spirituality using the framework of the Spiritual Needs

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Model and participated in weekly interdisciplinary team
meetings to share the results of this assessment with
health professionals.
Over the six month period, 69 patients were assessed

by the chaplain using the framework of the Spiritual
Needs Model. Of those patients proposed a meeting
with the chaplain, only one refused. Characteristics of
the participants are described in Table 1.
Based on this experience, spiritual needs assessment

with use of the Spiritual Needs Model was progressively
structured and systematised. In the course of this pro-
cess, a set of questions was gradually devised for use in

the interview to investigate the patient’s spiritual needs
and guidelines to conduct spiritual needs assessment
(e.g. patient’s consent, confidentiality) were defined. In
parallel, a structured analytical framework was devel-
oped to assess the severity of unmet spiritual needs, as
manifested in the interview.
This process resulted in the definition of the SDAT,

that is, a formalised assessment procedure to identify
unmet spiritual needs, to score the degree to which
spiritual needs remained unmet and to determine the
presence of spiritual distress.
This part of the SDAT development was approved by

the institutional Ethical Review Board of the University
of Lausanne.

c) Assessment of the face validity and acceptability of the
SDAT
It was considered important to assess the validity of the
SDAT. However, as no consensus exists regarding the
definition of spirituality and the dimensions that charac-
terize spirituality, no real “definitional standard” could
be said to exist [34]. Thus, true assessment of the con-
tent validity of the SDAT against a gold standard would
not have been possible. However, face validity, consid-
ered as being a particular type of content validity, was
assessed. Face validity refers to whether persons not
involved in the development of an instrument perceive
it as measuring what it is deemed to measure [35].

Validation of the
SDAT

Acceptability in
chaplains skilled in
using the SDAT

Face validity in
chaplains with no
experience of the
SDAT

Acceptability of the
SDAT in
interdisciplinary team
members

Conceptualisation of
Spiritual Needs

Model

Operationalisation of
Spiritual Needs Model

leading to definition of the
SDAT

Establishment of
multidisciplinary spirituality
working party

Dissemination of the Spiritual Needs Model

Integration of Spiritual Needs
Model into hospital geriatric
interdisciplinary care

Definition of the four
dimensions of spirituality in a
hospital setting

Definition of needs
corresponding to the four
identified dimensions

Definition of assessment
questions and procedure

Spiritual Distress
Assessment Tool (SDAT)

Implementation of the SDAT in wider clinical settings

Testing of
psychometric
properties

Figure 1 Process of SDAT development and assessment of face validity and acceptability of the SDAT.

Table 1 Patients’ characteristics

Characteristics Population (N = 69)

Age (years) 82.5 ± 8.3

Women (%) 78.3

Living alone (%) 62.5

Cognitive impairment* (%) 30.4

Depressive symptoms † 12.1

Basic ADL at admission ¥ 2.5 ± 1.6

* defined as a score < 24 at the Mini Mental State Examination (score ranging from 0 to 30, with higher scores indicating better cognition)

† defined as a score ≥ 6 at the 15-item Geriatric Depression Scale (score
ranging from 0 to 15, with higher scores indicating more depressive
symptoms)

¥ Katz’s basic Activities of Daily Living (score ranging from 0 to 6, with higher
score indicating better function)

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In this case, we established whether hospital chaplains
experienced in hospital pastoral care, who had not been
in any way involved in the development or use of the
SDAT, perceived the instrument as able to measure a
patient’s’ spirituality.
Face validity of the SDAT in chaplains with no experience
of the SDAT, but experienced in providing hospital
pastoral care
In order to assess these characteristics, a moderated
structured discussion group was conducted with cha-
plains practising at the chaplaincy of the University of
Lausanne Medical Center (see

Appendix

) who were
unfamiliar both with the Spiritual Needs Model and
with the SDAT. Of the six chaplains invited, four pro-
testant chaplains accepted the invitation, one declined
and one catholic chaplain was not available. Participants
were invited to watch a video of a pastoral interview
using the SDAT and subsequently participated in a
moderated discussion lasting two hours. Chaplains were
asked to compare the interview with their own way of
conducting a first pastoral encounter with a patient, to
determine whether all dimensions of a patient’s spiri-
tuality were addressed in the SDAT interview and to
express their view on the structured approach used to
assess a patient’s spirituality in the hospital setting.
Acceptability of the SDAT in chaplains already skilled in
using the SDAT
Assessment of acceptability is commonly made in health
services research with a view to determining the poten-
tial impact of proposed services, since services can only
be effective if delivered and taken-up as intended. It is
therefore important during implementation to assess
acceptability in both service providers and service users.
As the SDAT was specially designed to be used by

chaplains, the acceptability of the SDAT was assessed in
members of the chaplaincy of the University of Lau-
sanne Medical Center who were already trained in use
of the instrument. In this case, the aim was to ascertain
to what extent these chaplains perceived the instrument
as relevant to their work and to what extent they con-
sidered its use feasible within the hospital setting.
Assessment of acceptability of the SDAT’s use in other

interdisciplinary team members (medical and paramedi-
cal) has also been performed [36] and is to be published
separately.
All four chaplains skilled in application of the SDAT,

and working in different hospital departments, partici-
pated in two structured, moderated group discussions,
each lasting two hours. Topics covered included: meth-
ods and level of appropriation of the SDAT by the cha-
plains; acceptability of the sets of questions proposed for
the patient’s interview; definition of skills necessary to
identify and score unmet spiritual needs.

Results
a) Conceptualisation of spirituality and spiritual needs in
hospitalised persons: definition of the Spiritual Needs
Model (Table 2)
Overall, spirituality in the hospitalised elderly person
was defined as the particular coherence expressed when
describing one’s meaning of life, referring to one’s trans-
cendence and explaining one’s values.
Spirituality, in the particular context of hospital set-

ting, was defined as a multidimensional concept that
includes four dimensions considered to be interrelated:
Meaning, Transcendence, Values and Psycho-social
Identity.
The Meaning dimension was defined as that which

provides orientation to an individual’s life and promotes
his or her overall life balance.
The Transcendence dimension was defined as an

anchor point exterior to the person; the relationship
with an external foundation that provides a sense of
grounding.
The Values dimension was defined as the system of

values that determines goodness and trueness for the
person, as made apparent in his or her actions and life
choices.
The Psycho-social Identity dimension was defined as

the patient’s environment; those elements, such as
society, caregivers, family, and close relationships that
together make up a person’s singular identity.
In hospital care, the patient’s medical, psychological

and social needs are systematically defined, assessed and
addressed. The same approach has therefore been
applied regarding the patient’s spiritual needs. Needs
corresponding to each dimension of spirituality were
thus defined.
The four defined dimensions of spirituality and their

corresponding needs are summarized in Table 2.

b) Definition of the SDAT (Additional file 1: Table S1)
Using the Spiritual Needs Model, a set of questions was
developed to facilitate investigation of the patient’s
needs (Additional file 1: Table S1). These questions
serve as prompts to be used only if the patient does not
spontaneously mention anything related to the investi-
gated need.
Guidelines for administering the SDAT
The SDAT is administered according to the following
procedure:
First, in order to identify unmet spiritual needs, a

20-30 minute semi-structured interview is conducted by
the chaplain with the patient after having obtained his/
her consent.
Second, immediately following the interview, the cha-

plain conducts an assessment of how the patient spoke

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about his or her five spiritual needs, using the analytical
framework to determine the eventual presence of spiri-
tual distress.
Third, needs are scored on a 4-point Likert scale ran-

ging from 0 (no unmet spiritual need) to 3 (severe
unmet spiritual need). A global score of spiritual distress
may therefore range from 0 (no spiritual distress) to 15
(severe spiritual distress). Examples of statements made
by patients experiencing unmet needs are provided in
Table 3.
At the end of the interview, the chaplain tells the

patient precisely what information he or she intends to
relay to the interdisciplinary team members, and
requests the patient’s consent to proceed. When pre-
senting results of spiritual assessments to the team, spe-
cial attention is taken to avoid unnecessarily sharing
intimate information and to ensure confidentiality.

c) Assessment of the face validity and acceptability of the
SDAT
Face validity of the SDAT in chaplains with no experience
of the SDAT, but experienced in hospital pastoral care
Chaplains reported overall positive appraisal of the
SDAT.

The Meaning, Transcendence and Psychosocial Identity
dimensions were clearly acknowledged by this group.
The Values dimension and, in particular, its related
needs (need to maintain control; need for values
acknowledgement) were more debated. The group
mostly acknowledged that chaplains do not systemati-
cally address this dimension unless they perceive some
discomfort around these issues for the patient. Never-
theless, they generally agreed that this dimension was
part of the patient’s spirituality, as it reflects the
patient’s need to make meaningful life choices. Some
chaplains also commented that certain aspects of religi-
osity, such as connection with the faith community and
the need for ritual, should have been more clearly
assessed in the video interview. They considered that
these aspects should not simply be subsumed under the
Transcendence dimension, but viewed as an additional
dimension.
Their appraisal of the structured format for spiritual

assessment differed from that of the group of chaplains
skilled in using the SDAT (see below). They raised the
question of the overall goal of a pastoral interview; for
most, it is to engage with the patient and not to assess
or to evaluate disturbance in their spiritual health. They

Table 2 Spiritual Needs Model: dimensions of spirituality and corresponding needs in hospitalized patients

Dimension of
spirituality

Definition of dimension Needs associated with dimension

Meaning The dimension that provides orientation to an individual’s life
and promotes his or her overall life balance.

The Need for life balance: The need to rebuild a new life
balance and the need to learn how to better cope with illness
or disability.

Transcendence An anchor point exterior to the person; the relationship with an
external foundation that provides a sense of grounding. The
group considered that everyone has an external foundation,
even if different from God. For example, for some people, this
transcendence might be found in nature, beauty, or art.

The Need for connection: The need for connection with his or
her existential foundation and the need for Beauty (aesthetic
sense).

Values The system of values that determines goodness and trueness for
the person; it is made apparent in the person’s actions and life
choices.

*The Need for values acknowledgement: The need that
health professionals know and respect one’s values.
*The Need to maintain control: The need to understand and
to feel included in decision-making processes and to be
associated with health professionals’ decisions and actions.

Psycho-social
Identity

The patient’s environment; those elements, such as society,
caregivers, family, and close relationships that together make up
the person’s singular identity.

The Need to maintain identity: The need to be loved, to be
heard, to be recognized, to be in touch, to have a positive
image of oneself and to feel forgiven.

*According to the hospital setting, two different needs were clearly distinguished to translate the values dimension.

Table 3 Examples of statements made by patients experiencing unmet needs

Need for life balance “I know I’ve got to find a way to cope, but I just can’t manage. I just don’t have the strength any longer”

Need for connection “I think that God has abandoned me”;
“I am no longer able to paint and it was the painting that kept me in touch with the force that kept me going”.

Need for values
acknowledgement

“I’m just a number here. The staff doesn’t know who I am.”

Need to maintain control “I don’t know what I’m doing here in the hospital. Why hasn’t anyone given me any medicine?”

Need to maintain identity “My friends don’t come and visit me; my family has no idea of what I’m going through here; I just don’t know
myself any longer.”

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argued that a spiritual interview should be tailor-made
for each patient, and should, therefore, be less directive
or restrictive than the SDAT. Some reluctance was
expressed about using a structured format, as this
seemed to imply that spirituality could be reduced to an
assessment instrument. They perceived a risk of “medi-
calising” [37,38] spirituality and limiting its assessment
to a health perspective. Nevertheless, it was agreed that
the structured format of the SDAT would be of use
when integrating pastoral care into health care and
could help chaplains synthesise their evaluation and
transmit meaningful information to health professionals.
The group also agreed that a structured format could
stimulate the assessment of dimensions that are not sys-
tematically addressed by chaplains, such as the Values
dimension.
Acceptability of the SDAT in chaplains already skilled in
using the SDAT
Overall, the SDAT was perceived by the chaplains as a
useful adjunct to their pastoral interviews. They
reported that the instrument allowed for more precise
assessment of patients’ spiritual needs. They also
reported that the SDAT facilitated the communication
of their observations to health professionals, and helped
them clarify their potential role as well as their own
implication in patient care. The structured format of the
SDAT emerged as both an advantage (more efficient use
of time, better organisation of the interview, systematic
investigation of the four dimensions) and a disadvantage
(restricts the flexibility of the interview, conveys the
impression that spirituality can be “put in a box”). The
group related that they tended to use the SDAT when
asked by health professionals to visit a patient, the
instrument allowing for a better synopsis and transfer of
relevant information.
The set of standardised SDAT questions for the

patient’s interview was considered as acceptable and
appropriate by the group. Chaplains felt comfortable
enough with the instrument to consider potential useful
applications in other settings or with younger patients
(assuming that additional questions such as how they
saw their future in terms of work, family life, or children
were used).
Chaplains considered that it was not difficult to iden-

tify unmet spiritual needs during the patient interview.
In contrast, assessing the severity of unmet spiritual
needs proved more problematic. In particular, they
pointed to the issue of adequately distinguishing
between the severity of unmet spiritual needs and the
availability of resources to cope with these needs.
A patient with a severe unmet need for life balance may
either be with or without resources to face this unmet
need (e.g., he may or not have a good social network).
The chaplains noted that when coping resources were

absent, they tended to score more highly the level of
spiritual distress than when these resources were
present.
Numerous skills necessary to use the SDAT were out-

lined by the group, the most important being good com-
munication skills, such as the ability to build a
meaningful relationship with the patient before going
ahead with the semi-structured interview, and having
empathetic listening skills. A second group of required
skills was more related to knowledge, such as familiarity
with the four spiritual dimensions and their related
spiritual needs, and theological and pastoral skills.
A third group of skills included the capacity to analyse
and synthesise the interview, and, a fourth group, the
capacity to transmit relevant information to other team
members.

Discussion

This paper presents in detail the different steps in the
development of an instrument aimed to assess spiritual
distress in hospitalised older persons.
Overall, results show that the proposed conceptualisa-

tion of spirituality in hospitalised elderly patient as
defined in the Spiritual Needs Model and the corre-
sponding assessment instrument (SDAT) have face
validity in chaplains providing hospital pastoral care and
prove acceptable to those experienced in their applica-
tion. Furthermore, chaplains did not report a feeling of
confusion with psychological assessment, a criticism
sometimes made of other spirituality constructs [39].
Certain reservations were, however, expressed.
Some chaplains felt that the definition of the different

dimensions was somewhat unusual. The Meaning
dimension is widely recognised as central components
of spirituality [40,41]. In the literature, Meaning gener-
ally refers to the finding of a global meaning to life and
death, and is generally associated with purpose in life
[3]. Elderly patients often mention that because of their
“old age”, they have no purpose in life, but still see
meaning in life. Thus, the definition of Meaning given
in the Spiritual Needs Model refers to what provides
orientation to an individual’s life and promotes his or
her overall life balance, rather than to definitions of the
individual’s new projects. Special attention was also
given to the Values dimension. This dimension is less
frequently identified as a specific dimension of spiritual-
ity. However, this dimension was warranted by the
importance of recognising each patient’s personal values
so as to ensure respect for the patient’s autonomy, dig-
nity and integrity [42,43]. This was considered especially
important in the hospital setting, given the vulnerability
of elderly patient in this respect.
Second, some chaplains would have attributed a stron-

ger, more explicit, place to religious practice, considering,

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for example, that rituals should be viewed as an addi-
tional spirituality dimension. Third, an additional impor-
tant reservation concerned the raison d’être of pastoral
hospital work: several chaplains expressed their concern
that pastoral care could become medicalised and then be
seen as a simple adjunct to health care. These reserva-
tions will need to be adequately addressed when attempt-
ing to further integrate spirituality assessment and
management into routine care.
Interestingly, chaplains did not challenge our initial

assumption that spiritual distress results from unmet
spiritual needs. In fact, chaplains commonly recognized
that the most promising way to integrate spirituality
into health care is to be consistent with the other care
processes established by the interdisciplinary team and
the established institutional policy. This approach
implies that the same approach be applied to spiritual
needs as to bio-psycho-social needs. It seemed therefore
rational to define spiritual distress as unmet needs.
Although not formally assessed, information obtained

from patient contact during the development process
indicates the feasibility and acceptability to patients of a
systematic and structured bedside assessment of their
spirituality. Also, the chaplain’s participation in weekly
interdisciplinary team meetings to share the results of his
assessment has demonstrated the feasibility of integrating
spirituality assessment into routine interdisciplinary ger-
iatric care. A survey enquiring about interdisciplinary
team members’ appraisal of systematic spirituality assess-
ment was conducted and showed that the contribution of
the chaplain to improving patient care through weekly
team meetings was considered essential [36].
It is, however, acknowledged that the feasibility and

acceptability demonstrated is context-specific. Whether
similar acceptance will be observed in other settings
requires further study. This work was performed in a clini-
cal setting already familiar with a comprehensive approach
to patients’ needs; these conditions may prove to be a pre-
requisite for successful integration of spirituality assess-
ment and for the participation of chaplains in routine care.
The Christian origin and advanced age of patients enrolled
in this phase of the development probably facilitated the
acceptability of the encounter with the chaplain. Further
assessment of acceptability will therefore be needed in lar-
ger, more diverse, elderly populations.
Besides these acknowledged limitations, the present

work also has several strengths. The SDAT was devel-
oped according to a rigorous structured process: spiri-
tuality in hospitalized older patients was conceptualized
through a consensus process, and its dimensions and
their corresponding needs were then specified. The
model was subsequently implemented within a clinical
setting in order to operationalize further the assessment

process. This process, going from the definition of spiri-
tuality to the definition of an instrument to assess spiri-
tuality, has previously been adopted in the development
of other spirituality assessment instruments (e.g. The
spirituality Index of Well-Being [44,45]) and strengthens
the relevance of the instrument. Finally, face validity and
acceptability in experienced chaplains were assessed.
Though relatively long and complex, this approach had
the advantage of ensuring contextual relevance for the
instrument since issues regarding implementation could
be dealt with progressively and in situ.
Although the SDAT was developed specifically in a

population of hospitalized elderly patients, chaplains
working with different populations saw considerable
potential for use in other settings and in other age
groups. Our procedure of assessment (a semi-structured
interview) enables the patient to speak about spirituality
with his or her own words and from very different per-
spectives. This should ensure relevancy of the SDAT for
every patient, whatever their age or religious or spiritual
background. Ultimately, the quality and limitations of
the SDAT will be judged by the sustainability and disse-
mination of its use: by other chaplains, in other Depart-
ments and institutions, in research and evaluation, and,
ultimately, in different cultural and religious contexts.
Furthermore, as previously mentioned, the instrument’s
use is conditional on the availability of staff experienced
in interdisciplinary care and with access to appropriate
training facilities.
As yet, very few instruments have been developed on

the basis of a spiritual needs construct. Two instru-
ments, coming from nursing research, have been identi-
fied [31,46]. These two instruments were based on
qualitative studies of patients who were asked to
describe their specific spiritual needs. The approach pre-
sented here is unique because spiritual needs were
assessed on the basis of a previously defined concept of
spirituality. This structured approach ensures coherence
between theoretical work and the investigative process.

Conclusions
These preliminary results suggest that the SDAT is an
acceptable instrument to assess spiritual distress in hos-
pitalised persons. The instrument provides a tool for
communication between disciplines, based on a shared
vocabulary, and provides a new basis for integrating
spirituality into the patient’s plan of care. Further
research is underway to assess the SDAT’s acceptability
in a larger sample of elderly patients and to investigate
its psychometric properties. These are necessary steps
before its application in intervention studies; that is,
before using the SDAT to assess the impact of spiritual
distress on health outcomes and patient prognosis.

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Appendix
The chaplaincy of the University of Lausanne Medical
Center
This chaplaincy was created by the hospital manage-
ment together with both the Catholic and Protestant
churches and has responsibility for pastoral care within
the hospital and for hospital pastoral training.
Chaplains work in all departments of the hospital,

regardless of the patient’s religious affiliation.
The chaplaincy is composed of 7 ordained chaplains

(2 Catholic; 5 Protestant) and 5 lay chaplains (4 Catho-
lic; 1 Protestant).
External chaplains from other religious affiliations

(rabbis, imams, Greek orthodox priests) are solicited on
patient request.

Additional material

Additional file 1: Table S1: Structure of the Spiritual Needs Model
and the Spiritual Distress Assessment Tool.

Acknowledgements

Source of research support:
Service of Geriatric Medicine and Geriatric Rehabilitation, University of
Lausanne Medical Center (CHUV), CH- 1010 Lausanne, Switzerland.

Author details

1Service of Geriatric Medicine & Geriatric Rehabilitation, University of
Lausanne Medical Center (CHUV), 1011 Lausanne, Switzerland. 2Chaplaincy
Service, University of Lausanne Medical Center (CHUV), 1011 Lausanne,
Switzerland. 3Faculty of Theology and Religious Sciences, University of Laval,
QC G1V 0A6 Quebec, Canada. 4Institute of Social and Preventive Medicine
(IUMSP), University Hospital Center and University of Lausanne, Bugnon 17,
1005 Lausanne, Switzerland.

Authors’ contributions
SM planned the study, supervised the development of the tool, supervised
the validation procedure, and wrote the paper. ER conceptualized the tool,
and helped write the paper. CB helped planned the study and contributed
to revising the paper. GJ contributed to conceptualization of the tool and
revising the paper. EM contributed to revising the paper. BS conceptualized
the overall qualitative methodology, performed the validation and revised
the manuscript.
All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Received: 12 March 2010 Accepted: 13 December 2010
Published: 13 December 2010

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Pre-publication history

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doi:10.1186/1471-2318-10-88
Cite this article as: Monod et al.: The spiritual distress assessment tool:
an instrument to assess spiritual distress in hospitalised elderly persons.
BMC Geriatrics 2010 10:88.

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http://www.biomedcentral.com/1471-2318/10/88/prepub

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Abstract
Background
Methods
Results
Conclusions
Background
Methods
Basic concepts
Development of the Spiritual Distress Assessment Tool (Figure 1)
a) Conceptualisation of spirituality and spiritual needs in hospitalised persons: definition of the Spiritual Needs Model 33
b) Definition of the Spiritual Distress Assessment Tool (SDAT) and guidelines for administration
c) Assessment of the face validity and acceptability of the SDAT
Face validity of the SDAT in chaplains with no experience of the SDAT, but experienced in providing hospital pastoral care
Acceptability of the SDAT in chaplains already skilled in using the SDAT

Results
a) Conceptualisation of spirituality and spiritual needs in hospitalised persons: definition of the Spiritual Needs Model (Table 2)
b) Definition of the SDAT (Additional file 1: Table S1)
Guidelines for administering the SDAT
c) Assessment of the face validity and acceptability of the SDAT
Face validity of the SDAT in chaplains with no experience of the SDAT, but experienced in hospital pastoral care
Acceptability of the SDAT in chaplains already skilled in using the SDAT

Discussion
Conclusions
Appendix
The chaplaincy of the University of Lausanne Medical Center
Acknowledgements
Author details

• Authors’ contributions

Competing interests
References
Pre-publication history

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