RESEARCH ARTICLE Open AccessThe spiritual distress assessm.docx

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: [email protected]
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:[email protected]
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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
Page 2 of 9
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)
Page 3 of 9
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
Page 4 of 9
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.”
Page 5 of 9
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,
Page 6 of 9

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.
Page 7 of 9
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
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2318/10/88/prepub
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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Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
AbstractBackgroundMethodsResultsConclusionsBackgroundMet
hodsBasic conceptsDevelopment of the Spiritual Distress
Assessment Tool (Figure 1)a) Conceptualisation of spirituality
and spiritual needs in hospitalised persons: definition of the
Spiritual Needs Model 33b) Definition of the Spiritual Distress
Assessment Tool (SDAT) and guidelines for administrationc)
Assessment of the face validity and acceptability of the
SDATFace validity of the SDAT in chaplains with no
experience of the SDAT, but experienced in providing hospital
pastoral careAcceptability of the SDAT in chaplains already
skilled in using the SDATResultsa) 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 SDATc) Assessment of the face validity and
acceptability of the SDATFace validity of the SDAT in
chaplains with no experience of the SDAT, but experienced in
hospital pastoral careAcceptability of the SDAT in chaplains
already skilled in using the
SDATDiscussionConclusionsAppendixThe chaplaincy of the
University of Lausanne Medical
CenterAcknowledgementsAuthor detailsAuthors'
contributionsCompeting interestsReferencesPre-publication
history
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Assignment 1:
Create Article -Toolkit Parent Education: Home to School
Connections Grade K-3
For this Assignment, you will create (2) newsletter articles to
educate others on creating positive relationships.
Article 1: Parents Newsletter (1 page)
Scenario 1:The first article is for the parent newsletter that is,
sent to all families.
Write a 1- Page article on creating positive relationships
between school staff and families. In your article, include the
following:
1. Why home and school relationships are important. Provide a
rationale citing specific references to the Learning Resources
and outside resources you researched.
2. Strategies for creating positive relationships between home
and school. Ideas for using technology to increase interactions
between home and school.
Article 2: Staff only Newsletter (1 page)
The second article is for the staff-only newsletter that is, sent to
all staff at the school.Write a 1-page article on creating positive
school professional to student relationships. Keep in mind that
all school professional to student relationships are important,
including the secretary, the lunchroom aide, the custodian, etc.
In your article, include the following:
1. Why school staff and student relationships are important.
Provide a rationale citing specific references to the Learning
Resources and outside resources you researched.
2. Strategies for creating positive relationships between school
staff and students. Provide ideas for building relationships with
students from diverse backgrounds.
Include a reference page of at least 2 outside resources per
article (minimum of 4 resources) you used to support your
articles.

Helpful Reference
Gurland, S. T., & Evangelista, J. E. (2015). Teacher-student
relationship quality as a function of children’s expectancies.
Journal of Social and Personal Relationships, 32(7), 879–904.
Wilkins, J. (2014). Good teacher-student relationships:
Perspectives of teachers in urban high schools. American
Secondary Education, 43(1), 52–68.
Waddell, J. H. (2013). Working with families in urban teacher
education: A critical need for all students. Teacher Educator,
48(4), 276–295.
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

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