Keywords

Introduction

Psychosocial Challenges in Old Age

According to the psychosocial theory, human development is a product of the ongoing interaction between individual biological and psychological needs and abilities, on the one hand, and societal expectations and demands, on the other. Major changes in old age comprise changes in identity, roles, and relationships, due to reduction in active work roles and active parenting roles, declining abilities and health, probably loss of spouse, and anxiety of death. For psychosocial well-being, the challenge is to find new life goals, sources of personal meaning, adaptation of roles and relationships, and a new pattern to daily life in this stage (Newman & Newman, 2009). This article focuses on psychosocial challenges and well-being for older women, and therefore, gender is used as a major construct to understand this phenomenon.

Androcentry in Gerontology

When the Dharmashastra discusses Vanaprasthashram and Sannyasashram, they refer to men. It states that in Vanaprasthashram, the man should leave the village and go to the forest. He may go either with his wife or leaving her in the care of his sons. Thus, in the scriptures, women's role in old age is not identified independently. She has to facilitate the performance of men's social duties (Kapadia, 1966). Like religion and most of the disciplines, gerontology has also not been free from androcentry. Early research in gerontology focused explicitly or implicitly only on issues relating to older males (Abu-Laban, l992). While gerontology has not given importance to women's issues, in the 1970s, the women's movement, composed primarily of younger professional women, also did not define aging as a feminist issue. However, it is but natural that the patriarchal controls throughout their lives shape many of the problems faced by women in old age (Hooyman, l987).

Sexism and Gender in Old Age

While older men face the prejudicing ideology of agism, women face agism as well as sexism, making it double difficult. Sexism consists of attitudes, policies, institutional structures, and actions that discriminate against one sex (often but not always, against women), limiting freedom and opportunities (Griffin, 2008). For ages, it was believed that the subordinate status accorded to women in society is determined by biology (that is, sex), that it is natural and, therefore, not changeable. The distinction between “sex” and “gender” was introduced to deal with this tendency to attribute women’s subordination to their anatomy. Gender is a matter of culture; it refers to the social classification of men and women into “masculine” and “feminine.” Gender has no biological origin; the connections between sex and gender are not natural (Bhasin, 2000). Gender has determined access to resources such as access to education and health services, lower earning capacity and limited access to rights to land ownership, contributing to their vulnerability in older age (Helpage International, 2012). This vulnerability is faced by increasingly more women due to feminization of aging.

Feminization of Aging

With a few exceptions, women have longer life expectancies than men in both developed and developing countries. Globally, during 2010–2015, women outlived men by an average of 4.5 years (United Nations, 2015). In India, life expectancy at birth in 2009–13 was 65.8 for males and 69.3 for females (India: Ministry of Statistics & Program Implementation, 2016). The reasons relate to both female biology such as hormonal protective factors and fatal risk factors associated with male working conditions, lifestyles, and higher risk of injury (World Health Organization (WHO), 2007).

As a result of higher longevity among women, the sex ratio in the 60+ age group is better than that in the population as a whole (United Nations, 2015). It is interesting to note that in India, up to the Census of 1991, the number of elderly males exceeded the number of females, probably due to poorer health status of women at that time. In the last two decades, however, the trend has been reversed and the elderly females outnumber the elderly males (India: Ministry of Statistics & Program Implementation, 2016). According to the Census of India in 2011, there are nearly 104 million elderly persons in India; 53 million females and 51 million males (Helpage India, 2015).

Thus, because of higher longevity of women and higher proportion of women in the old population, the problems of aging are increasingly becoming women's problems. This is called “feminization of aging” (Helpage International, 2012).

Conclusion

In conclusion, the problems of older women are found to be not so much a product of the aging process per se as they are a product of the subordinate status of women throughout their life cycle. Women dominate the older person population in terms of numbers, but older women suffer more than men due to strong gender barriers that continue even in late age in a more explicit manner (Giridhar et al., 2015). In the context of agism and sexism, this article examines the challenges of changing status, roles, and relationships in family life as a wife, mother, mother-in-law, grandmother, and caregiver; and in marital life, and sexuality in old age. The article further discusses women’s challenges of coping with grief and bereavement, widowhood, and acceptance and planning for death. In this context of these changes, the challenge is to adapt one’s roles and relationships, find new life goals and sources of personal meaning, and a new pattern to daily life in this stage for achieving psychosocial well-being. For facilitating older women’s psychosocial well-being, the article recommends the psychosocial services of life skills development, facilitation of reminiscences and life reviews, and death education.

Challenges of Changing Family Life for Older Women

Living Arrangements

According to the 2011 Census of India, more than 56% of elderly persons live with their spouse and 32% live with their children. About five percent of elderly persons live alone, while another four percent live with other relations and non-relations (India: Ministry of Statistics & Program Implementation, 2016). Giridhar et al. (2015) note that a higher percentage of older women live with their children or grandchildren (46%) compared to only 12% of older men. This is not surprising as in India children are supposed to provide care in their old age. Preparation for old age includes the attempt to have at least one son to take care of one's needs in old age. Childless couples and those who have only female children begin at some point to consider alternatives such as remarriage, adoption, or the taking of a Ghar Jamai (son-in-law) with their old age in mind (Vatuk, 1975).

Changing Family Roles and Relationships

Stets and Burke (2000) note that femininity is associated with being expressive, emotional, tender, and sympathetic. This learned behavior is what makes up gender identity and determines gender roles (Williams et al., 1994). This identity makes even career women more family-oriented, and changes in this identity and roles are challenging for older women.

Traditionally, old age gave a high status to elderly women and power over her grown up children and the younger women in the family. The arrival of the daughter-in-law was supposed to reduce the workload of the aging woman. Conventionally, in India, both the women are supposed to be competitors for the attention of the son/husband and, therefore, rivals. The divide between mother-in-law and daughter-in-law, created to secure women's cooperation to patriarchy, gets aggravated with growing individualism in the liberalized scenario. The modern urban family is individualistic and consumeristic where relationships are considered secondary to the creation and satisfaction of wants (Pereira, 1997). Individualism has led to increased self-centeredness and the commodification of relationships. The elderly cannot claim authority or role in family decision making if they are not productive. On the contrary, they are often neglected in this scenario. The elderly women who generally do not have the ownership right to family housing or property tend to continue the household duties in order to prove useful to their family (Shah et al., 1995).

Becoming a grandparent brings a psychological transformation as well as a change in the family system. With the birth of the first grandchild, the elderly may begin to reflect on the life phases of their own childhood and parenthood. Depending on one’s level of engagement in the grandparent role, grandparenthood may require a renewal of parenting skills that have been stored away. A person’s parenting skills, patience, and knowledge come into play in a new configuration. However, this role is negotiated by their adult children (Newman & Newman, 2009). Women provide care to their grandchildren in a much less stressful state of mind, than when they were caregivers to their children. They are also known to be less authoritative and more indulgent with their grandchildren (Shah et al., 1995).

Challenges of Caregiving

Increased longevity has led to impairments and health problems and the need for caregiving for older persons. In the absence of appropriate services in developing countries, the responsibility for providing long-term care for very old/disabled/immobile older persons usually falls on the family. This can be a heavy burden for families with already stretched resources, especially when it prevents adults from working and children from attending school. Within the family, women provide most of the day-to-day care for older persons who need assistance in both developing and developed countries (United Nations, 2011).

The sexist ideology of patriarchy argues that because women give birth to children and are weaker, they, and not men, are biologically better at care of children, spouse, and the elderly in the family. However, caregiving work that women do all their life is not considered work in the patriarchal society. It is considered private as against men's work, which is market-oriented and public. Moreover, the provision of family care is often achieved at the detriment of female caregivers’ economic security and good health in later life (WHO, 2002).

In the future, India’s system of family-based support will not be able to withstand the increased numbers of older Indians, especially given increased female labor force participation, smaller numbers of more mobile children, widening generation gaps, and increasing burdens of costly-to-treat diseases such as diabetes, cancer, and stroke (Bloom, 2011, cited by Population Reference Bureau, 2012). In this context, an old woman is often the caregiver to her elderly husband, who is generally older than she is. Older women are also more likely than older men to be caregivers of children or sick relatives, particularly in families affected by migration or illness (Helpage International, 2012). However, the domestic and caring contributions of older women, which often enable family members to take paid work outside the house, are rarely acknowledged and are often belittled by older women and men themselves. As the number of very old women continues to increase and the pool of available caregivers continues to decrease, families and policymakers increasingly look for other options.

There is a need to recognize and address gender differences in the burden of caregiving and make a special effort to support caregivers, most of whom are older women who care for partners, children, grandchildren, and others who are sick or disabled. Moreover, it is important to recognize that older caregivers may become socially isolated, financially disadvantaged and sick themselves, and attend to their needs (WHO, 2002). Caregivers must be supported and nurtured to enable them to maximize the care they deliver, to manage the considerable stress that can accompany caregiving, and to be able to sustain a caregiving role over a long period of time—often many years. Part of the answer may lie in increased home and community support services (WHO, 2007).

Challenges of Neglect and Abuse

Domestic violence against the vulnerable family members has increased in the context of the nuclearization of family, separation of private and public spheres, increased individualism and commodification of relationships, and weak community supports. Everything that happens within the four walls of the modern family is considered a private matter, and no outside intervention is encouraged. Family violence, therefore, often remains invisible, undiscussed, and unchallenged (Bhasin, 2000). The elderly who are not considered productive are also vulnerable to violence.

Elder abuse is generally defined as physical, emotional, or sexual abuse of older persons by someone in a position of trust, which occurs worldwide. It can take place within the family, in hospitals, in old age homes or elsewhere. There are also specific threats related to traditional beliefs, including violence as a result of accusations of sorcery and violence against particularly vulnerable older persons such as migrants, older persons with disabilities, older persons in conflict situations, and older persons living in poverty, particularly the homeless (United Nations, 2011). High level of illiteracy and lack of remunerative occupation, among elderly women, in comparison with their male counterparts, make elderly women more vulnerable than elderly men, to get abused by their sons and daughters-in-law (Shah et al., 1995).

According to Giridhar et al. (2015), about 13% of rural older women and nine percent of urban older women have reported experiencing some form of abuse. For women, verbal abuse is the main form of abuse, and physical abuse is the least prevalent form. The abuser of the older women is generally the daughters-in-law.

The United Nations (2011) identified the following as risk factors of elder abuse:

  • Social isolation can increase family stress and decrease problem visibility or intervention.

  • Dementia can foster abuse or retaliation against abuse by the caregiver.

  • Shared living arrangements between the victim and the perpetrator with the frequency of contact serve to inflame conflict and abuse.

  • Pathology on the part of the perpetrator can provoke anger or frustration and reduce inhibitions for abuse occurrence.

  • Older women are at special risk of being abandoned and having their property seized when they are widowed in many societies.

  • For older persons in residential/institutional long-term care facilities, abuse is documented as having been perpetrated by staff, visiting family members and friends, and residents.

Conclusion

While grandparenting is a new source of psychosocial well-being, increasing number of elderly women experience loss of status and roles in the family. Since women have traditionally always linked their identity with their roles and relationships, the changes and vacuums in this area can lead to despair. Increased longevity, nuclearization of families, and increased female labor force participation also imply that the very old women continue to carry out household chores and provide caregiving roles. In the consumeristic and individualistic modern families, older women are also vulnerable to loneliness due to neglect and indifference from their children. Further, elderly women are more vulnerable than elderly men, to get abused by their sons and daughters-in-law.

Challenges of Changing Marital Life for Older Women

Married older persons are less likely than those who are unmarried to show signs of depression and to feel lonely and are more likely to report that they are satisfied with life. Being married has also been linked to lower mortality (United Nations, 2011).

Changing Marital Roles and Relationships

Gutmann (1987, cited in Turner, 1994) noted that the end of active parenting and earning in old age are thought to remove the context of gender role enactment in old age. He further suggested that, if gender typing were a power attribute, social behavior that is viewed as less important or less relevant to societal maintenance, would be seen as feminine. Social behavior in old age is being seen as less important and thus as less masculine. These changes are likely to bring about more closeness in husband–wife relationship in old age (United Nations, 1993). While increased closeness in the marital relationship in old age is a new source of pleasure, changing sexuality is a challenge and brings further changes in the marital relationship.

Challenges of Sexuality in Old Age

Menopause in Women and Implications

Menopause as cessation of menstrual periods and reproductive role of women. It generally takes place between 45 and 55 years of age, bringing a variety of physiological changes, some of which are the result of cessation of ovarian functions and others are an effect of the aging process (WHO, 1996). It is directly associated with physical symptoms including increases in vasomotor symptoms, vaginal dryness, pain during sexual intercourse, and central abdominal fat, as well as decreases in breast tenderness, bone mineral density, and sexual functioning (WHO, 2007). This can make sex uncomfortable. However, not all women lose interest in sex after the menopause. Some women find they can relax and enjoy sex even more now that they no longer have to worry about getting pregnant. Women may be less interested in sex than before as the result of other stress in their own or their partner’s life, and their interest in sex may return when this stress has gone (The Women’s Health Council, 2008). Although generally sexual interest and need continue throughout old age, for both men and women, at the level at which it was in the earlier decades (Starr, 1987), the many fallacious myths, surrounding menopause, have perpetuated a negative attitude about the decreased utility of women in the postmenopausal phase.

Menopause marks the beginning of a new stage for women, aging. The years before may have been taken up with rearing the family, building relationships, and career. Around the time of the menopause women’s relationships with your partner, parents, children, or close friends change as they too become older. Their attitude to work may change; they may look for new challenges or feel they want to slow things down (The Women’s Health Council, 2008). Regardless of differences in how it is experienced, the menopausal transition can provide an important focus, a time that can be used to reassess one’s health, lifestyle, and goals (WHO, 2007).

Many women go through this stage of their lives without any psychosocial problems. For those who do have problems, each woman’s experience may be different. Besides the physiological changes, women experience psychosocial changes, dramatically affected by sociocultural factors. For example, losing the bodily youth may lead to depression in women for whom it is an important part of their life. While there are many causes of depression and anxiety, the symptoms of the menopause may contribute to these feelings. For example, night sweats can disturb your sleep, and tiredness makes it harder to cope with stress. The changing hormone levels may also affect their mood. This is often a time of change and stress for women, and this can contribute to feelings of depression (The Women’s Health Council, 2008).

Sexual Behaviors in Old Age

Sexual interest and need continue throughout the life cycle for both men and women. The type and frequency of sexual behaviors in old age is contingent upon physical and psychosocial factors. Sexual behaviors not only comprise intercourse but range from petting to masturbation to intercourse. Whether sexually active or not, older persons have a continuing need for an intimate relationship to at least one other person. Sexual activity in old age can take the form of masturbation for those who do not or choose not to have a partner (McInnis-Dittrich, 2005). Long-lasting marriages tend to be more companionate in nature, emphasizing intimacy, and commitment over passion (Newman & Newman, 2009). However, old couples who do not have their own bedrooms in their homes shared with their children, or living in nursing homes, or old age homes, may not have adequate privacy for sexual behaviors (McInnis-Dittrich, 2005).

Agism in Sexuality

While the circumstances in old age may bring husband and wife closer to each other, agism discourages sexuality in this stage of life. Older adults face agist that is negative social attitudes about sexual activity that may inhibit their sexual behavior. These social attitudes include assumptions that very old adults do not have sexual desires, they cannot have intercourse because of sexual dysfunction, sex may be dangerous to their health, they are physically and sexually unattractive, and it is morally wrong or perverted for older adults to be sexually active (Crooks & Bayer, 2005, cited by Newman & Newman, 2009).

Gender Differences in Sexuality

Throughout life, women's sexuality is suppressed through dressing codes, restrictions on mobility, emphasis on early marriage, virginity and monogamy, imposition of purdah, limits on interaction between the sexes and exclusive emphasis on heterosexual relationship, in order to control women's reproduction. However, with the cessation of women's reproductive role with the onset of menopause, these restrictions are generally relaxed. However, asexuality is assumed to replace passive sexuality among women after menopause (Golub, 1992). Even when older women do not have children, they are generally called a mother, in harmony with her asexual image (Kua & Ko, 1998).

Arber and Ginn (1991, cited by Powell, 2001) claim patriarchal society exercises power through the sexualized promotion of a “youthful” appearance in women. Media also portray mature men as sexually attractive, but women in the postmenopausal age are depicted as neither sexually active nor sexually attractive, since society equates attractiveness in women with youth. Feelings of shame and revulsion toward their aging body may be sexually inhibiting for the older women (Kua & Ko, 1998).

Another gender difference in old age with reference to sexuality is that society is generally accepting of older men seeking out younger female partners, but negatively views older women seeking out partners (Kua & Ko, 1998). Moreover, with the uneven ratio of older men to older women, men may have more opportunities for sexual partners compared to women (McInnis-Dittrich, 2005).

Conclusion

Marital life in old age is likely to bring husband and wife together due to the end of active parenting and earning roles. Women also experience increased sexual freedom after menopause However, older women need to cope with the psychosocial challenges of implications of menopause and gender stereotype of sexuality changing from women being sexually passive to being asexual in old age. In this context, companionship, emphasizing intimacy, and commitment often overtake passion in marital relationship.

Challenges of Grief and Bereavement for Older Women

Challenges of Grief and Bereavement

Newman and Newman (2009) note that death is at once a certainty, in that all living things die, but the timing of death is not known. So, death is inevitable but unknowable. Yet we do not like to talk about it at any stage in our lives. However, in old age, anxieties related to one’s own and one’s spouse’s death start bothering the elderly. At this time, the realities about death are important to accept. In middle adulthood, most people experience the death of their parents. During young old age, one’s peers including siblings and spouses may die. These deaths are sources of psychological stress and require the emotional process of grief and mourning and the cognitive strain of trying to accept or understand death (Newman & Newman, 2009).

Challenges of Widowhood

Demography of Widowhood in Old Age

A major transition into old age occurs due to the loss of spouse that contributes to a feeling of increased insecurity among both men and women (United Nations Population Fund (UNFPA), 2011). Not having a spouse in the older ages is a cause for concern for both men and women. However, most of the older men in the world are married, while most of the older women are not, as they are likely to be widowed. The reasons is that women usually outlive their husbands—a circumstance linked both to women’s higher life expectancy and to the fact that they tend to marry men older than themselves. Moreover, men are more likely than women to remarry after being divorced or widowed. Because the surviving spouse is usually the wife, older women are very likely to become widows and spend their older years alone (United Nations, 2011). The 2001 Census of India shows that about half of all elderly women were widowed at that time, while only 15% of elderly men were widowers. In more advanced age of 80 years and above, 71% of women and only 29% of men having lost their spouses (UNFPA, 2011).

According to Giridhar et al. (2015):

  • In India, widows experience a shift in their living arrangements in old age from living with spouse to either living alone or living with adult children, a shift that fewer older men face.

  • About 10% of older women live alone as against two percent of older men. A significant reason for older women living alone is that their children are away.

  • A majority (69%) of older women who are living alone also prefer to live alone (that is they are able to cope) while only 35% of older men living alone prefer to live alone.

According to Giridhar et al. (2015), about 80% of older persons living alone are in contact with their children. They note that older women are less capable of initiating communication with their non-coresiding children due to inability to handle communication equipment by themselves without assistance from others than older men.

Sociocultural Challenges for Old Widows

Traditionally, to be a Suhagan is the best status a woman can attain among Hindus. The wife is supposed to be bound to her husband even after his death. Traditionally, on the death of the husband, the woman lives a life devoid of any status in the society. Besides facing the problems of bereavement, a widowed woman is particularly pushed to the periphery of the society, as a woman has any status in the society only if she is married. Sexuality outside of marriage is out of question for widows. They also have to renounce all the other joys of life. Moreover, they are considered unlucky, so generally not allowed to attend auspicious functions. While this situation is changing, the societal ideal in industrialized countries also emphasize the normalcy of not just marriage but also couple activities. As the status of women in many societies is linked to the status of their husbands, widows and unmarried older women can become particularly vulnerable to poverty and social exclusion (Helpage International, 2012).

Financial Challenges for Old Widows

With death of the spouse, the effect is more likely to be also financial for older women. Many widowed women depend on the husband’s pension, and those benefits may be too meagre to prevent poverty. Since women traditionally do not own land, housing, or other assets such as savings, they become and also feel more dependent. However, widowed women are more likely to have assets in their name compared to married women, since the asset is transferred to them on the death of their spouse (Giridhar et al., 2015). However, in some developing countries, women lack legal and enforceable property inheritance rights when the husband dies and have little or no recourse if the husband’s relatives move to take over the dwelling, landholding, or other property (United Nations, 2011).

Only 45% of older women living independently report receiving some financial assistance from their non-coresiding children. This is yet another cause of increased vulnerability among older women. About 21% of them (mostly those living alone) felt that the government should support them. There is also a good proportion of older women (23%, particularly in 60–64 age group) who felt that adults should be independent.

In 1997, I had carried out case studies of institutionalized elderly women, which showed that the elderly women’s social status changed when they lost their husband/men. Until their husband/men were alive, they had a place to live. Even for women who earned more than their husband, they did not have ownership of their matrimonial home. Thus, widowhood leads to social, emotional, and financial insecurity.

Conclusion

Older women are more likely to face death of the spouse than older men are and be less in contact with the non-residing children. They are, therefore, more likely to feel lonely. Older women also face the sociocultural challenges of widowhood and financial deprivation more than older men.

Summary of Psychosocial Challenges faced by Older Women and Services to Facilitate Psychosocial Well-Being

Summary of Psychosocial Challenges Faced by Older Women

While older men also face psychosocial challenges, the psychosocial challenges faced by older women are based in gender biases aggravated by age. Since women have traditionally always linked their identity with their roles and relationships, the changes and vacuums in this area can lead to despair. Older women need to cope with the psychosocial challenges of implications of menopause and gender stereotype of sexuality changing from women being sexually passive to being asexual in old age. Older women are more likely than older men to lose their spouse, face grief and bereavement, and life of widowhood. In the consumeristic and individualistic modern families, older widows are also vulnerable to loneliness and neglect and indifference from their children. Further, as discussed in this article, older women are more vulnerable than elderly men, to get abused by their sons and daughters-in-law. Older women are more likely to face death of the spouse than older men are and be less in contact with the non-residing children. They are, therefore, more likely to feel lonely. Older women also face the sociocultural challenges of widowhood and financial deprivation more than older men. Older women also need help in coping with death of the loved ones and accepting the certainty of their own death and planning what they think is a “good” personal death.

Many old women in India are active in various activities such as prayer, yoga, household chores, and social networking (Giridhar et al., 2015). These activities provide social support to older women. Such support is useful as:

  • It reduces isolation.

  • It reduces the impact of stressors.

  • It increases longevity (Newman & Newman, 2009).

Support centers for older persons need to be set up in every community, appropriate to local needs, decentralized, and democratically locally self-governed. These centers for older persons can provide the following services to promote psychosocial well-being of older women: workshops for life skills development, facilitation of reminiscences and life reviews, and death education.

Psychosocial Well-Being

Well-being is one domain of quality of life and is concerned with one’s subjective perception of and feelings about life, commonly operationalized in terms of “happiness” or “life satisfaction.” The term subjective well-being (SWB) is defined as an individual’s experience of affective reactions and cognitive judgments. The affective component is associated with emotions, feelings, and moods, while the cognitive component refers to what the individual thinks about his or her life satisfaction. Happiness is sometimes used interchangeably with SWB, but the terms mean different things. Assessing life satisfaction involves past experience and future expectations. Having a high SWB involves having “pleasant emotions, low level of negative mood, and high life satisfaction” (Diener et al., 2002, cited by Rojas, 2016).

Psychosocial well-being is essential not only for mental health but also for physical health, at preventive as well as remedial levels. The self-perception of healthy people, characterized by having positive feelings about themselves, a feeling of self-control, and an optimistic vision of the future, provides reserves of and a driving force for resources not only to cope with everyday difficulties but also with those which are especially stressful and even threatening for one’s existence (Taylor et al., 2000, cited by Vázquez et al., 2009).

Workshops for Life Skills Development

Importance

The psychosocial challenges that older women and men face can be very effectively dealt with by workshops for life skills development. These workshops are useful for psychosocial well-being of the caregivers of the elderly also. Older women and female caregivers may benefit from gender awareness integrated into these workshops.

Concepts and Modules

  • According to Newman and Newman (2009), life skills are psychosocial in nature. The psychological skills comprise self-awareness, proactive thinking skills, and emotional intelligence. The sociological skills include collaborative interpersonal relationship skills, family life education, and sexuality education.

Objectives

These modules can be conducted with the following objectives (For more details, see Desai, 2018).

Objectives of self-empowerment:

  • Identify one’s unique identity and balance it with group identities.

  • Learn to accept, value, and love oneself.

  • Learn to be assertive and avoid being passive or aggressive.

  • Take responsibility for one’s thinking, feelings, decisions, and behavior.

  • Develop integrity that leads to genuineness, honesty, and trustworthiness.

Objectives of proactive thinking skills:

  • Turn reactive thinking into proactive thinking skills.

  • Turn irrational thinking into rational and critical thinking skills.

  • Turn rigid thinking into flexible and creative thinking skills.

  • Turn negative thinking into positive thinking skills.

  • Develop decision-making skills.

Objectives of emotional intelligence:

  • Develop awareness of emotions in self and skills to express them.

  • Develop awareness of others’ emotions through sensitivity and empathy.

  • Learn to regulate healthy negative emotions and prevent unhealthy negative emotions.

  • Develop problem-solving skills.

  • Learn to enhance positive emotions of love and happiness.

Objectives of sensitive interpersonal relationship skills:

  • Develop positive perception of and positive feelings for others.

  • Learn to value adaptability and interdependence in relationships.

  • Learn the sensitive verbal, non-verbal, and listening skills.

  • Develop skills for giving and receiving positive feedback.

  • Learn the skills to identify win–win goals, giving and receiving negative feedback, and conflict management.

  • Learn the teamwork skills of commitment to group goals, group accountability, and consensual decision making.

Objectives of family life education:

  • Learn to democratize family’s internal dynamics.

  • Learn to democratize family’s interaction with its environment.

Objectives of sexuality education:

  • Obtain knowledge about sexual and reproductive anatomy.

  • Obtain knowledge about biological changes in menopause.

  • Learn to deal with psychosocial implications of menopause.

  • Develop positive values, attitudes, and social norms of sexuality.

  • Learn to enjoy changing sexual relationships.

Facilitation of Reminiscences and Life Reviews

Importance

In old age, accepting one’s past life, as it has been, is often a difficult personal challenge. The elderly may face a continuous haunting desire to be able to do things differently, or of bitterness over how one’s life has turned out. Most people have some regrets. The gradual deterioration or loss of certain physical capacities contributes to their frustration and discouragement. Facilitating reminiscences and life reviews for older women are also effective in helping them bring integrity to their life instead of despair. Reminiscence can be used to foster skills of self-understanding, conflict resolution, acceptance of life as lived, and the understanding that life is finite. Reminiscence is an important strategy in old age that promotes a sense of identity across the life cycle and allows a person to cope with change and loss (Serrano, 2016). As a prevention strategy, it has great potential for promotion of well-being in old age.

Concepts

Reminiscence is the intentional process of retrieving episodes personally lived in the past. This retrieval of past memories may or may not have a logic or sequence in terms of the topics recalled. Reminiscence tends to be highly spontaneous and mostly unstructured, without understanding and evaluation of the memories. On one hand, reminiscence provide people with the opportunity to relate episodes and/or tell their life history. On the other hand, especially in older adults, reminiscence can be used as a way to promote mental health and a prevention strategy for mental disorders as it helps a person feel more confident and self-assured when dealing with the changes related to old age (Serrano, 2016).

Approach

In contrast to simple reminiscence, discussed above, life review reminiscence is much more structured, focusing on the integration of positive and negative life events (Serrano, 2016). One’s life review may be a playful recalling of a life adventure and/or a painful review of some personal or family crisis. Individuals must be able to take pride in areas of achievement as well as be able to accept areas of conflicts, failure, crisis, or disappointment without being overburdened by a sense of inadequacy. Through this review, they can revise the meaning of past choices, decisions, and events by using current wisdom to understand or accept what took place in the past. The attainment of integrity is ultimately a result of the balance of all psychological crises that have come earlier, accomplished by all the ego strengths that have accumulated along the way. Integrity is an ability to integrate one’s past history with one’s present circumstances and to feel content with the outcome. In this process, a person seeks to find an integrative thread that makes sense of the life one has led without belaboring past mistakes. It helps them to appreciate the significance of the events in the formation of their unique adult personality (Newman & Newman, 2009).

Death Education

Objectives

Objectives of death education are:

  • Learn to cope with grief and bereavement after loss of a loved one.

  • Understand death from religions and other sources and accept death as a certainty.

  • Planning for a good personal death.

Coping with Grief and Bereavement

Grief refers to the cognitive and emotional reactions that follow the death of a loved one and comprises:

  • Preoccupation with thoughts of the deceased person.

  • Longing for the person.

  • Painful emotion.

  • Feeling of dissociation—disconnected from reality.

  • Sensory illusions that lead to the impression that the deceased person is still present (Newman & Newman, 2009).

Grief is an active process that involves choices in coping in which a person must do several things:

  • Acknowledge the reality of the loss.

  • Work through the emotional turmoil.

  • Adjust to the environment where the deceased is absent.

  • Loosen ties to the diseased (Worden, 1991, cited by Kail & Cavanaugh, 2007).

Bereavement is a long-term process of adjustment to the death of a loved one and is more all-encompassing than grief. It commonly includes:

  • Physical symptoms.

  • Role loss.

  • Seeking meaning in the loss.

  • Trying to solve problems that arise as a result of loss of the loved one.

  • A variety of intense emotions, including anger, sorrow, anxiety, and depression (Newman & Newman, 2009).

Bereavement may be expressed in very individual ways and may also be guided by cultural practices that shape the behaviors and activities of those in mourning. The bereavement process can include both confronting the loss and seeking ways to move away from or beyond the loss (Newman & Newman, 2009).

Based on his research with widows and widowers, Carr (2003, cited by Newman & Newman, 2009) suggested the following dimensions of what people perceive to be a good death of their spouse:

  • Spouse was at peace with the idea of dying.

  • Spouse was aware of the impending death.

  • Respondent and spouse discussed the death.

  • Respondent was with spouse at the moment of death.

  • Spouse led a full life.

  • Spouse was not in pain.

  • Spouse did not receive negligent care.

Understanding and Acceptance of Death

Different religions have different beliefs about death and life after death that influence the old persons thinking about death. Newman and Newman (2009) note that the very old are faced with the challenge of conflict between acceptance of death and the intensifying hope for immortality. Having lived longer than their cohort of friends and family members, they struggle to find meaning in their survival. One can get bound by the limits of one’s own life history, experiencing a great fear of extinction. A psychosocial sense of immortality may be achieved and expressed in the following possible ways:

  • One may live on through one’s children, sensing a connection and attachment to the future through one’s life and the lives of one’s children.

  • One may believe in an afterlife and or a spiritual plane of existence that extend beyond one’s biological life, based in one’s religion.

  • One may achieve a sense of immortality through creative achievements and their impact on others.

  • One may develop the notion of participation in the chain of nature. In death, one’s body returns to the earth, and one’s energy is brought forth in a new form.

  • One may achieve a sense of immortality through experiential transcendence, independent of religion.

Planning for a Good Personal Death

What is a Good Death: A “good death” means different things to different people. Some people might want to know when death is near, so they can have a few last words with the people they love and take care of personal matters. Some people might want to die quickly and not linger. Some people would like to be at home when they die, while some people want to be in a hospital where they can receive treatment for their illness until the very end. Some people want to be surrounded by family and friends; others want to be alone. Of course, often one does not get to choose, but having the end-of-life wishes followed, whatever they are, and being treated with respect while dying, are common hopes (National Institute on Aging, 2016).

Gawande (2010) noted that surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Reaffirming one’s faith, repenting one’s sins, and letting go of one’s worldly possessions and desires are crucial. Families need to offer prayers and put the elderly in the right frame of mind during their final hours. Last words come to hold a particular place of reverence.

Planning a Good Personal Death: Planning a good personal death includes the following:

  • Planning for religious and spiritual needs.

  • Planning physical comfort.

  • Resolving conflictual relationships.

  • Having a viewpoint on euthanasia.

  • Planning death-related rituals.

Planning for Religious and Spiritual Needs: People nearing the end of life may have spiritual needs as compelling as their physical concerns. Spiritual needs involve finding meaning in one’s life and ending disagreements with others, if possible. Many people find solace in their faith. Praying, talking with a priest from one’s religious community, reading religious text, or listening to religious music may bring comfort (National Institute on Aging, 2016). This may help them deal with concerns about the consequences of dying including fears of the unknown, loss of identity, etc. (Newman & Newman, 2009).

Planning Physical Comfort: The fear of personal death, with reference to the actual process of dying and the consequences of it, is natural and normal. Concerns about the process of dying include fears of being alone, being in pain, etc. (Newman & Newman, 2009). Physical discomfort can come from a variety of problems, which can be dealt with depending on the cause. For example, a dying person can be uncomfortable because of pain, breathing problems, skin irritation, digestive problems, temperature sensitivity, and fatigue (National Institute on Aging, 2016).

Resolving Conflictual Relationships: It is important to help the dying person manage any mental and emotional distress. Encouraging conversations about these feelings might be beneficial. Resolving conflicts in key personal relationships includes reframing negative emotions of hatred, anger, guilt, pain, depression, resentment, and so on into positive emotions of acceptance, forgiveness, love, and meaning in death, so that death can be faced with peace (National Institute on Aging, 2016).

Having a Viewpoint on Euthanasia: Euthanasia is the practice of ending life for reasons of mercy. Euthanasia can be passive or active. Passive euthanasia involves allowing a person to die by withholding available treatment, especially when the treatment would do nothing but prolong and make even more agonizing an already certain death. On the other hand, active euthanasia involves the deliberate ending of someone’s life, which may be based on clear statement of the person’s wishes or decision made by someone else who has the legal authority to do so. Usually this involves situations when a person is in a persistent vegetative state or suffer from the end stages of a terminal illness (Kail & Cavanaugh, 2007). Active euthanasia is also called mercy killing as it is done in order to end a person’s suffering (Newman & Newman, 2009). Older people may decide on a personal viewpoint on euthanasia.

Planning Death-Related Rituals: The death-related rituals have the advantage of offering a prescribed set of religions or cultural practices at a time when people may be too distressed to make complex decisions. These rituals address three critical aspects of death:

  • How to treat the physical body: cremation or burial.

  • How to address the fate of the spiritual aspect of the person—the soul.

  • How to meet the emotional needs of the survivors: mourning.