Functions of Personal Memory
Nostalgia and Childhood Play
Purpose in Life in the Face of Mortality
Symbolic Thinking in Stories of Parental Loss
Death and Dying
Dignity Therapy
Mechanisms of Dignity Therapy
Wisdom and Late Life Spousal Loss
Shaping the Final Story: Profiles of Resilience and Meaning-Making
Mechanisms of Dignity Therapy
Life Completion in Later Life
Dignity Therapy
Maintaining dignity at the end of life can be challenging for cancer patients. Dignity Therapy (DT) is an intervention that guides a patient through a structured life review process, resulting in a written Legacy Document that can be shared with the patient’s family members and friends. Though research has demonstrated that patients and families feel they benefit from DT, there has been a call for research to understand mechanisms that produce positive patient outcomes. The current NCI-funded study involves a cross-college collaboration aimed at addressing this issue in a sample of 204 older palliative care cancer outpatients. We will examine the empathic process involved in DT delivery and the extent of important psychosocial themes (purpose in life, meaning-making, and communion) in life story narratives produced by participants of DT. In terms of increasing the quality of care at end-of-life, this study will lead to a better understanding of when DT is most efficacious. It will guide honing of the intervention to improve patient care, with the goal of achieving meaningful psychosocial benefits for end-of-life cancer patients and their families.
Mechanisms of Dignity Therapy
This study seeks to investigate how two mechanisms, patient-level narrative richness and provider-patient empathy produce positive outcomes in Dignity Therapy, to focus provider training and intervention delivery. To do so, outpatients living with cancer (N = 203; M = 65.80 years; SD = 7.45 years; 66% women) from palliative care programs across the United States completed Dignity Therapy with a trained provider. Transcripts of their interview sessions were content-analyzed for patient-level narrative richness. Transcripts were also examined using interactional analyses to determine provider-level empathic communication. Changes in dignity impact, peaceful awareness of prognosis, and completion of existential tasks from pre- to post-intervention were assessed. The amount of narrative richness in patients’ Dignity Therapy sessions was positively associated with dignity impact (t = 3.09, p = .002) and completion of existential tasks (t = 2.65, p = .009) even when accounting for patient demographics. Providers’ level of empathic communication did not affect patient outcomes at traditional significance levels. Results were not moderated by patients’ symptom severity. Dignity Therapy benefits patients most when they richly engage in the interview process, narrating their life story and describing their legacy with elements of communion, meaning, and purpose. Future research might aim to follow up on forms of empathy or other provider behavior that elicit rich narratives during therapy.
Purpose in Life in the Face of Mortality
Having purpose in life is linked to wellbeing in healthy individuals (Byron & Perrin, 2008) and may be particularly important when facing illness (Musich et al., 2018). Purpose can be self-oriented (e.g., career development) or other-oriented (e.g., social service). Other-oriented purpose is particularly linked to positive mental health (Martela & Ryan, 2016). Women, and those who report greater spirituality, show stronger other-oriented purpose (Simpson et al., 2008; Xi et al., 2022). This study goes beyond past research, investigating the interaction of gender and spirituality in older persons with serious cancer. Aims were: (1a) examine main and interaction effects of gender and spirituality on having self-oriented purpose, and (1b) having other-oriented purpose, and (2) elucidate purpose in people’s lives using narrative exemplars. Palliative care outpatients (N=203, Mage =65.78 years; Range=55-88, 66% women) completed demographics and life story interviews. Interview transcripts were reliably content-analyzed for self- and other-oriented purpose. Main effect regressions indicate men were more likely to have a self-oriented purpose than women, B=0.16, t(177)=1.98, p<0.05, whereas women’s purpose was more other-oriented than men’s, B=-0.3, t(177) =-2.12, p<0.05. Gender and spirituality did indeed interact to predict other-oriented purpose: simple slope analyses B=-0.09, p<0.01 revealed that greater spirituality related to greater other-oriented purpose for women, but not men. Exemplars of other-oriented purpose from the narratives were diverse (e.g., assisting children with disabilities, human rights advocacy). Older adults’ sense of purpose is a central theme structuring their life story, as they look back on the life lived.
Nostalgia and Childhood Play
This is a collaborative project with colleagues at CON AMORE, Denmark. Project Leader: Dr. Alejandra Zaragoza Scherman. Nostalgia is a social emotion sometimes experienced when remembering one’s past. It can induce behavioral change and motivate future behavior (Sedikides & Wildschut, 2020). We are examining the effect of adults who have children recalling their own childhood and adulthood memories of play, with shopping memories as a comparison condition. Participants rate nostalgia of each memory, and complete measures of play attitudes, intent to purchase toys and games, and intent to engage their children and other adults in play (pre- and post-recall).
Wisdom and Late Life Spousal Loss
Spousal loss is a highly challenging but normative event in late life. Limited research has been conducted on individual differences in adaptation to spousal loss. The theoretical components of wisdom suggest it may differentially provide individuals with tools for adaptation. Another resource to consider in addition to wisdom is the process through which an individual infers the mental states of others, referred to as other-mentalization. A sample of 54 older adults (Mage = 81.59; SD = 7.57, range, 70- 96; 62.3% female) completed measures assessing wisdom and two aspects of loss adaptation. Participants also completed a Dying Days Memory Interview that elicited two open-ended narratives, one about the final memory with their deceased spouse and an additional memory from the final month of their spouse’s life. The first goal of this study is to assess the feasibility of developing and implementing a novel coding system for evaluating other-mentalization in narrative data. The second goal is to provide an initial analysis of the role of wisdom, presence of content-analyzed other-mentalization, and positivity of other-mentalization (i.e., through sentiment analysis) in loss adaptation. Two individual aspects of adaptation are considered: emotional adjustment to the loss 13 and positive integration of the loss event into one’s life story. Exploring individual differences such as wisdom and aspects of other-mentalizing (i.e., presence and positivity) may reveal ways older adults can best adapt to the loss of their spouse.
Symbolic Thinking in Stories of Parental Loss
Little is known about ways in which adults engage in symbolic thinking as part of grief. Symbolic thinking includes interpreting signs, sensing presence, or sustaining emotional bonds with the deceased, among other ways. Using Consensual Qualitative Research (CQR; Hill & Knox, 2021), we analyzed 14 archival dyadic interviews (N = 28 adults) from the online platform StoryCorps to examine symbolic thinking in parental loss narratives. Several unique domains were identified (e.g., sensing the parent’s presence, imagining the parent’s role in future life events, and imbuing everyday experiences with meaning related to the lost parent). Across domains, symbolic thinking took varied and individualized forms, helping adults maintain connection and reconstruct meaning. Furthermore, symbolic thinking surfaces most commonly in trusted relationships. Recognizing symbolic thinking can help informal and formal bereavement providers (such as family members, clergy, and therapists) support the personal and often subtle ways adults grieve and find meaning after a parent’s death.
Life Completion in Later Life
This project examines how older adults achieve a sense of existential life completion when facing serious or terminal illness. The initial step was testing a structural equation model in which terminal illness acknowledgment predicts life completion through the mediating role of narrative coherence in Dignity Therapy life stories, with communion and meaning-making modeled as moderators. To do so, narrative coherence is coded using GPT-4 trained on human-coded examples, enabling large-scale analysis of 204 narratives from older adults with cancer. This is followed by Consensual Qualitative Research (CQR) interviews with adults aged 70+ exploring how they define and evaluate life completion in their own words. Through these steps, quantitative modeling and qualitative inquiry are integrated to advance understanding of life completion.
Shaping the Final Story: Profiles of Resilience and Meaning-Making
People share stories about life with family beginning in early childhood (Fivush, 2011). When facing end-of-life, individuals’ final stories vary depending on challenges they experienced throughout their lives and the extent of meaning made. The study aims to develop idiographic resilience profiles (i.e., childhood/adulthood life stressors and individual coping resources) and examine profile differences in narrative meaning-making. Palliative cancer outpatients (N = 205; Mage = 66; 55-88 yrs) narrated their life story, creating a document to share with family, and completed coping measures. Stories were content-analyzed to extract life stressors (κ = .85) and meaning-making was coded (κ = .81). Four resilience profiles were identified through Latent Profile Analysis, labeled: Protected Travelers (51.22%), Secular Sailors (31.71%), Lone Navigators (10.24%) and Burdened Believers (6.83%). ANCOVA showed meaning-making was highest for Burdened Believers. Shaping the story of one’s life to share with family is a poignant, individualized therapeutic activity at end-of-life.