Aging in Israel: Research, Policy and Practice 9781412811644, 9781412811651, 9781315082806

Citation preview

ii

The Historiography of Psychoanalysis

Volume Editor Sara Carmel, Ben-Gurion University

Editorial Board Eliezer Ben-Rafael, Tel-Aviv University Shlomo Deshen, Tel-Aviv University Eva Etzioni-Halevy, Bar-Ilan University Elihu Katz, Hebrew University of Jerusalem Ernest Krausz, Bar-Ilan University Yochanan Peres, Tel-Aviv University Menachem Rosner, University of Haifa Yitzhak Samuel, University of Haifa Judith T. Shuval, Hebrew University of Jerusalem

Introduction

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First published 2010 by Transaction Publishers iv The Historiography of Psychoanalysis Published 2017 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN 711 Third Avenue, New York, NY 10017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business Copyright © 2010 by Israel Sociological Society. Sponsored by the Schnitzer Foundation for Research on the Israeli Economy and Society–Bar-Ilan University. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Catalog Number: 2009028962 Library of Congress Cataloging-in-Publication Data Aging in Israel : research, policy and practice / Sara Carmel, editor. p. cm. -- (Schnitzer studies in Israeli society ; v. 13) Includes bibliographical references. ISBN 978-1-4128-1164-4 (cloth : alk. paper)--ISBN 978-1-4128-1165-1 (pbk. : alk. paper) 1. Aging--Israel. 2. Older people--Israel. I. Carmel, Sara, 1943HQ1064.I7A32 2009 305.26095694--dc22 2009028962

ISBN 13: 978-1-4128-1164-4 (hbk)

Introduction

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Contents Sources Part 1: Introduction Prologue—Aging in Israel: Demographic Changes, Societal Adaptation, and Remaining Challenges Sara Carmel Part 2: Coping with Losses and Changes at Old Age 1. Coping with Losses and Past Trauma in Old Age: The Separation-Individuation Perspective Liora Bar-Tur and Rachel Levy-Shiff

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3

27

2.

Interpersonal Relatedness and Self-Definition in Late Adulthood Depression: Personality Predispositions and Protective Factors Avi Besser and Beatriz Priel

43

3.

Long-Term Bereavement Processes of Older Parents: The Three Phases of Grief Ruth Malkinson and Liora Bar-Tur

79

4.

Chronically Ill, Old, and Institutionalized: Being a Nursing Home Resident Hava Golander

105

5.

Self-Identity in Older Persons Suffering from Dementia: Preliminary Results Jiska Cohen-Mansfield, Hava Golander, and Giyorah Arnheim

123

Part 3: Social Diversity, Quality of Life, and Successful Aging 6. Contribution of Social Arrangements to the Attainment of Successful Aging: The Experience of the Israeli Kibbutz Uriel Leviatan

149

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The Historiography of Psychoanalysis

7.

The Effect of a Communal Life Style on Depressive Symptoms in Late Life Tzvia Blumstein, Yael Benyamini, Zahava Fuchs, Ziva Shapira, Ilya Novikov, Adrian Walter-Ginzburg, and Baruch Modan

169

8.

The Willingness to Enter a Nursing Home: A Comparison of Holocaust Survivors with Elderly People Who Did Not Experience the Holocaust Sonia Letzter-Pouw and Perla Werner

189

9.

Healthy Aging Around the World: Israel Too? A. Mark Clarfield, Elliot Rosenberg, Jenny Brodsky, and Netta Bentur

203

10. Elders’ Quality of Life and Intergenerational Relations: A Cross-National Comparison Ruth Katz and Ariela Lowenstein

213

11. Correlates of Successful Aging: Are They Universal? Howard Litwin

239

Part 4: Taking Care of and Caregiving—The Micro and Macro Levels 12. Terms of Visibility: Eldercare in an Aging NationState—The Israeli Case Haim Hazan

261

13. Immigration, State Support, and the Economic Well-Being of the Elderly in Israel Alisa C. Lewin and Haya Stier

277

14. Assisted Living for Older People in Israel: Market Control or Government Regulation? Israel Doron and Ernie Lightman

301

15. Fragmentation of Care for Frail Older People— An International Problem. Experience from Three Countries: Israel, Canada, and the United States A. Mark Clarfield, Howard Bergman, and Robert Kane

317

16. Old-Age Home in Jerusalem: Post-Occupancy Evaluation Naomi Carmon

335

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17. A Nursing Home in Arab-Israeli Society: Targeting Utilization in a Changing Social and Economic Environment Khalid Suleiman and Adrian Walter-Ginzburg

351

18. Life-Sustaining Treatments: What Doctors Do, What They Want for Themselves, and What Elderly Persons Want Sara Carmel

363

19. Modernization and Elder Abuse in an Arab-Israeli Context Howard Litwin and Sameer Zoabi

377

20. A Comparison of Well-Being of Demented vs. Physically Impaired Family Caregivers of Hospitalized Elderly Sara Meller

397

Part 5: Predictors of Survival at Old Age 21. Determinants of the Health and Survival of the Elderly: Suggestions from Two Different Experiences— Italy and Israel Antonella Pinnelli and Eitan Sabatello

411

22. Mortality Differentials among Israeli Men Orly Manor, Zvi Eisenbach, Eric Peritz, and Yechiel Friedlander

437

23. Gender Differences in the Self-Rated Health— Mortality Association: Is It Poor Self-Rated Health That Predicts Mortality or Excellent Self-Rated Health That Predicts Survival? Yael Benyamini, Tzvia Blumstein, Ayala Lusky, and Baruch Modan

453

24. The Will to Live and Survival at Old Age: Gender Differences Sara Carmel, Orna Baron-Epel, and Galia Shemy

473

25. Beyond Keeping Active: Concomitants of Being a Volunteer in Old-Old Age Dov Shmotkin, Tzvia Blumstein, and Baruch Modan

481

Sources We wish to gratefully acknowledge the permission to use copyrighted material granted by journals and publishers. Part 2: Coping with Losses and Changes at Old Age Ch. 1 is reprinted from: Bar-Tur, L., & Levy-Shiff, R. (2000). Coping with losses and past trauma in old age: The separation-individuation perspective. Journal of Personal and Interpersonal Loss, 5(2-3), 263-282. Reprinted by kind permission from Taylor & Francis Group, LLC., http://www.taylorfrancis.com. Ch. 2 is reprinted from: Besser, A., & Priel, B. (2005). Interpersonal relatedness and self-definition in late adulthood depression: Personality predispositions, and protective factors. Social Behavior and Personality, 33, 351-382. Reprinted with kind permission from Social Behavior and Personality: An international journal. Ch. 3 is reprinted from: Malkinson, R., & Bar-Tur, L. (2004). Long term bereavement processes of older parents: The three phases of grief. Omega 50 (2), 103-129. Reprinted with kind permission from Omega Journal. Ch. 4 is reprinted from: Golander, H. (1995). Chronically ill, old and institutionalized: Being a nursing home resident. Family and Community Health, 17(4), 63-79. Reprinted with kind permission from Lippincott, Williams & Wilkins. Ch. 5 is reprinted from: Cohen-Mansfield, J., Golander, H., & Arnheim, G. (2000). Self identity in older persons suffering from dementia: Preliminary results. Social Science & Medicine, 51(3), 381-394. Reprinted with kind permission from Elsevier. Part 3: Social Diversity, Quality of Life and Successful Aging Ch. 6 is reprinted from: Leviatan, U. (1999). Contribution of social arrangements to the attainment of successful aging- The experience of the Israeli Kibbutz. ix

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Journal of Gerontology, 54(4), 205-213. Copyright ©The Gerontological Society of America. Reprinted with kind permission from the publisher. Ch. 7 is reprinted from: Blumstein, T., Benyamini, Y., Fuchs, Z., Shapira, Z., Novikov, I., Walter-Ginzburg, A., & Modan, B. (2004). The effect of a communal lifestyle on depressive symptoms in late life. Journal of Aging and Health, 16(2), 151-174. Reprinted with kind permission from Sage Publications. Ch. 8 is reprinted from: Letzter-Pouw, S., & Werner, P. (2003). The willingness to enter a nursing home: A comparison of Holocaust survivors with elderly people who did not experience the Holocaust. Journal of Gerontological Social Work, 40(4), 87-103. Reprinted with kind permission from Haworth Press. Ch. 9 is reprinted from: Clarfield, M., Rosenberg, E., Brodsky, J., & Bentur, N. (2004). Healthy aging around the world: Israel too? Israel Medical Association Journal (IMAJ), 6, 516-520. Reprinted with kind permission from the Israel Medical Association Journal. Ch. 10 is reprinted from: Katz, R., & Lowenstein, A. (2003). Elders quality of life and intergenerational relations: A cross national comparison. Hallym International Journal of Aging, 5(2), 131-158. Reprinted with kind permission from Baywood Publishing Company. Ch. 11 is reprinted from: Litwin, H. (2005). Correlates of successful aging: Are they universal? International Journal of Aging and Human Development, 61(4), 313-333. Reprinted with kind permission from Journal of Aging and Human Development. Part 4: Taking Care of and Caregiving—The Macro and Micro Levels Ch. 12 is reprinted from: Hazan, H. (2000). Terms of visibility- Eldercare in aging nation state- The Israeli case. Journal of Family Issues, 21(6), 733-750. Reprinted with kind permission from Journal of Family Issues. Ch. 13 is reprinted from: Lewin, A.C., & Stier, H. (2003). Immigration, state support and the economic well being of the elderly in Israel. Research on Aging, 25(3), 195-223. Reprinted with kind permission from Sage Publications. Ch. 14 is reprinted from: Doron, I., & Lightman, E. (2003). Assisted living for older people in Israel: Market control or government regulation? Ageing and Society, 25(6), 779-795. Reprinted with kind permission from Cambridge University Press.

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Ch. 15 is reprinted from: Clarfield, M., Bergman, H., & Kane, R. (2001). Fragmentation of care for frail older people- an international problem. Experience from three countries: Israel, Canada and the United States. Journal of the American Geriatrics Society, 49(12), 1714- 1721. Reprinted with kind permission from Blackwell Publishing. Ch. 16 is reprinted from: Carmon, N. (1997). Post-occupancy evaluation of lifecare community for the aged in Israel. Journal of Housing for the Elderly, 12 (1-2), 63-81. Reprinted with kind permission from Haworth Publishing. Ch. 17 is reprinted from: Suleiman, K., & Walter-Ginzburg, A. (2005). A nursing home in Arab-Israeli society: Targeting utilization in a changing social and economic environment. Journal of the American Geriatrics Society, 53(1), 152-157. Reprinted with kind permission from Blackwell Publishing. Ch. 18 is reprinted from: Carmel, S. (1999). Life-sustaining treatments: What doctors do, what they want for themselves and what elderly persons want. Social Science & Medicine, 49,1401-1408. Reprinted with kind permission from Elsevier. Ch. 19 is reprinted from: Litwin, H., & Zoabi, S. (2003). Modernization and elder abuse. Research on Aging, 25(3), 224-246. Reprinted with kind permission from Sage Publications. Ch. 20 is reprinted from: Meller, S. (2001). A comparison of the well-being of family caregivers of elderly patients hospitalized with physical impairments versus the caregivers of patients hospitalized with dementia. Journal of the American Medical Directors Association, 2, 60-65. Reprinted with kind permission from the Journal of the American Medical Directors Association. Part 5: Predictors of Survival at Old Age Ch.21 is reprinted from: Pinnelli, A., Sabatello, E. (1995). Determinants of the health and survival of the elderly: Suggestions from two different experiences – Italy and Israel. European Journal of Population/Revue Européenne de Démographie, 11: 143-167. Reprinted with kind permission from Springer Science & Business Media. Ch. 22 is reprinted from: Manor, O., Eisenbach, Z., Peritz, E., & Friedlander, Y. (1999). Mortality differentials among Israeli men. American Journal of Public Health, 89(12), 1807-1813. Reprinted with kind permission from The American Public Health Association.

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Ch. 23 is reprinted from: Benyamini, Y., Blumstein, T., Lusky, A., & Modan, B. (2003). Gender differences in the self rated health- mortality association: Is it poor self-rated health that predicts mortality or excellent rated health that predicts survival? Gerontologist, 43, 396-405. Copyright © The Gerontological Society of America. Reprinted with kind permission from the publisher. Ch. 24 is reprinted from: Carmel, S., Baron- Epel, O., & Shemi, G. (2004). The will to live and survival at old age: Gender differences. Social Science and Medicine, 65(3), 518-523. Reprinted with kind permission from Elsevier. Ch. 25 is reprinted from: Shmotkin, D., Blumstein, T., & Modan, B. (2003). Beyond keeping active: Concomitants of being a volunteer in old-old age. Psychology & Aging, 18(3), 602-607. Reprinted with kind permission from APA.

Part 1 Introduction

Prologue Aging in Israel: Demographic Changes, Societal Adaptation, and Remaining Challenges Sara Carmel

Aging Societies—A Global Phenomenon The world is graying. Since the twentieth century, developed nations are undergoing a steady process of unprecedented demographic changes due to a decrease in the rate of birth, and a significant increase in life expectancy. In the developed nations, life expectancy has increased by an average of 30 years in less than a century. These developments have caused major transformations in the composition of populations in terms of the proportion of the various age groups. While the young age groups of children and adolescents have decreased, those of elderly persons aged 65 and over, have significantly increased. This relatively rapid global process of change is known as “the process of squaring the former demographic pyramid” or the “demographic revolution.” Among the nations, Japan, Monaco, and other European countries are considered the oldest nations, with between 17 and 23 percent of elders aged 65+ in their populations, while countries such as, Morocco, India, and Arab nations are currently considered the late initiation group, with less than 6 percent of elders. Israel, while being the oldest nation in the Middle East, is classified together with countries such as the U.S.A., Australia, and Argentina in the second tier of the aging pyramid, with an older population of about 10-13 percent (Table 1). Although there are nations where the longevity trend has been reversed, such as some of the former Soviet Union Republics and African countries, the prospect of a steadily aging population is common to most nations. For example, in 2025 the aged population is expected to reach 30 percent in Japan and around 3

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Aging in Israel Table 1 Percent of Elderly Persons Aged 65 and Over in Different Countries

Country

Percent

Country

Percent

Country

Percent

Monaco Japan Italy Germany Sweden

22.8 21.6 20.0 20.0 17.4

Canada Australia U.S.A. Argentina Israel

14.9 13.3 12.7 10.8 9.8

Turkey Morocco India Egypt Jordan

7.0 5.2 5.2 4.7 3.8

Source: US Census Bureau, International Data Base, 2008 http://www.census.gov/cgi-bin/ipc/idbagg

25 percent in a number of European countries. In Israel it is expected to reach 14 percent (United Nations, 2006). The remarkable growth of the older population worldwide creates new needs, opportunities, and challenges in the domains of economy, social and health services, leisure activities, and formal and informal support systems. Hence, aging is increasingly being recognized as the key global issue of the twenty-first century (for example, UN International Year of Older Persons, 1999; The Madrid International Plan of Action on Aging, 2002). The challenges of aging societies are especially problematic in the face of the currently widespread phenomena of ageism, cultural diversity, immigration and dearth of knowledge. Consistent with the situation in other developed nations, the absolute number and percentage of elderly persons in the Israeli population is increasing, while the percentage of younger persons is decreasing. Israel, however, differs from other developed countries in the pace of this demographic change, the composition of its population, and the ways of addressing the arising aging-related needs. Socio-Demographic Characteristics, Health and Well-Being of Israeli Elders Demographic Changes At the end of 2006, Israeli society comprised 7.1 million people, among which about 702 thousand persons were aged 65 and over. The growth of this population group has been exceptionally rapid in the sixty years of Israel’s existence. Upon its establishment in 1948, Israel was a young society. In only three decades the percentage of elderly persons in the population more than doubled, from 3.8 percent in 1948 to 8.6 percent in 1980 (Mashav, 2007). In the U.S.A., for example, a change in this scale occurred over the whole twentieth century. The population of people aged 75+, and especially of those aged 80+, grew even faster. While at the end of 1980, those aged 75+ accounted for 32 percent of people aged 65 and over, by the end of 2006, this percentage increased to 46,

Prologue

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and the group of elderly aged 80+ increased during this period from 14.4 percent to 26 percent. Additional statistics indicate that from 1980 to 1990, the average annual rate of growth was 6.3 percent for people aged 80 and older, 5.5 percent for those aged 75 and older and only 2.7 percent for those aged 65 and older (Mashav, 2008). These figures clearly indicate that not only is the proportion of elderly persons in the total population growing, but that the old population itself is rapidly aging as well. In comparison to other nations, life expectancy in Israel is relatively high (Table 2). In 2008, life expectancy at birth in Israel was 82.8 years for women, and 78.5 years for men, and at the age of 65, life expectancy was 19.9 years for women and 17.7 years for men (US Bureau of the Census, International Database, 2008). In the last three decades (since 1975) life expectancy has increased by 3.2 years for women and 2.7 years for men indicating that the gap between the genders is increasing. Although men’s life expectancy is shorter than that of women, Israeli men rank 6th in the world in life expectancy, while women rank 16th in the world (Mashav, 2007). In addition to the steady increase in life expectancy, and the decrease in the fertility rate per woman, Israel’s “open door policy,” under which every Jew is eligible to immigrate to Israel and receive immediate citizenship, has contributed to the increase in Israel’s aged population (Carmel, 2002). For example, the last wave of immigrants from the former Soviet Union, which began in 1989, significantly increased both the absolute number of elderly people in Israel and their proportion in the general population. At the end of 2002, those aged 65 and older accounted for 17 percent of this wave of new immigrants, while all Israelis in this age group constituted only 9.9 percent (Mashav, 2008). At the end of 2006, 22 percent of the population aged 65 and over, were new immigrants from the former Soviet Union (Mashav, 2008). Since its establishment, Israel is a country of immigrants, who have arrived from more than a one hundred countries. Heterogeneity has thus become a dominant characteristic of Israeli society. This fundamental characteristic is particularly prominent in the aged population, in terms of ethnicity, culture, Table 2 Life Expectancy at Birth in Selected Countries Country

Years

Country

Years

Country

Years

Monaco Japan Italy Germany Sweden

82 83 81 80 81

Canada Australia U.S.A. Argentina Israel

81 82 78 75 81

Turkey Morocco India Egypt Jordan

73 72 63 68 71

Source: World Health Organization, Statistical Information System, 2006.

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socioeconomic status, health and functioning, all of which have significant implications on social policy and services. Ethnic and Cultural Diversity About 76 percent of the Israeli population is Jewish, with the remaining 24 percent being Arabs. At the end of 2006, the aged Arab population was comprised of two thirds Muslims and one third Christians and Druze. The proportion of Arabs in the aged Israeli population is relatively low (7.3 percent). While 12 percent of the Jewish population in 2006 was in the 65+ age group, in the Arab population only 3.4 percent were 65+, indicating that the Arab population is significantly younger. This is mainly due to the relatively high fertility rate and, as a consequence, the high percentage of children in the Arab population. Similarly, among immigrants from Ethiopia only 5.4 percent were elderly aged 65+ (Mashav, 2008). In addition to being younger, elderly Arabs and Jews of Ethiopian origin are the most disadvantaged groups in the elderly Israeli population. In comparison to the total aged population, both groups have less education, lower income and more of them suffer from limitations in activities of daily living (ADL) such as in self washing, eating, dressing and mobility at home (Mashav, 2008). The percentage of elderly Arabs in the total population of elderly Israelis is expected to increase rapidly over the next two decades. The majority of elderly Jews in Israel are immigrants. Significant cultural diversity exists among elderly Jews. Until 1960, Jewish, native-born elderly accounted for only 3 percent of the elderly population. In 2006, this percent increased to 14, while in the total population, 66 percent were Israeli born. In the same year, the largest group of immigrant elders was comprised of people born in European or American countries (57 percent of the total aged population), about 15 percent of the elders were born in Asia, and 14 percent in North Africa (Mashav, 2008). Holocaust survivors form a special group of elderly people in Israel. An estimated 254,400 elderly holocaust survivors aged 65 and over lived in Israel in 2006 and comprised 36.2 percent of the total elderly population (Mashav, 2008). As a group, they are older than the total aged population. In 2006, 60.2 percent of holocaust survivors were aged 75 and over compared to 46 percent aged 75 and over in the general elderly population (Mashav, 2008). This group has significantly more needs and more unique needs. For example, in recent years it has been established that in comparison to other groups of elderly, more of the holocaust survivors suffer from health and well-being problems, including post traumatic syndrome disorder (PTSD), and have poorer psychological and social coping resources than their elderly counterparts (Landau & Litwin, 2000; Amir & Lev-Wiesel, 2003). In the coming years, the number of people in this group will significantly decrease.

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Socio-Economic Status In general, elderly Israelis rank significantly lower than younger adults on indicators of socioeconomic status such as education, and income. Within the aged population, elderly persons born in Israel and in European and American countries are older and apt to be more highly educated and with higher income than elderly people of Asian or African origin. However, the elderly immigrants who arrived to Israel in the early and mid-1990s from the former Soviet Union countries, despite being relatively younger and more educated than the Israeli elderly, have become an even weaker group in terms of their economic status, health, and subjective well-being (Carmel, 2001a; Carmel & Lazar, 1998; Carmel, Iecovich, & Sherf, 2007). Over the years, there has been a clear increase in the elderly population’s level of education. For example, while in 1970, 40 percent of elderly persons aged 65 and older had poor education (0-4 years of formal education), this number decreased to 27 percent in 1990 and to 17 percent in 2005. At the same time, the percentage of elders with high education (13+ years) increased from 11 percent in 1970 to 31 percent in 2005. A similar improvement is apparent in the economical status of the new cohorts of elders. The percentage of elderly Israelis who receive pensions from their previous workplaces is increasing, while the percent of persons who receive supplementary income from the government is decreasing. For example, the percent of elders receiving pensions from their former work place increased from 31 in 2000 to 35 in 2006, and the proportion of the aged receiving financial support from the government decreased from 45 percent in 1980 to 27 percent in 2005 (Mashav, 2007). These trends of improvement in the socioeconomic status of the population of elderly Israelis are expected to continue over the course of the twenty-first century when better-educated and wealthier cohorts will reach old age. Gender Differences Gender-related differences are conspicuous in all areas of life over the whole lifecycle including old age. In all the developed nations, the percentage of women in the population increases with age. In Israel, at the end of 2006, women comprised 57.2 percent of Israel’s elderly population. This percentage varied in different social groups, being significantly lower among the Arabs (53.7 percent), and higher among the new immigrants from the former Soviet Union (61 percent) (Mashav, 2008). Similar to other developed nations, Israeli women live longer than men, but are disadvantaged in terms of education, income, marital status, health, and subjective well-being (Carmel & Bernstein, 2003). For example, in 2006 significantly more elderly men than women received pensions from their workplace (42 percent versus 31 percent), or participated in the workforce (17 percent versus 5 percent) (Mashav, 2008).

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Aging in Israel

In general, the quality of life of Israeli elderly women is poorer than that of the men. For example, women tend to be the main caregivers of their family members. However, although they carry this burden throughout their life, they are paradoxically more isolated in old age than men, since more of them are unmarried (60 percent versus 22 percent) and live alone (36 percent versus 12 percent). Regarding health, women suffer more than men from physical and mental limitations: They complain more about physical problems (31 percent versus 18 percent), more of them suffer from dementia (19 percent versus 14 percent), and a higher percent of them live with functional limitations in activities of daily living (20 percent versus 12 percent) (Mashav, 2007). According to estimations of the World Health Organization, women in Israel are expected to live 10 years with limitations while men with 9 years (World Health Organization, 2004). In summary, despite the biological selection process that both genders go through as they age, and the growing similarity among the genders in social roles with aging, gender differences in health, functioning and well-being continue to exist in all the age groups within the population of elderly persons (Carmel & Bernstein, 2003). All of these gender differences contribute towards elderly women’s worse self-perceived well-being, in terms of satisfaction with life and the will to continue living (Carmel, 2001b; Carmel & Bernstein, 2003). Health and Well-Being Deterioration in health and functioning is part of the aging process. In the twenty-first century chronic diseases like coronary heart disease, cancer, stroke, diabetes, dementia, and obesity have overtaken acute infectious diseases and have become the prominent causes of disability and death of elderly persons in developed nations. The rates of people suffering from some of these diseases are rapidly increasing up to the level of becoming epidemics. For example, in just 20 years, the number of people suffering from diabetes, a disorder with detrimental effects, increased from 30 million to 177 million. By 2030 this number will increase to 366 million people worldwide, mainly among elderly persons (World Health Organization, 2007). Many of these diseases are lifestyle dependent, making them difficult to change. Advances in medicine have enabled the prolongation of life of people suffering from many of the currently prevalent diseases, but often cannot ensure a good quality of life. The increased awareness to elders’ health and well-being is expressed in current statistics, which evaluate not just life expectancy but also healthy life expectancy, that is, average years of life lived with satisfactory health and functioning status. According to these figures, in most countries people are expected to live 8-10 years with health problems and disabilities. Israelis are expected to live on average 10 years with impaired health out of the 81 years of life expectancy at birth (Table 2 and Table 3). This situation imposes not

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Table 3 Healthy Life Expectancy in Various Countries Country

Years

Country

Monaco Japan Italy Germany Sweden

73 75 73 72 73

Canada Australia U.S.A. Argentina Israel

Years

Country

Years

72 73 69 65* 71

Turkey Morocco India Egypt Jordan

62* 60* 53 59* 61*

*Data for 2003. Source: World Health Organization, Statistical Information System, 2008.

only suffering for the elders and their families, but also a significant economic burden on societies. In Israel, as elsewhere, elderly people are a very heterogeneous group in terms of health and functioning, ranging from the healthy, mainly in the age group of the “young-old” aged 65 to 74, through the “old-old” (aged 75-84), to the more frail and disabled “oldest-old,” aged 85 and over. The diversity is large among these groups, as well as within them, and varies in regard to different diseases and cultural groups: Cancer diseases are the first cause of death among elderly persons (23 percent), followed by heart diseases (21 percent), cerebrovascular diseases (8 percent), and diabetes (7.5 percent). However, the percent of people dying from these diseases varies with age. For example, while death from cancer diseases decreases with age (34 percent among the youngold, 24.6 percent among the old-old and 13.4 percent among the oldest-old), death from heart diseases increases, from 26 percent among the young-old to 38 percent among the oldest-old (Mashav, 2007). Although 19 percent of all elders (aged 65+) suffer from dementia—another epidemic of old age, the prevalence of dementia significantly increases with age, so that among persons aged 85+, 47 percent suffer from this group of diseases. The incidence of cancer is higher among Jews in comparison to Arabs. According to a national survey conducted in 2005, 37.4 percent of the elderly reported being in “very good” or “good” health in comparison to 77.4 percent among people aged 20 and over. The difficulties in adaptation to the many losses in old age are expressed in the suicide rates. In the year 2000, 22 percent of all suicides in Israel were carried out by people aged 65 and over, while the percent of elderly persons in the total population for that year was only 9.8 (Mashav, 2008). Literature in medical sociology has repeatedly shown the significant association between socio-economic status and health outcomes in terms of morbidity and mortality rates (Marmot, 2001; Diez- Roux et al., 2001; Wen, Browning, & Cagney, 2003). This global phenomenon can be detected among the Israeli aged population as well. For example, at the end of 2006, 16 percent of the elders

10

Aging in Israel

were limited in at least one of the activities of daily living (ADL). However, while among Israeli born Jews and Jews of European and American origin 14 percent suffered from limitations in ADL, this percent was significantly higher among Jews of African-Asian origin (18 percent), and highest among the Arabs (30 percent) (Mashav, 2008), correlating with the socioeconomic status of these different groups of elderly It is interesting to note that despite the many losses experienced during the aging process, including the deterioration in health and functioning, according to a survey conducted in 2004, 77 percent of elderly Israelis reported being satisfied with their lives (15 percent very satisfied and 62 percent satisfied) in comparison to 80 percent among adults aged 20 and over (Mashav, 2007). This finding indicates that the discrepancy in perceived well-being between the elders and younger adults in Israel is quite small. However, results of a more recent national study conducted in 2006-2007 on elders aged 65+, indicate that perceived well-being in terms of satisfaction with life and the will to continue living significantly weakens with aging, so that it is highest among the young-old and lowest among the oldest-old (Carmel, Iecovich, & Sherf, 2007). Arising Aging-Related Societal Needs and Challenges Care One of the concerns and challenges of aging societies involves providing quality care to the growing numbers of frail elders suffering from chronic diseases and functional limitations, many of whom need long-term care services for extensive periods of time. Most developed nations face significant difficulties in this area, since it is a multifaceted issue affecting many phases of personal and social life, with implications on the family, community, and national levels. On the personal and family levels, longevity is often related to a decline in the quality of life, due to changes in health status and deterioration in physical and/or mental functioning, while the personal resources for coping with these age-related losses are decreasing. In addition to one’s psychological resources and income, support from family members or significant others are the most important personal resources for adapting to age-related losses. However, the longer a person lives, the more likely that he/she will experience a decline in the availability of these resources. In recent decades, support from family members has diminished due to social developments such as, increased participation of women in the labor force, and changes in family structure including increased rates of divorce and single parent families. In view of these developments, on the one hand, and the longer life span of more family members who need assistance, on the other hand, much of the responsibility for, and care of frail elders, has been transferred from the family to the community and governmental services in many countries.

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In Israel, families have a dominant role in caring for elderly people. Their commitment and readiness to care for their elderly relatives is perceived as a natural obligation. This is embedded in the society’s value systems, norms of behavior and the law. Most of the main caregivers are middle aged and youngold women—spouses, daughters, or daughters-in-law—many of whom are still working outside the home with additional responsibilities of caring for husbands, children and grandchildren. This load has become heavier with the years, due to the need to care for increasing numbers of older relatives for longer periods of time. Many of the elderly are caregivers of spouses and/or very old parents, some of whom are ill and frail themselves. The additional physical and emotional burden of caregiving augments their risk for morbidity and mortality (Schulz, Vistainer, & Williamson, 1990; Schulz, & Beach, 1999). On the national level, caregiving of increasing numbers of frail elderly has become a significant global multidimensional social problem, with implications on the workforce, families, services and the national economy (MetLife Mature Market Institute and National Alliance for Caregiving, 2006; National Alliance for Caregiving and AARP, 2004; Arno, 2002). Although in countries such as the U.S.A. and Sweden, there is evidence of a small reduction in disability over time, in absolute terms, this burden will continue to grow (Freedman, Martin, & Schoeni, 2002). Western countries are facing a constant increase in the demand for care provision, including health and welfare community services, as well as paid care workers, while the current laws and networks of services, in numerous of the developed nations, are not satisfactory and many elders cannot find or afford hiring paid home caregivers (Feder, et al., 2000). Similarly, in Israel, national statistics and a recent national study of old Israelis, focusing on needs for services in three age-groups of elders, indicate that frailty and illness increase with aging, as do the needs for professional and nonprofessional paid caregivers (Mashav, 2007; Carmel, Iecovich, & Sherf, 2007). In addition, in Israel, as in many other countries, a significant scarcity of people who can provide home care services is reported, as well as a severe shortage of professionals, including geriatricians and family physicians, nurses and other health and welfare professionals (Stone, 2004; Harris-Kojetin, Lipson, Fielding, Kiefer, & Stone, 2003: Israel Ministry of Health, 2007). This gap between the demand for, and supply of, informal and formal caregivers is anticipated to increase in the coming years (Girion, 2006; Israel Ministry of Health, 2008). It can thus be concluded, that the needs for care of frail elders are increasing while the family resources are shrinking and national responses do not develop at a fast enough pace and scope in order to meet these needs. Health Services Due to the deterioration in health and functioning, elderly persons use significantly more health services than the total population. In Israel, elderly people

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consume more then 30 percent of the national expenditure on health, although comprising only about 10 percent of the total population. More detailed statistics exemplify this figure: In the years 2003-2004, 28 percent of all visits to doctors were of elderly aged 65+. In 2006, the proportion of hospitalizations was more than three fold higher among elderly persons than in the total population, and the average length of hospitalization was longer in the aged population as well (5.5 versus 4.2 days) (Mashav, 2008). Considering that the population of the old-old (aged 75+) is the weakest sector in the adult population according to physical and social criteria, and therefore also the heaviest consumer of health and social services, along with the rapid increase of this age group in the population, one of the most significant implications of the current and foreseen demographic trends is an augmented need for health and welfare services on the one hand, and programs for promoting health and functioning of elders, on the other hand. Leisure Similar to other nations, and despite the dominant negative stereotype viewing old people as unproductive, dependent, weak, and sick, the vast majority of elderly Israelis are independent and involved in their families’ lives, their communities and society even though no longer employed. However, a relatively high percent (20 percent) of the elders report frequent feelings of loneliness, and only a small percent of them work (10 percent) or volunteer (12 percent) (Mashav, 2008). These figures indicate that the growing group of independent elderly has particular needs for social involvement and support that require special attention. National Economy In addition to the increased need for health and welfare services, the general dependency of the aged population on national resources has increased over the years as indicated by the changes in the dependency ratios. For example, similar to other countries, Israel is facing a steady trend of increase in the old age dependency ratio (the ratio of people aged 65 and over to working persons, aged 20-64). In 2006, there were 176 elderly persons per 1000 people in the workforce. These numbers are expected to rise to 241 by the year 2025. When the number of another nonworking population group (ages 0 to 19), is added, the total dependency ratio in Israel is high relative to other developed nations, mainly due to the high percentage of children, and is expected to reach 745 per 1000 people in 2025 (Mashav, 2008). These developments have raised concerns regarding the ability to ensure pensions from workplaces and governmental support for the aged population.

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Addressing the Needs of Elderly Israelis Awareness of the needs of the large, heterogenic, and rapidly growing aged population intensified in the 1980s. Israeli society has addressed its aged population’s needs by issuing health and welfare laws and developing a wide range of community services. Guiding Value Systems The process of multifaceted societal adaptation to the socio-demographic changes and emerging needs was guided by Israel’s Jewish and democratic systems of values, as well as by a strong socialistic ideology, which shaped many of Israel’s institutions. For example, mandating filial responsibility to elderly parents by law stems from the system of Jewish laws and values. The protection of human and civil rights, including political rights, the right to privacy, personal autonomy, right over one’s body, and the right for quality and dignity of life are embedded in the Western liberal constitutional laws, and laws ensuring universal social security, old-age pensions, national health insurance and national long-term care derive mainly from the social-democratic welfare orientation (Shachar, 1995). Although significant changes have occurred over the years in the relative dominance of the collective socialistic ideology in Israel’s society, the commitment to a welfare society has not diminished, and the principles of these approaches are reflected in legislation and policies, as well as in the structure, availability, and accessibility of the various health and social services. Policies and Laws Over the years, Israel has launched a number of laws directed at protecting human rights and the dignity of old citizens: The country ensures by law a minimal level of income to its old population. In addition to a pension received from the workplace by persons who have retired, Israeli citizens above the official retirement age are eligible to receive an old-age pension from the National Insurance Institute (NII), contingent on their total income. After the age of 65 for women and 70 for men, this pension is unrelated to a person’s income. People for whom this is their only income, or whose overall income is lower than the poverty threshold, also receive a supplemental income from the NII, as well as social services from the Ministry of Welfare, according to their needs. In addition, a number of laws specifically address elders’ needs: The Elderly Citizens’ Act (enacted in 1989) grants elders financial benefits such as discounts on local taxes, tickets for cultural events and public transportation. The Sick Leave Act of 1993 protects family caregivers at their workplace by ensuring full dismissal compensation in case of resignation due to parental illness and a paid absence leave up to six days per year. The Law for Defense of Protected Persons

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(enacted in 1966) allows welfare officers of the court to intervene and take care of vulnerable elderly persons, based on their professional assessments, by using compulsory injunctions granted by the courts. For the first time, Amendment 26 to the Penal Code (1989) clearly defined a wide range of harmful behaviors typical of elder abuse as criminal acts deserving criminal punishment. This group of laws and The Law for the Prevention of Violence in the Family (1991) enable professionals to take care of helpless elderly persons and render protection from abuse and neglect by commission or omission. However, some forms of abuse are either not covered or only partially covered in the current legislation, as for example, economic exploitation (Doron, Alon, & Offir, 2004). Some general laws referring to human rights are especially significant for older adults: The basic law of Human Dignity and Liberty (enacted in 1992) which states that “Every person is eligible to protection of life, body and dignity” (section 4) renders protection of life to elders along with other weak sectors of society. The Patient’s Rights Law of 1996 formally regulates the doctor-patient relationship, and ensures, among other patient’s rights, open channels of doctor-patient communication, which is often lacking, especially in the case of elderly patients. The End-of -Life Care Law (enacted in 2006) recognizes the right of terminally ill patients to die with dignity in accordance with their beliefs and preferences by the use of advance directives. The law requires doctors and medical institutions not only to comply with patients’ wishes, but also to assist their patients in realizing these rights, thus addressing a growing need of the Israeli public and especially of aged people to openly deal with end-of-life care dilemmas and prevailing practices (Carmel, 1999). The System of Health and Welfare Services Since the establishment of the state, health care services have been available to a vast majority (94 percent) of the population. In 1995, Israel launched the National Health Insurance Law (NHIL), under which all Israeli citizens have health care coverage, regardless of income. Insurance covers ambulatory and hospitalization services, including medications. The government has set an incentive for development of health services for the elderly by its capitation system, according to which it provides higher financial allocations for elderly persons to the four competing Israeli sick funds providing health services. The highest percent of elderly persons are insured by the Clalit Health Services, which is also the largest sick fund, and has neighborhood clinics spread all over the country. In recent years, several sick funds inaugurated special multidisciplinary clinics of specialists in geriatrics for addressing the special needs of their old clients, as well as providing geriatric consultation to family and general physicians caring for old patients in the community. However, these services are still limited and do not ensure availability and accessibility to all of those who need it.

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15

The basic orientation that has guided Israel’s health and welfare policies in tending to the needs of independent as well as frail and disabled elderly persons has been to enable them to continue living in their own homes and communities as long as possible—“aging in place.” Accordingly, a wide network of welfare and long-term health services has been established throughout the country by public and private agencies. For independent elderly persons and for those who require limited services, social clubs and sheltered housing units have been opened. Disabled elderly persons’ needs have been addressed by the NHIL, and in part by the Long-Term Insurance Law, enacted in 1988. Under this law, people who need assistance in performing activities of daily living receive personal and domestic help in their homes by homecare workers. An alternative or complementary option under this law, is receiving a variety of personal and social services, including entertainment, physical exercise, meals, dentistry, social activities and transportation, in community day-care centers for disabled elderly. Large Israeli municipalities provide the “Meals on Wheels” service, which delivers hot, nutritionally balanced meals to the home, for a low subsidized price. Welfare services are also provided by social workers. In addition, the NII, many localities, and numerous charity organizations have developed a wide range of voluntary community services including home visits to ill or lonely persons, information and counseling services, loan of medical equipment and devices for disabled persons, and home repair projects. In hundreds of municipalities, programs of supportive communities have been implemented, under which all the needed services are provided, including transportation for medical purposes and home repairs. Due to The Long-Term Insurance Law and the wide network of community services, only 3.6 percent of elderly Israelis lived in institutions at the end of 2006 (Mashav, 2008). Long-term institutional care is provided in public and private old-age homes and in nursing homes for old persons. Access to these services is more problematic because by law they are financed partly by the Ministry of Health and partly by the patient and the patient’s adult children depending on their income, and regardless of the families’ willingness to participate in the cost. However, when a person’s condition requires complex nursing care, he/she has to be transferred to another institution where the services are provided and financed by the patient’s sick fund. This complex system is the source of one of the major problems in the continuity of care of older adults. Professional Education and Training The rapid increase in needy elders and the fast development of services for elderly persons created a situation where many of these medical and social services were provided by persons who lack comprehensive professional education in gerontology. Since the establishment of the State of Israel, institutions such as Malben, Mishan, JDC and ESHEL have made major contributions to the con-

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struction of institutions for old persons as well as to the recruitment, education and training of personnel to care for the aged, including courses for directors of nursing homes, nurse’s aides, day care center personnel, and volunteers. A department for continuing education and training in geriatrics and gerontology was opened by ESHEL in 1989. In the seventies, a cadre of doctors, nurses and social workers were sent by the JDC for training in geriatrics in Great Britain and the United States. Professionals from this group became the founding fathers of geriatrics in Israel, and the core of professional leadership in the development of geriatric services including the first geriatric wards in general hospitals, as well as of geriatric education. Currently, every medical school in Israel has a curriculum in geriatric medicine at the undergraduate level. Geriatrics was recognized as a specialization discipline by the Scientific Council of the Israel Medical Association in 1982. At the end of 2005, about 160 geriatricians were registered in Israel, almost the same number as in Canada, a country with five times Israel’s population (Clarfield, Brodsky, & Leibovitz, 2006). Academic programs in geriatrics and gerontology are nowadays included in the curricula of nursing, social work, and physiotherapy in almost all the universities. Social gerontology started to develop in the mid-fifties with the establishment of the Israeli Gerontological Society. In 1999, the first two MA programs in Gerontology were opened at Ben-Gurion and Haifa universities. These initiatives opened tracks of advanced education and training in gerontology and geriatrics for many professionals working in the field, as well as enhanced interest in gerontology among young scholars and promoted research in aging (Carmel & Lowenstein, 2007). In addition, research centers in aging were opened in four universities, and in 2007, the first research fund for studies in aging was launched by the newly founded Ministry for Senior Citizens. It can be summarized that all of these initiatives, together with the academization of geriatrics and gerontology, have had a significant positive impact in advancing research, knowledge, and the quality of elderly care in Israel. Challenges to Be Addressed Reducing economic dependency, the average numbers of years of disability, and maintaining a high quality of life in the wake of age-related loss and decline, have become major challenges for all aging nations. As described above, Israel has addressed these challenges by building an infrastructure of laws, policies, health and welfare services, long-term care institutions, education and training programs, as well as research. This system can be praised for many successes, however several problematic issues still remain to be addressed, and there is still a lot to learn and do in order to meet the many aging-related needs of our changing society. Following are some examples:

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In the Area of Caregiving, Education and Training The increasing needs for care of the frail have been only partly addressed. When considering health care services, the major weakness of the current system is expressed in significant difficulties in the continuity of care. The existing multiplicity in public and private services in terms of responsibility, ownership, provision of different kinds of services, and financing, causes duplications and fragmentation in the continuity of care. These social arrangements, in addition to being a crucial factor in the inefficient provision of services, are also confusing to the disabled elders, their families and their formal caregivers (Clarfield, Paltiel, Gindin, Morginstin & Dwolatzky, 2000). Fragmentation of different parts of health and welfare services under different authorities is a common problem in numerous developed nations caused mainly by the unplanned development of services in response to arising needs (United Nations, 2002). The current situation in Israel can be improved by adding long-term care to the “basket of health services” which is covered by The National Health Insurance Law and provided by the sick funds. Another means to promote the provision of all services for the elderly is by centralizing comprehensive health care and social services for elderly people under one coordinating authority. Such structural changes, should they occur, will enhance the efficiency and effectiveness of current services and ensure access to comprehensive and continuous care. A number of additional problems related to the provision of appropriate care to elders with functional limitations have to be resolved. Both laws, the NHIL and the Long-Term Insurance Law do not fully address health care needs and needs arising from the disability of elderly persons. For example, dental services are expensive and are not covered by the NHIL. In addition, the cost of medical services has remained high and the citizens’ personal expenditure on health care services has even increased since the enactment of the Law. Currently, physicians and patients often have to deal with monetary problems regarding aspects of care that are not included in the basket of services. These issues have to be resolved for all levels of society, but are especially crucial in the older age groups. Considering the importance of family caregiving for impaired elders and the nation, on the one hand, and their significant physical and emotional burden and high risk for morbidity and mortality, on the other hand, increased awareness of the needs of family and other informal caregivers must be promoted. Creating special services for informal caregivers, which incorporate support groups, education and training, has to be among the priorities of policy makers in the areas of health and welfare. For many of the frail elders and family caregivers, current governmental support under the Long Term Insurance Law is insufficient and many elders cannot find or afford hiring paid caregivers. This problem is intensified due to the current and anticipated shortage in skilled paid workers. The gap between the increasing demand for paid care workers and the shortage of people who

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can provide it has become a global problem (Stone, 2004; Harris-Kojetin et al., 2003). Another related problem is lack of skills among the existing workforce. Despite the accumulated current knowledge regarding care of the frail, most of the caregivers, whether paid workers or family members, provide intensive care to frail elders while lacking the needed knowledge and skills, and often, also the needed psychological resources. These concerns have to be addressed by developing training programs for nonprofessional paid-caregivers, which render certifications and provide emotional support. In addition to the scarcity of nonprofessional paid workers, a severe shortage of professionals in the field, including geriatricians and family physicians, nurses and other health and welfare workers is anticipated in the coming years (Girion, 2006; Israel Ministry of Health, 2007). The negative stereotype of elderly persons in postmodern societies and the ageism among professionals is probably one of the underlying causes for this situation (Carmel, Galinsky, & Cwikel, 1990; Carmel, Cwikel, & Galinsky, 1992; Butler, 1999). Hence, fighting ageism by encouraging positive images of aging, and enhancing recruitment of workers by creating a system of incentives for professional workers in the field, is a difficult, but timely challenge. Furthermore, with the expected increase of elderly persons in the population and their intensive use of medical services, not just geriatricians, but all medical and social personnel treating adults need updated education and training in the unique problems of the elderly. This can be achieved by introducing obligatory educational programs for professionals in school and through continuing education programs. Another problem related to professional caregiving involves the repeated reports about intentional as well as unconscious discrimination against the elderly in the provision of costly or complex health services (Butler, 1999). In addition, although the elders are the main consumers of drugs and other medical treatments for chronic and degenerative diseases, there is a clear tendency to exclude them from clinical trials on new treatments (McMurdo, Witham, & Gillespie, 2005). These phenomena in the medical system clearly hinder high quality care for elderly persons worldwide, and have to be addressed by changing approaches through education and legislation. One of the important challenges of heterogeneous societies is providing appropriate care to population groups with special needs such as minorities of different cultural backgrounds and new immigrants. Most elderly persons in these groups are of low socio-economic status, have communication problems because they do not speak the local language, and hold somewhat different beliefs regarding aging, healthy lifestyles, illness, and caring demands from their family members. Addressing the special needs of these groups by adapting the services to their specific needs and orientations demands increased knowledge, understanding, sensitivity, and special training of formal caregivers. Adding these components to the current Israeli system of services and education in geriatrics and gerontology, in combination with the ambitions and energies

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of many young and highly qualified professionals, will contribute directly and indirectly to improvements in the policies and services, hereby, continuously raising the quality of care and quality of life of elderly Israelis. In the Area of National Economy and Elder’s Well-Being The difficulties encountered by informal (family and other unpaid) caregivers have negative effects not only on the caregivers themselves but also on the national labor force and economy. For example, in the US, disruptions and absenteeism due to employees’ caregiving duties cost employers up to $33.6 billion per year (MetLife Mature Market Institute and National Alliance for Caregiving, 2006), and the value of unpaid caregiving has been estimated at 257 billion dollars annually (Arno, 2002). Finding the golden path for reducing such harmful outcomes on the national and personal levels, while supporting family care is thus a tricky, yet important challenge. Although the official age of retirement in Israel was recently raised, the dependency ratio on national resources has been increasing. Considering that the vast majority of elderly are and will be healthy and independent, more efforts have to be invested in adaptations in the pension system, and in enabling elderly persons to continue being productive citizens. Augmenting the age of retirement or canceling it, and increasing elders’ involvement in the workforce and in community and family life through incentives and other innovative social arrangements, are some of the means to achieve such changes. As described above, Israeli liberal legislation ensures safety, dignity and privacy for all, including old persons. However, due to lack of awareness, knowledge, and motivation of all the involved parties, these laws are not sufficiently and effectively implemented (Doron, Alon, & Offir, 2004). Hence, improving mechanisms for enacting the existing laws and empowering elderly persons by increasing awareness of their social rights, in the medical system and other national, public or private services, and facilitating the use of legal ways in case of need are necessary means to promote elder’s independence, and their involvement in social life. Implementation of health education, disease prevention, and health promotion programs are further means to strengthen elders’ personal responsibility, control, and self-care. Social changes of this kind have to be carefully introduced considering the expected dynamics in the needs of the changing population of elderly, their cultural characteristics, and societal milieu. Such interventions will not only reduce dependency on national resources, but also contribute to preserving elderly persons’ self-control, health, and dignity, improving their quality of life, and diminishing their needs for social and health services for long periods of time. Addressing these needs will demand changes in societal perceptions and orientations, as for example, recognizing older people as the valuable resources

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Aging in Israel

they are, and redefining what “old age” is. Should it be the chronological age or the functional age, and should old adults be forced to retire? Changes will also be needed in social policies regarding the system of pensions, law enforcement, social insurance, social and health services, all of which will enhance the creation of the desired “enabling environment”—socially, physically, economically and culturally—for healthy and frail elders. In the Area of Research The remaining challenges and needed changes, some of which were described above, are part of an ongoing and dynamic process of societal adaptation to aging. Successful adaptation to aging on the personal, family and community levels requires developing proactive insightful and skillful processes of planning and implementation. All of these largely depend on an ongoing process of quality control and extensive high quality research in all areas of aging. Research is needed for creating a dynamic infrastructure of knowledge, which will guide policies, improve existing services, and assist the planning of new ones, aid implementing new technologies, systems and approaches, as well as monitoring them for optimizing their effectiveness and efficiency. Furthermore, the ability to learn from each other in the current globalization era is a great advantage of our times, and we should make the most of it. Therefore, amplifying the current exchange of knowledge among societies, and increasing the cooperation within society, among institutions and professionals who specialize in the various areas of aging such as, caring, policies, research, and education, by establishing models and patterns for constant collaboration are important global and Israeli challenges. The institutionalization of such schemes will enrich knowledge, and continuously reveal innovative directions of research, education, policies, and services, and most importantly, increase interest in the field and motivation for active involvement of high quality students and professionals. In summary, seeking to identify the main issues and opportunities of aging and successfully responding to upcoming challenges is an art, and that art requires a proactive, insightful set of skills, adaptability, and planning. How well we learn this art determines the positive and problematic aspects of individual and population aging” (Carmel, Morse, & Torres-Gil, 2007, p. xix). Theme of the Book The following collection of Israeli papers exemplifies how research can promote knowledge about and understanding of needs and adaptation processes, assist in evaluating outcomes of policies and services on the personal, community, and national levels, as well as suggest required changes. The variety of topics on age-related research, policies, and practice reflects the wide range of research

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conducted in the domain of psycho-social aspects of aging by Israeli scholars. As such, it offers a glimpse into the knowledge base that has been built over the years on the aging process, the population of elderly people, and the national policies and network of services for the aged in Israel. The multidisciplinary approach, which is the core of the gerontological orientation, is expressed in the multiplicity of the authors’ professions, which include specialists in sociology, anthropology, psychology, social work, medicine, nursing, and law. The wide range of issues and the diverse, but complementary backgrounds of the contributing authors are indicators of the multifaceted phenomenon of aging and of the societal adaptation to this demographic change. A description of demographic changes, the following new societal needs, societal adaptation, and challenges remaining to be met by Israeli society are presented in the prologue. The first section of the book “Coping with losses and changes at old age” focuses on one of the most significant characteristics of the aging process, the frequently experienced losses in all areas of life, especially in health and functioning, as well as on protective factors in the processes of coping with some of these losses. Enhancing quality of life and successful aging are among the most desired goals of postmodern societies. The contribution of personal and social factors in achieving these outcomes is demonstrated in the papers of the second section, entitled “Social diversity, quality of life, and successful aging.” The multidimensional issue of “Taking care and caregiving” of the frail and dependent elders is addressed in the third section. The papers included in this section cover a wide spectrum of related issues on the macro and micro levels including guiding approaches, policies, medical and social services, formal and informal caregiving, and adaptation to aging in different cultural groups. The final section—“Predictors of survival at old age”- is devoted to the everlasting desire of humanity to unravel the predictors of longevity. In this section, a sample of Israeli longitudinal studies focusing on predictors of survival in the aged population is presented. Personal characteristics such as self-rated health, and the will to live, as well as social involvement in terms of volunteering, are among the revealed predictors of longevity, presented and discussed in the included papers. We hope that this collection will enhance awareness of the issue of aging in Israel and the related social challenges, provide some clues and suggestions for promoting policies and services as well as increase interest in research, thus contributing to the ultimate goal of seeing the advantages of aging societies and finding the right solutions to current problems for the benefit of Israeli elderly, Israeli society and aging societies worldwide. References Amir, M., & Lev-Wiesel, R. (2003). Time does not heal all wounds: Quality of life and psychological distress of people who survived the holocaust as children 55 years later. Journal of Traumatic Stress, 16, (3), 295-299.

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Arno, P.S. (2002). Economic value of informal caregiving. Annual Meeting of the American Association of Geriatric Psychiatry, Orlando, FL, February, 24. Butler, R. (1999). Ageism: Another form of bigotry. The Gerontologist, 9, 243-246. Carmel, S. (1999). Life-sustaining treatments: What doctors do, what they want for themselves and what elderly persons want. Social Science & Medicine, 49, 1401-1408. Carmel, S. (2001a). Subjective evaluation of health in old age: The role of immigration status and social environment. The International Journal of Aging and Human Development, 53, 91-105. Carmel, S. (2001b). The will to live: Gender differences among elderly persons. Social Science & Medicine, 52, 949-958. Carmel, S. (2002). Israel. In D.J. Ekerdt, R. Applebaum, K.C.A. Holden, S.G. Post, K. Rockwood, R. Schulz, R.L. Sprott, & P. Uhlenberg (Eds.), Encyclopedia of Aging. New York, NY: Macmillan. Carmel, S., & Bernstein, J. (2003). Gender differences in physical health and psychosocial well-being among four age groups of elderly people in Israel. The International Journal of Aging and Human Development, 56 (2), 113-131. Carmel, S., Cwikel, J., & Galinsky, D. (1992). An evaluation of changes in knowledge, attitudes and work preferences following courses in gerontology among medical, nursing, and social work students. Educational Gerontology, 18, 329-342. Carmel, S., Galinsky, D., & Cwikel, J. (1990). Knowledge, attitudes and work preferences regarding the elderly among medical students and practicing physicians. Behavior, Health and Aging, 1, 99-104. Carmel, S., Iecovich, E., & Sherf, M. (2007). Reality and desires in respect to provision of health care services to various groups of elderly persons by age, sick fund, geographical region, ethnicity, and socioeconomic status. Final Science Report, Jerusalem: The Israel National Institute for Health Policy and Health Services Research. Carmel, S., & Lazar, A. (1998). Health and well-being among elderly persons: The role of social class and immigration status. Ethnicity & Health, 3, 31-43. Carmel, S., & Lowenstein, A. (2007) Addressing a nation’s challenge: Graduate programs in gerontology in Israel. Gerontology & Geriatrics Education, 27(3), 49-63. Carmel, S., Morse, C., & Torres-Gil, F.M. (Eds.) (2007). Lessons on aging from three nations: The art of aging well (Volume I). Amityville, New-York: Baywood Publishing Company Inc. Clarfield, A.M., Brodsky, J., & Leibovitz, A. (2006). Care of the elderly in Israel: Old age in a young land. In M.S.J. Pathy, A.J Sinclair, J.E. Morley (Eds). Principles and practice of geriatric medicine (4th ed.). Chinchister, New York: Wiley and Sons Ltd. Clarfield, A.M., Paltiel, A., Gindin, Y., Morginstin, B., & Dwolatzky, T. (2000). Country profile: Israel. Journal of the American Geriatrics Society, 48, 980-984. Doron, I., Alon, S., & Offir, N. (2004). Time for policy: Legislative response to elder abuse and neglect in Israel. Journal of Elder Abuse & Neglect, 16(4), 63-82. Diez-Roux, A.V., Stein-Merkin, S., Arnett, D., Chambless, L., Massing, M., Nieto, F.J., Sorlie, P., Szklo, M., Tyroler, H.A., & Watson, R.L. (2001). Neighborhood of residence and incidence of coronary heart disease. New England Journal of Medicine, 345, 99-106. Feder, G., Cryer, C., Donovan, S., & Carter, Y. (2000). Guidelines for the prevention of falls. British Medical Journal 321, 1007-1011. Freedman, V.A., Martin, L.G., & Schoeni, R.F. (2002). Recent trends in disability and functioning among old adults in the United States. A systematic review. JAMA, 288, 3137-3146. Girion, L. (2006). Needs of patients outpace doctors. Los Angeles Times (June 4). Accessed June 8, 2006, at http://www.latimes.com.

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Harris-Kojetin, L., Lipson, D., Fielding, J., Kiefer, K., Stone, R.I. (2003). Recent findings on frontline long-term care workers: A recent synthesis 1999-2003. Washington, DC: Office of Disability, Aging, and Long-term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Israel Ministry of Health. (2007). Future of geriatrics in Israel. The Israeli Ministry of Health and The National Council for Geriatrics Committee. Landau, R., & Litwin, H. (2000). The effects of extreme early stress in very old age. Journal of Traumatic Stress, 13(3), 473-487. Marmot, M. (2001). Inequalities in Health, New England Journal of Medicine, 345(2), 134-136. Mashav. (2006). The elderly in Israel: Statistical Abstract 2005. Jerusalem: National Database, JDC-Brookdale Institute & Eshel. Mashav. (2007). The elderly in Israel: Statistical Abstract 2006. Jerusalem: National Database, JDC-Brookdale Institute & Eshel. Mashav. (2008). The elderly in Israel: Statistical Abstract 2007. Jerusalem: National Database, JDC-Brookdale Institute & Eshel. McMurdo, M.E.T., Witham, M.D., & Gillespie, N.D. (2005). Including older people in clinical research: Benefits shown in trials in younger people may not apply to older people. British Medical Journal, 33, 1036-1037. MetLife Mature Market Institute and National Alliance for Caregiving. (2006). The MetLife Caregiving Study: Productivity losses to U.S. business. Westport, CT: MetLife Mature Market Institute. National Alliance for Caregiving and AARP. (April, 2004). Caregiving in the U.S. Accessed December 12, 2008 at http://www.caregiving.org/data/04finalreport. Schulz, R., Vistainer, P., & Williamson, G.M. (1990). Psychiatry and physical morbidity effects of caregiving. Journals of Gerontology, 45B, 181-191. Schulz, R., & Beach, S.R. (1999). Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. Journal of the American Medical Association, 282, 2215-2219. Shachar, Y. (1995). History and sources of Israeli law. In A. Shapira, & K.C. DeWittArar (Eds.), Introduction to the law of Israel (pp. 1-16). Boston: Kluwer Law International. Stone, R.I. (2004). The direct care worker: The third rail of home care policy. Annual Review of Public Health, 25,521-537. United Nations. (2002). Report of the Second World Assembly on Aging. Madrid, 8-12 April 2002. New-York: Author. United Nations. (2006). World population prospects, the 2006 revision. New York: Author. US Bureau of the Census. (2008). Statistical abstract of the United States. Accessed December 12, 2008, at http://www.census.gov/. Wen, M., Browning, C.R., & Cagney, K.A. (2003). Poverty, affluence, and income inequality: Neighborhood economic structure and its implication for health. Social Science & Medicine, 57, 843-860. World Health Organization. (2004). World health report: Changing history. Geneva: Author. World Health Organization. (2007). World health statistics: Ten statistical highlights in global health. Geneva: Author.

Part 2 Coping with Losses and Changes at Old Age

1 Coping with Losses and Past Trauma in Old Age: The Separation-Individuation Perspective Liora Bar-Tur and Rachel Levy-Shiff Old age is a stage in life in which numerous changes associated with loss can be expected to occur in major life domains. Deterioration of health, retirement, relocation, occupational and financial loss, loss of social roles, identity, status, support, and the loss of spouse and significant others (siblings, friends) pose an ongoing threat to everyday functioning, forcing the individual to adapt. Thus, effective functioning in daily life presents a major developmental task for the aging (Baltes & Carstensen, 1996; Marsiske, Lang, Baltes & Baltes, 1995). There is marked variability in adjustment among the elderly, and despite the numerous losses associated with aging, many are well adjusted, and report experiencing high levels of well-being (George & Clipp, 1991; Wetle, 1990). Researchers have addressed those factors that determine the capacities of some elderly to maintain, or even improve their well-being, in the face of accumulating loss. Two major interrelated factors associated with adaptation have been recently discussed: resilience and resources (Baltes & Lang, 1997; Hobfoll & Wells, 1998; Ryff, Singer, Love, & Essex, 1998). Resilience, as postulated by Ryff et al. (1998), is defined as the maintenance, recovery, or improvement in mental and physical health following change (often experienced as change or loss). Resilience is an outcome of an individual’s resources operating as protective factors at the socio-demographic, psychological, social, and biological levels. Baltes and Lang (1997) assert that older individuals’ adaptation to loss depends on the availability of resources in the sensorimotor, cognitive, personality, and social domains of functioning. Thus, the more resources that are available, the easier it is for the individual to anticipate, confront, and adapt to aging losses. Indeed, research has identified a number of factors associated with enhanced 27

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or impaired adjustment among the elderly, such as the quality of marital relations, health, and financial status, yet a significant measure of variance remains unexplained (Larson, 1978). The question arises as to what adaptive processes are activated to counteract external stressors and increase resilience when other resources are in decline. As numerous resources (social, physical, and cognitive) are increasingly depleted, we suggest that the inner, psychological resources become of major importance at this stage of life. The association between psychological resources and the process of adaptation of the elderly to loss has not been widely investigated hitherto. The present perspective proposes that successful adjustment to losses in aging is associated with the development of a rich, inner world based on mental and emotional engagements. These engagements act as inner adaptive processes that help moderate the negative impact of aging losses, facilitate adaptation, and even ensure developmental gains. This perspective corresponds to the life-span developmental view, which places an emphasis on the interplay between internal and external factors, present and past experiences, and between gains and losses in adult development (Baltes, 1987). Losses and Gains along the Life-Span The experience of loss is an inherent part of human development and is associated with various life transitions. As individuals mature, they enter new social contexts and leave others, often experiencing an accompanying sense of loss (Rosenblatt, 1993). In recent years, the view of how people deal with major loss has been re-conceptualized, suggesting that with change there is also a potential for gain (Miller & Omarzu, 1998). Whereas previous perspectives assumed that successful coping with loss was attained by returning to a balanced pre-loss state, more recent perspectives suggest that individuals who suffer loss never completely return to their pre-loss state, as loss alters one’s self-identity or self-schema (Harvey, 1998). Furthermore, this may not even be an optimal goal. The developmental goal is to survive loss, come to terms with change, and integrate oneself into a new social context and identity. This new perspective is in line with Baltes’ (1987) developmental model, emphasizing the complexity, plasticity, and multi-directionality within the life span, with internal and external factors continuously influencing each other. Old age, according to Baltes’ developmental model, can be a dynamic and important phase in which intra-psychic processes are modified through physical and environmental changes. Ontogenetic development suggests also that there is no gain without loss and no loss without gain. Baltes (1987) nevertheless suggests that there is a systematic script to life-span changes in the relative allocation of resources. During childhood, the primary allocation of resources is

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directed toward growth; during adulthood, the predominant allocation is towards maintenance and recovery. In old age, more and more resources are required to regulate loss. We suggest that inner adaptive processes such as separation-individuation may affect both the regulation of loss, and the interplay between losses and gains, in the internal and external world. Loss imposes separations. Each separation, however, also bears potential for growth, which can be achieved through further individuation. The focus of this chapter is on losses and gains associated with inner processes of separation-individuation and the role they play in the adjustment of the elderly. Separation-Individuation along the Life-Span The theory of separation-individuation developed by Mahler (Mahler, 1968; Mahler, Pine, & Bergman, 1975) suggests that separation-individuation is a lifelong process. This process begins with psychological birth that, unlike its biological counterpart, involves a slowly unfolding intra-psychic dynamic. This dynamic is first manifested in early childhood and is later active as the intra-psychic process of adolescence, described by Blos (1967) as second individuation. After subsequently reappearing in young adulthood, the elaboration of these processes is later manifested with the inevitable crises, challenges, and tasks of middle adulthood (Colarusso, 1997). Colarusso argues that in each phase of adulthood there are specific adult developmental tasks to be negotiated. He proposes that the third individuation occurs in young adulthood, the fourth in middle adulthood, and the fifth in aging. Few have elaborated on the processes of separation-individuation during old age. Colarusso suggests that among the elderly, there are various common tasks, such as adapting to new types of relationships, the changing of one’s goals, facing the decline of physical vigor, and ultimately the separation of death. Coping with losses among the elderly is determined by previous separation-individuation resolutions, and may be moderated by the fulfillment of grandparenthood, and by the engagement with and the idealization of grandchildren. According to Colarusso, separation-individuation at this stage in life serves a number of defensive and developmental purposes. Cath (1997) has also noted that becoming a grandparent activates aspects of the first individuation and may bear potential for late-life emotional refueling. Discussing the separation-individuation process in old age, Cath describes how the human being moves from the early experience of learning to be with and attach to others, to the challenge in old age of separating from imperfect others and from unfulfilled aspirations. Cath suggests that the essence of separationindividuation in old age is reflecting on life, seeking universal wisdom. Thus, personal growth often comes through reminiscence, reflection, and consolidation.

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Elaborating on the separation-individuation process in aging, we suggest that despite multiple losses and separations, there are potential gains for personal development beyond grandparenthood and wisdom. Since aging often involves a diminution in the social sphere as well as a decline of biological processes, we contend that it is the inner world, which includes present and past representations of experiences, relationships and objects, which bears the primary potential of development and growth. Separation processes in aging involve emotional independence from external societal forces, achieved through selective disengagement from roles and objects that were part of the individual’s past reality and are no longer relevant and rewarding. Individuation is achieved through mobilization of inner resources for mental and emotional engagements, some of which cannot be fully expressed and observed in the outer world. Mental engagements comprise activities and interests with which the individual is cognitively involved and which occupy the mind. Emotional engagements include relationships with significant others during the life cycle and their representations in the inner world. Mental and emotional engagements may be interrelated, containing components of both the past and the present. These engagements with significant others, in the outer and the inner world, affect the older person’s well-being. Gains in aging may therefore be attained via emotional independence from external forces and through an increase in inner resources. This conceptualization is in line with Jung’s (1933) concept of individuation, Butler’s (1963) suggestion of life review, Neugarten’s (1977) findings on increased introversion with age, and Erikson’s (1963, 1984) concept of integrity and wisdom. Levinson, Darrow, and Kline (1978), have maintained that the primary developmental task of late adulthood is to find a new balance between involvement with society and with the self. Wisdom regarding the external world can be gained through a stronger focus on the self, as the individual becomes less interested in rewards offered by society. Through the creation of a new form of self-in-world, late adulthood can be a season as full and rich as previous ones. Ryff (1989), in viewing the possibility of continued growth and development in the later years, suggests that old age has its unique responses and challenges. Autonomy and self-determination, components of well-being, thus, can be achieved through the processes of separation-individuation, without necessarily having active social roles and relationships. According to Kernberg (1987), dealing with loss and separation is possible if individuals sense that their creativity has contributed to the strength and permanence of the “good” internalized object relations and that they have fulfilled their duties toward their loved ones. The ability to separate emotionally depends on reorganization of the inner world, so that there are representations of significant objects from the present and past with which relations can continue. A strong world of internalized object representations offers enrichment and support to the self. It enables one to accept loss and failure with a sense of sufficient in-

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ner resources to continue accepting oneself and to trust one’s own capacity to reconstitute a meaningful life. Narcissistic gratification from external sources is augmented by secondary narcissistic gratification from internal resources. It also allows elderly people to maintain a sense of mastery and autonomy during the reversal of generational roles when they become dependent on children or grandchildren. In terms of the balance between gains and losses, we posit that in old age, engagements in the inner world can complement and sometimes replace the diminishing external physical and social resources. Furthermore, since well-being is based on the meaning that a person attributes, rather than on the concrete experience (Ryff, 1989), a subjective feeling of well-being can prevail, despite significant loss. Separation frees the elderly from preoccupation with the past, enabling them to attain individuation by focusing on significant engagements in the present. The process of separation-individuation is thus the adaptive mechanism in aging, which helps reduce the impact of loss often experienced by many of the imposed changes in the last phase of the life cycle. The ability to disengage mentally and emotionally from certain aspects of life, and to fill the gap with alternative content, helps the aged retain integrity and self-esteem, thus maintaining a high level of well-being (Bar-Tur, Levy-Shiff, & Burns, 1998). Gains in aging may be achieved through individuation, as the individual continues to develop through enrichment of the inner world, while the external world is gradually shrinking. The following vignette is one such example: Mrs. B. is 90 years old and lives in a nursing home. Old age took its toll eight years ago, when her husband became ill and she could no longer continue her daily activities. Seven years ago, her husband passed away, and she decided to move into the home two years after her husband’s death, following a major deterioration in her own health. Numerous losses accompanied her relocation, including the loss of a large home, familiar environment, loss of respect and status, and loss of friends and neighbors. Following a period of bereavement, Mrs. B. gradually adjusted to her new life, and came to appreciate her new friends, lectures she attended, meals she received hassle-free, and especially the medical care and security she felt at the nursing home. All these were perceived as gains, compensating for the attendant losses. Despite her restricted mobility and autonomy, she maintained an active social life. She read a newspaper daily, listened to the radio, and watched television. She spoke on the telephone with her grandchildren almost every day, and supported them financially. The role of grandmother provided her with satisfaction and pride, and she regarded her grandchildren’s successes as the fruits of her life and that of her husband. Mrs. B. has successfully disengaged from aspects of her past life including objects, friends, and roles, and re-engaged in new roles as an active member of the home’s committee, as a proud grandmother, with new friends. In her inner world, she still maintained memories of her beloved husband and friends, her old

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home and her past. However, she realized that, at the age of 90, she was lucky to have found love, shelter, and care. Her individuation has been achieved, despite past and present losses, through the gains of grandparenthood, her activities in the nursing home, and through representations of life achievements, manifesting itself in feelings of well-being, autonomy, and self-esteem. Past Traumatic Loss and Its Impact on the Elderly Unlike Mrs. B., there are many elderly who experience traumatic losses from which they do not disengage. People who have experienced traumatic losses mobilize their resources to counter their effects, and may therefore suffer from extreme resource loss, and from a diminished resource reservoir when coping with later loss (Hobfoll & Wells, 1998). Hence, the question arises as to the particular effects of loss, associated with previous traumatic experience, on the elderly. Two issues can be addressed: whether past traumatic losses have longterm effects in aging, interacting with those losses associated with aging, and whether elderly people who have experienced traumatic loss in the past cope better or worse with the normative losses of aging. Miller and Omarzu (1998) contend that the occurrence of multiple losses can greatly impact one’s definition and perception of future loss experiences, as well as how well one copes with such events. They also postulate that individuals may use previous losses as yardsticks by which they “measure” their current level of grieving; however the operations of such processes are still unknown. Past traumatic losses, according to this view, thus interact with coping with aging losses. A substantial body of theory, often grouped as the “vulnerability perspective,” maintains that prior experience with extreme stress reduces the ability of individuals to withstand additional stress (e.g., Selye, 1976). This view is supported by a range of findings related mostly to loss of a family member (Lehman, Wortman, & Williams, 1987). The loss of a child has been found to have a pervasive impact, sometimes marked by chronic grief (Raphael, 1983), and by constant thoughts and feelings about the deceased accompanied by pain and guilt (Lehman et al., 1987; Rando, 1996; Rubin, 1993; Videka-Sherman, 1982). On the other hand, the “inoculation perspective” (e.g., Eysenck, 1988) maintains that stress contributes to the development of useful coping strategies. This perspective holds that each stressful event increases familiarity, thereby leading to a decline in perceived stress, enabling a more successful adaptation to future stressful events. In their review of coping with traumatic life events, Janoff-Bulman and Timko (1987) conclude: “The benefits derived from negative events include a new-found appreciation of life and a recognition of what is really important, as well as a more positive view of one’s own possibilities and strengths” (p.155). Pearlin and Skaff (1996) suggest that people may use their success in dealing with past stressful experiences to help them feel competent in mastering current adversity.

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A discussion of the effects of past traumatic loss may be enhanced by focusing on two types of such loss: the loss of a single significant other, and losses related to massive trauma, such as the Holocaust. How do Holocaust survivors, having experienced massive traumatic losses that no doubt depleted their resource reservoir, cope with losses in aging? Five decades of research and clinical studies yield a broad array of indicators. Numerous factors have been found to be involved in determining the coping and well-being of elderly survivors, including pre-war personal history, personality characteristics, age of survivors, nature of traumatic experience (primarily concentration camps, labor camps, and hiding), and post-war experience. These factors present complex models of adjustment, both along the life span and in old age, suggesting an interaction between past and present loss and between inner and external processes of adjustment. Late-Life Effect of Holocaust Losses Reports related to coping of Holocaust survivors in old age are incongruent and diverse, and may be classified within the two opposing perspectives of vulnerability versus inoculation. A significant body of data views aging survivors as a high-risk group for emotional pathology, suggesting that old age, with its multiple losses, may be particularly difficult for survivors (e.g., Eitinger, 1980; Nadler & Ben-Shushan, 1989). Dasberg (1987) argues that stressful events and losses in aging may be symbolically reminiscent of their earlier losses in the Holocaust. Danieli (1981, 1994) even suggests that for some survivors, old age in itself is particularly traumatic. Many survivors are particularly vulnerable to the changes that are part of the aging process. Unstructured time reduces defenses, and may reactivate intrusive thoughts, nightmares, somatic problems, guilt, and agitated depression, symptoms that are now recognized to be components of posttraumatic stress disorder (Danieli, 1981; Robinson Rapaport, & Durst, 1990; Safford, 1995; Steinitz, 1982). Steinitz’s (1982) findings, based on 550 non-institutionalized survivors, reveal that for many survivors, daily coping requires an individual to fill a meaningful family role, participate in various activities, and to be employed. These activities seem to provide a sense of self-worth as well as an opportunity to focus on present and future concerns, rather than on the past. However, these coping strategies are often inadequate, when the losses and disabilities associated with aging interact with Holocaust-related psychic wounds and chronic health problems. Memories, fears, and other psychological residual effects of the Holocaust may resurface for the first time in years, suggesting that survivors’ coping strategies are particularly vulnerable to the normal experiences of aging. Despite these findings, studies of community-dwelling, non-clinical survivor populations also reveal strong indicators of adaptation and coping in major life

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domains during adulthood, with numerous survivors working, maintaining economic stability, and raising families. Some studies have concluded that there is no serious psychological impairment to be found among survivors or among their children (e.g., Carmill & Carel, 1986; Eaton, Sigal, & Weinfeld, 1982). Helmreich (1992) contends that most of the survivors they interviewed were well adjusted, resourceful, and resilient. More than half the elderly survivors (55%) whom Kahana, Harel, and Kahana (1988) queried reported either that their Holocaust experience had no impact or made it easier for them to cope with aging. Fully 26 percent of Kahana et al.’s, (1988) Holocaust survivor interviewees said that their Holocaust experience made it easier for them to cope with the aging process (e.g., “Once you survive the Holocaust, you can survive normal aging”). Sadavoy (1997) argues that the more convincing data suggest that emotional reactivity may remain intense and dysphoric without affecting measures of adaptation and overt behavior. Shmotkin and Lomranz’s (1998) study comparing Israeli Holocaust and nonHolocaust survivors also supports the assertion that the trauma of the Holocaust may impair well-being, but may also promote reactions of accomplishment and a desire to place a stronger grip on life. Thus, impairment and mental suffering do not contradict successful coping and adjustment among survivors. Lomranz (1990) argues that the Holocaust experience helped prepare some survivors to respond appropriately to future loss. He (1998) suggests the concept of A-integration that may explain these contradictory findings. A-integration is conceived as an individual’s potential to experience well-being, without necessarily having integrated all the bio-psycho-social levels, including traumatic losses and experiences. Moreover, many people feel that their traumatic experience is incongruent with the prevailing cultural value system or ongoing modes of daily life (Janoff-Bulman & Berg, 1998), yet they live with this contradiction, are aware of it, and nevertheless lead productive, well-functioning lives. We may conclude that the gains revealed in the functioning and coping of many survivors enhance their external daily life, whereas in the inner world many continue their emotional engagements accompanied with the unresolved pain and grief associated with traumatic loss that cannot be healed. The losses of old age may act as a trigger for past traumatic repressed losses, and aging Holocaust survivors may therefore be more vulnerable and resource depleted. Whereas the long-term effects of massive trauma, such as the Holocaust, on the elderly have been demonstrated, the question arises as to how other discrete traumatic loss in the past, such as the loss of a child, affects the process of coping with the losses of aging. The Traumatic Loss of a Child and Old Age The traumatic effects of the death of a child have been described as pervasive, with patterns of chronic grief. Edelstein (1984) has discussed three unique

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qualities associated with the loss of a child: the loss of a part of oneself, of a link to the future, and of illusions regarding life, death, and existential issues. Rando (1996) has also discussed “survival guilt” and “out of turnness,” often experienced by bereaved parents. Both Edelstein and Rando suggest that the death of a child may be the most difficult loss to resolve, with the intensity of grief lasting longer than in other types of bereavement. Rubin (1993) found parents to be highly involved with their deceased child at the relational level, with their responses to loss occurring along two tracks: bio-behavioral, and ongoing attachment to the deceased. Pain is dominant in their lives. An examination of the long-term effects of the death of both a young or an adult child reveals a continuing engagement in thoughts and feelings concerning the deceased, sometimes accompanied by pain and guilt (Lehman et al., 1987; Rando, 1996; Rubin, 1993; Videka-Sherman, 1982). Trait and Silver (1989) found that even 23 years later, a considerable proportion of parents who had lost a child reported an ongoing cognitive and emotional involvement in the loss event. It appears that time has little effect on moderating the impact of the loss. Some individuals were unable to relinquish their involvement with loss and remained distressed much longer than might have been expected. All these studies point to the absence of a relationship between the time elapsed since the death and the well-being of bereaved parents (Edelstein, 1984; Moss, Lesher, & Moss, 1984). For elderly parents, the death of an adult child is a most difficult event, requiring the highest degree of adjustment. This experience turns into a dominant theme in their later life (Rubin, 1993; Tamir, 1993). Lesher and Berger (1988) found that elderly bereaved mothers suffered from a significant level of prolonged psychological distress. None of the mothers interviewed indicated that they had resolved or adjusted to their child’s loss. The themes that emerged in a group discussion with 29 elderly bereaved Israeli parents, whose sons were killed during military service (between 11 to 33 years ago), support previous findings that the passage of time has little effect on diminishing a parent’s grief or on relinquishing attachment to the deceased. The loss of a child is experienced as unnatural, unexpected, and always traumatic. Aging appears to increase internalized involvement with the long lost child, triggering fears of fading memories, as well as a need to eternalize the deceased. This strong attachment seems to continue in both external and inner representations of the lost child (Malkinson & Bar-Tur, 1999). Despite functioning normally and adequately, elderly bereaved parents bear the scars of traumatic loss in their inner world, supporting the concept of a distinction between the external and inner world. Klass, Sliverman, and Nickman (1996) have asserted that the bereaved hold the deceased in memory, often forever, and that such maintenance of inner representation is normal rather than abnormal. The authors suggest that these relationships can be described as interactive, despite the physical absence of

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the other. With time, this bond can take on new forms, yet the connection is maintained. As people mature and develop over the life cycle, their internal representations change. Adaptation to loss refers to how people reorganize their lives and their sense of self in a way that enables them to live in the present, including learning to deal with the extreme sadness and pain associated with loss. Resolution of grief is described by the authors as a process that continues beyond adaptation and coping with loss, as the memory and representation of the deceased continue across the life cycle. The results of our study (Bar-Tur, Levy-Shiff, & Burns, 1997) indicated a significant interaction between past traumatic losses and aging losses, in predicting well-being among the elderly. However, while losses related to the massive trauma of the Holocaust seem to impair the individual’s ability to cope with later losses, traumatic personal loss of a significant other seems to inoculate the individual against the effects of later loss, and even to contribute to personal growth. The evidence gleaned from interviews suggests that individuals who experienced a single traumatic loss (such as the death of a child) came to regard the losses of aging as secondary, enabling them to better cope with aging losses, and in some cases to turn these into opportunities to develop. These gains were achieved despite continued emotional and mental engagements with the deceased in the inner world. Our findings are consistent with the concept whereby people who weather a severe stressor may develop enhanced perceptions, a more positive view of their strengths, and a different perspective on future events (Janoff-Bulman & Berg, 1998; Janoff-Bulman & Timko, 1987). Nevertheless, despite the psychological and social reorganization manifested in the well-being and coping with loss among numerous elderly survivors of discrete trauma such as the loss of a child, or of multiple massive traumas such as the Holocaust, many continue to experience pain and grief in their inner world. This is consistent with recent perceptions of bereavement (Klass et al., 1996; Rubin, 1993). While bereaved parents live their lives side by side with the trauma, the traumatic effects of the Holocaust on survivors were repressed for years. Survivors did not undergo a legitimate mourning process, and were unable to experience acute grief while trying to survive. Grief is perhaps manifested through physiological or mental symptoms such as post traumatic stress disorder, yet Holocaust survivors are not yet post-trauma, since mourning is designed for loss, not for catastrophe (Roth, 1988). Aging-related losses may lead to various attempts to maintain continuity and self-esteem by turning to past memories. However, the supportive elements of reminiscence are often unavailable to survivors, as remembrance evokes traumatic memories (Sadavoy, 1997). Nadler and Ben-Shushan (1989) also assert that since the manifestation of psychological effects of massive victimization depends on the victims’ life circumstances, most survivors repressed trauma, and coped with the

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world by trying to rebuild what was lost. In old age, with the completion of such tasks, survivors focus less attention on the external world and the psychological effects of traumatization resurfaces. Furthermore, the particular emphasis which survivors place on the integrity of the family unit may increase their vulnerability to stress associated with the natural process of family disintegration. The following vignettes present two different modes of adaptation to aging losses as manifested in a Holocaust survivor, and in a survivor of a discrete traumatic loss, the death of a child. Mrs. M., aged 95, is the sole survivor of a prominent family from Poland. She lost her parents, younger brother, husband, and son in the Holocaust. Her survival during the war included horrific traumatic experiences. She immigrated to Israel in 1949, married a man who was also a lone survivor, and lived with him until his death in 1971. Her love and longing for her first husband, and especially for her son, never diminished. She thought and dreamt about them throughout her life. She rebuilt her life, becoming a teacher and then a headmistress, giving love and care to young children. Her emotional survival was achieved through a mission she took upon herself to bear witness to the Holocaust. She wrote books, poems, and newspaper articles, lectured, testified, and gave interviews, and built memorials to her family and those who perished. In her later years, while sick and weak, living alone in a small room in an old age home, she continues with her mission writing poems and letters, and telling young students her story and that of the loved ones whom she still carries in her inner world. She does not disengage from them or from her traumatic past. Despite her advanced age, loneliness, traumatic past losses and accumulating present losses, she is not depressed, is in fact well adjusted, possessing a sense of mastery. Such active and public engagement with the losses of the past represents a major gain, which helps to sustain hope and to cope with both past and present losses (for more details, see Bar-Tur & LevyShiff, 1994). Mrs. M.’s well-being is manifested in her individuation, achieved through continued mental and emotional engagements with the Holocaust and its traumatic losses, in the inner and outer world. Mr. L., aged 74, whose son was killed in 1975 while serving as an officer in an elite army unit, was an active member of an organization of bereaved parents in Israel. Since his son’s death, Mr. L. was involved in community activities aimed at helping bereaved families. At the age of 65, a malignant tumor was removed from his bowel. Soon after his operation, while in remission, he formed a support group for cancer patients. In addition, at the age of 72, despite his deteriorating health, he formed yet another support group, for elderly bereaved parents. When asked how he deals with his deteriorating health, he replied: “As long as I am active, I live; if I stop, I’ll die. Aging losses are not the issue; I can deal with them—compared to the loss of my son with which I deal with all my life. It made me stronger. The pain and weakness are only inside.” Like Mrs. M., Mr. L. is also engaged, mentally and emotionally, with activities related to the traumatic loss of his son. Active mental engagements

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in the outer world with bereaved and sick people enhance his well-being and individuation, despite continued emotional and mental engagements with the deceased in the inner world. Conclusions The present chapter proposes that separation-individuation processes operate as inner adaptive processes, regulating the interplay between losses and gains in aging. These processes are triggered by external changes and losses that require internal reorganization and resource regulation. Utilization of one’s inner resources can create an inner world rich with mental and emotional engagements, compensating for the diminishment of the external world. The processes of disengagement and individuation help moderate the negative impact of aging losses, facilitate adaptation, and even ensure developmental gains. Regulating the effects of loss is more complicated for those elderly who have experienced past traumatic losses. Multiple traumatic losses in the past deplete the resource reservoir, impairing adaptation and well-being. In terms of separation-individuation processes, we suggest that survivors of both significant traumatic loss or massive trauma such as the Holocaust, can never fully disengage from the representations of their beloved ones. Thus, the inner world remains of major importance in old age, and is likely to become more significant with time. Older survivors tend to function on two levels. In the external, functional world, many are well adapted; however, in the inner world they continue to be emotionally engaged with the deceased and may experience increased pain. Despite these engagements, findings reveal that individuals, who previously experienced a discrete traumatic loss, often came to regard aging-related losses as secondary, enabling them to better cope with those losses and, in some cases, to turn them into opportunities for further development. However, it appears more difficult for Holocaust survivors, as compared with bereaved parents or survivors of other discrete traumatic losses, to regulate and compensate for aging losses, as they carry in their inner world memories of an ongoing traumatic experience that defies mourning. For such survivors, disengagement from a diminishing outer world and increased engagement with their inner world may be too painful to tolerate. References Baltes, P. B. (1987). Theoretical propositions of life-span developmental psychology: On the dynamics between growth and decline. Developmental Psychology, 23, 611626. Baltes, M. M., & Carstensen, L. L. (1996). The process of successful aging. Aging and Society, 16, 397-422. Baltes, M. M. & Lang, F. R. (1997). Everyday functioning and successful aging: The impact of resources. Psychology and Aging, 12, 433-443.

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Bar-Tur, L., & Levy-Shiff, R. (1994). Holocaust review and bearing witness as a coping mechanism of an elderly Holocaust survivor. Clinical Gerontologist, 14, 3-15. Bar-Tur, L., Levy-Shiff, R., & Burns, E. (1997). Past traumatic losses and their impact on well-being of elderly men. Journal of Personal and Interpersonal Loss, 2, 379-395. Bar-Tur, L., Levy-Shiff, R., & Burns, E. (1998). Mental engagements as a moderator of losses of elderly men. Journal of Aging Studies, 12, 1-17. Blos, P. (1967). The second individuation process of adolescence. The Psychoanalytic Study of the Child, 14,113-121. New York: International Universities Press. Butler, R. N. (1963). The life review: An interpretation of reminiscing in the aged. Psychiatry, 26, 65-76. Carmill, D., & Carel, R. (1986). Emotional distress and satisfaction in life among Holocaust survivors: A community study of survivors and controls. Psychological Medicine, 16, 141-149. Cath, S.H. (1997). Loss and restitution in later life. In S. Akhtar & S. Kramer (Eds.), The seasons of life: Separation-Individuation perspectives (pp. 128-156). Northvale, NJ: Jason Aronson. Cohen, B. (1991). Holocaust survivors and the crisis of aging families in society. The Journal of Contemporary Human Services, 72, 226 -232. Colarusso, C.A. (1997). Separation-Individuation processes in middle adulthood. In S. Akhtar & S. Kramer (Eds.), The Seasons of Life: Separation-Individuation perspectives (pp. 75-94). Northvale, NJ: Jason Aronson. Danieli, Y. (1981). The aging survivor of the Holocaust: On the achievement of integration in aging survivors of the Nazi Holocaust. Journal of Geriatric Psychiatry, 14, 191-210. Danieli, Y. (1994). As survivors age, Part II. NCP Clinical Quarterly, 1-7. Dasberg, H. (1987). Psychological distress of Holocaust survivors. Israel Journal of Psychiatry and Related Sciences, 24, 243-256. Eaton, J., Sigal, J., Weinfeld, M. (1982). Impairment in Holocaust survivors of the Nazi Holocaust. American Journal of Psychiatry, 139, 773-777. Edelstein, L. (1984). Mental bereavement. New York: Praeger. Eitinger, L. (1980). The concentration camp syndrome and its late sequel. In J. Dimsdale (Ed.), Survivors, victims and perpetrators (pp. 127-162). New York: Hemisphere. Erikson, E. (1963). Childhood and society. New York: Norton. Erikson, E. H. (1984). Reflections on the last stage. The Psychoanalytic Study of the Child, 39, 155-167. Eysenck, H. J. (1988). Stress, disease and personality: The inoculation effect. In C. L. Cooper (Ed.), Stress research (pp. 121-146). New York: John Wiley. George, L. K., & Clipp, E. C. (1991). Subjective components of aging well. Generations, 15, 57-60. Helmreich, W. B. (1992). Against all odds--Holocaust survivors and successful lives they made in America. New York: Simon & Schuster. Harvey, J. H. (1998). The connection between grief and trauma. In J. H. Harvey (Ed.), Perspectives on loss: A source book (pp. 3-17). Brunner/Mazel. Hobfoll, S. E., & Wells, J. D. (1998). Conservation of resources, stress, and aging. In J. Lomranz (Ed.), Handbook of aging and mental health: An integrative approach (pp. 121-134). New York: Plenum Press. Janoff-Bulman, R., & Berg, M. (1998). Disillusionment and the creation of value: From traumatic losses to existential gains. In J. H. Harvey (Ed.), Perspectives on loss: A source book (pp. 35-47). Brunner/Mazel. Janoff-Bulman, R., & Timko, C. (1987). Coping with traumatic life events: The role of denial in light of people’s assumptive world. In C. R. Snyder & C. E. Ford (Eds.),

40

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Coping with negative life events (pp. 135-155). New York: Viking (original work published 1933). Jung, C. G. (1933). Modern man in search of a soul. New York: Harcourt, Brace, & World. Kernberg, O. (1987). Internal world and external reality. London: Aronson. Klass, D., Silverman, P.R., & Nickman, S.L. (1996). Continuing bonds: New understandings of grief. Washington, DC: & Francis. Kahana, B., Harel, A., & Kahana, E. (1988). Predictors of psychological well-being among survivors of the Holocaust. In J. Wilson, Z. Harel, & B. Kahana (Eds.), Human adaptation to extreme stress (pp. 171-192). New York: Plenum. Larson, R. (1978). Thirty years of research on the subjective well-being of older Americans. Journal of Gerontology, 33, 109-125. Lehman, D. R., Wortman, C. B., & Williams, A. F. (1987). Long-term effects of losing a spouse or child in a motor vehicle crash. Journal of Personality and Social Psychology, 52, 218-231. Lesher, E.L., Berger, K.J. (1988). Bereaved elderly mothers: Changes in health, functional activities, family cohesion, and psychological well-being. International Journal of Aging & Human Development, 26, 81-90. Levinson, D.J., Darrow, C., & Kline, E. (1978). The seasons of man’s life. New York: Knopf. Lomranz, J. (1990). Long-term adaptation to traumatic stress in light of adult development and aging perspectives. In M. A. Perris, S. Crowthet, S. E. Hobfoll, & D. L. Tennenbaum (Eds.), Stress and coping in later life families (pp. 99-121). Washington, DC: Hemisphere. Lomranz, J. (1998). An image of aging and the concept of integration. In J. Lomranz (Ed.), Handbook of aging and mental health: An integrative approach (pp. 217-250). New York: Plenum Press. Mahler, M. S. (1968). On human symbiosis and the vicissitudes of individuation. New York: International Universities Press. Mahler, M. S., Pine, F., & Bergman, A.(1975). The psychological birth of the human infant. New York: Basic Books. Malkinson, R., & Bar-Tur, L. (1999). The aging of grief: A perspective of bereaved parents in Israel. Death Studies, 23. Marsiske, M., Lang, F. R., Baltes, P. B., & Baltes, M. M. (1995). Selective optimization with compensation: Life-span perspectives on successful human development. In R. Dixon & L. Backman (Eds.), Psychological compensation: Managing losses and promoting gains (pp. 35-79). Hillsdale, NJ: Erlbaum. Miller, E.D., & Omarzu, J. (1998). New directions in loss research. In J .H. Harvey (Ed.), Perspectives on loss: A source book (pp. 3-20). Brunner/Mazel. Moss, M.S., Lesher, E.L., & Moss, S.Z. (1984). Impact of the death of an adult child on elderly parents: Some observations. Omega, 17, 209-218. Nadler, A., & Ben-Shushan, D. (1989). Forty years later: Long-term consequences of massive traumatization as manifested by Holocaust survivors from the city and the Kibbutz. Journal of Consulting and Clinical Psychology, 57, 287-293. Neugarten, B. L. (1977). Personality and aging. In E. Birren, & K. W. Schaie (Eds.), Handbook of the psychology of aging (pp. 616-649). New York: Van Nostrand. Pearlin, L. I., & Skaff, M. M. (1996). Stress and the life course: A paradigmatic alliance. The Gerontologist, 2, 239-247. Rando, T.A. (1986). Parental loss of a child. Champaign, IL: Research Press. Rando, T. (1996). Complications in mourning traumatic death. In K. Doka (Ed.), Living with grief after sudden loss (pp. 139-160). Washington, DC: Hospice Foundation of America.

Coping with Losses and Past Trauma in Old Age

41

Raphael, B. (1983). The autonomy of bereavement. New York: Basic Books. Robinson, S., Rapaport, J., & Durst, R. (1990). The late effect of Nazi persecution among elderly Holocaust survivors. Acta Psychiatrica Scandinavica, 82, 311-315. Rosenblatt, P.C. (1993). Grief: The social context of private feelings. In M.S. Stroebe, W. Stroebe, & R.O. Hansson (Eds.), Handbook of bereavement (pp. 102-111). New York: Cambridge University Press. Roth, S. (1988, May). The shadow of the Holocaust. Fourth conference of the Freud Center of The Hebrew University of Jerusalem. Rubin, S. (1993). The death of a child is forever: The life course impact of child loss. In M. S. Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement (pp. 285-299). Cambridge: Cambridge University Press. Ryff, C. D. (1989). Beyond Ponce de Leon and life satisfaction: New directions in quest of successful aging. International Journal of Behavioral Development, 12, 35-55. Ryff, C. D., Singer, B., Love, G. D., & Essex, M. J. (1998). Resilience in adulthood and later life. In J. Lomranz (Ed.), Handbook of aging and mental health: An integrative approach (pp. 69-96). New York: Plenum Press. Sadavoy, J. (1997). A review of the late-life effects of prior psychological trauma. The American Journal of Geriatric Psychiatry, 5, 287- 301. Safford, F. (1995). Aging stressors for Holocaust survivors and their families. Journal of Gerontological Social Work, 24, 131-153. Selye, J. (1976). The stress of life. New York: McGraw-Hill. Shmotkin, D., & Lomranz, J. (1998). Subjective well-being among Holocaust survivors: An examination of overlooked differentiations. Journal of Personality and Social Psychology, 75, 141-155. Steinitz, L. Y. (1982). Psycho-social effects of the Holocaust on aging survivors and their families. Journal of Gerontological Social Work, 4, 145-152. Tamir, G. (1993). Long term adjustment among war bereaved Israeli parents. In E. Malkinson, R. Witztum, & S. R. Rubin (Eds.), Loss and bereavement in Jewish society in Israel. Jerusalem: Cana Publishers. (Hebrew). Trait, R., & Silver, R.C. (1989). Coming to terms with major negative life events. In J. S. Uleman & J. A. Bargh (Eds.), Thoughts: The limits of awareness, intention and control (pp. 351-382). New York: Guilford Press. Videka-Sherman, L. (1982). Coping with the death of a child: A study over time. American Journal of Orthopsychiatry, 52, 688-699. Wetle, T. (1990). Successful aging: New hope for optimizing mental and physical wellbeing. Journal of Geriatric Psychiatry, 20, 3-11.

2 Interpersonal Relatedness and Self-Definition in Late Adulthood Depression: Personality Predispositions and Protective Factors Avi Besser and Beatriz Priel For age is opportunity no less Than youth itself, though in another dress, And as the evening twilight fades away, The sky is filled with stars, invisible by day. Henry Wadsworth Longfellow

The fastest growing segment of world population is the 65-plus age group. The share of the population over the age of 65 will continue to grow well into the next century. At present, approximately 13 percent of the population of the United States is over age 65. By 2030 that percentage will increase to more than 20 percent1 (Peterson, 1993: 103). This factor by itself indicates a need for personality researchers to understand the growth, development, and changes that occur in the late years. The present study deals with depressive symptomatology, which is considered to be a rather common problem afflicting those aged 65 and older (Butler, Lewis, & Sunderland, 1998). Although levels of depression are highest among old adults who are institutionalized, it has been estimated that approximately 15-20 percent of community-dwelling old adults experience significant depressive symptomatology (Beekman, Copeland, & Prince, 1999; Fry, 1993). Depression increases both health care use and costs (Badger, McNiece, & Gagan, 2000), and leads to functional decline and loss of independence (Espiritu et al., 2001). Moreover, depressive disorders in late adulthood are associated with increased all-cause mortality (e.g., Burvill, 1995; Lebowitz et al., 1997; Penninx et al., 1999) and are often implicated in 43

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the elevated rates of suicide among old adults (for a review, see Heisel, Flett, & Besser, 2002). Developmental theory posits that a main task of late adulthood is the review of efforts and achievements in the preceding stages (e.g., Erikson, 1963, 1982). Contemporary approaches define successful aging as the ability to cope with, and learn from, the challenges of life and aging (Wong, 1989; Wong, Reker, & Gesser, 1994). Late adulthood is a time very often beset with, numerous demanding adjustments, such as the need to adapt to the deterioration of physical strength and health, to retirement and reduced income, to the death of one’s spouse and close friends, the fear of one’s own death, and the need to establish new affiliations with one’s peer group. Because of the important losses that characterize the late adulthood period, preoccupation with issues of identity (Herzog & Markus, 1999) and relatedness (Charles & Pasupathi, 2003) are assumed to characterize this period. Current theoretical and empirical studies on life-span development show that, during the old adult period, perceptions of the self and relationships with others are renegotiated, imposing a reassessment of ones’ identity, ego integrity, and autonomy (e.g., Herzog & Markus, 1999; Pals, 1999), as well as close interpersonal relatedness (Charles & Pasupathi, 2003; Erikson, 1963, 1982; Johannes, 1996). This body of research suggests that impaired capacities in dealing with issues of self-identity and/or relatedness may have conspicuous deleterious effects in late adulthood. Blatt and colleagues (Blatt & Blass, 1996; Blatt & Shichman, 1983) proposed a model of normal personality development that is characterized by a dialectical interweaving of other and self-directness, as well as an evolving overall experience of Efficacy, which lead to a flexible balancing of the characteristic capacities involved in each of these processes. In reformulating Erikson’s epigenetic model of psychological development Blatt and colleagues (Blatt & Shichman, 1983; Blatt, 1990) illustrated the complex interaction between interpersonal relatedness and self-definition throughout the life cycle (Blatt, 1990: 304). This model assumes that individual differences in the relative emphasis on processes of relatedness and self-definition delineate two personality styles, each with favored modes of cognition and coping strategies (Blatt, 1974, 1990, 1991; Blatt, Cornell, & Eshkol, 1993; Blatt, Quinlan, Chevron, McDonald, & Zuroff, 1982). An overemphasis on issues of self-definition or relatedness results in dysfunctional cognitions and thoughts, and is assumed to constitute vulnerability to self-critical or dependent depression, respectively. The present study approaches, for the first time, depression in late adulthood within the context of this theory of development and depression vulnerabilities. The Interpersonal Relatedness/Self-Definition Vulnerability Model In Blatt’s conceptualization, interpersonal relatedness is defined as the capacity to establish mature, mutual, and satisfying interpersonal relationships,

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while self-definition refers to the development of positive, realistic, and integrated self-identity (Blatt, 1991). An adequate coordination between interpersonal relatedness and self-definition is the hallmark of optimal development and is assumed to reduce stress and lead to physical and psychological well-being (Blatt & Zuroff, 1992). An extreme or one-sided prevalence of one of these developmental processes leads to Dependency or Self-criticism, two basic vulnerabilities to depression or depressive personality styles. The constructs of Dependency and Self-criticism have been empirically validated using the Depressive Experiences Questionnaire (DEQ). The DEQ includes items chosen to represent common experiences, rather than overt symptoms, of depressed individuals (Blatt, D’Afflitti, & Quinlan, 1976), as well as experiences of Efficacy. The first DEQ factor, Dependency, included concerns about abandonment, helplessness and loneliness, and the need for close and dependent interpersonal relationships. The items loading on the second DEQ factor, Self-criticism, reflected a continuous preoccupation with failure, ambivalent feelings about self and others, and a self-critical stance (Blatt et al., 1976). In a recent extensive review Zuroff, Mongrain, and Santor (2004) concluded that Blatt’s concepts are continuous, nearly orthogonal dimensions that can be identified and measured independently from Neuroticism, depression, and social context. Thus, although attempts to link personality vulnerability research to the mainstream of personality research are important, Blatt’s personality vulnerability variables cannot be reduced to any one of the big-five variables, including Neuroticism. The propensity to depression among self-critical individuals has been amply demonstrated in different community samples (e.g., Besser, 2004; Besser, Flett, & Davis, 2003; Besser & Priel, 2003a, b, c; Besser, Priel, Flett, & Wiznitzer, 2004; Fichman, Koestner, Zuroff, & Gordon, 1999; Klein, 1989; Priel & Besser, 1999, 2000; Quimette & Klein, 1993; Santor & Zuroff, 1997; Zuroff, Igreja, & Mongrain, 1990). Empirical associations between Dependency and depression are more complex, indicating the presence of adaptive aspects of Dependency in addition to a propensity for depression (e.g., Aube & Whiffen, 1996; Besser & Priel, 2003a; Besser et al., 2004; Blatt, Zohar, Quinlan, Zuroff, & Mongrain, 1995; Bornstein, 1992; Mongrain, 1998; Priel & Besser, 1999, 2000. For recent reviews, see Blatt & Zuroff, 2002, and Zuroff et al., 2004). Parenthetically, it should be noted that the research cited above has focused on younger samples, and the ability of these personality orientations to predict depression in late adulthood has not been extensively studied. Recent research on the Dependency/Self-criticism vulnerabilities differentiate between negative and positive or adaptive (mature) and maladaptive (immature) aspects of Dependency; further analyses of the Dependency factor have shown it to include two sub-factors (Blatt, Zohar, Quinlan, Luthar, & Hart, 1996; Blatt et al., 1995; Rude & Burnham, 1995): the Neediness factor—an obsessive preoccupation with abandonment and separation, feelings of being unloved, and fear of loss; and, the Connectedness factor—the mature and more reciprocal type of

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interpersonal concern about one’s relationship with particular significant others. In addition, recent research has suggested that Self-criticism and Efficacy might reflect the negative and the constructive aspects of self development, respectively (Kuperminc, Blatt, & Leadbeater, 1997). Efficacy has been found to involve a sense of personal responsibility, inner strength, feelings of independence, and a sense of pride and satisfaction in one’s accomplishments, yet not extreme competitiveness (Blatt & Zuroff, 1992). Accordingly researchers have begun to view the Self-criticism and Efficacy factors as conveying negative and positive dimensions of the self, respectively (see Blatt, 2004). A main assumption of the present study was that old adults scoring high on the Connectedness and Efficacy factors might be less depressed. While Connectedness implies an ongoing interest in concern vis-à-vis significant others, the Efficacy factor of the DEQ model assesses a resilient, adaptive form of autonomy. Feelings of Connectedness with close others and of beliefs of self as autonomous and effective were assumed to be of particular relevance among old adults, given the prevalence of experiences of loss and a diminishing of capacities that characterize this period of human life (Rodin, 1986). Moreover, Connectedness and Efficacy may be conceptualized as the counterparts of dependent and self-critical vulnerabilities to depression, or as resilience or protective factors to the deleterious effects of excessive preoccupation with issues of relatedness and self-esteem. In the present study, therefore, we explored the assumption that Connectedness and Efficacy might serve as protective factors that moderate the adverse impact of high levels of Self-criticism and Neediness on depressive symptomatology (see Figure 2.1). Two main buffering factors—perceived social support and levels of fear of death—were assumed to intervene in the relationship between personality trait vulnerabilities and depression in late adulthood (see Figure 2.1). Centering on the combined effects of Neediness, Connectedness, Self-criticism, and Efficacy, we explored the roles of perceived social support and fear of death on the vulnerability/depression link in a community sample of old healthy and functioning adults. The plausible roles of perceived social support and death anxiety are discussed below. Perceived Social Support The idea that perceived interpersonal bonds play an important role in the regulation of distress is basic to conceptualizations of perceived social support in general (e.g., Cohen & Syme, 1985; Priel & Shamai, 1995; Sarason, Pierce, & Sarason, 1990), and in relation to late adulthood in particular (e.g., Antonucci, Fuhrer, & Dartigues, 1997; Kempen, van Sonderen, & Ormel, 1999; Pennix et al., 1999). These studies emphasize the role played by personal beliefs regarding the risks and advantages of seeking help as they effect the development and use of support resources (Vaux, 1992). Studies have consistently demon-

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Figure 2.1 The Theoretical Model: Trait vulnerabilities effect depression in late adulthood as a function of contextual buffering and personality protective factors. Situational Buffers Factors

Situational Buffer Factors Fear of Death

Social Support

d

d

Efficacy

Connectedness

Personality Vulnerability Factors

Neediness

Old Adults' Depression

Self-Criticism

Personality Protective Factors

Note. Figure 2.1 shows the conceptual models that underlie the current study. The figure outlines a moderational model, which assumes that personality vulnerability factors effect late adulthood depression and that these effects are moderated by personality protective and conceptual buffering factors. In other words, personality protective and contextual buffering factors (moderators) were assumed to qualify the effect of personality vulnerability factors (predictors) on older adults’ depression (outcome).

strated the protective effect of social support on physical and mental health outcomes during late adulthood (Cummings, Neff, & Husaini, 2003). Higher levels of social support have been associated with lower levels of depressive symptomatology in late adulthood, and have been found to buffer the effects of ill health, disability, bereavement, and other stressors (e.g., Wallsten, Tweed, Blazer, & George, 1999). The beneficial effects of social support have been linked both to greater psychological well-being (for example, self-efficacy, mastery, and decreased depressive symptomatology) and to reduced functional impairment (Antonucci et al., 1997; Kempen et al., 1999; Penninx et al., 1999).

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Moreover, old adults who express greater satisfaction with their social support report lower levels of depressive symptomatology, whereas dissatisfaction with social contacts and less-perceived available support, strongly predict symptoms of depression (Antonucci et al., 1997; Fry, 1993). We assumed that overemphasis on either Neediness or Self-criticism would be deleterious mainly when social support is perceived as lacking. Moreover, both self-critical and needy individuals were assumed to experience their environments as less supportive, in the first case because of concerns about losing autonomy or self-control, and in the second case because of the chronic experience of lack of, or uncertain support. The negative association between social support and Self-criticism has already been suggested by previous research among young adults, which has shown negative associations between social support and both Self-criticism and a depressive mood (e.g., Priel & Besser, 2000). Self-criticism and Neediness were expected to be associated with increased depressive symptomatology to the extent that they would be associated with low perceived social support, while high social support was expected to moderate or buffer these effects. Fear of Death Tomer (1992, 1994) defined fear of death as the anxiety a person experiences in daily life as a result of the anticipation of death. In contrast to a more acute fear elicited by an immediate threat to one’s life, fear of death is regarded as an ongoing state. Previous studies have correlated fear of death with numerous variables, such as loss of control, religiosity, social support, age, gender, ethnicity (for reviews see Cicirelli, 1999; Kalish, 1985; Neimeyer & Van Brunt, 1995; Pollak, 1979) and self-efficacy (Fry, 2003). Fear of death has been also found to be associated with depression (Neimeyer & Fortner, 1997), and the link between death anxiety and depression and related forms of psychological distress in older people has been confirmed in recent studies (Cully, LaVoie, & Gfeller, 2001; Wu, Tang, & Kwok, 2002). Coping with fear of death is a main developmental task in old adulthood. In an updated interpretation of Erikson’s theory, Wong et al. (1994) defined integrity—the main developmental task in late adulthood according to Erikson—as a state of mind centering on the conviction that life has been worthwhile and meaningful; this conviction implies a reconciliation of the discrepancy between real and ideal expectations. Despair and fear of death are the corollaries of the conviction that life has been wasted. Individuals who are able to achieve integrity in late adulthood can face death with less fear. A review by Fortner and Neimeyer (1999) reported a reliable, negative correlation between measures of ego integrity and death anxiety (for a comprehensive review of the correlates of death anxiety among old adults, see Fortner, Neimeyer, & Rybarczeck, 2000, as well as Neimeyer & Fortner, 2000). Fear of death is relevant to the study of Neediness and Self-criticism as vul-

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nerabilities to depression in late adulthood, since it relates to issues of fear of abandonment as well as fear of losing one’s identity and self-control (Devins, 1979; Florian & Kravetz, 1983; Thorson & Powell, 1988). In addition, the possibility that fear of death may moderate the link between personality vulnerability factors and depression can be extrapolated from terror management research indicating that high self-esteem seems to have an anxiety-buffering function among people exposed to death-related images (see Greenberg et al., 1992). Intuitively, it follows that people with a negative orientation toward the self, either in the form of Self-criticism or the need to protect a vulnerable sense of self by becoming overly dependent on other people, will be at risk for increased depression when they also experience an elevated level of death anxiety which is threatening, in and of itself. This is especially so for people who perceive inadequacies in the self. Accordingly, in the current study, we assumed that, in late adulthood, high levels of fear of death should strengthen the hypothesized link between Neediness and Self-criticism and depression. Health and economic deterioration are considered to be frequently involved in the levels of depression experienced in late adulthood (e.g., Stuart-Hamilton, 2000). Accordingly, the effects of these important variables might be confounded with the influence of personality factors on depression in late adulthood. Moreover, it can even be argued that putative imbalances in the negotiation of interpersonal relatedness and self-definition processes during the late adulthood period are the result of frequent major health or economic impairments. In order to study personality vulnerabilities within this age group we minimized the effects of serious deterioration processes by selecting a middle-class, high functioning, and relatively healthy sample of community-dwelling adults aged 65 to 75. Summary of Main Hypotheses Hypothesis 1 (H1): Efficacy and Connectedness were assumed to moderate and protect against the effects of Self-criticism and Neediness on depressive symptomatology in late adulthood: Self-criticism and Neediness were assumed to associate with increased depressive symptomatology during late adulthood to the extent that they were associated with low levels of Efficacy and Connectedness. Hypothesis 2 (H2): Social support was expected to buffer the effects of Self-criticism and Neediness on old adults’ depressive symptomatology: Selfcriticism and Neediness were assumed to associate with increased depressive symptomatology during late adulthood to the extent that they are associated with low levels of perceived social support. Hypothesis 3 (H3): Fear of death was expected to buffer the effects of Self-criticism and Neediness on old adults’ depressive symptomatology: Selfcriticism and Neediness were assumed to associate with increased depressive symptomatology during late adulthood to the extent that they are associated with high levels of fear of death.

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Methods Participants Our sample consisted of a community-dwelling sample of 237 adults in their late adulthood, ages 65 to 75 (M = 69.44, SD = 4.25), recruited from an urban area in southwest Israel. Participants were enlisted through community organizations, were contacted individually, and were volunteers. Only people able to read Hebrew and/or fluently comprehend spoken Hebrew were recruited. Table 2.1 summarizes the characteristics of the study sample as a whole and by gender. As can be seen in Table 2.1, participants were White (100 percent), married (74.3 percent), relatively well-educated (M = 12.45 years, SD = 3.94) and middle class (95.4 percent). The sample consisted of non-impaired individuals who were highly independent in everyday living (Instrumental Activity of Daily Living [IADL], M = 46.30, SD = 7.75) and in terms of the number of weekly leisure activities in which they participated (Advanced ADL [AADL], M = 9.42, SD = 2.11). Most participants perceived their health to be moderate (40.5 percent) or good (50.6 percent); and few participants reported bad/poor health (2.5 percent) or excellent (6.3 percent). The majority of the participants (76.4 percent) were not living alone. Measures Demographic variables. Participants filled up a demographic questionnaire indicating their dates of birth, years of education, marital status (married, separated/divorced, widowed, or never married), economic problems (none, minor and major) and if they lived alone or with a family member. Self-rated health measures. Self-rated health was measured in three ways: (a) asking people to rate their current health compared with that of their peers, using a 4-point scale of 1 (poor), 2 (average), 3(good), 4 (excellent); (b) asking people to rate their health changes during the past year (i.e., their current health as compared with their health in the last year), using a 3-point scale of 1 (less healthy), 2 (same), and 3 (better); and (c) an open-ended question asking people to report their medical problems, from which we determined the number of illnesses from which they suffered. Self-ratings of everyday functioning. The Instrumental Activity of Daily Living Scale (IADL; Lawton, 1971) is an 11-item measure that assesses a person’s perceived level of independence in performing instrumental tasks of daily living, such as managing finances, taking medication, using the telephone, shopping, preparing meals, housekeeping, and transportation. Items are rated on a 5-point scale ranging from 1 (independent) to 5 (highly dependent). In the present sample, we obtained Cronbach’s α internal consistency reliability coefficients of α = .81.

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Self-ratings of leisure activities. The Advanced ADL (AADL; Baich-Moray, Zipkin & Morginstein, 1994; Nir & Galinsky, 1998) was used to measure the engagement in leisure activities in late adulthood; this measure is assumed to assess the level of social adaptation. The measure consists of 14 items describing everyday leisure activities such as crafts, trips, watching TV, listening to the radio, participating in clubs, etc., each answered “yes” or “no.” In the present study, the participant’s score on the AADL was the sum of the reported activities. In our sample, we obtained Cronbach’s α internal consistency reliability coefficients of α = .78. Personality variables: Self-criticism, Neediness, Connectedness, and Efficacy. The Depressive Experiences Questionnaire (DEQ) was used to assess vulnerability to depression. The DEQ (Blatt, D’Afflitti, & Quinlan, 1976) is a 66-item scale that yields three orthogonal factors—Dependency, Selfcriticism and Efficacy—when subjected to a PCA with Varimax rotation. The first two factors assess patterns of experiences that contain predispositions to depressive states, and are therefore appropriate for use with a non-clinical population. The first factor, Self-criticism, reflects concerns about failure and guilt, Self-criticism, and being unable to meet high standards set by the self and by others (e.g., “It is not who you are but what you have accomplished that counts”). The second factor, Dependency, reflects a preoccupation with abandonment and separation, feelings of being unloved and fear of loss (e.g., “Without the support of others who are close to me, I would be helpless.”) Using a second-order factor analysis, Rude and Burnham (1995) identified two subscales within the DEQ Dependency Factor: Connectedness, which assesses adequate concern about close relationships (i.e., experiences of loss and loneliness in the context of a disruption of a particular significant relationship with a specific person, but without being devastated by the possible loss; and Neediness, which assesses excessive preoccupations and fears about interpersonal relationships, devastating feelings of helplessness, fears and apprehensions about separation and rejection, and intense concerns about the loss of gratification and support, but without a link to a particular individual or a specific relationship. The last factor, Efficacy, assesses personal resilience and inner strength (e.g., “I have many inner resources”). Internal consistency and test-retest reliability were adequate (Blatt et al., 1982). Items were converted to z scores and multiplied by the factor weight coefficient according to Israeli norms (Priel, Besser, & Shahar, 1998). Correlations between pairs’ scores on the DEQ factors, as obtained using the English and the Hebrew versions of the DEQ, had a mean of .91 (Priel et al.). According to Blatt et al. (1976), each of the standardized scores of the 66 items should be multiplied by the factor weight coefficient obtained in the normed sample for the loadings on Self-criticism, Dependency, and Efficacy. In this unit weight scoring system, all 66 items, relative to their factor weight coefficients, contribute to form the final scores of each factor.

Table 2.1 Demographic and Study Variables by Gender Variables

Women (n = 122, 51.5%)

Men (n = 115, 48.5%)

Sample as a Whole (N = 237)

Statistics a

Demographics Age (years)

69.05 ± 4.35

69.84 ± 4.13

69.44 ± 4.25

t(235) = 1.44, ns.

Completed Education (years)

12.19 ± 3.82

12.73 ± 4.07

12.45 ± 3.94

t(235) = 1.06, ns.

Living Alone (%) Yes

32.8

13.9

23.6

No

67.2

86.1

76.4

Yes

17.74

20.86

19.4

No

82.0

79.13

80.6

65.6

83.5

74.3

7.3

4.3

5.9

27.05

11.3

19.4

.9

.4

χ2 (1) = 11.67, p