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Is there a process of spiritual change or development associated with ageing? A critical review of research P. Dalby a a East Sussex County Healthcare NHS Trust, Eastbourne

Online Publication Date: 01 January 2006 To cite this Article: Dalby, P. (2006) 'Is there a process of spiritual change or development associated with ageing? A critical review of research', Aging & Mental Health, 10:1, 4 - 12 To link to this article: DOI: 10.1080/13607860500307969 URL: http://dx.doi.org/10.1080/13607860500307969

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Aging & Mental Health, January 2006; 10(1): 4–12

ORIGINAL ARTICLE

Is there a process of spiritual change or development associated with ageing? A critical review of research

P. DALBY East Sussex County Healthcare NHS Trust, Eastbourne

(Received 15 June 2004; accepted 31 December 2004) Abstract This review considers whether research shows a process of spiritual change or development associated with ageing. Spirituality was understood as that which is central to a sense of meaning and purpose in an individual’s life and pertains to the sacred or transcendent. Electronic literature searches were conducted to find research published 1985–2003 aimed at understanding spiritual change, themes and tasks in later life. A total of 13 studies were reviewed that looked at changes in spirituality over time, spiritual themes and tasks in a lifespan development context and Tornstam’s (Torstam, L. (1996). Gerotranscendence—a theory about maturing into old age. Journal of Aging & Identity, 1, 37–50) theory of gerotranscendence. The research reviewed suggested that some aspects of spirituality remain stable into old age but that there are identifiable spiritual tasks, needs and changes associated with ageing. Some common spiritual themes identified across the research were integrity, humanistic concern, changing relationships with others and concern for younger generations, relationship with a transcendent being or power, self transcendence, and coming to terms with death. These were not related to age per se, but to some of the challenges that age presents, and were mediated by cultural factors and individual differences. The findings and their limitations were discussed.

Introduction

Spirituality and aging Given the issues of loss, change, physical illness and mortality confronted in old age, the notion that a spiritual perspective becomes increasingly important may seem credible and appealing. Psychological theories from a broad range of perspectives could be said to support, in principle, the idea that there is a move towards spirituality in later life. For example, socio-emotional selectivity theory (Carstensen et al., 1999) proposes a greater emphasis upon emotionrelated goals as individuals become aware of the likely shortness of life remaining. Coming from a very different field of thought, Jung (1959) proposed that increasingly spiritual goals and pursuits, with an increase in introspection, are a natural part of the maturational process from mid to later life. Much of the research in spirituality and older age has looked at the relationship between spiritual or religious coping and health. Musick et al. (2000) states that approximately 370 studies dealing with the association between religion and physical health had been identified. Seifert (2002) also recommends research into religious coping and life outcomes as

a ‘practical’ area of study. However, some writers call for a greater understanding of spirituality and meaning for per se in old age (e.g., Kimble, 2001; Thompson, 1993). Providers of clinical services have a responsibility to take the ‘whole’ person into their work with clients (Langer, 2000) and the importance of integrating spiritual issues into the psychological care of older people has been noted (e.g., Koenig et al., 1996; Ortiz & Langer, 2002). Older people who are ‘more religious’ tend to demonstrate greater well-being than those who are not (McFadden, 1995), but less research has been directed towards a developmental understanding of spirituality in older people. If increased spirituality is related to increased health or well-being, then it would be of benefit to understand how this dimension of life manifests and changes in later life. Seifert (2002) warns against the ‘sentiment’ of assuming that spirituality automatically increases with age and calls for such ideas to be supported by empirical study. This review therefore poses the question: Is there a process of spiritual change or development associated with ageing that is documented by research? The aim of the review is to gather together the main threads of research that consider spirituality

Correspondence: Padmaprabha Dalby, East Sussex County Healthcare Trust, Rodborough House, 1, Upper Avenue, Eastbourne, BN21 3EZ. Tel: þ44(0) 13 23 648475. E-mail: [email protected] ISSN 1360-7863 print/ISSN 1364-6915 online/06/010104–9 ß 2006 Taylor & Francis DOI: 10.1080/13607860500307969


Spiritual development and ageing in later life from a developmental perspective, in light of this question.

Defining spirituality An extensive range of operational definitions has been employed within research, under the collective umbrella of spirituality, religiosity and religion. One of the important points of definition for social scientists in this field is the distinction between religion and spirituality. Hill and Pargament (2003) point out that ‘religion’ and ‘spirituality’ have increasingly been used in different ways in the literature. ‘Religion’ has tended to refer to the external, institutionalized, formal and doctrinal aspects of a religious life, whilst ‘spirituality’ has been used to refer to the personal, subjective experience. They suggest that the polarization between these two terms is unhelpful as a split between the institutional and personal ignores the fact that much spiritual expression occurs in a social context, often within an organized religion. Another term we find in the literature is ‘religiosity’, which Koenig (1994) uses to mean ‘the ‘‘contents’’ of one’s faith’ (p. xxiv) and, he says, ‘centres on a person’s relationship with God’. In practice, this term tends to be used in relation to quantifiable religious behaviours such as church attendance or prayer, as well as religious coping behaviours, beliefs and attitudes that can be measured. Koenig (1994) expresses the view that ‘spirituality’ is a broader term than ‘religiosity’ and may or may not include a relationship with God or a higher power. The present review, places the emphasis of enquiry upon the personal and subjective side of spiritual experience, rather than behavioural elements such as church attendance; behaviour may have many motivations, whereas understanding people’s experience more directly could arguably better assist understanding of developmental processes. Hill and Pargament (2003) suggest that: Spirituality can be understood as a search for the sacred, a process through which people seek to discover, hold on to, and, when necessary, transform whatever they hold sacred in their lives. (p. 65) It is this aspect of ‘the sacred’, they suggest, that distinguishes religion and spirituality from other aspects of life, and may include ‘concepts of God, the divine, ultimate reality and the transcendent’ (p. 65). We can understand reference to the transcendent as being that which is beyond or outside the individual human life or material realm. This review takes as its starting point Hill and Pargament’s (2003) definition of spirituality, which offers a broad understanding of this dimension of life and does not exclude organized religion. Many writers also emphasize a search for meaning or ‘meaning-making’ as a central aspect of spirituality (e.g., Aponte, 2002; MacKinlay, 2001b; McFadden, 1996; Ortiz & Langer, 2002). McFadden’s (1996)

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suggestion that spirituality can be seen as ‘the motivational and emotional foundation of the lifelong quest for meaning’ (p. 164) augments the above definition. Thus spirituality is understood here as being concerned with a search for meaning in relation to ‘the sacred’.

The developmental context It is notable, when we turn to consider the process of psychological development in old age that description of the psychological and spiritual dimensions of experience may start to become blurred. A number of psychological theories that consider developmental changes in later life touch upon the issues of an individual’s changing sources of meaning and relationship to the world, in such a way that consideration of spiritual matters seems to become important. Two key theories informed the current literature review. Erikson’s (1982) model of psychosocial development attempts to bridge psychological and spiritual development. It suggests eight broad stages of psychosocial development, at each stage of which a person must resolve a key conflict in order to develop a particular quality or strength associated with that life stage. In 1989, Erikson, together with his wife and another colleague, revisited the later stages of his theory, considering older people’s engagement with their lives and developmental tasks. They suggest that each life stage is re-addressed from the position of the current one. Hence it is proposed that, in the final stage, a process of life review occurs in which old conflicts and issues are revisited from a new perspective, achieving integrity as resolution is accomplished. They emphasize that the task for the final stage of life is paradoxical: to continue and develop a ‘vital involvement’ with life whilst facing and coming to terms with the ‘necessary disinvolvements of old age’ (p. 33). They suggest that the sense of a coherent and continuous identity is fundamentally threatened in old age and failure to manage this could lead to despair, disdain or dogmatism. The alternative, they suggest, is wisdom; that the sense of self transcends a time-bound identity such that one maintains a detached concern with life, in the face of death. More recently, Joan Erikson has offered a critique of the final stages of this model (Erikson, 1995, 1997). She suggests that the experience of old age is quite different to what she and her husband had supposed and that the very old person may feel far from wise as they struggle to come to terms with change in this stage of life. She advocates a ninth stage in which the task is to develop an attitude of retreat and retirement in relation to the world. She sees this as developing an increasingly spiritual perspective that is also described by the theory of gerotranscendence. Other writers have used Erikson’s theory as a basis of thinking about spiritual development in old age. For example, McFadden (1999) draws attention


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to the seventh and eighth stages of Erikson’s theory as representing two aspects of the spiritual life of older people. The penultimate stage, Generativity versus Stagnation, she sees as representing the ‘outward turn of the self towards the world’ (p. 1094) and suggests that religious commitment may help older people to find expression for an ethic of Generativity. The final stage of Integrity versus Despair is seen as representing an ‘inward turn’ and may be supported by meditative practices and the symbolic connections between humanity and the sacred offered by religion. Tornstam (1989, 1996) is a Swedish gerontologist and his theory of gerotranscendence (whilst, it may be argued, not explicitly addressing spirituality), is relevant to the question of this review and can be said to move on from where Erikson’s theory ends. Tornstam suggests that a ‘paradigm shift’ occurs as people age, in which they move from a materialistic and rational perspective on life to one that is increasingly ‘cosmic and transcendent’. This might be seen as a shift towards ‘the sacred’, in terms of the definition of spirituality adopted here. Tornstam’s theory may seem to bear resemblance to the earlier theory of disengagement (Cumming & Henry, 1961) in which it was posited that older people naturally withdraw from society and the roles of earlier life. A notable difference is that the theory of gerotranscendence proposes a reorientation towards a new perspective and experience of life that could be understood as spiritual, rather than simply a withdrawal from the mainstream of life. Tornstam suggests that gerotranscendence may be sped up (for example by a terminal illness in a younger person) or inhibited (for example by dominant views in a society that are contrary to the transcendent trend). Gerotranscendence manifests on three levels: the cosmic level, the self, and social and individual relations (Tornstam, 1996). At the cosmic level, changes in perception of time and space occur, there is a sense of connection to earlier generations, fear of death disappears, the mysterious dimension of life is accepted and there is an experience of rejoicing in large and subtle aspects of life. At the level of the self there is the discovery of hidden aspects of self, decrease in self-centredness, less concern with the body, increased altruism and the experience of ego-integrity. In terms of social and individual relations, relations take on changed meaning and importance, there is an increased need for solitude and an urge to abandon roles, and there is an understanding of the difficulty in separating right from wrong. Tornstam proposed these signs of gerotranscendence on the basis of qualitative interviews with a group of people aged 52–97. He suggests that the process of gerotranscendence is ‘intrinsic and culture free’ (Tornstam, 1989, p. 59) but will be modified by specific cultural patterns.

Methods Electronic literature searches were conducted using the electronic database PsycINFO 1985–2003 combining the key terms older, ageing, aging or gerontology with spiritu*, relig* or meaning. A search was also conducted for gerotranscendence. The resulting references were examined to identify research that focused primarily on spirituality in later life from a developmental perspective. References were excluded if their main focus was the link between spirituality and well-being or health. On this basis the search yielded 13 quantitative and qualitative studies. These are summarized in Table I. The studies retrieved varied widely in the extent to which they aimed to investigate theory; whilst some aimed firmly to explore one of the theories described above, others looked at broader notions of spiritual and religious engagement with little reference to theory.

Quantitative studies Baker and Nussbaum (1997) conducted a retrospective study with 60 residents of an American retirement community aged 68–100. Participants completed a questionnaire that asked about their current religious practice, spiritual dimension in their lives and similar questions related to when they were about 45 years old. The measures did not correlate with age, contrary to the researchers’ predictions. However, the mean scores for current spiritual dimension were greater than those for past (retrospective) spiritual dimension. When these scores were broken down, the difference between past and present seemed largely due to a change in the affective aspect of spiritual dimension, cognitive and behavioural remaining stable. The authors concluded that the respondents were stable in their current spirituality (indicated by lack of correlation with age) but that some change had occurred since the age of 45. This may be an unsophisticated interpretation of the data. The absence of correlation with age may indicate a diversity of relationships to spirituality across this wide age group. Given the diversity of experiences in later life, it may be over simplistic to expect a straight correlation with age. A cross-sectional study looking at differences between people of different ages looked at sources of meaning in life on a standardized scale (Bar-Tur & Prager, 1996). Participants were Israelis and divided into two groups of about 100 people: ‘young-old’ aged 65–79, and ‘old-old’ aged 80–93. Overall, the researchers found consistency between the two groups regarding what gave meaning to their lives. Responses differed significantly on a few items. The young-old rated experiencing wisdom, maturity and personal growth significantly higher than did the old-old group. They hypothesized that this, together


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Table I. Summary of studies reviewed. Authors

Participants

Methodology

Baker & Nussbaum 60 residents of an (1997) American retirement community, aged 68–100.

Cross-sectional self-report design. Postal questionnaire assessing religious practice, spiritual dimension and similar at age 45.

Bar-Tur & Prager (1996)

Independent groups design. Structured interviews eliciting demographic information and completing Sources of Meaning Profile Longitudinal design, beginning in 1920s. Ratings for spirituality and religiosity gleaned from semi-structured interviews at four points of adulthood. Personality rating (California Q set), intelligence (WAIS at young adulthood), rating of negative life experiences.

Wink & Dillon (2002)

Tornstam (1997)

Israelis in Tel-Aviv 106 aged 65–79 (mean 70.9) young-old. 104 aged 80–93 (mean 87.2) old-old. 154 older people comprising two cohorts aged 68–70 and 77–79. Data analysed for only 130.

2002 Swedish men and women aged 20–80.

Findings No correlation of age with religious practice or spiritual dimension. Self rated affective spiritual dimension significantly greater in present day than at age 45. Cognitive and behavioural spiritual dimension—no difference between present and past. Overall consistency in sources of meaning. Religious activity among least important items. Some group differences on individual items. Spirituality increases significantly from late-middle to older adulthood. Overall level of spirituality—low. Cohort differences in patterns of change apparent. Predictors of spirituality in old age: religiosity in early adulthood, spirituality in younger adulthood for men, negative life events in early adulthood for women, psychological mindedness. Correlations found between responses to some items and age, but not all. Three factors found to correlate with age but also other variables (gender, life crises, illness, profession).

Cross-sectional design. Mail survey of questions derived from gerotranscendence dimensions. Analysis of correlations between response to items and age. Factor analysis and then correlations of factors with group variables. Melia (2002) 26 Catholic nuns aged In-depth interviews consisting of Themes: relationship with loving 70–98 (mean 81.5). open-ended questions on prayer life. God; contribution to others; Transcriptions analysed for themes. change of prayer with age; working of the Holy Spirit within; time. Themes: connecting with spiritual In-depth interviews: What keeps Pincharoen & Nine older Thai people resources; healthy mind and body; you healthy/What is most Congdon (2003) living in USA, aged 60–82 living a valuable life; relationships important/valued in your life? (mean 69). 8 Buddhist and with family and friends; meaning Transcripts analysed for themes. one Christian. and confidence in death. Black (1995) 150 American, childless men, Structured interviews concerning Spirituality not important to the aged 58–93 years (mean 72.8). belief in an afterlife and men interviewed. supreme being. Ahmadi (1998, 13 Iranian Sufis living in A ‘life history approach’ to Some links between dimension of 2000) Sweden, aged 43–73. interviewing, with analysis in the gerotranscendence and Sufi tradition of grounded theory to thought and culture. Some draw out themes. dimensions particularly related to age. Ahmadi Lewin 12 Turkish Sufis, 17 secular Open ended interviews about All groups showed evidence of (2001) Turks aged 66þ. present situation, attitudes and gerotranscendence except secular past experiences, followed by Turks. thematic interviews to tap dimensions of gerotranscendence. Thomas (2001) 13 Iranian Sufis, 10 secular Iranians developed transcendent Iranians aged 65 þ (all in Sweden). view younger than Swedes. Ahmadi & 11 Swedish Protestants and 10 Gerotranscendence was Thomas (2000) secular Swedes all 67þ. linked to life satisfaction but not exclusively so. Melia (2001) 39 Catholic nuns, aged 68–98, In depth interviews covering personal 30 showed evidence for co-existence of activity, withdrawal and mean age 80. history, ageing process, retirement, gerotranscendence. Nine the process of meaning-making in maintained high activity levels. later life, faith and God. Transcripts analysed for themes and categories relating to gerontological theories.


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with differences on two other items, may indicate a shift in the old-old away from need-fulfilling pursuits and gratifications. We should also not rule out the possibility of this result being a cohort effect. Another interesting, but non-significant result, was that the greatest source of meaning in the old-old group was humanistic concerns; whilst in the younger group it was personal relationships with family and/or friends. Contrary to the previous study, these modest results do hint at some age-related differences in sources of meaning that could be broadly associated with spirituality. Although the research was not conducted in the context of psychological theory, these findings could be related to both Erikson’s (1989) and Tornstam’s (1996) theories. Levin (1997) calls for more longitudinal studies within the field of religious gerontological research. They are few in number. However one comprehensive study looked a two cohorts of participants from the 1920s to the present (Wink & Dillon, 2002). The cohorts comprised a group of people born in the late 1920s and a second group born about 10 years earlier. The participants took part in a large longitudinal study in America that tracked them through childhood and adolescence and then conducted four in-depth semi-structured interviews through adulthood. The researchers were able to analyse data from 230 participants who had attended all four of the adult interviews. Parts of the interviews that related to spirituality and religion were rated for spirituality and religiosity by two independent raters, each on five-point scales. Spirituality was rated according to evidence of ‘a personal quest for a sense of connectedness with a sacred other’ (p. 84) and evidence of spiritual experiences and practices to support this quest. Religiosity was rated according to the apparent importance and centrality of religion to the individual, evidenced by attending places of worship and similar. They found high agreement between raters. Other data that were collected included personality characteristics, intelligence at early adulthood, occurrence of negative life events and religious affiliation. Wink and Dillon found the data to be quite complex, but there was nonetheless a significant increase in spirituality from late-middle to older adulthood. This result was strongest for women. The researchers discussed the fact that only in the fourth interview were there specific questions about spiritual experience and practice, due to changing knowledge and understandings in social science and society as a whole. They considered that their methodology had minimized the possible biasing effects of this, but the possible influence of this changing methodology should not be completely ignored and the current author considers that the results should be viewed cautiously. Despite the increase in spirituality, they found that the mean rating for spirituality in old age was low,

suggesting that the majority of people in their groups had some interest in spiritual issues and may have had spiritual experiences, but did not engage in any spiritual practices. They also found that rank order of spirituality retained stability across the years. They found that there were cohort differences, the younger cohort having developed spirituality through adulthood whilst the older group became more interested in spiritual matters in later adulthood. The researchers suggested that this could be due to the cultural shift of the 1960s affecting each cohort differently. Finally, they looked for predictors of spirituality in older age and found that religiosity in early adulthood, spirituality in younger adulthood for men, negative life events in younger adulthood for women and the personality characteristic of cognitive commitment (psychological mindedness, introspection and personal insight) were all significant predictors. Spirituality was not found to have any significant relationship with intelligence or religious affiliation. This study, with the benefit of longitudinal data, reveals the complexity of the question of spiritual development through life. In 1997, Tornstam undertook a quantitative study to explore how gerotranscendence relates to age and other variables, given that it was seen as a phenomenon not exclusively linked to ageing (Tornstam, 1997). A mail survey was completed by 2002 Swedish people aged 20–85. The participants were asked to rate the extent to which statements derived from the gerotranscendence dimensions agreed with their experience. Factor analysis was performed on the results and yielded three dimensions: cosmic transcendence (transcendence of space, time and objects), coherence (ego-integrity) and solitude (changed meaning and importance of relations). Correlations were analysed between these factors and a number of group variables. Higher cosmic transcendence was found among women, selfgoverned professionals and students, those who had experienced a life crisis in the past two years and older people. The highest values of cosmic transcendence were found in the oldest respondents. Coherence was found to increase with age. There was no correlation between solitude and age, although this factor did correlate positively with suffering from illness. Performing correlational analyses on the answers to the individual statements in the survey, it was found that only some items correlated with age. Tornstam concluded that some questions tapped ‘general’ aspects of gerotranscendence, whilst others tapped ‘special’ aspects, which develop only in special conditions. He also proposed cohort effects in some cases. The general aspects proposed were affinity with earlier generations, importance of the principle of life over an individual life, a feeling of affinity with the universe, decreasing fear of death, increased sense of coherence in life and increasing need for tranquillity and solitude.


Spiritual development and ageing

Qualitative studies McFadden (1999) suggests that qualitative interviews and approaches may be more suited to looking at the changing nature of spirituality over time. Melia (2002) interviewed 26 nuns, aged 70–98, about their prayer life. They expressed both the belief that in prayer they could help others and the feeling that their relationship with God deepened as they grew older, reflecting ‘outward’ and ‘inward’ aspects of spiritual life, as hypothesized by McFadden (1999). Prayer increasingly became more silent and contemplative. The nuns also spoke of a growing sense of continuity extending through their lives which gave them a sense of integration and meaning. MacKinlay (2001a) reports two related studies in which she aimed to develop an understanding of the ‘naturally occurring skills of spiritual development in later life’ (p. 152). In her first study she interviewed 24 independent-living older people living in Australia (mean age 78.7), concerning questions about meaning in life, growing older and relationship to God, where relevant. Participants were a combination of Christians and those without religious affiliation. Analysing the interviews according to Grounded Theory, she developed a model of spiritual themes and tasks of ageing. She put this model to the test in interviews with older people living in a nursing home (mean age 75.3). At the centre of MacKinlay’s model are the tasks of finding ultimate meaning in life and affecting a response to ultimate meaning. She found that most people were able to isolate the ultimate meaning to one or two components, such as relationship with people or with God. Responses to ultimate meaning included attending church, prayer, meditation (Christian or Eastern) and appreciation of music or art. Interacting with these central tasks are four themes and tasks of ageing; she describes the themes as self-sufficiency/ vulnerability, wisdom/provisional to final meanings, relationship/isolation and hope/fear. The associated tasks are described as transcending disabilities and loss, searching for final meanings, finding intimacy with God and/or others and finding hope. MacKinlay is suggesting here that there are spiritual tasks that are special, although not exclusive, to old age. Her research suggested that older people need to transcend the limitations brought by old age through their relationship with whatever brings meaning in their lives. She also found evidence for a process of older people searching to make sense of the lives they have lived. MacKinlay suggests that the model applies equally to those who do and do not have a religious identification. We can see parallels between MacKinlay’s model and Erikson’s suggestions for the last stage in life. A recently reported study looked at the spirituality of nine older Thai people living in America (Pincharoen & Congdon, 2003). Participants were

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eight Buddhists and one Christian aged 60–82. They were asked to talk about what was most valued and important to them at this point in their lives, and how they kept healthy. The themes that emerged were: (1) connecting with spiritual resources; (2) finding harmony through a healthy mind and body; (3) living a valuable life; (4) valuing a tranquil relationship with family and friends; and (5) experiencing meaning and confidence in death. These themes do seem to echo those of MacKinlay (2001a), albeit with differing emphasis. Once again, finding peace in relation to life’s past struggles and successes (cf. integrity) was important, as well as contributing to both society and the family (cf. generativity). Although the researchers did not mention the theme of transcendence, participants spoke of turning more to meditation and spiritual practices as they aged, which brought peace of mind. Comparing qualitative studies such as those reported here is clearly not easy, however we can wonder about the cultural influence in the Pincharoen and Congdon (2003) study perhaps contributing to the nature of the emergent themes. The authors commented that the participants were unaccustomed to describing their feelings and sharing inner personal thoughts. The studies so far reported in this section offer a generally positive picture of spiritual development in old age but the study by Black (1995) tells a different story. She interviewed 150 American childless men aged 58–93 years. Black reports that, regardless of religious affiliation, these men universally sought meaning through the pursuit of youthfulness and youthful goals and considered spirituality irrelevant because of contentment within the present. There appeared to be no hint of the men working with spiritual developmental tasks. Black considered this discourse on spirituality to be a product of American culture and the fact that the men had lived through the Great Depression. Although this points to the importance of experience and culture in shaping spirituality, a narrower conception of spirituality may have contributed to the limited picture gained of these men. The questions asked were concerned with belief in an ‘afterlife’ and a ‘supreme being’: these topics are less broad than those of some of the other studies reported, and might not have encouraged the men to talk about what gave their life meaning. The qualitative studies reviewed so far uncover themes concerning what brings meaning to the lives of the older people studied. They point to spiritual tasks and needs associated with old age, however it is not clear to what extent these might be universal. One theme that does seem to emerge quite consistently is that of integrity, in terms of bringing meaning to one’s past and present life. Another important theme was transcendence, in the sense of finding meaning beyond the immediate experiences of physical ageing and its associated losses. The study by Black (1995) suggests that spirituality may


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not always be seen as relevant for older people, and that cultural influences and life experience are important. The other main group of studies reviewed investigate the theory of gerotranscendence. At first glance, Tornstam’s description of gerotranscendence may seem an unrealistic and even romantic view of ageing, despite the resonance of some aspects with Erikson’s better-known theory. The research that has followed the theory may be said to temper the enthusiastic theoretical proposals with the complexity and diversity of people’s experiences. A number of papers report a group of connected studies looking at gerotranscendence in different cultures (Ahmadi, 1998, 2000, 2001; Ahmadi & Thomas, 2000; Thomas, 2001). These researchers set out to examine the relationship between religion, culture and gerotranscendence. They hypothesized that factors such as being religious and living in a culture that promotes spiritual aspects of life would promote development of gerotranscendence, whilst having a more secular outlook and culture would delay gerotranscendence. They chose secular and religious participants in three different countries, carrying out open-ended life narrative interviews, followed up by thematic structured interviews tapping the dimensions of gerotranscendence. The populations comprised Turkish Sunni Sufis and secular Turks, Iranian Shi’a Sufis and secular Iranians living in Sweden and Swedish Protestants along with secular Swedes. All participants were aged 65 and over. The data were examined and coded for themes connected to the dimensions of gerotranscendence. It was found that in all groups except the Turkish secular sample, there was some evidence of gerotranscendence. In an attempt to explain the difference between the Iranian and Turkish groups, Ahmadi (2001) suggests that Shi’a Sufism (the religion of the Iranian sample) has caused mystical ideas to be integrated into the Iranian culture, whereas Sunni Sufism communicates a more esoteric aspect of Islam and has not brought mystical ideas into Turkish culture as a whole. In the native Swedish groups, gerotranscendence was seen to develop at a generally later age than in the Iranian people living in Sweden. Ahmadi (2001) suggests that this ‘delay’ is due to the more secular and materialistic culture of the former groups. The researchers had expected no evidence of gerotranscendence among the secular Swedish sample, however the result obtained caused them to reconsider Swedish culture as one in which some mystical-type ideas are integrated. Although we might criticise this post hoc speculation to justify the results in support of the theory, these arguments do point to the importance of culture and environment in the development of features of gerotranscendence. The researchers’ accounts of their data include interview extracts illustrating different aspects of

gerotranscendence. These accounts are rich, and valuable in providing a meaningful picture of the dimensions. They also clearly illustrate the way in which people perceived as non-religious by their communities have nonetheless developed perspectives that could be understood as seeking for the sacred within life, and in that sense, spiritual. Ahmadi (2000) has undertaken some work comparing different cohorts on dimensions of gerotranscendence. A similar methodology was adopted as described in the previous studies, but the participants were Iranian Sufis aged 43–73 years, who had been practising Sufism similar lengths of time. The dimensions of gerotranscendence that seemed to be linked to age were concerned with self and relationships: self-confrontation, self-transcendence, changed meaning and importance of relationships and recognition of the difficulty in separating right from wrong (Ahmadi, 1998). Ahmadi (2000) offers an in-depth report of interviews with a 60-year-old and a 47-year-old Iranian Sufi taken from this data. The interview material is used to show that whilst both interviewees demonstrate aspects of a transcendent perspective on life, the older person is more developed on these dimensions. Once again, the rich interview data is illuminating as the 60-year-old woman talks about how she has used experiences of ageing to help her in her spiritual development and relationship to life. Few studies have been conducted on gerotranscendence outside of this research group. Melia (2001) found little evidence of Tornstam’s ‘paradigm shift’ in a group of elder Catholic nuns, rather a deepening of existing faith and values. She acknowledges, however, that she might not have tapped all the dimensions of gerotranscendence in her interviews and analysis. The studies of gerotranscendence reviewed here point to partial support for the idea that age brings a changing relationship to ‘the cosmic’, self and social relationships. These changes appear to be linked to age, but not exclusive to it, and are not universal. They seem to be mediated by life experiences, gender, religious beliefs and practice, and culture. Discussion and conclusions Given the diversity of studies reviewed and their limited number, only tentative conclusions can be drawn. There appears to be some evidence of an increase in spirituality or aspects of gerotranscendence with age in a number of the populations studied (Ahmadi, 1998, 2000, 2001; Ahmadi & Thomas, 2000; Baker & Nussbaum, 1997; Thomas, 2001 Tornstam, 1997; Wink & Dillon, 2002). Some of the studies suggest particular spiritual tasks, needs and changes associated with ageing that would merit further research (MacKinlay, 2001; Pincharoen & Congdon, 2003). Some common themes identified across the qualitative research


Spiritual development and ageing were integrity, humanistic concern, changing relationships with others and concern for younger generations, relationship with a transcendent being or power, self transcendence, and coming to terms with death. These were not related to age per se, but to some of the challenges that age presents, such as coping with health problems and disability, facing mortality, coping with losses and coming to terms with the life one has lived. How people respond to these will be influenced by culture, life experience, life-long beliefs and other individual differences. The gerotranscendence literature highlighted the complexity of the relationships between culture, religious beliefs, life events, age and the development of a perspective that could be interpreted as spiritual. There is not conclusive evidence to suggest that gerotranscendence occurs in all cultures, or in people who do not have religious beliefs. There are also likely to be diverse individual understandings of what constitutes a search for meaning in relation to the sacred. Tornstam’s concept of gerotranscendence does not specifically include a relationship with a higher power, which for some might make it more of a secular concept than a spiritual one. However, arguably, the ‘paradigm shift’ that Tornstam proposes does overlap with a spiritual dimension. Moreover, if older people do, in general, make this kind of shift, it is important to understand its likelihood and nature. Some of the research found that individuals having a religious or spiritual identity was not a necessity for tasks or themes that might be seen as spiritual to occur (Ahmadi, 2001; MacKinlay, 2001b). This, again, may be a controversial point, depending on the interpretation of what is spiritual. If this were the case, it may be that some older people find themselves having spiritual experiences or reflections but have little context in which to place them. Research into the experiences of non-religious older people would be of interest to explore this possibility further. Much of the research reviewed was qualitative. This generally reflects recommendations of writers concerned with deepening understanding of older people, who are increasingly seen as a diverse group influenced by life experience and culture (e.g., McFadden, 1999; Thompson, 1993). However, we must be aware of the potential for bias present within qualitative research and further quantitative research on some of the themes highlighted in qualitative research would be valuable. McFadden (1999) also recommends that future research should investigate theory. This would enable a number of researchers to contribute to the same body of knowledge, as in the research on gerotranscendence. This author would recommend further research investigating both the gerotranscendence theory and MacKinlay’s (2001) model of spiritual themes and tasks. Further understanding of spiritual development would also be gained by appropriate longitudinal methodologies

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(Levin, 1997). Unfortunately it seems that the resource commitment required for such work renders it quite rare. The present review has its limitations. Literature concerning the link between spirituality and life outcomes was generally excluded. This may have resulted in a number of studies being missed that would have contributed to the question of the review. It was also restricted to studies of cognitively intact people; understanding the spirituality of people with dementia is also a topic of considerable relevance, particularly given the increasing importance given to understanding the experience of people with dementia (e.g. Kitwood, 1997). In conclusion, this has been a review of a small and diverse body of literature that has highlighted the complexity of the question of spiritual development and ageing. It is hoped that attention has also been drawn to the fascinating data that have been collected, contributing to our understanding of a dimension of life in old age that may be hard to fathom but certainly merits further enquiry.

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