Chapter 9 Mental health across the lifespan
A lifespan approach
A lifespan approach (lifespan developmental psychology) encompasses the sequence of events and experiences in a life from birth until death. Goals of the approach are to describe development, to explain how change occurs throughout the lifespan and to optimise development through the application of theory to real life (Peterson 2004).
Recent conceptualisations of a lifespan approach emerge from the work of Baltes, who proposed a nonlinear theory emphasising the multidimensional and non-integrated nature of human development. A nonlinear model refutes the idea that there is a definite sequential pathway for development or an ideal endstate or conclusion to development. Baltes challenges the idea that an ideal end-state is ever achieved or desirable. He defines development as ‘selective age related change in adaptive capacity’ (Baltes, Staudinger & Lindenberger 1999, p 476). Baltes’ view supports the idea that development consists of a series of losses and gains. Losses and gains occur throughout the lifespan as new skills are acquired and the individual experiences certain benefits as a result; however, they may also experience a lack of continuity in other skills or abilities. For example, the older adult may not have the memory capacity of a younger person but they may develop pragmatic or problem-solving strategies (such as the use of mnemonics) which result in similar performance, thus compensating for age-related deficits (Baltes & Baltes 1990). An additional gain of development is creativity. Creativity is perceived as essential in our ability to constantly develop new strategies, such as improved problem solving, to compensate for age-related losses.
BOX 9.1 A lifespan approach: key points
The tenets that guide an understanding of the lifespan approach include a belief that:
A lifespan approach to nursing practice
Critical thinking challenge 9.1
Explain what is meant by ‘the lifespan’ and ‘a lifespan approach for nursing’. Discuss how knowledge of lifespan theories and concepts contributes to nursing practice.
Mental health across the lifespan
‘Ideal’ development
Cognitive, perceptual, emotional and social functioning are dimensions of growth and development that are not well understood even though they are crucial to each individual’s wellbeing and mental health. Development itself is difficult to define and hints that ‘improvement’ is part of a developing state. The literature on ageing (Baltes & Baltes 1990; Bevan & Jeeawody 1998) explores how we can age ‘successfully’. The following outcome measurements are proposed:
‘Good’ outcomes of development proposed by Maslow (1968), Erikson (1963) and Allport (1961) all describe criteria that are normative; that is, they assume that everyone is the same and that there is a general standard which, if achieved, can lead to an ideal end-state. As noted earlier, this assumption has been challenged. It can be useful, however, to define development as an ideal state so that factors that are barriers to achieving this state can be explored, and ways of encouraging development can be addressed through health-promoting nursing interventions and a holistic approach to practice.
Abraham Maslow (1968) outlined a path of motivation to self-actualisation (see Ch 8) and outlined fifteen characteristics of the self-actualised person. Gordon Allport (1961) defined the mature personality by describing six dimensions, and Erikson’s theory (1963) identified ‘wisdom’ as the ideal end-state of development, but acknowledged that positive outcomes of each stage were contingent upon meeting a challenge or completing a task.
These theorists share a similar philosophy of humanism, yet each has contributed unique insights into the process of development. Erikson’s ‘stages’ differ from Maslow’s and Allport’s as they more clearly identify a process (stages) that needs to be undertaken whereby one may achieve mastery of the task of that stage. Erikson’s theory suggests that a person may be unable to achieve mastery of one of the developmental tasks due to external factors, such as a loss, or injury, which may disrupt the person’s development. Maslow proposed a set of preconditions for self-actualisation that, if unmet, also interfere with development (see Ch 8). Aspects of the human condition that are of interest to developmental theorists include personality as well as psychosexual, cognitive, psychosocial, moral and gender development. Each of these aspects affects the mental health status of the developing person.
The ideal outcomes of development (listed in Table 9.1) highlight the characteristics of optimal wellbeing and mental health, but the course of life and significant events can disrupt this ideal. Factors that can disrupt the path of normal development will be discussed further in this chapter.
Table 9.1 Ideal outcomes of development
| Characteristics of the self-actualised person (Maslow 1968) | Dimensions of maturity (Allport 1961) | The ‘eight stages of man’ (Erikson 1963) |
Stages and theoretical issues in human development
Theories of personality development such as the biomedical, psychological (psychoanalytic, behaviourist, cognitive and humanistic) and sociological (discussed in Ch 8) assist us to understand human behaviour. Some theorists developed a lifespan approach and devised ‘stages’ to explain how changes occurred across the lifespan. Stage theories were initiated by the evolutionary perspective of Charles Darwin, who believed that human development could be understood through the study of childhood. Darwin’s work was significant in introducing a scientific approach to the study of development. Stage theories support the idea that individual development can be measured and monitored according to a set of expected ‘norms’ at average ages when certain milestones are achieved.
Freud
Sigmund Freud (1856–1939) proposed three personality structures, which, if functioning in balance, help the person resolve the conflicts of different psychosexual stages of personality development. Maturation is the desired outcome of the individual successfully moving through four psychosexual stages (from infancy to adolescence). Chapter 8 outlines the stages and characteristics of each stage. The relevance of Freud’s theory lies primarily in its ability to assist the nurse in understanding patient behaviours that appear inconsistent with age or the expected level of development, or behaviour and habits that are excessive or unexplained by other assessment frameworks. The concepts of regression and fixation are integral to this understanding.
Fixation refers to behaviours that indicate unmet needs or unresolved conflicts of a particular psychosexual stage. For example, the id is the dominant personality structure during infancy (oral stage, 0–12 months). If the infant failed to receive adequate oral gratification, frustration could result, and if over-attention was given to meeting oral needs the child may continue to have a preoccupation with their mouth as they grow, resulting in habits such as heavy smoking in adulthood. Similarly, any frustration or over-gratification experienced during the anal stage (1–3 years) could result in anal fixation and result in stubbornness, selfishness or slothfulness. According to this theory, parents have a significant role in ensuring the child’s needs are met in a balanced and consistent manner.
Criticisms of Freud’s stages refer to the prominence given to sexual issues as a framework for development, and its lack of testing across cultures (Berk 2001).
Erikson
Erik Erikson (1902–1994) envisaged successful personality development as an outcome of conflict resolution throughout eight ‘psychosocial’ stages. The relevance of Erikson’s psychosocial theory for nurses is that it assists the nurse with increased interpersonal understanding of the individual’s biological, psychological, spiritual and social dimensions. Stages highlight the central concerns of individuals at different times in their life and identify challenges that may contribute to vulnerability. Nurses are able to consider the tasks of each stage and integrate these understandings into appropriate assessment and planning. In addition, the nurse may convey an understanding to the patient of the importance of their concerns, increasing empathy in the nurse–patient relationship. A brief description of the conflicts and outcome of each stage is given in Table 9.1 and application of the theory to practice is outlined further in this chapter.
Evaluation of Erikson’s work highlights criticisms that stage theories propose a ‘normative’ or standard recipe for development. Erikson has also been criticised for his optimistic view of people (Roazen, cited in Welchman 2000) that negates the complexity and flaws in human nature. Welchman states: ‘His affirmative view of human potential is a warning not to label antisocial behaviour as pathological’ (Welchman 2000, p 120). Erikson used male subjects in his work, which led to criticisms that the male experience is understood as universal. Carol Gilligan, a student of Erikson, developed a critique of his work and proposed a need for a separate chart for women to account for differences in experience and challenges through life (Welchman 2000). Gilligan developed theories of women’s development being associated with relationships with others; her ideas are explored later in this chapter.
Piaget
There are several key concepts in Piaget’s theory. Adaptation is the mechanism by which development occurs, as the structures of the mind ‘adapt’ to better represent the external world. According to this theory the individual develops ‘schemas’ or behaviour patterns. When a new item is incorporated into the existing schema, ‘assimilation’ occurs. ‘Accommodation’ occurs when the individual is unable to assimilate the new item into the existing schema. The schema is altered to accommodate the new item. An example would be when a baby reaches for and grasps an object (the baby will assimilate the action into a ‘grasping schema’); the baby then accommodates as it modifies its grasp for a range of differently shaped objects. The aim of this process is to achieve equilibrium, thereby increasing the sophistication of thinking and understanding (Peterson 2004).
Piaget was interested in how children think, reason and learn. He proposed the stages outlined in Box 9.3.
BOX 9.3 Stages of cognitive development
Source: adapted from Peterson 2004.
Long-held beliefs about the perceptual abilities of children have been challenged by research on the perceptual systems of infants, which reveals that neonatal behaviour encompasses goal-directed and spatially coordinated behaviours and is not merely reflexive, as previously understood through the work of Piaget. Bertenthal (1996) believes that further research is required to explore the development of infants’ perception, action, object recognition and representation functions. Piaget concluded that cognitive development did not undergo significant change after adolescence. Recent enquiry and research into the post-formal operations stages of adulthood demonstrate a further limitation of his theory (Berk 2001).
Moral development
Piaget was concerned with moral as well as cognitive development. As he saw it, the maturing minds of adolescents experienced disequilibrium as a result of discussions with peers. Disequilibrium was seen as an opportunity for growth and development for the adolescent as they sought resolution of the particular dilemma (Golombok & Fivush 1994; Piaget 1932, 1977). But as with Piaget’s general developmental theories, recent researchers have found that morality begins at a much earlier age, although not always at such a sophisticated level (Darley & Shultz 1990; Shultz & Wells 1985).
Lawrence Kohlberg (Kohlberg 1986; Kohlberg, Levine & Hewer 1983) developed a stage-based model in which people functioning at the higher levels were seen as being able to use a justice orientation in their moral decisions. A justice orientation emphasises the need for reason and detachment in decision-making. Kohlberg saw moral development as an internal process that happens as a result of increasing cognitive maturity with little external influence. His assessment of morality was based on people’s responses to hypothetical moral dilemmas. Unfortunately, many nursing authors have tended to use his theory with no recognition of the many criticisms of his work. Critics have observed that his view of justice is limited to one theoretical perspective, and that his methodology was flawed and biased as it used only young male participants and ignored family influences. Others have pointed out that moral thoughts do not always result in moral behaviours (Bailey 1986).
Carol Gilligan (Brown et al 1991; Gilligan 1982, 1987, 1998) emphasised a care orientation, where the relatedness of individuals to each other is seen as important in moral decision-making. Initially she proposed that women used a care orientation, whereas men used a justice-based approach. This aroused much controversy at the time. Her current view is that males and females use either a justice or a caring ‘voice’, depending on the situation and the issue, although most males and females do appear to favour the style she originally proposed for each sex. Females are therefore not seen as inferior to men in their decision-making, but different. Other findings have supported this view (Donenberg & Hoffman 1988; Pratt, Golding & Hunter 1984).
Attachment, parenting and family factors
Eisenberg (2000) and Stillwell et al (1997) carried out longitudinal research across various age groups from infancy to adolescence demonstrating how, through attachment, children and adolescents progressively develop a conscience. Research has often found that a bond between mother and child is the most significant factor (Garmon 2000; Park & Roberts 2002).
Research into parenting styles has also contributed to understanding moral development. In the 1960s Barbara Baumrind (1971) studied parents and their children. She described three parenting styles, which have since been extensively studied and are used frequently by child and adolescent workers:
White (1996), an Australian researcher, argues that moral development is more complex than simple developmental stage theories. She sees family adaptability, cohesiveness and degree of family communication as critical factors (White 1996). The early work of research scientist John Bowlby and Canadian psychologist Mary Ainsworth has generated a model of attachment known today as secure-base phenomenon. The notion of a secure base has moved beyond the parent–child dyad to include the significance of secure attachment in all relationships. It proposes that when an individual—child or adult—has a secure attachment to a stronger, supportive other, they are then capable of responding to the needs of others (Waters et al 1995).
Implications for nursing practice
Moral development theories are useful in helping to understand the children and families with whom nurses work. Without making value judgments or blaming, one can sometimes understand, for example, that the individual who has become involved in antisocial or criminal behaviour may not have done so simply because of a ‘deficient personality’, but possibly because of suffering deficits in childhood. The person with severe anxiety, inappropriate guilt or poor self-esteem may be so due to authoritarian parenting. We as nurses might also be helped in understanding our own moral development and its influence on our ethical behaviour as professionals. The importance of a secure base, or a reliable relationship that encourages growth and exploration of the world, is important for us all.
The complex nature of human development is reflected in the diversity of theoretical approaches to its study. Each of the aforementioned theories focuses on different dimensions of human development. Theories can be used eclectically in practice and integrated into a lifespan approach to help understand human development and behaviour. Additional concepts to assist in a more comprehensive understanding of the developmental process incorporate those already mentioned, which focus on the importance of interpersonal relationships in development, and those following, which highlight the interplay between the person and their environment, which Richard Lerner popularised as ‘developmental contextualism’ (Lerner 1991).
Vulnerability, risk and resilience
An individual is said to be resilient when they have had good outcomes ‘in spite of serious threats to adaptation or development’ (Masten 2001, p 228). Resilience and risk go hand in hand. Resilience helps to explain why some children with significant or numerous risk factors do not develop psychopathology when others do.
Resilience has been identified in a number of ways in the research over the past twenty years. Studies have examined people at all phases of the lifespan, some focusing on the variables that may put an individual at risk, others on factors that may offset risk. These variable-focused studies of resilience (Masten 2001) have been useful in identifying interventions that can lessen the impact of adversity and threat, either by building assets and increasing protective factors (teaching parenting skills, decision-making, coping) or by reducing risk (prenatal care to prevent premature births). For example, in high-risk individuals, poor parenting and cognitive skills are more likely to result in antisocial behaviour if a child is under threat or in adverse conditions. Alternatively, if the child receives positive, supportive parenting and has adequate cognitive skills (protective factors), it is more likely that more adaptive behaviour will result if the child is exposed to adversity or threat. These individuals are considered to be resilient.
Several additional factors have been associated with resilience: a positive sense of self, self-efficacy (competence), self-regulation of mood, cognitive abilities, perseverance, and relationships or contact with significant nurturing adults or a supportive community (Jacelon 1997; Masten 2001). In a study of homeless youth, resilience was represented by a sense of self-reliance (Rew et al 2001). Youths with self-reported resilience were less likely to engage in lifethreatening behaviours and experienced less loneliness and hopelessness. Antonovsky described ‘generalised resistance resources’ as contributing to resilience in children. Examples are ‘adaptability on the biological, psychological, social and cultural levels; profound ties to concrete, immediate others; and formal or informal ties between the individual and family’ (Antonovsky 1979, cited in Werner & Smith 1982, p 160). Living in environments that support a sense of coherence, even if through one significant person, was found in resilient children (Werner & Smith 1982).
Resilience can also be applied to families. Positive change can result in a family system despite adversity, such as a family member having a mental illness. It has been found that resilient families take a problemoriented approach when a diagnosis of mental illness is made to a family member and they are quick to accept the reality of the illness in their lives (Marsh et al 1996). Deveson (2003), in describing her personal story, relates how a sense of coherence and meaning in life has mediated against illness, crises and death. Her book Resilience provides the nurse as reader with personal insights into resilience as a concept at work across the lifespan.
Resilience as a concept and tools which attempt to measure it continue to be researched. Critical evaluation of the research conducted to date suggests that it is a concept that assists us to understand not only the processes affecting people who are at risk (Luthar, Cicchetti & Becker 2000) but also its role in mental health throughout life.
The concept of thriving applies to both physical and psychological wellbeing and is a positive growth response by the individual to threat or danger (Bergland & Kirkevold 2001). Unlike resilience, where the person’s development continues along a predicted path, thriving means that the person is ‘better off’ after an adverse event than they were before, and may achieve better physical, social, cognitive and emotional development (Carver 1998). This concept can help explain anomalies in expected developmental outcomes for certain clients. For example, some clients may experience disruption during their development, yet somehow thrive despite it. Others may suffer and fail to thrive from those same experiences, which can result in an increased risk for mental health problems.
Psychological thriving ‘occurs when a person, after going through a traumatic situation, acquires new skills and/or knowledge that may promote mastery of similar situations in the future. This in turn leads to the belief that it is possible to cope with other difficult situations’ (Bergland & Kirkevold 2001, p 247). The concept of thriving requires further research for application to mental illness and lifespan development. The multidimensional nature of the concept suggests that it has relevance for examination of positive growth episodes throughout the lifespan.
Maturity, or a higher level of ego functioning, is achieved through adversity as a result of a person’s adapting to an expectation not being met or experiencing loss (King 2001). The idea that difficult and challenging times are opportunities for growth is consistent with the literature on resilience and thriving. Baltes & Baltes (1990) contribute the idea of ‘adaptivity’ or ‘behavioural plasticity’ to explain how cognition, memory and coping skills work together to assist the individual to deal with life’s stressful events.
Many of the concepts and ideas derived from observations and research, as outlined above, find support through application in everyday practice. Additional concepts such as optimism, pessimism and goal orientation derived from psychological theory (not discussed in this chapter) also play a part in explaining human development and understanding how it intersects with mental health and illness. More research exploring these concepts in the context of lifespan stages and culture needs to be undertaken so that nurses and other healthcare professionals can use these important concepts in practice to enhance care. Chapter 11 provides information on the assessment of strengths and risk factors.
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