Patricia L. Eldershaw and Janice M. Morse
SELF-TRANSCENDENCE AND SELF-REFORMULATION: ONE CONCEPT OR TWO?
I could tell you my adventures—beginning from this morning,” said Alice a little timidly: “but it’s no use going back to yesterday, because I was a different person then.
—Lewis Carroll, Alice’s Adventures in Wonderland (1865/1977, p. 140)
For individuals who face life-threatening or terminal illness, two concepts are used in research to account for the altered affect and behaviors that occur when they emerge from suffering. The first concept is self-transcendence; the second, self-reformulation or the reformulated self. These two concepts compete to explain what has been characterized as the peaceful affect that occurs in the later stages of serious illness, and are sometimes used interchangeably. Therefore the purpose of this chapter is to explore the confusion associated with these concepts. Are they the same concept with two names, or are they different? As these concepts have been broadly applied in a variety of health care contexts, such as in individuals facing a terminal diagnosis and in rehabilitation from serious illness, it is, therefore, important to carefully compare self-transcendence and the reformulated self for differences, diagnostic potential, and possible ramifications for therapeutic intervention. By exploring the “concepts in use” literature, we will compare the course, attributes, and outcomes of each concept, with the aim of identifying overlap (if any) and the variations between the two concepts.
The term self-transcendence has come to be widely used to refer to a process whereby individuals encounter life-altering or threatening events that compel a dramatic change in self-perception and culminate in an improved sense of well-being, acceptance, and an expanded worldview. The concept of self-transcendence has a lengthy history in psychology and philosophy. This section covers some of the central definers of this experience.
Viktor Frankl (1966) developed the concept from his observations as a prisoner in a Nazi concentration camp. He observed that some prisoners exhibited a capacity to transcend and find meaning in life despite living in life-threatening and appalling conditions. He posited that self-transcendence means, “that being human always points, and is directed, to something, or someone other than oneself—be it a meaning to fulfill or another human being to encounter. The more one forgets himself—by giving himself to a cause to serve or another person to love—the more human he is and the more he actualizes himself” (1959, p. 110). Frankl believed that transcendence was central to human existence.
Psychologist Abraham Maslow positioned self-transcendence at the pinnacle of his Hierarchy of Needs, claiming it represents “the very highest and most inclusive or holistic levels of human consciousness, behaving and relating, as ends rather than means, to one-self, to significant others, to human beings in general, to other species, to nature, and to the cosmos” (1969, p. 66). According to Daniels (2001), Maslow identified 35 aspects of self-transcendence including, “loss of self-consciousness, mystical fusion, letting be, letting things happen, unselfish love, getting off the merry-go-round, enjoying the cosmos, being self-determined, surpassing one’s limitations, being independent of culture, being fully accepting of the self, doing one’s duty, accepting death, having intrinsic conscience, being absorbed in what one is doing, integrating dichotomies, and being metamotivated” (pp. 3–4). Maslow’s characterization of transcendence is not a point of inevitable arrival, but a state that only very few of the most optimistic people would intermittently achieve.
Religious scholar David Chidester identifies four philosophical orientations of transcendence that characterize the ways in which death has been imagined and attended to by human culture: ancestral, cultural, mythic, and experiential transcendence (Chidester, 2001). Ancestral transcendence recognizes the lineage inheritance of past ancestors living on through their children. Cultural transcendence places emphasis on the surviving community’s collective memory of the dead. Dying rituals sustain the link between those who have passed and their continuity with the living community. Mythic transcendence appears in narratives about death and the afterlife (Chidester, 2001, pp. 40–41). It is the fourth pattern, experiential transcendence, that resembles the clinical understanding of the concept. Experiential transcendence reflects “profound and often intense psychological experiences that embrace death in acceptance or ecstasy. Death may be embraced by accepting it as the end of life; perhaps such an acceptance results in an experience of psychological tranquility” (2002, p. 14).
In the course of the past three decades, self-transcendence has emerged as an important scientific concept in nursing theory and research. As a concept, transcendence was brought to the attention of nursing through oncology and spirituality, and first used in the field in the mid-1980s. Reed, in her earlier studies on well-being and health, based her understanding of transcendence on Martha Roger’s theory (Reed, 1991a, 1991b, 1996), developing the concept deductively. In this way, transcendence came to be viewed as “a characteristic of developmental maturity, expansions of self-boundaries and an orientation toward broadened life perspectives and purposes” (1991b, p. 64). At this time, Reed also developed an instrument derived from her early clinical practice to measure the experience referred to as the self-transcendence scale (STS; Reed, 1987; 2009). This 15-item, 4-point Likert survey aimed to measure the extent to which an individual expressed the qualities considered to be associated with transcendence. For example, participants ranked their level of acceptance of aging, changes in physical ability, finding meaning in past experiences, and acceptance of death as a natural part of life. Over the years, Reed developed and expanded her definition so that by 2003 she defined self-transcendence as:
The capacity to expand self-boundaries intra-personally (toward greater awareness of one’s philosophy, values, and dreams), inter-personally (to relate to others and one’s environment), temporally (to integrate one’s past and one’s future in a way that has meaning for the present), and trans-personally (to connect with dimensions beyond the typically discernable world). (Reed, 2003, p. 147)
Intrapersonal aspects of the transcendence experience were considered those directed toward self. Accordingly, a crisis event, such as life-threatening illness, can be understood as a catalyst for enhanced self-awareness. Under such circumstances, individual relations and an increased sense of connectedness with others reflected the interpersonal aspects of transcendence. The transpersonal element of transcendence is experienced as a heightened awareness of God, spirituality, or a higher power. In 2008 and 2010, Reed presented self-transformation as a mid-range theory, moving from vulnerability to self-transcendence, with an outcome of well-being. Self-transcendence is expressed through “sharing wisdom with others, integrating the physical changes of aging, accepting death as a part of life” (2010, p. 108).
The second researcher influencing the development of the concept of self-transcendence was Coward, who completed her dissertation in 1991, and was a student of Reed. Coward’s (1990) research was quantitative, showed a correlation between the STS and emotional well-being, which Reed considered as evidence of construct validity for the STS (Reed, 2009, p. 398). Importantly, Coward (1990) subsequently conducted a qualitative phenomenological study with breast cancer patients describing transcendence as “a sense of being healed, to increased valuing of self, to easing the fear and pain of loss, and to savoring of the small moments of life” (p. 167). Four themes emerged from this study that Coward believed to be the basis for the transcendent experience:
1. “an incident that generates intense negative feelings and emotions” (physical and emotional pain, fear of death, anger, despair over personal losses, which encourage one to look for ways to “find new meaning in ands purpose for living”;
2. “great effort” and risk to acquire new skills to overcome and “confront one’s fears”;
3. emotional sense of healing and well-being, a “sense of physical lightness and relief of burden”; and
4. both helping another and accepting help from others, and a “sense of receiving, in return more than what has been given” (Coward, 1990, p. 167).
Similar findings were found in her phenomenological study with women with AIDS (Coward, 1995).
Despite this important descriptive work, research continued primarily quantitatively using the STS. The scale has been applied to numerous populations across a variety of illness scenarios, as well as to healthy adults. Self-transcendence has been associated with well-being (Coward, 1996), positive mental health outcomes, and inversely correlated with depression (Ellermann & Reed, 2001; Nygren et al., 2005; Stinson & Kirk, 2006; Reed, 2009), and cognitively intact nursing home patients (Haugan, Rannestad, Hammervold, Garasen, & Espnes, 2012). Self-transcendence was regarded as an effective coping strategy for individuals experiencing a range of chronic illnesses, such as rheumatoid arthritis (Neill, 2002), HIV (Mellors, Coontz, & Lucke, 2001; Ramer, Johnson, Chan, & Barrett, 2006), survivors of cancers (Chin-A-Loy & Fernsler, 1998; Farren, 2010; Pelusi, 1997; Thomas, Burton, Quinn, & Fitzpatrick, 2010), liver transplant patients (Bean & Wagner, 2006), and homelessness (Runquist & Reed, 2007). High levels of self-transcendence were found among residents in long-term care facilities who experienced positive nurse–patient interactions (Haugan & Innstrand, 2012) and among caregivers of patients with dementia (Acton & Wright, 2000) and terminal illnesses (Enyert & Burman, 1999). High self-transcendence has been described in nurses’ experience caring for others (Park, 2005) and work engagement among nurses in acute care settings (Palmer, Quinn, Reed, & Fitzpatrick, 2010). A negative correlation was found between self-transcendence and burnout among nurses (Hunnibell, Reed, Quinn-Griffin, & Fitzpatrick, 2008). Several studies reported a correlation between increased age and self-transcendence.
Reed has considered the wide application of the STS to be confirmation of the content validity of the STS; “based on a thorough literature review to specify the domain of content with careful attention to construction and refinement of items” (Reed, 2009, p. 398). Yet, at the time that the scale was developed (1987), Reed did not identify the literature used, and the concept had not been previously addressed in the nursing literature. Construct validity was “demonstrated by correlation with a measure of emotional well-being” from Coward’s 1990 dissertation (Reed, 2009, p. 398). Recent independent confirmatory factor analysis of the STS with a Norwegian nursing home population showed a two-factor solution with 35.3% of the variance (Haugan et al., 2012, p. 155).
In this section we have attempted to identify the central definers of this complex phenomenon, with specific emphasis on its usage in health care. Comparatively, the concept of self-reformulation has had limited exposure in the research literature. As noted previously, there is considerable overlap and important defining differences that distinguish these experiences and warrants further examination.
Self-reformulation, also a scientific concept but developed qualitatively, was identified by Carter (1994) in her study of long-term survivors of breast cancer patients. Characterizing the process as one that constitutes a “reinter-pretation of self,” Carter noted at that time that the changes that she was seeing in her study did not fit self-transcendence as it was described. Self-reformulation results from the experience of a self that is mortal, accompanied by a loss of one’s previous identity associated with health, career, and relationships. An attendant awareness of a self that is vulnerable to a relapse of cancer is present, as is a shift in focus toward one’s self and close relationships. An acquired sense of self as a survivor is definitive of reformulation in this context.
In subsequent qualitative studies, self-reformulation was characterized by a disregard for material things; a changed affect characterized by an ability to reorder life priorities, an appreciation for one’s own abilities and the exiting of unsatisfying relationships (Mayan, Morse, & Eldershaw, 2006, pp. 20–26). Self-reformulation was most apparent when the person emerged from suffering, more specifically, when they faced death and subsequently recovered (Morse & Carter, 1996). The concept was used to describe the state when one emerged from emotional suffering, hope “seeped in,” and the person began to assemble a revised and enhanced sense of self (Morse, 2001, 2011). Self-reformulation is considered the ideal goal of rehabilitation and a state of health.
Similarly to the concept of transcendence, self-reformulation has been applied in a variety of contexts, from patients suffering chronic illnesses (Elofsson & Öhlén, 2004; Ohman, Söderberg, & Lundman, 2003) to survivors of cancer (Carter, 1994; Frank, 2003; Kinney, 1996; Vachon, 2001), severe burn trauma (Russell et al., 2013), individuals with multiple sclerosis (Pollock & Sands, 1997), coronary artery disease (CAD; Lukkarinen, 1999), to caregivers (Enyert & Burman, 1999; Hall, 2001), hospital patients (Woogara, 2005); those recovered from serious illness (Mayan, Morse, & Eldershaw, 2006) and to individuals experiencing homelessness (Boydell, Goering, & Morrell-Bellai, 2000).
COMPARING THE CONCEPTS
As the foregoing summary demonstrates, to date, there has been a lack of consensus about the definition of each concept and about the attributes that distinguish the associated experiences. At the same time, there has been scant critical appraisal of existing definitions. Assuming the two experiences are distinct, the manner in which they have been utilized in the clinical and research literature has convoluted these two concepts and confused researchers. The lack of attention to the definitions of these concepts has resulted in their misapplication: they are sometimes used interchangeably; the attributes assigned shift from one to another, and their definitions overlap. Therefore, the purpose of this article is to analyze each of these concepts by exploring existing definitions of self-transcendence and self-reformulation as they are used in the nursing literature, and if necessary, to refine their definitions and to evaluate their utility for clinical application.
On the Derivations of Concepts
Behavioral concepts are clusters of behaviors that usually appear together and work to achieve a certain function. They may be derived from common use (as a lay concept) or developed purposefully in research (as a scientific concept). While lay concepts are formed from everyday observations, through consensus, labeling, and usage, they are defined in the dictionary, are not static, and their meaning may change over time. Scientific concepts, on the other hand, may be quantitatively derived for use in quantitative inquiry, developed with tight, operational definitions, according to the standards of replication, are judged to have validity, and are measurable. Quantitatively derived concepts are operationalized, measurable, generalized through randomized sampling strategies, and the outcome is measurement of the concept, often correlated with other variables. Alternatively, they may be qualitatively derived scientific concepts, closely linked to reality, observable or recognizable, and have been identified, delineated, and developed through qualitative inquiry, and the outcome is a well-developed concept that may even be incorporated into abstracted explanatory model or theory through which the concept or theory generalized.
From the initial reading of the literature, a table was prepared so that the major definitions could be compared and contrasted both within each concept and between concepts. The table also lists the context of the study, the characteristics or attributes and circumstances, and outcomes. Next, we asked questions of these two concepts:
• Is there a difference in context in which each was used, or do they apply to the same phenomena?
• Are there similarities in the course of the illnesses (i.e., the timing) in which the concepts are applied?
• Is there a difference in the structure (attributes) of the concepts?
• Is there a difference in the outcomes for each concept?