Families in Later Life: Challenges, Opportunities, and Resilience

Abstract

This chapter examines the challenges, opportunities, and resilience of individuals, couples, and families in later life. Increasingly, older adults with prospects of greater longevity and years of good health are re- visioning possibilities for meaning and satisfaction. Salient issues in this phase concern retirement and financial security, grandparenthood, chronic illness and caregiving, end-of-life issues, and the loss of loved ones. Clinical guidelines and case illustrations address common problems and encourage the potential for personal and relational integrity and positive growth in intimate, companionate, and intergenerational bonds.

Full text

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THE EXPANDED
FAMILY LIFE CYCLE
Individual, Family, and Social Perspectives
FIFTH EDITION
Monica McGoldrick
Nydia Garcia Preto
Betty Carter
The Graying of the Family
Declining birth rates, health care advances, and in-
creasing longevity are contributing to the unprec-
edented rise in the number and proportion of older
people in societies worldwide (Kinsella & He,
2009). In the United States, average life expectancy
has increased from 47 years in 1900 to over 78 years
by 2010, with women outliving men by 4 to 5 years
(National Center on Health Statistics, 2012). Our ag-
ing population is also becoming more racially and
ethnically diverse. However, health care disparities
in prevention and treatment take a heavy toll on low-
income families, especially in blighted communities.
Life expectancy for African Americans is signifi-
cantly lower than for Whites particularly for Black
Introduction
This chapter examines the challenges, opportunities,
and resilience of individuals, couples, and families
in later life. Increasingly, older adults with prospects
of greater longevity and years of good health are re-
visioning possibilities for meaning and satisfaction.
Salient issues in this phase concern retirement and
financial security, grandparenthood, chronic illness
and caregiving, end-of-life issues, and the loss of
loved ones. Clinical guidelines and case illustra-
tions are offered to address common problems and
to encourage the potential for personal and relational
integrity and positive growth in intimate, compan-
ionate, and intergenerational bonds.
Learning Outcomes
r Describe how older populations and the family life course are changing in today’s world.
r Examine the challenges and opportunities that retirement presents to individuals and families.
r Explain the impact that financial security, or lack thereof, has on later life.
r Identify and describe the benefits of grandparenthood for each generation in a family.
r Describe the challenges posed by chronic illness for both individuals and families.
r Discuss challenges faced by caregivers during later life.
r Describe how later life challenges of parents interact with developmental issues of their children at their
concurrent life phases.
r List and describe the developmental tasks for families after the loss of a loved one.
Chapter 18
Families in Later Life: Challenges,
Opportunities, and Resilience
Froma Walsh
For age is opportunity no less than youth itself, though in another dress, and as the evening twilight fades
away, the sky is lled with stars invisible by day.
—Longfellow
Our elders never became senile because they were needed right to the end. Aunts and uncles taught you the
philosophies and principles that you lived and worked by.
—Lavina White—Haida Nation, Alaska.
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Text
In M. McGoldrick, B. Carter, & N. Garcia Preto (Eds.) (2016). The expanding family life cycle: Individual, family, & social perspectives. (5th ed.), New York: Pearson.

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relationship to meet changing developmental priori-
ties of both partners over a lengthened life course.
While divorce rates are in the spotlight, it is perhaps
more remarkable that over 50 percent of first mar-
riages last a lifetime. Increasingly, couples are cel-
ebrating 50 and 60 years of marriage. Also, many
single, divorced, and widowed older adults are find-
ing happiness in new relationships. As one woman
in her 70s remarked, “If I could count all three of my
husbands, I’ve been married for over 40 years!”
Over a long lifetime, two or three marriages,
with periods of cohabitation and single living, are
becoming increasingly common, creating complex
kin networks in later life (Walsh, 2012b). Single
older adults and couples who are unmarried or with-
out children forge a variety of significant bonds with
siblings, cousins, nephews and nieces, godchildren,
close friends, and social networks. In our mobile
world, many relationships are carried on at a distance
and sustained through frequent cellphone and Internet
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ding, birth, family gathering, or other milestone now
joyfully witness and even participate in the event.
The family and social time clocks associated
with aging are also more fluid. As many become
grandparents and great-grandparents, others are
beginning or extending parenthood. With various
assisted reproductive strategies, adults in middle
age, both gay and straight, are having children. With
remarriage, come new stepparent relationships. Men,
who commonly remarry younger women, often raise
second families in later years.
The dramatic societal transformations over
recent decades have increased intergenerational
differences between traditional and contemporary
roles and relationships. For instance, elders may
expect daughters, but not sons, to be readily avail-
able to provide care when most women at midlife
are now in the workforce, with stressful conflict-
ing demands (Brody, 2004). Tensions are particu-
larly likely between older immigrants, who carry
more traditional values from their cultures of origin,
and younger generations raised in our society. For
instance, traditional Eastern Asian families value
harmony and filial piety and expect that elders will
be honored and obeyed. Cultural dissonance arises
when younger generations depart from those norms.
men. Of note, among persons who survive to age
65—and eligibility for Medicare—the differences
in remaining life expectancy diminish, and even
more so at the age of 75. Hispanics have the highest
life expectancy, attributable at least, in part, to their
strong kinship support networks.
The baby boom generation will soon swell the
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cent in 1950 to 20 percent by 2030. With medical
advances and healthier lifestyles, increasing num-
bers are living into their 80s, 90s, and past 100. For
most Americans, older adulthood is being redefined
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mostly healthy and vibrant and the very old, over 85,
the fastest-growing segment of the older population
and the group most vulnerable to serious illness and
disabling conditions. Although research and clinical
approaches tend to be individually oriented, family
bonds are central in later life.
Assess your comprehension of the graying of the
family by completing this quiz.
The Varying and Extended
Family Life Course
The family life course is becoming ever more length-
ened and varied (Walsh, 2012b). Four- and five-gen-
eration families add both opportunity and complexity
in balancing members’ needs and family resources
(Bengtson, 2001; Bengtson & Lowenstein, 2003).
Increasingly, adult children past retirement, with lim-
ited resources, are involved in caring for their elders.
Multigenerational relational networks are becoming
smaller and top-heavy, with a declining proportion
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erational tensions are likely, with global economic
downturns and uncertainty in employment and ben-
efits affecting both young and old. The trend toward
having few or no children will leave aging persons
with fewer intergenerational connections and strain
family resources for financial and caretaking support.
Pathways through middle and later life are
increasingly varied. With greater life expectancy,
couples raising children may have 30 to 40 years
ahead after launching them. It is challenging for one
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many cling to youth and strive to recapture it, facing
aging with dread or denial.
A grim picture of aging has been portrayed
in the trajectory view of progressive deterioration,
decline, and loss, ending in death. Biomedical and
mental health fields have tended to pathologize later
life, focusing on disorders and disability and dis-
counting functional difficulties as an irreversible part
of aging. Negative stereotypes of older persons have
fostered pessimistic assumptions by clinicians that
they are less interesting than younger clients, a poor
investment for therapy, and too resistant to change.
They are too often treated custodially, with a pat on
the hand and a medication refill.
A larger vision of later life is required, recog-
nizing the potential change, growth, and new learning
that can occur. Scholars are reformulating concep-
tions of later years. Some propose three distinct
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85); and very old age (85 and over). Senior scholars
joke that their own definition of old age is a few years
older than their current age. Extended middle age is a
dynamic, new cultural shift for most people in their
60s and early 70s, who are healthy, active, and pro-
ductive. Lawrence-Lightfoot (2009) calls this period
“the third chapter” of adulthood, when traditional
norms, rules, and rituals of careers seem less encom-
passing and restrictive; when many women and men
embrace new challenges and search for greater mean-
ing in life. In her interviews, individuals across races
and social classes related stories involving loss and
liberation, vulnerability and resilience, looking back
and giving forward to others. Their vital engagement
in life, while appreciating its unpredictable course,
involves the need for grieving losses and reinvent-
ing themselves and their future, the need for new
structure, purpose, and leisure for new learning and
experimentation in uncharted post-career years. As
assisted living and more extended care are needed,
new possibilities for living arrangements and com-
munity involvement are being envisioned for more
satisfying and meaningful later years.
The vital importance of family bonds
Stereotypes of American families have held that
adult children do not care about their elders; have
Family therapy can facilitate family harmony with
new mutual understanding by empowering family
members to draw on personal strengths, recognizing,
negotiating, and incorporating multiple worldviews
and values (Lee & Mjelde-Mossey, 2004).
Aging gay men and lesbian women meet needs
for meaning and intimacy in varied ways, influenced
by their past experiences, present life circumstances,
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2000; Neustifter, 2008). Those who built life struc-
tures with their sexual orientation closeted before
the gay rights movement often find greater authen-
ticity and freedom of expression in open committed
relationships and possibilities for marriage in later
years. Many older gay men, who survived the HIV/
AIDS epidemic that ravaged the gay community,
confronted both their mortality and tragic loss of
partners and friends earlier in life passage.
To be responsive to the growing diversity of
relationships and households in society, our view of
“family” must be expanded to fit the lengthened and
varied life course. Therapeutic objectives must be
attuned to the challenges and preferences that make
each individual, couple, and family unique. We will
need to learn how to help family members live suc-
cessfully in complex and changing relationship sys-
tems, buffer stressful transitions, and make the most
of their later life experiences.
Assess your comprehension of the varying and
extended family life course by completing this
quiz.
From Ageism and Gerophobia
to a Larger Vision of Later Life
Our society has not readily confronted the challenges
of later life or seen the opportunities that can come
with maturity. Our gerophobic culture has held a fear-
ful, pessimistic view of aging as decay, with the elderly
stereotyped as old-fashioned, rigid, boring, useless,
demented, and burdensome. Institutionalized forms of
ageism perpetuate workplace discrimination. Adults
older than 50 years have disproportionately lost jobs
in the recent economic recession and are least likely
to be rehired. With social media glorifying youth,
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addressed the priorities and assets of older adult
members. A life course perspective on family devel-
opment and aging is required, emphasizing both con-
tinuity and change.
Later-life transitions and challenges
The family as a system, along with its elder members,
confronts major adaptational challenges in later life.
Changes with retirement, grandparenthood, illness,
death, and widowhood alter complex relationship
patterns, often requiring family support, adjustment
to loss, reorientation, and reorganization. Many dis-
turbances are associated with difficulties in family
adaptation. Yet such challenges also present oppor-
tunities for relational transformation and growth.
A family’s approach to later-life challenges
evolves from its earlier patterns, life experiences,
and cultural worldview. Systemic processes that
develop over the years influence the ability of family
members to adapt to losses and flexibly meet new
demands. Certain established patterns, once func-
tional, may no longer fit changing priorities and
constraints. For families who have raised children,
their launching from home sets the stage for rela-
tionships in later life. With the structural contraction
of the family from a two-generational household to
the couple or single parent, relationships with young
adult children are redefined and parental involve-
ment typically refocuses on individual and couple
life pursuits. Most parents adjust well to this “empty
nest” transition and welcome their increased freedom
from childrearing responsibilities (Neugarten, 1996).
Yet, many parents continue to provide financial and
emotional support through college and beyond, and
many adult children, for economic reasons, return to
the nest.
infrequent, obligatory contact; and dump them in
institutions. Many presume that older adults are too
set in their ways to change longstanding interaction
patterns. In fact, family bonds and intergenerational
relations for most Americans are mutually benefi-
cial, dynamic, and coevolving throughout adult life
(Bengston, 2001). Families provide most social in-
teraction, caregiving assistance, and psychological
support for elderly loved ones. The vast majority
of older adults live independently or with children
or other relatives, including siblings and very aged
parents.
Most couples who weather the inevitable
storms in long lasting relationships and childrearing
report high relationship satisfaction in their post-
launching years, with more time and resources for
individual and shared pursuits. Priorities for compan-
ionship and caregiving come to the fore. Although
sexual contact may be less frequent, intimacy can
deepen with a sense of shared history. New satisfac-
tions are found in shared activities, such as travel,
and in bonds with grandchildren.
The importance of sibling relationships com-
monly increases over adulthood (Cicirelli, 1995).
The centenarian Delany sisters, born into a southern
African American family, pursued careers and lived
together most of their lives, crediting their remark-
able resilience to their enduring bond. They shared
enjoyment in conversation and laughter, watched
over each other, and saw their differences as balanc-
ing each other out (Delany & Delany, 1993).
Most older Americans in good health prefer
to maintain a separate household from children, yet
they sustain frequent contact, reciprocal emotional
ties, and mutual support in a pattern aptly termed
“intimacy at a distance” (Blenkner, 1965). The prox-
imity of family members and contact by phone and
the Internet are especially important to those who
live alone. Adult children and grandchildren also
benefit in many ways from frequent contact with
elders. However, in our mobile society, uprooting
for jobs or retirement can strain the ability to provide
direct caregiving and support in times of crisis.
In an ageist social context and a clinical focus
on family childrearing phases, the family literature
has given scant attention to the family in later life,
other than caregiving challenges, and has rarely
Assess your comprehension of from ageism and
gerophobia to a larger vision of later life by
completing this quiz.
Retirement
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justment for individuals and couples. Those who are
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shift in expectations and later-life plans. Because of
the stigma of dependency in our dominant culture,
with its ethos of self-reliance, most older adults
are reluctant to ask for or accept financial assistance
from their adult children; issues of pride and shame
keep many from even telling their children that they
are financially strapped. A family consultation is
helpful to enable discussion of sensitive issues, con-
textualize the situation, and find respectful ways to
be of assistance.
In traditional homemaker/breadwinner mar-
riages, couples may have difficulty with the hus-
band’s retirement, accompanied by losses of his
job-related status and social network, especially if
they have been uprooted from kin and social net-
works to accommodate career moves. Another chal-
lenge involves a retired husband’s incorporation
inside the home, with changes in role expectations,
time together, and the quality of interaction. If he
feels that he has earned full leisure yet expects his
wife to continue to shoulder household responsi-
bilities, her resentment likely will build. Dual-earner
couples may get out of sync if one continues working
past the other’s retirement. For successful adapta-
tion, couples need to renegotiate their relationship to
achieve a new balance. With priorities and concerns
shared through open communication, relational resil-
ience can be strengthened as partners pull together
to reshape their lives, plan financial security, and
explore new interests to provide meaning and satis-
faction (Walsh, 2015).
When a child has filled a void in a marriage, it
can complicate a couple’s subsequent adjustment to
retirement.
CASE ILLUSTRATION
Maria, Luis, and Raul
Maria, 63, brought her husband Luis, 67, for treat-
ment of alcohol abuse since his retirement. Living
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had returned home after a divorce. Longstanding
close attachment between the mother and son had
stabilized a chronically conflictual marriage over
the years, when Luis had worked long hours outside
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healthy and financially secure are reinventing later
life, from the stereotyped retreat in a comfortable
rocking chair to new structure and purpose, with
time for leisure, learning, and new pursuits. Family
therapist Lorraine Wright has relabeled retirement
as “preferment,” a transition offering the opportu-
nity to refocus energies to fit emerging needs and
preferences. Many take on meaningful projects
or new careers; some start riding Harleys and join
motorcycle clubs.
For most, retirement involves the loss of job
roles, status, and productivity, valued as our cul-
ture’s (male) standards for identity, success, and
self-esteem in adult life. Whether retirement was
desired or forced will affect adjustment. Even when
early retirement or a job layoff is due to the economy
or a company’s relocation, self-doubts can linger, as
well as anxiety and bitterness at the loss of benefits
and security. Loss of income and one’s role as finan-
cial provider can significantly strain relationships.
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dren or retirement, can add further dislocation and
loss of connections with nearby family and social
networks, as well as familiar services and trusted
health care providers. Losses are felt in giving up a
home in which children were raised and many mile-
stones experienced.
A successful transition involves a reorienta-
tion of values and goals and a redirection of energies
and relationships. The trend for older adults to move
away to age-segregated retirement developments has
been shifting to a preference to remain in or near their
communities. Many downsize from suburban homes
to apartments close to shopping, restaurants, cultural
opportunities, and young people. Many parents wait
for adult children to settle, planning to move to be
near them and their grandchildren. With job mobil-
ity so common, some elders experience subsequent
uprooting to follow their children yet again. Often,
adult children live in different regions, and grandpar-
ents shuttle around to spend time with all.
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those who lack retirement savings and benefits. In
the current economic downturn, many must continue
working long past retirement age. Those who have
lost jobs and benefits must find new work, but face
age discrimination. Such pressures force a major
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with knowledge of five or more generations, are in
a unique position to connect the younger genera-
tions with those that came before them through their
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grandchildren may enjoy a special bond that is not
complicated by the responsibilities, obligations, and
conflicts in the parent–child relationship (Mueller &
Elder, 2003). It is often said that grandparents and
grandchildren get along so well because they have
a common enemy. Such an alliance can be prob-
lematic if a grandchild is triangulated in a parent–
grandparent conflict.
CASE ILLUSTRATION
Sharleen
After the death of her father, Sharleen, age 32, a sin-
gle parent, and her son Shaun, age 6, moved in with
her mother to consolidate limited resources. Shaun’s
misbehavior and disrespect toward Sharleen brought
the family to therapy. At the first session, Shaun went
to his grandmother for help in taking off his boots.
She quickly took over the discussion while Sharleen
shrank back. Shaun, sitting between them, glanced
frequently to his grandmother for cues. Each time
Sharleen and her mother started to argue, Shawn
drew attention to himself. He ignored Sharleen’s
attempts to quiet him, but responded immediately to
his grandmother.
The grandmother complained that she was
overburdened by having to take care of “both chil-
dren.” Sharleen felt that her mother undercut her
efforts to take more responsibility by criticizing
everything she did as “not right,” meaning not her
way. We explored the impact of the grandfather’s
recent death from a heart attack. The grandmother
was devastated by the loss and uncertain how to go
on with her life. Taking charge to help her daugh-
ter raise Shaun filled the void. Feeling ashamed of
her financial needs, it also gave her a sense of value.
We considered the loss and changes for all three
generations and then directed attention to realign-
ing relationships so that Sharleen could be a more
effective mother with her son while honoring the
grandmother’s valuable contribution and her role as
now home all day, felt like an unwanted intruder.
Lacking job and breadwinning status as sources of
self-esteem, he felt like an unworthy rival to his son
for his wife’s affection at a time in his life when he
longed for more companionship with her. Competi-
tive struggles fueled Luis’s drinking, erupting into
angry confrontations, as Maria sided protectively
with their son.
In Latino families, as in many ethnic groups,
parent–child bonds are commonly stronger than the
marital dyad. However, in this family, a pattern that
had functioned over many years became a highly
conflictual triangle when retirement disrupted the
relationship system.
Assess your comprehension of retirement by
completing this quiz.
Grandparenthood
As people live longer, growing numbers become
grandparents and great-grandparents (Drew &
Silverstein, 2004). The experience can hold great
significance, as Margaret Mead (1972), on becoming
a grandparent, described “the extraordinary sense of
having been transformed not by any act of one’s own
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hood can offer a new lease on life in numerous ways.
First, it fulfills needs for generativity through one’s
descendants, easing the acceptance of mortality. As
Mead experienced, “In the presence of grandparent
and grandchild, past and future merge in the present”
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cence of one’s own earlier childrearing and child-
hood experiences. Such perspectives can be valuable
in gaining appreciation of one’s life and parenting
satisfactions despite regrets one may have.
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alters intergenerational relationships (Spark, 1974).
When adult children become parents, it presents
an opportunity for reconnection and healing of old
intergenerational wounds, as they begin to iden-
tify with the challenges inherent in childrearing
and develop more empathy for their parents’ best
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progressively degenerative conditions are common.
Health problems and severity vary greatly. Among
seniors aged 65 to 84, arthritis, high blood pressure,
and heart disease are most prevalent. By the age of
85 or older, the risks of cancer and extensive disabili-
ties increase, combined with cognitive, visual, and
hearing impairment. Physical and mental declines
contribute to, and are exacerbated by, depression and
anxiety. Suicide rates also increase with age, particu-
larly for older White men.
Because our society lacks a coherent approach
to care for people with disabling chronic conditions,
too many live with poor health and lack access to
quality services. Families in poverty, largely in
minority groups, are most vulnerable to environ-
mental conditions that heighten the risk of serious
illnesses, disabilities, and caregiver strain, as well
as early mortality. Diseases such as asthma, diabe-
tes, high blood pressure, and heart disease are most
prevalent among the poor.
Family caregiving for the growing numbers
of frail elderly is a major concern (Qualls & Zarit,
2009). By 2020, it is expected that 14 million per-
sons will need long-term care. As average fam-
ily size decreases, fewer children are available for
caregiving and sibling support. In 1970, there were
21 potential caregivers for each person 85 or older;
by 2030, there are expected to be only 6 potential
caregivers, severely straining intergenerational
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aged 40 to 44 had no biological children intensify
concern about the provision of care as this group
reaches advanced age (Kinsella & He, 2009).
With later childbearing, many at midlife—the
so-called sandwich generation—are caring simul-
taneously for their children and for aging parents,
grandparents, and other relatives. Finances can be
drained as children’s college expenses collide with
medical expenses for elders. Increasingly, adult chil-
dren past retirement, with their own declining health
and resources, assume care for their parents. The
average age of caregivers is 57, but 25 percent are 65
to 74, and 10 percent are over 75. The role of primary
caregiver has traditionally been assigned to women;
currently, nearly three in four are wives, daughters,
or daughters-in-law. Now that the vast majority of
women are in the workforce, earning essential family
head of the household. Sharleen agreed to respect
her mother’s wishes about how she wanted her home
kept as her mother agreed to respect Sharleen’s ways
of childrearing and to support her parental leadership.
In poor communities with high rates of early
pregnancy, grandparenting commonly occurs early.
(SBOENPUIFST PGUFO JO NJEEMF BHF DPNNPOMZ
provide childcare, especially when single parents
must work. In kinship care, many grandparents are
assuming the primary role in raising their grandchil-
dren, either through legal guardianship or informal
arrangements, when parents are unable to assume
responsibility, as in cases of disability, substance
abuse, or incarceration (Engstrom, 2012). While this
meets a crucial need for the youngsters, it often takes
a toll on grandparents’ health, especially when they
are on a limited income and have other heavy respon-
sibilities. A family council meeting can involve oth-
ers, such as aunts and uncles, in supportive roles and
QSPWJEF SFTQJUF GPS UIF HSBOEQBSFOU (SBOEGBUIFST
are often hidden resources; even those who may not
have been involved in raising their children may wel-
come the opportunity to play a mentoring role for
grandchildren.
For many older adults, foster grandparenting
can enrich later life, serve as a resource for single and
working parents, and provide connectedness across
the generations, especially where more informal con-
tacts are lacking in age-segregated living arrange-
ments. Seniors can also be encouraged to volunteer
in childcare centers and after-school tutoring and
mentoring programs, contributing their knowledge
and interest, helping children learn, and enhancing
their development.
Assess your comprehension of grandparenthood
by completing this quiz.
Chronic Illness and Family
Caregiving
As our society ages, the number of people with
chronic conditions is increasing and those impaired
are living longer than ever before (Aldwin & Baun,
2007). Even for those in good health, fears of loss of
physical and mental functioning, chronic pain, and
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and forgets to serve it. With impaired memory, judg-
ment, and “sundowning,” they may wander off, get
lost, and forget who they are and where they live.
They may make disastrous financial decisions. As
the illness progresses, it is most painful for loved
ones when they are not even recognized or are con-
fused with others, even with those long deceased.
(FOUMF IVNPS DBO FBTF TVDI TJUVBUJPOT BT JO POF
DBTF"UBXFFLMZEJOOFSXJUIIJTQBSFOUTBT%BWJET
mother cleared the table and went into the kitchen,
IJTGBUIFSMFBOFEPWFSUPIJNBOETBJEi%JEZPVTFF
that woman there? If I wasn’t a married man I could
really go for her!” David replied, “Dad, you are the
MVDLJFTUNBOPO FBSUICFDBVTFZPV "3&NBSSJFEUP
her—she’s your wife!” They laughed together and
his mother enjoyed the compliment.
With limited medical interventions for Alzhei-
mer’s disease, treatment primarily addresses symp-
tom management and custodial care. Most families
try to keep their loved one at home as long as pos-
sible, yet it is particularly difficult when caregivers
live at a distance and must travel back and forth fre-
quently. Part-time or full-time nurses or paid caregiv-
ers, extended family, and social support networks are
crucial in coping with stresses, providing respite, and
dealing with crisis situations. Adult daycare programs
offer a therapeutic milieu, contact with others, and
pleasurable activities for the impaired person as they
relieve caregiver strain. Family psychoeducation pro-
vides useful illness-related information and manage-
ment guidelines over the course of an illness, reduces
caregiver anxiety and depression, and addresses func-
UJPOBMBOESFMBUJPOBMMPTTFT3PMMBOE
Family intervention issues and priorities
With all elder caregiving, family intervention pri-
orities include (1) stress reduction; (2) information
about the medical condition, functional abilities, lim-
itations, and prognosis; (3) concrete guidelines for
sustaining care, problem solving, and optimal func-
tioning; and (4) links to supplementary services to
support family efforts. Communities need to support
families through a range of services, from day pro-
grams to affordable assisted living, as well as com-
mitment to active participation of elders, including
those with disabilities, in community life.
income, a juggling of work and family roles can be
exhausting (Brody, 2004).
Elders with chronic conditions increasingly
receive care at home, often requiring costly treat-
ments and medications, frequent hospitalizations,
and intensive home-based care for daily function-
ing. Family and friends are the front lines of support.
Nearly three quarters of disabled people rely exclu-
sively on these informal caregivers (Qualls & Zarit,
 /BUJPOBM "MMJBODF GPS $BSFHJWJOH  ""31
2009). Prolonged caregiving takes a heavy toll.
Eighty percent of caregivers provide help 7 days a
week, averaging 4 hours daily. In addition to house-
keeping, shopping, and meal preparation, two thirds
assist with feeding, bathing, toilet, and dressing.
The lack of useful management guidelines by most
medical specialists adds to confusion and frustration.
Some aspects of chronic illness are especially disrup-
tive for families, such as sleep disturbance, incon-
tinence, delusional ideas, and aggressive behavior.
One symptom and consequence of family distress is
elder abuse, which can occur in overwhelmed fami-
lies, stretched beyond their means and tolerance, or
in families with a history of substance abuse and
violence.
Dementia: The long goodbye
Progressive brain disorders are among the most dif-
ficult conditions for families. Alzheimer’s disease
and other dementias affect 1 in 10 people older than
65 years—and nearly half of persons older than
85 years. Alzheimer’s disease has been aptly called
“the long goodbye” because of the progressive losses
of functioning, identity, family roles, and relationships.
These ambiguous losses complicate caregiving and
mourning processes (Boss, 1999). The irreversible
course of this devastating disease can last from a few
years to more than 20 years, becoming an agoniz-
ing psychosocial and financial dilemma for fami-
lies. Over time, mental and physical capacities are
stripped away in gradual memory loss, disorienta-
tion, impaired judgment, and loss of control over
bodily functions. In early stages, family members,
not understanding the disorder, often become frus-
trated when the individual repeatedly asks the same
questions, forgets earlier answers, or prepares a meal
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CASE ILLUSTRATION
The Zambrano family
Mrs. Zambrano, an 82-year-old widow, was hospi-
talized with multiple somatic problems and second-
ary symptoms of disorientation and confusion. She
complained that her two sons, Vince, age 46, and
Tony, 43, did not care whether she lived or died.
The sons reluctantly came for a family interview.
Tony believed that his mother’s hospitalization was
merely a ploy for sympathy, to make him feel guilty
for not being at her beck and call as Vince was. He
said that he had learned to keep his distance. Vince
IBTCFDPNFJODSFBTJOHMZGSVTUSBUFE5IFNPSFIF
did for his mother, the more helpless and critical
she became. He felt drained by her neediness and
complaints and was resentful toward Tony. This
SFQFBUFEBQBUUFSOJODIJMEIPPE8JUIUIFGBUIFS
often away on business, the mother had turned to
Vince to meet her needs. The brothers were helped
to realign their relationship to share responsibilities
and to gain appreciation of their mother’s losses,
loneliness, and anxiety that her life was slipping
PVUPGIFSDPOUSPM3BJTFEUPCFiEPFSTuBOEQSPC-
lem solvers, they felt helpless in the face of decline,
death, and loss, no matter how much they did for
her. They were encouraged to take turns visiting
her and simply to be more fully present, sharing
stories and reminiscences, which eased her anxi-
ety, improved her functioning, and reassured her of
their love.
From designated caregiver
to caregiving team
In approaching all serious illness, we need to expand
the traditional narrow focus on one individual who
is designated as the caregiver to a collaborative ap-
proach to caregiving, involving all family members
as a caregiving team. Most often, one adult child
becomes overburdened and siblings are on the side-
lines, unsure how to be supportive (Bedford, 2005;
Siblings and the Life Cycle, Chapter 10). The shar-
ing of responsibilities and challenges can become an
Family dynamics may require attention. For
couples, chronic illness and disability can skew the
relationship between the impaired partner and car-
egiving spouse over time. It can deplete financial
savings and dash plans for the golden years. Couple
therapy can help partners to gain mutual empathy;
address such issues as blame, shame, and guilt; and
rebalance their relationship to live and love as fully
as possible.
Intergenerational issues around autonomy
and dependency come to the fore as aging parents
lose functioning and control over their bodies and
their lives. Meeting their increasing needs should
not be seen as a parent–child role reversal, which
can be infantilizing and shaming. Even when adult
children give financial, practical, and emotional
support to aging parents, they do not become par-
ents to their parents. Despite frailties or childlike
functioning, aged parents have had many decades of
adult life experience and deserve respect as elders.
Family therapists can facilitate conversations about
dependency issues with sensitivity and a realistic
appraisal of strengths and limitations. Many elders
XPSSZBCPVUCFJOHBCVSEFOPOMPWFEPOFT(JWJOH
children the power of attorney also involves a loss
of self-determination. In many cases, adult children
have to challenge a parent’s judgment and take con-
trol of risky behavior. In our mobile society, driv-
ing a car is a symbol of independence and freedom.
Older adults, especially men, often refuse to give
up driving, even with seriously impaired vision,
reflexes, and judgment, and may be unwilling to
admit the danger. In one family, the sons had to take
away the father’s keys, only to find he had driven
again using other keys hidden away. Next, they
removed the car’s battery; the crafty father called
a service station to install a new one. With caring,
firmness, and humor, rather than angry rebuke, they
appreciated the father’s cleverness while taking fur-
ther precautions.
In some cases, an aging parent, losing control
and functioning, may become overly dependent on
adult children. While one adult child may become
overly responsible through anxiety or prior role func-
tioning, others may distance themselves. A vicious
cycle may ensue, with escalating neediness, burden,
and resentment.
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Placement planning
The point at which failing health requires considera-
tion of extended-care placement can be a crisis for
the whole family. Placement is usually turned to only
as a last resort, when resources are stretched to the
limit, and in later stages of mental or physical de-
cline. Still, feelings of guilt and abandonment and
stereotypes of institutionalization can make a place-
ment decision highly stressful.
CASE ILLUSTRATION
The Gupta Family
.ST(VQUBDBMMFEGPSIFMQTUBUJOHUIBUTIFiGFMUIFMQ-
less to control” her teenage son and feared that he
“needed to be institutionalized.” A family assessment
revealed an escalating cycle—his defiance of her
attempts to control his every activity—over the past 8
NPOUITTJODF.ST(VQUBTNPUIFSIBECFFOCSPVHIU
to live in their home. She wept as she described her
mother’s deteriorating Parkinson’s condition, feeling
unable to provide round-the-clock care. She couldn’t
sleep at night after finding her mother on the floor
one morning. Her control struggles with her son
EFGMFDUFEIFS IFJHIUFOFEDPODFSOUIBUIFSNPUIFST
condition was beyond her control and institutionali-
zation might be needed. This provoked a crisis for
IFS"U IFSGBUIFSTEFBUICFE BZFBSFBSMJFS IFIBE
asked her to promise that she would always care for
her mother. She had also heard stories that in regions
of India, widowed women were banished from their
homes and communities. She could not bear to aban-
don her mother. She felt alone with her dilemma, as
her husband had distanced, preoccupied by his work.
This case underscores the importance of inquiry
about elderly family members even when problems
are presented elsewhere in the family system. It is
also crucial to explore a spouse’s distancing and lack
of support. In this case, the husband revealed that he
was trying to avoid his own hidden guilt over having
left the care of his dying mother to his sisters. This
crisis now became an opportunity for both of them to
explore ways together to provide the best care in this
opportunity to strengthen bonds and heal strained
relationships. In families torn by past grievances,
conflict, or estrangement, caregiving is likely to be
more complicated. Life-and-death decisions can be
emotionally fraught.
CASE ILLUSTRATION
JoEllen
JoEllen, 38 years old, was deeply conflicted when
her father, hospitalized for complications from
chronic alcohol abuse, asked her to donate a kidney
to save his life. She felt enraged to be asked to give
up something so important when he had not been
there for her as a father over the years. He had been
a mean drunk, often absent and many times violent.
She was also angry that he had brought on his dete-
riorated condition by his drinking and had refused to
heed his family’s repeated pleas to stop. Yet, a dutiful
daughter and a compassionate Christian woman, she
did not want her father to die because she denied him
her kidney.
I broadened the dilemma to include her sib-
lings, suggesting that she discuss it with them,
but JoEllen dismissed the idea, saying they were
estranged and rarely in contact. I then encouraged
her to talk with her mother, who informed her that
the father had also asked her siblings for the kid-
ney donation. JoEllen was furious that old rivalries
XPVMECFTUJSSFEVQXIPXPVMECFTFFOBTUIFHPPE
giving child or the bad selfish ones. She now took
initiative to get the siblings together. When they met,
old rivalries melted as they began to grapple with the
dilemma.
I widened the focus forward, suggesting that
they begin to envision how they might collaborate,
proactively, to meet future challenges that might arise
in caring for both aging parents. With this conver-
sation, the eldest brother volunteered his kidney for
their father. He was less conflicted because he remem-
bered good times with the father before his problem
with drinking. The others offered to support him and
agreed to keep in contact and to contribute to their par-
ents’ future well-being, forging a new solidarity.
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death, but what is a natural death in our times? Most
elderly persons die after a long, progressively wors-
ening illness and disability. Medical technologies
prolonging life and the dying process pose unprec-
edented family challenges. It is crucial to address
elders’ needs for dignity and control in their own
dying process as well as palliative care for comfort
and pain alleviation. Clinicians need to work with
families to reduce suffering, discuss important end-
of-life decisions, and make the most of precious time
together (Walsh, 2015).
Later life is a season of cumulative losses of
loved ones, friends, and peers. Family adaptation
to loss involves shared grieving and a reorganiza-
tion of the family relationship system (Walsh &
.D(PMESJDL"WPJEBODFTJMFODFBOETFDSFDZ
complicate mourning. When patient and family
hide knowledge of a terminal illness to protect one
another’s feelings, communication barriers create
distance and misunderstanding, prevent prepara-
tory grief, and deny opportunities to say goodbyes.
Therapists can assist family members with feel-
ings of helplessness, anger, loss of control, or guilt
that they could not do more. It is usually easier for
younger family members to accept the loss of elders
whose time has come, than for elders to accept the
loss—and their own survival—of siblings or their
own children or grandchildren who die first. The
death of the last member of the older generation is
a family milestone, signifying that the next genera-
tion is now the oldest and the next to face death. It is
important, also, to address the impact of an elder’s
death for grandchildren, often their first experience
with death and loss.
Spousal bereavement can be a highly stressful
transition, with a wide range of responses in adap-
tation. Women, with a longer life expectancy than
men, and tending to be younger than their husbands,
are more likely to be widowed, with many years of
life ahead. Women tend to anticipate the prospect
of widowhood (Neugarten, 1996). Men tend to be
MFTT QSFQBSFE 5IF JOJUJBM TFOTF PG MPTT EJTPSJFOUB-
tion, and loneliness contributes to an increase in
death and suicide rates in the first 2 years. Social
contact is often more disrupted for men, since wives
tend to link their husbands to family and social net-
works, especially after retirement. Yet the long-term
situation, both in-home and in a care facility, without
abandoning their loved one—or each other.
Family sessions, best done proactively, can
enable members to assess needs and both kin and
community resources and to share feelings, concerns,
and mutual support in reaching a decision. Often,
new solutions emerge that can support the elder’s
remaining in the community, with part-time or full-
time in-home nursing care or in assisted living.
3FTQJUFGPS DBSFHJWFSTJTDSVDJBMUPUIFJSXFMMCFJOH
When extended care placement is needed, therapists
can help families view it as the most viable way to
provide adequate care and support their efforts in
navigating the maze of options and coverage.
The importance of prevention for healthy and
satisfying later years cannot be overstressed (Weil,
2005). Efforts are needed to lower risk factors that
EJNJOJTIMJGFFYQFDUBODFBOEXFMMCFJOHUIFSBNQBOU
increase of obesity, fast foods, sedentary life styles,
and the loss of family ties, community participation,
and productive employment or activity. We must
also revision chronic care beyond the narrow focus
on medical services and nursing homes. A report
DPNNJTTJPOFECZUIF3PCFSU8PPE+PIOTPO'PVOEB-
tion well over a decade ago (Institute for Health and
Aging, 1996) advanced a broader view to address
chronic care challenges for the twenty-first century.
5IFSFQPSUFOWJTJPOFE BTZTUFNPG DBSFBTQFDUSVN
of integrated services—medical, personal, social,
and rehabilitative—to assist people with chronic
conditions to live fuller lives. A continuum of care is
needed to ensure that individuals and their families
receive the level and type of care to fit their condition
and changing needs over time and to support inde-
pendent living, optimal functioning, social connec-
tions, and well-being.
Assess your comprehension of chronic illness and
family caregiving by completing this quiz.
End-of-Life Challenges and Loss
of Loved Ones
Dealing with terminal illness is among families’
most painful challenges, complicated by agonizing
end-of-life decisions. Most people hope for a natural
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disappointments or as evidence that they are valued
more than the new partner. Burial can be a conten-
UJPVT JTTVF XIFUIFS XJUI UIF EFDFBTFE TQPVTF BOE
parent of children or with the new partner. Family
therapists can facilitate important discussions and
planning to avert later conflict.
hardships are greater for widowed women with more
limited financial resources.
The psychosocial tasks in the transition to
widowhood involve grief over the loss and reinvest-
ment in future functioning. Despite profound initial
grief and challenges in daily living, most surviving
spouses are quite resilient over time (Butler, 2008).
Most report becoming more competent and inde-
pendent, and take pride in coping well; only a few
view the changes entirely negatively. A realignment
of relationships in the family system also occurs
8BMTI  .D(PMESJDL  'BNJMZ BEBQUBUJPOBM
tasks involve shared acknowledgment of death and
mutual support through the grief process, trans-
forming shared experiences and physical presence
into continuing bonds through spiritual connection,
memories, stories, and deeds. Attention must also
turn to the reality demands of daily functioning and
self-support. Wherever possible, clinicians and adult
children should help both partners to anticipate and
prepare for widowhood. Many need to acquire new
skills for independent living. The initial adjustment
to being physically alone, in itself, is difficult. Within
1 to 2 years, most bereaved spouses regain interest
in others and new activities. Further dislocation may
occur if the family home is given up or if financial
problems or illness block independent functioning.
In such cases, many widows move in with adult chil-
dren, siblings, or a very aged parent.
3FNBSSJBHFJTDPNNPOGPSNFOCVUMFTTTPGPS
women. Not only are there fewer available men but
also many prefer not to remarry, especially if they
have had heavy spousal caregiving responsibilities
and are reluctant to take on that role again. Economic
and legal issues, such as bequests for children, lead
some older couples to live together—or separately—
as committed companions without formal marriage.
Critical to the success of remarriage is the relationship
with adult children and their approval of the union.
Problems can arise when a child views remarriage
as disloyal to the deceased parent. Adult children
may be shocked by an aged parent’s intimacy with a
new partner—especially when they cannot conceive
of the elderly as attractive or sexually active. Some
assume that a new mate is interested only in money.
Conflict over a will frequently arises, particularly if
children view inheritance as compensation for earlier
Assess your comprehension of end-of-life
challenges and loss of loved ones by completing
this quiz.
Cross-Generational Interplay
of Life Cycle Issues
In every family, the later life challenges of par-
ents interact with salient developmental issues of
their children at their concurrent life phases. With
increasing diversity in family patterns and the ten-
dency toward later marriage and childrearing, differ-
ent pressures and conflicts may arise. The issues that
come to the fore between an older adult parent and
young adult child will likely differ from those that
arise between a parent and a middle-aged child. Ten-
sions are heightened when developmental strivings
are incompatible.
CASE ILLUSTRATION
Julia
Julia, in her mid-20s, was beginning a social work
career and engaged to be married when her 63-year-
old mother, who lived 2,000 miles away, was diag-
nosed with congestive heart failure. Julia felt torn.
Her love and sense of obligation were countered by
reluctance to put her new job and marriage plans on
hold indefinitely. The situation was complicated by
issues of separation and identity, which are norma-
tive in early adulthood. Julia had always been close
to her mother and relied on her direction and sup-
port. Her geographic distance from home in the life
that she had established bolstered her self-reliance.
Now as she was on the threshold of adult commit-
ments, her mother needed her most and Julia feared
losing her.
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In our culture, young adults are emerging
from the search for identity into issues of commit-
ment and preoccupation with making initial choices,
such as a life partner, career, and residence, choices
UIBUEFGJOFPOFTQMBDFJOUIFBEVMUXPSME3FTQPOE-
ing to caregiving needs and threatened loss of aging
parents at this life stage may be fraught with con-
flict. Clinicians need to help young adults offset the
cultural push for family disconnection and prioritize
relationships with their elders approaching the end
of life.
Successful Aging: Meaning
and Connection
Abundant research, including recent neuroscience
findings, reveals that the aging process is much more
variable and malleable than was long believed (Butler,
2008; Cozolino, 2008). Elders can enhance their own
development by actively approaching their challeng-
es and making the most of their strengths and options
(Baltes & Baltes, 1990). Studies of normal adult de-
velopment and family functioning find that a variety
of adaptive processes, rather than one single pattern,
contribute to successful later-life adjustment (Birren
& Schaie, 2006). This diversity reflects differences
in family structures, individual personality styles,
gender roles, and ethnic, social class, rural versus
urban, and larger cultural influences. The develop-
ment of new modes of response and aspects of life
that were earlier constrained enables a greater role
flexibility and adaptation that contribute to life sat-
isfaction.
Betty Friedan’s (1993) analysis of interna-
tional studies on aging suggests that older adults may
actually integrate problems at a higher level than the
young, particularly in attending to ethical and con-
textual issues. From studies of different populations,
Friedan noted that many women who were the most
vital in later life had experienced profound change
and discontinuity. Those who were most frustrated,
angry, and depressed had held on rigidly to earlier
constraining roles or had repeated them. What distin-
guished women who were vital was not which roles
they played in earlier adulthood, but rather whether
they had developed a sense of purpose and structure
for making life choices and decisions.
Phone contact became increasingly strained.
Julia’s mother saw her failure to return home as
uncaring and selfish. Julia made a brief visit, feeling
guilty and upset. The uncertain course of the illness
made it difficult to know how long her mother would
live or when to plan trips. Julia sent her mother
gifts. One, picked with special care and affection,
was a leather-bound book for her memoirs. On her
next visit, Julia discovered the book, unopened,
on a closet shelf. Deeply hurt, she screamed at her
mother to explain. Her mother replied, “If I wrote
my memoirs, I’d have to say how much you’ve let
me down.” Julia, very hurt, cut her visit short. Mean-
while, conflict escalated with her fiance, and the
wedding plans were canceled. Deeply upset by the
breakup, Julia phoned her parents for consolation.
Her mother expressed her own disappointment at the
canceled plans, saying that she now had nothing to
live for. A few hours later, she had a stroke. Julia,
too angry to respond, put off a trip home. Her mother
died 2 weeks later. Julia scarcely grieved, throwing
herself into her work and a new relationship. When
that relationship broke up, delayed grief and remorse
surfaced, bringing her for therapy. In learning more
about her mother’s life and losses, Julia found out
that her mother’s own mother had expressed disap-
pointment in her as she was dying. In gaining com-
passion for her mother, she also reached out to her
father, to know and appreciate him better while there
was time.
In this case, the mother’s developmental needs
at the end of life occurred “off-time” from the per-
spective of the daughter’s developmental readiness
and out of sync with her age peers. Terminally ill,
the mother needed to draw her family close and to
feel that she had successfully fulfilled her role as a
mother. The young adult daughter was threatened by
the closeness and dependency at a time of impending
loss, when she was not yet secure in her own life and
felt her culture’s pressure for autonomy. A transgen-
erational anniversary reaction complicated the situa-
tion as unresolved issues from the mother’s estranged
relationship with her own mother before her death
were revived, adding fuel to the conflict, disappoint-
ment, and estrangement at her own life’s end.
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The Wisdom and Spirit of the Elders
There is growing recognition that later years and re-
lationships have a significance of their own. In Erik-
son’s theory of human development, old age was seen
as a critical period, when individuals review earlier
life experiences and their meaning in the quest to
achieve integration and overcome despair at the end of
life’s journey. In this process, new adaptive strengths
and wisdom can be gained. The task of achieving in-
tegration is challenging, as older adults face the fi-
niteness of life and awareness of past deficiencies,
hurts, and disappointments. Vital involvement in the
present is essential. Some look for models of aging in
parents or grandparents; others look to friends, com-
munity members, and even iconic figures, from the
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Nelson Mandela and the Dalai Lama. Such attributes
as humor, compassion, curiosity, and commitment
contribute to a sense of integrity. Interviews with oc-
togenarians reveal many pathways for integration and
reconciliation of earlier life issues (Erikson, Erikson,
& Kivnick, 1986). For the most resilient aged people,
past trauma and inescapable missteps are put into per-
spective. Even those who do not achieve integration
are actively involved in meaning-making efforts to
reach some acceptance of their lives.
A common thread in successful aging is the
dynamic process as older people come to see them-
selves not as victims of life forces, or defined by their
limitations, but rather as resilient, with the capac-
ity and initiative to shape as well as be shaped by
events (Walsh, 2012a). Overcoming life’s adversities
involves the courage to reach out, seeing aging as
a personal, relational, and spiritual evolution, seek-
ing new horizons for learning, change, and growth.
A priority for clinicians is to recognize and draw out
sources of meaning and fulfillment and to facilitate
efforts by older adults and families to integrate the
varied experiences of a lifetime into a coherent sense
of self, relational integrity, and life’s worth.
In contrast to the redefinition of self that many
women experience with menopause, launching of
children, widowhood, or divorce, Valliant (2002)
found that many aging men’s identities continue
to be heavily invested in career success and sexual
potency. Such culturally based “proofs” of masculin-
ity generate anxiety, a sense of deficiency, and a void
as these powers diminish. Notably, Vaillant (2012)
found that meaningful relationships were the most
important factor in men’s successful aging. Love and
intimacy might take many forms, deepening over
time. It is important to challenge constraining views
and explore possibilities for personal and relational
fulfillment.
Similarly, successful family functioning in
later life requires strong relational connections and
flexibility in structure, roles, and responses to new
developmental priorities and challenges (Walsh,
2012a, 2015). As patterns that may have been
functional in earlier life phases no longer fit, new
options can be explored. With the loss of function-
ing and death of significant family members, others
are called upon to assume new roles, responsibili-
ties, and meaningful connections. In doing so, they
develop new competencies and enhanced sense of
worth. Therapists can invite couples and families
to reflect on the choices they have made in life and
now wish to make for their remaining time, seeing
their alternatives as both limited and extended by
personal belief systems, gender, ethnic, and cultural
identity, and social and economic position. These
choices are never simple; most often they are com-
plex and intertwined with the needs and decisions
of others.
As Lightfoot-Lawrence (2009) found, many
older people from varied walks of life approach
maturity with celebration, finding possibilities in
aging for enrichment and unexpected pleasures. For
her, the greatest reward of parenting has been delight
in her fully-grown progeny, considering them to be
friends with an extra dimension of affection. She
finds it powerfully reassuring at this time to think of
life, and each day, as time to be fully savored. Many
find it to be the best time of life, feeling freer to be
themselves, reporting less conflict and more balance;
better able to know and use their strengths; and surer
of what matters in their lives.
Assess your comprehension of successful aging:
meaning and connection by completing this
quiz.
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The Significance of Relational
Connections
We are relational beings. A family system orientation
considers the broad network of relationships, identi-
fying and recruiting potential resources for resilience
in the immediate and extended family, including
informal kin. Even in troubled families, “relational
lifelines” for resilience can be found. Some individu-
als are good listeners and are emotionally supportive;
others may be good problem solvers or bring good
cheer and needed laughter. In fostering the resilience
of aging family members, positive contributions
might be made by siblings, adult children and god-
children, nephews, nieces, and grandchildren, friends,
and even former spouses. One woman, aged 81, hos-
pitalized with a life-threatening illness, greeted two
visitors. To one, an acquaintance, she introduced the
other, her former husband, saying “We were married
in the past, but now we’re close friends.”
Companionate bonds, social ties, and com-
munity connections become increasingly valued
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link between social contact, support, and longevity.
Elders who visit often with friends and family and
maintain a thick network of diverse relationships
are likely to live longer than those with few kin and
social resources (Litwin, 1996). Baby boomers are
creating “villages” of interdependence, so that they
and their elders can live independently for as long
as possible with community interaction, stimulat-
ing involvement, and access to needed services.
Faith communities play an increasingly important
role with aging, from shared communal values and
rituals, involvement in congregational activities and
community service, to practical, emotional, and spir-
itual support in times of need.
Longtime and childhood friends become
increasingly valued; many reconnect at reunions
and through Internet social networks. Old flames are
sometimes rekindled in later life. Old friends connect
us to our younger selves and offer perspective on our
emerging lives. A woman in her mid-60s, anxious
that her forgetfulness was an early sign of Alzhei-
mer’s disease, found humor and relief after her col-
lege roommate reminded her that she had always
been absent minded.
King and Wynne (2004) proposed the concept
of family integrity as the achievement of older adults’
developmental striving toward meaning, connection,
and continuity within their multigenerational family
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transformation of relationships over time respon sive
to members’ changing life cycle needs; (2) resolu-
tion or acceptance of past conflicts and losses; and
(3) shared creation of meaning by passing on individ-
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family integrity generates a deep and abiding sense of
peace and satisfaction with past, present, and future
family relationships.
Notable in this life phase is the search for life’s
transcendent meaning. Spiritual beliefs and practices,
whether within organized religion or not, come to the
fore with aging, sustaining resilience for most elderly
people (Schaie & Krouse, 2004; Walsh, 2009c).
3FTFBSDIEPDVNFOUTUIFQPXFSPGQFSTPOBMGBJUIBOE
contemplative practices, such as prayer, meditation,
and rituals, to strengthen well-being and healing by
triggering positive emotions and brain activity and
by strengthening immune and cardiovascular sys-
tems. For instance, a study of elderly patients after
open-heart surgery found that those who were able to
find hope, solace, and comfort in their religious out-
look had a survival rate three times higher than those
who did not. What matters most is the ability to draw
on the power of faith to give meaning to precarious
life challenges and to life itself. Belief in a spiritual
afterlife, and reunion with loved ones and ancestors,
offers solace and comfort.
The search for identity and meaning is a life-
long process. Individuals and their families organize,
interpret, and connect experiences in many ways.
We must be sensitive to the culture and time in which
families and their members have lived and the con-
tribution of critical events and structural sources of
meaning. For some, religion is most salient; for oth-
ers, it might be humanistic values, ethnic heritage,
or their education that enabled them to rise out of
poverty. Many elders show enormous potential for
continual self-renewal as they forge new meaning
and purpose in their later years. Emerging research
suggests that older adults with a greater purpose in
life have a reduced risk of Alzheimer’s disease and
mild cognitive impairment (Boyle, et al., 2010).
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CASE ILLUSTRATION
Rita
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chiatric unit, diagnosed with a confusional state
and acute paranoia after an incident in which she
accused her landlord of plotting to get rid of her.
3JUBT JODSFBTJOH WJTVBM JNQBJSNFOU XBT NBLJOH
independent living more difficult and hazardous. Her
apartment was in disarray. She was socially isolated,
stubbornly refusing assistance from “strangers.”
Her only surviving family member, a sister, lived in
BOPUIFSTUBUF5IFIPTQJUBM TUBGG EPVCUJOH UIBU 3JUB
could continue to function independently, planned
BOVSTJOH IPNFQMBDFNFOUGPS IFS3JUB WFIFNFOUMZ
objected, insisting on returning to her own apart-
ment. Hospitalization was extended “to deal with her
resistance.”
A family therapist’s strength-based interviews
XJUI3JUBMFEUPBOFXBQQSFDJBUJPOPGIFSBTBDBQB-
ble person and to a more collaborative plan. Asked
what she valued about living alone, she replied, “I’m
not alone; I live with my books and my birds.” The
therapist expressed interest in hearing more about
IFSMJGF3JUBIBECFFOBUFBDIFSIBQQJMZNBSSJFE
without children until her husband’s death 10 years
earlier. Her beloved father died the following year.
After those painful losses, she withdrew, deter-
mined never to become dependent on anyone again.
3JUBDFOUFSFEIFSMJGFPOIFSXPSLTIFXBTLOPXO
as a “tough cookie,” respected by colleagues for
her perseverance with challenging students. Since
retirement, she had immersed herself in her books, a
vital source of her resilience, enhancing her cogni-
tive functioning and pleasure, and transporting her
beyond her immediate circumstances. Many books
held special meaning, inherited from her father, a
scholar. They revived her close childhood relation-
ship with him, when he had spent countless hours
SFBEJOHUPIFS/PX3JUBTMPTTPGWJTJPOXBTNPTU
distressing, cutting her off from her valued connec-
tions. She enjoyed the chattering and singing of her
birds and did not want to give them up with a move.
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involved intense pride in his part-Native American
heritage, a hardiness in adversity, and a will to survive
Companion animals play a vital role for the
well-being and resilience of many elderly (Baun,
Johnson, & McCabe, 2006; Walsh, 2009a), espe-
cially those living alone. As one woman related,
“My cats have been my constant companions and
support—through marriage, divorce, remarriage
and widowhood.” Studies in nursing homes and
dementia units find that animal-assisted therapy
and weekly visits by volunteers with their pets sig-
nificantly brighten mood, increase social interaction
and appetite, and enhance the overall well-being of
residents (Filan & Llewellyn-Jones, 2006). Clini-
cians should explore the meaning and significance
of animal companions and their loss. Bereavement
can be profound with the death of a cherished pet or
with forced relinquishment when moving to a senior
residence or nursing home that does not allow pets
(Walsh, 2009b).
Assess your comprehension of the significance
of relational connections by completing this
quiz.
Clinical Challenges and
Opportunities: A Resilience-
Oriented Approach
A resilience-oriented approach to practice (Walsh,
2003, 2006, 2012a) engages elders collaboratively,
affirms their personhood, and focuses on their
strengths, resources, and potential. We show inter-
est in their life journey, with compassion for their
struggles, suffering, and losses, and with affirma-
tion of their courage and endurance. We encourage
their efforts for meaning, purpose, joy, and connec-
tions, with conviction in their potential for personal
and relational growth. We see their value in the
lives of others and draw on kin and social networks
to support their optimal functioning and well-being.
In contrast, the traditional clinical focus on later life
decline and deficits too often leads professionals
to objectify the elderly, become unduly pessimis-
tic, underestimate their resourcefulness, and make
plans for them based on what professionals think
best.
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A conjoint family life review expands the
benefits of individual life-review sessions (Lewis &
Butler, 1974) found to assist in the integration of ear-
lier life stages, facilitating acceptance of one’s life and
approaching death. Sharing reminiscences can be a
valuable experience for couples and family members,
incorporating multiple perspectives and subjective
experiences of their shared life over time. The pro-
cess of sharing the varied perceptions of hopes and
dreams, satisfactions, and disappointments enlarges
the family story, builds mutual empathy, and can heal
old wounds. Earlier conflicts or hurts that led to cut-
offs or frozen images and expectations can be recon-
sidered from new vantage points (Fishbane, 2009).
Misunderstandings and faulty assumptions about one
another can be clarified. Successive life phases can be
reviewed as relationships are brought up to date. Indi-
viduals in later life are often able to be more open and
honest about earlier transgressions or shame-laden
family secrets. Past mistakes and hurts can be more
readily acknowledged, opening possibilities for for-
giveness (Hargrave & Hanna, 1997). At life’s end, the
simple words, “I’m truly sorry” and “I love you” mean
more than ever. Family photos, scrapbooks, genealo-
gies, reunions, and pilgrimages can assist this work.
Stories of family history and precious end-of-life
conversations can be videotaped and preserved. The
transmission of family history to younger generations
can be an additional bonus of such work.
Looking ahead
Families should be encouraged to be proactive in
considering and preparing for such challenges as
transitional living arrangements and end-of-life de-
cisions, discussions that are commonly avoided.
Future-oriented questions can also open up new pos-
sibilities for later life fulfillment. One son worried
about how each of his parents would manage alone
on the family farm if widowed, but he dreaded talk-
ing with them about their death. Finally, on a home
visit, he gathered up his courage. First he asked his
mother, tentatively, whether she had ever thought
about what she might do if dad were the first to
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I’d sell the farm and move to Texas to be near our
grandkids.” Her husband shook his head and replied,
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revealed these strengths. At first glance, all appeared
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had organized her environment in a system that made
sense to adapt to her visual impairment. She had
color-coded food containers with a magic marker;
arranged clothes by function; and stacked books by
subject, easily locating what she needed.
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as pathological denial of dependency needs. Yet self-
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the failing of her primary mode of adaptation—her
vision—that brought confusion and anxiety. Her
reluctance to become dependent made her reject
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a religious organization that sent Brothers to read to
her whenever she called. She could allow help when
she took initiative and had some control in the rela-
tional boundaries. This positive experience became
a model for building a resource network to support
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agement, she agreed to contact trusted neighbors and
shopkeepers for occasional assistance. She initiated
weekly phone contact with her sister, which led to
enjoyable visits with her niece, who loved hearing
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Applying the concept of resilience to the fam-
ily as a functional unit, a family-resilience approach
affirms the potential in couples and families for
healing and growth over the life course, tapping
into their strengths and building resources as they
confront later life challenges (Walsh, 2003, 2006,
2012a). Caregiving and end-of-life challenges also
hold potential benefits, deepening and enriching
relationships, if family members are encouraged to
make the most of precious time. Because unresolved
conflicts and cutoffs may accompany children and
grandchildren into their future relationships (Bowen,
1978), it is important to avert the fallout of hurt, mis-
understanding, anger, alienation, sense of failure,
and guilt. Strains can be prevented and repaired by
helping family members to redefine and reintegrate
their roles and relationships as they age and mature
(King & Wynne, 2004).
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responsibility, or empathic difficulties. As we better
appreciate the elders in our own families, attend to
our own losses and grievances, and explore our own
growing maturity, therapeutic work with individuals,
couples, and families in later life will take on deeper
meaning and possibilities for growth.
The complexity and diversity of family net-
works in later life require careful clinical assessment.
(JWFOUIFQSFWBMFOUQBUUFSOPGJOUJNBDZBUBEJTUBODF
we must look beyond the sharing of a household to
identify significant relationships and potential bonds.
Drawing a genogram with an elder can be useful in
identifying those who are significant and could be
drawn upon for support and/or companionship, such
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Problems involving family relationships with elderly
members are often hidden behind complaints of
marital distress or child-focused symptoms. Older
adults are more likely to present somatic complaints
than emotional or relational problems. Family rela-
tionships can exacerbate or alleviate their suffering.
The stressful impact of chronic illness on loved ones
requires attention to family needs for support, infor-
mation, caregiving guidelines, respite, and linkage to
community resources. Families are our most valuable
resources in providing not only caregiving but also
a sense of worth, lasting emotional ties, and human
dignity in later years and in approaching life’s end.
We can strengthen their resilience by understanding
their challenges and supporting them in our social
policies and provision of health care.
Developmental models for understanding
growth and change in later life need to include wis-
dom and integrative understanding of the values and
meanings that are salient to elders. Clinical services
must be flexible to fit the diversity of older people
and their significant relationships and to support
optimal functioning and integration in the com-
munity. It is important to engage in lifelong learn-
ing, keep active in meaningful pursuits, strengthen
kinship bonds, rekindle old friendships, and make
new ones.
Ecological models are also required to develop
policies, programs, and living arrangements that
fit the emerging needs and preferences of older
adults and foster their optimal well-being (Aldwin
& Igarashi, 2012). The importance of community—
“Well if that isn’t the darnedest thing! I’ve thought a
lot about it too, and if your mother weren’t here, I’d
sell the farm and move to Texas!” This conversation
led the couple to sell the farm and move to Texas,
where they enjoyed many happy years with their
children and grandchildren.
Expanding Our Developmental Lens
Clinical literature and training programs tend to em-
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and families raising children. At launching of the
young adults, attention follows the younger genera-
tion into their own life course and family formation,
relegating the parent generation to the margins, as
extended kin. The term “postparental” is unfortunate,
as parents never cease to be parents, with lifelong
concern for the well-being of their children—and
any grandchildren. The term “family of origin” con-
notes an older generation left behind, with clinical
inquiry about past influence. Because more people
are living healthier and longer lives than in the past,
we lack role models for later-life family relations,
just as we lack appropriate labels and role defini-
tions. We need to expand our developmental lens
to the full life course, addressing the assets, needs,
and concerns of individuals, couples, and families in
their later years. I once assigned a group of medi-
cal students to interview an older couple about their
life course. The (male) students looked stunned. One
acknowledged that he had never had a real conversa-
tion with an older person, including his parents, and
he had never considered what his own aging would
look like. This led us to a valuable discussion of age
segregation in our society and professional ageism
stemming largely from our culture’s preoccupation
with youth and avoidance of the reality of aging,
losses, and death.
As clinicians, we need to deepen awareness of
our own apprehensions and biases and enlarge our
perspective on the whole life course. We need to gain
appreciation for what it is like to mature and become
old, for relationships to evolve and grow stronger
or be lost, and for new ones to develop, meeting
emerging priorities. Our own painful issues with our
aging family members—and denial of our own aging
process—may contribute to anxiety, avoidance, over-
M18_MCGO8060_05_SE_C18.indd 356 19/03/15 4:05 PM

$IBQUFS r 'BNJMJFTJO-BUFS-JGF$IBMMFOHFT0QQPSUVOJUJFTBOE3FTJMJFODF 357
long life? How can we contribute to people’s ability
to live and to love with vitality into advanced old
age? Important in the resilience of our society is a
sense of pride in age, the value of history and life
experience, and the capacity to adapt courageously
to change. Elders can be encouraged to draw on their
rich experience to inform both continuity and inno-
vation, as society’s historians and futurists. The wis-
dom of our elders, linked with the energy and new
knowledge of the young, can be the basis for rich
interchange and planning for the future.
reflecting location, a sense of shared connection or
neighborhood cohesion, and feelings of belonging—
is instrumental to positive mental health in later life.
The World Health Organization (2007) has stressed
the need to redesign the social and built environ-
ments for today’s aging population, with “aging in
QMBDFuBQSJPSJUZOFBSGBNJMZGSJFOETOFJHICPSTTFS-
vices, shopping, entertainment, and other amenities.
The WHO’s “Age-Friendly Cities” initiative encour-
ages communities to become more inclusive of older
adults, emphasizing enablement rather than disabil-
ity, and friendly for all ages, encouraging interaction
of residents young and old.
This expansion of later life has been called the
“aging revolution.” What will we do with this gift of
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