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Narrative Group Intervention to Rediscover Life Wisdom Among Hong Kong Chinese Older Adults: A Single-Blind Randomized Waitlist-Controlled Trial

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Abstract

Background and Objectives We developed a new group practice using strength- and meaning-based Narrative Therapy (NT) for older Chinese living in Hong Kong (HK), to enhance their life wisdom. This paper reports on the intervention and its short- and longer-term effectiveness. Research Design and Methods A randomized waitlist-controlled trial (RCT) was conducted. A total of 157 older adults were randomly recruited, of whom 75 were randomly assigned to the intervention group which received four two-hour bi-weekly NT sessions using the ‘Tree of Life’ (ToL) metaphor. The others were placed on a waitlist. Perceived wisdom was assessed using the Brief Self-Assessed Wisdom Scale (BSAWS). Assessment occurred at baseline (T0), end of treatment (T1), and four (T2) and eight months later (T3). Over-time effects of NT on wisdom scores were assessed using latent growth curve models with time-invariant covariates for impact. Results The intervention (NT) group showed significant, sustainable over-time within-group improvement in perceived wisdom. Moreover, compared with the control group, the NT group showed significant immediate improvements in perceived wisdom [F(2.726, p = 0.041)], which were maintained at all follow-up points. This effect remained after controlling for age, gender and educational level [TML(11) = 17.306, p = 0.098, RMSEA = 0.079, CFI = 0.960]. No adverse reaction was recorded. Discussion and Implications NT underpinned by a ToL methodology offers a new theory to understand, promote and appreciate perceived wisdom in older Chinese living in HK. It contributes to psychotherapy and professional social work practice for older Chinese.
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© The Author(s) 2021. Published by Oxford University Press on behalf of The
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Narrative Group Intervention to Rediscover Life Wisdom among Hong Kong Chinese Older
Adults: A Single-Blind Randomized Waitlist-Controlled Trial
Esther Oi Wah Chow, MSW, RSW, PhD, *, and Sai-Fu Fung, BSocSc, MA, PhD
Department of Social and Behavioural Sciences, City University of Hong Kong, Hong Kong
*Address correspondence to: Esther O. W. Chow, MSW, MNTCW, PhD, RSW, Department
of Social and Behavioural Sciences, City University of Hong Kong, Tat Chee Avenue,
Kowloon, Hong Kong. -
---
- ---
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Funding
This is a General Research Fund project, which is funded by the Hong Kong University Grant
Committee (Project number: 9042296).
Conflict of Interest
No conflict of interest has been declared by the authors.
Acknowledgements
Special thanks to the Editor, colleagues, and the reviewers in providing very helpful
suggestions and comments on the paper. The principal investigator also acknowledges Dr.
Jacky Cheung, Phoebe Chan, William Chiu for their professional and clinical support to this
project, and the community collaborators for recruiting participants from their contacts. The
research team would also like to express our gratitude to the participants and their families
who actively contributed in the study and extend a special thanks to Vivian Kam, Lisa Li, and
Hardev Singh for providing research support during various stages of the study.
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Abstract
Background and Objectives: We developed a new group practice using strength- and meaning-
based Narrative Therapy (NT) for older Chinese living in Hong Kong (HK), to enhance their life
wisdom. This paper reports on the intervention and its short- and longer-term effectiveness.
Research Design and Methods: A randomized waitlist-controlled trial (RCT) was conducted. A total
of 157 older adults were randomly recruited, of whom 75 were randomly assigned to the
intervention group which received four two-hour bi-weekly NT sessions using the ‘Tree of Life’ (ToL)
metaphor. The others were placed on a waitlist. Perceived wisdom was assessed using the Brief
Self-Assessed Wisdom Scale (BSAWS). Assessment occurred at baseline (T0), end of treatment (T1),
and four (T2) and eight months later (T3). Over-time effects of NT on wisdom scores were assessed
using latent growth curve models with time-invariant covariates for impact.
Results: The intervention (NT) group showed significant, sustainable over-time within-group
improvement in perceived wisdom. Moreover, compared with the control group, the NT group
showed significant immediate improvements in perceived wisdom [F(2.726, p = 0.041)], which were
maintained at all follow-up points. This effect remained after controlling for age, gender and
educational level [TML(11) = 17.306, p = 0.098, RMSEA = 0.079, CFI = 0.960]. No adverse reaction was
recorded.
Discussion and Implications: NT underpinned by a ToL methodology offers a new theory to
understand, promote and appreciate perceived wisdom in older Chinese living in HK. It contributes
to psychotherapy and professional social work practice for older Chinese.
Keywords: Wisdom, Narrative therapy, Tree of life, Randomized controlled trial, Latent growth curve
models
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Translational Significance: Older adults generally accumulate valuable wisdoms throughout their
lives. But neither they, nor others, may recognize the value of these. This may constrain problem-
solving, self-esteem and relationships with others. In four bi-weekly sessions, older Chinese adults
participated in collaborative conversations with a narrative therapist to re-examine their life
experiences and recognise their accumulated wisdom. The intervention significantly improved self-
perceptions of wisdom compared to baseline, and a control, with short- and longer-term
effects. Narrative therapy could be employed to assist older adults to recognise the value of their
wisdoms, to enhance their self-worth and participation in family and community.
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INTRODUCTION
The topic of “wisdom” is a growing field of research in psychology and social gerontology (Glück et
al., 2013; Glück, 2018; Staudinger & Gluck, 2011). It is a concept that has been documented for many
years as a source of human strength (Erikson, 1997). It has attracted increasing empirical
investigations in relation to positive psychology (Fung, Chow, & Cheung, 2020; Luna, Van Tongeren,
& Witvliet, 2017). Despite pioneering work conducted in the 1970s and early 1980s (Bangen, Meeks,
& Jeste, 2013; Ferrari & Weststrate, 2013; Seligman & Csikszentmihalyi, 2000; Staudinger & Gluck,
2011), it is only recently that consensus has been reached on the definition of the concept of
wisdom (Jeste, 2010). It is described as a multidimensional construct learned and developed
through reflection of life-lessons, which enables individuals not only to grow individually, but also to
positively contribute to the common good. In fact, life wisdom has been found to have a profoundly
positive influence on older peoples’ life satisfaction, independent of other life circumstances (Ardelt,
2004). Research also suggests that wise individuals age more successfully than people with less
wisdom (Ardelt, 2000; Cheung & Chow, 2020).
The development of wisdom in older Chinese is largely related to critical life events. Wisdom in old
age is an attitude towards life, developed through reflection, after individuals have experienced both
favourable and unfavourable life circumstances (Ardelt & Jeste, 2018; Chow, 2018). In contrast to
the leading Western definition of wisdom, the concepts of Chinese wisdom place less emphasis on
expert knowledge and intelligence. Instead, accumulation of life experiences is viewed as a
dominant determinant of wisdom (Webster, 2003, 2007). Chinese people tend to emphasise
reflective aspects, including self-reflection and self-insight (Ardelt, 2003; Webster, 2007). Reflections
on life lessons over their lifespan result in wisdom (Ardelt & Jeste, 2018; Jeste et al, 2010).
Consistent in part with the Western model of wisdom, components of Chinese wisdom include
aspects of cognitive understanding about life (Ardelt, 2003; Cheung & Chow, 2020).
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Concepts of Chinese wisdom distinguish between individual and collective wisdom. The current
discussion in research largely focuses on individual wisdom (Ardelt, 2003; Glück & Bluck, 2013;
Webster, 2007). Collective wisdom is seldom mentioned or investigated, and thus requires further
exploration. Collective aspects of wisdom demonstrate the cultural collective nature of the Chinese
population (Cheung & Chow, 2020). Old age itself is not a sufficient condition for the development
of wisdom; rather, life experiences, and the readiness of society to accept wisdom associated with
old age are more important, and relevant to the discussion (Ardelt & Jeste, 2018; Jeste et al, 2010;
Staudinger & Gluck, 2011).
In line with theories of lifelong psychosocial growth and life course principles of human development
and agency (Schriver, 2020), older adults generally possess rich and valuable wisdoms concerning
many important aspects of life. However, how best to preserve and transfer wisdom for the
common good remains unanswered (Webster, Westerhof, & Bohlmeijer, 2014). There is little
empirical evidence on whether the wisdoms of older adults can be harnessed for their own benefit
as well as for others. This may be due to physiological decline associated with ageing, and pervasive
societal ageist attitudes (North & Fiske, 2015). The current health and social care training primarily
focuses students on people’s problems, symptoms, deficits, instead of their efficacy, wisdom, and
coping strengths. Thus, the use of language and diagnostic deficits may disempower older people by
saturating them with pathologies. This is likely to totalize the persons with problem-saturated life
events, and adversely affect their sense of self and their aging identity. With proper methods for
wisdom rediscovery and recollection, and an appropriate platform to share wisdoms with others, the
wealth of wisdoms of older people might be leveraged for greater societal good.
Over the past few decades, an increasing body of literature has consistently shown that wisdom is
positively related to individual eudemonic and hedonic well-being. Wisdom scores predict levels of
generativity, ego integrity and positive psychosocial values, such as personal growth and sense of
coherence (Webster, 2007, 2010). This is also related to civic engagement and altruism (Bailey &
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Russell, 2012), benefit-finding in terminally ill patients (Costa & Pakenham, 2012), and forgiveness
and psychological well-being (Taylor, Bates, & Webster, 2011). Hence, identifying an intervention
with empirical evidence of a positive impact on the recognition, rediscovery, and rejuvenation of
older adults’ life wisdom will be an important addition to the current scant body of evidence.
Wisdom and Narrative Therapy (NT): NT emphasises personal experience and elaboration of
meaning, and it has attracted increasing attention in the practice of psychotherapy and social work
(Danner, Robinson, Striepe, & Rhodes, 2007). NT primarily focuses on people’s personal expression
of their life experiences (Freedman, 1996; Madigan, 2019; Morgan, 2000; White, 2007). NT views
people as experts in their own lives, who possess abilities, knowledge, and wisdom that assists them
to cope with difficult life situations. It emphasises the importance of an individual’s subjective
perception and experiences of a problem, construction, and co-construction of the relative nature of
reality and being, as well as enduring problem-solving capacities built on experiences of previous
successful coping. Wisdom has been linked to increased self-knowledge in the context of
autobiographical reasoning (Randall, 2011), and the appraisal of life-lessons for personal growth and
common good (Jeste et al., 2010). NT assumes that throughout their lives, people accumulate critical
elements of personal inner resources, including knowledge, beliefs, values, hopes, loves,
competence and commitments (White, 2007). Thus, NT offers a persuasive paradigm of practice to
identify and recollect those critical elements, apply them to manage individual life challenges across
the lifespan, and to convey them in a manner that will benefit others at societal, familial, and
individual levels.
Narrative gerontology (de Medeiros, 2014; Randall & Keyon, 2004) sheds light on new ways of
responding to the stories of multiple identities assumed by older adults throughout their lives. It is
essential to delineate the backbone of the narrative with research on reminiscing and life review to
distinguish their uniqueness before NT can be further deliberated and applied. While reminiscence is
a recall of memories, which is usually a pleasurable experience of the narrator, life review is a critical
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analysis of one’s life history. By examining each developmental stage, it helps to resolve past
conflicts and overcome unsuccessful earlier life events in achieving ego integrity (Josselson, 2006).
Through collaborative conversations, narrative therapists engage people to freely recollect sparkling
incidents important incidents in life in the process of re-authoring their life stories to accommodate
transitions and challenges. This preserves their preferred identity and reconstructs their future
(White, 2007).
This study applied an innovative NT-based intervention embedded in an inclusive theoretical
framework to help older Chinese living in Hong Kong (HK) to recognise, better understand and better
reconnect with their wisdom, and to provide opportunities for them to transfer their wisdom for the
benefit of others in HK. The paper reports on the intervention itself, and its short and longer-term
effectiveness.
Hypothesis: The group which received NT fused with ToL methodology would demonstrate a
significantly greater positive change on wisdom scores, compared with the control group.
METHOD
Study design: Single-blinded randomized controlled trial (RCT).
Reporting criteria: This study was reported in line with the CONSORT statement (See Figure 1).
Theoretical framework: The intervention used the Tree of Life (ToL) methodology, which is based
on collective narrative practice. The metaphor of ToL has been widely used clinically, initially with
children (Ncube, 2006), and subsequently extended to young and older adults (Denborough, 2004,
2008; Dickson, 2009). It was initially developed as a response to trauma, but it is also a useful tool
for wider conversations for non-therapeutic purposes, such as intergenerational acknowledgement
and environmental education (Denborough, 2008). This is the first attempt to use the ToL metaphor
as a method to illuminate, rediscover, and recollect the life wisdom in the context of HK. The use of
ToL is a “good-fit” with the narrative approach to understanding wisdom accumulation over one’s
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lifespan. By examining one’s past and present, the many aspects of one’s life and self-identity are
symbolised, reflected, and embedded in the different parts of the tree. It addresses issues of losses,
strengths, and ups and downs in one’s life (Chow & Nelson-Becker, 2010). Exploring wisdom via ToL
is also made possible by identifying older adults’ future hopes and dreams and identifying ways in
which they plan to achieve them based on the wisdoms that they have learned from the past. The
metaphor of ToL is a sound, integrative, and respectful approach to enable older adults to speak
about different aspects of their lives.
The ToL Conversations: The ToL process consists of four sessions, each of which lasts for two hours
(see Online Supplementary Material for the protocol I and II):
Session 1: Tree of Life;
Session 2: Forest of Life;
Session 3: When the Storms Come; and,
Session 4: Celebration of Life.
Participants and Procedures: The target population was Chinese people aged 55 and older, living in
different major HK regions: Kowloon, New Territories, and HK Island. Inclusion criteria were that
they: (1) had experienced at least two critical life experiences/life lessons; (2) were able to perform
basic daily functional activities independently; (3) were physically mobile (including with walking aids
or a wheelchair); (4) possessed normal cognitive ability; (5) did not experience active psychotic
symptoms, such as hallucinations or delusions; (6) were not currently experiencing acute crisis with
severe stress; and (7) were willing to work in small groups.
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Sample Size Calculation: The sample size was determined by power analysis (Cohen, 1992). Ryan,
Enderby, and Rigby (2006) found that the estimated effect size of NT intervention is 0.4. The
standardized difference (0.4) was calculated assuming a standard deviation of five, which was
estimated using references from those working with older adults (Shyu et al., 2008). With a 5%
significance level (two-tailed) and power of 80%, a sample size of 72 is estimated. Since a control
group of similar size was needed, the recruited sample size was set as 144. If there are six
participants in a group, at least 12 intervention groups and 12 waitlist control groups are required
during the study period.
Institutional Review Board (IRB) approval was obtained from the City University of Hong Kong.
Informed written consent was sought from all participants before commencing the trial, and consent
was confirmed at each intervention session.
Invitations were sent to 41 District Elderly Community Centres (DECCs) to recruit potential
participants. Nominees were invited to the City University of HK for a pre-study group interview to
confirm eligibility for study enrolment. Exclusion criteria were that potential participants: (1) tested
poorly for cognitive capacity, using the Mini-Mental State Examination (MMSE) with a cut-off score
at 23 (Blake et al., 2002); (2) manifested active psychotic symptoms, such as hallucinations or
delusions (which could pose threats to other members or divert group processes); (3) were
intellectually challenged or suffered from personality disorders (which might render them
unable to grasp what was being imparted, or may be too critical or rigid to participate fully in
group processes); (4) lacked motivation to work on problems (as motivation was crucial for
participants to ensure that they attended all group sessions); and (5) had a record of one or
more suicidal attempts or violent behaviour (which may negatively affect the small group
environment of the intervention).
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Eligible consenting participants were randomly assigned to pairs using a computerised method of
minimisation (Pocock, 1983). One of each pair was then randomly assigned to the intervention
group and the other to the waitlist control group. To minimise uneven distribution of known
variables, randomisation occurred after stratification by age group (55 to 65 years, 66 to 75 years, 76
to 85 years), as well as region of residence.
Intervention: The intervention was delivered in four bi-weekly sessions conducted at 12 centres
located around Hong Kong. Participants allocated to the intervention group were divided into 12
small groups which met at one of the centres (usually the closest to their home). The wait-list
control participants received no intervention, but they were invited to join the intervention when
the study was completed. Two narrative therapists with advanced NT training and extensive
experience were recruited to lead the NT groups, with each session having specific concepts,
objectives, and implementation plans with defined details (see the protocol in the Online
Supplementary Material for detailed practice).
The intervention was assessed for the fidelity of implementation (FOI) through pre-group briefing,
training, and videotaping all group sessions, coupled with bi-weekly peer debriefing and supervision
provided by the PI, to ensure the procedure was standardised (Gearing et al., 2011). To evaluate the
FOI, we adopted the method proposed by Keith, Hopp, Subramanian, Wiitala, and Lowery (2010) to
compare the differences in outcomes observed among the centres and between therapists.
Participants were offered a coupon worth HK$40 (i.e., US$5) after each session, as compensation for
transport, travel costs and inconvenience, or recompense for extraordinary household arrangements
(such as requiring care for an ill or older relative, or grandchildren). Participants who completed four
sessions received HK$160 (US$20) at the final session to cover additional costs.
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Waitlist control group: We adopted a waitlist control design as we wanted to ensure that all eligible
participants could receive the intervention. The waitlist control group was offered access to NT after
the study finished.
Study measurement procedure: Trained (blinded) interviewers conducted pre-test/baseline
interviews and quantitative assessments (T0) for all participants. After the intervention had been
delivered, all participants were again assessed at a post-intervention interview at two-months (T1),
at four-months (T2) and eight-months (T3) post intervention. Narrative conversations of each session
throughout the intervention and assessment phases were documented for clinical evidence,
including attentiveness, involvement, and responsiveness.
Measures: A purpose-built questionnaire sought sociodemographic information from participants,
including age, gender, location of residence and educational level. Perceived Wisdom was measured
items from the Self-Assessed Wisdom Scale (SAWS) (Webster, 2003; Webster, 2007). SAWS is a 40-
item questionnaire reflecting the five components of wisdom (critical life experiences,
reminiscence/reflectiveness, openness to experience, emotional regulation, and humour).
Participants responded to each question using a Likert-type scale, where 1 reflected “strongly
disagree” to 6 reflecting “strongly agree”. The SAWS has been shown to have good reliability (i.e.,
test-retest and internal consistency) and different forms of validity (Thomas et al., 2019). In response
to recent controversies related to the factorial validity of SAWS (Alves, Morgado, & Oliveira, 2014;
Ardelt, 2011; Bangen et al., 2013; Taylor et al., 2011; Webster, 2003, 2007; Webster, Taylor, & Bates,
2011), this study used the nine-item Brief SAWS (BSAWS) (Fung, Chow, & Cheung, 2020). This
comprised SAWS items 6, 18, 22, 23, 27, 29, 34, 36 and 40. The BSAWS has been shown to
adequately capture the five SAWS domains. For this study, the BSAWS was back-translated into
Chinese (Brislin, 1970; Cha, Kim, & Erlen, 2007) and the internal reliability was confirmed by
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Cronbach’s α at 0.81 (Cronbach, 1951) and McDonald’s omega at 0.81 (McDonald, 1999; Revelle &
Zinbarg, 2009; Zinbarg et al., 2005).
Data Analyses: Descriptive statistics were generated for the demographic and clinical variables.
Assuming group equivalence at baseline and using an intention-to-treat (ITT) approach (Alshurafa et
al., 2012; Hollis & Campbell, 1999; Lachin, 2000; Montedori et al., 2011), independent within-group
t-tests were performed to test the immediate effect and the long-term (sustainability) effect of the
treatment, at each measurement timeframe (two-, four- and eight-months posttreatment) (i.e., T1,
T2 and T3). Repeated measures ANOVAs with a Greenhouse-Geisser correction (Girden, 1992;
Greenhouse & Geisser, 1959) determined differences between intervention and control groups at
the different time points. Finally, structural equation modelling latent growth curve models with
maximum likelihood estimation were used to evaluate the impact of NT on respondents, considering
repeated measurements on perceived wisdoms and other contextual variables (Cheong, MacKinnon,
& Khoo, 2003; Duncan & Duncan, 2004; Jones, 2012; Long, 2012; McArdle & Epstein, 1987).
Model 1 was an unconditional latent growth curve model fitted to analyse the effect of overall
intervention on perceived wisdom in different time frames (T0 - T3). Latent growth curve modelling
with time-invariant covariates for impact of NT on wisdom scores (Model 2, 3 and 4) were
performed to examine if the trajectories varied by conditions, including repeated measurements
nested within participants, and participants within experimental conditions, age, gender, and
educational attainment. As suggested in the structural equation modelling literature, the chi-square
value may be subject to the effect of sample size (Bentler & Bonett, 1980; Kline, 2005), hence the
following fit indices were used to determine whether the model had an adequate fit, i.e.:
Comparative Fit Index (CFI) >.950, standardised root mean square residual (SRMR) < .080 and Root
Mean Square Error Approximation (RMSEA) < .080 ((Browne & Cudeck, 1993; Hu & Bentler, 1999).
The cases with missing data were handled with the maximum likelihood procedure (Collins, Schafer,
& Kam 2001; Schafer & Graham 2002).
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All analyses were computed with IBM SPSS 26.0 and R computing environment version 3.6.1 with
lavaan package 0.6-5 (Rosseel, 2012).
RESULTS
Fidelity of intervention: None of the outcome measures differed significantly between centres or
therapists, indicating that the sessions were run similarly despite location and leader.
Sample: Over 240 participants made inquiries about study participation or were nominated by one
of the 18 participating DECCs. 172 potentially eligible participants agreed to be screened for
eligibility, and of these, 157 were deemed to be eligible and consented to join the study (91.28%
recruitment). Table 1 reports participant demographic characteristics and Figure 1 reports the
CONSORT diagram.
Amongst the N = 157 participants who commenced the study, 21 (13.38%) dropped out before the
post-treatment (T1) data collection. This was within acceptable guidelines, particularly given the age
of participants (Schulz, Altman, Moher, 2010). Among the 75 intervention group participants, eight
(n = 8) (10.67%) dropped out at T1 (post-treatment, two months after baseline: three (37.5%)
dropped out after the first session as they were unable to travel to the intervention centre by
themselves; three (37.5%) dropped out after the second session because of family obligations, and
two (25%) dropped out after the third session because of health concerns: one was hospitalized, and
another had to rest at home. Thus, there with 89.33% success participation in all four sessions.
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There was a higher dropout rate among 82 wait-list control group participants: thirteen (n =
13 (15.85%)) from the waitlist group at T1 (two months after baseline): seven (53.85%
decided to withdraw because of other commitments; four (30.77%) moved; and two (15.39%)
returned to Mainland. The dropout rate was stable during T2 data collection (four months
after baseline): no drop out for the intervention group, and only one from the wait-list control
group because the participant was moved. By the last measurement point (T3, i.e., 8 months
from baseline), n = 98 were measured (five (3.7%) had died, seven (5.6%) had returned to
Mainland China, and 9 (6.6%) had moved residence and were unable to be traced.
There was no significant between-group difference in any demographic. Many participants were
female (intervention group 74.4%, control group 74.7%). The Mean age in the intervention and
control groups was 73.12 years (SD = 9.12) and 71.99 years (SD = 7.90) respectively.
< Insert Table 1 here >
< Insert Figure 1 here >
Table 2 reports the outcome measures for both groups, over the study period. Overall, mean scores
for the perceived wisdom measure differed significantly between time points between the
intervention and control groups [F(2.726, 256.228) = 2.894, p = 0.041]. There was no significant
between-group difference in wisdom scores at T0. The intervention group showed significant within-
group improvement in perceived wisdom immediately after the intervention (T1) and maintained
this improvement over time (at 4-months (T2) and 8-months (T3)). There was no difference between
groups at T1, however, significant within-group differences of all outcome variables were observed
at both four-months (T2) and 8-months (T3) follow up, with the intervention group showing greater
improvement.
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<Insert Table 2 here>
The hypothesis was thus supported, as those who received NT fused with ToL methodology
demonstrated a significant positive change in wisdom scores compared with the wait-list controls.
Table 3 reports the results of structural equation modelling of latent growth curve models.
Model 1 supports the significant impact of NT on wisdom scores (from ANOVA models). To further
examine the effectiveness of NT on wisdom scores, Model 2 and 3 attempted to include conditions
such as control versus experimental (without specifying the time points) and demographic variables,
such as age, gender and educational level. None of these factors significantly impacted on the
wisdom scores.
<Insert Table 3 here>
Time invariant covariates, i.e., T0, T1, T2 and T3, were introduced in the conditional latent
growth curve model (Model 4). There were no differences between experimental and control
group’s wisdom scores (S.E.) = 1.185 (p = .504) after the first intervention (T1). Notably, the control
group demonstrated significant wisdom score differences with the intervention group at T2, with S.E
= 3.250 (p = .027). This effect was controlled with age (S.E. = .033, p = .873), gender (S.E. = -.127, p =
.389) and education level (S.E. = .094, p = .792). The model also indicated good fit, with [TML (11) =
17.306, p = .098, RMSEA = .079, CFI = .960, SRMR = .045]. All the above models did not rely on
correlating the error terms to fulfill the requirements of acceptable fit. There were no adverse
reactions from study participation.
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DISCUSSION
This study is the first to apply an RCT design to evaluate the effectiveness of a theoretically
developed NT intervention on recollecting and improving perceived wisdom in older Chinese living in
HK. Compared with being on a waiting-list, an NT intervention infused with ToL metaphor was
effective in supporting older adults to recognise, better understand and better reconnect with their
wisdom, in the short and longer-term. The findings thus concur with current evidence which
suggests that wisdom can be enhanced by reflecting on critical life experiences; wisdom scores are
positively associated with well-being, mastery, hope, and meaning in life; and the benefits of an
intervention to enhance wisdom can be preserved over time (Ardelt, 2011; Glück & Bluck, 2013;
Fung, Chow & Cheung, 2020; Webster, 2007; 2015).
The underpinning tenet of NT views people as wise and resourceful, and posits that wisdom is
accumulated through life lessons and experiences, consistent with theories of psychosocial and
lifespan development. ToL methodology emphasizes the use of strength- and meaning-based
construction to rescue and record older people’s problem-solving capacities, principles and purpose
in life, and successful coping. For example, in identifying the “aerial roots” from older trees, older
people may find “prop roots” that mature into thick, woody trunks, which with age, can become
indistinguishable from the primary trunk. Our study provides support for the safe use of NT for
Chinese older adults in HK to positively improve their perceived wisdom, like prop roots, which
uphold and become beneficial to their general physical and mental health, and validate their wisdom
of life (Bailey & Russell, 2012; Costa & Pakenham, 2012; Webster, 2007, 2010).
Another contribution of this study to the body of knowledge is providing empirical evidence to
support the effectiveness of an NT intervention fused with ToL methodology to rediscover life
wisdom. The effects of NT in the existing literature have mainly been measured by qualitative
outcomes (Denborough, 2008; Dickson, 2009; Hardtke & Angus, 2004; Josselson, 2006; Kogan &
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18
Gale, 1997; White, 2007). This study attempted to quantitatively measure perceived wisdoms in
older adults, which paves the way to study the effect of NT on other populations in different
societies (Semmler & Williams, 2000).
There are significant clinical implications from this study, particularly in recollecting enhanced
wisdom. These include: 1) rediscovering older adults’ wisdom formally and systemically; 2)
witnessing “wisdom” in practice to enhance and renew older adults’ self-worth and preferred
identity, thus promoting “aging with dignity”; 3) encouraging the practice of “wisdom recognition”
to enhance participation of older adults in groups and community, thus promoting “active aging”; 4)
promoting the practice of “wisdom transfer” which encourages peer and cross-generational sharing
of effective life management and life planning to promote “productive aging”; 5) enhancing public
awareness and recognition of the importance of older adults’ wisdom as critical “social capital”; 6)
acknowledging the potential contributions of older adults to society and human development as
“positive aging”; 7) recognising the importance of “wisdom transfer” to revitalise respect and
appreciation for older adults at both societal and familial levels, and promoting “respectful aging”;
and 8) acknowledging that the importance of “wisdom transfer” is likely to facilitate the
development of innovative holistic public aging policy initiatives.
The ToL metaphor provided a vivid and coherent framework in narrating different aspects of oneself,
and one’s life externally, with ample space to understand, accommodate and transcend the
differences, and organize these human experiences in the context of individual worldviews within
the framework of existential philosophy. Gaining the understanding of therapists’ own worldview,
and participants’ (who come to consult the therapist) worldview are key elements in enhancing
cross-cultural effectiveness. Different ToL metaphors can be found in different parts of the world.
Adopting the ToL metaphor, which initially evolved in Africa (Ncube, 2006), is an advanced method
by which to rediscover life wisdom for Chinese older adults (Chow & Fung, 2020). This highlights the
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TOL’s capacity to innovate and broaden thinking in cross-cultural practice, as well as further
strategies to enrich cross-cultural counselling and psychotherapy.
Strengths of the study are the high level of interest in participating in it, from older Chinese, its
91.28% response rate during recruitment, and the high retention rate throughout the study. Those
who dropped out all had valid reasons for doing so (health, family obligations) rather than
disinterest in the therapy. Moreover, the attrition rate from the intervention group was similar to
the recently reported longitudinal RCT of older adults in HK (Jiang, 2019).
However, this study has limitations. There are more females than males utilizing DECC services;
therefore, the sample recruited for this study potentially represented those women who were more
active and sociable, and who wanted to participate in community services. Also, as the study had an
exclusion criterion of lack of motivation, this may have limited the external validity of study findings.
Finally, there was a higher dropout rate (15.85%) from the waitlist control groups at T1 (post-test,
two months after baseline) compared to the intervention group (10.66%). We hypothesise that
those in the waitlist did not want to wait until intervention group had completed all assessments.
We recommend that the next research investigating NT in this population adopts a more active
control group, such as a Treatment as usual (TAU) practice, so that participants in all groups
experience concurrent parallel interventions.
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CONCLUSION
This RCT provides support for NT, coupled with a new paradigm of clinical practice (ToL metaphor)
on significantly, safely, and sustainably improving and consolidating wisdom in older Chinese living in
HK, compared with a waitlist control group. The intervention effects lasted up to eight months post-
intervention. These findings have profound theoretical implications for professional psychotherapy
and social work practice, in terms of a strength- and meaning-based approach to late life
development, as well as proposing a new theory in understanding wisdom in older adulthood.
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Figure 1. CONSORT Table of the Study
NT (Intervention)
(n = 75)
Assessed for eligibility
(n = 172)
Pre-group screening
Not randomized (n = 7)
Ineligible (n = 2)
Refused to join (n = 6)
Randomized
(n = 157)
Control (n = 69)
13 Dropout: 7 withdrew; 4
moved; 2 returned to
Mainland
NT (Intervention) (n = 67)
8 Dropout:
After 1st session: 3 (Unable
to attend independently)
After 2nd session: 3 (family
obligations)
After 3rd session: 2 (health
conditions)
Control (n = 68)
1 Dropout: moved
NT (Intervention)
(n = 67)
Baseline (T0)
Baseline plus 2 month (T1)
(n =136)
Baseline plus 4 months (T2)
(n = 135)
Wail-list Control
(n = 82)
Control (n = 49)
19 Dropout: 10 withdrew; 4
moved; 3 returned to
Mainland; 2 passed away
NT (Intervention) (n = 49)
18 Dropout: 6 withdrew; 5
moved; 4 returned to
Mainland; 3 passed away
Baseline plus 8 month (T3)
(n = 98)
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Table 1. Participant demographic characteristics
Variables
NT group
(n = 82)
Control group
(n = 75)
Overall
(n = 157)
Age, mean (SD)
73.12 (9.12)
71.99 (7.90)
72.6 (8.55)
Gender, n (%)
Male
21 (25.6%)
19 (25.3%)
40 (25.5%)
Female
61 (74.4%)
59 (74.7%)
117 (74.5%)
Education level, n (%)
No formal education
14 (17.1%)
12 (16.0%)
26 (16.6%)
Primary education
23 (28.0%)
27 (36.0%)
50 (31.8%)
Secondary education
28 (34.1%)
17 (22.7%)
45 (28.7%)
Tertiary education
16 (19.5%)
14 (18.7%)
30 (19.1%)
Missing
1 (1.2%)
5 (6.7%)
6 (3.8%)
Marital status, n (%)
Single
9 (11.0%)
6 (8.0%)
15 (9.6%)
Married
35 (42.7%)
29 (38.7%)
64 (40.8%)
Divorce/separated
8 (9.8%)
7 (9.3%)
15 (9.6%)
Widowed
29 (35.4%)
33 (44.0%)
62 (39.5%)
Other
1 (1.2%)
0 (0.0%)
1 (0.6%)
Note. NT = narrative therapy.
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Table 2. Mean differences between intervention and control group by outcome measures
Time Intervals
Wisdom Scores
Control Group (SD)
Experimental Group (SD)
All (SD)
Baseline (T0)
35.17 (9.66)
(n = 75)
35.85 (8.69)
(n = 82)
35.53 (9.13)
(n = 157)
Baseline plus 2 month (T1)
35.69 (8.97)
(n = 67)
37.51 (7.86)
(n = 69)
36.61 (8.45)
(n = 136)
Baseline plus 4 month (T2)
35.90 (8.67)
(n = 67)
39.49 (6.08)
(n = 68)
37.70 (7.66)
(n = 135)
Baseline plus 8 month (T3)
36.50 (10.47)
(n = 49)
39.06 (7.22)
(n = 49)
37.78 (9.04)
(n = 98)
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29
Table 3. Results for unconditional and conditional latent growth curve models for impact of
narrative therapy on wisdom scores
Variables
Model 1
Model 2
Model 3
Model 4
Means or intercepts
i (intercept)
36.119*
35.502*
43.887*
43.811*
s (slope)
0.760*
0.432
-1.979
-1.949
Variance residual variance, and covariance
i (intercept)
42.683*
42.274
39.606*
39.595*
s (slope)
0.895
0.746
1.135
1.197
Covariance of s and i
-0.844
-0.982
-1.728
-1.736
Covariate regressions
i on
Age at baseline
-0.183
-0.182
Gender (female versus male)
0.683
0.683
Education level
1.462
1.458
Group (control versus experimental)
1.194
1.355
s on
Age at baseline
0.033
0.033
Gender (female versus male)
-0.126
-0.127
Education level
0.095
0.094
Group (control versus experimental)
0.644
0.602
T0 BSAW*group (control versus experimental)
1.185
T1 BSAW*group (control versus experimental)
1.446
T2 BSAW*group (control versus experimental)
3.250*
T3 BSAW*group (control versus experimental)
2.366
Model fit statistics
Model chi-square
9.819
11.223
20.063
17.306
Degree of freedom
5
7
13
11
CFI
.969
.973
.956
.960
RMSEA
[90% CI]
.101
[.000-.194]
.080
[.000-.162]
.077
[.000-.140]
.079
[.000-.147]
SRMR
.049
.044
.047
.045
N
95
95
92
92
Note. CFI = comparative fit index; RMSEA = root-mean-square error of approximation; CI = confidence interval;
SRMR = standardized root-mean-square residual. All covariates are mean centered.
*p < .05.
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