Lifespan

Erikson's theory

Erik Erikson is probably the most well known developmental psychologist whose lifespan theory extends into adulthood. Other theorists, such as Freud and Piaget, only extended their theories to puberty (Freud's ‘genital stage’) and around age 11 (Piaget's ‘stage of formal operations’. See Chs 1 and 2 for more information on these.). Perhaps the complexities with adulthood and the lack of well-defined, discrete, developmental stages directly related to age have challenged theorising in this area.

The three main stages of Erikson's theory relevant to adulthood are the stages of intimacy versus isolation, generativity versus stagnation and integrity versus despair (Erikson 1950, 1982, Erikson & Erikson 1997) (see Ch 2, Table 2.2). The stage of intimacy versus isolation is characterised by either the seeking of companionship and intimate love with another person or becoming emotionally isolated and fearing rejection or disappointment. This stage is usually said to occur during early adulthood and is often associated with the chronological ages of 18–24 years. In terms of healthcare practice, health professionals who recognise that people at this stage may be struggling to come to terms with intimacy issues and those multiple factors that contribute to isolation can serve a very useful role in assisting clients to successfully resolve this stage. For example, linking clients with support services, community organisations or self-help programs and groups can go a long way in preventing issues that could become more serious if left unrecognised and reinforce their isolation. This is supported by considering the relationship between social isolation and mental disorders such as schizophrenia (e.g. Cantor-Graae 2007) and that three in four mental disorders occur before age 24 (Kessler et al 2005).

Middle adulthood, according to Erikson, is characterised by a contribution to the next generation, usually through work or employment or having a family (i.e. generativity) or by becoming socially inactive (i.e. stagnation). One of the limitations of the application of Erikson's theory is that it can be interpreted as an either/or dichotomy; whereas, in reality, adults may find that in some aspects of their lives they have been generative but in other aspects have a sense of stagnation. Take, for example, a woman who is highly successful in her career but who never had children. While she may have a strong sense of generativity in her career, she may have regrets for not having had children (being stagnant in that area), although we must not assume that someone who has not had children would have regrets. However, it is also usually not this simple. For example, many families also contribute to their siblings' families rather than have their own families (see section on adoption later in this chapter) and this could be considered either generativity or stagnation, depending upon how the person sees it. It is therefore important to consider diversity in the development and understanding of these concepts and the importance of considering assumptions that might be made around these concepts. Always check with clients about their own understanding of where they are at in life.

Finally, in Erikson's theory, older adults make sense of their lives either as having integrity (i.e. being meaningful) or they may despair about the things that they did not achieve or accomplish in life. Erikson's theory is usually considered in the context of an individual and his or her resolution of these stages. However, the wider social context has much to contribute to these stages of development. For example, health professionals, again, can serve an important role in assisting clients to develop a sense of integrity rather than despair when working with people who are chronically ill or those nearing the end of life.

Kohlberg's theory

Kohlberg's theory of moral reasoning (1976) included three levels and six stages, roughly from age four to adulthood (see Table 3.1). Level I, or preconventional morality, includes stages 1 (orientation towards punishment and obedience) and 2 (individualism and exchange). Level II, or conventional morality, generally relates to children aged 10–13 and includes stages 3 (maintaining mutual relations and approval of others) and 4 (social concern and conscience or maintaining the social order). Level III, or postconventional morality, includes stages 5 (social contract or individual rights and democratically accepted law) and 6 (morality of universal ethical principles). Stages 5 and 6 are most relevant to adulthood and healthcare, although Kohlberg postulated that some people never enter these stages. In stage 5, people are rational and can be thoughtful and critical of laws and legal issues but inevitably will conform to laws and human rights as morally ideal. In stage 6, however, universal ethical principles will outweigh legal concerns in a moral dilemma. Kohlberg also later included a stage 7 (the cosmic stage) in which people would be able to see the impact of their action on the greater world, rather than only their immediate world (Kohlberg & Ryncarz 1990).

In terms of healthcare, the relevance of Kohlberg's theory is obvious. There are many moral and ethical dilemmas that health professionals contend with on a regular basis and the resolution of these dilemmas will partly depend on where a person is at in terms of these stages and how the dilemmas are resolved. But it is perhaps too restrictive to view these as internal stages of moral development. Dealing with moral dilemmas regularly and the social and structural systems in place to facilitate this, such as the quality of debates with coworkers or the policies in place surrounding moral dilemmas, will influence the resolutions of these dilemmas. Take, for example, the issue of euthanasia or, for a less contentious issue, the use of a medication that has serious side effects. Kohlberg's theory would suggest that how you think about these issues can differ with a more or less developed sense of moral reasoning. Therefore, health professionals need to consider all forms of reasoning and not just believe there is only one right or wrong answer to euthanasia or medication.

Health professionals will not only benefit from understanding Kohlberg's theorising in their own practice, but consideration of Kohlberg's stages in respect of clients will help in treating clients. For example, issues of violence, drug abuse and even parenting can be understood better by considering these stages of moral development. Health professionals might consider that some clients will be thinking about these issues very differently and this may influence how health professionals will interact with and understand their clients.

Carol Gilligan is a theorist who argued that human development theories (especially Kohlberg's) do not adequately account for development as it relates to girls and women (Gilligan 1982). In her research with pregnant women contemplating abortion, she found that conflicts with responsibility to self and to others related to moral development for women that is not adequately addressed in Kohlberg's theory. Overall, Gilligan found that morality for women relates to an ethic of care and suggested that differences between men and women should not be minimised (Gilligan & Farnsworth 1995). Although some research (e.g. Jaffee & Hyde 2000) has shown that Gilligan's critiques of Kohlberg's theory were unjustified, her theorising drew attention to the often male-dominated theorising in human development.

Others' theories

Limitations to these classic theories have resulted in the need for theories that are more contextual and not so limited to Western notions of individuality and chronological age (Qin & Comstock 2005). These more recent theories include the ecological approach of Urie Bronfenbrenner (1979, 2004), Paul Baltes' lifespan perspective (Baltes 2000, Baltes & Baltes 1990, Baltes et al 2006) and the lifespan model of developmental challenge (Hendry & Kloep 2002, Kloep et al 2009).

Bronfenbrenner's (1979, 2004) theory considers individual development in a wider social context that includes micro (e.g. family and work), meso (the interactions between the individual's social connections e.g. your mother interacting with your partner), exo (the social connections that the individual's social connections have e.g. your partner's work colleagues) and macro systems (e.g. religion and politics). Bronfenbrenner's system, also called a ‘bioecological’ system, is multidirectional in that it is not only the social systems that impact on the individual but that the individual also impacts on those systems (Fig 3.1). ‘Development is not something that just “happens” to the individual person but an interactive, dynamic process that involves all the system levels of a society' (Hendry & Kloep 2002 p 12).

Lifespan perspectives, or lifespan theories, of human development consider development across the full lifespan and suggest that to fully understand someone's development, one needs to consider how life events influence development. The lifespan perspective also considers important social and political factors that impact on development such as policies impacting on Aboriginal Australians (like the ‘stolen generations’) or economic conditions (such as the global financial crisis). Marion Kloep and Leo Hendry, proposed such a lifespan model of developmental challenge (Hendry & Kloep 2002, Kloep et al 2009). In their model, the concepts of challenges, resources, stagnation and decay feature prominently (2002). Basically, in this model, people have ‘potential resources’, and these resources influence how an individual will respond to various challenges (‘potential tasks’) that will occur throughout life. Resources include an individual's biology, social resources, skills, self-efficacy and structural resources. An interesting feature of this model is the relationship between task demands (whether there are many or few) and the availability of resources and how they relate to feelings of anxiety or security, and whether the task is then a risk, a challenge or routine. If tasks are often routine and the resources exceed the task, then stagnation can result. Also, if there are not enough resources and the tasks are risky, then decay can result.

Take, for example, a person who is overworked with high family demands but on a low income. Over time, the resource pool will deplete and the person's development risks ‘decay’. Success, in this model, is ‘development’ and development can contribute more resources to the pool. However, people can be in a state of ‘dynamic security’ in which their resource pool is full and there are not many challenges. This is not necessarily an ideal situation because boredom can ensue. It is in this way that the model is also interesting, in that individuals are active players through their seeking or not seeking challenges to continue their development. If people do not seek out a challenge they may then be in a state of ‘contented stagnation’. On the contrary, ‘unhappy stagnation’ occurs when there are no challenges but the individual does not have the resources to seek them out.

Kloep and Hendry's lifespan model of developmental challenge (Fig 3.2) is useful for health professionals because it reflects the complex realities of people's lives that we observe in real situations. Health professionals are in a position where they may see people experiencing a challenge (e.g. a health condition or an accident) and can determine whether people and their families have the resources to successfully develop through the challenge. From the client's perspective, a health professional who assists in identifying these factors will contribute to improved outcomes, both from the healthcare situation and more holistically for the client.

Marriage, partnership and family

Being in a close relationship with another person, either through marriage, a civil union or co-habitation, is perhaps one of the most significant milestones of human life. With around 50% of the adult population currently married, and certainly many more in other forms of close and lasting relationships, and a variety of health and legal implications for those who are married or not, it is certainly an important topic for health professionals. Marriage and civil unions are also currently a highly politically charged topic worldwide. Although some countries now have legalised civil unions (i.e. a legally recognised relationship between people of either the same or opposite sex), same-sex relationships are not nationally legally recognised in many countries including Australia (although civil unions are recognised in some states, Australian Marriage Equality 2012). In New Zealand, the Civil Union Act 2004 came into effect in 2005 (Department of Internal Affairs 2011). Even so, in Australia, in 2009–10, there were 23,000 documented same-sex couple families (Australian Bureau of Statistics (ABS) 2011).

With the huge religious and cultural diversity of Australia, mate selection, marriage, partnership and family are correspondingly diverse (de Vaus 2004, Hartley 1995). We might think that differences in marriage fall into distinct categories of ‘love marriages’ or ‘arranged marriages’ or we may have our own ideas about what it is that makes up a family. These ideas are strongly influenced by our own family, the media and other social influences.

A family, according to the ABS, is two or more people, one of whom is at least 15 years of age, who are related by blood, marriage (registered or de facto), adoption, step or fostering, and who are usually resident in the same household (ABS n.d.). This definition is a very Western conception and revolves around the concept of the ‘nuclear’ family. In that definition, for example, ‘family’ who do not live in the same household are not considered to be part of that family unit. The ABS also identifies couple families with and without children, one-parent families, step families and blended families but these, too, are basically variations on ‘nuclear’ family conceptions. However, how families are conceptualised can differ quite drastically in different cultural groups. For example, for some, the ‘family’ would not exclude those who ‘are not usually resident in the same household’ and the relevance of the ‘household’ may have different meanings for different people and groups. For some people, companion animals are very much considered to be part of the ‘family’, though they would not be included in official records or documentation.

Marriage is generally considered to be a permanent and legally recognised arrangement between two people that includes both a sexual and an economic relationship with mutual rights and obligations. An endogamous marriage is one where the bride and groom are from the same group (like Italians marrying other Italians or Jewish people marrying other Jewish people) and an exogamous marriage is one in which the partners are from differing groups (like a Catholic marrying a Muslim or someone from Iraq marrying someone from France). For example, for some Australian Aboriginal groups it is important to marry outside of one's ‘skin group’ and to marry someone from certain other skin groups only.

While only monogamous marriages are legal in Australia and New Zealand (i.e. only have one husband or wife), it is perhaps useful to know that this is not the case in all countries around the world, and with increasing migration from non-Western countries, health professionals should be aware of other types of marriage arrangements. For example, polygamy, or marriage to multiple spouses, is desirable in many Islamic countries and communities, where it is acceptable and even expected for men to have up to four wives (also called polygyny), but this arrangement is illegal in Australia. Less common are polyandrous marriages where a woman has more than one husband at the same time. Perhaps more common in Australia and New Zealand is serial monogamy, or successive marriages that may be short or long term.

There are also various notions of relatives that are important for health professionals to recognise. For example, consanguineal kin are people who are related by blood, ancestry or descent and affinal kin are people who are related by marriage. In-laws and their relatives are therefore affinal kin. Adopted kin are family created through adoption and fictive kin are those who you might consider to be related to you, like calling your best friend your sister or a family friend your ‘aunt’.

Figures 3.3 and 3.4 illustrate only two of the many ways that relationships in a family can be construed. Figure 3.3 shows the Euro kinship pattern while Figure 3.4 illustrates the Dravidian kinship pattern. The Euro kinship pattern is common in Western groups, while the Dravidian system is found in South India and in some Aboriginal and Oceanic groups. These are only two kinship patterns and there are a number of other ways in which relationships between blood and marriage can be understood. However, in Australia and New Zealand, perhaps the Dravidian and the Euro patterns are most common.

In Euro kinship, siblings are called brothers and sisters and offspring from the brothers and sisters of one's mother and father are called cousins. The brothers and sisters of one's mother and father are not distinguished and are referred to as aunts or uncles, based on gender. Similarly, the parents of one's parents are referred to as grandmother or grandfather, again, depending on gender.

In Dravidian kinship, on the other hand, a person can have multiple mothers and fathers and sisters and brothers who are outside the immediate family unit. For example, the sister of one's mother is also called mother and the daughter or son of that mother is called a brother or sister. In terms of parenting (discussed next), this kinship pattern can be very useful. For example, if a teenage boy, whose biological father is not available, is getting into trouble, then another ‘father’ may be called upon to offer guidance. In terms of healthcare, a mother's sister may take children to healthcare appointments in her role as another mother. Another characteristic in Aboriginal kinship systems is ‘avoidance relationships’, which is the avoidance of, or not interacting with, certain relatives out of respect. For example, a man and his mother-in-law constitutes an avoidance relationship.

Overall, the number of marriages per year, and the marriage rate, has decreased over time (Hayes et al 2011, Statistics New Zealand 2012). Age at marriage has been steadily increasing, and living together before getting married (i.e. cohabitating) is now a very common practice (Hayes et al 2011, Statistics New Zealand 2012).

Marriage is an important consideration of health professionals because of the research showing various relationships between marriage (or being single) and health (Jaffe et al 2007). For example, people who are married have a longer life expectancy: ‘Marriage reduces the risk of an earlier death as a person is less likely to participate in risky behaviour and more likely to nurture or “guardian” each other's health through promoting good diet and physical care' (Elliot 2008 p 1). A large study in the United States by the Centers for Disease Control and Prevention (CDC) (Schoenborn 2004) found that married people were overall (except in bodyweight) healthier than people who were not married. This research also showed that marriage benefits the health of men more so than women. This better health includes being less likely to suffer various conditions such as headaches or back pain, as well as healthier lifestyle factors such as not smoking, not drinking alcohol or not being physically inactive. Married men, however, were more likely to be overweight, which might lend some credibility to the old saying that the best way to a man's heart is through his stomach! Interestingly, the patterns did not hold for people who were living together but not married. Their health was similar to the poorer health reported by divorced or separated adults (Schoenborn 2004).

Divorce and family breakdown

Like marriage, partnership and having a family, divorce and family breakdown are major milestones in adult development when they occur, and can have both positive and negative consequences. These effects depend on the social contexts and consequences of the divorce or family breakdown. For example, divorce with children involved can be very complicated, but the outcomes largely depend on how these complications are managed (Amato 2010). While there is a large body of research showing negative health consequences of divorce (Amato 2010, Schoenborn 2004), staying in violent marriages or in highly dysfunctional relationships may be more harmful (Amato 2010, Emery 2009). Whether those involved marry again is another consideration in the interpretation of the health consequences of divorce. When working in healthcare with people who have divorced or separated from long-term partners, or children of parents who have divorced, it is important to get a full contextual picture of the family situation before making assumptions about the health and social effects.

Parenting, caregiving and re-conceptualising children

Data indicate that the average Australian family includes roughly 1.7 children who are, on average, 18 months different in age (Hayes et al 2010). The mother would have been about 30 years old when she had her first child and chances are the couple will have divorced after 12 years of marriage. While this can contribute to a static and narrow view of families in Australia and New Zealand, the reality is that family composition, parenting and divorce are highly diverse and change drastically over time (Cribb 2009, de Vaus 2004, Hayes et al 2010). Take, for example, sole-parent households, blended families, teenage parents, same-sex parents, fostering, adoption and grandparents taking responsibility for bringing up their grandchildren. Becoming a parent or the caregiver of children is a major milestone of adulthood, challenging identity and social roles. In fact, being a parent or carer of children changes almost everything a person does and can do.

As discussed in Chapter 2, parenting is an important contributor to children's development, but it is highly complex and diverse. One of the complexities of parenting relates to the different ways of parenting or interacting with children. Most research has been conducted in Western countries, with corresponding biases in terms of what is considered to be 'good parenting', as well as how parenting styles are represented.

For example, as discussed in Chapter 2 (see Box 2.3) one popular version of parenting includes four dimensions: authoritative, indulgent, neglectful and authoritarian (Baumrind 1991, Baumrind et al 2010). Although authoritative parenting is generally considered a preferable parenting style in the Western context, there are communities and contexts in which this parenting style would be considered inappropriate. Consider a context in which the environment is socially or physically dangerous, such as a socially and economically depressed locale with high rates of violence. In this context, authoritative parenting might not be beneficial and authoritarian parenting might have better health and social outcomes for children. Similarly, in a context in which being educated is the most important and useful goal and the environment is less risky, then authoritative or even indulgent parenting may be preferable.

Another issue related to parenting style is the way a society or parents view children. In some contexts children are viewed as an economic resource for parents because they can gain employment and bring money into the household, or they can work around the house and thereby relieve the parents for employment purposes, or they will marry into another family and attract wealth. In some contexts, babies may be considered dispensable in poverty conditions or other problematic conditions (Omokhodion & Uchendu 2010, Scheper-Hughes 1985). In contexts with greater social and economic stability, such as in the West, children may be viewed more idealistically and seen as people in themselves rather than as resources for the family.

Dharmalingam (1996) studied family size preferences in a small village in southern India where there were two major industries: a brickwork and a beedi factory (beedis are a type of cigarette). Children could begin employment at the age of five years. Dharmalingam found several interesting things. First, villagers who were more economically disadvantaged reported wanting more children than those who were better off. About 50% of those who wanted more children reported wanting as many as possible or as many as God gave them. From a Western perspective this seems irrational because those with less money and fewer resources should want fewer children. However, the social logic is quite clear when children are considered as resources: those who are economically more disadvantaged have greater benefits with more children because they attract more resources than what they use. However, when Dharmalingam asked the villagers about their reasons for having boys or girls, direct economic reasons were usually ranked third. But the major reasons for having boys were so that they could inherit the property, provide security against risks and provide for the parents in their old age. All of these are to do with economic resources.

Importantly, when children are considered as a resource, parenting patterns will be very different from when children are not seen in that way (Scheper-Hughes 1985). Advising people in different social and economic contexts to reduce the number of children they have because of the problems associated with the increasing world population, while good-intentioned, may inadvertently result in compromising their standard of living and social and economic resources. The values that are derived in one social and economic context can be harmful when applied in a different context.

In greater socially and economically advantaged contexts, having fewer children has greater advantages and benefits, especially in relation to education and the cost of education, particularly in many Western contexts. Having fewer children provides for a greater share of the resources because of the way that resources are allocated or structured in Western societies. Therefore, having fewer children and educating them better has the same social logic spelt out by Dharmalingam's participants but built upon the particular social and economic context.

Health professionals are often in the position to observe family dynamics and interactions between caregivers and children and it is important to recognise and not be critical of dynamics that may seem unusual or different from one's own way of doing things. Family relationships and how children are viewed within the family depends heavily on the context, milieu or culture in which people have been raised and it is these factors that may not be easily accessible to health professionals.

Parenting and attachment theory

With an increasing diversity of family composition and parenting roles, particularly in developed Western countries, there has been greater attention to the role of ‘mothering’ in society and in families. Early theorists such as John Bowlby emphasised that mothers are of crucial importance to children and developed his original attachment theory primarily based on clinical observations and monkeys raised without their mothers. He believed, and the ethos at the time agreed wholeheartedly, that mothers are of special importance to raising healthy and happy children as the primary caregiver, and described this bond as of ‘lasting psychological connectedness between human beings’ (Bowlby 1969 p 194).

While the early attachment of children to parents and others is not disputed and has had a revival of late (Holmes 2011), attachment no longer refers solely to mothers and their children. Depending on how mothering is defined, it may or may not involve only women as mothers. Consider, for example, Arendell's (2000) definition of a mother as someone who does the relational and logistical work of child rearing. This work can be done by men or women. For example, currently, in Sweden, men can be considered to be ‘mothering’ under some conditions of work practice and have time off work. However, others have argued that the role of motherhood is unique for women and that men cannot fully be ‘mothers’ (Doucet 2006). Riggs and Due (2010) discuss the complexities in relation to gay male parents and surrogacy in India, arguing for greater recognition of issues of gender as well as power and privilege and how that intersects with roles of mothering and caretaking.

In terms of considerations for health professionals, again, the diversity of parenting roles and relationships cannot be underestimated. How health professionals manage diversity in practice can significantly impact on healthcare and health outcomes.

Employment, career and lifestyle

Employment and careers are obviously important to our life stages, but research shows that the nature of career development has changed over time. While parents or grandparents may have been employed in the same place for their entire adult life, many people today make substantial career changes throughout their working life. Again, while the majority of Australians and New Zealanders will finish high school and then go on to either trades training or university before moving into a career, there is a substantial minority who will not navigate such a clear path to employment opportunities and career options.

In Australia Census data show that the percentage of families with children with both parents employed has gradually increased to 63% in 2009–10, while the percentage of families with children where neither parent is employed has gradually decreased from 7% in 1996 to 5.4% in 2006 and 5% in 2009–10 (ABS 2011). The employment status of parents is related to the age of dependent children in the household (ABS 2011). For example, as children get older, there is a higher proportion of parents employed. Overall, the 2009–10 data show an increase in the employment of mothers, with 66% of mothers employed in couple families with dependent children (compared with only 59% in 1997) (ABS 2011). Additionally, in lone mother families with dependent children, in 2009–10, 60% were employed, but in 1997 only 46% were employed. Although there are a number of economic benefits for families when the caregivers are employed, this also means that there are many children in homes where the only parent is working. There are many social and health effects of these arrangements and they are not necessarily all positive.

‘Being employed’ is a major aim and milestone of adulthood and has a number of health benefits. Equally, being unemployed can negatively impact on health, as can being employed in the wrong job or in poor working conditions (Bambra et al 2010, Benach et al 2010). Underemployment is when someone is employed at a level lower than their qualifications or skills. Overemployment, in contrast, is the employment of someone in a position that requires greater skills or knowledge than what the person has. Both of these conditions can be stressful and adversely impact on health. Additionally, poor work environments and high-risk jobs can make employment more problematic than beneficial.

Lifestyle patterns largely develop during early adulthood with the development of social circles, employment and education and family (married or not, having children or not). Lifestyle patterns that develop during early adulthood – such as smoking, alcohol or other drug consumption; religious or spiritual activity; physical activity; and dietary habits – reveal their impacts in middle adulthood. Lifestyle, in health psychology, has largely been a concept relevant to individuals and research, and intervention in this area has largely focused on individual behaviour change. However, lifestyle is inextricably linked with social conditions, economic circumstances such as employment, place of residence and the larger community.

Spirituality and wellbeing

The massive growth in literature and research relating to spirituality and religion and their relevance to wellbeing and health is testament to the importance of these topics for contemporary health professionals. During adulthood, religious or spiritual development can change dramatically depending on many factors such as social groups that one is involved with, employment situations and major life events (especially traumatic ones). Additionally, beliefs and practices may change more than once. This is known as ‘religious mobility’ or ‘religious switching’. For example, someone may become involved in a new church through the invitation of someone at work, but then, perhaps after moving to a new town, may find that their church attendance ceases, but they commence other activities, such as joining a social running group.

Overall, research generally finds that religiosity or spirituality contribute to improved wellbeing and can contribute to health improvements and healing from illnesses (Koenig et al 2012), although these benefits can change with religious switching (Scheitle & Adamczyk 2010). Spirituality, while once (and still often) synonymous and used interchangeably with ‘religion’ and organised religious practices (e.g. Catholicism, Islamism and Buddhism), has become a field of study on its own, encompassing both secular and religious practices. In this sense, the definition proposed by Gomez and Fisher (2003) is apt: ‘… spiritual well-being can be defined in terms of a state of being reflecting positive feelings, behaviours, and cognitions of relationships with oneself, others, the transcendent and nature, that in turn provide the individual with a sense of identity, wholeness, satisfaction, joy, contentment, beauty, love, respect, positive attitudes, inner peace and harmony, and purpose and direction in life’ (Gomez & Fisher 2003 p 1976).

La Cour and Hvidt (2010) described the three domains of secular, spiritual and existential orientations in terms of meaning-making in relation to health and illness. They consider the three domains in relation to knowing (cognition), doing (practice) and being (importance), providing a useful tool to extract some of the complexities of these important topics. For example, using this framework, researchers can tease out some of the relationships between religion and health such as the social supports often associated with some religious practices (e.g. going to church) or the influence of meditation or prayer activities on health.

Given the importance of links between religion or spirituality and health, health professionals may find it very beneficial for clients to have their religious or spiritual needs considered, particularly in acute care or end-of-life contexts. For example, a recovering alcoholic undergoing inpatient cancer treatment may find it helpful for healthcare staff to assist with locating a local 12-step recovery meeting. Twelve-step recovery groups are based on spiritual principles and belief in a ‘higher power’ to relieve one of their addictions. Health professionals may also recommend, when appropriate, that clients explore religion or spirituality as part of their healing processes.

Demography

In order to appreciate the importance of age and ageing in healthcare practice, a look at the statistics or the demography of the population is essential. For example, different population groups have different age structures. This is shown in ‘population pyramids’ such as depicted in Figure 3.5.

Figure 3.5 illustrates the percentage of the population in five-year age groups for the Indigenous and non-Indigenous population of Australia. We can deduce from this figure that the social issues for human development might vary considerably for Indigenous and non-Indigenous Australians. For example, while non-Indigenous Australians have a greater proportion of people in the middle-age groups, Indigenous Australians have a greater proportion of the population represented in the younger age groups. The social impact of that is the greater demand on older Indigenous Australians for child care (compared with non-Indigenous Australians) but greater demands on non-Indigenous Australians for elderly care. These data illustrate the importance of a wide range of factors (in this case, population structure) when considering human development.

Other demographic factors that are important to consider in healthcare include, for example, the populations living in urban, rural or remote areas and access to health services. It is also important to consider gender and place of birth and languages spoken as important considerations in healthcare. With an understanding of the demographics of the places where we live and work, we can potentially anticipate and prepare for ensuring that the health services we provide are appropriate and meeting the needs of the clients we see.

Chronic illness and other health issues

Chronic illness, disability and other health issues increasingly become a part of reality as people age. Health psychology has also gained an increasing role in chronic and other illnesses because of the growing recognition of behavioural and social factors contributing to these conditions. For example, in 2010, ischaemic heart disease, cerebrovascular disease and dementia and Alzheimer's disease were the top three underlying leading causes of death in Australia (ABS 2012). With the ‘ageing’ population of Australia, it is perhaps not surprising that for the leading causes of death in Australia, dementia and Alzheimer's disease have gone from rank 8 in 1997 to rank 6 in 2001 to rank 4 in 2006 and in 2010, rank 3. Deaths from dementia and Alzheimer's disease have nearly doubled since 1997 (from 3294 in 1997 to 6542 in 2006) and are more likely to affect women than men (ABS 2008).

For health professionals, these statistics suggest that illnesses are more common partly because people are living longer. But, more importantly, as people age and certain illnesses become more prevalent, people will increasingly need care and specialised processes and equipment. For example, there has been an increase in the need for dialysis machines for kidney disease stemming from diabetes. Therefore, not only are there a greater number of people with various illnesses, but also people are required to travel to access specialised equipment and care and their final years may be involved with hospitals rather than living close to families.

Death, dying and bereavement

The topics of death, dying and bereavement are often addressed in the context of older people but obviously they can affect people of all ages. They are discussed here because death, dying and bereavement become more likely as people grow older and therefore are a major part of human development for adults. Death, dying and bereavement may affect people differently depending on many factors such as the contexts of the death (e.g. whether by an accident or after a long illness), the family and support situation available (to both the person who dies and those who love or have cared for them), and economic circumstances.

Bereavement has been defined as the ‘objective situation of a person who has suffered the loss of someone significant’ (Boerner & Wortman 2001 p 1151) and grieving relates to the emotional experience of a bereavement. Perhaps the most well known theory of stages of bereavement is Elizabeth Kubler-Ross' model, which suggests that people go through stages of denial, anger, bargaining, depression and acceptance. While the model has been useful in helping people understand their emotional experiences during a time of bereavement, it has been argued that this theory has been taken too literally, is too simplistic and has not necessarily been supported in the literature (Boerner & Wortman 2001). The idea of staged bereavement can also contribute to professionals placing too much emphasis on the stages and then pathologising people who do not go through the stages in the way a model, such as Kubler-Ross', predicts (Boerner & Wortman 2001). Some research has looked at applying ideas from stress and coping to understand grieving (Stroebe & Schut 2001).

A review by Stroebe et al (2007) of the health outcomes of bereavement suggested that there are a number of risk factors that increase vulnerability to problems with bereavement. Death of a spouse, in terms of stressfulness of life events, ranks as the most stressful experience that people have (Holmes & Rahe 1967). Grieving after someone dies is normal and, indeed, not grieving, especially if the death was of a close family member or friend, would be seen as problematic. Reactions to bereavement are generally classified according to affective (emotional), cognitive (thought-based), behavioural, physiologic-somatic and immunological and endocrine changes. Overall, bereavement increases physical ill health and physical health complaints, as well as the incidence of seeking healthcare. Complicated grief, however, is when the psychological and social aspects of grieving exceed what might be considered ‘normal’ (Ray & Prigerson 2007).

As with research on other topics relevant to health psychology (e.g. trauma and stress), it should not be surprising that research in bereavement is also exploring the positive aspects of grief and challenging previously held notions. For example, Schaefer and Moos (2001) looked at positive growth (see also literature on posttraumatic growth) following bereavement and Heilman (2005) looked at the diversity of the grief experience, particularly the positive dimensions, following the 9/11 attacks on the World Trade Center in New York. Other research has explored the possibilities of creativity and art as therapy in bereavement (Bolton 2007). Chapter 11 also examines loss resulting from death, dying and bereavement.

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Australian Indigenous HealthInfoNet

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HealthInsite

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