Middle and Late Adulthood: Social Emotional Development PDF

Middle and Late Adulthood: Social Emotional Development Learning Objectives: Middle and Late Adulthood Social Emotional Development 1. Define generativity and describe its importance to mental health. 2. Discuss evidence that adults make meaning of their lives to achieve a sense of integ...

Middle and Late Adulthood: Social Emotional Development Learning Objectives: Middle and Late Adulthood Social Emotional Development 1. Define generativity and describe its importance to mental health. 2. Discuss evidence that adults make meaning of their lives to achieve a sense of integrity. 3. Discuss mood and anxiety symptoms and disorders in middle and older adulthood. 4. Discuss positive and negative emotions and emotion regulation in middle and older adulthood. 5. Discuss important attachment relationships in middle and older adulthood. 6. Discuss caregiving in middle and older adulthood. 7. Discuss the development of the dominance system after early adulthood. 8. Describe the influence of the dominance system on personality traits and disorders. 9. Discuss personality variables associated with longevity. Challenge (Age) Question Driving Developmental Adaptation Virtue Trust vs. Mistrust How can I be safe enough to survive? Hope (0-1 years) Autonomy vs. Shame and How can I take care of myself? Will Doubt (1-3 years) Initiative vs. Guilt How can I have power? Purpose (3-6 years) Industry vs. Inferiority How can I learn to use the tools of my culture? Competence (6-12 years) Identity vs. Role Confusion Who am I? How do I fit into my community? Fidelity (12-21 years) Intimacy vs. Isolation How can I love? Whom do I love? Love (21-41 years) Generativity vs. Stagnation What contribution can I make to my community? Care and Self-Preoccupation How can my life matter? (41- end of life) Integrity vs. Despair How can I make sense of my life? Wisdom (End of life) Did my life matter? Table 0-1. Stages of Human psychosocial development according to Erikson (1959). As we finish our discussion of the lifespan in Part 3 of the textbook, we will review the major themes from Parts 1 and 2. You will then have a lifespan perspective on human nature. In this chapter we seek to understand the whole person. We examine how people make meaning of their lives and grow during adulthood and how adults combine the many parts of themselves into a unified whole. The psychosocial theory developed by Erikson (1959) is useful to students of the helping professions. Working with people of diverse ages will be much easier if you take time to study and memorize the stages presented in Table 1. At each stage a central question drives development, but for the rest of the lifespan, that question remains important for the person. For example, the need for safety and trust in others begins at birth and is important throughout the lifespan. The psychological stages of human development correspond to the biological stages of the human life history. Human psychology and biology have been shaped by adaptive challenges posed by living in harsh environments over the last 150,000 years. As you think about life after age 40, keep in mind that the stages of middle and late adulthood are uniquely human and not shared with the great apes (Hawkes et al., 1998). Only humans can live the equivalent of an entire hominin lifespan after fertility stops. The long human lifespan evolved for a reason. Table 2 shows ages of important life events in middle and older adulthood. Older adults have important contributions to make to their families and communities (Van Schaik & Burkart, 2010)! Adult Developmental Milestone ♂Age (SD) ♀Age (SD) Launching first child 46.7 (6.0) 45.7 (4.2) Launching last child 47.1 (7.2) 48.9 (4.2) Grandparenthood 52.5 (2.5) 47.8 (4.6) Climacteric change 45.7 (7.0) 47.0 (5.1) Divorce 37.0 (6.8) 36.1 (8.2) Frailty of parents 44.4 (5.4) 41.9 (10.8) Death of mother 33.6 (14.8) 37.3 (12.0) Death of father 36.0 (11.1) 35.6 (11.6) Retirement (anticipated) 62.1 (3.8) 62.7 (6.6) Being old (anticipated) 72.6 (9.9) 75.8 (6.8) Table 0-2. Average age of adult developmental milestones from one study (Perrig-Chiello & Perren, 2005). During middle and older adulthood, people experience life transitions that can affect their adjustment and mental health (Table 2). The first of these transitions is offspring leaving home. On average both men and women are also coping with the climacteric at this same time. Many middle-aged adults assist with the care of grandchildren and care for elderly parents while they hold down a job (Chapter 3). They are “sandwiched” between their parents and children. Selection I concentrate all my energy on a few things. Selection I always direct my attention to my most important goal. Selection (loss-based) When something requires more and more effort, I think about what exactly I really want. Optimization I make every effort to achieve a given goal. Optimization When I want to achieve something, I wait for the right moment. Compensation When things aren’t going so well I accept help from others. Compensation For important things, I pay attention to whether I need to devote more time or effort. Table 0-3. Representative items on the Selection, Optimization and Compensation Inventory (Baltes et al., 1999).. 2 Self-regulation processes are important to adaptation in middle adulthood. Self- regulation enables individuals use personal, social, and material resources to accomplish their life goals. In middle and older adulthood resource losses tend to outpace gains (Riediger et al., 2006). Use of resources (e.g., time, energy) toward personal growth decreases with age because individuals must invest their resources into maintenance and coping with losses. The Selective Optimization with Compensation (SOC) theory proposes that individuals select goals and strategies to best achieve their goals. They also optimize their use of resources and compensate for losses they have (Riediger et al., 2006). The socioemotional selectivity theory (SST) proposes that future time perspective is important to self-regulation in middle and older adulthood (Carstensen et al., 2003). When people sense they have lived more years than they have left they think about what they want to accomplish in their remaining years. Middle-aged adults want to contribute to the next generation and have meaning in their lives (Pinquart, 2002). In middle and older adulthood, social relationships are the most important source of meaning in life. The desire to have meaning and to contribute leads to generativity. Generativity vs. Stagnation and Self-Preoccupation Throughout their 20s and 30s adults are busy earning their place in society through the work they do, the intimate partnerships they make and the children they give birth to. The 40s mark the end of fertility and giving birth for women. At this time both men and women become increasingly concerned with generativity (McAdams et al., 1993). As adults come to realize that more life is behind them than ahead of them, they desire to contribute in ways that are lasting. They ask themselves, What contribution can I make to my community? and How can my life matter? Loyola Generativity Scale 1. I try to pass along the knowledge I have gained through my experience 4. I feel as though I have made a difference to many people. 6. I have made and created things that have had an impact on other people. 10. Others would say that I have made unique contributions to society. 12. I have important skills that I try to teach others. 19. People come to me for advice. 20. I feel as though my contributions will exist after I die. Table 0-4. Representative positive items from the Loyola Generativity Scale (McAdams & de St Aubin, 1992). Erikson defined generativity as “the concern in establishing and guiding the next generation” (Erikson, 1950, p. 240) 240). Generative concerns extend beyond raising children and include everything one generation passes down to the next, such as products, technology, knowledge, beliefs and values (Villar et al., 2024). Generative individuals participate in all the institutions that define community life (artistic, musical, religious, political, educational, governmental, etc.). They also contribute to the lives of other individuals through personal relationships. Acts of generativity enable adults to cultivate the virtue of care. Middle aged adults feel “a desire to invest (their) substance in forms of life and work that will outlive the self” (Kotre, 1996, p. 10). 3 Figure 0-1. Model of generativity (McAdams & de St Aubin, 1992). Erikson introduced the concept of generativity; and McAdams and de St. Aubin (1992) developed and validated a scale (Table 2) to measure it and a theory to explain it (Figure 1). Motivation for generativity comes from extrinsic sources such as cultural roles and expectations and from intrinsic sources (the social behavioral systems: attachment, caregiving and dominance). Caring motivation causes people to want to contribute to the welfare of others and agency causes people to want to create a legacy that outlasts themselves. Motivations give rise to concerns and commitments and these fuel actions. Generative emotions and actions remembered over time form narrative identity. Adults define themselves “by fashioning a personal myth or life story that provides life with unity, purpose, and meaning” as you learned in the last chapter (McAdams & de St Aubin, 1992, p. 1006). Identity work continues the entire lifespan. People never stop making meaning of their lives and experiences. Generativity scripts or schemas are mental road maps that tell a person what they should be doing at their age. Adults seek to create and live out generativity scripts that specify what they plan to do to leave a legacy of the Self for future generations (McAdams & de St Aubin, 1992). Throughout this book we emphasized that humans are born with social behavioral systems that are shaped by early development. Although change is possible, people have characteristic attachment, caregiving and dominance styles. Generative motivation and thoughts are intrinsically motivated through social behavioral systems, so generativity is like a personality trait (McAdams et al., 1993). Individual differences in generativity are stable over years, so high and low generativity can characterize a person. High generativity is associated with wellbeing (de Medeiros & Ermoshkina, 2024; Hofer et al., 2008). Later in this chapter we discuss how social behavioral systems cause personality traits to be stable in adulthood. Culture has a lot to do with how individuals develop and live out the balance between agency (dominance) and caring (caregiving) over the lifespan. Social behavioral systems are inborn in all humans, but culture and experiences shape them. Generativity is expected to be present in most individuals across cultures because generativity reflects caring and dominance motives. Research comparing adults around the world shows that in non-WEIRD nations generativity is expressed more as caring and in WEIRD nations it is expressed more through agency (Hofer & Busch, 2024). Although poverty and loss of health limit the expression of generativity, exercise of agency and caring enables coping. Generative actions provide people with meaning in life especially when they have suffered (Black & Rubinstein, 2009). Generative actions are a means of self-transcendence (McAdams, 2008). 4 Clinical mental health clinicians should consider the importance of generativity and meaningful life goals to their clients/patients. Although generativity may peak and then decrease if people become frail, the desire to contribute can last into old age (McAdams et al., 1993). Mental health treatment should assist all individuals in building a life worth living. Even people with dementia express generativity through helping those around them (de Medeiros & Ermoshkina, 2024). “Contributing” is part of the ACCEPTS, Emotion Regulation, DBT skill. As Erikson noted, lack of generativity is associated with stagnation and self-absorption. As you learned in the last chapter, self- absorption leads to suffering (de Medeiros & Ermoshkina, 2024; McAdams, 2008). In this textbook we do not separate the lifespan into middle and older adulthood based on chronologic age because health is more important than age. For some people health declines earlier than it does for others; and declining health is not always due to risky health behavior. As health declines, people tend to reminisce more and look back at their lives. This reminiscence characterizes the integrity vs. despair stage. Adults may question whether they were able to achieve their life goals and whether they contributed to the next generation. Even though Erikson proposed separate stages for generativity and integrity vs. despair, adults live out both stages at the same time (Hearn et al., 2012). People may perform generative actions until the end of their lives. Generativity and Work after Early Adulthood In 2023, one in five adults over age 64 was employed and 62% worked full-time. Workers working part-time often consider themselves to be retired (Braga, 2023). (Read more about older workers.) The average age of retirement is now 63 years for women and 65 years for men. Age to collect full retirement benefits was 65 years for those born before 1938, 66 years for those born between 1943 and 1954, and it is 67 years for those born 1960 and later (Social Security Administration, 2024). Work is an important expression of generativity for both men and women. Work directly influences 3 of the 5 social determinants of health. People who work are more likely to have better insurance and healthcare access. They also have higher incomes and economic security. Finally, the workplace is a source of social connection and contributing through work is a source of meaning for people. Given that more people are living older and healthier than ever before it makes sense they would keep working longer. Person and organizational factors foster the expression of generativity and when generativity is expressed through work, people and organizations benefit. Within the person, motives such as agency (from the dominance system), and caring (from the caregiving system), and desire to work underlie generativity concerns (Figures 1 and 2). Organizations promote generativity by providing challenging jobs and granting workers more autonomy. Work hours and pay are also important. People with higher expressed work generativity have higher well-being and more job satisfaction. They are more inclined to mentor younger workers. Generative people more frequently take on volunteer work after retirement (Doerwald et al., 2021; Wiktorowicz et al., 2022). 5 Figure 0-2. Generativity at work (Doerwald et al., 2021). Impact of Retirement People retire at the age when health problems become more prevalent. Therefore, it is difficult to determine if mental and physical health is adversely affected by retirement. Some studies report increased depression after retirement, while others show decreased depression (Bonsang & Klein, 2012; Dave et al., 2008; Horner, 2014; Van der Heide et al., 2013). A recent meta-analysis of US longitudinal studies found that “complete retirement leads to a 5-16 percent increase in difficulties associated with mobility and daily activities, a 5-6 percent increase in illness conditions, and 6-9 percent decline in mental health, over an average post-retirement period of six years” (Dave et al., 2008, p. 497). These losses result from inactivity and social isolation. Unless a person takes steps to stay active and perform other social roles, retirement brings loss of social contact and isolation. Involuntary retirement is more frequently associated with adverse outcomes (Dingemans & Henkens, 2014). Integrity vs. Despair People do more reminiscing as they age (as discussed in the last chapter). They may ask themselves, ‘What does my life mean, and how do I feel about that? What have I to grieve, to be proud of, to make up for, and what remains to be done about these things?’’ (Hearn et al., 2012, p. 2). The fact that people from middle age onward do this is one reason why life review therapy is helpful for older adults. Clinicians can help people look back on their lives in a balanced compassionate way. Because reminiscing occurs in the entire second half of life and is connected to generative concerns and peoples’ beliefs about what they have accomplished, Generativity vs. Stagnation and Integrity vs. Despair are not strongly related to age after 50. Research shows that these two stages occur simultaneously until the end of life (Ryff & Heincke, 1983). Wisdom is the ability to look at ones present and past life in a compassionate, balanced way (Hearn et al., 2012; Oxman, 2018). 6  Definitions of Integrity and Despair (Ryff & Heincke, 1983) Ego Integrity: Adapted to triumphs and disappointments of being; accepts personal life as something that had to be; views past life as inevitable, appropriate, and meaningful; is emotionally integrated; has resolved past conflicts and has a sense of having taken care of things. Despair: Fears death; has feelings of disgust and despair regarding past life; is concerned with shortness of remaining time; fails to accept previous life as meaningful and appropriate; has a sense of insufficient time to start another life and try alternative roads to fulfillment; disappointed with choices made. Items that Measure Integrity vs. Despair 19. As I look over my life I feel the need to make up for lost time. (R) 20. I feel that I have the wisdom and experience to help others. 31. I have many regrets about what I might have become. (R) 56. I feel at peace with my life. 73. If I could live my life over there is nothing I would change. Table 0-5. Representative Integrity vs. Despair Items from the MEPSI (Darling-Fisher & Leidy, 1988). Whereas generativity and stagnation are opposite ends of a continuum of productivity or perceived productivity, integrity and despair are two different (but correlated) constructs (Ryff & Heincke, 1983). Table 3 defines these constructs and shows self-report scale items that measure them. The transcultural need to be generative through caring, creating, and contributing also comes with a downside that can lead to despair. Adults who are unable to achieve their generative goals may have regrets. Also, beyond individual regrets, the expectation that older adults continue to contribute may put pressure on people whose health is failing. In short there is a “dark side” to generativity that may cause despair (Villar et al., 2023). To cope with the dark side, those who can’t do as much as they used to can take solace in what they have accomplished. The reality of generativity vs. stagnation leads directly to the reality of integrity vs. despair but both depend a great deal on luck and circumstances. Older adults are embedded in families and/or communities, so that other people and society influence how much people feel integrity and despair in old age. Despair may result from losses people suffer, particularly, the loss of attachments. Social Isolation and loneliness increase risk for mood and anxiety disorders in older adults. Mood and Anxiety Disorders in Middle and Older Adulthood Erikson observed that as people age, they fight the tendency to sink into despair (Hearn et al., 2012). Memories of a life well lived and thoughts about not regretting choices help boost mood. The cognitive-behavioral model of depression shows that mood, memories and thoughts are connected such that memories and thoughts influence mood, and the reverse is also true. Mood influences the memories and thoughts that a person notices. Change mood, change thoughts AND change thoughts, change mood (Beck & Beck, 2011). The prevalence of clinical depression in groups of older people is related to both life events and the biology of aging. Biology directly impacts mood and colors 7 how someone interprets their past and present. Social isolation and loneliness impact biology, cognition and mood (Hawkley & Cacioppo, 2010). Whereas peak physical health occurs in the early 20s, peak psychological health occurs roughly between 40 and 65 years (Mirowsky & Reynolds, 2000; Petrova & Khvostikova, 2021). Mood and anxiety disorders often co-occur. Sex differences in mood and anxiety disorders are found primarily in adolescents and young adults. Women are at increased risk before menopause but at equal risk thereafter (Faravelli et al., 2013). The impact of biology on mood occurs in every phase of the lifespan. The prevalence of mood and anxiety disorders increases after age 65 in comparison to the lower prevalence in people between 40 and 65. Older people have an increased prevalence of symptoms of depression and clinically severe symptoms of depression in comparison with middle-aged adults (Petrova & Khvostikova, 2021) but not in comparison to young adults (Mirowsky & Reynolds, 2000). The exact prevalence of depression in older adults depends on the criteria used to define depression. Estimates range from 4-20% (Petrova & Khvostikova, 2021; Vandeleur et al., 2017). Dementia and other physical disabilities increase risk for depression and anxiety (Blazer, 2003). About 80% of older people without medical illness or dementia recover from clinical depression with treatment (Blazer, 2003). Older people with medical comorbidities require more intensive intervention (Blazer, 2003). Different biological, psychological and social factors account for the increased prevalence of mood and anxiety disorders in young and older adults. Young adults’ biology and behavior is geared towards establishing their place in the social hierarchy. Older adults’ biology and behavior is geared toward coping with aging and continuing to contribute to the family and community. Throughout life individuals are embedded in a family and community. In what follows we discuss adult development of emotion regulation and behavioral systems. We discuss emotional adaptations to mature adult life in the context of the reward and threat systems and the social goals of attachment, caregiving and dominance. Sexual development in middle and late adulthood was discussed in Chapter 2 of this volume. Emotions and Emotion Regulation in Middle and Older Adulthood We evaluate every waking moment as to whether it is pleasant, unpleasant or neutral (Crane, 2013). We turn toward pleasant things and away from unpleasant things. We do this because there is a brain reward system (the BAS) and a brain threat detection system (the BIS). These two systems define the two categories of our emotional lives (Gray, 1990). In Part 1 you learned about early development of the Behavioral Approach (AKA Activation) System (BAS) and the Behavioral Inhibition System (BIS) and we emphasized that observations of inborn temperament reflect the BAS, BIS and biological differences in emotion regulation. In Part 2 you learned about the BAS and BIS in adolescence and early adulthood and related these again to self-regulation capacities (impulse control and emotion regulation). In this section, we discuss the BAS, BIS and emotion regulation after early adulthood and how positive and negative emotions impact wellbeing. 8 The BAS is the reward system of the brain and so is connected to the experience of positive emotions including happiness, joy, love, emotions self-esteem (good feelings about the self). Perhaps surprisingly, older adults (>65 years) report more happiness on a day to day basis than young adults (Carstensen et al., 2011; Gross et al., 1997). Older adults also recover their happiness faster following negative mood induction (Kliegel et al., 2007). Better emotion regulation likely accounts for older peoples’ experience of positive emotions. Due to perceiving the value of remaining years to live, many older adults choose to spend their time in more satisfying relationships and activities (SST, Socioemotional Selectivity Theory) (Carstensen et al., 2003). When relationships are more satisfying, people feel more love and are happier. Older people generally try to avoid conflict in close relationships. As couples get older, they tend to use humor and validation with each other during conflict (Verstaen et al., 2020). Older adults are aware that their stress resistance is limited and so they choose activities that are not overstimulating or stressful. One 20 year longitudinal study found that positive emotions were associated with better cardiovascular health (Boehm et al., 2020). Another study found that positive emotions predicted maintenance of functional status in older adults (Brummett et al., 2011). Clinicians can use these findings to consider the significance of emotional dysregulation in adults. Because on average older adults report more happiness, unhappiness is more abnormal in older adults than in younger adults. Lack of happiness can be addressed by skills training of positive emotions as is done in DBT and MBCT (Crane, 2013; Linehan, 2014). Although many older adults may use effective strategies to cope and increase positive emotion others may need help doing so (Isaacowitz & Blanchard-Fields, 2012). In Parts 1 and 2, you learned that although anger is a positive emotion, it is a BAS emotion. Specifically, anger results from frustration of reward and people higher in social dominance experience more anger. Social dominance decreases after age 40, and the experience and expression of anger (on average) is lower in older adults (Kunzmann et al., 2014). Uncharacteristic anger and irritability may be symptoms of neuropsychiatric disorders. One way psychologists study emotions is through activating them with film clips or pictures (Kliegel et al., 2007). This method, diary records and self-report show that emotional reactions are preserved throughout life. Older people may even have stronger emotional reactions, they are just better at regulating emotion (Hay & Diehl, 2011; Kliegel et al., 2007; Orgeta, 2009). Throughout the lifespan effective emotion regulation predicts positive emotion, less negative emotion and stronger interpersonal ties. In comparison to younger adults, middle-aged adults use more proactive emotion regulation strategies and older adults us more passive strategies (avoiding conflict, looking at the bright side) (Blanchard-Fields et al., 2004; Yeung et al., 2011). To review, emotion regulation is how individuals influence which emotions they have, when they have them, and how they experience and express them (Gross, 1998). Clinicians should be aware that sadness and emotion dysregulation are not part of healthy aging and consider the cause of these symptoms especially if they are uncharacteristic of a person. 9 Some people are more prone to sadness, fear and anxiety than others. Neuroticism is the personality trait defined as the tendency to experience these negative emotions. Neuroticism begins as part of temperament early in life and in a percentage of children it high levels continue into adulthood and persist. Studies of neuroticism in groups of people find that the trait is stable after early adulthood, but some individuals may also show change (12% in one study) (Bazana et al., 2004; Costa et al., 2019). The Attachment System in Middle and Older Adulthood Development of the attachment system begins at birth and attachment scripts reflect a person’s trust in others and the extent to which they allow others to meet their needs. After early childhood the attachment system contains scripts about receiving care, reciprocity of care and loyalty (Bat Or & Ishai, 2020; Halpern, 1997). Friends and family members take care of each other and show loyalty. When cultivating social bonds, a person incorporates others into their Self-concepts and narratives. Narratives of the benefits of receiving care and positive concepts of others are part of the secure attachment script. People who fear being let down by others have ambivalent attachment and those who are pessimistic about others meeting their needs have avoidant attachment. There are scripts that go along with these styles that arise from narratives of disappointment within social bonds. The attachment system enables people to ask for help and allows them to feel safe when they are with others. Attachment styles― secure, ambivalent, and avoidant persist throughout the lifespan but people do shift styles during childhood, adolescence and adulthood. Positive relationship experiences promote security; and hardship along with negative relationship experiences connects to avoidant attachment and dismissing attitudes toward attachment needs (Magai et al., 2001). Attachment styles in young adults are similar to those of children and teens with about 55–65% of respondents secure, 22–30% avoidant, and 15–20% ambivalent (Magai et al., 2001). In older adults the predominant attachment style is avoidant and ambivalent attachment is infrequently observed (Magai et al., 2001). Avoidant attachment is more common in traumatized individuals and those who have a smaller number of people they can rely on (Magai et al., 2001). Avoidant attachment behavior serves a Self-protective function for people who are trying to buffer themselves against being let down by others. Self-reliance can be useful when people are capable and healthy. When aging leads to disability, people must rely on others, either happily or unhappily depending on the scripts of attachment they have. Therefore, as people age, avoidant attachment can be maladaptive and a risk to health (Magai et al., 2001). Help rejecting behavior on the part of elders who need care may cause clinicians and family members to feel helpless and frustrated. Understanding the cause of help rejection can make caring for elders easier. Social exchange theory explains that people try to balance what each person gets (benefits) and what each person gives (costs) in the relationship (Laursen & Hartup, 2002; Nakonezny & Denton, 2008). People value reciprocity or equality of benefits and 10 costs of relationships. The principle of exchange operates in all adult relationships (romantic partnerships, parent-offspring, sibling, and friendships). You already know (from Part 1) that the attachment and caregiving systems are linked yet separable. The caregiving system motivates altruistic care of others when relationship benefits are not equal (Preston, 2013). Secure attachment enables people to accept unreciprocated care. When older adults are no longer able to reciprocate care, they rely on relationships they have previously invested in (romantic partners, family members and friends) (Cheng et al., 2015; Silverstein et al., 2002), and on the altruism of others (Silverstein et al., 2002). Older adults may be more willing to accept care from a family member they previously cared for. Due to ambivalence about receiving care, “family members do not contribute to older adults’ feelings of well-being despite being named more often as key supporters and providing substantial support” (Siebert et al., 1999, p. 529). Friends are more important to older adults’ wellbeing as discussed below. In biopsychology we consider the ultimate cause of behavior. That is the function and phylogeny of behavior (Part 1, Chapter 1). By valuing reciprocity individuals can protect themselves. Through reciprocity people try to avoid being taken advantage of by parasitic others (family members and friends). Reciprocity ensures that people have relationships that are fair to both parties. Fairness and reciprocal social exchange is part of individual relationships for all hominin species (that is phylogeny). Individuals become distressed and angry when others fail to live up to the norm of fair social exchange (de Waal, 1998). Through the caregiving system, humans can transcend tit for tat exchange rules and give altruistic, unreciprocated care. Adult humans can care for other adults the same as they would a dependent child. No other species does this. Elders receiving care may feel shame at being treated as dependent and for violating reciprocity rules. As discussed in Part 1, attachment leaves individuals of all ages vulnerable to grief when they lose the ones they love. Chronic medical conditions and disabilities may reduce people’s ability to cope with loss of attachment relationships. Sadly, older adults who survive longer than their family members and friends suffer the pain of losses at a time in life when they have less resiliency. Contrary to age stereotypes, older people do not become used to these losses. A person’s most import attachments are toward those they live with. In 2022, there were 57.8 million adults age 65+ living in the U.S. (31.9 million women and 25.9 million men); 59% lived with their spouse or partner, 28% lived alone, 13% with extended family or long-term care (National Council on Aging, 2024). The median income for older adults was $29,740, (most older adults need material support) (National Council on Aging, 2024). There are only 5.9 million adults over 85 years of age, 40 percent live alone, including in independent living or assisted-living facilities and 60% live with spouses or family (Lerman & Cocco, 2023). These statistics show that many older people are alone and at-risk for loneliness, and the risk increases with age. 11  Loneliness in Adulthood De Jong Gierveld Loneliness Scale 1. I experience a general sense of emptiness. 2. I miss having people around me. 3. I often feel rejected. 4. There are plenty of people I can rely on when I have problems. 5. There are many people I can trust completely. 6. There are enough people I feel close to. Table 0-6. Items on a measure of loneliness (Gierveld & Van Tilburg, 2010). Loneliness is the distress that happens when there is a mismatch between a person’s social needs and the quantity and quality of their existing relationships (Gierveld & Van Tilburg, 2010). Table 4 shows items on a common scale used to measure loneliness that clinicians can use to screen for loneliness. Loneliness is an important public health issue. Several longitudinal studies found that loneliness predicted all-cause mortality after controlling for age, sex, chronic diseases, alcohol use, smoking, self-rated health, and functional limitations (Hawkley & Cacioppo, 2010). In response to these findings the UK and US governments are developing strategies to combat loneliness among older people (Prohaska et al., 2020). Risk factors for loneliness include low quality relationship with parents during childhood, living alone, bereavement, low social participation, and decline in health status (Burns et al., 2022; Dahlberg et al., 2022). Why would loneliness lead to death? One theory says that it causes chronic stress from fear and anxiety. This stress reduces healthy behaviors, increases unhealthy behaviors and leads to elevated stress hormone levels (Hawkley & Cacioppo, 2010). People who live alone may also have accidents and health problems when no one is around to help. Close Relationships in Middle and Older Adulthood In Part 2, Page 147 we explained the functions of adult friendship (Table 9-5): 1. Stimulating companionship or joint participation in exciting activities; 2. Emotional security or sense of safety; 3. Support including emotional, informational, and material; 4. Reliable alliance or trust and loyalty; 5. Self-validation or encouragement and confirmation; 6. Intimacy or sharing of feelings. These qualities of friendship apply to all adult relationships including those in the family. Attachments to romantic partners, adult children, aging parents, peers (friends and extended family) are important to adult wellbeing because they are sources of security (Item 2), and material and emotional support (Item 3). For each relationship we discuss the benefits of healthy relationships and the impact of loss of significant people during adulthood. We note that 29% of adults aged 50 years and older in 2021 had never married, while many of these individuals are cohabitating, they also have close relationships with friends (Carr & Utz, 2020; Marino, 2023). 12 Marriage and Long-term Partnerships Determinants of Relationship Satisfaction Couple interaction and communication. Experience of intimacy. Time spent together. Sexuality. Passion. Need fulfillment (love and emotional security). Relationship ideals. Table 0-7. (Bühler et al., 2021). In Part 2, Chapter 10 we discussed intimate partnerships in early adulthood and the assessment of dyadic adjustment and relationship satisfaction (p.165). Dyadic adjustment and relationship satisfaction decline over the first 10 years of a relationship and also with age until people reach their early 40s (Bühler et al., 2021). Both age and relationship duration determine how satisfied people are. The low point of marriage happens when people are in their early 40s. At that time marital satisfaction is a standard deviation below satisfaction at age 25 (Bühler et al., 2021). Giving birth and raising children accounts for some of the decline in relationship satisfaction before middle adulthood. But the decline occurs even in childless couples (Twenge et al., 2003). Between age 45 and 65 relationship satisfaction increases and then levels off or declines after age 65 (Bühler et al., 2021). The same factors determine relationship satisfaction over early, middle and older adulthood (Table 6) (Bühler et al., 2021). When offspring reach adulthood, the couple has more time to spend together, communicate, experience intimacy and have sex. Then due to aging of the reproductive system, sexual function may be impaired (Chapter 1) and relationship satisfaction can decline again or level off. Sexuality is important for relationship satisfaction, affectionate bonds and health. You can think of sexual pleasure as a benefit the members of a couple give to each other. That benefit balances out other costs of the relationship. Women in relationships with men who are more than 5-10 years older may have less sex and may be less satisfied with their sex lives and relationships (Silva, 2019). Given that health problems increase in frequency with age, a five-year age difference becomes more significant when the younger partner reaches age 70. Another way to assess relationship quality (benefits and costs) is to ask about how much support the partner provides and how much strain exists in the relationship (Table 7). Support and Strain define four groups of couples― supportive (high support, low strain), ambivalent (high support, high strain), indifferent (low support, low strain), and aversive (low support, high strain). One recent study of adults between 57 and 85, the National Social Life, Health and Aging Project (N = 953 couples) found that husbands and wives most often do not agree as to how much support and strain there is in a marriage. Supportive relationships were reported by 42% of wives and 35% of husbands (who tended to perceive more strain (57% high strain for husbands vs. 47% high strain for wives)). In about 1% of couples, both members report their relationship is 13 indifferent (low support, low strain); 8% of husbands and 11% of wives report their relationship is indifferent. About 20% of men and women reported aversive relationships these relationships are costly and have little perceived benefit. Support Items Strain Items a) how much your spouse understands a) how much tension there is between the way you feel about things. you and your spouse b) how much you can depend on your b) how often you have an unpleasant spouse to be there when you really need disagreement with your spouse them. c) how much your spouse shows concern c) how often things become tense when for your feelings and problems. the two of you disagree d) how much you can trust your spouse d) how often your spouse says cruel or to keep their promises to you. angry things during a disagreement e) how much you can open up to your e) how often the two of you both refuse to spouse about things that are really compromise during disagreement important to you. Table 0-8. Support and strain in long-term partnerships (Schuster et al., 1990). High strain was associated with loneliness for both men and women. Women who reported indifferent relationships were also likely to be lonely (Hsieh & Hawkley, 2018). The impact of poor marital quality on loneliness was not reduced by good relationships with friends and relatives. Other studies show it is better to be single than live in a marriage with high conflict (K. Williams, 2003). Marital conflict can cause elevated stress hormones and immune suppression in older adults (Kiecolt-Glaser et al., 1997). In addition to predicting loneliness, marital quality (support and strain) also predicts successful aging defined as maintaining good health, preserving cognitive and physical function, and sustaining emotional well-being with high social engagement (Novak et al., 2023). Often members of a couple have the same lifestyle (diet and exercise habits) and so either age successfully together or not until their 70s when more people have health problems that could not be prevented (Novak et al., 2023). Clinicians are likely to encounter people in their 50s and 60s with significant marital strain that may affect their health (Umberson et al., 2006). Marital strain impacts unhealthy people more than healthy people (Warner & Kelley-Moore, 2012) but also physical and psychological health problems impact relationships. Aging of individuals occurs in a family context but healthcare efforts often only target individuals and not families. Clinicians should (1) screen partners of patients with health problems, (2) offer referrals for relationship education and couples therapy to target psychological and relational health, and (3) enroll and target both partners in health promotion efforts (since family members share a common lifestyle) (Novak et al., 2023). Sexual Minority Marriages and Partnerships There are an estimated 2.4 million LGBT adults 65 years of age and over in the US. These adults face a double or triple “whammy” of discrimination as they experience 14 agism, sexual identity discrimination and perhaps racism. In terms of the social determinants of health these isms and the associated stress/trauma are significant. Successful aging may be different for sexual minorities (Pereira & Banerjee, 2021). Whereas about 20% of heterosexual and 25% of lesbian and bisexual women elders live alone, about half of older gay and bisexual men live alone (Kim & Fredriksen- Goldsen, 2016). For individuals identifying as heterosexual, the marital relationship, more than any other, holds the greatest significance for health (Umberson et al., 2006). Is this also true for gay, lesbian and bisexual adults? The answer is yes. Living with a spouse or partner buffers against loneliness for sexual minority elders. Those who live with a spouse or partner perceive more social support, have larger social networks, have less internalized stigma and are less likely to conceal their identity. Together these factors account for 45% of the risk for loneliness. Marriage and romantic partnerships predict longevity, life satisfaction, health, and wellbeing in LGB individuals (M. E. Williams, 2012). Low relationship quality predicts depression in partnered LGB individuals. Read more about providing services to aging LGBTQ individuals. Gray Divorce As the Baby Boomer Cohort aged, their divorce rates increased relative to their parent’s generation while those of subsequent cohorts decreased slightly. In 1990, when the first of the Baby Boomers was 45 years old, fewer than one in 10 people getting divorced was over 50 years old. In 2010 more than 1 in 4 divorcees were over 50; in 2019 1 in 3 divorcees was over 50 years old. Historically, older people lost their partners through death, now they also lose them through divorce. Among older women, about one- quarter lost husbands through divorce. For older men, a majority (52%) lost wives through divorce (S. L. Brown & Lin, 2022). Sociologists attribute the high gray divorce rate to the Baby Boomer cohort, but other risk factors include prior divorce, unemployment, less education and ethnic minority status. Clinicians are likely to encounter divorced or divorcing people over 50. In 2019, an estimated 533,111 individuals between 50 and 64 years of age divorced; and 177,704 individuals over 65 divorced (S. L. Brown & Lin, 2022). Adults have to weigh the financial and stress costs of a divorce against the benefits of living with reduced conflict (Huff, 2023). Qualitative studies indicate that some couples delay divorce until their children finish high school (Crowley, 2019). Many older people who divorce are happier and relieved to have their freedom back (Crowley, 2019). Long-Term Partner and Spousal Bereavement The death of a spouse or long-term partner is one of the most stressful life events a person can endure. Most people become widow(ers) in later life when they are in their early seventies (Naef et al., 2013). Bereavement is more common for women, who are younger when it happens and who live more years thereafter. In 2019 there were 15 million bereaved spouses in the US and 80% or 12 million of them were women (Liu et al., 2020). 15  Usual Grief Reaction 1) Distressingly strong yearnings for that which was lost. 2) Feeling the need to cry at times. 3) Painful to recall memories of the deceased person. 4) Sometimes missing the deceased. 5) Can’t avoid thinking about the deceased. 6) Things and people remind me of deceased. Table 0-9. Symptoms of grief (Ott et al., 2007). One recent meta-analysis that included 2,263,888 participants from 15 prospective cohort studies found that bereavement is associated with a small to moderate increased risk of death from all causes in the first 6 months after the spouse’s death (relative risk of 1.41). Risk of death due to cardiovascular conditions may be nearly double in the first 30 days after bereavement (Carey et al., 2014). Overall death risk decreases after 6 months and remains higher for men than women. Other studies looking at causes of death after bereavement find deaths are due to cardiovascular disease, stroke, cancer, and accidents or violence (Hart et al., 2007). Quasi- experimental research using the identical co-twin as a control offers some proof that death is directly related to bereavement (Lichtenstein et al., 1998). Other studies find that economic factors may play a role in bereavement death (Liu et al., 2020). Attachment theorist John Bowlby and Dr. Elizabeth Kubler-Ross wrote about stages of grief they observed when working with bereaved and terminally ill persons (read more). Grief was proposed to progress through a series of stages from “numbness-disbelief, separation distress (yearning-anger-anxiety), depression-mourning, and recovery” (Maciejewski et al., 2007). While the stage theory has not been confirmed, the symptoms of grief have been verified and research has begun to separate normal reactions from clinical distress (Maciejewski et al., 2007; Ott et al., 2007) (Tables 8 & 9). Most people report high levels of acceptance of the death even immediately thereafter (Maciejewski et al., 2007). Grief is characterized by emotional pain and sadness and longing or yearning for the deceased person. Yearning and longing can include preoccupation with the deceased person. These symptoms tend to come and go over the course of a day. Struggling to accept the death is associated with bitterness, shock, and numbness. The deceased partner was part of the bereaved individual’s narrative and conceptual Self, and it takes time for the Self to adjust. (A bereaved person might say they feel they have lost part of themselves.) Difficulty reengaging with life, identity disturbance, role uncertainty, and feeling life is meaningless are signs that the Self has not yet adjusted (Maccallum et al., 2023). Loneliness is also common in people who report having lost part of themselves (Robinaugh et al., 2014). People who have a hard time believing the death happened have a more difficult time adjusting and that is more common with a sudden unexpected death (Maciejewski et al., 2007; Ott et al., 2007). Clinicians can diagnose “uncomplicated bereavement” when caring for people within the first year of spousal loss (Pies, 2014). Symptoms of grief usually decrease by 6 (ICD 11 criterion) to 12 months (DSM 5 criteria) (Maciejewski et al., 2007). Persistent high intensity symptoms that last more than 6 months are less common and may indicate a 16 clinical level distress (Ott et al., 2007). DSM 5 and ICD 11 include “Prolonged Grief Disorder” as a clinical syndrome (Table 9). Severe emotional pain and feeling empty (Self disturbance) are central to the prolonged grief syndrome (Robinaugh et al., 2014). Emotional pain is highly correlated with feeling like part of the Self was lost (Killikelly et al., 2023). Careful clinical evaluation can distinguish between prolonged grief, major depression and post-traumatic stress disorder as these are distinct syndromes that may co-occur (Karatzias et al., 2022; Malgaroli et al., 2018; Pies, 2014). Depression predicts increased risk of death for the bereaved (Domingue et al., 2020). People at risk for disabling, prolonged grief are those who depended on the deceased for security and companionship and sudden unexpected death may also increase risk (Naef et al., 2013). Throughout the lifespan, strong attachment leads to greater bereavement with loss of the loved person. One recent review states, “constructing a new identity as widow/er and striving for independence in the face of disrupted everyday activities and routines, loneliness, health concerns and changed relationships within the family and social network are essential features of older persons’ bereavement experience” (Naef et al., 2013, pp. 1008, emphasis added) (read article in nursing journal). One third of bereaved elders report clinically relevant depressive symptoms (Szabó et al., 2020). More than half report emotional loneliness post-bereavement, and prolonged grief is present in up to 12% (Maciejewski et al., 2007; Szabó et al., 2020). DSM 5 Prolonged Grief Disorder B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month: 1. Intense yearning/longing for the deceased person. 2. Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death). C. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month: 1. Identity disruption (e.g., feeling as though part of oneself has died) since the death. 2. Marked sense of disbelief about the death. 3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders). 4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death. 5. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future). 6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death. 7. Feeling that life is meaningless as a result of the death. 8. Intense loneliness as a result of the death. Table 0-10. Criteria for DSM 5 Prolonged Grief Disorder. 17 Clinicians want to know how best to support widows and widowers. Many hospitals offer bereavement groups that offer psychoeducation and support for people who have lost close friends and family members. We do not yet know if these groups help prevent prolonged grief disorder and depression but groups that contain a mindfulness component may be more effective (Davidow et al., 2022; Wittouck et al., 2011). Clinicians can help bereaved individuals by normalizing their experience, “eliciting and compassionately listening to their narratives of their relationship with the deceased and the death, and regularly “checking in” regarding their grief experiences as a way of monitoring for prolonged grief (Iglewicz et al., 2020). Bereaved elders should also be screened for depression at regular intervals. Bereaved people with prolonged grief should be referred for evidence-based bereavement-care either CBT or complicated grief therapy (CGT). These approaches help individuals accept and cope with the loss and assist them with living life without the deceased. CGT has seven core interventions: “(1) understanding and accepting grief, (2) managing painful emotions, (3) planning for a meaningful future, (4) strengthening ongoing relationships, (5) telling the story of the death, (6) learning to live with reminders, and (7) establishing an enduring connection with memories of the person who died” (Iglewicz et al., 2020, p. 90). These interventions assist with emotion regulation and construction of a new narrative identity. Same-Sex Partner Bereavement LGB individuals have additional risk for bereavement related decreased health and well- being. Loneliness is more prevalent in LGB elders and agism and sexual minority discrimination may interfere with LGB individuals receiving support. Clinicians may assume that elders get used to loss and they may not understand the needs of LGB elders (Fenge, 2017). LGB partners also experience disenfranchised grief defined as grief in the context of a loss that is not or cannot be openly acknowledged, publicly mourned or socially supported (Doka, 2002). The three components of disenfranchised grief are (1) the lack of social recognition of the grieved relationship, (2) the lack of recognition of the bereavement experience for the griever, and (3) the lack of acknowledgement of the personhood of the grieving individual (McNutt & Yakushko, 2013). Identity enables a person to navigate their social relationships, and the death of a long- term partner changes a person’s identity. Public acknowledgement of the loss helps a person adjust to their new identity without the deceased. Some LGB individuals must grieve the death of their partner in the context of others denying the legitimacy of the relationship and their love. Disenfranchised grief increases risk for depression and prolonged grief disorder. Clinicians who acknowledge the legitimacy of the elder, their relationship and their grief potentially provide a corrective emotional experience for the elder (McNutt & Yakushko, 2013). 18 Repartnering in Midlife and Beyond Repartnering in middle or later adulthood is a new phenomenon due to more people living longer and remaining healthy. It is more common after divorce than death of a spouse for both men and women. There is a large sex difference in repartnering. In one study of adults aged 50 and over, 15.3% of divorced women remarried; 8.6% were cohabitating and 76.1% were single. For widows 50 and over, 94% were single, 3.6% remarried and 2.4% were cohabitating. For divorced men, 28.3% were remarried, 14.6% were cohabiting, and 57.1% single. For widowers, 75.7% were single, 17.6% were remarried and 6% were cohabitating. The likelihood of repartnering increases with time since the marital dissolution either through death or divorce. Likelihood of repartnering decreases with age for women but not for men (S. L. Brown et al., 2018). Whereas young adults form partnerships to raise a family, older adults form partnerships for love, companionship and material support (Koren, 2022). Just as many couples who raise a family together report being in love, qualitative studies indicate that the ability to fall in love with a new partner persists throughout life (Koren, 2022). Healthy single adults over 50 often want to date and many participate in online dating. Some couples choose not to live together and instead “live apart together,” these couples have similar levels of wellbeing as those who live together (Wu & Brown, 2024). Elders who repartner have higher life satisfaction (Gloor et al., 2021) and less loneliness (Wright et al., 2020). Sexual activity that includes touching and other intimacy lowers risk for depression in older adults (Ganong & Larson, 2011). Studies of the benefits of marriage (discussed above) include this group of individuals who have repartnered. Relationships with Adult Offspring Even though many aging people prefer to live alone rather than with their families, research shows that most benefit from co-residence (Lee & Kim, 2022). Older adults provide and receive affection, care, and financial support. Adults over 55 years of age are less lonely, happier and have more self-acceptance if they reside in a multigenerational household (Lee & Kim, 2022). The benefits of multigenerational living extend cross-culturally. The psychological benefits of multigenerational household living can be contrasted with the risk of seasonal virus transmission to older adults. During the COVID-19 pandemic in the UK middle aged adults living with children were 17-21% more likely to die (A. K. Ghosh et al., 2022). In the US, multigenerational household living increased risk of death by 11% at the height of the pandemic (Nafilyan et al., 2021). To protect babies in the household older adults should receive a whooping cough booster vaccine (read more). To protect themselves from viruses brought into the household by children, older adults should be vaccinated for RSV, influenza and COVID-19 (read more). Among middle-aged and older adults who have adult offspring not living with them, 71% have offspring living close by (within 30 miles) (Choi et al., 2020). Families with more education tend to disperse more and live more than 500 miles apart (Choi et al., 2020). In the USA and Europe, young adults delay marriage and career, these two factors tend 19 to keep them close to their parents. Whether or not offspring reside with parents, as they get older the relationship is increasingly one of mutuality, interdependence and friendship. The six friendship characteristics listed on Page 7 go together such that relationships that are high in intimacy and emotional support are also high in practical support. Parents and offspring help each other more when the relationship is closer and help is reciprocal (Cheng et al., 2015). Young adults are more helpful when parents are ill or having problems (Cheng et al., 2015). Middle-aged parents report receiving less support than young adult offspring report providing (Cheng et al., 2015). Adult offspring-parent relationships are closer when parents spent more time with children when they were young (Silverstein et al., 2002). Closeness is a lifelong habit in families where reciprocity is high and family ties are valued. Figure 0-3. Source. Friends and Friendship Networks in Middle and Older Adulthood According to socioemotional selectivity theory, when people reach middle age and realize that their time is limited, they want to focus on what is most important and beneficial (Carstensen et al., 2003). They limit their social life to fewer more significant 20 relationships. Whereas young adults seek to expand the Self and social networks, mature adults invest their time in relationships with high payoff. The number of social partners decreases over the span of adulthood. Whereas loneliness is the subjective feeling that happens when a person does not have enough companionship to meet their needs, social isolation is objective and refers to infrequent social contacts and lack of participation in social groups. Subjective loneliness and objectively measured social isolation are related. People who are socially isolated tend to be more lonely (Taylor, 2020). However, a person can suffer from social isolation and loneliness or one and not the other (Schutter et al., 2022). Social isolation is associated with increased mortality independent of reported loneliness (Schutter et al., 2022). People are prone to increasing social isolation as they get older. Internet use may help reduce this social isolation for some (Nedeljko et al., 2021). There are three kinds of social isolation, isolation from family, isolation from friends, and isolation from community group activities. The first friend many children have is a sibling (Stocker et al., 2020). Among factors that predict sibling closeness in middle adulthood are living parents, sister-sister relationship, full siblings and lack of parental favoritism. It is common for siblings to be in touch at least weekly in person, over the phone, and/or through social media. Social support (emotional, instrumental, and informational) is the most important function of sibling relationships across the lifespan. Tension in sibling relationships is associated with illbeing (Stocker et al., 2020). Leisure activities with friends (including family members) are important for subjective wellbeing. Over the course of middle and older adulthood the amount of time spent in leisure activities with friends and family decreases (Huxhold et al., 2014). In several studies leisure activities with family members were not as fulfilling and even associated with higher levels of negative emotions (Huxhold et al., 2014). In studies of older adults over the last 40 years, time with friends outside the family has consistently correlated with positive affect and wellbeing (Huxhold et al., 2014; Larson et al., 1986). People choose their friends based on desirable characteristics and so likely enjoy being around them more (Siebert et al., 1999). Older adults usually have friends they have known many years (Fingerman et al., 2024; Siebert et al., 1999). Friends are more consequential for older adults than for middle-aged adults (Huxhold et al., 2014). Beyond friendship, sense of community, and neighborhood atmosphere are important for older adults’ wellbeing (Gan et al., 2021). Elder Abuse Elder abuse is defined as psychological, physical, sexual, financial abuse or neglect of those over the age of 65 (Table 10) (Roberto, 2016). Due to the increasing number of dependent elders worldwide it is a global public health problem (Dong, 2015). The prevalence of abuse in the US ranges from 10% of cognitively intact elders to 47% of those with dementia (Dong, 2015). Disabled elders are often isolated and so it is important the clinicians who have contact them screen for this issue (Table 11). Given 21 the prevalence of the problem, a clinician seeing between 20 and 40 older adults a day could encounter more than one victim of elder mistreatment daily (Pillemer et al., 2015). Clinicians and other helping professionals are mandated by law to report elder abuse to Adult Protective Services in all 50 states of the USA (Thomas & Reeves, 2024) (read more about Adult Protective Services). Abuse Category Definition Psychological The infliction of anguish, pain, or distress through verbal or nonverbal acts. Physical The intentional or reckless use of physical harm or physical coercion that may result in bodily injury, physical pain, or impairment. Sexual Non-consensual sexual contact of any kind with an older adult. Financial The illegal, unauthorized, or improper use of an older person’s resources for monetary or personal benefit, profit, or gain, or that results in depriving an older person of rightful access to, or use of, benefits, resources, belongings, or assets. Neglect The failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder. Self-Neglect An adult’s inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks. Table 0-11. Types of elder abuse (source). Perpetrators are usually family members (e.g., spouse, adult child, grandchildren, nieces/nephews), friends, and others elders trust and rely upon for help (Roberto, 2016). Elder abuse by intimate partners may be a continuation of lifelong abuse or occur in a new relationship (Roberto, 2016). While most adult children provide good care of their parents, caregiver stress can increase risk for abuse. Adult children who perpetrate are often dependent on their parents for housing, financial assistance and/or emotional support. Drug and alcohol abuse by spouses and adult children as well as narcissistic and antisocial personality traits increase risk for abuse perpetration (Roberto, 2016). Elder Abuse Screening Questions 4. Who makes decisions about your life—like how you should live or where you should live? 7. Do you feel that nobody wants you around? 10. Has anyone forced you to do things you didn’t want to do? 11. Has anyone taken things that belong to you without your O.K.? 15. Has anyone close to you tried to hurt you or harm you recently? Table 0-12. Items from the Hwalek-Sengstock Elder Abuse Screen Tool (HS-EAST) (Moody et al., 2000). In 1975, Congress amended the Social Security Act to include Title XX, which required states to enact protective services for abused or neglected elders and in 1987 Congress amended the Older Americans Act (Title I) to address the protection of older adults from abuse, neglect, and exploitation (Jackson, 2016). In the 1990s state laws recognized elder abuse as a crime (Jackson, 2016). The consequences of elder abuse include physical injuries (such as wounds, head injuries, and broken bones); exacerbation of existing health problems; depression and anxiety; premature nursing home and hospital placement; and increased mortality risk (Pillemer et al., 2015) (read more about elder abuse). 22  The Caregiving System in Middle and Older Adulthood Effective parents are sensitive to their children’s needs (due to the caregiving sensor) and are motivated to respond according to these needs (due to the caregiving actuator). That means parents put their own needs aside. Again, we explained that when an individual becomes a parent, they reduce investing in self so they can invest in the next generation. Empathy and mature self-regulation are required for effective parenting. Without self-regulation a person cannot put their own needs aside to care for someone else. Self-regulation enables caring to be fun and energizing rather than a draining chore. Self-regulation skills also help parents to care for themselves enough to stay healthy so they can care for their children. Table 0-13. Caregiving and parenting as explained in Part 2, Chapter 11, P.207. Caregiving in humans is complex behavior that depends on the function of the brain’s caregiving network that performs the functions of the caregiving system (Swain, 2011). This network evolved to enable parenting (Table 10), then further evolved to include care of mates and others in the group (Preston, 2013; Van Schaik & Burkart, 2010). To review, a system is organized around a goal. To achieve that goal, it has sensors that provide information about whether (or not) the goal has been reached. A system also has actuators that perform the functions necessary to achieve the goal. Sensitivity refers to sensing what others need and responsiveness means knowing how to meet that need and doing it. Accurate empathy and sensitivity indicate the caregiving sensor is functioning well. Responsive behaviors that meet the needs of the other indicate the actuator is functioning well. Caregiving working models contain scripts of how caring interactions unfold. These scripts come from a person’s narrative autobiographical memory and previous experiences of receiving and giving care. The attachment and caregiving systems are linked through neurochemistry in the implicit emotional brain and through explicit cognitive scripts of the cerebral cortex. Because carers often must put their own needs aside to care for another person, Self- transcendence is part of the caregiving system (Schwartz, 2017). Self-regulation is required for this self-transcendence. Caregiving is rewarding and so benefits the carer. Notice that caregiving and sexual gratification are both rewarding in an artificial way― due to dopamine, endorphins and other brain chemicals. This artificial reward helps to offset the costs of caregiving and sexual behavior. Costs are due to spending time and energy in activities other than those the Self needs to thrive. Caregiving adaptations evolved in humans because the benefits of caring for individual fitness (survival of offspring) exceeded the costs to individuals. Simply put, in the human evolutionary past, caring individuals survived and reproduced more than those who did not. Beyond genetics, cultural beliefs evolve based upon survival of the individuals that have them (Dawkins, 1976). Over generations adaptive beliefs survive more than maladaptive beliefs. Beliefs about the importance of caring for others, especially family members, are passed down from generation to generation. 23 Humans are the most caring species on Earth, is a theme repeated throughout this text. Students may have a difficult time reconciling the psychological and physical abuse within families with the caring aspect of human nature. Throughout this text we explained the biopsychological perspective as we discussed proximate and ultimate causation of abusive behavior. In terms of proximate causation, abusive behavior is motivated by the dominance system, and for most people abuse is held in check by the caregiving system (Blair et al., 2005). Some people lack this safeguard because the caregiving system failed to develop properly (Leedom, 2014, 2017a). The ability of the caregiving system to check dominance behavior depends on genetics and early development (Leedom, 2014). Why are some people unable to care for others? Ultimate causation completes the answer to this question. If most humans give care, other humans can exploit that behavior (Mealey, 1995). Mathematical models from sociobiology demonstrate that in many species the number of individuals who care is in equilibrium with the number of individuals who exploit and that many species have different behavioral forms individuals can manifest (Dugatkin & Reeve, 2000). The situation in humans is more complex because rather than being a dichotomy of yes/no, there is a continuum of caring in the human species. Nonetheless, given that there are so many humans, there are many people who lack the ability to give care. Although lack of caring is genetic and so runs in families, not all individuals within a family are affected. Exploitative, uncaring individuals impact everyone who is close to them (Leedom, 2017b) (read more). Dysfunctional Caregiving Styles Caregiving System Scale Factor Item Avoidant 1. When I see people in distress, I don’t feel comfortable jumping in to help. Avoidant 3. I sometimes feel that helping others is a waste of time. Avoidant 7. I don’t invest a lot of energy trying to help others. Anxious, Intrusive 8. I sometimes try to help others more than they actually want me to. Anxious, Intrusive 10. When people don’t want my help, I still sometimes feel compelled to help. Anxious, Intrusive 20. I sometimes feel that I intrude too much while trying to help others. Anxious 2. When helping people, I often worry that I won’t be as good at it as other people are. Anxious 14. I often worry about not being successful when I try to help others who need me. Anxious 16. When I decide to help someone, I worry that I won’t be able to solve the problem or ease the person’s distress. Table 0-14. Items from the Caregiving System Scale (Moreira et al., 2018). In common with attachment styles, caregiving styles are stable and related to personality traits (to be discussed) (DuBois, 2012). Insecure attachment styles and dysfunctional caregiving styles are correlated such that people with preoccupied attachment tend to also be anxious about their caregiving (Table 11). People with avoidant attachment also avoid caregiving (Table 11) and are dismissive of intimacy and companionship needs (DuBois, 2012; Moreira et al., 2018). Intrusive and controlling caregiving behavior correlates with psychological and physical abuse perpetration 24 (Gabbay & Lafontaine, 2016; Green & Werner, 1996). Intrusive caregiving is part of social dominance and avoidance of caregiving is correlated with social dominance (Green & Werner, 1996). Sensitivity and responsiveness determine caregiving capacity throughout adulthood (Collins et al., 2006; Collins & Ford, 2010). Functional caregiving is positively related to empathy, self-transcendent values and high levels of prosocial behavior (DuBois, 2012). Individuals are embedded within a family that includes generations. Because of linked lives between generations, the events, trajectories, or transitions occurring within one family member’s life may impact the lives of the other family members. “Children’s, parents’, and grandparents’ lives are intricately and dependently intertwined across each generation’s life course” (Gilligan et al., 2018, p. 113). Beyond the parenting role, during middle and older adulthood many people find themselves in the role of caregiver for grandchildren or other adults. This caregiving poses unique challenges as described next. Grandparents Raising Grandchildren Ten percent of grandparents (7 million) live in the same household as their grandchildren and 32% of these are primary caregivers (US Census Bureau, 2020) (Figure 3). In 2011, 55% of grandparents were primary caregivers for three years or more; 38% for five years or more; 23% for one to two years; 21% for less than a year. Nine percent of grandparents who are primary caregivers of grandchildren are over 70 years old (Pew Research Center, 2013). In 2011 ethnicity was unrelated to primary caregiving by grandparents, but poverty was a risk factor. Teen pregnancy, death of a parent, mental and physical illnesses, incarceration, and addictions are among the reasons grandparents become primary caregivers (Martin et al., 2020). When grandparents act as primary caregivers, the children they care for often have special needs due to having been neglected or abused, exposed in utero to drugs of abuse, or exposed to parents’ mental illness or addiction (Joshi & Lebrun-Harris, 2022). Compared with children in parent-led households, those in grandparent-led households have: 1) more dental problems; 2) more overweight/obesity 3) more emotional, mental, and developmental health conditions and 4) more special health care needs (Joshi & Lebrun-Harris, 2022). Caring for these children is challenging, but placement within the family is often better for the child than foster care with non-relatives (Kelley et al., 2021). “Grandparents contribute immensely to the development of our society by alleviating the expenses associated with the placement of children in foster care or non-kin households” (Harris et al., 2021, p. 167). However these older adults have to overcome a number of practical challenges without the assistance they need (Harris et al., 2021). Obtaining custody of a child requires that grandparents navigate a difficult legal system. Those without formal legal custody cannot receive public assistance on behalf of the child and cannot give consent for educational placement and medical treatment. Grandparents raising grandchildren may have financial difficulties due to quitting jobs or retiring early to give care and the added expense of the child. Alternatively, they may have the added stress of working full-time while raising children. 25 Housing difficulties are common because senior housing often does not permit children. In recognition of this housing problem, in 2003 Congress passed the LEGACY (Living Equitably—Grandparents Aiding Children and Youth) Act to train front-line staff to help grandparents qualify for housing assistance and to provide financial help to those seeking to remodel their homes to accommodate a grandchild (Hayslip & Kaminski, 2005). Many custodial grandparents worry they will pass away before their grandchildren are independent. Visit AARP for more information and a list of resources for custodial grandparents. Figure 0-4. Recent census data about grandparents co-residing with grandchildren. Grandparents raising grandchildren are a heterogeneous group ranging in age from late 30s to older adulthood. Other important differences include preexisting mental and physical health problems, financial resources, and the circumstances that led to the primary caregiver role (Crowling et al., 2015). The stress involved in caring for grandchildren increases risk for depression and other mental health difficulties, but the effect size is small (Kelley et al., 2021). Grandparents also benefit from providing care because they are experienced with childrearing and the role can give them a sense of purpose. Many enjoy close, loving relationships with their grandchildren and are 26 reassured knowing their grandchildren are being cared for properly (Hayslip & Kaminski, 2005; Sumo et al., 2018). Parenting styles of grandparents have not been researched enough to come to any conclusions. Several intervention programs have been developed to assist custodial grandparents. Most are multidisciplinary and include legal assistance. Successful programs provide in-home care and group support (Sumo et al., 2018). Grandparenting After parents, grandparents are the most important adults in children’s lives. Grandparent financial and educational support enhances child success, and most grandparents enjoy that role more than they enjoyed raising their own children (Carr & Utz, 2020). Nearly 94% of older adults who have children are grandparents, and about 50% will live to be great-grandparents. Those who reside more than 100 miles from their grandchildren have difficulty maintaining close relationships and are more likely to be detached and distant (Table 14). Beyond geographic proximity, parents can either limit or facilitate relationships with grandchildren. Parents who have strong relationships with their parents are more likely to encourage grandparent involvement (MaloneBeach et al., 2018). Grandparents provide instrumental support to their adult offspring and grandchildren if they have good health and financial resources. Grandparents who regularly provide care for children while parents are working, have two roles― surrogate parent and grandparent. Study Grandparenting Style Types Formal― follow what they regard as their proper and prescribed role (Neugarten & Fun seeker― relation to the grandchild is informal and playful. Weinstein, 1964) Surrogate parent― Parent figure when parents are working. Reservoir of family wisdom― parenting authority, advice giver. Distant figure― Sees children only on holidays and special occasions. (Cherlin & Influential― Highly involved in all aspects of grandchild’s life. Furstenberg, Supportive― Highly involved but not with discipline. 1992; Mueller et Passive― Moderately involved in their grandchild’s life. al., 2002) Authority― Authority figures for their grandchild. Detached― The least involved in their grandchild’s life Table 0-15. Grandparenting styles. Researchers have studied the grandparent role by interviewing and surveying grandparents and grandchildren (MaloneBeach et al., 2018). Frequency of contact is important to maintaining a quality relationship. Fun, shared activities and intimacy (knowing each other) increase relationship quality. Grandparents are friends, mentors, coaches, advisors and providers and they need not be disciplinarians (Table 15) (MaloneBeach et al., 2018; Mueller et al., 2002). Caring for Aging Adults with Disabilities Take a mindful few minutes to consider, who should care for adults over 50 who are unable to fully care for themselves? Their life partners, children, aging parents, and/ 27 or siblings could provide paid or unpaid care or perhaps a social safety net should pay for care? Think through your own beliefs about the role of family caregiving so you will know what bias you may bring to this common clinical situation. Family caregiving is usually aimed at preventing institutionalization and is provided mostly by adults 50 years and older (Grossman & Webb, 2016). According to the National Alliance for Caregiving and AARP, in 2014, over 34 million people provided unpaid care, support, or services to an adult older than 50 years (Family Caregiver Alliance, 2015). “At $470 billion in 2013, the value of unpaid caregiving exceeded the value of paid home care and total Medicaid spending in the same year, and nearly matched the value of the sales of the world’s largest company, Wal-Mart ($477 billion);” just under half of that valued care was provided to adults with dementia (Family Caregiver Alliance, 2015).This unpaid care is also called “informal care.” What types of assistance do older adults with disabilities need? Disabled adults may need assistance with activities of daily living (ADLs, e.g. toileting, bathing, dressing, grooming, feeding, transferring), instrumental ADLs (IADLs, e.g., cooking, finances, laundry, shopping, transportation) and help accessing medical services and taking medication. In one study, veterans with dementia needed assistance with at least one, and on average four, of the following: bathing, dressing, grooming, toileting, eating, and getting around inside the home (Grossman & Webb, 2016). Providing this care for adults is more difficult than providing for children. In several studies caregiver stress was found to be lower if the care recipient was more agreeable (Grossman & Webb, 2016). Adults may resist care, and they may lack insight into their need for care. Family members may feel badly about acting against an adult’s expressed wishes. The conflict over care can be stressful. Caring for a family member is easier when the person in need of care lives in the same household (Grossman & Webb, 2016). Who provides informal care for adults with disabilities? Parents provide care for adult children with life-long disabilities. For those who develop disabilities later in life the caregiver is most often the spouse and after that an adult son or daughter including sons and daughters by marriage. Women provide more informal care than men (Grossman & Webb, 2016). Those who give care are themselves likely to be over 50 years old and may also be caring for their minor children or grandchildren (Grundy & Henretta, 2006). Many people provide care to more than one family member, this is called compound caregiving. What kind of support do caregivers need? To prevent poverty and decreased standard of living caregivers need support to retain employment, such as access to adult daycare programs or in-home care during working hours. Depending on the nature of the care recipient’s disability, caregivers may need disorder specific information, help accessing services, training, emotional support, and respite (relief from the caregiver role). The balance between the rewards and costs of caregiving depends on the relationship between the caregiver and recipient, the amount of care, and the recipient’s cooperativeness. 28 Caring for Aging Parents Middle adulthood is a time when many people care for children or grandchildren and aging parents― the sandwich generation gives to both offspring and parents (Grundy & Henretta, 2006). A middle aged woman who has close ties with her adult children and helps them, is also likely to be helping her parents and/or in-laws (Grundy & Henretta, 2006). The average adult caring for their parent, lives with or close to the care recipient, works full time (60%), has children (38%), and provides care up to 100 hours per month (Conway, 2019). In these families with close ties between generations, elders with disabilities often reciprocate care by performing tasks they can still do and by providing emotional support, Elders who continue to contribute, express generativity, and have improved mood (Huo et al., 2018). When middle aged adults care for adult children and parents, they provide care at some cost to themselves. Caregiving can take a toll on a person and impact their mental and physical health (Grossman & Webb, 2016; Wang, 2024). A person who works full-time has a limited number of hours to do household and caregiving tasks, self-care and leisure activities. After age 40 it is especially important that adults exercise at least 2.5 hours per week, sleep 7 hours a night, receive social support/affection and experience pleasant moments each day (CDC, 2024b, 2024a; Linehan, 2014). Decisions to care for another at an expense to the Self are based on perceptions of the other person’s needs and beliefs about the right thing to do (Silverstein et al., 2006). Beliefs about caring for parents are part of Filial piety which is higher in Black and Asian as compared to White families in the US (Conway, 2019; Fingerman et al., 2011). People often feel good when they care for their parents, and they feel good about providing care. These good feelings offset some of the costs of caregiving (Fingerman et al., 2011). Offspring who care for aging parents come up with their own coping strategies and reflect on their own inevitable aging (Conway, 2019). The care recipient’s level of need and their uncooperative or abusive behavior (if present) contribute to caregiver stress. Furthermore, caregiving occurs in the context of the prior relationship that could have been strained or abusive toward the caregiver (Kong et al., 2021). The life course perspective asserts that earlier life experiences influence later outcomes and relationships. An estimated 9.4–26% of those caring for parents experienced abuse and/or neglect by the care recipient (Kong et al., 2021). Clinicians caring for elders are likely to encounter families where the disabled elder was once (and perhaps still is) abusive. While some formerly abused and neglected offspring distance from parents others do not (Kong et al., 2021; Parker et al., 2018). The parent-child relationship can continue despite a history of neglect and/or abuse. Psychological abuse often goes unacknowledged or unrecognized by the survivor and others (Follingstad, 2011). For those that continue a relationship there is a spectrum of involvement and coping. Some neglected and abused individuals undergo post traumatic growth that leads to meaning- making, self-transcendence and greater coping ability. For others, caregiving of the 29 abuser may trigger trauma memories. Resentment, trauma and mood symptoms may lead to maladaptive coping strategies such as substance use. As a group, these individuals do not have adverse reactions to caregiving, the adverse reactions are specific to caring for the parent (Kong et al., 2021). Caregiving of a formerly neglectful/abusive parent may be more challenging if the offspring feels coerced into providing care (Kong et al., 2021). Perceptions of decreased choice arise due to the level of need, demands made, and beliefs in Filial piety. Disability, terminal illness and death of the abusive and/or neglectful parent all pose special challenges for adult offspring. The death of the parent may trigger grief about the losses the individual suffered in childhood such as, the loss of safety, dignity, belonging, and a cohesive sense of self (Kong et al., 2021). The death of the abusing parent may be the time when the survivor loses hope that the abuser will apologize or take responsibility for their prior actions. The survivor and those supporting them may have to accept that, “‘unfinished business’ may not be attended to prior to a parental perpetrator’s death: family relationships may not be reconciled nor healed and forgiveness may not be sought or given” (Kong et al., 2021, p. 517). Survivors may experience disenfranchised grief if others are relieved at the death of the abusive parent. Mental health professionals encounter many middle-aged people who suffered child abuse and neglect and who have parents with narcissistic and antisocial personality traits. Considering the magnitude of this problem there is little evidence-based guidance for clinicians. Read more on NCBI. There are two books written for the public on this topic, Your turn for care: Surviving the aging and death of the adults who harmed you (L. S. Brown, 2012); Senior Sociopaths: How to Recognize and Escape Lifelong Abusers (Andersen, 2021). Caring for Adult Offspring with Disabilities (Note: In this section we continue to consider how the costs of caring for vulnerable and/or disordered adults should be divided between families and the whole society.) Parents of adult children with intellectual developmental disabilities (IDD), addiction, or serious mental illness (SMI) may have lifelong-caregiving responsibilities and financial burden. Whereas developmental disabilities are present from birth, serious mental illness and addiction develop in late adolescence and early adulthood when caregiver burden declines for most parents. Those who care for disabled adult offspring are at increased risk for compound caregiving as their parents and partners come to also need care. The phenomenon of linked lives manifests when the problems of offspring impact parents and grandparents (Gilligan et al., 2018). When one member of a family suffers or is dysfunctional, the entire family system is affected. Individuals vary as to how they cope in family systems where other members are sick or disordered. Some may disengage from the family and suffer costs related to loss of ties and support. Others may stay at a cost to themselves, and still others may be able to thrive despite difficult 30 circumstances (Avieli et al., 2022). To thrive, people must somehow meet their own needs for self-actualization and generativity. Providing care for a disabled child is a commitment that requires sacrifices in other life domains (Avieli et al., 2022). Serious mental illness including major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post-traumatic stress (PTSD) and borderline personality disorder (read more) affects about 6.3 percent of the population. Prior to the 1950s individuals with CMI resided in state facilities. Currently it is “impossible for people with severe mental illness to find appropriate care and shelter” (Yohanna, 2013). Individuals with SMI often become homeless, or reside in nursing homes, intermediate care facilities, jails, and prisons when families are unable to care for them (Yohanna, 2013). Of the more than 10 million American adults with SMI, 30- 60% live with their parents for periods of time between hospitalizations and/or depend on their families for assistance. Many parents of SMI individuals are over 65 years of age (Kaufman et al., 2010; Raymond et al., 2017). Parents notice behavioral changes Parents recognize the problem is serious We See the Problem Parents decide to do something Parents seek to name the problem with a diagnostic lable We Name Parents seek information about diagnosis and treament options the Problem Parents navigate the mental health system We Navigate Parents interact with police, emergency services, inpatient and the System outpatient providers Redefine family life Redefine goals and expectations We Endure the Problem Plan for an uncertain future Figure 0-5. Stages of parenting adult offspring with serious mental illness (Raymond et al., 2017). The Transtheoretical Stages of Change Model describes how people go from not seeing they have a problem to coping with it (Prochaska & Velicer, 1997). Parents whose offspring develop SMI, go through a series of stages on their way to acceptance of and coping with the offspring’s SMI (Raymond et al., 2017). Clinicians can use Figure 4 to consider how to best assist parents in the various stages. Parents in the early stages benefit when clinicians describe the problem behavior and name it. Parents in the later stages need help navigating and accepting the injustice in our mental health system. They also need help deciding how to balance their own needs with their 31 caregiving responsibilities. Clinicians may struggle to understand why parents assist offspring at such a cost to themselves (Band-Winterstein et al., 2014). “Parents of adult children with mental illness have greater levels of caregiver burden, poorer health, higher rates of chronic health conditions, poorer self-reported health, and elevated levels of general medical symptoms than parents whose children do not have disabilities or parents of individuals with developmental disabilities” (S. Ghosh et al., 2012, p. 1118). While adults with SMI suffer with their mental health conditions, a subset also abuse family members. Mental illness can impact empathy and comorbidities can increase aggression (Johnson et al., 2012). Often psychiatric admissions are precipitated by assaultive behavior and up to 40% of family members report having been assaulted by their family member with SMI. As parents age and develop health problems they may be increasingly victimized by abusive offspring with SMI (Band-Winterstein et al., 2014). In addition to listening to concerns of parents, clinicians can refer them to the National Alliance on Mentally Illness (NAMI). NAMI, the nations largest grass-roots mental health organization, operates support groups for parents and others coping with mental illness in a family member. Caring for Sick and Disabled Partners and Spouses As the members of a couple advance in age, one may come to rely on the other more. A relationship that used to be reciprocal may become one sided with one member performing household duties and caring for the other. Cancer, debilitating medical issues, mental illness, or dementia can lead to the need for care. Spousal care can increase adherence to treatment for elders with medical problems (Trivedi et al., 2012). However, spouses provide care at a cost to themselves. Many older adults who planned to work full- or part-time into their 70s, have financial losses from medical expenses and working less after their spouse becomes disabled. Devasting illness in one member of a couple is devastating to the other due to witnessing the deterioration and suffering of their loved one and all the practical disruptions that occur. When caring for partners in each of these circumstances caregivers may assist with ADLs and take over household tasks the partner used to do (Calasanti & Bowen, 2006). For most heterosexual American couples that means husbands take over housework they may not have done in years, and wives take over driving, automobile maintenance and yard work. When assisting their partner with ADLs, caregivers value helping them maintain their appearance and dignity (Calasanti & Bowen, 2006). In addition to this work, the caregiver may need to process the loss of leisure activities the couple used to do together. The caregiver must decide if and how they are going to socialize or have fun without their partner. They must grieve the loss of the life they had and the life they thought they