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Social identity reconstruction through education : a program for older women Hodgins, Grace M. 1991

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SOCIAL IDENTITY RECONSTRUCTION THROUGH EDUCATION: A PROGRAM FOR OLDER WOMEN by GRACE M. HODGINS B.Sc.N., University of Saskatchewan, 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF ADMINISTRATIVE, ADULT AND HIGHER EDUCATION DEPARTMENT OF COUNSELLING PSYCHOLOGY We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH August 1991 (c) Grace M. Hodgins, COLUMBIA 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Admin., Adult S Higher Ed. Counselling Psychology The University of British Columbia Vancouver, Canada Date September 5, 1991 DE-6 (2788) A B S T R A C T A s u b s t a n t i a l n u m b e r o f o l d e r w o m e n a r e a d v e r s e l y a f f e c t e d b y m i l d t o s e v e r e l e v e l s o f d e p r e s s i o n . I n t h i s s t u d y t h e S o c i a l H e a l t h O u t r e a c h P r o g r a m ( S H O P ) , a n e d u c a t i o n a l i n t e r v e n t i o n o r i g i n a l l y d e v e l o p e d f o r m i d d l e - a g e d w o m e n , w a s m o d i f i e d a n d i m p l e m e n t e d w i t h d e p r e s s e d a n d n o n - d e p r e s s e d o l d e r w o m e n . T h r o u g h a n e d u c a t i v e p r o c e s s , p a r t i c i p a n t s l e a r n e d w a y s t o s t r e n g t h e n p e r s o n a l s o c i a l n e t w o r k s a s a m e a n s o f a u g m e n t i n g s o c i a l i d e n t i t y a n d o v e r c o m i n g d e p r e s s i o n . T h e p u r p o s e s o f t h e s t u d y w e r e : 1) t o m e a s u r e t h e i m p a c t o f S H O P o n o l d e r w o m e n ' s l e v e l s o f d e p r e s s i o n a n d d e m o r a l i z a t i o n , a n d o n t h e i r s o c i a l n e t w o r k s ; 2 ) t o d e t e r m i n e f a c t o r s e i t h e r w i t h i n o r o u t s i d e o f S H O P t h a t h e l p e d o r h i n d e r e d t h e i r p r o g r e s s d u r i n g t h e p r o g r a m ; a n d 3 ) t o d e s c r i b e a n d a n a l y z e t h e i r e x p e r i e n c e o f d e p r e s s i o n . A t o t a l o f 1 5 w o m e n , a g e d 5 8 t o 7 6 , p a r t i c i p a t e d i n a 2 0 s e s s i o n v e r s i o n o f S H O P o v e r a t e n w e e k p e r i o d . M e a s u r e s o f d e p r e s s i o n a n d d e m o r a l i z a t i o n w e r e o b t a i n e d b e f o r e , a f t e r a n d t h r e e m o n t h s f o l l o w i n g t h e p r o g r a m ; s o c i a l n e t w o r k s m e a s u r e s w e r e a l s o o b t a i n e d a t t h r e e m o n t h f o l l o w - u p . P a r t i c i p a n t s ' p e r c e p t i o n s a b o u t t h e i r e x p e r i e n c e o f d e p r e s s i o n , a n d a b o u t p r o g r a m f a c t o r s a n d o t h e r c o n c u r r e n t a s p e c t s o f l i f e t h a t h e l p e d o r h i n d e r e d t h e i r p r o g r e s s d u r i n g t h e p r o g r a m , w e r e o b t a i n e d i n p o s t - p r o g r a m i n t e r v i e w s . O u t c o m e s v a l i d a t e d S H O P'S a p p r o a c h a n d d e m o n s t r a t e d t h a t w i t h s l i g h t m o d i f i c a t i o n t h e p r o g r a m i s a s e f f e c t i v e w i t h o l d e r w o m e n a s i t i s w i t h m i d - l i f e w o m e n . P a r t i c i p a n t s w h o w e r e i i d e p r e s s e d a t p r e - t e s t showed a s i g n i f i c a n t d e c l i n e i n d e p r e s s i o n s c o r e s ; on measures o f d e m o r a l i z a t i o n , changes were i n t h e d i r e c t i o n e x p e c t e d , a l t h o u g h n o n - s i g n i f i c a n t . P a r t i c i p a n t s r e p o r t e d s i g n i f i c a n t g a i n s t o t h e i r s o c i a l networks i n terms of p e o p l e and groups added. Content a n a l y s i s of i n t e r v i e w d a t a y i e l d e d 205 h e l p i n g i n c i d e n t s and 130 h i n d e r i n g i n c i d e n t s t h a t o c c u r r e d d u r i n g t h e program p e r i o d ; from t h e s e , 20 c a t e g o r i e s of f a c t o r s t h a t advanced p a r t i c i p a n t s ' p r o g r e s s d u r i n g t h e program, and 19 c a t e g o r i e s of f a c t o r s t h a t impeded t h e i r p r o g r e s s , were d e t e r m i n e d . T h i s s t u d y s u p p o r t e d t h e view t h a t f o r many o l d e r women d e p r e s s i o n o r i g i n a t e s i n t h e i r s o c i a l environment. The f i n d i n g s v a l i d a t e d SHOP'S e d u c a t i o n a l program as a means of i n c r e a s i n g s o c i a l p a r t i c i p a t i o n , r e - c o n s t r u c t i n g s o c i a l i d e n t i t y and overcoming d e p r e s s i o n . TABLE OF CONTENTS Abstract i i Tables v i Figures v i i Acknowledgements v i i i I. INTRODUCTION 1 Older Women i n an Aging Society 2 Longevity and Li v i n g Arrangements 2 Income 3 Health Status and Educational Attainment 5 Prevalence of Depression 6 Consequences of Depression 7 Interventions For Depression 8 Social Networks as a Focus of Educational Intervention 10 Purposes of the Study 11 Hypotheses 12 Operational Definitions 12 Organization of the Study 13 Scope, Limitations and Significance of the Study ... 13 II. LITERATURE REVIEW 15 Social Perspectives on Depression and Intervention . 16 Social Identity Degradation 17 The Social Network as Source of Social Identity . 18 Social Identity D e f i c i t Depression 19 A Psychosocial View of the Depressive Process ... 20 Implications for Intervention 21 Social Identity and Depression 23 Evidence on the Social Identity D e f i c i t of Older Women 2 3 Risk Factors for Depression Among Older Women ... 27 Older Women's Experience of Depression 31 Social Identity Reconstruction Strategies 34 Health-Promoting Social Networks 34 Types of Network Augmentation Programs 36 Educational and Small Group Strategies 36 Intervention Outcomes 41 Summary 48 III. METHODOLOGY 51 The Research Methodology 51 Design of the Study 51 The Setting 53 Recruitment 53 Screening 55 Subjects 56 Dropouts 57 Instruments and Data C o l l e c t i o n Procedures 59 Data Analysis Procedures 62 i v The Educational Methodology 64 Modifications to the SHOP Program 64 F a c i l i t a t o r ' s Role and Instructional Techniques . 65 Program Evaluation 66 IV. FINDINGS AND DISCUSSION 67 Outcome Measures 67 Levels of Depression and Demoralization 67 Impact on Social Networks 7 0 A c t i v i t i e s and Processes that Helped or Hindered Participants' Progress i n SHOP 76 Categories and Descriptions of Helping Factors .. 77 Discussion of Helping Factors 81 Categories and Descriptions of Hindering Factors . 83 Discussion of Hindering Factors 87 Evaluation of Program Content 88 The Experience of Depression 91 Summary of F i e l d Notes 97 Impact of Low Income on Social P a r t i c i p a t i o n .... 97 Communication with Physicians 98 The Need for Alternatives to Medication 99 Development of 'Voice' 100 Setting Personal Goals: A New Experience 100 Individual Support of Participants 101 V. SUMMARY AND RECOMMENDATIONS 102 Summary 102 Recommendations 110 Adapting SHOP for Women i n Later L i f e 110 Extension of the Social Health Outreach Program . 112 Guidelines for F a c i l i t a t o r s 112 Experience as a Base for Planning Interventions . 114 Education of Professional and Lay Leaders 114 Conclusion 115 REFERENCES 117 APPENDICES 124 Appendix A - Recruitment Materials 124 A - l : Recruitment Poster 124 A-2: Recruitment Poster 125 A-3: Cover Letter 126 Appendix B - Research Instruments 127 B - l : Centre for Epidemiological Studies Depression Scale (CES-D) 127 B-2: General Well Being Schedule (GWB) 128 B-3: Background Information Interview 131 B-4: Post Program Interview 132 B-5: Follow-up Interview 133 Appendix C - Post Program Interview Summaries 134 Appendix D - Program Materials 142 D-l: Goals of SHOP and Course Outline 142 D-2: SHOP Evaluation 143 v TABLES L i s t of Tables 1: Participant Sociodemographic and Health-Related Characteristics 58 2: Means and Standard Deviations for CES-D and GWB Measures at Pre-, Post and Follow-up Evaluations, For the Whole Group, the Non-Depressed, and the Depressed ) 68 3: Social Network Changes Reported by Participants at 3 Month Follow-Up 75 4: Helping Factors Reported by Participants 78 5: Hindering Factors Reported by Participants 84 6: Participant Rating of SHOP Content 89 7: Frequency of Responses on the Experience of Depression 93 v i FIGURES L i s t of Figures 1: Design of the Study 52 2: Network Map of Depressed Participant 72 3: Network Map of Non-Depressed Participant 73 v i i Acknowledgements A sincere thank-you to the 15 women who participated i n the Social Health Outreach Program (SHOP). Their willingness to "get involved" made t h i s study possible. Their contributions v i a sharing of experiences, discussion of issues, and evaluation of the program fostered a l i v e l y learning exchange and furthered the development of SHOP. I thank the many volunteers of the Mature Women's Network, and the following two seniors' organizations for providing support, space and r e c r u i t i n g assistance for SHOP: the 411 Dunsmuir Seniors' Centre Society, i n p a r t i c u l a r Madge Sasvari, Ursula Kasting, and Mike Melnyk; and the West End Seniors' Network, esp e c i a l l y Kay Stovold, and Jean McFadgen. I am grateful to Anna Baron, employment consultant, who assisted with the screening process and provided encouragement during the start-up phases of both groups. The patient advice and support of my advisory committee were indispensible i n moving t h i s project to completion. Thanks to Dr. James Thornton for his open o f f i c e door, for introducing me to many people i n the 'gerontology' network, and for encouraging me to 'stretch' a l i t t l e further; to Dr. Beverly Burnside for her non-stop encouragement, p r a c t i c a l advice and expertise throughout t h i s project; to Dr. John C o l l i n s for his ever-ready telephone presence and his patient guidance to a ' s t a t i s t i c a l beginner'; and to Dr. Norman Amundson for his advice and feedback. I am grateful to my colleagues Barbara Berry, Barbara Clough Sharon Harold and Janet Ray for t h e i r i n t e r e s t , 'pep c a l l s ' , and friendship which sustained me and were a highlight of t h i s experience. I extend h e a r t f e l t appreciation to my husband, Doug, for his unstinting encouragement, support and sense of humour throughout t h i s undertaking; and to our children, Daniel and Amy, for t h e i r goodwill and a f f e c t i o n . v i i i I. INTRODUCTION Many older women i n Canada suffer from depression, and the number i s expected to increase as the population ages (Gee & Kimball, 1987). Older women are a rapidly growing sector of Canada's population (McDaniel, 1986); the majority are reaching retirement age with limited s o c i a l and economic resources, primarily as a resul t of occupying t r a d i t i o n a l female ro l e s . These socio-economic disadvantages place older women at r i s k for depression (McEwan, Donnelly, Robertson, & Hertraan, 1991). Although older women require resources outside themselves to overcome depression, there i s a dearth of knowledge to inform p o l i c y or program i n i t i a t i v e s ; there are few attempts i n the l i t e r a t u r e to understand depression or related interventions from the viewpoint of older women. For many, the accessible treatment option i s antidepressant drug therapy, an approach which frequently causes troublesome side e f f e c t s , and f a i l s to address the range of factors contributing to t h e i r depression. Educational interventions are needed that are aimed at preventing or a l l e v i a t i n g depression among older women, p a r t i c u l a r l y depression that i s rooted i n soci o - c u l t u r a l as well as health phenomena. A preliminary step i n such an undertaking involves understanding older women's experience and using t h e i r experience as a base for an educational intervention. In addition, i t i s necessary to discern older women's perceptions about which aspects of intervention are e f f e c t i v e . This study was undertaken to provide further information 1 about older women's perspectives on the experience of depression and on an educational intervention designed with t h e i r needs i n mind. The impact of the intervention as a means of a l l e v i a t i n g depression was assessed. As background, t h i s chapter provides a p r o f i l e of older women, pointing out the challenges they face i n an aging society. It i s argued that t r a d i t i o n a l medical and psychological therapies f a i l to address the s o c i a l roots of older women's depression, and that alternative interventions are needed. Social network augmentation as a focus of educational intervention i s discussed as a strategy suited to the needs of many older women. The purpose, scope, limitations and significance of the study are c l a r i f i e d along with operational d e f i n i t i o n s and hypotheses. OLDER WOMEN IN AN AGING SOCIETY Most women manage t h e i r aging well; however, a considerable number grapple with rolelessness, s o c i a l i s o l a t i o n , poverty and health problems. Such circumstances, for many older women, dictate a d a i l y monotony and hardship that engenders depression. Longevity and Living Arrangements On average, women outli v e men i n almost a l l parts of the world (Mercer & Garner, 1989). Consequently, older women outnumber older men by a sizable margin. In Canada, i n 1981 there were 124 females for every 100 males i n the age group 65-79, and 184 females for every 100 males i n the 80 and over category (Health & Welfare Canada, 1983). Given longevity 2 patterns, a sizable chunk of the average woman's l i f e w i l l be spent i n old age. A related projection i s that many women w i l l experience widowhood. Matthews (1987) reported that i n Canada widows outnumber widowers by almost f i v e to one. This finding i s considered to be a re s u l t of three factors: the longer l i f e span of women; t h e i r tendency to be two to three years younger than husbands; and t h e i r tendency to remain widowed i f they become widowed. By 1981 the average age at widowhood had increased so that 69.1% of widows were over 65 (Matthews, 1987). Although the number of older women who are divorced, separated or never-married i s small compared to the number of widows, the number i s growing (Mercer & Garner, 1989). Considering the above s t a t i s t i c s i t i s not surprising that i n developed countries, where there i s a trend toward l i v i n g alone, most older women l i v e on t h e i r own, not with families or in i n s t i t u t i o n s . This tendency to l i v e alone seems to stem from a desire on the part of many older women to maintain privacy and independence and "not be a burden" on others. It does not appear to be due to family unwillingness to assume caregiving roles (Mercer & Garner, 1989). Income Economically the picture for older women i n Canada i s bleak, i n fact, income has been c i t e d as t h e i r number one problem (Nishio & Lank, 1987). The picture i s p a r t i c u l a r l y grim for unattached older women (mostly widows, some divorced and separated), who emerge as f i n a n c i a l l y one of the poorest segments 3 of the Canadian population. Gee and Kimball (1987) reported that i n 1985 about 60 percent of unattached women aged 65 and over existed at or below the poverty l i n e set at $8,000 for an in d i v i d u a l . An additional 18 percent had incomes just above that, between $8,000 and $9,999. In sum, approximately 78 percent of older, unattached, women were poor or close to i t . Nishio and Lank (1987) attributed the poverty of older women to two main sources—pension system inequities and the fact that women work i n lower paying jobs. In addition, they stressed that older women are more l i k e l y than older men to be poor or dependent on t h e i r families for support because of no remuneration for work i n the home, and because employment patterns are commonly interrupted i n order to nurture children or care for f r a i l family members. Gee and Kimball (1987) argued that women's dependent f i n a n c i a l status r e f l e c t s gender-based di v i s i o n s of labour. Women's homefront roles are unpaid and t h e i r work outside the home i s generally considered secondary to primary domestic duties. Thus, as a re s u l t of devalued labour roles both inside and outside the home, women tend to be f i n a n c i a l l y dependent on men. Gee and Kimball (1987) pointed out the l i k e l i h o o d of continuing poverty for older women, ...many of the variables that have led to high rates of poverty among the present population of older women continue to operate for younger women. In other words, future cohorts of elde r l y women are l i k e l y to experience high levels of poverty as well, although 4 perhaps not as high as today's older women (p. 59). Health Status and Educational Attainment Mercer and Garner (1989) compare the health status of older women and men as follows, "women report higher morbidity than men and have lower mortality rates; women are, as a group, hospitalized more often than men; they receive the majority of surgical procedures; consume more drugs than do men (especially psychotropics); and are i n s t i t u t i o n a l i z e d more often than men" (p. 37). In addition, these authors maintain that older women experience s i g n i f i c a n t l y greater physical mobility problems than older men. Educationally, although the gap i s narrowing, the le v e l of education attained by older people i s well below that of younger people. Gender differences are apparent i n that older women are less l i k e l y than older men to have completed secondary school (Mercer & Garner, 1989). Thus, a composite picture of older women emerges. Relative to t h e i r male counterparts, women are more l i k e l y to l i v e longer and l i v e alone i n the l a s t quarter of t h e i r l i v e s . They w i l l probably have less income and more chronic i l l n e s s than men, and they w i l l have less education than both older men and younger people. This means that many women face the prospect of aging without adequate finances, and with dismal chances for employment at a time when they may be adjusting to widowhood, l i v i n g alone and dealing with health problems. This s i t u a t i o n , according to Olson (1988), s i g n i f i e s that "Clearly, our society maintains 5 women's subordinate s o c i a l , economic, and sexual statuses into old age. Moreover, the issues and problems confronting younger women tend to become exacerbated as they age" (p. 106). Prevalence o f Depression Given the constraints facing older women, i t i s reasonable to view them as vulnerable to depression; however, i t i s d i f f i c u l t to pinpoint a prevalence rate for depression among t h i s group for several reasons: 1. Epidemiological studies d i f f e r i n how they define and measure depression. 2. Estimates of depression rates based on these methodologically d i f f e r e n t studies vary widely and are of questionable accuracy. 3. There are no reported comprehensive reviews of depression incidence and prevalence studies from the point of view of older women. Gurland and Toner (1982) analyzed studies of the general eld e r l y population and found the following: 1. Ten to f i f t e e n percent of older people suffer from c l i n i c a l l y s i g n i f i c a n t depression. 2. The rates of demoralization syndrome (less severe symptoms) are thought to be double that of c l i n i c a l depression. 3. At mi d - l i f e rates of depression are much higher i n women than men, but after m i d - l i f e the rates r i s e for men and f a l l for women. 4. After age 75 men have higher rates of depression than 6 women. Gurland and Toner distinguish between " c l i n i c a l l y s i g n i f i c a n t depression" and "demoralization syndrome", intimating that the l a t t e r i s a d i f f e r e n t and milder phenomenon than the former. As w i l l be seen, however, evidence from the Social Health Outreach Program (SHOP) shows that demoralization i s a feature of both mild and severe depression i n women; th i s suggests that d i s t i n c t i o n s i n levels of depression on the basis of demoralization may be a r t i f i c i a l . Consequences of Depression At present, a considerable number of older people suffer from depression unaided; less than a quarter receive help for the problem (Klerman, 1983). This i s considered to re s u l t from several factors: few older people use t r a d i t i o n a l mental health services (Beck & Pearson, 1989); physicians who are uninformed about l a t e - l i f e depression may dismiss the symptoms as part of the aging process; and, manifestations of depression i n older people resemble those of other conditions (e.g. dementia) and are often missed or misdiagnosed. For older people the consequences of undetected, ongoing depression may be severe, including: withdrawal and alienation from family and friends, avoidable suffering, premature retirement, malnutrition, over-medication, addictions, premature aging, unnecessary i n s t i t u t i o n a l i z a t i o n , and suicide (Gurland, Dean & Cross, 1983). Numerous questions about depression among older women remain unanswered. Nonetheless, the problem i s pressing and w i l l 7 continue unless immediate steps are taken to adequately address the f i n a n c i a l , health, educational and s o c i a l needs of older women. INTERVENTIONS FOR DEPRESSION The study of depression i s plagued by controversy and considerable divergence of opinion regarding i t s d e f i n i t i o n , cause and treatment. Coyne (1986) described the study of depression as thoroughly fragmented and polarized. She suggested that enormous differences i n terminology, interpretation and emphasis must be confronted before an integration of perspectives on depression i s achieved at th e o r e t i c a l and practice l e v e l s . While current l i t e r a t u r e advances m u l t i f a c t o r i a l models of depression, such approaches have yet to be re f l e c t e d i n interventions which tend to centre around the methods of a pa r t i c u l a r d i s c i p l i n e . When depression among older women i s detected i t i s usually medically treated. A diagnosis i s made based on presenting symptoms and most often medical treatment takes the form of psychotropic drug therapy (D'Arcy, 1987). Yet Strauss and Solomon (1983) described the range of studies of drug therapy for the treatment of depression i n older people as "severely limited" (p. 16). In another review, Gerson, Plotkin and Jarvik (1988) described the extent of investigation as "appallingly small" (p. 311) and stressed that older people experienced undesirable side effects associated with a l l of the antidepressant drugs reviewed. Glantz and Backenheimer (1988) contended that older women are a 8 group at high r i s k for adverse drug reactions and physician-perpetrated drug abuse involving p r e s c r i p t i o n psychotropic drugs. The evidence suggests that psychotropic drug therapy may cause as many problems for older women as i t solves. Of related in t e r e s t , Lundervold & Lewin (1990) demonstrated that older people have clear preferences with regard to treatment for depression, rating behavior therapy as s i g n i f i c a n t l y more acceptable than medication. Psychological methods such as behavioral, cognitive and analytic therapy have been applied with depressed older people; however, these are used infrequently as compared to drug therapy. Most writers who discuss psychotherapy contend that counsellors have paid limited attention to older people, r e f l e c t i n g a general aversion toward working with them (Sparacino, 1980; Steuer, 1982; Wellman & McCormack, 1984). In addition, Chaisson-Stewart (1985) pointed out the limited amount of outcome research on psychotherapy with depressed older people. Two recent studies offered encouraging results with psychotherapy based on cognitive, behavioral and analytic p r i n c i p l e s i n a group setting (Steuer, Mintz, Hammen, H i l l , Jarvik, McCarley, Motoike & Rosen, 1984) and a one-to-one setting (Gallagher-Thompson, Hanley-Peterson & Thompson, 1990). However, there i s an absence of studies that have analyzed these therapies from the perspective of older women. Tr a d i t i o n a l medical and psychological interventions for depression are increasingly viewed as too narrow for older women (Gatz, Pearson & Fuentes, 1984). These 9 therapies tend to focus on the int e r n a l world of the ind i v i d u a l older woman (e.g. biochemistry or cognitive processes) placing the onus for change on her. In fact, her depression may be a r e a l i s t i c response to oppressive s o c i a l r e a l i t i e s such as rolelessness and poverty which are external to her and often beyond her sphere of influence. A clear challenge to pr a c t i t i o n e r s i s to design non-t r a d i t i o n a l interventions which acknowledge the context of older women's l i v e s . Gatz, Pearson and Fuentes (1984) maintained that a whole range of services, including t r a d i t i o n a l ones, should be available to older women when they are needed and wanted. These authors emphasized that the burden of change i n improving the well-being of older women must be so c i o - c u l t u r a l . S O C I A L NETWORKS AS A FOCUS OF E D U C A T I O N A L I N T E R V E N T I O N A large body of research demonstrated that s o c i a l t i e s and so c i a l support are s i g n i f i c a n t l y related to peoples' health status (see for example: Cassel, 1976; Berkman & Syme, 1979; Orth-Gomer & Johnson, 1987). A s o c i a l network, i n stru c t u r a l terms, i s a set of t i e s or linkages among a group of people. In functional terms, i t i s a set of relationships within which interpersonal feedback and s o c i a l support are exchanged. Even though the mechanism of action l i n k i n g s o c i a l networks to health i s s t i l l unknown, there i s support for the notion that strengthening of s o c i a l networks i s a desirable goal of intervention, p a r t i c u l a r l y with those older people whose interpersonal contacts have dwindled due to retirement, moving, 10 or health problems of themselves and others i n t h e i r networks (Minkler, 1981; Isr a e l , Hogue & Gorton, 1984). One successful educational intervention aimed at augmenting the s o c i a l network as a means of overcoming depression was conducted by Burnside (1990). She developed and tested the innovative Social Health Outreach Program (SHOP) as a treatment for depression i n middle-aged women. Her research, which t h i s study extends, i s further discussed i n Chapter II. PURPOSES OF THE STUDY In t h i s study the Social Health Outreach Program (SHOP) was adapted and conducted with two groups of older women. Since i t was expected that the issues a f f e c t i n g older women would be simi l a r to the issues they faced e a r l i e r i n l i f e , much of the o r i g i n a l program content was retained. However, because common stereotypes associate aging with i n t e l l e c t u a l decline, and because attempts to measure the impact of educational intervention as a means of a l l e v i a t i n g older women's depression are absent i n the l i t e r a t u r e , i t was important to demonstrate the effectiveness of such an approach with t h i s group. The purposes of the study were: 1. To determine the impact of p a r t i c i p a t i o n i n SHOP on participants' levels of depression and demoralization and on t h e i r s o c i a l networks. 2. To determine participants' perceptions about which a c t i v i t i e s and processes helped or hindered t h e i r progress during an educational intervention for depression. 3. To describe participants' experience of depression. HYPOTHESES This study tested the following hypotheses: 1. P a r t i c i p a t i o n i n SHOP w i l l reduce women's depression and demoralization. 2. P a r t i c i p a t i o n i n SHOP w i l l increase the size of t h e i r s o c i a l networks. OPERATIONAL DEFINITIONS P a r t i c i p a t i o n was defined as attendance at SHOP sessions. Social network changes were defined as participants'perceptions of changes to t h e i r s o c i a l networks at 3 months following SHOP, as compared to before the program. Depression For the purpose of consistency with e a r l i e r research, the diagnosis of depression was determined using Diagnostic Interview Schedule c r i t e r i a . Level of depression was defined and measured using the Centre for Epidemiological Studies Depression (CES-D) Scale; a score of 16 or greater defined depression. Demoralization was defined as a score of 70 or less on the General Well Being Schedule. 12 ORGANIZATION OF THE STUDY Chapter II examines the th e o r e t i c a l and research base supporting the intervention applied i n the study, and elaborates on socio-environmental issues related to older women's depression. A rationale i s provided for small group, educational interventions aimed at augmenting s o c i a l networks i n helping women overcome depression. Chapter III outlines the design of the study including a detailed description of the research and educational methodologies. Chapter IV presents the research findings and analyzes them according to the questions addressed by the study, and i n re l a t i o n to findings of other research. Chapter V provides a summary and discusses recommendations for program planning with older women. Suggestions for future research are included. SCOPE, LIMITATIONS AND SIGNIFICANCE OF THE STUDY This study does not provide a comprehensive analysis of depression i n older women. Nor does i t review i n d e t a i l the range of treatments for depression. Rather, t h i s investigation describes the application of a small group, educational intervention based on a soci o - c u l t u r a l view of depression among older women. The findings of the study must be generalized with caution. Subjects were volunteers who possessed s u f f i c i e n t psychological resources to seek out the program and were ph y s i c a l l y able to get 13 to the program. Although i t i s reasonable to assume that many-older women are similar to these participants, t h i s group does not represent a l l older women. The potentials of the SHOP program as a community-based strategy to help older women avoid or overcome depression and re-integrate i n the community are enormous. The significance of the study l i e s i n i t s potential to inform program planning and service provision for older women—a marginalized and rapidly expanding group. 14 I I . L I T E R A T U R E R E V I E W This chapter reviews the theory and research underpinning the program applied i n t h i s study. It examines older women's depression as i t i s understood from a s o c i a l perspective. Literature related to the following areas was reviewed: depression and intervention from a s o c i a l perspective; evidence about s o c i a l i d e n t i t y d e f i c i t among older women and factors that place them at r i s k for depression; older women's experience of depression; and guidelines for s o c i a l i d e n t i t y reconstruction programs with older women. F i r s t , a b r i e f comment on the current state of research l i t e r a t u r e pertaining to older women. One of the main c r i t i c i s m s of t h i s l i t e r a t u r e i s that most of i t i s descriptive and based on no t h e o r e t i c a l perspective; an occurrence which can pa r t l y be explained by the fact that the study of women and aging i s quite new. In a review of l i t e r a t u r e on older women Robinson (1986), writing from a health f i e l d perspective, concluded that much of the research on older women i s atheoretical. Furthermore, Robinson noted that evaluative research about the results of intervention projects with older women was generally absent. Gee and Kimball (1987) contended that the f a i l u r e to incorporate women into mainstream t h e o r e t i c a l perspectives on aging r e f l e c t s the general marginality of women i n society. Furthermore, these authors observed that research on aging women tends to focus on th e i r f a m i l i a l and reproductive roles and functions (e.g. widowhood, caregiver, menopause) and only to a limited 15 extent addresses roles which take place outside of the home (e.g. labour force or volunteer r o l e s ) . SOCIAL PERSPECTIVES ON DEPRESSION AND INTERVENTION One of the pi v o t a l issues i n building a theory of depression i s the question of cause. Scholars currently describe depression as a multidimensional phenomenon influenced by, and influencing, s o c i a l , b i o l o g i c a l and psychological factors. Within these broad parameters the s o c i a l roots of depression are widely acknowledged as a pragmatic focus of intervention. Models which locate the or i g i n of depression within individuals (e.g. as cognitive or b i o l o g i c a l disorders), and treatment programs based on these views, are increasingly viewed as inadequate for older women who face gla r i n g s o c i a l and economic disadvantages. While there i s no doubt that b i o l o g i c a l and cognitive changes are part of the phenomenon of depression, one of the assumptions of t h i s study i s that for many older women such changes are not a cause of depression, but rather an ef f e c t . Following Burnside (1990), t h i s study presumes that for most older women such problems as depressed mood, low motivation, anxiety, low self-esteem and negative thinking, may be interpreted as symptoms of demoralization i n response to a depressing l i f e . According to th i s view the primary focus of intervention should be the woman's so c i a l world, and the central aim should be integration or reintegration i n an id e n t i t y - a f f i r m i n g and supportive community network. Social cause perspectives on depression rest on studies 16 which demonstrate that rates are high among those who are i n some way s o c i a l l y disadvantaged, for example those who are unemployed, poor, el d e r l y or female. Most older women occupy a l l of these statuses. Evidence on the relationship of s o c i a l factors to depression among older women i s reviewed l a t e r i n the chapter. Social Identity Degradation Sarbin (1970) provided a conceptualization of depression which accounts for the fact that those who have lower socio-economic status (e.g. finances, housing, education) are more l i k e l y to be depressed that those who have adequate resources (Blazer & Williams, 1980; Goldberg, Van Natta & Comstock, 1985). He introduced the notion that the forerunner of mental breakdown or dysfunctional behavior i s the "degraded s o c i a l i d e n t i t y " . In thi s perspective the focus i s not on the in d i v i d u a l , rather the indi v i d u a l i s viewed as a member of a c o l l e c t i v e , acting and int e r a c t i n g with others. The individual's i d e n t i t y i s s o c i a l l y determined through role relationships i n s o c i a l settings. The indi v i d u a l enacts a s o c i a l role, and relevant others provide feedback which influences the individual's sense of value or s e l f worth. In describing the process of s o c i a l i d e n t i t y degradation Sarbin (1970) f i r s t explained how an individual's s o c i a l i d e n t i t y i s valued. He proposed that t o t a l value can be determined by assessing the following dimensions of the s o c i a l roles occupied by an i n d i v i d u a l : 1. Status refers to the position of the role i n a s o c i a l 17 structure. In our society status i s granted to those who enact achievement roles (e.g. judge, doctor, professor), not ascribed roles (e.g. r e t i r e e , mother). 2. Value refers to po s i t i v e or negative feedback conferred for enacted roles. Performance of achievement or chosen roles may be valued on a scale anywhere from low to high. In contrast, granted or ascribed roles earn no value, but nonperformance of these roles generates negative s o c i e t a l sanction (e.g. neglecting parental duties). 3. Involvement i s the degree of p a r t i c i p a t i o n of s e l f i n the role enactments (e.g. amount of time, energy) and whether or not there are legitimate opportunities for obtaining role distance or being "out of r o l e " . Such opportunities are absent when one occupies only granted r o l e s . According to Sarbin, an individual's s o c i a l i d e n t i t y becomes degraded when the in d i v i d u a l has few opportunities to engage i n role behaviors that have elements of choice and that are valued by s e l f and others. The Social Network As Source Of Social Identity A s o c i a l network can be defined as that set of personal contacts through which the in d i v i d u a l maintains an i d e n t i t y and receives s o c i a l support, that i s , emotional support, material a i d and services, information and new s o c i a l contacts (Walker, MacBride & Vachon, 1977). From a life s p a n perspective, Kahn and Antonucci (1980) conceptualized the personal s o c i a l network as a convoy, a set of people surrounding an ind i v i d u a l who i s moving 18 through l i f e . The s o c i a l roles that an i n d i v i d u a l plays at d i f f e r e n t points i n the l i f e course are the basis for interpersonal relationships within the convoy. These relationships are characterized by the giving and receiving of s o c i a l support. Fisher (cited i n Minkler, 1981) contended that individuals create t h e i r personal networks from a small set of s o c i a l l y structured alternatives. In t h i s sense an individual's position i n the s o c i a l structure determines what opportunities w i l l be available for forming s o c i a l relationships and what resources the i n d i v i d u a l may possess to pursue those t i e s . Burnside (1990) stressed that s o c i a l s o c i a l i d e n t i t y i s what your s o c i a l network says you are and that the roles one occupies throughout the l i f e span construct the shape of the convoy or network. As s o c i a l roles and the related personal network undergo change, s o c i a l i d e n t i t y changes. Burnside defined s o c i a l i d e n t i t y as the aggregate of roles and statuses associated with an i n d i v i d u a l . Social Identity D e f i c i t Depression Burnside (1990) maintained that a s a t i s f a c t o r y s o c i a l i d e n t i t y i s a universal need of a l l people. She stressed that i t i s feedback from others on "how we're doing" which forms the basis of our self-concept. In Burnside's (1990) view people who occupy low status or marginal s o c i a l roles have a hard time retaining a p o s i t i v e self-concept and sense of self-esteem. Burnside asserted that a chronic s o c i a l i d e n t i t y d e f i c i t due to lack of rewarding s o c i a l roles and status i s at the root of most 19 female depression, low self-esteem and anxiety. A Psychosocial View of the Depressive Process Freden (1982) explained how s o c i a l i d e n t i t y d e f i c i t may relate to manifestations such as anxiety, low self-esteem and depression. Like Sarbin (1970) and Burnside (1990), Freden argued that depression i s determined primarily by conditions i n the s o c i a l environment. He proposed that there are several interconnected elements i n the depressive process. The f i r s t i s r e s t r i c t i v e e x t r i n s i c circumstances over which the ind i v i d u a l exerts l i t t l e control, for example s o c i a l group a f f i l i a t i o n s based on sex or class; a r i g i d , i s o l a t e d family system; and past trauma. Such external circumstances spawn two other elements of the depressive process, namely, r i g i d action patterns and a limited range of possible actions. These are exemplified by persons who tend to apply the same solution to a l l problems, depend on a limited number of people for self-esteem, or perceive very few action alternatives as f a l l i n g within t h e i r range of a b i l i t y . To i l l u s t r a t e , Freden c i t e d the example of women who are brought up to adopt the t r a d i t i o n a l female r o l e . Such women often have s o c i a l r e s t r i c t i o n s imposed on them i n regard to how extensively they can investigate the world and, consequently, they may have a limited repertoire of possible actions to apply when confronted with problems. Furthermore, i n keeping with s o c i a l l y structured t r a d i t i o n a l female role expectations, many of these women l i v e i n situations i n which t h e i r self-esteem i s 20 almost s o l e l y contingent on a relationship with a man. If such a relati o n s h i p i s nonexistant or threatened, for whatever reason, the woman's self-esteem i s i n jeopardy. In Freden's (1982) explanation having a healthy self-esteem and avoiding depression rest on having access to a range of action opportunities. When one can neither see nor have access to alternative actions as a way to counter threats to s e l f esteem in untenable situations, anxiety and depression are probable. Freden summarized the depressive process as follows: external circumstances that are inaccessible to influence rai s e the avoidance of anxiety to the le v e l of a primary goal, and self-esteem i s reduced; r i g i d action patterns are enforced i n order to keep anxiety and fear of the uncertain at bay; the limited range of action opportunities reduces self-esteem, which i n turn renders the i n d i v i d u a l more vulnerable i n any c r i s i s involving a further threat to his already f r a g i l e sense of self-value (p. 172). Implications for Intervention A key issue i n depression i s the question of how to prevent and a l l e v i a t e i t . A common theme i n the work of Sarbin (1970), Freden (1982) and Burnside (1990) was that the roots of depression are not within the in d i v i d u a l ; rather, they are i n the wider s o c i a l context. Accordingly, these authors emphasized that strategies to prevent or a l l e v i a t e depression must address, at d i f f e r e n t l e v e l s , the s o c i a l environments of those affected. On a micro-social l e v e l , Sarbin (1970) suggested that case-finding procedures should proceed, not on the basis of psych i a t r i c symptoms, but rather on the basis of i d e n t i f y i n g individuals with degraded s o c i a l i d e n t i t i e s . To adopt t h i s approach p r a c t i t i o n e r s would have to learn to recognize when so c i a l i d e n t i t y degradation i s occurring and to create situations which give potential sufferers opportunities to be p o s i t i v e l y valued. Burnside's (1990) view was that the most appropriate therapy for socially-caused depression should occur at a macro-level, that i s , s o c i a l and economic inequities which create disadvantaged sub-groups should be eliminated. This approach emphasized that depression i s a s o c i o - p o l i t i c a l issue, a viewpoint which Burnside noted i s well understood by community seniors' organizations that promote income assistance, better housing and transportation as mental health measures. On the public agenda, however, the s o c i a l and p o l i t i c a l roots of mental i l l n e s s are just beginning to be recognized i n Canada. Burnside referred to a report commissioned by the Canadian Mental Health Association which concluded that the mental health of women w i l l improve only when we raise t h e i r status i n society. Burnside (1990) argued, however, that depression can be addressed on a micro-social l e v e l . Women can learn to promote t h e i r own mental health by stengthening t h e i r personal s o c i a l networks and involving themselves i n esteem-building community a c t i v i t i e s . When pra c t i t i o n e r s are involved i n t h i s process t h e i r role i s to help women acquire the knowledge, s k i l l s and confidence they need to re-integrate i n a supportive community. Freden (1982) proposed that actions to prevent or ameliorate depression must be applied at several i n t e r r e l a t e d l e v e l s : 1) society and i t s i n s t i t u t i o n s ; 2) primary groups such as family, friends, school and work; 3) external l i f e , that i s , what people do; and, 4) the inner l i f e which includes peoples' perceptions and experiences. Freden emphasized that an intervention for depression w i l l meet with limited success i f the so c i a l s i t u a t i o n which i s undermining the individual's s e l f worth p e r s i s t s . Conversely, to help people overcome depression, Freden argued that i t i s not enough to recommend changes i n society and in the subject's s o c i a l s i t u a t i o n . Depressed people often need help to move beyond c r i p p l i n g negative self-images and b e l i e f s . SOCIAL IDENTITY AND DEPRESSION A degraded s o c i a l i d e n t i t y stemming from s o c i a l disadvantage and marginalization i s often at the root of depression i n older women. Research findings on the s o c i a l i d e n t i t y of older women, and the contribution of s o c i a l factors to t h e i r depression, support t h i s view. Evidence on the Social Identity D e f i c i t of Older Women The l i t e r a t u r e indicates that older women are at r i s k of developing a s o c i a l i d e n t i t y d e f i c i t . In our society "older woman" i s a low status, undervalued role beset by the i l l s of ageism and sexism. Breytspraak (1984) pointed out that although some stereotypes cast older people i n a pos i t i v e l i g h t (e.g. they are viewed as fr i e n d l y , wise, and generous), on balance most are negative (e.g. older people are viewed as f r a i l , f o r g e t f u l , grouchy, mentally slower, closed-minded and unproductive). This same author described how many older people i n t e r n a l i z e these stereotypes and come to label themselves as inadequate. Matthews (1979) contended that, given the current milieu, "oldness" creates a spoiled personal i d e n t i t y . She f i r s t described how people use appearance to communicate t h e i r i d e n t i t y , values and attitudes; an e f f e c t i v e process insofar as appearance can be f a i r l y e a s i l y interpreted. In the case of older people, Matthews argued that the behavioral correlates of wrinkles and gray hair are not clear; thus, ambiguity and uncertainty become elements of the i d e n t i t y of older people along with the demeaning experience of being old i n a youth-oriented society. The s o c i a l i d e n t i t y of older women i s further jeopardized by the sexist notion that the worth of a female i s defined i n terms of her youth and attractiveness. Cohen (1984) underscored how the media and the beauty industry brainwash women, from childhood on, to believe that what counts i s a beautiful face and body, and that women are only creditable i f they f i g h t the v i s i b l e signs of t h e i r aging. In interviews with many women Cohen (1984) found that a l l struggle with myths that depict women's aging as a time of inevitable decline characterized by diminished i n t e l l i g e n c e , 24 vigor, sexual attractiveness and usefulness. Furthermore, many-women who were successful and powerful admitted to spending large amounts of energy, time and money to appear younger, softer and more feminine. Cohen stated, "The endless harping on the decline of our bodies cannot help but af f e c t our feelings about our value as human beings. Many women I interviewed, es p e c i a l l y those older than sixty, claimed that t h e i r perceived declining physical appearance made them f e e l i n v i s i b l e " (p. 14). The majority of older women manage to reta i n a po s i t i v e s e l f esteem while negotiating the in s u l t s of old age. In interviews with 142 elde r l y women MacRae (1990) found that most managed to construct a meaningful role and a sense of personal worth through t h e i r interpersonal relationships associated with involvement i n voluntary organizations and informal s o c i a l network t i e s . Matthews (1979) found that the older women she interviewed had, through experience, learned strategies which helped them maintain an acceptable sense of s e l f worth. For example, i n the interpersonal sphere they sometimes concealed t h e i r age or avoided situations i n which oldness would be t h e i r central i d e n t i t y (e.g. walking through groups of teen-agers on the side-walk i n front of the K-mart). Matthews pointed out that older women have fewer avenues than mainstream "normals" for reducing s t r a i n and reclaiming themselves from the s o c i a l stigma of being old. Moreover, some of the s e l f preservation t a c t i c s they use have the ef f e c t of separating them s t i l l farther from mainstream s o c i a l l i f e (e.g. avoiding identity-threatening s i t u a t i o n s ) . 25 I t i s e v i d e n t i n C o h e n ' s ( 1 9 8 4 ) w o r k t h a t a l t h o u g h w o m e n e v o l v e c r e a t i v e s t r a t e g i e s t o d e a l w i t h t h e m u l t i p l e i n s u l t s o f a g i n g ( e . g . t h r o u g h i n t e r g e n e r a t i o n a l s u p p o r t s a n d s e l f - h e l p ) , m o s t s t r u g g l e t o o v e r c o m e t h e s o c i a l r e a l i t i e s i m p o s e d o n t h e m . C o h e n r e p o r t s , I f o u n d t h a t m o s t w o m e n o v e r s i x t y a r e f a r f r o m c o n t e n t . I i n t e r v i e w e d t h e m a b o u t t h e i r f e e l i n g s , p e r c e p t i o n s , a n d p e r s o n a l e x p e r i e n c e s i n a s o c i e t y t h a t i s y o u t h -o r i e n t e d a n d y o u t h - o b s e s s e d . T h e y e x p r e s s e d b e w i l d e r m e n t a n d d i s m a y a t t h e p r e j u d i c e , i n d i f f e r e n c e , a n d a l i e n a t i o n t h e y s u f f e r . M a n y a r e f r i g h t e n e d t h a t i f t h e y o p e n l y s t a t e t h e i r a n g e r , t h e y w i l l s u f f e r g r a v e c o n s e q u e n c e s . T h e y a r e r e p e a t e d l y t o l d b y p o l i t i c i a n s , b y t h e m e d i a , b y a c a d e m i c s , b y g e r o n t o l o g i s t s t h a t t h e y a r e f a r b e t t e r o f f t h a n t h e i r f o r e s i s t e r s . " F a r b e t t e r o f f " u s u a l l y t r a n s l a t e s i n t o s u r v i v i n g c o n s i d e r a b l y b e l o w t h e p o v e r t y l i n e . T h e q u a l i t y o f t h e i r l i v e s i s g e n e r a l l y a b y s m a l , f o r t h e y a r e a l i e n a t e d , a n d a b a n d o n e d , c u t o f f f r o m t h e m a i n s t r e a m o f l i f e . A s a s o c i e t y , w e d o n o t r e s p e c t o r a d m i r e o u r o l d e r w o m e n . We f o r c e t h e m t o l i v e f i n a n c i a l l y , e m o t i o n a l l y , a n d i n t e l l e c t u a l l y i m p o v e r i s h e d l i v e s a n d e x p e c t t h e m t o b e g r a t e f u l t o u s ( p . 1 0 ) . C o h e n ' s c o n c l u d e d t h a t i n o u r s o c i e t y o l d e r w o m e n m u s t e x p e n d s u p e r h u m a n e n e r g y t o a c h i e v e a s a t i s f y i n g l i f e . 26 Risk Factors For Depression Among Older Women Few studies have explored r i s k factors for depression from the point of view of older women. For th i s review, evidence on the contribution of s o c i a l factors to t h e i r depression was gleaned from four studies of the general el d e r l y population and two studies of older women. Blazer and Williams (1980) compared 147 depressed subjects (98 women and 49 men, aged 65 and over) with 850 non-depressed subjects (526 women and 324 men, aged 65 and over) to determine the r e l a t i v e frequency of certain demographic, s o c i a l , economic and health c h a r a c t e r i s t i c s . They found the following: 1. There was a s i g n i f i c a n t l y higher percentage of widowed women and men i n the depressed group compared to the non-depressed group. 2. In the depressed group there was a s i g n i f i c a n t l y higher percentage of women and men with impaired s o c i a l and economic resources and impaired a c t i v i t i e s of d a i l y l i v i n g . 3. Of those older people who were depressed (14.7%), 6.5% had depressive symptoms associated with impaired physical health. Blazer and Williams (1980) concluded that "Much of what i s ca l l e d 'depression' i n the el d e r l y may actually represent decreased l i f e s a t i s f a c t i o n and periodic episodes of gr i e f secondary to the physical, s o c i a l and economic d i f f i c u l t i e s encountered by aging individuals i n the community" (p. 442). Murphy (1982) compared 100 depressed subjects (68 women and 32 men, aged 65 to 87 years) with 200 non-depressed subjects i n 27 the general population to investigate the hypothesis that s o c i a l factors are related to the onset of late l i f e depression. She found the following: 1. Older people who experienced severe l i f e events, major s o c i a l d i f f i c u l t i e s or poor physical health were s i g n i f i c a n t l y more l i k e l y to become depressed. 2. Severe l i f e events and major s o c i a l d i f f i c u l t i e s i n combination increased the r i s k of developing depression. 3. Older people with lower socio-economic status had a higher incidence of depression. 4. Those older people without a confiding relationship were at s i g n i f i c a n t l y greater r i s k for developing a depression. Murphy (1982) concluded, though some personalities appear to be more vulnerable to developing depression, these people are no more at r i s k than the 'well adjusted' u n t i l faced with a sudden c r i s i s i n t h e i r l i v e s , a major s o c i a l problem, or loss of health. We cannot hope to change personality much and we s h a l l not be able to prevent the occurrence of many severe events, but improvements i n s o c i a l conditions and better health care might go some way to improving the mental health of older people (p. 141). Murrell, Himmelfarb and Wright (1983) investigated the correlates of depression i n a community sample of 936 males and 1516 females aged 55 years and over l i v i n g i n the U.S.A. The results reported are consistent with e a r l i e r research: 28 1. Income, education, number of rooms i n dwelling and tenure were s i g n i f i c a n t l y related (inversely) to depression. 2. There was no difference i n depression rates between blacks and whites when adjusted for socioeconomic status. 3. Men and women i n disrupted marital statuses had s i g n i f i c a n t l y higher rates of depression than the married and never married. 4. The best predictor of depression was ov e r a l l physical health and t h i s relationship was not a function of older age. Goldberg, Van Natta and Comstock (1985) investigated whether or not certain demographic and s o c i a l network c h a r a c t e r i s t i c s of 1,104 older women were related to t h e i r l e v e l of depressive symptoms. Analysis of interviews with white, married, women aged 65-75 years l i v i n g i n the U.S.A. revealed the following: 1. Women with low socieconomic status ( i . e . poor housing quality, low educational attainment) were more l i k e l y to experience depression than women with high socioeconomic status. 2. The percentage of women with high levels of depressive symptoms was largest among those with poor qua l i t y s o c i a l networks ( i . e . small size; no members l i k e s e l f i n age, sex and r e l i g i o n ; low le v e l of intimacy; no confidant; a husband who was not a confidant). Holzer, Leaf and Weissman's (1985) study of 1570 women aged 65 and over i n the U.S.A. revealed the following relationships to depression: 1. There was a higher prevalence of depression for separated or divorced women than for married, widowed or single never-married women (recently bereaved subjects were excluded from the widowed group). 2. The lowest prevalence of depression was found for women l i v i n g with a spouse. 3. The highest prevalence of depression was found for those subjects l i v i n g with a c h i l d or parent. 4. There was a s l i g h t l y lower prevalence of depression i n high income category subjects and the highest prevalence of depression was i n subjects with the lowest educational attainment. F i n a l l y , Krause (1987) interviewed 351 people (66% female) aged 65 and over to examine the relationship of chronic f i n a n c i a l s t r a i n and s o c i a l support to depressive symptoms. He found the following: 1. Older people suffering from chronic f i n a n c i a l s t r a i n tend to report s i g n i f i c a n t l y more symptoms of depression than do those with fewer f i n a n c i a l problems. 2. Those older adults who give and receive more s o c i a l support report fewer symptoms of depression i n times of f i n a n c i a l s t r a i n than those who give and receive less s o c i a l support. Findings across these studies c l e a r l y demonstrated that s o c i a l l y disadvantaged and marginalized older women (the majority of the subjects were female) were at greater r i s k for depression than women who have adequate s o c i a l and economic resources. In addition, physical health problems contributed s i g n i f i c a n t l y to th e i r depression. OLDER WOMEN'S EXPERIENCE OF DEPRESSION When designing interventions for older women i t i s necessary to understand t h e i r subjective experience of depression. Aronson (1990) observed that when the re a l terms of older women's experience are understood, then we w i l l have a more comprehensive basis for developing s o c i a l p o l i c i e s and programs b e n e f i c i a l to a l l women. A r t i c l e s that address older women's experience of depression are few i n number. Those that do, focus on symptom patterns or p r o f i l e s (see for example Holzer, Leaf & Weissman, 1985; Newmann, Engel & Jensen, 1990) rather than older women's perceptions of t h e i r experience. Depression affects people with varying degrees of int e n s i t y . The "blues" are considered to f a l l within the realm of normal reactions to the disappointments and frustrations of l i f e . Within the realm of depressive "disorders" are a range of af f e c t i v e experiences. Blazer (1982) reported that at one end of the spectrum are milder depressed states characterized by the following: 1. feelings such as sadness, despondency, hopelessness, anxiety and i r r i t a b i l i t y . 2. cognitive changes r e s u l t i n g i n poor concentration and uncertainty i n making decisions. 3. physical symptoms such as fatigue, sleep disturbances, weight loss or gain (more commonly l o s s ) , nausea and constipation, 31 slowed body movements and slowed speech or, i n contrast, agitation and pacing. 4. motivational changes such as an i n a b i l i t y to take i n i t i a t i v e sometimes even on simple tasks. At the other end of the spectrum are severe depressive states characterized by intense, incapacitating melancholy with psychotic episodes. A recurring theme i n the l i t e r a t u r e was that the phenomenology of depression i s somewhat d i f f e r e n t among older people r e l a t i v e to other age groups. The g i s t of t h i s observation i s that, although the symptoms of depression i n the elder l y are similar to those of younger people, there i s a tendency for older depressed people to give less emphasis to the mood disturbance and more emphasis to the somatic experience of depression (Gurland & Toner, 1982). Some authors (Blazer, 1982; Gatz, Pearson & Fuentes, 1984) suggested that older people experience fewer g u i l t feelings, s e l f - c r i t i c a l thoughts and s u i c i d a l impulses than younger people. In contrast, these authors maintained that older peoples' depression was manifested more commonly by apathy, low energy, and loss of motivation, sleep disturbances and loss of appetite. Two recent investigations, however, did not support the contention that depression was manifested d i f f e r e n t l y i n older, versus younger, women. Holzer, Leaf and Weissman (1985) analyzed symptom p r o f i l e s of three groups of women: 1) younger women, 2) older women who experienced depression e a r l i e r i n l i f e , and 3) older women whose f i r s t depressive episode was after age 65. They found a general s i m i l a r i t y i n the symptom p r o f i l e s of these three groups, and concluded that there was no evidence that older women experience depression d i f f e r e n t l y than younger women. The authors suggested that "depression for eld e r l y females i s much the same process as depression among younger women and ...there i s no evidence for a special set of mechanisms being operative among elde r l y female respondents... depression i n elde r l y females i s very much an extension of the depressive process experienced by younger females" (p. 184). Newmann, Engel and Jensen (1990) attempted to develop a better understanding of the depressive symptoms experienced by older women. They analyzed the symptom p r o f i l e s of 344 older women and found two main patterns emerging. One symptom pattern suggested the presence of a more severe, c l i n i c a l depression syndrome and the other suggested a milder form of di s t r e s s , which the authors believed was r e f l e c t i v e of a "depletion syndrome", or a reaction to the stresses and strains of l i f e . The stable features of the "depletion syndrome" were feelings of worthlessness, d i s i n t e r e s t , loss of appetite, hopelessness, and thoughts of death, dying and suicide. Women exhibiting the milder form of dist r e s s tended not to display a depressed mood or feelings of g u i l t or self-blame. While t h i s study does not compare symptom patterns across age groups, i t does point out that the experience of depression i n older women i s similar to that of other groups—a complex phenomenon characterized by varying degrees of sever i ty . SOCIAL IDENTITY RECONSTRUCTION STRATEGIES The t h e o r e t i c a l perspective framing th i s study implies that e f for t s to reduce depression among older women must be d irec ted toward the o v e r - r i d i n g goal of achieving a healthy s o c i a l i d e n t i t y . P a r t i c i p a t i o n i n rewarding s o c i a l r o l e s , through an act ive s o c i a l network, i s e s sent ia l i n creat ing the amount and kind of feedback needed to b u i l d and sustain such an i d e n t i t y . While actions toward th i s aim can and should occur on macro and m i c r o - s o c i a l l e v e l s , th i s study concentrates on the l a t t e r . Accordingly , th i s sect ion reviews l i t e r a t u r e from which guidel ines emerge for designing network augmentation intervent ions for older women. Topics covered inc lude: c h a r a c t e r i s t i c s of health promoting s o c i a l networks; types of s o c i a l network augmentation programs; educational and group intervent ions as methods of choice; and f i n a l l y , outcome studies on small group, educational intervent ions with young and middle-aged depressed women, and group cognit ive therapy with depressed older people. Health Promoting Social Networks An adequate personal s o c i a l network structures an i n d i v i d u a l ' s s o c i a l i d e n t i t y and provides the support needed to master the challenges of d a i l y l i v i n g and navigate the inev i tab le c r i s i s of l i f e . A resurgence of in teres t and research i n the area of s o c i a l support over the 1980's expanded the knowledge 34 base about s o c i a l networks. Seeman, Kaplan, Knudsen, Cohen and Guralnik (1987) demonstrated that i n older populations large s o c i a l networks promote health and protect against disease and death. George, Blazer, Hughes & Fowler (1989) found that healthy-s o c i a l networks contribute to the r e l i e f of depression i n older people. Network dimensions which contribute p o s i t i v e l y to mental health have been i d e n t i f i e d . Minkler (1981) referred to studies which point to the following network c h a r a c t e r i s t i c s as health promoting: adequate network size, presence of a confidant, and interpersonal r e c i p r o c i t y . Studies reviewed e a r l i e r i n t h i s chapter (see for example Goldberg, Van Natta & Comstock, 1985; Krause, 1987) are consistent with Minkler's finding. Burnside (1990) maintained that there i s no one health-promoting network structure, rather there are variations between indiv i d u a l s , and throughout one individual's l i f e span, regarding what constitutes a healthy network. Like Minkler (1981), Burnside found that large network size and presence of a confidant were health-promoting. In addition, Burnside suggested that the following network c h a r a c t e r i s t i c s appear to be health-promoting: presence of many friends; links to community organizations; a r e l a t i v e l y loose-knit structure ( i e . not a l l network members know each other) with at least one dense cluster; some degree of homogeneity (members l i k e s e l f ) ; and, friends and acquaintances outnumbering r e l a t i v e s (p. 66). In l i g h t of the above, network augmentation programs for older women should aim to help them create a network featuring the above c h a r a c t e r i s t i c s . Types o f Network Augmentation Programs Biegel, Shore and Gordon (1984) conducted a comprehensive overview of network interventions with older people. Their research revealed seven main categories of network interventions c l i n i c a l treatment, family caregiver enhancement, case management, neighborhood helping, volunteer l i n k i n g , mutual a i d / s e l f help, and community empowerment. They describe each type of intervention along the following dimensions: the kind o intervention modality, professional roles most central to each modality, who the c l i e n t i s , who the helper i s , where the intervention i s occuring geographically, and f i n a l l y , the le v e l of help (prevention, treatment or r e h a b i l i t a t i o n ) . Biegel, Shor and Gordon's framework provides a useful tool for understanding the range network interventions; however, as the authors point out, i n practice such programs are not i n discrete categories. Instead, multiple approaches may be combined i n a single intervention. These authors do not discuss s p e c i f i c strategies for older women, rather they target the general e l d e r l y population. E d u c a t i o n a l and S m a l l Group S t r a t e g i e s Education i s a key means of providing s o c i a l experience and stimulating learning (Thornton, 1986); as such, education can be considered one approach to helping older women "learn t h e i r way out of a depression". From a lif e - s p a n perspective, learning i s considered an essential developmental process, i n which meaning i s derived out of experience (Thornton, 1986). The learning process i s operational throughout the l i f e of every i n d i v i d u a l and, i n t h i s sense, can be considered an indispensible aspect of the development of older women. Positive behavior changes, which r e f l e c t learning outcomes, are essential i n overcoming depression. Learning can occur i n many settings and can be s e l f -or other-directed; nonetheless, educational and small group learning forums support participants' e f f o r t s to strengthen t h e i r personal networks and reconstruct t h e i r s o c i a l i d e n t i t i e s . Education-oriented interventions have the potential to contribute d i r e c t l y to the goal of helping older women achieve healthier s o c i a l i d e n t i t i e s . Participants i n educational a c t i v i t i e s assume the role and i d e n t i t y of "learner" i n contrast to the negatively tinged "sick r o l e " , which tends to be aff i x e d to depressed people and therapy group participants. The negative perceptions of the "mentally i l l " l a bel held by older women (Beck & Pearson, 1989), and the hesitancy of older people to use t r a d i t i o n a l mental health services are described i n the l i t e r a t u r e ( F i l i n s o n , 1986). Well designed educational a c t i v i t i e s can contribute to older women developing the knowledge, s k i l l s , and sense of s e l f worth prerequisite to s o c i a l p a r t i c i p a t i o n i n the wider community. But to accomplish t h i s aim education must be viewed as more than a transmission of information to enhance coping or adaptation. 37 Rather, i t must be viewed as a means of stimulating learning and experiencing which enables an older woman to transform her view of herself and of women c o l l e c t i v e l y , and to act on her new insight s . Mezirow (1990) defined transformative learning as "the process of making a new or revised interpretation of the meaning of an experience, which guides subsequent understanding, appreciation, and action" (p. 1). He argued that "emancipatory" education to foster such transformative learning involves c r i t i c a l r e f l e c t i o n on the v a l i d i t y of the set of b e l i e f s and assumptions that structure the way we interpret our experiences. Furthermore, i t involves c r i t i c a l s e l f - r e f l e c t i o n of how one has posed problems and of one's own meaning perspective or frame of reference for inte r p r e t i n g experience. F i n a l l y , transformative learning includes subsequent action based on new insights. The c r i t i c a l r e f l e c t i o n and perspective-shift processes that Mezirow (1990) described can enable older women to create and value t h e i r own knowledge about what i t means to be an aging woman i n th i s society. Changed perspectives occur, for example, when a group of older women r e f l e c t on, analyze, and discuss t h e i r l i f e experiences, and what shaped them. They learn that many experiences were common to a l l women. In such a milieu an older woman can reframe her perception of herself from "a f a i l u r e , who should be blamed" to "one of many women who have endured i n an often h o s t i l e society". The notion that personal experience can be tapped as a 38 powerful learning resource i s well recognized by adult educators. Personal experience as a source of knowledge i s a key guiding p r i n c i p l e i n feminist education (Hayes, 1989). From the perspective of educational gerontology, Moody (1990) suggested "that the education of older people should be grounded i n l i f e experience: i n the history and the l i f e cycle of the learner" (p. 23). The Women's Movement has evolved educational models which address the marginalization of women. Building on t h i s base and a resource development perspective, Harold (1991) described four essential components of education that i s aimed at helping older women strengthen t h e i r resources, including s o c i a l i d e n t i t y . These components can be viewed as program development guidelines for p r a c t i t i o n e r s who work with older women. F i r s t , education for older women should encourage the kind of p a r t i c i p a t i o n which helps them develop t h e i r "voice" i n a way that counteracts t h e i r experience of i n v i s i b i l i t y . Harold's notion of "voice" included expressive capacities ranging from verbal power and fluency to the a b i l i t y to create meaning and knowledge out of one's own experience. Secondly, such education should teach s k i l l s such as communication and assertiveness, problem posing, problem solving and goal setting. These are the kinds of s k i l l s which foster s o c i a l confidence and s e l f - e f f i c a c y . Thirdly, Harold proposed that resource development education for older women should foster horizontal networking. She argued that many services for older adults set up a v e r t i c a l relationship between professional as " e x p e r t " and c l i e n t as " s u b j e c t " c r e a t i n g an i d e n t i t y of incompetence f o r t h e o l d e r p e r s o n . H a r o l d s t a t e d , "The g o a l of h o r i z o n t a l n e t w o r k i n g i n e d u c a t i o n i s t o encourage t h e development and enlargement of t h e i n d i v i d u a l women's peer network t o s t r e n g t h e n her s o c i a l and p e r s o n a l i d e n t i t y as a v a l u a b l e , competent and ' t h i n k i n g ' p e r s o n " (p. 115). F i n a l l y , r e s o u r c e development e d u c a t i o n w i t h o l d e r women s h o u l d s t i m u l a t e an awareness t h a t problems do not o c c u r i n i s o l a t i o n ; r a t h e r , i n d i v i d u a l l i v e s a r e moulded by s o c i e t a l as w e l l as i n d i v i d u a l f o r c e s . Such e d u c a t i o n r e q u i r e s t h e p r o c e s s e s of r e f l e c t i v e and e x p e r i e n t i a l l e a r n i n g d e s c r i b e d above, i n which p e r s o n a l p e r s p e c t i v e s a r e t r a n s f o r m e d . An e d u c a t i o n a l group r a t h e r t h a n i n d i v i d u a l c o u n s e l l i n g i th e method o f c h o i c e i n h e l p i n g o l d e r women s t r e n g t h e n t h e i r s o c i a l networks. B e s i d e s t h e more o b v i o u s advantage of economy, such an approach i s l o g i c a l when a d d r e s s i n g d e p r e s s i o n o r o t h e r problems engendered by s o c i a l i n v i s i b i l i t y , o r p o w e r l e s s n e s s . Groups p r o v i d e a medium i n which t h e s u p p o r t n e c e s s a r y f o r s e l f -a c c e p t a n c e , s o c i a l c o n n e c t i o n and a c t i o n i s a v a i l a b l e (Cox, 1989). Groups a r e i n k e e p i n g w i t h t h e p e r s p e c t i v e espoused i n t h i s s t u d y ; t h a t i s , h e l p i n g an o l d e r woman d e v e l o p a c o l l e c t i v e not i n d i v i d u a l , p e r s p e c t i v e on her e x p e r i e n c e i s t h e p r e f e r r e d i n t e r v e n t i o n approach t o p r e v e n t i n g o r r e s o l v i n g d e p r e s s i o n . The l i t e r a t u r e p o i n t s out t h e b e n e f i t s of group i n t e r a c t i o n f o r o l d e r p e o p l e . Therapy groups a r e b e l i e v e d t o promote t h e f o l l o w i n g " h e a l i n g " f u n c t i o n s w i t h o l d e r p e o p l e : 1) p r o v i s i o n o 40 information, an opportunity to develop cohesiveness among members, and acknowledgement of the u n i v e r s a l i t y of members' problems (Van Servellen & Dull, 1981); 2) provision of mutual emotional support, an opportunity to "try out" new roles or behaviors, friendship, interpersonal learning, and options for p a r t i c i p a t i n g i n d i f f e r e n t roles (Edinburg, 1985); 3) provision of a setting for meaningful s o c i a l interaction, a forum for feedback about in d i v i d u a l problems from which alternatives may be obtained, and an opportunity to work through unresolved c o n f l i c t s (Tross & Blum, 1988); and f i n a l l y , 4) provision of contacts with therapists who serve as role models, a forum for r e a l i t y testing, a supplement to other forms of therapy, and an opportunity for members to help each other (Lazarus, 1989). The paramount value of therapy groups appears to be i n the provision of mutual support including information, feedback, advice, camaraderie, a sense that one i s not alone with a problem and encouragement. The group provides a supportive arena for participants to observe and experiment with new r o l e s - - e s s e n t i a l processes i n reconstructing s o c i a l i d e n t i t y . Although these functions are attributed to therapy groups, i t i s l i k e l y that other groups (e.g. educational or s e l f help) impart similar preventive and curative benefits. In fact, most group modalities are characterized by both therapeutic and educative elements. Intervention Outcomes Although the l i t e r a t u r e describes models for a variety of health promotion programs, there are few evaluation studies of educational, or any, interventions designed to reduce depression among older women. In an overview of a l l types of group work with older women Burnside (1989) located only 13 a r t i c l e s , including anecdotal and descriptive ones, spanning the period 1953 to 1987. Out of these 13 a r t i c l e s , only three targeted reduction or prevention of depression as a goal of intervention, and only two reported depression-related outcomes. One was a reminiscence group with 15 nursing home residents who met for 6 sessions. The only reported outcome was a "downward trend i n depression score". The other group was described as a weekly discussion\therapy group which met at a seniors' centre. The outcome was reported as a "fluctuating pattern i n participant's depression scores using the Hamilton Depression Inventory over an 18 month period". Burnside described the domain of group work with older women as "uncharted" and stressed the need for an improvement i n the amount and qu a l i t y of work i n th i s area. For t h i s investigation, three studies of socio-educational interventions with young and middle-aged depressed women were reviewed. In addition, outcomes of cognitive-behavioral and psychodynamic group therapy with older people were reviewed. Haussmann and Halseth (1983) conducted a 13 week (2 hrs., once a week) group program for 14 r u r a l , depressed women averaging 35 years of age. They described t h e i r approach as socio-educational, with participants taking an active role i n voicing and working on personal concerns as the program progressed. Educational content centered on the following topics: s o c i a l i z a t i o n messages g i r l s and women receive, depression, assertiveness, anger, sexuality, community resources and women's a c t i v i t i e s . Instructional techniques included: b r i e f lectures and handouts, short homework assignments, and small group discussions about such topics as personal experiences and rights, career and l i f e s t y l e choices, dealing with anger, nurturing oneself and networking. Refreshment breaks which encouraged mutual support and informal network building were included. Participants' written, subjective evaluations of the program were po s i t i v e , r e f l e c t i n g an increased sense of personal power and a decrease i n depression and helplessness. The investigators attempted to objectively measure depression levels using the Centre For Epidemiological Studies Depression Scale (CES-D); however, results were reported as "inconclusive" due to a low return rate from participants who completed the questionnaire at home. Based on feedback from the written evaluations the authors concluded, "rural women can be assisted in decreasing t h e i r depression through a non-traditional, feminist approach. Important i n t h i s process i s learning to challenge s o c i e t a l role expectations and to develop a healthy d e f i n i t i o n of one's s e l f " (p. 113). Gordon and Ledray (1986) reported on a 14 session intervention (2 hrs., once a week) led by two professional nurses who had received t r a i n i n g i n group intervention. Ten depressed, middle-aged women were assigned to a treatment group and eleven were assigned to a control group and given the opportunity to par t i c i p a t e i n future treatment groups. Educational content included the following topics: goal setting, feelings and depression, cognitions and feelings, self-worth, relationships, communication s k i l l s , assertiveness, c o n f l i c t management and decision-making, stress, relaxation, exercise, n u t r i t i o n , menstruation\menopause and strength building. Instructional techniques included lecture, discussion, other small group a c t i v i t e s (not described) and homework assignments. Outcome data from t h i s study r e f l e c t mixed findings. One measure (Beck Depression Inventory - Si g n i f i c a n t Other Report) demonstrated s t a t i s t i c a l l y s i g n i f i c a n t treatment effects i n reducing subjects' depression; however, findings from the other measure (Beck Depression Inventory - Self Report) were not consistent with t h i s . The authors speculated that t h i s could be due to subjects' hesitancy to report improvement, or an u n r e l i a b i l i t y i n the pre-test sample. In evaluating the program the authors noted that, given the study design, i t was not possible to determine which program factors were responsible for the improvement i n le v e l of depression experienced by women i n the treatment group. The Social Health Outreach Program (SHOP), applied i n t h i study, was o r i g i n a l l y developed and tested by Burnside (1990) through an action research process. She i n i t i a t e d SHOP as a so c i a l treatment for the depression reported by many women seeking membership to the F i r s t Mature Women's Network Society, 44 non-profit organization i n Vancouver, Canada. The central aim of SHOP i s to empower participants through group support to overcome depression and raise t h e i r self-esteem by achieving a healthy s o c i a l i d e n t i t y through s o c i a l p a r t i c i p a t i o n . Group p a r t i c i p a t i o n , education and network building are core elements of t h i s program. SHOP participants attended sessions for 12 weeks (2 hrs., twice a week). Educational content covered such topics as what constitutes a healthy s o c i a l network; personal network assessment; theories of depression; the medicalization of l i f e problems; women and alcohol abuse; sleep disorders; eating disorders; and the relationship of gender roles, marriage and s o c i a l networks to mental health. In the "retooling" component of the program participants learned such s k i l l s as cognitive strategies to combat negative thinking, communication and assertiveness. The "recycling" component of the program was designed to support participants i n the process of enacting t h e i r s o c i a l goals, which for many related to gaining employment. It included exercises on goal s e t t i n g and resume preparation. Throughout the sessions the importance of building network t i e s and community involvement were stressed. Instructional techniques included short lectures by the f a c i l i t a t o r or guests, small group discussion, homework assignments and i n class a c t i v i t i e s such as network mapping and completing a personal strengths inventory. Burnside (personal communication, October, 1990) reported on a t e s t of SHOP'S e f f e c t i v e n e s s . F i f t y - o n e women, aged 45 to 65, diagnosed 'depressed' (non-psychotic, non-bi-polar) were randomly assig n e d t o e i t h e r treatment or a w a i t - c o n t r o l c o n d i t i o n . Using CES-D scores as the dependent v a r i a b l e , i t was found t h a t p o s t -program scores of the treatment group had decreased s i g n i f i c a n t l y (by 45%), while c o n t r o l group scores had d e c l i n e d by o n l y e i g h t p ercent. A f t e r going through the program, the w a i t - l i s t e d group's CES-D scores showed a s i g n i f i c a n t decrease (42%) over p r e - s t a r t - u p s c o r e s . R e t e s t i n g one year l a t e r demonstrated SHOP'S long term e f f e c t i v e n e s s , the combined CES-D scores of both treatment and w a i t - c o n t r o l groups s u s t a i n e d a 35 percent d e c l i n e over pre-program s c o r e s . Burnside concluded t h a t SHOP i s an e f f e c t i v e treatment f o r d e p r e s s i o n i n middle-aged women. Two s t u d i e s of group c o g n i t i v e therapy with o l d e r people were l o c a t e d . Steuer e t . a l . (1984) a p p l i e d c o g n i t i v e - b e h a v i o r a l group therapy (n=10) and psychodynamic group therapy (n=10) with depressed, e l d e r l y , community d w e l l i n g v o l u n t e e r s . Subjects attended at l e a s t 26 out of 40 therapy s e s s i o n s (1 1/2 hr s . , once or twice a week) over a nine month p e r i o d . Both groups demonstrated s t a t i s t i c a l l y s i g n i f i c a n t r e d u c t i o n s i n observer and s e l f - r e p o r t e d d e p r e s s i o n and a n x i e t y . The authors concluded t h a t both approaches were e q u a l l y e f f e c t i v e i n r e l i e v i n g d e p r e s s i o n . Yost, B e u t l e r , C o r b i s h l e y and A l l e n d e r (1986) developed a comprehensive guide t o a p p l y i n g group c o g n i t i v e therapy with depressed o l d e r people. Based on t h e i r c l i n i c a l experience, Yost e t . a l . advocated a f l e x i b l e , e c l e c t i c approach i n group therapy 46 with older people, incorporating a wide range of procedures to help them develop "the s k i l l s needed for s e l f - a s s e r t i o n and s e l f -acceptance, which w i l l help them restore interpersonal and s o c i a l contacts" (p. 13). The view of these authors was that a desirable treatment for older people would resemble an educational approach rather than a dynamic, i n t e r a c t i o n a l therapy group. Beutler et. a l . (1987) explored the r e l a t i v e and combined effectiveness of the drug alprazolam (Xanax) and group cognitive therapy among older people experiencing major depressive disorder. A t o t a l of 56 depressed subjects (31 women) aged 65 or over were treated over a 20-week period i n one of four groups: alprazolam support, placebo support, group cognitive therapy plus placebo support, and group cognitive therapy plus alprazolam support. The cognitive therapy followed the form developed by Yost et. a l . (1986). Depressive symptoms were measured by s e l f -reports on the Hamilton Rating Scale for Depression and the Beck Depression Inventory, and by Sleep E f f i c i e n c y recordings. Although subjects i n a l l groups improved over time, improvement was s i g n i f i c a n t l y affected by cognitive group therapy and was non-significantly affected by alprazolam. In addition, subjects i n group cognitive therapy sustained t h e i r improvement over a 3 month follow-up period i n contrast to non-group therapy subjects. The study f a i l e d to f i n d s p e c i f i c cognitive changes that might explain the d i f f e r e n t i a l improvement i n group cognitive versus drug-based therapies, leading the authors to conclude that "the q u e s t i o n s r e m a i n s , t h e r e f o r e , a s t o w h e t h e r c o g n i t i v e g r o u p t h e r a p y i s m o r e e f f e c t i v e t h a n o t h e r f o r m s o f p s y c h o l o g i c a l i n t e r v e n t i o n o r , s i m p l y , o f g r o u p s u p p o r t " ( p . 5 5 5 ) . T r o s s a n d B l u m ( 1 9 8 8 ) r e v i e w e d s t u d i e s o f g r o u p t h e r a p y o u t c o m e s w i t h o l d e r p e o p l e . T h e y f o u n d r e s u l t s t h a t c h a r a c t e r i z t h e g e n e r a l p s y c h o t h e r a p y o u t c o m e l i t e r a t u r e , t h a t i s , s i m i l a r b e n e f i t s a r e a c h i e v e d e v e n w h e n d i f f e r e n t t h e r a p y a p p r o a c h e s a r e u s e d . T h e s e a u t h o r s s u g g e s t e d t h a t e l e m e n t s p r e s e n t i n a l l t h e t h e r a p i e s ( e . g . t h e r a p i s t a t t e n t i o n , i n t e r p e r s o n a l c o n t a c t , a n d e m p a t h y ) l i k e l y e x p l a i n t h e u n i f o r m b e n e f i t s . SUMMARY T h e c o n c e p t s o f s o c i a l i d e n t i t y d e g r a d a t i o n a n d s o c i a l i d e n t i t y d e f i c i t e x p l a i n h o w t h e d i s a d v a n t a g e d s t a t u s o f o l d e r w o m e n p l a c e s t h e m a t r i s k f o r d e p r e s s i o n , a n x i e t y a n d l o w s e l f e s t e e m . C h i e f a m o n g t h e f a c t o r s c o m p r o m i s i n g o l d e r w o m e n ' s m e n t a l h e a l t h a r e t h e s t i g m a s a t t a c h e d t o b e i n g o l d a n d f e m a l e a n d t h e d i f f i c u l t i e s a c c o m p a n y i n g s o c i o - e c o n o m i c s t r a i n a n d c h r o n i c h e a l t h p r o b l e m s . T h e m a j o r i t y o f o l d e r w o m e n m a n a g e t o n e g o t i a t e o l d a g e a n d c a r v e o u t a l i f e f o r t h e m s e l v e s , m a i n l y b y i n v o l v i n g t h e m s e l v e s i n v o l u n t e e r o r g a n i z a t i o n s a n d i n f o r m a l s o c i a l n e t w o r k s . N o n e t h e l e s s , t o o m a n y s u c c u m b t o t h e i n s u l t s o l a t e r l i f e b e c a u s e t h e y s i m p l y d o n o t h a v e t h e s o c i a l a n d p e r s o n a l r e s o u r c e s t o d o o t h e r w i s e . T h e n o t i o n t h a t d e p r e s s i o n r e s u l t s f r o m a s o c i a l i d e n t i t y d e f i c i t i m p l i e s t h a t p r e v e n t i v e a n d r e m e d i a l p r o g r a m s s h o u l d f o c u s o n i m p r o v i n g o l d e r w o m e n ' s s o c i a l e n v i r o n m e n t . 4 8 Evidence on factors that place older women at r i s k for depression suggests that macro-level p o l i c i e s and programs must be aimed at ensuring that women of a l l ages have access to adequate income and housing, appropriate health and support services, and opportunities for education, t r a i n i n g and employment. Micro-l e v e l i n i t i a t i v e s must be aimed to help depressed women create healthy s o c i a l i d e n t i t i e s through mutual group support, education, s k i l l development and network augmentation. Health-promoting s o c i a l networks are p a r t i c u l a r l y c r u c i a l during times of diminished health, marital disruption, bereavement and f i n a n c i a l s t r a i n . But the degree to which interventions are ef f e c t i v e i n strengthening older women's i d e n t i t y and reducing depression w i l l depend on how well program designers are informed about older women's experience, and on how well programs f i t older women's learning needs. According to the l i t e r a t u r e , educational and small group approaches are the methods of choice i n promoting the kind of learning and experiencing which helps older women achieve healthy s o c i a l i d e n t i t i e s . Results on outcome studies of small group, education-oriented programs applied with young and middle-aged depressed women, and depressed older people, indicate that such strategies are e f f e c t i v e i n reducing depression. None of the studies demonstrated s p e c i f i c program components (e.g. cognitive therapy, psychoanalysis procedures, or education) as responsible for the b e n e f i c i a l outcomes. The findings suggested that the ingredient common to a l l of the interventions was " r e l a t i o n a l " support, and that t h i s factor may be the one that produced po s i t i v e change. The main premise of the Social Health Outreach Program i s that s o c i a l involvement and r e l a t i o n a l support are essential elements in achieving a healthy s o c i a l i d e n t i t y and overcoming depression. 50 I I I . METHODOLOGY T h i s s t u d y i n c o r p o r a t e d two m e t h o d o l o g i c a l components : 1) The r e s e a r c h me thodo logy s e c t i o n w h i c h i n c l u d e s d i s c u s s i o n on s t u d y d e s i g n , s e t t i n g , r e c r u i t m e n t , s c r e e n i n g , s u b j e c t s , d r o p o u t , i n s t r u m e n t s , d a t a c o l l e c t i o n p r o c e d u r e s , and d a t a a n a l y s i s p r o c e d u r e s ; and 2) The e d u c a t i o n a l me thodo logy s e c t i o n w h i c h d e s c r i b e s how t h e o r i g i n a l S o c i a l H e a l t h O u t r e a c h Program (SHOP) was a d a p t e d f o r t h i s s t u d y i n t e rms o f p rogram g o a l s and c o u r s e o u t l i n e , f a c i l i t a t o r ' s r o l e , and i n s t r u c t i o n a l t e c h n i q u e s . THE RESEARCH METHODOLOGY De s i g n o f t h e Study Two groups o f women, aged 58 - 76 , p a r t i c i p a t e d i n an a d a p t e d v e r s i o n o f SHOP. The main a ims o f t h e SHOP program were t o h e l p o l d e r women augment t h e i r p e r s o n a l s o c i a l ne tworks and a c h i e v e h e a l t h i e r s o c i a l i d e n t i t i e s , t h u s r e d u c i n g d e p r e s s i o n . A q u a s i -e x p e r i m e n t a l , t i m e s e r i e s r e s e a r c h d e s i g n was a p p l i e d as i l l u s t r a t e d i n F i g u r e 1. Da ta c o l l e c t e d t h r o u g h q u e s t i o n n a i r e and i n t e r v i e w p r o c e d u r e s were used t o d e t e r m i n e t h e f o l l o w i n g : 1) t h e i m p a c t o f t h e i n t e r v e n t i o n on p a r t i c i p a n t s ' l e v e l s o f d e p r e s s i o n and d e m o r a l i z a t i o n , and on t h e i r s o c i a l n e t w o r k s ; 2) t h e i r p e r c e p t i o n s about w h i c h a c t i v i t i e s and p r o c e s s e s h e l p e d , and w h i c h h i n d e r e d , t h e i r p r o g r e s s d u r i n g t h e p rog ram; and , 3) t h e i r p e r c e p t i o n s o f t h e e x p e r i e n c e o f d e p r e s s i o n . 51 F i g u r e 1: D e s i g n o f t h e S tudy P u b l i c announcement and r e c r u i t m e n t p r o c e s s began S c r e e n i n g ; p r e - t e s t s a d m i n i s t e r e d ( C E S - D ; GWB) SHOP commenced B a c k g r o u n d I n f o r m a t i o n I n t e r v i e w s c o n d u c t e d SHOP ended; e v a l u a t i o n q u e s t i o n n a i r e s c o m p l e t e d ; P o s t - t e s t s ( C E S - D , GWB) and P o s t P rogram I n t e r -v i e w c o m p l e t e d 6 weeks b e f o r e p rogram 2 weeks b e f o r e p rogram Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 A d m i n i s t r a t i o n o f : F o l l o w - u p I n t e r v i e w ; CES-D and GWB. 3 months a f t e r p rogram ends 52 The Setting The SHOP program was conducted at two busy seniors' centres close to downtown Vancouver. These s i t e s were chosen for several reasons: 1) They were re a d i l y accessible by public transportation and one was located i n an area where women could walk to the centre; 2) They were community based and not associated with t r a d i t i o n a l mental health services, which older women tend not to use; 3) Research on older peoples' learning a c t i v i t i e s has demonstrated that seniors' centres were a sponsor of choice (Clough, 1990), and f i n a l l y , 4) The centres operated on a drop-in basis, o f f e r i n g an array of opportunities to pa r t i c i p a t e i n educational and recreational programs, or as a volunteer. Selecting these s i t e s also f a m i l i a r i z e d participants with a senior centre i n the event that some might view i t as a place to "get involved" a f t e r completing SHOP. Recruitment The r e c r u i t i n g process targeted older women, l i v i n g independently i n the Vancouver area, who were able to get to a senior centre on t h e i r own. Recruiting was a challenging task which began about seven weeks p r i o r to the f i r s t session of the program. The following strategies were used: 1. Three seniors' groups were addressed d i r e c t l y i n order to provide verbal and written information about the program and to i n v i t e them to c a l l for further information, or to suggest the program to t h e i r friends. 2. The program was l i s t e d i n a parks and recreation brochure 53 which outlined l o c a l programs for seniors. 3. A feature a r t i c l e was printed i n two community newspapers. 4. A paid advertisement was run i n the Province newspaper. 5. Women on the Mature Women's Network waiting l i s t for SHOP were contacted. This wait l i s t was established when e a r l i e r SHOP programs were unable to accomodate a l l applicants. 6. Local agencies that provide services to seniors were informed about the program and i n v i t e d to make r e f e r r a l s . Information sheets about the program were delivered to the following agencies: seniors' centres, health department seniors' wellness programs, a community mental health centre, a seniors' outreach program neighborhood houses, g e r i a t r i c short stay assessment and treatment centres and community l i b r a r i e s . Although each strategy produced at least one phone c a l l , number three was the most successful. The need to adjust the language of mental health to terminology that i s meaningful to older women i s discussed i n the l i t e r a t u r e (Beck & Pearson, 1989). The i n i t i a l recruitment poster used i n t h i s study (see Appendix A-l) was viewed somewhat dimly by senior centre personnel. Two of them suggested that the language was too "heavy". One volunteer commented, "This comes across as a b i t negative. Who wants to t a l k about depression, i t ' s too depressing". As a r e s u l t of t h i s feedback, promotional material was revised and prospective participants were i n v i t e d as follows: "Learn ways to restore your s o c i a l confidence, b u i l d support i n your l i f e and overcome depression i n an atmosphere of 54 friendship and support" (see Appendix A-2). Screening A l l prospective volunteer participants were f i r s t informed about the program and the research. They were made aware that the aim of the research was to improve the quality and delivery of programs and services for women. They were assured that t h e i r responses would be kept c o n f i d e n t i a l , and that a numbering system had been devised to assure the anonymity of the data. They were asked to sign a consent form (see Appendix A-3). In addition participants were in v i t e d to inform t h e i r physicians about t h e i r p a r t i c i p a t i o n i f they so desired, although i t was not mandatory. The screening interviews started two weeks p r i o r to and continued into the f i r s t week of the program mainly because some women arrived at session one without having c a l l e d ahead of time. The purposes of these interviews were to meet the women, inform them about the program, answer any questions, and administer three instruments: the National Institute for Mental Health Diagnostic Interview Schedule (DIS) (Helzer & Robbins, 1988), the Centre for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977), and the General Well Being Schedule (GWB) (Fazio, 1977). The DIS has been established as a r e l i a b l e and v a l i d t ool that can be used to detect a broad variety of psychiatric conditions and can be applied by trained lay or c l i n i c i a n interviewers for screening as well as diagnosis. The DIS was o r i g i n a l l y devloped for use i n a large U.S. survey commissioned by the National Institute of Mental Health (Helzer & Robins, 5 5 1988). Since the CES-D scale measures l e v e l of depressive symptoms only, the DIS was administered by a trained lay inteviewer i n t h i s study to establish a diagnosis of depression, and to screen out women with any of the following disorders: bipolar disorder, phobias, panic disorder or untreated alcoholism. The decision was made to exclude women with these conditions from the study since i t was f e l t that they l i k e l y required treatment s p e c i f i c to t h e i r problems f i r s t , i n order to benefit from SHOP. The diagnosis of depression was established so that data on participants who met the DIS depression c r i t e r i a could be added to an already established data base on SHOP outcomes. However, the change i n emphasis for t h i s version of SHOP meant that i t was no longer being promoted exclusively as a treatment for depression and, thus, a diagnosis for depression was not a req u i s i t e for in c l u s i o n . As a resul t participants had levels of depression ranging from "severe" to "non depressed". Although the i n i t i a l intent i n t h i s study was to include only women 65 and over, 3 depressed women aged 58, 59 and 63 expressed inter e s t i n p a r t i c i p a t i n g . A decision was made by the researcher to accept women 55 and over, i n keeping with the wishes and admission p o l i c y of the seniors' centres hosting the program. Subjects A t o t a l of 15 women from Vancouver and New Westminster, B r i t i s h Columbia completed the program. The f i r s t group session ran from November, 1989 through January, 1990 and the second ran from end January to mid A p r i l , 1990. A p r o f i l e of participants 56 i s provided i n Table 1. Most of the participants l i v e d alone (73%), and most were not employed (93%). In addition, over half of the subjects reported l i m i t i n g physical d i s a b i l i t i e s (53%), and one t h i r d reported using psychotropic drugs regularly (33%). The subject group was di s s i m i l a r to the general population of older women i n Canada as follows: most of the subjects were unattached due to divorce, separation or single status (73%), rather than widowhood; the average educational attainment was grade 12, which i s s l i g h t l y higher than that for women of th i s age group; and f i n a l l y , they had s l i g h t l y higher incomes—while almost half of the unattached subjects (47%) had annual incomes of $10,000 or less, for the general population of unattached older women, 78% l i v e on $10,000 or less annually, (Gee & Kimball, 1987). D r o p o u t s Since severely depressed and non-depressed women were mixed i n the groups there was some concern that t h i s might have a detrimental e f f e c t on group cohesion and on depressed participants' sense of belonging. In the November to January group t h i s was not a problem. One of the non-depressed participants i n i t i a t e d lunch outings and a c t i v i t i e s outside the group which many of the depressed women joined and enjoyed.N There were no dropouts from t h i s group and attendance was excellent. In the January to A p r i l group one depressed woman withdrew stating she "could not keep up with the discussion". She may have been more w i l l i n g to continue had she perceived 57 TABLE 1 PARTICIPANT SOCIODEMOGRAPHIC AND HEALTH-RELATED CHARACTERISTICS Variable (n=15) Findings Age Range ss- 76 years Mean 6 years L i v i n g Arrangements Alone 11 (73%) With spouse or adult c h i l d 4 (27%) Marital Status Never-married 3 (20%) Married 2 (13%) Widowed 2 (13%) Divorced or Separated 8 (53%) Reported Annual Income Non Married $ 0 - 2,000 1 ( 7%) 5,000 - 9,999 6 (40%) 10,000 - 14,999 4 (27%) 15,000 - 19,999 2 (13%) Married $40,000 and over 2 (13%) Employed 1 ( 7%) Not employed 14 (93%) Level of Education P a r t i a l high school 4 (27%) Completed high school 7 (47%) P a r t i a l or complete university degree 4 (27%) Limiting Physical D i s a b i l i t i e s None 7 (47%) One or Two 8 (53%) Level of Depression at Pre-test <16 on CES-D 5 (33%) 16 or greater on CES-D 10 (67%) Previous Depression Episodes None 4 (27%) One 3 (20%) Two or more 8 (53%) Psychotropic Drugs None 11 (73%) One or Two 4 (27%) 58 others i n the group to be l i k e herself. Thus, the "mixed" nature of the group may have been problemmatic i n t h i s case. Many of the women i n both groups were coping with physical health problems, most often a r t h r i t i s or back problems. Although t h i s did not af f e c t attendance i n the f i r s t group, i t did res u l t i n absenteeism for some members of the second group. In addition, four women dropped out of the second group--three due to fear of f a l l i n g i n poor weather conditions (snow, ice) and a fourth when she got a job. Instruments and Data C o l l e c t i o n Procedures The Centre For Epidemiological Studies Depression Scale  (CES-D) (see Appendix B-l) i s a 20 item self-report scale designed to determine l e v e l of depressive symptoms i n the general population. Its o r i g i n a l development was based on c l i n i c a l findings, frequency of item use i n other depression questionnaires and factor analytic studies (Radloff, 1977). The r e l i a b i l i t y and v a l i d i t y of the CES-D has been established over a wide variety of sub-groups including the elde r l y (Radloff & T e r i , 1986). Test items relate to depressed mood, feelings of q u i l t and worthlessness, fearfulness, helplessness and hopelessness, physical and cognitive slowing, loss of appetite and insomnia. The scale measures current l e v e l of depressive symptoms and does not measure duration or prevalence over a l i f e t i m e . The potent i a l range of scores i s 0 to 60; i n thi s study, following previous research (Radloff & T e r i , 1986), depression was operationally defined as a score of 16 or greater. Scoring for 59 each item i s on a four point scale and the sum of the numbers for each item represents the t o t a l . Scoring for p o s i t i v e l y worded items (4,8,12,16) i s reversed. In t h i s study the CES-D was administered at screening, post-test and 3 month follow-up. Some participants asked to do the questionnaire o r a l l y at the screening session and the researcher accommodated t h i s request. The General Well Being Schedule (GWB) (see Appendix B-2) i s a sel f - r e p o r t instrument which, i n va l i d a t i o n tests, has been found to constitute a unidimensional scale measuring what has been l a b e l l e d as distress/depression by Fazio (1977), and demoralization by Link and Dohrenwend (1980). Murrell and Himmelfarb (1983) found a s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n between the GWB and the CES-D as measures of mental health i n an elder l y population. The 18 item GWB sub-scale asks participants to report on mental status symptoms "during the past month"; so does not indicate duration or prevalence throughout a l i f e t i m e . The potential range of scores on the GWB subscale i s 0 to 110; scores of 70 or less indicate distress\demoralization. In t h i s study the GWB was administered concurrently with the CES-D at screening, post-test and 3 month follow-up. The main purpose, as with the DIS, was to r e p l i c a t e procedures used i n previous SHOP research and contribute to the data base. Previous SHOP research used the GWB as a measure of demoralization with a view toward exploring the assumption that female depression i s a manifestation of low morale. Background Information Interviews (see Appendix B-3) were 60 conducted i n order to outline sociodemographic and health-related c h a r a c t e r i s t i c s of the study sample. Interviews were conducted during the f i r s t few weeks of the program. Post Program Interviews (see Appendix B-4) were the main source of data i n regard to participants' experiences of depression before the program and t h e i r perceptions about what factors helped or hindered t h e i r progress during the program. The interviews were conducted i n the week immediately following SHOP. The procedure followed an in-depth interviewing approach developed by Amundson and Borgen (1987, 1988) to study the experience of unemployment. This approach combines phenomenological and c r i t i c a l incident procedures to arrive at subjects' perceptions about t h e i r experience. In t h i s study each interview lasted from 30 to 45 minutes and was audiotaped. Interviews began with open-ended questions designed to encourage participants to describe, with a minimum of imposed d i r e c t i o n , t h e i r experience of depression and t h e i r experience during the SHOP program. Later the interview questions addressed s p e c i f i c a l l y the high points and low points for participants' during the program, either i n SHOP or outside the program, and t h e i r expectations for the future. Appointments for interviews were scheduled i n the l a s t program session and were conducted i n the week following the program. Follow-Up Interviews (see Appendix B-5). At the end of the program participants were informed that they would be contacted i n approximately three months for a follow-up interview. They 61 were contacted by telephone to arrange a time to meet. Appointments were half an hour i n duration and were designed to s o l i c i t information about the following: quantitative changes that occured i n p a r t i c i p a n t s ' s o c i a l networks following SHOP; and, any comments they wanted to make about SHOP a f t e r a period of r e f l e c t i o n . Data Analysis Procedures The quantitative data was analyzed using the S t a t i s t i c a l Package for the S o c i a l Sciences (SPSS). Each p a r t i c i p a n t was assigned a code l e t t e r f o r recording sociodemographic information and t e s t scores. Network changes and t e s t score changes were calculated from the raw data. The main s t a t i s t i c a l measures used i n t h i s study included: the Pearson product-moment c o r r e l a t i o n c o e f f i c i e n t to show the degree of r e l a t i o n s h i p between means, and t - t e s t s of paired means to determine whether or not pre-, post- and follow-up changes were due to chance. S i g n i f i c a n c e l e v e l was set at p <_ .05. The q u a l i t a t i v e data was analyzed using content analysis of interview data based on a method o r i g i n a l l y developed by Flanagan (1954) and extended by Amundson and Borgen (1987; 1988); and on a method used by K e l l e r , Leventhal and Larson (1989). The content analysis process consisted of the following steps: 1. Transcribing of taped interviews. 2. Summarizing of interviews (see Appendix C) to provide an overview of p a r t i c i p a n t s ' experience of depression and t h e i r experience during the program. 62 3. Conducting a v a l i d i t y check of these summaries. Eight out of 15 participants (53%) were contacted by telephone. The decision on who to contact was made on the basis of the ease with which they could be reached by telephone. Respondents were informed that a summary of t h e i r experience before and during the program would be read to them, and after, they would be asked to v e r i f y the accuracy of t h i s summary. A l l of the respondents f e l t the summary accurately r e f l e c t e d t h e i r experience. One requested a small change of wording i n regard to a medical problem to protect her anonymity, and a second requested addition of the sentence, "what I learned i n SHOP was how to beat the blues". 4. Writing "meaning units" on cards, as derived from analysis of tran s c r i p t i o n s . 5. Grouping responses to the f i r s t question into broad categories which r e f l e c t the main themes i n participants' experience of depression before the program. A card sort procedure was used. 6. Next, establishing categories of helpful, and hindering, a c t i v i t i e s and processes during the program by sorting meaning units v i a themes, as derived from from responses to the remaining interview questions. 7. R e l i a b i l i t y check of the category system. A student who had completed an M.A. i n education was asked to assign meaning units for each subject to the established categories. The 86% agreement rate exceeded the 80% rate c r i t e r i o n established as an acceptable standard. 63 Based on the effectiveness of t h i s methodology established i n e a r l i e r studies, and on the v a l i d i t y and r e l i a b i l i t y checks i n th i s study, i t i s reasonable to conclude the following: the summaries accurately represent participants perceptions of t h e i r experience of depression; and, the category system i s a r e l i a b l e representation of which a c t i v i t i e s and processes participants perceived as helpful, and which they perceived as hindering, to t h e i r progress during the program. THE EDUCATIONAL METHODOLOGY Modifications to the SHOP Program SHOP has evolved over time based on feedback from participants and evaluation by the program designers. Although SHOP'S o r i g i n a l purpose was "sociotherapy" for depression i n middle-aged women, the program can be modified and applied i n a variety of ways. Besides extending SHOP to an older group of women, for t h i s study several adaptations were made: 1. The program length was reduced to 20 sessions (2 hrs., twice a week). This decision was made when i n i t i a l p u b l i c i z i n g of a 36 session (18 week) program yielded a limited response. Senior centre programmers suggested that many older people would hesitate to commit to an 18 week program. 2. In view of reduced program time, some content was deleted. Since most of the women were not seeking a paying job, some sessions devoted to resume preparation and job 64 finding were omitted. Material r e l a t i n g to depression was substantially condensed as well. 3. For t h i s version of SHOP the author conducted a l l of the sessions with resource "experts" featured i n some (a pharmacist, a sleep disorders s p e c i a l i s t , a seniors' network coordinator, a senior centre board member). E a r l i e r SHOP programs used d i f f e r e n t f a c i l i t a t o r s , with appropriate expertise, for each of three components--"education", "retooling" and " r e c y c l i n g " — with resource experts brought i n for some of the sessions. The program goals and a course outline for the 20 session version of SHOP are described i n Appendix D-l. F a c i l i t a t o r ' s Role and Instructional Techniques Since SHOP aims to empower participants, and following SHOP'S established policy, the f a c i l i t a t o r did not adopt an "expert" stance. "Being f a c i l i t a t i v e e s s e n t i a l l y means that the worker i s helping others, including other persons and t h e i r support systems, to do the doing by increasing t h e i r capacities for problem-solving" (p. 142, Biegel, Shore & Gordon, 1984). Other roles the f a c i l i t a t o r assumed are: program coordinator, instructor, resource provider, counsellor, supporter and li n k e r (stimulating network development). The f a c i l i t a t o r for t h i s group was the researcher, a 35 year old graduate student. At the f i r s t session she discussed with participants the difference between herself and them i n terms of age and l i f e experience. Participants were in v i t e d to comment i f they considered t h i s a p r o b l e m a t t h e o u t s e t o r d u r i n g t h e p r o g r a m . The age d i f f e r e n c e was no t p e r c e i v e d as a p r o b l e m t h e n o r l a t e r . The f o l l o w i n g i n s t r u c t i o n a l t e c h n i q u e s c r e a t e d an i n t e r -a c t i v e l e a r n i n g e x p e r i e n c e : " m i n i " l e c t u r e s f o l l o w e d by-d i s c u s s i o n , s m a l l g roup i n - c l a s s a c t i v i t i e s and d i s c u s s i o n , r e f l e c t i o n on l i f e e x p e r i e n c e , ca se s t u d i e s and homework a s s i g n m e n t s . I n a d d i t i o n , t h e f a c i l i t a t o r i n f o r m a l l y encouraged humour and some l i g h t - h e a r t e d n e s s i n t h e s e s s i o n s . Program Evaluation D u r i n g t h e f i n a l p rogram s e s s i o n p a r t i c i p a n t s c o m p l e t e d a w r i t t e n SHOP e v a l u a t i o n q u e s t i o n n a i r e (see A p p e n d i x D-2) w h i c h was d e s i g n e d t o s o l i c i t f eedback about SHOP a c t i v i t i e s . Q u e s t i o n n a i r e i t e m s f o c u s e d on s p e c i f i c knowledge and s k i l l deve lopment s e s s i o n s . R e s u l t s a r e d i s c u s s e d i n C h a p t e r I V . 66 IV. FINDINGS AND DISCUSSION The findings of the study are presented and discussed i n f i v e sections: 1) outcome measures; 2) a c t i v i t i e s and processes that helped, or hindered, participants' progress during the Social Health Outreach Program (SHOP); 3) evaluation of SHOP program content; 4) participants' experience of depression; and 5) summary of f i e l d notes. OUTCOME MEASURES Levels of Depression and Demoralization Table 2 summarizes Centre for Epidemiological Studies Depression Scale (CES-D) and General Well Being Schedule (GWB) scores at pre-, post- and three month follow-up i n t e r v a l s , for the whole group (n=15), and for two subgroups that evolved from the data analysis--those who were depressed at pre-test (n=10) and those who were non-depressed at pre-test (n=5). As w i l l be seen, depressed participants test scores on CES-D and GWB measures d i f f e r e d i n comparison to non-depressed participants. Participants' CES-D and GWB scores were expected to improve from pre-test to 3 month follow-up; however, i t was anticipated that a temporary heightening of depressive symptoms may occur at post-te s t related to sadness or concern over the group ending. The whole group, on average, showed an improvement of 2.3 units i n CES-D scores from pre- to post-test (9%; p = .4); the improvement continued through to follow-up for a t o t a l pre- to follow-up difference of 5.6 units (22%; p = .06). TABLE 2 MEANS & STANDARD DEVIATIONS FOR CES-D & GWB MEASURES (*) AT PRE-, POST, & FOLLOW-UP EVALUATIONS FOR WHOLE GROUP, DEPRESSED, & NON-DEPRESSED PARTICIPANT GROUPINGS Variable Measure Pre-Test Post-Test 3 Month Follow-up Whole Group n= CES-D M= SD= 15 25.06 15.31 14 22.78 12.05 15 19.40 12.94 Depressed Group CES-D n= M= SD= 10 33, 11, 50 01 10 25.20 11 .87 10 23.40" 12.73 Non-depressed n= Group M= CES-D SD= 5 8.20 3.76 4 16 . 75 11.75 5 11.40 10.06 Whole Group GWB n= M= SD= 13 57.77 24.98 13 61.23 22.70 13 60.23 20.24 Depressed Group GWB n= M= SD= 9 48 . 88 24 . 65 9 56 24 55 26 9 54.55 21. 65 Non-depressed n= Group M= GWB SD= 4 77 . 75 10 . 34 4 71. 16, 75 68 4 73.00 8 . 67 (*) CES-D - Centre for Epidemiological Studies Depression Scale GWB - General Well Being Schedule Pre- to follow-up difference s i g n i f i c a n t at p = .004 68 In regard to GWB, the mean difference i n scores from pre-test to post-test (3.5 units; 6%; p = .4), and from pre-test to follow-up (2.5 units; 4%; p = .5) revealed s l i g h t but non-significant improvement. For the whole group, scores on the CES-D scale were s i g n i f i c a n t l y correlated to scores on the GWB schedule which measures demoralization. The co r r e l a t i o n between mean change i n GWB and mean change i n CES-D from pre-test to follow-up was -.58 (p =.01). In other words, on average, as CES-D scores decreased, GWB scores increased; thus supporting previous analyses which pointed out that the GWB measures some of the same constructs as the CES-D (Murrell and Himmelfarb, 1983). Depressed participants' CES-D scores, on average, dropped by 8.3 units from pre- to post-test (25%; p = .058) and an additional 1.8 to follow-up, for a t o t a l pre- to follow-up improvement of 10.10 units (30%; p = .004). Three of the 10 subjects who were depressed at pre-test were non-depressed at 3 month follow-up. Non-depressed participants' CES-D scores, i n contrast, increased by 8.5 points from pre- to post-test, and dropped back by 5.3 points at 3 month follow-up for a net pre- to follow-up increase of 3.2 u n i t s — s t i l l within the non-depressed score range. Thus, non-depressed participants' scores showed the anticipated end-of-program heightening of symptoms and a return toward 'normal' scores at 3 month follow-up. A comparison between depressed versus non-depressed 69 particpants on mean change i n CES-D scores from pre-test to follow-up showed that the two groups d i f f e r e d s i g n i f i c a n t l y at p = .05 on a t - t e s t of paired means. This suggests a treatment ef f e c t for the depressed subjects. GWB scores followed a pattern similar to CES-D scores for the depressed and non-depressed groups. On the GWB the depressed group showed an average pre- to post- improvement of 7.7 units (16%; p = .2) and a dropping back at follow-up for a net pre- to follow-up improvement of 5.7 units (11.6%; p = .30). The non- depressed group showed an average GWB decrease of 6.0 units (7%) from pre-test to follow-up, and a 2 unit improvement at follow-up (non-significant). CES-D and GWB outcomes demonstrate that SHOP had a p o s i t i v e impact i n reducing participants' levels of depression and demoralization, p a r t i c u l a r l y for those women who were depressed at pre-test. The depressed women showed a sharp decline i n CES-D scores from pre- to post-test with no heightening of symptoms when the program ended. The declining trend, although not as pronounced, continued to 3 month follow-up. Impact on Social Networks Obtaining a measure of s o c i a l networks required a sensitive approach from the researcher i n view of participants' feelings of v u l n e r a b i l i t y about revealing t h i s type of information. During the fourth program session participants created personal network maps based on written logs kept over a two week period. Some of the depressed participants who had very small networks 70 d i s l i k e d the mapping exercise and hesitated to p a r t i c i p a t e . Their feelings were exemplified i n the comments of two women: "I found the exercise depressing. I've never had a s o c i a l network except for one period i n my l i f e when I was single with no kids, and was doing a l o t of swimming". "This exercise i s depressing. It shows what a shambles my l i f e i s " . To i l l u s t r a t e , the network maps of a depressed woman and a non-depressed woman are r e p l i c a t e d on a smaller scale i n Figures 2 and 3. On the maps each segment of the "pie" represents a role sector i n the woman's l i f e ; the t i n y squares represent people known by her i n each role sector. People seen or contacted by telephone at least every two weeks are closer to the centre of the map ( s e l f ) ; people seen less often are further from the centre. As i s evident, the depressed participant indicated that she had very few network members (6), and 'role sectors' (4 or 5). In contrast, the non-depressed woman's network map had many members (100+), and revealed a greater variety of 'role sectors' (8). Although i t was possible to b u i l d a learning s i t u a t i o n around the exercise (e.g. discussion of factors that influence s o c i a l networks at d i f f e r e n t points i n l i f e ) , the researcher decided that i t was not appropriate to pursue detailed before and a f t e r network data from participants when they were obviously f e e l i n g so vulnerable about i t . 71 F i g u r e 2: Network Map of a Depressed P a r t i c i p a n t 72 Figure 3 : Network Map of a Non-depressed P a r t i c i p a n t 73 Thus, to obtain a measure of changes i n s o c i a l networks, at a three month follow-up interview participants were asked to report on network changes i n terms of people and groups. They reported retrospectively on how many friends, acquaintances, professionals and groups (including courses taken and new volunteer roles) were added to, or l o s t from, t h e i r networks. Table 3 reports the number of people and groups added to, or l o s t from, each participant's s o c i a l network; i t also reports the mean additions and losses of people and groups for depressed participants, non-depressed participants and the whole group. Participants' networks changed, on average, as follows: 1) depressed participants had a net gain of 4.2 people and 1.7 groups, and non-depressed participants had a net gain of 5.0 people and 1.2 groups--there was no s i g n i f i c a n t difference between these two groups; 2) when the whole group was considered, participants had a net gain of 4.5 people (z = .347; p = .000) and 1.5 groups (z = 3.61; p = .000). Thus, on average, participants reported s i g n i f i c a n t l y more additions of people and groups to t h e i r networks than losses i n the three month period following SHOP. In comparison, depressed participants added fewer people and more groups to t h e i r networks r e l a t i v e to non-depressed participants; however, no s i g n i f i c a n t differences emerged between these two participant groupings. The findings support the hypothesis that women who pa r t i c i p a t e i n SHOP w i l l increase the size of t h e i r s o c i a l networks. Moreover, the findings indicate that SHOP mobilized 74 TABLE 3 SOCIAL NETWORK CHANGES REPORTED BY PARTICIPANTS AT 3 MONTH FOLLOW-UP # of People # Groups Participant added l o s t added l o s t Depressed A 0 0 3 0 B 5 0 1 0 D 0 2 0 1 E 3 0 3 0 G 6 1 0 1 I 1 1 4 1 J 9 1 0 0 K 17 2 4 0 L 0 0 3 0 0 8 0 2 0 •depressed F 8 0 2 0 H 12 0 3 0 C 7 2 1 1 M 1 1 1 0 N 1 1 0 0 Mean Whole Grp 5.2 .7 (+4.5) 1.8 .3 (+1.5) Depressed 4.9 .7 (+4.2) 2 .3 (+1.7) Non- 5.8 .8 (+5.0) 1.4 .2 (+1.2) Depressed People - includes friends, acquaintances or professionals. Groups - includes organizations participants joined as a member, volunteer, or employee and lei s u r e i n t e r e s t (e.g. educational and recreational) groups. 75 the depressed participants to take action on increasing t h e i r involvement i n community groups. ACTIVITIES AND PROCESSES THAT HELPED, OR HINDERED, PARTICIPANTS' PROGRESS IN SHOP While CES-D and s o c i a l network measures established the b e n e f i c i a l outcomes of SHOP, they did not c l a r i f y what produced these p o s i t i v e changes. The Post Program Interview (see Appendix B-4) was undertaken to determine participants' perceptions about change factors; that i s , which factors advanced, and which impeded, t h e i r progress during the program. With a minimum of imposed structure, participants were encouraged to t a l k about t h e i r experience during the SHOP program, and high points or low points they experienced during that time. The intent was to illuminate a c t i v i t i e s and processes, either i n SHOP or outside of SHOP, that had moved them forward or set them back, during the program. Based on the t h e o r e t i c a l assumptions of t h i s study, one would expect that helping factors would relate to participants' increasing t h e i r s o c i a l involvement, augmenting t h e i r s o c i a l i d e n t i t y and experiencing a greater sense of s e l f worth. Conversely, hindering factors would deter them from s o c i a l p a r t i c i p a t i o n and undermine t h e i r s e l f worth. Spec i f i c factors reported by participants as helpful or hindering during SHOP were determined by analyzing responses to Post Program Interview items. The 15 women in t h i s study reported 205 helping and 130 hindering incidents which occurred either i n or outside of SHOP during the program period. An analysis of incidents led to the development of 20 categories of helping, and 19 categories of hindering, a c t i v i t i e s and processes which are described i n the following sections. Categories and Descriptions of Helping Factors Table 4 shows how often and how many participants mentioned each helping category. Those mentioned by 25% or more participants are then described, including d i r e c t quotations. Positive Future Plans. A sense of pos i t i v e planning, goals or intentions for the future. "I'm going to be more i n t e l l i g e n t about how I handle my health.... I' m gonna monitor things and I'm going back, i n two weeks and I'm gonna be asking alot of questions (of her doctor). I bought myself a big fat notebook and I went to the doctor and t o l d her that from now on I'm going to write down during our t a l k " . "My goal i s to get back on my feet and f i n d a place to l i v e " . SHOP Routine and Process Experiencing SHOP as something to look forward to; that having the structure of the regularly scheduled sessions provided a focus; a sense that coming to SHOP was enjoyable\pleasurable, worthwhile, i n t e r e s t i n g or stimulating. "The structure does give r e l i e f . I would l i k e to structure my l i f e a l o t more". "These sessions have been a great joy to me and I r e a l l y have looked forward to them". "I enjoyed coming to the group because i t was int e r e s t i n g " . 77 TABLE 4 HELPING FACTORS REPORTED BY PARTICIPANTS No. of times mentioned Categories No. of S % of S. mentioning mentioning factor factor Positive future plans SHOP Routine\Process Positive image\outlook Family\friend support Recognizing improvement in s e l f or si t u a t i o n Mutual support\aid Reassessment of s e l f Keeping active Relief i n f e e l i n g better Learning from experience Pursuing interests Positive thinking Sense of contribution L i f e s k i l l s Leadership Relaxed atmosphere Homework\handouts Absorping others success Information Religious A f f i l i a t i o n 23 25 23 12 29 23 23 7 6 4 4 3 3 4 4 4 3 2 2 1 14 11 10 8 7 7 7 5 5 4 3 3 3 2 2 2 2 2 2 1 93 73 66 53 46 46 46 33 33 26 20 20 20 13 13 13 13 13 13 6 78 Positive ImaqeXOutlook. A pos i t i v e acknowledgement about s e l f or one's accomplishments; a pos i t i v e attitude toward one's si t u a t i o n and other people; a sense of p o s s i b i l i t y or optimism, that problems can be solved; that a d i f f i c u l t y i s not insurmountable. "I thought I'd make an appointment to have lunch with M. She l i v e s near my doctor...if she says no I won't f e e l rejected...I'11 t r y again". "I r e a l i z e d I've been a good l i s t e n e r . . . I guess I appear very open about myself". FamilyXFriend Support. Feeling encouraged or recognized or experiencing companionship with family or friends outside of SHOP. "I sent a card to a male f r i e n d who I hadn't seen i n awhile. We ended up having coffee. We had a great time". "I've seen and talked to people that were kind to me. It r e a l l y boosts your self-esteem". Recognizing Improvement i n Self or Situation. An acknowledgement that one has enacted posi t i v e behavior change; f e e l i n g u p l i f t e d as a re s u l t of recognizing an improvement i n oneself, one's actions, one's si t u a t i o n or relationships with others. "I actually did a l i t t l e b i t of cooking. That's the f i r s t time I've been able to get close to preparing anything". "I surprised myself with being able to s o c i a l i z e with the women in the group". "I was r e a l l y bogged down u n t i l halfway through SHOP and then I began to think i t s not the end of the world". 79 Mutual Support\Aid. An experience of belonging, companionship, comaraderie or friendship i n SHOP. An exchange of support, assistance, solace, encouragement and recognition among SHOP group members; helping each other. "I had soulmates i n the group. I r e a l l y f e l t kinship and less i s o l a t e d " . "It was nice, the fact that we went to lunch and the company those days". "The others gave me t h e i r phone numbers and I can phone any of them". Reassessment of Self. Experiencing an increased understanding or insight about oneself or one's s i t u a t i o n . "I can't stand just melding i n with the woodwork...A few times I was shocked at what I was saying and I was almost sick when I went home. But then I thought, well i t feels good and I want people to accept the person I r e a l l y am, not what they i n i t i a l l y thought I was". "What works i s I understand myself so much better. You know I've l i v e d to t h i s age without knowing a few things about myself". Keeping Active. A sense that i t helps to keep busy by engaging i n physical a c t i v i t i e s , getting out of the house or apartment, or joi n i n g a community a c t i v i t y . "I f e e l as long as I'm able to keep moving i t s best not to s i t down...try and keep active while I can". "It i s helpful to make myself go out everyday". Relief i n Feeling Better. A f e e l i n g of being i n better s p i r i t s or f e e l i n g good; a sense of r e l i e f . "I r e a l l y am surprised at how much better I f e e l . In fact, I f e e l completely normal". "I am t r y i n g to be r e a l l y t r u t h f u l . . I think I have been f e e l i n g better since SHOP". 80 L e a r n i n g from E x p e r i e n c e . A p p r e c i a t i n g l e a r n i n g from r e f l e c t i o n on t h e e x p e r i e n c e o f s e l f and o t h e r s i n g roup d i s c u s s i o n o r o n e - t o - o n e e n c o u n t e r s ; g e t t i n g i d e a s from o t h e r s ; s e e i n g how o t h e r s l i v e . " I a l w a y s l i k e t o l e a r n from p e o p l e . . . t h a t ' s how I l e a r n , b e t t e r t h a n from b o o k s " . "The o t h e r s gave me i d e a s about t h i n g s you c o u l d do and a c t i v i t i e s " . Discussion of Helping Factors When t h e h e l p i n g f a c t o r s were a n a l y z e d t h e p r o m i n e n t ones i n v o l v e d s e l f w o r t h , s o c i a l i d e n t i t y o r s o c i a l p a r t i c i p a t i o n . S e v e r a l h e l p i n g f a c t o r s r e f l e c t e d t h a t many p a r t i c i p a n t s were d e v e l o p i n g a h e a l t h i e r v i e w o f t h e m s e l v e s : p o s i t i v e f u t u r e p l a n s ; p o s i t i v e s e l f image and o u t l o o k ; r e c o g n i z i n g improvement i n s e l f o r s i t u a t i o n ; r e a s s e s s m e n t o f s e l f ; and r e l i e f i n f e e l i n g b e t t e r . O t h e r h e l p i n g f a c t o r s r e f l e c t e d an i n c r e a s e i n s o c i a l i n v o l v e m e n t : SHOP r o u t i n e / p r o c e s s ; f a m i l y / f r i e n d s u p p o r t ; m u t u a l s u p p o r t o r a i d f rom SHOP members; and l e a r n i n g from l i f e e x p e r i e n c e . S i n c e p a r t i c i p a n t s were s p e c i f i c a l l y a s k e d about t h e i r e x p e c t a t i o n s f o r t h e f u t u r e , i t i s no t s u r p r i s i n g t h a t such a h i g h p e r c e n t a g e o f them (93%) m e n t i o n e d p o s i t i v e i n t e n t i o n s o r g o a l s f o r t h e f u t u r e . I t was c l e a r t h a t p a r t i c i p a n t s found i t b e n e f i c i a l t o have a m e a n i n g f u l f o c u s and i n v o l v e m e n t i n t h e i r l i v e s . T h i s was e v i d e n t i n t h e i r comments about l o o k i n g f o r w a r d t o coming t o SHOP, e n j o y i n g SHOP because i t was i n t e r e s t i n g , and p l a n n i n g f o r t h e f u t u r e . I n l i g h t o f p a r t i c i p a n t s ' e x p e r i e n c e s 81 of boredom and aimlessness p r i o r to SHOP i t i s not surprising that they found the structure, process and goal orientation of the sessions to be helpful (see section on The Experience of Depression, p. 94). They experienced r e l i e f through focusing t h e i r attention and energy on SHOP, instead of on negative emotions and thoughts. Throughout the program, several participants continued to assuage feelings of depression through physical a c t i v i t y and "keeping busy" as they had done before the program. SHOP'S format as a group educational program, rather than a dynamic therapy group, encouraged participants to concentrate on issues and circumstances external to themselves and, thus, helped them to begin moving beyond the devastating s e l f - c r i t i c i s m which was part of t h e i r depression experience. Several participants mentioned that i t was helpful to learn from r e f l e c t i o n on t h e i r own, and others, l i f e experience--a factor which also emerged as helpful on written program evaluations. There i s an in t e r e s t i n g p a r a l l e l between the findings of th i s study and those of Amundson and Borgen (1988), who determined helping factors for unemployed people (average age 34.6 years) enrolled i n group employment counselling. They found that helping factors were those which met participants' basic needs for community, meaning and structure. Similar to younger unemployed people, the older women i n t h i s present study reported helping factors that met t h e i r needs for meaningful and regular s o c i a l involvement. Both older women and the unemployed occupy undervalued roles according to our society's standards, 82 and consequently, i t i s d i f f i c u l t for them to maintain a healthy s o c i a l i d e n t i t y . Categories and Descriptions of Hindering Factors Hindering factors, those that impeded participants' progress, as reported by participants are presented i n Table 5. Those categories mentioned by 25% of the participants are described and i l l u s t r a t e d . Negative Thinking. Having s e l f - c r i t i c a l thoughts--seeing oneself as useless, as a f a i l u r e , or as not t r y i n g hard enough; having thoughts that focus on problems and negative attributes of others, death or suicide. "I've made so damn many mistakes that you can't get over them a l l . . . I r e a l l y loused i t up". "I f e e l so frumpy, you know, my hair and wrinkles". "I wake up at six o'clock... the f i r s t thing on my mind i s problems". Lack of Sense of Belonging i n SHOP. Experiencing feelings of "not f i t t i n g i n " to the SHOP group, a sense of being d i f f e r e n t than the others i n the group. "Nobody's phoned me, and I know they phone one another". "At f i r s t I thought these others don't know what I'm going through, they don't look depressed". Feelings of Loneliness, Isolation . The experience of missing people who had died or moved away; f e e l i n g a lack of closeness to friends or family; expressing a sense of having no friends; f e e l i n g i s o l a t e d and alone during periods of unstructured time. 83 TABLE 5 HINDERING FACTORS REPORTED BY PARTICIPANTS No. of times mentioned Categories No. of S mentioning factor % of S mentioning factor Negative thinking 17 8 53 Lack of sense of belonging in SHOP group 14 7 46 Feelings of loneliness 11 7 46 Physical health problems 17 5 33 Pessimistic about future 10 5 33 Sleep\energy problems 9 5 33 Family\spouse problems 9 5 33 Boredom 8 5 33 Christmas\birthday 7 5 33 Money\transportation\ housing problems 9 4 26 Diminishing mental f a c u l t i e s 3 2 13 SHOP exercises too personal 2 2 13 Indecision 2 2 13 Lack of motivation 3 2 13 SHOP program ending 3 1 6 Negative contacts outside of SHOP 3 1 6 Negative memories 1 1 6 SHOP journal keeping 1 1 6 Watching TV news 1 1 6 84 "I f e e l far away where I l i v e . I miss the West End because i t was so easy to get around there". "I've had alot of depression. I'm fine when I'm here but then I go home and f i n d myself alone". "I think the pain of losing B. w i l l always be there. B. and I saw each other every day". Physical Health Problems. Feeling frustrated, discouraged, resentful or worried about health problems, pain and loss of mobility or expressing concern over same. "I've been worrying about breast cancer and my health". "I'm s t i l l i n pain and i t makes me mad... I haven't been getting out because i t s too hard walking around. I'm t i r e d of i t " . "I have too many health problems a l l at the same time...I f e e l exhausted with it..My l i f e seems l i k e nothing but aches, pains and physio". Pessimistic About Future. A pessimistic, uncertain or hopeless sense about the future. "My future expectations are lousy... There's only one way to go when you're old--downhill". "My view of the future i s not very good. Dark and dim. I think my days are numbered". Sleep\Enerqy Problems. Experiencing feelings of insomnia, fatigue or l i s t l e s s n e s s . "At night time I l i e there awake i n the dark. Can't sleep". "I s t i l l f e e l a l i t t l e t i r e d . I wish that weren't there". Family\Spouse Problems. Experiencing worry or concern over family or marital problems. "I never t o l d anyone how bad my marriage was...I had a bad marriage. My husband treated me as a c h i l d " . 85 " V i s i t i n g my d a u g h t e r I came home f e e l i n g d e p r e s s e d abou t what I saw. W e ' r e a l l v e r y d i f f e r e n t , p o l e s a p a r t . I t t u r n s my s tomach t o see what t h o s e k i d s a r e d o i n g . N o t h i n g i n t h e house w o r k s . I c a n ' t s t a n d i t . . . M y one g r andson i s w i t h d r a w i n g . I came home t h i n k i n g "Oh God, i f o n l y I c o u l d do s o m e t h i n g f o r t h e s e k i d s . Bu t I d o n ' t t h i n k i t i s my p l a c e . I t ' s j u s t v e r y h a r d and my h e a r t i s r e a l l y heavy w i t h t h a t m i d d l e c h i l d " . Boredom. E x p e r i e n c i n g a sense o f b e i n g " f e d up" w i t h u s u a l a c t i v i t i e s , o f f e e l i n g "cooped up" o r s t i f l e d from s p e n d i n g t o o much t i m e i n t h e house o r a p a r t m e n t ; f e e l i n g b o r e d . " I s o r t o f l o s t t r a c k o f b e i n g c l o s e t o p e o p l e i n t h a t sense o f t a l k i n g about i n t e r e s t i n g t h i n g s . I ' m i n t e r e s t e d i n i d e a s and w o r l d e v e n t s and p o l i t i c s , and most p e o p l e d o n ' t want t o t a l k about t h i n g s l i k e t h a t . They j u s t want t o t a l k about t h i n g s l i k e what t h e y cooked f o r d i n n e r a n d , t h e y went ou t w i t h t h e i r c o u s i n , I mean, i t was no t t h a t e x c i t i n g " . " I ' m d o i n g t h e same v o l u n t e e r w o r k . I t ' s v e r y b o r i n g " . C h r i s t m a s o r B i r t h d a y . A n t i c i p a t i n g o r e x p e r i e n c i n g C h r i s t m a s \ b i r t h d a y , o r t h e p e r i o d a f t e r , as a n e g a t i v e t i m e o f t h e y e a r , due t o b e i n g a l o n e , w o r r y i n g about f a m i l y p r o b l e m s o r b e i n g a f f e c t e d by t h e d u l l w e a t h e r . " I a l w a y s f e e l s o r t a down a f t e r C h r i s t m a s w i t h t h e d u l l w e a t h e r " . " I d o n ' t l i k e C h r i s t m a s . I a n t i c i p a t e i t more t h a n I s h o u l d and d o n ' t l o o k f o r w a r d t o i t " . M o n e y \ T r a n s p o r t a t i o n \ H o u s i n q C o n c e r n s . E x p e r i e n c i n g s t r e s s o r c o n c e r n o v e r l a c k o f money, f e a r o f l o s i n g an i ncome , o r s a f e t y c o n c e r n s . " T h e r e ' s u n b e l i e v a b l e t u r n o v e r where I l i v e . So many I knew and l i k e d have moved a w a y . . . T h e r e a r e t h i n g s t h a t make me ne rvous about t h e p l a c e . A man w i t h a gun and a boy t h a t was t h r e a t e n i n g p e o p l e . T h e r e ' s been a r a s h o f r o b b e r i e s . . . I h a v e n ' t done s c h o o l b o a r d c l a s s e s i n t h e p a s t 2 y e a r s on a c c o u n t o f no t w a n t i n g t o go ou t a t n i g h t . Tha t has p u t me back a l o t " . 86 "So much of my a c t i v i t y depends on the weather. I don't have a car. When you have to slosh through muck and mire for three blocks, you think twice about going out". Discussion of Hindering Factors Participants reported far fewer hindering factors (130), as compared to helping factors (205), during the program period. Involvement i n SHOP brought a po s i t i v e dimension to participants' l i v e s , r e l i e v i n g some of t h e i r boredom, and counteracting the negative overlay i n t h e i r thoughts and emotions. Some of the factors which exerted a negative e f f e c t on participants p r i o r to SHOP continued to influence them during the program—an expected finding since most participants' circumstances were of long duration (e.g. chronic depression and health problems, i s o l a t i n g l i v i n g conditions, family problems). A l l of the predominant categories of hindering factors could have the e f f e c t of undermining participants' s o c i a l p a r t i c i p a t i o n and s o c i a l i d e n t i t y . It i s important to observe that while negative, s e l f -c r i t i c a l thinking was mentioned most often as the factor hindering participants' progress, the reverse, p o s i t i v e thinking was far down on the l i s t of factors perceived to help progress. But p o s i t i v e thinking would be necessary for participants to develop a healthy self-image and po s i t i v e plans for the future. It appears that participants applied p o s i t i v e thinking as a "tool" to help them take p o s i t i v e action i n t h e i r l i v e s (e.g. getting involved i n meaningful s o c i a l a c t i v i t i e s ; setting goals and making plans; and constructing a kinder self-image). 87 W h i l e m o s t p a r t i c i p a n t s t h o r o u g h l y e n j o y e d S H O P a n d l o o k e d f o r w a r d t o a t t e n d i n g , s o m e c o n t i n u e d t o e x p e r i e n c e d e p r e s s i o n d u r i n g t h e p r o g r a m , p a r t i c u l a r l y w h e n a l o n e o n w e e k e n d s o r w h e n h e a l t h p r o b l e m s k e p t t h e m h o u s e b o u n d . S o m e p a r t i c i p a n t s r e p o r t e d f e e l i n g a l a c k o f b e l o n g i n g i n t h e S H O P g r o u p . T h i s m a y h a v e r e s u l t e d f r o m s e v e r a l f a c t o r s : c o m b i n i n g d e p r e s s e d a n d n o n -d e p r e s s e d p a r t i c i p a n t s i n t h e g r o u p s , a n d t h u s , c a u s i n g t h e d e p r e s s e d o n e s t o f e e l " d i f f e r e n t " ; s o m e p a r t i c i p a n t s j o i n i n g t h e g r o u p i n t h e t h i r d s e s s i o n , a f t e r a n i n i t i a l c o h e s i v e n e s s h a d a l r e a d y f o r m e d ; a n d f i n a l l y , n e g a t i v e t h i n k i n g t e n d e n c i e s , w h i c h a r e t y p i c a l i n d e p r e s s i o n ( i e . " I d o n ' t f i t h e r e , n o b o d y c a l l s me a n d I k n o w t h e y c a l l e a c h o t h e r " ) . E v a l u a t i o n o f SHOP Program Content C o n s i d e r a b l e v a r i a t i o n e m e r g e d r e g a r d i n g w h i c h s p e c i f i c c o u r s e c o m p o n e n t s w e r e r a t e d b y p a r t i c i p a n t s a s m o s t o r l e a s t h e l p f u l ( s e e S H O P E v a l u a t i o n f o r m , A p p e n d i x D - 2 ) . T h o s e p l a c e d i n t h e " m o s t h e l p f u l " c a t e g o r y , b y a t l e a s t 2 5 p e r c e n t o f p a r t i c i p a n t s , a r e p r e s e n t e d i n T a b l e 6 . N o n e o f t h e c o m p o n e n t s w e r e r a t e d " l e a s t h e l p f u l " b y 2 5 % o r m o r e o f p a r t i c i p a n t s . I n t e r m s o f w h a t s h o u l d b e a d d e d t o o r d e l e t e d f r o m t h e p r o g r a m m o s t p a r t i c i p a n t s f e l t i t w a s a p p r o p r i a t e " a s i s " . H o w e v e r , t h e f o l l o w i n g a d d i t i o n s t o t h e p r o g r a m w e r e s u g g e s t e d : a l i s t o f s u p p l e m e n t a l r e a d i n g o b t a i n a b l e a t t h e l i b r a r y ; i n c r e a s e d t i m e o n p r o b l e m s o l v i n g a n d g o a l s e t t i n g ; a s o u r c e o f f u r t h e r a d v i c e o n o n e ' s c a p a b i l i t i e s f o r e m p l o y m e n t o r v o l u n t e e r i n g ; i n c r e a s e d g r o u p s i z e t o c o m p e n s a t e f o r a b s e n c e s d u e t o i l l n e s s ; a 88 TABLE 6 PARTICIPANT RATING OF SHOP CONTENT (n=13) Component of Percentage of Subjects SHOP Content Rating Component as "Most Helpful" Learning through r e f l e c t i o n on your own experience 46% Assessing the adequacy your personal network. 40% Changing s e l f - t a l k from negative to pos i t i v e 40% Communicating i n d i f f i c u l t situations 40% Problem solving 40% Goal setting 40% Social health, s o c i a l roles, s o c i a l p a r t i c i p a t i o n 33% Different views on the cause of depression 33% Thought-stopping and creative worrying 33% Personal s o c i a l networks 26% Opportunities to participate/volunteer 26% 89 discussion on facing death; and, an extended program--one participant commented "I f e e l l i k e we're just getting started and now we're f i n i s h i n g " . The evaluation item, "Since attending SHOP I f e e l " , was responded to by the following numbers of participants: a l o t better (5), moderately better (2), a l i t t l e better (6), about the same (0), worse (0). While a l l participants judged the course to be h e l p f u l , some commented on t h e i r ongoing struggles with health problems or depressive emotions. Examples of participants' comments about the program follow: "What I have learned coming to SHOP i s that I can think". "Very helpful program for anyone working t h e i r way back from depression, anxiety or other s o c i a l problems into a s a t i s f y i n g , meaningful, enjoyable l i f e s t y l e " . "...I've been given so much information that I did not know about p r i o r . The two main goals for me were to f i n d ways to increase my personal network and to investigate more worthwhile a c t i v i t i e s . From the class I have the p o s s i b i l i t y of three new friends. It's up to me to act on what has been presented to us". "Unfortunately missed several sessions because of health reasons, but found the ones I attended interesting, educational and very worthwhile. I also appreciated the opportunity of meeting other people i n the group..." "Very well structured course ... good leadership... most everyone had time to speak...would be better to have everyone sta r t from the beginning of the course". "A course l i k e t h i s should be rea d i l y available to everybody who feels the need..." "I f e e l that a l l the s o c i a l education i s of l i t t l e value to me when my physical health i s so poor". "My only question i s , i s SHOP r e a l l y geared to the needs of depressed people? It seems to me the course presupposes the w i l l , energy and i n i t i a t i v e of a reasonable healthy 90 (mentally, emotionally) participant. When one i s depressed i t r e a l l y i s n ' t possible to tackle a l l those s e l f -improvements no matter how much one would wish to do t h i s . I'm VERY glad I came, though, and am sad i t i s ended". The l a s t comment raises the issue of SHOP'S appropriateness for severely depressed women. In the controlled t r i a l of SHOP with women aged 45-65 (discussed i n Chapter I I ) , the mean CES-D score (34) was i n the 'severe' range. There were only 3 drop-outs out of 36 participants i n t h i s t r i a l , and results demonstrated that severely depressed women did take action on expanding t h e i r s o c i a l networks. Thus, previous applications of SHOP suggest that i t i s appropriate and b e n e f i c i a l with severely depressed women. THE EXPERIENCE OF DEPRESSION The main themes describing participants' depression experience were derived by summarizing and analyzing t h e i r responses to questions on the Post Program Interview (see Appendix B-4). The open-ended interview format imposed a minimum of structure, for example: The purpose of th i s interview i s to r e f l e c t upon and capture some of your experience over the past two to three months... Think back to just before you started SHOP...How were you f e e l i n g then? What were your thoughts like? And what was your d a i l y a c t i v i t y like? The analysis included reponses from 10 depressed participants, plus one non-depressed women who described herself as "just coming out of a bad depression". Responses were transcribed on to cards, sorted, and grouped into broad themes. Each theme i s recorded i n Table 7, along with the number of participants 91 mentioning i t , the number of times i t was mentioned, and verbatim i l l u s t r a t i o n s . The themes mentioned most often and by the most participants included: f e e l i n g bored or looking for a c t i v i t y ; thinking negatively; f e e l i n g sad\despondent; f e e l i n g desperate\a sense of urgency; experiencing low energy; t r y i n g to keep active; f e e l i n g lonely\a lack of companionship; and f e e l i n g frustrated due to health d i f f i c u l t i e s and concerns. The most prominent aspect of participants' experience was boredom or lack of meaningful a c t i v i t y . Burnside (1990) argued that boredom may be a key contributing factor i n depression. She proposed that inadequate stimulation at s o c i a l , physiological and psychological levels may cause symptoms of distress such as depression. Seven of the depressed women i n th i s study spoke of being "fed up" and "needing something to do" when describing t h e i r experience before the program. Because older women are not part of mainstream productive society, they are vulnerable to boredom unless they are able to a c t i v e l y seek stimulating involvement. For women who are constrained by limited finances, geographic i s o l a t i o n or d i s a b i l i t i e s , maintaining involvement i s challenging. A second aspect of participants' depression was s e l f -c r i t i c a l thinking which r e f l e c t s s o c i a l i d e n t i t y d e f i c i t . Yost et. a l . (1986) argued that western society's negative attitude about advancing age i s conveyed to older c i t i z e n s , and can lead to self-devaluative thinking and depression among them. TABLE 7 FREQUENCY OF RESPONSES ON THE EXPERIENCE OF DEPRESSION Major Categories of Responses with Examples N. of Participants N. of Times Mentioned Feeling Bored, Looking for A c t i v i t y  7 14 1. I was fed up with my l i f e . 2. I r e a l l y needed something to do. 3. I was "cooped up". 4. I didn't have too much to do and was looking for an a c t i v i t y that makes you think a l i t t l e . 5. I needed something to f i l l my time because I had just moved here. Thinking Negatively 6 11 1. I couldn't think of one useful thing I'd done. 2. I f e l t my whole l i f e had been a shambles, a f a i l u r e . 3. My mind was racing too much. 4. I was c r i t i c i z i n g myself. 5. I was worrying about what i s my future going to be. 6. I was wondering what i s i t a l l for and how long w i l l i t l a s t . Feeling Sad/Despondent 5 14 1. I was f e e l i n g very low..very de-pressed. . close to psychotic. 2. I was r e a l l y i n a deep p i t . I re-member once crying for 3 hours i n bed. I couldn't stop. 3. I was pretty depressed. 4. I f e l t sadness. 5. I was depressed or something. I didn't f e e l good..in turmoil. 93 T a b l e 7 ( c o n t i n u e d ) F e e l i n g D e s p e r a t e \ A S e n s e o f U r g e n c y 1. I w a s f e e l i n g d e s p e r a t e . . I h a d n o w h e r e t o l i v e . . t h i n g s w e r e g r i m . 2 . I w a s d e s p e r a t e l y a n x i o u s t o s e e s o m e o n e . 3. I w a s f e e l i n g d e s p e r a t e t o f i n d a w a y t o d e c i d e w h a t I ' m g o i n g t o d o w i t h t h e r e s t o f m y l i f e . L o w E n e r q y X L o w M o t i v a t i o n 1. I w a s v e g e t a t i n g . 2 . I w a s s t a y i n g i n b e d a s l o n g a s I c o u l d , e v e n i f n o t a s l e e p . 3. I w a s a b i t t i r e d . T r y i n g t o K e e p A c t i v e 1. I h a d t o w a l k e v e r y d a y , t h a t m a d e m e f e e l b e t t e r , b u t i t d i d n ' t l a s t . 2 . I w o u l d g e t d r e s s e d e v e r y d a y a n d g o o u t . 3. I t h e l p e d t o g o f o r l o t s o f w a l k s . , t o g e t o u t o f t h e a p a r t m e n t . L o n e l i n e s s X L a c k o f C o m p a n i o n s h i p 1. I m i s s e d m y f r i e n d s w h o d i e d . I s p e n t s o m u c h t i m e w i t h t h e m . 2 . I w a s m i s s i n g m y f r i e n d s a n d m y s o n . 3. I h a d t h i s f r i e n d w h o d i e d t w o y e a r s a g o . B e c a u s e m y f r i e n d i s n ' t h e r e , I d o n ' t h a v e e n o u g h t o f i l l m y t i m e . H e a l t h D i f f i c u l t i e s X C o n c e r n s 1. I w a s f e d u p b e c a u s e o f t w o f r a c -t u r e s a n d n o t g e t t i n g a n y h e l p . 2 . I w a n t e d i n f o r m a t i o n a b o u t i f I h a d e n o u g h m e n t a l f a c u l t i e s l e f t s o I c o u l d f i n d a w a y t o p r o v i d e f o r m y s e l f . 94 Participants' responses did not support the contention found in the l i t e r a t u r e that, compared to younger people, older peoples' depression i s more often characterized by somatic complaints, l i s t l e s s n e s s and apathy, rather than mood-related depressive f e e l i n g s . Participants reported experiencing a host of emotions i n d i c a t i v e of depressed mood. While some f e l t low energy and tended to stay i n bed, t h i s was expressed less frequently than feelings l i k e sadness, despondency and desperation. It i s possible that older people do not declare t h e i r "negative" feelings as re a d i l y as younger people, and therefore appear to place more emphasis on somatic symptoms. Because participants became acquainted with t h i s researcher over time, and a tr u s t developed, they may have f e l t comfortable expressing "negative" emotions. One potential consequence of assuming that older peoples' depression i s manifested p h y s i c a l l y i s r e f l e c t e d i n Dobson's (1989) a r t i c l e on cognitive therapy outcomes. In discussing examples of c l i e n t s who may not be suitable candidates for cognitive therapy he comments, " . . . i t has been argued that depressed g e r i a t r i c patients are better candidates for pharmacotherapy, because the nature of t h e i r symptomatology i s often characterized by the so-called vegetative, or physical signs..." (p. 418). While Dobson does state that the u t i l i t y of cognitive therapy for older people requires further investigation, such a comment implies a bias toward using drug therapy, and away from using cognitive therapy, with older people based on the possibly erroneous generalization that older people experience depression p h y s i c a l l y more so than emotionally. Losses, p a r t i c u l a r l y bereavement and i l l n e s s , contribute to loneliness and depression among older people (Yost et. a l . , 1986). In t h i s present study, participants spoke of t h e i r d i f f i c u l t i e s replacing a companion and " f i l l i n g " time aft e r friends died. In addition, chronic health problems and f r u s t r a t i o n with physician contacts emerged as a component of t h e i r experience. The one p o s i t i v e experience mentioned by depressed participants was physical a c t i v i t y . Several found r e l i e f through walking and "getting out of the apartment". This supports O'Brien and Vertinsky's (1990) assertion that physical exercise can elevate mood state and r e l i e v e tension i n older women, in short, i t can act as an anti-depressant. For comparison purposes, the statements of four participants, who were non-depressed p r i o r to SHOP, were reviewed. Examples of non-depressed participants' responses to the question about t h e i r experience before the SHOP program are as follows: Participant H I was finding i t d i f f i c u l t because my mother died i n July. I was missing my mother and at the same time I was thinking freedom and a new s t a r t . I was t r y i n g to keep involved. Participant M I had gotten into a volunteer s i t u a t i o n and i t wasn't working out so I quit. I miss the people. I had nothing lined up to do...I was casting about... looking for something meaningful. 96 Participant C Up to now retirement has been dealing with health problems. I decided I have to do something d i f f e r e n t . Participant N I keep looking for things I can get involved i n . I'm always looking for friends, r e a l friends. The experience of "looking for something to do" or looking for friends was common to both depressed and non-depressed participants i n d i c a t i n g t h e i r i n t u i t i v e understanding that involvement i s b e n e f i c i a l . Non-depressed participants were c l e a r l y seeking meaningful a c t i v i t y i n SHOP. In contrast, depressed participants disclosed much more about experiencing d i s t r e s s i n g thoughts and emotions, and seeking r e l i e f from these. Thus, participants i n both groups were pursuing involvement and friendship, but depressed participants were struggling to move beyond overwhelming thoughts and emotions. SUMMARY OF FIELD NOTES Throughout both SHOP programs written observations and informal discussion notes were coll e c t e d . This information yielded insights about older women's views and about what affects t h e i r experience. Themes which emerged, and which were not addressed through e a r l i e r data analysis, are summarized i n the following sections. Impact of Low Income on Social Participation Although seven out of f i f t e e n participants managed t h e i r l i v i n g on incomes of $10,000 a year or less, s u r p r i s i n g l y few complained about lack of money. However, two participants whose marriages had ended were t e r r i f i e d about not having enough income to sustain them through o ld age since they had no work, pension. Low income affected one women's confidence to p a r t i c i p a t e s o c i a l l y , although coming to SHOP appeared to boost her confidence: "A nice th ing happened to me th i s week and I wondered i f i t re la ted to coming here (SHOP). A woman from church, who I've been wanting to get to know, i n v i t e d me to her house. I've been turning her down, f e e l i n g I can't (afford to) r e -c iprocate , but th i s time I went. And I stayed a l l afternoon and when I made overtures to go she asked me to stay". Another woman hes i tated to volunteer, because buying presentable c lo th ing and bus , t i cke t s put too great a s t r a i n on her budget. Communication with Physicians Most p a r t i c i p a n t s had some type of chronic i l l n e s s (e .g . a r t h r i t i s , back problems, u lcers) and phys ic ian-pat ient in terac t ions emerged as an i ssue . Many par t i c ipant s were a f r a i d to pose questions to a doctor. Part of th i s hesitancy appeared to be re la ted to e a r l i e r l earning about authori ty f igures . Two women's comments i l l u s t r a t e t h i s , "We were ra i sed to respect anyone i n authori ty and you c e r t a i n l y d i d n ' t question them.. .you do what your doctor says and don't ask questions". "When I was younger you never questioned your doctor. They had studied and they knew a l o t about i t , so you d i d n ' t question i t " . But part of t h e i r hesitancy appeared to stem from a fear of c o n f l i c t or r e j e c t i o n by the doctor based on e a r l i e r negative outcomes af ter asking questions. A woman commented, "One doctor kicked me out of the o f f i c e for asking a 98 question". Another woman reported f e e l i n g badly aft e r asking her doctor about stopping a medication. She described the doctor's comment as follows, "Well, that's f i n e , I guess you won't be needing to see me anymore". The woman's interpretation of that incident was that her doctor was angry about the question and would no longer accept her as a patient. The group agreed that i t i s now more acceptable to ask for information. One woman commented, "People read more now, and they know more...you can get a lo t more information" ( i e . about health, i l l n e s s and treatments). Another woman shared her method of monitoring her drug therapy, "I keep a l i t t l e book with a record of how I react to di f f e r e n t drugs my doctor prescribes for me and whether they work or not. At f i r s t , she (doctor) looked at me kind of funny, but now she's used to i t and thinks i t ' s a good idea". The Need f o r A l t e r n a t i v e s t o M e d i c a t i o n s A majority of the participants expressed the view that they did not want to take medications of any kind unless there was no alter n a t i v e . This b e l i e f appeared to stem from e a r l i e r experiences with mood-altering medications and fears that medications would cloud t h e i r thinking capacity. Several women commented as follows about t h e i r experiences with mood-altering medications, "I took sleeping p i l l s . It was pretty rough getting o f f . I did i t myself, cold turkey". 99 " I t o o k t r a n q u i l i z e r s when my k i d s were s m a l l . When I had a c a r a c c i d e n t I r e a l i z e d t h e y were a f f e c t i n g me". "I t o o k an a n t i d e p r e s s a n t f o r a few months about a y e a r ago, but I q u i t . I t made me s l e e p y . I was yawning and i n a daze". One woman's comment i l l u s t r a t e s her f e a r s about not b e i n g a b l e t o t h i n k c l e a r l y i f on a n t i d e p r e s s a n t d r u g s , " I r e f u s e d d e p r e s s i o n t a b l e t s when my d o c t o r o f f e r e d them t o me. I guess you c o u l d c a l l me a non-compliant p a t i e n t , but wouldn't i t be a w f u l t o be o l d , a l o n e and drugged?" D e v e l o p m e n t o f ' V o i c e ' The n o t i o n of ' v o i c e ' i m p l i e s power, b u t i t a l s o encompasses t h e a b i l i t y t o communicate e f f e c t i v e l y — v e r b a l l y , non v e r b a l l y and i n w r i t i n g ( H a r o l d , 1991). A t t h e b e g i n n i n g o f SHOP s e v e r a l p a r t i c i p a n t s ' s p e a k i n g p a t t e r n s l a c k e d c o n f i d e n c e (e.g. shaky, s o f t , h e s i t a n t ) . I n a d d i t i o n , one woman r e p o r t e d t h a t she c o u l d not c o n c e n t r a t e enough t o r e a d o r w r i t e . As t h e program p r o g r e s s e d s e v e r a l women p r o j e c t e d themselves i n a more c o n f i d e n t manner--the v o i c e s of t h r e e women become s t r o n g e r and t h e i r speech more f l u e n t ; f o u r t o o k n o t i c a b l y b e t t e r c a r e o f t h e i r appearance; one, who s a i d she c o u l d n ' t w r i t e b e f o r e t h e program, sent h a n d w r i t t e n C h r i s t m a s c a r d s t o t h e o t h e r group members'; and f i n a l l y , a n o t h e r r e p o r t e d t h a t t h e communication s e s s i o n s encouraged her t o go up and t a l k t o someone a t a s o c i a l e v e nt. S e t t i n g P e r s o n a l G o a l s : A New E x p e r i e n c e Only one p a r t i c i p a n t r e p o r t e d h a v i n g e v e r engaged i n a g o a l s e t t i n g e x e r c i s e . Almost a l l o f t h e p a r t i c i p a n t s found i t d i f f i c u l t t o s e t g o a l s f o r t h e m s e l v e s - - t h e y d e s c r i b e d f e e l i n g 100 "stuck". D i s c u s s i o n about t h i s experience r e v e a l e d t h a t f o r some women t h e i r h e s i t a n c y was r e l a t e d t o the term "g o a l " , or t o the exp e c t a t i o n s i m p l i e d by a g o a l . T h e i r comments f o l l o w , "I don't s e t g o a l s . I hate t h a t word. But I have l i s t s " . "What i f I s e t a goal and then f a i l ? I t seems as i f you're d r i v e n when you set g o a l s " . Another woman's comment echoes the consensus of the group t h a t they had o f t e n made d e c i s i o n s i n t h e i r l i v e s based on s u r v i v a l , or on others needs, and not t h e i r own a s p i r a t i o n s , "I've never had any g o a l s . Before i t was set out f o r me. Go t o work, look a f t e r my house and r a i s e my son. That's a l l I c o u l d handle". The one woman who had set goals r e p o r t e d a sense of accomplishment, "I s e t goals f o r the day and goals f o r the year. I t helps me see t h a t I've accomplished something. I f you're a p e r f e c t i o n i s t l i k e me you need t h a t " . Individual Support of Participants Throughout the program, i n d i v i d u a l s telephoned or approached the f a c i l i t a t o r t o d i s c u s s problems which they d i d not want t o r a i s e i n the group (e.g. m a r i t a l / f a m i l y i s s u e s , j o b - r e l a t e d problems, concerns about i n t e r p e r s o n a l r e l a t i o n s h i p s with group members or people o u t s i d e the group, worries about t h e i r h e a l t h ) . S e v e r a l women remarked t h a t t h i s p e r i o d i c support was u s e f u l . One woman wrote, "I t h i n k the most h e l p f u l were the con v e r s a t i o n s I had with (the f a c i l i t a t o r ) a f t e r w a r d because (a) my p o i n t of view was respe c t e d , which i s r a r e among p r o f e s s i o n a l s , and (b) o f t e n a p r a c t i c a l , s e n s i b l e approach would come out of the d i s c u s s i o n s " . 101 V . SUMMARY AND RECOMMENDATIONS SUMMARY A large number of older women i n Canada are depressed; estimates indicate that 10 to 15 percent of people over 65 experience c l i n i c a l l y s i g n i f i c a n t depression, and double that suffer from less severe, but nonetheless d i s t r e s s i n g , symptoms. The problem i s expected to increase i n magnitude; women aged 65 and over are the fastest growing sector of the population, and having occupied t r a d i t i o n a l female roles, the majority reach retirement age with limited s o c i a l and economic resources--known r i s k factors for depression. The consequences of depression can be devastating, yet few older people receive treatment for t h i s problem. That t h i s occurs i s probably due to the following: 1) older people are low u t i l i z e r s of t r a d i t i o n a l mental health services, 2) physicians may dismiss depression as part of the aging process and, 3) depression i s often "masked" by medical conditions and may be missed or misdiagnosed. There have been few investigations as to what type of intervention best suits the needs of depressed older women. Alternatives to psychotropic drug therapy are essential; evidence indicates that many older people are prone to p a r t i c u l a r l y severe side e f f e c t s , and that older women are a group at high r i s k for inappropriate and over-prescription of these drugs. Psychotherapy i s one alternative, but the one-to-one version i s costly and inaccessible to many older women, they 102 are low u t i l i z e r s of such therapy, and i t has not been evaluated from t h e i r point of view. Social phenomena are considered to be at the root of much of the depression experienced by older women. It follows that interventions to prevent or r e l i e v e such depression should centre on improving the s o c i a l context of sufferers l i v e s and on minimizing the p o t e n t i a l l y demoralizing impact of circumstances l i k e unemployment, poverty, negative s o c i e t a l stereotyping, bereavement and chronic i l l n e s s . This study approached depression among older women from a s o c i a l perspective. Following Burnside's (1990) research, the personal s o c i a l network was viewed as the source of s o c i a l i d e n t i t y ; and thus, the locus of intervention. An educational intervention, the Social Health Outreach Program (SHOP) was applied. SHOP i s designed to augment women's s o c i a l networks, expand the number of roles they occupy, strengthen t h e i r s e l f -esteem, and, thus, a l l e v i a t e depression. Previous research demonstrated SHOP'S effectiveness i n reducing depression among women aged 45 - 65 (Burnside, 1990). SHOP was modified i n order to adapt i t to the needs of women aged 65 and over. The purposes of the study were: 1) to measure the impact of SHOP on participants' levels of depression and demoralization, and on t h e i r s o c i a l networks; 2) to determine t h e i r perceptions about which a c t i v i t i e s and processes helped, and which hindered, t h e i r progress during the program; and 3) to describe and analyze t h e i r experience of 103 depression. A t o t a l of 15 women, aged 58 - 76, i n two separate groups completed a 10 week (2 hrs., 2 times a week) version of SHOP at two senior's centres. Centre for Epidemiological Studies Depression Scale (CES-D) and General Well Being Schedule (GWB) measures were obtained at pre-test, post-test and 3 months following SHOP. Gains and losses i n participants' s o c i a l networks were determined at a 3 month follow-up interview. Data pertaining to participants' experiences of depression and t h e i r perceptions about which a c t i v i t i e s and processes helped, and which hindered, t h e i r progress were coll e c t e d at a post-program interview. Participants average age was 65.6 years. The majority were depressed at pre-test (n=10) and several were non-depressed (n=5). Most l i v e d alone, and about half l i v e d on incomes of less than $10,000 annually. Most were not employed; however, three " r e t i r e d " participants expressed inte r e s t i n part time employment either as an income supplement or as a form of regular a c t i v i t y . On average, participants had s l i g h t l y higher levels of education than the general population of older women. F i f t y three percent described themselves as having one or more l i m i t i n g physical d i s a b i l i t i e s , and a similar percentage reported two or more previous episodes of depression. The majority were not taking psychotropic drugs, and chose to avoid t h i s type of therapy. Outcome measures supported the effectiveness of SHOP as an intervention to reduce depression and augment older women's 104 s o c i a l networks. Participants' scores on the CES-D, on average, were reduced from pre- to post-program (9%); improvement continued through follow-up for a t o t a l reduction of 22% (p = .06). Participants' scores on the GWB were improved by an average of 6% pre- to post-program; scores dropped back s l i g h t l y through follow-up for a t o t a l gain of 4% (p = .5). Participants who were depressed at pre-test had d i f f e r e n t outcomes on depression measures than p a r t i c i a n t s who were non-depressed at pre-test. Depressed participants CES-D scores were improved at post-test (25%) and s i g n i f i c a n t l y improved at 3 month follow-up (30%, p = .004). Their GWB scores were improved at post-test (16%) and dropped back s l i g h t l y through to follow-up for a t o t a l gain of 1 1 % (p = .3). Three of the participants who were depressed at pre-test reached the l e v e l of non-depressed at 3 month follow-up. Thus, for depressed women, outcomes supported the hypothesis that p a r t i c i p a t i o n i n SHOP reduced levels of depression. In contrast, non-depressed participants' CES-D scores showed a temporary increase i n depressive symptoms at post-test with a return to normal levels at 3 month follow-up. Their GWB scores were s l i g h t l y lower at post test and 3 month follow-up than at pre-test. The impact of SHOP on participants' s o c i a l networks was measured at a 3 month follow-up interview. Participants reported, on average, s i g n i f i c a n t net gains of 4.5 people and 1.5 groups to t h e i r networks i n the three month period following SHOP. The majority of depressed and non-depressed participants 105 expanded t h e i r s o c i a l networks. The findings supported the hypothesis that p a r t i c i p a t i o n i n SHOP increases the size of women's s o c i a l networks. A c t i v i t i e s and processes that helped, and those that hindered, participants' progress during SHOP were determined i n order to c l a r i f y which factors generated p o s i t i v e outcomes for p a r i t i c i p a n t s . In 45 minute post-program interviews, participants reported 205 helping and 130 hindering incidents. From these, 20 categories of helping factors and 19 categories of hindering factors were developed. Helping categories mentioned by at least 25% of participants in decreasing order of frequency were: po s i t i v e future plans (93%); the routine and process of coming to SHOP (73%); p o s i t i v e self-image and outlook (66%); f r i e n d and family support (53%); recognition of improvement i n s e l f or sit u a t i o n (46%); mutual support/aid from SHOP group members (46%); reassessment of s e l f (46%); keeping active (33%); a sense of r e l i e f about f e e l i n g better (33%); and, learning through r e f l e c t i o n on experience (26%) . Hindering categories mentioned by at least 25% of participants i n decreasing order of frequency were: negative s e l f - c r i t i c a l thinking (53%); lack of sense of belonging i n SHOP (46%); loneliness (46%); physical health problems (33%); pessimism about the future (33%); sleep/energy problems (33%); family\spouse problems (33%); boredom (33%); Christmas/birthdays (33%); and, money/transportation/housing problems (26%). 106 For most participants the a c t i v i t i e s and processes that helped them during SHOP can be described as follows: coming to a regularly structured a c t i v i t y that stimulated t h e i r interest and got them out, thus, r e l i e v i n g boredom; focusing on p o s i t i v e events and plans, rather than on negative thoughts and emotions; experiencing support, companionship and comaraderie within the group and from family or friends outside the group; r e f l e c t i n g on t h e i r own and others' l i f e experiences and as a r e s u l t viewing themselves i n a more po s i t i v e l i g h t ; and, f i n a l l y , sensing some r e l i e f from the overwhelmingly negative emotional and thought overlay of depression. These findings support the main premise of SHOP--that regular involvement i n rewarding s o c i a l roles i s an essential source of stimulation, and i t generates the kind of person-to-person in t e r a c t i o n and feedback that helps people b u i l d and sustain a p o s i t i v e self-esteem. Participants' o v e r a l l experience was more po s i t i v e during SHOP as compared to before the program; however, as expected, several factors continued to influence them negatively: s e l f -c r i t i c a l thinking, loneliness and boredom p a r t i c u l a r l y when alone on weekends; worries about "not f i t t i n g i n " to the SHOP group; and, being housebound due to health problems. While negative s e l f - c r i t i c a l thinking topped the l i s t of hindering factors mentioned by participants, the opposite, posi t i v e thinking, was far down on the l i s t of helping factors. This finding implies that depression interventions must go beyond cognitive strategies to counteract negative thinking. Rather, techniques to stop 107 negative thinking and promote po s i t i v e thinking should be viewed as only one of several strategies to promote s o c i a l re-integration, p o s i t i v e planning for the future, and reframing of one's view of s e l f — p r o c e s s e s which i n turn generate p o s i t i v e thoughts. Negative thinking habits should be addressed because of t h e i r undermining impact on a woman's ef f o r t s to p a r t i c i p a t e s o c i a l l y , not because they are the source of her depression. Depressed participants' comments revealed that t h e i r depression stemmed from s o c i a l i s o l a t i o n , s o c i a l i d e n t i t y d e f i c i t and physical health problems. The aspects of t h e i r experience mentioned most often i n decreasing order of frequency are as follows: boredom or lack of stimulating a c t i v i t i e s ; negative, s e l f - c r i t i c a l thinking; sadness/despondency; urgency/desperation; low energy/low motivation; t r y i n g to keep active; loneliness/lack of companionship; and, health problems. A l l aspects of depressed participants' l i v e s that were mentioned, except getting out of the apartment and walking, were negative. Depressed and non-depressed participants commented that they were looking for "friends" or "something to do" before coming to SHOP. This r e f l e c t e d t h e i r peripheral status i n society and indicates t h e i r i n t u i t i v e understanding that meaningful s o c i a l involvement i s c r u c i a l to well-being. Several additional issues r e l a t i n g to participants' experiences emerged in f i e l d notes: 1. Low income c u r t a i l e d the e f f o r t s of some to get involved s o c i a l l y . Buying adequate clothing and bus t i c k e t s for 108 volunteering, and reciprocating s o c i a l l y , were perceived to st r a i n t h e i r limited finances. Fears about being destitute i n old age were expressed. 2 . Most participants f e l t frustrated about t h e i r interactions with physicians. This stemmed from a hesitancy to ask an "authority figure" questions, and from previous r e j e c t i o n by physicians af t e r having asked a question. One participant reported s t a r t i n g a personal health record and receiving a pos i t i v e response from her physician. 3 . Most participants wanted alternatives besides medication to fi g h t depression. Several had experienced negative side effects from psychotropic drugs and some feared that such drugs would impair t h e i r thinking. 4. P a r t i c i p a t i o n i n SHOP helped some of the women strengthen t h e i r 'voices' v i a increased morale and energy. Observable changes i n behavior included: increased speaking fluency and power; neater, more a t t r a c t i v e dressing and grooming; increased e f f o r t s to read and write; and, greater s o c i a l confidence. 5. For a l l but one participant, setting personal goals was a new and d i f f i c u l t experience. Some d i s l i k e d the term "goal" and others f e l t pressured by the expectations implied i n a goal. But for most, they had never set goals because t h e i r l i v e s were contingent on others' needs, not t h e i r own. 6. Two helpful aspects of the program were: informal instructor support of individuals outside of class; and taking a one or two week break half way through the program. The instructor 109 observed that on returning a f t e r the break participants were pleased to see each other; members of both groups seemed more relaxed and open with each other. RECOMMENDATIONS This study supports the view that for many older women depression originates i n t h e i r s o c i a l environment. Moreover, i t points out the value of educational intervention as a means of helping older women to reconstruct s o c i a l i d e n t i t y , increase s o c i a l p a r t i c i p a t i o n and, thereby, a l l e v i a t e depression. The following recommendations for practice and research are drawn from the findings. Adapting SHOP for Women i n Later L i f e The outcomes of t h i s study show, as expected, that with s l i g h t modification SHOP i s as e f f e c t i v e with older women as i t i s with m i d - l i f e women. Furthermore, participants' perspectives on which a c t i v i t i e s and processes advanced, and which impeded, t h e i r progress during SHOP support and reinforce i t s approach. The revisions required to extend SHOP to older women were minimal. The program was shortened to 10 weeks when i n i t i a l advertising of a 19 week program yielded one response (see Chapter III for d e t a i l s ) . Although response to the shorter version was stronger i n the recruitment phase, when the program ended several participants expressed the view that i t was "not long enough". It i s recommended that longer versions, or second phases of SHOP, should be available for women who need more time 110 than 10 weeks i n a supportive group atmosphere to i n i t i a t e l i f e changes. Beyond program length, additional modifications to SHOP involved s h i f t s i n emphasis as opposed to str u c t u r a l program changes. When promotion of SHOP as a "treatment for depression" met with limited success, i t was decided to pub l i c i z e i t as an educational program i n which women could learn ways to "restore s o c i a l confidence, b u i l d support i n t h e i r l i v e s and overcome depression". The l a t t e r approach was more successful. It i s recommended that p r a c t i t i o n e r s use pos i t i v e language i n outreach and r e c r u i t i n g e f f o r t s ; however, on a cautionary note, changing the language of recruitment influences who comes to the group, and f a c i l i t a t o r s must then be prepared to work with mixed groups (e.g. depressed and non-depressed p a r t i c i p a n t s ) . Because the majority of women i n t h i s study were r e t i r e d and planned to remain so (only one was employed), program content on s o c i a l p a r t i c i p a t i o n emphasized volunteer roles rather than employment roles. However, three of the non-employed women i n the study expressed some intere s t i n part-time work; two were considering i t as an income supplement, and a t h i r d was seeking a structured a c t i v i t y . It i s recommended that employment-related content be made available to those 'retired' women i n SHOP programs who want i t ; for example, r e f e r r a l s to an employment counselling agency that spec i a l i z e s i n re-entry with older workers could be arranged. A s h i f t i n emphasis evolved, as i t would i n any group, from the experiences that participants raised i n discussions. The women i n th i s study, es p e c i a l l y those i n t h e i r late 60's and early 70's, spoke of issues unique to t h e i r cohort (e.g. r a i s i n g children as a single parent i n the 1940's). As i s essential i n any educational a c t i v i t y , f a c i l i t a t o r s should be prepared to bui l d discussions around experiences that are relevant to groups with p a r t i c u l a r l i f e h i s t o r i e s . Extension Of The Social Health Outreach Program Older women are a heterogeneous group i n terms of intere s t s , experiences and problems. No one intervention approach w i l l address a l l of t h e i r needs. SHOP provides an adaptable model for preventive or restorative educational intervention. SHOP should be modified according to the experiences and interests of s p e c i f i c groups of older women vulnerable to s o c i a l i d e n t i t y d e f i c i t (e.g. those i n is o l a t e d r u r a l areas, caregivers, ethnic minorities, chronically i l l , those recovering from alcohol or drug dependence, widows, and women leaving marriages). Alternate versions of SHOP should be extended to such groups and the impact studied from p r a c t i t i o n e r s ' and older women's perspectives. It i s recommended that SHOP should be incorporated and researched as part of health promotion a c t i v i t i e s . Guidelines for F a c i l i t a t o r s The findings suggest that SHOP'S effectiveness i s increased when the f a c i l i t a t o r takes the following actions: 1) adopting a collaborative stance, not an "expert" stance. 112 2) challenging participants' negative views of themselves and suggesting other possible self-images as appropriate. 3) promoting network-building between participants and the host organization. 4) promoting network-building among group members by c i r c u l a t i n g l i s t s for those who wish to p a r t i c i p a t e i n a telephone number exchange, using name tags u n t i l participants know each others' names, setting up coffee breaks, and supporting lunch or out-of-class outings. 5) r e i n f o r c i n g participants' progress by noting and commenting on any observable changes. 6) encouraging regular physical a c t i v i t y . 7) promoting belonging i n the group by d i f f u s i n g participants' sense of f e e l i n g "different" than the others. 8) providing informal i n d i v i d u a l support to participants outside of group time as requested. It i s recommended that the f a c i l i t a t o r set i n motion a follow-up process p r i o r to the program ending. This i s p a r t i c u l a r l y important i n shorter version programs. The f a c i l i t a t o r can collaborate with participants on what form the follow-up should take (e.g. group meetings over increasing time i n t e r v a l s , i n d i v i d u a l telephone contacts or interviews, or informal get-togethers). In addition, the f a c i l i t a t o r should a l e r t participants to alternative s o c i a l supports when the program ends (e.g. senior peer counsellors, senior centre personnel). 113 Experience As A Base For Planning Interventions The women i n thi s study experienced depression characterized by factors amenable to intervention--boredom, sadness, loneliness, and s e l f - c r i t i c a l thinking--clear evidence that SHOP'S central focus on s o c i a l network augmentation v i a education and group support was on track. Research needs to further explore the phenomenon of depression among the diverse population of older women; research should attempt to understand the phenomenon from t h e i r perspective and from the perspective of others close to them. Practitioners should be aware of how older women experience depression and use the information as a basis for planning interventions. Programs which f a i l to take older women's perspectives into account may be a waste of time. At best, p o s i t i v e outcomes may be short-lived, e s p e c i a l l y i f women remain i n circumstances that generate depression. Education of Professional and Lay Leaders Opportunities should be made available for p r a c t i t i o n e r s to become informed about issues and problems a f f e c t i n g older women, and to upgrade t h e i r knowledge and s k i l l s enabling them to implement e f f e c t i v e educational interventions with small groups of older women. A proposal has been i n i t i a t e d through the Mature Women's Network Society (Vancouver, Canada) to conduct SHOP leadership t r a i n i n g programs for professional and lay f a c i l i t a t o r s - - a s a method of extending SHOP to a broader audience of women. 114 C O N C L U S I O N Canadian society i s just beginning to come to terms with population aging. While a commitment to "quality of l i f e " for a l l older people has been voiced at the i n s t i t u t i o n a l l e v e l , s o c i a l change toward t h i s end has been slow to evolve. In the current s o c i e t a l context, too many older women fi n d themselves at the sidelines of s o c i a l l i f e and are there rendered i n v i s i b l e . Under these circumstances i t i s a daunting challenge, es p e c i a l l y with limited resources, to sustain a d a i l y l i f e that generates focus, meaning and s e l f worth, as opposed to stagnation, boredom and demoralization. Thoughtfully crafted educational programs can serve to equip older women, i n d i v i d u a l l y and c o l l e c t i v e l y , with the s e l f -awareness, knowledge and s k i l l s needed to a l t e r t h e i r experience. Findings of t h i s study and previous research demonstrated that the Social Health Outreach Program i s an education-oriented intervention that e f f e c t i v e l y helps middle-aged and older women establish or sustain health-promoting s o c i a l networks, rebuild t h e i r s o c i a l i d e n t i t y and reduce depression. At present, however, older women receive minimal attention as a potential c l i e n t e l e for educational programs, counselling or other human services. Consequently, there are few exi s t i n g programs that have been designed according to the needs of, and in collaboration with, older women. 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Cognitive-behavioral and psychodynamic group therapy i n the treatment of g e r i a t r i c depression. Journal of Consulting and C l i n i c a l  Psychology, 52, 80-189. Strauss, D. & Solomon, K. (1983). Psychopharmacological intervention for depression i n the elde r l y . C l i n i c a l  Gerontologist, 2, 3-29. 122 Thornton, J. (1986). L i f e l o n g learning and education: A conceptual progression i n the l i f e course. In D. Peterson, J. Thornton, & J. Birren (Eds.), Education and aging. New York: Prentice-Hall. Tross, S. & Blum, J. (1988). A review of group therapy with the older adult: Practice and research. In B. Maclennan, S. Saul & M. Weiner (Eds.), Group psychotherapies for the el d e r l y . Madison: International Un i v e r s i t i e s Press. Van Servellen, G. & Dull, L. (1981). Group psychotherapy for depressed women: A model. Journal of Psychosocial Nursing  and Mental Health Service, 19, 25-31. Walker, K., MacBride, A. & Vachon, M. (1977). Social support networks and the c r i s i s of bereavement. Social Science  Medicine, 11, 35-41. Wellman, F. & McCormack, J. (1984). Counseling with older persons: A review of outcome research. The counseling  psychologist, 12, 81-96. Yost, E., Beutler, L., Corbishley, M. & Allender, J. (1986). Group cognitive therapy: A treatment approach for depressed  older adults. Toronto: Pergamon Press. 123 Appendix B-l The Centre for Epidemiological Studies Depression Scale INSTRUCTIONS FOR QUESTIONS. Below i s a l i s t of the ways you might have f e l t of behaved. Please t e l l me how often you have f e l t t h i s way during the past week. 0 - Rarely or None of the Time (Less than 1 Day) 1 - Some or a L i t t l e of the Time (1-2 Days) 2 - Occasionally or a Moderate Amoung of Time (3-4 Days) 3 - Most of A l l of the Time (5-7 Days) During the past week: 1. I was bothered by things that usually don't bother me, 2. I did not f e e l l i k e eating; my appetite was poor. 3. I f e l t that I could not shake off the blues even with help from my family or friends. 4. I f e l t that I was just as good as other people. 5. I had trouble keeping my mind on what I was doing. 6. I f e l t depressed. 7. I f e l t that everything I did was an e f f o r t . 8. I f e l t hopeful about the future. 9. I thought my l i f e had been a f a i l u r e . 10. I f e l t f e a r f u l . 11. My sleep was r e s t l e s s . 12. I was happy. 13. I talked less that usual. 14. I f e l t lonely. 15. People were unfriendly. 16. I enjoyed l i f e . 17. I had crying s p e l l s . 18. I f e l t sad. 19. I f e l t that people d i s l i k e d me. 20. I could not get "going". Radloff, L. & T e r i , L. (1986). Use of the Centre for Epidemiological Studies-Depression Scale with older adults. C l i n i c a l Gerontologist, 5_, 119-135. 127 Appendix B-2 G E N E R A L WELL-BE ING S C H E D U L E (GWB) R E A D — T h i s t ac t i on e l th« examinat ion c o n t a i n ! ques t ions about how you feel and how things hov* been going wi th y o u . For each ques t ion , mark (X) the i i i l w t i which best a p p l i e s to y o u .  I. How hov* you been fool ing In geneto l? ( D U R I N G T H E P A S T MONTH) 1. ( M l ) I £ j I n e x c e l l e n t s p i r i t s 11 | I n v e r y t o o d s p i r i t s 1 r - ] I n t o o d s p i r i t s m o s t l y 4 [ [ j I h a v e b e e n u p a n d d o w n i n s p i r i t s a l o t 5 I n l o w s p i r i t s m o s t l y • • fJD I n v e r y l o w s p i r i t s Havo you boon bothered by n e r v o u i n e t s or your " n e r v e s " ? {DURING THE P A S T M O N T H ) ( M T ) I E x t r e m e l y s o - - t o t h e p o i n t w h e r e I c o u l d n o t w o r k o r t a k e c a r e o f t h i n f f 1 [ J J . V e r y m u c h s o l £ j Q u i t e a b i t 4 Q S o m e • - e n o u ( h t o b o t h e r m e 5 fjj A l i t t l e Hove you boon in firm control of your behavior , thoughts, •mot ions OR footings? ( O U R I N G T H E P A S T M O N T H ) 3. [DOJ) t [~J Y e s . d t l i n i t e l y S o I \ | Y e s . f o r t h e m o s t p a r t J r~] G e n e r a l l y s o 4 PJj N o t t o o well * CZ} and I a m ' ZTi N o ' * n o " ' " r " v e , v disturbed  L_) N o - * n o ' ' * m * o m e w n a t disturbed 4. Hovo you folt so i o d , d i scouraged , hope l e s s , or hod so many problems that you wondered if anything was worthwhi le? ( D U R I N G T H E PAST MONTH) ( M l ) 1 fJTJ E x t r e m e l y s o - - t o t h e p o i n t t h a t I h a v e j u s t a b o u t l i v e n u p 2 V e r y m u c h SO } L7J Q u i t e a b i t 4 £j S o m e - - e n o u f h t o b o t h e r m e » fJH A l i t t l e b i t ft • N o t a t a l l 5. Hove jrtw been under or felt you were under ony s t ra in , s t ress , • ( pressure? ( D U R J N G T H E P A S T MONTH) S. (wj) 1 L3) Y e s - - a l m o s t m o r e t h a n I c o u l d b e i r or s t a n d 2 I I Y e s q u i t e a b i t o f p r e s s u r e 1 Q Y e s - - s o m e - m o r e t h a n u s u a l 4 Q Y e t - - s o m a - b u t a b o u t u s u a l s Q Y e s - a l i t t l t 128 How happy, satiified, or pleated hove you b«cn with your personal lile? (DURING THE PAST MONTH) (w*) i Extremely happy - could not have been more satisfied or pleased 2 Q Very happy 3 f_n Fairly happy 4 Q Satisfied - - pleased 5 Q Somewhat dissatisfied 6 Very dissatisfied Have you had ony reason lo wonder if you were losing your mind, or losing control over the way you oct, talk, think, (eel, or of your memory? ( D U R I N G T H E P A S T MONTH) 7. ( M 7 ) i Q Not at all 2 • Only a little 3 f^j Some - - but not enough to be concerned or worried about 4 £j Some and I have beer, a little concerned s [23 Some and I am quite concerned e Yes. very much so and I am very concerned 8. Have you been anxious, worried, or upset? ( D U R I N G T H E P A S T / M O N T H ) [008/ I • Extremely so - - to the point of being srek or almost sick 2 P^ J Very much so 3 r^Z Quite a bit 4 i I Some - - enough to bother me 5 . ~ A little bit 6 " Not at all Have you been waking up fresh ond tested? ( D U R I N G T H E P A S T M ONTH) 2 ~ Most every day 3 '• 1 Fairly often 4 1 1 Less than half the time 5 Rarely 6 '• 1 None of the time 10. Have you been bothered by ony illness, bodily disorder, pains, or feors obout youf heolth? ( D U R I N G T H E P A S T M O N T H ) 10. 010) i All the time 2 Most of the time 3 r~ A good bit of the time 4 Some of the lime s : j A little of the time 6 ' . None of the time 11. Hos your doily life been full of things that were 11. interesting to you? (DURING THE PAST MONTH) All the time 2 ! Most of the time 3 ~ j A good bu ol the time 4 r^j Some of the time 5 ^2 A l'«t'« of the lime e ' i None of the time 12. Hove you fell down-hearted ond blue? (DURING 12. THE PAST MONTH) \0\2) i ~ All of the time 2 ^2 Most of the time 3 : A jood bit of the time 4 (3 Some of the time s t~j A little of the time 6 f ~ l None of the lime 129 1 3 . H o v « y o u b e e n f e e l i n g e m o t i o n a l l y s t a b l e 1 3 . ( o n d t o r . o l y o u r s e l f ? {DURING T H £ P A S T ' MONTH) I (ju) I L7J A l l o f the t i m e j l ) M o i t of t h e t i m e 1 A g o o d bit of the t i m e « tjj S o m e o l the t i m e s 1 ) A l i t t l e o f the t i m e s | 1 N o n e of the l i m e 1 4 . H o v e y o u f e l t t i r e d , w o r n o u t , u s e d - u p , or 14. • e x h a u s t e d ? (DURING THE P A S T M O N T H ) J (OU) i Q A l l of the t i m e 1 LD M ° s ' o f t h e t i m e 3 • 1 A f o o d bit o f the t i m e 4 Q S o m e o f the t i m e i Q A l i t t l e o f the t i m e e Q N o n e of the t i m e I S . H o w c o n c e r n e d or w o r r i e d o b o u t y o u r H E A L T H I S . h o v e y o u b e e n ? ( S U R I N G T H E P A S T M O N T H ) F o r e o c h o l t h e lout s c a l e s b e l o w , n o t e t h a t t h e w o r d s a t e o c h e n d o f t h e 0 t o 10 s c a l e d e s c r i b e o p p o s i t e f e e l i n g s . C i r c l e o n y n u m b e r a l o n g t h e b a r w h i c h s e e m s c l o s e s t t o h o w y o u h a v e g e n -e r a l l y f e l t D U R I N G T H E P A S T M O N T H . (oils) 0 1 J 3 4 5 » 7 « v l O M l 1 I I i i 1 I I Nol Very concerned concern 1;-»< a l l 1 6 . H o w R E L A X E D or T E N S E h o v e you been? 16. (DURING T H E P A S T M O N T H ) • (OU) O I 7 3 4 5 » 7 » v l O ! 1 1 l l 1 1 1 1 1 1 1 1 Very Very , relaxed tense 17 . H o w m u c h E N E R G Y . P E P , V I T A L I T Y h o v . 17. you f , l t ? ( D U R I N G T H E P A S T M O N T H ) '• (0W) 0 1 7 3 4 5 » 7 « » '0 1 M l ' M l i No t n e r £ y , Very I AT A L L . ENERGET IC , , l i s t l e s s dynamic 1 8 . H o w D E P R E S S E D o . C H E E R F U L 18. hov* you been? ( D U R I N G T H E P A S T M O N T H ) ! (Oil) 0 1 ? 3 4 5 • 7 t ? 10 i I 1 1 1 1 1 ! 1 1 1 1 • Very Very i d e p r e s s e d c h e e r f u l Fazio, A. (1977). A concurrent v a l i d a t i o n study of the NCHS  General Well Being Schedule. (DHEW Publ i c a t i o n N. HRA 78-1347). H y a t t s v i l l e , Md.: U.S. National Center for Health S t a t i s t i c s . 130 Appendix B-3 Background Information Interview The purpose of t h i s interview i s for me to ask you some questions about your background, for example, where you l i v e , what grade you completed i n school, etc. As you know, you are under no obligation to p a r t i c i p a t e , so i f you would prefer to omit any questions, please l e t me know. 1. Age: 2. Marital status: 3. Parental status: 4. How many years of schooling did you complete? less than seven years junior high school p a r t i a l high school high school diploma (or trade school equivalent) p a r t i a l university professional degree 5. Current employment status: 6. Within which of the following categories does your current annual income f a l l ? 1) unmarried under $2,000 2,000 - 4,999 5,000 - 9,999 10,000 - 14,999 15,000 - 19,999 20,000 - 24,999 25,000 and over 2) married under $5,000 5,000 - 9,999 10,000 - 14,999 15,000 - 19,999 20,000 - 24,999 25,000 - 29,999 30,000 - 39,999 40,000 and over 7. Li v i n g Arrangements: 8. History of depression (including f i r s t onset, c h r o n i c i t y ) : 9. Do you have any physical handicaps or disabling diseases? 10. Prescription drugs: 131 Appendix B-4 P o s t P rogram I n t e r v i e w The pu rpose o f t h i s i n t e r v i e w i s t o r e f l e c t upon and c a p t u r e some o f y o u r e x p e r i e n c e o v e r t h e p a s t two t o t h r e e months . 1. T h i n k back t o j u s t b e f o r e you s t a r t e d S H O P . . . How were you f e e l i n g then? What were y o u r t h o u g h t s l i k e ? And what was y o u r d a i l y a c t i v i t y l i k e ? 2 . Now, p l e a s e r e f l e c t on t h e t i m e s i n c e SHOP s t a r t e d . . . . How have you been f e e l i n g ? And what have y o u r t h o u g h t s and d a i l y a c t i v i t i e s been l i k e ? 3 . T h i n k i n g back t o j u s t when t h e p rogram s t a r t e d . . . D e s c r i b e what you c o n s i d e r t o be y o u r l o w e s t p o i n t s s i n c e t h a t t i m e . F o r example , s t a r t i n g w i t h t h e f i r s t l ow p o i n t you can remember, what happened e x a c t l y and why was i t d i f f i c u l t f o r you? Any o t h e r s ? 4. Now t h e h i g h p o i n t s . S t a r t i n g w i t h t h e f i r s t h i g h p o i n t , what happened e x a c t l y and why was i t a h i g h p o i n t f o r you? Any o t h e r s ? 5. What a r e y o u r e x p e c t a t i o n s about t h e f u t u r e r i g h t now? 132 Appendix B-5 F o l l o w - U p I n t e r v i e w The p u r p o s e o f t h i s i n t e r v i e w i s t o f o l l o w - u p on y o u r e x p e r i e n c e i n t h e 3 months s i n c e SHOP ended , and t o g e t an upda te on y o u r s o c i a l n e t w o r k . The q u e s t i o n s w i l l seem f a m i l i a r s i n c e we have d i s c u s s e d t h e m a t e r i a l b e f o r e . 1. T h i n k back t o when SHOP ended and r e f l e c t on y o u r e x p e r i e n c e s i n c e t h e n . . . H o w have you been f e e l i n g ? What has y o u r t h i n k i n g been l i k e ? What has y o u r d a i l y a c t i v i t y been l i k e ? 2 . Now I ' d l i k e t o d i s c u s s what changes have o c c u r r e d i n y o u r s o c i a l n e t w o r k , i n te rms o f p e o p l e o r g roups added t o y o u r n e t w o r k , o r l o s t f rom y o u r n e t w o r k . . . I have added "new p e o p l e " . P l e a s e c a t e g o r i z e new p e o p l e i n te rms o f a c q u a i n t a n c e / f r i e n d / c o n f i d a n t / p r o f e s s i o n a l . i n d i v i d u a l s have " l e f t " my ne twork ( c a t e g o r i z e as above . I have added new "groups" t o my ne twork ( o t h e r t h a n one t i m e e v e n t s ) . P l e a s e s p e c i f y n a t u r e o f g roup and f r e q u e n c y o f a t t e n d a n c e . I have s t o p p e d a t t e n d i n g g r o u p s / o r g a n i z a t i o n s ( p l e a s e s p e c i f y ) . I have have no t t a k e n p a r t i n a c o u r s e / p r o g r a m s i n c e SHOP ( p l e a s e d e s c r i b e n a t u r e and p u r p o s e ) . I have have no t done v o l u n t e e r work s i n c e SHOP ( p l e a s e d e s c r i b e ) . What e l s e w o u l d you l i k e t o t e l l me abou t y o u r p l a n s o r a c t i v i t i e s ? Now t h a t y o u ' v e had 3 months t o r e f l e c t , what comments w o u l d you make abou t y o u r e x p e r i e n c e i n SHOP? 133 Appendix C P o s t P rogram I n t e r v i e w Summaries The f o l l o w i n g summaries p r o v i d e anonymous " s n a p s h o t s " o f p a r t i c i p a n t s , c r e a t i n g a more h o l i s t i c and c o n t e x t u a l r e p r e s e n t a t i o n o f t h e i r e x p e r i e n c e . The l e t t e r a s s i g n e d t o each p a r t i c i p a n t i s no t he r i n i t i a l . P a r t i c i p a n t A : A . r e p o r t e d t h a t b e f o r e she j o i n e d SHOP she was l o o k i n g t o b e l o n g t o a d i f f e r e n t g roup t h a t was i n t e r e s t i n g , t h a t made he r t h i n k , and t h a t was easy t o g e t t o . She d i d n ' t want t o r e p e a t some a c t i v i t i e s t h a t she had a l r e a d y t r i e d , and was i n t e r e s t e d i n m e e t i n g some new p e o p l e . She was f e e l i n g a b i t annoyed w i t h h e r s e l f because she t h i n k s o f t h i n g s t o do b u t has t r o u b l e g e t t i n g a round t o d o i n g them. A . e n j o y e d coming t o t h e group because t h e m a t e r i a l was i n t e r e s t i n g and she e n j o y e d m e e t i n g p e o p l e . She f e l t i t was e n c o u r a g i n g t o hea r abou t t h e s u c c e s s e s o f o t h e r p e o p l e - - i t gave h e r i d e a s abou t t h i n g s she c o u l d d o . A l t h o u g h coming t o t h e g roup s t i r r e d up he r t h o u g h t s a b i t , she found i t h e l p f u l because i t e n c o u r a g e d he r t o t h i n k about how t o improve he r s i t u a t i o n . The p rogram ended no t l o n g a f t e r C h r i s t m a s , a t i m e when A . f e e l s " s o r t a down" and " b o r e d " , p a r t l y due t o t h e d u l l wea the r w h i c h keeps he r i n t h e house more t h a n she w o u l d l i k e . Over C h r i s t m a s , A . v i s i t e d a r e l a t i v e who encouraged he r t o move t o e a s t e r n Canada . W h i l e i t was good t o v i s i t t h i s r e l a t i v e , A . d i d n o t t h i n k she wanted t o move e a s t ; however , she was m u l l i n g t h i s o v e r i n he r m i n d . A . i s t h i n k i n g about what s p e c i f i c a c t i v i t i e s she can p u r s u e i n t h e f u t u r e . P a r t i c i p a n t B : B . came t o SHOP because she r e a l l y needed s o m e t h i n g t o do and was l o o k i n g f o r a s t r u c t u r e d a c t i v i t y . A l s o , he r d o c t o r s u g g e s t e d t h e p rogram and she wanted t o f o l l o w t h i s a d v i c e . I n t h e t i m e b e f o r e SHOP, B . was f e e l i n g v e r y d e p r e s s e d , s t a y i n g i n bed as l o n g as she c o u l d w o n d e r i n g "what i s l i f e f o r anyway" and "how l o n g i s i t g o i n g t o l a s t " . She g o t d r e s s e d and went o u t e v e r y day f o r mea l s i n s p i t e o f how she was f e e l i n g . B . r e a l l y e n j o y e d coming t o t h e g r o u p . She d i d n ' t f e e l o b l i g a t e d t o make i t and a p p r e c i a t e d t h e g r o u p ' s f r e e a tmosphe re . She found t h a t t h e p e o p l e i n t h e group were v e r y 134 ( A p p e n d i x C c o n t i n u e d ) i n t e r e s t i n g , a n d s h e e n j o y e d t h e i r c o m p a n y f o r l u n c h . S h e s u r p r i s e d h e r s e l f w i t h b e i n g a b l e t o s o c i a l i z e w i t h t h e w o m e n i n t h e g r o u p . D u r i n g S H O P B . n o t i c e d t h a t s h e d i d m o r e w a l k i n g a n d s h e c o m p l e t e d t h e h o m e w o r k a s s i g n m e n t s . S h e r e c o g n i z e d t h a t s h e i s a g o o d l i s t e n e r a n d t h a t s h e h a d c o m e t o a p o i n t w h e r e s h e w a s b e t t e r a b l e t o a c c e p t t h i n g s s h e c a n ' t c h a n g e . B . e x p e r i e n c e d f e e l i n g s o f r e l i e f w h e n a t S H O P ; h o w e v e r , h e r f e e l i n g s o f d e p r e s s i o n c o n t i n u e d a t h o m e , e s p e c i a l l y o v e r t h e w e e k e n d s w h e n s h e w a s a l o n e . A l t h o u g h B . f e l t a w a r e o f a l a c k o f k n o w l e d g e t h r o u g h n o t b e i n g a r e a d e r , s h e r e a l i z e d t h a t s h e h a s a f a i r i n t e l l i g n e c e t o h a v e w o r k e d h e r w a y u p t o a p o s i t i o n o f o f f i c e m a n a g e r b e f o r e s h e r e t i r e d . S h e a m a z e d h e r s e l f b e c a u s e s h e p i c k e d u p a n e w s p a p e r o n e d a y - - b e f o r e s h e c o u l d n ' t k e e p h e r m i n d o n a n y t h i n g l i k e t h a t . C h r i s t m a s o c c u r r e d a b o u t m i d w a y t h r o u g h t h e p r o g r a m . B . s p e n t i t a l o n e a n d w a s p l e a s e d t o h a v e m a n a g e d " a l r i g h t " . B . s t a t e d t h a t h e r e x p e c t a t i o n s o f t h e f u t u r e a r e " n o t g r e a t b u t i t s u p t o m e " . S h e n o t e d t h a t s h e i s a p e r s o n w h o s e e m s t o b e " s e a r c h i n g a l l t h e t i m e " . P a r t i c i p a n t C : B e f o r e t h e p r o g r a m C . s p e n t m o s t o f h e r r e t i r e m e n t (2 y r s . ) d e a l i n g w i t h h e a l t h p r o b l e m s . S h e d e c i d e d t h a t s h e n e e d e d a c h a n g e . W h i l e k e e p i n g b u s y h a d h e l p e d h e r t o f e e l " n o t t o o b a d " , s h e d e s c r i b e d a n u n d e r n e a t h f e e l i n g o f b o r e d o m , u s e l e s s n e s s , h o p e l e s s n e s s a n d a s e n s e t h a t t h e r e w a s t o o l i t t l e t i m e l e f t i n h e r l i f e t o g e t o v e r e a r l i e r m i s t a k e s . C . l o o k e d f o r w a r d t o S H O P a n d w a s g l a d s h e w a s a t t e n d i n g . S h e p a r t i c u l a r l y e n j o y e d b e i n g w i t h p e o p l e a n d t a l k i n g a b o u t t h e k i n d s o f t h i n g s s h e w a n t e d t o t a l k a b o u t . A l t h o u g h C . l o o k e d f o r w a r d t o t h e " d o i n g " a s p e c t o f c o m i n g t o S H O P , s h e s o m e t i m e s f e l t i n c o m p a t i b l e w i t h t h e o t h e r w o m e n , a s t h o u g h w h a t s h e t a l k e d a b o u t " p u t t h e m o f f " . S h e f o u n d s o m e o f t h e o n e - t o - o n e w o r k t o o p e r s o n a l . D u r i n g t h e p r o g r a m C . r e a l i z e d t h a t s h e e x p e r i e n c e d l o w s e l f - e s t e e m a n d t h a t s h e h a d a t e n d e n c y t o p u t n e g a t i v e t h o u g h t s i n t h e w a y o f d o i n g t h i n g s . C . f e l t a " r e a l l e t d o w n " w h e n t h e p r o g r a m e n d e d . S h e d e s c r i b e d t h e l a s t d a y a s " t h e l o w e s t d a y I ' v e h a d t h i s w i n t e r " . S h e w o u l d l i k e t o s e e s o m e s t r u c t u r e a d d e d t o t h e p r o g r a m r e : w h a t p e o p l e a r e g o i n g t o d o a f t e r w a r d . C . s t a t e d t h a t s h e e x p e c t s d e c l i n i n g e n e r g y i n t h e f u t u r e , a n d h e r p l a n i s t o g e t t h r o u g h e a c h d a y a i m i n g t o m a i n t a i n h e r p r e s e n t c a p a c i t i e s . P a r t i c i p a n t D : I n t h e t i m e b e f o r e a t t e n d i n g S H O P , D . w a s e x p e r i e n c i n g 135 (Appendix C continued) mixed emotions. While she had started to resolve some problems, i n general she was fed up with her l i f e , and was not looking forward to Christmas and her birthday. D.'s a c t i v i t y was limited because of health problems and she was f e e l i n g frustrated about ongoing pain, and angry about receiving limited help and support. Her thoughts tended to be s e l f c r i t i c a l and she reported noticing that angry feelings were surfacing more often. During SHOP D. at times f e l t l i k e q u i t t i n g . It i r r i t a t e d her when new members joined lat e , as i t changed the "tenor" of the group. While she f e l t l i k e confonting some of the members who seemed "high pressure", she did not want to be i n c o n f l i c t . She decided to resolve these feelings of i r r i t a t i o n by l i s t e n i n g . She would have preferred i f the sessions hadn't reached such a personal l e v e l . D. reported that she had more pos i t i v e feelings about her own l i f e ofter the group started. She noticed that she didn't put herself down as much as before. She f e l t less i s o l a t e d and experienced a sense of kinship i n the group. While at times she shocked herself by speaking out on certain issues, she f e l t good about expressing herslef and not being a "phoney". She's hoping i n the future to f e e l happier and to f i n d a nice companion. Participant E: E. reported that before the program she was f e e l i n g very low, very depressed and at times close to psychotic. She had l e f t an abusive marriage and had no place to c a l l home. She f e l t desperate and worried about what her future was going to be. E. looked forward to SHOP and described i t as her "oasis". She l i k e d the warm, easy, no-pressure atmosphere and the relaxed st y l e of the instructor. E. noticed that half-way through the program she began to f e e l less "bogged down". She started to r e a l i z e that i t would have been stupid to stay i n such a destructive marriage. She f e l t that the "how-to" approach i n SHOP was helpful and opened up some avenues for her. She enjoyed the other women and looked forward to going for lunch with them. E. expressed the desire to have the group continue to meet i n some format for discussions. Her future goal was to f i n d a place to l i v e and "get back on my feet". Participant F: F. was just coming out of a bad depression at the time SHOP started and she was f e e l i n g desparately anxious to see someone. Her thoughts were quite negative and s e l f - c r i t i c a l . She was just getting back into d a i l y a c t i v i t i e s and was looking for something to occupy her time. 136 (Appendix C continued) F. f e l t unhappy about s t a r t i n g the program late and having to miss the lunch outings. Hoever, she did f e e l more encouraged and hopeful as a resu l t of things that came out i n the meetings. In p a r t i c u l a r she found i t useful to consider some of her successes i n l i f e . She found that each group meeting brought things to mind, often p o s i t i v e . F. often f e l t frustrated about medical problems that limited her a b i l i t y to get around and necessitate her having to l i e down during the day to manage her energy needs. Sometimes she f e l t discouraged about family problems. F. has thought about doing some writing i n the future and she hoped to make a fri e n d out of the group. Participant G: G. reported that before attending SHOP she was quite depressed. There were days when i t was "just awful", when she was "down so low that i t was too hard to look on the bright side of things". Her thinking at the time was very negative and s e l f -c r i t i c a l . She described the f e e l i n g as being " r e a l l y i n a deep p i t " . She wasn't able to figure out why she was depressed. She was walking everyday due to a problem with her leg and that would help for awhile, but i t didn't l a s t . G. described herself as always w i l l i n g to t r y something new. When she heard about SHOP, she went ahead and made an appointment. She f e l t hopeful thinking, "this w i l l be of some use". During the program the high point for G. was being i n the group and r e a l i z i n g that i f you look for friends they're out there. She also had a more po s i t i v e experience at Christmas time. G. was surprised at how much better she did f e e l after the program and described herself as f e e l i n g "completely normal". After the program she f e l t she understood herself better, and she was thinking more p o s i t i v e l y . She expects i n the future to be better able to handle anything negative that comes up and she thinks s h e ' l l take more chances. She feels she now knows how to "beat the blues". Participant H: H. was experiencing mixed feelings before the program started. She missed her mother who had died several months before (H. was the caregiver for her mother). At the same time she was thinking "freedom and a new s t a r t " . She was tr y i n g to keep involved i n the community. 137 (Appendix C c o n t i n u e d ) H. a p p r e c i a t e d t h a t b e i n g p a r t of t h e program a l l o w e d her t o be honest w i t h her f e e l i n g s of sadness a f t e r her mother and b e s t f r i e n d d i e d . She b e l i e v e d t h a t t h e s o c i a l p a r t s of t h e program (e.g. l u n c h o u t i n g s ) were r e a l l y i m p o r t a n t t o b u i l d a sense of t r u s t i n t h e group, and a l s o t o g i v e t h e p a r t i c i p a n t s a chance t o f e e l "grounded" a f t e r a l l t h e i n s i g h t f u l t h i n k i n g d u r i n g s e s s i o n s . She a p p r e c i a t e d t h a t t h e l e a d e r t o o k a f a c i l i t a t o r r o l e i n s t e a d o f l e c t u r e r . I n t h a t way, group members were a b l e t o f i n d out f o r t h e m s e l v e s . H. f e l t a g r e a t t h i n g about t h e program was was t h i n k i n g about t i m e s when she's been s u c c e s s f u l i n her l i f e . She r e a l l y a p p r e c i a t e d t h e chance t o f i n d out about some of her s t r e n g t h s . She f e l t happy t o see t h a t SHOP had changed t h e o t h e r women t o o . H. found t h e thought s t o p p i n g and g o a l s e t t i n g s e s s i o n s h e l p f u l , p a r t i c u l a r l y she found h e r s e l f b e i n g more r e a l i s t i c about g o a l s . She a p p r e c i a t e d t h e one-to-one i n t e r a c t i o n s i n t h e s e s s i o n s because she f e l t p a r t i c i p a n t s r i s k e d more. She d i d not l i k e j o u r n a l k e e p i n g — i t was " t e d i o u s " . She sugg e s t e d a f o l l o w - u p component be b u i l t i n t o t h e program. P a r t i c i p a n t I : I . has had trou b l e s o m e h e a l t h problems f o r a number of y e a r s . P r i o r t o SHOP she was a b l e t o walk around; however, she e x p e r i e n c e d p a i n from her b u t t o c k s t o her l e g s and r e c e i v e d a l o t of p h y s i o t h e r a p y . A t t h e ti m e SHOP s t a r t e d , I . was f e e l i n g "cooped up" i n her apartment and was t h i n k i n g i t would be good f o r her t o get out and see o t h e r p e o p l e . A t t e n d i n g SHOP was a p o s i t i v e e x p e r i e n c e i n t h a t she found i t i n t e r e s t i n g t o hear about o t h e r p e o p l e ' s e x p e r i e n c e - - i t h e l p e d her t o f e e l more connected w i t h t h e w o r l d . I.'s h e a l t h problems i n t e n s i f i e d d u r i n g t h e co u r s e and she had t o miss s e v e r a l s e s s i o n s . She f e l t d i s c o u r a g e d and r e p o r t e d t h a t her l i f e seemed f i l l e d w i t h i l l n e s s . She r e p o r t e d a v e r y s c a r y happening, of f a l l i n g i n t h e c r o s s w a l k on a v e r y busy s t r e e t . A t t h e program end, I . was f e e l i n g e x h a u s t e d w i t h t o o many h e a l t h problems a t th e same t i m e . P a r t i c i p a n t J : On i n t e r v i e w J . r e p o r t e d t h a t she has e x p e r i e n c e d f e e l i n g s o f u s e l e s s n e s s f o r many y e a r s . A l t h o u g h t h e SHOP program d i d not a l l e v i a t e t h o s e f e e l i n g s , J . r e a l l y e n j o y e d coming t o SHOP and s t a t e d t h a t she has "VERY p o s i t i v e f e e l i n g s about i t " . She l o o k e d f o r w a r d t o coming t o t h e s e s s i o n s . A t t i m e s i n t h e s e s s i o n s J . f e l t t h a t she was more d e p r e s s e d t h a n o t h e r p e o p l e . A t t h e s e t i m e s she h e l d back from s a y i n g t h i n g s t h i n k i n g t h a t o t h e r s "wouldn't want t o hear i t " . 138 ( A p p e n d i x C c o n t i n u e d ) J . f e l t t h e p rogram was more f o r d e p r e s s e d p e o p l e who j u s t needed some d i r e c t i o n , r a t h e r t h a n f o r p e o p l e who t h i n k " I j u s t c a n ' t " . J . r e p o r t e d t h a t a s o u r c e o f g r e a t s u p p o r t and encouragement i n he r l i f e i s he r c h u r c h and he r f a i t h . J . i s l o o k i n g f o r w a r d t o t a k i n g some e d u c a t i o n a l c o u r s e s i n t h e f u t u r e . P a r t i c i p a n t K : K . s t a t e d t h a t b e f o r e t h e p rogram s t a r t e d she was f e e l i n g v e r y s a d . She f e l t d e s p e r a t e t o f i n d a way t o make d e c i s i o n s abou t how t o p r o v i d e f o r h e r s e l f . She was w o r r i e d because she f e l t t h a t he r memory had d i m i n i s h e d compared t o f i v e y e a r s ago . She wanted t o f i n d s o u r c e s o f i n f o r m a t i o n about he r c a p a c i t i e s so she c o u l d make d e c i s i o n s abou t he r l i f e . When K . was no t a t work , she was s p e n d i n g most o f he r t i m e i n b e d . A t work , she was a s k e d t o p e r f o r m d u t i e s w h i c h a g g r a v a t e d a m e d i c a l c o n d i t i o n . T h i s c r e a t e d an u n c e r t a i n t y about a f u t u r e i ncome . K . ' s a n x i e t y abou t b e i n g a b l e t o keep t h e j o b i n t e r f e r e d w i t h he r a b i l i t y t o remember t h i n g s . A t t h e t i m e K . was f r u s t r a t e d because she was no t g e t t i n g s a t i s f a c t o r y m e d i c a l h e l p . She f e l t " p a t r o n i z e d " by he r d o c t o r . D u r i n g t h e p rogram K . f e l t as t hough she was c h a n n e l i n g he r ene rgy i n t o a d i r e c t i o n . She found r e l i e f i n h a v i n g a s t r u c t u r e d a c t i v i t y . She t h o u g h t she was f e e l i n g b e t t e r d u r i n g t h e p rogram and r e p o r t e d f e e l i n g c a l m e r i n c e r t a i n s i t u a t i o n s t h a n she w o u l d have e a r l i e r . She found i t h e l p e d t o know she had a p l a c e t o d i s c u s s t h i n g s . K . s t a t e d t h a t she hoped i n t h e f u t u r e t o ge t t h e i n f o r m a t i o n she needs t o make d e c i s i o n s and t o have a s c h e d u l e t h a t i n c l u d e s t i m e t o p u r s u e c r e a t i v e i n t e r e s t s . P a r t i c i p a n t L : B e f o r e t h e p rogram s t a r t e d L . was f e e l i n g "cooped u p " , " t i r e d " and " i n t u r m o i l " . She was m i s s i n g f r i e n d s who had d i e d and w i t h whom she had spen t a g r e a t d e a l o f t i m e . She had been home a l o t f o r two months due t o i l l n e s s . She was b e g i n n i n g t o l o o k f o r s o m e t h i n g t o f i l l h e r t i m e . L . r e p o r t e d a f e e l i n g o f r e l i e f i n coming t o SHOP. She d e v e l o p e d new i n t e r e s t s and s t a r t e d t o go o u t more . She p a r t i c u l a r l y e n j o y e d a t t e n d i n g a community c e n t r e and g e t t i n g i n v o l v e d w i t h f r i e n d s . L . r e p o r t e d t h a t he r f i n a n c i a l f u t u r e i s s e c u r e and t h a t she i s mak ing p l a n s t o t r a v e l w h i l e she s t i l l c a n . 139 ( A p p e n d i x C c o n t i n u e d ) P a r t i c i p a n t M : M . was f e e l i n g "at l o o s e ends" b e f o r e SHOP s t a r t e d . She was " c a s t i n g about" f o r some m e a n i n g f u l p rogram o r a c t i v i t y t o p u r s u e . She had s t o p p e d a p r e v i o u s v o l u n t e e r a c t i v i t y w h i c h was no t s a t i s f a c t o r y and she m i s s e d some o f t h e p e o p l e a s s o c i a t e d w i t h t h a t . What M . l i k e d most abou t SHOP was t h e e x p o s u r e t o p o s s i b l e a c t i v i t i e s and v o l u n t e e r o p p o r t u n i t i e s . She f e l t she "knew more when she f i n i s h e d t h e p rogram t h a n when she s t a r t e d " , and a p p r e c i a t e d t h e emphas is on l e a r n i n g from o t h e r p e o p l e r a t h e r t h a n f rom b o o k s . She s t a r t e d m a k i n g e f f o r t s t o c u l t i v a t e t h e a c q u a i n t a n c e p a r t o f he r n e t w o r k . M . f e l t " q u i t e good" a t t h e end o f t h e p rogram w i t h a sense o f " a n t i c i p a t i o n " . She t h o u g h t she w o u l d p o s s i b l y p u r s u e d e v e l o p i n g f r i e n d s h i p s w i t h a c o u p l e o f g roup members. P a r t i c i p a n t N : P r i o r t o SHOP, N . was l o o k i n g f o r t h i n g s t o ge t i n v o l v e d i n . She was m i s s i n g a l o n g t i m e f r i e n d who have d i e d . She e x p r e s s e d t h e d e s i r e t o f i n d a " r e a l " f r i e n d and n o t e d t h a t she was w o r k i n g on t r y i n g t o be l e s s j u d g e m e n t a l and f a u l t - f i n d i n g when she met p e o p l e . A l t h o u g h N . was t r y i n g t o keep a c t i v e and e n j o y e d t h e SHOP g r o u p , she f e l t b a d l y when h e a l t h p rob l ems l e f t he r " c r i p p l e d up" and u n a b l e t o g e t o u t f o r s e v e r a l s e s s i o n s . T h i s h e a l t h p r o b l e m c o n t r i b u t e d t o he r f e e l i n g w o r r i e d , f r u s t r a t e d and r e s e n t f u l . N . r e p o r t e d t h a t d u r i n g t h e t i m e o f b e i n g shu t i n she t h o u g h t abou t f a c i n g t h e f a c t o f d e a t h and wondered about t h e a f t e r l i f e . She was p a r t i c u l a r l y t r o u b l e d w i t h f e e l i n g s o f i ncompe tence due t o he r l a c k o f m o b i l i t y . One t h i n g t h a t r e a l l y " b o o s t e d he r s e l f - e s t e e m " was t a l k i n g t o p e o p l e who were k i n d t o h e r . N . ' s ma in w i s h f o r t h e f u t u r e was t o r e g a i n he r h e a l t h and m o b i l i t y and t o be a b l e t o do s o m e t h i n g w o r t h w h i l e . P a r t i c i p a n t 0: J u s t b e f o r e SHOP s t a r t e d 0. was t h i n k i n g she s h o u l d s t a r t d o i n g s o m e t h i n g t o f i l l h e r t i m e . Because she had e x p e r i e n c e d a r e c e n t move f o l l o w i n g t h e d e a t h o f he r husband , she was " m i s s i n g l i t t l e e v e r y d a y t h i n g s " t h a t she was used t o i n he r o t h e r l o c a t i o n . She f e l t t h a t she had t o do s o m e t h i n g p r e t t y q u i c k l y becuase he r "mind was r a c i n g " and she w a s n ' t a b l e t o s l e e p . A t t i m e s 0. f e l t s t i f l e d i n he r apa r tmen t and found i t h e l p f u l t o g e t ou t and go f o r w a l k s o r do some s h o p p i n g . I t was c o m f o r t i n g 140 (Appendix C continued) to see other people who were doing the same thing. 0. enjoyed coming to the SHOP sessions and her view was that the group was good. She found that having something to look forward to reliev e d boredom, and the structured a c t i v i t y was he l p f u l . 0. f e l t encouraged by t a l k i n g to people at the volunteer centre and plans to look into volunteer work afte r moving to her new apartment. 141 Appendix D-l Goals of SHOP To help p a r t i c i p a n t s : 1. Define s o c i a l health and understand what contributes to i t . 2. Gain knowledge about issues related to demoralization and depression. 3. Evaluate the health of t h e i r s o c i a l networks using a mapping technique. 4. Establish goals for augmenting t h e i r s o c i a l netowrks. 5. Develop or refurbish the s k i l l s needed to reach t h e i r s o c i a l goals. 6. Identify a community role that i s of intere s t to them. Course Outline 1. Introduction to SHOP (overview) 2. Social Health, Social Roles, Social P a r t i c i p a t i o n 3. Introduction to the Personal Network 4. Introduction to "Self Talk" 5. D i f f e r i n g Views on the Cause of Demoralization and Depression 6. Enhancing "Self Talk" 7. Drugs, and Behavioral Treatment of Insomnia 8. Introduction to Communication 9. Increasing Your Success i n Communication 10. Communicating i n D i f f i c u l t Situations 11. Personal Social Networks 12. Social Networks and Health 13. Problem Solving 14. Setting Social Goals 15. "Taking Stock" - the Strengths Inventory 16. Rediscovering Interests and A b i l i t i e s 17. Volunteering and Other Community Roles 18. The Resume 19. Summary and Evaluation 20. Wrap-Up Celebration 142 Appendix D-2 SHOP Evaluation Since attending SHOP I f e e l : about the same as before l i t t l e better , moderately better , a l o t better_ worse SHOP'S main components w i l l now be outlined. Please read t h i s over to refresh your memory. Then, under the headings l i s t e d below, please comment. EDUCATION: 1. Social Health, Social Roles, Social P a r t i c i p a t i o n 2. Learning Through Reflection On Your Experience 3. Different Views on the Cause of Depression 4. Personal Social Networks 5. Assessing the Health of Your Personal Network 6. Medication Safety 7. Managing Sleep Problems SKILLS: 8. Changing Self Talk from Negative to Positive 9. Thought Stopping and "Creative Worrying" Techniques 10. Increasing Your Success i n Communication 11. Communicating i n D i f f i c u l t Situations 12. Problem Solving 13. Goal Setting 14. Inventory of Interests and A b i l i t i e s 15. Opportunities to Participate or Volunteer Which components were most helpful for you, personally? Why? Which were least helpful? Why? What would you add to SHOP? Why? What would you delete? Why? General Comments: (Please use reverse side i f necessary) 143 

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