DOI: 10.1111/ajag.12025

Research Successful transition to later life: Strategies used by baby boomers Kay Wilhelm and Liesbeth Geerligs School of Psychiatry, University of New South Wales; and Faces in the Street, St Vincent's Urban Mental Health and Wellbeing Research Institute, Sydney, New South Wales, Australia

Carmelle Peisah School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia

Aim: We sought to understand strategies employed by baby boomers to maintain well-being and facilitate transition to later life. Method: A non-clinical cohort (n = 139) provided qualitative data about well-being strategies. Thematic data analysis provided insights for those with high and low life satisfaction (based on Satisfaction with Life Scale) and quantitative data from previous waves provided predictors of life satisfaction decades later. Results: Longitudinal predictors were depression history (cognitive trait and repeated episodes) and quality of partner’s care. ‘Highly satisfied older people’ reported proactive strategies, contrasted with lack of planning by ‘dissatisfied older people’. ‘Resilient older people’, with high life satisfaction despite repeated depressive episodes, reported benefit from strategies dealing with adversity, including depression. Discussion: Strategies of ‘satisfied older people’ support theories of proactive coping and demonstrate the importance of developing adaptational skills to support later life satisfaction. In ‘resilient older people’ adaptive strategies can lead to achievement of life satisfaction despite repeated depressive episodes. Key words: coping strategy, depression, life satisfaction, qualitative research, resilience, successful ageing.

Objectives Australia is being transformed by societal ageing, as the large Baby Boomer cohort starts to reach retirement age and proportionately more of the population is aged 65 and over. ‘Successful ageing’ involves active engagement with life, social connections and mre subjective perceptions of health and well-being [1–5]. A recent model of well-being emphasised the importance of proactively adopting positive strategies before the challenges and deficits of later life begin [5]. This concept has much in common with ‘strengths-based Correspondence to: Professor Kay Wilhelm, Faces in the Street, St Vincent’s Urban Mental Health and Wellbeing Research Institute, St. Vincent’s Hospital. Email: [email protected] Australasian Journal on Ageing, Vol 33 No 2 June 2014, 81–85 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA

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adaptation’ in positive psychology [6] and builds on Erikson’s work [7], highlighting the importance of successful negotiation of life transitions. The transition from late middle- to early old-age has been identified as an important phase in the ageing process, as ‘successful ageing must be prepared long in advance’ [5]. A cohort of baby boomers has been followed up since 1978 (see Methods). The initial research assessed risk factors for anxiety and depression [8], but the focus has changed to consider questions related to life satisfaction and well-being. The longitudinal study design allowed a well-documented psychiatric history for each participant [9]. The current study aimed to identify strategies (i) associated with high and low life satisfaction and (ii) used by ‘resilient older people’ (reporting high life satisfaction despite a history of repeated depressive episodes).

Method Participants are part of a longitudinal cohort study of 165 postgraduate teaching students that commenced in 1978, with follow-up waves at 5-yearly intervals since. By 2008, the cohort comprised 139 participants, after attrition due to death (n = 9), physical illness (n = 2), mental illness (n = 3), and refusal to continue participation and inability to be located (n = 12). Participants had a mean age of 53 (SD = 2.5) years, and 67% were women; 74% were married or living with a partner; 26% were single, separated or divorced; 88% were currently working, while 12% had already retired. At the 30-year follow-up in 2008, participants completed some self-report measures that had been gathered at baseline in 1978 and at subsequent 5-yearly follow-ups. These included: 1 Eysenck Personality Inventory-Neuroticism scale (EPI-N [10]), a 24-item measure with higher scores indicating higher neuroticism. 2 Costello Comrey Trait Depression Inventory (CCDI [11]), a 14-item scale designed to an individual’s tendency to experience depressive mood. 3 Rosenberg Self-esteem Scale (RSE [12]), a 10-item measure, with lower scores representing higher selfesteem. In 1983, 1998 and 2008, participants also completed the Intimate Bond Measure (IBM [13]), a 24-item measure of satisfaction, consisting of two subscales assessing ‘care’ and ‘control’ between partners in an intimate relationship. 81

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Lifetime depression history was assessed from the summative record of each participants’ depressive episodes using DSM criteria derived from interviews using the Composite International Diagnostic Interview (CIDI [15]) at each 5-yearly wave. In 2008, participants also completed the Satisfaction with Life Scale (SWLS [14]), a 5-item measure, with scores ranging from 5–35, where higher scores indicate greater life satisfaction; physical health status was rated on a 5-point scale (excellent/very good/good/fair/poor). After completing the 30-year follow-up in 2008, participants were sent a semi-structured interview via mail or email, asking them to outline their future life plans and strategies used to maintain health and well-being. The first author (KW), a psychiatrist who has worked with the cohort since 1978, then conducted a follow-up telephone interview to clarify and explore their answers and probe for more depth. Analysis Quantitative data were analysed using SPSS v18 (SPSS Inc., Chicago, IL, USA). Data pertaining to continuous quantitative measures were analysed using a series of correlation matrices and stepwise regression models. Data pertaining to categorical measures were assessed using a series of c2 tests of independence. Qualitative interviews were coded and subjected to methods of thematic analysis to identify the themes related to wellbeing, ageing and retirement amongst those in the lowest and highest quartiles of successful ageing, as assessed by current life satisfaction. Open coding to derive major themes from the participant’s responses was followed by axial coding to draw connections between the themes and ideas identified in the separate interviews [16,17]. Using themes derived within and across participants and related to concepts from the existing literature, a model of ageing strategies in this transitional age group was developed [18]. Interpretative rigour and validity of the analysis were maintained by (i) triangulation (corroboration of qualitative data using multiple information sources) using physical health status and SWLS ratings to verify qualitative data; and (ii) providing direct quotes (in italics) and examples when presenting themes [18]. We were interested in the subjective experiences of those at the extremes of the quantitative measure of life satisfaction (SWLS) as well as those with histories of recurrent depression who maintained well-being. We thus explored whether distinct themes related to ageing and well-being emerged from those with high and low SWLS scores and those with recurrent depression who reported high SWLS scores. Ethics approval was obtained from the Human Research Ethics Committee of the University of New South Wales. 82

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Results Independent sample t-tests and c2 tests of significance revealed no significant differences in sex, marital status or depression history (lifetime history of major depression) between those who remained in the study and those who dropped out. Those who dropped out of the study were significantly older at baseline. For the Physical Health Ratings: 22% reported their health as ‘excellent’, 35% ‘very good’, 33% ‘good’, 9% ‘fair’ and 1% ‘poor’. For lifetime depression history 53% reported at least one episode of major depression and 22% had repeated episodes [9]. The mean SWLS score was 25.4 (SD = 6.5), consistent with a mean of 24.5 in a study of Australians in their thirties [19]. To predict life satisfaction at 30-year follow-up, the longitudinal variables (self-esteem, optimism, neuroticism, depression data and partner satisfaction ratings) from 1978 baseline and 1983 waves were entered into a stepwise regression (see Table 1). Only three were significant predictors: lifetime number of depressive episodes, baseline trait depression (1978) and IBM care score (1983) and together, they accounted for 34.5% of the variance in current life satisfaction (P < 0.001). Qualitative analysis revealed a series of themes related to ageing and well-being which distinguished those rated as ‘extremely satisfied’ according to Diener’s cut-off ranges (SWLS scores over 31/35 [10]). In comparison, we took quotes from ‘dissatisfied/extremely dissatisfied’ participants (SWLS scores of 14/35 or below [14], forming the bottom 10% of the sample). In comparing the satisfied older people (n = 16: four men, 12 women) with the dissatisfied older people (n = 15: five men, 10 women), the satisfied older people had lower mean lifetime rates of major depression of 0.1 (SD = 0.5) versus 1.8 (SD = 1.5) and lower mean scores for trait depression in 2008 (18.1 (SD = 5.4) vs 45.4 (SD = 16.1)). We also compared mean scores for the same people at baseline in 1978 and found that the satisfied older people reported mean scores of 23.6 (SD = 11.1; range 12–59) versus 40.0 (SD = 13.4; range = 17–41) 30 years previously.

Table 1: Longitudinal predictors of current Satisfaction with Life Scale scores at 30-year follow-up Variables assessed Lifetime number of depressive episodes Perceived care from partner at 1983† Trait depression at 1978

Standardised beta

Significance (P )

-0.3 0.2 -0.2

0.000 0.033 0.008

†Scale not available at baseline and many cohort members partnered between 1978 and 1983. Australasian Journal on Ageing, Vol 33 No 2 June 2014, 81–85 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA

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Themes emerging from analysis of the satisfied older people’s data 1 Planning, preparation and transition: Participants understood they were in a transition period requiring proactive planning, focused goal setting and realistic achievable plans: My main priority for the next decade is to ensure that I’m fully prepared (mentally, physically, financially) for retirement in 5–7 years from now. I set goals and work towards them so I have constant achievements and success. 2 Maintenance: Participants had, by this life stage, identified ‘what worked’ for them in achieving well-being (whether pursuing creative outlets, social connection or physical activity), with particular emphasis on maintaining achievements and focussed, forward planning: I want to make sure that my husband and I maintain our health, friendships and interests. To maintain good health and to continue to work effectively while planning for retirement. 3 Social connectedness: Participants’ future plans almost invariably involved maintaining or nurturing relationships and pending more/better quality time with friends and family, particularly partners: I want to enjoy the family. To live and laugh with my partner. 4 Passing on the baton: Participants focussed on supporting and guiding children or younger work colleagues: To watch my kids grow and be well set for the future. To enjoy my kids and grandchildren. [By teaching] we are nurturing the next generation . . . I am conscious of setting a good example, leading by example. 5 Smelling the roses: Participants were conscious of ‘time ticking on’ and themes of appreciation, gratitude and savouring pleasures emerged: [I have] conscious gratitude for good things, active enjoyment of them. I make an effort to be involved in things that make me feel good. [Happiness] comes from the simple things around us, from working and contributing, from being a friend and not missing the beauty around us. Thankful for every day I have. Themes emerging from ‘dissatisfied older people’ 1 Lack of forward-planning: Responses to questions regarding plans for the next decade and retirement reflected either avoidance or absence of planning for the future, as typified by the following statements: Australasian Journal on Ageing, Vol 33 No 2 June 2014, 81–85 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA

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I don’t know if I am very good at it [well-being] . . . I haven’t got any plans for retirement. I haven’t really thought that far ahead . . . 2 Disengagement: Participants tended to engage in mental or behavioural disengagement: I do nothing to maintain my well-being. I do lie on the floor to have a nanna nap when my back is aching, does that count? Everything will be OK when this day ends and I can be inside watching TV. All I have to do is to be able to hold out until this all ends and then I can watch TV. 3 Sublimation and distraction: Compulsive work was used as a means of distraction and disengagement from leisure and well-being-focused activities and a justification for lack of planning or self-care: I don’t get enough free time – tied to a BlackBerry® and work 7 days a week. I don’t think I will want to stop working. Themes emerging from ‘resilient older people’s data’ These following quotes are from 15 participants with a history of repeated (two or more episodes over lifetime) and in many cases current depressive episodes, who reported current life satisfaction scores of ‘satisfied’ or ‘extremely satisfied’. Their self-rated health scores ranged from ‘good’ to ‘excellent’ with an average of 3.75, despite four also having a significant concurrent chronic illness (cancer (n = 3), diabetes with renal failure (n = 1) ). Their strategies reflected selfawareness and awareness about depression. 1 Insight: A long-term perspective often encompassed both insight and acceptance: The suggestion . . . that my depressive states could be conceived as chronic rather than acute, liberated me from anguishing about failing to ‘solve’ my ills, and focused me more on managing the demons when they emerged. It made depression less a personal failing, and more subject to my efforts to control it via management. That was life saving. Now I can feel it (depression) arising and I know it is part of my makeup, something I will have to go along with. Generally I can still work and go about my normal life but sometimes will find a quiet time. 2 Cognitive strategies The tried and proven strategy that works best for me is letting go of all the negative stuff – letting it fly over the top of my head, just letting go. CBT techniques to keep me on a positive track . . . awareness of good and beautiful things/events, taking time to enjoy them. 83

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3 Behavioural strategies Creative outlets pull me out of depression . . . I started writing furiously and that stops me thinking about the physical. I am doing more physical exercise; I find if I feel good then I am usually more resilient.

Conclusions These data come from a homogenous cohort which does not attempt to represent the normal variability in an adult population. All group members were tertiary educated. Participants reported very low rates of cigarette, alcohol and illicit substance use. They had negligible forensic history, high rates of help-seeking among both men and women, and high prevalence of anxiety and depression. [8,9]. They are consistent and articulate reporters of their experience and provide a window into the concerns of better educated Baby Boomer cohorts. Also, their well-documented depression history allows exploration of the concept of resilient ageing. Our choice of a life satisfaction measure as a proxy for successful ageing was narrow, although in keeping with the recent shift in the literature towards self-defined, psychological proxies of successful ageing [19]. The proposition that many older adults who suffer from mental or physical health conditions still consider themselves to be ‘ageing well’ [1,5] was borne out by the data from our ‘resilient older people’. While the longitudinal predictors of current life satisfaction revealed the importance of lifetime depression history, both as a cognitive trait and in terms of repeated depressive episodes, our qualitative data suggest that ‘resilient older people’, who had high life satisfaction despite a lifetime history of repeated episodes, had adopted selective behavioural and cognitive strategies in the face of their depression history and had benefited by them. The adaptive strategies reported by the more satisfied, thriving participants provided empirical support for several theoretical models of successful ageing. Satisfied participants tended to focus on appropriate, achievable goals in specific chosen areas, consistent with the Selection-OptimisationCompensation (SOC) model proposed by Baltes and Carstensen [20], which suggested that as people age, they seek to maximise positive and minimise negative affect by pursuing realistic and emotionally satisfying goals in selected domains. This is consistent with Seligman’s theory of signature strengths, where greater satisfaction is gained from living a life which allows identification and use of individual’s unique skills and talents [6]. The satisfied participants also endorsed strategies consistent with Seligman’s positive psychology research, such as ‘savouring’ every-day moments and ‘counting their blessings’. The importance of planning and preparation was reflected by the satisfied participants, who identified the need to 84

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equip themselves for the coming changes associated with later life transitions. This is in keeping with the proposition that proactive coping can prepare individuals for expected losses and future challenges and provide a buffer against the stress of the change itself [5]. The importance that participants placed on spending time with their families and working to support their children or younger colleagues is consistent with Erikson’s [7] theory of generativity and highlights the importance of mentoring and social connection. Sharing wisdom with younger colleagues or family enabled participants to maintain a sense of agency and progression, which leads to greater life satisfaction and enjoyment of the benefits of the ageing process. In contrast, ‘dissatisfied’ participants tended either to abstain from adopting strategies or to use distraction; both were means of ignoring the challenges of ageing. Submersion in work or lack of forward planning can be viewed as examples of repression or displacement, two of the less adaptive defence mechanisms associated with poorer life satisfaction and less successful ageing demonstrated in earlier research by Vaillant and colleagues [21], who also highlighted the importance of personal control over lifestyle. Our results are in keeping with this research, as the active strategies chosen by the satisfied participants showed a level of control and agency not seen in the responses of the dissatisfied participants. Well-being strategies adopted by the resilient older people included insight, acceptance and traditional cognitive and behavioural techniques for depression. They pursued appropriate help-seeking from their GPs, psychologists and psychiatrists and had both an understanding of their personal experience of depression and a strong sense of what strategies served them best in times of sickness and health. Recent work has suggested that acceptance is a quality held by older people in general [22] and further that reflecting and reviewing one’s life can have beneficial effects for depressed adults who are over 50 years of age [23].

Practical applications: Late middle age as a preparatory period for ageing The maladaptive strategies of less satisfied participants highlight potential areas for change and intervention. Ouwehand et al. [5] suggest that coping skills and strategies required for ageing well should be taught to adults before the problems of ageing occur. Pilots of such interventions have had promising results, with participants both willing and able to acquire these new skills in their mid-tolater life years [24] and even some with depression history report ageing successfully and using proactive strategies. Such skills-based programs may also be informed by approaches taken by resilient people who go on to achieve well-being despite such health challenges as multiple past episodes of depression. Australasian Journal on Ageing, Vol 33 No 2 June 2014, 81–85 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA

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Acknowledgements The work is supported by NHMRC Program Grants 222708 and 510135, an Infrastructure Grant from the Centre for Mental Health, NSW Department of Health and Faces in the Street, St Vincent’s Urban Mental Health and Wellbeing Research Institute. We thank Inika Gillis for some statistical analyses and editing and, most importantly, the cohort members for their generous input of time and interest over the course of the study.

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Key Points • Lifetime depression history (as cognitive trait and multiple episodes) predicted life satisfaction decades later. • Satisfied older people were proactively planning for retirement. • Resilient older people reported adaptive strategies to counter a history of multiple depressive episodes.

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Successful transition to later life: strategies used by baby boomers.

We sought to understand strategies employed by baby boomers to maintain well-being and facilitate transition to later life...
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