Chapter 17: Adjustment Disorders & Life-Cycle Transitions

1. Chapter 17: Adjustment Disorders & Life-Cycle Transitions Fall, 2012 Dr. Mary L. Flett, Instructor

2. Overview • Upsetting but normal emotions may result from difficult life events. • Adjustment disorders are a response to stress that, while clinically significant, are not severe enough to be diagnosed as a mental disorder • Other conditions that may be the focus of clinical attention include • partner relational problems • bereavement • phase of life problems • Adult development includes its own challenges • Life cycle transitions (adulthood, family transitions, later life)

3. Adjustment Disorders: Symptoms • Clinically significant symptoms in response to stress, but not severe enough to be diagnosed as a mental disorder • Similar to acute stress • DSM does not go into detail on these issues • Erik Erikson’s Stages of Development • Focus is on resolving conflict of particular stage • Is not pathological unless conflict remains unresolved and causes problems

4. Adjustment Disorders: Symptoms

5. Adjustment Disorders: Symptoms • Erikson believes resolution of identity crisis allows young adults to embark on a journey toward achieving long-term life goals (first crisis of adulthood) • One life-goal is forming intimate relationships and true intimacy (second crisis of adulthood) • Third crisis of adult life is generativity vs. stagnation – career and family achievements • Last stage – integrity vs. despair • integrity comes from acceptance instead of regret • Despair comes from impossible desire to change the past and yearning for a second chance

6. Adjustment Disorders: Symptoms • Other adult stage theorists focus on social relationships • Daniel Levinson • “Seasons” in a Man’s Life (roughly 20-year intervals) • Early adult transition • Midlife transition • Late adult transition • Caution in interpreting stages of adult development • Many factors that influence adult development • Transitions may not be so predictable • Don’t know when life will “end” so how can transitions be predicted

7. Adjustment Disorders: Symptoms • Don’t ask “who am I” until young adulthood • Create a life story • Resolve identity crisis • Changes in roles and relationships • College, career, family • Conflicts in parent-child relationships • Individuation • Conflicts between moving toward, moving away, moving against (Horney, 1939) • Increased relationships with peers; decreased relationships (and influence) by parents

8. Adjustment Disorders: Symptoms • Emotional Turmoil • Young people experience more intense & volatile emotions than adults • Uncertainty about relationships and roles increases feelings of anxiety

9. Adjustment Disorders: Diagnosis • DSM-III listed “identity disorder” as a mental disorder; DSM-IV demoted it to focus of clinical attention • Frequency of Identity Conflicts • Takes longer to become an “adult” than a generation ago • Cultural climate plays role • Economics play role

10. Adjustment Disorders: Diagnosis • Causes of Identity Conflicts • Most successful young adults have parents who continue to provide support and supervision while allow them to increase independence • Identity crisis may be reflection of Western, industrialized societies • Gender roles influence formation of identity • Women may form an identity based on relationships rather than career

11. Adjustment Disorders: Treatment • Evidence suggests many young adults seek counseling during this time of life, but no one approach has been studied to determine effectiveness • Supportive, non-directive therapy seems to be the best

12. Family Transitions: Symptoms • Typically involve addition or loss of members • Includes marriage • Parenting • Empty nest • Divorce/re-marriage

13. Family Life Cycle

14. Family Transitions: Symptoms • Family conflict • Marital satisfaction declines after birth of first child • Power struggles and intimacy struggles • Reciprocity • Positive feelings reflected back; negative feelings overlooked • Negative feelings reflected back; positive feelings overlooked • Demand & withdrawal pattern • Wife becomes more demanding; husband withdraws • Conflicts go unresolved • Marital conflicts lead to fights with children

15. Family Transitions: Symptoms • Emotional Distress • How the conflict is expressed • Sharing of anger • Use of “you” is predictor of problems; “I” a predictor of resolution of problems • Unresolved conflicts lead to emotional distress • Emotional distress linked with depression • Painful part of separation and divorce

16. Family Transitions: Symptoms • Cognitive Conflicts • Changes in family roles cause problems; “Who am I now?” • Role change in divorce; death of spouse • Acceptance and change a must if harmony is to be achieved

17. Family Transitions: Diagnosis • Families and relationships not in DSM; just individuals • Some argue there needs to be categories for families & partnerships known as relational disorders • Frequency • Census Bureau collects information on certain family transitions • Marriage & Divorce • Childbirth outside of marriage

18. Family Transitions: Causes • Psychological Factors • Communication includes • verbal and nonverbal behaviors • John Gottman identified following styles of communication as being critical in a relationship • Criticism • Contempt • Defensiveness • Stonewalling

19. Family Transitions: Causes • Psychological Factors • Family Roles • “Traditional” roles vs. “Androgynous” • Androgynous is happier! • Social Factors • Poverty, unemployment, crowded living conditions, limited social support can cause substantial distress • Teenage pregnancy, non-marital childbirth divorce, family violence

20. Family Transitions: Causes • Biological Factors • Chicken and Egg debate: Does family distress cause individual distress or vice versa? • Onset of menstruation (menarche) has interesting biological correlation • step father in home, earlier menarche • mother’s early age of menarche, early age for daughter(s)

21. Family Transitions: Treatment • Prevention Programs • “Couples Weekends” & “Encounter Groups” • Historically run by the Church • Few data on couples of color or LGBT couples • Pre-Marital Counseling • Work on communication issues, explore values, identify potential conflicts and learn problem-solving skills • Couples Therapy & Family Therapy • Focus is on changing relationships, not individuals • Negotiation skills • Break cycles of negative interactivity

22. Family Transitions: Treatment • Cognitive Behavioral Couples Therapy • Emphasizes moment-to-moment interactions • Styles of communication • Strategies for solving problems

23. Later-Life Transitions: • When does “old” start? • 65 is an arbitrary marker • Physical and emotional changes occur in the 40’s and 50’s • Menopause for women • 60s typically is a change from working to retired • 70’s and 80’s are focused more on physical ailments and mortality • 90s and 100+ typically housed in long-term care facilities, out of “mainstream”

24. Later-Life Transitions: • Ageism • Form of social prejudice • View of elders as stubborn, irritable, bossy, and complaining • Elders “disappear” into 55+ retirement communities or nursing homes • Frequent observations that “I am not useful any more”

25. Later-Life Transitions: Symptoms • Physical Functioning and Health • Decline with age when disease process is present • Physical activity is a good predictor of psychological well-being • Menopause • Average age of onset in US is 51 years • “Hot flashes” • Mood swings • Memory changes • Hormonal changes and role changes

26. Later-Life Transitions: Symptoms • Sensation & Physical Movement • Gradual decline of sensory systems throughout life, but most noticeably after age 70 • Eyes adapt to darkness or light more slowly • Hearing loss • Sensitivity to taste, smell, and touch decline • Muscle mass changes • 80% of muscle strength retained • Bone loss, particularly after menopause, is problem form women • Chronic illness • Arthritis, cardiovascular disease, cancer, diabetes, sleep disorders

27. Later-Life Transitions: Symptoms • Life Satisfaction, Work & Relationships • Psychological well-being remains remarkably intact, in spite of physical changes • Positive relationships • Spiritual/Religious beliefs • Greater sense of “mastery” in personal and work relationships • Retirement a “mixed” blessing • For those who want to continue to work, it brings more choice • For those who have to work, it brings stress • For those who can’t work, it brings loss and status changes

28. Later-Life Transitions: Symptoms • Erikson’s Integrity v. Despair • Finding meaning in life • Who am I now? • How do I compare to who I thought I was? • Relationships • Quality of friendships is important, not number • Having a support system • Family relationships • Siblings • Children • Grandchildren

29. Later-Life Transitions: Symptoms • Relationships • Loss of spouse/partner particularly difficult • Remarriage/new relationships • Health issues, including HIV • Concerns by children; elder abuse • Grief & Bereavement • “Grief” is the emotional and social process of coping with loss • “Bereavement” is a specific form of grieving in response to loss of a loved one (may include pets!)

30. Later-Life Transitions: Symptoms • Grief & Bereavement • Elizabeth Kubler-Ross – 5 stages of dying • denial • anger • bargaining • depression • acceptance • Actual experience for most people is not linear, but all stages are experienced universally

31. Later-Life Transitions: Symptoms • Grief & Bereavement • Experience of loss is different at different times of life • Loss of child • Unexpected death of “young” person • More prepared for death of an elder because “s/he lived a long life” • Bereavement is in DSM as a disorder

32. Later-Life Transitions: Symptoms • Mental Health • Mood and anxiety disorders most common • Psychological issues are under-treated in elders • Suicide risk is especially high • Rational suicide • Assisted suicide

33. Later-Life Transitions: Diagnosis • Gerontology is the multidisciplinary study of aging • Young-old (65-75) • Old-old (75-85) • Oldest-old (85+) • More women in oldest-old

34. Later-Life Transitions: Frequency • 1 in 8 people living in the US is over 65 • 3.5 million are 85+ • Baby boomers will be a wave of aging challenges • Poverty rates are higher among elders • More women than men; more women living alone • Community-dwelling elders are more common than long-term care/residential care; this is changing

35. Later-Life Psychological Problems: Causes • Good physical health is most important contributor to feelings of life satisfaction • Health behavior associated with better outcomes • Exercise, good diet, moderate Etoh consumption • All tied to improved cognitive functioning • Not about longevity; healthy active life until death • Spiritual belief and practices very important • Help to deal with loss • Help to cope with decline in physical functioning

36. Later-Life Psychological Problems: Treatment • Good medical care and collaboration among providers is key • Behavioral gerontology • Focus is on maintaining or improving quality of life • End of life issues