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The Effectiveness of Logotherapy in Mitigating the Social Isolation of neglected Institutionalised Older People

The Effectiveness of Logotherapy in Mitigating the Social Isolation of neglected... Abstract There are various types of elder abuse; one of the most prevalent and most harmful abuses is neglect. Social isolation is one of the most common consequences of neglect, with an inability to find meaning in life closely associated with both these issues. One intervention that might be used with older people suffering from neglect and social isolation is Logotherapy—a meaning-based intervention. The aim of this study is to examine the effectiveness of Logotherapy in mitigating the social isolation of older people suffering from neglect. This study was developed using a quantitative research design, and with a purposive sample of forty-three socially isolated older individuals in a single institution for the elderly in Cairo, Egypt. The study follows a quasi-experimental study model. A social disconnectedness scale and a perceived isolation scale were used to assess both degrees of social isolation. The intervention lasted for twelve weeks, with two weeks of follow-up work. A significant difference emerged between the intervention and control groups. The results indicate that enabling older people to experience meaning in life by emphasising the value of social relationships and interactions has a positive effect on their social networks. Logotherapy, intervention, elderly, elder abuse, neglect, social isolation Introduction Elder abuse is seen today as a significant public, social and health problem. The term ‘elder abuse’ was first used in British scientific journals in 1975 in connection with the term ‘granny battering’ (Chalise, 2017). More recently, it has been defined as ‘a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’ (Choi and Mayer, 2000, p. 6). Some researchers such as Rudnick and Teaster (2013) suggest that elder abuse has long been hidden from the public view and considered a private issue. Choi and Mayer (2000) emphasise that the abuse and neglect of older persons are definitely not a modern phenomenon; however, concern around this issue as a social problem began only in the 1970s. Statistics from the World Health Organization (2018) indicate that, globally, the number of cases of elder abuse is projected to increase as many countries have rapidly ageing populations. It is predicted that the global population of the elderly will more than double by 2050. It is also warned that, if the proportion of elder-abuse victims remains constant, the number of victims will increase to 320 million by 2050. However, more optimistic researchers such as Pettigrew et al. (2014) and the Irish Association of Social Workers (2011) argue that increasing attention is being paid to alleviation of the suffering caused by elder abuse, with this increased awareness resulting from a growth in global concern regarding human rights in general and associated issues such as population ageing. Band-Winterstein et al. (2014) emphasise that elder abuse has now been recognised as both a social and a health-related problem, with awareness about the issue increasing in the last thirty years. They also demonstrate that both theoretical and empirical knowledge of this field has been established over these years. One key type of elder abuse is neglect—a severe problem affecting the physical, emotional and material well-being of many elderly people (Band-Winterstein et al., 2014). Cornwell and Waite (2009) argue that neglect of the elderly can lead to their social isolation. This isolation has been principally attributed to the tendency for older people to experience shrinking social relations, hectic lives of their relatives and the increasing possibility of health problems (Nicholson, 2012). As a result, a great deal of attention has been paid to the problems associated with social isolation. The Irish Association of Social Workers (2011) reflects on the significant role played by social work professionals who, while co-operating with a network of other professionals, work to detect signs of neglect and to provide appropriate interventions and preventive services. Social work has produced various forms of interventions aiming to mitigate the social isolation of older people. One approach that was developed by Victor Frankl (1955) and has been implemented by practitioners is Logotherapy. It is defined as a meaning-oriented therapy that aims to help individuals acquire a greater sense of meaning in their lives through enhancing their motivation for change (Somov, 2007). Logotherapy has three main roots. These are, first, philosophical roots, which can be expressed through existentialism and phenomenology; then spiritual roots, which are expressed through a commitment to the human being as an irreversibly spiritual creature; and, third, psychological roots that can be seen in psychoanalysis and individual psychology (Kimble and Ellor, 2001). The loss of a sense of a meaning to life can greatly affect the vitality of the elderly. Indeed, the crisis of ageing can well be seen as a crisis of meaning. The elderly may often be challenged to make sense of life at a stage when many changes and losses arise (Kimble and Ellor, 2001). It is usual that ageing brings a number of weaknesses and diminishments but, if the elderly are to cope with these positively, they need to create a sense of meaning in their life. This study will focus on examining the effectiveness of Logotherapy in mitigating the social isolation of neglected older people. Literature review Research available on elder abuse indicates that it exists in both developed and developing countries (Chalise, 2017). Yon et al. (2017) present a study conducted on evidence from fifty-two studies in twenty-eight countries from diverse regions, including from twelve low- and middle-income countries. Their study found that the elder-abuse problem is evenly distributed among developing and developed countries. Elder abuse A number of studies have highlighted the negative effects of elder abuse. For example, Rezaeipandari et al. (2016) have argued that the general health status of older people who have experienced abuse is significantly worse than those who have not, as the abuse increases vulnerability to disease. The possible physical, psycho-social and social consequences of elder abuse are numerous and varied. They may include physical effects such as sleep disturbances and nutrition, and psychological effects such as stress and depression, while the social effects can be seen mainly in the diminishing of social relations and in social isolation (Center for Disease Control and Prevention, 2018). Many researchers indicated that psychological and emotional abuse are the most harmful types of elder abuse. Also, many elderly mentioned that physical abuse could heal but psychological pains were emotionally destructive and damaging to the self-worth and sense of self (New Brunswick Nursing Home Association, 2018). Powell (2012) has added that elder abuse has not received sufficient public consideration, as it tends to be thought of as a private, domestic issue. Hence, it seems clear that more attention needs to be paid to tackling elder abuse and associated issues at a public-health and social level. The World Health Organization (2018) emphasises that elder abuse has existed in all cultures without noticeable variations in its causes and forms. Even in developing countries, where, it is widely agreed, family is traditionally highly valued and family members’ needs should be fulfilled, these recent decades of globalisation, industrialisation, urbanisation and modernisation have weakened the traditional family and community networks that provided care to older people (Chalise, 2017). Similarly, researchers such as Bowes et al. (2012) argue that, although clear gaps exist between service provision and people experiencing mistreatment due to structural and contextual factors, cultural factors have a relatively minor impact on levels of elder abuse. Neglect Neglect is considered to be the most prevalent category of elder abuse, comprising an estimated 58 per cent of all reported cases (National Center on Elder Abuse, 2017). Although there are some differences in defining the term ‘neglect’, most researchers have agreed that neglect is the failure to take care of the elderly by not providing the assistance they require for good health, a feeling of safety and the achievement of well-being (Taylor et al., 2016). Choi and Mayer (2000) argue that the majority of the perpetrators of the abused and neglected elderly are family members. This includes spouses, adult children and other relatives, while non-relative perpetrators are home-health aides, paid or unpaid care-givers and neighbours. The National Institute of Justice in the USA funded a study aimed at identifying the characteristics of care-givers who carry out elder mistreatment. Findings indicated that half of the perpetrators were using drugs or alcohol at the time of the abuse, three in ten perpetrators had a history of mental illness, over a third of were unemployed and four in ten were themselves socially isolated (National Institute of Justice, 2017). Neglect, then, whether perpetrated by family members or non-family members, is an enormously harmful problem, endangering all aspects of the lives of elderly people (Pettigrew et al., 2014). Social isolation Social isolation is both a cause and a result of elder abuse. It is a significant risk factor for the abuse, so that an older adult who is socially isolated has a higher chance of experiencing elder abuse (Connecting Edmonton Seniors, 2018). Equally, as Taylor et al. (2016) explain, social isolation is a symptom of elder abuse. Debate still continues over whether neglect is the greatest cause of social isolation among the elderly, compared to the other categories of elder abuse. In either case, the abused elderly are ignored and live in a restricted social environment (World Health Organization, 2018). Researchers, such Gardiner et al. (2016), have argued that social isolation is the most critically important issue affecting older people, with Holwerda et al. (2014) predicting that it will become an even more pressing problem in the coming years. Sangeeth and Solomon (2014) have argued that older people generally tend to have a lower level of social relationships, and thus are highly likely to feel socially isolated. Other researchers have also commented on social isolation in the elderly and its ramifications. Taylor et al. (2016) state that one of the common causes of social isolation is the failure to assist institutionalised older people in participating in various forms of socialisation. Very importantly, Stillman et al. (2009) have also argued that social isolation reduces the perception of the meaningfulness of one’s life. Researchers such as Nicholson (2012) and Pettigrew et al. (2014) have pointed out the consequences of this, emphasising the importance of maintaining social interactions in later life in order to preserve well-being. Pre-existing literature in the field has outlined a growing range of interventions that have been developed in order to mitigate social isolation and its consequences (Gönen, 2015). One type of intervention is befriending, where an older individual is provided with visits or phone contact in order to help them carry out tasks, such as shopping (Bernard, 2013). Mentoring is usually focused on helping older people to achieve a short-term goal (Windle et al., 2011). Further models have also been developed, such as coping strategies, leisure, mindfulness and meditation (Toepoel, 2013). Nicholson (2012) notes that, in addition, group services and wider community engagement such as day-centre services can enable older people to expand their social relationships. Lelkes has shown that older people who use the internet and have regular contact with members of a social network have a lower chance of being isolated. In the case of the elderly who might have difficulty in dealing with electronic devices, consistent practice can be provided to overcome this challenge. Religion also plays an important role in the life of many of the elderly and can provide opportunities for reducing social isolation (Krause, 2008). Attending religious services regularly has been shown to reduce levels of social isolation and loneliness (Kobayashi et al., 2009). Researchers have argued that religious practice encourages followers to build and maintain social ties through its prompts towards social integration and its provision of social support (Rote et al., 2013). Gardiner et al. (2016) have argued that the range and scope of effective interventions have not yet been sufficiently understood. Hence, more attempts to examine the effects of both individual and group activities are needed in order to identify the most appropriate methods to mitigate social isolation (Kobayashi et al., 2009). Logotherapy It is widely believed that finding meaning in one’s life is a universal human factor in living happily. Robatmili et al. (2015) argue that assisting older people to acquire meaning and purpose in life can help them to develop a satisfactory and hopeful existence. Robatmili et al. (2015) refer to Frankl (2006), who argues that the emotional emptiness that results from a lack of meaning in life is one of the most difficult psychological issues facing individuals in modern times. In response to this belief, Frankl was inspired to develop the therapeutic approach of Logotherapy. Logotherapy has been variously defined. Robatmili et al. (2015) define it as a psychological treatment that aims to help individuals to appreciate their existence. Chan (2017) sees it as a meaning-oriented therapeutic treatment that can help clients address various problems in a number of areas related to finding a sense of meaning in their lives. There have as yet been few studies on the implications of Logotherapy for the older population, but its effectiveness has generally been examined in terms of how it can be used to deal with other specific segments of the population. For example, Robatmili et al. (2015) show that Logotherapy can offer long-term relief from underlying feelings of meaninglessness and depression in university students. There have also been some speculative suggestions, however, that Logotherapy might provide an appropriate method to alleviate the social isolation of older people. Gönen (2015), for example, has argued that meaning in life can be an effective approach in assisting older people to enjoy a happy and active old age. Chan (2017) has emphasised that a sense of meaning in life is important for the well-being of any client’s psychological health and, therefore, its promotion should be a key facet of social work practice. Additionally, MacKinnon et al. (2014) have stated that finding this sense of meaning might emerge as a potential outcome of social work intervention through the practitioner’s attempts to help their clients to focus on the positive things in their lives and remain positive in the face of difficult circumstances. The aim of this study, then, is to examine the effectiveness of Logotherapy in alleviating the social isolation of the neglected older population. Methodology Research type and research methods This study was developed using a quantitative research design. A quasi-experimental model design was implemented in order to identify the impact of an independent variable, Logotherapy, upon the dependent variable, social isolation. The sample A purposeful sample was used in the study, consisting of forty-two neglected older people between the ages of sixty and seventy who are residents of the institution (see Table 1). The institution is the one of largest private elderly care institutions in Egypt, having 140 elderly residents in permanent indoor stay services and forty other elderly people who frequently attend in the day-care services. The institution provides several services such as physical therapy, health care, entertainment programmes and social services. Table 1 Demographic characteristics of the study sample (n = 43) Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Table 1 Demographic characteristics of the study sample (n = 43) Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Sampling procedure The sampling procedure was carried out in several stages. The researcher first identified the number of residents who could be categorised as suffering from neglect, based on the neglect scale used and social work records (an elderly person’s case record that includes a section on older problems). This number stood at ninety-one. Out of these neglected residents, the study focused on those who are also contending with social isolation. Of the ninety-one neglected residents, forty-nine were found to be socially isolated, according to social worker records. In order to be certain that all these individuals were in fact socially isolated, scales of social disconnectedness and perceived isolation were applied. This enabled the researcher to assess the degree to which each individual was experiencing social isolation. The results of these scales showed that only forty-three residents could be categorised as truly socially isolated according to this framework. The sample used in this study was therefore reduced to forty-three individuals, all between the ages of sixty and seventy. The researchers randomly divided this group into two: the intervention group (with twenty-two individuals) and the control group (with twenty-one individuals). Instruments The two scales used to assess each individual’s degree of social isolation were a social disconnectedness scale and a perceived isolation scale. These scales were developed by Cornwell and Waite using data from the National Social Life, Health, and Aging Project (NSHAP)—a nationally representative, population-based study of community-residing older adults. NSHAP conducted in-person interviews with 3,005 individuals, aged fifty-seven to eighty-five years. The initially single scale integrates multiple indicators of isolation into two scales: one assessing social disconnectedness and one assessing perceived isolation (Cornwell and Waite, 2009). The social disconnectedness scale assessed two main factors: a lack of robustness in social networks and a lack of participation in social activities. Cronbach’s alpha model was used to measure internal consistency reliability, with a score of 0.73 emerging. The perceived isolation scale measured two main factors: lack of social support and loneliness. The reliability of the scale had a Cronbach’s alpha score of 0.70. The scale was further examined, and validated, in another sample taken from another elder-care agency with a sample size of ninety-three. These findings showed that inter-item correlations were adequate to good. Hypothesis of the study The present study involved one main hypothesis and two sub-hypotheses. The main hypothesis is ‘There are statistically significant differences between the intervention and control groups in mitigating the social isolation of neglected older people after using Logotherapy’. Two sub-hypotheses emanated from the main hypothesis: There are statistically significant differences between the intervention and control groups in mitigating the social disconnectedness of neglected older people after using Logotherapy. There are statistically significant differences between the intervention and control groups in mitigating the perceived isolation of neglected older people after using Logotherapy. Intervention description Ethical approval was obtained from the Human Ethics Committee of Assiut University. Consent forms were also completed by the participants. The ethical considerations about the research include: that participants are not involved in any physically, socially or emotionally risky situations; that the confidentiality of participants is ensured; that participants have the right to withdraw from the study at any time they may choose to; that all information is safe and secured; and that the dignity of the participants is respected. The intervention lasted for twelve weeks, with two weeks of follow-up work. Two types of activity were used to provide activities and support: twenty-four group intervention sessions and sixty-six individual interviews, which mainly focused on individual counselling. The intervention was designed to help elderly individuals find something personal to them that was meaningful in their lives, such as the importance of friendship, building more robust social networks, finding social support and participating in social activities. The intervention consisted of twenty-four group sessions lasting twenty to thirty minutes each, and sixty-six individual interviews, with three interviews for each participant, each interview session lasting thirty to forty-five minutes. The intervention was carried out by two Ph.D. students who had good experience in carrying out such interventions (a minimum of two years each). The intervention consisted of three stages: Stage 1 (Interviews 1–4): This stage aimed to create professional relationships with the participants, to clarify the components of the intervention and to give basic information about Logotherapy. In this stage, the therapists also asked participants to identify their feelings about the problem in question, and explain the negative consequences of social isolation across different aspects of their lives. Stage 2: Intervention (Interviews 5–10): The aim of this stage was to provide the elderly individuals with a sense of meaning in their own lives by highlighting the importance of their social networks and interactions with others. They also participated in different activities (based on their interests) both inside and outside the care agency, with the facilitators outlining the positive consequences of these steps on their social and psychological lives. Due to the importance of spirituality in the lives of older people, many activities were focused on social interactions of this type. The facilitator also enabled entertainment time with partners and attending agency activities to encourage friendships, such as encouraging group dining. Technology can also play an important role in creating opportunities for social interaction, which themselves can be an effective technique for dealing with the problems of isolation. With this in mind, some of the group members were taught technological and internet-use skills at this stage. This had a three-fold purpose: to increase their chances of social interaction, to increase their number of friends and to increase the frequency of their communication with friends and family via social-media platforms. Stage 3: Sustainability (Interviews 11–14): The aim of this stage was to strengthen and reinforce the positive results of the intervention by rewarding desirable outcomes to ensure continuity through follow-up. Strategies and techniques The therapists used a number of strategies and techniques to alleviate social isolation. One common strategy was home assignments as part of an action plan; cognitive behavioural assignments and tasks were given to the participants after each session and each individual interview. Many activities were included in this strategy, such as reading, group prayer, eating in a group, using Facebook and taking part in the ‘walking together programme’ ( examples of behavioural assignments). A number of other techniques included empathic reflection; this was to enable individuals to examine their own behaviours related to their isolation and the causes of such behaviours. The paradoxical intention method was also applied, whereby the elderly were persuaded to intentionally engage in behaviours they feared through imagining the worst possible outcomes for their behaviour before they attempt them. Furthermore, individual participants might be given a leading role in some activities, where they had to co-operate with others in order to carry out specific tasks. Attitude modification was also used to relieve feelings of sadness and despair, and thus to broaden and strengthen the participants’ sense of the meaningfulness of their lives. One of the most interesting techniques used in the intervention was Logo drama, which involved conducting group sessions in which each elderly individual would tell a story about his/her life. Another technique used was compensatory self-improvement; this was to help elderly individuals to benefit from their untapped abilities, such as giving speeches to their peers. Logo analysis strategy enhanced the individuals’ sense of the meaning of life and encouraged them to take advantage of their creative capabilities during social activities. When ideas arose that were difficult to explain, such as a friend’s prosperity or the importance of social interaction, facilitators used the parable method, which involves telling a number of stories with an allegorical meaning and message. Another method—cognitive restructuring—was used to build knowledge and beliefs about the problem of social isolation and its social and psychological impact. A straightforward training method was also used. Notably, there were two types of task being achieved. One was independent tasks, which the elderly individual can do by themselves, such as reading or watching TV. The other type of task was facilitator tasks, where parties in the agency or home help the elderly to achieve their tasks. These are done when it would be difficult for the individual to achieve their task without help. Examples of such tasks include a gym trainer helping an elderly person use some device at the gym or a technical trainer helping someone elderly to use Facebook, etc. An important factor used in all the intervention stages was reinforcement; this was used to maintain the progress achieved by the other strategies and techniques. Participants received positive reinforcement, depending on how far and how well they achieved the desired behaviour (the tasks) needed to increase their sense of the meaningfulness of life. Examples of the reinforcements were rewards such as shopping vouchers and free meals in some restaurants. Statistical analysis In order to analyse the data, a t-test for the significant difference between two means was used to test the research hypothesis using the Statistical Package for the Social Sciences (SPSS, version 21). Significance was found at P = 0.05. Results Table 1 reveals the demographic characteristics of the study sample. The mean age of the intervention group was 67.9 whereas, in the control group, it was 68.5. Also, as the table indicates, about two-thirds (67.4 per cent) of the elderly participants in the study were male. The average length of time participants had lived in the agency was 5.1 years in the intervention group and 3.7 years in the control group. The table also illustrates the marital status of the elderly participants; more than half were widowed (58.1 per cent) and 10.3 per cent were married. It should be noted that the distribution of participants by marital status was almost equal in the two groups. Table 2 shows the results of the t-test for the research groups in relation to the social disconnectedness and the perceived isolation of neglected older people. Table 2 Results of t-test for control (n = 21) and intervention group (n = 22) for the sub-hypotheses (t-table = 2.422 and α= 0.05). Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant Table 2 Results of t-test for control (n = 21) and intervention group (n = 22) for the sub-hypotheses (t-table = 2.422 and α= 0.05). Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant At the base line, namely before the therapy was started, the results showed no significant difference in disconnectedness between the intervention and control groups (t = 0.84, α = 0.05). This means that, before the application of the Logotherapy, the participants of both groups experienced a similar level of social disconnectedness. However, after the intervention, the table illustrates definite differences between the control and intervention groups (t = 5.37, α = 0.05). In addition, a comparison between the two groups at the follow-up stage again showed a significant result at α = 0.05 (t = 3.95). These results clearly indicate that significant changes were found between the two groups both after the intervention and in the follow-up stage. Thus, the first hypothesis, which is ‘There are statistically significant differences between the intervention and control groups in mitigating the social disconnectedness of neglected older people after using Logotherapy’, is accepted. Results regarding the perceived isolation of the neglected elderly were very similar. At the base line, before the therapy, the results indicated no significant difference between the research groups α = 0.05 (t =0.81). In contrast, a comparison made after the intervention between the control and intervention groups found a significant difference (t = 4.76). At the follow-up stage, the comparison between the two groups also showed a significant result at α = 0.05 (t = 4.13). These results conclude that significant differences can be seen between the intervention and control groups, both after the intervention/therapy and in the follow-up stage. Thus, the second hypothesis, which is ‘There are statistically significant differences between the intervention and control groups in mitigating the perceived isolation of neglected older people after using Logotherapy’, is accepted. Table 3 shows t-values to compare the older people in the research groups before (B), after (A) and in the follow-up (F) for different sub-hypotheses (t-table = 2.539, α = 0.05). Table 3 T-values to compare the older people before (B), after (A) and the follow-up (F) in research groups for different sub-hypotheses (t-table = 2.539, α= 0.05). Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 Table 3 T-values to compare the older people before (B), after (A) and the follow-up (F) in research groups for different sub-hypotheses (t-table = 2.539, α= 0.05). Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 It was assumed that Logotherapy would make a significant difference in mitigating the social isolation of neglected older people after they went through a Logotherapy process. In order to test the hypothesis of the research and its sub-hypothesis, t-tests were examined for both groups at all levels of intervention. A number of comparisons were used with each sub-hypothesis. These comparisons are the differences before and after the intervention, the differences before the intervention and at follow-up stage, and finally the differences after the intervention and at the follow-up stage. Such comparisons were applied with both research groups. For the control group, the results were found to be not significant before and after the intervention at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 0.76, Sub-hypothesis 2 = 0.98). For the control group, the results showed no significant difference before the intervention and at follow-up stages at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 0.58, Sub-hypothesis 2 = 0.38). The results also showed no significant difference after the intervention and in the follow-up stages, at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 0.69, Sub-hypothesis 2 = 0.76). The same comparisons were made for the intervention group, but with different results. When a comparison was made before and after the intervention, the result was significant at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 4.26, Sub-hypothesis 2 = 3.57). Such significant differences reflect how much the elderly were able to interact through Logotherapy. Again, the results showed a significant difference between before intervention and at the follow-up stage, at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 5.19, Sub-hypothesis 2 = 1.63). But the results showed no significant difference after the intervention and follow-up stages at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 1.63, Sub-hypothesis 2 = 1.98). It is thus evident that the t-test for the intervention group revealed distinct and positive changes in the two dimensions after the intervention and at the follow-up stage, when compared to the baseline test, which was before the intervention. Such changes were not evident in the control group. The results clearly show that Logotherapy has a remarkable effect on the two factors of the social isolation of neglected older people in the participants of the intervention group. In addition, both the social worker in the agency and the therapists indicated that many changes could be observed in the intervention group as a result of applying the Logotherapy, namely: social network sizes (number of friends) increased; interactions with colleagues were increased; social participation in the activities inside the agency had increased (according to the attendance activity records); social support had improved, especially through the residents’ friends (noted through the observations of social workers); physical symptoms such as a sense of fatigue were reduced among the intervention group (based on the records from the nurse and feedback from the social worker at the agency); there was an increase in the use of social media on the internet in the intervention group. The results of the main hypotheses were in line with those of other studies (Gönen, 2015). Many studies have also agreed with the results of the first hypothesis (Windle et al., 2011) and of the second hypothesis (Robatmili et al., 2015). All of these similar studies have shown the efficacy of interventions in alleviating social isolation. Further, the results of the current study indicate that Logotherapy plays an important role in alleviating social isolation among the elderly. Discussion The present study aimed to clarify the effects of using Logotherapy in mitigating social isolation among the elderly. Before carrying out the intervention, all the elderly in both groups (intervention and control) were assessed as having a problem with social isolation. The findings also indicated that, in most of those suffering from social isolation, this isolation was linked to the lack of a sense of meaning in their lives (Kobayashi et al., 2009). The findings indicated that Logotherapy had a positive effect on neglected elder individuals suffering from social isolation. The therapy significantly mitigated both aspects (sub-hypotheses) of social isolation through the application of the therapy techniques in the intervention group. Further, no difference was found in the control group at any of the stages tested, while the findings showed significant differences between the control group and the intervention group both after the intervention and in the follow-up stage. As studies have shown, one-to-one interventions are great tools in alleviating loneliness and social isolation (Bernard, 2013) and a strong point of Logotherapy is that it pays great attention to individualising therapy. In this study, for example, individual (one-to-one) interventions were widely used, and each elderly person was given the opportunity to express their personal interests and concerns. Further, as Nicholson (2012) has indicated, group sessions are effective in improving social involvement. One of the reasons for social isolation is that ‘the things that once gave their lives meaning in the past may be missing or at least changed in their present state of dependency’ (Frankl, 2006, p. 151). One of the aims of Logotherapy is to find possibly new sources of the meaning of life for the elderly. In addition, because the goal of Logotherapy is to stimulate the will to meaning (Kimble and Ellor, 2001), the intervention was focused on establishing the meaning of friendships and the importance of having friends in our life. Elderly people felt they have meaning in their life when they are doing certain voluntary activities, such as group activities, group leadership and helping other elderly people. Individual counselling was also helpful and improved feelings of well-being in the elderly intervention group; similar findings can be seen in Dickens et al. (2011). Awareness of the importance of interaction with others and of having friends was an essential target in the intervention. The results regarding this are also in line with the literature (Van Orden et al., 2012). In addition, the study bears out the ideas of Julom and de Guzmán (2013), who explained that spiritual fulfilment could wipe out the negative experience of the past. Due to the importance of spirituality in the lives of older people, many of the intervention activities were spiritually focused—a method that is in line with findings and recommendations of many other studies, such as that by Rote et al. (2013). It is important to note that many elderly individuals often struggle to find activities to engage in during their leisure time, hence the facilitation of joyful and fun activities and the creation of opportunities for social interactions used in the study. These techniques proved successful and agree with Fawcett’s (2012) findings. The use of social media (e.g. Facebook, Twitter, Instagram, etc.) was another important intervention technique to increase social interaction. The successful results of this are borne out by a number of other studies, which indicate that Social Network Services (SNS) can play an important role in improving social skills in the elderly, alleviating loneliness and therefore decreasing social isolation (Coelho and Duarte, 2016). The results concur with a number of studies which indicate that greater use of the internet was the most effective intervention in increasing social support and decreasing some aspects of loneliness (Heo et al., 2015). Increasing the number of friends and social networks in the intervention group reduced people’s sense of social disconnectedness, which bears out the ideas of Pettigrew et al. (2014). In summary, the present study agreed with other international research indicating that social isolation can be effectively treated through different techniques and interventions, such as befriending, mentoring (Bernard, 2013), partnering (Cattan et al., 2005), leisure, mindfulness and meditation (Toepoel, 2013), using the internet (Lelkes, 2013), group services and wider community engagement (Nicholson, 2012), individual activities (Gardiner et al., 2016) and the acquisition of a sense of meaning in life (Somov, 2007; Gönen, 2015). We can conclude that the positive changes achieved in the intervention group are a result of many factors, namely (i) the formation of a therapeutic professional relationship, (ii) changing their sense of the meaninglessness of life, (iii) the discovery of meaning within meaninglessness and (iv) pursuing meaning and being motivated to achieve it. Implication for research and practice The findings of the current study have a number of implications for use of the Logotherapy intervention to treat social isolation among the institutionalised elderly. This study can help elderly people and their families to become aware of the problem and can help them to prevent it before the older person enters residential care. The research emphasises the importance for an elderly person to have meaning in their life, as well as the importance of their having friends. We suggest that other studies should be carried out with a longer follow-up stage, so that the continuity of the effectiveness of Logotherapy can be explored. More research is also needed with elderly people over seventy years of age. Conclusion The results showed the effectiveness of Logotherapy in mitigating the social isolation of older people. 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World Health Organization ( 2018 ) ‘Elder abuse’, available online at http://www.who.int/mediacentre/factsheets/fs357/en/ (accessed 5 March 2018). Yon Y. , Mikton C. , Gassoumis Z. , Wilber K. ( 2017 ) ‘ Elder abuse prevalence in community settings: A systematic review and meta-analysis ’, The Lancet Global Health , 5 ( 2 ), 147 – 56 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

The Effectiveness of Logotherapy in Mitigating the Social Isolation of neglected Institutionalised Older People

The British Journal of Social Work , Volume 48 (4) – Jun 1, 2018
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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.
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0045-3102
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1468-263X
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Abstract

Abstract There are various types of elder abuse; one of the most prevalent and most harmful abuses is neglect. Social isolation is one of the most common consequences of neglect, with an inability to find meaning in life closely associated with both these issues. One intervention that might be used with older people suffering from neglect and social isolation is Logotherapy—a meaning-based intervention. The aim of this study is to examine the effectiveness of Logotherapy in mitigating the social isolation of older people suffering from neglect. This study was developed using a quantitative research design, and with a purposive sample of forty-three socially isolated older individuals in a single institution for the elderly in Cairo, Egypt. The study follows a quasi-experimental study model. A social disconnectedness scale and a perceived isolation scale were used to assess both degrees of social isolation. The intervention lasted for twelve weeks, with two weeks of follow-up work. A significant difference emerged between the intervention and control groups. The results indicate that enabling older people to experience meaning in life by emphasising the value of social relationships and interactions has a positive effect on their social networks. Logotherapy, intervention, elderly, elder abuse, neglect, social isolation Introduction Elder abuse is seen today as a significant public, social and health problem. The term ‘elder abuse’ was first used in British scientific journals in 1975 in connection with the term ‘granny battering’ (Chalise, 2017). More recently, it has been defined as ‘a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’ (Choi and Mayer, 2000, p. 6). Some researchers such as Rudnick and Teaster (2013) suggest that elder abuse has long been hidden from the public view and considered a private issue. Choi and Mayer (2000) emphasise that the abuse and neglect of older persons are definitely not a modern phenomenon; however, concern around this issue as a social problem began only in the 1970s. Statistics from the World Health Organization (2018) indicate that, globally, the number of cases of elder abuse is projected to increase as many countries have rapidly ageing populations. It is predicted that the global population of the elderly will more than double by 2050. It is also warned that, if the proportion of elder-abuse victims remains constant, the number of victims will increase to 320 million by 2050. However, more optimistic researchers such as Pettigrew et al. (2014) and the Irish Association of Social Workers (2011) argue that increasing attention is being paid to alleviation of the suffering caused by elder abuse, with this increased awareness resulting from a growth in global concern regarding human rights in general and associated issues such as population ageing. Band-Winterstein et al. (2014) emphasise that elder abuse has now been recognised as both a social and a health-related problem, with awareness about the issue increasing in the last thirty years. They also demonstrate that both theoretical and empirical knowledge of this field has been established over these years. One key type of elder abuse is neglect—a severe problem affecting the physical, emotional and material well-being of many elderly people (Band-Winterstein et al., 2014). Cornwell and Waite (2009) argue that neglect of the elderly can lead to their social isolation. This isolation has been principally attributed to the tendency for older people to experience shrinking social relations, hectic lives of their relatives and the increasing possibility of health problems (Nicholson, 2012). As a result, a great deal of attention has been paid to the problems associated with social isolation. The Irish Association of Social Workers (2011) reflects on the significant role played by social work professionals who, while co-operating with a network of other professionals, work to detect signs of neglect and to provide appropriate interventions and preventive services. Social work has produced various forms of interventions aiming to mitigate the social isolation of older people. One approach that was developed by Victor Frankl (1955) and has been implemented by practitioners is Logotherapy. It is defined as a meaning-oriented therapy that aims to help individuals acquire a greater sense of meaning in their lives through enhancing their motivation for change (Somov, 2007). Logotherapy has three main roots. These are, first, philosophical roots, which can be expressed through existentialism and phenomenology; then spiritual roots, which are expressed through a commitment to the human being as an irreversibly spiritual creature; and, third, psychological roots that can be seen in psychoanalysis and individual psychology (Kimble and Ellor, 2001). The loss of a sense of a meaning to life can greatly affect the vitality of the elderly. Indeed, the crisis of ageing can well be seen as a crisis of meaning. The elderly may often be challenged to make sense of life at a stage when many changes and losses arise (Kimble and Ellor, 2001). It is usual that ageing brings a number of weaknesses and diminishments but, if the elderly are to cope with these positively, they need to create a sense of meaning in their life. This study will focus on examining the effectiveness of Logotherapy in mitigating the social isolation of neglected older people. Literature review Research available on elder abuse indicates that it exists in both developed and developing countries (Chalise, 2017). Yon et al. (2017) present a study conducted on evidence from fifty-two studies in twenty-eight countries from diverse regions, including from twelve low- and middle-income countries. Their study found that the elder-abuse problem is evenly distributed among developing and developed countries. Elder abuse A number of studies have highlighted the negative effects of elder abuse. For example, Rezaeipandari et al. (2016) have argued that the general health status of older people who have experienced abuse is significantly worse than those who have not, as the abuse increases vulnerability to disease. The possible physical, psycho-social and social consequences of elder abuse are numerous and varied. They may include physical effects such as sleep disturbances and nutrition, and psychological effects such as stress and depression, while the social effects can be seen mainly in the diminishing of social relations and in social isolation (Center for Disease Control and Prevention, 2018). Many researchers indicated that psychological and emotional abuse are the most harmful types of elder abuse. Also, many elderly mentioned that physical abuse could heal but psychological pains were emotionally destructive and damaging to the self-worth and sense of self (New Brunswick Nursing Home Association, 2018). Powell (2012) has added that elder abuse has not received sufficient public consideration, as it tends to be thought of as a private, domestic issue. Hence, it seems clear that more attention needs to be paid to tackling elder abuse and associated issues at a public-health and social level. The World Health Organization (2018) emphasises that elder abuse has existed in all cultures without noticeable variations in its causes and forms. Even in developing countries, where, it is widely agreed, family is traditionally highly valued and family members’ needs should be fulfilled, these recent decades of globalisation, industrialisation, urbanisation and modernisation have weakened the traditional family and community networks that provided care to older people (Chalise, 2017). Similarly, researchers such as Bowes et al. (2012) argue that, although clear gaps exist between service provision and people experiencing mistreatment due to structural and contextual factors, cultural factors have a relatively minor impact on levels of elder abuse. Neglect Neglect is considered to be the most prevalent category of elder abuse, comprising an estimated 58 per cent of all reported cases (National Center on Elder Abuse, 2017). Although there are some differences in defining the term ‘neglect’, most researchers have agreed that neglect is the failure to take care of the elderly by not providing the assistance they require for good health, a feeling of safety and the achievement of well-being (Taylor et al., 2016). Choi and Mayer (2000) argue that the majority of the perpetrators of the abused and neglected elderly are family members. This includes spouses, adult children and other relatives, while non-relative perpetrators are home-health aides, paid or unpaid care-givers and neighbours. The National Institute of Justice in the USA funded a study aimed at identifying the characteristics of care-givers who carry out elder mistreatment. Findings indicated that half of the perpetrators were using drugs or alcohol at the time of the abuse, three in ten perpetrators had a history of mental illness, over a third of were unemployed and four in ten were themselves socially isolated (National Institute of Justice, 2017). Neglect, then, whether perpetrated by family members or non-family members, is an enormously harmful problem, endangering all aspects of the lives of elderly people (Pettigrew et al., 2014). Social isolation Social isolation is both a cause and a result of elder abuse. It is a significant risk factor for the abuse, so that an older adult who is socially isolated has a higher chance of experiencing elder abuse (Connecting Edmonton Seniors, 2018). Equally, as Taylor et al. (2016) explain, social isolation is a symptom of elder abuse. Debate still continues over whether neglect is the greatest cause of social isolation among the elderly, compared to the other categories of elder abuse. In either case, the abused elderly are ignored and live in a restricted social environment (World Health Organization, 2018). Researchers, such Gardiner et al. (2016), have argued that social isolation is the most critically important issue affecting older people, with Holwerda et al. (2014) predicting that it will become an even more pressing problem in the coming years. Sangeeth and Solomon (2014) have argued that older people generally tend to have a lower level of social relationships, and thus are highly likely to feel socially isolated. Other researchers have also commented on social isolation in the elderly and its ramifications. Taylor et al. (2016) state that one of the common causes of social isolation is the failure to assist institutionalised older people in participating in various forms of socialisation. Very importantly, Stillman et al. (2009) have also argued that social isolation reduces the perception of the meaningfulness of one’s life. Researchers such as Nicholson (2012) and Pettigrew et al. (2014) have pointed out the consequences of this, emphasising the importance of maintaining social interactions in later life in order to preserve well-being. Pre-existing literature in the field has outlined a growing range of interventions that have been developed in order to mitigate social isolation and its consequences (Gönen, 2015). One type of intervention is befriending, where an older individual is provided with visits or phone contact in order to help them carry out tasks, such as shopping (Bernard, 2013). Mentoring is usually focused on helping older people to achieve a short-term goal (Windle et al., 2011). Further models have also been developed, such as coping strategies, leisure, mindfulness and meditation (Toepoel, 2013). Nicholson (2012) notes that, in addition, group services and wider community engagement such as day-centre services can enable older people to expand their social relationships. Lelkes has shown that older people who use the internet and have regular contact with members of a social network have a lower chance of being isolated. In the case of the elderly who might have difficulty in dealing with electronic devices, consistent practice can be provided to overcome this challenge. Religion also plays an important role in the life of many of the elderly and can provide opportunities for reducing social isolation (Krause, 2008). Attending religious services regularly has been shown to reduce levels of social isolation and loneliness (Kobayashi et al., 2009). Researchers have argued that religious practice encourages followers to build and maintain social ties through its prompts towards social integration and its provision of social support (Rote et al., 2013). Gardiner et al. (2016) have argued that the range and scope of effective interventions have not yet been sufficiently understood. Hence, more attempts to examine the effects of both individual and group activities are needed in order to identify the most appropriate methods to mitigate social isolation (Kobayashi et al., 2009). Logotherapy It is widely believed that finding meaning in one’s life is a universal human factor in living happily. Robatmili et al. (2015) argue that assisting older people to acquire meaning and purpose in life can help them to develop a satisfactory and hopeful existence. Robatmili et al. (2015) refer to Frankl (2006), who argues that the emotional emptiness that results from a lack of meaning in life is one of the most difficult psychological issues facing individuals in modern times. In response to this belief, Frankl was inspired to develop the therapeutic approach of Logotherapy. Logotherapy has been variously defined. Robatmili et al. (2015) define it as a psychological treatment that aims to help individuals to appreciate their existence. Chan (2017) sees it as a meaning-oriented therapeutic treatment that can help clients address various problems in a number of areas related to finding a sense of meaning in their lives. There have as yet been few studies on the implications of Logotherapy for the older population, but its effectiveness has generally been examined in terms of how it can be used to deal with other specific segments of the population. For example, Robatmili et al. (2015) show that Logotherapy can offer long-term relief from underlying feelings of meaninglessness and depression in university students. There have also been some speculative suggestions, however, that Logotherapy might provide an appropriate method to alleviate the social isolation of older people. Gönen (2015), for example, has argued that meaning in life can be an effective approach in assisting older people to enjoy a happy and active old age. Chan (2017) has emphasised that a sense of meaning in life is important for the well-being of any client’s psychological health and, therefore, its promotion should be a key facet of social work practice. Additionally, MacKinnon et al. (2014) have stated that finding this sense of meaning might emerge as a potential outcome of social work intervention through the practitioner’s attempts to help their clients to focus on the positive things in their lives and remain positive in the face of difficult circumstances. The aim of this study, then, is to examine the effectiveness of Logotherapy in alleviating the social isolation of the neglected older population. Methodology Research type and research methods This study was developed using a quantitative research design. A quasi-experimental model design was implemented in order to identify the impact of an independent variable, Logotherapy, upon the dependent variable, social isolation. The sample A purposeful sample was used in the study, consisting of forty-two neglected older people between the ages of sixty and seventy who are residents of the institution (see Table 1). The institution is the one of largest private elderly care institutions in Egypt, having 140 elderly residents in permanent indoor stay services and forty other elderly people who frequently attend in the day-care services. The institution provides several services such as physical therapy, health care, entertainment programmes and social services. Table 1 Demographic characteristics of the study sample (n = 43) Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Table 1 Demographic characteristics of the study sample (n = 43) Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Characteristics Experimental (intervention) group Control (comparison) group Overall Mean age (years) 67.9 68.5 68.2 Female (%) 8 6 14 Male (%) 14 15 29 Years living in the agency (years) 5.1 3.7 4.4 Marital status Married 2 1 3 Divorced 7 8 15 Widowed 13 12 25 Sampling procedure The sampling procedure was carried out in several stages. The researcher first identified the number of residents who could be categorised as suffering from neglect, based on the neglect scale used and social work records (an elderly person’s case record that includes a section on older problems). This number stood at ninety-one. Out of these neglected residents, the study focused on those who are also contending with social isolation. Of the ninety-one neglected residents, forty-nine were found to be socially isolated, according to social worker records. In order to be certain that all these individuals were in fact socially isolated, scales of social disconnectedness and perceived isolation were applied. This enabled the researcher to assess the degree to which each individual was experiencing social isolation. The results of these scales showed that only forty-three residents could be categorised as truly socially isolated according to this framework. The sample used in this study was therefore reduced to forty-three individuals, all between the ages of sixty and seventy. The researchers randomly divided this group into two: the intervention group (with twenty-two individuals) and the control group (with twenty-one individuals). Instruments The two scales used to assess each individual’s degree of social isolation were a social disconnectedness scale and a perceived isolation scale. These scales were developed by Cornwell and Waite using data from the National Social Life, Health, and Aging Project (NSHAP)—a nationally representative, population-based study of community-residing older adults. NSHAP conducted in-person interviews with 3,005 individuals, aged fifty-seven to eighty-five years. The initially single scale integrates multiple indicators of isolation into two scales: one assessing social disconnectedness and one assessing perceived isolation (Cornwell and Waite, 2009). The social disconnectedness scale assessed two main factors: a lack of robustness in social networks and a lack of participation in social activities. Cronbach’s alpha model was used to measure internal consistency reliability, with a score of 0.73 emerging. The perceived isolation scale measured two main factors: lack of social support and loneliness. The reliability of the scale had a Cronbach’s alpha score of 0.70. The scale was further examined, and validated, in another sample taken from another elder-care agency with a sample size of ninety-three. These findings showed that inter-item correlations were adequate to good. Hypothesis of the study The present study involved one main hypothesis and two sub-hypotheses. The main hypothesis is ‘There are statistically significant differences between the intervention and control groups in mitigating the social isolation of neglected older people after using Logotherapy’. Two sub-hypotheses emanated from the main hypothesis: There are statistically significant differences between the intervention and control groups in mitigating the social disconnectedness of neglected older people after using Logotherapy. There are statistically significant differences between the intervention and control groups in mitigating the perceived isolation of neglected older people after using Logotherapy. Intervention description Ethical approval was obtained from the Human Ethics Committee of Assiut University. Consent forms were also completed by the participants. The ethical considerations about the research include: that participants are not involved in any physically, socially or emotionally risky situations; that the confidentiality of participants is ensured; that participants have the right to withdraw from the study at any time they may choose to; that all information is safe and secured; and that the dignity of the participants is respected. The intervention lasted for twelve weeks, with two weeks of follow-up work. Two types of activity were used to provide activities and support: twenty-four group intervention sessions and sixty-six individual interviews, which mainly focused on individual counselling. The intervention was designed to help elderly individuals find something personal to them that was meaningful in their lives, such as the importance of friendship, building more robust social networks, finding social support and participating in social activities. The intervention consisted of twenty-four group sessions lasting twenty to thirty minutes each, and sixty-six individual interviews, with three interviews for each participant, each interview session lasting thirty to forty-five minutes. The intervention was carried out by two Ph.D. students who had good experience in carrying out such interventions (a minimum of two years each). The intervention consisted of three stages: Stage 1 (Interviews 1–4): This stage aimed to create professional relationships with the participants, to clarify the components of the intervention and to give basic information about Logotherapy. In this stage, the therapists also asked participants to identify their feelings about the problem in question, and explain the negative consequences of social isolation across different aspects of their lives. Stage 2: Intervention (Interviews 5–10): The aim of this stage was to provide the elderly individuals with a sense of meaning in their own lives by highlighting the importance of their social networks and interactions with others. They also participated in different activities (based on their interests) both inside and outside the care agency, with the facilitators outlining the positive consequences of these steps on their social and psychological lives. Due to the importance of spirituality in the lives of older people, many activities were focused on social interactions of this type. The facilitator also enabled entertainment time with partners and attending agency activities to encourage friendships, such as encouraging group dining. Technology can also play an important role in creating opportunities for social interaction, which themselves can be an effective technique for dealing with the problems of isolation. With this in mind, some of the group members were taught technological and internet-use skills at this stage. This had a three-fold purpose: to increase their chances of social interaction, to increase their number of friends and to increase the frequency of their communication with friends and family via social-media platforms. Stage 3: Sustainability (Interviews 11–14): The aim of this stage was to strengthen and reinforce the positive results of the intervention by rewarding desirable outcomes to ensure continuity through follow-up. Strategies and techniques The therapists used a number of strategies and techniques to alleviate social isolation. One common strategy was home assignments as part of an action plan; cognitive behavioural assignments and tasks were given to the participants after each session and each individual interview. Many activities were included in this strategy, such as reading, group prayer, eating in a group, using Facebook and taking part in the ‘walking together programme’ ( examples of behavioural assignments). A number of other techniques included empathic reflection; this was to enable individuals to examine their own behaviours related to their isolation and the causes of such behaviours. The paradoxical intention method was also applied, whereby the elderly were persuaded to intentionally engage in behaviours they feared through imagining the worst possible outcomes for their behaviour before they attempt them. Furthermore, individual participants might be given a leading role in some activities, where they had to co-operate with others in order to carry out specific tasks. Attitude modification was also used to relieve feelings of sadness and despair, and thus to broaden and strengthen the participants’ sense of the meaningfulness of their lives. One of the most interesting techniques used in the intervention was Logo drama, which involved conducting group sessions in which each elderly individual would tell a story about his/her life. Another technique used was compensatory self-improvement; this was to help elderly individuals to benefit from their untapped abilities, such as giving speeches to their peers. Logo analysis strategy enhanced the individuals’ sense of the meaning of life and encouraged them to take advantage of their creative capabilities during social activities. When ideas arose that were difficult to explain, such as a friend’s prosperity or the importance of social interaction, facilitators used the parable method, which involves telling a number of stories with an allegorical meaning and message. Another method—cognitive restructuring—was used to build knowledge and beliefs about the problem of social isolation and its social and psychological impact. A straightforward training method was also used. Notably, there were two types of task being achieved. One was independent tasks, which the elderly individual can do by themselves, such as reading or watching TV. The other type of task was facilitator tasks, where parties in the agency or home help the elderly to achieve their tasks. These are done when it would be difficult for the individual to achieve their task without help. Examples of such tasks include a gym trainer helping an elderly person use some device at the gym or a technical trainer helping someone elderly to use Facebook, etc. An important factor used in all the intervention stages was reinforcement; this was used to maintain the progress achieved by the other strategies and techniques. Participants received positive reinforcement, depending on how far and how well they achieved the desired behaviour (the tasks) needed to increase their sense of the meaningfulness of life. Examples of the reinforcements were rewards such as shopping vouchers and free meals in some restaurants. Statistical analysis In order to analyse the data, a t-test for the significant difference between two means was used to test the research hypothesis using the Statistical Package for the Social Sciences (SPSS, version 21). Significance was found at P = 0.05. Results Table 1 reveals the demographic characteristics of the study sample. The mean age of the intervention group was 67.9 whereas, in the control group, it was 68.5. Also, as the table indicates, about two-thirds (67.4 per cent) of the elderly participants in the study were male. The average length of time participants had lived in the agency was 5.1 years in the intervention group and 3.7 years in the control group. The table also illustrates the marital status of the elderly participants; more than half were widowed (58.1 per cent) and 10.3 per cent were married. It should be noted that the distribution of participants by marital status was almost equal in the two groups. Table 2 shows the results of the t-test for the research groups in relation to the social disconnectedness and the perceived isolation of neglected older people. Table 2 Results of t-test for control (n = 21) and intervention group (n = 22) for the sub-hypotheses (t-table = 2.422 and α= 0.05). Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant Table 2 Results of t-test for control (n = 21) and intervention group (n = 22) for the sub-hypotheses (t-table = 2.422 and α= 0.05). Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant Hypotheses Stage Groups Decision significance Control Intervention SD SD T Sub-hypothesis 1 Before intervention 0.478 0.503 0.84* Not significant After intervention 0.515 0.577 5.37 Significant Follow-up 0.497 0.577 3.95 Significant Sub-hypothesis 2 Before intervention 0.765 0.436 0.81* Not significant After intervention 0.651 0.489 4.76 Significant Follow-up 0.348 0.599 4.13 Significant At the base line, namely before the therapy was started, the results showed no significant difference in disconnectedness between the intervention and control groups (t = 0.84, α = 0.05). This means that, before the application of the Logotherapy, the participants of both groups experienced a similar level of social disconnectedness. However, after the intervention, the table illustrates definite differences between the control and intervention groups (t = 5.37, α = 0.05). In addition, a comparison between the two groups at the follow-up stage again showed a significant result at α = 0.05 (t = 3.95). These results clearly indicate that significant changes were found between the two groups both after the intervention and in the follow-up stage. Thus, the first hypothesis, which is ‘There are statistically significant differences between the intervention and control groups in mitigating the social disconnectedness of neglected older people after using Logotherapy’, is accepted. Results regarding the perceived isolation of the neglected elderly were very similar. At the base line, before the therapy, the results indicated no significant difference between the research groups α = 0.05 (t =0.81). In contrast, a comparison made after the intervention between the control and intervention groups found a significant difference (t = 4.76). At the follow-up stage, the comparison between the two groups also showed a significant result at α = 0.05 (t = 4.13). These results conclude that significant differences can be seen between the intervention and control groups, both after the intervention/therapy and in the follow-up stage. Thus, the second hypothesis, which is ‘There are statistically significant differences between the intervention and control groups in mitigating the perceived isolation of neglected older people after using Logotherapy’, is accepted. Table 3 shows t-values to compare the older people in the research groups before (B), after (A) and in the follow-up (F) for different sub-hypotheses (t-table = 2.539, α = 0.05). Table 3 T-values to compare the older people before (B), after (A) and the follow-up (F) in research groups for different sub-hypotheses (t-table = 2.539, α= 0.05). Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 Table 3 T-values to compare the older people before (B), after (A) and the follow-up (F) in research groups for different sub-hypotheses (t-table = 2.539, α= 0.05). Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 Group Stage Sub-hypothesis 1 Sub-hypothesis 2 B A B A Control group B 0.76 0.98 F 0.58 0.69 0.38 0.76 Intervention group B 4.26 3.57 F 5.19 1.63 3.12 1.98 It was assumed that Logotherapy would make a significant difference in mitigating the social isolation of neglected older people after they went through a Logotherapy process. In order to test the hypothesis of the research and its sub-hypothesis, t-tests were examined for both groups at all levels of intervention. A number of comparisons were used with each sub-hypothesis. These comparisons are the differences before and after the intervention, the differences before the intervention and at follow-up stage, and finally the differences after the intervention and at the follow-up stage. Such comparisons were applied with both research groups. For the control group, the results were found to be not significant before and after the intervention at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 0.76, Sub-hypothesis 2 = 0.98). For the control group, the results showed no significant difference before the intervention and at follow-up stages at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 0.58, Sub-hypothesis 2 = 0.38). The results also showed no significant difference after the intervention and in the follow-up stages, at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 0.69, Sub-hypothesis 2 = 0.76). The same comparisons were made for the intervention group, but with different results. When a comparison was made before and after the intervention, the result was significant at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 4.26, Sub-hypothesis 2 = 3.57). Such significant differences reflect how much the elderly were able to interact through Logotherapy. Again, the results showed a significant difference between before intervention and at the follow-up stage, at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 5.19, Sub-hypothesis 2 = 1.63). But the results showed no significant difference after the intervention and follow-up stages at α = 0.05 for the two sub-hypotheses (Sub-hypothesis 1 = 1.63, Sub-hypothesis 2 = 1.98). It is thus evident that the t-test for the intervention group revealed distinct and positive changes in the two dimensions after the intervention and at the follow-up stage, when compared to the baseline test, which was before the intervention. Such changes were not evident in the control group. The results clearly show that Logotherapy has a remarkable effect on the two factors of the social isolation of neglected older people in the participants of the intervention group. In addition, both the social worker in the agency and the therapists indicated that many changes could be observed in the intervention group as a result of applying the Logotherapy, namely: social network sizes (number of friends) increased; interactions with colleagues were increased; social participation in the activities inside the agency had increased (according to the attendance activity records); social support had improved, especially through the residents’ friends (noted through the observations of social workers); physical symptoms such as a sense of fatigue were reduced among the intervention group (based on the records from the nurse and feedback from the social worker at the agency); there was an increase in the use of social media on the internet in the intervention group. The results of the main hypotheses were in line with those of other studies (Gönen, 2015). Many studies have also agreed with the results of the first hypothesis (Windle et al., 2011) and of the second hypothesis (Robatmili et al., 2015). All of these similar studies have shown the efficacy of interventions in alleviating social isolation. Further, the results of the current study indicate that Logotherapy plays an important role in alleviating social isolation among the elderly. Discussion The present study aimed to clarify the effects of using Logotherapy in mitigating social isolation among the elderly. Before carrying out the intervention, all the elderly in both groups (intervention and control) were assessed as having a problem with social isolation. The findings also indicated that, in most of those suffering from social isolation, this isolation was linked to the lack of a sense of meaning in their lives (Kobayashi et al., 2009). The findings indicated that Logotherapy had a positive effect on neglected elder individuals suffering from social isolation. The therapy significantly mitigated both aspects (sub-hypotheses) of social isolation through the application of the therapy techniques in the intervention group. Further, no difference was found in the control group at any of the stages tested, while the findings showed significant differences between the control group and the intervention group both after the intervention and in the follow-up stage. As studies have shown, one-to-one interventions are great tools in alleviating loneliness and social isolation (Bernard, 2013) and a strong point of Logotherapy is that it pays great attention to individualising therapy. In this study, for example, individual (one-to-one) interventions were widely used, and each elderly person was given the opportunity to express their personal interests and concerns. Further, as Nicholson (2012) has indicated, group sessions are effective in improving social involvement. One of the reasons for social isolation is that ‘the things that once gave their lives meaning in the past may be missing or at least changed in their present state of dependency’ (Frankl, 2006, p. 151). One of the aims of Logotherapy is to find possibly new sources of the meaning of life for the elderly. In addition, because the goal of Logotherapy is to stimulate the will to meaning (Kimble and Ellor, 2001), the intervention was focused on establishing the meaning of friendships and the importance of having friends in our life. Elderly people felt they have meaning in their life when they are doing certain voluntary activities, such as group activities, group leadership and helping other elderly people. Individual counselling was also helpful and improved feelings of well-being in the elderly intervention group; similar findings can be seen in Dickens et al. (2011). Awareness of the importance of interaction with others and of having friends was an essential target in the intervention. The results regarding this are also in line with the literature (Van Orden et al., 2012). In addition, the study bears out the ideas of Julom and de Guzmán (2013), who explained that spiritual fulfilment could wipe out the negative experience of the past. Due to the importance of spirituality in the lives of older people, many of the intervention activities were spiritually focused—a method that is in line with findings and recommendations of many other studies, such as that by Rote et al. (2013). It is important to note that many elderly individuals often struggle to find activities to engage in during their leisure time, hence the facilitation of joyful and fun activities and the creation of opportunities for social interactions used in the study. These techniques proved successful and agree with Fawcett’s (2012) findings. The use of social media (e.g. Facebook, Twitter, Instagram, etc.) was another important intervention technique to increase social interaction. The successful results of this are borne out by a number of other studies, which indicate that Social Network Services (SNS) can play an important role in improving social skills in the elderly, alleviating loneliness and therefore decreasing social isolation (Coelho and Duarte, 2016). The results concur with a number of studies which indicate that greater use of the internet was the most effective intervention in increasing social support and decreasing some aspects of loneliness (Heo et al., 2015). Increasing the number of friends and social networks in the intervention group reduced people’s sense of social disconnectedness, which bears out the ideas of Pettigrew et al. (2014). In summary, the present study agreed with other international research indicating that social isolation can be effectively treated through different techniques and interventions, such as befriending, mentoring (Bernard, 2013), partnering (Cattan et al., 2005), leisure, mindfulness and meditation (Toepoel, 2013), using the internet (Lelkes, 2013), group services and wider community engagement (Nicholson, 2012), individual activities (Gardiner et al., 2016) and the acquisition of a sense of meaning in life (Somov, 2007; Gönen, 2015). We can conclude that the positive changes achieved in the intervention group are a result of many factors, namely (i) the formation of a therapeutic professional relationship, (ii) changing their sense of the meaninglessness of life, (iii) the discovery of meaning within meaninglessness and (iv) pursuing meaning and being motivated to achieve it. Implication for research and practice The findings of the current study have a number of implications for use of the Logotherapy intervention to treat social isolation among the institutionalised elderly. This study can help elderly people and their families to become aware of the problem and can help them to prevent it before the older person enters residential care. The research emphasises the importance for an elderly person to have meaning in their life, as well as the importance of their having friends. We suggest that other studies should be carried out with a longer follow-up stage, so that the continuity of the effectiveness of Logotherapy can be explored. More research is also needed with elderly people over seventy years of age. Conclusion The results showed the effectiveness of Logotherapy in mitigating the social isolation of older people. 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Journal

The British Journal of Social Work – Oxford University Press

Published: Jun 1, 2018

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