Ego Integrity vs. Despair in Long-term Care

Dr. Laura P. Etre, Psy.D.

Admission to a Nursing Home for long-term care is a significant life event that often triggers adjustment related psychiatric symptoms or exacerbates pre-existing psychiatric disorders.   Not surprisingly, Nursing Home residents have been found to have lower levels of life satisfaction and psychological well-being than community residents.   From a developmental perspective, residents with depression and other mood presentations may have difficulty negotiating the psychosocial tasks of aging as outlined by Erik Erikson (1950).   Having an understanding of ego integrity and its implications for the assessment and treatment of our resident population could assist in symptom reduction and greater life acceptance.   

Erikson believed that our prime motivation for development is social and that we have an internal drive to interact with others.  He identified eight psychosocial conflicts that individuals navigate throughout their life span with the goal of developing a stage specific virtue which becomes part of one’s ego skills:

  • Trust vs. Mistrust – Hope
  • Autonomy vs. Shame and Doubt – Will
  • Initiative vs. Guilt – Purpose
  • Industry vs. Inferiority  – Competence
  • Identity vs. Role Confusion – Fidelity
  • Intimacy vs. Isolation – Love
  • Generativity vs. Stagnation – Care
  • Ego Integrity vs. Despair – Wisdom

Erikson characterized the final stage as a time of reflection with the task of looking back on life and integrating it into a coherent and acceptable whole.  If successful, negative past experiences are reconciled and ego integrity and wisdom develop.  If unsuccessful, feelings of regret, guilt and despair develop.   In long-term care settings we are faced with residents who are actively grappling with these types of conflicts.  Are those residents who feel that they have lived a meaningful and acceptable life more resilient as they adapt to medical stressors, increased dependence and the reality of living away from home?  Not always.  It can be argued, however, that reconciling negative past experiences and moving toward ego integrity can support symptom reduction and overall adjustment.   To that end, life review or reminiscence was viewed by Erikson as vital in resolving the ego integrity vs. despair conflict.

The field of Reminiscence was introduced by Robert Butler (1963) who proposed that reviewing one’s life allowed older adults to increase their overall well-being.  Reminiscent interventions have developed since that time and vary in intensity, structure and modality (individual vs group):

  • Simple Reminiscence – mainly unstructured autobiographical storytelling promoting social interaction
  • Life Review – structured with focus on integration of positive/negative life events to promote self-acceptance
  • Life Review Therapy – provides conditions to restructure memories and promote self-change

               Reminiscent interventions are often paired with other treatment approaches such as Cognitive Behavior Therapy, and can be integrated into the conceptualization and treatment course of a resident case.   In deciding what type of reminiscent intervention to use, it is important to account for factors such as setting, level of psychological distress and cognitive status of the individual.  For example, when conducting group therapy in a skilled nursing facility with residents who have mild-moderate dementia, the use of Simple Reminiscence would be a more appropriate approach than Life Review Therapy. 

Research targeting life satisfaction for Nursing Home residents, which has been used as one measure of ego integrity, has found a positive correlation with reminiscent interventions.   The field of Reminiscense continues to develop and be adapted for various settings and clinical presentations.  In long-term care, facilitating some form of life reflection to promote acceptance and psychological stability can serve as one therapeutic tool that we offer to our settings.