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Exploring academics beliefs about the meaning of life to inform mental health clinical practice
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Exploring academics beliefs about the meaning of life to inform mental health clinical practice ⁎
Xanthe Glawa,b, , Michael Hazeltona, Ashley Kablea, Kerry Indera a b
School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia School of Nursing, Midwifery and Paramedicine, Faculty of Health, Australian Catholic University, 33 Berry St, North Sydney, NSW 2059, Australia
A R T I C LE I N FO
A B S T R A C T
Keywords: Beliefs about the meaning of life Meaninglessness Existential crises Depression Mental health
The aim of this research was to understand academic's beliefs about the meaning of life to gain knowledge to inform mental health clinical practice and research. Qualitative research was conducted using descriptive text and interviews from a sample of Australian midlife academic staff from one university who described their beliefs about the meaning of life. Their beliefs included that: life is a journey of self-development, is about religious or non-religious beliefs, is about living well, is about family, love and relationships, and is about making a difference. These findings may be used by mental health clinicians to help clients explore their beliefs about the meaning of life. Consumers with depression may suffer from meaninglessness, existential crises, severe depression and risk suicide. Working on understanding their beliefs about the meaning of life may result in better mental health outcomes for these people.
Introduction The meaning of life is a question that humans have been pondering for centuries. What does it all mean? Why are we here? What are we meant to be doing? How can we make our lives more meaningful? Meaning of life questions were traditionally and historically discussed in philosophy or theology rather than in empirical research. Yet meaning in life and its importance to people's lives is now contemporarily often discussed in other disciplines such as psychology, nursing, anthropology, sociology, and gerontology (Bhullar, 2019; Steger et al., 2013; Steger, Kashdan, Sullivan, & Lorents, 2008). However, the meaning of life question is still not integrated into current mental health clinical practice. So far attempts to better understand the meaning of life question have been inconclusive, yet the attempt to answer this question influences everyone's views about how they will live their lives (Kernes & Kinner, 2008). Understanding beliefs about the meaning of life and the consequences of experiencing meaninglessness in life could be very beneficial for mental health professionals working with people with exacerbations of depression such as suicidal ideation and increased risk of suicide. Failure to respond to human spiritual needs for meaning creates an existential dilemma that, if left unrecognised or unresolved, may result in depression, apathy, boredom, hopelessness and a loss of the will to
live (Beck, Rawlins, & Williams, 1984; Frankl, 1959; Reker, Peacock, & Wong, 1987; Trice, 1986). Previous research has reported that lack of meaning may lead to interpersonal and physical health problems (Hill et al., 2017) and stress (Park, 2005). Lack of meaning has also been found to relate to psychopathology (Hill et al., 2017), depression (Mascaro & Rosen, 2005; Steger, Frazier, Oishi, & Kaler, 2006; Steger & Kashdan, 2009); substance abuse, suicidality (Wnuk, 2007, 2008, 2010), loneliness (Bhullar, 2019), anxiety (Steger, Mann, Michels, & Cooper, 2009), post-traumatic stress disorder (Owens, Steger, Whitesell, & Herrera, 2009; Steger, Frazier, & Zacchanini, 2008) and lower levels of well-being (Hill et al., 2017). Loss of meaning in life has also been associated with psychological distress and physical illness (Steger et al., 2009; Wong, 2000). Consequently, this presents an opportunity and rationale for more research to understand this complex issue to influence current clinical practice by promoting better outcomes for mental health consumers. This article seeks to answer the research question: What are the beliefs about the meaning of life in midlife academic staff with or without depression? There is a strong rationale to explore and further research meaning of life and to consider the implications for people with mental illness. Mental health clinicians are in a key position to be able to help those with mental illness explore and answer these fundamental questions. Therefore, this study focuses on the meaning of life related to
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Corresponding author at: School of Nursing, Midwifery and Paramedicine, Faculty of Health, Australian Catholic University, 33 Berry St, North Sydney, NSW 2059, Australia. E-mail addresses: [email protected] (X. Glaw), [email protected] (M. Hazelton), [email protected] (A. Kable), [email protected] (K. Inder). https://doi.org/10.1016/j.apnu.2020.02.009 Received 9 November 2019; Accepted 8 February 2020 0883-9417/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Xanthe Glaw, et al., Archives of Psychiatric Nursing, https://doi.org/10.1016/j.apnu.2020.02.009
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Study participants
depression, suicide, mental health clinicians and the clinical practice implications that can be applied to this topic; specifically, in midlife academic staff with or without depression. A literature search was conducted in 2016 and only three empirical research papers (Hill et al., 2013; Kernes & Kinner, 2008; Kinnier, Kernes, Tribbensee, & Puymbroeck, 2003) and five prominent theorists were located that addressed beliefs about the meaning of life (Glaw, Kable, Hazelton, & Inder, 2017).
All participants were Australian citizens, between the ages of 40–60 years and nine were female. All participants were married except one who identified as a lesbian with no current or past partner and some participants had children. They came from a range of disciplines and were academic staff from an Australian multi-campus university, with campuses in regional, capital city and international locations. Two participants had academic and professional positions, working parttime in both positions. This study sample included three associate lecturers, six lecturers, one senior lecturer and one researcher. This cohort included six participants who reported never having been diagnosed with a mental illness and five participants who reported having been diagnosed with depression or depression and anxiety. Three of these participants reported a long and severe history of depression with current symptoms (measured by the DASS 21 instrument). Two participants had a history of severe depression with no current symptoms. The similar numbers of participants in each group was coincidental. The rationale for recruiting academic staff from one university was the limited timeframe for completion of the study. A point of difference between the two groups was the level of functioning. Participants in the self-reported depression group needed more prompting, support and guidance to do what was required to participate in the study; whereas, those in the non-depressed group were able to complete the tasks required for the study without any assistance.
Methods A qualitative study was conducted using data collection methods of participant descriptive texts and interviews. Demographic data and two mental health screening assessments – Depression, Anxiety and Stress Scale (DASS 21) (Lovibond & Lovibond, 1995) and Kessler 10 (K10) (Kessler, 1992) at baseline and photographic data (results reported separately) were also collected from a sample of Australian midlife academic staff at a regional university in Australia in 2016. The study setting was a regional university in Australia. The study sample was Australian university academic staff in midlife with or without a diagnosis of depression. Participants were recruited to two study groups, that is, a group with depression (ranging from low to severe) and a group without depression. This study used purposive (non-probability) voluntary sampling (Blaxter, Hughes, & Tight, 2013). This approach resulted in a self-selected sample of voluntary participants. Recruitment was conducted via the university's homepage with interested staff being invited to participate after assessing their eligibility for inclusion in the study. Participant criteria included having a minimum of an undergraduate degree, aged 40 to 60 years (midlife) and having either suffered from clinical depression that had been diagnosed by a psychiatrist, doctor or mental healthcare professional, or having never suffered from depression or any other mental illness. They also had to be Australian citizens, and English speaking. More detail about the study methods (study sample, sampling approach, recruitment, participant eligibility and data collection) is reported in a previous methodology article (Glaw, Inder, Hazelton, & Kable, 2017). To determine eligibility, the participants in the depression group filled out the DASS 21 (Lovibond & Lovibond, 1995) and this was used to measure the level of depression, anxiety and stress and the severity of symptoms (low, moderate, severe or extremely severe). The K10 scale (Kessler, 1992) was used to measure the level of current psychological distress as a baseline. Participants also gave self-reported data of past or current symptoms and whether they had a formal diagnosis of depression. These mental health screening assessments were also used on the non-depressed participants to confirm their status of no depressive illness and therefore their eligibility to be included in the non-depressed group. Recruitment resulted in 11 eligible, consenting participants. Participants were asked to write about what they believe the meaning of life to be, and to list as many ideas as they wished. At interview participants were invited to discuss their ideas and beliefs about the meaning of life. The interviewer used an unstructured interview schedule with open-ended questions to explore the topic in detail. Interviews were digitally recorded and subsequently transcribed verbatim. All data were de-identified in transcripts and electronic data files, and only pseudonyms were used to identify participants. Participant's selected their own pseudonyms to maintain confidentiality and are used in the attribution of excerpts throughout this article. Trustworthiness was increased by using multiple data collection methods resulting in a collection of deeper, richer and multi-dimensional data. Interpretive thematic analysis was used to synthesize findings from the data. Ethics approval was provided by the university Human Research Ethics Committee (Ethics approval number: H-20150331).
Data analysis Data analysis was undertaken between August 2016 and January 2017 and involved interpretative thematic analysis (Braun & Clarke, 2006; Harding, 2013; Liamputtong, 2013) using the participants descriptive text that they had submitted. They had been asked to write about their beliefs about the meaning of life in whatever way they chose. This article presents the findings from the analysis of the descriptive text submitted by participants and interview data. All participants submitted descriptive text about their beliefs about the meaning of life. Interpretative thematic analysis was used to create categories and then to generate themes. Firstly coding was performed to break up the data and to find some of the commonalities (Liamputtong, 2013). Then the analysis involved identifying initial themes that emerged from the data (Harding, 2013). Subsequently, searching was undertaken across the data set to find repeated patterns which were then analysed and the themes developed (Braun & Clarke, 2006). Interpretive thematic analysis continued to narrow the themes, placing them in order from most commonly described to less commonly described themes, based on statements made by the participants. At fortnightly meetings, the data were discussed and the process by which themes were developed was critiqued. Throughout these meetings findings and themes were discussed and challenged, and important questions were raised in relation to study participants' beliefs about the meaning of life. Final analysis of the patterns and meanings that emerged from the data was conducted and a number of differences and similarities between individuals and the two groups emerged. Findings The following themes emerged using interpretative thematic analysis of the descriptive and interview data: 1. 2. 3. 4. 5. 2
The The The The The
meaning meaning meaning meaning meaning
of of of of of
life life life life life
is is is is is
a journey of self-development about religious or non-religious beliefs about living well about family, love and relationships making a difference
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The overall findings regarding beliefs about the meaning of life in this study indicate that the most commonly described theme was that the meaning of life is a journey of self-development and self-improvement. The second most commonly described theme was religious and non-religious beliefs. The third most commonly described theme was the meaning of life is to live well, the fourth most commonly described theme was family, love and relationships, and the last most commonly described theme identified was that the meaning of life is about making a difference by either helping others, making a contribution to the world or leaving a legacy. According to participants in this study meaning of life is encapsulated in these five themes. This may or may not be reflective of the general population as this is a small and occupationally narrow (group of academic staff) study sample. However, the findings provide some indication of what midlife academics believe contributes to perceived meaning in their lives.
I do not find meaning in religion or even spirituality. Sienna. I believe in reincarnation, that our souls are here to learn lessons so they can evolve spiritually. Skye. The soul's only goal is to grow, to evolve spiritually. Skye. It's like the ultimate spiritual experience in being able to be a part of a physical level existence. Byron. The meaning of life is about living well Participants reported the meaning of life to be about living well with descriptions like: Life is short and you just gotta try and make the most of it, live every day like it's the last one. Summer.
The meaning of life is a journey of self-development
There's that book ‘the top five regrets in life’ and the top one is work, why didn't we work less. They must have known something. Summer.
Participants in the self-reported depression group did not see selfdevelopment as an important area, although they did identify it as part of the meaning of life. The self-reported depression group participants seemed to place much less importance on self-development than their counterparts in the non-depressed group who placed a great deal of emphasis on this area, which is why it ranked as most important to them and most commonly described. Participants described the meaning of life as a journey of self-development extensively and said things like:
Living well for me is being creative and enjoying life; like creating ideas, being involved, enjoying and creating art, music, literature, relaxing, play, exercising, holidays, leisure and laughing, playing games with my dog and relaxing with my family and friends and having good food; that's what life is all about to me. Paisley. The meaning of life is about family, love and relationships
Self-development is the ultimate goal in life, as Carl Jung said, the self is our life's goal. Skye.
Participants explained the meaning of life to be about family, love and relationships with quotes such as:
My main and most meaningful roles are being me, caring for myself, living to my values, learning and improving, investing in myself. Paisley.
The meaning of life for me is about family and those around you who bring warmth and kindness to your soul. Mia.
I believe we all have our own journey. Byron.
I have lived through seeing two people close to me pass away. And on both occasions, there were no CEOs there when they were dying. No bosses. No work colleagues. Not even friends right at the end; just wonderful family. Summer.
I also looked at purpose. So what am I here for then…and that's simple for me to be the best I can be. Ava. The meaning of life is about religious and non-religious beliefs
The meaning of life is about making a difference Participants in the self-reported depression group wrote and spoke strongly about their atheist beliefs and the meaning of life; and this was the only category in which the self-reported depression group provided more data than their counterparts in the non-depressed group. Participants talked about the meaning of life in terms of religious or non-religious beliefs, there were a range of ideas and they explained it like this:
The least described theme was the meaning of life is about making a difference: One of my greatest experiences that gives me true meaning in life is the ability to make a positive difference in someone else's life. If I am able to truly help someone, make a positive difference, give empowerment, direction when all seems hopeless, in a sense give someone hope, then I feel like all the bad things in life don't seem to matter nearly as much. Byron.
As a Christian I believe that I have been born for a purpose and that my life should reflect the essence of God which is love and relationship. Velvet.
… using my own skills, abilities, knowledge and I guess my own sense of power to assist and work with others is often something that makes me feel like life is all worth it. Byron.
I do not believe there is an afterlife as told by religions. This, my friends, is it. Physically, I will continue as my corpse contributes to the planet, which I see as a closed system. My spirit will live on in the children I leave behind, my legacy and stories for a time, but not forever. Summer.
I believe it is important to be open, compassionate and available to others. I do not want my own long and deep struggles with crippling depression and severe anxiety to make me hard and unkind, but to open me up to deeper compassion for others. Velvet.
I don't need to proclaim, rather just do. My actions are not for a higher order purpose or in order for me to pay my way to a better eternal life, simply the act or acts, give me a meaning to my life. Ava.
The life of an individual – good or bad, short or long – is a contribution to the world (universe). The value, to humans, of that contribution comes from how the life is ‘used’ and how it affects those around it. Taylor.
My beliefs about the meaning of life: What a question. I honestly do not know. Essentially I am atheist. Sienna. … once you're dead, you're dead, as far as I'm concerned, I don't have a faith. Violet. 3
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Discussion
studies have shown that addressing the spiritual needs of the consumers can enhance their recovery (Mueller et al., 2001). The level of dysfunction seen in participants in the self-reported depression group is similar to that found in people presenting for treatment in the clinical setting. The symptoms of depression typically include a markedly diminished interest or pleasure in all or almost all activities, most of the day, nearly every day; a lack of emotional reaction to activities or events that usually result in an emotional response; psychomotor agitation or retardation nearly every day; fatigue or loss of energy almost every day; and diminished ability to think or concentrate or indecisiveness almost every day (American Psychiatric Association, 2000, 2013; Andrews, 2013; Treatment Protocol Project, 2004). To some extent this clinical picture is consistent with what was observed in the self-reported depression group in this study. Depression adversely affects the ability of people to function effectively in the everyday tasks of life and this would almost certainly extend to academic work which requires high level cognitive functioning, sound organisation skills, energy and drive, and the capacity to work under pressure. Reduced functioning due to depressive symptoms would very likely undermine high level academic performance and thus stunt successful career development. The resultant frustrations and disappointments would also likely further fuel depression and anxiety. For the participants so affected it would be surprising if this was not experienced as deeply traumatic. The experience of depression is consistent with the difficulties participants in the self-reported depression group faced, in undertaking the tasks required by involvement in the study. The findings of this study are similar to data reported by Kinnier et al. (2003) in which eminent people discussed their beliefs about the meaning of life. For the eminent respondents in that study the meaning of life involved: “life is to be enjoyed”, “we are here to love and help others”, “it is a mystery”, “there is no cosmic meaning”, “we are here to serve or worship God”, “life is a struggle”, “we must make a contribution to society”, “our mission in life is to seek wisdom/truth, and to become self-actualized”, “we must create meaning for ourselves”, and “life is absurd or a joke”. Five of the themes reported by Kinnier et al. (2003) are similar to those reported in this study. Kinnier et al. (2003) concluded that the range of responses was complex and often contradictory, with no one consensual theme emerging (Kinnier et al., 2003), but that there are a group of themes that may be common, which has also been seen in this present study. A Grounded Theory study by Kernes and Kinner (2008) investigated psychologists' beliefs about the meaning of life. In this study the participants largely rejected the notion of there being a grand, all-encompassing design to life. Instead they supported the belief that the meaning of life is to love, help, and show compassion for others (Kernes & Kinner, 2008); a finding similar to that of this present study. Mental health clinicians may have a role in encouraging and supporting individuals to find their own answers to the meaning of life question. There are common themes for many people but answering the meaning of life question is largely an individual pursuit. Existential therapies can be utilised for work of this kind, or mental health clinicians could guide and explore these fundamentally important questions with consumers as part of their general approach to providing help. This would likely provide consumers with the ability to make sense of their lives. Mental health clinicians could ask questions specifically related to the themes of this research such as: Do I embrace opportunities for self-development and improvement? Do I have religious or philosophical beliefs that help me to make sense of my life and its purpose and meaning? Am I living well (doing things I like to do)? Are family, love and relationships meaningful and fulfilling in my life? Have I contributed to, or made a difference by helping others, making a contribution to the world or leaving a legacy? Mental health clinicians could ask these questions and tailor therapies and treatments to individually suit the beliefs and needs of those with whom they are working. The two groups in this study have nominated common areas where many find meaning of life, which could help clinicians in their
Overall, there was a variety of ideas put forward from both groups about the meaning of life. The non-depressed group provided more data overall, particularly in the categories of self-development and spirituality. Self-development involves activities that improve awareness and identity, develop talents, facilitate employability, enhance quality of life and help individuals reach their dreams and aspirations. Spirituality is also about growing the self. It is about personal growth of the human spirit or soul in search of value and meaning in life. People with depression often struggle to find motivation and this can have a negative impact on their capacity to do the things necessary to grow, learn and develop; the symptoms of depression can work against the realisation of personal achievement in all areas of life. It is noteworthy that participants in the self-reported depression group did not see self-development as an important area, although they did identify it as part of the meaning of life. The self-reported depression group participants seemed to place much less importance on self-development than their counterparts in the non-depressed group. Selfcare, self-growth, self-improvement and self-development are important areas for a meaningful life as this study has revealed. Consequently, it seems important that mental health clinicians assist people living with depression to work on their self-development, selfdiscovery and self-care needs. Addressing such needs would likely entail greater collaboration between the clinical service provider and the person living with mental illness; seeking ways to increase meaningfulness and enhancing beliefs about the meaning of life. The findings of the study also suggest that exploring options for boosting religious beliefs and spiritual involvement could be important aspects of recovery, contributing to improved health and mental health outcomes and reducing suicidality. Enhancing self-development has also been shown to improve self-esteem and selfawareness, improve social skills, facilitate employability, build personal strengths and talents, assist in setting and achieving goals, increasing quality of life, and to act as a buffer against mental illness, and helps create a healthy and meaningful life (Dervic et al., 2004; Flannelly, 2017; Hill et al., 2013; Mueller, Plevak, & Rummans, 2001). Participants in the self-reported depression group wrote and spoke strongly about their atheist beliefs and the meaning of life; and this was the only category in which the self-reported depression group provided more data than their counterparts in the non-depressed group. In previous studies religion has been found to be a buffer against depression in later life (VanderWeele, Li, Tsai, & Kawachi, 2016). There is also evidence that religious involvement or spirituality is associated with mental and physical health, more so than atheism (Mueller et al., 2001). Atheism has been shown in some studies to be a causal factor for suicide for some individuals, and religious affiliation has been reported to be associated with less suicidal behaviour in depressed inpatients (Dervic et al., 2004). A perhaps unexpected outcome of this study has been the extent to which a number of participants spoke freely about their atheist beliefs. All but one participant disclosed that they had no formal religious affiliations. While the prospect of health practitioners discussing religion and spiritual beliefs with consumers is potentially sensitive, this is an area that might be worthwhile considering in relation to protective factors against depression and other forms of mental and physical ill health. While unlikely to be helpful in cases where consumers express strong atheist beliefs, for those with a religious affiliation, or a history which includes a past affiliation, such a discussion could be beneficial. According to the 2003 World Health Organisation report on international male suicide rates, the highest male suicide rates are found in countries where a high percentage of the population holds atheist beliefs, and the ten nations with the lowest male suicide rates have populations with a high percentage of people involved in religion (Dervic et al., 2004). This ought to be of interest to health practitioners working with people living with depression who may be suicidal. A number of 4
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Clinical implications
clinical practice guide and support the consumers with whom they work to improve their depression, suicidality and meaning in/of life.
In the clinical context, people should be encouraged and supported to identify their own beliefs about the meaning of life. Addressing meaninglessness and the existential crisis is an area that mental health clinicians can work on. Mental health clinicians could ask questions specifically related to the themes of this research such as: Do I embrace opportunities for self-development and improvement? Do I have religious or philosophical beliefs that help me to make sense of my life and its purpose and meaning? Am I living well (doing things I like to do)? Are family, love and relationships meaningful and fulfilling in my life? Have I contributed to or made a difference by either helping others, making a contribution to the world or leaving a legacy? These are questions every human being is likely to ask and seek answers for at some point in their lives. It is human nature to seek personal growth in all areas of life, so mental health clinicians can help consumers, particularly those with depression; to work through these important questions and construct/affirm their beliefs about the meaning of life. This could result in improved mental health outcomes, because without the answers to these questions, consumers may struggle to see the point of living. If left untreated, such people can experience meaninglessness, existential crisis, severe and chronic clinical depression and may eventually contemplate suicide (Dunn & O'Brien, 2009; Frankl, 1959; Steger et al., 2006; Steger & Kashdan, 2009). Consumers may choose suicide if they do not have any goals or do not see a reason to live. So, this is an important area to address in mental health therapeutic relationships. Treatment should focus on creating a positive future as outlined by the consumer not the clinician. The therapeutic relationship is one of equality and should help the consumer clarify and work towards goals, experiences and attitudes; which will aid them in finding their personal life meanings (Hill et al., 2017; Lukas, 1979; Mirhaghi, Sharafi, Bazzi, & Hasanzadeh, 2017; Molkenthin, 2017; Moreno-Poyato et al., 2016). Mental health clinicians can teach consumers how to love and nurture themselves and to discover and grow the self. They can provide support and guidance, providing a place for those with whom they work to identify, express, and reflect on their sources of meaning in life and what they believe the meaning of life to be. Clinicians can walk alongside such individuals to help them alleviate feelings of alienation and existential frustration. Support could be provided to nurture, guide and inspire those who struggle with their search for meaning in life and to affirm the universality of the human search for meaning and acknowledge distress when other options seem to be lacking. Clinicians could normalize and encourage such a search; offer ideas about strategies that might open doors to multiple possibilities of meaning and affirm the worth of searching. Inviting people in distress to read and listen to others' experiences that illustrate success can be helpful in such quests. Current therapies can be utilised for helping consumers explore the meaning of life question. They include: existential counselling/therapy, existential psychotherapy, meaning-centred counselling, meaningcentred psychotherapy, Logotherapy, spiritual therapy, religious cognitive-emotional therapy and humanistic therapy. These therapies involve exploring the human existence rather than focusing on psychopathology. They largely focus on exploring the deeper parts of the self to gain a better understanding of what is most important in life. The more effective interventions are likely to be those that are evidenced based and are orientated towards recovery/wellness goals rather than treatment goals. Typically, goals are often related to reducing risk, preventing relapse and reducing re- hospitalisations, whereas recovery goals include the persons individual goals, dreams, and aspirations. They set a path for the future. They focus on what the person with mental illness wants, rather than on what they should avoid (Thornicroft, Szmukler, Mueser, & Drake, 2011). The demands of nursing work often leave little time for this type of work or for nurses to even talk to consumers due to their heavy
Limitations and strengths The limitations of this research included the recruitment of nine females and two males to the study. This gender imbalance may have resulted in the phenomenon of interest being investigated more through female perspectives. Recruitment of a more gender balanced study sample may have produced different results. However, the study was designed to recruit a purposive voluntary sample; in effect participants self-selected by answering an advertisement in the internal university staff newsletter. One of the main limitations of this research is that the findings may not be transferable to other age groups or groups of midlife adults. The participants were university staff. The use of academic staff as participants in the study, potentially restricted the transferability of the findings. A strength of this research included the purposeful recruitment of participants who had experienced the phenomenon of interest, and embraced the opportunity to discuss their beliefs about the meaning of life. They reported having found the process immensely cathartic, enjoyable, and beneficial to their own lives and futures as it encouraged deep reflection on the important things in their lives. Some participants even suggested they thought they had gained more from participation in the research than the research team, as the experience allowed them to analyse their lives in ways they had not done previously, generating valuable insights about themselves. Participants in the self-reported depression group also reported feeling that involvement in the study had been valuable; they expressed a desire to make a difference in mental health research and practice, and they felt they had been able to do so through involvement in the study. In addition, academic staff typically have advanced thinking and reflective skills, and in many instances, this resulted in the generation of rich and nuanced data. Trustworthiness and rigour The trustworthiness and rigour of this study focused on strategies described by Shenton (2004) and Cope (2014) for ensuring trustworthiness in qualitative research. The four elements for ensuring trustworthiness – credibility, transferability, dependability and confirmability. Strategies used to demonstrate credibility or internal validity included using well recognised and established research methods such as in-depth interviews, and early familiarity with the study culture. In addition establishing a good rapport with participants, asking probing questions to extract further information, conducting regular debriefing meetings with the research team, obtaining peer scrutiny by experienced researchers, using reflective commentary to demonstrate the credibility of the researchers, member checking of the data after interview, using thick descriptive data to ensure the reader has access to detailed information to understand the research, and comparing findings with literature from previous research all contributed to the credibility of this study. Strategies used to demonstrate potential transferability included providing enough information to enable comparisons, and providing sufficient information about the study context and participants to allow for the transfer of findings and their application to other similar situations. Dependability was demonstrated by using overlapping data collection methods and providing detail about methods to enable researchers to repeat the work in other settings. Strategies to ensure confirmability included constructing an audit trail, and documenting step-by-step processes followed and decisions made; and presentation of quotes that depict emerging themes (Cope, 2014). 5
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workloads (Mirhaghi et al., 2017), increased administrative tasks and high nurse-consumer/patient ratios (Moreno-Poyato et al., 2016). These are all major obstacles to developing the therapeutic relationship (Moreno-Poyato et al., 2016), and in many instances the nurse constructs the therapeutic relationship within the parameters of the nurseconsumer relationship (Molkenthin, 2017). This relationship involves a power imbalance that often meets the professional goals of the nurse rather the consumer's goals (Mirhaghi et al., 2017). This approach many overlook the consumer's history, future and aspirations concerning their meaning of life, and occurs during the period when they are most unwell and most vulnerable. If mental health clinicians look for opportunities to ask those with whom they are working about how they derive meaning, this may trigger new ideas and insights. Encouraging people to think about what they believe is the meaning of life, may reset therapeutic expectations, and contribute to a recovery journey. Implementing the findings within clinical practice may be restricted by resources as mental health funding is often geared more towards symptom management rather than addressing recovery goals. That is, the organisation of services and the mindsets and clinical practices of individual practitioners are typically geared towards managing risk, reducing the likelihood of relapse, and avoiding re-hospitalisation. While important, such concerns primarily address symptom management and fall well short of addressing the principles and practices of recovery embracing the goals, dreams and aspirations of the people receiving mental health services. Sometimes in practice there is a focus on what the client wants rather than on what the clinician thinks they should do or avoid. However, mental health clinicians need more time to explore these existential issues with the people with whom they are working; treatment ought to look beyond the reduction of symptoms to consider what can be done to facilitate recovery and help people live better lives. However, a focus on recovery goals is often not possible given the organisation and resourcing of mental health services. Often inadequate staffing levels, inappropriate staff mix and high consumer/ patient acuity, among other things, combine to weaken prospects for working within a framework of recovery-oriented mental health practice. Nonetheless, it is important that mental health clinicians don't give up on recovery; there are likely to be numerous opportunities for individual clinicians to work in greater depth with some people, and it is likely that the insights from this study will prove helpful in such situations. It is recommended that further research be conducted on different groups. This was a small cohort of academic staff, and so, studying nonacademic mid-life community members may provide broader views of beliefs about the meaning of life.
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Funding The lead author was awarded an Australian Postgraduate Award (APA) scholarship to complete this study. Declaration of competing interest The authors report no conflicts of interest. References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5th ed). (Arlington, VA). Andrews, G. (2013). Management of mental disorders. Darlinghurst, NSW: Clinical Research Unit for Anxiety and Depression, University of New South Wales, School of Psychiatry. Beck, C. M., Rawlins, P. R., & Williams, S. R. (1984). Mental health - psychiatric nursing: A holistic life-cycle approach. St Louis: The C.V. Mosby Company. Bhullar, N. (2019). Beliefs about the meaning of life in American and Indian college students: Similar or different? Psychological Studies, 64, 420–428.
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Contents lists available at ScienceDirect
Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
Exploring academics beliefs about the meaning of life to inform mental health clinical practice ⁎
Xanthe Glawa,b, , Michael Hazeltona, Ashley Kablea, Kerry Indera a b
School of Nursing and Midwifery, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia School of Nursing, Midwifery and Paramedicine, Faculty of Health, Australian Catholic University, 33 Berry St, North Sydney, NSW 2059, Australia
A R T I C LE I N FO
A B S T R A C T
Keywords: Beliefs about the meaning of life Meaninglessness Existential crises Depression Mental health
The aim of this research was to understand academic's beliefs about the meaning of life to gain knowledge to inform mental health clinical practice and research. Qualitative research was conducted using descriptive text and interviews from a sample of Australian midlife academic staff from one university who described their beliefs about the meaning of life. Their beliefs included that: life is a journey of self-development, is about religious or non-religious beliefs, is about living well, is about family, love and relationships, and is about making a difference. These findings may be used by mental health clinicians to help clients explore their beliefs about the meaning of life. Consumers with depression may suffer from meaninglessness, existential crises, severe depression and risk suicide. Working on understanding their beliefs about the meaning of life may result in better mental health outcomes for these people.
Introduction The meaning of life is a question that humans have been pondering for centuries. What does it all mean? Why are we here? What are we meant to be doing? How can we make our lives more meaningful? Meaning of life questions were traditionally and historically discussed in philosophy or theology rather than in empirical research. Yet meaning in life and its importance to people's lives is now contemporarily often discussed in other disciplines such as psychology, nursing, anthropology, sociology, and gerontology (Bhullar, 2019; Steger et al., 2013; Steger, Kashdan, Sullivan, & Lorents, 2008). However, the meaning of life question is still not integrated into current mental health clinical practice. So far attempts to better understand the meaning of life question have been inconclusive, yet the attempt to answer this question influences everyone's views about how they will live their lives (Kernes & Kinner, 2008). Understanding beliefs about the meaning of life and the consequences of experiencing meaninglessness in life could be very beneficial for mental health professionals working with people with exacerbations of depression such as suicidal ideation and increased risk of suicide. Failure to respond to human spiritual needs for meaning creates an existential dilemma that, if left unrecognised or unresolved, may result in depression, apathy, boredom, hopelessness and a loss of the will to
live (Beck, Rawlins, & Williams, 1984; Frankl, 1959; Reker, Peacock, & Wong, 1987; Trice, 1986). Previous research has reported that lack of meaning may lead to interpersonal and physical health problems (Hill et al., 2017) and stress (Park, 2005). Lack of meaning has also been found to relate to psychopathology (Hill et al., 2017), depression (Mascaro & Rosen, 2005; Steger, Frazier, Oishi, & Kaler, 2006; Steger & Kashdan, 2009); substance abuse, suicidality (Wnuk, 2007, 2008, 2010), loneliness (Bhullar, 2019), anxiety (Steger, Mann, Michels, & Cooper, 2009), post-traumatic stress disorder (Owens, Steger, Whitesell, & Herrera, 2009; Steger, Frazier, & Zacchanini, 2008) and lower levels of well-being (Hill et al., 2017). Loss of meaning in life has also been associated with psychological distress and physical illness (Steger et al., 2009; Wong, 2000). Consequently, this presents an opportunity and rationale for more research to understand this complex issue to influence current clinical practice by promoting better outcomes for mental health consumers. This article seeks to answer the research question: What are the beliefs about the meaning of life in midlife academic staff with or without depression? There is a strong rationale to explore and further research meaning of life and to consider the implications for people with mental illness. Mental health clinicians are in a key position to be able to help those with mental illness explore and answer these fundamental questions. Therefore, this study focuses on the meaning of life related to
⁎
Corresponding author at: School of Nursing, Midwifery and Paramedicine, Faculty of Health, Australian Catholic University, 33 Berry St, North Sydney, NSW 2059, Australia. E-mail addresses: [email protected] (X. Glaw), [email protected] (M. Hazelton), [email protected] (A. Kable), [email protected] (K. Inder). https://doi.org/10.1016/j.apnu.2020.02.009 Received 9 November 2019; Accepted 8 February 2020 0883-9417/ © 2020 Elsevier Inc. All rights reserved.
Please cite this article as: Xanthe Glaw, et al., Archives of Psychiatric Nursing, https://doi.org/10.1016/j.apnu.2020.02.009
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Study participants
depression, suicide, mental health clinicians and the clinical practice implications that can be applied to this topic; specifically, in midlife academic staff with or without depression. A literature search was conducted in 2016 and only three empirical research papers (Hill et al., 2013; Kernes & Kinner, 2008; Kinnier, Kernes, Tribbensee, & Puymbroeck, 2003) and five prominent theorists were located that addressed beliefs about the meaning of life (Glaw, Kable, Hazelton, & Inder, 2017).
All participants were Australian citizens, between the ages of 40–60 years and nine were female. All participants were married except one who identified as a lesbian with no current or past partner and some participants had children. They came from a range of disciplines and were academic staff from an Australian multi-campus university, with campuses in regional, capital city and international locations. Two participants had academic and professional positions, working parttime in both positions. This study sample included three associate lecturers, six lecturers, one senior lecturer and one researcher. This cohort included six participants who reported never having been diagnosed with a mental illness and five participants who reported having been diagnosed with depression or depression and anxiety. Three of these participants reported a long and severe history of depression with current symptoms (measured by the DASS 21 instrument). Two participants had a history of severe depression with no current symptoms. The similar numbers of participants in each group was coincidental. The rationale for recruiting academic staff from one university was the limited timeframe for completion of the study. A point of difference between the two groups was the level of functioning. Participants in the self-reported depression group needed more prompting, support and guidance to do what was required to participate in the study; whereas, those in the non-depressed group were able to complete the tasks required for the study without any assistance.
Methods A qualitative study was conducted using data collection methods of participant descriptive texts and interviews. Demographic data and two mental health screening assessments – Depression, Anxiety and Stress Scale (DASS 21) (Lovibond & Lovibond, 1995) and Kessler 10 (K10) (Kessler, 1992) at baseline and photographic data (results reported separately) were also collected from a sample of Australian midlife academic staff at a regional university in Australia in 2016. The study setting was a regional university in Australia. The study sample was Australian university academic staff in midlife with or without a diagnosis of depression. Participants were recruited to two study groups, that is, a group with depression (ranging from low to severe) and a group without depression. This study used purposive (non-probability) voluntary sampling (Blaxter, Hughes, & Tight, 2013). This approach resulted in a self-selected sample of voluntary participants. Recruitment was conducted via the university's homepage with interested staff being invited to participate after assessing their eligibility for inclusion in the study. Participant criteria included having a minimum of an undergraduate degree, aged 40 to 60 years (midlife) and having either suffered from clinical depression that had been diagnosed by a psychiatrist, doctor or mental healthcare professional, or having never suffered from depression or any other mental illness. They also had to be Australian citizens, and English speaking. More detail about the study methods (study sample, sampling approach, recruitment, participant eligibility and data collection) is reported in a previous methodology article (Glaw, Inder, Hazelton, & Kable, 2017). To determine eligibility, the participants in the depression group filled out the DASS 21 (Lovibond & Lovibond, 1995) and this was used to measure the level of depression, anxiety and stress and the severity of symptoms (low, moderate, severe or extremely severe). The K10 scale (Kessler, 1992) was used to measure the level of current psychological distress as a baseline. Participants also gave self-reported data of past or current symptoms and whether they had a formal diagnosis of depression. These mental health screening assessments were also used on the non-depressed participants to confirm their status of no depressive illness and therefore their eligibility to be included in the non-depressed group. Recruitment resulted in 11 eligible, consenting participants. Participants were asked to write about what they believe the meaning of life to be, and to list as many ideas as they wished. At interview participants were invited to discuss their ideas and beliefs about the meaning of life. The interviewer used an unstructured interview schedule with open-ended questions to explore the topic in detail. Interviews were digitally recorded and subsequently transcribed verbatim. All data were de-identified in transcripts and electronic data files, and only pseudonyms were used to identify participants. Participant's selected their own pseudonyms to maintain confidentiality and are used in the attribution of excerpts throughout this article. Trustworthiness was increased by using multiple data collection methods resulting in a collection of deeper, richer and multi-dimensional data. Interpretive thematic analysis was used to synthesize findings from the data. Ethics approval was provided by the university Human Research Ethics Committee (Ethics approval number: H-20150331).
Data analysis Data analysis was undertaken between August 2016 and January 2017 and involved interpretative thematic analysis (Braun & Clarke, 2006; Harding, 2013; Liamputtong, 2013) using the participants descriptive text that they had submitted. They had been asked to write about their beliefs about the meaning of life in whatever way they chose. This article presents the findings from the analysis of the descriptive text submitted by participants and interview data. All participants submitted descriptive text about their beliefs about the meaning of life. Interpretative thematic analysis was used to create categories and then to generate themes. Firstly coding was performed to break up the data and to find some of the commonalities (Liamputtong, 2013). Then the analysis involved identifying initial themes that emerged from the data (Harding, 2013). Subsequently, searching was undertaken across the data set to find repeated patterns which were then analysed and the themes developed (Braun & Clarke, 2006). Interpretive thematic analysis continued to narrow the themes, placing them in order from most commonly described to less commonly described themes, based on statements made by the participants. At fortnightly meetings, the data were discussed and the process by which themes were developed was critiqued. Throughout these meetings findings and themes were discussed and challenged, and important questions were raised in relation to study participants' beliefs about the meaning of life. Final analysis of the patterns and meanings that emerged from the data was conducted and a number of differences and similarities between individuals and the two groups emerged. Findings The following themes emerged using interpretative thematic analysis of the descriptive and interview data: 1. 2. 3. 4. 5. 2
The The The The The
meaning meaning meaning meaning meaning
of of of of of
life life life life life
is is is is is
a journey of self-development about religious or non-religious beliefs about living well about family, love and relationships making a difference
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The overall findings regarding beliefs about the meaning of life in this study indicate that the most commonly described theme was that the meaning of life is a journey of self-development and self-improvement. The second most commonly described theme was religious and non-religious beliefs. The third most commonly described theme was the meaning of life is to live well, the fourth most commonly described theme was family, love and relationships, and the last most commonly described theme identified was that the meaning of life is about making a difference by either helping others, making a contribution to the world or leaving a legacy. According to participants in this study meaning of life is encapsulated in these five themes. This may or may not be reflective of the general population as this is a small and occupationally narrow (group of academic staff) study sample. However, the findings provide some indication of what midlife academics believe contributes to perceived meaning in their lives.
I do not find meaning in religion or even spirituality. Sienna. I believe in reincarnation, that our souls are here to learn lessons so they can evolve spiritually. Skye. The soul's only goal is to grow, to evolve spiritually. Skye. It's like the ultimate spiritual experience in being able to be a part of a physical level existence. Byron. The meaning of life is about living well Participants reported the meaning of life to be about living well with descriptions like: Life is short and you just gotta try and make the most of it, live every day like it's the last one. Summer.
The meaning of life is a journey of self-development
There's that book ‘the top five regrets in life’ and the top one is work, why didn't we work less. They must have known something. Summer.
Participants in the self-reported depression group did not see selfdevelopment as an important area, although they did identify it as part of the meaning of life. The self-reported depression group participants seemed to place much less importance on self-development than their counterparts in the non-depressed group who placed a great deal of emphasis on this area, which is why it ranked as most important to them and most commonly described. Participants described the meaning of life as a journey of self-development extensively and said things like:
Living well for me is being creative and enjoying life; like creating ideas, being involved, enjoying and creating art, music, literature, relaxing, play, exercising, holidays, leisure and laughing, playing games with my dog and relaxing with my family and friends and having good food; that's what life is all about to me. Paisley. The meaning of life is about family, love and relationships
Self-development is the ultimate goal in life, as Carl Jung said, the self is our life's goal. Skye.
Participants explained the meaning of life to be about family, love and relationships with quotes such as:
My main and most meaningful roles are being me, caring for myself, living to my values, learning and improving, investing in myself. Paisley.
The meaning of life for me is about family and those around you who bring warmth and kindness to your soul. Mia.
I believe we all have our own journey. Byron.
I have lived through seeing two people close to me pass away. And on both occasions, there were no CEOs there when they were dying. No bosses. No work colleagues. Not even friends right at the end; just wonderful family. Summer.
I also looked at purpose. So what am I here for then…and that's simple for me to be the best I can be. Ava. The meaning of life is about religious and non-religious beliefs
The meaning of life is about making a difference Participants in the self-reported depression group wrote and spoke strongly about their atheist beliefs and the meaning of life; and this was the only category in which the self-reported depression group provided more data than their counterparts in the non-depressed group. Participants talked about the meaning of life in terms of religious or non-religious beliefs, there were a range of ideas and they explained it like this:
The least described theme was the meaning of life is about making a difference: One of my greatest experiences that gives me true meaning in life is the ability to make a positive difference in someone else's life. If I am able to truly help someone, make a positive difference, give empowerment, direction when all seems hopeless, in a sense give someone hope, then I feel like all the bad things in life don't seem to matter nearly as much. Byron.
As a Christian I believe that I have been born for a purpose and that my life should reflect the essence of God which is love and relationship. Velvet.
… using my own skills, abilities, knowledge and I guess my own sense of power to assist and work with others is often something that makes me feel like life is all worth it. Byron.
I do not believe there is an afterlife as told by religions. This, my friends, is it. Physically, I will continue as my corpse contributes to the planet, which I see as a closed system. My spirit will live on in the children I leave behind, my legacy and stories for a time, but not forever. Summer.
I believe it is important to be open, compassionate and available to others. I do not want my own long and deep struggles with crippling depression and severe anxiety to make me hard and unkind, but to open me up to deeper compassion for others. Velvet.
I don't need to proclaim, rather just do. My actions are not for a higher order purpose or in order for me to pay my way to a better eternal life, simply the act or acts, give me a meaning to my life. Ava.
The life of an individual – good or bad, short or long – is a contribution to the world (universe). The value, to humans, of that contribution comes from how the life is ‘used’ and how it affects those around it. Taylor.
My beliefs about the meaning of life: What a question. I honestly do not know. Essentially I am atheist. Sienna. … once you're dead, you're dead, as far as I'm concerned, I don't have a faith. Violet. 3
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Discussion
studies have shown that addressing the spiritual needs of the consumers can enhance their recovery (Mueller et al., 2001). The level of dysfunction seen in participants in the self-reported depression group is similar to that found in people presenting for treatment in the clinical setting. The symptoms of depression typically include a markedly diminished interest or pleasure in all or almost all activities, most of the day, nearly every day; a lack of emotional reaction to activities or events that usually result in an emotional response; psychomotor agitation or retardation nearly every day; fatigue or loss of energy almost every day; and diminished ability to think or concentrate or indecisiveness almost every day (American Psychiatric Association, 2000, 2013; Andrews, 2013; Treatment Protocol Project, 2004). To some extent this clinical picture is consistent with what was observed in the self-reported depression group in this study. Depression adversely affects the ability of people to function effectively in the everyday tasks of life and this would almost certainly extend to academic work which requires high level cognitive functioning, sound organisation skills, energy and drive, and the capacity to work under pressure. Reduced functioning due to depressive symptoms would very likely undermine high level academic performance and thus stunt successful career development. The resultant frustrations and disappointments would also likely further fuel depression and anxiety. For the participants so affected it would be surprising if this was not experienced as deeply traumatic. The experience of depression is consistent with the difficulties participants in the self-reported depression group faced, in undertaking the tasks required by involvement in the study. The findings of this study are similar to data reported by Kinnier et al. (2003) in which eminent people discussed their beliefs about the meaning of life. For the eminent respondents in that study the meaning of life involved: “life is to be enjoyed”, “we are here to love and help others”, “it is a mystery”, “there is no cosmic meaning”, “we are here to serve or worship God”, “life is a struggle”, “we must make a contribution to society”, “our mission in life is to seek wisdom/truth, and to become self-actualized”, “we must create meaning for ourselves”, and “life is absurd or a joke”. Five of the themes reported by Kinnier et al. (2003) are similar to those reported in this study. Kinnier et al. (2003) concluded that the range of responses was complex and often contradictory, with no one consensual theme emerging (Kinnier et al., 2003), but that there are a group of themes that may be common, which has also been seen in this present study. A Grounded Theory study by Kernes and Kinner (2008) investigated psychologists' beliefs about the meaning of life. In this study the participants largely rejected the notion of there being a grand, all-encompassing design to life. Instead they supported the belief that the meaning of life is to love, help, and show compassion for others (Kernes & Kinner, 2008); a finding similar to that of this present study. Mental health clinicians may have a role in encouraging and supporting individuals to find their own answers to the meaning of life question. There are common themes for many people but answering the meaning of life question is largely an individual pursuit. Existential therapies can be utilised for work of this kind, or mental health clinicians could guide and explore these fundamentally important questions with consumers as part of their general approach to providing help. This would likely provide consumers with the ability to make sense of their lives. Mental health clinicians could ask questions specifically related to the themes of this research such as: Do I embrace opportunities for self-development and improvement? Do I have religious or philosophical beliefs that help me to make sense of my life and its purpose and meaning? Am I living well (doing things I like to do)? Are family, love and relationships meaningful and fulfilling in my life? Have I contributed to, or made a difference by helping others, making a contribution to the world or leaving a legacy? Mental health clinicians could ask these questions and tailor therapies and treatments to individually suit the beliefs and needs of those with whom they are working. The two groups in this study have nominated common areas where many find meaning of life, which could help clinicians in their
Overall, there was a variety of ideas put forward from both groups about the meaning of life. The non-depressed group provided more data overall, particularly in the categories of self-development and spirituality. Self-development involves activities that improve awareness and identity, develop talents, facilitate employability, enhance quality of life and help individuals reach their dreams and aspirations. Spirituality is also about growing the self. It is about personal growth of the human spirit or soul in search of value and meaning in life. People with depression often struggle to find motivation and this can have a negative impact on their capacity to do the things necessary to grow, learn and develop; the symptoms of depression can work against the realisation of personal achievement in all areas of life. It is noteworthy that participants in the self-reported depression group did not see self-development as an important area, although they did identify it as part of the meaning of life. The self-reported depression group participants seemed to place much less importance on self-development than their counterparts in the non-depressed group. Selfcare, self-growth, self-improvement and self-development are important areas for a meaningful life as this study has revealed. Consequently, it seems important that mental health clinicians assist people living with depression to work on their self-development, selfdiscovery and self-care needs. Addressing such needs would likely entail greater collaboration between the clinical service provider and the person living with mental illness; seeking ways to increase meaningfulness and enhancing beliefs about the meaning of life. The findings of the study also suggest that exploring options for boosting religious beliefs and spiritual involvement could be important aspects of recovery, contributing to improved health and mental health outcomes and reducing suicidality. Enhancing self-development has also been shown to improve self-esteem and selfawareness, improve social skills, facilitate employability, build personal strengths and talents, assist in setting and achieving goals, increasing quality of life, and to act as a buffer against mental illness, and helps create a healthy and meaningful life (Dervic et al., 2004; Flannelly, 2017; Hill et al., 2013; Mueller, Plevak, & Rummans, 2001). Participants in the self-reported depression group wrote and spoke strongly about their atheist beliefs and the meaning of life; and this was the only category in which the self-reported depression group provided more data than their counterparts in the non-depressed group. In previous studies religion has been found to be a buffer against depression in later life (VanderWeele, Li, Tsai, & Kawachi, 2016). There is also evidence that religious involvement or spirituality is associated with mental and physical health, more so than atheism (Mueller et al., 2001). Atheism has been shown in some studies to be a causal factor for suicide for some individuals, and religious affiliation has been reported to be associated with less suicidal behaviour in depressed inpatients (Dervic et al., 2004). A perhaps unexpected outcome of this study has been the extent to which a number of participants spoke freely about their atheist beliefs. All but one participant disclosed that they had no formal religious affiliations. While the prospect of health practitioners discussing religion and spiritual beliefs with consumers is potentially sensitive, this is an area that might be worthwhile considering in relation to protective factors against depression and other forms of mental and physical ill health. While unlikely to be helpful in cases where consumers express strong atheist beliefs, for those with a religious affiliation, or a history which includes a past affiliation, such a discussion could be beneficial. According to the 2003 World Health Organisation report on international male suicide rates, the highest male suicide rates are found in countries where a high percentage of the population holds atheist beliefs, and the ten nations with the lowest male suicide rates have populations with a high percentage of people involved in religion (Dervic et al., 2004). This ought to be of interest to health practitioners working with people living with depression who may be suicidal. A number of 4
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Clinical implications
clinical practice guide and support the consumers with whom they work to improve their depression, suicidality and meaning in/of life.
In the clinical context, people should be encouraged and supported to identify their own beliefs about the meaning of life. Addressing meaninglessness and the existential crisis is an area that mental health clinicians can work on. Mental health clinicians could ask questions specifically related to the themes of this research such as: Do I embrace opportunities for self-development and improvement? Do I have religious or philosophical beliefs that help me to make sense of my life and its purpose and meaning? Am I living well (doing things I like to do)? Are family, love and relationships meaningful and fulfilling in my life? Have I contributed to or made a difference by either helping others, making a contribution to the world or leaving a legacy? These are questions every human being is likely to ask and seek answers for at some point in their lives. It is human nature to seek personal growth in all areas of life, so mental health clinicians can help consumers, particularly those with depression; to work through these important questions and construct/affirm their beliefs about the meaning of life. This could result in improved mental health outcomes, because without the answers to these questions, consumers may struggle to see the point of living. If left untreated, such people can experience meaninglessness, existential crisis, severe and chronic clinical depression and may eventually contemplate suicide (Dunn & O'Brien, 2009; Frankl, 1959; Steger et al., 2006; Steger & Kashdan, 2009). Consumers may choose suicide if they do not have any goals or do not see a reason to live. So, this is an important area to address in mental health therapeutic relationships. Treatment should focus on creating a positive future as outlined by the consumer not the clinician. The therapeutic relationship is one of equality and should help the consumer clarify and work towards goals, experiences and attitudes; which will aid them in finding their personal life meanings (Hill et al., 2017; Lukas, 1979; Mirhaghi, Sharafi, Bazzi, & Hasanzadeh, 2017; Molkenthin, 2017; Moreno-Poyato et al., 2016). Mental health clinicians can teach consumers how to love and nurture themselves and to discover and grow the self. They can provide support and guidance, providing a place for those with whom they work to identify, express, and reflect on their sources of meaning in life and what they believe the meaning of life to be. Clinicians can walk alongside such individuals to help them alleviate feelings of alienation and existential frustration. Support could be provided to nurture, guide and inspire those who struggle with their search for meaning in life and to affirm the universality of the human search for meaning and acknowledge distress when other options seem to be lacking. Clinicians could normalize and encourage such a search; offer ideas about strategies that might open doors to multiple possibilities of meaning and affirm the worth of searching. Inviting people in distress to read and listen to others' experiences that illustrate success can be helpful in such quests. Current therapies can be utilised for helping consumers explore the meaning of life question. They include: existential counselling/therapy, existential psychotherapy, meaning-centred counselling, meaningcentred psychotherapy, Logotherapy, spiritual therapy, religious cognitive-emotional therapy and humanistic therapy. These therapies involve exploring the human existence rather than focusing on psychopathology. They largely focus on exploring the deeper parts of the self to gain a better understanding of what is most important in life. The more effective interventions are likely to be those that are evidenced based and are orientated towards recovery/wellness goals rather than treatment goals. Typically, goals are often related to reducing risk, preventing relapse and reducing re- hospitalisations, whereas recovery goals include the persons individual goals, dreams, and aspirations. They set a path for the future. They focus on what the person with mental illness wants, rather than on what they should avoid (Thornicroft, Szmukler, Mueser, & Drake, 2011). The demands of nursing work often leave little time for this type of work or for nurses to even talk to consumers due to their heavy
Limitations and strengths The limitations of this research included the recruitment of nine females and two males to the study. This gender imbalance may have resulted in the phenomenon of interest being investigated more through female perspectives. Recruitment of a more gender balanced study sample may have produced different results. However, the study was designed to recruit a purposive voluntary sample; in effect participants self-selected by answering an advertisement in the internal university staff newsletter. One of the main limitations of this research is that the findings may not be transferable to other age groups or groups of midlife adults. The participants were university staff. The use of academic staff as participants in the study, potentially restricted the transferability of the findings. A strength of this research included the purposeful recruitment of participants who had experienced the phenomenon of interest, and embraced the opportunity to discuss their beliefs about the meaning of life. They reported having found the process immensely cathartic, enjoyable, and beneficial to their own lives and futures as it encouraged deep reflection on the important things in their lives. Some participants even suggested they thought they had gained more from participation in the research than the research team, as the experience allowed them to analyse their lives in ways they had not done previously, generating valuable insights about themselves. Participants in the self-reported depression group also reported feeling that involvement in the study had been valuable; they expressed a desire to make a difference in mental health research and practice, and they felt they had been able to do so through involvement in the study. In addition, academic staff typically have advanced thinking and reflective skills, and in many instances, this resulted in the generation of rich and nuanced data. Trustworthiness and rigour The trustworthiness and rigour of this study focused on strategies described by Shenton (2004) and Cope (2014) for ensuring trustworthiness in qualitative research. The four elements for ensuring trustworthiness – credibility, transferability, dependability and confirmability. Strategies used to demonstrate credibility or internal validity included using well recognised and established research methods such as in-depth interviews, and early familiarity with the study culture. In addition establishing a good rapport with participants, asking probing questions to extract further information, conducting regular debriefing meetings with the research team, obtaining peer scrutiny by experienced researchers, using reflective commentary to demonstrate the credibility of the researchers, member checking of the data after interview, using thick descriptive data to ensure the reader has access to detailed information to understand the research, and comparing findings with literature from previous research all contributed to the credibility of this study. Strategies used to demonstrate potential transferability included providing enough information to enable comparisons, and providing sufficient information about the study context and participants to allow for the transfer of findings and their application to other similar situations. Dependability was demonstrated by using overlapping data collection methods and providing detail about methods to enable researchers to repeat the work in other settings. Strategies to ensure confirmability included constructing an audit trail, and documenting step-by-step processes followed and decisions made; and presentation of quotes that depict emerging themes (Cope, 2014). 5
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workloads (Mirhaghi et al., 2017), increased administrative tasks and high nurse-consumer/patient ratios (Moreno-Poyato et al., 2016). These are all major obstacles to developing the therapeutic relationship (Moreno-Poyato et al., 2016), and in many instances the nurse constructs the therapeutic relationship within the parameters of the nurseconsumer relationship (Molkenthin, 2017). This relationship involves a power imbalance that often meets the professional goals of the nurse rather the consumer's goals (Mirhaghi et al., 2017). This approach many overlook the consumer's history, future and aspirations concerning their meaning of life, and occurs during the period when they are most unwell and most vulnerable. If mental health clinicians look for opportunities to ask those with whom they are working about how they derive meaning, this may trigger new ideas and insights. Encouraging people to think about what they believe is the meaning of life, may reset therapeutic expectations, and contribute to a recovery journey. Implementing the findings within clinical practice may be restricted by resources as mental health funding is often geared more towards symptom management rather than addressing recovery goals. That is, the organisation of services and the mindsets and clinical practices of individual practitioners are typically geared towards managing risk, reducing the likelihood of relapse, and avoiding re-hospitalisation. While important, such concerns primarily address symptom management and fall well short of addressing the principles and practices of recovery embracing the goals, dreams and aspirations of the people receiving mental health services. Sometimes in practice there is a focus on what the client wants rather than on what the clinician thinks they should do or avoid. However, mental health clinicians need more time to explore these existential issues with the people with whom they are working; treatment ought to look beyond the reduction of symptoms to consider what can be done to facilitate recovery and help people live better lives. However, a focus on recovery goals is often not possible given the organisation and resourcing of mental health services. Often inadequate staffing levels, inappropriate staff mix and high consumer/ patient acuity, among other things, combine to weaken prospects for working within a framework of recovery-oriented mental health practice. Nonetheless, it is important that mental health clinicians don't give up on recovery; there are likely to be numerous opportunities for individual clinicians to work in greater depth with some people, and it is likely that the insights from this study will prove helpful in such situations. It is recommended that further research be conducted on different groups. This was a small cohort of academic staff, and so, studying nonacademic mid-life community members may provide broader views of beliefs about the meaning of life.
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