On Purpose: A Renewed Direction for Full Engagement in Life and Health with Vic Strecher Part 1

On Purpose A NEW DIRECTION FOR HEALTH-

RELATED BEHAVIOR CHANGE

Victor J. Strecher, PhD, MPHProfessor, University of Michigan School of Public Health

email: [email protected]: Vic Strecher@dungbeetlepress

mailto:[email protected]

mailto:[email protected]

High Tailored Testimonial

Tailoring Variables Used In This Case:

+ Age+ Gender+ Ethnicity

+ Marital status+ Smoking status of spouse

+ Child in home+ Physically active+ # of cigs smoked

+ Job status+ Barrier

+ Social Support

Information/advice

Stories

MORE RELEVANT MESSAGES

MORE ELABORATION AND MEMORY,

LESS WORK

MOREBEHAVIOR CHANGE

Episodic memories

Decision-making

[email protected]

Research Real world

Change

OPERATIONS RESEARCHVol. 56, No. 6, November–December 2008, pp. 1335–1347issn 0030-364X�eissn 1526-5463�08�5606�1335

informs®

doi 10.1287/opre.1080.0588©2008 INFORMS

OR FORUM

Personal Decisions Are the LeadingCause of Death

Ralph L. KeeneyThe Fuqua School of Business, Duke University, Durham, North Carolina 27708,

[email protected]

This paper analyzes the relationships between personal decisions and premature deaths in the United States. The analysisindicates that over one million of the 2.4 million deaths in 2000 can be attributed to personal decisions and could have beenavoided if readily available alternative choices were made. Separate analyses indicate 46% of deaths due to heart diseaseand 66% of cancer deaths are attributable to personal decisions, about 55% of all deaths for ages 15–64 are attributableto personal decisions, and over 94% of the deaths attributable to personal decisions result in the death of the individualmaking the decisions. Relative to the current 45%, retrospective appraisal suggests that roughly 5% of deaths in 1900and 20%–25% of deaths in 1950 could be attributed to personal decisions. These results suggest that more effort directedtoward improving personal choices regarding life risks may be an effective and economical way to save lives.

Subject classifications : risk; decision making; decision analysis: applications; health care; information systems:management; statistics: data analysis.

Area of review : Special Issue on Operations Research in Health Care. OR Forum.History : Received July 2006; revisions received March 2007, September 2007, February 2008; accepted April 2008.

Participate in the OR Forum discussion at http://orforum.blog.informs.org.

1. IntroductionThis paper investigates a different framing of the majorcauses of death in America. With this frame, the major causeof death is not heart disease or cancer, nor is it smoking orbeing overweight. The leading cause of death is personaldecision making, which leads to over one million deathsannually. Framing the situation this way suggests differenttypes of potentially effective alternatives to improve this cir-cumstance. Making better personal decisions could poten-tially prevent millions of premature deaths per decade.The logic is straightforward. A review of the medical lit-

erature indicates that heart disease and cancer are the lead-ing medical causes of death in the United States (Centersfor Disease Control and Prevention 2002a). This raises thequestion of what causes heart disease and cancer. Certainly,a multitude of factors do. Two major causes are smoking(Centers for Disease Control and Prevention 2002b) andbeing overweight (Allison et al. 1999), each resulting inover 400,000 deaths annually (Mokdad et al. 2004). Hence,many people conclude that the leading causes of prema-ture death are smoking and being overweight. We extendthis logic by asking what causes smoking and being over-weight? One answer is personal decision making, becausesmoking and being overweight result from several choicesthat were made by each individual. With different per-sonal choices, such circumstances could have been avoided.Other personal decisions that lead to significant prematuredeaths include drinking too much alcohol, vehicle deaths,

and homicide and suicide. Collectively, personal decisionslead to more than one million premature deaths annually.This is both bad news and good news. It is certainly a

terrible circumstance where so many people die because ofpersonal decisions. The good news is two-fold. First, indi-viduals can take much more control of their personal fateregarding death. Second, improving decision making is lessexpensive and, at least in some cases, may be more effec-tive in reducing premature death than are technological,medical, or public policy remedies.This paper is organized as follows. Section 2 outlines the

relationships between personal decisions and subsequentfatalities. Section 3 presents the information used to calcu-late the number of fatalities attributable to personal deci-sions, both by classes of decisions and age groups. Section 4presents additional analyses and insights about the medi-cal causes of deaths attributable to personal decisions, theproportion of deaths in different age groups attributable topersonal decisions, and a perspective on the changes in theproportion of deaths attributable to personal decisions overthe last century. Section 5 summarizes the implications ofthis study and suggests research using the ideas here toavoid substantial numbers of premature deaths.

2. Structuring the ProblemThe main claims in this paper are that personal decisionsresult in large numbers of premature deaths and that readilyavailable alternative choices could have avoided many of

1335

Keeney: Personal Decisions Are the Leading Cause of Death1336 Operations Research 56(6), pp. 1335–1347, © 2008 INFORMS

Figure 1. Influences of personal decisions on causes of death.

Personal decisions concerning Actual causes of death Medical causes of death

Smoking

Alcoholic diseases

Diet

Exercise

Drinking alcohol

Doing drugs

Take your own life

Condom use

Criminality Homicide

Suicide

Illicit drugs

Unprotected sex

Accidents

Being overweight

Smoking Diseases of the heart

Malignant neoplasms (cancer)

Cerebrovascular diseases (stroke)

Chronic lower respiratory diseases

Diabetes Mellitus (diabetes)

Influenza and pneumonia

Unintended injuries

Chronic liver disease and cirrhosis

Hypertension and hypertensiverenal disease

Diseases of the circulatory system

AIDS

Intentional self-harm (suicide)

Assault (homicide)

Other

Note. An arrow means “influences.”

these premature deaths. Thus, we need to carefully defineour meanings for the terms personal decisions, readily avail-able alternatives, and premature deaths. Figure 1 indicatesthe main influences of personal decisions on subsequentfatalities. The figure illustrates, for example, that an individ-ual’s decisions about diet and exercise influence being over-weight, which influences, among others, the likelihoods ofdiseases of the heart and cancer (i.e., malignant neoplasms),which can each lead to death.A personal decision is a situation where an individual

can make a choice among two or more alternatives. Thisassumes that the individual recognizes that he or she hasa choice and has control of this choice. Readily availablealternatives are alternatives that the decision maker wouldhave known about and could have chosen without investingmuch time or money. For the premature deaths examinedin this paper, there are typically many decisions leading upto that death for which readily available alternatives couldhave been available. For some of these decisions, the indi-vidual may not have had control over the choices. Our anal-ysis assumes that for at least one of these many decisions,the individual does control the choice of a readily availablealternative that, if chosen, could have avoided the specificpremature death. A readily available alternative does notmean that it would be easy to choose because habits, socialpressure, or genetic predisposition can render some alterna-tives very hard to select.

Some elaboration may clarify the notion of a “death dueto a personal decision” as used in this paper. Essentially,it is defined by the categories of deaths analyzed and thedecisions that lead to them. It intentionally excludes any sit-uations requiring heroic decisions, extraordinary foresight,or more knowledge than common sense. One can die froma fall while walking or from choking from eating. One cer-tainly could have made a decision to avoid that walk orto eat something else, but common sense excludes suchdecisions from our analysis. The same is true for deaths tocommercial flyers and to military personnel, although otherchoices could have been made in each situation. A kid whojoins a gang makes a personal decision, perhaps in his ownself-interest, to do so. If he later is killed by a rival gang,his killer made a decision that led to his death. Hence, mycalculations include this as a death due to a personal deci-sion. Subsequently, I estimate the total of such deaths thatresult in the decision maker’s own death.

A premature death resulting from a personal decisionis defined to be one where an individual dies sooner thanwould have been the case if a different choice had beenmade. Deaths attributable to obesity or automobile wrecksdue to drunk driving or not wearing a seat belt are examplesof premature fatalities. The key notion here is attributable.Suppose, for example, that data indicate that smoking triplesone’s risk of dying from a particular cancer at age 60.Hence, if 300 smokers die from this cancer at age 60, the

What do you know? Are you an expert on boiling water? This water isn’t so hot. Now go away,

I’m getting kind of sleepy...

We’re defensive

We’re all defensive

Ego breaks open - then you see who you really are!

Death is very likely the single best invention of life.

It is life’s change agent.

“Do not act as if you were going to live ten thousand

years. Death hangs over you. While you live, while it is in your power, be good.”

Marcus Aurelius

Another way?

Good mother. Good spouse.In control. Attractive.

“These studies, in concert with previous research, suggest that values affirmation reduces defensiveness via self-transcendence...”

Ego Threat No Ego Threat

“you weren’t picked” “you were picked”... but “randomly chosen to

work alone

Social exclusion

92 College Students

“Please taste-test these cookies”

empathysupport needslarger than self

growthrelationships

Self-transcendent

values

powerwealth

independenceattractiveness

prestige

Self-enhancement

values

Daily routine (no values)

empathysupport needslarger than self

growthrelationships

Self-transcendent

values

powerwealth

independenceattractiveness

prestige

Self-enhancement

values


8.2

4.9

2.8

4.04.8

4.3

Self-transcendent

values

Self-enhancement

values


Self-transcendent

values

Self-enhancement

values


Ego Threat No Ego Threat

Ego threat by type of value affirmed on self-regulatory exertion (measured by # of cookies eaten) F for interaction = 5.45, p<.01

# o

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ORIGINAL ARTICLE

Effect of a Purpose in Life on Risk of IncidentAlzheimer Disease and Mild Cognitive Impairmentin Community-Dwelling Older PersonsPatricia A. Boyle, PhD; Aron S. Buchman, MD; Lisa L. Barnes, PhD; David A. Bennett, MD

Context: Emerging data suggest that psychological andexperiential factors are associated with risk of Alzhei-mer disease (AD), but the association of purpose in lifewith incident AD is unknown.

Objective: To test the hypothesis that greater purposein life is associated with a reduced risk of AD.

Design: Prospective, longitudinal epidemiologic studyof aging.

Setting: Senior housing facilities and residences acrossthe greater Chicago metropolitan area.

Participants: More than 900 community-dwelling olderpersons without dementia from the Rush Memory andAging Project.

Main Outcome Measures: Participants underwentbaseline evaluations of purpose in life and up to 7 yearsof detailed annual follow-up clinical evaluations to docu-ment incident AD. In subsequent analyses, we exam-ined the association of purpose in life with the precur-sor to AD, mild cognitive impairment (MCI), and the rateof change in cognitive function.

Results: During up to 7 years of follow-up (mean, 4.0years), 155 of 951 persons (16.3%) developed AD. In aproportional hazards model adjusted for age, sex, and edu-cation, greater purpose in life was associated with a sub-stantially reduced risk of AD (hazard ratio, 0.48; 95% con-fidence interval, 0.33-0.69; P! .001). Thus, a person witha high score on the purpose in life measure (score=4.2,90th percentile) was approximately 2.4 times more likelyto remain free of AD than was a person with a low score(score=3.0, 10th percentile). This association did not varyalong demographic lines and persisted after the addi-tion of terms for depressive symptoms, neuroticism, so-cial network size, and number of chronic medical con-ditions. In subsequent models, purpose in life also wasassociated with a reduced risk of MCI (hazard ratio, 0.71;95% confidence interval, 0.53-0.95; P=.02) and a slowerrate of cognitive decline (mean [SE] global cognition es-timate, 0.03 [0.01], P! .01).

Conclusion: Greater purpose in life is associated with areduced risk of AD and MCI in community-dwelling olderpersons.

Arch Gen Psychiatry. 2010;67(3):304-310

A LZHEIMER DISEASE (AD) IS

one of the most dreadedconsequences of aging,and the identification ofmodifiable factors associ-

ated with the risk of AD is a top publichealth priority for the 21st century, par-ticularly given the large and rapidly in-creasing aging population. Although rela-tively few such risk factors have beenidentified, emerging data suggest that a va-riety of potentially modifiable psychologi-cal factors (eg, conscientiousness, extra-version, and neuroticism) and experientialfactors (eg, social networks) are associ-ated with risk of AD.1-4 Purpose in life, thepsychological tendency to derive mean-ing from life’s experiences and to possessa sense of intentionality and goal direct-edness that guides behavior, has long been

hypothesized to protect against adversehealth outcomes.5-9 Indeed, purpose in lifehas been linked to positive outcomes, in-cluding better mental health and happi-ness, and it was recently reported that pur-pose in life is associated with longevity.9-14

However, the association of purpose in lifewith the risk of AD remains unknown.

In this study, we tested the hypothesisthat greater purpose in life is associatedwith a reduced risk of incident AD usingdata from more than 900 participants ina large community-based epidemiologicstudy of aging, the Rush Memory and Ag-ing Project.15 In subsequent analyses, weexamined whether these associations per-sisted after adjustment for several poten-tial confounders. Next, we examined theassociation of purpose in life with the de-velopment of mild cognitive impairment

Author Affiliations: RushAlzheimer’s Disease Center(Drs Boyle, Buchman, Barnes,and Bennett) and Departmentsof Behavioral Sciences(Drs Boyle and Barnes) andNeurological Sciences(Drs Buchman, Barnes, andBennett), Rush UniversityMedical Center,Chicago, Illinois.

(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 67 (NO. 3), MAR 2010 WWW.ARCHGENPSYCHIATRY.COM304

©2010 American Medical Association. All rights reserved. at University of Michigan, on September 19, 2011 www.archgenpsychiatry.comDownloaded from

Purpose in life and reduced risk of myocardial infarctionamong older U.S. adults with coronary heart disease:a two-year follow-up

Eric S. Kim • Jennifer K. Sun • Nansook Park •

Laura D. Kubzansky • Christopher Peterson

Received: June 6, 2011 / Accepted: February 7, 2012! Springer Science+Business Media, LLC 2012

Abstract This study examined whether purpose in life

was associated with myocardial infarction among a sampleof older adults with coronary heart disease after adjusting

for relevant sociodemographic, behavioral, biological, and

psychological factors. Prospective data from the Health andRetirement Study—a nationally representative panel study

of American adults over the age of 50—were used. Anal-

yses were conducted on the subset of 1,546 individualswho had coronary heart disease at baseline. Greater base-

line purpose in life was associated with lower odds of

having a myocardial infarction during the 2-year follow-upperiod. On a six-point purpose in life measure, each unit

increase was associated with a multivariate-adjusted odds

ratio of 0.73 for myocardial infarction (95% CI, 0.57–0.93,P = .01). The association remained significant after con-

trolling for coronary heart disease severity, self-rated

health, and a comprehensive set of possible confounds.Higher purpose in life may play an important role in pro-

tecting against myocardial infarction among older Ameri-

can adults with coronary heart disease.

Keywords Purpose in life ! Heart attack ! Myocardial

infarction ! Coronary heart disease ! Positive psychology !Meaning in life

Coronary heart disease is the leading cause of death among

both men and women in the United States—responsible forone in every six deaths (Heron et al., 2009). It imposes

immense physical, psychological, social, and financial

burden on individuals, families, and society as a whole.Ongoing research efforts have focused on identifying the

risk and protective factors that prevent coronary heart

disease and promote heart health.Past research has mostly looked at the impact of negative

psychological states or traits (e.g. depression, anxiety, and

cynical hostility) on health outcomes such as myocardialinfarction (Kubzansky & Kawachi, 2000; Rozanski et al.,

2005; Whooley et al., 2008; Wulsin & Singal, 2003). More

recently, an increasing number of researchers have investi-gated how positive psychological characteristics such as

optimism and positive emotions protect against illness and

promote health and longevity (Chida & Steptoe, 2008;Pressman & Cohen, 2005; Peterson et al., 1988; Seligman,

2008; Steptoe et al., 2009; Xu & Roberts, 2010). The iden-

tification of positive psychological constructs that protectagainst illness is particularly important for the rapidly

expanding segment of older American adults facing the dual

threat of declining health and skyrocketing health care costs.Purpose in life is among the positive constructs that

contemporary psychologists have studied because of its

potential to predict and promote better health (Boyle et al.,2009; Frankl, 1959; Maslow, 1962; Peterson, 2006; Ryff &

Keyes, 1995). The definition of purpose in life varies

throughout the field, but it is usually conceptualized as anindividual’s sense of directedness and sense of meaning in

his or her life (Steger et al., 2006). The terms ‘‘purpose in

life’’ and ‘‘meaning in life’’ are often used interchangeablyin the literature.

Recently, purpose in life has been studied as an

important determinant of health outcomes, specifically,

E. S. Kim (&) ! J. K. Sun ! N. Park ! C. PetersonDepartment of Psychology, University of Michigan, 2250 EastHall, 530 Church Street, Ann Arbor, MI 48109-1043, USAe-mail: [email protected]

L. D. KubzanskyDepartment of Society, Human Development, and Health,Harvard School of Public Health, Boston, MA, USA

123

J Behav Med

DOI 10.1007/s10865-012-9406-4

Please cite this article in press as: N.H. Rasmussen, et al., Association of HbA1c with emotion regulation, intolerance of uncertainty, and purposein life in type 2 diabetes mellitus, Prim. Care Diab. (2013), http://dx.doi.org/10.1016/j.pcd.2013.04.006

ARTICLE IN PRESSPCD-315; No. of Pages 9

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 3 ) xxx–xxx

Contents lists available at SciVerse ScienceDirect

Primary Care Diabetes

j o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / p c d

Original research

Association of HbA1c with emotion regulation, intolerance ofuncertainty, and purpose in life in type 2 diabetes mellitus

Norman H. Rasmussena,c,!, Steven A. Smithb,e, Julie A. Maxsonc, Matthew E. Bernardc,Stephen S. Chad, David C. Agerter c, Nilay D. Shahe

a Department of Psychiatry and Psychology, Division of Integrated Behavioral Healthcare, Mayo Clinic, Rochester, MN, USAb Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USAc Department of Family Medicine, Mayo Clinic, Rochester, MN, USAd Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USAe Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA

a r t i c l e i n f o

Article history:Received 19 December 2012Received in revised form28 March 2013Accepted 16 April 2013Available online xxx

Keywords:Emotion regulationHbA1c

Intolerance of uncertaintyPrimary carePurpose in life satisfaction

a b s t r a c t

Background: The extant literature lacks breadth on psychological variables associated withhealth outcome for type 2 diabetes mellitus (T2DM). This investigation extends the scope ofpsychological information by reporting on previously unpublished factors.Objective: To investigate if intolerance of uncertainty, emotion regulation, or purpose in lifedifferentiate T2DM adults with sustained high HbA1c (HH) vs. sustained acceptable HbA1c

(AH).Subjects and methods: Cross-sectional observational study. Adult patients with diagnosedT2DM meeting inclusionary criteria for AH, HH, or a nondiabetic reference group (NDR)were randomly selected and invited to participate. Patients who consented and participatedresulted in a final sample of 312 subgrouped as follows: HH (n = 108); AH (n = 98); and NDR(n = 106). Data sources included a survey, self-report questionnaires, and electronic medicalrecord (EMR).Results: HH individuals with T2DM reported lower purpose in life satisfaction (p = 0.005) com-pared to the NDR group. The effect size for this finding is in the small-to-medium range usingCohen’s guidelines for estimating clinical relevance. The HH–AH comparison on purpose inlife was nonsignificant. The emotion regulation and intolerance of uncertainty comparisonsacross the three groups were not significant.Conclusions: The present study determined that lower purpose in life satisfaction is asso-ciated with higher HbA1c. In a T2DM patient with sustained high HbA1c, the primary care

Abbreviations: AH, acceptable A1c; CCI, Charlson comorbidity index; DERS, difficulties in emotion regulation scale; HH, high A1c; ICD-9,International Classification of Diseases, ninth edition; IUS-12, intolerance of uncertainty scale, short form; LET, life engagement test; NDR,nondiabetic reference group; PHQ-9, patient health questionnaire–depression scale; T2DMM, type 2 diabetes mellitus.

! Corresponding author at: Department of Family Medicine & Department of Psychiatry and Psychology, Division of Integrated BehavioralHealthcare, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. Tel.: +1 507 634 7011; fax: +1 507 266 4733.

E-mail address: [email protected] (N.H. Rasmussen).1751-9918/$ – see front matter © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.pcd.2013.04.006

Purpose in life and reduced incidence of stroke in older adults: 'The Health andRetirement Study'

Eric S. Kim ⁎, Jennifer K. Sun, Nansook Park, Christopher PetersonDepartment of Psychology, University of Michigan, Ann Arbor, USA

a b s t r a c ta r t i c l e i n f o

Article history:Received 13 July 2012Received in revised form 19 January 2013Accepted 22 January 2013

Keywords:StrokePurpose in lifeMeaning in lifeHealthy agingPositive psychology

Objective: To determine whether purpose in life is associated with reduced stroke incidence among olderadults after adjusting for relevant sociodemographic, behavioral, biological, and psychosocial factors.Methods: We used prospective data from the Health and Retirement Study, a nationally representative panelstudy of American adults over the age of 50. 6739 adults who were stroke-free at baseline were examined. Amultiple imputation technique was used to account for missing data. Purpose in life was measured using avalidated adaptation of Ryff and Keyes' Scales of Psychological Well-Being. After controlling for a comprehen-sive list of covariates, we assessed the odds of stroke incidence over a four-year period. We used psycholog-ical and covariate data collected in 2006, along with occurrences of stroke reported in 2008, 2010, and duringexit interviews. Covariates included sociodemographic factors (age, gender, race/ethnicity, marital status,education level, total wealth, functional status), health behaviors (smoking, exercise, alcohol use), biologicalfactors (hypertension, diabetes, systolic blood pressure, diastolic blood pressure, BMI, heart disease), nega-tive psychological factors (depression, anxiety, cynical hostility, negative affect), and positive psychologicalfactors (optimism, positive affect, and social participation).Results: Greater baseline purpose in life was associated with a reduced likelihood of stroke during the four-yearfollow-up. In a model that adjusted for age, gender, race/ethnicity, marital status, education level, total wealth,and functional status, each standard deviation increase in purpose was associated with a multivariate-adjustedodds ratio of 0.78 for stroke (95% CI, 0.67–0.91, p=.002). Purpose remained significantly associated with a re-duced likelihood of stroke after adjusting for several additional covariates including: health behaviors, biologicalfactors, and psychological factors.Conclusion: Among older American adults, greater purpose in life is linked with a lower risk of stroke.

© 2013 Elsevier Inc. All rights reserved.

Introduction

Chronic diseases cause an immense amount of social, financial,and personal burden. As researchers uncover the links between psy-chological factors and physical health, the search for psychologicalfactors linked with disease onset intensifies. The logic behind thissearch is that the identification of such psychological factors maylead to innovative prevention and treatment efforts.

One condition, stroke, is especially costly for the US health caresystem. The prevalence of stroke among U.S. adults is roughly 7 million,with approximately 795,000 new cases reported annually [1]. In addition,the estimated direct cost of the condition in 2007 was $25.2 billion [1].Because the risk for stroke increases with age, the identification ofhealth-promoting constructs is particularly important for the expandingsegment of older American adults facing the dual threat of declininghealth and rising health care costs.

While past research has mostly examined the detrimental impactof negative psychological states or traits (e.g., depression and anxiety)on health outcomes [2–4], researchers havemore recently begun inves-tigating how positive psychological characteristics (e.g., optimism andpositive emotions) protect against illness and promote physical health,healthy behaviors, and longevity [5–13]. Among these positive psycho-logical characteristics, purpose in life is a construct that contemporarypsychologists have studied because of its potential to predict and pro-mote better health [14–19]. Greater purpose has been associated witha reduced risk of Alzheimer's disease [20], reduced risk of heart attackamong individuals with coronary heart disease [21], and increased lon-gevity in both American and Japanese samples [14,22]. The definitionof purpose in life varies throughout the field, but it is usually conceptu-alized as an individual's sense of directedness andmeaning in his or herlife [23]. The term “purpose in life” and “meaning in life” are often usedinterchangeably in the literature.

While prospective studies examining the association betweenpurpose in life and cerebrovascular disease are uncommon, one recentstudy of 2959 Japanese respondents found an association between aone-item purpose in life measure and reduced stroke mortality over a

Journal of Psychosomatic Research 74 (2013) 427–432

⁎ Corresponding author at: 2250 East Hall, 530 Church Street, University of Michigan,Ann Arbor, MI 48109-1043, USA. Tel.: +1 914 826 4477; fax: +1 734 615 0573.

E-mail address: [email protected] (E.S. Kim).

0022-3999/$ – see front matter © 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.jpsychores.2013.01.013

Contents lists available at SciVerse ScienceDirect

Journal of Psychosomatic Research

Krause, N. (2009). Meaning in life and mortality. Journal of Gerontology: Social Sciences, 64B(4), 517–527, doi:10.1093/geronb/gbp047. Advance Access publication on June 10, 2009.

© The Author 2009. Published by Oxford University Press on behalf of The Gerontological Society of America.All rights reserved. For permissions, please e-mail: [email protected].

517

THE purpose of this study was to see if older people who have a strong sense of meaning in life tend to live

longer than older adults whose sense of meaning is not as strong. Although researchers do not agree about how to defi ne meaning in life, the defi nition proposed by Reker (2000) provides a useful point of departure. He defi nes a sense of meaning as “ a cognizance of order, coherence, and purpose in one ’ s existence, the pursuit and attainment of worthwhile goals, and an accompanying sense of fulfi ll-ment ” (p. 41).

The roots of sociological interest in meaning go back at least to the work of Weber ( Gerth & Mills, 1958 ). Weber argued that behavior is not determined by an objective sense of meaning. Instead, he maintained that behavior arises from subjective meanings that are developed by the indi-vidual. However, the notion of meaning is perhaps most evident in the discussion by Weber of religious theodicies, which are religious explanations that provide meaning in situations where meaning has been threatened. More re-cently, Berger built upon the Weberian tradition by propos-ing that meaning is a subjective phenomenon that is created jointly during the process of social interaction: “ [M]en to-gether engage in constructing a world, which then becomes their common dwelling ” ( Berger & Pullberg, 1965 , p. 201, emphasis in the original). Antonovsky (1987) was one of the fi rst sociologists to examine meaning in life empirically. Embedded in his multifaceted Sense of Coherence Scale is a dimension he calls “ meaningfulness. ”

A number of studies suggest that a strong sense of mean-ing in life is associated with better physical health (e.g., Krause, 2004 ) and better mental health (e.g., Reker, 1997 ), but there appears to be only one study that empirically eval-

uates the relationship between meaning in life and mortality ( O ’ Connor & Vallerand, 1998 ). These investigators found that at the bivariate level, a stronger sense of meaning in life is associated with a lower mortality risk. However, they go on to report that the relationship between meaning and mor-tality is no longer statistically signifi cant once the effects of age, sex, and self-rated health have been added to the model. Taken as a whole, the results provided by O ’ Connor and Vallerand appear to suggest that meaning in life plays a relatively inconsequential role in determining mortality. Even so, there are two reasons why the relationship between meaning in life and mortality needs to be reevaluated.

First, the data for the study by O ’ Connor and Vallerand (1998) were provided by 129 nursing home residents. More-over, 86% of these older study participants were women. As a result, it is diffi cult to tell if the fi ndings from this study can be generalized to older men and women who are not living in nursing homes.

Second, the fact that the relationship between meaning and mortality is no longer statistically signifi cant once self-rated health was entered into the model points to a poten-tially important mechanism that should be investigated further. More specifi cally, this pattern of fi ndings suggests that meaning in life may exert an indirect effect on mortality that operates through health: Meaning affects health, and health, in turn, infl uences the odds of dying. There are three reasons why it makes sense to focus on this indirect effect. First, the overwhelming majority of older people die be-cause they are physically ill ( U.S. Department of Health and Human Services, 2004 ). So, if psychosocial factors such as meaning infl uence the odds of dying, then they are likely to do so because they affect an older person ’ s health. If

Meaning in Life and Mortality

Neal Krause

Department of Health Behavior and Health Education, School of Public Health and the Institute of Gerontology, University of Michigan, Ann Arbor .

Objectives. The purpose of this exploratory study was to see if meaning in life is associated with mortality in old age.

Methods. Interviews were conducted with a nationwide sample of older adults ( N = 1,361). Data were collected on meaning in life, mortality, and select control measures.

Results. Three main fi ndings emerged from this study. First, the data suggest that older people with a strong sense of meaning in life are less likely to die over the study follow-up period than those who do not have a strong sense of meaning. Second, the fi ndings indicate that the effect of meaning on mortality can be attributed to the potentially important indirect effect that operates through health. Third, further analysis revealed that one dimension of meaning — having a strong sense of purpose in life — has a stronger relationship with mortality than other facets of meaning. The main study fi ndings were observed after the effects of attendance at religious services and emotional support were controlled statistically.

Discussion. If the results from this study can be replicated, then interventions should be designed to help older people fi nd a greater sense of purpose in life.

Key Words: Meaning in life — Mortality .

at University of M

ichigan on August 7, 2011psychsocgerontology.oxfordjournals.org

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nloaded from

Intensive meditation training, immune celltelomerase activity, and psychological mediators

Tonya L. Jacobs a,*, Elissa S. Epel b, Jue Lin c, Elizabeth H. Blackburn c,Owen M. Wolkowitz b, David A. Bridwell d, Anthony P. Zanesco a,Stephen R. Aichele e, Baljinder K. Sahdra a, Katherine A. MacLean f,Brandon G. King a, Phillip R. Shaver e, Erika L. Rosenberg a, Emilio Ferrer e,B. Alan Wallace g, Clifford D. Saron a,h

aUC Davis Center for Mind and Brain, Davis, CA, USAbUC San Francisco Department of Psychiatry, San Francisco, CA, USAcUC San Francisco Department of Biochemistry and Biophysics, San Francisco, CA, USAdUC Irvine Department of Cognitive Science, Irvine, CA, USAeUC Davis Department of Psychology, Davis, CA, USAfDepartment of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USAg Santa Barbara Institute for Consciousness Studies, Santa Barbara, CA, USAhUC Davis Medical Center M.I.N.D. Institute, Sacramento, CA, USA

Received 22 January 2010; received in revised form 28 August 2010; accepted 17 September 2010

Psychoneuroendocrinology (2011) 36, 664—681

KEYWORDSMeditation;Neuroticism;Perceived control;Purpose in life;Stress;Telomerase

SummaryBackground: Telomerase activity is a predictor of long-term cellular viability, which decreaseswith chronic psychological distress (Epel et al., 2004). Buddhist traditions claim that meditationdecreases psychological distress and promotes well-being (e.g., Dalai Lama and Cutler, 2009).Therefore, we investigated the effects of a 3-month meditation retreat on telomerase activityand two major contributors to the experience of stress: Perceived Control (associated withdecreased stress) and Neuroticism (associated with increased subjective distress). We usedmediation models to test whether changes in Perceived Control and Neuroticism explainedmeditation retreat effects on telomerase activity. In addition, we investigated whether twoqualities developed by meditative practice, increased Mindfulness and Purpose in Life, accountedfor retreat-related changes in the two stress-related variables and in telomerase activity.Methods: Retreat participants (n = 30) meditated for!6 h daily for 3 months and were comparedwith a wait-list control group (n = 30) matched for age, sex, bodymass index, and prior meditationexperience. Retreat participants received instruction in concentrative meditation techniques andcomplementary practices used to cultivate benevolent states of mind (Wallace, 2006). Psycho-logical measures were assessed pre- and post-retreat. Peripheral blood mononuclear cell samples

* Corresponding author at: UCD Center for Mind and Brain, 267 Cousteau Place, Davis, CA, 95618 USA. Tel.: +1 415 219 4583.E-mail address: [email protected] (T.L. Jacobs).

ava i l ab le at www.sc ienced i rect .com

journa l homepage: www.el sev ier.com/locate/psyneuen

0306-4530/$ — see front matter # 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.psyneuen.2010.09.010

TELOMERE

PURPOSE

Regular article

Purpose in life predicts treatment outcome among adult cocaine abusersin treatment

Rosemarie A. Martin, (Ph.D.)a,⁎, Selene MacKinnon, (Psy.D.)a,Jennifer Johnson, (Ph.D.)b, Damaris J. Rohsenow, (Ph.D.)a,c

aCenter for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USAbDepartment of Psychiatry and Human Behavior, Brown University, Providence, RI 02912, USA

cProvidence VA Medical Center, 830 Chalkstone Ave., Providence, RI 02908, USA

Received 15 June 2010; received in revised form 14 September 2010; accepted 6 October 2010

Abstract

A sense of purpose in life has been positively associated with mental health and well-being and has been negatively associated withalcohol use in correlational and longitudinal studies but has not been studied as a predictor of cocaine treatment outcome. This studyexamined pretreatment purpose in life as a predictor of response to a 30-day residential substance use treatment program among 154participants with cocaine dependence. Purpose in life was unrelated to cocaine or alcohol use during the 6 months pretreatment. Aftercontrolling for age, baseline use, and depressive symptoms, purpose in life significantly (p b .01) predicted relapse to any use of cocaine andto alcohol and the number of days cocaine or alcohol was used in the 6 months after treatment. Findings suggest that increasing purpose inlife may be an important aspect of treatment among cocaine-dependent patients. © 2011 Elsevier Inc. All rights reserved.

Keywords: Cocaine; Purpose in life

1. Introduction

Spirituality has a prominent role in substance abuse self-help programs, such as Alcoholics Anonymous (AA) andother 12-step treatment programs. The construct of spiritu-ality consists of beliefs, practices, and experiences (Miller &Thorensen, 2000) and can be broadly defined as that whichgives people meaning and purpose in life (Puchalski, Dorff& Hendi, 2004). Having a sense of purpose, meaningfulness,or goals in life in particular has been described as importantin overcoming adversity and is associated with improvedpsychological and physical well-being (Reker, Peacock, &Wong, 1987). A major aspect of spiritual growth in AA is toattend to lack of purpose in life (Carroll, 1993). Althoughspirituality has been said to be one source of purpose in life

(e.g., Elkins, Hedstrom, Hughes, Leaf, & Saunders, 1988),purpose in life could derive from a variety of life goals andvalues (e.g., Maslow, 1970; Rokeach, 1979). One function ofgoals, values, or a sense of purpose is to motivate behaviortoward preferred experiences consistent with the purpose orvalues (Wagner & Sanchez, 2002). Whether one's purpose inlife is to have a family, material possessions, power, orenlightenment, purpose in life may motivate behavior changeby means of perceived discrepancy of values and goals withbehavior (Miller & Rollnick, 2002).

Within social learning theory (Bandura, 1977, 1997),purpose in life may help define a set of reinforcers that arealternatives to the drug use an individual is seeking.Alternative reinforcers may prevent reliance on the use ofdrugs and alcohol. Another conceptualization consistentwith social learning theory could be that substance-dependent individuals lack coping skills for handlingdaily life without using substances. Having a sense ofmeaning in life can be viewed as a coping resource (Miller,Westerberg, Harris, & Tonigan, 1996) and can beprotective in high-risk situations for using (Finney, Moos,

Journal of Substance Abuse Treatment 40 (2011) 183–188

⁎ Corresponding author. Center for Alcohol & Addiction Studies,Brown University, Box G-S121-5, Providence, RI 02912 USA. Tel.: +1 401863 6656; fax: +1 401 863 6697.

E-mail address: [email protected] (R.A. Martin).

0740-5472/10/$ – see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.jsat.2010.10.002

On Purpose: A Renewed Direction for Full Engagement in Life and Health with Vic Strecher Part 1

Health & Medicine

Transcript of On Purpose: A Renewed Direction for Full Engagement in Life and Health with Vic Strecher Part 1