When Confucius meets Erikson: An innovative life review program on Chinese seniors with probable dementia

Abstract

Before Erikson proposed the life stages, Confucius concluded an autobiographic review of his entire life in about 500 BC. Confucius’ life stages may be closer to the life experiences of Chinese older adults. Therefore, the purpose of this study was to examine the effect of the life review program on cognitive ability, life satisfaction, meaning of life, and ego integrity. The experiment was based on a single-group time-series design with a four-time test across 21 weeks. The evoking materials were horticultural activities held in seven weekly sessions. The innovative life review program was in accordance with a combination of Confucius’ and Erikson’s life stages. Nine participants completed all sessions. There was a significant positive effect of time on participants’ cognitive ability and meaning of life after the program. A combination of Confucius’ and Erikson’s life stages can be more advantageous for Chinese older adults than only Erikson’s life stage.

Keywords

cognition cultural difference horticulture mental health reminiscence therapy

Introduction

Reminiscence therapy has been a common strategy and intervention in long-term facilities for older adults who have experienced cognitive decline, depression, anxiety, and fear of death due to the advancement of their diseases (Syed Elias et al., 2015). It is an easy and common program in long-term care facilities that targets psychological benefits to older adults, improving life satisfaction (Wu & Koo, 2015), meaning of life (Chippendale & Boltz, 2015), integrity (Moral et al., 2015), cognitive functions (Duan et al., 2018), and mental health (Shellman, 2016).

Erikson proposed a developmental theory that outlines eight life stages of psychosocial development during which strengths are created that are “necessary for a mutual involvement in an ever-increasing social radius, from infancy to adulthood and into old age” (Erikson et al., 1994). However, 2000 years before Erikson, Chinese teacher, politician, and philosopher Confucius concluded an autobiographic review of his life at the late stage, as follows:

“At the age of 15, I was determined and devoted myself to learning; at 30, I established in my profession; at 40, my doubts faded; at 50, I fully committed myself to my mission, granted by Heaven; at 60, my ear was attuned; at 70, I followed my heart/desire without overstepping the mark.” (Sun, 2008, p.563, p.563)

Today, this famous saying not only represents the strengths of Confucius’ personal life at different stages but also guides the Chinese people to pursue their lifelong goals and complete their life tasks at certain ages. Confucius emphasized that, as humans develop, each person should gain certain strengths at a certain age by accumulating knowledge and experience through continuous learning. The comparison between the life stages of Confucius and Erikson is shown in Table 1. There are several points in common between their life stages. They both mentioned the purpose and competency of learning in the early life stages. Profession and generativity are goals in the middle life stage. Finally, according to both theories, people have enough knowledge and experience to integrate their lives. Older adults identify through self-integration. They reveal who they really are at the later life stage and live freely as themselves under a situation of self-control. However, while Confucius’ life stage starts at 15 years, Erikson’s life stage starts at birth. The main difference between these two philosophies is that Confucius emphasized that a man should be firm in his willing without being confused by the outside world. This is because significant others can somehow impact an individual’s success in the goals of life stages in the Chinese culture. On the other hand, Erikson emphasized ego and individual experiences in life stages, although he also relies on the relationship with the family and the next generation in order to eventually achieve self-integration. This discrepancy is also reflected in leisure studies that point out that the Easterners are more collectivist than individualistic compared to westerners (Walker, 2009).

Table 1.

Comparison between Confucius’ and Erikson’s life stage.

Age (years)	Confucius’ life stage	Age (years)	Erikson’s life stage
		0–1.5	Basic trust versus mistrust (hope)
		1.5–3	Autonomy versus shame and doubt (will)
		3–5	Initiative versus guilt (purpose)
		5–12	Industry versus inferiority (competency)
		12–18	Identity versus role confusion (fidelity)
15–30	I determined and devoted myself to learning	12–18	Identity versus role confusion (fidelity)
15–30	I determined and devoted myself to learning	18–40	Intimacy versus isolation (love)
30–40	I established in my profession
40–50	My doubts faded
50–60	I fully committed to my granted mission by heaven	40–65	Generativity versus stagnation (care)
60–70	My ear was attuned	40–65	Generativity versus stagnation (care)
60–70	My ear was attuned	65+	Ego integrity versus despair (wisdom)
70+	I followed my heart/desire without overstepping the mark

Purpose

Therefore, the purpose of this study was to examine the effect of the Horticultural Life Review Program (HLRP), which is a new reminiscence approach, on cognitive ability, life satisfaction, meaning of life, and ego integrity. Since the participants are Chinese older adults, the life review program is based on the life stages of both Confucius and Erikson to guide the participants to evaluate their life experience. The evoking materials comprise horticultural activities that recall memory. We hoped that the HLRP could be influential and thus promoted as a widespread technique for the benefit of the mental well-being of older adults.

Methods

Participants and setting

Participants were recruited from a day care center in southern Taiwan, which is open 5 days a week for the older adults in need (over 65 years). All participants signed the consent and agreement form before the experiment.

Intervention

The intervention was designed as a life review program with horticultural activity (Whear et al., 2014). The themes of each session were based on the life stages from Confucius and Erickson’s theories. The first session was to talk about hope, will, and purpose, and the leader guided participants in identifying expectations from important others during their childhood using the metaphor of a seed-planting activity. The second session was to remind participants of the competency they enjoyed in their school age, and the leader facilitated participants reconnecting with the playful, fun, and childlike part of themselves to revitalize energy by playing with the toys made by plant. The third session was to confirm the diligence and fidelity of the young adult age, and the leader helped participants strengthen their sense of identity and self-esteem by making a self-portrayal plant mask. The fourth session was to discuss the meaning of independence, mental maturity, and love of middle adulthood, and the leader inspired participants to talk about the value of the self in the family and society by growing vegetables and herbs. The fifth session was to arouse spiritual maturity and a caring spirit, and the leader guided participants in evaluating their relationships with family members and significant others by creating a mixed plant pot. The sixth session emphasized acceptance of their current situation, and the leader facilitated participants recognizing their own contributions to the next generation through herb propagation. The final session was to unify self-identification for the second time, the group reviewed the former sessions, and the leader helped each participant value their own life’s worth.

The program was held through weekly one-hour sessions for seven consecutive weeks, and its protocol is shown in Table 2. Each session comprised four parts: (1) introduction, (2) reviews of the last week, (3) main activities, and (4) closure and Q&A. The sessions were conducted by a social worker and two or three staff (nurses and nursing assistants) as helpers. All participants underwent the program as group members at the same time. The evoking materials were gardening and horticulture items, such as soils, flowerpots, stones, scissors, rooting accelerator, seeds, vegetables (herb, orange, pomelo, apple, tomato, and so on), and other related materials. All participants received a Certificate of Completion in the final session.

Table 2.

Design of objective and activities in sessions.

Session	Age (years)	Life-transforming tasks (Confucius)	Life goal (Erikson)	Activity name	Objective	Summary of activities
1	0–5	—	Hope, will, and purpose	Seeds for hope	To guide participants to identify expectations from others and evaluate their sense and satisfaction of personal autonomy from past experiences	Plant seeds for miniature citrus trees
						Write greeting cards for the plants and commit to nurturing them
						Tips: Comparing the card writing with parents passing on values and beliefs to the next generation
2	5–15	—	Competence	Childhood memories of courage and energy	To facilitate participants to reconnect with the playful, fun, and childlike part of themselves to revitalize energy	Engage participants in fun team competitions with traditional toys made of plants, such as wooden pinball game with longan seeds, bamboo leaf boat race, dart game with stick-tight seeds etc.
2	5–15	—	Competence	Childhood memories of courage and energy		Tips: Leverage player experience to bring out strengths and stamina
3	15–30	Diligence	Fidelity	Peek-a-boo—Underneath the mask	To help participants strengthen the sense of identity and self-esteem	Make a self-portraying mask with leaves and flowers
3	15–30	Diligence	Fidelity	Peek-a-boo—Underneath the mask		Participants share their self-concepts and external images with each other
4	30–50	Independence and mental maturity	Love	Plant, nurture, and harvest!	To inspire commitment and perseverance that participants once had to sustain themselves or family, guiding them to appreciate their productivity and contribution to the family and society	Plant vegetables and herbs in containers
						Participants learn basic plant care skills
						Tips: Nurturing the plants resembles to putting constant efforts at work
5	50–60	Spiritual maturity	Care	Mix and match to thrive together	To guide participants to evaluate their relationship with family members and significant others	Create mixed plantings in pots
5	50–60	Spiritual maturity	Care	Mix and match to thrive together		Tips: Choosing plants of varying heights create visual interests, while putting household plants with similar needs together promises the best of luck to thrive together—compare it with how tolerance for differences and adaptation leads to family cohesion and strength
6	60–70	Acceptance	Wisdom	Hope for next generation	To facilitate participants to recognize their own contributions to the next generation and encourage bring back the experience and feeling as the caregiver of the family	Propagate herbs from cuttings
						Guide participants to different methods of herb propagation
						Tips: Compare propagation with nurturing and guiding the next generation
7	70+	Unification: Reconnect with self, others, and the ultimate	Ego integrity	Joy of harvest	To facilitate reconciliation with the inevitable losses in life, interpretation of difficult life events with constructive perspectives; Opening a window into the meaning and efforts that can be made to thrive in old age	Enjoy the harvest: Prepare food and drinks with vegetables and herbs grown earlier
7	70+	Unification: Reconnect with self, others, and the ultimate	Ego integrity	Joy of harvest		Tips: Compare the activity with celebrating all the achievements in life

Research design and data collection

Single-group time-series design was used in the experiment. Data were collected in four phases for 21 weeks (every 7 weeks) by two trained graduate students. The first phase aimed at understanding the participants’ cognitive and psychosocial properties at the initial stage (the first week), while the second phase aimed at collecting the cognitive and psychosocial properties before the intervention (the eighth week). The intervention was held between the eighth and the 14th week. The third phase aimed at collecting the cognitive and psychosocial properties immediately after the intervention (the 14th week). The final phase comprised the follow-up test (the 21st week).

Measurement and data analysis

The following four structural questionnaires were used: (1) Mini-mental Status Examination (MMSE) and Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) to measure participants’ cognitive abilities, (2) Ego Integrity Scale, (3) Life Satisfaction Scale (LSS), and (4) Meaning of Life Scale (MOL). The Friedman test, a nonparametric alternative to the one-way ANOVA with repeated measures, was used to analyze data by phases.

Results

Demographic characteristics

The average age is 79.00 ± 6.16 years. 7 (77.78%) participants were female. 7 (77.78%) participants were widowed. 4 (44.44%) participants were not educated before. 2 (22.22%) participants admitted to the day care center for 3 years, 3 (33.33%) participants admitted for 2 years, and 4 (44.44%) participants admitted for less than 1 year. In health status, 3 (33.33%) participants were diagnosed with mild physical dysfunction, 5 (55.56%) participants were diagnosed with mild dementia, and 1 (11.11%) participant was diagnosed with moderate dementia.

Cognitive ability and psychosocial properties

The Friedman test was conducted to compare cognitive ability and psychosocial properties in the four phases, and the results are shown in Table 3. The result demonstrated that the cognitive ability has improved immediately after the intervention and after 7 weeks. The feeling of meaning of life immediately decreased after the intervention and recovered 7 weeks later. However, there was no significant difference in the scores for Life Satisfaction Scale and Ego Integrity Scale in the four phases.

Table 3.

Comparison of psychosocial properties in 4 phases by the Friedman test.

Scale	Phase (median)				Chi-square	p	Post hoc
Scale	1	2	3	4	Chi-square	p	Post hoc
MMSE	14	12	17	17	7.791	0.048	3,4>2
LOTCA	73	75	83	77	7.989	0.046	3>1
LSS	10	11	11	11	2.262	0.520
MOL	13	13	11	15	12.038	0.007	4>3
EIS	39	42	37	42	6.000	0.112

MMSE: Mini-Mental Status Examination; LOTCA: Loewenstein Occupational Therapy Cognitive Assessment; LSS: Life Satisfaction Scale; MOL: Meaning of Life; EIS: Ego Integrity Scale.

Discussion

The results revealed that the participants’ cognitive abilities improved after the intervention of HLRP. The MMSE and LOTCA scores increased significantly after the intervention. The LSS, MLS, and EIS scores decreased immediately after the intervention and increased in the follow-up test. According to the previous qualitative research design of reminiscence therapy, the possible reason for this score variation could be that the participants need more time to rebuild self-concept, reconsider their past experiences, integrate their opinions, and evaluate themselves (Lin & Li, 2013).

Participants joined the HLRP program to review their life stages according to the life stages of Confucius and Erikson. In order to achieve the objective of each session, they brought memories of learning, work, profession, awards, doubts, granted missions, and desires. Through the horticultural activity, the growing plants reflected their life experiences as a metaphor from youth to old age. The HRLP helps older adults to know and integrate themselves better and brings more psychological benefits. In addition, the HRLP constituted by the combination of the life stages of Confucius and Erikson may have more advantages for the Chinese older adults than only constituted by Erikson’s life stage. First, Confucius’ life stages begin at 15 years of age. It is easier for older adults to remember the experiences of adolescence than to bring the memories of infancy and early childhood. Second, because of cultural differences, the Chinese are required to study and work hard in their lives. Confucius’ life stages are similar to their real life experiences, which can be noted in statements such as “I was determined and devoted myself to learning” and “I established in my profession.” Third, participants mentioned many of their children and grandchildren. The appraisal of their life stages is essentially based on the success or failure of their descendants rather than in their own achievements. Confucius indicated that the relationship with beloved others led to self-integrity in later life.

Conclusion

Reminiscence therapy could be designed differently, according to participants’ individual backgrounds, hobbies, needs, and past experiences. The program planner should set an objective that can be accomplished in each session. During the innovation HLRP intervention, the ability, mood, and health of the older adult should be monitored to control the progress of each session. There were no studies demonstrating a negative influence of reminiscence and horticulture for older adults. In this study, the life stages were important themes, especially regarding a combination of Confucius’ and Erikson’s life stages for the Chinese older adults with dementia.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Ministry of Science and Technology, Taiwan, under Grant [NSC-102-2410-H-003-096].

Institutional Review Board (IRB) Name and Institution

The research ethic was approved by the National Taiwan University Research Ethics Committee (NTU-REC 201301HS018).

ORCID iDs

Li-Jung Lin

Hsin-Yen Yen

Li-Jung Lin is an Associate Professor in Graduate Institute of Sport, Leisure, and Hospitality Management, National Taiwan Normal University. She earned her doctoral degree in park, recreation, and leisure studies at School of Kinesology, University of Minnesota, Twins, USA She currently certified as therapeutic recreational specialist and horticultural therapist registered. Her research interests are therapeutic recreation and horticultural intervention for aging population, particularly with dementia.

Hsin-Yen, Yen is an Assistant Professor in School of Gerontology Health Management, Taipei Medical University. He got a PhD degree in Graduate Institute of Sport, Leisure, and Hospitality Management, National Taiwan Normal University, Taiwan. Besides, he also has a registered nursing license in Taiwan. His research interests are physical activity, recreation therapy, behavior change technologies, wearable devices, and health tourism.

References

Chippendale

Boltz

(2015). Living legends: Effectiveness of a program to enhance sense of purpose and meaning in life among community-dwelling older adults. American Journal of Occupational Therapy, 69(4). DOI: 10.5014/ajot.2015.014894.

Duan

Chen

Liang

Zheng

Tang

(2018). Psychosocial interventions for Alzheimer’s disease cognitive symptoms: A Bayesian network meta-analysis. BMC Geriatrics, 18(1), 175. DOI: 10.1186/s12877-018-0864-6.

Erikson

Kivnick

H. Q.

(1994). Vital involvement in old age. New York, London: WW Norton & Company.

Lin

L. J.

K. Y.

(2013). A qualitative study on the ego-integrity of outpatients with mild to moderate dementia through a recreational life review program. Physical Education Journal, 46(4), 459–474. DOI: 10.6222/pej.4604.201312.1312.

Moral

J. C. M.

Terrero

F. B. F.

Galán

A. S.

(2015). Effect of integrative reminiscence therapy on depression, well-being, integrity, self-esteem, and life satisfaction in older adults Juan. The Journal of Positive Psychology, 10(3), 240–247. DOI: 10.1080/17439760.2014.936968.

Shellman

J. M.

(2016). Examining patterns and functions of reminiscence in a sample of black adults: Implications for psychiatric nurses. Archives of Psychiatric Nursing, 30(3), 387–392. DOI: 10.1016/j.apnu.2016.01.006.

Sun

(2008). Confucian educational philosophy and its implication for lifelong learning and lifelong education. International Journal of Lifelong Education, 27(5), 559–578. DOI: 10.1080/01411920802343269.

Syed Elias

S. M.

Neville

Scott

(2015). The effectiveness of group reminiscence therapy for loneliness, anxiety and depression in older adults in long-term care: A systematic review. Geriatric Nursing, 36(5), 372–380. DOI: 10.1016/j.gerinurse.2015.05.004.

Walker

G. J.

(2009). Culture, self-construal, and leisure motivations. Leisure Sciences, 31(4), 347–363.

10.

Whear

Coon

J. T.

Bethel

Abbott

Stein

Garside

(2014). What is the impact of using outdoor spaces such as gardens on the physical and mental well-being of those with dementia? A systematic review of quantitative and qualitative evidence. Journal of the American Medical Directors Association, 15(10), 697–705. DOI: 10.1016/j.jamda.2014.05.013.

11.

L. F.

Koo

(2015). Randomized controlled trial of a six-week spiritual reminiscence intervention on hope, life satisfaction, and spiritual well-being in elderly with mild and moderate dementia. International Journal of Geriatric Psychiatry, 31, 120–127. DOI: 10.1002/gps.4300.