Depression is the most prevalent impairment of psychosocial function in older adulthood (Miller, 1999). Approximately 20% of older adults suffer from clinically significant symptoms of depression (Steiner & Marcopulos, 1991). The researchers* observations from clinical experience in a psychiatric private practice suggests many individuals with depression describe feelings of being alone. The consequences of aloneness are multifaceted for older women. Gerontological nurses with a clear understanding of aloneness will be able to provide a more holistic approach in their care of older women.
The results of this concept analysis of aloneness, based on Walker and Avant's (1999) approach, are interpreted with qualitative data, as suggested by Morse (1995). These data were obtained by the authors in a previous study of the meaning of being alone for older women being treated for depression (Wilkinson & Pierce, 1997). Depression, as it is defined for this study, includes individuals meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria (American Psychiatric Association, 1994) for major depressive disorder (single and recurrent), dysthymic disorder, or depressive disorder not otherwise noted. Context-dependent antecedent conditions and defining attributes for aloneness were made possible by incorporating the rich data provided by these older women into cases portraying the concept.
Defining the concept of aloneness is difficult because many people use the word aloneness and loneliness interchangeably. The Merrian-Webster's Collegiate Dictionary (1998) defines aloneness as "separated from others... the objective fact of being by oneself" (p. 32). Parsons (1997) stated being alone can occur in a physical sense. For instance, an individual can be alone in a house. However, being alone can also occur in the sense of an individual standing alone in a given situation. An example is a son who stands alone, apart from other siblings in the family, in the decision-making process of nursing home placement for a father.
Individuals can feel alone, but not in the sense of being lonely (Parsons, 1997). According to the American Heritage Dictionary of the English Language (1992), aloneness does not necessarily imply feelings of unhappiness. Although loneliness is defined as "lack of companions and often connotes painful awareness of being alone" (Merrian-Webster's Collegiate Dictionary, p. 686), loneliness also implies solitude, which is a state of being alone or remote from others when there is a desire for companionship (American Heritage Dictionary of the English Language, 1992). Donaldson and Watson (1996) noted that loneliness is associated with a number of physical and psychological pathologies for older adults.
Psychosocial and health-care related databases were searched for the concept of aloneness. Literature, although sparse, from the 1980s and 1990s describes the concept of loneliness, distinguishing between loneliness and aloneness. Loneliness is depicted as the perceived subjective condition that may or may not cooccur with being alone (Larson, 1990; Parsons, 1997; Ryan & Patterson, 1987). In contrast, aloneness is described as a perceived objective experience of being separate from others. This subtle, but important, distinction is critical in determining varying aspects of aloneness associated with health or loneliness, and possibly depression.
Mixed findings about the experience of aloneness were reported in the general literature. On the positive side, Larson, Csilszentmihalyi, & Graef (1982) suggested that individuals who are less self-conscious and take the opportunity for personal renewal, demonstrate improved moods following periods of aloneness. Conversely, these same authors noted that other individuals might experience depression and feel lonely during periods of aloneness. Hoeffer (1987) has documented causes of loneliness, such as poor health and widowhood. Blai (1989) found the health consequences of loneliness are depression and suicide.
The effects of loneliness on well and chronically ill adults are well represented in the literature by numerous authors (Foxall & Ekberg, 1989; Holmen, Ericsson, Andersson, & Winblad, 1992; Ryan & Patterson, 1987). However, existential aloneness, a component of resilience, is thought to be an important contributing factor to healthy psychosocial adjustment for older adults (Wagnild & Young, 1990). Existential aloneness is
the realization that each person's life padi is unique; while some experiences are shared, there remain others diat must be faced alone (Wagnild & Young, p. 254).
Steen (1991), in a phenomenological study, reported the structure and meaning of the experience of recovering from clinical depression for 22 middleaged, White women. In Phase One of the women's recovery process, existential alienation and pain, aloneness was identified as a sub-theme. Early in the women's depression, Steen noted that these women identified reconciling their experience of aloneness as critical to moving through their recovery process into making connections and cultivating the self. In another phenomenological study, Parsons (1997) identified aloneness and loneliness, considered together, as one of nine themes present for eight male caregivers of family members with Alzheimer's disease. Here, aloneness and loneliness were interrelated with the other themes to form the whole experience of caregiving for these male caregivers.
The concept of aloneness is examined in very few articles and research. The work of Fischer and Phillips (1982); Peplau, Bikson, Rook, and Goodchilds (1982); Porter (1994); Suedfeld (1982); and Wilkinson and Pierce (1997) are representative of these efforts. Fischer and Phillips interviewed 1,050 randomly selected adults in 50 northern California communities in an effort to explored who is alone and depict social isolation. The inclusion criteria for this sample were not linked to medical diagnoses. Of 1,050, 576 were adult women isolated from non-kin. For example, key characteristics of the woman at risk for aloneness as reported by Fischer and Phillips were:
* Low education.
* Being married.
* Not working.
According to Peplau 's research team, women are better able to initiate and maintain relations with relatives and friends than are men. However, Peplau et al. (1982) reported that being old is frequently associated with aloneness, being without a spouse, and living in a one-person household. Peplau et al. concluded that ambivalence is connected to aloneness, because being old and alone can be a symbol of independence and autonomy, or a sign of social failure and loneliness.
Suedfeld (1982) concurred that a large number of individuals have been taught isolation is bad and react accordingly with negative feelings, fear, and dysfunction. If the environment is approached in a different or contrary manner, as in some cultures, aloneness can heal, and solitude can transcend loneliness and be used to achieve a higher level of personal growth and fulfillment. In another study, Porter (1994) examined older widows' experiences living alone. Porter identified four phenomena of their lived-experience:
* Making aloneness acceptable.
* Going [my] own way.
* Reducing [my] risks.
* Sustaining [my] self.
Although questions related to the issue of quantity versus quality of social interactions have been raised in a few studies (Larson, 1990; Riberio, 1989; Ryan & Patterson, 1987), the concept of aloneness remained an enigma until recendy. From 1994 through 1996, Wilkinson and Pierce (1997) explored the lived-experience of aloneness for eight older women being treated for depression in northern Ohio. This sample of women were mostly White, in the same phase of recovery from depression, between 55 and 75 years of age, and living independently in non-institutionalized settings. Of these women, 2 were married, 2 were divorced, and 4 were widowed; and 6 of the women lived alone. The analysis identified two major experiences of self for all of these participants: aloneness in depression and aloneness in recovery. Five paired, and somewhat dichotomous, themes defined the essence of aloneness:
* Vulnerability and self-reliance.
* Fear and hope.
* Helplessness and resourcefulness.
* Loss of control of self and selfdetermination.
* Identity confusion and selfreflection.
All the participants expressed profound feelings of moving among the five paired themes as they gained clarity and insight into experiencing depression and recovery. This study by Wilkinson and Pierce helped describe the concept of aloneness. Within this context, and using Walker and Avant's (1999) guidelines and Morse's (1995) recommendations, attributes of aloneness were delineated. This article describes the antecedent conditions, defining attributes, and consequences of aloneness for older women being treated for depression.
Antecedent conditions are necessary circumstances that must occur before the aloneness process begins (Figure). According to Wilkinson and Pierce (1997), the women described being by one's self as a "necessity" to monitor and attend to their varying needs for time alone. For these women, it did not seem to matter if being alone was self-imposed or otherwise forced - the results were the same. One of these women captured the essence of aloneness when she said, "It will make you a better person if you just try to take a little time for yourself."
Aloneness was defined as vacuous and imposing when the women were depressed. The women worried about what was "going to happen" to them. They felt "frightened, helpless, and out of control." They seemed to lack the ability to form connections with others. The women described, in terms of life cycle development, an inability to stabilize their internal state of chaos. They depicted their environment as devoid of meaning, when depressed.
The women's burgeoning recovery was unique and vicissitudinous. It paralleled the changes of the seasons without a calendar to clearly mark the transition from aloneness in depression to aloneness in recovery. After the depression started to abate, these older women were able to view aloneness as an opportunity - a blank canvas to be colored with their own unique thoughts, needs, and experiences. Aloneness now meant they were now able to:
* Make decisions.
* Regain a sense of hope.
* Be resourceful.
* Enjoy the freedom to come and go and do as they wanted.
* Explore their sense of self.
The women were able to make connections with others as they desired. Aloneness was a positive experience in terms of life cycle development - the women were able to build an authentic life structure in which they found a balance between involvement with society and with the self (Figure).
Defining or critical attributes, characteristics indicative of the concept, are aggregates associated with the word aloneness, as pictured in the Figure. This section is based on the authors' previous work (Wilkinson & Pierce, 1997). When the women were depressed, they viewed aloneness as being vulnerable, fearful, and helpless, and as having a loss of control of self and identity confusion. As the women progressed in their recovery from depression, they viewed aloneness as being self-reliant, hopeful, and resourceful and having self-determination and self-reflection. This twostaged experience of aloneness was represented by loss of control of self and identity confusion followed by self-determination and self-reflection.
CONSEQUENCES OF ALONENESS
Consequences refer to outcomes of the aloneness process as diagrammed in the Figure. For the women in the study by Wilkinson and Pierce (1997), aloneness in depression was a sign of failure, according to criteria defined by Peplau et al. (1982). After these women were in recovery from their depression, their aloneness was a signal of independence and autonomy (Peplau et al., 1982). In Suedfeld's (1982) terms, these women in recovery from their depression felt aloneness not only helped them heal, but also facilitated their overall health. Similar to the findings of Wagnild and Young (1990), once in recovery, aloneness moved these women toward a greater sense of psychosocial adjustment.
Antecedent conditions, defining characteristics, and consequences are exemplified in the following model, borderline, and contrary cases. Morse (1995) recommends that actual situations (i.e., the women's stories presented in this article) as data be used as a technique of concept development. Rodgers and Knafl (1993) reported using focus groups to describe the concept of grief. Thus, findings from the Wilkinson and Pierce (1997) study are incorporated in the following cases. The names of the women are fictitious, but the cases are real. These cases illustrate what the concept of aloneness is and what it is not.
A model case is constructed to illustrate the concept aloneness. The model case includes all of the defining attributes presented in the Figure and no other attributes (Walker & Avant, 1999).
Irene is a 79-year-old widow who sought treatment for her depression secondary to a recent hospitalization for chronic obstructive pulmonary disease. She had lived independently for 12 years following the death of her husband. Her recent decline in health and resultant dependence in activities of daily living led to her decision to move from assisted living into her daughter's home. Irene soon regretted that choice because she felt she was "an imposition to her daughter and son-in-law," even though they denied feeling any burden.
Irene felt alone in the way that an individual stands alone in a given circumstance. This loss of independence and an increased awareness of her own inevitable mortality triggered a major depressive episode. During her initial therapy sessions, Irene expressed feelings of "vulnerability and fear." She felt "helpless" in many ways secondary to the dependencies she faced with her declining health. Because Irene required constant oxygen and was physically frail, she described experiencing a profound "loss" of her sense of "self and control" of her activities. Irene disclosed feeling "trapped" within her aging body and dependent circumstances. She experienced bouts of tearfulness each day and discontent while being with others and alone. She anguished over the psychological demands to interact with her family and the desperate sadness of being alone.
Figure. Model of the aloneness process for older women currently being treated for depression.
By processing her feelings and reflecting on the past and current life circumstances, Irene was able to gain insight into the existing gifts and attributes still in her possession. Realizing she was still very mentally astute, she began using the telephone and computer as tools to interact, shop, and challenge her mind intellectually. This increased her self-reliance and allowed her to use resources that promoted feelings of independence and self-control. Her ability to be alone stabilized. Irene felt "confident" as a result of reentering the world in an interactive way. She reported that this confidence allowed her to feel as though she had "something to contribute when spending time with friends and family." She became increasingly aware of the need for a balance between time alone and with others and was able to establish a meaningful life structure to promote well-being of self, despite her persistent health problems. Irene moved back into assisted living because she missed her time alone.
A borderline case is an instance containing some of the defining attributes of the concept being examined (Walker & Avant, 1999). The following borderline case fits the criteria established by Walker and Avant, because all the defining attributes presented in the Figure are not represented.
Ruth is 84 years old and resides in her home of 54 years. Her life-long mate has been deceased for 22 years.
She sought treatment for a recurrent major depression. Ruth complained of feeling "hopeless, sad, and frightened." While alone she experienced feelings of "confusion and desperation." During these periods, Ruth would have a family member present at all times. Her dependency on others to make basic decisions substantially increased and she lacked insight into strategies to combat her depression.
Because of her lack of self-reliance, Ruth's therapy specifically focused on how to structure her time. Secondary to the support of her large family, Ruth began to spend time home alone. However, she was unable to tolerate more than 1 to 2 hours of aloneness. During this time, she needed specific activities that her family planned. The family negotiated a schedule, and Ruth's daughters coordinated with other family members to ensure that Ruth was not left for alone any period of time. As time passed, her depression improved, but she continued to feel "confused and overwhelmed," if left on her own for longer than very brief periods. Her family continued to structure her time, both alone and with others. Ruth became only marginally selfreliant and resourceful. She felt "hope" because she was taken care of, but lacked the resources necessary to find time alone a meaningful and growth producing experience. She learned to tolerate being alone, but was unable to control and structure her own Ufe. Ruth continued to struggle with emotional dependency.
Contrary cases are clear examples of what the concept is not (Walker & Avant, 1999). The woman described in the following example did move from depression into a state of recovery. Her life only became stabilized with external help, as a result of being alone.
For the past 47 years, Julia resided with her husband, Henry. She experienced recurrent major depressive disorder. She expressed profound feelings of "abandonment," and felt she could "control" all aspects of her life. She tried to control her life events but was not able to do so. She expressed strong suicidal ideations, with a plan and intent to harm herself when left alone. Julia refused hospitalization because she did not want to be separated from Henry and other family members. The family agreed to provide 24-hour support and supervision for her.
Julia did not improve with psychotherapy, but graduaUy responded to medication and electro-convulsive therapy. However, this process required several months of intervention and constant support. This was the worst episode of depression JuUa had experienced, and her feelings of "abandonment" did not remit Despite clear improvements in her emotional affect and cognitive function, Julia became suicidal when isolated from others. Henry quit his part-time, post-retirement job to be with her. She frequently stated, "I'll die if Fm left alone...but I'm in control." In reaUty, death is experienced as the ultimate loss of control. Julia experienced being alone as "abandonment" that triggered in her the inability to control feelings of emotional and physical well-being.
CLINICAL IMPLICATIONS FOR NURSING
Concept analysis results in (Walker & Avant, 1999):
* Defining ambiguous terms used in theory, practice, education, and research.
* Providing operational and orientational definitions with a clear theoretical base.
* Understanding the underlying attributes of a concept.
* Facilitating research instrument development.
* Promoting development of nursing diagnoses.
In clinical practice, gerontological nurses working with psychiatric clients must observe the subtle clues of aloneness using astute observational and listening skills. Perceived physical separation on the part of the cUent, as well as the sense of being alone in a situation, must be continually assessed. Additionally the antecedent conditions, defining attributes, and consequences of aloneness must be assessed and reassessed over time by nurses who work with older women experiencing depression and recovering from depression.
Based on these assessment data, gerontological nurses in mental health settings can make accurate nursing diagnoses. Work toward further refinement and development of the concept of aloneness lays the needed groundwork for a new nursing diagnosis. Current possible nursing diagnoses include:
* Self-esteem disturbance.
* Impaired social interaction.
* Ineffective individual and family coping.
* High risk for violence (selfdirected).
Finally, nursing treatment interventions, planned in conjunction with these women, can be developed and implemented. For example, some older women have used physical activity, meditation, and prayer interventions to help establish healthy aloneness (Wilkinson & Pierce, 1997). Of particular value is the use of reframing the burden of aloneness into the opportunity for self-discovery and expression. Older women who are depressed need reassurance that aloneness is a transient and temporary experience because the capacity and opportunity for engaging with others, no matter how infrequent, still exists.
Teaching students and nurses in gerontological practice to put together antecedent conditions, defining attributes, and consequences to critically assess all elements of aloneness presents a challenge for educators. Learners must be able to distinguish between important and unimportant elements for aloneness. Nurses practicing in gerontological settings must understand how feeling vulnerable, fearful, helpless, and experiencing loss of control of self and identity confusion puts clients at risk for being unsuccessful in coping with aloneness. These feelings may drive clients to do something that may put their Uves at risk.
Aloneness is a concern for older women receiving treatment for depression and for those in recovery from depression. When women are in recovery from their depression, gerontological nurses must focus on helping them build skills of self-reliance, hopefulness, resourcefulness, self-determination, and self-reflection. Nonetheless, further nursing research is needed to understand the concept of aloneness in its fullest dimension. More study is needed in a variety of settings and with other populations, such as individuals living in suburban and rural communities and men. After further differentiation of aloneness from loneliness occurs, then aloneness meets the criteria for rigor as a concept.
The concept of aloneness, as presented in this article, is from the viewpoint of older women with depression and in recovery from depression. Using a qualitative methodology for describing the concept of aloneness, new insights and unique patterns of aloneness in several situations were identified. The results provided gerontological nurses with new information that has clinical relevance and application about the conceptual category of aloneness. Understanding what aloneness is and how it operates in the Uves of older women being treated for depression is fundamental for providing effective nursing interventions in geriatric settings. Additionally, with awareness of aloneness from the perspective of older women, nurses working in gerontological arenas, community health settings, and clinics and physicians' offices, can promote not only quality of care, but also quaUty of life for these women.
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