Telehealth dignity therapy for community-dwelling older adults: feasibility and potential efficacy

ABSTRACT

Research investigating accessible positive psychology interventions for older adults is lacking. We examined the feasibility and potential efficacy of Telehealth dignity therapy (TDT), a brief psychotherapy involving life review, culminating in the creation of a transcribed life story. Feasibility was measured by participant satisfaction levels and attrition rates. In accordance with past dignity therapy research, we investigated changes in participants’ meaning in life (MiL) before TDT, after TDT, and at three-month follow-up. Other secondary wellbeing outcomes were assessed. Twenty participants completed the program and reported high levels of satisfaction. Participants’ MiL and life satisfaction significantly improved between before and after TDT, and MiL gains were maintained at three-month follow-up. The program was found to be a feasible, timely, and potentially efficacious positive psychology intervention for community-dwelling older adults. Future larger-scale, controlled research is required to consolidate these findings.

KEYWORDS:

• Dignity therapy
• telehealth
• meaning in life
• older adult

Introduction

The prevalence of depressive and anxiety symptoms in older adults is high (Chui et al., 2015; Sutin et al., 2020; Vahia et al., 2010). Past literature with older adults has predominantly focussed on the amelioration of mood disturbances in those with diagnosed illnesses (Gething et al., 2003). This disease model approach neglects the majority of older adults who will never reach clinically significant levels of distress (Reynolds et al., 2015). In contrast, the positive psychology movement focusses on enhancing the wellbeing of all individuals (Seligman & Czikszentmihalyi, 2000). A positive psychology approach to ageing highlights and nurtures the strengths of older adults, which are often neglected in favour of their decrements (Ranzijn, 2002). As enhancing mental wellbeing has been shown to protect individuals from experiencing clinically significant emotional distress (Burns et al., 2022; Heisel & Flett, 2014; Koivumaa-Honkanen et al., 2004), adopting a positive psychology approach may help lessen the proportion of older adults that advance to diagnosable mental illnesses.

Dignity therapy is a brief psychotherapy that is guided by a series of 12 questions that prompt participants to reminisce about the past, reflect on their roles and accomplishments, and consider the legacy they would like to leave behind (Chochinov, 2012; Chochinov et al., 2005). Sessions are audio recorded and transcribed so that participants can inscribe their legacy and choose to pass on their wisdom to their loved ones (Chochinov, 2012). Dignity therapy aims to imbue participant’s lives with a sense of meaning, consistent with a positive psychology approach. However, dignity therapy was originally designed for terminally ill patients and no known research has explored its used as a positive psychology intervention in a generally healthy community-dwelling older adult population. Further, dignity therapy was designed as a face-to-face psychotherapy; the extent to which can be delivered by telehealth remains to be investigated.

Two systematic reviews examining the efficacy of dignity therapy when conducted face-to-face found that participants consistently report higher levels of satisfaction with dignity therapy, compared to controls (Fitchett et al., 2015; Martínez et al., 2017). There is little evidence that dignity therapy eases psychological distress for those experiencing low levels of baseline distress (Martínez et al., 2017). However, for those experiencing high levels of baseline distress, one study found statistically significant improvements in depressive and anxious symptomology for those receiving dignity therapy (Julião et al., 2014), while another found significant reductions in anxiety, but no improvement in depression (Rudilla et al., 2016). Although the evidence of dignity therapy ameliorating distress is equivocal, both systematic reviews highlighted promising findings that indicate that dignity therapy may enhance wellbeing. Past research has found that participants reported dignity therapy helped make them feel that their life was more meaningful in both residential aged care (Hall et al., 2012) and those with terminal illnesses (Chochinov et al., 2011).

The subjective sense that one is living a meaningful life is often referred to as meaning in life (MiL). Several studies have found lower levels of MiL for older adults, compared to younger adults (Musich et al., 2018; Pinquart, 2002; Pourebrahim & Rasouli, 2019), with some evidence that MiL begins to decline after individuals reach 60 years (Aftab et al., 2019). Lower levels of MiL in later life are related to worse depressive symptoms (Haugan, 2014; Volkert et al., 2019), and cognitive functioning (Aftab et al., 2019; Sutin et al., 2020). Moreover, higher MiL in old age has been shown to protect against suicidal ideation and risk of suicide (Heisel et al., 2016). Therefore, proactively targeting older adults’ MiL through positive psychology interventions such as TDT, may act to reduce the proportion of individuals that advance to experience clinical levels of emotional distress and cognitive impairment. Recent research has converged on the tripartite structure of MiL comprising mattering (belief in the inherent significance of one’s life), comprehension (a unified and coherent life narrative), and purpose (having meaningful goals to strive toward) (George & Park, 2016; Martela & Steger, 2016). The most widely used measure of MiL utilising the tripartite structure is the Multidimensional Existential Meaning Scale (George & Park, 2017). However, recently Fallon et al. (2023) explored the factor structure of MiL in a sample of community-dwelling older adults finding support for a 2-factor solution labelled (a) mattering (in line with previous research) and (b) consolidation (which represents an amalgamation of the putative comprehension and purpose factors). Fallon et al. proposed that the constituent parts of MiL are different in later life as older adults are more likely to consolidate the past (comprehension) with the future (purpose). This view has been supported by other work suggesting that older adults display higher levels of integration between past and present perceptions of self, or self-continuity (Löckenhoff & Rutt, 2017).

It is important that psychology interventions are accessible. Delivering psychotherapy via telehealth can help reduce the cost of accessing treatment and are more accessible to rural populations (Shore et al., 2007; Simpson et al., 2020). Bentley et al. (2020) explored the delivery of dignity therapy online for individuals with terminal illnesses, finding high levels of acceptability. However, participants were given the choice to complete dignity therapy via videoconference or email, hence, they were not able to make specific conclusions about the effect of the treatment as distinct from mode of delivery. Further, the study was conducted with terminally ill patients and the promise of dignity therapy as a positive psychology intervention for non-terminally ill older adults was not explored. Only one other known study has explored the application of dignity therapy for generally healthy community-dwelling older adults (Hughes, 2019), however this study was conducted face-to-face.

Fallon et al. (2022) conducted a small-scale pilot study of telehealth-enabled dignity therapy (TDT) for community-dwelling adults. Five participants successfully completed the program and TDT resulted in similar statistics for time spent to deliver, and participate in TDT, compared to other dignity therapy studies (Bentley et al., 2020; Chochinov et al., 2011), suggesting that TDT is practical for community-dwelling older adults to complete. Participants reported a high degree of satisfaction with TDT. Additionally, participants reported encountering no major technological barriers to engaging in TDT. They experienced the treatment as beneficial, reporting that TDT offered them an opportunity to inscribe their legacy, deepen connections to others, reach self-insight, and form an integrated view of self that enhanced a compassionate acceptance of the past. Participants reported experiencing new benefits from their involvement with TDT for the entire duration of the feedback interview period, lasting three-months after their final TDT session.

Although Fallon et al. (2022) found that TDT was regarded by participants as acceptable, practical and potentially beneficial, the small sample size (N = 5) limits the generalisability of these conclusions. In this study, we aimed to better ascertain the feasibility of TDT, including an analysis of attrition rates, reasons for attrition and an examination of participants’ satisfaction with the therapy when delivered by telehealth across a larger sample. As past research has found that dignity therapy may be effective in enhancing participants’ sense of meaning (Chochinov et al., 2011; Hall et al., 2011), we also aimed to investigate the potential efficacy of TDT for enhancing community-dwelling older adults’ MiL, which represented our primary outcome variable regarding efficacy. Additionally, we conducted exploratory investigations into changes in other wellbeing outcomes (ego integrity, life satisfaction, positive affect, and depressive symptoms). As participants in Fallon et al. (2022) reported reaping benefits from TDT for three months after their involvement in the study, we assessed changes in outcome measures at three time-points: baseline, post-intervention and three-month follow-up.

This study aimed to explore the feasibility (participant satisfaction and attrition rates) and potential efficacy of TDT for enhancing MiL and other wellbeing outcomes. We hypothesised that MiL would improve between baseline and post-intervention, and secondarily, these improvements would be sustained at three-month follow-up (vs baseline). We also predicted that participants would report higher levels of wellbeing at post-intervention and follow-up compared to baseline.

Method

Study design and recruitment

This was a single-arm study with outcome measures recorded at three time-points: baseline, post-intervention and at three-month follow-up. Participants also completed a survey indicating their levels of satisfaction with TDT. The study was approved by the Swinburne University Human Research Ethics Committee (project number: 20200359).

A study advertisement was sent to individuals on the mailing list of the Swinburne Wellbeing Clinic for Older Adults – a network of more than 2000 researchers, clinicians, aged care workers, individuals interested in late-life mental health, older adults and their families. Prospective participants contacted the researcher to express their interest in participating. A telehealth screening interview was conducted to assess prospective participants’ eligibility for the study.

Individuals were eligible for the study if they a) were 60 years or older (or 50 years for individuals of Indigenous or Torres Strait Island descent), b) spoke English fluently, c) lived in the community in Australia, d) were proficient in computer skills (e.g. completing online surveys, email correspondence, undertaking online video calls), e) were cognitively able to participate in the program (as measured by an equivalent score of 24 or greater on the Structured Mini-Mental Status Examination (Molloy & Standish, 1997), modified for telephone administration), f) had access to a computer with reliable internet connection, and g) had ability to complete online questionnaires unassisted (i.e. vision-impaired individuals were excluded from the present study). Criterion f and g were added after the conclusion of the previous pilot study (Fallon et al., 2022) indicated a need for additional eligibility criteria for successful engagement with TDT. After screening, individuals eligible for the study were invited to provide written informed consent.

Participants

Forty-one individuals expressed their interest in the study. The first five individuals to respond to the advertisement were selected for the earlier pilot study, as previously reported (Fallon et al., 2022). Of the remaining 36 individuals, three chose to not participate after receiving more study information, 13 individuals did not respond to follow-up emails to organise a screening interview, and the 20 remaining individuals met eligibility criteria and consented to participate in the study. Given that this study was designed as a pilot feasibility study, no power analysis was conducted.

Intervention

Participants were given the choice to complete this study via phone or videoconferencing. TDT sessions were conducted in line with the process outlined in Chochinov (2012). The choice of telehealth modality was determined by participants (i.e. they chose to complete TDT via their favourite videoconferencing platform, or phone call). Dignity therapy is guided by a series of 10 questions that prompt respondents to reflect on the past, inviting them to discuss the lessons they have learned, so that they can pass on this wisdom to loved ones if they wish. John Fallon (first author; JF) conducted all the TDT sessions, which lasted approximately 60 minutes and were conducted weekly. The number of sessions varied between participants, with a maximum of five sessions offered. Sessions were audio recorded and transcribed using Otter.ai – an online transcription service powered by artificial intelligence. Transcription errors were corrected by JF and minor changes were made to improve narrative flow. The transcribed document constituted a ‘Generativity Document’ and participants were emailed an electronic version and mailed a physical version at the completion of the study.

Operationalising wellbeing

We operationalised wellbeing in accordance with past research that advocates for the selection of specific wellbeing measures that are relevant to the population of interest (Kashdan et al., 2008). As such, wellbeing was operationalised according to Vanhoutte’s (2014) model of subjective wellbeing in older adulthood, comprising eudaimonic (striving toward actualising one’s potential), cognitive (life satisfaction), and affective wellbeing (moods and emotions). Eudaimonic wellbeing was operationalised as MiL and ego integrity – one’s ability to look back on their life narrative with a sense of coherence and pride, which is considered a fundamental task in later life (Erikson, 1959). MiL was assessed via a multidimensional scale (MEMS) to provide greater precision regarding which specific MiL components were impacted by TDT. However, considering there is still little evidence regarding the structure of MiL in older adulthood, we also administered the widely used unidimensional Meaning in Life Questionnaire (Steger et al., 2006). Cognitive wellbeing was assessed according to Diener’s (1984) conceptualisation, which entails an evaluation of global life satisfaction according to a set of idiosyncratic standards. Last, affective wellbeing was operationalised as levels of depressive symptoms and positive affect.

Measures

During the screening interview, demographic details were recorded including age, gender, marital status, education level, and country of birth. Additionally, participants were administered a shortened telephone-based 20-item version of the Structured Mini-Mental State Examination (SMMSE; Molloy & Standish, 1997). The original 30 item version of the SMMSE was modified by removing items (questions 2d, 2e, 6, 7, 9, 10, 11 and 12) that could not be administered by phone – a procedure permitted by the SMMSE user’s guide (IHACPA, 2019). Scores were converted to a percentage and compared against a modified cut-off score of 16/20 (80%), to match the traditional threshold of 24/30 on the unmodified SMMSE, which indicates cognitive impairment (Folstein et al., 1975). The SMMSE is a validated and widely used measure of cognitive impairment across a range of domains including orientation, attention and calculation and recall.

After completing the TDT program, participants completed a modified version of the Participant Feedback Questionnaire (PFQ), which was used in previous research on dignity therapy (Bentley et al., 2014, 2020). The original version of the measure was modified by removing 12 items that were deemed less pertinent to a community-dwelling population (see Table 1 below for items administered). The shortened PFQ is a 12-item self-report survey that prompts participants to evaluate their level of satisfaction with TDT (e.g. I have found TDT to be satisfactory) and potential benefits obtained from their participation in TDT (e.g. TDT has made me feel more hopeful). Responses are recorded on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Table 1. Mean and standard deviation scores on the participant feedback questionnaire.

I have found TDT to be helpful to me	4.47 (0.62)
TDT has given me a sense of looking after unfinished business	4.18 (0.88)
TDT has helped me feel more worthwhile or valued	4.00 (0.87)
I have found TDT to be satisfactory	4.41 (0.51)
TDT made me feel that my life is currently more meaningful	3.94 (0.97)
TDT has given me a heightened sense of purpose	4.00 (0.87)
TDT has made me feel more hopeful	3.82 (0.81)
TDT has helped me feel closer to the people who mean the most to me	4.12 (0.86)
I believe TDT has or will be of help to my family	3.82 (1.01)
I believe TDT could change the way my family sees or appreciates me	3.65 (0.79)
I would recommend TDT to other people and family members*	4.59 (0.51)
I recommend that TDT be made available to other people as an online therapy	4.65 (0.49)

The PFQ is scored on a five-point scale: 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree), 5 (strongly agree).

*Item modified from Bentley et al(Bentley et al., 2020). to exclude ‘ … who are dealing with life-limiting conditions’.

To assess MiL, we administered the Multidimensional Existential Meaning Scale (MEMS; George & Park, 2017). To reduce respondent burden, we administered a shortened 10-item version of the MEMS, removing five items with the lowest factor loadings (items 1, 2, 4, 6 and 8); this shortened version of the MEMS has been validated in a similar sample, displaying strong internal consistency (Cronbach’s alpha > .96; Kono et al., 2020). The MEMS assesses MiL across three subscales (comprehension, mattering, and purpose) with responses recorded on a 7-point Likert scale ranging from Very strongly disagree to Very strongly agree. In line with the findings from another study (Fallon et al., 2023), we utilised a 2-factor structure of MiL comprising mattering and consolidation.

As the multidimensional structure of MiL utilised in the MEMS remains equivocal, and MiL is our primary outcome variable, we also administered the unidimensional Presence subscale of the MiL Questionnaire (MLQ) which is used widely and has displayed strong reliability (Cronbach’s alpha = .82) and validity (Steger et al., 2006). The MLQ prompts respondents to state how much they agree with statements about how meaningful their lives currently are on a 6-point scale ranging from Absolutely untrue to Absolutely true. Higher scores on the MLQ indicate the presence of higher levels of MiL.

An additional measure of eudaimonic wellbeing particularly relevant to older adults is ego integrity, which was assessed using the Northwestern Ego-Integrity Scale (NEIS; Janis et al., 2011) – a 15-item tool measuring ego-integrity on a 7-point scale from Strongly disagree to Strongly agree. We utilised the short form of this measure comprising 5-items that loaded most strongly onto an ego-integrity factor in another study utilising a similar sample of older adults, exhibiting strong internal consistency (Cronbach’s alpha = .74; Westerhof et al., 2017). Higher scores reflect greater levels of ego-integrity.

The Satisfaction with Life Scale (SWLS; Diener et al., 1985) was used to measure life satisfaction. The SWLS is a 5-item measure of life satisfaction prompting respondents to evaluate their levels of satisfaction with life on a 7-point scale from Strongly Disagree to Strongly Agree, with higher scores indicating more life satisfaction. In a sample of older adults, the SWLS has displayed strong reliability (Cronbach’s alpha = .90) and validity (von Humboldt & Leal, 2017).

To assess positive affect, we administered the 10-item positive affect subscale of the Positive and Negative Affect Schedule (PANAS; Watson et al., 1988). The PANAS has strong psychometric properties including high internal consistency (Cronbach’s alpha = .86–.90) and test-retest reliability (Watson et al., 1988). Respondents are asked how often they’ve felt various emotions in the past week on a 5-point scale from Very slightly or not at all to Extremely, with higher scores indicating more intense affect.

Negative affect was assessed by the widely used Centre for Epidemiological Studies Depression Scale (CESD-10; Andresen et al., 1994), which prompts respondents to record the frequency of depressive symptoms they experienced in the past week on a 4-point scale from Rarely or none on the time (less than 1 day) to All of the time (5–7 days). The CESD-10 has displayed strong reliability (Cronbach’s alpha = .71) in a similar sample of community-dwelling older adults (Lee & Chokkanathan, 2008). Higher scores are reflective of enhanced depressive symptoms.

Statistical analysis

Rates of attrition were calculated by monitoring the proportion of individuals who consented to participate in the study, but failed to complete their Generativity Document. Reasons for attrition were documented to evaluate the barriers to the successful completion of TDT. Average scores on the PFQ were documented.

To evaluate the preliminary indications of efficacy of TDT, we planned to conduct paired-samples t-tests for scores on outcome measures. Due to our small sample size, we tested the assumption of normality using the Shapiro-Wilk test (Mishra et al., 2019). For outcomes with non-normal distributions, we conducted the non-parametric equivalent of the paired-samples t-test – the Wilcoxon signed rank test.

Due to the novel nature of TDT for community-dwelling older adults, this phase of the research was deemed exploratory, hence we did not conduct a power analysis to formally assess changes in outcome measures. Therefore, changes in outcomes reflect preliminary indications of efficacy. We did not adjust for multiple comparisons as per Rothman (2012). All analyses were conducted using SPSS and p-values < .05 (two-tailed) were deemed statistically significant.

Results

All 20 participants successfully completed the program, creating a Generativity Document. Therefore, no attrition occurred during the study. Sample demographics included: 13 females, 7 males, M_age = 72.90 years, SD_age = 8.45 years. Regarding country of birth, 12 participants were born in Australia, two were born in Poland and the UK, and one each in USA, Canada, New Zealand, and India. Sixteen of the participants held an undergraduate university degree or higher. Thirteen of the participants were married, two were widowed, and five were single. Nineteen participants completed TDT via videoconferencing, and one completed TDT via phone voice-call. The average number of TDT sessions for the sample was 3.70 sessions (SD = 0.98, minimum = 2, maximum = 5). All data were collected between February 2021 – January 2022.

Of the 20 participants, three did not complete the PFQ due to being inadvertently omitted by the researchers. Table 1 displays the scores on the PFQ for the 17 participants that completed the survey, showing high levels of acceptability for all questions.

All 20 participants completed all outcome measures at each timepoint. To assess the preliminary indications of efficacy we compared scores on outcomes between baseline and post-intervention, and between baseline and three-month follow-up. For several outcomes, the distribution of differences between scores on outcomes at paired timepoints deviated significantly from normality. For these variables, we conducted the Wilcoxon signed rank test instead of the paired sample t-test. The means and standard deviations of all outcomes and the statistical tests of differences are displayed in Table 2.

Table 2. Means (and standard deviations) of outcome measures across timepoints.

				T1 v T2		T1 v T3
	T1	T2	T3	t or z	p	t or z	p
Consolidation	40.4 (4.9)	42.5 (5.2)	41.6 (5.6)	2.16	.043*	1.32	.203
Mattering	15.4 (4.4)	15.8 (4.1)	16.0 (3.9)	0.93	.366	1.26	.225
MiL Global (MLQ)	28.2 (4.6)	29.5 (5.2)	29.7 (4.3)	2.19^a	.028*	2.57	.019*
Ego Integrity	22.6 (4.4)	23.7 (5.4)	23.0 (5.3)	1.88	.076	0.56	.582
Life Satisfaction	26.4 (6.9)	28.1 (6.2)	27.6 (5.8)	2.30^a	.022*	1.30	.210
Positive Affect	33.1 (6.9)	33.5 (6.0)	33.7 (5.7)	0.32	.750	0.28^a	.776
Depress. Symptoms	8.5 (5.2)	6.5 (3.8)	8.0 (4.8)	−1.60^a	.109	−0.38	.706

T1 = pre-intervention; T2 = post-intervention; T3 = three-month follow-up

^aWilcoxon signed rank test (z) reported as assumption of normality was violated

* Statistically significant result (p < .05)

Our primary hypothesis was related to changes in MiL before and after TDT. Between baseline (T1) and post-intervention (T2), statistically significant differences between scores of MiL were recorded for Consolidation (a subscale of MiL measured via the MEMS), t = 2.16, p = .043, d = .42, and MiL global (measured via the MLQ), z = 2.19, p = .028, r = .49. Both of these effect sizes are considered as small to moderate (Cohen, 1988; Rosenthal, 1996). Additionally, for MiL global (measured via the MLQ), participants recorded significantly different scores between baseline and three-month follow-up (T3), t = 2.57, p = .019, d = .34, which represents a small effect (Cohen, 1988). All other changes in MiL scores were non-significant.

Secondarily, we conducted exploratory investigations into the effect of TDT on other wellbeing outcomes. Participants recorded significantly different scores for life satisfaction between baseline and post-intervention, z = 2.30, p = .022, r = .51, which represents a large effect (Rosenthal, 1996). However, this difference was not maintained at follow-up. Differences in participants scores on all other measures of wellbeing were non-significant; however, the pattern of these differences suggested a trend towards improvement for all outcome variables.

Discussion

This study assessed the feasibility and indications of efficacy of TDT for community-dwelling older adults. All participants successfully completed TDT, indicating the feasibility of the program. Moreover, participants reported high rates of satisfaction with the study. Regarding preliminary indications of efficacy, from baseline to post-intervention, participants’ MiL and life satisfaction significantly improved. From baseline to three-month follow-up, participants’ MiL displayed statistically significant improvements. All other changes in outcome measures were not significant.

The findings from our study demonstrate the feasibility of TDT for community-dwelling older adults. No attrition occurred over the course of the study, and all participants reached the state of creating their Generativity Document. Further, participants reported high levels of satisfaction with the study, with all 17 participants that completed the PFQ stating that they would recommend TDT to friends and family. These findings are consistent with past research that has consistently shown high levels of acceptability from participants that completed dignity therapy online (Bentley et al., 2020) and face-to-face (Chochinov et al., 2011; Hughes, 2019). In the present study, all participants completed the study via videoconferencing except for one participant who chose to complete TDT via telephone voice-call, suggesting a clear preference for video-based psychotherapy over phone-based contact, which supports past research (Killen & Macaskill, 2015).

Although dignity therapy was originally designed to be delivered face-to-face, our findings suggest that the dignity therapy protocol is feasible and acceptable when delivered by telehealth. In fact, all participants that completed the PFQ reported that they would recommend that TDT be made available to others as a telehealth-enabled intervention. Similarly, the participants in Fallon et al. (2022) previously conducted TDT pilot study (N = 5) reported no major technological barriers to engaging in TDT and that the benefits of the online modality (e.g. enhanced convenience and comfort) outweighed the minor technological setbacks they encountered. Moreover, despite concerns that the online and relatively brief nature of TDT would result in a lack of the therapeutic rapport necessary for successful psychotherapy, participants reported a strong sense of connection to the therapist (Fallon et al., 2022). This previously completed pilot study in combination with the present study’s 100% completion rate indicate that community-dwelling older adults are able to overcome technological barriers and successfully engage in dignity therapy delivered via telehealth.

We also aimed to investigate the preliminary indications of efficacy of TDT for community-dwelling older adults. From baseline to post-intervention, participants’ global MiL and MiL consolidation increased, and from baseline to three-month follow-up, these statistically significant improvements in global MiL were sustained. The observed improvements in MiL are consistent with past research that found enhanced MiL in participants that completed dignity therapy face-to-face compared to controls, in residential aged care (Hall et al., 2009) and those with terminal illnesses (Chochinov et al., 2011). Therefore, it appears that community-dwelling older adults experience similar benefits to individuals living in institutionalised care and those with terminal illnesses. Further, TDT resulted in improvements in participants’ consolidation (a putative dimension of MiL) from baseline to post-intervention, indicating that improvements in MiL may be driven by this component of MiL. Perhaps the life review process inherent in TDT results in enhancing a sense of consolidation – reconciling the event of the past, and aligning this narrative with future goals (Fallon et al., 2023). Further research with larger sample sizes is required to verify these findings. In contrast, no significant changes were observed for the MiL subscale mattering, the belief that one’s life is significant (Martela & Steger, 2016). The mattering subscale on the MEMS (George & Park, 2017) assesses mattering by asking respondents questions such as ‘Even a thousand years from now, it would still matter whether I existed or not’. Such items may be related to respondents’ spiritual beliefs and hence, may be less amenable to change. Nonetheless, other MiL scales and subscales showed significant improvements. Enhanced MiL has been found to be associated with a host of improved mental and physical health outcomes in later life, including reduced depressive symptoms (Haugan, 2014; Volkert et al., 2019), cognitive impairment (Aftab et al., 2019; Sutin et al., 2020), suicide risk (Heisel et al., 2016), and risk of mortality (Krause, 2009). Hence, MiL could represent an attractive early intervention target to protect health older adults from advancing to clinical disease.

This study also found improvements in life satisfaction post-TDT compared to baseline, which were not sustained at three-month follow-up. No other significant changes were observed between scores on outcomes at baseline compared to post-intervention or follow-up. However, after completing TDT, mean scores increased for all positively valenced outcomes (MiL, life satisfaction, ego integrity and positive affect) and decreased for all negatively valenced outcomes (depressive symptoms, negative affect), as would be expected if TDT was effective in enhancing wellbeing. As our study was underpowered and not large enough to detect statistically significant minor changes in outcomes, we expect to find more significant findings in future larger-scale trials. Our findings may point toward the efficacy of dignity therapy in enhancing mental wellbeing. Past dignity therapy research conducted face-to-face with terminally ill patients has reported mixed finings (Martínez et al., 2017), with some evidence of improvements in depressive and anxious symptomology in those experiencing high levels of baseline distress (Julião et al., 2014). In non-terminal populations, there is some support for dignity therapy enhancing wellbeing, but little evidence for the amelioration of emotional suffering (Fitchett et al., 2015). Hence, it appears that community-dwelling older adults experience similar benefits – enhanced wellbeing with equivocal findings related to the alleviation of distress – to other populations that have received dignity therapy, although further research is required.

There are several limitations to these findings. First, as the present study did not include a comparator group, findings regarding efficacy are preliminary. Second, our sample was not representative of the population. Namely, participants in this study were mostly female, highly educated, and born in Australia. Third, along with the lack of diversity in our sample, the small sample size further limits the generalisability of our findings. Future research should employ more diverse samples that better reflect the community-dwelling older adult population, and sufficiently powered, controlled study designs. Nonetheless, our findings indicate that MiL and life satisfaction are two candidate measures that should be assessed in future TDT research, and that such research should employ follow-up assessments up to three-months. Further, we recommend that future research compares the effect of different modality types (e.g. videoconferencing, telephone, email) on TDT outcomes, to ascertain the impact of these decisions, and better inform practice.

Conclusion

TDT is feasible, acceptable and associated with improvements in MiL and life satisfaction for community dwelling older adults without life limiting illnesses. Participants successfully completed TDT, with none dropping out prior to creation of the Generativity Document. Participants were very satisfied with the program. Despite our small sample size, we found statistically significant improvements in MiL and life satisfaction. Our research provides a basis for such larger trials in finding that dignity therapy can be delivered entirely via telehealth to help promote the wellbeing of community-dwelling older adults. Targeting this population may help to inadvertently reduce disease burden across society by protecting individuals from advancing to clinical levels of distress.

Acknowledgments

The authors would like to thank the participants who were involved in this study, without whom, none of this would have been possible. It was an honour to bear witness to your wisdom.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Study data are available from the corresponding author, JF, upon request.