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The Comparative Effectiveness Among Institutionalized

and Non-Institutionalized Elderly People

in Taiwan of Reminiscence Therapy

as a Psychological Measure

Jing-Jy Wang

ABSTRACT: This study examined the comparative effects of reminiscence on self-esteem, self-health perception,

depressive symptoms, and mood status of elderly people residing in long-term care facilities and at

home. A quasi-experimental design was conducted, using pre-intervention and post-intervention tests

and purposive sampling. Rosenberg’s Self-Esteem Scale (RSE), Health Perception Scale (HPS),

Geriatric Depression Scale Short Form (GDS-SF), and Apparent Emotion Rating Scale (AER) were

used as study instruments. Each subject was administered pre- and post-experimental tests at a four

month interval and all subjects underwent weekly individual reminiscence intervention. Forty-eight

subjects completed the study, with 25 institutionalized elderly people and 23 non-institutionalized

home-based elderly people. Independent t-tests and paired t-tests were conducted to measure the

differences in variable means between and within groups. A significant difference was found between

groups in mood status post-test (t = 5.96, p < .001) and significant differences were noted in self-health

perception, depressive symptoms, and mood status (t = -2.56, 2.83, -3.02; p = .018, .009, .007) between

the pre- and post-intervention tests in the institutionalized group. These results suggust that

reminiscence therapy is especially appropriate for older people who reside in care facilities.

Implementing strategies that enrich the lives of elderly people residing in long-term cares is crucial,

and reminiscence offers a method for promoting healthy aging.

Key Words: reminiscence therapy, self-esteem, self-health perception, depressive symptom, mood status.

Introduction

In Taiwan, the elderly population currently constitute

9.29% of the total population, and is expected to increase to

20.67% of the population by 2027 (Ministry of Interior,

2004, August). Elderly adults have been one of the most

unrecognized and under-served members of the popula-

tion, especially in terms of care services focused on their

physical health. Because of the growth of the elderly popu-

lation, interventions that nurses can perform to improve

health and the quality of life of the elderly are needed.

Additionally, elderly adults residing in care facilities are at

an even greater risk of developing mental problems, such as

low self-control, depression, and low moods. Cost-

effective, therapeutic, and non-pharmacological interven-

tion may therefore be particularly effective for this group.

Burnside and Schmidt (1994) identified various therapeu-

tic practices for older people, including reality orientation,

remotivation therapy, music therapy, dance movement

therapy, family sculpting, and reminiscence therapy.

Among these, reminiscence therapy has been considered

effective in promoting the quality of life and well-being of

older people in western societies (Chong, 2000). However,

reminiscence therapy has also been applied in Chinese

societies such as Hong Kong since the 1980s (Fong, 1993).

Yet there are very few studies, either in English or Chinese,

237

Journal of Nursing Research Vol. 12, No. 3, 2004

RN, PhD., Associate Professor, Department of Nursing, Fooyin University

Received: March 25, 2004 Revised: July 16, 2004 Accepted: July 26, 2004

Address correspondence to: Jing-Jy Wang, No. 151, Chinh-Hsuen Rd., Ta-Liao Rural Township, Kaohsiung County 831, Taiwan, ROC.

Tel: 886(7)781-1151 ext. 620; Fax: 886(7)783-5112 Email: [email protected]

reporting the effect of reminiscence therapy on older Chi-

nese people. Research focusing on reminiscence therapy to

improve the mental health of the elderly has become neces-

sary.

Reminiscence and Self-esteem, Self-Health

Perception, and Depression

Low levels of self-esteem; self-health perception, and

depressive moods often bother Taiwanese elderly people.

In Taiwan, approximately 33-37% of older adults per-

ceived their health status as being poor to fair (Wang,

Snyder, & Kaas, 2001). Menec and Chipperfield (2001)

studied a group of home-based elderly and discovered that

low self-rated health predicts poorer functional ability and

more physician visits and hospitalization. A study con-

ducted by Bailis, Segall, and Chipperfield (2003) con-

cluded that people’s perception of health can change in

response to a variety of events; such as relocating to an

unfamiliar environment. Wang (2004) conducted a study to

examine the level of self-esteem among community elderly

and found that 18.7% of institutionalized elderly and

19.1% of home-based elderly demonstrated low self-

esteem. Furthermore, the incidence of geropsychiatric dis-

orders in elderly residents in long-term care is roughly

80%, with depression being the most common emotional

disorder (Jones & Beck-Little, 2002). The prevalence of

depressive symptoms was found to be 34% to 56% in stud-

ies conducted in Taiwan (Fuh, Liu, Wang, Liu, & Wang,

1997; Wang et al., 2001).

The maintenance of a positive self-image is important

in helping people to deal with the negative impact of aging

on their lives. The therapeutic value of reminiscence is

thought to promote self-esteem and self-worth for people

in old age (Bulter, 1963). Lappe (1987) used a four-group

pre- and post intervention test design to examine the effects

of reminiscence therapy on the self-esteem of the institu-

tionalized elderly and found significant differences among

the groups. Research exploring the role of reminiscence

therapy has indicated that it is a beneficial process associ-

ated with higher perceptions of personal health and life sat-

isfaction (Cook, 1991). In addition, failure to integrate

one’s own life experiences is seen as contributing to

despair and depression (Erickson, Erickson, & Kinvick,

1986). Studies have examined the benefits of reminiscence

for the elderly, and concluded that reminiscence generally

reduces depression and confusion, and increases autonomy

and life satisfaction (Haight & Hendrix, 1998). Moreover,

Fry (1983) also conducted structured and unstructured

reminiscence therapy to treat depression among the elderly

with positive results, and concluded that reminiscence

therapy helped the depressed elderly to focus on meaning

in past life events.

Unfortunately, very few systematic studies of remi-

niscence in older Taiwanese people have been published

except for one study conducted by Hsiao, Yin, Shu, Yeh,

and Li (2002). Hsiao et al. conducted a reminiscence study

to examine the effectiveness on depression among the

elderly. This is the only study examining the effects of rem-

iniscence on depressed institutionalized elderly, and only

nine subjects participated in the eight-week study. In addi-

tion, in Hong Kong, Fong (1993) conducted a reminiscence

therapy to alleviate the depression of Chinese older people.

Both studies found that reminiscence therapy is effective in

alleviating the depression of older people. No further study,

however has investigated the effect of reminiscence on

self-esteem and self-health perception of elderly people

with the particular purpose of comparing those relocated to

institutions and those who reside at their own homes. On

the other hand, Taiwan lacks sufficient psychological care

to assist elderly individuals to develop to their full potential

as current health care systems are failing to meet the mental

health needs of older adults. Nurses need to design thera-

peutic and innovative interventions. Yet no study has been

conducted to compare effects of reminiscence on self-esteem,

self-health perception, depressive symptoms, and mood

status of elderly people residing in long-term care facilities

and at home. The purpose of this study thus attempted to

compare the effectiveness of reminiscence as a therapeutic

modality for promoting self-esteem, self-health percep-

tion, and mood status and for lessening depressive symp-

toms among the elderly who reside in community care

facilities and at home.

The theoretical foundation of this study was adapted

from Erickson’s developmental theory and Bulter’s life

review process. Erickson (1963) outlined eight stages of

human development spanning the life cycle from birth to

death. The final stage is ego integrity vs. despair. The

elderly must develop ego integrity, a sense of satisfaction

with life and its meaning and a belief that life is fulfilling

and successful. According to Bulter (1963), a person who

achieves ego-integrity in old age will believe that his or her

life has significance and meaning and is fulfilled. Bulter

(1963) extended Erikson’s theory and believed that ego

integrity is attained through recalling one’s past and an

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J. Nursing Research Vol. 12, No. 3, 2004 Jing-Jy Wang

evaluative perspective. This process is called the life

review, and Bulter (1963) believes it is a universal mental

process brought about by the realization of approaching

dissolution and death. According to Atchley (1989), as

individuals move from one stage to the next and encounter

changes in their lives, they attempt to order and interpret

changes by recalling their pasts. This provides an impor-

tant sense of continuity and facilitates adaptation. Reminis-

cence can provide a mechanism by which individuals adapt

to changes that occur throughout life. It also entails a pro-

gressive return to an awareness of past experiences, allow-

ing salient life experiences to be reexamined and reinte-

grated. Older people must therefore recall what has hap-

pened before in order to maintain continuity.

Definition of Terms

Reminiscence is defined as recall of past events dur-

ing intervention. Participants are encouraged to talk about

these past events, often assisted by aids, such as photos,

music, objects and videos of the past (Bulter, 1963; Orrell

& Woods, 2001).

Self-esteem is self-acceptance or a basic feeling of

self-worth (Rosenberg, 1965).

Self-health perception is characterized as the evalua-

tion of information that people have about their own health

or personal evaluations of health experiences (Stewart &

Ware, 1988).

Depressive symptoms are characterized as sadness,

low mood, pessimism, self-criticism and self-blame, retar-

dation or agitation, slow thinking, poor concentration, and

appetite and sleep disturbances.

Mood status denotes emotional state, including affec-

tive and psychotic symptoms.

Methods

A quasi-experimental design was conducted utilizing

pre- and post-intervention tests and purposive sampling.

The study instruments were administered via face-to-face

interview and observation.

Sample and Setting

Through purposive sampling, a sample of 58 elders

was recruited from a variety of community care facilities

and home care agencies in southern Taiwan that were free

of similar interventions. The recruitment of subjects for

two groups was terminated when subjects in each group

reached the desired number. Institutionalized elderly are

those elderly people who have relocated to any geriatric

care facility for more than six months and home elderly are

those that reside at their own home. Inclusion criteria

included adults aged 65 years or older, capable of verbal

communication, able to speak either Mandarin or Taiwan-

ese, and demonstrating no obvious cognitive impairments.

Although cut-point score of the Geriatric Depression Scale

(GDS) was not one of the inclusion criteria, participants

showed significant lower post-intervention GDS scores in

both groups compared to their pre-intervention scores.

However, only 52 subjects agreed to participate in this

study and only 48 completed the study, including 25 insti-

tutionalized and 23 home-based elders, death, relocation,

and acute illness, yielding a final completion rate of

82.75%.

Instruments

Four instruments were used for data collection. These

were (1) Rosenberg’s Self-esteem Scale (RSE) (Rosenberg,

1965). The scale consists of 10 items with responses

reported along a four-point scale. Total scores can range

from 10 to 40. The convergent validities on item correlations

were .56 and .83 (Rosenberg, 1965). The scale correlated .59

to .60 with Coopersmith’s Self-esteem Inventory. Reliability

has been shown to be good by Rosenberg (1965) who

reported reproducibility coefficients of .85 to .92. (2) Health

Perception Scale (HPS) by Stewart and Ware (1988). The

HPS is a 5-item subscale from Health Status Questionnaire

(HSQ). Total scores can range from five to 25. The inter-

nal-consistency reliability of the HPS was .87 (Davies &

Ware, 1981). Correlation coefficients with four health

subscales, Physical Functioning, Role Functioning, Social

Functioning, and Mental Health, were .53, .57, .53, and .45,

respectively. (3) Geriatric Depression Scale short form Chi-

nese version (GDS-SF) by Chan (1996). GDS-SF contains

15 items related to psychophysiological indicators of

depression. Respondents answer each of the items with (1)

yes or (2) no in relation to how they have felt over the past

few weeks. Scores can range from 0 to 15 with a cutoff point

of equal to or greater than seven suggesting a large number

of depressive symptoms. The reliability and validity of the

Chinese version used in this study were exceptional. Internal

consistency reliability was .89, test-retest reliability was .85,

criterion-related validity was .95, and concurrent validity

was .96 (Chan, 1996). (4) Apparent Emotion Rating Scale

(AER) by Snyder et al. (1998). AER contains six affective

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Reminiscence in Mental Health J. Nursing Research Vol. 12, No.3, 2004

states, including pleasure, interest, anger, anxiety, depres-

sion, and tranquility. Total scores can range from 0 to 90.

The scale was administered through direct observation. An

inter-rater reliability of anxiety had the lowest agreement

(82%), while 100% agreement was found for interest.

Cronbach’s alphas of .55 to .58 were found. Furthermore, a

correlation of .30 was found with GDS (Snyder et al., 1998).

Procedure

After institutional and home care agencies’ consent

forms were obtained, the researcher met with individual

subjects, explained the purpose of the study, assured sub-

jects of confidentiality and anonymity, and finally invited

their participation. Written or oral consent was obtained

from each subject before pre-intervention data collection.

Subjects met with the researcher individually and weekly

for 16 weeks, after which a post-intervention measurement

was conducted. To facilitate constancy, both the data col-

lection procedures and the intervention were administered

by the same person. The researchers were licensure and

master’s prepared nurses with a specialty area on geronto-

logical nursing or psychiatric nursing and they had re-

ceived reminiscence training prior to the intervention.

They were alert to any signs of negative emotional reac-

tions of elderly people and to provide rest or terminate the

intervention session.

Intervention

In this study, individual reminiscence served as the

intervention form. Although individual reminiscence ses-

sions are time consuming, one-to-one sessions facilitate a

good relationship between the subject and the researcher.

They also tend to be best for Chinese elderly persons who

are shy in character. In this study, the researcher met with

each subject weekly for-mostly-45 minutes to one hour

over a period of four months. The reasons for this variabil-

ity in the duration of the intervention were the frailty of the

subject and the nature of the reminiscing. The natural ten-

dency to reminisce and recall past events was used during

each reminiscence session except the initial session, which

was for the purpose of establishing a trusting relationship.

Unstructured reminiscing was conducted, during which the

subject was invited to talk about his or her past experiences

or feelings, with no specific topic upon which to reflect

being suggested. However, events such as childhood expe-

riences, marriage, family life, the hardships of war, and

previous jobs were listed as a protocol to serve as hints only

when extended silences occurred. Subjects were free to

repeat any events they wished and the researcher would

focus on listening. There was no difference on the protocol

used between home-based elderly and institutionalized

elderly. Evocative materials, such as old photos, record-

ings of old songs and radio programs, and other relics of the

past were used to evoke memories and stimulate conversa-

tion between researchers and individual subjects.

Results

Demographics

Table 1 lists demographic characteristics for each

group. The subject ages ranged from 65 to 95 years, with

the mean age being 75.69 (SD = 8.11). Male subjects con-

stituted 56.3% of the total while 66.7% of the subjects were

illiterate. The high illiteracy rate is understandable since

the Taiwanese government only began to require six years

of formal education for all children after World War II,

meaning few of the elderly generation received an educa-

tion. Subjects who had lost their spouses, constituted

56.3% of the total and 16.7% had no children. Chi-square

analysis revealed no significant demographic differences

between the institutionalized and non-institutionalized

groups except marital status. A greater proportion of wid-

owed subjects in the institutionalized group seemed unsur-

prising for elderly people who reside in care facilities.

Effectiveness of Reminiscence

Table 2 lists the pre and post-intervention test mean

scores between the institutionalized and non-institutionalized

groups obtained from administering RSE, HPS, GDS-SF,

and AER. Independent t-tests were used to measure the dif-

ferences in variable means between groups. Pre-intervention

analysis revealed no statistically significant difference

between groups in terms of all dependent variables mea-

sured (t = -.31, .46, .71, .60; p = .76, .64, .48, .55 respectively).

However, when the effectiveness of the intervention was

measured by comparing the mean post-intervention scores

of the institutionalized group and non-institutionalized

group, it revealed no significant difference between groups

in terms of self-esteem, self-health perception, and depres-

sive symptoms (t = -.11, 1.70, -1.09; p = .91, .10, .28); how-

ever, a significant difference between groups on mood sta-

tus was found (t = 5.96, p < .001), indicating that the insti-

tutionalized group experienced a significant effect on

mood status after therapy but the non-institutionalized

240


group did not. Table 2 also illustrates the effectiveness of

reminiscence therapy within each group, through paired

sample-t analyses. Significant differences were noted in

self-health perception, depressive symptoms, and mood

status (t = -2.56, 2.83, -3.02; p = .018, .009, .007) between

the pre- and post-intervention tests on the institutional-

ized group. However, no significant difference was found

on all dependent variables measured between the pre- and

post-intervention tests on the non-institutionalized group

(p > .05).

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Table 1

Demographic Characteristics of the Study Subjects (N = 48)

Institutionalized (n = 25) Non-institutionalized (n = 23) Total (n = 48)

Variables n % n % n % �2/p

Age .884

65-75 11 44.0 13 56.5 24 50.0

76-85 11 44.0 7 30.4 18 37.5

86 and above 3 12.0 3 13.1 6 12.5

Gender .386

Male 17 68.0 10 43.5 27 56.3

Female 8 32.0 13 56.5 21 43.7

Years of Education .120

Illiterate 19 26.0 13 56.5 32 66.7

1-5 years 6 24.0 3 13.1 9 18.8

6-10 years 0 6 26.1 6 12.5

Over 10 years 0 1 4.3 1 2.1

Marital Status .000***

Married 2 8.0 9 39.1 11 22.9

Widow 18 72.0 9 39.1 27 56.3

Single 4 16.0 2 8.7 6 12.5

Divorced/separated 1 4.0 3 13.1 4 8.3

Income Status .316

Adequate 3 12.0 1 4.3 4 8.3

Fair 14 56.0 10 43.5 24 50.0

Not adequate 8 32.0 12 52.2 20 41.7

Number of Children .092

None 5 2.0 3 13.1 8 16.7

1-3 children 11 44.0 13 56.5 24 50.0

4-6 children 7 28.0 7 30.4 14 29.2

7 and more children 2 8.0 0 2 4.1

*** p < .001.

Table 2.

Pre-Post Tests Between the Institutionalized and the Non-Institutionalized Groups (N = 48)

Institutionalized (n = 25) Non-institutionalized (n = 23)

Pre-test Post-test Pre-test Post-test

Variables M SD M SD p M SD M SD p

Self-h-perception 13.6 5.2 15.9 4.8 .018* 12.9 5.8 13.2 5.8 .826

Self-esteem 24.5 4.6 25.6 3.7 .667 25.0 5.8 25.7 4.4 .401

Depressive sympt. 8.5 4.8 6.3 4.1 .009** 7.6 4.1 7.5 3.7 .901

Mood status 59.4 33.7 76.3 20.7 .007*** 54.8 14.7 51.5 9.9 .233

* p < .05; ** p < .01; *** p < .001.

Discussion

This study was different from previous studies (Cook,

1998; Cook, 1991; Lappe, 1987; Jones & Beck-Little,

2002; Puentes, 2001), in that both institutionalized and

non-institutionalized elderly residents were included and

compared. The results implied that the response of subjects

in the institutionalized group displayed significantly higher

reported mood status compared to the non-institutionalized

group on the post-intervention test measure. This finding is

consistent with other findings supporting the use of remi-

niscence to boost the mood status of institutionalized older

adults (Cull, LaVoie, & Gfeller, 2001; Fry, 1983; Stevens-

Ratchford, 1992). Low mood status resulting from a

depressive institutional environment is predictive and rem-

iniscence therapy may be effective in helping these older

adults to deal with low morale. Additionally, the lack of

communication among residents of long-term care facili-

ties may be detrimental to their mood status and the advan-

tage of one-to-one reminiscence in this study may provide

subjects with an opportunity for self expression.

The results also showed that subjects in the institu-

tionalized group obtained significant benefits from the

intervention and showed significant changes in their self-

health perception, depressive symptoms, and mood status

on the post-intervention test but the non-institutionalized

group only showed a slight improvement in these vari-

ables. According to Bulter, Lewis, and Sunderland (1991),

reminiscence therapy gives relocated older people oppor-

tunities to replace their accomplishments, to resolve re-

placement conflicts, and to find new significance and

meaning in their lives, thereby relieving their depression.

Fry (1983) also confirmed that reminiscence training re-

duces self-reporting of depression by subjects and boosts

feelings of self-confidence and personal adequacy. This

was supported by Berghorn and Schafer’s study (1987),

which concluded that residents whose values adapted to

nursing home life poorly gain more effective outcomes

from reminiscence therapy. Reminiscence may be a thera-

peutic procedure allowing for self-expression and commu-

nication and providing the elderly with a formal outlet for

expressing strong affects, unresolved feelings and fears

which they have tried to repress (Fry, 1983). During ther-

apy, reminiscence therapy also provides a warm, listening

and empathetic environment to help subjects feel free to

engage in overt reminiscence. It thus, boosts their morale

and results in an enhanced mood status.

Although reminiscence therapy has proven to be a

valuable intervention for the home-based elderly (Jones &

Beck-Little, 2002), only slight improvement was found

among the home-based elderly subjects of this study. The

reason may be the high physical functioning of these sub-

jects. Of the home elderly, 78.3% demonstrated a total

independence on ADL (activities of daily living) scores

and only 5.6% had ADL scores below 90. Parker (1995)

postulated that the lower the level of functioning of an indi-

vidual the greater the tendency to reminisce. Thus, elders in

this study who functioned well and adjusted their values so

that they felt relatively similar to the way they felt in their

familiar home environment, were the least likely to be

affected positively by such an intervention.

While the findings of this study are puzzling, they are

consistent with other earlier reports that reminiscing did not

increase self-esteem (Stevens-Ratchford, 1992; Cook,

1991). Several explanations may account for these findings.

While the study extended for 16 weeks, the one hour of rem-

iniscing per week may not have been intensive enough to

change subjects’ self-esteem. Also, the RSE might not have

been sensitive enough for use with this age group since it

was not developed using the elderly population. Finally,

even though there was no statistically significant finding to

support the improvement of subjects’ self-esteem, the group

means indicate that there was a trend in that direction.

This study had some limitations. First, the sample size

for each group was not large enough and was voluneer-

based, thus limiting the generalization of results. Second,

although study sites were restricted to those that were free

of planned intervention, other environmental and personal

variations might still exist among subjects. Additionally,

post-intervention test data were collected only once, imme-

diately following the intervention, so long-term effects

were not recorded.

In sum, the findings imply that participation in remi-

niscence activities is a positive and worthwhile experience

for older institutionalized persons. The findings of this

study can therefore, be applied in long-term care planning.

Long-term caregivers can learn reminiscence therapy in

their daily care of the elderly. However, to ensure reminis-

cence therapy is effective in Chinese societies, nurses also

must consider the specific cultural values and experiences

of older Chinese people. Nurses are needed for evaluating

and designing interventions targeting the mental health

needs of older adults, especially those residing in long-term

care facilities. Consequently, it seems plausible that strate-

242


gies for enriching the lives of elderly people residing in

long-term care are crucial, and that reminiscence offers a

method of promoting healthy aging.

Further research should include replication of this

study with a larger sample size, and examine the efficacy of

reminiscence for treating and preventing other mental health

indicators in elderly people suffering from dementia. In

addition, in-depth interviews to explore the common and/or

most effective content and quantity of reminiscence in

stiuations that occur in various life transitions are needed.

Acknowledgment

The author would like to thank the National Science

Council of Taiwan for financially supporting this research

under Contract No. 89-2314-B-242-012 and 90-2314-

B-242-002.

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