Copyright 1997 by
The Cerontological Society of America
The Cerontologist
Vol. 37, No. 2, 250-256
Research concerning caregivers of persons with dementia has predominantly been guided by a
stress/adaptation paradigm. This paradigm, however, does not fully address the issue of how
caregivers manage to do so well under difficult circumstances. Existentialism offers an
alternate theoretical view for exploring this issue. This article compares and contrasts these
two paradigms — their key elements, strengths, and limitations, and areas of convergence and
divergence. It identifies implications for future theory development,
research, and clinical practice.
Key Words: Caregivers, Dementia, Existentialism, Stress/Adaptation
Theoretical Perspectives Concerning Positive
Aspects of Caring for Elderly Persons
With Dementia: Stress/Adaptation
and Existentialism1
Carol J. Farran, DNSc, RN, FAAN:
In our clinical practice and research of caregivers of
persons with dementia, we remember specific caregivers who seem different from any others — their
stories are poignant, they dramatically describe their
experiences with caregiving, and we use their eloquent words to serve as examples for other caregivers. They present themselves in majestic serenity,
calmness, and a sense of "being at peace" with what
they are doing and experiencing. We look at them and
wonder — What makes them different? How is it that
as they experience the pain and sorrow of seeing a
loved one succumb to dementia, they do so in such a
poetic manner? These are the caregivers who have
inspired us to look at the positive aspects of caring for
persons with dementia and to understand this phenomenon clinically, empirically, and theoretically.
The majority of research concerning caregivers of
persons with dementia has used a stress/adaptation
paradigm. This perspective has primarily focused on
negative stressors and outcomes associated with this
experience (Kramer, 1997). More recent family caregiving literature has suggested that we broaden the
current paradigm to include positive aspects concerning the caregiving process, resources, and outcomes (Deimling, 1994; Lawton, Moss, Kleban,
Glicksman, & Rovine, 1991; Pearlin, Mullan, Semple,
& Skaff, 1990). Questions that emerge, however,
1
An earlier version of this article was presented at the 48th Annual
Meeting of The Cerontological Society of America, Behavioral and Social
Sciences Section, Los Angeles, CA, November 1995. This project was
funded in part by the following National Institute on Aging Grants: P30AC10161 and R01AG-09416. The author gratefully acknowledges the comments
of Betty J. Kramer, M. Powell Lawton, and Baila Miller.
2
Address correspondence to Carol J. Farran, DNSc, RN, FAAN, Rush
University College of Nursing and Rush Alzheimer's Disease Center, RushPresbyterian-St. Luke's Medical Center, Chicago, IL 60612.
250
include: What are these positive aspects of caregiving? Are they background variables, resources, appraisals and/or outcomes? How should they be measured? Can causal relationships be determined? and
What types of research designs can help us answer
these questions?
These questions can immobilize us on one hand,
or they can encourage us to examine "new ways of
looking at old problems." New ways may involve
taking an entirely different approach — a different
epistemology, a fresh theoretical view, a new research design, or a humble admission that some
questions will never entirely be answered. The purpose of this paper is to take a new look, to examine
our current empirical stress/adaptation paradigm in
light of a philosophical and almost intuitive paradigm, existentialism; to identify key elements,
strengths, and limitations, to identify areas of
convergence/divergence of each perspective; and to
identify implications for future theory development,
research, and clinical practice.
Stress/Adaptation: An Overview
Two somewhat similar but general stress/
adaptation models have guided family caregiver research: 1) the Double ABCX model (McCubbin &
Thompson, 1987), and 2) the cognitive phenomenological theory of psychological stress (Lazarus &
Folkman, 1984). Two models, most commonly used
and more specific to caregivers of persons with dementia, have primarily evolved out of Lazarus &
Folkman's general model (Lawton etal., 1991; Pearlin
et al., 1990). Critiques of these models and comparisons of their similarities/dissimilarities have previously been published (Kramer & Vitaliano, 1994).
The Gerontologist
Although there are variations in these conceptualizations (Kramer, 1997), recurring constructs describe
the caregiving process, including background and
contextual variables, stressors, resources, appraisals, and outcomes. Adaptation defines the entire
process that occurs in response to the stress of caring
for a person with dementia.
Two more recent but interrelated areas of progress
have included a focus on the positive aspects of caregiving (Kramer, 1997) and the delineation of positive
and negative outcomes (Lawton et al., 1991). Positive
constructs that have been identified include satisfaction, uplifts, rewards, gratifications, growth and
meaning, enjoyment, and benefits (see Kramer, 1996
for a review of existing studies). The focus on positive
aspects of caregiving is not without its challenges,
however. Notably, what are these positive aspects?
Are they related to caregiver attitudinal variables,
caregiver characteristics, resources, specific coping
strategies, appraisals, or outcomes? What theory
guides their development, and how can they be
operationalized? (See Kramer, 1997 for a more complete discussion of these issues). The second area of
progress lays the foundation for examining predictors
of both the positive and negative outcomes associated
with caregiving (Lawton et al., 1991).
The major strength of the stress/adaptation theoretical perspective rests in its empirical philosophy of
science. Namely, underlying assumptions of this philosophy, when applied to caregiver research, suggest that the parts can be operationalized; the whole
can be represented by the corresponding parts; and
stressors, resources, appraisal, and outcomes have a
causal relationship.
A second strength that emanates out of this philosophy of science, rests on the vast improvement in the
operationalization of these general constructs in the
past fifteen years, including: stressors; resource variables such as coping (Kramer & Vitaliano, 1994),
personal control, self-efficacy, knowledge, and hardiness; primary and secondary appraisal; and emotional and physical health outcomes (George & Gwyther, 1986; Schulz, Visintainer, & Williamson, 1990).
Four major limitations of the stress/adaptation paradigm and its relationship to positive aspects of caregiving can be identified. First, it has been noted that
these positive aspects of caregiving are poorly defined and poorly operationalized (Kramer, 1997).
Second, nearly half of the studies conducted to date
had no theoretical base. Of those that did, a wide
variation of theoretical perspectives were identified,
including stress/adaptation, social exchange, work,
motivation, job satisfaction, and existentialism (Kramer, 1997). Third, the majority of these studies were
quantitative, and fourth, the stress/coping paradigm
has identified far fewer predictors of positive than of
negative outcomes (Lawton et al., 1991). Each of
these limitations are discussed in greater detail in the
following discussion.
It is no wonder that the positive aspects of caregiving are poorly defined — perhaps the terms stress
and positive aspects are opposites that cannot be
reconciled. Stress implies that something is wrong.
Vol. 37, No. 2,1997
Although one of the earliest terms, eustress, implies
that stressors can also have positive aspects (Selye,
1976), our more recent conceptualizations have focused on the negative aspects of stress and caregiving. The term "adaptation" implies that caregivers
make the necessary "adjustment," but the term
adaption does not necessarily facilitate the notion
that one might "go beyond" the situation to find
positive aspects associated with such a stressful experience as caregiving. These terms may also be
poorly defined because researchers were following
intuitive hunches—they saw something clinically, or
heard caregiver research subjects saying something
that the existing empirical measures did not capture.
Instead of ignoring it, they tried to capture the essence of this unknown (Cartwright, Archbold, Stewart, & Limandri, 1994). The fact that these positive
constructs are poorly operationalized naturally follows their poor definition and the difficulty in operationalizing less pathologically oriented constructs.
The lack of and somewhat disparate theoretical
perspectives underlying these positive constructs reflect primarily the logical positivistic approach taken
with respect to caregiving research to date. This philosophy of science assumes that variables can be
operationalized (stressors, resources, appraisals, and
outcomes). It assumes that as we understand the
parts, in terms of what is given/what is received, what
motivates persons, and what satisfactions are received, that we will understand the whole. Furthermore, it assumes that if we can measure and understand each of these parts, that these parts will have a
direct relationship with the end result or outcomes.
The existing theoretical perspectives that have been
used to identify, operationalize, and explain these
positive perspectives tend to be more mechanistic
and do not necessarily facilitate the notion that something new or positive can be made of an experience
that may also be stressful (Cartwright et al., 1994).
The quantitative nature of current caregiver research follows this existing philosophy of science.
While there is nothing inherently wrong with this perspective, it has not been entirely successful in helping
us to understand the whole, and particularly, how it is
that caregivers make sense out of, and even develop
positive perspectives through, these experiences.
The stress/adaptation paradigm has assisted us in
more clearly identifying the links between caregiving
stressors and negative outcomes, but has provided
far fewer predictors of positive outcomes. Numerous
studies have examined correlations between positive
aspects of caregiving and outcomes, but fewer have
used multivariate methods (see Kramer, 1997b for a
more comprehensive review). Of note are three
studies with caregivers of persons with dementia that
found differential predictors for positive and negative caregiver outcomes. Lawton, Rajagopal, Brody,
and Kleban (1992) found that positive affect was differentially predicted by caregiver satisfaction and
that depression was more affected by burden for
both Black and White caregivers. Kramer, in two
studies, found that activities of daily living and the
quality of the prior relationship predicated satisfac251
tion, while symptoms, caregiving duration, marital
history, and perceived stress regarding lADLs predicted depression (Kramer, 1993a).
Where do we go from here? The stress/adaptation
perspective has worked well to an extent. Are there
existing theoretical paradigms that can contribute
toward finding this missing link — that of understanding how it is that caregivers do so well under
difficult circumstances? Are there theoretical perspectives that are less mechanistic, but at the same
time contribute toward our understanding of the
whole? Can these theoretical perspectives guide us
with our research methods and design? Existentialism is posited as one alternative perspective that may
assist us in answering some of these questions.
Existentialism: An Overview
Existentialism is a philosophical perspective that
addresses such questions as "Who is man?" and
"What does it mean to exist or to be human?" It
makes certain assumptions about difficulties associated with being human, such as: each person experiences isolation at some point in an indifferent universe; each person suffers or despairs at some time
in his/her life; and there are two things a person must
do alone — to be born and to die. This perspective
acknowledges the fact that humans have the potential to experience existential vacuum — times when
one's goals are not met, times when there are feelings of nothingness, meaninglessness, anxiety, and
isolation. This perspective also identifies the tension
between being free to make choices while at the
same time assuming responsibility for what life sets
before one, and the natural consequences of
actions. Furthermore, it addresses the tremendous
capacity that humans have to experience hope, to
transcend and find meaning in the midst of difficult
life experiences (Frankl, 1963, 1967, 1978; Nauman,
1971; Yalom, 1975,1980).
Philosophers, theologians, psychologists, clinical
practitioners, novelists, and poets have based their
work on existentialism. Viktor E. Frankl, a Viennese
psychiatrist, is one of the major proponents of an
existential paradigm. He based his clinical practice
on logotherapy — helping people find meaning in
the midst of both mundane and critical life experiences. He further expanded this perspective under
more extreme personal experiences in German concentration camps during World War II. His easy-toread, lay rendition of this perspective, Man's Search
for Meaning, became well known in the1960's (1963).
Another well known lay presentation of an existential
perspective is Kushner's When Bad things Happen to
Good People (1981).
Levine et al. (1984) appear to be one of the first
groups who took some of the basic themes of existentialism and applied them to the process of caring
for persons with dementia. They suggested that
spouses of persons with dementia "live in a prison,
struggle on a battlefield, and languish in a concentration camp" (p. 222). Furthermore, they suggested
that existential freedom may confront caregivers
with "terrifying new choices" and may be reflected
252
in "a fear of unwelcome possibility" (p. 220) — that
is, caregivers face the freedom to choose not to
become caregivers, but may become so frightened in
considering this possibility that they may act out of
fear instead of "true choice" (p. 220).
Few caregiver studies have specifically identified
an existential perspective. Our own experience with
open-ended, qualitative caregiver responses led us
to consider this paradigm along with the construct of
finding meaning through caregiving (Farran, KeaneHagerty, Salloway, Kupferer, & Wilken, 1991). Initial
attempts to interpret these qualitative data through
the lens of a stress/adaptation perspective left some
of the story untold, namely, how to account for the
positive aspects of caregiving reported by 90% of the
caregivers (N = 94). Our further exploration of theories of loss/grief helped us to "explain" the feelings
of loss and powerlessness, experienced by 84 and 82
percent of the caregivers, respectively; cognitivebehavioral perspectives helped us to interpret the
personal choices caregivers reported making with
respect to their experiences, but no one perspective
seemed to pull it all together.
A somewhat serendipitous re-reading of Frankl's,
Man's Search for Meaning, and an introduction to his
professional writings (1967, 1978) suggested that
"this was it." Namely, that difficult experiences provide caregivers the opportunity to find provisional
and ultimate meaning; that the process of finding
meaning or seeing the positive is a choice caregivers
can make; that their pre-existing values provide a
basis for meaning; and that caregivers have responsibility for right action and conduct (Farran et al., 1991;
Frankl, 1967,1978).
Two subsequent studies enabled us to develop
and test the Finding Meaning through Caregiving
measure derived from these qualitative data. The
measure was validated with general loss/grief, finding meaning, and religiosity measures (N = 46); the
measure was further validated with a larger sample of
Black and White caregivers using caregiver-specific
measures {N = 208; Farran, Miller, Kaufman, Donner, & Fogg, 1996). A third study examined finding
meaning as a resource variable in the prediction of
caregiver depression and global role strain in this
same sample of Black and White caregivers (N =
208). Mean differences between Black and White
caregivers were found for each of the three Finding
Meaning subscales, namely: Blacks reported lower
levels of loss/powerlessness and higher levels of provisional and ultimate meaning than White caregivers.
Multivariate analyses suggested that finding meaning
had direct effects in the prediction of two negative
caregiver outcomes (Global role strain and depression) but was not moderated by race (Farran, Miller,
Kaufman, & Davis, in press).
Several caregiver studies, using a stress/adaption
perspective, have identified constructs similar to
finding meaning. Pearlin etal., (1990) identified personal meaning as a positive caregiver resource. Lawton et al., (1992) identified traditional caregiver ideology as a potential predictor of positive caregiver
outcomes.
The Gerontologist
major contributions, and still other areas where an
existential paradigm appears to extend the stress/
adaptation paradigm.
Early attempts to operationalize existential constructs, such as finding meaning, were done by Crumbaugh and Maholick in their development of the Purpose in Life measure (1969) and the Seeking of Noetic
Goals test (Crumbaugh, 1977). A more recent and the
most comprehensive theoretical and empirical work,
using a life-span approach, has focused on development of the Life Attitude Provide-Revised (LAP-R),
Sources of Meaning Profile (SOMP), and Ladder of
Life Index (LOLI; Reker, 1992; Reker, Peacock &
Wong, 1987). The LAP-R, SOMP, and LOLI were used
to validate the Finding Meaning through Caregiving
measure (Farran et al., 1996b), and show that empirical
validation of these constructs is possible.
Along this same line, Ryff and colleagues have used
a social-psychological approach, including developmental psychology, clinical psychology, and mental
health, to affirm the importance of psychological wellbeing. Six dimensions of well-being have been verified using factor analyses. They include: personal
growth, purpose in life, autonomy, environmental
mastery, positive relations with others and selfacceptance (Ryff, 1989a, 1989b; Ryff & Keyes, 1995;
Ryff, Lee, & Na, 1993; Ryff, Lee, Essex, & Schmutte,
1994). These six factors have many similarities to what
has been identified as provisional meaning from an
existential perspective (Farran et al., 1991,1996).
The major strengths of an existential perspective
rest on its philosophy of science. Existential perspectives are deeply intuitive, and assume an interpretive
or phenomenological perspective (Reker & Wong,
1988; Yalom, 1980). This perspective suggests that
the whole can only be understood in context and
from the perspective of the persons involved — the
impaired family member, the family caregiver, and
other family members (Levineetal., 1984). It assumes
that humans are capable of symbolization and suggests that they "more than" respond to their environment, that they have the power to potentially
"transcend" the boundaries of their past, present
and future, and to both "discover" and "create"
meaning. Clinical and theoretical work suggests that
existentialism is relevant to caregivers of persons
with dementia (Frankl, 1967, 1973; Levine et al.,
1984), and empirical work further supports the
operationalization of these constructs (Farran &
Keane-Hagerty, 1991; Farran et al., 1996; Lawton et
al., 1989; Pearlin et al., 1990; Reker & Wong, 1988;
Ryff etal., 1993,1994,1995).
Model Similarities
Stressors/Suffering. — Stress/adaptation and existential paradigms use similar terms in reference to
difficult life experiences. A stress/adaptation paradigm uses more discrete and specifically operationalized terms that refer to care-receiver and caregiver
stressors. Care-receiver characteristics and potential
stressors include the impaired family member's illness severity, cognitive status, problematic behaviors, and functional status. Caregiver indicators most
commonly associated with stress include depression, psychotropic drug use and alterations in physical health (Kramer, 1997; Lawton et al., 1989; Pearlin
etal., 1990).
An existential perspective uses the broader term,
"suffering," and suggests that when individuals experience difficult life events they suffer on physical,
psychological, social, and spiritual levels (Missene,
1984; Soelle, 1975). Both of these perspectives identify the multidimensional aspect of stress and/or suffering. The stress/adaptation perspective has succeeded in identifying and operationalizing discrete
stressors, while an existential paradigm speaks to
overall effect of the caregiving experience — that of
potentially suffering.
A number of limitations concerning existentialism
can be noted. An existential perspective is not empirical in the typical sense. Its components cannot be
readily identified within a model, and relationships
among constructs are not necessarily assumed to be
linear, as with a stress/adaptation perspective. Empirical validation of existential constructs has also
lagged behind its basic tenets.
Stress/Adaptation and Existentialism:
Complementary Paradigms?
There are areas where the stress/adaptation and
existential paradigms have direct similarities, other
areas where the stress/adaptation perspective makes
Vol. 37, No. 2,1997
Negative and Positive Components/Dialectical Relationships. — A second major area where direct
similarities exist between these two models concerns
their interpretations about positive and negative
model components. Earliest caregiver research, using a stress/coping paradigm, primarily reflected
negative aspects of caring for a person with dementia
(Lawton et al., 1991). More recent caregiver research
has identified potentially positive aspects (uplifts;
Kinney & Stephens, 1989), positive mediating or resource variables such as managing meaning (Pearlin
et al., 1990), traditional caregiving ideology (Lawton
et al., 1989), and positive outcomes such as caregiver
satisfaction (Lawton et al., 1989).
An existential paradigm assumes that positive and
negative experiences and feelings have a dialectical
relationship — one cannot experience a full range of
health without at some point experiencing nonhealth or illness; one cannot be hopeful without
having experienced hopelessness, nor can one experience meaning without having experienced meaninglessness (Farran, Herth, & Popovich, 1995; Frankl,
1963, 1967, 1978). This dialectical relationship between potentially positive or negative constructs further supports the simultaneous existence of hassles
and uplifts (Kanner, Coyne, Schaefer, & Lazarus,
1981; Kinney & Stephens, 1989), caregiver distress
and well-being or satisfaction (George & Gwyther,
1986; Lawton et al., 1991), depressive symptoms, and
finding meaning (Farran et al., 1996a; Lawton et al.,
1992). The coexistence of these potentially positive
and negative (or dialectical) constructs provides fur-
253
ther support for a recursive model of caregiving
(Lawtonetal.,1991).
Model Differences
There are two areas where major differences are
noted between these two paradigms — one, in terms
of interpretation, and two, in terms of operationalization. A stress/adaptation is very cognitive, rational,
and linear in its interpretation. This perspective suggests that caregivers identify their stressors and their
level of distress, they draw upon their resources and
may subsequently reappraise their situation. When
they cope with these issues, problem-focused or
cognitively oriented strategies have been most effective in dealing with stress-related outcomes (Haley,
Levine, Brown, & Bartolucci, 1987). What may be
missing is the broader context and fluid perspective
offered by existentialism.
An existential paradigm, on the other hand, espouses values, freedom of choice, responsibility,
and consequences of actions (Nauman, 1971; Yalom,
1980). Frankl (1963) suggests that values play a major
role in determining how persons deal with difficult
life circumstances. Values may be expressed as caregivers creatively deal with their situation. They may
be expressed experientially through relationships or
feelings that persons have toward others. They may
also be expressed through attitudes or life beliefs. An
existential paradigm also maintains that persons have
freedom of choice, but this freedom is imbedded in
moral responsibility (Callahan, 1988; Klein, 1989) and
a willingness to assume the consequences for their
actions.
More recent caregiver research has explored the
relationship between such attitudinal variables and
stress, including: feelings of obligation (Albert,
1992), reciprocity, continuing a family tradition, mutual concern (Lawton et al., 1992), marital closeness
and gratification (Montenko, 1989), and inner
strength, social captivity, intimacy, love, and social
distance (Braithwaite, 1996). Largely unexplored
within caregiver research, however, are those values
which motivate persons to become caregivers and
the values that assist persons in dealing with difficulties associated with caregiving on an ongoing basis.
Also unexplored are caregivers' feelings of choice.
Do caregivers make a free choice to provide care to a
family member, or is this choice made out of fear
(Levine et al., 1984)? And finally, as clinicians and
researchers, we are concerned about the negative
consequences of caregiving. Are these natural consequences of a difficult life experience, or can we
intervene to promote more positive consequences?
It would appear that an existential paradigm may
assist us in asking some of these more difficult questions and a stress/adaptation perspective may assist
us in operationalizing such constructs as suffering,
values, choices, responsibilities, consequences of
actions, transcendence, and meaning.
Extension of the Model
There are two areas where an existential perspective not only builds upon, but could extend the
254
stress/adaptation paradigm. These include the area
of coping/transcendence and transformation, and
management/discovery or creation of meaning.
Coping/Transcendence and Transformation. —
The stress/coping paradigm has placed considerable
emphasis on coping — affective or emotion-focused,
and cognitive or problem-focused (Lazarus and
Folkman, 1984). An existential perspective, while not
referring to coping per se, acknowledges the affective (suffering, hope/hopelessness, meaning/
meaninglessness) and cognitive aspects (freedom of
choice) of dealing with difficult life situations, but
adds one important dimension — transcendence or
transformation of the experience or situation — that
is, the ability to "make sense of" or "rise above"
one's external situation.
While the stress/adaptation perspective refers to
the notion that caregivers may "reinterpret" and/or
"accept" their situation, an existential perspective
refers to transcendence and transformation of mind
and affect (Reker, 1991). This transformation may
occur as caregivers reappraise the situation, but in
this case, caregivers go one step further to "transform" the situation to something new (Cartwright et
al., 1994). Caregivers may identify making cognitive
and/or motivational changes, but they also identify
such things as having grown through the experience
of caregiving and becoming a stronger, better person because of this experience (Farran et al., 1991).
Frankl (1963, 1967, 1978) generally refers to this
ability to rise above one's immediate situation as
"will to meaning" or finding meaning through suffering. He suggests that persons "create" meaning by
making choices. In a situation of caregiving, for instance, these choices may include, but not be limited
to, making a choice as to whether to become a
caregiver at all, or making choices about one's attitude toward the caregiving situation such as appreciating the positive, finding paradox in the situation,
taking one day at a time, and/or using a sense of
humor (Farran et al., 1991). While many of these
approaches are similar to cognitive coping strategies,
a person's philosophical or life belief values distinguish how caregivers with particular value systems
may be "different from" or do "more than" just
making cognitive changes.
Management of Meaning/Discovery or Creation of
Meaning. — The major area where an existential
paradigm extends a stress/coping paradigm is with
respect to meaning. A stress/coping paradigm most
commonly asks, "What does it mean to provide care
to an impaired family member in terms of caregiving
tasks (stress appraisal), what resources are available
to caregivers, and what effect does this experience
have on caregivers (outcomes)?" An existential paradigm, on the other hand, asks, "How can I discover
or create meaning?"
Pearlin and colleagues, in their stress/coping caregiver model, suggested that management of meaning could serve as a caregiver resource variable
(1990). An existential paradigm suggests that meanThe Gerontologist
ing might function as both a resource variable or an
outcome variable. That is, positive approaches such
as finding meaning may "predict" more positive
emotional and/or physical health outcomes, but
higher levels of health might also "predict" higher
levels of finding meaning, suggesting a potential
reciprocal relationship overtime (Reker, 1994).
An existential perspective suggests that the process of finding meaning through difficult life experiences is based upon the values one embraces and
the choices one makes, as well as one's willingness
to assume responsibility for right action and conduct. FrankI (1963) also suggests that provisional and
ultimate meaning exist. Provisional meaning refers to
more short-term or transitory experiences that provide life with meaning, while ultimate meaning refers
to a person's exploration of deeper meanings in life
often associated with one's spiritual nature (Missine
& Willeke-Kay, 1985). In a qualitative study, caregivers reported finding provisional meaning when
they saw their care recipient's positive response to
care, felt confident that they were providing good
care, and through their own feelings that they were
growing or changing as a result of caring for their
relative (Farran et al., 1991).
Reker, in using an existential framework, suggests
that meaning can be both "discovered" and "created" (1991). For example, a caregiver with a
religious/spiritual value system may provide care for
a family member because it is "God's will" and
thereby discover or attribute meaning to a difficult
situation that otherwise might be meaningless. On
the other hand, a caregiver might also seek to "create" meaning in this situation. This "creation" of
meaning rests upon the "transformative" process
described earlier.
The major area of difference between an existential and stress/adaptation perspective is that in the
former, it is assumed that meaning can be discovered
or created — that is, one's situation can be changed
or transformed. This process has been likened to the
alchemists who desired to turn mundane elements
into gold (Cartwright et al., 1994).
Summary and Recommendations
The stress/coping paradigm, as applied to caregiving, is based upon a strong empirical history, but
current trends have suggested that this model
should be broadened. This article has proposed that
an existential paradigm serves as one alternative
method for extending this existing model. The article
has identified areas where stress/coping and existential models overlap, where they have distinct differences, and where an existential paradigm extends
the stress/coping paradigm, namely, with respect to
its attention to values, moral decisions, and the ability of humans to both discover and create meaning
through transcendence and transformation of difficult life experiences.
Combining what we know from a stress/coping paradigm and what we might learn by incorporating existential perspectives suggests that we may be able to
use more extensive research designs and methods to
Vol. 37, No. 2,1997
more fully answer the following questions. Prospective studies of caregiving could assist us to answer
such questions as "What abilities do persons bring
with them prior to assuming caregiving responsibilities, and how do these characteristics influence the
caregiving process and outcomes?" and "How do
prior values influence the decision to provide care to
an impaired family member, and the process and
outcomes associated with this experience?"
Studies that combine qualitative and quantitative
methods (Pearlin, 1992) would help us to address
such questions as "Can we assume that if we measure physical, mental, social, and spiritual aspects of
suffering, that we have captured the essence of suffering?" "Can we ever assume that we can capture
the full impact of what families experience in terms
of their suffering over the 5, 10 or 20 years during
which time they may care for a family member with a
chronic illness?" "How is it that family caregivers
"make sense" of these experiences and do so well
under difficult circumstances?" "Might there be
caregiver resources that have not yet been identified
and operationalized?" "What abilities do caregivers
develop while they are in the process of caregiving?"
"How is it that people find or create meaning?"
Longitudinal studies might answer such questions
as, "Can the transformative process of creating meaning be articulated by caregivers, and might it change
over time?" and "How does the experience of caring
for a family member affect the caregiver after the
death of the impaired family member?" "Is meaning
only discovered or created during the caregiving experiences, or does this process continue after caregiving responsibilities have been relinquished?" Intervention studies might focus on such questions as,
"Can finding meaning be taught and if so, how?" and
"What influence might the ability to find meaning
through difficult experiences have on caregiver outcomes?" (Farran & Keane-Hagerty, 1991).
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Received October 1, 7996
Accepted October 6, 1996
The Gerontologist
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