Ah Love! could thou and I with Fate conspire
To grasp this sorry Scheme of Things entire,
Would not we shatter it to bits—and then
Re-mould it nearer to the Heart’s Desire!
Omar Khayyam (1965, Rubaiyat 73)
Introduction
Life follows a natural process of beginnings and endings, or transitions that can enhance or hinder transformation and self-growth. Most people make approximately 10–20 major transitions over their lifetime. Most transitions are triggered by a turning point or event (Sugarman 2004). The way the individual responds to the trigger is more important than the trigger itself (Rogers 1991). That is, change is neither good nor bad: the way the individual perceives the change makes it one or the other.
Adaptation to small transitions often occurs through learning: however, more significant transitions that challenge self-identity, beliefs, behaviour and hope require significant reflection, healing and adaptation. Accepting change, even positive change, healing and adapting usually takes time (Williams 1999).
Transitions are crucial opportunities for healing, self-growth and development (see Chapter 5) and self-growth is possible until the moment of death, which some people regard as the ultimate transformation. Life transitions are challenging because they force people to let go of the familiar and move into the future. Making major transitions involves grieving and follow a similar emotional roller coaster as grieving over any loss (Kubler-Ross 1969). Transitions are also part of an individual’s spiritual life journey (becoming) and usually require some degree of change: although most people tend to resist change, even when the benefits are clear.
The seven ages of man
There are many psychological and philosophical theories to explain common life stages and transitions: most encompass psychological, social, spiritual and moral development from various perspectives. Many of these theories also influenced teaching, learning and health-care practices. Such life stages are often referred to as the ‘ages of man’.
The ‘ages of man’ is a well-known theme in art and literature: but the number of ‘ages’ described varies, for example ancient philosophers such as Aristotle described three or four ages, while medieval philosophers usually described seven ages.
One of the best-known descriptions of the ‘seven ages of man’ is Jaques’ monologue in Shakespeare’s (1964) play As You Like It (Act II Scene iv), which begins:
First, the infant, mewling and puking in his nurse’s arms
Shakespeare then describes childhood, the lover, the soldier, the justice, old age, and finally the seventh stage, dementia and death:
In that second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
The aim of each stage is to redefine the self. Jung referred to the search for identity as ‘individuation’, Maslow called it ‘self-actualisation’ and Sheehy ‘gaining authenticity’. These terms all refer to the process of defining the ‘individual self’, fulfilling group expectations and achieving a balance between independent creative freedom and belonging to a common group.
Common descriptions of life stages include infancy and adulthood but the stages of childhood and adolescence are perhaps better known than the stages of adulthood. The latter is the main focus of this chapter. Although people’s experiences and emotional responses to life transitions are individual and personal, there are many commonalities (Erikson 1950; Williams 1999; Sheehy 1995). Erikson (1950) believed that although many personality characteristics are inborn, some are learned from the challenges and support the child receives as they mature, and significantly, the effects of culture and events in the external world such as war.
Thus, Erikson regarded development as an outcome of the interaction among genetic programming, the psyche and ethos (cultural) influences. Erikson indicated the child’s world gets bigger as they grow and mature and regarded failure as the result of cumulative negative events.
In contrast, Levine (2008) regarded human development as a spiralling cycle rather than hierarchical stages that each need to be completed before the next stage begins. Likewise, some versions of Kubler-Ross’ (1969) grief cycle portray the grief response as a circle consisting of various stages:
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Some later versions of the grief cycle include ‘shock’ as the first stage of grief and insert a ‘testing’ stage after the depression stage. Significantly, the grief cycle is not peculiar to death and dying: these emotional reactions apply to any bad news and loss. The diagnosis of diabetes represents bad news and loss for many people (Chapters 2 and 10) and many people with diabetes experience most, if not all the stages in Kubler-Ross’ grief cycle (figure 15.1, Dunning 2009, p. 420). Others accept the diagnosis and are relieved ‘it’s diabetes and not something worse like cancer’.
Interestingly, life transitions are sometimes regarded as major crises. The two Chinese characters wēi jī are widely believed to mean danger and opportunity by motivational speakers, but the interpretation may not be completely accurate. Wēi jī does contain elements of both meanings. Wēi means danger or risk; jī has many secondary meanings including crucial point (similar to the western trigger or turning point). Linguistic experts generally agree a close approximation of the meaning is ‘precarious moment’ (Mair 2009); thus, the way the individual views the precarious moment and deals with the situation makes the crisis an opportunity or a threat. Wēi jī is shown in Figure 8.1.
Figure 8.1 Wēijī, the Chinese character for crisis, with special thanks to Yen Yang for the calligraphy.
Common major life transitions
A broad overview of human growth and development and the major transitions (ages and stages) are shown in Table 8.1. As indicated, the focus of this chapter is on adult life transitions. Life transitions are defined as:
Predictable changes in our lives associated with a discontinuity with the past. With each change we must give up the protective structures which have carried us through and then face the world anew.
Emotional Wellness Matters (1998–2004)
Bridges (1991) divided transitions into three major stages: an ending, a neutral zone and a new beginning. It is essential that people let go of the old/known in order to move on to a new beginning. New beginnings can be challenging, especially when the trigger event is unexpected and viewed as a threat or danger. Endings are difficult for most people: ‘better the devil you know than the one you don’t’. Some people avoid letting go by clinging to their old, known ways (denial); others dismiss the old: ‘it’s in the past, it’s no longer relevant’. Most experts maintain it is important to let go because closure is a critical part of transformation and enables the person to move on (Bridges 1991; Sheehy 1995; Levine 2008).
In addition to the three major transitional stages, Bridges (1991) described the ending process as having four stages: disengagement, disidentification, disenchantment and disorientation.
Disengagement
Disengagement involves making a break from usual roles, activities and situations. Disengagement refers to psychological disengagement and the ability to reflect on the past objectively. It does not necessarily entail physically leaving or moving.
Disidentification
Disidentification refers to reflecting on and adjusting self-concept, for example, changing one’s concept of being a younger person and accepting one has reached middle age (the mid-life crisis) or accepting oneself as a person with diabetes when the diagnosis is made (see Chapter 2). Inner conflict can occur and impede the transition process if self-concept is not adjusted.
Table 8.1 Broad stages of growth and development organised according to the primary development tasks in each stage; however, the ‘boundaries’ of each stage are not fixed: individual differences need to be considered.
These definitions come from many sources; refer to Box 1. In addition to classification by age, life stages are defined culturally and socially. These ages and stages influence learning and skills acquisition. They impact on and are affected by diabetes.
| Life stage/transition Stages are variable but occur about every 6–10 years | Major ‘tasks’ associated with the stage People question and reappraise existing life structures and explore possibilities for the future |
| Early childhood: birth to age 8 | Associated with rapid growth. The primary task is developing skills including fine motor skills Socioemotional development occurs at about 1 year. Thus, attachment becomes critical and the quality of the attachment can affect later relationships Cognitive development including acquiring language By 8, children have a basic understanding of some abstract concepts but still reason in a concrete way and have difficulty understanding abstract concepts |
| Middle childhood: 8–12 | The primary development task is integration, within the individual and within the social context Cognitive skills, personality, motivation and inter-personal relationships develop and children learn to value society Independence increases, friendships and interests develop Skills required for academic success become more complex and challenging |
| Adolescence: 12–18 | A diverse number of changes occur simultaneously and bring many new responsibilities and move the adolescent towards independence The primary development task is forming an identity Individuals develop their self-concept within their peer group. Conflict between identity and role can occur as the individual tries to match who they want to be with what is socially acceptable and meet other people’s expectations Hormonal, mood changes and behaviour influence each other, fluctuate and can affect self-esteem Adolescence is usually accompanied by a growth spurt and cognitive development; but growth varies among individuals and between the genders Sexual maturation occurs during adolescence |
| Early adulthood: 18–30 | Begin to develop meaningful relationships and their work and life path The individual can become isolated if they are unable to develop satisfying relationships with a partner and friends and may seek or avoid commitment |
| Mid-life: 30–40 | Perplexing dissatisfaction can occur and is often associated with an event such as loss of a job or divorce, which can be a shock and triggers the need to re-authenticate self People may have outgrown some of their earlier life choices and explore neglected aspects of the self such as likes and dislikes and hobbies Ages 37–42 are peak anxiety years |
| 40–50 | ‘Life begins at 40’ Stagnation and disequilibrium often occur in the early 40s: people ask: ‘was it worth it? Is this all there is?’ Mid-40s is often a period of stability and renewed purpose and independence |
| 50–60 | Often a more settled time Many people prepare to retire or retire, which might create financial constraints and new opportunities |
| Older age: over 60 | Many people remain active but physical and mental changes become apparent Some people develop health and other problems that affect their independence Preparing for end of life care becomes more important as the person grows older Friends and relatives may die and create loneliness and stress |
Disenchantment
When an individual’s situation and self-concept changes, they question past actions and assumptions that supported and defined the old situation, for example the belief that their marriage would ‘last forever’ or they would always be young and healthy.
Disorientation
Disorientation is often uncomfortable and confusing. Things that were meaningful no longer seem so important. Frankl (1969) agreed with other psychologists that biology and conditioning shape people’s personalities and behaviours but maintained people were multidimensional and possessed free will (choice) to determine the meaning and purpose of their lives and take responsibility for their decisions.
Once the ending process is accomplished and the person resolves the emotional issues, they enter the neutral zone.
Neutral zone
In the neutral zone, people often take time to be alone and think, reflect and/or pray without the constraints of the old world. People often emerge from the neutral zone with new insights that prepare them for the new beginning. Thus, the neutral zone can be a time of healing and renewal in preparation for a new beginning.
A new beginning
As new information and experiences are understood and put into context, individuals develop the confidence to move on. People may seek external signs of their new beginning, but essentially the change comes from within through reflection and applying their new self-knowledge. When the new direction is clear, the new life stage begins. Significantly, new beginnings require continuity with the past because the past is a valuable knowledge store and resource for the future. Compassionate understanding of and insight into what the transition means to the individual and therapeutic support from health professionals, family and friends can enhance the likelihood the person will find meaning in the event and make a positive transition and self-growth.
As people go through the transition stages they:
- Experience a range of emotions such as loss of control, anxiety, anger, self-doubt, confusion, vulnerability and loss of self-esteem/self-image. However, the initial reaction depends on a number of factors including whether the transition is positive or negative and the individual’s coping style, locus of control and resilience.
- Experience a defining moment when they begin to accept the need to change—the turning point.
- Enter a recovery phase where the individual acknowledges the need to let go of the past in order to move forward. Letting go of the past is not the same as rejecting it.
- Begin to feel hopeful and optimistic about the future, self-esteem increases and they begin to feel able to take control over the situation and the future. There is a difference between being ‘in control’ and controlling. The latter concerns micromanaging: being in control refers to attending to what can be done, focusing on the positive, utilising available resources and being proactive.
People move backwards and forwards through the transition stages; the transition may take some time to accomplish, often months to years. Some very poignant accounts of significant health issues clearly show the human potential to heal and that people continue to find meaning and recreate the self, even in the face of devastating disease, for example Bailey’s The Sound of a Wild Snail Eating (2011) and Bauby’s The Diving Bell and the Butterfly (1997), Sacks’ The Man Who Mistook His Wife for a Hat (1985) and the movie The Doctor (1991) (Levinson 1978).
These stories highlight the importance of ‘knowing what sort of person has a disease’ (Hippocrates 460–377 BC) and could be essential reading for all health professionals.
Major life transitions
Major adult life transitions happen at roughly the same ages for all people and are associated with common feelings. Rogers (1991) suggested people should view life as a flowing process and accept themselves as a continual ‘stream of becoming’ rather than as an unchanging finished product. Life transitions can be key risk times for people with diabetes ‘going off the rails’, being ‘out of control’, having blood glucose ‘all over the place’, not undertaking appropriate self-care and hence suffering emotional distress.
These reactions suggest turning points and life transitions should be considered when taking a health and diabetes history, planning diabetes education and care, the annual complication assessment and when an individual is emotionally distressed.
Table 8.2 Major diabetes-related transitions that are superimposed on or drive usual life transitional stages.
During life and diabetes-related transitions, unstable blood glucose levels and emotional reactions are common and can affect self-care and coping.
| Diabetes-related transitions | Relationship to stages of the major life transitions |
| Predicaments | Normal |
| Diagnosis of diabetes | Ending of the old but it is common for people to deny the diagnosis, often for a long time in an attempt to hold onto the old/known life |
| Diagnosis might occur during another illness, a diabetes complication or during pregnancy | |
| These factors create additional uncertainty, fear and vulnerability | |
| Moving among care services, especially moving from child to adult care settings | Ending and a new beginning and may be neutral for some people |
| Commencing insulin especially for people with type 2 diabetes | Often engenders fear and the need to reassess life habits |
| Developing a complication | Loss |
| End of life | The ultimate transition |
In addition to life transitions and their effects on diabetes, diabetes-related transitions occur and also require the individual to reflect on and adjust to change (see Table 8.2). It can be particularly difficult for an individual with diabetes when a life transition coincides with a diabetes-related transition, which is common, for example when a woman develops gestational diabetes during pregnancy and learns she needs insulin or when an adolescent moves from paediatric diabetes services to adult services.
Transitions cause significant stress within relationships. For example, most married couples enter major life transitions such as the mid-life crisis at different times; unless they have a good relationship and communicate effectively, the marriage may not survive. Moving from paediatric to adult care is stressful for the individual and their family and often involves several simultaneous transitions, for example, leaving school, leaving home and commencing work or university.
Key transition triggers/turning points for people with diabetes include leaving school and leaving home, commencing university, graduating from university, marriage and childbirth (Rasmussen et al. 2007). Some transitions such as childbirth have sub-stages: prenatal, pregnancy, and post-natal, which have different risks and require different problem-solving and coping strategies, some of which threaten independence. Rasmussen et al. (2007) found the transition to motherhood triggered a guilt dynamic between mothers and daughters that caused them stress and to question themselves, which had not been recognised previously.
Sometimes people do not make successful transitions—they remain ‘stuck’ often in the ending stage and are unable to move on. Some people want to stay within the security of the known, for example people with type 2 diabetes often try to avoid commencing insulin:
No matter what I do I cannot get my blood levels [glucose] down. Now the doctor is saying I am not eating the right things and I have to do exercise or he will put me on insulin. That is the last straw—the failure straw. I am trying to look after my wife since her stroke I can’t start insulin now.
The degree of support and quality of the relationships available to the individual and their sense of personal control over the situation have a significant effect on the transition process, but ultimately the transition and related decisions are the individual’s responsibility. As Dr Seuss said:
You have brains in your head.
You have feet in your shoes.
You can steer yourself any direction you choose.
You’re on your own, and you know what you know.
And you are the only one who’ll decide where you’ll go.
(Dr Seuss 1990)
Signs a person may be entering or is in a life transition
People respond differently to major crises but there are some common behaviours that could indicate an individual is entering a major transition. These include:
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