Before we proceed, let us clarify what we mean by spirituality. Social scientists draw a distinction between spirituality and religion, where the latter tends to refer to the external, institutionalized, formal, and doctrinal ways by which people engage with some concept of the sacred, transcendent, or divine (Dalby, 2007). Spirituality, by contrast, refers to personal, subjective, existential experiences (Gijsberts et al., 2011; de Jager Meezenbroek et al., 2012).

Theories of spirituality emphasize the human need to search for meaning and purpose in life (Muldoon and King, 1995; Daaleman et al., 2004; Emmons, 2006), and the universal desire to feel “at peace” (Steinhauser et al., 2006). These theories highlight how spirituality, especially in secularized Western societies, allows people to feel the divine within themselves, rather than as an external higher entity (Heelas, 2000), or link spirituality to a sense of connection with the essence of life (de Jager Meezenbroek et al., 2012).

There is a general consensus that spirituality is multidimensional in nature (Puchalski, 2012; Steinhauser et al., 2017). de Jager Meezenbroek et al. (2012), for example, described four dimensions of spirituality: Connectedness with transcendence as a higher being, connectedness with the self, connectedness with others, and connectedness with nature. Similarly, Fisher’s (2010) model of spiritual health and wellbeing recognizes four domains: (a) The personal domain, which deals with self-awareness as a source of meaning, purpose and values in life; (b) the communal domain, which concerns the quality and depth of interpersonal relationships; (c) the environmental domain, which relates to the notion of unity with the environment; and (d) the transcendental domain, which relates to one’s relationship with a higher entity. Those models both center around different orientations of spirituality. By contrast, Gijsberts et al. (2011), following a systematic review of instruments measuring spirituality in end-of-life populations, distinguish between three measurable dimensions of spirituality: spiritual wellbeing (e.g., peace); the spiritual cognitive behavioral context (e.g., spiritual beliefs, spiritual activities, and spiritual relationships); and spiritual coping.

Spirituality tends to develop during later adulthood, even in secular modern societies (Wink and Dillon, 2002, 2008; Moberg, 2008). Specifically, people tend toward more spiritual perspective from mid-life onward, where spirituality takes on an increasingly central role as people cope with aging and the approaching end of life (Gijsberts et al., 2011). Several explanations have been put forward for the development of spirituality in later adulthood, including awareness of one’s mortality that comes at midlife, and changes of priorities in life, since before midlife, external constraints associated with launching a career and establishing a family tend to be dominant. Other studies suggest that the adversities related to old age, such as the loss of meaningful others, exposure to ageism, and restricted mobility can direct many older adults toward spirituality as a resource (Wink and Dillon, 2002). Tornstam’s theory of gerotranscendence holds that as people age, they undergo a shift in perspective, from a materialistic and rational view of the world to one that is cosmic and transcendental (Tornstam, 1997). Gerotranscendence typically includes a redefinition of the self and relationships to others and a new understanding of fundamental existential questions. It is characterized by an increased feeling of affinity with past generations and a decreased interest in superfluous social interactions. Individuals become less self-concerned and interested in material things, and more selective in their choices of social and other activities (Hyse and Tornstam, 2009).

Studies have found associations between spirituality and various aspects of mental health and wellbeing in old age (McCauley et al., 2008; Reutter and Bigatti, 2014; Malone and Dadswell, 2018). Spirituality contributes for example to promoting and maintaining resilience in later life (Manning, 2013). It is associated with increased life satisfaction over time, and can influence older adults’ interpretations of events, making events seem generally meaningful, and determining whether events are seen as opportunities, rather than threats and demands (Cowlishaw et al., 2013). Spirituality can also act as a buffer against death anxiety (Budhiraja and Midha, 2017). Spirituality is also associated with lower COVID-19-related anxiety (Prazeres et al., 2020). In addition, spiritual fortitude, which refers to the ability to draw on spiritual resources in the face of stressors, is related to various facets of mental health, such as meaning in life, spiritual wellbeing, and perceived posttraumatic growth (Zhang et al., 2021).

Some studies investigating how spirituality may improve mental health in older age (e.g., reducing depressive symptoms) have focused on specific domains or dimensions of spirituality (Rykkje et al., 2013; Han and Richardson, 2015; Thauvoye et al., 2018; Lifshitz et al., 2019). The present study adds to this literature by exploring how different domains of spirituality were stimulated by the current intervention, following the orientational models of Fisher (2010) and de Jager Meezenbroek et al. (2012). This intervention is focused on the creation of digital photocollages together with narrative elements of dignity therapy.

Dignity therapy (Chochinov, 2002, 2012; Chochinov et al., 2005) is a brief individualized form of narrative psychotherapy, targeted at individuals of any age approaching the end of life (e.g., the terminally ill), as well as the older population (Fitchett et al., 2015). Dignity therapy involves the preparation of a physical generative document, which is based on the client’s personal narratives. The process of creating the generative document is structured around eight themes: generativity, continuity of self, role preservation, maintenance of pride, hopefulness, aftermath concerns, and care tenor (Chochinov et al., 2005). The full process is intended to increase people’s sense of purpose and preserve their dignity by giving them the opportunity both to reflect upon their lives, and to turn their life narratives into a resource for others (Chochinov et al., 2004). In the current intervention we related to these themes through three topics, one for each session: (1) Turning points in the personal narrative; (2) personal legacy; and (3) future perspectives. We describe our protocol in detail in the Supplementary Material.

Integrating the use of photographs within dignity therapy has been found to facilitate recollection and to help clients structure their narratives. Photographs serve as a projective stimulus, helping elicit past experiences, themes, and visual expressions that support the creation of the narrative (Testoni et al., 2019b, 2020, 2021). More precisely, visual images in photographs can reveal themes and topics which cannot be expressed by words alone, such as emotions, embodied expressions, and muted or sensitive aspects of personal experience (Weiser, 2018; Testoni et al., 2020, 2021). The photographs used in the therapy may be the personal snapshots or family photos belonging to the individual, or may come from some other source (e.g., stock images or art photos).

Collage is a popular practice in which participants select various materials and images, compose them, and attach them to a surface (Raffaelli and Hartzell, 2016; Russo-Zimet, 2016; Kaimal et al., 2020). Collage-making is an effective way of helping older adults process their memories and life experiences (Stallings, 2010; Keisari et al., 2022b). The creative process stimulates personal content and memories, while still allowing for a reflective distance that promotes verbalization and communication (Raffaelli and Hartzell, 2016). Collage also enables people to engage in art-making with less perceived threat, because it does not demand high technical skills (Stallings, 2010).

This study focused on the creation of digital photocollages, in which participants selected and composed photographs using software tools. Our previous findings show that the projective stimuli of digital photographs supported older adults’ narratives and engaged them in a more embodied emotional experience. Creation of a digital photocollage can thus serve as a visual generative document for participants’ life-stories (Keisari et al., 2022b). This study examined how expressions of spirituality were stimulated and reflected in this online creative arts intervention for older adults. Specifically, we explored which domains of spirituality were stimulated by the creative process, and expressed in the final created products (the photocollages).

Twenty-four community-dwelling older adults took part in the study, including 12 in Italy and 12 in Israel. Participants were recruited through community coordinators, social workers at day centers, and family members. Inclusion criteria for the study were: (1) An age of 78 years or over (i.e., late aging); (2) a Mini-Mental State Examination above 24 (reported by social workers and family members), indicating normal cognitive performance (Woodford and George, 2007); (3) absence of any mental disorder or major depression; (4) vision and hearing sufficient to engage in online conversation; and (5) access to a computer screen large enough to engage in the creative process (smartphone screens were not appropriate).

After receiving initial consent to take part in the study, the researchers conducted an introductory phone call with all participants to explain the study aims and content. Participants provided formal verbal recorded informed consent at the start of the first online session (see below).

The study was approved by the Ethics Committee for Experimentation, University of Padua (confirmation number 0581B1B9C39761AE3C03AD3D93EFDEE9) and by the Ethics Committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa, Israel (confirmation number 366/21). To preserve confidentiality, pseudonyms are used for the participants.

The short intervention involved a series of individual online sessions, in which participants made three photocollages. The sessions were structured around themes drawn from dignity therapy. Each session was focused on the exploration of one theme: (1) Turning points in the personal narrative—significant life events and related themes, roles, and coping resources (McAdams, 2001; Chochinov et al., 2002; Keisari and Palgi, 2017); (2) personal legacy—how the participant wished to be remembered, and what values and lessons they would like to pass on to their loved ones (Chochinov, 2002; Testoni et al., 2021); and (3) future perspectives—desires, thoughts and concerns regarding the future and the end of life (Lang and Carstensen, 2002; Testoni et al., 2015, 2017). The full protocol (Keisari et al., 2022b) and TIDieR checklist (Hoffmann et al., 2014) can be found in Supplementary Material.

The sessions were conducted via Zoom, with the “share screen” function operational. At the start of each session, the themes and related questions were introduced by the therapist using as prompts a set of artistic photos, selected in advance for their ability to serve as visual metaphors for that session’s theme (Weiser, 2004). The full pool comprised about 80 photographs, either original images by Israeli photographers Michal Fattal and Yehudit Liberman, or licensed photos obtained from the iStock website.¹ Participants were asked to view the presented photographs, choose those that most reflected their own personal experiences in relation to the themes raised by the therapist, and arrange them together within a blank space on the screen. This was done using PowerPoint software, which is available on most computers and enables flexibility in the creative process of selecting, cropping, positioning, and titling digital photographs. Participants were also permitted to select and incorporate personal photographs, or other photographs taken from the Internet (all such photos were replaced by licensed photographs from the iStock website for this publication). At the end of the process, the digital photocollages were printed and sent to the participants.

The sessions were conducted by the first (SK), second (SP), fourth (TE), and fifth (GM) authors, with each participant working with one therapist. The first author is a supervisor and drama therapist specializing in clinical gerontology. The second and fourth authors were doing internships in clinical psychology and drama therapy, and the fifth author was a master’s degree student in clinical psychology. Two of the therapists (native Italian speakers) conducted the sessions in Italy, and two (native Hebrew speakers) in Israel. The sessions were conducted as a therapeutic process, so that the relationship with the researchers were therapeutic in nature, as this provided a safe, positive and corrective experience for the participants to promote self-development.

To ensure adherence to the protocol, the first (SK) and sixth (IT) authors conducted five training sessions with the team (2.5 h each) prior to the intervention in order to gain familiarity and practice how to deliver the intervention. In addition, 90-min online supervision sessions were held twice a week during the course of the study by the first author. During these sessions, the student therapists were able to discuss their work and receive professional support. Overall, 22 supervision sessions were conducted.

All sessions were video-recorded and later transcribed for analysis. The qualitative data collected for the study thus included both a verbal component (the transcribed sessions) and a visual component (each participant’s chosen photographs and photocollages).

The analysis employed abductive reasoning, a pragmatist approach to analyzing qualitative data (Tavory and Timmermans, 2014). Following this approach, we began by drawing observations from the data (both verbal and visual), and then sought to make sense of those observations by examining them against theories and conceptualizations found in the literature (Timmermans and Tavory, 2012; Brinkmann, 2014; Earl Rinehart, 2020). This process led us to narrow our focus to the dimensions of spirituality revealed by the data. Specifically, we asked the following question: which dimensions or domains of spirituality were stimulated by the creative process, and expressed in the final created products (the photocollages)?

After selecting our research question, we conducted a polytextual thematic analysis (Gleeson, 2020) of both the verbal and visual data. The dataset was analyzed by the four researchers who had conducted the therapy sessions, using the Atlas.ti 9 cloud software, which allows for a team of researchers to work and analyze the same data together using a shared code set. The visual data were analyzed in relation to the participants’ perspectives. Accordingly, the analysis focused on the participants’ reflections on the visual images, their description (e.g., in terms of colors, shapes, movements, and texture), and the subjective experiences prompted by the photographs and the final photocollage. In addition, the final art products of photocollage were also analyzed by the research team, who took ongoing notes on the themes during the observation.

In the first step, the four researchers reviewed the data of the verbatim transcriptions along with the visual photograph and photocollage data. The verbal data were produced in three languages: Italian, Hebrew, and English (as three of the Israeli participants were native English speakers, their sessions were conducted in English).

In the second step, the researchers conducted an initial coding of the data. The initial coding was conducted in the original language. The two Italian researchers (SP and GM) coded the Italian data, and the two Israeli researchers (SK and TE) coded the Hebrew and English data.

Initial coding by two researchers served to maintain reflexivity since the researcher who conducted the session as a therapist, had an insider’s perspective on the data, whereas the other had an outsider’s perspective. Both perspectives shed light on the effects of one’s position vis-à-vis the phenomenon (Berger, 2015).

To allow the Italian and Israeli researchers to work together, the codes were labeled and defined in English. During this stage, the four researchers met twice a week to review and discuss sample quotations from the transcripts, to ensure that the code definitions were consistent and appropriately applied to the responses. In cases of disagreement, the researchers discussed the coding process until an agreement was reached. These team consultations during the analysis process served to identify possible projections and content missed by the researchers (Berger, 2015).

In the third step, following the abductive reasoning (Tavory and Timmermans, 2014), after the initial set of codes was created, the researchers examined the codes against the theories and conceptualizations in the literature to identify significant broader patterns of meaning, and the codes were grouped into themes and subthemes. For example, the researcher identified the codes of “sense of contributing,” “couplehood as coping resource,” “generativity,” “friendship as coping resource,” “forgiveness,” “universalism,” “care in the family,” and grouped them into three themes: “Connectedness with significant others,” “a sense of contributing to others,” and “caring for humanity.” In the next step, the researchers created links between these three themes to form one core theme labeled “connectedness with others.” The coding and analysis processes ended when theoretical saturation occurred and new data could not contribute to the theme (Fusch and Ness, 2015).

In the fourth step, the candidate themes were checked against the dataset and refined if needed. At this stage, selected quotations were translated to English to enable the third (HO) and sixth (IT) authors to review the thematic map. Note that the translation was verified by the two native speakers (Italian and Israeli) to ensure that no meaning was lost during the translation process. Finally, in the fifth step, the themes and subthemes were organized to create a model.

The first theme represents expressions of spirituality that involve connectedness to the self. This theme manifests as an interest in and pursuit of inner knowledge of the self, despite the changes that accompany older age. The theme has four subthemes: continuity of the self, positive solitude, self-care, and an integrative view of the self.

The second theme, already mentioned, represents expressions of spirituality that involve connectedness with other people. Three subthemes were identified within this theme: connectedness with significant others, a sense of contributing to others, and caring for humanity.

The third main theme relates to feelings of connectedness with nature and with other living creatures.

Yossi, an 80-year-old Israeli man, selected an image of a man, seen from behind, gazing out over a wintry landscape (Figure 9) to represent the value of profound connectedness with the world. The image allowed Yossi to relate COVID-19 as a transient event:

Nature can also symbolize connectedness to other generations and the deceased, as Tova, an 82-year-old Israeli woman, explained. We may note here again how the environmental domain overlaps with the communal. Just as connectedness with nature linked Lea to her memories of friendship, for Tova a connection with nature helps her cope with the loss of her beloved husband:

This theme also includes elements of gratitude and appreciation for the simplest things in life. Francesco, an 85-year-old Italian man, when asked to think of a title that would summarize the essence of the three photocollages he created, proposed “The sun gives you the strength to live”:

The final theme represents spirituality as expressed in connectedness with a transcendent reality or power. The Italian and Israeli participants related differently to this theme. As nearly all of the Italian participants in this study were religious Catholics, many chose images that either had an explicit religious theme or could be interpreted as religious; and they positioned those images more centrally than the Israeli participants. As such, the Italian photocollages often related to faith and religiosity as something that one can cling to during times of adversity. Margherita, an 83-year-old Italian woman, chose a photograph of a church to represent a hope that both she herself and younger generations would keep faith as a coping resource. She called this photo “For a better future”:

Elena, an 87-year-old Italian woman, chose a photograph of a couple looking at the sunset to talk about how she and her husband discovered their spiritual dimension. She explained how faith helped her to cope when her husband was ill in cancer.

She later added how her faith helped her to accept the difficulties and restrictions that followed the COVID-19 pandemic. She positioned a photograph of a cross above all the other photos in her photocollage, explaining that it was the most important one and that she wanted it to embrace all the others:

For the Israeli participants, traditional Jewish rituals and prayers served as a path to the transcendence domain, rather than religious faith itself, as presented by the Italian participants. Moshe, an 81-year-old Israeli man, positioned the photo depicting a candle (Figure 10) to describe how the Jewish ritual of lighting candles on Friday night helped him to cope with the absence of his wife. This is another example, too, of how the domains of spirituality sometimes overlap. For Moshe, a connection with the domain of transcendence created a path to the presence of his deceased wife.

Next to this photo, Moshe positioned the photograph of a man gazing out over a solitary landscape and added: “And the part where I sit there alone, put it [in the photocollage] […] next to the candle.” He also asked us to include the poem by Holland (1910) in the collage, to further represent and reflect the continuous bond with his deceased wife.

Noah, a 91-year-old Israeli man, chose a photograph of perching birds (Figure 11) to represent his appreciation of life and nature. He also linked this image to a Jewish prayer which expresses gratitude for being alive:

The expressions of spirituality stimulated by the creative process capture the multidimensional nature of spirituality as shown in the literature (Fisher, 2010; de Jager Meezenbroek et al., 2012; Puchalski, 2012). This is one of the first studies to use visual artistic methods to explore these dimensions with the older population. The findings show how photographs, as projective stimuli, allow for intense spontaneous expressions of spirituality in a manner that is flexible and responsive to different needs and perspectives. This is important, because other studies’ findings show that maintaining a connection to different dimensions of spirituality is associated with better mental health and coping in times of adversity, both in general (Whitehead and Bergeman, 2012; Thauvoye et al., 2018; Lifshitz et al., 2019) and specifically during the COVID-19 pandemic (Ribeiro et al., 2020; Lucchetti et al., 2021; Keisari et al., 2022c). The ability of the intervention to connect the participants to the various domains of spiritually as coping resource is crucial, since studies have shown that the COVID social distancing restrictions caused psychological distress for many, including more symptoms of depression (Fountoulakis et al., 2022; Keisari et al., 2022a).

The current findings contribute to the growing body of studies that use photographs with older participants to prompt greater expression and deeper exploration of the participants’ thoughts, feelings and experiences (Kohon and Carder, 2014; Tishelman et al., 2016; Platzer et al., 2021). While most studies in the field use the photovoice method, which refers to the participants’ own production of photographs in relation to the research topic (Baker and Wang, 2006; Woda et al., 2018; Chui et al., 2020), or photo elicitation, which refers to the use of photographs in qualitative interviews to encourage participants to reflect on particular topics (Platzer et al., 2021), the current study with photocollage uses both ways: the photographs served as projective stimuli to elicit the personal content, and as raw material collected by the participants to make their own artistic product. This stimulated personal content, while also capturing and containing it in a concrete artwork that the participants could then create, observe and reflect upon (Keisari et al., 2022b).

The differences that were found between the Italian and Israeli participants in this sample mirror the familiar and well-established observation that within secular Western societies, people are likely to search for meaning in life within themselves, rather than on the basis of external rules or a connection with a higher entity (Heelas, 2000; de Jager Meezenbroek et al., 2012). These findings also point to the importance of considering intercultural differences in spirituality, and in the dominance of different spirituality domains (Thauvoye et al., 2018; Lifshitz et al., 2019), when designing interventions aimed at offering or strengthening spiritual care.

To the best of our knowledge, this is one of the first studies to develop an online creative arts intervention for older adults, which can be conducted during periods of social distancing (Kordova and Keisari, 2020; Feniger-Schaal et al., 2022). As such, the method goes beyond the current COVID-19 pandemic, as it can also be applied in other circumstances that entail social isolation—for example, among individuals who are homebound or have limited mobility (Milaneschi and Penninx, 2014). This creative online intervention can also be implemented in palliative care, as it is based in part on dignity therapy, known to make a key contribution to the wellbeing of individuals at the end of life (Chochinov, 2012; Fitchett et al., 2015; Testoni et al., 2019a). The current findings are also in line with studies indicating that interventions based on dignity therapy support the existential tasks faced by the majority of older adults, such as settling relationships, and preparing legacies of memory and shared values, as well as preparing for the end of life (Fitchett et al., 2015; Scarton et al., 2018).

Finally, the research methods and findings presented here can enrich narrative therapy protocols for the aging population, such as dignity therapy (Chochinov, 2002) and life review (Westerhof and Slatman, 2019). We found that both engaging with the individual images in the photographs, and the act of meaningfully positioning them in photocollages, helped participants find spiritual meaning in their personal narratives. Thus, narrative therapy protocols could benefit from being expanded to include the visual and creative elements of photocollage.

By definition this study consisted of a sample of older adults with access to the Internet and videoconferencing applications. This sample is thus not representative of other groups of older adults experiencing high levels of social isolation during the COVID-19 period, such as nursing home residents, individuals experiencing cognitive decline, or those lacking access to the Internet. The short-term nature of the intervention is also a concern. As mentioned, most of the older adults in the current study were living alone during the social restrictions of COVID, and a longer-term process might have been more beneficial for them.

Future research would benefit from replicating the current intervention with various aging populations, such as older adults with dementia, and in different care settings, such as nursing homes. It is also important to examine the experience of participating in a long-term intervention as a creative process that encourages learning and growth over time. Future studies might also examine the effect of longer-term creative online interventions on various wellbeing measures.