key: cord-0781078-ebh59adi
authors: Flett, Gordon L.; Heisel, Marnin J.
title: Aging and Feeling Valued Versus Expendable During the COVID-19 Pandemic and Beyond: a Review and Commentary of Why Mattering Is Fundamental to the Health and Well-Being of Older Adults
date: 2020-06-15
journal: Int J Ment Health Addict
DOI: 10.1007/s11469-020-00339-4
sha: 8446fd41ddabcaba3b9d0684f29e788cced63f5d
doc_id: 781078
cord_uid: ebh59adi

The current commentary and review examines the potentially protective role of feelings of mattering among elderly people during typical times and the current atypical times associated with the COVID-19 global pandemic. Mattering is the feeling of being important to others in ways that give people the sense that they are valued and other people care about them. We contrast this feeling with messages of not mattering and being expendable and disposable due to ageism, gaps in the provision of care, and apparently economically focused positions taken during the pandemic that disrespect the value, worth, and merits of older persons. We provide a comprehensive review of past research on individual differences in mattering among older adults and illustrate the unique role of mattering in potentially protecting older adults from mental health problems. Mattering is also discussed in terms of its links with loneliness and physical health. This article concludes with a discussion of initiatives and interventions that can be modified and enhanced to instill a sense of mattering among older adults. Key directions for future research are also highlighted along with ways to expand the mattering concept to more fully understand and appreciate the relevance of mattering among older adults.

This article is about the need to matter among older people. The quote above from Nancy Schlossberg from her seminal work on mattering versus marginalization reflects the fact that even though people can and do differ enormously, they share a need to feel valued and significant to other people who care about them. They also share a basic need to feel connected to other people and feel a sense of fit rather than feeling like a misfit. These common needs to matter to others and to belong fit well the general belief that people of all backgrounds are more similar than they are different, and that we should focus to a greater degree on commonalities and what brings us together than on apparent differences which can serve to divide us.

The need to matter applies to people of all ages and of vastly different backgrounds and cultures. It is a feeling that is relevant from the cradle to the grave and it is a global and universal need. There is still room for individual differences, however; some people will always have a stronger need to matter than will others, just as some may be more sensitive to perceived social connections and support. Moreover, at present, billions of people feel like they actually do matter, while billions of other people feel like they do not matter or they do not matter as much as they should. This sense of not mattering enough is especially common among people who feel marginalized and left behind for social, political, economic, or other reasons, rather than feeling cherished and valued as human beings.

The current article is both a review and a commentary focused on mattering in older people. It is based on a thorough and systematic search using multiple search engines, including Google Scholar, to identify any relevant research conducted on mattering among older people. Most of the review focuses on articles in refereed journals, but detailed empirical results found in two key chapters are also provided (see Fazio 2009; Pearlin and LeBlanc 2001) . Our overarching goal was to be as contemporary and as up-to-date with both our review and our commentary as possible. In this regard, we also refer to national and international events pertaining to the treatment and care of older people that have quite recently occurred during the pandemic.

So why our current focus on the need to matter among older adults? And why focus on this need now at this point in time? There are three interrelated reasons. First, in their work that introduced the mattering concept, Rosenberg and McCullough (1981) observed astutely that mattering is particular relevant for two groups of people-young people and elderly people. Specifically, they suggested that, "Mattering may be relatively high among children and adults, among adolescents and old people. The young child feels that he matters because the world revolves around him, because he is the center of the universe. The adult matters because he runs the world" (p. 180). Regarding the relevance of mattering to older people, Rosenberg and McCullough (1981) went on to note that mattering is tied closely with the transition to retirement. Here they addressed the core fear that haunts many retirees by noting that, "It has been suggested that one problem of retirement is that one no longer matters; others no longer depend upon us" (p. 180).

Second, the need for older people to feel like they matter and to wonder how much they actually do matter is a very salient theme right now as the COVID-19 global pandemic continues. The messages from many political leaders are centered appropriately on urging people to engage in physical distancing, while awaiting development of vaccines and antibodies because this practice will help stop the spread of the virus and this is especially required to protect older and immunocompromised people who are more susceptible to the ravages of the coronavirus. This message is often wrapped around the theme that older people are cherished and we need to do whatever it takes to protect their health and well-being during this high-risk period. This focus includes the recognition that self-isolation practices implemented to counter COVID-19, albeit well-intentioned, disproportionately impact older adults and urgent action is needed to limit the mental health and physical health impacts among isolated older people (see Armitage and Nellums 2020) .

Finally, it is generally accepted that there are many challenges that have been brought about by the COVID-19 global health crisis and the requirement that people engage in physical isolation. Anxiety is heightened due to concerns about personal safety and the uncertainty of how and when the pandemic will be resolved. Moreover, as noted above, physical distancing has led to the experience of social isolation among some people, especially those who are living alone and those who may lack web-enabled smartphones or other electronic devices that could help them remain in contact with friends and loved ones. Loneliness is already a profound public health concern, especially among older people, and physical isolation is adding exponentially to the social isolation that is typified by loneliness. It was a grave concern in the USA before the pandemic; this was illustrated by the US Senate Special Committee on Aging chaired in 2018 by Susan Collins, United States Senator from Maine. This committee held hearings on the topic "Aging Without Community: The Consequences of Isolation and Loneliness." The disruption to daily routines and restriction of usually pleasurable activities as a result of the pandemic, including visiting with friends, children, and grandchildren, is also having a strong impact on people. Given these changes, Flett and Zangeneh (2020) outlined how and why mattering is an essential resource for coping with and adapting to the pandemic. It was argued that everyone needs a sense of significance and being important to others in the best of times, but this is especially the case in challenging times and in anxiety-provoking crisis situations that entail being separated from others. This argument is particularly germane to the life experiences of older people coping with this global health crisis. Older members of society have many reasons to be fearful and many have already been grappling with loneliness and mental health problems.

Unfortunately, expressions of concern about the health and welfare of older people and apparent steps taken to ensure their well-being are at variance with current realities. Global statistics are mounting in ways that confirm that concerns about older people and their mortality are not overstated. There is growing evidence from various parts of the world of the disproportionate death and dying among older people (see Onder et al. 2020; Promislow 2020) . Over 90% of deaths related to COVID-19 were of individuals 60 years or older, and more than 50% were over 80-an age group with a mortality rate 5 times that of the global average. Residential care homes, including long-term care (LTC) and assisted living (AL) homes, have been hit especially hard and account for more than half of pandemic-related deaths worldwide (see Comas-Herrera et al. 2020) , posing a realistic source of existential anxiety and distress for older residents and their families. Close-quarters living and limited access to personal protective equipment increase the risk of transmission, which, together with healthcare challenges associated with staffing shortages, results in multiple fatalities.

The numbers of deaths are troubling but even more disconcerting are seemingly endless stories of neglect and mismanagement that have appear to be costing people their lives. Key needs, both tangible and emotional, have been neglected and this is relevant to our premise because neglect is regarded as a primary precipitant of feelings of not mattering (see Flett et al. 2016a) .

Some of the more heinous incidents and situations involving apparent neglect of older adults in the context of the COVID-19 pandemic are listed in Table 1 . This table contains a chronology of select occurrences. Comparable events have already resulted in a litany of class action lawsuits by family members and urgent calls for public health inquiries to not only increase accountability but lead to necessary systemic change and better practices and procedures going forward.

In addition to the incidents and situations in Table 1 , an exposé in The Montreal Gazette revealed one nursing home that apparently concealed the deaths of 31 residents and many of these people died after most staff members abandoned the facility (see Feith 2020) . Some seniors did not have dignified deaths; indeed, the report indicated that they had gone for days without water, food, or a diaper change (Derfel 2020) . More generally, actual occurrences include refusals of hospitals to provide treatment, improper treatment of deceased elders, and sending patients confirmed to have the virus to nursing homes, thereby increasing the risk for elderly residents. Physical distancing requirements are having additional impacts on the ability of long-term care homes and assisted living residences to care for their older residents; prohibitions against large group meetings mean that residents cannot eat in cafeterias and common rooms, further limiting social connection, and overwhelming staff members who now must deliver food individually, limiting the amount of time and attention that they can pay to residents. These subtler impacts of the pandemic on the health and well-being of older adults are likely not being evaluated.

A more recent exposé by The Globe and Mail of the situation in Ontario, Canada, also paints an exceptionally unfavorable picture. This article about this investigation is titled "Systematic failings fuelled care-home outbreak" (see Howlett 2020) . It is based on an extensive series of interviews and a review of documents filed with the Ontario Supreme Court, as well as Ontario Ministry of Labour inspection reports, and internal corporate records. Key shortcomings included having home inspections conducted by telephone and the Chief Table 1 Chronology of select pandemic-related incidents and situations in 2020 connoting that older people do not matter or do not matter enough March 24, 2020-Spanish military finds corpses and seniors abandoned in care homes (Benavides 2020) April 26, 2020-Italy's Lombardy region wracked by exceptionally high number of deaths, totally about half of deaths in Italy. Deaths including thousands of elderly people described by one WHO official as a "massacre"; regional government makes decision on March 8th to place patients with COVID-19 virus in nursing homes and staff in some homes instructed to not wear protective masks because masks will scare the residents (Winfield 2020) May 1, 2020-Horrific deaths in an Australian nursing home reported after an infected nurse works six shifts despite having mild virus symptoms. Family members of residents express upset about inconsistent communication (Zishuo 2020) May 13, 2020-Sweden's herd immunity strategy and failure to enact lockdown leads to mass deaths in Swedish elder care homes; "terrible numbers" dramatically underestimated due to decision to only count deaths of persons who had COVID-19 test (Shilton 2020) May 14, 2020-Decision of New York to send recovering COVID-19 virus patients to nursing homes characterized as "a fatal error" (Mathews 2020) May 15, 2020-Elderly patients characterized as "sacrificial lambs" detected with coronavirus are released back to care homes in April; 12 elderly people at St. Nicholas Care Home in Liverpool, England, die after hospital discharge (Kelly and Coen 2020) May 18, 2020-Hospitals in Lima, Peru, stop admitting elderly patients with coronavirus in part due to lower recuperation rates relative to younger patients (Torres 2020) May 19, 2020-Nurses in care homes in Sweden allege that people ill with the virus and 65 or older are refused access to hospital and life-saving equipment despite potentially having many years to live (Savage 2020) May 20, 2020-Report surfaces that older people in Hamilton, Ontario nursing home were transferred to St.

Joseph's Healthcare but one male patient was forgotten and left entirely by himself in the evacuated nursing home (Frketich 2020) Medical Officer of Health waiting until April 21st to issue the decree that everyone in longterm care homes is to be tested for COVID-19.

The deplorable conditions at sites in Ontario were confirmed by a Canadian military report that detailed conditions of severe neglect deemed to reflect "borderline abuse" or actual abuse in Ontario care homes along with "blatant disregard" for basic infection control measures (see Stephenson and Bell 2020) . Deplorable situations came to light in five residences once military personnel were deployed to assist in long-term care homes. Ontario Premier Doug Ford described these accounts as horrific and Prime Minister Justin Trudeau expressed his strong feelings, concluding that, "It is the elderly who are suffering the most in this pandemic."

The stories that have emerged thus far underscore the lack of resources and planning that have left too many older people and staff members in vulnerable and potentially lifethreatening situations. For instance, in Canada, the deaths continue to escalate across most provinces and this dovetails with years of concerned frontline people and academic scholars calling for improvements and more resources for the care system. These calls have been renewed and extended (see Béland and Marier 2020) . Collectively, it has been estimated that four out of five COVID-19-related deaths in Canada have been linked with senior homes (see Brean 2020) . Given these emerging realities in Canada and elsewhere, it would be reasonable for older people in many countries to feel that professed concerns about their well-being either represent "lip service" or implemented safeguards simply add up to "too little" and "too late" given strong evidence of widespread system failure. The circumstances listed in Table 1 demonstrate some horrific situations in nursing homes and long-term care facilities in various parts of the world.

Second, some very troubling views about older people in general have been expressed during the pandemic. Some views have come from political leaders, while others have come from members of the media and social media influencers. These views have led some authors to consider whether the pandemic will worsen the narrative about aging in terms of the proliferation of stereotypes. These are often signified by referring to the pandemic with harsh social media hashtags such as "#boomerremover" and "#grandmakiller" (see Eisenberg 2020) . Ironically, as many younger people are commenting that their grandparents' generation saved the world by fighting fascism and oppression, they are saving it by sitting around at home, and there is a lack of recognition that those same grandparents are now being sacrificed in panicked efforts to forestall an anticipated financial collapse. What is also being missed is the opportunity to learn and benefit from the survival resources and resiliency factors cultivated by older adults who have lived through times of war, oppression, discrimination, and financial collapse.

As the statistics accumulate, it is natural for older people who are aware of these developments to become increasingly alarmed and demoralized not only about their health status prospects but also by the overarching question of whether they matter at all to other people. Indeed, some older people have wondered openly about exactly when they became disposable (see Socken 2020) . Maria Branyas, a 113-year old survivor of the 1918 Spanish Flu epidemic, stated that "the elderly are the forgotten ones of society" (The Guardian 2020). This serves as a poignant counter-point to the quote attributed to Gandhi that "the true measure of any society can be found in how it treats its most vulnerable members." Older adults who have already felt marginalized and who have been subject to prejudice due to racism or classism may be particularly susceptible at present to feelings of not mattering to other people. Unfortunately, some politicians have gone so far as to suggest that economic considerations must become the priority, even if it means the loss of lives. The argument here is that balance is needed and perhaps physical isolation and the shutdowns have gone too far or are now doing more harm than good from an economic perspective focused on costs versus benefits. It has been openly and crassly suggested by too many politicians that people who survive the pandemic will just have to live with the loss of other people, especially elderly people, because it is time to end social distancing in order to restart the economic engine as it is too dire to let it idle any longer. Public calls to restart the economy, even if so doing confers health risks in vulnerable groups, can increase perceptions of lack of social worth among older adults, and this is especially among older adults who are sensitized to cues suggesting that they do not matter.

Another factor that has been identified as a factor during the pandemic that promotes the image of older people as being less important and contributes to ageism is that under certain circumstances, chronological age is listed as a deciding factor for determining which of two people in equal need are given a ventilator (for a discussion, see Fraser et al. 2020) . They are also several instances of people being denied access to hospital treatment because of their age (see Table 1 ). It has been observed that older people are made to feel less significant as individuals by policies that characterize all older people as the same and fail to reflect the heterogeneity and varying levels of functioning and vitality among them. This too is regarded as a contributor to ageism (see Fraser et al. 2020) .

Bob Seger reminded us in one of his classic songs that it is easy for some people to "Feel Like a Number." It is not difficult to take it personally when someone contends that it is just too bad, but some people may need to be sacrificed and needed medical equipment and supplies should be deployed to protect younger people. But how does it feel? One woman responded on Twitter in early May 2020 by expressing her emotions in a clear and undeniable way in response to a televised segment she had watched. Anne reminded us how it feels by saying, "That man you just had on said my life doesn't matter, that I am expendable, that I don't matter. I am a mother, wife, grandmother, community activist, community volunteer, I knit, I MATTER! I MATTER! I can't be sacrificed so he can go to Walmart!"

When it comes to lived experiences during the pandemic, this feeling of being expendable is, of course, not limited to older adults, but extends to others who are socially disadvantaged. Findings are accumulating of the heightened risk of COVID-related morbidity and mortality among Hispanic and African Americans. There have additionally been numerous reports from people of varying ages who are either refusing to go to work or who have quit their jobs given worry about their personal safety; however, it should be evident to any observer that the feeling of not being valued by the employer is also very salient and very strong among these workers. Acts of defiance and disengagement should not be surprising; there is growing research evidence of how being made to feel unimportant and insignificant in the work setting is tied to turnover, work disengagement, and various negative emotions (Jung 2015; Jung and Heppner 2017; Richards et al. 2017) . The importance of mattering versus not mattering extends to healthcare workers. Although some retired healthcare workers experience a sense of mattering when called back into service, one recent study found that nurses with lower levels of work mattering reported more burnout and less engagement (Haizlip et al. 2020) . In contrast, workers thrive and flourish when they are valued and they know they matter. Even small gestures and individualized inquiries about the personal life of the employee can have a huge positive impact.

These are important themes for further consideration, but the current review article focuses on the need to matter among older adults. Our analysis examines relational mattering (i.e., mattering to other people) as described by Rosenberg and McCullough (1981) . Statements about what should or should not happen at a broader level in institutions are more a reflection of the type of mattering known as societal mattering, which was a theme introduced by Fromm (1941). People can be evaluated in terms of how much they feel they matter to others and to society. Societal mattering is also quite important; indeed, many older people could feel like they are experiencing "double jeopardy." The person who does not feel significant to specific others and who does not feel significant to the broader community or society is someone who is at considerable risk in terms of both one's mental health status and physical health status. There is a third type of mattering known as "existential mattering" that is also distinct and involves assessments of whether one's life matters (see George and Park 2014) ; this issue is also of relevance to many older adults and will be addressed in our discussion of meaningcentered research with older people.

As suggested above, people know how it feels to them when they have been treated like they do not matter, so it should be easy to understand how many older people are feeling right now. Our interest in the health and well-being of older people and their concerns are longstanding; we have conducted research over the past two decades on the risk and resilience factors associated with suicide and suicide ideation among older adults (Heisel and Flett 2006, 2016; . This work has also resulted in the creation of the first measure of suicide ideation tailored specifically to the needs and lives of older people, the Geriatric Suicide Ideation Scale (Heisel and Flett 2006) , which assesses sociocultural and existential factors (i.e., its "Loss of Personal and Social Worth" and "Perceived Meaning in Life" subscales) in addition to thoughts and wishes to die and for suicide. Recently, concerns have been expressed about an anticipated spike in suicide behavior and deaths among older adults as a result of the pandemic (see Wand et al. 2020) . The Royal College of Psychiatrists has just estimated that there could be a six-fold increase in suicide attempts among older adults (see Hymas 2020) . Suicide prevention researchers and public health experts have warned the public of a substantial increase in suicide rates among older adults, given COVID-related increased fear and despair, restriction of physical access to social supports and mental healthcare programs, and financial anxiety due to the impact of stock market volatility on retirement savings. The Spanish Flu was associated with increased rates of suicide, and elevated suicide risk was reported for older adults in Hong Kong in the aftermath of the 2003 SARS epidemic, due in part to the negative impact of physical distancing and isolation (see Chan et al. 2006) . It is our contention that any increase will be fuelled not only by anxiety, stress, uncertainty, and isolation, but also the broader messages that convey to older people that perhaps they simply do not matter.

One theme that has emerged from our research and from that of other investigators is that given the risks that face vulnerable older people, it is vitally important to promote positive protective factors and competencies that heighten their resilience and engagement and involvement. We agree with Rosenberg and McCullough's (1981) contention that mattering is vital for everyone, but it may be especially vital for older people. However, mattering deserves much more focus among psychologists than it has received thus far; knowledge of whether an older person feels like she or he matters to others is fundamental to understanding this person and how life is going and how it is likely to go in the future. It is our hope that the current review and analysis will serve as a catalyst for a much greater emphasis on the role of mattering and its many potential benefits among scholars who conduct research with older adults and professionals who are in positions to implement practices and procedures to enhance their health and mental health.

Relevant research on mattering among older adults is summarized below. As is typically the case, these research investigations are mostly variable-centered studies that investigate levels of mattering and associations between mattering and other variables in large samples with participants who are either rapidly approaching or who have already reached the ages associated with being an older person. It is important to reiterate before launching into an overview about this research that mattering is about the individual person. That is, it is about the significance of the older person's individual story and life narrative. It is about whether the individual feels seen and heard and valued versus invisible and unheard and someone who does not count to the people in their lives and perhaps society as a whole.

If mattering is as relevant as we claim it is, then it should be possible to identify themes related to feelings of not mattering or of feeling unimportant and expendable when the focus shifts to qualitative accounts of the experiences of individual people. This is clearly the case. For instance, a study of perceptions of preventive home visits yielded four categories including a mattering-based category centered around the theme "it made me visible and proved my human value" (see Behm et al. 2013 ).

Berglund and Narum (2007) interviewed 282 women ranging in age from 75 to 93 years old. Six categories emerged including a relationships category with content reflecting both belonging and mattering. Specifically, one participant observed, "Being in the company of my dear ones gives me a sense of belonging. It's nice to know that someone cares and they in turn can count on me when they need help or someone to talk to" (p. 43).

Another analysis of long-term care environments by Pope et al. (2006) resulted in residents identifying several things that made them feel significant (i.e., they mattered) versus insignificant (i.e., they did not matter). Feelings of insignificance were trigged by events or treatment that evoked feelings of loss of control. Feelings of insignificance are also rooted in insensitive treatment. An examination of factors contributing to loneliness included input from one longterm resident who said he was being shunned by his adult children (see Roos and Malan 2012) . His social pain is reflected in his statement that, "They don't want me anymore. I feel like I don't exist to them." Other analyses point to feeling insignificant because of not being consulted about decisions that pertain directly to personal care and well-being (Fetherstonhaugh et al. 2013) .

A phenomenological analysis of suicidal tendencies among older adults by our colleague Sharon Moore identified themes of not mattering such as "no one cares" and "I am no longer needed" and the sorrow in the realization of "not being depended on anymore by other people" (see Moore 1997) . These are commonly expressed themes among people who feeling insignificant and perhaps expendable.

Comments from participants in our study of Meaning-Centered Men's Groups (MCMG; see Heisel and The Meaning-Centered Men's Group Project Team 2018) for men over the age of 55 who were concerned about or struggling with the transition to retirement further underscore the central role of mattering in the mental health and well-being of middle-aged and older adults moving into their later years. Qualitative findings from study exit interviews highlighted general themes relevant to mattering in enhancing participant satisfaction with the group experience, including being valued and respected, mutual camaraderie, fellowship, and belonging. A looming sense of missing each other was at the heart of requests to extend the sessions and find ways for group members to remain in contact.

Finally, the need to feel a sense of mattering was clearly evident in the responses that 22 older people with mental health problems generated as part of a concept mapping exercise. This study by Wilberforce et al. (2018) was conducted to inform the development of a new measure of quality of mental health services for older people. One category that emerged to characterize excellent services was labeled "personal qualities and relationships." This category included several references to the mattering construct such as care providers who are really interested and listen to and understand the older person (i.e., my care worker really listens to me). One elderly person made explicit reference to a worker who showed compassion and that they mattered. The essence of this concept category was a sense of humanity stemming from being treated as a real person by someone who is joining with the older person and is truly interested in spending time with her or him, and is not just passing through.

Collectively, these accounts underscore how mattering can be linked with joy and flourishing, but the feeling of not mattering can be associated with deep psychological pain. Moreover, mattering needs to be embedded in therapy and counseling services. In general, the insights yielded from these accounts attest to the merits of future qualitative research that extensively examines the lived experience of feelings of mattering versus not mattering to others and perhaps to society.

Below, we describe the mattering construct in more detail and some elements that need to be added in order to more fully capture the relevance of mattering versus not mattering to older people. This description is then followed by a comprehensive overview of research conducted thus far that illustrates the benefits of mattering among older people.

What is mattering? Rosenberg and McCullough (1981) introduced mattering and the components that comprise this construct. Mattering reflects our need to feel like we are significant and important to other people. Rosenberg and McCullough (1981) focused on three components: (1) the sense that other people depend on us; (2) the perception that other people consider us to be important to them; and (3) the understanding that other people are actively paying attention to us. Rosenberg (1985) added a fourth component reflecting the sense that other people have expressed that they would miss us if we were no longer around. Subsequently, Schlossberg (2009) identified a fifth element-feeling appreciated by someone. This component emerged following interviews with adult caregivers who indicated what made them feel like they mattered to those people receiving their care.

Prilleltensky (2020) sees mattering as involving both the sense of having value to other people and giving value to other people; thus, mattering reflects both giving and receiving in ways that provide feelings of personal significance and importance. The notion of enhancing the self by becoming someone who matters to others was shown in a case excerpt described by Karp (1996) in his book about people struggling with the sadness of chronic depression. Marco struggled for years with profound depression but nevertheless had to assume the caregiver role when his mother suffered a prolonged illness and it became clear that she would never get better. When asked whether there was anything in it for him, Marco replied, "It made me feel important" (p. 153) and it forced him to put his own "stuff" aside for the time being. Whereas a commonplace clinical response is to seek to alleviate stress from individuals struggling with depression, this example demonstrates the value in challenging clients to focus meaningfully on the needs of others rather than attending exclusively to their own emotional difficulty.

Most recently, Killen and Macaskill (2020) illustrated the relevance of giving value to others in a qualitative study of the positive life events reported by older adults. They conducted a revealing analysis of the diary entries of 88 elderly people in order to arrive at a revised model of positive aging. One category that emerged from their analysis was being of value to others. This category involved doing something to help friends or family members or the broader community and receiving notes of appreciation from others.

Some entries reflected expressions of mattering. For instance, one woman noted in her diary that, "Husband coming downstairs after going to bed specifically to give me a hug and kiss goodnight, what could be better to confirm that one matters!' (F70) (p. 12). Collectively, 468 diary entries reflected the positive affect stemming from having value to other people.

The components of mattering outlined above likely vary in their relevance according to an individual's current life stage, albeit with the caveat that all components are important to some degree. The need to feel that others depend on them is critical for older people. This observation accords with conclusions from sage scholars who point to the benefits that accrue when older people feel needed and wanted because other people are relying on them. Findings of great longevity among older adults in Japan who continue working into their 8th or 9th decades of life further demonstrate the very real health benefits that can accrue from feeling valued and that one has a purpose (see Jenkins and Germaine 2019). Erik Erikson proposed in his developmental theory that a key stage for middle-aged and older people is generativity versus stagnation. The positive resolution of this stage is care. Although they did not discuss mattering per se, Erikson et al. (1986) emphasized in their analysis of vital involvement that older people who show caring and engage in nurturing of younger people, especially younger family members (e.g., grandchildren), will spread feelings that clearly resemble feelings of mattering. Similarly, George Vaillant's (2002) classic analysis of the lives of older people who took part in the longitudinal Harvard Study of Adult Development also emphasized giving to others in ways that foster positive and mutually caring relationships in ways that benefit the self. These acts of caring can be focused on young family members but of course, in many instances, also involve caring for disabled relatives and friends. Vaillant (2002) warned that it is possible for dedicated younger adults to become so engaged in providing care to aging parents that it can amount to too much sacrifice if such caregiving activities become all-consuming; he suggested that this can result in depleting the self by "giving the self away" to others. Vaillant (2002) suggested that the benefits of giving to others are better and more evident when a person is older because caring for others is more self-determined and does not feel like an overwhelming obligation. Similarly, Erikson et al. (1986) suggested that generative acts from elderly people directed at younger family members are more beneficial when other people are shouldering the daily responsibility for younger people and older people can focus on being generative.

How protective can it be to feel a sense of mattering to younger people who have come to depend on an older person? Erikson et al. (1986) described an elderly woman who acknowledged during her interview that she actually refrained from taking her own life because she knew how much she was loved and admired by her grandchildren (i.e., she mattered). The feeling of mattering provides a sense of connection and comfort and a source of resilience that is a strong buffer of life problems and feelings of stress and distress (for discussions, see Flett 2018a; Flett et al. 2019) , especially during the pandemic (see Flett and Zangeneh 2020) . We discuss this protective role in reducing suicide risk in more detail in a subsequent section of this article.

We now turn to a discussion of ways to extend the mattering construct to more fully capture the relevance of mattering versus not mattering to older people. These additional ways of capturing individual differences in mattering are important from a conceptual perspective, but they also extend the potential focus of preventive interventions and open up additional directions for future research.

The original conceptualization of mattering from Rosenberg and McCullough (1981) focused on it as a feeling state and as a psychological need that is central to how people define themselves. A strong case can be made for the argument that the need to matter is just as important to people as are other key needs such as the need for autonomy, the need for competence, and the need for connection with others. Rosenberg and McCullough (1981) discussed at length and demonstrated with their extensive data that mattering should not be equated with self-esteem. Several researchers have confirmed that mattering goes beyond selfesteem when predicting key outcomes (e.g., Flett and Nepon 2020; Flett et al. 2016a Flett et al. , 2016b Matera et al. 2020) . Accordingly, any framework built around the notion that people need selfesteem should be modified to reflect that people need self-esteem but they also need to matter to other people.

Here it should be underscored that while the conceptual focus for the construct is on the need to matter, most existing measures of mattering such as the General Mattering Scale assess perceived levels of mattering to others and not the actual need to matter (for a discussion, see Flett 2018b). Accordingly, research must focus jointly on the need to matter to other people and perceptions of achieved levels of mattering to other people.

We contend that some other elements of the mattering construct are missing from the literature and clearly must be added in order to more fully capture what mattering and not mattering means to everyone, but especially older people. Additional elements of the mattering construct are identified below. Some of these elements have been discussed elsewhere, but they have not received much emphasis from a conceptual perspective until now.

Flett (2018b) suggested originally that there is a key element of the mattering construct that has not been considered or measured thus far-the fear of not mattering to other people. Flett (2018b) proposed that people with a strong need to matter to others and who are also characterized by an insecure attachment style could become preoccupied with the fear of losing connections with the people whom they matter to and who matter to them.

Research on this facet of the mattering construct is in an early phase. Casale and Flett (2020) discussed at length how this fear of not mattering is especially relevant during the pandemic and how it is seemingly more germane at present than other fears such as the fear of missing out or the fear of negative evaluation. This element seems especially relevant to older people who have become isolated or socially disconnected or fearful of being forgotten as this global health crisis unfolds. Elderly people who are cognizant of public statements about the expendability of whole segments of the population or the use of age as a key criterion to determine the allocation of scarce medical resources could have their general worries and levels of anxiety exacerbated by this particular fear. People who fear being alone may have also developed this fear of not mattering, and it could add to feelings of helplessness and hopelessness and perhaps resentment.

This particular aspect of mattering may be especially relevant among some people who are in the process of dying. It is common to hear of people who just wanted to know that they have mattered to someone who cared about them and they have worries that this was not the case. It is not uncommon, among end-of-life care providers, to witness older adults at the end of life provide reassurance and comfort to family members who are struggling emotionally with the thought of the older person's impending death. A need for reassurance of having some significance to others should be especially salient among people who fear that they have not really mattered to anyone.

A reasonable question to ask is, "What is worse-never having the sense of mattering to others or feeling a sense of mattering to others but then losing it?" A key element of the mattering construct that has received almost no attention thus far is the loss of mattering to others. Elderly people who live long enough to outlive others and, as a result, experience loss of mattering via their losses can become very dejected if they have not found ways to maintain a sense of mattering or to still feel good about having mattering to the departed.

There are many ways for older people to experience a loss of mattering to others. This may take the form of becoming a caregiver to young grandchildren who have parents employed full-time outside the home and then feeling no longer needed when these grandchildren are old enough to take care of themselves. Complex family situations involving divorce and conflict may also result in a reduction in opportunities to matter for those older people who are no longer included in family activities. Alternatively, a loss of mattering could take the form of losing physical mobility and no longer being able to fulfill an active volunteer role. And, of course, it could involve the loss of perceived mattering that results when an older person transitions to retirement and no longer feels important and significant to others, perhaps along with a loss of a sense of purpose. These transitions can be felt acutely by the older people who still very much need the sense of validation that is derived through mattering to other people.

The loss of mattering can contribute to depressions that are due not only to loss of mattering but also a perceived loss of self. This observation fits with the many case examples of extremely depressed people who acknowledge that they no longer feel like their old selves and their first goal is to feel like themselves again. Although they may not realize it, this translates into again having a feeling of mattering to others. As noted earlier, our Geriatric Suicide Ideation Scale contains a component subscale that assesses the perceived Loss of Personal and Social Worth. This factor is highly associated with a host of negative psychological factors, including depression, hopelessness, loneliness, and suicide ideation (e.g., Heisel and Flett 2006 . Pearlin and LeBlanc (2001) stand alone as the only researchers thus far to focus extensively on the loss of mattering. Their focus was on bereaved caregivers.

Their research showed that the death of a dependent relative (a spouse or parent with dementia) among caregivers resulted in a loss of mattering and contributed to depression, and the greater the loss of mattering among caregivers, the greater their level of depression 1 year later (Pearlin and LeBlanc 2001) . What is especially important about this finding is that it suggests that it is not simply a loss of activity or change in routine or sadness about having lost a loved one that is associated with depression, but rather the loss of connection, of feeling needed, and of mattering to others.

We will conclude this segment by newly proposing another aspect of the mattering construct that applies universally but seems essential among older people. A fifth element of the mattering construct that is worth considering involves personal assessments of whether an individual who needs to matter sees herself or himself as someone who perhaps does not currently have a sense of mattering, but still feels that they are capable of engaging in behavior that will generate feelings of mattering to other people. This aspect of mattering can be regarded as a specific type of self-efficacy reflecting the perceived capacity to generate feelings of mattering by engaging with other people or contributing to the community in meaningful ways. This emphasis of a specific type of self-efficacy is suggested in general by research attesting to the protective role of other specific ways of framing self-efficacy among older adults (e.g., Paggi and Jopp 2015; Stephan et al. 2011) .

The concept of the capability to matter to others follows from a line of investigation in the personality field that began when Wallace (1966) observed astutely that certain personality characteristics could be measured as abilities or capabilities. Capabilities focus on what is possible or feasible versus what is typical, which is what personality traits tend to reflect. There has not been extensive research on personality capabilities despite their clear relevance to understanding people and the individual differences among them. One key exception is the work by Martin (1987, 1988) , who illustrated the usefulness of assessing personality capabilities in the interpersonal domain. They showed that capability and trait ratings of interpersonal characteristics are relatively orthogonal, and both capability and trait ratings are associated with low self-esteem and anxiety. The implications of these findings are clear: individual differences in trait ratings and capability ratings are quite different in their nature. Similarly, just as it is possible to distinguish such things as a person's usual level of agreeableness and their capability of being agreeable, both subjectively and objectively, it should also be possible to distinguish a person's degree of mattering to others and their capability of being someone who could matter to others.

It is likely that the perceived capability to matter to others overlaps to a substantial degree with feelings of loss of mattering. Conceptually, it stands to reason that believing that one can still matter to others should moderate the negative impact of diminished feelings of mattering on depression and other negative psychological outcomes. Some people will feel both a loss of mattering and a diminishment in their perceived capability to matter to others, perhaps as a consequence of having physical or cognitive declines that impact their ability to interact with other people. Fazio (2009) has discussed how mattering to others can be impacted by personal circumstances and limitations that can also limit the frequency of positive social interactions. Hopefully, such individuals will have people in their lives to whom they matter, and these people will be able to continue to demonstrate that they care about them and will take care of them.

The next segment of this article consists of a review of existing research with an emphasis on mattering among older people. There are now enough articles on mattering among older people to get a clear sense of how mattering protects older people who have it and disadvantages those older people who do not feel like they matter to others. We then conclude with an analysis of applications in the form of preventive interventions and a discussion of directions for future research.

Our research review focuses on four topics. First, we examine the role of mattering in protecting against loneliness and social disconnection. Next, we summarize research confirming that there is a negative association between mattering and depression. Third, in keeping with a positive psychology orientation, we consider research illustrating the positive association between mattering and psychological well-being. Finally, mattering is examined in terms of its role in positive physical health outcomes. Results linking mattering with greater life satisfaction are also highlighted. Most of the research investigations conducted on mattering in the elderly fit into these themes with the exception of some work examining the role of religiosity and mattering among older people (see Lewis and Taylor 2009; Schieman et al. 2010) .

Loneliness is a serious problem facing many elderly people, and there are indications from extensive research that loneliness exacts both a devastating mental toll and a physical toll on older people. Empirical research has supported the position that loneliness not only contributes to health problems, it may actually be a causal factor in early mortality (see Holt-Lunstad et al. 2015; Luo et al. 2012) . Fromm (1941) first discussed the association between being and feeling isolated and feelings of not mattering in his book Escape From Freedom. He proposed that individuals who achieve a sense of freedom from others also pay a price in terms of feeling both isolated and insignificant (see Fromm 1941) . Combined feelings of loneliness and of not mattering can be dangerous; this should especially be the case for exceptionally lonely older people who feel like they do not matter. This is just one of the many reasons why the situations brought about or exacerbated by the global health crisis may prove lethal for many older people.

Research on mattering and loneliness is quite limited. The most extensive study was conducted by Flett et al. (2016a, b) . This research with a sample of university students showed that lower scores on the General Mattering Scale (GMS) were associated with loneliness and this association was quite robust (r = − 0.62). Moreover, feelings of not mattering and loneliness were both associated with reports of various forms of childhood maltreatment. Other analyses of this cross-sectional data yielded support for mattering as a mediator of the link between childhood maltreatment and loneliness. Work is continuing in our lab on the link between feelings of not mattering and loneliness and the initial evidence continues to suggest a strong link between these interpersonally-based psychological factors.

How are these factors associated among the elderly? Initial evidence of a strong negative association between feelings of mattering and loneliness came from an investigation by Kadylak (2020) of 675 adult Internet users 65 years or older with a mean age of 73.93 years. The main focus of this work was to examine reactions to "phubbing" which is the tendency to focus on technology in a way that also involves ignoring someone else. Low mattering would exist if an elderly person (or anyone) was being ignored by someone absorbed in technology. Mattering was assessed by the 24-item Mattering Index by Elliott et al. (2004) . The measures also included an eight-item loneliness scale and measures of self-reported health, depression, and the five-item Satisfaction with Life Scale (Diener et al. 1985) . The depression results from this study are reported in the next section. Analyses established that mattering was linked robustly with lower levels of loneliness and higher levels of life satisfaction. Interestingly, although it was not associated significantly with self-reported health status, levels of mattering were significantly lower among participants with lower levels of socioeconomic status and among those who were widows or widowers. Lower mattering was also linked with more frequent family phubbing expectancy violations (i.e., attention of others was expected but not obtained). Finally, mattering mediated the link between intergenerational family phubbing expectancy violations and loneliness.

Evidence of a link between low mattering with less social connection was provided in a study by Francis et al. (2019) . They examined how the frequent use of informational communication technology (ICT) can enhance the functioning of older adults in retirement communities. This was an extensive project that was part of a randomized control treatment study with five waves of data collection. The participants were 199 older adults with a mean age of 81.61 years. Mattering was assessed with the five-item GMS (Marcus and Rosenberg 1987) . A negative link was found between mattering and assisted living, suggesting perhaps that mattering becomes diminished as a function of age-related declines in functioning. This interpretation seems consistent with the experience of older adults in residential care who are allowed to soil themselves before being assisted in toileting by on-site support workers; it is hard to conceive of a clearer message that one does not matter than to be subjected to this sort of indignity. The main analyses showed that higher levels of mattering were associated with more extensive ICT use. It was also linked positively with a self-report measure of social network connectedness known as the Lubben Social Network Scale (see Lubben and Gironda 2004) . Mediational analyses established further that social network connectedness mediated the association between ICT use and mattering in this sample of elderly people.

Collectively, initial research with older people suggests that any links proposed between feelings of not mattering and feelings of isolation and social disconnection are well-founded. Research with a lifespan perspective is now needed to examine mattering and loneliness from a longitudinal perspective. Some complex associations likely exist, especially if mattering is studied with an extended scope that includes the fear of not mattering and the perceived loss of mattering.

The predominant clinical research focus thus far in the mattering field has been on the negative association between mattering and depression. Flett (2018b) summarized numerous reasons why lower mattering to others should be associated with higher levels of depressive symptoms. An association would be expected given the negative self-worth judgments that are common to both. Also, people with low levels of perceived mattering should have less perceived and actual social support which could have provided a buffer from depression. Dixon (2007) conducted the initial study of mattering and depression in the elderly. A sample of 167 older adults (39 men, 128 women) completed a 25-item measure of mattering developed by the author. The participants had a mean age of 83.5 years. Dixon (2007) only reported the results for the overall score on this mattering measure even though it was comprehensive and assessed global mattering, but also mattering to significant others and friends and other family members, including any grandchildren. Dixon (2007) found that mattering was linked robustly with less depression (r = − 0.64). Other results from this study are reported in a subsequent segment of this article. Chippendale (2013) also evaluated the link between mattering and depression on a smaller scale in a sample of 47 older adults from four senior's residences in New York City. Mattering was assessed with a single but highly face valid item (i.e., I feel valued and important). This item was taken from the Duke Social Support Index (Koenig et al. 1993) . Participants also completed a brief one-item measure of self-reported health status and the full version of the Geriatric Depression Scale (GDS: Yesavage et al. 1983 ). The one-item measure of mattering (i.e., feeling valued and important) was associated negatively with depression (r = − 0.56). Secondary analyses indicated that among those people who were severely depressed according to the GDS cutoffs, it was the case that none of these people indicated any level or degree of agreement with the mattering item (i.e., no person with depression felt a sense of mattering).

Another study by Wight et al. (2015) of 315 gay identified men from the USA further illustrated the role of mattering in reduced levels of depression. The authors noted that their focus on mattering stemmed in part from reports found commonly among aging gay men of feeling invisible to other people. Their participants had been part of a longitudinal study conducted over three decades, but Wight et al. (2015) focused on data collected in 2012 and 2013. The average age of participants was 60.7 years with an age range of 48 to 78 years. Overall, 61% of the participants were HIV-negative. Mattering was assessed with the GMS (Marcus and Rosenberg 1987) . Other measures in the study included a measure of internalized gay ageism with items such as "Aging is especially hard for me because I am a gay man." Depression was assessed with the CES-D Depression Scale (Radloff 1977) . The CES-D was administered many times over three decades and this enabled the researchers to identify five depression trajectories. These trajectories were controlled for in subsequent statistical analyses. The results of a regression analysis predicting the most recent CED-D score found that elevated depression scores were uniquely and significantly associated with lower levels of mattering and higher levels of internalized gay ageism. Other analyses pointed to mattering as a mediator of the link between internalized gay ageism and depression; that is, higher levels of gay ageism were associated with lower mattering which, in turn, was associated with higher levels of depression. No support was found for mattering as a moderator variable.

Another study of functional limitations by Redmond and Barrett (2015) included data on mattering and depression. This longitudinal study of over 1300 adults from Miami-Dade County in Florida found that lower scores on an extended version of the General Mattering Scale were associated with depression and increases in depression over time. This study is relevant because it had a broad representative sample with participants from three age groups (18-49 years, 50-69 years, and 70-93 years) who had a mean overall age of 57.03 years.

Finally, the study by Kadylak (2020) described above on reactions to phubbing among 679 Internet users also included a two-item depression scale. It was found once again that mattering was associated robustly with lower depression.

As noted earlier, the study by Dixon (2007) of 167 elderly adults also included indices of wellness and purpose in life. Wellness was examined only as a total score. The correlational analyses conducted by Dixon (2007) found that mattering was linked with purpose in life (r = 0.58) and with overall wellness (r = 0.62). It is especially noteworthy that a regression analysis predicting overall wellness showed that mattering, purpose in life, and depression all were significant, unique predictors, suggesting that mattering is neither simply a synonym for purpose in life or wellness, nor the opposite of depression, but is an unique variable in its own right.

Myers and Degges-White (2007) examined mattering and levels of wellness among older adults in a retirement community. The participants were 142 residents (50 men, 92 women) who ranged in age from 73 to 101 years old and who had a mean age of 83 years old. Perceived stress was also assessed. Mattering was assessed with the five-item GMS (Marcus and Rosenberg 1987) . Wellness was assessed with the Five-Factor Wellness Scale (Myers and Sweeney 2005) which taps 5 domains of wellness and provides 23 measures in total. Correlational analyses found that mattering was not associated with perceived stress, but it was associated significantly with overall levels of wellness (p < 0.002). Overall, mattering had significant positive links with 11 of the 23 individual measures of wellness.

A third study by Piliavin and Siegl (2007) reported findings from the Wisconsin Longitudinal Study. This long-term study began decades earlier. The report from Piliavin and Siegl (2007) examined a large sample of participants who were assessed in 2004 when they were approximately 64 years old. The main focus of this work was to evaluate the potential benefits over time of volunteering. Mattering was assessed with six items from the Mattering Index by Elliott et al. (2004) . Well-being was assessed with five-item or six-item subscale measure of Ryff's (1989) Well-Being Scale. It was a composite well-being measure comprised of four subscales tapping self-reported environmental mastery, purpose in life, personal growth, and self-acceptance. The results showed that even when controlling for levels of well-being when assessed in 1992, it was the case that greater subsequent psychological well-being was predicted by mattering and a host of other factors, including social integration, years of education, and being female. Other analyses suggested that social integration mediated the link between volunteering and well-being, and mattering mediated the link between volunteering and well-being. It was concluded that when someone does not have a high level of social connection, direct engagement in volunteering can boost well-being and this is underscored, at least in part, by an enhanced feeling of mattering to others.

Mattering should be protective in terms of physical health because it should act as a stress buffer, especially following interpersonal stressors that involve negative social exchanges (for a discussion, see Fazio 2009 ). Similarly, mattering should be associated with positive health behaviors and self-care to the extent that people who perceive that they matter to others have internalized this perception and so feel that they matter to themselves.

The study by Chippendale (2013) described above that was conducted with 47 participants included a one-item assessment of self-reported health status. The one-item measure of mattering had a positive association with health status (r = 0.18), but this association did not achieve statistical significance. This could reflect the small sample size and the reliance on single-item measures. Kadylak (2020) also did not find a link between mattering and a brief measure of health status. However, the study of ICT frequency by Francis et al. (2019) described earlier also included a one-item measure of self-reported health status; mattering was associated significantly with higher health status among these 199 participants. Fazio (2009) described the results of the first assessment point from the Aging, Stress, and Health Study (ASH) in a published chapter on mattering. The initial assessment was based on 1167 adults who were 65 years or older from Washington and two counties in Maryland.

Participants were categorized as young-old (65-74), old (75-84), and old-old (85 or older). Four items were used to measure mattering in terms of importance to other people and another four items assessed other people depending on and counting on the person. It was found that levels of mattering decreased significantly with age; both mattering components were significantly lower in the old-old group versus the young-old group. Most noteworthy for our purposes was the finding that better self-reported physical health status was linked positively with the two facets of mattering. Also, engagement in volunteer roles was also associated with higher levels of mattering. Hence, remaining engaged in physical activities and in doing for others overcome the negative impact of aging on perceptions of mattering.

The most relevant research conducted thus far suggests that mattering may help reduce the impact of "the wear and tear" on the body at a precise time when people are increasingly susceptible to the onset of disease and major illnesses. A key investigation by Taylor et al. (2019) examined 1026 adults from Tennessee. They ranged in age from 22 to 69 year olds. The sample included 296 people between the ages of 47 and 57 years old and another 178 people who were 58 years old or older. They were evaluated on levels of allostatic load across 10 physiological indicators. These indicators contained various objective measures (e.g., blood pressure, cholesterol, high-density lipids, etc.). Participants also reported chronic health conditions. The mean level of chronic health conditions for the sample was 2.76. The analyses found that age is associated with increased allostatic load, and this association is substantially greater among adults with low or moderate levels of mattering. These data suggest that a sense of not mattering plays an increasing role in poor physical health outcomes among older adults. Ironically, with worsening health, the interpersonal others with whom older adults increasingly spend their time are healthcare providers; clinicians who work with older adults are thus strongly encouraged to be sensitive to, and seek to enhance, their older clients' feelings of mattering.

Analyses of chronic health conditions found that age was associated with more chronic health conditions, as would be expected, but mattering was associated with fewer reported chronic health conditions. However, levels of mattering did not interact with age to predict the number of chronic health conditions. While these findings need to be evaluated in future research to determine their replicability, employing multi-item measures and larger sample sizes, it does seem that mattering plays a protective role in health functioning, especially among older adults. Taylor et al. (2019) went on to conclude that, "There is reason to believe that mattering may be a better predictor of health and well-being relative to other conceptualizations of social relationships" (p. 1842). In particular, they posited that mattering should outperform social support in terms of health and well-being.

Collectively, the results summarized above paint a positive image of the older person with a sense of mattering to others but a bleak image of the older person who feels insignificant, unimportant, or worthless to self and others. Much more research is needed, but mattering is clearly protective in terms of being associated with less depression and greater well-being, and there are strong indications that mattering provides a platform for better health. Also, initial data suggest that older people with a sense of mattering have lower loneliness and greater social connection. These findings combine to suggest that the older person who is able to maintain and extend a sense of mattering to others is someone who should cope reasonably well with the pandemic. Once again, however, the situation is qualitatively different and untenable for elderly people who feel like they do not matter to others. These tendencies should be exacerbated if this is accompanied by the feeling of not mattering to the community or the broader society. Flett et al. (2019) maintained that one of the key distinguishing features of mattering relative to other psychological constructs is that mattering translates well into actions and themes that can be incorporated into practical applications with a prevention and promotion focus. The potential relevance of mattering is considered below as part of a brief overview of some existing preventive interventions for older adults designed to enhance the sense of connection and relatedness to others and decrease social isolation and psychological distress.

There now has been extensive research on the social isolation of older adults and the impact of loneliness and disconnection. The extent of this focus is reflected by there being at least two separate scoping reviews of research on isolation and social disconnection (see Courtin and Knapp 2017; O'Rourke et al. 2018) . There is little doubt that anyone stands to gain from having more positive social interactions and a greater sense of interconnectedness with other people, but this is especially the case for older people who find themselves quite isolated. Below we will provide a brief description of two interventions designed jointly to enhance social connections and improve mental health. Mattering could be added as a key element in each instance.

Van Orden et al. (2013) implemented a program in Rochester, New York called the Senior Connection as a potential way of preventing suicide among elderly people. The essence of this program is that seniors who have expressed an interest in volunteering have that interest directed toward becoming a peer companion of another senior who is vulnerable and isolated, perhaps to the extent of becoming suicidal. The conceptual premise of this work is provided by the interpersonal theory of suicide by Joiner and colleagues. This is a key element because ideally prevention attempts are guided by theory and conceptualization.

Two main themes are at the core of this interpersonal theory. People are suicidal because they feel like: (1) they do not belong with others; and (2) they have become a burden to other people. A program such as the Senior Connection will certainly address the sense of not belonging. Moreover, the senior companion can openly discuss and refute the notion that their vulnerable partner is a burden to others.

Where could mattering enter this picture? There is a tendency to equate belongingness with mattering, but these two interpersonal constructs are distinct. Someone can feel like they belong in a group yet still feel not valued or recognized within the group. Flett (2018b) has also described empirical findings showing that belonging and mattering are distinct concepts in various research investigations. These results suggest that the Senior Connection could be reframed to place a specific emphasis on how the actions and verbal interactions that take place between companions can emphasize that both are valued. One premise guiding work on mentors and mentees is that the mentor gives value to the mentee, but the mentor also receives value as a result of having a role that makes a difference in the life of someone else.

Mattering is also relevant to another program being led by the second author. This intervention has received the support of the Movember Foundation and it is geared toward lowering suicide risk and enhancing the psychological resilience of men transitioning to retirement. It is rooted in the work conducted by the authors on the role of meaning in life in promoting psychological well-being and reducing risk for suicide among older adults (see Heisel and Flett 2014) . This program and its initial effectiveness are summarized in Heisel et al. (2020) . This new paper outlines the preliminary results for the MCMG (also see Heisel and The Meaning-Centered Men's Group Project Team 2018). The MCMG is a 12-session existentially oriented, community-based, psychological group intervention. Delivery of the MCMG sessions is in community settings. Recruitment is based on promoting this opportunity as a "men's group dealing with adjustment to retirement" rather than as a "psychotherapy group" in an attempt to normalize any concerns about retirement. Two male facilitators lead the groups. The groups are comprised typically of 10 men who share the fact that are all facing the transition to retirement.

A full description of positive initial findings is beyond the scope of this review article. It is worth noting, however, that Heisel et al. (2020) made explicit reference to the potential role of mattering, and that the theme that each participant matters is implicit in the philosophy of this humanistic-existential group. Our evaluation of the topics covered throughout the program identified many points where a more extensive focus on mattering could be implemented. For instance, of course, it is a simple matter when describing the purpose of the group in the initial meeting to emphasize the theme "you matter" as a reason for the existence of the program. Mattering promotion can also be nonspecific in terms of providing opportunities to be seen and heard within a context where "everyone counts." Some specific session themes fit naturally with the nature of the mattering construct and how to instill a feeling of mattering in a person facing retirement. For instance, one segment examines the benefits of volunteering and becoming a mentor for someone else; mattering through mentoring is quite viable. The role of mattering can also be highlighted in sessions seven and eight that collectively address meaning in relationships, friendships, business relations, and camaraderie, and meaning in love experiences with significant others, children, extended family, and even pets.

One of the final sessions is focused on meaning in life and generativity. This session also represents a platform for the theme of giving a sense of mattering to the self by giving to others. The facilitators lead participants through the "Clarence Challenge"-named after the angel in the Frank Capra movie "It's a Wonderful Life"-asking them to imagine that an angel has materialized in front of them and shows them a movie reel of their life, specifically focusing on all of the contributions that they have made in life and the positive impact that they have had on others. After reflecting on these contributions, and listing them explicitly on paper, they are then asked to project themselves one decade into the future and imagine that Clarence the Angel reappears in 10 years' time and reveals to them all of the good that they can still do. They are specifically invited to "focus on the lives you will have touched, the value you will have contributed to the lives of those around you, whether your family, friends, neighbors, community, or even strangers. Then mark down (below) the impact that you can still make on the world around you over the coming decade." This highlights the facet of mattering that involves the perceived capability or capacity to matter to others, both now and in the future. It goes without saying that positive group experiences should foster the development of bonds among group members who come to matter to each other. This appears to be the case, as some former group members have continued socializing with one another following the end of the group, including one group that has been meeting on a monthly basis for nearly 4 years following the end of their group; ironically, their most recent scheduled breakfast meeting was canceled due to COVID-related prohibitions against group get-togethers. Although it is beyond the scope of this review, the most recent MCMG group was temporarily halted due to COVID; however, following receipt of research ethics approval, this group was reconvened online to positive effect.

As suggested above, regardless of the specific content that comprises an intervention, we feel that there is much to be gained by highlighting the mattering theme prior to implementing an intervention so that participants understand that they are valued and their involvement is truly appreciated. It goes without saying that this value needs to be shown and lived rather than merely mentioned. This sense of being significant will resonate with those older people who have been feeling ignored or discounted. It should certainly be "music to the ears" of any older people who is troubled by messages and events during the pandemic that make them feel expendable and disposable rather than valued and cherished.

Numerous topics for future research have already been outlined in earlier segments of this article, so we will focus on only a few key themes that merit much more investigation. Some of the work outlined below would benefit from a general approach that pits mattering versus other related constructs (e.g., belongingness, social support) in order to further establish the uniqueness and predictive utility of mattering.

First, and foremost, the literature on the role of feelings of not mattering in suicide risk is beginning to build but, to our knowledge, there has not been research thus far focused on the potentially protective role of mattering among older people. Research is imperative given growing concerns about suicidal tendencies among older people, especially during the pandemic. Some studies have provided indirect evidence of the proposed association between mattering and lower suicidality, but programmatic research from a longitudinal perspective is urgently needed. Regarding this indirect evidence, one study linked family connectedness with reduced suicide ideation among older adults (Purcell et al. 2012) . Measures of connectedness often include item content that assesses mattering (see Flett 2018b) . In this instance, family connectedness was assessed with a four-itembased measure of family-based reasons for living. Our anlysis indicated that one of these items is directly relevant to mattering (e.g., My family depends on me and needs me), while two of three remaining items constitute indirect indicators of mattering (i.e., would be missed by others). Another investigation established links between measures of belongingness and reduced suicide ideation among older adults (McLaren et al. 2007 ). Once again, however, the two belongingness measures each had a small subset of items reflecting mattering to others (e.g., have felt valued in the past). Thus, the results actually signify that lower suicide ideation is linked with both mattering and belongingness.

The study above on family connectedness was based on a four-item measure comprised of items designed to tap reasons for living. This is noteworthy because one way to frame mattering is to consider it as a core reason for living, and research findings support reasons for living in promoting optimism and reducing risk for suicide among older adults (e.g., Britton et al. 2008; Edelstein et al. 2009; Hirsch et al. 2007 ). Accordingly, one possibility for future research is to incorporate mattering as a key theme in existing measures of reasons for living. This fits with the results of a qualitative analysis indicating that the feeling of not mattering was identified as an overarching theme among elderly people with a desire for a hastened death (see Van Wijngaarden et al. 2015) .

Finally, Rosenberg and McCullough (1981) observed that mattering is especially important when people are facing a transition, and as such, it seems evident that more research is needed on the role played by mattering as people continue to age and they undergo a variety of impactful transitions. The focus thus far has been on mattering and retirement and there is a clear need for programmatic research on mattering and retirement; additional important moments of transition can include downsizing one's home or moving into a residential care home; experiencing health-related changes, widowhood, or other significant interpersonal losses; and anticipation of one's own mortality. Schlossberg (2009) also proposed "the mattering recipe." It has four ingredients: (1) getting involved and staying engaged, (2) harnessing the power of invitations, (3) taking initiative, and (4) doing your best to make others feel like they matter.

Initial evidence attests to the benefits of mattering for retired workers. Froidevaux et al. (2016) described a longitudinal investigation with 178 retirees. GMS scores were associated with positive affect, life satisfaction, and social support, and mattering was a mediator of the link between social support and positive affect. Froidevaux et al. (2016) concluded that preventive efforts to enhance retirement adjustment should feature the mattering theme.

In summary, the current article examined mattering and the need to feeling valued and significant and contrasted it with feelings of expendability among older people in usual times and in times of crisis such as the current global health pandemic. It has been mentioned often that the arrival of COVID-19 has brought existing gaps and systemic problems into the light; we suggest that it has also illuminated a mattering gap. There is a clear need for older adults to be treated in ways that enhance their sense of mattering and enjoy the benefits of feeling significant and important rather than feeling expendable and disposable. This extends to the need to substantially increase the resources available to our older people, including training more mental health professionals to address the needs of older people who do not feel like they are priorities. Humanistic approaches may be particularly consonant with such an approach, and we have outlined elsewhere the potential value of humanistically oriented interventions in enhancing well-being and reducing risk for suicide among older adults (Heisel and Duberstein 2016) .

The facets of the mattering construct were described in this article and elements of the construct relevant to older people requiring much more attention were identified (e.g., the fear of not mattering and the loss of mattering). Research was summarized which shows consistently the ways in which mattering is protective in terms of its links with higher levels of wellbeing and lower levels of depression and loneliness. Mattering was also considered in terms of its link with physical health and its adaptive role as a buffer of the link between stress and physical health. The findings are generally in keeping with the premise advanced by Rosenberg and McCullough (1981) that mattering is especially relevant among older people. It is vital for individuals, professionals, and communities to promote experiences of mattering among older adults so that our seniors can benefit fully from an enduring feeling of mattering to others and to society in general. It is our hope that this review and analysis will serve as a catalyst for a much greater emphasis on mattering as a way of promoting resilience among the elderly. We also hope it will serve as impetus for further research and applications that document how older people benefit enormously from chronic exposure to settings and situations that reinforce how much they matter and in which they know they are cherished.

Funding Information Gordon Flett was supported by the Canada Research Chairs program. This work was supported, in part, by funding from the Movember Foundation to the authors.

COVID-19 and the consequences of isolating the elderly. The Lancet Public Health

Preventive home visits and health -experiences among very old people

COVID-19 and long-term care policy for older people in Canada

Spanish military finds dead bodies and seniors completely abandoned in care homes

Quality of life demands comprehension and further exploration

Four out of five COVID-19 deaths have been linked to seniors homes

Reasons for living, hopelessness, and suicide ideation among depressed adults 50 years or older

Interpersonally-based fears during the COVID-19 pandemic: reflections on the fear of missing out and the fear of not mattering constructs

Elderly suicide and the 2003 SARS epidemic in Hong Kong

Factors associated with depressive symptoms among elders in senior residences: the importance of feeling valued by others

Mortality associated with COVID-19 outbreaks in care homes: early international evidence

Social isolation, loneliness and health in old age: a scoping review

Records reveal chaos in the days before staff abandoned the Herron

The satisfaction with life scale

Mattering in the later years: older adults' experiences of mattering to others, purpose in life, depression, and wellness

Development and psychometric evaluation of the Reasons For Living -Older Adults Scale: a suicide risk assessment inventory

Will COVID-19 make the decline narrative of aging worse?

Mattering: empirical validation of a social-psychological concept

Vital involvement in old age

Sense of mattering in late life

COVID-19: Premier Legault confirms 31 dead at Dorval care residence

Being central to decision making means I am still here!: the essence of decision making for people with dementia

The handbook of school-International Journal of Mental Health and Addiction based mental health promotion: an evidence informed framework for implementation

The psychology of mattering: understanding the human need to be significant

Mattering versus self-esteem in university students: associations with regulatory focus, social feedback, and psychological distress

Mattering as a vital support for people during the COVID-19 pandemic: the benefits of feeling and knowing that someone cares during times of crisis

Antecedents, correlates, and consequences of feeling like you don't matter: associations with maltreatment, loneliness, social anxiety, and the five factor model

Mattering as a unique resilience factor in Chinese children: a comparative analysis of predictors of depression

Mattering and psychological well-being in college and university students: a review and recommendations for campus-based initiatives

Does ICT use matter? How information and communication technology use affects perceived mattering among a predominantly female sample of older adults residing in retirement communities

Ageism and COVID-19: what does our society's response say about us? Age and Ageing

The role of mattering as an overlooked key challenge in retirement planning and adjustment

Escape from freedom

Existential mattering: bringing attention to a neglected but central aspect of meaning

Mattering: how organizations, patients, and peers can affect nurse burnout and engagement

Working sensitively and effectively to reduce suicide risk among older adults: A humanistic approach

The development and initial validation of the Geriatric Suicide Ideation Scale

Psychological resilience to suicide ideation among older adults

Do meaning in life and purpose in life protect against suicide ideation among community-residing older adults

Does recognition of meaning in life confer resiliency to suicide ideation among community-residing older adults? A longitudinal investigation

Meaningcentered men's groups: initial findings of an intervention to enhance resiliency and reduce suicide risk in men facing retirement

A positive psychological approach to suicide: advances in mental health and addiction

Reasons for living, meaning in life, and suicide ideation: investigating the roles of key positive psychological factors in reducing suicide risk in community-residing older adults

Future orientation moderates the relationship between functional status and suicide ideation in depressed adults

Loneliness and social isolation as risk factors for mortality: a meta-analytic review

Systemic failings fuelled care-home outbreak: 27 die at Hagersville, Ont., seniors' residences as officials at every level missed early opportunities to prevent spread of coronavirus. The Globe and Mail

Attempted suicides by elderly may be increasing six-fold, says royal college

Living well in older age: what can we learn from the Japenese experience?

Interpersonal and societal mattering in work: a review. The Career Development Quarterly

Development and validation of a Work Mattering Scale (WMS)

An investigation of perceived family phubbing expectancy violations and well-being among U.S. older adults. Mobile Media and Communication

Speaking of sadness: depression, disconnection, and the meanings of illness

Sent into care homes like sacrificial lambs: horrific evidence reveals that elderly with virus were sent away from hospital into facilities then devastated by fatal outbreaks. The Daily Mail

Positive ageing: to what extent can current models of well-being categorize the life events perceived as positive by older adults?

Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals

The social significance of religious resources in the prediction of mattering to others

Social networks and social exclusion: sociological and policy perspectives

Loneliness, health, and mortality in old age: a national longitudinal study

Mattering: it's measurement and significance in everyday life

Perceived mattering to family and friends, self-esteem, and well-being

New York sent recovering coronavirus patients to nursing homes: "it was a fatal error

The association of depression and sense of belonging with suicidal ideation among older adults: applicability of resiliency models. Suicide and Life-Threatening Behavior

A phenomenological study of meaning in life in suicidal older adults

Aging well in an upscale retirement community: the relationships among perceived stress, mattering, and wellness

Manual for the Five Factor Wellness Inventory

Interventions to address social connectedness and loneliness for older adults: a scoping review

Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy

Outcomes of occupational self-efficacy in older workers

The structure of personality capabilities

Functional flexibility: a new conception of interpersonal flexibility

Extending self-esteem theory and research: sociological and psychological currents

Health benefits of volunteering in the Wisconsin Longitudinal Study

The perception of depression in long-term care residents: a qualitative study using resident journals

Mattering at the intersection of psychology, philosophy, and politics

A geroscience perspective on COVID-19 mortality

Family connectedness moderates the association between living along and suicide ideation in a clinical sample of adults 50 years and older

The CES-D Scale: a self-report depression scale for research in the general population

The link between functional limitations and depressive symptoms: the explanatory role of self-conceptions

Understanding physical educators' perceptions of mattering: validating of the Perceived Mattering Questionnaire-Physical Education

The role of context and the interpersonal experience of loneliness among older adult people in a residential care facility

Self-concept and psychological well-being in adolescence

Mattering: inferred significance and mental health among adolescents

Happiness is everything, or is it? Explorations on the meaning of psychological well-being

Coronavirus: what's going wrong in Sweden's care homes?

Religious involvement, beliefs about God, and the sense of mattering among older adults

Marginality and mattering: Key issues in building community

Revitalizing retirement: reshaping your identity, relationships, and purpose

Failure to halt COVID-19 spread leads to mass deaths in Swedish elder care homes

When did elderly people like me become disposable?

Subjective health and memory self-efficacy as mediators in the relation between subjective age and life satisfaction among older adults

Military teams raise concerns about conditions at Ontario care homes

113-year-old coronavirus survivor: the elderly are the forgotten ones of society

Hospitals in Peru's capital won't admit elderly patients sickened with COVID-19 into overcrowded ICU wards due to their "risk of morbidity

Aging well: surprising guideposts to a happier life from the hallmark Harvard Study of Adult Development

The Senior Connection: design and rationale of a randomized trial of peer companionship to reduce suicide risk in later life

Ready to give up on life: the lived experience of elderly people who feel life is completed and no longer worth living

COVID-19: the implications for suicide in older adults

Internalized gay ageism, mattering, and depressive symptoms among midlife and older gay-identified men

The patient experience in community mental health services for older people: a concept mapping approach to support the development of a new quality measure

Many failures combined to unleash death on Italy's Lombardy

Development and validation of a geriatric depression screening scale: a preliminary report

Calls for inquiry into "horrific" COVID-19 deaths at Australian nursing home