MY AGING: THERAPEUTIC ETHOS OF OLD AGE

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MY AGING: THERAPEUTIC ETHOS OF OLD AGE

My Aging: Therapeutic Ethos of OLD Age*

Author: Viktor Kagan (Germany)

 

Girl in shabby trousers stopped suddenly,

squatted in front of them.

“Oldies, where do you belong?”

– Boris Vasilyev

 

I’m just a professor of life,

student in the department of death.

– Pablo Neruda

 

This is my first attempt to verbalize experience acquired in the area of geronto-psychotherapy that at first was quite vague for me, but over the last 9 years a few factors have converged.

I am 65. My teacher, Professor Samuil Mnukhin, was only approaching this age when I saw him for the first time and heard a phrase that would define the course of my professional life: “The responsibility of medicine is to struggle for life. The purpose of psychiatry is to struggle for the human being.” He seemed an old man to me then. Nowadays, when I get a consolation prize for being a senior in the form of a 10% discount at supermarkets, I feel perhaps somewhat similar as in a comment by Mark Pevzner, “not elderly, but already having lived for some time.” However, I live now in a way that would insure no financial burden on my children in the future. And when I am on duty and visit nursing homes, yes, I do consider if this particular one would fit me. And the joke, “Children should be loved because they will be choosing a nursing home for you,” sounds quite differently for me now than it did a dozen years ago.

During these years people closest to me passed away leaving me the patriarch of an extended family. Their departure from life was long and difficult. So while it cost them suffering, it gave me a fortunate opportunity to walk with them the last steps of their lives and ponder about things that would otherwise be left uncontemplated. Passing away, of each of them brought back the past experiences of encountering deaths of relatives, friends and teachers. Each death created reflections in the mirrors of other deaths and the number of mirrors multiplied. By the way, this process goes on and on.

So it happened that throughout these years of my professional life, the majority of my patients were over 70, immigrants from the former Soviet Union and Americans, all representing a wide ethnic and cultural spectrum. They range from people with degrees and diplomas,whose CVs contained long lists of high rankings and prestigious awards, to people with no more than few grades of preliminary school. Some living with their children, some separately. Many reside in all sorts of social institutions like assisted living facilities, nursing homes, and other places. Some are married, some have boyfriends or girlfriends, and some are alone. There are those in good physical shape, others frail. Some have clear minds and good memories, some have more or less serious mental disabilities. But in one way or another, all of them are approaching the final stage on their life path and are noticing the emerging contours of the destination. Some get to their final station, and the handful of earth on their coffins puts the period in my work with them. Some lie in graves alongside the graves of my parents and my brother, whom they knew or were friends.

Although old age is a time in which all four givens of existence proposed by Irvin Yalom (the inevitability of death of each of us and those whom we love: freedom to create our life the way we want it to be; our existential loneliness; and finally, the absence of any unquestionable and obvious meaning of life) are most clearly and vividly manifested, there is almost no research about  existential therapy with patients of this age. The Russian-speaking Google gives 12 matches for “geronto-psychotherapy,” none of which has any relation to psychotherapy, even less for existential psychotherapy. International Google shows 32 links of the same, useless type. The reasons for this, in my opinion, lies in the triangle of multiple, interlacing factors: 1) fear of existential therapists to enter into this marginal zone, 2) lack of resolve of existential psychologists to create new typologies for this group, 3) focusing of attention not on the essentia of age, but on existentia per se. But for me it seems interesting and, I hope, potentially productive to discuss an existential approach in therapy with people who have come to psychotherapy in the golden years of their lives.

When does old age begin? Where is the threshold beyond which a person becomes old? Essentia would suggest the moment when physical aging reaches certain “critical mass” and is accompanied by the critically narrowing field of social demand. In today’s Western  societies, the social threshold of old age is the retirement age. Some retire at this prescribed age, while others do it much later. Followers of existentia would say that old age is when a person feels old and adjusts his or her behaviour and life accordingly. However, this does not define experience of old age. It develops along with accumulating existential experience of the individual being, absorbing socio-ethnocultural “portraits” of old age and stereotypical attitudes towards it carried on by generations, especially the generation of children. Instead of suggesting some typology, here are some examples.

In the late 1990s, at a Sunday market in the centre of Vilnius, I saw an old woman sitting on a bench and knitting a doll. Standing next to her was a simple hanger with a display of her finished dolls, striking both by craft and design. I’ve never seen anything like that before or after. Maria is 102 years old, lives alone. Her monthly pension barely covers her apartment expenses. She is happy (words are just words, but her face and her eyes tell more than any speeches) that she can spend Saturday and Sunday here (in the Soviet days this was impossible). She finds pleasure being among people, earning some money for living and for wool for her dolls. One of these dolls still lives with my granddaughter, her namesake.

Carl Whitaker in “Midnight Musings of a Family Therapist” writes about old age. “The last five years of my teaching career, which ended in my 70s, and the next five years in retirement turned out to be more alive, more creative and happier than the previous forty ” and “somebody said that it was such a great time of life, that it would be shame to waste it in youth. I would add to that my recent discovery that old age is such a great time that it is a shame to wait for it for so long! One reason being freedom from all kinds of fears, a sense of security in old age that comes with a notion that nothing is worth worrying about any more. People have the right to believe anything, but their beliefs cannot make me feel uncomfortable or change. I like my life and I can sit back and enjoy its flow. Youth is a nightmare of doubts; middle age, a tedious, hard marathon; old age, an enjoyable dance (perhaps with wobbly knees, but the pace and the beauty become more natural, and uninhibited). Old age is a joy. This age knows more than it says. It is not too eager to talk either. Life is just for living.”

Mikhail Prishvin shares similarly lighthearted perception of old age. “This is what happiness is all about: to live to old age and when the back gets bent, still not to bow to anyone, at anything, not to drift away but to strive upward, and to keep increasing the number of tree-rings in one’s trunk.” And: “My stronghold is no more the number of years I have lived, but the quality of my days. It is important to cherish each and every day of one’s life.” In the last autumn of his life at the age of 81, he gave a brilliant metaphor for how he perceives old age: “The reason why it is so valuable to be in the village during the Fall is because you can feel how fast and scary life sweeps by you, however, while you are sitting somewhere on a stump, facing the dawn and losing nothing. Everything stays with you.”

A face of old age is not always turned to the dawn.

10-12 years ago, I happened to advise a man concerning his relationship with a friend. “I am torn between the desire to help him,” lamented the man, “which I understand is not something I can do, and resentment.” His friend, a famous and talented scientist and a respected “self-made” man, had carved his career with his own proper hands. Always demanding, categorical and uncompromising, he cherished this kind of attitude somewhat romantically, which, as it naturally happened, was not devoid of directiveness and conflict. At first, it helped him rise to a considerably high position. In time, however, his rigidity became increasingly at odds with the required flexibility of his administrative position and with his relationship with others causing him periods of depression with a severe psychosomatic component. It resulted in a  situation where he faced a choice between humiliating demotion to a position subordinate to his former inferior whom he did not regard as a noteworthy scientist, or retirement. At the age of 60, he felt cornered. Eventually he chose the latter and sank into depression, entangled in a vicious circle of now truly medical problems. All that he previously wanted to do and write, but did not have time for, still remained undone and unwritten. By the age of 63, he essentially walled himself off his life and broke almost all relationships. He expressed his attitude towards life in a letter to my client with whom he was associated for more than forty years: ” …since I’ve been silent, I’ve experienced resentment and anger at everyone and everything. Resentment and anger have become the norm for me, but I do not tell that to anyone, only explode from time to time. I hate people, all of them are enemies. Well, regarding you… I just burst with rage, look, you are so subtle and humane, but…” What followed was a tirade in the spirit of the stories by Mikhail Zoshchenko that severed the relationship between these two men. It was clear that this was a kind of cry for help.  We proceeded to talk about possible responses. I am not aware of what happened to these two men and their relationship afterwards, but my client’s words, ”He is so afraid of death that he buries himself in the grave alive,” got engraved in my memory.

In any case, one’ relation to death is one of the main experiences of old age. Death remains the ultimate mystery, even when it is so close and we get used to its proximity:

 

He smiled in his dream about something,

turned and fell silent, passing away.

“How fortunate: fell asleep and never woke up,”

whispered old men in the graveyard.

Later they drank vodka, shared memories

without much grief, though,

as if just whiling away their time

and waiting for their own demise.

 

The mind says, “I, too, will go. I do not lament death nor do I hope for immortality. I do not believe in miracles. I am not a snowflake nor a star, and I will be gone for ever and ever,”(Yevgeny Yevtushenko). The heart has difficulty accepting the permanence of death. The mind is there to help like a loving and caring husband, with whom the heart has lived an entire life.

He is slightly over 80. She is almost 80. They are Muscovites living in America apart from their kids for already 18 years. Unfortunately, her mind is slowly declining, so lapses in her memory happen occasionally and her behaviour often gets somewhat childish. They both come to the day centre for the elderly, where we do some work. For this particular session, she comes in with few of  carefully saved articles from various newspapers authored by her: “Please, read. What do you think of them?” She blossoms once she hears that I like them. They would like to collect her articles into a little book to leave as a memory to their children, but they have discovered it is very expensive. I tell her about online publishing where the book can be published for free as long as they themselves prepare the original templet on the computer. She calls in her husband, and the discussion continues between three of us. The idea seems to be attractive, however, impractical since they do not have a computer. “What about the children?” I ask. Oh, they have wonderful children, caring and affectionate. During birthday celebrations, their kids save them all the hassle and take to their homes or to a restaurant. Nevertheless, they are incredibly busy. Their son works on a computer all day long, so how can they ask him to strain his eyes after work, too. “Yes,” I say, “that’s great, a few days ago I passed a restaurant where I wanted to take my parents, but never did. So now every time I pass by it, I feel guilty.” They insist on excuses for their kids. “Right,” I say, “children not doing something for their parents – probably, all that is trifles, but my sense of guilt for not doing enough for my parents still weigh on me. Do you want this for your childre­n?” “Definitely not!” So I tell them, “Hopefully, we will pass away before our children and, of course, we do not want to be a burden for them. However, the best we can do for them is to help them not to feel guilty once we are gone.” Gradually, we come to the understanding that it would be most feasible to collect all of her articles, sort them out and then, passingly, share this idea of the book with their children. They would explain that it would be a heart warming legacy for them to leave such a memoir behind for the children and grandchildren. The kids, on their own, can decide when they can do it. I saw that this conversation was not easy for them. Despite having already paid for their plots in a cemetery, they have difficulties having a direct conversation with anybody about death and the wishes and plans related to that. But at parting both of them for the first time since we work together, hugged and kissed me.

After this session, I felt at peace about the couple. Their desire to avoid irreversibility of death and to exist in the form of a book or at least as a collection of articles in a special folder brings live meaning into their lives. Before they in their loneliness were clinging to each other and only rarely opened up to other people in the Centre, now they visit it more often and have more friends.

The subject of death is almost never mentioned as a reason for coming to therapy, but almost always, in one way or another, it crystalizes during the course of treatment. Psychosomatic and/or emotional symptoms that break through to real life are the manifestations of suppressed fear of death, or at least voices that fear uses to announce its presence.

Of course, it is possible to work with the symptoms that patients present, giving them freedom to work out their core existential problems on their own. If that is the therapist’s deliberate choice, it can be quite a productive strategy, upon condition that while working with just the symptoms he does not lose focus on the “background” issues, is able to note changes and is able to help the patient introduce achievable improvements to his internal existential thinking. An approach like this may even be preferable, for example, with less educated clients or those afflicted with alexithymia who have difficulty in verbalizing their emotions. It may also be used in cases when there is noticeable cultural discrepancy between therapist and patient, precluding the establishment of shared ground of myths, archetypes, and behavioral styles.

Leo, a 68-year-old African-American, has only his younger sister left from the entire family. She lives on the other side of America and visits him once or twice a year. He saw seven years of schooling in his life and many years of blue collar work. He ended up in a nursing home about eight years ago when the illness affecting his legs prevented him from both going to work and living independently. Moreover, he has a host of other health problems. He gets around in a “scooter ,” an electric wheelchair which he manages skillfully. He used to be the roommate of another patient of mine. I had observed him several times refusing help and moving himself from the “scooter” into the bed, a grueling twenty minutes process. Leo became my patient because of a severe sleep disorder, troublesome relationships with the staff, and refusal to remove gallstones and undergo surgery of bilateral ptosis.

For the first five or six sessions, he would formally greet me, continue to watch TV with his head thrown back because of ptosis, resembling an angry camel. Or if the TV was turned off, he would snooze with his eyes closed or pretended to be snoozing. Eventually I realized that he watched only news and football. So at the next session, I asked him a question about football, admitting at once being completely ignorant about it. He casually explained to me something I couldn’t completely understand, mostly because of his ‘ebony’ – quite specific English. I had to watch one or two games a week to know a bit more about American football. Our contact started to improve little by little, and now I  had to adjust to his style of communication and behaviour. He did everything very slowly and thoroughly, as if tasting things, and the manner of his conversation reminded me of Pasternak: “Let’s drip words like trees in the garden drip sap, absent-mindedly, generously, a drop, a drop, a drop.” And that is how we worked in this slow rhythm, sometimes with just few phrases per session, until one day he said, “I have ceased calling upon death.” Eventually he gave consent for the first operation, later agreed to the second. When it was time for me to leave that nursing home, he said at the parting, “You were a good friend, but now I can cope myself,” and turned back to the TV screen, where guys ran around kicking a ball.

Working existentially when possible, formal theoretical knowledge about death or active discussion of issues of death is not so much important for the therapist; what he really needs is to listen and hear how this theme echoes in actual experiences of the client.

Life is a salad bar,” says 78-year-old Joseph. “Want some salad ?” I ask in return. “Yes,” he says, “while working I used to go for lunch to a nearby restaurant. They had an awesome salad bar there! But my restaurant is about to close. Who cares about salad anymore?”

He confirmed to me once more that as a person grows older it is an open conversation about death that he needs more and more. I don’t mean philosophical discourses and examples from the lives of “great people,” but a heart-to-heart “I – Thou” conversation about one’s own death as an inevitable part of one’s future.

Dona, 87, taught English literature at the university. She has a large family and many friends. “Death is a taboo subject,” she says, “I cannot talk about it with anyone. They talk about all sorts of nonsense as if they really believe I’m some sort of Methuselah in a skirt.  And then they get mad at me and I end up feeling guilty. “

Only very, very few have the courage for what Anthony Surozhsky writes about: “My mother was dying from cancer for three years. She had an operation that was not successful. The doctor informed me and added: “Of course, you do not tell anything to your mother.” I replied, “Of course, I will.” And I did. I remember I went to her and said that the doctor called and informed that the operation failed. We were silent and then my mother said, “Then I will die.” And I said, “Yes.” And then we stayed together in silence, communicating without words. We did not think anything special. We were standing in the face of something that came into life and turned everything upside down. It was not a ghost, evil or horror. It was something definitive that we had to meet, not yet knowing how it would manifest. We stayed together in silence for as long as it felt right. Later life went on. But as a result two things happened. One, neither my mother nor myself have been walled up in lie. We did not have to play games and we were not left without help. I never needed to enter my mother’s room with a false smile or words. We never had to pretend that life wins, that death and disease retreat, that the situation was better than it actually was, when we both knew the truth. There was not an instance where we would be deprived of mutual support. There were times when my mother felt she needed help. She would call and I would come and we would talk about her death, about loneliness. Other times I would be the one who could not bear the pain of separation. I would then go to her and we would talk about it. She, as my mother, despite her condition, would support and comfort me about her death. Our relations were deep and truthful, void of any lies.” That is how they could contain the whole truth in all its depths.

This is exactly what a psychotherapist has to be able to do when working with the elderly and why it is necessary to first clarify one’s own relationship with death, so that his psychotherapy would not take the shape of cold abstraction or a strained pep talk.

78-year-old Leslie, a lonely bachelor, artist, lover of luxury sports cars, and rich.  No one to pass on the money, so no sense to save it now. He can afford a private room in a nursing home. When I come to see him for the first time, this is the dialogue that takes place:

‘Who are you?” he started at once, “Psycho-olo-gist?? I’ve had three like you, and they’ve all clouded my brains with stupid lectures. Go on, start!”

“I definitely would, if you insist,“ I said, “but I hate lecturing. I prefer good whiskey.” A little lie as I see there are some bottles of whiskey on a couple of paintings standing at the walls in his room. “Strong coffee, cigarettes…”

“Do not give me this crap!’ He demanded. “It’s not going to work! I have cancer! Now, crank the music box and sing me your ignorance about death!”

“Yes, I understand and I’m sorry. I am just a student in the department of death. You know more about it.”

After a long pause, he said, “Yes, I know.”

This was the beginning of our work with him for the next seven months. But there were times when my personal issues in relationship with death turned out to be a hurdle in my work.

When death is no longer over the horizon, as it was earlier in life, but comes closer and closer, what changes is the relationship with time.

 

Sprawled dead on the pavement lies time

like a discarded cigarette butt or an abandoned kitten thrown through a window

well could it jump by itself from so high

desperate to be just a bit of use to the one

who already for hours loiters away with a mobile on balcony

tickling ears of someone in far away streets

the sun begins to set

a red-haired man

scurrying for a bottle treads on red leaves

his heel gets hard pressed into time

loud mother

drags home her resisting brat

you dolt shrieks stop scampering once

time can’t wait now get to your homework

and her worn slipper brushes on time

a mercedes pulls in steps out serious fellow

cleans traces of unlucky bird from the hood

stomping on time and cursing

whatever that flies

jaws of the door swallow him cleanly

time lies unnoticed and nobody cares

only the oldie that sits on a bench seemingly dozing

bones crackling gets up and hobbles towards time

bends over he will pick up it can be handy

knows not for what but good thing needs not to be wasted

pity for time

it must hurt thinks he or perhaps still alive

maybe I’ll nurse it rooms will look not so empty

in the flat forgotten by all

fear not he coos I don’t hurt you and gives time a hand

a freckled laddy, chasing a ball, swings his foot

and kicks time and sends it all flying

into nowhere like a rag doll into the trash

the oldie whispers almost in tears why was that boy

surprised cub stares in doubt grandpa that’s nothing

nothing to cry it’s just some unfortunate time

there’s plenty of that

tired sun sets in a waste between buildings

evening has come

 

Time is diluted, less saturated with events. It plods by slowly and flies away instantly. It may be noon with only lunch to fill the time, then evening quickly comes and another day is gone. This is partly due to the increasing asthenia that changes psychological time and partly due to the fact that most ordinary actions now require more effort. Age related asthenia is exacerbated by fatigue, but also to a certain extent by impoverishment and meaninglessness of life hidden in its shadow. Could it be that this complex cocktail of physiological, psychological and social concerns gives rise to questions repeated every hour or so that children cannot help smiling at: “Maybe I need to go to the toilet … Perhaps I could call NN”? Could it be that we hear in this a new, different experience of savoring every moment of life? Will the psychotherapist notice it and how will he respond to that?

In the everchanging flow of time arises a sense of loneliness that escalates changes further. This is true even when the elderly live with their children and the relations in the family are good:  differences in spaces of life, incommensurability of intensity and speed of living carry their toll. This is even more acute when elderly people live separately or in a special care facility.

I met Judy when she, being 84, moved to a nursing home on her own will (”I ‘m becoming a burden to my children”). Day in and day out, she would lay in bed, barely touching the food, sadness almost never leaving her still beautiful face. She lived in a small town from which she had ventured out only few time in her entire life. She married at 16 and had nine children, all her life always turned around her family and home. Her loving and ever growing family often gathered together. In the most recent family reunion photographs, all the members barely fit into the frame.

Judy was the soul of motherhood and dearly loved by her family. Almost every day someone came to spend time with her. Weather permitting, they would take her out for a roll in her wheelchair through the garden or they would take her to a restaurant. But still, she remained depressed. She says, “I came here ​on my own decision and I don’t regret it, but I did not know that it would be so difficult. I really miss them all. I’m so glad to see them, but every time I see them it reminds me that my life will never be the same as it was.” She was prescribed antidepressants, but was still rather depressed. “I take the pills. What’s necessary is necessary, but unfortunately, they cannot replace my family.”

When we browsed through pictures of her family, she talked about all her children and, with some nudging from my part, recalled her earlier years. Gradually, her stories become more elaborate and more alive as she told me memories that were genuinely funny.

One day upon my arrival, I didn’t find her in her room but in the central hall way, where she was intermittently dozing off and watching people. After some time, we settled her back in her room where she complained that her children have completely stopped visiting her. In general, it’s not uncommon for family visits to start frequently, only to slowly taper from daily visits to weekly visits, to eventually visits that may occur monthly or multiple months. For several weeks we worked with her ​​feelings about it until it dawned on me to talk with one of her social workers. It turned out that her children were visiting her just as frequently as they’ve been visiting her this whole time. It became apparent that there were lapses in her memory. However, the impairment was not so bad. She asked about my children and learned that I have a granddaughter, whom she asked to see in a photo. I promised to bring a photo, but it happened so that I visited Judy only in two weeks. The first thing she said when she saw me was, “You promised to show pictures of your granddaughter!”

We discussed the situation with the social worker. She got in touch with Judy’s children and after a few days they hung a large calendar on the wall in her room on which all visitors were to leave their clearly readable signatures. There was hardly a day without one or two signatures. A week later, Judy was coming back to life. Every time I visited her, we turned to the calendar with the signatures and she happily recalled how she spent time with this or that person. One day, Judy told me that when she used to sit in the lobby waiting for her children, “time runs so slow for the one who is waiting, but for the visitor time is comparatively so short.” Now, when she looks at the calendar, her time is filled, “How could I have thought about my children that way? It’s because of memory, only memory …”

Time acquires special value and brings out very contradictory feelings. “It is terrifying when you feel eighteen inside and you enjoy the beauty of music, poetry, and painting, and then, suddenly, it’s time to leave, though you have not managed anything yet, you have just barely started living!” – wrote once Russian actor Faina Ranevskaya. The elderly sometimes remind me of the Japanese who can spend hours upon hours observing a flower or birds at play. For the observer, it appears to be passivity of an elderly, and only once in a while it is possible to catch a glimpse of reverence for life behind that. It is especially clear when the fear that Ranevskaya wrote about gives way to humbleness and being at peace with their imminent departure.

He is no longer in the world. We worked with him for three years, starting from the time when he was 79 when he was greatly bothered by inversion of his usual sleeping cycle. He fought in the war, then for more than 30 years he drove a produce truck, working night shifts and sleeping during the day. He was a master at cards and playing dominoes. A tough man, pushy and rude, but then he fell ill with cancer. After two months of severe suffering at home, when his children who were taking care of him thought he was about to die, he improved some and started to come to the Day Center. Prior to this, he was a solid, burly man, who now looked like a walking hanger. Upon his arrival, he went straight to rest for a couple of hours, totally exhausted after half an hour ride on the bus. Soon afterwards though, he got up and slowly made his way to the play room, waiting patiently for a seat at the game table. His previous burly self would have been already sitting there, unmovable. But now he simply watched others play cards, dominoes or billiard. His face radiated soft and gentle contentment that was completely genuine, he literally savored every instant. Once, at one of such moments he was noticed by a woman, some 15 years his junior and a former doctor, quite colourful, subtle and happy-go-lucky type. The man had been her neighbour a year ago, still quite healthy then, and had pursued her in his typical unceremonious way, but she had indignantly turned him down. Her face was frozen in astonishment, and later at his funeral she told me,”Goodness gracious, if I had known he was like this, would I have behaved like that?”

The loss of loved ones (I mean the loss of a husband, wife or children) at old age is not only a loss, but a reminder of one’s own mortality and perhaps the absence of absolute meaning of one’s own life. Also it falls upon the soil already well fertilized by prior experiences of loss. So losses, on one hand, become somehow expected and familiar, and on the other hand, experience of living with them is accumulating. Personal mosaics of experience, in spite of obvious commonality, always acquire own unique feel for each individual. For therapeutic work, what is important is the ability for the therapist to instantly connect with the common and the unique in the gestalt experiences of the patient and to be ready for the unpredictable and its power to overturn the assumptions and expectations of the therapist.

This woman was 78 when, two weeks after her husband’s death, she began to attend the Day Centre. She approached me on the very first day, which is not really usual for immigrants from the former Soviet Union. ”I need to work with you a bit.” She surprised me already on our first session, when, after talking a little about the loss of her husband, she moved to tell about her childhood, and her story continued for the next seven sessions with only short and occasional returns to her husband’s death.

Her parents lived in a small Ukrainian town. Her father was an engineer, her mother a pediatrician. She was a “doctor’s daughter” and compared to other children she was always neat, well-groomed with cute ribbons in her hair. She seemed to have everything one needs for a happy childhood. She remembered trips with her mother to the pioneer camps (the Soviet equivalent for scout camps), where her mother worked. It was there that her “specialness” (not externally, but inside she was always proud for her mother-doctor ) swelled up even brighter. On the first days of WWII, her father was sent to the front and never returned. She and her mother soon after the outbreak of war had to evacuate and at one of the stations lost each other, lost forever. The pampered child and “mommy’s girl” ended up in some orphanage in the Caucasus. Memories of grief in the story were replaced by the memories of feeling helplessly offended when her head was shaved bald and, suddenly, she was like “everyone else.” One day, when everyone left the building, she stayed behind. It was a bright, sunny day. From the second floor window, she saw the marketplace with lots of people and a cart underneath the window on which a man and a woman were sitting. In the crystal clear blue sky she saw several airplanes beautifully shimmering in the sun. She turned to walk to the door when she heard behind her a terrible explosion followed by screams. She ran to the window. In the smoke and chaos, the man who was just sitting in the cart was now shouting in an inhuman voice from underneath the two horses, whose bellies were burst open. The woman on the cart was screaming as well, but people ran past them. No one stopped to help them. It was the first bombing of the city by Germans.

From then on, session by session, she would retell the story with more and more detail. I thought she was pushing aside her recent loss with the old pain. Then I noticed that her story narrowed more and more down to the scene at the window. On the ninth session, she said, “I remember myself standing at the window, pressing my back to a column, there were two such columns in the room. I stand there and see and hear everything, I recall every single dot, but can’t understand…no, I don’t understand and don’t feel anything and can’t move…” She paused lowering her eyes and lost in thought. There was silence for a minute, until I asked her, “Is this what you feel now, after your husband’s death?” She slowly, as if waking up from a sleep, lifted her head, “Yes.” We sat in silence for a while. I felt something important for her was happening and did not want to interrupt it, so said goodbye. In the following few sessions, we worked through a big chunk of what is called the “psychotherapy of acute grief.” We still work with her, but now for other reasons: illness, major surgery, trauma. Not long ago, during our regular session, she said, “I sometimes wonder why I am telling you all these things that I have never told anyone else… and wouldn’t say” I did not insist on asking her why.

I want to get back to what Ranevskaya talked about  (“… you are eighteen within…”):

 

Years go by giving in to fatigue,

to the dry firewood crunch of the knee …

Only the soul, not bound by old age,

does not go silent in embrace of one’s age.

***

They sit on benches with dignity, gossiping, staring,

then go home with joints awfully crackling,

ashamed to admit that the soul grows old never,

and eyes still frolic youthfully shining.

 

And not just the eyes… Old age is also a time for love, ordinary, earthly love that connects two people in flesh and soul. In late unions, whether they are legalized or not, attention is usually placed on “someone to give a glass of water.” In fact, there are two vital aspects to this phrase: to have somebody who will give me a glass and the desire that there be someone to whom I could give a glass. Old age is also a time of love, a special love for one who you know will soon someday cease to be.

A boyfriend and a girlfriend. He is 90, she is 95. I happened to work shortly with each of them at different times and for different reasons. However, it was soon apparent that they were not fit for psychotherapy both by outlook and culture and by thorny characters. In dealing with others, they are very difficult to be around. But with each other, they are two angels. They would walk holding hands, spending hours talking with each other or doing something  together. They feel good with each other. Seeing them both glowing with happiness, I understood that psychotherapy was not for them simply because they had each other.

The ending of a relationship very often is perceived and experienced with even more distress than the death of a spouse with whom one has lived for decades.

A man whom I truly loved (he is not among us anymore) and who was a friend of my parents happened to be exactly in a situation like that. He was a pilot in WWII. His nickname was Lucky Bear (was shot more than once, burned with his plane, but every time survived). He was sent on missions where sending anyone else was too risky. After the war he became a husband and father, one who could be harsh at times, but could cook and do laundry, and even sew, if needed. He moved to America with his children and wife, who was paralyzed already for two years. For four years he was the “homemaker ” and caregiver. Several years after her death, he met a woman eight years junior with whom they established a seemingly wonderful boyfriend/girlfriend relationship. It was so beautiful that their adult children gladly accepted each one in their families. But after five happy years together she left him. He was pushing 80, while she preferred a man who was younger, stronger, and more fun. All his persistent attempts to restore the relationship were in vain. When the breakup became an obviously final and undeniable fact, he became completely lost in a severe, prolonged reactive depression. He withered physically right away, abandoned his friends and did not get out of the house any more. He could not think about anything except her. Typical suggestions to “escape” the affliction by reading or watching TV led to the opposite result: plots of books and movies were only triggers for his love, pain, and jealousy. All his anger was directed at the happy rival, who lived closer to her and “seduced her with a car.” However, not even the mildest shadow of his anger could ever fell on her, as she remained his “heavenly image.” Whenever he talked about her, there were tears or trembling admiration on his face, or both. “They say to me, listen, find yourself another woman, look how many there are and even better than her. “But that’s impossible,” he would say, “no one smells like her.” We had worked with him for about a year when he finally started to make some tiny progress recovering from grief. I can hardly name a technique that I did not use in this case. What did work only worked to the extent that we managed to perceive his loss in an existential context.

It was exactly him who helped me not just to know, but to really feel the living light of love in the later years that, in hindsight, enabled me to see and experience in a totally different light the elderly years of my already deceased parents. He also helped me be with my current patients, responding to their ability to love and their particular need for love.

Alexei Purin has very precisely “captured” and conveyed the relationship between life, love and death in the existential field: “What acid corrodes the soul to such extent, what horrors cause such chill, as being mortified when you step out of depth to dryness of the land, and water drips from heavy strands of yours? Dilated pupils drink night’s freshness, reflecting silver fringes of ribbed clouds. It’s tearfully pity that life, this mount of jelly fish, so melts away. Be not afraid of death: she is your sister.”

But, getting back to death… Sooner or later, death moves from mental reality to a reality of life staring you in the face. The therapist cannot die with the patient, but he can walk with him (not merely alongside him), and be alive with him on this final journey. The boundaries of the physical and the spiritual, high and low, ordinary and extraordinary, words and touches, therapeutic and human, are blurred here losing their earlier relevance. Co-existence provides assistance to the departing being, consoled suffering turns into an existential phenomena, existential work tempers pain … It is possible to tell a therapist what cannot be told to relatives and what would seem too earthly or insignificant to mention to a priest.

 

They say there is less suffering in the afterlife

if there is plenty of that in this life. Perhaps it’s true,

or not. No one has yet returned from there.

 

Two years ago, when she was going on 94,

she once told me, “You are praying for me poorly.

I have lived far too long. It’s way past my time, but for some reason, I’m still alive.”

I replied that I’d pray better, just didn’t know when to start:

right away or wait five months or so

to hold the next great-great-great-grandson in her arms.

She thought for a while, then looked at me, saying, “You’re clever,”

and added, “It won’t hurt if God waits for me a bit more.

What do you think?” And she, great-granddaughter of Theodor Herzl,

did live to see her great-great-great-grandson and to hold him in her arms.

Healthy lad. Grandfather Herzl would have been delighted.

Seemed like time to start praying. But there was bris* still ahead

and then children’s birthdays, no need to upset them with dying,

Later she said, might as well celebrate her 94th birthday with her children,

and then…

 

Time started washing her out, like a river washes its banks.

Just recently she was telling me, blushing like a girl,

“You know, doctor, it is amazing, but the soul does not age.”

Always looking primed up as if guests were already at the door of her castle, her half of the room in the nursing home.

Now she greeted me either wearing a bathrobe or lying in bed

or forgetting to put in her dentures, made by her late husband,

or finding out that it is Thursday only upon my arrival.

Her Russian blending less and less with her singsong Yiddish.

Her girls, one just below seventy, the other well over,

she raised them on her own to the rumbling lullaby of the war that killed their father as soon as the war set about.

She married him at sixteen.

They still preferred to think that mom simply did not wish to.

So she talked about life and death only with me.

“I hope,” she said, “God hears me, nivroko**, and stops tormenting.

Why torment me for so long? If you truly love me, you would help me die.”

“Really,” I asked her, “you want to see from the afterworld me being in prison?”

“No,” she replied, “but I can’t take it any longer.”

 

Once I came and she was in a coma. I thought God

had heard her pleas and wanted to take her away in her sleep.

God’s goes to God, but medicine managed to bring her back.

However, she lost her eyesight and got confined to bed.

Her girls come twice a day bringing chicken soup,

They know everything now, but – they  must do at least something.

I come on Thursdays. Diapers and pillows.

She soars in a dream between this world and that.

I hold her hand, talk about something or just sit in silence.

Some twenty minutes later she opens her unseeing eyes:

“Is that you? So it is Thursday today. I knew you would come.”

She does not call for death anymore, for she sleeps in death’s embrace.

She talks with me about that.

And I, not to litter the space with words, just stroke her hand. She laments for her children, who are so tired of caring for her lingering life,

and she herself is tired as well.

And so Thursday draws near and I come again. Yet again…

She is further and further away. Her voice grows softer and softer.

The little boat of her soul sails to the space beyond the horizon

where the ocean of this life flows into celestial waters

and dissolves in them.

 

Shortly before his death, her husband told her: “Don’t worry.

If afterlife doesn’t treat me well, I will come back.”

But he hasn’t returned yet…

 

*  Bris (Yiddish) – circumcision

** Nivroko ((Yiddish) – not  to overlook

 

Memento mori… and still “we live of death but thinking naught” (Yevgeny Yevtushenko). Old age is the time of life when we start thinking and preparing for it. No matter how we live, our lives are colored and saturated with preparations for the departure that is inevitably approaching. Psychotherapy, as Irvin Yalom points out in his book Staring at the Sun, rarely brings in the apprehension of death to its discourse. “Therapists avoid this subject for many reasons: they deny either the existence or significance of the anxiety of death; they assert that the anxiety of death is actually a concern about something else; they may be afraid to ignite their own fears or feel too baffled or despaired about human mortality.” I believe that the first two reasons are merely a rationalization of the true reasons for this avoidance: a personal anxiety or fear about the finiteness of life. Working with the elderly, where we cannot avoid the topic of death, our fears of death turn out to be the major obstacle.

However, the anxiety of death cannot be reduced to fear or dread. It carries a lot of potential to improve the quality of life in general, and in old age in particular, and for the therapist, his personal and professional growth. People often ask me if I do not burn out working every day with seniors and in the proximity of death. At first, it was not easy. But these were the patients who gave me a new and, as I catch up with them on the path to my final destination, a particularly valuable experience of life and death as its integral part. For this I am infinitely grateful.

 

Kids playing hide and seek.

Porridge simmering on stove.

Life labours tilling flower beds

And worshipping beauty.

Salt sparkles on a loaf of bread.

The scent of crunchy cucumber.

Birds pick mosquitos,

Snacks tiny in the sky.

Sweet smell of tuberose.

Woodpecker’s lazy drum against a pine.

Death drowsing in the shade of birch,

And smiling, still asleep.

* Having chosen the genre of an essay, I allowed myself to use my own poems as an equal part of the text, without referencing them, as well as other few quotes, in the bibliography. – VK

* The texts of the poems by the author and other poets translated from Russian verbatim. – Ed.

 

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