H istorically, professional interest in the elderly has been concerned with economic matters - food, finances, shelter, and subsistence. Now that some of these concerns have somewhat abated, it is the emotional and mental aspects of the lives of older people that clamor for attention, as do enforced idleness, ill health, and isolation. There is still much to be done in all aspects of the problem, for there is no doubt that growing old has its particular hurdles in this rapidly changing culture. It is this and the mental hygiene of aging that I want to discuss with you, for there is little to be gained if we are granted a long life and are fated to spend it in uselessness and isolation, to say nothing of ending ingloriously in senile psychoses.
"Mental hygiene" is a nebulous term that seems to change in description and meaning depending on who is using it and the conditions under which it is used. Thus it carries with it an air of Alice in Wonderland, whereby "a word means exactly what 1 choose it to mean, nothing more, nothing less." We will make it a bit more definite here by saying we simply mean that there are emotional states that, if understood and kept in mind, might make some aspects of aging a little easier. Mind you, there are no 10 easy lessons or how-to books to be had; we can only point out attitudes and approaches that might ease the way.
There is a form of mythology that has developed around the thought of growing old and that sees it as a gray, shadowy end of the line in which we slowly but surely lose our best self and our enjoyment of life. This stereotyping of aging has created an unnecessary fear of it and has contributed to the negative and somewhat hostile attitude with which it is regarded.
Stereotypes of differences in aging ran rampant a decade or so ago. Adolescents were stereotyped as rebels; they, in turn, decided not to have confidence in anyone over 30 years of age. This stereotype has eased a bit, but the one regarding the elderly has not fared so well. There are still those who visualize the aged as poor, isolated, sick, and unhappy or, on the other hand, as rigid, powerful, unpleasant, and reactionary. In either instance, it makes the natural phenomenon of aging seem particularly unattractive. Fortunately, concerned people have been able to dispel some of these unhealthy pictures of growing old and have been able to show that they are based on preconceived notions rather than on facts.
Our first task, then, in our search for a hygiene is to try to convince our brethren that old age is not a disease and is not necessarily something that must be looked on with dread or distaste; rather, it is the normal, natural unfolding of life's plan. Our mission is also to try to show that, even though some of us may become ill on the journey, all is not lost - we do not thus become a people apart. The difference between us becomes one more of degree than of kind, and we would do well to remember James Russell Lowell's dictum:
Console yourself, dear man and brother; whatever you may be sure of, be sure at least of this - that you are dreadfully like other people. Human nature has a much greater genius for sameness than originality.
While the unsettled conditions that beset the nations today may seem new, they are new only in their trappings. Our experience by now should indicate that we are born to trouble and may depend on it, and while we live in this world we will have it, though with intermissions. But despite this, there is no need to be depressive - for there is always hope, and hope is the very heart and center of the human being. Hope is man's best resource, and we move into the future to the degree that we have this neglected virtue.
Nouwen and Gaffney1 speak of the wisdom of converting wishes to hope - you wish that; you hope in. Wishes have concrete objects, such as cars, houses, promotions, and wealth. Hope is open-ended and is built on a trust that the other will fulfill his or her promises. A marriage built on wishes is in constant danger, but a marriage built on hope is full of possibilities, since it is the partners themselves who count and not what they can do or have.
Conversion from wishes to hope thus asks for a slow process of disengagement in which we are willing to detach ourselves from many little and big things of the moment and open our arms to the future.
"This disengagement does not take place when someone is labeled old by society. The disengagement which makes hope possible requires a changed perception of time and death by around middle life."1 We will have more to say about this later.
Fatuous though it may sound, it is nonetheless true that the best preparation for meeting the psychologic problems of declining years is sound mental hygiene in early life. Aring2 believes that one could do worse in raising children than to dedicate them to the avoidance of senility. Over a century ago, Aring reports, Daniel Drake, a physician, wrote of the importance of formative experience in letters to his children. Perhaps he was acquainted with a similar statement by Leonardo. Drake said:
If a provident temper of mind makes you desirous of guarding against the gloomy insignificant, the sad and solitary nothingness of old age, you must accomplish it by industry in youth. Industry is particularly appropriate since, in our declining years, the knowledge acquired in early life is almost all that remains with us; the first inscriptions on the tablet of the mind are the last to be effaced. What a resistless motive for early diligence is suggested by this important law of human nature; and from its frequent violations how few like Nestor in The Iliad become in old age the living oracles of wisdom to the rising generation.
This dissertation is pointed towards the prevention of isolation and desolation that are hazards in old age. Isolation results in impaired thinking and altered emotional response; along with diminishing flexability, it can lead to unrealistic interpretations.
In the formative experience of childhood, the development of perception is important; the failure to develop perception is a calculated risk. It is the primary duty of parents, teachers, and their surrogates to introduce to the young the useful awareness of the world. Early perceptual development sets the barometers for the remainder of life. One worries about the lack of this insight by parents and teachers, who today seem to be immersed in the pursuit of the relevant. That pursuit came to be a fetish for a while, and its effects - as well as the inflation of school grades - are beginning to show up as students apply for admission to schools of higher learning.
Strangely, or perhaps not so strangely, René Dubos3 made a statement that is in the same vein:
The development of biological and mental faculties is conditioned by their use during the early stages of life; similarly the maintenance of these faculties depends upon their continued use during the later stages of life. The validity of the ancient dictum "Use it or lose it" has been recently confirmed by a biomedical investigation.
Along with the development of biologic and mental factors in youth, there develops an emotional set that is also conditioned by its use and frequently lays down engrams that manifest themselves in later life. Thus, the observation of the ancients that many of the complaints of old age are due not to old age but to men's characters and tempers - and that calmness and happiness in early life are antidotes to these depressive complaints - has now been confirmed by scientific study.
Unfortunately, however, we cannot go back to teach these truths to those who require help with their emotional problems. Our task is now to treat the conditions that plague the sufferers and tend to separate them from the mainstream of current events. But we can warn others that the approach of old age is an inexorable part of living. It avails one nothing to fight against it, to lose vitality, or to become embittered. If possible, we should try to have young adults and people in middle life learn that the process of aging can offer a person a great challenge for maturing.
The old fixed rules of mental health still hold, especially those connected with keeping the lines of communication open with family and friends. In order to be meaningful, the communication must be within the frame of reference that the times require. This is not always easy for older people, for their interest is frequently in the past, in the time in which they were important cogs in the family and social structures. Present-day happenings are sometimes prone to be interpreted in the frame of reference of long ago, and there results a pathetic clinging to ancient habits and customs. The urgent need to be needed in many women whose children have grown up and departed is an example. Instead of finding new interests, some mull over what used to be and a number of them become candidates for involutional melancholia, a depressive disease of middle life.
In others, the reawakening of maternal feelings may lead to fastening emotionally upon a grandchild and disagreement with the parents about the care and discipline of the child; sometimes it is competition for the child's affections. There is a need for mental hygiene constructions here, as well as a much wider recognition that emotional stress imposed on the elderly by demands to adjust to a new life produces psychologic reactions comparable with those imposed on adolescents by demands to adjust to adult life.
This is worthy of note. Just as children must adapt to new status, so must the adult adapt. The way each group adjusts to change determines their future.
The saying that one is as old as he feels is not simply a flippant remark. Pathologists have shown at autopsies that the brains of some people who had been labeled senile demonstrated few serious pathologic changes. On the other hand, some people who had occupied important positions to the end manifested evidence of severe brain pathology. The trouble with many people who exhibit senile behavior is that they have quit - they have given up. They have failed for some reason, recognized or unrecognized even by themselves, to stay in the mainstream of daily life. To lose interest in life at any time - especially in this fast-moving culture - means to be soon left behind. One is thus affected mentally and physically, and depression of varying degrees ensues.
Monotony hastens disinterest and regression. Then comes further isolation and the danger of sitting staring into space or into a television set that is on or off, lost in memories, as many of the residents of fleabag hotels are now fated to do. Many of these people may be reasonably sound physically (even though older people frequently have at least one chronic disease), yet they are not flexible enough to make the necessary readjustments to grow old gracefully. To salvage them, we must fill their time, try to revive their interest in life, and encourage them to use their brains and their hands.
Time and again, one can see the mental and physical deterioration that follows rapidly upon cessation of responsibility and productivity, but few have noted the individual's own part in that deterioration. Some people are affected adversely by dread of the mere passage of time. They are allergic to the killing phrase "three score and ten." Unofficially one might call this a "time neurosis," though I dread diagnoses by epithet. Whatever one calls it, it has unpleasant consequences. It implies that one must stoop under the cumulative burden of years.
One occasionally hears of men who die within a year or two after retirement, apparently because of a loss of motivation to continue. It is as if they begin to search for signs of senescence because of the loss of a routine begun years before.
The demoralizing effects of attitudes like these are obvious. It is the task of mental hygiene, teaching from whatever possible source, to recognize them and treat them before they become fixed. What can make the lives of these people meaningful? It is obvious that more than good physical health is required. It is necessary that they, in some way, find a vocation or avocation that interests them and revives their sense of worth.
Many old people can figuratively be said to be walking textbooks of pathology; some feel reasonably well; some are disabled. We find ourselves increasingly looking for the person within the aged body in order to understand these discrepancies of disease and disability. Our science is inadequate in this regard. We, as physicians, solve bodily ills by doing something to the body - by giving digitalis, penicillin, sedatives, or stimulants. But aging is different. Experience shows that those who age well have different relationships to their bodies. This is as important as the success of our drugs. We do not realize often enough that the healing forces needed may reside within our patients themselves. The healing power can be augmented by their relationship to and confidence in the physician.
What do we do when our concepts fail? We shed all preconceptions and really listen to what the patient has to say. Absolute honesty is required, not only of words but also of feelings. In return for our honesty, the patient will be honest with us.
In teaching families the mental hygiene of aging, we must instruct them to seek a middle ground between two extremes. The first is indifference or neglect of older family members; the second is sentimental overconcern that encourages older people to tyranny, meddling, or the exploitation of younger lives. If we can agree that in the faulty adjustment of older people cerebral decline plays a much less important role than is generally believed, we must begin to implement the recommendations of the White House Conference on Aging, particularly those ensuring a comprehensive system of care with assessment of the problem, education to preserve health, supportive services to maintain it, and rehabilitation and long-term care when necessary. Whenever possible, there should be the development of alternatives to institutional care. Home-care systems are the trend for the future, preferably hospital-based. We shall amplify this later, for it will require proper preparation and support to help the family handle what might be a traumatic situation.
Retired persons, gradually bereft of the companionship of old friends and co-workers, characteristically become lonesome, complaining, and self-centered and may make excessive demands on children, physicians, or ministers. The children, busy with their own families, generate feelings of guilt, and problems arise.
The problem of loneliness deserves more time than we can give it here - it is a significant universal emotional experience with far-reaching consequences for good or evil. Loneliness has been called man's oldest theme, and much of his poetry and literature is concerned with his efforts to break through its distressing bonds. It was the first thing God pronounced "not good" when he decreed that man needed a companion, and today the diagnosis is exactly the same as it was in the Garden of Eden. Loneliness is "not good"; strangely, however, some people are never less lonely than when they are alone. Chopin complained of being "alone, alone, alone," even when he was surrounded by others. Thomas Wolfe saw the essence of human tragedy in loneliness, while Rogers thought that "through the wide world only he is alone who does not live for another."
The contributions of loneliness and other emotional factors to the disorders of old age are now firmly established. Thus, the efforts at prophylaxis - mental hygiene, if you will - are important. It has to begin well beforehand, for when old age arrives for many people, especially those in metropolitan areas, that period frequently means loneliness and isolation. No one knows about many of these old folks, and no one seems to care. They fear they will die, but more than that they fear that they will die alone, unnoticed by anyone. Nationally, one out of every four admissions to mental hospitals and one out of every four suicides involve people over the age of 65. The mental hygiene of this is to educate as many people as possible about the possibility of and the prevalence of depression. But here again, there are only a few who care enough to look for the symptoms and follow through with treatment even if it is available. As for the critics who blame these people for not saving for a rainy day, they could not: for many of them, every day of their lives was a rainy day.
The preparations for and the problem of retirement are also subjects that require much more time than we can give them here. It is usually a hazard and, again, something that requires planning well in advance. This certainly should come under the heading of mental hygiene, for, except in rare instances, even in those who are prepared, it is a bit of a shock. The retirement dinner and the gold watch are not simply a mark of appreciation but also a farewell gesture to one's fellow workers. If this is not done carefully, it could be an assignment to oblivion. No one can pass from an allconsuming way of life to one of inactivity without a few emotional repercussions. A "job decompression" should be set up several years before retirement and the worker led into full retirement gently. In general, he should be helped to maintain his faith in his ability to face problems, thus preserving a feeling of personal worth. One can see a preview of this drama in what we call a "weekend neurosis," usually found in busy men. They do reasonably well during the week, but they wilt on the weekends and do not know what to do with themselves.
The real issue at this stage of aging and retirement is one of ability to cope with change. It is not a solid state - there is no sharp dividing line at the time of retirement.
A retired person retains all his attributes, his foibles, his joys, and his sorrows and all the hangups that the human being is heir to. He will take all his emotional problems with him, just as he took them to work with him every morning.
I am unalterably opposed to a sharp cuttingoff of men at the age of 65, though I know all the reasons cited for and against the practice. I favor a retirement age left open between the ages of 62 and 70 and governed by the person's health and abilities. There are several ways in which this could be accomplished - but that is another story.
It is a truism that the prevention of mental illness, the prophylaxis or the mental hygiene of prevention in any age, is a complex task, for it implies a control of causes. Obviously, in many categories of mental illness, the causes are not clearly established; yet we cannot neglect or simply walk away from them, nor can we sit by the roadside and weep. Though it is difficult to know where to begin our preventive measures, the mere fact of their multiple causation does not preclude some effort at therapy. Clinical experience indicates that an attack upon One or more of the causative possibilities may give symptomatic relief, and even that is quite worthwhile. The chain of events that has led up to the disorder is sometimes no stronger than its weakest link, particularly if that link has been recently forged.
Admittedly, prevention and prophylaxis against mental disorders in the elderly represent an overwhelming task. Fortunately, a large number of people are becoming interested in the subject. I shall not go into the possibilities of crisis intervention, home-visit teams, and other preventive attempts - you are probably better acquainted with this than I am.
One can visualize conditions in everyday life that require the care and treatment of those who become anxious, fearful, or depressed. Their coping mechanisms have failed, and they become disorganized. Tension increases to the breaking point, and help is needed if the person is to be saved from breakdown, suicide, or some other catastrophe. This, in turn, has an effect on the people around the person, sometimes to the point where they are no longer of help to him and, in fact, they themselves become disorganized. Call this crisis management, brief therapy, prophylaxis, mental hygiene, or anything you wish, for it presents an opportunity to help one or more persons to grow or, if neglected or badly handled, to deteriorate. During a crisis, people are more susceptible than at other times to the influences of calmer heads. When situations or people are teetering in the balance, a relatively minor intervention may be a deciding factor.
It is in the community that the final dramas of help and rehabilitation are to be played, and this in itself constitutes a hazard. Persons can be refurbished in institutions and their confidence restored, but if they run into a stone wall oí neglect, rejection, or hostility in the community, the results can be tragic. Therefore, the message is plain - the return to the family and the community should be carefully prepared lest the transition result in regression to a state too difficult to bear. The physician, the community worker, and all concerned can never afford to forget how closely related are the phenomena of normal and pathologic aging and how indistinct their lines of demarcation and how easily, under a wide variety of factors, one may be transferred to the other.
It is obvious that if our belief in the dignity of man is to be anything but a catch phrase, we shall have to find some workable solution to the present-day wastage of human resources. Social planning for the utilization of the retired and other aging groups is laudable for some, while it appears artificial for others. Like it or not, this problem is upon us. Could men be like Cato, who at 84 wrote treatises, studied a new language, and every evening repeated the events of the day so that he might keep his memory in order? It could be, as Cato said, that "the man living in the midst of such studies keeps his mind in full stretch like a bow and never allows it to go into old age by becoming slack."
In summary, then, the methods of prevention and the management of the emotional problems of the elderly are neither as difficult nor as futile as was - and in some instances still is - generally believed. Psychiatrists have changed their opinions considerably over the years and now look at these people as having problems and as having chosen special ways of meeting them. That way is sometimes pathologic and obviously misguided, but it was chosen in order to avert a disaster.
The major psychotherapeutic objective in treating people, especially older people, is the maintenance of emotional security and a sense of personal dignity without their having to adopt behavioral patterns and reaction formations that are disturbing to others. Everyone is deeply concerned with the preservation of his own dignity and sense of worth as a person. This is a powerful motivating force and accounts for the individual's striving - yet the elderly are constantly reminded by a number of incidents and attitudes that they are less beloved and less esteemed than they used to be.
The secondary objective is the interpretation of the problems of the aged to those who are responsible for their care and the gaining of their tolerance and active assistance in achieving the primary goal of lessening the feeling of social loss and the sense of uselessness and the desolation of older people, one-third of whom must live in circumstances below the poverty line.
What shall we say to ourselves at this juncture? First, that in the ordinary course of events and barring tragedy, we too are fated to become old and all the things mentioned above will in some way face us. Then we can ask, What makes older people fail?
1. Rejection of the fact that growing old is inevitable. There is nothing more pathetic than persons who are unwilling to recognize that they really are no longer growing or who forget that each age has its distinctive beauty.
2. Another pitfall is to be envious or resentful of younger people. It takes courage and magnanimity for older persons to see young people attain the peaks of their lives without being envious of them. Only by a free and interior letting-go of what is proper for an earlier life can one face the prospect of aging without fear and discontent.
3. Besides these two pitfalls, there is another grave danger of aging that especially needs to be guarded against, the oft encountered egoism of old age. This often manifests itself as materialism, and caprice and selfishness show themselves. There is a desire to dominate and sometimes an attempt to tyrannize one's own family and surroundings.
Recognizing that there can be a complaint of loneliness, we should know that there is a normal existential loneliness that has psychologic overtones and leads men to yearn for things of the spirit. This can help and vivify. The irrational form is the isolation of the hurt and angry. This is destructive, and it bodes no good for anyone.
Here the trouble lies within ourselves. The conquest of loneliness can be accomplished by all who are willing to seek and weed out two obstacles that are at the bottom of the trouble - self-love and hostility. Both make it impossible to communicate properly with those close to us and render us unable to see or feel a real relationship with others.
Actually, our families, friends, and fellow workers are extremely important to us. We are all important to one another. It is our mundane, everyday role of businessman, husband, brother, or father that is keenly felt when we are deprived of it. If we complain that most of our troubles on earth are due to people, we should realize that we might have more troubles without them. We had better keep this in mind and try to learn to be more understanding of each other. This will help with our existential loneliness.
All these concepts, taken together, constitute a segment of the mental hygiene of aging.
1. Nouwen, H.. and Gaffney. W. J. Aging: The Fulfillment of Life. New York: Doubteday & Company, 1974.
2. Aring. C. W. On aging, senescence and senility. Ann. Intern. Med. 77 (1972). 137-140.
3. Oubos, R. The despairing optimist. The American Schotar 45 (1975-76). 702-708.