The Psychological Tasks of Aging

Our fairy tales and myths are full of the “magical elderly.” Witches sorcerers, and wise magicians are generally pictured not as young, or even middle-aged, but as old. Even God, Jehovah, is seen as an elderly gentleman. In everyday mundane reality however, old age is considered the least interesting phase of a person’s life. Elderly people are often asked to stay out of the way, not make waves, and not be a nuisance to those who are younger. 

We make the mistake of assuming that because the elderly are old, they are no longer subject to change or further development. This attitude leads us to ignore older people and to deny their value within the social structure, the human family. Younger people do not, as a rule, take the time to listen to and observe the elderly uncritically. We make the assumption that old age is merely a state that reflects the decay of mid-life capabilities, that there is nothing going on there. Often this assumption acts as a self-fulfilling prophecy. When we do go home to see our parents or elderly relatives, this assumption leads us to perceive their lives as unchanging. We experience the same old house, the same furniture, and the same conversations. We  like to think of our parents as the vigorous adults they were when we were children. We are horrified to see them show signs of ossification. The implications are frightening: we know that we will become them. 

Sooner or later, however, we may be forced by circumstance to pay attention to our aging relatives. Perhaps one parent will die and the other will be left alone. Perhaps there will be an accident or incapacitating illness. In any case, there will be a situation that directly confronts us with the elderly. 

A reunion with parents, reestablishing the family as a care-giving unit, can act as a catalyst in the lives of all concerned. In the film, On Golden Pond, this reunion and reconnection is touchingly portrayed. The grown daughter comes home to visit her parents, with all her unresolved feelings of hurt and anger making her rigid and impatient. Her elderly father is often difficult. The more he feels his age - the disorientation, forgetfulness and anxiety - the more difficult he is. Yes there comes a moment when there is a softening. It is as if knowledge of mortality creates a certain atmosphere of fundamental simplicity. Petty issues fade away. 

Aging is characterized by a more and more vivid awareness of mortality. When we are around older people, we begin to discover things that are not so evident in the lives of those who are younger. Part of our discovery is that the elderly remind us of our own mortality, and it is this that often gives rise to our denial. Old age is largely an unexplored territory. “More people are now living into the eighties and beyond, but very little is known about development in those years.” This is not surprising, given the prevailing attitudes of our culture and the relative newness of the phenomenon of a large percentage of the population living to extreme old age. 

It takes courage to grow old. In myths and legends, the hero is known by how he faces death. Every old person makes a heroic journey and their strength is drawn from their connection with family, friends and community.

Given the proper support, old people will work to give the next generation the essence of their life’s understanding. Our culture’s inclination to institutionalize the ill, the elderly and the dying, as a means of meeting their care-needs, deprives the next generation of witnessing the process of old age and the intimate knowledge of mortality. Thus, as a culture, we lose our depth and our roots. 

At Dana Home Care, we provide a caring environment for frail and dying people. We have had the opportunity, through spending thousands of hours caring for the elderly, to glimpse the rich psychological processes taking place for the extremely old. 

The characteristic behaviors of older people, often mistakenly considered mere symptoms of decrepitude, are in actuality what we call the Psychological Tasks of Aging. We have experienced the urgency with which old people come back again and again to these issues, and the often-heroic effort involved in facing them. These Psychological Tasks of Old Age are: slowing, life review, transmissions and letting go. 

SLOWING 

The most obvious mark of mortality we see in the elderly is that they have slowed down. This slowing is an extremely gradual process, except in cases of physical trauma or illness. It begins in the thirties and continues throughout life. 

For most normal, healthy individuals, intellectual decline with age is relatively minor. The decline that does occur by and large revolves around one crucial function: speed. Aging is, in general, a time of slowing, slowing not only of gait and motor performance and metabolic processes, but of certain intellectual and recall functions, too. 

The physical slowing of advanced age is a completely pervasive experience. In extreme old age - the eighties and nineties - it may take a person ten minutes to button his shirt, half an hour to go to the bathroom. For the extremely old person, a large part of the day is consumed by the tasks of bodily maintenance. This deceleration has powerful psychological implications. 

The elderly take longer at specific tasks; therefore they have the opportunity to pay attention to detail. Old people are famous for being particular about little things. Youth, in its rush, often finds this irritating. It takes an act of will for us to stop and listen to our elders as they tell us how to fold a plastic bag, how to make the bed, or how to mail a letter. 

Our fast-paced culture does little to accommodate the slowing of age and infirmity. The emphasis everywhere is on efficiency. Street lights change before elderly pedestrians can get across the street, making the old person feel and look ridiculous. The clerk in the supermarket doesn’t have time to help his or her aged customer sort out coupons, making the older person feel and appear befuddled. Clerk and customer alike, are pressed by the line of people waiting and the relentless speed of the environment. There are a thousand small ways in which older people are shaken daily by the rapid pace of the world. 

The panic and confusion that older people experience when confronted with situations moving too quickly for them can have tragic results. They can lead to serious depression and to what has been called “the spiral of senility.” In this configuration, moments of forgetfulness or disorientation “create anxiety, which in turn creates dependence, more forgetfulness, more fear and anxiety, and finally the kind of confused and  withdrawn behavior that leads to the categorization of ‘senility.’” Given this scenario, it is not surprising that  many elderly people withdraw increasingly into isolation. There is so much risk involved in going out into a fast-paced world and in meeting new people that it feels safer to stay at home.

Along with physical inability to keep up with the rapid pace of younger people, the elderly person can suffer shame and humiliation at memory blocks, losses of physical competence, and at falling into states of  confusion. Coupled with this is panic – a growing fear of becoming totally incapacitated, unable to fend for themself in a sharply competitive society. 

Dr. Robert Kastenbaum of Wayne State University conducted an experiment in order to demonstrate the behavioral impact that slowness can have on the elderly. Dr. Kastenbaum invented a game in which a sped-up environment created a condition in college students he called “pre-experiencing age.” He gave each of his young students a time-limited task of matching up sets of card files. At first each student was allowed five minutes to complete the task. Then, without the students’ knowledge, Dr. Kastenbaum gradually began to accelerate the pace of the experiment, cutting the take time first to four minutes, then to three, then to two. Pressed by the shortened time, the young students began to “act old” - that is, flustered, confused, dithering, and paralyzed in the decision-making function. 

Old age accomplishes slowing down, whether the person intends it or not. Ethel, an eighty-eight-year-old woman, described her experience of aging as being “without that extra reservoir of energy we can call on in youth.” She had been reminded of her age as she walked up the stairs in her home. Approaching the staircase, she had been thinking of other things and started to run up, as had been the habit of her youth. On the second step, her body protested. She simply could not do it. She was not in ill health and she could walk up the stairs, but she was eighty-eight-years-old and had to go slowly. 

The challenge of old age lies in making a relationship with slowing, relaxing into being rather than doing. It is a kind of built-in renunciation. There is no longer the future to consider. One’s life has simplified; one develops routines and lives by them as a monk follows the monastic schedule. 

Few elderly people are able to accomplish this relaxation. They are traumatized by both personal losses and internalized cultural attitudes, by isolation and relegation to institutions. Old people are no longer integrated into daily, family and community life. Our culture no longer respects our ancestors. The undermining of the elderly in this culture, the demands made on them to stay young or stay out of the way, deprives old people of the environmental support necessary to accomplish the Psychological Tasks of Old Age. 

Senility or Alzheimer’s Disease is not, as described by physicians, completely the result of organic impairment. Rather, it is a kind of collapse or paralysis in the face of an overwhelming situation. In its last stages, this collapse resembles Bruno Bettleheim’s description of the “walking corpses” in the concentration camps.  Anyone who has walked into a nursing home has seen the blank, staring faces, the hands reaching out to pluck at one’s sleeve. Like the camp victims, the elderly have been broken down by an aggressive and uncaring environment. 

For the elderly in our culture, deprived as they are of role models, moments of forgetfulness are charged  with enormous fear. Without a supportive environment, and burdened with diagnoses of hopelessness such as Alzheimer’s and senile dementia, an older person can become psychologically paralyzed. This is particularly true if the elder person in question has endured traumatic loss and/or ill health. 

Natural aging unfolds only in a caring environment; one rich in life, communication, and relationship. In hunter-gatherer societies, the elderly tend the domestic sphere, help raise the children, and act as living libraries. They are central to community life. Younger members of the society are taught to slow to the pace of their elders and wait respectfully. In such a culture, the Psychological Tasks of Old Age are completely accommodated. 

In our society, an old person is fortunate indeed to spend his last years in a supportive environment. When this is possible, one can witness the genuine magic of aging. 

LIFE REVIEW 

The process of slowing gives rise to what Dr. Robert Butler refers to as “life review.” The term “life review” implies a conscious process of systematic reflection. This process may indeed be rational and systematic, as in the cases of older people who sort through all of their possessions deciding who will inherit them upon their death, or who will undertake the writing of an autobiography. There is, however, a dream–like quality to the life review process, which gathers momentum from a growing awareness of mortality and from the growing weight of a lifetime of experiences and impressions. Dr. Butler describes “the progressive return to consciousness of past experiences, in particular the resurgence of unresolved conflicts which can now be surveyed and reintegrated.” He goes on to say: 

. . . the old are not only taking stock of themselves as they review their lives, they are trying to think and feel through what they will do with the time that is left and with whatever emotional and material legacies they may have to give others. 

This process of introspection is a kind of inner cooking or brewing. The flame is the knowledge of mortality,  the ingredients are a lifetime of perceptions, experiences, and relationships as yet unprocessed, and the vessel is the human heart. Again and again, one is struck by the urgency of this process in older people, their need to generalize, to philosophize, to try to understand what their life has meant. Repetition of stories about one’s life is part of the process of finally understanding one’s identity. 

“My husband was a doctor, my son is a doctor, my daughter is a lawyer,” an elderly woman, Rose, repeated many times. What this comment really pointed to were Rose’s feelings about her own identity. Rose was an  example of an older person whose process had become stuck. Due to a combination of physical and psychological trauma and increasing social isolation, she had been reduced to “senility.” She appeared to have no short-term memory, was anxious and paranoid. She said the same things over and over again for hours and was unable to care for herself. 

Once established in an appropriately caring environment, Rose was able to relax. No matter what her complaints, there was someone there to listen sympathetically. Her litany changed and her dilemma became clear: “My husband was a doctor, my son is a doctor, my daughter is a lawyer, and I am an old rag.” 

For Rose, processing the material of her life meant expressing her rage and disillusionment. Because of her extreme memory loss, the process was accomplished not by means of recollection of stories and images of the past, but by repetition. Rose would repeat the same four or five questions or statements throughout the day, occasionally interspersed with other comments. The list of repeated statements and questions might change slightly, but the unifying tone was one of anxiety and irritation. 

Her repetition expressed her sense of paralysis in the face of the task of evaluating her life. Her obstacle was a profound sense of unfairness, a bitter feeling of disappointment. She’d had a good husband, but now he was gone. She’d had a big house, but now it was gone. She’d had two children and now they were gone. What was anything worth in the face of all that? 

Rose needed a completely accommodating environment in which to process the shocking knowledge of her own mortality. No one had listened to her for years. It took her a while to realize that people were not only listening to her, but questioning her on the details of her life, genuinely interested in getting to know her.

As Rose began to realize the kindness and the patience of the people caring for her, she began to relax. She had what she needed in order to continue with her process: a number of genuine relationships, friends who were committed to hearing her out and receiving what she had to give. She did not regain her memory, but became a pleasant and reasonable person, genuinely concerned about those around her and appreciative of the beauty and kindness of everyday life. Through the life review process, Rose was able to free herself from bitterness. She attained an equanimity that astonished her family. 

TRANSMISSION 

The fruit of life review for the elderly is the accomplishment of transmission, or handling on to others the essence of their knowledge of the world around them: how to do things; how to think about things; how to simply be. 

Old people urgently want to give others all the little precious things they have distilled: how to make a potpourri by drying flower leaves and scraping orange rinds, how to can string beans, how to fold the towels. But often it is not so much the content of what is being said that is really the gift. It is the fact of exchange itself. When the older person extends, and you receive, something non-conceptual happens - a sort of spark in the space, which is a glimpse of the elderly person’s world. It is this gesture of generosity that is characteristic of old age; old people need to be benefactors. They long to pass on the knowledge they have, the particular kind of awareness they have gained, the kind of detail and precision that shine in their slower world. 

Transmission happens on many levels. Obviously, transmission is what is told and given, but it is also in the atmosphere being shared. If the listener is relaxed enough to slow down and pay attention, somehow, the joint acknowledgement of mortality creates tremendous softness. Those who care for the elderly can receive the gift of a powerful perspective, in which petty things fall away. Simplicity seems to dawn and we are able to see the essence of the elderly person’s humanness. When we see their humanness, it reminds us of our own. They are leading the way we will someday follow. They are providing a role model. Our culture teaches us to fear age and death, but when we see an elderly person approach death and die, in their own natural way, it contradicts our fearfulness. 

The courage required in growing old, and the heroic beauty that can dawn in the midst of decrepitude are most vivid in the act of transmission. Elaine, a woman in her eighties, suffered a series of physical traumas, one of which occurred at my own home. She fell and broke her wrist. She became extremely anxious, not knowing whom to blame. Trauma had brought her, in addition to injury, a frightening sense of vulnerability. 

Elaine was an extremely intelligent woman, a writer. In the midst of these difficult times, I gave her a manuscript of mine to critique. One day, I received a panicky call from her. She had to talk to me, so I went over. 

She was obviously unwell. Her wrist, now in a cast, was painful. She was having other discomforts, as well. Her good hand was trembling and she was almost too weak to talk. On a table in front of her was my manuscript, on which she had made detailed notes. 

Elaine did not want to discuss her injuries or her disrupted plans, as I had supposed. She wanted to talk about writing. She had one thing to tell me, and that was how to make writing “strong.” Pausing every few minutes to put her head back, shut her eyes and rest, Elaine spoke for an hour and a half, going over my pages in detail. All of her comments had to do with the power of language, what weakens sentences, what  gives them thrust. That was what she had worked all her life to perfect and that was what she had to tell me, despite feeling so ill. In fact, Elaine’s sense of mortality and vulnerability brought on by her recent trauma made the task of transmission that much more urgent. 

LETTING GO 

All of the Psychological Tasks of Aging are part of the letting go process. Slowing is a beginning, the gradual reversal of the momentum of a lifetime. It is a means of shifting gears from the process of accumulation - of experiences, objects, and relationshsips - that characterizes youth and middle age to the old age process of  sorting and giving away. Life review and transmission are a kind of tidying up before one goes. Letting go has been described as “making one’s peace” or as acceptance of death. 

Sitting quietly with Rose, I could feel her panic build. She would start asking anxious questions: “Am I sick? Am I crazy? Am I going to die?” My responses were honest, but ordinary, nothing to hang onto particularly. Finally Rose would sit back and say, “Oh well.” Since there were no satisfactory answers, she simply let go  of the questions. Often at these moments of letting go, Rose would make a joke or simply laugh. Letting go  is often related to humor. Humor is a leap beyond conceptual mind, a necessary step in the process of letting go. As one tries to make sense of everything, one realizes that one can’t. That is the joke of old age. One is left with the simplicity of being, the vividness of perception and memory, and the fullness of one’s heart. 

The letting go process is often marked by tremendous tenderness. As Rose went further into letting go she would gaze into the face of a person speaking to her and say, “You are so beautiful.” Her awareness of the countryside as she went for her daily drive became poetic. She was intoxicated by the sight of flowers. Riding along in the car, she would occasionally burst into song, “. . . Silver threads among the gold. . .” then  giggle like a girl This period of bliss lasted a few weeks and preceded a decline into the more brutal process of physical death, a painful labor of several weeks in Rose’s case. Letting go does not necessarily precede physical death. Sometimes there are obstacles to letting go, such as the aggression of an institutional environment, unresolved family issues, or the absence of care-givers adequate to support and facilitate this process. Sometimes letting go happens in response not to one’s own death, but to a loss or personal tragedy of some kind. 

A friend tells the story of her grandmother, who had always been gracious and soft-spoken. Another granddaughter had married badly and the grandmother blamed herself. She felt that if only she had spoken  directly to her granddaughter about her reservations before the marriage, the tragedy would have been averted. The old woman was determined that, from that moment on, she would no longer pretend. She dropped her previous social façade and became a different and very direct person. 

Letting go may not be a brief transition, but can take years. This process may be frightening both to old people and to their families. What we think of as senility - confusion, and physical and psychological frailty - often has to do with letting go. 

Old people let go of the same things that children busily acquire. Children busily try to figure out what different things are named and how they work together. Old people let go of all that. They have already used  that knowledge and don’t need it anymore. They need a different kind of knowledge to make the transition  into death. 

The tools of conceptual mind are no longer of particular use in extreme old age. The internal pressures relate to a different order. Workday logic falls apart when one is reviewing and concluding at the end of life, preparing to let go. At that point, with the good fortune of a supportive environment, a kind of poetry dawns.

What is extremely interesting is that these tasks of old age can be accomplished even by an elderly person  who is very confused. We have seen this often, that befuddled old ladies who we have to lead from one room to the other are actually teaching us. They couldn’t be more accurate, they couldn’t be more kind, yet they seem to have no ability to manage their own faculties. This is an odd phenomenon. And for us, who at  this point still place a high value on thinking straight, it is almost incomprehensible. 

Letting go is the task that is perhaps least easy for younger people to relate to. In younger years, our prime directive is to hang on at all cost. Particularly, we feel we must hang on to the exercise and the results of using conceptual mind - the precise, logical, thinking process. The elderly are letting go of that and of the behavioral patterns associated with it. It is a process of stripping away. 

During the process of letting go, all sorts of things may come up - a sense of starkness, the unspeakable, painful things we wish wouldn’t come up. In a sense, we who are care-givers take the journey with the elderly or dying person and it is not always so sweet. Along with their problems, we may be confronted with our own resentment, our boredom, our fear, our restless desire to rev up and speed around. This journey often stirs up tremendous resistance. We are not used to such stark simplicity. 

Losing abilities, losing people, and having life reduced to a bare-bones situation, in which it may take fifteen  minutes to get from the living room to the bathroom, produce a simplicity that younger people don’t often experience. It can be very mysterious sitting with an older person who is going through the letting go process. It has a slightly eerie quality to it, but it is very interesting. It is like watching them try to piece together a poem, reaching tentatively for what line comes next. There is a kind of secret there. Old age hones life down to a simple routine. And in the midst of that state there is an elaborate precision of detail that comes from no longer being scattered in every direction and constantly mulling over hopes and plans for ten years hence, which is the kind of collection that young people carry around in their heads all the time. 

The main point is not to dismiss an old person who is going through that kind of dream-like remembering, shifting and not knowing. Our culture fears letting go of conceptual mind but other cultures do not necessarily share this attitude. A friend told me the story of the reaction of a Mexican Indian village to a demented elderly woman who wandered into town one day, no one knew from where. She was taken in by the villagers and cared for with reverence. To the Indians, her confusion was an indication of her link with the gods. 

FACILITATING THE TASKS OF OLD AGE 

The intrinsic structure observed in the Psychological Tasks of Aging requires a specific stance on the part of the therapist, family member, or care-giver working with an elderly person. In the first place, we must reduce our own speed when entering into the slower world of an older person. Otherwise, the two people will not be able to see each other. To put the two modes of being in place, we must spend time with the older person. Rather than spending a begrudged ten minutes during a perfunctory visit, we must actually sit down and wait, for hours if necessary, to settle into the feeling of their world. 

Caring for the elderly is not just cleaning someone’s house or emptying bedpans. There is also the perceiving of the journey people have made in their lives. And that can change all one’s preconceptions about what it means to be alive in this world and to move through life. 

We must make the effort to slow to the other person’s pace, to calm our restlessness and wait while they slowly accomplish small tasks or undertake to tell us in detail exactly how something should be done. When we can slow down our own pace, the elderly can start to relax, and we can share with them the art of appreciating the moment at hand. 

Slowing often means just being present in an ordinary way. If we are tense, restless and impatient with the slower pace, the elderly become anxious. Just as Dr. Kastenbaum’s college students, when pressed to speed up, became “paralyzed in their decision-making, engaged in random actions and became jittery and agitated,” older people become tense and flustered in the face of their children’s rapid-fire speech and impatient attitudes. 

When I take eighty-eight-year-old Mr. Brown to a doctor’s appointment, he sees me standing by the door with my coat on and rushes to get ready. He throws open the closet and fumbles through the garments. His elegant, bony, old hands fly like nervous birds. Clearly he has forgotten what he is looking for. After locating  coat and hat, he cannot find his glasses and hurries around the apartment searching ineffectually. He eventually finds them in his pocket. After about a half hour of this, we are ready to go. 

Mr. Brown is a delightful companion and an excellent chess player, but he is old and cannot hurry. As Dr. Kastenbaum’s study showed, when things move too quickly, one’s performance - and just as important, one’s motivation - drops precipitously.” When older people are allowed more time to perform, they are generally able to do as well as younger people. 

The processes at work in both childhood and aging proceed naturally, unfolding at their own pace, which is different for each individual. Both progressions can be either undermined or supported, depending on the environment created by others and their attitudes. 

The elderly need other people with them in order to perform their tasks of aging. Without people, they don’t have the opportunity to accomplish these tasks: to slow down without being considered a nuisance, to distill whatever it was that their lifetime of perceptions and experiences brought them, to pass on their conclusions, and to let go in a natural and flowing manner. For an elderly person to die in isolation, without having accomplished these tasks, is a great tragedy. 

We can make friends with old and dying people because, fundamentally, we know what is going on with them. We have had similar experiences ourselves, even though we are not, at the moment, necessarily dying. Dying has a familiar quality. It is as if we have a tiny version of it in our own lives. We have birth and growing up and decline and death happening day-to-day, moment-to-moment. The elderly person is going through a  larger version of the same thing. 

Unfortunately, the special awareness of old people, and their distilled experiences, are not regarded as important in our society. Yet without that continuity, from generation to generation, the results can be detrimental to society as a whole, as well as to the individual. Perhaps our country, in particular, is suffering from this kind of extreme deprivation of “generational” continuity. In breaking with the “Old World” to establish the “New World,” we left our ancestors behind. Yet, without that passing from hand-to-hand, the result is a rootless, groundless, youthful, consumer-oriented, superficial culture. We cannot understand the opportunity presented us by the care-needs of our old people. 

One of the significant differences between the elderly and the young is the degree to which conceptual mind plays a major part in things. Our society leaves little space for a condition of living where conceptual mind is relatively unimportant. But the last phase of life involves, for most people, a shift in emphasis from logical  thought to a more intuitive, emotional mode. Here again is a similarity between the first and last five years of life, where conceptual mind does not hold primacy. 

According to psychologist M.A. Lieberman, individuals approaching death are “preoccupied in an attempt to hold themselves together - to reduce the experience of chaos.” This period of decline and preparation for the separation from life is inevitable, though its length may vary from a few days to several years. As people get older and gradually slow down, as their awareness of mortality becomes more vivid, they are indeed preoccupied. 

After birth, dying is the greatest transition that we experience. During times of transition we are fragile, vulnerable to panic, unsure of ourselves or of anything else. During the last stage of life we need a caring  environment, the security of friends and relatives who are concerned and willing to help. As we become absorbed in the inner process of resolving and letting go of our lives, we lose interest in past concerns and activities. Yet, we very much need protectors, people willing to see that we, and our world, are maintained. 

As care-givers, we must always take our cues from the elderly themselves. We can trust that if we tend to the details of environment and daily maintenance, and surround our old people with kindness and respect, the fragile flower of old age will unfold. 

I’m suggesting that there is an organic, evolutionary dynamic in the elderly that happens even in the midst of confusion, which is tremendously potent and valid. There is some real victory and celebration possible even in the midst of existential decrepitude. We must do all that we can to see that every one has that final and  crowning opportunity.