Women and Therapy in the Last Third of Life

The Long View

Valory Mitchell, Valory Mitchell

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317987291
• Edition: 1
• Topic: Medicine
• Subtopic: General Health

What is distinct about the last third of life, about women, that makes psychotherapy different? In this diverse collection, the psychological meanings and challenges of the last third of life are explored, as the capacity of the psyche expands, sense of time changes, and some questions take on new vibrance and urgency. Some chapters shine their light on women therapy clients - on their precarious sociocultural predicament in a sexist/ageist time and place, on intrapsychic changes that follow from changing bodies, relationships, involvements and emergent needs of the self. Other chapters enter the largely unexplored territory of changes in the therapy process itself - where some decide against therapy altogether, while others describe a rich revision of familiar elements of therapy, greater authentic presence, a changed standpoint on the power of the therapeutic relationship.

Standing inside the ''last third'' and looking back on their own lives, several women psychotherapists offer a rare window into their private experience across time and their perspectives on the challenges and the gifts that they, and other women, may realize in the last third of their lives as they consider who they have become, who they are, and who they can be.

This book was based on a special issue of Women and Therapy.

Less Time Ahead, More Behind: Being a Psychotherapist in the Last Third of Life

SUSAN H. SANDS

Psychoanalytic Institute of Northern California, San Francisco, California

For those of us in the last third of life, there is less time ahead and more time behind. The greater proximity to death can lead not only to expansions of the self but to a profoundly revelatory lowering of defenses: it can allow us to acknowledge reality in a way not before possible. The recognition that “life is short” leads to a pruning of activities. The accumulation of years behind us increases perspective and offers a greater sense of the whole. We have ever more “ages inside us,” allowing empathy with ever more patients of different (actual and internal) ages. We are more pragmatic, self-regulated, integrated, simply human. There is greater freedom from the rules. The psychotherapy profession, by its very nature, encourages these and other emotional transformations through aging.

As I sit in my Berkeley psychotherapy office, my second home, I know that at 62 I am very different than I was when I began doing this work 30 years ago, or, for that matter, 10 or 20 years ago. I am in the last third of my life—although where in that last third is as yet undetermined. Two things are incontrovertibly true of me now as compared to then. I am closer to death and I have lived more; that is, I have less time in front of me and more time behind. It is these two simple facts that I wish to elaborate in what follows.

LESS TIME AHEAD

When death comes may it find you alive.

—African proverb (2005)

My greater proximity to death brings with it a growing awareness of my own mortality and, if I do not run from it, a greater acceptance of it. As I move inexorably closer to death, it becomes harder to deny its inevitability. Calvin Colarusso (1998) writes:

In late adulthood, the subjectively perceived distance from death is for many a more important organizer of subjective time sense than chronological age. As we age, we look towards death, and we look away. Freud ascribes his companions’ inability to feel joy in the beauty of the summer scene around them to “a revolt in their minds against mourning.” (p. 306)

I too find myself looking at death, then looking away … looking, looking away. In his famous 1973 book, The Denial of Death, Ernest Becker (1973) writes that “consciousness of death is the primary repression, not sexuality” (p. 96) and argues that the “terror of death” is a primary motivator of human activity:

The idea of death, the fear of it, haunts the human animal like nothing else: it is a mainspring of human activity—activity designed largely to avoid the fatality of death, to overcome it by denying in some way that it is the final destiny for man. (p. ix)

In our contemporary culture, we are in a veritable frenzy to try to find “solutions” to the “problems” of aging and death—antiaging serums, life extension programs, age reversal cream—so that we can live “happily ever after.” In his essay “On Transience,” the 59-year-old Freud (1916) exclaims (through the character of “the poet”):

No! it is impossible that all this loveliness of Nature and Art, of the world of our sensations and of the world outside, will really fade away into nothing. It would be too senseless and too presumptuous to believe it. Somehow or other this loveliness must be able to persist and to escape all the powers of destruction. (p. 303)

The sages agree: the anticipation of death, which informs the later stages of life, leads to a narcissistic crisis. How we respond to this challenge determines in large part how well we will do in the final third. Our various adaptations to this narcissistic crisis, which have been much discussed by psychologists and poets alike, seem to fall into two categories: first, the defenses, which include denial, dissociation, sublimation, bitterness, materialism, and realistic attempts to reverse the appearance of aging and/or to prolong life; and, second, the so-called transformations of narcissism, like creativity, generativity, and expansion of the sense of self.

Expansions of Self

It is the expansion of self-experience that interests me most. The most often discussed way of extending the self, explored first by Erik Erikson (1950), is through “generativity,” which he defined as “the interest in establishing and guiding the next generation” (p. 231). Erikson makes it clear that we become generative not only through parenthood but also through other forms of altruistic activity and creativity—among which, I would argue, is doing psychotherapy. Heinz Kohut (1966), in his paper on “Forms and Transformations of Narcissism,” introduces the idea of “cosmic narcissism.” He argues that those who are able to accept “transience” (i.e., having a finite existence) “do so on the strength of a new, expanded, transformed narcissism: a cosmic narcissism which has transcended the bounds of the individual” (p. 268) and which can, as it were, cushion us in later life from the fear of our personal mortality. He also sees the acceptance of transience as an essential part of wisdom, which he views as the crowning human achievement. Kohut leaves this idea of cosmic narcissism frustratingly vague, but he clearly intends his concept to go beyond generativity to an expansion of self that includes the world and that has as its precursor the early primary identity with the mother. Recently, Charles Fisher (2008) has taken up the concept of an expanded sense of self and how it can provide a creative response to the emotional crisis of facing one’s mortality. He argues persuasively that such an expanded self, which can include one’s intimates and/or extended clan and/or the world at large, constitutes a “new emotional configuration” in which

self and object partially overlap without confusion or blurring of boundaries. Mutual interests overshadow competing interest—not merely because it is useful to the person to cooperate with others—but because others are taken as being part of oneself, while still remaining themselves …. the other is treated as a valued part of oneself. (p. 17)

It is my belief that we as psychotherapists are privileged to both live and practice an expanded self more than people in most other professions. The very nature of the work we do helps us negotiate, in a number of ways, the narcissistic crises of older age and impending death. For one thing, doing psychotherapy is a powerful form of generativity. I can feel a great deal of investment in and attachment to my patients as well as pride in their accomplishments—at the same time that my professional training hopefully dissuades and protects me from unhealthy narcissistic investment and overidentification. I do, in certain ways, take my patients into me, and I do in some ways live through them. Moreover, my long years of training and experience in empathy and containment allows and encourages me to both enter into the worlds of my patients and to receive, “hold,” and metabolize their unformulated experience in my very being. More contemporary theory on intersubjectivity gives us further metaphors with which to understand ongoing mutual, reciprocal influence within the analytic dyad—that is, all the ways in which we and our patients interpenetrate, on unconscious as well as conscious levels. Complexity theory, or nonlinear dynamic systems theory, takes us one step further into an expanded self as we imagine ourselves embedded in whole systems and fields of mutual influence, to the point where it is hard to conceptualize any longer where one person or entity ends and another begins.

Seeing Things As They Are

The ideas I have discussed thus far remain in the psychological realm, assuming that an expanded self, however felicitous, is an adaptation to a narcissistic crisis. There is, however, another way to approach our fears of death. The greater awareness of death that comes with aging can lead not only to adaptive new defenses (including expansions of self) but, even more importantly, to a profoundly transformative lowering of defenses. I suggest that the shedding of the veils that accompanies a true encounter with our own mortality allows us to see into and acknowledge reality in a way that is not before possible. There is a new ability to see things as they are.

If, as Becker (1973) argues, all fears are built around our fears of death, and death anxiety is a central part of all anxiety, then, as we become more comfortable staring death in the face, we become more able to meet head-on the other rudely unsettling challenges of life. Picture, if you will, our defenses against our mortality as a much too large lid, one that covers not only death but all manner of difficult, overwhelming, or intolerable experience. If we can crack the lid on death, we may be more able to see and acknowledge our many other fears, doubts, and regrets. Alongside awareness of death, our other challenges may appear more like blips on the radar screen. If we can confront the enormity of our own personal dissolution, then we are much more able to be with what is. We become “sadder but wiser.” There is a touch of resignation and of the tragic but, hopefully, not too much depression.

In Buddhist thinking (e.g., Buddhaghosa, 1999), Death is one of the Four Messengers whom Prince Siddhartha (later to become the Buddha) encountered when he first explored the world outside his palace gates. The messengers (which also include aging and sickness) are teachings, harbingers of the reality we all have to face. The awakening of the mind to old age and death occurs when we realize at a gut level that these experiences are actually going to happen to us and not only to those other people. The Buddha sent his followers out to the charnel grounds to contemplate the state and decomposition of the body as the first step toward imagining the state and decomposition of one’s own dead body and the awakening of the mind that can ensue. For Buddhists, the meditation on death is the supreme meditation.

We are fortunate as psychotherapists to be able to practice, many hours a day over many years, the containment of difficult emotions and truths, including aging, sickness, and death. With this ongoing practice comes a more profound understanding of the reality of human existence. Hedda Bolgar (2006), a psychoanalyst and political activist, says in a film interview conducted when she was 97 years old:

I live by one idea now, which is that in analysis we don’t try to avoid things, we don’t try to hide things. We are committed to uncovering things and dealing with it. And I think that needs to be true of the relationship with the patient and it needs to be true of how you live and it needs to be true in every way.

It is this increasingly open-eyed relationship to life (and death) that can make us more and more useful to our patients. We can become more able to be with whatever they bring to us. We are less vulnerable and reactive. Our own defenses are less easily mobilized in reaction to our patients’ material. Our empathy can deepen, and our ability to provide containment can become more effective, encompassing, and reliable. If we, as older therapists, are able to stay with our awareness of the inevitability of death and our own finitude and not be carried away into manic defenses, I believe we have lifted a major veil and can better help our patients accept “the way things are.” We are not truly alive until we can feel ourselves a part of the ongoing cycle of birth, aging, and death that reveals itself all around us and that is the truth of existence.

And till thine this deep behest:

Die to win thy being!

Art thou but a dreary guest

Upon earth unseeing.

—Johann Wolfgang von Goethe (1828)

As we age, moreover, we experience the actual deaths of loved ones. I have recently experienced the once-unthinkable death of my mother. Now, no member of my lineage stands between me and my own death. I have seen friends and mentors die. I have discovered that I can endure these painful experiences and survive. The first time I saw death was at the burning ghats in Varanasi, India. I was 27. Since I had only seen death in movies, I somehow expected the experience to be accompanied by sudden, terrifying organ chords. But there were none. I saw bodies burning and melting and falling apart. There was a horrible stench. But the process was undeniably natural, and I felt great curiosity and excitement and especially relief to actually see death with my own eyes. I knew at that time (and I was right) that I would never again look at death—or life—in the same way and that I myself would never be the same. Similarly, as I watched my mother decline during her final few weeks, I experienced firsthand the revelation of the Hospice movement (2006): death is as natural a process as birth. Death proceeds through predictable stages. Activity slows. There is a turning inward. Bodily processes start shutting down. Need for food and drink decreases. Sleepiness increases. Breathing becomes intermittent and finally stops. Heart rate becomes irregular and finally stops. The body cools.

Truly opening oneself to the reality of death can lead to dramatic changes not only in one’s sense of self but also in how one chooses to live one’s life. From the Kleinian perspective, our confrontation with death gives us another chance to work through the depressive position (e.g., Jaques, 1965), leading to further relinquishment of unconscious omnipotence. We can become more able to tolerate loss and dependency and to sustain love for the important people in our lives despite their shortcomings and destructive aspects. Even death itself can be held as a good object rather than a persecutory one. All this brings greater serenity and emotional stability.

These and other transformations of the self through the aging process are, of course, not always possible. We may not have the internal resources to allow such psychic transmutations, and our later years may be filled—as Erikson (1950) suggested—not with increasing integrity but with despair. But if we are fortunate, our recognition that the future is circumscribed and that time and energy are limited (“life is short”) can lead to a pruning of our activities to include, as is possible, only the most crucial and enjoyable. Freud (1916) writes, “Transience value is scarcity value in time. Limitation in the possibility of an enjoyment raises the value of the enjoyment” (p. 304).

As we increasingly acknowledge “scarcity value in time,” we come to know that there is limited time for our patients as well as for us. With my patients, I have more of a sense of cutting to the chase. Why wait? I myself live closer to what is important and valuable to me. The essential question beckons: what am I called to do in the time that remains?

MORE TIME BEHIND

Only at the end, can one see what it’s all about.

—Margaret Atwood (year unknown)

I have been considering the impact of living in a subjective universe in which there are many fewer years ahead of me than behind and in which the closeness of death and the shortness of time are constant companions. I would now like to turn my gaze backward to the years behind me. What do I find? A huge accretion of experience. As I continue to move inexorably through the unique arc of my particular life, there is more and more to look back on. More and more of the lifecycle opens out behind me. As I see the endless repetitions of my own behavior patterns and those of humankind-at-large, it is harder and harder not to notice and take stock. I have a greater sense of the whole. I recognize patterns. I gain “perspective.”

“Only at the end, can one see what it’s all about,” asserts Margaret Atwood (year unknown). in an interview on the novel-writing process. Similarly, as I advance toward my own end, I can almost see my own life as a story with by now well-developed themes, style, “voice,” and characters—a story that I am continuing to write and revise, adding new themes and characters and stumbling on surprise plot twists and unexpected character development. As the years pile up behind me, the essence of my life—with its unique contours, textures and hues—comes increasingly into focus, like a photographic image emerging from the developing bath. Parenthetically, I find a parallel in my own writing: I have come to expect that I will not really understand my own papers until years after writing them.

As I age, I am aware of more and more ages inside me. I contain and am constituted by all the ages that I have lived, and I can experience them simultaneously within me, with their different needs, feelings, quirks, abilities, vulnerabilities, behaviors, and preferences, and I can feel the synergy of their ongoing negotiations, struggles, and collaborations. This knowledge offers a tremendous advantage in doing psychotherapy, as in life. Our awareness of having ever more different-aged selves within us allows us to better empathize with and identify with ever more patients of all different ages—and with all of their different internal ages—as well as with the parents, children, and all the other people in our patients’ lives. The more parts of us that we have available—and of course I don’t just mean ages—the more we can find analogies between ourselves and others and the many, deep streams of connection.

“Simply Human”

As I get older, there is the deepening understanding that “life is hard.” This sobering realization allows me to more easily resonate with the troubles of others with a sense of shared humanity and less sense of distance or separation or (in clinical terms) pathologizing. We are all brothers and sisters in this dark night. The gradual accretion of experience and understanding over the lifespan can give us more compassion, which Buddhist psychology understands as the trembling of the heart in the face ...