Dr. Sarah Eagger
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Love is a fundamental aspect of spirituality. There is so much
one could say about Spirituality and Ageing and indeed, so much one
could say about love. Where to begin? Most health settings now have
guidelines for whole person care in which spiritual needs are
acknowledged. However these are focused in specific ways for older
people.
Spirituality
I will start with two definitions of spirituality to put the
work done in old age psychiatry into context. One brief but pithy
definition is, 'The rediscovery of lost humanity'.
The American National Interfaith Coalition on Ageing describes
it as an 'affirmation of life in relationship with God, self,
community and environment that nurtures and celebrates
wholeness'.
Values, relationships and the discovery of meaning and purpose
in life - all these intangibles are of vital importance to us as
human beings. This is what Spirituality is to do with.
Love
As healthcare professionals we may feel uncomfortable with the
word, or the idea of, love. Maybe we feel easier describing 'love
in action' - in other words, the effect of love in the kind of work
we do - care, compassion, consideration, kindness, mercy, empathy
and sympathy.
I have in the past been moved and inspired by the writings of
Stephanie Dowrick (2000) and I would like to précis a passage from
her book 'The Universal Heart'.
'It's clear that at the beginning of a human life and again
at the end, love - expressed through delight, gratitude, constancy,
interest, good humour, kindness - is what matters most to us. The
absence of love is something that countless people experience on a
daily basis. They may call it loneliness, isolation,
dissatisfaction or emptiness. Often they have become strangers to
love and strangers to themselves. Love joins us to others - we need
that - the longing to care for others and be cared for is
fundamental to our shared human nature. We are social beings, using
our relationships throughout our lives to find out not only what we
are capable of giving, but also to discover whom we are; what makes
sense to us, what insight we can achieve, what kind of life we are
in the process of creating. Love connects us and inspires us. Our
well being as a society depends absolutely on whether we, as
individuals, are willing to care about how life is for other
people. A safe society is one where trust exists and concern for
others is readily expressed. If we are cut off from our capacity to
give and receive love, we go beyond loneliness, we become dangerous
to others as well as ourselves. A life worth living is a life of
love. And anything worth discovering about love will deepen not
just one but every one of our relationships. Just as crucially,
though, love joins us to the deepest part of ourselves. It allows
us to know that our own life has legitimacy, that from our own
inner world we can reach out to give willingly to other people and
receive what they can give us'.
Another publication that has inspired me is the 'Living Values'
guide from the Brahma Kumaris World Spiritual University (BKSU
1995).
'Love is the principle which creates and sustains human
relations with dignity and depth. It's the bedrock for the belief
in equality of spirit and personhood. The basis of real love
between people is spiritual. To see another as a spiritual being, a
soul, is to see the reality of the other. To be conscious of that
reality is to have spiritual love; each person, complete from
within, independent yet totally interconnected, recognizes that
state in the other. Love is not simply a desire, a passion, an
intense feeling for one person or object, but a consciousness,
which is simultaneously selfless and self-fulfilling. Love can be
for one's country, for a cherished aim, for truth, for justice, for
people, for nature, for service, and for God. Spiritual love takes
one into silence and that silence has the power to unite, guide and
free people'.
Love as a Value
In 1994 the British Medical Association held a summit on 'Core
values for the medical profession'. The summit called for a
re-evaluation, redefinition and restatement of core values, which
it defined as 'ancient virtues distilled over time'. Those at the
meeting recognised these values - derived from the doctor-patient
relationship and based on love, caring and sharing - as the
profession's greatest asset, greater even than scientific knowledge
and sophisticated technology.
The core values of the medical profession identified by that
summit were caring, compassion, integrity, competence,
confidentiality, responsibility, advocacy and the spirit of
enquiry.
McWhinney (1998) writes that responding to suffering is a moral
obligation, that compassion is not just conditional upon evidence
of its effectiveness. The relationship between doctor and patient
is a covenant, an undertaking to do what is needed, beyond the
terms of the contract. Sticking with a person through thick and
thin is hard work, an act of love - active love, tenacity - a whole
science (or a whole art). The healing relationship between
practitioner and patient carries strong moral obligations and
mutual commitments. McWhinney feels we have forgotten the
importance in medicine of presence and the continuity of
responsibility.
Dr. Kieran Sweeney (2000) maintains that the relief of suffering
is central to the responsibility with which we are entrusted. He
believes trust and self-discipline are vital to this. Trust in
others is one of the central human solutions to the unbearable
uncertainty of being ill, and, indeed, for some the unbearable
uncertainty of existence. Self-discipline implies a degree of
self-knowledge. This helps us to recognise what the patient is
experiencing and to have insight into the meaning of that
experience for them as unique individuals.
Challenges of Old Age
As night follows day, so old age brings change and loss and with
it dependency, isolation, loneliness and depression. But it can
also be a time of great spiritual growth and awareness and for
some, a celebration of wisdom borne of experience. People of all
ages share basic humans needs; love, faith, hope, peace and
worship. Older people are no different and certainly these needs
can take on a particular poignancy in old age.
It is normal to view old age with some apprehension. The
depletions of ageing multiply with the loss of role, bereavement
and domicile. Undoubtedly they have an impact on 'personhood' in
ways that we can but barely imagine when we are younger - our
self-image and identity slowly drain away and ultimately we face
death. Our society tends to be ageist and marginalizes older
people, making them feel a burden. In western culture there is such
an emphasis on achievement and the work ethic that there simply
isn't the appreciation of wisdom of old age as an essential and
significant ingredient of society. It would appear that in eastern
societies it is more custoMary to respect and honour one's
elders.
Yet, as the pastoral director of Methodist Homes for the Aged,
Jewel (1999) reminds us, in the book Spirituality and Ageing, this
is a time when the elderly have a real need for the affirmation of
their continuing value as unique and socially connected human
beings and their wisdom as a resource for others.
I recall here Erickson's eighth stage of psychosocial
development - Integrity versus Despair (1982). According to
Martindale (1998), integrity in old age is the capacity to
assimilate (integrate) the value of one's full life experience, to
be and to continue to be - through having been - able to hold onto
the worthwhile aspects of one's life. These include conscious and
unconscious memories of having been valued and loved. It implies
being sufficiently free of persecutory guilt as a result of having
been able to love. Facing death also shapes the spirituality of
many older people. The unfinished business of human relationships
and the need to become reconciled with significant others becomes a
high priority; the deepest desire is to die at peace. To try to
heal painful memories and perhaps even the basic need to be at one
with God (whom, or whatever, he, she or it might be) as death
approaches is a legitimate focus. Towards the end of life there is
the search for integration (a sense of wholeness in a spiritual
sense), to pull life together and make sense of it as a whole.
Old Age Psychiatry
In Old Age Psychiatry we deal with much co-morbidity. The
elderly with mental health problems often have the triple
disadvantage of problems associated with ageing, physical illness
and mental ill health - depression, paranoia and dementia. What of
those who have 'turned their face to the wall' and feel there is
nothing for them to live for anymore? Is this an illness requiring
electro convulsive treatment, or a justifiable response to the end
of life?
Swinton (2001), in his book Spirituality and Mental Healthcare,
gives us a holistic model of the major disorders that incorporates
spirituality.
'Spirituality and depression' (Swinton page
167)
Swinton describes depression as a profoundly spiritual illness
that digs to the heart of a person's spirit and forces people to
face experiences of meaninglessness and hopelessness. We know that
this can be devastating in its consequences. Swinton believes the
spiritual dimension has the potential to reframe experiences and
enable people to reinterpret them in ways that are therapeutically
helpful. He also believes that dementia provides us with the
possibility of reframing from a spiritual perspective.
'Spirituality and dementia' (Swinton page
166)
When we ask the question 'what does it feel like to
have dementia?' rather than simply 'what is dementia?' we
begin to see this particular condition in a very different light.
Swinton highlights work that has shown clearly the importance of
recognising the continuing personhood of people with dementia, even
in the midst of neurological degeneration. When viewed from the
sufferer's perspective, dementia is found to have hidden
psychological and spiritual dimensions that are masked by the
dominance of the medico-biological discourse. Focusing on the
former offers new possibilities of re-humanisation for people with
this illness. Swinton encourages interventions such as a
therapeutic presence that helps to reconnect those, who are by
definition, becoming disconnected from self, others and God.
Certainly we are challenged to find spirituality capable of
embracing dementia, a condition in which so much is stripped away
that only the essence may seem to remain. This confronts our usual
notions of personhood. I was extremely gratified to find that the
late Tom Kitwood, a psychologist and leader in dementia care from
Bradford, had put love at the centre of his circle of the main
psychological needs of people with dementia in his book Dementia
Reconsidered (Kitwood1997).
Kitwood also quotes a carer who described persons with dementia
as showing 'an undisguised and almost child-like yearning for
love'. By love is meant a generous, forgiving and unconditional
acceptance, a wholehearted emotional giving without any expectation
of direct reward. The presence of dementia, it is suggested, may
provoke a psycho-spiritual crisis in carers. 'If we do not deal
with our own issues of love, and grief around the failures of love,
we cannot live with Alzheimer's disease'.
How we Love
I know that in our daily practice we reveal aspects of love in a
myriad of ways. It is often the kind word, a touch or loving look
that has the most significance for the patient. As Martindale
describes (1998), we have an 'everlasting connection' with those
who may have… nothing. At times we are the only human connection
our patients have. We become their family, their world and, even
immodest though it may sound, their reason to live. The rules of
standard psychiatry seem to change, to become more flexible and
respond in a humane way to the situations we face. We are there to
affirm, validate, acknowledge, listen, witness, to hear confession,
to hear their story, to love and allow ourselves to be loved. We
help with the tasks of resolution and integration.
I recall a patient who was finding it difficult to come to terms
with his loss of skills as a builder and I related the Daoist idea
of the increasing value of quiet and reflection in old age. I told
him that Daoists regarded it as one of the tasks of old age to sit
beside running water and contemplate! He then realised how much
time he spent sitting by his fishpond and how much he enjoyed it
and was delighted.
We talk about facing death. The disclosure of hitherto
well-guarded concerns will only occur if the therapist creates a
climate of trust and is non-judgemental. What enables trust and the
unspoken to be spoken?
My colleague Dr. Mark Ardern (2001) in his chapter on 'Dynamic
psychotherapy in the setting of the old age psychiatry department',
states that such therapy is most likely to be supportive. He goes
on to describe how a basic premise is that the patient's ego is
insufficient to allow personality change and the prospect of
insight is limited. One aim of supportive psychotherapy is to
locate weaknesses in the patient's defensive structure and bolster
these by the therapist's active encouragement. The therapist still
constructs a psychodynamic formulation to avoid alienating the
patient or precipitating psychiatric illness. Therapists observe
the transference and counter-transference but by and large keeps
these ideas to themselves.
It is assumed that the major factors in the success of
supportive psychotherapy are the therapists' reliability and
empathy. As the patient's unconscious preoccupation is with
impending dependence, the dependability of the therapist is
especially crucial for the elderly. Patients may not need to be
seen frequently, but for the internalisation of the good object
will have to be sure that the therapist is psychically available.
For some patients the therapist may conclude that weaning away is
not possible. In these cases the patient's dependence is actively
cultivated. The notion of encouraging dependence can seem alien to
other branches of psychiatry. In these situations, we also try to
foster a dependence on 'the team', so that a community is
available, rather than the burden having to be placed on a single
individual. Patients can experience a new kind of parenting that
provides containment.
In group therapy for older people, they are also able to show
concern for each other. In these groups the process of pairing does
not have to suggest destructive sub-grouping but can be of
self-restorative value. There are also potential benefits in extra
- group socialisation and it is often unavoidable. Group
psychotherapy with older people is likely to require a greater
tolerance of behaviours. In a mature group some patients will act
as co-therapists, not necessarily a defensive manoeuvre.
Generally speaking, the emphasis of our work moves from one of
change to acceptance. We are co-workers in the task of rearranging
the bricks that make up the architecture of character, rather than
replacing them.
In his book Spirituality and Ageing, Jewell (1999) remarks that
we so often hear old people say 'Why don't I die? I don't want to
be a burden to others'. He feels we should never allow this to go
unanswered as it signifies hopelessness. Instead, he tells old
people 'you are never a burden if people love you. Those who
do, have the joy and privilege of looking with tenderness, concern
and intelligence at someone they love. But in return you must be
able to receive graciously and make it as easy as possible for them
to love you. If you receive with a cramped heart you are saying 'I
would prefer to receive nothing from you but I am a
victim'.
We all depend on one another's love and must learn at all ages
how to receive it with gratitude and grace.
All patients are vulnerable, ours especially so. They often
can't communicate in the conventional sense, yet really respond to
our loving attitude. I don't have to tell you that this is not easy
to sustain, day in day out, with the sheer intensity of the work. I
continuously see how much love is reflected in work we do in
dementia care.
I would like to relate a further passage from Stephanie
Dowrick's book 'The Universal Heart' that illustrates this
point.
'I was told a quite exceptional story about two people I
have observed together on several occasions. The younger man Geoff
is profoundly intellectually and physically disabled. He has no
speech. His movements are limited and out of control. He is also
deaf and blind. The older man Bill is the volunteer, who comes
unfailingly each day to see Geoff, to talk to him, hold his hand,
share news with him and let him know he is loved. Nothing too
remarkable in that you may think. But what about this? When Bill
enters the large building where Geoff lives, Geoff starts moving,
smiling, and making the noises that are for him the nearest
approximation to speech. He cannot hear Bill coming, but through
his senses he knows that Bill is in the building, even when Bill is
still several rooms away. Geoff is someone whose powers of
comprehension would seem to be minimal. Yet the sense that he has
of Bill's presence, and the comfort and delight he draws from that,
is unfailingly acute.'
This really does demonstrate the mysterious power of love and
it's central role in caring. I see this on the wards every day.
The team
A team with high morale and a clear sense of purpose is
inherently of benefit to patients. One that is split, and at war
with itself, will lead to patients being caught in the middle. Our
ability to care depends to a large extent on our own experience of
being cared for and valued. As well as being loving practitioners,
we need loving institutions. This could also go some way towards
protecting patients from practitioners acting out their own needs
in the healthcare setting, for instance, the need for power,
control, to be liked, wanted and cared for. These needs can be more
healthily contained in an atmosphere of good staff support.
We need to care for and love each other. A very touching
experience for me in our unit was after the death of a staff
member's young child. The staff group held a spiritual service
where each contributed a ritual and spoke to support the mother and
acknowledge their own grief.
It may be easy to talk about love but a relevant question for
all of us is how to be compassionate in caring for our patients
without personally becoming emotionally drained,
compassion-fatigued or 'burned-out'. By burnout, I mean a state of
physical, emotional and mental exhaustion caused by long-term
involvement in situations that are emotionally demanding.
Learning to be compassionate without suffering burnout is a
skill. Compassion is something that we all innately posses, yet we
need to practise and refine its use. It is learning to be alongside
patients in their suffering by seeing them as souls like ourselves
and yet at the same time not to identify personally with all their
physical, mental and emotional issues. It is remaining emotionally
detached from patients, yet keeping a spiritual, loving
connection.
Finally, we can only be compassionate towards others if we have
the same compassion towards ourselves. This means nourishing
ourselves at all levels, physical, mental and spiritual. How do we
do this - how can we allow compassion to flow in from others, and
from the universe, to replenish ourselves from a spiritual filling
station, as it were? How can we tap into a source of love and mercy
and keep ourselves topped up? Surely this is what spiritual
practices offer, such as prayer, devotion, meditation and
contemplation.
What patients say
A patient told me 'Love from you means not to be shunned, that
you listen to me, I'm not cut off, that you are concerned about me
and kind - it may even be physical, such as touching me on the arm
in a reassuring way, or holding me in your mind.'
I've come to realise many aspects of love through my own work
running a support group for people in the early stages of dementia.
When asked whether patients in the group ever think about God,
their quick replies reveal their preoccupations. 'What I want to
know,' asks one, ' is not whether we think about God but does God
think about us?' Another patient said, 'No one asks you how you are
going to prepare to meet your God'.
In groups we have the privilege of hearing the anxieties and
frustrations of older people that would not normally be discussed
in a social setting. Some of our patients in the day hospital
requested that we acknowledge the passing on of some of the
patients. We assisted them in their own plan of having a small
service on All Souls Day, having a book of condolences and a bench
in the day hospital garden to commemorate those that had passed on.
It was not just a memorial to those departed or reassurance that
they too would be remembered when their turn came. This
acknowledgement of their spiritual needs was also an act of
love.
References
Ardern, M. (2001) 'Clinical Practice: Dynamic Psychotherapy with
Older Persons' Chapter in Psychiatry in the Elderly (Eds.
Jacoby, R and Oppenheimer, C.) OUP 3rd Edition
Brahma Kumaris World Spiritual University (1995) Living
Values, A Guidebook. London
British Medical Association (1994) Core Values for the
Medical Profession in the 21st Century. Published Report.
Dixon, M., Sweeney, K. (2000) The Human Effect in
Medicine. Radcliffe Medical Press ISBN 1 85775 369 0
Dowrick, S. (2000) The Universal Heart. Viking Press
ISBN 0 670 88584 3
Erickson, E.H. (1982) The Life Cycle Completed. Norton
and Co. New York and London
Jewell, A. (ed). (1999) Spirituality and Ageing.
Jessica Kingsley ISBN 1 85302631 X
Kitwood, T. (1997) Dementia Reconsidered. OUP ISBN 0335
19855 4
Martindale, B. (1998) 'On Ageing, Dying, Death and Eternal
Life' Psychoanalytic Psychotherapy Vol.12: 3 259 -270
McWhinney, I, R. (1998) 'Core Values in A Changing
World' British Medical Journal Vol. 316: 1807 -1809
Swinton, J. (2001) Spirituality and Mental Health Care.
Jessica Kingsley ISBN 1 85302 804 5
Discussion
Reported by Dr. Daphne Wallace
It was voiced that there is a danger of 'compassion burnout' and
the need for refreshment for the self, which may be through various
means including prayer or meditation. It was suggested that in Old
Age Psychiatry we are privileged to be able to respond to neediness
and dependency. It was noted, however, that recruitment into work
with older people is not good, especially in nursing. Possibly the
professionalisation of nursing has made the situation worse by
increasing the distance between nurse and patient.
In the discussion that followed, the assessment of spiritual
needs was discussed at length with reference to the work of Michael
King and to the Handbook of Religion and Health, edited by Koenig,
Larsson and McCulloch. It was suggested that measurement scales
were useful, as a door opener to introducing spiritual needs into
mental health curricula. It is hard to offer love when faced with
rejection and criticism, not least from colleagues. In particular,
there is the danger of collusion with the patient's view of self as
a failure with nothing to give. Each person has it in them to love
but we find that difficult to communicate. Equally, it's important
not to feel guilty at what we can't do.