Book Reviews, Specializations

A Geriatrician Advocates for the Elderly

When I reached 50, friends began advising me to color my hair. I laughed – given what I’d been through in my 40s, I was proud of the evidence that I’d made it that far.

In “Elderhood,” Louise Aronson reflects on a career in gerontology (the medical specialty that focuses on the elderly) to expose the cultural disease of opportunism that infects our experience of aging – both within medicine and the larger culture.

The challenge of caring for the elderly is that normal aging changes body chemistry, making invalid many of the strategies pursued when caring for adults. Since all medications and medical procedures are proven for adults, gerontologists must understand the entire body when planning care. The liver and kidneys no longer may be able to eliminate drugs before harmful side-effects occur. As conditions accumulate, physical therapy requirements may overwhelm the patient’s decreased stamina. And procedures designed to restore full functioning in younger patients may instead cut short the life of a less resilient senior.

Paradoxically, the complexity of caring for a senior created the opportunity for Aronson to operate for most of her career as a dying breed: the home-calling general practitioner. Financial limits meant that radical treatments were often out of reach to her patients, and so common-sense behavioral and environmental adaptations were acceptable options. Perhaps not surprisingly, many seniors report greater satisfaction with their care when offered options that preserve their social setting, whereas hospitalization would have left them isolated for long periods – if not permanently.

Unfortunately, Aronson’s written contribution to this public debate was triggered by burn-out. Systemic factors – medical specialization, rigorous reimbursement policies, and profit-conscious administrators – generated resistance to providing the kinds of care that were best for her patients. To illuminate those factors, Aronson’s writing develops two themes in parallel: how medical care should evolve as a patient ages, and then the professional history that finally drove her to collapse in frustration when praised for her outstanding performance. While laudable in intent, the mixing of these two stories dilutes the focus of the book. In the end, only the most careful reader can form an independent judgment about Aronson’s views.

To a degree, Aronson seems to have accepted this outcome. Her afterward opens with a quote in which another author describes his work as a polemic – as intended to stimulate emotions that would drive political change. Taking this as Aronson’s goal, “Elderhood” builds a strong case: 50% of doctors “burn out” as Aronson did, and leave medical practice. More desperately, young and heavily indebted doctors choose suicide at rates far higher than the general public. It is only the narrowly qualified specialists that thrive, and they are precisely those unable to deal with the complexity of aging. Aronson takes the point further, believing that myopia extends even to treatment of “normal” adults – precisely because there is no “normal” adult. The inability of the specialist to anticipate the side-effects of their treatments eventually traps patients in the medical system as the treatment of side-effects creates further side-effects until the patient runs out of financial resources.

From the perspective of hypnotherapy, however, it is the first thread (the evolution of care with age) that is most important – and specifically to those of us seeking to serve the senior population. Aronson draws upon her clinical experience to illustrate the shifting goals of aging patients. To distinguish them, she proposes that we consider the stages of senior, old, elderly, and aged. These are wrapped in life’s third act – elderhood (the first two acts being childhood and adulthood). Aronson’s purpose is to hone our sensitivity to the opportunities and challenges of growing old.

Most of society relates to growing old as the loss of youth. Those visible changes – wrinkled skin, gray hair, and decreased vitality – appear long before we lose our creative potential. Seniors, therefore, are those still seeking opportunities after leaving their adult career. Their unique gifts are discernment, patience, and a surrender of financial ambition that allows them to prioritize options that benefit their community.

Medically the principle concern for the senior is decreased recuperative capacity. Senior illness and injury can trigger a debilitating cascade that speeds decline. This is therefore the stage to begin defining preferences for managing the inevitable decline. Aronson sets the two poles of the spectrum as “breathing at all costs” and non-intervention. Aronson’s illustrations tend to support “comfortable longevity” as the best compromise.

As aging continues activity begins to match the expectations generated by appearance. We become “old.” In planning gatherings and outings, compromises are made for reduced stamina. This transfers to medication – “adult” prescriptions should be screened for new or enhanced side-effects. With conditions that require surgery, discomfort may best be managed with lifestyle changes.

“Old” is also the stage where social changes begin to cascade. This follows naturally as life-long friends relocate and die. While still fairly active, this may be the best time to move to a dedicated retirement community, simplifying lifestyle while developing new friendships. Aronson emphasizes, however, the benefits of multi-generational households – once a necessity but now an overlooked option that enriches the lives of both youngest and eldest family members.

“Elderly” follows when management of medical complaints begins to dominate our days. Aronson dwells on the challenges posed by America’s utilitarian ethic. Cab drivers speed away from elderly fares, and private and public spaces become inhospitable – both physically and socially. Aronson warns that our failure to accommodate the elderly condemns us to suffering in our elderly years and denies us the opportunity to reap the insights gained from their lived experience.

In treating the elderly, Aronson condemns our modern “disease management” system. Essential practical needs are not recognized as medical expenses, creating “penny-wise and pound-foolish” practices that allow minor inconveniences (such as nutritional deficits and hearing loss) to evolve into serious conditions before services are provided. Worse, when those conditions arise, the influence of medical specialists means that the course of treatment often depends on which doctor is available first.

Ultimately, of course, the principle concern is managing the decline of the “aged” to death. Even here, Aronson offers inspirational tales – a bed-ridden grandfather who became tutor to the neighborhood’s school children. She argues for advanced planning and hospice over the isolating and desperate institution of the nursing home.

While I only outline the changes that define the transitions between the stages of elderhood. Aronson’s monumental work draws upon her experience in geriatric practice to illuminate the psychological needs that evolve from reinvention (seniors), to isolation (old) to wellness (elderly), and finally into mortality (aged). While somewhat diluted by her indictment of the medical establishment, Elderhood is rich with insight for those seeking to support each of these distinct communities.

Relationships, Specializations

Loss and Grieving

To know loss is to confront change.

People, pets, homes and jobs are not just things – they are the backdrop for our behavior. When we first acquire them, we are conscious of learning to adapt to their presence. Over time, those changes become automatic behaviors managed by the subconscious, woven together as a pattern for our life. Remove one element and the pattern vibrates. It may be a trivial disruption, such as when we lose a penny. Or it may be a near-collapse, such as when we lose a child.

When the loss is great, we may be overwhelmed and seek to avoid change. Most directly, we may deny the loss. We might imagine that the loved one will walk through the door any second, or that after the tornado we’re at the hotel on vacation. When denial becomes a permanent condition, the sufferer should be referred to a licensed mental health professional.

Another strategy is to cultivate dependency. We may expect other people to care for us, take refuge in pleasant experiences, or consume substances (food and drugs) that boost our energy and mood.

Healing begins when we discard denial and dependency to accept that we need to change our lives. Specializing in behavior change, a hypnotherapist can help with that journey.

The mind is always seeking health, and so hypnotherapy works with the mind. In planning therapy for loss, then, we should understand how the mind responds to loss. I cover two accepted frameworks for loss before offering my own perspective.

Kubler-Ross

Elizabeth Kubler-Ross broke ground with her study of how terminally ill patients dealt with loss and grief. In the popular formulation, the process follows five stages, but the middle three stages can become a whirlpool. The stages are:

  • Denial
  • Anger
  • Depression
  • Bargaining
  • Acceptance

We’ve already discussed denial and its helpmate, dependency.

Anger is the natural reaction to the realization that there is no answer to “Why?” It can be focused on the self for past misbehavior (such as cigarette smoking) or toward others (the tobacco companies). In the grief process, anger is important because it breaks down neural pathways. It is a mechanism used by the mind to get rid of behaviors that no longer serve us. In the context of a broken heart, this is clearly necessary: we need to stop acting like we did when we had a romantic partner and prepare ourselves to seek a more fulfilling relationship. In the case of a terminal illness, anger prepares us to accept that life as we knew it is going to end.

If the loss is due to illness, persistent anger also has dangerous consequences: it stimulates the sympathetic nervous system, which increases inflammation in our tissues. This can inhibit healing or even stimulate metastases.

Depression is a term in psychology used when we are unable to respond to the world. In severe cases, that manifests as avoidance. The highly depressed person can end up hiding in a darkened room. It is more severe than denial because while in denial we can at least function. What is different is that while in depression we are recovering from the mental disorder created by anger and gathering energy to create a new life.

After anger has softened our old behaviors and depression has allowed us to gather strength, we begin bargaining. This can take two forms. The less helpful is whining: “Dear God, what do I need to do to make this cancer go away?” Whining often loops back into anger and depression. The better is imagining: “If I heal from cancer, I will commit more of my time to charitable work.” Imagining builds new behaviors to replace those erased by anger.

Imagining prepares us to move forward to the last stage: acceptance. Acceptance is a great gift. It is the ability to take life one day at a time, savoring every moment and opportunity, while trying to enrich the experience for ourselves and others. Having achieved that wisdom, you will hear people say that getting divorced (or sick with cancer or arrested or…) was “the best thing that ever happened to me.”

Trujillo

Through his teaching and trauma response work, Timothy Trujillo has developed tools to aid those trying to recover from loss. Where Kubler’s focus is practical (“This is how people grieve”), Trujillo offers a metaphor for healing. Trujillo starts every therapy with the mind/body connection, establishing that it is possible to feel good.

The table elaborates the physical metaphor for psychic healing:

Stage Physical Healing Psychic Healing
Whole    
Injury    
Hemostasis Stop bleeding Separation from trauma
Inflammation Clear damage, fight infection Release old behaviors
Proliferation Repopulate with new cells Evolve new behaviors
Remodeling Cells organize as tissue Reconstruct relationships
Adaptation Compensate for lost function Deal with unexpected consequences
Recovery Return to normal

The power of this metaphor arises from the fact that often recovery from psychic trauma is impeded because the wound is projected into the body, causing discomfort to persist. In emphasizing the body’s natural healing powers, the client associates increased physical comfort with psychic healing. In effect, the conscious mind no longer interferes with the subconscious effort to restore balance and harmony.

Confronted by traumatized communities, Trujillo captured this psychological transition as a hypnotic script titled “The Five-Minute Miracle” (https://timothytrujillo.com/projects/five-minute-miracle).

Beyond Healing

If we have a wonderful relationship that falters and fails, do we want to release those cherished memories and behaviors? Or do we want to learn from the failure and expand our vision of future possibilities? Not just sexual satisfaction, for example, but also children and society?

Loss and wounding both have negative connotations. We have seen that at the end of grieving, we achieve a positive resolution – but the steps along the path are dreary, to say the least. With physical wounds, we can be awed and humbled by our natural healing powers, but in most cases after recovery we are less capable than before the injury. The metaphor suggests that the mind will also lose function during grieving. Why should we accept that?

I refer a simpler, positive model. Like Trujillo, I recognize the connection between mind and body, but would emphasize that it goes both ways. The reason we say the old lover’s name is because we remember them when our cheek is kissed. We have associations between physical sensation (the kiss) and old behaviors (saying their name).

The first step in recovery from loss, then, should be creating space within the self. This can be done many ways, but all involve intense physical exertion with focused attention. Shaking our fist at the sky is one example, as is a long, wracking cry. Other methods are possible: I use Sunday dance celebrations to create space within myself; others might go rock climbing. The point is to be aware that we are consciously creating these sensations of exhaustion within ourselves.

The next step is to rest until our energy recovers. Finally we imagine what we can do with this new awareness and energy. That inevitably collides again with loss: we would like to have dinner with lost spouse, but that’s not possible. So we return to creating space inside ourselves, resting and imagining until we have established that it is myself that needs dinner.

How is this space inside created? In my view, it is from the heart. When I weep or dance, I have the sense of something inside bearing witness to me and my loss. If I allow it, it flows from that deep inner source and enters the situation as it is to bring healing – not just to myself, but to everyone that will accept it.

A Hypnotist’s Support

How is this model facilitated by hypnotherapy? When anger (or other negative emotions) are entrenched, I start with a hand clasp induction; otherwise a simple eye fascination suffices. Complete awareness of the self is built through a long progressive relaxation starting at the feet with particular attention paid to expansion around the heart to allow the emanation of light. Gathering all the resources of the being and the represented potential, the progressive passes up the neck and over the back of the head to rest over the forehead, above the prefrontal cortex where all planning is done.

From there the therapeutic strategy depends upon the specific needs of the client. Those in deep grief often need to establish resources in the subconscious landscape through free-form therapeutic imagery. That work leads to reconstruction of their self-image. Those seeking to implement behavioral changes may have fear responses to clear using desensitization.

Between sessions, breathing meditation and mindfulness reinforce personal boundaries. Dream therapy can be used to assess the readiness to change, to release resistance, and to focus subconscious attention to find constructive solutions to specific behavioral problems.

Specializations

Occasional Pain? Look Within…

I don’t know anyone that doesn’t run their life right up to the edge. Even when we go on “vacation” we fill up the time with sight-seeing and entertainment, rather than sitting still and getting back in touch with ourselves.

When we finally push ourselves over the edge, we get sick – perhaps a migraine, often a cold or flu, not infrequently a muscle strain, and most seriously cancer or joint degeneration.

The point is that it’s not the all-nighter or the move or the argument that brings on the specific illness or injury. The problem reflects the burdens of everyday living that we carry in that part of the body. That move or job change just pushed it over the edge.

So if you have occasional pain that your doctor can’t diagnose, the next place to point the finger is at your lifestyle and attitudes. The pain is a signal from your subconscious that something is out of whack. If the point isn’t clear, through hypnotherapy I can help you encourage the subconscious to be more specific, and then build effective responses to the challenges it’s been trying to manage.

Call me at 805-775-6716 – and Bring Your Whole Self to Life.

Specializations

War of the Psyche – 6 of 6

Victory Over Death

In the era of Alexander the Great, conquest was used to propagate culture. In the terrifying era of battlefield massacre, wars were fought to preserve the nation-state. With the development of nuclear weaponry, finally civilized nations realized that military readiness must serve only one purpose: preservation of the peace.

Peace is not easy, for tensions exist in every relationship. Nations with different languages and customs cannot just dissolve their borders – their citizens would argue and fight. To ensure that tensions do not boil over, treaties and pacts must be negotiated.

The parallels with death are critical. Death is also a form of separation. We would like it to be gradual and gentle, but often it is not.

A sudden violent death can confuse a spirit. A Japanese doctor who was trysting outside of Nagasaki reported encountering a victim of the blast, charred skin crusted from head to toe, walking away from the city. The victim dropped dead upon seeing the horror in the doctor’s eyes.

Warriors can get lost in their mastery of death, seeking only killing for its own sake. Warriors that fight to protect peace are therefore right to feel virtuous. When they were nurtured within the confines of a peaceful society, love was offered freely to them by adults and peers. Given those gifts, many PTSD victims consider themselves to be “weak.” I see the matter more sympathetically.

The only way a warrior can go into the modern battlefield is to suspend understanding of the dangers they face. Those that remain effective in combat are those that ignore the realities unfolding around them. It is those that take it in – that see the death and destruction, that allow their souls to bear witness to it – that fall into despair.

Upon returning home, warriors may be numb because modern war is inhumanely destructive. Souls torn from broken bodies travel with the returning veteran. Those souls hang on to the veteran’s sympathy, either hoping to escape death’s merciless grip or hoping to receive confirmation that their sacrifice was of value.

The only alternative to this kinship with the departed is to avoid the trauma of loss. In “War,” Junger remarks that fresh troops arriving in Afghanistan were immediately sorted by veterans. Those that are not taken in are those that fall first – not infrequently when marching to their position. The veterans somehow know to avoid them, and thereby escape the grief of their loss. The hapless rookies are consigned to death.

But that is knowledge gained from experience, and so comes too late. In “Combat Stress Reaction,” Zahava Solomon offers the opinion that almost every warrior comes back with trauma – it is just that most of them don’t report it. Where the PTSD casualty is “weak,” the functional veteran is hardened.

In either case, the veteran is a wound in the heart of a peaceful society. They struggle with violent outbursts, unreliable productivity, and substance abuse. Culturally, they become death’s viruses.

So where is healing in this picture? To find it we must return to the insight offered at the beginning of the last section: the mind is a time-travel device. In combat, the well-trained corps functions as a single gestalt, drawing upon shared tactical concepts to think their way through a successful engagement. But at a deeper level, the entire field of combat is tied together in a struggle against death. That fear is universal. Enemy combatants are equally victims of circumstance and deserve equally to be liberated from fear.

Coming back into a peaceful society, the warrior enters that greatest and most valiant struggle. Where love was once received from parents without reflection, the PTSD casualty now must choose to receive love and guard its benefits. When that choice is made, the surrender reveals an infinite source of unimaginable power. Whether it is called God, Source, the Universe or The Good, it steps into the warrior’s mind to reveal that death is only a temporary separation that is pierced by love.

This is the individual warrior’s road to peace. When that hope is projected universally, the goal of every wise warrior is brought into reach: the insanity of modern warfare is apprehended equally in all cultures, and a durable peace becomes possible.

Part 1 || Part 5