by Janine Gagnon Corbeil, Psychologist, and octogenarian
One day, I was approached by a psychology magazine wanting to publish a piece on aging and psychotherapy. I consulted some works about aging and, inspired by Laura Perls’ phrase, “Growing old or getting old”, I named the article, “The Aging Therapist: A Degeneration or Maturation Process?”
The article, which discussed, among others, the process of self-actualization for aging psychotherapists, was refused because it was deemed too positive, even overly optimistic. The then young and now defunct Revue québécoise de Gestalt was interested in publishing the article (1994).
That was nearly thirty years ago.
On the one hand, prejudice surrounding old age was and still is prevalent. In The Fountain of Age, Betty Friedman related how during an international seminar held in 1983, entitled “Health, Productivity, and Aging”, conference-goers were obstinately resistant to the idea of productive aging. The title of the conference notwithstanding, the representatives, high officials and geriatricians from all over the western world, only wanted to talk about Alzheimer’s, senility, and nursing homes. “Old people have earned the right to rest and be taken care of”, they repeated. Clearly, there and elsewhere, it was an exclusively medico-curative approach, not to mention a collection of stereotypes, which prevailed at the seminar.
On the other hand, the concept of self-actualization has always been familiar to the successors of humanistic psychology, a perspective on human nature first introduced by Carl Rogers (1942), who considered the human being as overall positive and growth-seeking. Maslow (1954), who formulated the definition, reclaimed Rogers, as well as Goldstein, Jung, Adler, Horney, Fromm, May, all authors who, according to him, shared the same filiation.
In their research on the elderly, Leclerc and Poulin remind us of this filiation, adding that Everett Shostrom had developed a tool to measure self-actualization.
During their presentation at the ACFAS conference, they shared this translation of the self-actualization concept as defined by Maslow: “The relative degree to which a person develops their psychological potential and more or less exerts it over their past experience and their adaptive behaviour.” (Leclerc and Poulin, 1985)
At the time of the article on aging and practicing psychotherapy, I was quite removed from any problems related to old age. But now, during the pandemic, I find myself in the vulnerable age category. However, I do not recognize myself in the description hammered into us, day and night, about our vulnerability. While there is a physiological vulnerability for our age group, not only do I not identify with it, but I do not see it in a number of aged people of my quite lively entourage.
It seems opportune, as much for the health of those in advanced years as for society as a whole, to get away from the omnipresent medico-curative thinking and instead consult specialists who advocate a more psycho-preventive approach. “A complex mosaic of aging, forming an immensely rich and diverse narrative,” is what Lefrancois calls “differential aging.” (Lefrancois, 2004)
The authors consulted above constitute part of the data which inspired the text that follows. I will begin with a nuanced presentation of the characteristics of aging, followed by an exploration of what challenges face those caregivers of frail elderly people.
The Pandemic and Seniors
On a daily basis, the death toll related to COVID-19 assaults us. According to the statistics provided by the Quebec government, 80% of those who died are in the age category of 70 plus. An additional 9% can be found in the age category of ten years younger. In France, doctors have explained that the deaths of those aged 69 years or less consists of people suffering from other underlying illnesses, like obesity, arterial hypertension, cholesterol problems, etc.
Needless to say, the situation is no doubt the same in Quebec. Could there be a cultural trait hypothesis here? Explaining that comorbidities affect the death rate invites the possibility of prevention and individual responsibility, whereas concealing such a fact calls on fear, a primary mechanism of infantilization.
The statistics presented daily by our government and the media have the merit of shedding light on how the vulnerable individuals within the aged population have been treated until now by our public powers. We cannot hide that the problem has spread like wildfire, as evidenced by our high death rate. In the past, the only solution to negligence was silence, and now even that risks erosion. The public powers are now asking for help, offering bonus after monetary bonus to contain the disaster, but the personnel, who have been underpaid, ignored, and disregarded are no longer answering the call.
We often hear in the media that history will one day shed light on what is happening today, but already there are already a number of voices speaking up. On May 12 in the La Presse newspaper, a letter by Claude Castonguay denounced the treatment reserved for the aging population for some time now as “a shameful disaster.” This situation is distressing for everyone, and effectively tarnishes the image of our beautiful province.
The data on the mortality rates for the institutionalized elderly people and on the replenishment of resources bring with it a number of traps it would be urgent to not fall into.
The first trap is the horn effect the statistics can have in making us lose sight of the phenomenon of aging populations as a whole. The second trap has to do with the kind of help that has been promised.
-1-Overall characteristics of the aging population
A good deal of research on seniors has shown evidence of a causal link between physical health and mental health, while quite a few authors wish that from this point on attention should be placed on the reverse, i.e., the link between mental health and physical health. “Self-actualization proves to be a determining factor of physical health after 65 years,” (Leclerc, Lefrancois and Poulin, 1992); this scientific data cannot be ignored in the current pandemic circumstances afflicting us.
The subgroup of aged people who are dependent constitutes around 10% of the population aged 60 years and more. The majority of the rest, being 90% of those aged 60 plus are considered either functional (80%) or very active and still in possession of their creativity, which humanistic psychology has identified as self-actualization (10%). These data remind us that 90% of the population aged 60 years or more are active and contribute in no small way to the economy as well as the well-being of society. These seniors pay their taxes, travel, and explore the planet. They fill our concert halls, cinemas, shows, as well as our libraries. They go to restaurants and clothing stores, etc. Without this 90% of the population, the culture and leisure spheres would have a much reduced figure. We should also note that the 80% stratum (functional individuals) fulfill important volunteering roles; their recent isolation, however, has made us aware of their importance in charity work. Not to mention the support they provide for the preceding generation, their old parents, as well as the following generations, those of their children and grandchildren.
Among the self-actualized seniors (10%), we often cite big names like Freud, Jung, Picasso, Michelangelo, Tolstoy, Verdi, Victor Hugo; very recently, essayist and philosopher Edgar Morin, 98 years old, published an E-book, Festival d’incertitudes. (Festival of uncertainties). And, in our Gestalt community, Erving Polster, who also turned 98. Bravo, Erv!
Quebec, too, has a number of people of advanced years who have made their mark. Father Benoit Lacroix, an author of books until a very late age, died at 100 years old; the sociologist Guy Rocher, recently broadcast, is still active and in top shape even at 95 years; writer Antonine Maillet , 90 years old, just published Lettres de mon phare. Maillet has stated that she loves speaking to the elderly. “They have memories to share,” she adds. The journalist and playwright Janette Bertrand, 95 years, very active herself, was recently on one of our weekly broadcast programs where she invited and coached for a while women who had never written before to start writing down their own biography. She added: «Do it for yourself, in your own interest. Your 60 year old children will not be interested anyhow» Bravo!
All this to name but a few. A documentary presented in 2011 on octogenarian men and women discussed their abundant passion for their work, and the filmmaker Fernand Dansereau created a trilogy on old age, including the titles, Le vieil âge et le rire (Old Age and Laughter), L’érotisme et le vieil âge (Old Age and Erotism) and at age 91, Le vieil âge et l’espérance (Old Age and Hope).
«Self-actualizing people are involved in a cause outside their own skin…. devoted, working at something which is very precious to them, some calling or vocation in the old sense» (Maslow, 1971, 43). In the same spirit, Laura Perls writes about the «…Genuine sacrifice in giving up something of personal value for the union with something greater.» (92, 77).
“They give off the impression of vitality, a fundamentally optimistic attitude as well as the great intellectual curiosity of creative and adaptive people. They have projects; they want to learn and to practice their memory.” (Leclerc and Poulin, 1985)
Even if the COVID-19 pandemic has served to underscore the great vulnerability of the aged population, especially of those living in institutions, it is crucial to not lose sight of these data. This is yet another example of the horn effect, that is, of a biased vision of reality, where the overall perception of those aged 60 or more is tinted by the circumstances of the most vulnerable 10%. These perceptions are shared among the general population as well as by those caring for the most vulnerable.
“Many studies reveal stereotypes, negative images, and false conceptions of old age among the majority of young people and adults in our North American societies.” (Leclerc and Poulin 1985)
These stereotypes manifest in the way in which we compromise those most vulnerable as well those aged 60 or more in general. It has become clear that we need to engage with and observe old age from new angles, because these stereotypes exist not only in the minds of the those who intervene and general population, but also in the minds of those with the power to finance help for the elderly with reduced autonomy. The fact that 90% of people aged 60 years and more also share these age-related stereotypes only adds to the problem.
The official discourse, exacerbated by the pandemic, distorts the perspective on the reality of old age. As outlined by Betty Friedan in her book The Fountain of Age (1993), the leaders’ discourse on aging only deals with deficiencies, and« the conventional psychology of aging is almost completely devoted to a study of its discontents» ( p. 71).
These biases, shared among those with power and responsibility in the field, resonate in the collective imagination, which sees only the weakness of old age, warping all perspectives on the reality of this stage of life.
“We seem to favour a philosophy of caretaking which has opened the door to a paternalistic attitude where the expert seems to know what an aged person needs better than the aged person in question,” writes sociologist Richard Lefrancois.
An illustration of this point is in the fact that, until recently, those aged sixty years and more figured only very rarely into studies on the development of personality. René L’Écuyer, a psychologist who did research on the notion of self-concept, discovered that there existed no scale for the development of this concept for people aged 60 or more. In other words, it would seem that, between 60 and 100 years of age, either we stop existing, or nothing happens in our heads. He has published La restructuration des perceptions de soi chez les personnes âgées de 60 à 100. For him, “The concept of self is essentially dynamic and changing; it organizes itself into a coherent whole where perceptions are organized hierarchically in terms of importance relative to one another and this reorganization evolves throughout one’s life through progressive differentiations, associated with steps or stages of development.” (L’Écuyer, 1992).
-2- Help has been promised, but what will happen to care personnel who deal with burdensome issues?
Although there seems to be plenty of help available at the moment, it is temporary. It is important that we ask what will happen to the care personnel once the crisis is over. We will have no doubt raised their salaries, but that would not seem sufficient in terms of meeting caregivers’ needs. Similarly, will we be adequately prepared to deal with the psychological repercussions for those caregivers who deal with the burdensome issues of disease and death? We hear a lot about how we are in the midst of a crisis; the media shows us articles on people experiencing true horrors, but until now, those we call “our guardian angels” have been largely ignored.
Unfortunately, despite all the announced measures, we never hear talk about psychological support offered to these caregivers. Even if the immediate emergency forces us to try and stop the slaughter, emotional support has been virtually nonexistent until now. Media seems to highlight our “guardian angels” these days, which is quite welcome, but what will happen after?
Moral and psychological support is indispensable
There are a number of studies that confirm that psychological support is indispensable.
Caregivers in long-term care homes are constantly confronted with degeneration and the end-of-life. Seeing these situations inevitably forces caretakers to consider their own deaths, the image which most mortals endeavour to forget by any means possible. It’s no coincidence that, when presented with the needs of the aging population with reduced autonomy, public powers here and around the world turn a blind eye.
The current emergency, facing a virus which has brought humanity to its knees, forces society to finally take a good look at the most vulnerable among us, those who are too often crammed into worn-out places which we prefer not to look on.
In France, psychologists have shared their findings relating to care services dealing with those affected by the virus. These psychologists have discussed how it’s crucial that there be individuals present and willing to listen to the personnel. Spain, likewise, had caregivers participate in groups where they could express their feelings—anger, anxiety, frustration, etc.—in an atmosphere of mutual emotional support.
A number of authors have focused on the vulnerability of those dealing with onerous issues. After all, these are empathetic people whose professional capacity has them repeatedly confront traumatic and painful experiences with their clients. M.S. Cerny (1995) discusses such heroic caregivers; on that note, she adds, “there is a cost to caring.” By that she refers to things like post-traumatic stress syndrome, secondary traumatic stress, and compassion fatigue, which affect those who cannot turn away from their daily professional obligations (Figley, 1995).
Data from researches in three fields of psychology, psycho-traumatology, as well as those on the phenomenon of empathy and burnout—helps clarify the issue often called compassion fatigue (Gagnon Corbeil, 1999). In the context of COVID-19, compassion fatigue only adds to the undeniable physical fatigue that these people experience on a daily basis while putting their own lives at risk.
The current crisis evokes wartime discourse. When “our guardian angels” return from this war, they will need ears to listen and platforms to tell their stories. Boris Cyrulnic, who published multiple works on trauma and resilience, insists on the need to share one’s story, that this story be heard and understood, and that this is “how one masters the past,” he writes.
For the vacant positions in the future, the salary raises will be necessary but insufficient
There are a number of positions still vacant. First of all, if we want to elicit enough interest and if we want to keep these workers in a rewarding work environment, there are a number of conditions that must be met. Failing to do so risks repeating the shortage that currently prevails.
The pandemic has brought out the powerful and very human instinct of mutual support. For this reason it is essential that we offer intervention workers the group peer-support that is indispensable when facing human misery. They also need a harmonious work atmosphere, not to mention adequate support from society.
This relational support requires close bonds, which are entirely opposed to the impersonal administrative super structure which Quebec seems to have a knack for creating.
How many intervention workers work in a milieu where their efforts figure in a theoretical framework and have competent supervision? These ingredients are absolutely essential for those who must deal with the complex and difficult issues in the line of duty.
What kind of budget is dedicated to providing additional training to these workers’ basic training? This kind of training is indispensable to professional evolution, and professional evolution can never be disassociated with personal evolution.
How many intervention workers have access to group support where they can express the formidable challenges they faced during their week? The presence of this kind of support is necessary for preventing compassion fatigue, secondary traumatic stress, and burnout.
Of course, we can already hear the immediate argument on endless budgetary restrictions. But we should recognize that this kind of mentality impoverishes exactly the theoretical thinking and practical knowledge that would help deal with today’s painful problems. How can we demand that the personnel respect this vulnerable clientele when this personnel themselves are not respected in their work and as human beings?
According to the same research, if these conditions are not respected, we risk having personnel systematically becoming so overwhelmed and isolated that they develop a kind of aloofness; being desensitized serves then as a survival mechanism, but at a cost on the quality of their interventions.
Our premier admitted in a press conference that, as a Quebecker, he was ashamed of how we have been treating the most vulnerable in our aged population.
Once the crisis has passed and the national coffers slam shut again, if there is a deficit in not merely financial and technical but also psychological and social support, we run a high risk of returning to our old practices and forgetting about any kind of improved care quality, when in fact much more is necessary to see to the individual needs of each person suffering and in end-of-life care.
Beyond adequate funding, it is also important to reshape the all-too-common approach which saw very little attention given to those care givers.
Research often mentions the necessity of preventing burnout and defection in care centers. This prevention figures primarily in social politics, which requires collective and political reflection on our approach to sickness in old age. It is a matter of ethics of care rather exclusively that of a cure (Mesnage, 2011).
The phenomenon of losing one’s autonomy in aging needs to be looked at upstream and reconsidered on every level if we want society to be able to look itself in the mirror without too much shame. This reconsideration will be increasingly required as life expectancy rises.
A Psycho-Preventive Approach
According to a number of researchers, it is in the government’s best interest to understand that preventive expenses dedicated to the education and development of the population at large in conjunction with similar training for the aged population will benefit not only seniors but society as a whole. Such a move would constitute a psycho-preventive approach as opposed to an exclusively medico-curative one, which, until now, has prevailed. The causal link between education and quality of life is an established fact. We likewise see that good mental health has a positive effect on physical health.
«If more aged people need less recourse to medical resources, chances are that public expenses for this part of the population will be substantially relieved in the years to come» (Lefrançois et Poulin, 1992)
Serious reflection on the ailments and needs of frailty in old age requires a multidisciplinary approach and perspective, where the dimension of affect, both for caregiver and receiver, is taken into account.
We seem to believe that future, modern senior homes will be the remedy to the situation. But such establishments will simply not be enough, as they must offer an emotional presence for both those individuals nearing end-of-life and those caregivers who see to their well-being.
Furthermore, if old age makes us so vulnerable, we must not forget that autonomous individuals represent 90% of the aged population. We must see to it that they are developed by preventive and educative means, in order to preserve the greatest number of them for as long as possible.
A home support strategy for those who need it, which is both concrete and emotionally supportive, would permit an autonomous person of age to stay in their everyday social environment. Provided it is possible, wouldn’t that kind of arrangement be preferable to any kind of “placement”? It would be a more humane and certainly more economical solution for the health system, one which would no doubt be privileged by many people with chronic conditions to have a caring presence. Moreover, as opposed to what is happening at present, such a presence would favour a connection, thus the most stable presence possible. The aged persons who need regular service from CLSCs admit that they never deal with the same person twice. It is impossible, then, to create a connection supporting mental health as much as physical health, and that would be true for the caregiver as much as the one receiving care.
Each society, each civilization has its own unique philosophy in its vision of old age. In the last years of his life, the great Charles De Gaule admitted that aging was like a shipwreck. For those caretakers who are daily witnesses to these shipwrecks—the difficulties of old age and the death that follows—prerequisite training would be essential for nurturing that principle of personal respect our PM discussed in his press conferences.
The Dalai Lama always says: Presence is healing. Indeed, to be present is already a form of caring. Moreover, it doesn’t cost millions and it has the considerable advantage of taking care of the intervention workers themselves. Big Pharma, as we tend to call it, would make less money, but everyone, the sick as well as the caregivers, would have a more serene, more humane atmosphere for the last stages of life.
Research and Consulted Works
Cyrulnic, B. (2019) La nuit, j’écrirai des soleils. Paris, Odile Jacob.
Figley, Ch. R. Ed. (1995). Compassion fatigue: Coping with Secondary Traumatic Stress Disorder in Those who the Traumatized . New York, Brunner/Mazel, Psychosocial Stress Series.
Friedman, B (1993), The Fountain of Age, New York, Simon & Schuster.
Gagnon Corbeil, J. (1994). Être thérapeute et vieillir. Processus de dégénérescence ou de maturation? Revue québécoise de Gestalt, Vol. 1 # 3, 113-129. Montréal, les Éditions de l’AQG.
Gagnon Corbeil, J. (1999) La fatigue de compassion chez les intervenants qui transigent avec la violence familiale et conjugale, Dans : Jacques Broué et Clément Guèvremont, Éditeurs, Intervenir auprès des conjoints violents. Montréal, les Éditions Saint-Martin.
L’écuyer, R. (1992), La restructuration des perceptions de soi chez les personnes âgées de 60 à 100 ans, Colloque de l’association québécoise de gérontologie.
L’écuyer, R. (1994). Le développement du concept de soi de l’enfance à la vieillesse. Montréal. Les Presses de l’Université de Montréal.
Leclerc, G., Poulin, N., (1985), Profil d’actualisation des personnes âgées “participantes”, Colloque sur la recherche en gérontologie, 53ième congrès annuel de l’ACFAS, Université du Québec à Chicoutimi.
Leclerc, G., Lefrançois, R., Poulin, N., (1992), Vieillissement actualisé et santé, Rapport-Synthèse, GRASPA, Université de Sherbrooke.
Lefrançois, R. (2004), Les nouvelles frontières de l’âge. Montréal, Les Presses de l’Université de Montréal.
Maslow, A. (1954) Motivation and Personality. New York, Harper & Brothers.
Maslow, A. (1971) The Farther Reaches of Human Nature. New York, The Viking Press.
Mesnage, C. (2011) Éloge d’une vieillesse heureuse. Paris, Albin Michel.
Perls, L .(1992), Living at the Boundary. Hithland, NY, The Gestalt Journal.
Perls, L. (1993), Vivre à la frontière, Traduit de l’Américain par Janine G. Corbeil. Bordeaux, Les Éditions l’Exprimerie.
Rogers, C. (1942), Counseling and Psychotherapy. New Concepts in Practice. Cambridge, Houghton Mifflin Company.
Janine Gagnon Corbeil
Psychologist, and octogenarian