بررسی اضطراب مرگ افراد مسن از طریق تحولات تکاملی

Victoria, an elderly woman who had recently moved into the nursing home, became friends with Betty, who had been living in the home for 5 years. They spent the majority of their days in each other’s company, going to activities, visiting with other nursing home residents, or simply sitting together and chatting. One day, Victoria awoke to the sad news that Betty had died. Stunned, Victoria asked what had happened, then why, and gradually began to weep and call out Betty’s name. As the minutes ticked by, Victoria continued sobbing with seemingly no end to the torrent of tears. The nurse, who had informed Victoria, was overwhelmed by the intensity of Victoria’s grief and her inability to stop crying even when comforted. She was particularly flustered by the fact that Victoria was grieving so deeply for someone she had met only a few months before. Unable to contain her own anxiety, the nurse said, “Oh, don’t worry. It’s not really true, I was just kidding. Betty is in her room—resting.” Victoria, confused and undoubtedly horrified that the nurse would “kid” with her in this way, immediately stopped crying. The nurse, who may have acted with the best of intentions, was not aware that she was infantalizing an adult 50 years her senior. Afterwards, when asked why she lied to Victoria, she said she felt she had rescued Victoria from emotions that were causing her more harm than good. Later that morning, Victoria, cognitively intact but understandably confused by the incident, recounted this story to me, and I had the unfortunate task of bearing the bad news for a second time. Victoria was still fraught with anxiety and grief, but felt safe enough the second time around to process the truth in a setting where her strong emotions were accepted and simply allowed to be. The tendency among healthcare workers in nursing facilities to avoid issues of death and other existential concerns can lead to misguided attempts to direct the clients to think about positive things, no matter how superficial or untruthful this may be for the clients. Victoria’s experience is one of many similar incidents I have witnessed while working in a nursing facility for 6 years. Watching these stories unfold, I have become aware of a great need for an existential outlet in the nursing home, where residents can express their fears and sorrows. I also have had a growing awareness that confronting my own existential concerns was necessary to allow others to do the same. Psychotherapists from different theoretical backgrounds and practical approaches have documented the pervasive conflicts that arise from death anxiety and other existential concerns among clients of all ages and psychological make-up Erikson 1950, Marshall 1975, Fromm 1976 and Yalom 1980. According to Yalom (1980), what distinguishes existential psychotherapy from other approaches to psychotherapy is that it “emphasizes a different kind of basic conflict: neither a conflict with suppressed instinctual strivings nor one with internalized significant adults, but instead a conflict that flows from the individual’s confrontation with the givens of existence” (p. 8). This paper will discuss how the existential issue of death anxiety, coupled with the existential concerns of responsibility and freedom, existential isolation and meaninglessness, are related to the core conflicts facing older adults living in a longterm healthcare facility. Using case studies of a group of nursing home residents in an ongoing drama therapy group, I will attempt to illustrate how one particular improvisational form of drama therapy, Developmental Transformations, creates a safe container for exploring these issues. Through play, these clients are afforded an opportunity to ease their existential agitation and increase their intimacy with and support of each other. Speaking with Victoria after the above-mentioned incident, I learned that she was not only grieving for Betty, but also for herself. She felt hit in the face with her own inevitable demise, wondering about the meaning and the loneliness of death. Eventually, like Victoria, we are all struck with the existential given that we are born alone, and we die alone. We create the lives we live, and we seek meaning in a universe that provides no obvious answer to the questions “Why am I here?” and “What is the meaning of life?” From an existential point of view, these are the most pressing concerns of human life Yalom 1980 and Fromm 1976. Contemplating the given that we will die, and that no living person can take that final journey with us or completely understand us while we live, we are confronted with two fears: the fear of death and the fear of isolation. Recognizing that we create our own lives, we are faced with our freedom, and the overwhelming responsibility with which it is entwined. Seeking meaning in our work, our relationships, our lives, we are forced to consider the possibility that everything, ultimately, is void of meaning. Those on the path to self-discovery through psychotherapy may eventually find themselves leaning against these existential truths, inevitably learning that these truths are bony and have no soft resting places. The therapist with an existential approach to psychotherapy attempts to create a space for clients to confront these givens of existence and the conflicts that arise from them. The existential psychotherapist provides a soft spot on which the client can pause and reflect as she bumps into death anxiety, existential isolation, freedom, responsibility, and meaninglessness. Eventually it is the work of both the therapist and the client to enlist the powers of these truths in the pursuit of self-knowledge, personal growth, and change. The therapist knows “the confrontation with the givens of existence is painful, but ultimately healing” (Yalom, 1980 p. 14). Developmental Transformations, an improvisational form of both group and individual drama therapy, is one form of existential psychotherapy. It utilizes the encounter between the therapist and the client, the playspace, and the embodiment of images and roles as the primary modes of healing Johnson 1991, Johnson et al 1996 and Johnson 2000. The intent of Developmental Transformations is to decrease the level of existential angst the client experiences by deepening the potential for intimacy she has with others (i.e., the therapist, members of a therapy group, and ultimately, family members and friends outside of the therapy session). The playspace, “an imaginal realm of play established by the drama therapist, within which the session occurs,” (Johnson, 1993, p. 183), is where the soft resting place can be found for the client who is confronting the existential givens of life. Older adults living in a nursing facility are in a position particularly suited to confront existential concerns. There is a poignant recognition among many nursing home residents that being old and in a nursing home means one is closer to death than most physically well people who are living in the community. Munnichs (1966) refers to this recognition that death is near at hand as “awareness of finitude” (p.4). Living in a healthcare facility means for many residents that they are physically isolated from their previous lives, including their significant family members and friends. The loss of loved ones, sometimes including children who have died or who choose not to be involved in their lives, brings issues of interpersonal and existential isolation to the fore. Yalom (1980) addressing the subject of existential isolation, quotes a psychiatric patient living in a hospital as saying “I don’t exist when I’m alone” (p. 374). When nursing home residents are given a place to express and explore existential concerns, similar sentiments are communicated. In Developmental Transformations sessions, these sentiments are manifested metaphorically through play. Living in an environment where there are many rules and regulations, time schedules, and decisions made without consulting the client, older adults are confronted with issues of autonomy, freedom, and responsibility. A nursing home resident may find herself asking, “If I no longer make my own decisions, am I truly free? How can I take responsibility for my life in a situation where responsibility appears to be taken away from me?” I have heard elder clients refer to the nursing home over and over again as a prison. Although many often discuss their physical aches and pains, I have rarely heard them say that they are imprisoned by their own bodies or illnesses. I have heard little recognition that they may be imprisoned by their own lack of awareness that they are inherently free. Psychotherapy provides a unique opportunity for these clients to recognize that the externals in their lives, such as nursing home surroundings, schedules, illnesses, have little to do with their intrinsic freedom. When existential issues are recognized, awareness of this innate freedom is more likely to be acknowledged. Despite the compounding of external troubles in old age, some clients are aware of their own inner freedom. I once had a client describe to me how much pain she was in due to several physical conditions, including a nagging heart condition, swollen, arthritic legs, and old age in general. She said, “I’m ninety-four years old. What is God waiting for?” I responded, “Madeline, you don’t seem very happy.” She answered, “Oh, no, I’m not unhappy. I’m happy. I’m just sick. There’s a difference, you know. I have lived a good life, done many things, you know, known many people. I am ready, and I am not afraid to die.” Her attitude toward death is reminiscent of a story about a great spiritual master who sat meditating, knowing that an evil warrior was on his way to murder him. When the warrior entered the temple, the monk sat quietly, showing no fear. The warrior, enraged by the Zen master’s lack of terror, drew his fearsome sword and cried, “Are you aware that I could run you through with this sword without a second thought?” The Zen master replied, “Are you aware that I could let you run me through with that sword, without a second thought?” How is it that some older adults tolerate death anxiety better than others, and how can this tolerance be cultivated by others, who may not have as strong a sense of inner freedom? Not everyone is like this spiritual master, and not everyone is like Madeline, whose lifetime of sturdy spiritual practice helped her cope with death anxiety. Spiritual practices may indeed be an effective way for elders to manage the fear of death. It is this author’s belief, however, that another pathway to coping with death anxiety is to share these fears with others through play, creating bonds of intimacy that attempt to consciously defy the existential givens of life. Buber (1965) states that the meaning of life is to be found in relationships: “A great relationship breaches the barriers of lofty solitude, subdues its strict law, and throws a bridge from self-being to self-being across the abyss of dread of the universe” (p. 175). The older adults I worked with were ripe to share of themselves and to listen to others with the same existential concerns. However, despite the clients’ readiness to expand their inner horizons and to make great strides in their personal growth by attending to existential truths, most therapies in nursing facilities are not centered on dealing with these issues. Instead, these issues are often pushed aside and ignored altogether. Most professionals enter the healthcare field out of a sense of wanting to help others, and many healthcare workers choose to work in nursing homes out of a genuine affection for older adults and their stage in life. There is no denying that more traditional therapies offered in nursing facilities are necessary, such as physical therapy, occupational therapy, therapeutic recreation. However, rarely are there opportunities for residents to express existential concerns without coming up against deaf ears, or perhaps more accurately, denial. Even creative arts therapists, psychologists, and other psychotherapists schooled in assisting clients through overwhelming emotional traumas, may tend to avoid stepping into existential areas with clients, perhaps due to an inability on their part to face their own existential conflicts. “The patient is not the only source of denial of course. Frequently, the denial of the therapist silently colludes with that of the patient. The therapist no less than the patient must confront death and be anxious in the face of it. Much preparation is required of the therapist who must in everyday work be aware of death.” (Yalom, 1980, p. 204)

Older adults living in a nursing home have a need to express and explore death anxiety and other existential concerns in a safe, accepting environment. The Developmental Transformations session provides an existential outlet for these clients, an arena where the existential truths of life can be expressed through play. By entering an embodied encounter in the playspace, clients are able to relieve their existential angst, and increase their sense of intimacy with the therapist and with each other. Love and intimacy in a nursing home “compensates for the pain of isolation” (Yalom, 1980, p. 363). The drama therapy sessions presented above illustrate how clients can face their fears, and forge the boundaries between souls. They have shown me how, even though we are all born alone and die alone, we can be together in our aloneness. Coming up against the bony truths of the existential givens of life, the older adults in this nursing home found a soft resting place within the Developmental Transformations group.