In the Shared Experience theatre company’s inspirational 1995 staging of George Eliot’s Mill on the Floss, Maggie Tulliver, the novel’s main protagonist, was played by three actresses. They represented Maggie successively as a free spirited and passionate child, an adolescent stifled by religious conviction, and as a young woman, once again self-confident and able to be assertive. The co-directors of the production depicted these formative life phases, and the significant transitions they represented, by keeping each actress on stage. Therefore, behind the more self-aware responses of Maggie’s burgeoning maturity, the audience could see the impetuous and heartfelt reactions of the child and the conflicted inhibition of the adolescent, each a simultaneous influence beneath her ‘visible’ current persona.

This captivating visual metaphor portrays the self as both a continuum and a multifaceted entity, whose responses in the present moment derive substantially from the layered effect of previous life stages, with all the potential for conflict, but also for growth and integration, that can imply. It illustrates graphically how the person one has become continues to bear the imprint of previous change, and of how it was negotiated.

As we grow older this layering inevitably becomes more complex and subtle, as many developmental theorists, perhaps most notably Erikson1, have suggested. The number of transitions encountered increases, each containing new aspects of experience, and each with the potential to evoke or be influenced by earlier pivotal times. I believe that the incremental nature of this layering effect is one of the most important distinguishing features of therapeutic work with older adults.

Recent research, presented at a conference of the British Psychological Society, has pointed to the phenomenon of a ‘later life crisis’2, occurring between the ages of 60 and 69. The research suggests it is most commonly triggered by bereavement or illness, and is characterised by a reappraisal of previous values and aspirations. 

These findings are very welcome, particularly in the context of an increasing cultural reluctance to acknowledge and value the later stages of life3. They are, however, unlikely to surprise anyone who has offered therapeutic support to people in their 60s, especially as the additional transition represented by retirement, often momentous in view of its impact on identity and structure of daily living, also most commonly falls in this decade.

At the time the research emerged there was some debate as to whether, in view of our greater expectation of longevity, the later life crisis might more realistically be viewed as the midlife crisis recontextualised  within an increased lifespan. My own experience, as a counsellor who has specialised in working with older people, suggests that transitional critical periods in later life, as they most typically manifest, are not a deferred response to circumstances that might previously have been encountered at an earlier life stage, but rather a distinct phenomenon that has always existed. Nevertheless, the way in which they are experienced and processed is likely to be heavily influenced by earlier significant transitions.

Ageing and the self

The effects of ageing take many of us by surprise. I have lost count of the number of times I have been told by clients facing illness, infirmity or memory loss, ‘I never thought this would happen to me’. We fail to imagine the realities of ageing and so remain emotionally and psychologically unprepared for them. It is unsurprising then that so many older clients who enter counselling describe an internal sense of a younger self, whose perspective is in conflict with the restrictions the process of ageing can bring. This theme, with the spectrum of emotions that can accompany it, and the re-evaluation it inevitably demands, represents a rich and valuable area to explore within therapy. It naturally conjures retrospection, an impetus to assimilate the changes that accompany ageing, and the possibility of imagining and shaping the future on the basis of a more realistic appraisal of one’s current circumstances. Within this process lies the potential for recognition and assimilation of the ‘versions’ of oneself who inhabited earlier life phases, and consequently greater personal integration.

Jung wrote, when reviewing his life: ‘There is no linear evolution; there is only circumambulation of the self’4. I feel that later life transitions might usefully be viewed in this way: as the self revisited in the light of new experience. Rather than the solipsism this might suggest, Jung was describing the ongoing possibility of conceptualising one’s life within the broader frame that additional lived experience can allow. Hence our sense of self may be augmented, rather than diminished, by later transitional experiences: perhaps paradoxically in view of the increasing limitation that characterises physical aspects of ageing.

Jung’s hypothesis has an evident cyclical implication. Although the term ‘later life crisis’ suggests a single, perhaps prolonged event, clearly critical periods of difficulty and re-evaluation in later life are not confined to a single decade, but are more likely to coincide with specific and possibly repetitious circumstances such as bereavement and physical and psychological illness. For this reason, the older age psychiatrist Dr Marc Agronin5 makes a distinction between age-associated issues and the chronological age at which they are encountered, which may vary according to circumstance. He also emphasises that adaptation to ageing is a highly individual process, that we each have an ‘adaptive style’, and that this aspect of our personality can change profoundly, as the theatrical metaphor at the beginning of this article suggests.

Attitude can undoubtedly be crucial. A major longitudinal study of adult development conducted at Harvard University revealed a number of components that are likely to predict successful adaptation to ageing. Among these is the suggestion that subjective attitudes to health are better predictors of wellbeing in old age than health viewed objectively in medical terms6. Certainly, worry about health can be debilitating and inhibiting and so can mitigate against participation in meaningful activity, or the sort of future planning that fosters self-confidence and hope. Older people who have begun to experience ill health are often called upon to tread a path between the extremes of excessive concern and self-neglect, and I have noticed that those who are able to adopt a robust and pragmatic attitude tend to fare better.

It is therefore very important to allow for significant individual variation when offering psychological support to an older client group, who are sadly often categorised as homogeneous by non-specialist services, and indeed some parts of the media. Factors such as physical age, personal history, current circumstances, and attitude to ageing and the issues that accompany it, will all influence how a transition is negotiated. This is not to suggest that themes cannot be drawn from kindred experiences that may typify later stages of life, rather that they should never obscure the unique perspective of individual clients.

In saying this, I feel it is nevertheless salutary to acknowledge how hard it is to envisage the realities of extreme old age, described by Diana Athill, in a stark comment as a time in which ‘the body gives no more pleasure’7, and which to some extent are universal. The many conversations I have held with older people suggest most of us are ill equipped to imagine the experiential world of the very elderly until we reach that stage ourselves, a challenge therapists who work with this client group, but who are mostly younger, frequently come to recognise. Clearly, there is also a qualitative difference between adaptations in attitude and lifestyle a relatively healthy person facing retirement might be called upon to make and those that more typically confront people who are living, increasingly commonly, into their 80s or 90s. The latter are far more likely to involve the challenge of adjusting to the inevitability of recurrent loss. In addition, restrictive health conditions and reduced mobility, growing likelihoods towards the end of life, are factors which can markedly diminish the possibility of responding to one’s circumstances proactively. Hence the ease with which one might previously have altered one’s environment, engaged in new pursuits, or been able to form new relationships, are all likely to decrease. Seemingly generic statements such as ‘I’ve always been an active person’ can reveal a deep sense of loss, also a new uncertainty regarding the future. Similarly, where disability occurs in old age it allows little time to learn the coping skills that might be available to a younger person.

Nevertheless, individuals may respond to these archetypal challenges very differently. Existential psychotherapy speaks of a ‘way of being in the world’8. In part, I understand this to mean a manner of inhabiting one’s circumstances that is intrinsic to each individual. The concept of an adaptive style might therefore be described as one’s way of being in the world in response to change. As a broad instance, some personalities find it easier to relinquish, others feel the need to fight ageing.

Sometimes a stance towards life, acquired when young, can remain relatively constant. An example that comes to mind is of an elderly Jewish client, whom I met shortly after she had been diagnosed with a dementia that would increasingly deprive her of the ability to read and write. Despite a pragmatic awareness of the consequences of her condition, she spoke movingly of her profound gratitude at having been able to complete an important literary project ‘in time’, also for the constant love and support of her family. On learning more about her life, I came to feel that this remarkable reaction to adversity had its roots in a lifelong sense of good fortune which derived from the prescience her parents had shown in getting her onto the Kindertransport, and therefore escaping the atrocities of the Holocaust.

Role models and re-evaluation

I have also been struck by the extent to which earlier role models can continue to influence the way we negotiate transitions in later life, with the attitudes or behaviours that were once displayed by a parent or other significant forebear particularly likely to re-emerge in response to current challenge. Of course, older clients in transition may also re-evaluate early formative influences, sometimes rejecting, but more often modifying, an inherited belief or approach. 

As an example of this, a practising artist in her 70s, who sought help because her drinking was out of control, during our work together became able to reflect on the way in which her relationship with alcohol developed, and in so doing identified two particular sources. The first stemmed from her mother who was a suffragette but who, in accordance with the time in which she lived, had been forced to give up her teaching post when she married. In consequence, as an art student, my client would drink pints of beer, which was then very unusual for women, to demonstrate parity with her fellow students who were mainly male. She saw this as a way of expressing her sense of emancipation as a woman, and also of defining herself as someone more able to exercise independence than had been possible for her parents’ generation.

The second influence came from her tutors, some of whom were highly cultured with considerable reputations in the art world. From them, she learned a love of fine wines and international cuisine, and she came to realise that her aesthetic appreciation of wine derived strongly from these associations with glamour and the broadening of her early horizons. Therefore, her initial relationship with alcohol was characterised by a sense of expansiveness and increased possibility, also an element of rebellion. Because alcohol had become associated with the development of her identity as an artist and a woman moving more freely in a world where previously men had dominated, it had evolved into a metaphor for liberation and autonomy. This insight allowed her to appreciate that, paradoxically, her current relationship with alcohol represented a source of restriction, through its destructive effect on her health and confidence. Seeing this clearly informed her resolve to become abstinent, which she achieved, while still honouring the former role of alcohol in her life by continuing to serve wine to guests when she hosted dinner parties9.

Considering age and era as cultural factors

As these brief examples illustrate, early factors within an older person’s cultural background can continue to have a profound bearing upon the way they negotiate transitions, a prominent component being the era in which they grew up, and its surrounding mores. To broaden this point, the stoicism I frequently encounter in my oldest clients, by its very prevalence, clearly derives from an earlier collective response to adversity. Toughing it out or making do, characteristics that were particularly encouraged during wartime or periods of austerity, may re-emerge as a personal philosophy in times of current individual difficulty.

I have sometimes heard counsellors who are unused to working with older clients lament this phenomenon, viewing it as an unwillingness or inability to express feelings such as rage, despondency and frustration, and thereby find relief or catharsis. However, in addition to representing a personal resource that can serve well in the face of hardships that accompany old age, stoicism might also be seen as a style of communication that says much about the way an individual’s background continues to inform their response to change. Therefore, I feel it is helpful to view the stoic client’s way of sharing information, and particularly of disclosing intimate material, as a probable aspect of the culture of reticence and forbearance in which it was often formed. 

This type of client may convey much while saying little. I remember once facilitating an older men’s group in which the members complemented the robust health and upright posture of a former guardsman, who later quietly sought me out to acknowledge in a single sentence how well his wife, now deceased, had looked after him. I find it difficult to describe the wealth of feeling and meaning conveyed by these few words. 

On another equally nuanced occasion, a 96-year-old former engineer, recently bereaved after a marriage of 74 years, recalled in seemingly objective language how the loss of his wife reminded him of their first separation during wartime.

While the simplicity of his account nevertheless conveyed a palpable sense of grief, he was also reminded of a time when he felt potent, skilled and able to adapt rapidly to the dramatically changing circumstances he had encountered. As our work together continued, similar memories seemed to connect him to a renewed appreciation of these resources within his personality and, a lifelong practical man, with help from family members he began to undertake small decorating tasks within his home.

This example notwithstanding, many events in later life can create an erosion of identity, a frequent component of crisis in older people, and perhaps nowhere is the layering effect of previous transitions more evident than in bereavement. When we are bereaved, we lose a person but also our role in relation to that person. When we have fewer roles that connect us to others, our sense of self is more easily diminished, and our sense of relatedness more difficult to sustain. Hence, the psychological effects of bereavement can be incremental, especially as, in later life, the experience of bereavement may be contextualised within a broader frame of loss.

For many people, retirement also can represent the loss of some integral aspects of identity, particularly for those whose working role has been central to their lives. Work typically offers structure and routine, which some retirees find difficult to replicate in the absence of any external imperative. Having listened to many descriptions of my older clients’ daily activities, I believe it is difficult to overestimate how much reassurance we draw, and sense of self we derive, from the simple habits of daily life; also how disconcerting it can be when these are changed abruptly. Crucially, however, unlike bereavement, retirement is an
experience that can usually be planned for, although its consequences may nevertheless be hard to anticipate. In recent times, organisations such as Age UK have encouraged us to approach retirement as a process, rather than the fixed event it was once considered to be10. The discussions I have had with clients who are considering the issue of retirement suggest that, in psychological terms, this ideally involves a gradual and conscious disassociation from our working role and the habits that accompany it, while simultaneously new possibilities are considered and put in place.

Narrative and integrating the past

‘...the person’s concept of self can best be understood as comprising a self-narrative that tells the story of the whole of a life,’ writes Polkinghorne11. ‘This self-narrative gives coherence to the multiplicity of episodes, events and relationships experienced in the course of a life to date, including the prospective anticipation of its ending.’

I hope the brief extracts of client work I have included above demonstrate how the act of describing and reflecting upon salient events within an extensive personal history can enrich and clarify an older person’s sense of who they are and how they became that way. The past, viewed at random, can easily seem like a collection of disparate episodes, particularly when age distances us from early memories. Retrospection, and the stories that accompany it, are a natural resource for therapists working with older clients, and the stories older people tell offer testimony to the unifying tendency inherent in therapeutic narrative. The ability to view one’s current lifespan more holistically, to develop an appreciation of cause and effect, to clarify and describe belief systems and to recognise and integrate value from previous experience, are all possibilities for older people in transition who seek help from therapy.

My former colleague, the psychiatrist Dr Martin Blanchard, has written passionately about the nihilistic attitudes to old age that so often prevail in modern culture9. Nihilism is one of the ways we defend against disappointment. It could perhaps be viewed as a fear of hoping, and hope, sadly, is often portrayed as an exclusive province of the young. However, as a character in a story by Penelope Fitzgerald suggests:
‘Growing old is… a crime of which we grow more guilty every day’12. If we are able to acknowledge this self-evident truth, the process of ageing, in which we are each involved, can lend us empathy with those who are like us but have progressed further.

Mike Fox currently works as a specialist haematology counsellor at University College London Hospital. With Lesley Wilson, he is co-author of Counselling Older People with Alcohol Problems (Jessica Kingsley Publishers; 2011).

References

1 Erikson EH. Childhood and Society. London: Vintage; 1995.
2 http://www.bps.org.uk/news/annual-conference-paper-looks-later-lifecrisis
3 http://www.jrf.org.uk/sites/files/jrf/older-people-and-high-support-needs-full.pdf
4 Jung CG. Memories, dreams, reflections. London: Fontana; 1972.
5 Agronin ME. Therapy with older clients. New York: WW Norton & Company Inc; 2010.
6 Valliant GE. Ageing well. Boston: Little, Brown; 2002.
7 Comment heard on a radio programme (unsourced). For more information, see www.spectator.co.uk/books/427721/growing-old-gracefully-2/
8 http://poeticsofaging.org/wordpress/wp-content/uploads/2011/11/Bugental-and-Yalom-article.pdf
9 Fox M, Wilson L. Counselling older people with alcohol problems. London: Jessica Kingsley Publishers; 2011.
10 Adams GA, Beehr TA (eds). Retirement: reasons, processes, and results. New York: Springer Publishing Company; 2003.
11 Polkinghorne DE. Cited in McLeod J (ed). Narrative and psychotherapy. London: Sage Publications Ltd; 1997.
12 Fitzgerald P. The means of escape. London: Flamingo; 2001,