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A Subject in Search of Meaning: Frailty and Dignity in Very Old Age.

An ageing population and increased life expectancy are a characteristic of the Western world. Nevertheless, as Roger Fontaine writes, "although we should be glad about this fact, it should also be stressed that old age reveals profound discrepancies between individuals. In fact, we should not speak of `old age' but `old ages'. Specialists make a distinction between normal old age, successful old age, and pathological old age."(1)

Catherine Guchet(2) points out that, at the end of the twentieth century, two images of old age coexist, utilitarian in conception: that of `flamboyant' old age and that of `dependent' old age. The latter is associated with a loss of autonomy and dignity, especially for subjects affected by senile dementia,(3) described as `unconscious'.(4) We shall focus on these more problematic forms of old age.

An old story

Jean-Pierre Bois observes that ambivalence towards old age is not new: "Since Plato and Aristotle, Cicero and St Thomas Aquinas, old age has given rise to many images and thoughts, ranging from the most facile denigration to the most unrealistic apologia."(5)

At the end of the eighteenth century, with the rise of the working class, social status for the great majority of individuals was no longer linked to a land-holding system but to the exercise of a trade. For the old person, who no longer had either ownership or productive capacity, marginalization, whether real or symbolic, therefore became the order of the day in both the family setting and in society at large. In the eighteenth century an observer in the Revermont summarized this kind of situation well:
   Sometimes the fate of parents who have poured out affection onto their
   children warrants real pity because of the scant regard paid to them, once
   nothing more is to be expected from them. The treatment they receive seems
   every moment to repeat that they have become a burden and it is time their
   useless life came to an end.(6)


These practices of exclusion did not wait for the industrial revolution: they were unofficially accepted, and all the more so if the parent was "mad". Moreover, many texts refer to abandoning parents or even, in extreme cases, to murdering them.

From the Middle Ages onwards, relief institutions, which were in reality often institutions of exclusion, were established to look after those who were poor on account of their age, above all if their were affected by "poverty resulting from senility",(7) rejected and incapable of securing their own living. Over the centuries, these institutions flourished in response to a growing need, to such an extent that in the "nineteenth century there was no large town without its old people's almshouse".(8)

This brief historical overview illustrates the legacy of previous generations and its impact on our current behaviour towards an elderly person deemed "useless" -- this old and so-called "demented"(9) person who frightens us, who we would not in any circumstances wish to resemble, and whom it is sometimes easier to forget, so much do we deny the idea of death. For surely the term `senile dementia'(10) describes the death of the spirit and the dementia sufferer as `living-death'? It is not surprising, therefore, that a society such as ours seeks to separate all frail subjects in order to hand them over to carers whose mission -- to `suppress' all physical and moral suffering -- reflects the dominant utopia, the dream of all-powerful technology.

The limits of a neurobiological model

The biomedical model has constructed a nosological framework constantly enriched by fuller and more detailed semiological descriptions. The technique consists in identifying the partial or total deficiency of such-and-such neurological function. Neurobiology adds new clues but it does not change the basic data. From one loss to the next, all ageing becomes a process of deficit until the ultimate, terrifying loss of thought through irreversible lesions of the brain, giving rise to this vivid image, which attempts to describe the tragedy: imagine the brain like a house full of lights(11); one by one, those lights are turned off, with no possibility of switching them on again, at least at present, while we wait for the results of the very large number of research programmes focusing on the illness.

Among the illnesses to which the elderly person is exposed, "senile dementia" is a good example of the risk of the disappearance of the frail and sick subject when attention is focused upon the study of the illness alone.

The entire illness is based round this anatomical lesion. Giving it the prime role reduces the clinical assessment to the status of `deficit-reporter'. The patient is no more than an Alzheimer's sufferer. The epistemological drift of this trend is still far from adequately recognized.(12)

The diagnosis of senile dementia as an incurable disease currently predominantly determines the fate of these patients and considerably limits the action of the therapist, whom it also binds hand and foot. Reduced to the bodily envelope of what they can or can no longer do, the patient becomes unrecognizable and condemned to a meaningless survival. Once the diagnosis has been made, his or her incurable incapacity becomes what ties him or her to the world. `Caring' for a dementia-sufferer boils down to attempting to do what has been established as impossible. In Marie-Francoise Rochard's analysis of the situation, dementia patients suffer from the dichotomy that exists between a curable disease and a chronic incurable disease. In our health care system, curable diseases are part of active medicine, for which the health system takes responsibility, whilst incurable diseases are sent off to two levels: that of research, which may one day make it possible for these diseases to be reintegrated once more with the previous domain, and that of disability and dependence under the responsibility of local social activities. This dichotomy, introduced for economic and administrative ends, has made it possible to address the problem of the creation of specially-adapted homes whereas before they vegetated parked in hospices. Huge battalions of geriatric patients embarked on the ship Incurable have difficulty finding a place, floating without anchorage, tossed between the two banks, social security and health, which both reject them.

In these chronic impairment diseases, a cure which involves restitution of the integral whole (ad integrum) is impossible. It is therefore down to proxies to compensate the disability created by the impairment, through the adaptation of the environment. However, the question of the adaptation of the subject to their illness is not asked: this requirement should be met by others. Admittedly, translating this lack of adaptation into a need for aides should improve patients' care, but there is no analysis of the dynamic of transformation, with its creations and blockages, that is brought about by this need. Once again, the question of the effects of this lack upon the family circle is not mentioned.

With advancing age, the norms are not challenged: the "normal" elderly are those who behave like adults, who have the same aspirations and the same desires. We only accept half-heartedly that their performance will not be the same.

Relation as the key to meaning

It is time to ask ourselves about the legacy we are leaving future generations, to become aware that by reducing the very elderly to the sum of their impairments, we steal their place as a subject, that is, as a `speaking being'.

What to do, then? It is a question of learning once more how to listen, see, and feel; of going back to the observation and description of `dementia' subjects; of starting to listen to the carers again, to what those who spend long periods with them every day have to say, to approach the behaviours of those closest to them with a change in emphasis in order to listen to what they have to say about their spouse or their parent. Following the example of numerous clinicians like Louis Ploton, Marion Peruchon, and Michele Grosclaude, we have gathered observations which allow this particular psychological life to emerge.

When we seek to know the elderly sick better, it is apparently a question of eliciting the meaning of some of their words and behaviours, but the messages are not easy to interpret because these patients are so disconcerting and unpredictable. However, we can get round the question of their dignity as persons, as well as that of the free spaces we leave them.(13)

The issue is one of preserving the identity of the disorientated individual at all costs, to be its guarantor regarding the individual him- or herself, their family, and the institution itself, going beyond outward appearances and considering each one as a separate and entire individual with their own history. That is surely the key to orientation of our different practices and one which will also enable us to construct a paradigm of theoretical development.

Affirmation of the existence of a psychological life in an elderly "demented" person, whatever the extent of their disorientation, postulating this affective and emotional life when the means to express it are no longer present, makes it possible to turn this key.

Life's balance-sheet: a task to complete

The very last stage of old age has a meaning, on the pattern of other life stages. At the social level, and for the subsequent generations, the elderly person is witness to a lineage. On the personal level, they have another task to finish: drawing up a balance-sheet of their life, grieving for themselves. Thus Boris Cyrulnik quotes R.N. Butler:
   the "life review" has been put forward as a form of psychotherapy for old
   people. It is a question of a mental process which appears naturally,
   whatever one's culture, through the gradual return to consciousness of past
   experiences, notably the resurgence of unresolved conflicts ... For the
   old, it is always today.(14)


Since Freud, everybody has agreed in recognizing the liberating and structuring effects bound up with the expression of emotions. It seems to us that observations concerning hysterical cases are also applicable to dementia-sufferers: "not only ... [do] they remember the painful experiences of the distant past, but ... they are strongly affected by them. They cannot escape from the past and neglect present reality in its favour."(15) The crisis operates to restore an individualizing historicity at the very heart of suffering.

Jung observed that "past experience, not registered psychologically, can be registered again at times of subsequent experiences, which it influences and which, in turn, confer on it a meaning which it did not originally possess".(16)

Erikson, in his turn, proposed the hypothesis of life tasks to be accomplished at different stages in life.(17) A personal history is made up of crises -- orientating, disorientating, and reorientating. An incomplete task can always be taken up and played through, at one age and then another throughout life.

The attitude of the caregiver appears to be crucial in facilitating this process. As Carl Rogers suggests, it should be non-directive and non-judgemental to enable the individual, feeling themselves to be treated confidentially and acknowledged, to be themselves.(18)

Following Erik Erikson, in her "Validation theory" (see below, Appendix) Naomi Fell proposes seeing a meaning for this final stage of existence.(19) For those she calls the "old-old" it is a question of a final task in the ordering of their life to deal with unresolved conflicts from the past, which will enable them to rediscover their psychological integrity through reconsidering their life before they die.

Like an actor who returns to the stage after the end of the performance to relive internally the different moments of the play, savouring the most successful and playing through his mistakes, in the twilight of their lives the elderly review their existence. They put their affairs in order before they leave the world's stage. They make a psychological restoration of the painful events in their life to give them a dimension that is more compatible with their dignity as a human being. Sometimes, however, this behaviour is barely comprehensible to the people immediately around them, who do not have the life experience of the individual and the experience of old age. We accept the reactions of a child or an adolescent, we have been in their shoes. Those of an old person are accepted with greater difficulty. Often this inner work is accomplished fairly smoothly, but in some, psychologically less resilient, thwarted by the individuals around them who are unaware if not positively hostile, manifestations of aggression and sadness may appear. They crystallize in a withdrawal into themselves and may aggravate a pre-dementia condition.

Ageing, according to Naomi Feil, operates at two levels -- like the other stages in one's life -- at a physiological level and at a social and psychological level. On the physiological level, the ageing of the brain entails relative sensorial isolation, linked to the progressive deterioration of the sensory organs. Eyesight and hearing deteriorates, whilst reduced mobility and decrease in attention span diminish receptivity to social stimuli. The elderly person "retreats into their shell". As experiments on sensory isolation have clearly established, mental images are then, paradoxically; reinforced. On the psychological and the social level the perceptible weakening of relations with the external world enables the very old person to return inside themself to set their life in order. He or she makes an active, although imagined, return to his or her past life and does so in his or her own way. The cerebral functions which filter and control the emotions are altered. The elderly person expresses their feelings when it is appropriate and also at inopportune moments, whether they understand them or not. This process awakens a succession of earlier emotions. "[These old-old people] must pack for their final move. They sort out dirty linen stashed in the storehouse of the past. They are busy; irresistibly drawn to wrap up loose ends."(20) On the threshold of death, each human being, whether they are aware of it or not, whether they wish it or not, reviews the totality of their life with the intelligence of their deepest psyche. When recollection is engulfed in those grooves of the memory where all the secret wounds accumulated during existence, then, just as the arm of a record player plays a scratched groove over and over again, so the old person constantly returns to their hurts without being able to free themselves from them. The gulf which separates them from reality becomes wider and deeper. As sensorial isolation gradually increases, it leads to the folding-in upon themself of the vegetative state, the terminus of a long and painful journey for the old person and for their close relatives.

To conclude

The process of ageing exposes the individual to multiple losses. And the utilitarian vision of old age rouses the spectre of the ultimate loss of the spirit, making the Other a reprieve of the death sentence. The history of our societies reveals a constant ambivalence, producing denial or exclusion of the elderly. This ambivalence challenges our own humanity.

However, around so-called "dementia" subjects and those close to them, across the alternating periods of lucidity and confusion, we discover another language, simultaneously verbal, symbolic, and non-verbal. It is made up of distortions, projections, telescopings, abrupt changes of subject, displacements, metaphors ... but it speaks to us of what can be felt, of the identity in which the joys and hurts of the affective life are grounded. This presumes that we are then capable of accepting everything which the patient expresses as a manifestation of their original way of being, with simply the authentic desire to enter into communication with them, to be human to a human being, without any preconditions. Verbal and non-verbal communication methods are tools which help build bridges towards the patient, to rejoin the other person in their world model.

As Naomi Feil comments,
   When we gain empathy with the disoriented, we begin to understand the
   reasons behind their disorientation ... We can gain insight into our own
   hang-ups. We can learn to recognize our own unresolved life tasks. We can
   work on completing those tasks now -- before we reach very old age. We can
   find a repertoire for coping with losses. If we face scary feelings when
   we're young, we won't be stuck with a backpack of dirty laundry when we get
   to be very old. We need to prepare for old age while our speech, logic, and
   social controls are intact and we have the capacity to change.(21)


Henceforth the old person, even the dementia-sufferer, will rediscover their role in social transmission by making us witnesses of their errors and successes, their hurts and their joys, the things that animate a life.

Notes

(1.) Roger Fontaine (1999). Manuel de psychologie du vieillissement. Paris: Dunod.

(2.) Catherine Guchet (2000). Chronique d'une mort programmee. Revue de la Federation JAMALV: Le long mourir, 60, March, 9-13.

(3.) Etymologically, `dementia' stems from de and mens, demented, deprived of reason, without thought, out of the mind. It was only in the nineteenth century that J.-E.D. Esquirol, Director of La Salpetriere, made the first exact description of dementia, concluding that "the mentally backward has always been poor, whereas the dementia-sufferer was rich and has become poor".

(4.) J. Messy (1992). La personne agee n'existe pas. Paris: Editions Rivages.

(5.) Jean-Pierre Bois (1989). Les vieux, de Montaigne aux premieres retraites. Paris: Fayard.

(6.) J.-P. Gutton (1988). Naissance du vieillard. Paris: Aubier, collection historique.

(7.) E Blanchard, S. Blique, M.-Y. George, J. Prentzynsky (1993). La validation, un outil pour vivre avec les personnes agees et disorientees. Societe Gerontologique de l'Est (Salines Royales d'Arc and Senans, A.G.E.), March, 127-37.

(8.) J.-E Bois, Les Vieux, de Montaigne aux premieres retraites, op. cit.

(9.) Jean-Pierre Bois op. cit.

(10.) We should note that problems with memory or disorientation are not part of `good-quality' ageing. Moreover, memory problems can be mild or short-term and are not evidence of an illness. Not every memory disorder is senile dementia. And, with the very old, not all dementia-type illnesses are Alzheimer's Disease.

(11.) See J. Madeleine Nash (2000). The new science of Alzheimer's. Time Magazine, 24 July, 56-63.

(12.) Marie-Francoise Rochard (1994). Soignants face a la demence. Memoire pour la capacite en geriatrie. Rouen.

(13.) This concern led us to found, over ten years ago, a French-speaking association of medico-social professionals, carers, and representatives of civil society. This association, APVAPA (Association pour promouvoir la Communication et la Validation avec les personnes agees) is a forum for the exchange of views, reflection, and education, and for multi-focused and interdisciplinary research. It develops education programmes designed for professionals and close relatives and supports action for improvement in the quality of life of dementia-sufferers (www.initialis.com / dwp / apvapa).

(14.) Boris Cyrulnik (1993). Les nourritures affectives. Paris: Odile Jacob editions.

(15.) Sigmund Freud (1990). The Origin and Development of Psycho-Analysis (1910). In The Major Works of Sigmund Freud. Great Books of the Western World, 54, 2nd edition. Chicago: Encyclopedia Britannica, p. 4, Col. 1.

(16.) C.G. Jung (1973). Ma vie: souvenirs, reves et pensees. Paris: Dunod.

(17.) E. Erikson (1978). Reflexions on Aging: Aging and the Elderly. Atlantic Highlands, N.Y.: Humanities Press.

(18.) Carl Rogers (1995). Le developpement de la personne. Paris: Dunod.

(19.) Naomi Feil (1993). The Validation Breakthrough: Simple Techniques for Communicating with People with `Alzheimer's-Type' Dementia. Baltimore and London: Health Professions Press.

(20.) Ibid.

(21.) Ibid. pp. xxvi-xxvii. We have also used and adapted for very old age skills taken from communication techniques propounded, among others, by the general semantics of Korzybsky, the systemic approach developed by the Palo Alto School, the transactional analysis of Eric Berne, the neuro-linguistic programming of Grindler, Bandler and, above all, Robert Dilts, the reconstruction of life histories by means of the genogramme as mapped out by Anne Ancelin Schutzenberger and so on.

(22). Naomi Feil grew up in an old person's home, where her psychologist father was administrator. This was how she met Florence Trew (1872-1963), who later made it possible for her to begin to `understand' senile dementia. Naomi Feil spent thirty years working with people like Florence Trew. Thanks to all these disorientated old people, she could observe, "When present time and place fade, when work goes, when rules no longer matter, when social obligations have lost meaning, a basic humanity shines through.... When their eyes fail and the outside world blurs, very old people look inside. They use their vivid mind's eye to see. People from the past became real. When recent memory goes and time blurs, very old people begin to measure life in terms of memories, not minutes. When the very old lose their speech, similar sounds, rhythms, and early learned movements substitute for words. To survive the present-day losses, the very old restore the past. They find much wisdom in the past." Naomi Feil (1993), op. cit., pp. xxv-xxvi.

(23.) F. Blanchard, S. Blique, M.-Y. George, and J. Prentaynsky (1993), op. cit. 127-37; E. Hall (1971). La dimension cachee. Paris: Seuil; Paul Watzlawick, Janet Helmick Beavin, and Don D. Jackson (1970). Une logique de la communication. Paris: Seuil. [English-language editions: (1967; 1968) Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies and Paradoxes. New York: Norton; London: Faber.]

(24.) Carl Rogers (1995). Le developpement de la personne. Paris: Dunod.

(25.) R. Bandler and J. Grinder (1976). Structure of Magic: A Book about Language and Therapy. Palo Alto: Science and Behaviour Books.

(26.) Naomi Feil (1993), op. cit.

Appendix

The history of an encounter(22)

Florence Trew [was] a resident of a nursing home ... I was 8 and she was 68 in December 1940 when we first met ... Mrs Trew was my best friend in The Home ... I loved her low, clear, resonant voice. Her voice soothed me. Her voice trembled only once, when she read me a page in her diary.

She had found me sobbing ... I told Mrs Trew that my mother loved my brother better ... Mrs Trew understood these iniquities. To heal my hurt, she produced her diary, which she always carried in her big black shiny purse. Mrs Trew found the page she wanted with her fingers, without looking. She touched the paper and froze. She squeezed her eyes shut.... Her sweet lyrical voice changed to a dull, flat, lifeless monotone. The words on the page spoke themselves without her soul.
   June 10, 1891. Dear Diary: My mother hasn't changed. She embarrassed me
   again today, just like she did [before] ... It was ... [the] Parent-Teacher
   Night. She was talking to Miss Nelson just before the bell rang. My mother
   pointed her finger at me while she was talking, making everybody look at
   me: ... "I'm worried about Florence. I don't want her lugging that creaky
   rabbit around all her life." ... She moved toward me until she towered over
   me, holding out her hand for Creaky. "Creaky is mine," I said. I loved
   Creaky so much that I stuttered. I held his string tighter, hiding him
   under my desk. Daddy had made him for my third birthday, just before he
   left us for good. Creaky's white pointed ears were smooth as velvet.
   Touching them made me feel peaceful, almost as if Daddy were with me ... My
   mother grabbed Creaky so hard that his hind left snapped off. She ... threw
   Creaky into ... [the] waste-basket ... I ran up to save him. [But] Miss
   Nelson took the wastebasket with Creaky away.


Mrs Trew closed her diary and her eyes. I put my hand in hers. "What happened then?" I whispered.

"I died," she answered.

I said goodbye to my friend Florence Trew in 1950.... In 1963, I returned to Cleveland to do postgraduate studies, teach, and to work with the disoriented residents at The Home where I grew up....

[My attention] was drawn to a ... massive chair ... [trapping a] tiny old woman. Mechanically, she pounded the metallic tray imprisoning her. "Cree. Cree. Cree," her low scratchy voice belched.... Her hands caressed an invisible object ... only she could see ... She grabbed my wrist and held it tight. I looked at her long fingers, the nails brittle, her forearm splotched with liver spots ... her tiny wrist. I saw her name band.

"Florence Trew." ... I saw Mrs Trew in my mind's eye. Twenty years earlier she had been 65 years old ... Together, we had earned 30 cents a day picking spongy red rubber from wornout tires to benefit the war effort. The two of us had won the Red Rubber Pickers Award. Mrs Trew had hung the medal on her door....

"Remember our medal, Mrs Trew?" ... She heard. She looked straight into my eyes ... [and] whispered my nickname, "Mimi, Mimi, get me out of this chair."

"You can't untie her," the nursing assistant warned me. "She fell three times last week trying to get away. If you untie her and she falls again, you are responsible."

"What happened?" I whispered to Mrs Trew, bending very close.

"They threw him away. Make them give him back, Mimi. Please." Mrs Trew's voice held the same soft ring of long ago. Her blue eyes were clear. Her hands holding mine were strong.

"Who?" I asked. "Mrs Trew, who did they take away from you?"

"Creaky. She threw him in the wastebasket." Mrs Trew pointed to the nurse.

"That's the nurse, Mrs Trew, not your mother."

Mrs Trew shook her head, disappointed in me. She turned away; tuning me out to stare into space, moaning softly, "Cree. Cree. Cree."

I persisted. "Mrs Trew did you have a stroke?" I wondered about her recent memory. She stared at me, speechless. Her lips formed words but no sound. She sat limp, resigned, conforming her body to the restraints. She sighed, "I'm dead."

I argued. "Mrs Trew, you can't be dead. You are talking to me!"

"Honey, you are hearing things," Mrs Trew said sadly.

"Do you want to die, Mrs Trew?" I asked softly.

"Yes." Her answer was sharp and clear. "Creaky and I are rubbish. Red Rubber Rubbish. Rub. Rub. Rub a dub dub. Throw us in the trash can!" ...

Mrs Trew started to cry; whispering between sobs, "Poor Creaky. She tore your legs. Your white ear is so soft. Get me out of this chair. Help! Help!" Mrs Trew screamed.

I put my arms around Florence Trew.

A hoarse male voice shouted, "She's nuts, lady. You can't help her. Help me!" ...

The nursing assistant gave me a dirty look.... She tightened Mrs Trew's restraint with a brisk, efficient yank ... Mrs Trew swished her foot hard against the nursing assistant's shin. Mrs Trew hollered, "Give me back Creaky, you bitch. I hate you! All the children in this classroom hate you!" ...

She never looked at Mrs Trew, but grabbed her chair and wheeled her quickly down the long hallway; talking to the chair back. "Sweetie, you shouldn't use those bad words. You know better than that. A bitch," she explained patiently, "is a female dog. I am not a female dog. I am your nurse and I love you. It's time to go beddy-by. Everything will be just fine, honey." Her voice drifted, honey-toned, through the corridor and finally faded.

Mrs Trew never had the chance to turn her head and look back at me. Florence Trew and I never had a chance to say good-bye. She died that night.

Naomi Feil, The Validation Breakthrough, op. cit., pp. xix-xxv.

Florence Trew had repressed these feelings throughout her life. She had buried her anger against her mother deep within her. It was only after she had lost her autonomy, her husband, her house, her daughter, her sight, her short-term memory, and her mobility, after eighty years, that she relived these painful memories. Day after day, she screamed after her mother. For her, her nurse-carer was only a shadow. Florence Trew's optic nerves had been damaged, but she could see very clearly with her mind's eye. For her, the vague outlines in the wheelchairs became the children sitting at their school-desks. She returned to her past to heal old wounds.

An Approach to the Possible: Validation

Validation is an approach that makes it possible to communicate with the very old who have been diagnosed as having Alzheimer's-type senile dementia.

This method rests on three main foundations:

* a theory, based on a concept of personal development through life tasks;

* a practice, using different verbal and non-verbal communication techniques;

* an attitude, empathy, which one might define as a quality of listening which enables one to return to share in the emotional experience of the person cared for while never, nonetheless, appropriating it to oneself.

At the theoretical level, Naomi Feil, taking up the work of Erik Erikson, adds a task for the very elderly that she calls "Resolution", the last life stage, in the course of which the individual undertakes the re-reading of his or her life and draws up a balance-sheet.

Through the observation of elderly dementia-sufferers, she identifies four possible levels in the course of this stage: malorientation, time confusion, repetitive motion, and vegetation, characterized by specific attitudes and behaviours at each of these levels. She formulates a series of hypotheses about the reasons why these people act as they do.

Behaviours usually considered embarrassing by those around them, such as wandering, kleptomania, or repeated cries, are viewed as verbal or non-verbal manifestations, in the course of which the individual communicates information to us about their vision of the world and their expression is always relevant to the subject's history, even if it is inappropriate for their environment. Knowing that there is a meaning to the strange behaviour of the individual modifies the conduct of the interlocutor.

When Mrs D. heaps all her things pell-mell into the open case on her bed and throws two or three objects onto the floor, interpreting it as an attempt to run away, shutting her case and taking it away would cast her into desperate silence. It is enough simply to listen to the question she is mumbling: "What should this woman take with her, when death comes to find her soon?" Metaphorically, she is trying to sort out her memories by packing her bag before the great departure.

On other occasions, it can be simply a question of reliving past pleasures or of reactivating sensorial memories in order to keep boredom and stress at bay, and to ward off unhappy feelings of uselessness and loneliness.

These communication techniques proposed by Naomi Feil are inspired in particular by works resulting from the systemic approach of the Palo Alto School,(23) Carl Rogers's work on the care relationship,(24) and on neurolinguistics.(25) They help the care-giver to build bridges towards the disorientated individual, to share in their "world model", their affective reality, while keeping the right boundaries in place between themselves and this other, for whom they are caring.

To do this, neither lying nor calling to mind the objective reality of the moment are admissible. Rather than focusing on what is lacking, the care-giver attempts to identify the function of the demand in order to satisfy the underlying need.

In the story of Florence Trew, the missing object was her "Creaky", whose purpose was to soothe, thus satisfying her need for security.

We can imagine that, "validated", she would have recalled the loss of "Creaky" and have been able to revive and express the sense of injustice which she experienced at that time. Thus acknowledged, Mrs Trew could also have expressed the legitimate nature of such feelings and found relief.

There are other possible approaches to caring for the very old and disorientated, such as reminiscence, life review, reality orientation, remotivation, behaviour modification, and psychotherapy.

These other techniques seem to us less well adapted to individuals who have reached the Resolution stage. Most of these approaches require a level of consciousness and/or insight which these individuals are no longer capable of maintaining because of their impairments, especially in judgement and reason. Moreover, some of them are of no use in the stages of repetitive motion and vegetation.(26)
F. Blanchard, F. Duarte, and E Munsch
Rheims and Cernay
(translated from the French by Juliet Vale)


(This article was written in collaboration with S. Blique, M.-Y. George, K. Munsch, M.-E Rochard-Bouthier, members of APVAPA.)

Francois Blanchard was born in Reims in 1947 and is a doctor, lecturer in public health at the University of Reims and head of the department of geriatrics in the University Hospital. He has set up several university networks with INSERM in Europe and France to carry out research programmes on the quality of life of psychiatric patients and also on the factors contributing to fragility in advanced age. He has published a number of articles on this topic in scientific journals. He chairs the Association Francophone des Droits de l'Homme Age (AFDHA; Francophone Association for the Rights of the Elderly) and was the founding chair of APVAPA. As a member of the Conseil National de l'Enseignement Superieur et de la Recherche (National Higher Education and Research Council), he is involved in the advancement of the teaching of gerontology.

Fernande Duarte was born in Portugal in 1972 and studied psychology at Toulouse II-le-Mirail. During a period of experience at Mazamet Hospital she became interested in the management of elderly disoriented patients and the problems surrounding the later stages of life. She now works as a clinical psychologist and is an active member of JALMALV and APVAPA. Working in collaboration with medical teams at Cernay Hospital she has contributed to the development of socio-therapeutic activities designed to meet to the interpersonal needs of the elderly.

Frederic Munsch, who was born in 1955 in Mulhouse, is a geriatrician and psychogeriatrician. As a hospital clinician he was head of department at Cernay Hospital from 1987 to 1999 and was a founding member of APVAPA. He is interested in the care of the mentally disturbed elderly and support for those close to them. He practises Ericksonian therapy, is a master practitioner of NLP and a trainer for Validation, and divides his working time between hospital, teaching and training professionals for the medico-social field. He has published articles in scientific journals.
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Author:Blanchard, F.; Duarte, F.; Munsch, F.
Publication:Diogenes
Date:Jun 22, 2000
Words:5686
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