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The problem of meaning in long-term care.


The Determinants of Meaning

What gives meaning to human life? The determinants of meaning have been categorized by the existential psychoanalyst Irwin Yalom. (1) First, is the meaningfulness of the things that people do for the sake of the world around them. Family is the most natural way to extend yourself in the world and into the future beyond yourself by having and raising children. A second determinant is the meaning found in work. People also derive meaning from intellectual inquiry or the production of art.

There is a third set of meaningful experiences that we take from the world. These are also determinants of meaning. There is a lucky subset of people who can sit on a bench watching the ants go by in a line on the sidewalk. This is enough to make these people sigh and marvel at the wonder of existence. And then there are the rest of us, who need a trip to Yosemite National Park for that kind of experience.

Encounters with significant people also lend meaning to life. For many people, a close relationship with a mentor, a rosh yeshivah or a rebbe, for example, adds meaning to life.

There is a "middle" set of determinants-less active but hardly passive-and these are the issues that we believe in, that we are willing to take an ultimate stand on and even die for. These determinants obviously contribute meaning to our lives.

If you wanted to find a concerted effort to provide all these determinants to frail elders, you need look no further than the Miami Jewish Home, a special place where great efforts are made to address the determinants of meaning and keep them in people's lives. The facility has two-hundred-year-old trees and beautiful places to meditate. Residents can keep in touch with their families through teleconferencing. There are some staff members whose sole job is to teach elders how to use the Internet in order to be in touch with friends and family. There is pet therapy for those who benefit from this way of expressing love and affection. And the arts department has weaving and ceramics.

These images are very different from those presented to you by other speakers today. Over seven hundred people live at the Miami Jewish Home, and so there are a variety of experiences there. Some of the residents find ways to volunteer to help other residents who are less fortunate. My favorite hundred-year-old resident wove the marriage canopy for her great-granddaughter's wedding last year and the prayer shawl for her great-grandson's bar mitsvah.

The Problem of Uprooting

No matter how high the standard of the care, however, after a person enters an assisted facility or into long-term care, family ties are inevitably disrupted. This problem is particularly acute in Florida, where often the resident's family lives far away. A community is always left behind. The case can be made that a new community is embraced, but it is not the community you went to work in every day, or the community where you raised your children.

There are ways to find work in an assisted living facility or a nursing home. The work tends to be voluntary and thus has questionable value to the people doing the work.

Religion may be difficult to practice, especially for people who don't come with much religious experience. As Rabbi Lipskar points out, it is certainly not impossible, but it can be difficult. It also depends on the type of religion and how multi-ethnic the facility is.

In a facility, autonomy is exchanged for care and structure. Loss of freedom is a major issue in all types of residences. Every insititution follows some routine, so that no one is really master of his or her own morning. Control of one's experience is usually limited.

The Miami Jewish Home is fortunate in having deep and varied resources. Many other facilities are not as lucky. But even with the best possible setting, the bottom line is that death is approaching. For many people, this creates a finite time line and a deep sense that the meaning of their remaining life is very limited. It's always tempting to say that the answer to this problem is to add more religion, because religion transcends death and gives meaning.

Rabbi Soloveitchik on Religious Experience and Meaning

The first question, certainly for any Western religion, is why human life is meaningful. Rabbi Joseph Dov Soloveitchik, a giant of religious thought, reminds us that the other shoe also drops on this issue:
   Chancing suddenly upon G-d [a religious experience], man becomes
   aware of his evanescence, and the absurdity of a conditioned and
   relative existence. Infinity swallows up finitude.... Little man
   forfeits his identity when he is confronted by the all-inclusive
   Divinity.... A bounded being disappears in the eternal

   So, a genuine religious experience, while elevating, cleansing,
   transcending, also at the same time, shows our existence to be
   absurd, conditional, relative, and finite. A genuine religious
   experience does both of these things at the same time.

   In short, either the anticipated loss of our existential awareness
   or the forfeiture of its valuableness, which means either death or
   the loss of meaning, is the source, not of pain, but of suffering.
   Suddenly man sees himself confronted with nobility, at either a
   factual or an axiological level, confronting the inevitability that
   our lives are very finite and that the meaning in our lives is

In other words, while a genuine religious experience adds meaning, it also shows how insignificant and meaningless we are from a larger perspective. Rabbi Soloveitchik now makes a key point: it cuts both ways.
   However, as in the case of mathematics, an equation works both
   ways. Not only is the apocalyptic experience catastrophic, but the
   converse is also true. Whenever there is a catastrophic experience,
   there is disclosure. Man is confronted by G-d.

A catastrophic experience, one which threatens existence and meaning, like old age in general and an assisted-living facility or a nursing home placement in particular, makes room for an expanded spiritual awareness. This realization that the determinants of meaning are eroded is not something that necessarily needs to be fixed. It is something that needs to be understood and appreciated.
   Only sickness somehow makes us encounter death in all its ugliness
   and sharpness, and his rendezvous with nihility leaves a mark upon
   our consciousness. Our heart engages in a dialogue with nihility
   and this dialogue should never be terminated. Recollections of our
   finite destiny is part of the message of suffering. (2)

This is not unlike the Lubavitcher Rebbe's advice to the Israeli soldier that we heard in Dr. Elfenbeim's presentation. Suffering is ripe with potential. We should study the worldview of sufferers, because in many ways it is clearer than our own. They have a clearer philosophical understanding of the meaning of their lives. How do you assimilate this profundity if you are not a Soloveitchik?

A Cathartic Ritual for the Transition Day

How can we elevate and alleviate the crisis of an uprooted elder entering into a facility? We're not talking here about unfortunate victims of late-stage dementia but elders still in possession of their faculties and needing help from assisted living or a nursing home.

We can borrow from the methods that all cultures use, and that is- rituals. Rituals are classically used in many cultures to bridge transitions. They do not require intellectual sophistication, and they are potent with meaning. In the same religious setting a Nobel laureate and a very simple person stand next to each other, use the same liturgy, and both have a satisfactory, deep experience. Rituals celebrate or influence cognition as well as belief, attitude, affects, and behavior. A ritual also costs less than psychotherapy, group therapy, or family therapy and can be done in a long-term care setting.

There are many aspects of established religion that are adequate to the task of giving meaning. There are rituals for the transitions of coming of age, marriage, and death, but there is no ritual for the particular transition from independent living to assisted living or a nursing home. Therefore, Dr. Marc Agronin, Rabbi Eli Feldman, and I proposed an admission ritual, which we call the New Horizon ceremony. We wanted to help people deal with this transition in an appropriate way. The goal of our admission ritual is to acknowledge that it is in fact a big transition, to acknowledge the strength that a person brings with him to a long-term care assisted-living facility, and to acknowledge that there is still hope, there is still a future. We also want to acknowledge the fact that there is frailty, because again it is this that makes room for the expanded awareness, and we want to acknowledge the uncertainty looming ahead. Most important, we want to acknowledge that the person is now at a point where meaning is challenged. Moving into an assisted-living facility or nursing home is a very complicated business, both for the resident and the families, and for the staff as well. Our primary goal in terms of meaning is to have people understand the nature of their own situation at this pivotal time.

The New Horizon ceremony is a structured celebration to help new residents and their families with the nursing home transition. It has been fashioned deliberately in a way that can be used in a wide variety of settings, not only in a Jewish home and not only in a Jewish setting. The ceremony is held preferably on the day of admission in a room at the facility.

It is important to bring a lot of family and friends of the new resident. It is important that there be some new neighbors and a staff member. It is critically important that there be a leader who understands the goal of the event. This could be the resident's own clergyman or the facility social worker, who has been appropriately trained for the occasion.

The New Horizon Ceremony

The ceremony goes like this. First of all, there is food, and there are introductions, since not everyone knows each other. The ceremony should be both practical and symbolic. The guests are asked to bring a useful gift and a symbolic gift-a picture, a poem, something carrying additional meaning. The person is given a triptych of three picture frames-one with a photograph of him or her from the past, one with a photograph of the present, and the third one open, to emphasize that there still is a future here. There's a friend we haven't met yet, experiences yet to come.

Unpacking and decorating is a powerful, emotionally laden way to deal with the fact that this is a transition. There is a lot of crying when people pack up their homes before they make the move, and there is a lot of crying when they unpack and arrange their new space for the first time. It is critically important that this process be bound up in a ritual.

Promises should be exchanged. People from the person's past and people from the person's future should make modest promises like, "I shall call you once a week," "We shall go shopping together," or "I shall introduce you to your new neighbors." The promises are not so much to address the issue of meaning but to smooth out other aspects of the transition.

If this is a Jewish home, there's more food. Then the leader asks the new resident structured questions. This is the essential part of the ceremony. The leader asks, "What is the hardest thing you ever did?" We have a lot of military veterans, Holocaust survivors, and people who endured the depression, all of whom have struggled and prevailed.

"Do you think that living here will be hard?"

"What was the most fun you ever had? What do you think might be fun here?"

"Tell us about a time you were really scared. Are you a little scared now?"

"What do you hope will happen to you this coming year?"

The biggest, most difficult question is, "What has made your life meaningful?"


(1) Irwin Yalom, Existential Psychotherapy (NY: Basic Books, 1980).

(2) Joseph Dov Soloveitchik, Out of the Whirlwind: Essays on Mourning, Suffering and the Human Condition (NY: Ktav, 2003) pp. 120-130.

See also:

William James, The Will to Receive.

Viktor Frankl, Man's Search for Meaning and Man's Search for Ultimate Meaning.


Since this presentation was given in 2003, the team at the Miami Jewish Home has developed an assessment tool to help measure the impact and effectiveness of the ritual intervention. At this writing, the project awaits funding for implementation.

Robert J. Bergman, MD is a native of Miami and a graduate of the University of Miami School of Medicine. He has served on the geriatric medicine faculty at UCLA and is currently a faculty member at the University of Miami. From 1998 to 2004 he served as medical director of the Miami Jewish Home and Hospital for the Aged at Douglas Gardens, the largest long-term care facility in the southeastern United States.

Dr. Bergman made aliyah with his family in 2004 and now practices internal medicine and geriatrics in Jerusalem.

A Brookdale fellow, Dr. Bergman has authored and coauthored over a dozen publications in clinical geriatrics.
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Author:Bergman, Robert J.
Publication:B'Or Ha'Torah
Article Type:Essay
Geographic Code:7ISRA
Date:Jan 1, 2006
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