Eight Reflections on Seniors as Patients

List three older people that were in your life as a child.

• Of these, choose one of these persons to focus on for just a moment: Consider something important they shared with you at that time.

• How might that important message yet influence your care of elders now?

• What do you believe that elders are most afraid of?

• What is there about elders that you do not yet understand?

• What is your best gift to your elder patients?

• How will you know if you are succeeding in elder care?

• What pleasures do you expect to continue to receive in elder care?

These questions are arranged in a hierarchical fashion. They are designed to give us an opportunity to think about and reflect on our care of elders. They elicit memories that may influence our care of elders. They invite reflection on what we believe are important concerns of elders.  They illuminate our expectations regarding how we will be as we care for our elders.

Alan S. Wolkenstein, MSW

Clinical Professor of Family Medicine (Ret.)

University of Wisconsin School of Medicine and Public Health

Behavioral Sciences Consultation Service

School of Nursing: Concordia University of Wisconsin

Journey of Elders: Three Clinical-Educational Sessions

Recently retired from over thirty years of teaching and research in graduate medical education, Professor Alan S. Wolkenstein will be joining us for three hour long sessions to share his insights, experiences, and vision in caring for our elder residents and of ourselves. He is a licensed clinical social worker and family therapist and specializes in the impact of illness on people and families, and the challenges and rewards of elder care. He is nationally recognized as a master educator and deeply appreciates and supports the knowledge, skills, and experiences of the group he is facilitating.

The three sessions will use principles of Small Group Experiential Learning (SGEL) and Adult Education. Much of the materials he will be presenting for discussion and interactive reflective learning stem from his career in teaching Human Behavior and Behavioral Medicine to Primary Care physicians in training and clinical practice, medical students, and allied health care professionals.

Come join Professor Alan as he discusses the life journey of our elders, their joys and dreams, their losses and lamentations, their on-going transformation, and the possibility of enhanced best care of them and of those of us who plan for and care for our elderly.

Goal:

Our three sessions will enable us to spend time together in exploring, assessing, and strengthening our individual and collective (professional) self-awareness, enhance our individual clinical care skills, and enrich our careers of service, dedication, and honor of our gentle elderly.

Objectives:

*Using SGEL to help us create the kind of supportive and nurturing environment to do our work best.

*Utilizing Adult Education Principles to enhance how we practice the practice of elder care.

 *Honoring our past experiences as a means to reflect on new and challenging ways to care for ourselves in the work of elder care.

Session 1: “The Lost World of the Elderly.”

Discussion of the “Lost World” Philosophy of Empathy-Based Resident Care

Use of time in the Ancient Greek tradition to enhance our work

Is our work a job, a career, or a passion?

In the Hebrew tradition (part of the afternoon prayer)

“In the moment” as a resident-care philosophy

Quality of Life among the elderly

“Critical Issues” in resident care

Feedback- Planning next session with a journal entry of your work

Session 2: “Transformative Experiences to Reflect on in Our Work”

How do we self-assess the quality and meaning of our work with elders?

Discussion of our own social support and community based group care

The three interdependent “uninvited guests” of many of our residents: loneliness, isolation, and fear

To fully heal ourselves, we must first release the pain generated by our work and in our important relationships

Feedback

Session 3: Grieving and Losses of the Elderly

From experiencing losses, to their grieving and lamentations, to their transformation

Our parallel experiences

The difficulties in “objective-based care”

How to do our own grief work- If we do our grief work, we will not burn out or become impaired professionals

“Critical Issues” in self-care

Viktor Frankl: “A Will To Meaning”

Feedback and evaluation

Thank you for participating in these collaborative sessions

Alan S. Wolkenstein, MSW

 Clinical Social and Family Therapist

Clinical Professor of Family Medicine

University of Wisconsin School of Medicine and Public Health

Wolkenstein and Associates,LLC

Mequon, Wisconsin

262 243 5489

Alan.Wolkenstein@gmail.com

·         

The Key to Nurturing Your Relationships

Nurture your relationships with everyone important to you. Otherwise, they will fall away ...

 We can never have enough people in our lives. They form the continuity that is absolutely essential to good quality of life. Seniors report difficulties in retaining friendships in that people pass away or even move away.

What seems almost worse to me is when we let relationships "drift."  We do not pay attention to them and they "drift" away from us, as if we have more important things to be doing, thinking about, or planning. While we have little to no control over people moving, or unfortunately dying, "drifting" can be prevented by paying exquisite attention to our relationships.

However when other are gone, it is important to seek out new relationships.This can difficult to do,The skills to seek, find, and create these new relationships can be learned, but generally from someone who has the training and expertise to guide and mentor the seeker. The need to get connected and be connected is a very human need.

You can let go of almost anything and still feel you have enough, if you nourish your relationships with everyone important to you. And this requires your attention to small details. Let me suggest that these are details that we can easily let slip by us if we are not paying attention to this important task.. 

Multiple Reflections on Caring About a Dying Person

I first met Joe when I was consulting on the Teaching Service at the hospital. The Family Medicine resident asked me to see Joe with him because the options for care were becoming less and less, and he felt unskilled as a new physician in training with this very uncomfortable and anxiety provoking experience.  I was introduced to Joe as the Behavioral Sciences Educator and Joe said he didn't need a shrink,but he needed a way out of this cancer. Joe told me that his cancer was "impossible to control" and he was expected to make some difficult decisions about his future:  nursing home, hospice, but returning home was probably not possible, and there was not much more the hospital could provide. So, Joe and the doctor had a few days to think this through, but since the resident was uncomfortable doing this alone, he asked me to be part of the conversations. Little did I suspect how much of Joe's life I would be part of and share, and for how long I would think about him.

This work is what I do and we met, the three of us, for some grueling and tough talks.  We also asked the hospice nurse to join us for a session, and Joe's questions became more and more intense as she explained about the concept of hospice and she said the word death.  I remember even now, how the word filled the room with an eerie intensity that brought tears to the doctor's eyes and Joe was speechless as the word sunk in beneath his emotional defenses. I heard him almost whisper " I am going to go to hospice to die. What do you think, Professor?" I waited a moment and then said that how he felt was really more important and valuable than what I felt. But if he really wanted to know, I felt a sense of sadness. "You are right Professor, I feel sad, and scared, and very hopeless."

There were lots of other professionals that made a steady stream in and out of Joe's room. Other physicians such as the oncologist, a hospitalist, an attending physician, many residents and students of medicine and nursing, and of course the hospice nurse. Joe told me that all these people seemed to stem his loneliness, except at night when he would feel lonely and fearful and isolated from the world. He would wake up out of a sound sleep, shaking, and almost out of breath.  I said they were like "visitors", but uninvited, unannounced, and unheralded. I decided to share about myself and said that when I had been diagnosed with cancer and a had a bad prognosis, these same  three "visitors" came to me at night. I would also wake up terrified and oftentimes weep from the sense of being so alone and isolated from others, even though there were always others, and so fearful for my life and future. Joe said nothing, and there was a quiet in the room that lasted and lasted. Finally, he spoke. " I am glad you told me. It must have been hard to do." It was.

Energy between us picked up after that. We began discussing deep breathing, imagery training, and basic meditation. I related that it was frequently helpful for me, many i had worked with, and I knew it would be helpful for him.  Joe just took to all this.  He said it was like learning a new language to help him deal with his life now and his death.

I met his family also.  Two sons and their wives and four grand children. They talked with the oncologist and hospice nurse and it was so difficult for then all. I almost wished I could make all this go away, and Joe could return to his home and live many fruitful years. It was not to be and one day Joe was transferred to hospice.

Joe called from there and asked me to visit him. There was much he was now ready to talk about. And so, we made a plan. I would stop at Joe's every Friday on my way to the hospital and we would talk; no therapy, no patient and therapist, just two guys on their own journey through life, meeting and sharing, with an occasional Jungian concept thrown in so I wouldn't get too rusty.

I suggested a family meeting when Joe talked about his will and plans for his estate. He wanted his grand  children to get a good chunk of it and his children to get the rest. I asked him to think about the following questions and respond to them  before he decided on all this.

1.  Who am I?
2.  Where do I come from?
3.  Where am I going?
4.  What are my "gifts" to others?
5.  What do I want my legacy to be?

Joe shrugged and said OK, Alan (first time he called me by name), let me see what is really going on in my mind.  That is still fine, it's my body that is not fine. Joe completed the questions and we spent an hour on the phone one night going through them. I won't share his answers, but he changed parts of his will. When I asked what did he plan, he said he had his  lawyer keep the grand kids where they were, but that he wanted an endowment at a small community college for student grants in his name and his wife's, who had passed many years ago, for the rest of his estate."I really do want a legacy that will live through my grand children from their inheritance, and the students who will use my endowment for college."

I brought up God and religion and even the concept of heaven. Joe looked at me and I will never forget what he said. "Alan, you are an educated and very smart man. Why would you bring up such stuff? And don't say it is a requirement of your job." My response was that I would certainly want him to speak to some chaplain if he had questions or concerns that were out of my league. "No."

. Joe began to feel time running out on him and was on increasing doses of medication to help him feel comfortable from the pain. We reinforced the early meditation and imagery training with hospice staff, who all took to him so easily. I was pleased they were so kind to him. One Friday, he told me that the "visitors" had left, as they had for me. No announcements, no playing of bugles, and no warning. For both of us, they left and never came back.  He was proud of this and said it was a real accomplishment for a guy who was dying not to be so afraid.

The following day I went back because i had a feeling there was something else going on. Joe was in what first sounded like a shouting match with the Chaplain-Rabbi. Joe blurted out that the Rabbi said it didn't matter if he ever went to synagogue or even believed in God, but only that he believed in a "something " for himself after he died. Joe began to weep and said that he wanted desperately to believe that he and his wife would "morph through the universe forever".  The Rabbi held Joe and asked me to join in. Now, here was a guy who had a non-possessive warmth..that anyone could join the circle in Joe's behalf, and that was just fine with him and with me.  As the Rabbi left, Joe told him not to expect any contribution from him.The Rabbi turned and blessed Joe. What a collaborator he was.

Since Joe had opened an emotional place we were now in, I suggested a family meeting. I wondered if it would be their last, but one in which I would ask to be there and facilitate the meeting.  Joe must choose the people he wanted to be there and what he wanted to say and what he hoped to hear.   I then suggested the additional areas below to include with his thoughts to complete the circle of Joe's life.  This was challenging for us both, for Joe was going to spell out his requests for a funeral and no family gathering after, but the tomb stone he wanted and how it was to be paid for. Joe wanted to be buried next to his wife, Hildy.  Then he winked at me and said it would be easier for him to find Hildy's soul if he was next to her so they could begin their morphing around the universe.

So, here are the components I suggested to Joe:

1.  Forgive me for my mistakes and mindless ideas and comments.

2.  I forgive all of you for your mistakes.

3.  I have tried to be a good father and grand father and forgive me when I have failed.

4.  I love you all and am sorry I did not tell you or show you enough of my love.

5. I am sorry I have to leave you.

6. Goodbye.


As I look back, I remember the room Joe was in, with all his family around him.  He decided to ask the grand children to attend with the idea they could skip out to the hall if they needed or wanted to.They all stayed and as the sunset began to show through the windows, Joe said all he wanted to say and then even more. He talked about his great excitement at seeing his family thrive after a rough time he and Hildy had in Europe before immigrating to the United States. That he was pleased with them all and was sad to have to leave. Each  adult-child had something to say to Joe, as did their partners and the kids also. The smallest one climbed on Joe's bed, hugged him and said, "Goodbye Gramps, I will miss you."

As they all piled out of the room, Joe asked me to stay. He told me that he and I shared the same religion but that he respected whatever my personal views on that were. He also instructed me to not go to his funeral or his shiva (eight religiously prescribed days of family mourning) as his family insisted on having. " Our relationship is ours." Joe also told me no rushing to the hospice if they called me that he was passing. He grabbed my arm and said that some part of my spirit was within him and made him feel sort of OK, and that he would return it after he passed, since he would not need it any longer. Even I had nothing to say at that point but to hug him and leave.

Joe passed away the next morning.  No bugles, no announcement, no fanfare.

As I reflect back on this meeting,there was something very emotional, spiritual about it.There was this intensity that filled the room with energy and warmth that is not there in any other kind of family meeting.  I have spoken with other therapists, ministers, nurses, and volunteers who conduct and  guide such meetings, and they all seem to agree that this phenomena occurs, but some had been reluctant to talk about or share it with others.  Strange that we do not easily share such an acute sort of blessing.

While not alluding to this in the story of Joe, it is paramount that anyone of us who was with him in most any circumstance had to be fully "in the moment" with him.  In other words, we must have the insight, skills, and desire to be completely in that moment with him; physically, emotionally, and spiritually. Sometimes, we can fool people about how smart we are or how much we know, but never about whether we are fully in the moment with them. In other words, that we are not preoccupied with what we have not accomplished before, or overly anxious  about what we will do later. We are simply to be here and now for them. This is the only bridge to real compassion and deep empathy with someone who is struggling with life and death.

Finally, for those who have traveled this journey as I did with Joe, there is a calmness that pervades us, a settling in of our most intense feelings, and a sense of gratitude for the experience. It has been said that for many elders, life is a series of loses. What makes it easier to cope with this reality, is the ability to say good bye to those we love the most. Joe was indeed lucky to be able to do so.  Maybe, just maybe, this made his passing easier for him and for those left to mourn him. I know it did for me.

May Joe's spirit have found that of his wife's, and may they have begun their morphing around the universe. I sure hope so.

Six Dynamics to Consider in a Grief Response

                                                                  
                                         Six Dynamics to Consider in a Grief Response


Abstract

Family physicians should be at the forefront of understanding and assessing incomplete grief responses of patients. This has not been the case for many physicians. Doing so requires a specific curriculum and motivated-well trained  faculty, and learners interested in, willing to learn, and emotionally strong enough to do this work. However, I have found that residencies are troubled by what to teach, how to teach, when to teach, and where to teach it. Residents may have uncomfortable feelings, disinterest, cultural barriers , and occupied with so many other tasks to invest themselves in the process of it.. 
Come join me in looking at a patient who had a family physician who overcame the obstacles and learned the skills to assess and in this case, make a referral to me.



Jack came to the office at the request of his family physician.  The physician was an individual I had trained  to assess and diagnose grief reactions. The physician had called earlier and indicated that he was sure Jack was suffering from a disrupted grief response and needed professional intervention.

Jack appeared more than apprehensive when he sat down in the office.  I decided to say nothing and see what he would be willing or able to talk about. Jack finally spoke and described feeling sad and lonely since his father had died six months ago. He shared that his father had become a great friend to him over the years and his sudden heart attack and death left Jack feeling devastated. “I can’t seem to get over it.” 

The physician also noted that had developed a sleeping problem and had lost some weight.  Jack could not concentrate and seemed to feel off balance.  The other two siblings were “doing better” according to Jack, although his mother was also seeing the physician for weight gain and high blood pressure. I wondered if they were really doing better. Jack forced a smile and said I had just created a riddle.

At no time did I sense any real feelings from Jack. His conversation was highly verbal but not emotional. Where were the emotions for a young man with such a great loss? Why would Jack have a need to get over his loss so quickly?  Why did he not permit himself to feel his loss and then his grief, really feel it?  While we say that time heals, we must do something healing in that time in order to heal.  Since all healing comes from within, I suspected Jack needed some guidelines and therapy to begin now, the process of grieving his terrible loss. Lastly, deep and intense feelings of sadness are early prerequisites of a grief response, but are not in themselves a grief reaction.

There were at least six dynamics regarding this situation. There may be more, but probably not less:

1.       People seldom allow themselves sufficient time to complete their grieving.

2.      There are physical responses to grieving.

3.    . Jack was "off balance" from his loss and needed to make emotional and psychological corrections to regain a sense of balance in his life

4.      A lack of awareness of how to feel and then grieve were skills and experiences Jack needed.

5.      Dealing with the obsessive components of loss and grief.

6.     Family responses to a grieving situation.

What would he accept from me, a stranger who entered his world?  A world of apparent loneliness, isolation from himself and others, and fear of his own unknown. He talked of not sleeping well and obsessing over how he was notified of his father’s death, and  he then believed  he lost his way emotionally. I was impressed with how lonely and isolated Jack felt. He was also afraid of his own future. A future without his father so  there were differentiation issues to be part of any therapy work

I asked Jack to consider joining a grief group at his local hospital, and think about therapy to help make the corrections needed to balance himself again. That six months was probably too early to complete a grief response, and that he may have to go back and begin again; this time with more appropriate guidelines to feel, experience his loss, and then move to real grieving. I told him it was a lot to think about but we live in a world in which we seldom teach our children how to mourn us, how to grieve us, and how to live through the experience and hopefully come out stronger than before. Our society really is not  much better at any of this either. I suggested he talk this over with his physician and his minister. We needed all the allies we could collaborate with.

 Finally, I suggested a family meeting to talk about the loss of the father and how they might be able to help each other with mutual grieving and the healing as a family. I  also began a discussion about how obsessive thoughts about his father’s death and Jack’s sense of loss tended to take his emotions and feelings in a downward spiral and create difficulties in concentrating and positive activities of daily living (ADL’s.)

Jack asked for a week to talk with these other people and would then get back to me with his answer.  By the way, Jack returned and this time was ready to work....he struggles, but he says his challenges are worthwhile.

While life frequently seems to be about losing what we love most, it is made easier and more comforting when we can learn how to  honor our ability to grieve and mourn our losses. We are then transformed and can move on, because life is so precious.
This case was referred to me by a family physician who believed that Jack needed more, much more, if he was to return to a life of real meaning and purpose. The outcome is yet unknown, but Jack has taken the beginning steps to a healing sense of grief; and made possible by a physician aware and sensitive to Jack's needs.
Teaching the nuances of this important and difficult work is always to be done. The obstacles can be resolved by investing in clarifying and meeting the needs of our residents to learn in a safe, emotionally responsive, and protected educational environment.

Six Observations When Someone Comes to You to Talk...

Why is that people come to talk to you? What do they want from you? Why now?  Can you give them what they are asking for? Are you the right person for them?
Well, I have been thinking about these questions for a long time and suggest that there at least six observations you should consider before agreeing to be part of these conversations.

1. Is the person coming to see you for advise, recommendations and an action plan?

2. Is the person coming to solicit your thoughts, feelings, beliefs, etc. and they will produce an action plan?

3.  The person is looking for your input about something, but really plans no action or behavioral changes as a result, at least for now?

4. How will engaging in any of these conversations effect your relationship?

5. What feelings will be generated by these conversations in both of you?

6.  What if the person is simply collecting opinions from a variety of sources and you happen to be one of the many?

 Bob came to me and asked my advise about Thomas.  Bob had just been appointed Director of our firm and told me that Thomas had been spreading rumors and telling people that he should have gotten the job and that Bob got it unfairly.

I suggested that Bob invite Thomas in and tell him that any further such actions would be insubordination and he would fire Thomas. Bob listened, asked no questions and left my office.  Shortly after, I heard Thomas going into Bob's office, the door closed and  after five minutes, Thomas emerged and shuffled down the long hallway. Bob reappeared and said he did it. I asked how it went and he said fine and left.  We never spoke of it again because that one time he said we were never to discuss it!  Bob never asked my advice again, ever, even though Thomas reversed course and became a loyal and faithful employee.

Several years later, Bob moved up the corporate ladder and never said goodbye.  When I would see him, he gave me a look like we have a secret and a secret it will stay.  Since the result worked well, what happened? Since Bob refused to share his insights and reflections I will do mine. I believe Bob was very uncomfortable admitting his insecurity and uncertainties. At a time when the stakes were high for him, he was unable to put together a plan to help himself. I believe he felt that regardless of the outcome, he would not put himself into a position that would make him feel the way he did.
In retrospect, I never felt any less regard for him when he asked my advice, for we all can be in that position. I only felt sad that Bob never gave himself the chance to be OK with me. Maybe next time someone comes to me, I will ask, " How do you think our relationship will change as a result of this conversation?" Well, maybe I will not.

Michael is a Very Brave Guy

Michael is a very successful business executive.  He was referred to me by another therapist who is a friend of his and understandably did not want to cross boundary lines with him.  She described the presenting problem as one in which Michael was up for promotion to CEO and the Chairman of the Board  of his company was not very impressed with him.

Michael came to the office looking and sounding bright and charming, but with a sadness streak that burned through his speech and manner. He denied being sad but admitted to great anxiety and a dread of failure if he should not be promoted. He perceived the Chairman as out to show Michael’s weaknesses and that Michael was perceived as potentially bringing a great many problems to the business. Problems that would not be there with another person to be chosen for the position.

I wondered why he wanted the promotion and why was it so important to him. (I had learned long ago that asking seemingly obvious questions frequently led to wonderful diagnostic information and a possible source of a pathway to some sort of healing). Michael became overtly anxious as he described the unfairness of the other man, the persecution he felt, and a litany of accusations against this man that would have filled my note book if I had been taking copious notes.  I had not.  And yet I still did not understand and asked him again.  This time he turned in his chair towards me and threatened to walk out if I was not paying attention. I went to the door and asked the secretary to come into the room.  I asked her if she thought I was the kind of therapist who did not pay attention to his clients. “Oh no,” she said, “The Prof is extremely competent and gives all his clients his full attention.” I said thank you and she left. Michael was speechless and I asked the question again. This time, he began to sob and told me that he had been keeping a secret for all his professional years. That he was always afraid that someone would realize he is incompetent and not worthy of the success he had enjoyed.  That the Chairman was absolutely correct and Michael was not fit to be promoted.

 A waterfall of pain and suffering and anxiety began to pour forth from him. Sometimes, it is best to let people express their feelings fully, and I thought this was the time. Michael then began quietly sobbing and said he was ashamed to reveal such emotions, such painful and sad emotions. I said nothing, giving him a chance to express even more emotion. . He repeated his words and then I shared my willingness to be there for him if he wanted to explore the why, the how, the history, and some positive skills and insights to replace his giving up of the great sadness and confusion about himself as a person.

Sometimes, but not always, a therapist will keep some rein on the expression of such feelings with a client.  My instinct said that he would be OK and that his ego would not deteriorate by these expressions.  At other times, I will sense a breakdown of reality testing and ego strength and offer a tissue which is a clue for the client to bring the expression to a close, for now. Whether I let them continue or offer a tissue is always explained to the client later in terms of why I was doing what I am doing.  It is not about my being uncomfortable with their pain or that what they are expressing is alien and inappropriate. No one wants to feel exposed and vulnerable, so I gauge my response on where they are emotionally and psychologically during these floods of affect and feelings. Of course, other therapists may deal with similar situations differently, and that is what makes each therapist unique and may appeal to different types of clients.

It was almost time to conclude the session and I offered Michael a plan to consider. Sometimes, I negotiate a plan and sometimes not. Not this time. I offered two more session with him alone, for there was much I did not yet understand, one session with Michael and his wife, Millie, one session with Millie and their four almost adult children, and a final session with Michael in which I would hope to present a treatment plan with goals and objectives and a time frame for us. Michael agreed to this plan and then asked for my fees. After I told him, he laughed and called it “pocket change.” “I spend more for dinner and a bottle of wine.” Hum”, I said, “many folks would be in a financial disadvantage and ask for a discount.” He brushed aside my comment and extended his hand and agreed again to the pre-therapy and diagnostic phase of this work. Interesting that he agreed twice, which seem to imply to me that he was relieved with the plan in that someone had gone beyond the intense emotionality of all this and  had taken the lead for a while: an experience he had not had in a long time.

What was behind this sense of failure and fear of being “found out,” how did he achieve so much already with these secrets behind his image, how much of this affected his role as partner and parent, what will he want from me, can I be of real therapeutic help to him? Questions like this filled my mind as I straightened the office and awaited my next client. It was early in the evening and I had a full schedule of clients ahead of me.

Therapy is tough work; therapy is for courageous and brave people who are willing to make that special step into the unknown. To make a commitment to reveal their most intimate experiences and feelings and to partner and collaborate with a therapist.  We have skills and abilities and a desire for those suffering and in pain to find a reduction in suffering and pain while seeking new pathways to being and becoming. It is also rigorous work for us as therapists and tests our deepest intention and purpose as healers
.

I wonder how this will turn out…I am optimistic for Michael. He has taken that first anxious step. One can seldom appreciate how hard it is to appear at our door for the first time. I believe he is a brave guy.

What to be Thinking About in a Family Meeting with an Elder.

  Carolyn called several months ago. She heard of me through her realtor, in that the two of us have collaborated on a number of home sales that involved elders and their adult children.  Each of the situations was an emotional mess and so was this one. Carolyn and her two sibs had “pushed” their widowed father to sell his condo and sign up for a retirement home.  Now, he is refusing to sign the papers for the sale, pack his “stuff” and move.  He is essentially doing nothing in their view...but he was doing something.  Just about what I would have predicted.

I told Carolyn to call for a family meeting at the father’s condo, but not to expect too much.  I showed up and rang the bell.  Charles, the father, did not answer the door.  Rather he was in the kitchen reading the New York Times. Bob, one of the other siblings had let me in and announced he had had it with the “old man” and did not want to stay. George, the oldest was drinking a glass of wine and looked very uncomfortable.
 I convened the family and suggested that Charles tell the family of his disappointments in them. I chose that term for special reasons. Did he let them have it and Bob started inching for the door- “no”, I said, “you all need to hear this”. And then each adult-child explained their concerns about Charles’ situation: poor housekeeping, no food in the fridge, looking disheveled, and not caring for himself, and, never satisfied for anything they did for him. Charles used both denial and rationalization in response.  “These are not problems and I can handle them anyway”. He was equally enraged they invited my friend the relator over and convinced him into thinking that Charles was ready to sell and move on.  He was not! In fact, Charles prided himself with his independence and had lots of reasons to explain his behavior.  They threw in his forgetfulness and he replied that what he forgot was not worth remembering.

I sensed there was enough blame, shame, anger, disappointment, and family rage to go around and decided to offer a plan.  That Charles not move, not sell, get a housekeeper on a weekly basis, a cook who would  figure out what he needs in the kitchen and shop for him, make an appointment with a geriatric center for an evaluation, and we would convene in a month. Charles was lucky to have the funds to pay for all this home based comforts, but each situation is different and this one was affordable.

The children were to stay away, let tempers cool, and I would make weekly home visits with Charles to look at, assess, and do some reasonable planning with him, not for them.  He refused and then changed his mind. He said I might be saner than they are but I could not guarantee much; but what we could do was a lot better than the chaos they were in.

You know the conclusion already. Charles balked and gave me lots of grief but indeed found a service in his community that provided all I asked for.  He had an assessment and came out of it in good health but saddened by so many losses in his life he never seemed to get over one and he had another. There seemed to be no respite for him from losses. No grieving. no lamenting, and no time for transformation.
Charles and I had lunch every week at his place ( cooked by the terrific chef) and we talked, really talked, abut all his losses and wishes yet unfulfilled. He was angry and unhappy and sad.  He did not want to go live near old folks, because he was only 81 and did not want to catch “old people” by being near them.

No more moves or changes for Charles…for now. Let him really settle in and try to find some balance in his life, learn how to grieve his losses, seek to find some purpose in his life, and figure out how to work more effectively with his children. I insisted he get back on schedule with his primary care physician and retain all the folks he had hired. They are his support to keep him out of the retirement home. I do hope this works for him and for his children.  If the pressure is off of them, maybe they can get back at pursuing their personal goals and wishes, and let Charles struggle with his.  The struggle is worth it..

In retrospect, we know that conversations like the ones they initially had as a family are difficult to do well; they follow major losses and are not existential on their own. Everyone seems to have an opinion as to what is best, everyone has a major stake in the outcome, and no one feels very comfortable doing them.  We seldom have the insight or skills or even to be aware of the big picture to do them well. But we do them anyway and lament how poorly they become.  Families can be splintered and dysfunctional in meeting the needs of any of its members.

 I can’t promise a great outcome every time, but convening the family with a guide or mentor skilled in the process of family meetings can be very helpful. The final outcome for Charles is unknown, but he is still the father; just needed a companion for lunch on a weekly basis.