What Do Our Elders Fear?

What do our elders fear?  A fictional Tom Booker in “Horse Whisperer” replied “Getting old and getting useless.” But we know there is more.  Much more.  Professor Alan S. Wolkenstein has spent the last thirty years treating and mentoring elders with physical and emotional losses, written and published about them, researched, reflected, and thought with them.

 As we age, we are prone to lose: loss of connections with loved ones, family, friends, important social and cultural roles, changes in health status, and especially a loss of continuity of beliefs and values. Such loses create sadness, grieving, and lamentations that  affect how elders  make their  way in the world, their expectations, their beliefs about spirituality and sometimes even about God. So many that I have worked with suffer from such deep emotional pain that fulfilling their goals and dreams seems to be for them no longer possible.  Assessing these loss-grieving and eventual journeys to eventual transformation through newly designed “Quality of Life” parameters can offer us an in-depth lens to more meaningfully understand them, more wisely engage with them, and more keenly impact our clinical and direct services with them.

Elders need people they can rely on, trust, and believe in. They need professional caregivers they can rely on, trust, and believe in. How can we best train ourselves and our learners and students to be such people for them? Since our work with geriatric populations is difficult and very important, let us continue to seek the knowledge, skills, and intention to be of service to those entrusted to our care.

Come along as we explore the journey of elders to better understand them and enhance their efforts to cope with their emotional challenges and physical obstacles.  A society is oftentimes measured by how it treats its very young and very old; the challenge to care for them and care for ourselves is a worthy challenge.

Taking a Look at the "Sandwich Generation"

A significant component of any comprehensive and holistic health care assessment includes a Quality of Life evaluation of patients, especially among our elderly: how they attempt to cope and adapt with the tasks of their age, regardless of illness, inhibited activities of daily living (ADL's), their ongoing physical and emotional losses, grief experiences and lamentations, and finally,their ultimate transformation as elders.


The Family Life Cycle, consisting of anticipated stages of family life, tasks required by the family and its members to complete, and skills needed to accomplish these goals is also available to facilitate the evaluation process.²   

In other words, families move through predictable stages by utilizing specific skills to accomplish appropriate tasks. By not having the necessary coping and adapting skills, families may be forced to move ahead regardless of whether they completed their tasks or not. Many of these families become problematic by not being able to really do well in any subsequent stage(s), and thereby become deficient in meeting individual family member needs, goals, and aspirations. Within some families, they become “stuck” at a particular stage because of their inability to move ahead and individuals in the family are hampered in their efforts. In other words, each person’s needs within the family may be enhanced or inhibited by their family’s successes or limitations in meeting their family’s goals and objectives.  In the psychological sciences, we refer to these phenomena as independent and interdependent variables.

We had defined five initial stages of the family. Subsequent evaluation revealed that there may be more than five, but unlikely be less than five stages. Variations that alter stages and their tasks can include: severe family problems, permanent marital separation, divorce, widowhood, remarriage/blended families, and single parent-hood, late in life family development, alternative lifestyles, traumatic social/cultural events, war, depression, and natural disasters.

The stage that includes the sandwich generation is Stage 3, or called “The Transitional Years                                  (Children becoming non-dependent to leaving home).

      Tasks: Launching children

                  Reevaluation of roles: evolution from parents back to partners as                

                  their primary role

                  Career changes

                  Bodily changes
                  Changes in relationship to their aging parents: from children to degrees of care                             giving, evaluating parents for quality of life, safety, and future security

                                                     SANDWICH GENERATION 

The sandwich generation is an important facet of this stage of the family; for the children  are hopefully becoming (in many ways) independent while the elder-parents are becoming more dependent. This is potentially a time of very emotional and anxiety producing experiences. (Difficulties here spill over into other important areas and have a negative impact on achieving family tasks and on overall family stability). Not only for the elders themselves, but for their adult-children, who describe feelings of being "caught" by the differing and opposite needs of their parent(s) and their own children. They can perceive themselves as being emotionally insecure and sometimes even greatly inadequate in caring for either their parent(s) or their children: not only because of the difference in needs, but in their real or imagined lack of skills and experience-based wisdom to be effective. Many tell me that neither their children nor their parents have much faith in their abilities or even in them. 

The last stage in the family life cycle we have named "Later Years: Retirement to Death
Tasks: Acceptance of change
            Bodily changes
            Coping with probable loss of partner
            Deal with realities of living arrangements
            Importance of intergenerational and social contacts
            Maintaining Integrity of Self
            Maintaining a life of meaning and purpose 

(It is understandable that conflicts and turmoil can envelop a family when confronted with such different and varied stages, especially when they are happening simultaneously.. Many families simply lack the skills and knowledge to enhance these stages. However, many families get through them with a minimum of conflict and with much success and therefore deeply enjoy the fruits of these stages.)  

            
           

                                                               THE BIG TALK

So many adult-children have to focus on  uncomfortable discussions, or “The Big Talk”, of serious challenges, such as a probable need for living arrangement changes for their parent(s).
Let us focus on this particular challenge because it exemplifies many such issues confronting a family. This need for living arrangement changes generally follows a number of potential-loss experiences by the parent(s). Loss of a partner, significant changes in health status, degrees of declining mobility, decline in evaluating critical issues, loss of income, changes in social status, financial setbacks, and loss of important family and friends due to death or moving away, are some of their losses of great significance. They can oftentimes respond with deep grieving to these losses, especially if there is no respite between them and little chance to try to re-balance their lives and cope with both their losses and their grieving.

 This may be the first time adult-children witness their parent(s) becoming afraid, anxious, and emotionally unsure of their own future. Elder-parents are facing a new world for themselves, one of different rules and expectations. It is also a world in which their dependence on their adult-children intensifies, and the adult-children may also share the same insecurity and anxiety. We know they may share feelings and emotions of anger, great sadness, and fear. They may soon come to realize that their lives will never be quite the same again, and suddenly, the future for all in the family is the “potential unknown”³.

The process of selling a family home, with its myriad of memories and sense of earlier family stability, and then moving to an assisted living facility or adult community is not an existential experience in itself. It oftentimes follows a period of major losses by parent(s) and emotional grieving that can tax both the elder parent(s) coping and adapting skills and the resiliency of their adult-children.

While Quality of Life is of great importance in all stages of the Family Life Cycle, it has special significance (and requires special attention) in the stage that also illuminates the particulars of the sandwich generation. We know that it affects adult-children, their families, and their elder-parent(s). We also believe that inter-generational strength can come from its greatest struggles: if the family gives itself what it needs to safely navigate its difficulties, and uses the wisdom gained from its experiences.

Ernest Hemingway once said “The world breaks everyone and afterward many are strong in the broken places.” ⁴ While I believe some of us, but not all, are so negatively affected by our experiences, I also believe that the most difficult experiences can make us stronger than we were before. Sometimes, but not always, we need assistance from guides and mentors. Both elder-parents and their adult-children can benefit from consultation with an experienced Elder Family Therapist who has already traveled these same paths and can cautiously guide a family through these difficult times.

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Losses in elder continuity (the home and its sense of belonging), and losses in elder connections (important persons in their lives) impacts negatively on all other parameters of Quality of Life among our elders.⁵  It is not surprising that family conversations about the possibility of changing residences invoke such high degrees of emotionality for all of the family...

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1.Wolkenstein, Alan S., Lawrence, Steven L., and Butler, Dennis J. Teaching Family: The Family Medicine Chart Review. Family Systems Medicine. 3(6), 1985, 171-178.
2. Wolkenstein, A. and Butler, D. Quality of Life Among the Elderly: Self Perspectives of Some Healthy Elderly. Gerontology and Geriatrics Education. 1992, 12, 59-68.
3. Small, Jeffrey. The Breath of God. West Hills Press. New York. 2011.

4.  4. Hemingway, Ernest. A Farewell to Arms. Scribner’s.New York, 1929.

5.     5.   Wolkenstein, M. Evan. A Quality of Life Wheel: A Tool for Reading, Understanding, and Living. Ravsak. Summer,2012.

See also:

Wolkenstein, A., Wolkenstein, ME., and Simona, K. The Card: An Educators Encounter with Cancer. Family Medicine. 2004. 36(2), 137-140.

Wolkenstein, Alan S. and Wolkenstein, M. Evan. Signposts of the Cancer Journey. Coping with Cancer Magazine. 2009. January-February. 

Wolkenstein, Alan S. An Odyssey Within Prostate Cancer; For Men and Their Partners. Ortho-Centacour Biotech-Caregiver Section. www. myprostatecancerroadmap.com

Professor Alan S. Wolkenstein, MSW,  is trained in both Sociology and Psychiatric Social Work. He is retired Clinical Professor of Family Medicine at the University of Wisconsin School of Medicine and Public Health. He last served as Professor of the Behavior Sciences Consultation Service for Concordia University of Wisconsin, where his students and faculty knew him as Prof.

Alan is a veteran of 35 years of teaching, education, and research in graduate medical education and is nationally recognized as an expert in the education of physicians and health care professionals in human behavior and family dynamics. He also had a private practice in which he worked with individuals and families struggling with health issues, difficult relationships, and elders attempting to find balance and focus in a world that is often perceived as harsh, unpredictable, and unforgiving.

 Having lived with and through cancer and being a senior himself, gives Prof a personal perspective to work with individual and families negotiating their way through life's multiple experiences and challenges.