Old man going

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To some extent, the deterioration caused by age is inevitable – we simply have little a priori indication of how fast it will proceed or how much impact it will have. There is, after all, no question as to the final outcome, merely a degree of uncertainty as to its form and timing. One outstanding problem is that the process is non-linear: from a relatively early age, various biological processes begin to slow down or cease (and others start) but the impact may not be felt for many years. The key factor in determining the impact is how we ourselves perceive and respond to the process as a whole: we are poorly equipped to notice gradual change which, as a result, tends to go un-noticed until a significant event makes it obvious to us. Suddenly we become aware that we are less physically able, less mentally agile and the impact of this realization can be dramatic: few of us succeed in ignoring it and, for many, it can be a profoundly upsetting occasion. Much is made of the need to accept that which cannot be changed and to do so with good grace. Equally, however, we talk about “growing old disgracefully” and, to a degree, this rejection of the concept of ageing confers some ownership of and control over the process or at least our perception of it. We can accept the inevitable with dignity or we can lash out against it and refuse to accept what will inescapably happen, at least until much later in the process.

The ageing process is not elegant – rather it leads inexorably to a loss of elegance. Those qualities which once lent dignity, physical attractiveness and an air of competence and confidence are slowly but surely diminished as physical and cognitive functions become less efficient. The realization that this process is under way can also have an emotional impact whereby our deterioration leads to a sense of impotence in the face of a process that impersonally depersonalizes us by slow degrees. We can, to an extent, influence some aspects of these processes (albeit in minor ways): exercise, diet and so forth may have some useful impact in certain individuals but even here, digestive problems and the symptoms of degenerative conditions such as arthritis may impact upon how much control one can actually exert over the process as a whole.

However, there is also another and more extreme response: fear. This fear is an irrational response to the breaking down of (especially) physical systems and can have a paralyzing impact upon our ability to function normally. Most people have suffered from a panic attack at some – usually stressful – time of their lives: such attacks are almost never fatal and recovery is usually quick and complete. However, during the attack itself, we cease to be able to function at any useful level beyond the “fight or flight” reflex. Imagine then, finding oneself in a more-or-less continuous state of panic from within which can be glimpsed moments of normality. This can be one (admittedly extreme) response to the realization that one has lost control and is growing old. As with most bodily problems, there are good days and bad days but the overall impact is sometimes to create a beleagured figure, stripped of a sense of identity and reminiscent of Shakespeare’s Lear crying out on the “blasted heath”: the world spins catastrophically around us and nothing is within our control any more – not, of course, that any such control ever really existed anyway.

A process that we are all aware of from an early age and to which we are all unavoidably committed seems, by itself, an insufficient reason for such an extreme reaction. It seems to me that the extremity of reaction is unlikely to come from one’s normal daily thought processes which know of, and to some extent, must have already accepted and/or incorporated the idea of growing old. I have sometimes wondered whence comes this more extreme fear and have postulated that, where there is no obvious cause (such as, for example, serious illness or close bereavement), the source may be that contentious area of the psyche that has been called the unconscious. Under normal circumstances, we appear to have a psychic immune system that protects us from the breakthrough of this elemental medium and its intrusion into our everyday lives. It would be wrong to suggest that fear is the only content of the unconscious but it is perhaps the most undesirable and hence the most (usually) supressed by our defences. However, one cannot help but speculate that this immune system, in common with our organic one, becomes less effective with age and thereby renders us more vulnerable to infection by fearful ideas and unwanted emotions every bit as much as by bacteria or viruses. We see our bodies and minds begin the process of degeneration and we conclude, not unreasonably, that all our systems are making a headlong dash towards entropy, leaving behind a partial vacuum. Nature, we are told, abhors a vacuum so it is into this vacancy that our increasingly permeable psychic immune system admits the pathogens of fear and, once infected, the infestation is hard to eradicate.

Taking the infection analogy further may allow us to consider possible models for treatment. Traditionally, one is expected simply to accept the process (although some allowances are made for negative responses such crankiness, forgetfulness and so forth). This may work well enough where the infestation is (perceived as being) minor: we shrug wryly and write an outbreak off as “a senior moment”. However, a more virulent infection may demand therapeutic intervention. The obvious solution to excesses of fear and anxiety is sedation, whether chemically or psychologically induced. By such means, we no longer experience the symptoms to an unacceptable extent and the impact of the process is ameliorated. Unfortunately, the process is not stopped or reversed by such symptomatic treatment and when “medication” is withdrawn, symptoms may reappear. Unfortunately, relief comes at a price: the deadening of cognition and experience, the literally stunning impact of the chemical cosh by which we are simply denied the ability to feel anything at all, be it good or bad. Worse news still is that the treatment may have masked a further deterioration: taking analgesics may mean that we no longer experience pain but they usually have little or no impact upon the disease that causes it and can mask unwanted changes.

This is bad news for the sufferer: damned if one does and equally damned if one does not. Clearly, there is a need for some form of treatment that brings relief but, equally, this relief must go beyond the symptomatic: some kind of change must be effected that either allows us to cope with the fear or, perhaps better, eradicates it altogether. If the source of elemental fear is external to our conscious minds, it seems unlikely that we can hope to attack and weaken it at source. If we accept the existence of a collective unconscious, this will contain concepts that are and have been common to billions of people over thousands of years and must be regarded as a powerful force indeed – one against which the individual cannot realistically hope to prevail. So can we force the genie back into the bottle and, if so, how?

If one cannot change or stop the stimulus, then perhaps one can change the response. A hayfever sufferer cannot hope to eradicate pollen (and, anyway, think of the awful consequences if such a thing were possible) but can take medication that does one of two things: either it renders the patient less sensitive or, alternatively, simply blocks the symptomatic responses. There is a case for caution here: one can effect a change in the patient’s susceptibility only by changing the patient and, equally, as I have argued above, symptomatic treatment may do no more than throw a concealing blanket over a serious condition.

In the treatment of psychological disorders, the obvious similes of these different approaches are behavioural therapies and psychotropic medication. Both have shown themselves to be of use but they work in profoundly different ways and are based upon entirely different concepts of how our brains operate. On one hand, we can take a reductionist view that our conscious experience is an emergent manifestation of complex electrochemical processes: from this it follows that we can administer therapies based upon electrical and chemical intervention with the reasonable expectation that they will have an impact. As we learn more about these processes, we may hope to improve the precision of our interventions. Unfortunately, our ability to impact upon these processes exceeds that of our comprehension of them: drug therapies may be effective in some respects but are essentially a rather simplistic way of influencing thought: the best of current knowledge cannot make a direct and causal connection between the details of specific mental activities and the individual chemical reactions that create them. The reductionist model is, I believe, of too low a resolution to offer us a clear image of mental processes and thereby provide a basis for therapeutic intervention.

On the other hand, I suggest that the best that we can probably do at present is to adopt a model whereby our emotional state is considered as a matrix within which cognition occurs and by which it is coloured. Through the use of chemistry, we can alter the composition of this matrix in such a way as to favour certain cognitive activities and outcomes over others. By way of analogy, we might consider the emotional matrix as a body of water in which fish (representing our thoughts) can live. If we change the water from fresh to salt, we would expect to find that different fish thrive while others die out. If our minds were as simple as this, drug therapy would be ideal: a chemically induced change in our psychic environment could be set up to favour the type of thinking that we wished to encourage and hence, eliminate that which is unwanted. Once again, this is a simplistic model but one that offers at least a functional and comprehensible modality.

On one level, the process of cognitive behavioural therapy is not functionally dissimilar: certain types of thought processes are encouraged and others discouraged. The mechanism differs but the desired therapeutic outcomes remain broadly the same. Behavioural science is well established and understood at a number of levels from Pavlov’s dogs and Skinner’s pigeons to more sophisticated forms of indoctrination such as “brainwashing”. Indoctrination is a strongly pejorative word to many and its use does a disservice to the motives of sincere therapists who have used behavioural techniques in the genuine interests of their patients. It is a literally valid term, nonetheless, since the therapist sets out to change the ways in which the patient responds to a given stimulus from the unwanted responses of neurosis to the more desirable ones of “normality”. The idea is based upon deliberate reassessment of established inappropriate responses such that the instinctive reaction to a given stimulus changes to a new and different one. By using this technique to address a number of stimulus/response sets, the aim is to build up an overall scenario of changed reactions. The patient’s world is not changed but his/her instinctive responses to it are modified in what is hopefully a positive direction for the patient’s psyche as a whole.

Both approaches work to some extent and bring benefit to many. They work, quite rightly, with what is susceptible to change and that is either the context in which cognition occurs or it’s predisposition to certain outcomes. What they do not – indeed cannot – do is to alter the world itself. If I am depressed because I think the world is a dreadful place, I am invited to think that it is not so bad after all and that the dreadfulness is actually a matter of my defective perception. The cynic may consider this process to be little more than an invitation to internal dishonesty and denial that may simply store up problems for a later time.

These therapies are therefore largely effective as long as we take the view that our psychological problems are internal and self-generated and that they can be treated by tinkering with the generative process. If, however, we believe that, to some extent at least, they may be responses to stimuli from outside our consciousness, it is clear that they can only be of limited usefulness and here we return to the idea that unreasoned fear (and perhaps other neuroses) are symptomatic of a form of psychic incontinence whereby the “membrane of self” that separates one individual from another is unduly permeable. The robust wall of identity that surrounds and supports the psyche of the young and strong can be weakened by inter alia, age or illness and this may lead to a loss of a clear sense of individual self or position in relation to others. We may, with some risk, take this analogy further and return to the idea that unreasoned fear (or other such emotion) is a collectively held phenomenon that is normally held back by our personal identity for as long as it is sufficiently robust to do so: where this robustness is compromised, fear may begin to seep in and further undermine its ability to function as before.

The ageing process as manifested in contemporary society may tend, in some subjects, to lead to a loss of identity and thereby have the potential to bring about just such a compromise of individuality. The high-flying executive or dedicated teacher retires to become what exactly? The question “What do you do?” (i.e. what – and hence who – are you?) is not answered meaningfully by the response “Oh I’m retired ….. I used to be ….. “. The answer may not be meaningful in a real sense but it is certainly hugely significant. In Western capitalist society, we tend to be defined not by who we are but by what we do and once this latter property loses the definition that work gives it, our public identity is eroded. It can be argued that who we are is defined by our individual creative achievements be they made manifest in business, the arts and sciences or any other form of meaningful expression. In a real sense, what we are is a product of what we create. We are the sum of the ideas that we express and when the process of expression stops, creativity may wither and hence the integrity of personal identity may be compromised. Without this surety, we may become increasingly vulnerable to the kind of external influences mentioned earlier: we are thereby made less certain, less robust and more susceptible to the compromising of our psychic immune system. A vicious circle evolves.

Are such compromises inevitable and can they be resisted? It would seem that the majority of individuals are, if not immune, not overly affected by these problems but there remains a rump of individuals who find themselves in straits – sometimes dire – for reasons that they cannot comprehend. Sadly, for them, clinical psychology and psychiatry-as-it-is-practised have little to offer since their practitioners (quite reasonably) base themselves upon problems that are readily susceptible to solution. They do this with all good intention by devising functional and hence potentially treatable models of the psyche that work (more or less) for the majority of patients. A successful practitioner is measured, not by his comprehension of difficult cases but by his cure and relapse rate and, increasingly, by his ability to meet financial targets. A model that is of limited applicability is not a useful one in this scenario.

Practitioners have legitimate professional and personal aspirations too that are deserving of respect and, taking these factors together, it may be that, for a significant number of patients, there is no sanctuary or other help to be found within the confines of conventional practice. The argument for alternatives that follows from this is clearly one that edges nervously towards what the current professional wisdom would regard as mysticism or pseudoscience and, in so doing we run the risk of encountering hopeless quackery. The patient deserves better and this implies the need for a re-appraisal of how we approach the whole issue of our responses to psychological disorder: we need to ask whether the models of the psyche upon which current therapeutic practice is based are complete and universally viable and, if they are not, we must be prepared to reconsider our approach in the light not of what we know but of what we apparently do not know.

Am I making a case for the tortuous abstractions and indulgences of psychoanalysis? I think not. The idea that our psyche may not be entirely our own is difficult to accept on an instinctual basis without resort to such complexities as Jungian archetypes and their significance. The universality of such components is also far from being beyond question. It seems somehow illogical to postulate the impact of an archetype upon someone who has no awareness, let alone comprehension of it. This is not, however, to adopt an elitist perspective but rather to raise a contextually important question: is our individual experience unique or is it susceptible to categorization and, if so, is it reasonable that the categories should be based upon classical mythology? In the experience of the majority, this is clearly not so and we may reasonably assume (with some pomposity) that only classical scholars are susceptible to classically expressed neuroses.

What does seem to me to emerge, however, is the idea that the contents of the psyche amount to more than the sum total of the conscious self: there is more inside of me than is purely me – there is other content that is not part of my self alone but is of some other provenance. This might be the elusive collective unconscious or it might be something altogether different: what seems clear to me is that I am more than the sum of my parts. I am the sum of parts that are mine and other parts that I do not own or control: like my genetic inheritance, they are part of me yet are not me per se.

Current practice in the UK tends to focus upon cognitive and chemical therapies since these produce relatively direct results in a substantial proportion of cases: they are successful practices. However, they do not work effectively for everyone since they are based upon relatively simple (and, in my opinion, incomplete) models. It is easy, indeed tempting, to insist that these models are not only valid but that they are the only correct ones and talk of the unconscious is so much mystical mumbo-jumbo promulgated by neurotic middle class Europeans. There may be some truth in this but the experience of a substantial number of people tends to suggest that there is a degree of substance to some theories of the unconscious and that it can itself have a significant impact upon the functioning of their psyches.

This is a dangerous contention since conservative approaches may wish to dismiss such ideas as a narcissistic neurosis in themselves. It follows that problems that do emerge from or are affected by the unconscious are clearly going to be difficult to treat since, by conventional reductionist wisdom, they do not exist. What most concerns me is that, in a busy world led by budgets and targets to be met, contemporary therapeutic practice has no capacity for these issues and that it therefore necessarily bases itself upon a pragmatic but overly simplistic model of the psyche. In so doing, it makes it impossible to offer a meaningful response to those who find themselves out in darkest night upon the blasted heath.