Dr.phil. Elisabeth Lukas ist Klinische Psychologin und Psychotherapeutin; seit 1986 leitet Sie das "Süddeutsche Institut für Logotherapie GmbH" in Fürstenfeldbruck bei München.
Adresse: Süddeutsches Institut für Logotherapie, Geschwister-Scholl-Platz 8, D-8080 Fürstenfeldbruck.
What is behind Depression among the Elderly?
Logotherapy and the Treatment of Geriatric Depression
Claudio Garcia Pintos
Depression is certainly one of the most important and common disorders that old people may suffer from. It is also a problem therapists must strive to solve. Psychotropic medications cannot be considered the only therapeutic strategy, and traditional psychotherapy does not provide satisfactory results.
The author distinguishes depressive reactions, depressive syndrome, and depressive disease as the three stages of depression in the elderly, attempting to clarify the differences. Logotherapy is considered an effective and affective resource to respond to the "unheard cry for meaning" which is behind geriatric depression.
Die Depression ist zweifellos eines der häufigsten Leiden, denen alte Menschen ausgesetzt sind. Sie ist aber auch eines der ungelösten Probleme, die der Therapeut zu lösen hat. Psychopharmaka können keinesfalls als einzige therapeutische Strategie betrachtet werden; die traditionelle Psychotherapie andererseits hat keine befriedigenden Ergebnissse bei der Behandlung der Altersdepression aufzuweisen.
Der Autor unterscheidet drei Stadien der Altersdepression, nämlich die depressive Reaktion, das depressive Syndrom und die depressive Erkrankung. Die Unterschiede zwischen diesen drei Stadien werden im dargelegt. Die Logotherapie erweist sich als wertvolle Hilfe bei dem Versuch, eine Antwort auf die "Frage nach dem Sinn" zu finden, die in Wahrheit hinter der Altersdepression steckt.
As stated in an earlier publication (Garcia Pintos 1988), I consider that sometimes geriatric depression is generated by a feeling of meaninglessness, a crisis of identity vacuum. I would like to refer to the exogenous-noogenous depressions as a very common disease in old age. Contrary to common belief, I suggest we should stop assuming that depression in old age is inevitable and that nothing can be done to improve this situation except prescribing medicine. Advances in psychogerontology have shown us that old people possess enough spiritual potentials to face and get through the problems and discouragements of this evolutional crisis, putting aside the belief "ageing = depression".
Now, what can we do for depressed aged? Statistics show us that depression is one of the most common diseases that affect old age, but are we ready to give valid and efficient answers to this fact? This is a very important question as, if we are able to give proper answers to this problem of ageing, we would help to make ageing a more satisfactory stage in life. Let us analyze the situation:
First of all I contend that we are really able to give valid and efficient answers to depressed old people. The first answer should be to give a precise and correct diagnosis; even though this seems to be obvious, we should be very careful at this stage. Generally, in the presence of a depressive symptom, we tend to prescribe drugs, psychotropics which control the anguish of the patient. Although this therapy is successful in the case of organic depressions, it is useless in controlling exogenous-noogenous ones. That is why, sometimes for a lack of a definite diagnosis, some serious depressions turn chronic as time passes, and medication only controls the external manifestations of the depression (for example, insomnia disappears).
Now, considering briefly the possible outcomes of the differential diagnosis, we will see that in each case it will be appropriate to prescribe a particular therapy. Thus we conclude:
1.1 Endogenous Depression:
a) If it accompanies a chronic illness, we should prescribe the appropriate therapy for the disease, at the same time controlling the evolution of an organic depression by psychotropics or antidepressive drugs.
b) In the presence of a depression which is the symptom of a psychopathology, the treatment should be identical to (A).
c) In the case of a depressive personality that has suffered from a depression (manifest or latent) all his or her life, we should prescribe a therapeutic process based on psychotropics, because the degree of chronicity of the depression limits the psychotherapeutic possibilities. Nevertheless a supporting therapy could be of great advantage.
1.2 Exogenous-noogenous Depression:
Both the reactive and the endoreactive forms are very common in ageing, even if they are not diagnosed as such. This is the case with those depressions which are activated by factors of various origins that break the emotional balance of aged people.
Those depressors may be psychophysical (e.g. natural senile deterioration), social or environmental (e.g. retirement), existential (situations that personally affect the individual, e.g. widowhood), and spiritual (to think that life has no meaning).
In most of these cases, we identify noogenous depressions revealing an existential frustration and a feeling of insatisfaction in the individual concerning his life. The depression of the aged is a result of the frustration of the natural human interest to find a meaning in life; it is a kind of desperation or existential-spiritual anguish, resulting from the tension between the conscience of what has already been achieved and the perception of what has not been achieved yet and is believed impossible to accomplish any more.
In these specific cases, I consider important the psychotherapeutic implementation of techniques that could conduct or lead the person out of this existential crisis, in order to fulfill a natural human task - to find appealing meanings in and for his life. We should bear in mind that as psychotherapists we are inserted in a bipolar field: on the one hand there is a human being looking for an appealing and satisfying meaning for his or her existence in a new period of life, and, on the other hand, a meaning that is waiting to be fulfilled. Those conductive techniques correspond with the logotherapeutic approach and are called REMINISCENCE (or "Life-Review Therapy") and APPEAL techniques.
REMINISCENCE has already been thoroughly studied (Frankl 1979, Merriam, Kahana, McMahon, Rhudick, Coleman, Havighurst, and others). It has proved to be successful in the majority of cases in order to promote an affective and effective adaptation to ageing, a reduction of a feeling of loneliness and isolation, an increase of life-satisfaction and self-esteem, and an extension of the cognitive function, that is, it operates as an excellent defense strategy that enables personal reorganisation in the ageing crisis.
The programs that put into practice this reminiscence technique have been successful in the treatment of geriatric depressions. Reminiscence may help old people to find a meaning to their own lives.
By means of the APPEAL technique, we appeal to the healthy remainder of the depressed elderly person so that these healthy potentials could help the patient find out of the depression he is immersed in. This technique tries to turn the patient into a therapeutic instrument against his own depression, leading him directively to exercise the functions and assume the responsibilities and tasks that he can manage even while being depressed. We must realize that the elderly, in spite of his emotional attitude, has several resources which are not emotionally involved with his state of mind, resources which are not depressed. He can walk or practice sports, knit or take part in social activities, do his shopping, and the like. We must urge him to put into practice these tasks, even if he does not feel like doing them, taking this appeal as a professional prescription. If we prescribed him to take medicine he would do so even being depressed; our appeal to those undepressed resources must be considered in the same therapeutic way.
Once we have activated these resources through simple and daily activities like the ones mentioned above, we have already made a first step towards success: the elder has realized that he can manage to get out of his depression by means of his own potentials.
We have thus opened a new effective road along which the elder will discover that his life has not finished just because of his age, and thet he can be interested in developing new projects that may turn his last years into meaningful ones. When men have to face finitude, the best we can do is help them find an aim in their lives. Our role as psychotherapists will be to mediate between those undepressed resources on the one hand, and the achievement of a hopeful and satisfactory ageing on the other hand, appealing for this objective to the universal human tendency towards a meaningful existence.
As Viktor Frankl points out, when architects want to underpin an arch that is falling down, they increase the burden on it so that its parts join together more firmly. In the same way, if therapists want to fortify the mental health of their patients they must not be afraid of increasing the load and guide them towards a meaningful life.
The emotional collapse that is reflected in a serious depressive state can be repaired when from the recognition of the self-fulfillment possibilities the elder starts looking for meaningful and appealing purposes in his life. That is how he can recognize his life, recovering enough strength and freedom to get out of the depressive pit.
The most immediate consequence of this process which responds to the appeal stimulus is the appearance of a new attitude towards the own being-in-the-world. When reality becomes unchangeable - and being 60, 70 or 80 years old is irreversible - we can only modify our attitude in order to rescue ourselves from the bitterness of feeling old. We can develop a wise attitude, recognizing the limits and misfortunes of ageing but living them with dignity and overcoming the conditionings they present.
To sum up, the logotherapeutic appeal technique is an excellent tool in the treatment of the geriatric depression. It can make the psychogerontologist's dream of promoting a meaningful and lively ageing come true. We must rely on the inner human resources and try to get a therapeutic alliance with those forces by appealing to them in an effective way.
The discovery of a meaningful goal in and for the patients' lives is the most important step in the appeal technique in order to guide them to the resolution of the existential crisis of facing old age as an apparently meaningless stage. It will let us obtain excellent results in the treatment of geriatric depressions mainly for three reasons:
1) they (reminiscence + appeal technique) promote the recognition of those circumstances that used to give meaning to the elder's own life.
2) they promote the recognition of personal resources and life potentials, strengthening the self-esteem.
3) they originate an active and productive search for new meanings and appealing goals, encouraging man to assume the wonderful task of living.
2. An Example: Ada's Case
The consultation started after an attempt to commit suicide by taking pills. Her intention had been well announced and had just been put into action. I found Ada suffering from a severe confusional state with a remarkable disorientation regarding time/space and the recognition of people, signs of distress, restlessness, sleep disturbances and other symptoms. She was permanently remembering sad events of her life such as abandonment, deaths and physical suffering. She was reiterative. Willing to give an answer to the questions, with great anguish she recounted fantasies, described events which had never occured and sometimes showed a certain paranoid fancy with respect to the lady who was taking care of her and for her son and daughter as well. These ideas did not turn into delusions, but they remained paranoid fancy. She lived practically isolated in her room, in bed almost all day long.
I started working with Ada in March 1988, setting as the first goal the containment of the syndrome of confusional state, interpreting the intention of committing suicide, that naturally worried her son and daughter, as a demand for attention and help which, when aptly treated, would take away the spectre of a new real attempt.
Blind and almost postrate because of her muscular difficulty, speaking and communicating were the only chance she had to get out of herself and meet others. To censure or restrain this channel meant forcing her slowly into an even greater seclusion.
As a step of the process, her son and daughter were trained and the lady who assisted her was asked to take Ada out every day, to the street or at least up to the entrance hall. The idea was to make her get in touch again with all noises, automobile horns, people going and coming in the street, greetings of neighbors, the wind against her face, the cold, the heat, the sun, the hardness of the floor, including noises of buses and its exhaust pipes, etcetera. All of them had been part of Ada's daily routine for many years as she had lived there since she had had her eldest daughter; now she had long been deprived of this stimulus.
According to the result she got in the Geriatric Depression Scale (GDS, T.L.Brink and others), she showed a severe depression. The PIL Test (Crumbaugh), was used as a means to organize the approach to different topics. However, the PIL Test proved that Ada was going through a meaning crisis. She had lost her most relevant identity structures (she was a widow, no longer a pianist or professor, not even a reader or a traveller), and this tore down her value structure. Nothing seemed to make sense and she went through desperation to confusion and to a severe depression. Encountering decadence and nothingness, she showed a depressive noogenic disease. Thus, she looked for suicide as a solution to kill that experience of desperation and hopelessness. Her days were a whirl of painful memories which got hold of her and according to her own words "chased her day and night". The recurrent mental pictures were her mother's death after a long agony - she had suffered from a terminal illness -, the blood spots on the walls of her father's room who had died alone suffering from a hemorrhage produced by a disorder of the prostate - her father's bloody hand prints were left on the walls on his way crawling to the bathroom where he finally died -, her husband's agony, her best friend's suicide - only 3 years ago - and other objectively less dramatic but emotionally important sorrows.
With this burden, added to her own life condition, Ada only wished to die and she refused, consciously or unconsciously, to recover even from her organic diseases.
Slowly and with an intensive plan of reminiscence, I aimed to break that painful fancy and include in the memory circuit non-painful contents. I focussed on those related to her maternal grandfather - key in her affective history -, her contact with music, especially the piano, the best memories of her mother and the efforts she had made so that she could learn to play the piano, and aspects of her father, severe but kind, a communist ever involved in political meetings and street demonstrations.
Slowly we started to approach the piano, her studies, concerts and pupils. In fact, it was not easy to lead and restrain those memories without falling into a painful depressive self-compassion for the present decadence.
One day, Ada was waiting for me in the living room. That was the only time during her treatment that we met in a place which was not her own room. "Vladimir", her piano, was in the living-room. Ada gesticulated as never before when she spoke, even sat up to dramatize situations, within her possibilities. In that interview, the topic of music appeared again. She talked about the difference between a composition ending "in crescendo" and one ending "in diminuendo". After her explanation I involved her in the following dialogue:
ME: What makes a play end one way or the other?
ADA: Well....it depends on the content of the play and the composer's will.
ME: It means each composer, you for example, decides whether his play will finish with a glorious chord or not?
ADA: Sure...as you say... if it finishes in crescendo, it finishes with a glorious chord...
ME: Almost as it happens with our own life, doesn't it?
ME: One decides whether his life will finish in diminuendo or in crescendo, whether one will leave this world "without sorrow nor glory" or will finish it with all his power...with glory...
ADA: ...You are right...it is like that...
ME: I believe the life of an artist can't finish but in crescendo, because the artist is the one who can always find, compose, invent or create an answer to his life...
ADA: ...Yes...it should be like that...
ME: Truly ... it should be like that...
A few days later, when I visited her and greeted her as usual ("Hello Ada, how are you?"), she answered "Very well, thinking life is worthwhile living. I have just decided I will not give in easily". It was September-October 1988. Her clinical condition was stable and balanced. She had definitively lost her eyesight. Through those months there had been lapses and moments of great depression, but in general Ada's psychic state was good. In those days, her daughter got pregnant for the first time, after having been married for seven years. Thus, a new hope and expectation grew. Ada was rapidly regaining roles. Not only had she not lost her role as a professor (1), but she also discovered a new one - the role of grandmother - and at the same time she re-created her role as a mother, since her daughter asked her questions about pregnancy and the future bringing up of her baby, thus making her feel needed as a mother. From then on, Ada's situation improved in every sense. I told her to contact on institution for the blind where she was trained to move about the house without any risk and with security. She accepted my suggestion with enthusiasm.
I encouraged her to use a tape recorder so that she could listen to her tapes of Berta Singerman (a very important Argentine actress who used to recite poems). I taught her to use the buttons of the tape recorder as if they were the keys of a piano; thus, DO was EJECT, RE was STOP, MI was PLAY, FA was FFW and SO was RWD. To my surprise, one day she welcomed me with a copybook in which she had written something. We were in June 1989, and with quite legible handwriting, she had written two things:
"a word of good memory"
"That who can see
all the things in me
and in whom I see everything, that one
will love me and I will too
The only thing I could not understand was that word "Adik", that finally turned out to be a name, the name of her first love, a love which had been frustrated by social differences. (She was of a very humble condition and he belonged to a very wealthy family). Ada knew she had written something, but she could not remember what it was. When I read the phrases aloud, her face brightened up with joy, in the first place because the written words were legible, and in the second place, for Adik's memory. During the following interviews, we focused our attention on him. Ada enjoyed talking about him. We talked about love, her affairs and her marriage. She had married a very kind man but she had never really loved him. It was really a "word of good memory" or perhaps, a pleasant memory which encouraged her to write. The fact was that Ada was now also able to write. A month had passed since her first writing. At the very beginning I tried to persuade her into writing again but then I realized that she would do it on her own whenever she wanted. A month later, when I no longer insisted, she wrote two phrases again:
"The greater part of the science of life
"A thick and dull cloak
for all the things
that must be forgotten"
She did not remember what she had written and when I asked her what she had wanted to express or what she had been thinking about when writing that, she answered, "it may be a defense against bad memories that sometimes are likely to invade me... like deaths...". And she added, "I remember my grandfather... a nice memory...he was a gentleman...he resembled Anatole France".
During the following days, Ada wrote some phrases, seemingly out of context, each time more legible and with even better handwriting. Thus, she once wrote:
like a greasy stick"
She commented to me that when she wrote it she might have been thinking that the one who climbs by evil means, finally falls down. Ada's last writing is the following:
the absence, the
When I reminded Ada what she had written - she never remembered what - and pointed out it was a very nice phrase, she told me:
"Yes...it is very nice but...ah!...
know what?...in fact it is a beautiful
sonata by Beethoven who usually gave
a name to each movement...".
Anyway, and in the particular case of Ada, it is still a beautiful and meaningful phrase, indeed.
I do think that the presentation of Ada's history is interesting because it clearly shows the complementary roles of the appealing and the life review or reminiscence techniques in the treatment of a noogenic depressive disease.
Ada truly suffered from the disease and from a negative identification with "not being", decadence, nothingness; her desperation and her feeling of meaninglessness carried her to suicide as an alternative to make that painful experience come to an end. As it has been shown, working with "reminiscence" guided her to a point where she could find a fact in her history which had been lost; by "appealing" we started to work on that fact now rescued and recovered. From then on, the way towards meaning followed its course.
3. Final Thoughts
Everyone must eventually face the ageing crisis which is really a crisis of identity. At that moment, each of us will be questioned about himself. But who will be the questioner, the inquirer? - Life, life itself. Is it then a philosophical situation? Of course not, it is not man questioning about life, it is life questioning man about his own, singular, real, concrete, daily life. Thus it is a vital situation and that is why I say that each of us will face it at the proper time. In that moment, we will have to go through a deep conflict, because our identity itself seems to be lost. Retirement, widowhood, deaths, diseases, children's growth, social changes, and other impacts will checkmate us just as if we had lost our memory as a result of a knock-out and did not know who we are. Then the way we decide at this crossroads will point out our transit to a meaningful, a depressed or a weakly old age.
As in Ada's case, there are people who cannot resist this feeling of identity vacuum, adopting for themselves an archetype pretending to cover that vacuum. Usually the "juvenile archetype" or the "wreck archetype" are then adopted. They illustrate the intention of man to cling to vigorous yestertimes or let oneself fall down into an anticipated end. In this case we can talk about a "depressive disease", and depressive symptoms manifest the key of this disease: man gives up his search for a meaningful answer, adopting a mask, a borrowed answer. When man gives up this search for meaning, he goes through a noogenic depressive disease.
The reminiscence scheme looks for facts in the individual's history which would let him know himself, remember himself, recall himself; appealing encourages his present "want to be" so that he sticks with and orients himself towards his original "should be" or to the fulfillment of a meaningful destiny for himself.
In every case, we also must accept that the primary resource is the elderly themselves. As existential companions, we guide the process (not the person); we become a kind of catalyst, inducing an uncontrolled reaction. Then we become spectators of a wonderful and intense humanization process in a life which seemed to be destined to end without sorrow or glory.
As Ada wrote in her last writing, when the elderly has already said "goodbye" and his life is practically an "absence", through reminiscence and appealing we can help them to "return".
4. Summary: Logotherapy and the Treatment of the Geriatric Depression.
From the very beginning, ageing means an important trouble for mankind. We may find many attempts to discover the "fountain of eternal youth", some of them developed by magicians and false scientists, but other ones, proposed by geriatricians and professional searchers. Nowadays, medical progress provides us with a quite considerable life-span, but man is still looking for more years to live.
Geriatricians are working in the attempt to provide an answer to this longing; psychologists are doing their own to provide quality to life, to those later years. That is why a few decades ago there appeared a new branch in psychology, known as "Psychogerontology". It pretends to make psychotherapy accessible to elders, but it has failed in two ways: first, it pretends to transfer the clinical strategies for adults to elders, ignoring the fact that old people represent a particular population with particular characteristics, so that those strategies must be recreated or indeed created; second, psychogerontology pretends to approach elders by way of psychoanalysis, individual psychology, conductive schemes, and others, considering the instinctive conflict as the key of their situation.
I am convinced that the only psychotherapeutic strategy to approach the elders' situation is provided by Logotherapy, because it is prepared to guide people to discover the meaning of life and its constituents, like suffering, isolation, freedom, health, disease, love, death. It recognizes the person of the individual behind his or her situation and condition, and it does not regard power or pleasure, but spirituality as a powerful means to transcend our present in order to reach our goals.
And of course, suffering, isolation, freedom, health, disease, love and death are daily troubles on elders' life. They are difficult to solve approaching them from the will to power or the will to pleasure. They only find a significant resolution from the will to meaning.
Logotherapy is the most valid psychotherapeutic strategy to approach the elders' situation and condition, their daily life and their mental or emotional diseases. It provides a very important horizon of diagnostic instruments and, mainly, an endless world of resources to resolve the human situation, namely the universal will to meaning of a human being. Its psychotherapeutic techniques are particularly recommended for those psychogerontologists who contend to lead their patients to be aware that their lives are still an incomplete task, encouraging them to pledge themselves in order to complete it by living a meaningful and satisfactory ageing, far from the heavy and misty ghost of depression.
(1) She had 4 classes with one of her ex-pupils who was preparing a solo performance and wanted Ada's opinion on it.
Garcia Pintos, Claudio C.: "Depression an the Will to Meaning: a Comparison of the GDS and the PIL Test in an Argentine Population", Clinical Gerontologist, vol.7 (3/4), Spring/Summer 1988, USA
Lukas, Elisabeth: "Meaning in Suffering", Institute of Logotherapy Press, Berkeley, California, EEUU; 1986.
Frankl, Viktor E.: "El Hombre en Busca de Sentido", Ed.Herder, Barcelona, 1980
Frankl, Viktor E.: "La Idea Psicologica del Hombre", Ed.Herder, Barcelona, 1979
Frankl, Viktor E.: "La Psicoterapia al Alcance des Todos", Ed.Herder, Barcelona, 1983