John: We have sometimes sent therapeutic letters to the family for this reason but written in simpler more direct plain English so they can be got hold of and thought about more easily. I remember, recently, we gave the family we were seeing a wonderfully intricate and technically crafted ref lection, which just went into the stratosphere over the family’s heads. We wrote a more humble letter afterwards saying we think we missed the point for the family! Truth to tell, we were trying so hard not to be critical of a dominant family member that we positively connoted the whole family situation into a kind of meaningless wallpaper through the feedback. Melanie: I think it can be hard sometimes to get the balance right between respecting the emotional complexities of sessions and the verbal simplicity needed. My colleague noticed problems with traditional verbal ref lective feedback when working with people with cognitive impairment: she started visually summarising it on a f lipchart, structuring it into families’ strengths, themes and emotions (Jorgensen-Taylor, 2018). The sheet could be taken home or kept for the next session. Our teams experimented with her approach and found it helped trainees too. Jeffery et al. (2019) also wrote about using visual methods such as sculpts, and ‘filling in verbal gaps using embodied understandings and the experience of non-verbal exchanges’. John: I like that idea. Whatever makes us comfortable and relaxed in giving feedback that the family can take in and digest has to be the main communication objective of all we do. Melanie: I recall working with a couple where joining was complicated and we all needed to try to make sense of verbal gaps. The man had a diagnosis of early onset dementia. His wife was initially insistent that he should have individual sessions. He seemed depressed to her and, as he had worked as a psychotherapist, she knew how much he valued therapy. Individual sessions were ineffective due to his level of cognitive impairment but I suspect, because we had offered what she had initially requested, she was then much more open to couple sessions. Meeting them together we sensed that, with


Context 169, June 2020


the ‘scaffolding’ support of his wife, although he did not appear to always follow the content of sessions, and we could not always understand him, the therapy seemed to bring the couple closer through our efforts to make sense of what was going on. At times, he would say a phrase that gave the impression he was emotionally in tune with what his wife was saying. For example, he said that he “ felt at the back” that then helped us to ref lect together on whether this conveyed perhaps an awareness of what he had lost, or was losing, or his position in the conversation. Even when the dementia progressed to the extent that he contributed few words and sometimes walked in and out of the sessions, it was important to his wife that he participate. She used the time to think through the dilemmas they faced as a couple. She identified that it was when her husband was alone and unoccupied that he seemed to her to be depressed. She arranged more outside input for him and, coming to the realisation that in fact she was low in mood, requested carer-support sessions for herself. John: That’s very good, creative and person-centred. We have also discussed the need to hold in mind older adults’ cultural attitudes and ideas about mental health, for example about shame, stigma and anxieties about the social outcomes of impaired mental health; their ideas about authority and dependency – the ‘stiff upper lip’ that can get in the way of accessing and engaging with family therapy. Melanie: And the kinds of, often traumatic, experiences that frequently come up with older adults, which may be different from those of younger clients – such as about the second world war, evacuation, impact of different gender expectations and, particularly if clients are from black, Asian and minority ethnic groups, their experiences in the UK and abroad in different social contexts from those of previous generations. John: There are clearly stories from the ‘Windrush’ generation and World War 2 refugees, coping not just with loss and dislocation but with the ‘ethnic tribalism’, if I can call it that, of the ‘native culture’. In Canterbury, the older adult population is very homogeneous, so we don’t get so many stories of social


dislocation, I suspect, as London or large British cities would. Our team has been shared in stories


of 80-somethings being held up as children in the Blitz and, in two cases, seeing the ‘Pool of London’ a ‘pool of fire’. These were very compelling almost poetic and cinematographic accounts. One man in his eighties also recounted seeing newsreel footage of the liberation of Belsen as an adolescent. It remained with him as a troubling presence all his life. Another woman recalled taking her mother to hospital when she was seriously ill. The mother had suffered enduring anxieties all her life. When her mother died, she emitted a terrifying scream as she did so. Our client reacted within 18 months of the age of her mother’s passing and had been driving our colleagues in the mental health services to exasperation, ringing up, sometimes daily, to regale them with the same repetitive dreads and paralysing fears. She could not reproduce the scream, despite our encouragement to do so. We empathised with her the dreadedness of it and how it had left her feeling totally alone and lonely. Her husband of 53 years felt powerless, and disqualified from being in anyway helpful to her. Melanie: It sounds really important that you were able to link her experience and behaviour now as an older woman with the loss of her mother at roughly the same age. What was the outcome of therapy with this couple? John: I guess this is still ‘a work in progress’. She certainly took notice, as did her husband and the ref lecting team, when I emitted a terrifying scream twice during the session to help give her permission to realise it was a natural reaction – a repression of life force energy if you like. Even if she couldn’t reproduce it, we suggested she have a reproduction of the Edvard Munch picture ‘The Scream’ hung up around the house so she could have a reminder. A member of the team, who was also her key worker, took out his mobile phone and showed her there and then what the Munch looked like. What instant benefits from instant technology! We have learned she is no longer phoning in three or four times a week and will be following up shortly. Of course, it helps enormously to have her key worker in


35


Growing old disgracefully and working with the disgracefully old: Signifi cant landmarks in the ‘unexplored territory’ of older adulthood


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