a talk for Social Work in Progress

Last month I went up to Boston to give a talk at the invitation of my friend Sarah Wright, founder and director of Social Work in Progress. The organization provides staffing for healthcare and eldercare organizations; the audience was a mix of administrators, directors of nursing and social workers; and I was honored to kick off its community education and professional development program series in Sarah’s beautiful new office in historic downtown Dedham.

photo credit: Gretje Ferguson Photography

Below, the transcript of my talk, to which people responded warmly. From my end, the best part was hearing from one person after another how gratifying they found working with older people.  

fear ageism, not aging
For a couple of years now I’ve been working on a project called Staying Vertical, which was originally about people over 80 who work. Finding terrific people to interview – blue-collar as well as white – turned out to be easy, and I learned a lot about the benefits of working.

No big surprises there, but a funny thing happened on my way to a book proposal: The more people I talked to and the more I read, the greater the discrepancy that emerged between my notion of late life — a steady slide into disability, depression, dementia and puffy white shoes — and the reality. Here are a few things I learned, which are probably familiar to you geriatric professionals but that took me by surprise:
•  the vast majority of older Americans are functionally independent, and are healthy until they come down with the illness that does them in.  Only four percent — down from 5 over the last decade — lives in nursing homes.
• Ninety percent of the remainder is cognitively fit. Yes, Alzheimer’s is a huge problem, and yes, the risk increases with age, but our general level of dread is way out of line. Most forgetfulness is not Alzheimer’s, or dementia, or even necessarily a sign of cognitive impairment.
• Older people are not more depressed than other age groups (although their depression is less likely to be treated or even noticed). Numerous studies show that people are happiest at the beginnings and the ends of their lives.
It took a while for the scared boomer in me to catch up with the social scientist, but when the two converged it was exhilarating. It came in the form of a counter-intuitive realization: the more I learned about growing old, the less terror it held.
Another realization was less exhilarating: that my upbeat focus on older workers was only a transit visa: safe passage into territory that I’d been too scared to enter. I’m still afraid of dying, but the getting older part is looking better all the time. My fear of dying has diminished too, because I’ve learned that it’s most of the old old do not share it. They don’t want to die, but they’re not preoccupied by its imminence. The significant probability that I’ll find my way to their really big part of the pie chart comforts me. Data beats dread.
There’s still plenty to dread. Who doesn’t flinch at the ugly aluminum devices that help us stay vertical (or close): the cane, the screechy walker, the lurking wheelchair? Joints ache, hearing goes, beloved friends and family die. But you’d think nobody has a good old age anymore, let alone a good death. American culture is eerily deaf to all but the negative aspects of late life. Glossing over the real and inevitable losses does no one any favors, but neither does the presumption that even highly circumscribed lives are not worth living. From the outside, what people lose as they age is more obvious than what they gain, so we presume that older people are worse off than they themselves experience.

“We have to be very careful not to project our own fears of aging,” writes geriatric psychiatrist Marc Agronin in his book How We Age. “Their lives can be way better than we imagine.” It was Agronin who introduced me to what Henry James dubbed “the psychologist’s fallacy”: the illusion that we can ever know what another person is experiencing. Meeting a new patient who had just lost her husband of 70 years, Dr. Agronin asked with deepest sympathy, “How has it been to be alone after so many years?” The 93-year-old woman paused, then replied, “Heaven.” Finally free of his repressive presence, she threw herself into the nursing home’s social life for the 7 years that remained to her.

A talk by gerontologist Tom Funicane of Johns Hopkins gave me more perspective on the psychologist’s fallacy. Describing the often utterly unpredictable turns that end-of-life decisions can take, Dr. Funicane quoted a Mexican saying: “The appearance of the bull changes once you enter the ring.” The bull looks different. One example he gave was of an extremely straight-laced woman who was struck by a form of dementia that completely disinhibited her. She told dirty jokes, she lifted her skirts, she flirted with her grandsons. There was no doubt that the woman would have been horrified, but also no doubt that she was having a fine time, which made the transition bearable for those who loved her. Another data point from Funicane: right after the accident that turns people into quadriplegics, most say they don’t want to go on living. A year later, the bull looks different: 60% rate their quality of life as good or excellent.

Something was shifting in my head. Instead of averting my gaze, I started actually looking at the older people I encountered. When I’d see an older guy on a park bench, I no longer presumed he was lonely; I wondered whether he’d like some company. When I’d spot an older woman crumpled in a wheelchair, instead of automatically feeling sorry for her, I wondered if she was enjoying the sunshine. That ugly little voice inside my head no longer muttered, “Put me out of my misery if I get like that.” Instead it muttered — a little nervously, I admit — “the bull looks different, the bull looks different.”

That was a critical turning point. Because when we’re young, we simply can’t imagine being old. We all think we’re somehow going to be exempt, get a free pass, and this magical thinking never entirely stops. Aging is a public process, yet the years sneak up. The face in the mirror startles, because it looks so much older than we feel. But I was turning a corner. I was becoming, to borrow geriatrician Joanne Lynn’s phrase, an “old person in training.” I’d stopped conceiving of old age as something that happened to other people, and started thinking about what mine might actually be like.

That inner reckoning came as a huge relief. Not only because the scenarios that came to mind just weren’t that bad. But because it loosened the grip of an exhausting delusion: that the old were somehow not me — future me, that is. And that resolved a vicious inner conflict. Like all of us, I wanted to grow old, yet the prospect terrified me. That irrational aversion to what we will become — the reflex that my daughter dubbed the “yuck/pity factor” — is a form of self-loathing. It’s where ageism takes root in our own minds. Think about the nature of ageism: it’s the only ism turned against the self. There’s no psychological need to defend against stereotypes — racist, sexist, ageist — when they apply only to others. Once I stopped envisioning old people as “other,” I started waking up to my own internalized prejudices. I stopped inserting “still” when describing people over, say, 70, as in She’s still driving or He’s still working. • I stopped find “senior moment” quips funny – not only because they reinforce a bogus stereotype but because the middle-aged people nervously making these jokes are colluding in a collective narrative of premature decline. It’s as though they’re moving up their own expiration dates! • I realized that cosmetic surgery, at any age, was not OK. • I saw that romance and passion were not off limits to the very old, and wondered why I’d never questioned the preposterous notion that sex is best when you’re young. • I stopped mourning my 94-year-old godmother’s severe short-term memory loss, instead enjoying the humor and enthusiasm and curiosity that remain and that keep her very much my Anne. • I started looking for beauty in the no-longer-young, and am trying to be more forgiving of gravity’s pull on my own flesh. The goal? Quoting age scholar Margaret Morganroth Gullette: “Enticements to look younger — like enticements to look whiter, or thinner, or anything other — could finally be rejected as bigotry.”

Becoming aware of ageist thinking in myself freed me up to see it in society at large, which brought me to another critical turning point. if I was too squeamish to face my own fears, to challenge my own prejudices, how could I demand something different of the people and institutions around me?
American culture places such an emphasis on self-reliance and self-improvement that we tend to think that aging is a personal problem. When you’re mired in apprehension and self-reproach, you don’t look around for context or comrades. But we age in culture: In early America, the old were exalted (to a fault – there was little opportunity for younger citizens). Visualize the way Ben Franklin dressed: white wig; long, stiff overcoat, stockings exposing the lower legs. Those were fashions that flattered the older body and concealed its flaws.

Now everyone wears spandex. The pendulum has swung to the other extreme. American society has made enormous progress in combating racism and sexism and homophobia, but no one blinks at the suggestion that older people are befuddled or asexual or conservative or can’t work a cell phone. Or serene or wise, for that matter. Some children are wise, and plenty of older people are idiots. The true hallmark of late life, as you in the field are well aware, is heterogeneity. There’s a saying among geriatricians that if you’ve seen one 80-year-old, you’ve seen one 80-year old. The aging process is governed by a whole range of variables – genetics and personality, compounded by class, gender and race — over which we have varying degrees of control. Growing old is hard enough without baseless stereotypes and unwarranted pessimism making it harder than it needs to be.

I stopped being afraid and realized, in that phrase from the ‘60s, that I’d had my consciousness raised. I came to understand that it was ageism that has Americans botoxing at 30, facing job discrimination at 40, treating menopause like a disease at 50. It’s ageism that promotes life-extension fantasies and “anti-aging” remedies. As Margaret Gullette points out, “anti-aging” = anti-life. Living means growing older.

The aging process isn’t the issue. The issue is how attitudes towards that process are culturally constructed. People aren’t born ageist. Those attitudes are created by a capitalist society that has less and less use for larger and larger segments of the population. Fear ageism, not aging!
Ageist attitudes are buttressed by alarmist demography, which portrays the longevity boom as either crisis or burden. Social Security bankrupt! Medicare exhausted! Lazy oldsters retiring, leaving outnumbered millennials to support them (the fallacy of the fixed lump of labor, another ageist myth). Or, greedy geezers refuse to relinquish jobs to the deserving young. These zero-sum scenarios, in which the old benefit at the expense of the young, sell newspapers – and justify the hand-wringing and budget-cutting. Lost in the process is the fact that resources for caring for people over 65 are often discussed as if they were intrinsically scarce, rather than the result of policy decisions.

This youth/decay binary — the devaluation of everyone over 30-something — demeans the life course. It makes it far harder to convey a nuanced picture of late life. It makes it all harder to address legitimate anxieties about the years ahead: that most Americans might make it to the ends of their lives with decent healthcare and a modicum of financial security. Interest in aging peaks during recessions, when it’s likely for a given demographic — old people, say — to be demonized for being dependent. And the government really isn’t interested in looking after our frailest citizens. At Ground Zero there was an evacuation plan for pets, but not for nursing homes. There are no national standards for professional in-home caregivers. The first federal elder abuse policy was finally signed into law by Obama, but it’s not funded so it has little effect. Research into the basic biology of aging is grossly underfunded.

I’ll end with the example of ageist thinking that I find the most grotesque: the growing anxiety on the part of older Americans that they might “live too long” and “become a burden” – in other words, “cost too much.” According to the nonprofit Alliance for Aging Research, most of the 4800 people over 65 who die every day incur reasonable, low costs. Only about 3 percent of those deaths are actually very expensive. But you wouldn’t know it from all the hostile rhetoric about old people — sick old people, yet — who have the temerity to want to stay alive. You rarely hear about undertreatment, which is rampant. There’s little discussion of the role that sexism, racism, and ableism play: women are more likely to live longer, to be poorer, and to be coerced; women of color the more so. • even if that 3% were higher; • even though overtreatment largely reflects the nature of American medicine and the reluctance of both patients and doctors to discuss end-of-life decisions;

at any age, people deserve choices at the ends of their lives. The criteria for medical procedures, to quote bioethicist Felicia Ackerman, should be the “desire to stay alive, medical need, and a reasonable chance that the procedure will work.” I want to grow old in a society that respects that desire.
I want to work against the deadliest form of internalized ageism: that as mobility diminishes, suicide changes from option to duty. During the 20th century, new awareness and mass actions transformed society: the Civil Rights movement, the women’s rights movement, the LGBT rights movement, the disability rights movement. In the 21st century, as the world population ages at an unprecedented rate, the challenge is ageism: confronting discrimination on the basis of age and organizing to resist it.

I need your help. You may have heard of George Lakoff, a cognitive scientist/ author of The Elephant in the Room, who studies why liberals are lousy at framing political debate. We think that reason alone — facts and figures — will carry the day. But reason requires emotion and most emotion is unconscious. According to Lakoff, the value that underlies every progressive policy is empathy. Empathy gets its political power from its moral force, which is a consequence of brain structure: mirror neuron circuitry. If I want to increase the ranks of “old people in training,” I need – to quote Lakoff – to “argue powerfully and emotionally from the moral perspective of empathy and responsibility, protection and empowerment.”

As a writer, I know the way to do that is through stories. They’re what stick with us, and move us. So please give some thought to whose stories besides my own would serve that purpose, and where I can find them.