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BOOK REVIEW |
Professor of Psychology University of Wisconsin Oshkosh Oshkosh, WI 54901
A Guide to the Spiritual Dimension of Care for People With Alzheimer's Disease and Related Dementia: More Than Body, Brain, and Breath, by Eileen Shamy. Jessica Kingsley Publishers, London, 2003, 224 pp., $26.95 (paper).
Growing Old in Christ, edited by Stanley Hauerwas, Carole Bailey Stoneking, Keith G. Meador, and David Cloutier. William B. Eerdmans Publishing Company, Grand Rapids, MI, 2003, 310 pp., $24.00 (paper).
Vital Connections in Long-Term Care: Spiritual Resources for Staff and Residents, by Julie Barton, Marita Grudzen, and Ron Zielske. Health Professions Press, Baltimore, MD, 2003, 223 pp., $23.95 (paper).
An undergraduate student in my Adult Development and Aging class once came to me with a pained expression on his face and said, "After taking this course, I know I don't want to get old." Had I utterly failed to teach him to think about aging using a life span developmental perspective that articulates both the losses and the gains of growing older? I could rationalize by recalling this student's intermittent class attendance and the papers his peers wrote about interviewing older adults and discovering their many gifts. Nevertheless, his comment and his distress remind me that holding onto hope about aging in our time is an enormous challenge for individuals and societies.
Three books published in 2003 echo themes of the difficulty of remaining hopeful about life in old age. Two depict hope rooted in Christian community while the third advocates for a nonsectarian form of spirituality with hope as its core value. These books all assert that hope springs from authentic interpersonal relationships nurtured by the telling and hearing of stories. They disagree about the types of communities that support hope about aging and the content of the narratives conveying that hope.
For Stanley Hauerwas and his colleagues, editors of Growing Old in Christ, hope lies in a radical vision of Christian discipleship lived within the time-transcending community of the church and nourished by the gospel story. Julie Barton, Marita Grudzen, and Ron Zielske—authors of Vital Connections in Long-Term Care: Spiritual Resources for Staff and Residents—find hope linked to a "higher being or a higher level of existence" (p. 5); for them, hope grows "when one person supports another person" (p. 5), often by sharing life stories. Eileen Shamy affirms her own spirituality as Christian in her book, A Guide to the Spiritual Dimension of Care for People with Alzheimer's Disease and Related Disorders: More than Body, Brain, and Breath. Yet, she attempts to write in a way that is "acceptable to most of the world faiths" and to those whose spirituality lies "outside formal faith/belief structures" (p. 19). Nevertheless, Shamy concludes her account of ministry to people with dementia closer to Hauerwas and his colleagues than to Barton, Grudzen, and Zielske. No person with dementia gets better, but for Shamy, the Christian story of "defeated love's power" (p. 200) offers hope in the form of "a new life of order and harmony in a community in which there are no exiles" (p. 200).
Despite their differences, these authors all agree about the harm caused by contemporary society's split vision of old age as either a time of despair and loss, or of vigor and growth. Reading these three books raises troubling questions that can be set within a particular context provided by a recent paper titled "The Decline of Organized Religion in Western Civilization." It asserts that "overall the Nones [people who profess no religious preference] do a better job of retaining their youth than any religion does" (Altemeyer, 2004, p. 88). Will this "decline" have a significant impact upon the psychological and social conditions under which people and communities grow old in the future? How will an increasingly secular society reflect upon the meaning of older people's lives, particularly those afflicted with dementia? These books offer no answers to these questions, and, undoubtedly, there are many sides to the debate over the contributions of "organized religion" to attitudes about aging and the care of older people. Nevertheless, one wonders what resources young people like my student will call upon as they navigate through adult life in a society that will be shaped in multiple ways by the fact that 20% or more of the population will be aged 65 and older.
Hope as Counter-cultural
Stanley Hauerwas, professor of theological ethics at Duke University's divinity school, holds a strongly counter-cultural view of aging. The book that he and his colleagues edited presents a collection of writings that declare the corruption of common visions of hope for perpetual youth or hopelessness over inevitable decay. For them, the goal of a long life is not to demonstrate productive or successful aging, nor even to experience well-being. Rather, life's meaning derives not from the length of years, but from the individual's commitment to live and to die "in Christ."
With the exception of Judith Hays and Keith Meador, who have published many research papers on subjects like geriatric depression and religious coping, the chapter authors in this volume are not well known in gerontology. Most of the contributors are professors of theology, religious studies, and ethics. Though they do not cite the usual gerontological literature rooted in the behavioral and social sciences, they have all thought deeply about the meanings of aging, suffering, dementia, and death.
The 14 chapters in the Hauerwas volume cover a wide array of important subjects, beginning with Biblical and historical perspectives on aging. Although these topics have been reviewed in other publications, these authors bring fresh insights to their interpretations of scripture and descriptions of aging in the early Christian church and in the medieval era. The middle section of the book addresses "critical perspectives on modern problems of aging." It includes a chapter on the social construction of aging that deftly interweaves discussions of aging in literature of the 19th and 20th centuries with a pointed discussion of the ethical complexities of aging in the 21st century. Other chapters critique the "therapeutic culture" of aging, cultural stereotypes of old people, and the disastrous economics of medicine and death in later life that can only be resolved if elders are cared for "within the context of the ecclesial community" (p. 147). The final chapter in this section also deals with death, this time in terms of the mutual gifting that occurs in caregiving at the end of life. The last section of the book describes Christian practices of growing old. Here we read about friendship, rituals, virtuous behaviors, generational conflict (particularly in the context of churches), and two final chapters on physician-assisted suicide and memorial practices in our times.
Despite the many diverse topics addressed in this book, several strong themes knit the chapters together: respect for narrative and storytelling, emphasis on community, critique of the worship of autonomy, and hopefulness that bears the burden of dependency and suffering. Hope for aging in these authors' view lies not in the biomedical, psychological, or social policy advances produced by gerontologists but in the promises of the gospel and the authentic practice of Christian community. Thus, Growing Old in Christ not only proclaims a counter-cultural view of aging, but as a result of many of its authors' association with the confessional movement of Christianity, it challenges work that separates spirituality from specific religious beliefs, traditions, and institutions. The very title of this book clearly states the editors' intention of proclaiming a new vision of growing old in our time, one that inevitably will produce some discomfort among gerontologists, even those who have accepted the notion that older adults' religiosity and their spiritual lives ought to be legitimate topics of study.
Hauerwas, declared by Time Magazine in 2001 to be "America's best theologian," would undoubtedly be bemused by responses to this book's title. One gerontologist who has spent many years studying aging and religion described it to me as "heavily evangelical," basing his judgment solely on the title and his stereotypes about narrow-minded, fundamentalist religion. I, too, experienced some dissonance about this book's title. While reading it in preparation for writing this essay, I attended a conference on the neuroscience of emotion and was aware of the impression I might convey to people who saw me reading it. Realizing that no one at that scientific meeting would object to my reading a book on "growing old in Buddhism" or "atheists growing old," I was acutely aware of the sorry state of Christianity in our time because many people identify it with reactionary politics, while others simply view it as irrelevant.
Although this book is unapologetically Christian, in the introduction Carole Bailey Stoneking states the authors' hope that for non-Christians it will "generate conversation and reflection on both the problems and the gifts of aging" (p. vii). The chapters are scholarly and yet accessible to persons not trained in theology. The fact that they so acutely analyze contemporary cultural attitudes about aging without referring to the standard gerontological literature is refreshing. Moreover, the authors do not just reserve their jeremiads for a culture that promotes anti-aging medicine, has created a windfall for plastic surgeons, abhors dependency, and rather casually accepts physician-assisted suicide. American Christian churches come under critical scrutiny as well. For example, in their essay on friendship and aging, Hauerwas and Yordy write: "Churches are more likely to be shaped by the American way of growing old than by the kind of responsibilities we think are incumbent on the elderly in Christian community" (p. 182). In a similar vein, in a powerful essay recalling Philip Rieff's (1966) book, The Triumph of the Therapeutic, Meador and Henson declare, "Is there not a sort of dementia of the soul in the life of the church, a forgetfulness of the truth, when we trade in our powerful salvific traditions and give way so readily to such assumptions as those undergirding a therapeutic culture?" (p. 107).
Although it is not counter-cultural in our time to be critical of Christian churches, it runs against accepted gerontological practice to be critical of older people while at the same time being committed to resist the political and social conditions that reinforce ageism. Because gerontologists are so acutely aware of the tenacity of ageism in this culture, one rarely hears from them any criticism of older people. One exception is Robert Kastenbaum's (1993) brilliant essay on "postmodern aging" in which he castigated certain older people for their racial prejudice but also offered a sympathetic account of why they so easily embraced that prejudice. In a similar vein, Hauerwas and Yordy state, "old people are still called to discipleship in the community, and that discipleship may involve radical change in their way of life" (p. 177). In other words, they, too, must be held accountable for their acts and listen to the voices of their friends who encourage them toward greater faithfulness. Hauerwas and Yordy also believe that older people have a responsibility to tell and retell the Christian story "if the church is to survive as church" (p. 182). These authors state that they "rightly expect Christians to grow old wisely" (p. 183). Sitting passively in the pew on Sunday morning is not sufficient in their view for living this faith into late life. The final responsibility Hauerwas and Yordy lay upon older adults is the most difficult: The church must ask older persons "to teach us how to die" (p. 183).
Is this too much to ask? Perhaps it is, given the contemporary split between unrealistic optimism and morbid pessimism about aging. These authors, however, ground their hope neither in the scientific management of aging nor in romantic images of healthy, attractive, well-behaved old people. As expressed by Stoneking, Christian eschatology shapes and celebrates hope while resisting the "seductiveness of optimism, the barrenness of pessimism" (p. 86). She speaks to persons of all ages when she continues:
Hope requires such resistance: It requires that we face the unraveling of the knot that ties us to needing and wanting more for ourselves. It requires that we assemble reminders enabling us to recognize that self-deception is a permanent possibility. It requires that we attend to the disorderly text of our lives and learn to recognize moral commitments that are in fact more profound than our customary descriptions can suggest (p. 86).
Hope for Improved Institutional Care
The cultural perspectives on aging and older people so thoroughly critiqued by Hauerwas and colleagues have created the conditions that make a book like Vital Connections in Long-Term Care necessary. Julie Barton, Marita Grudzen, and Ron Zielske are all caring, compassionate individuals who work closely with long-term care residents and with the staff who provide their care. They know only too well the demands that dehumanize the care of frail elders. Nearly all training for long-term care staff concerns "cares," a fascinating distortion produced by pluralizing a word that implies human concern and turning it into activities like bathing, feeding, dressing, and ambulating that paradoxically often prevent human beings from showing genuine care. This book presents a different approach to training, one that guides people to consider their own spiritual nature and values so they can better recognize the spirituality of residents, no matter how frail.
This is a book not so much to read as to use in designing workshops. It contains a wealth of useful information and many specific ideas to integrate into staff training. The authors in the Hauerwas volume present a ringing indictment of a culture that refuses to come to terms with dependency, but their intellectual vocations give them some distance from the daily toil of the people to whom Barton, Grudzen, and Zielske address their work. These persons must respond to the many diverse, complex, and intimate needs of highly dependent individuals, and they must do so promptly and efficiently in order that at least a minimum level of care is given to all for whom they are responsible. As we know from many ethnographic studies of long-term care facilities, this is very hard work. Barton and colleagues make the important case for calling their work "serving" and not "helping." They emphasize this difference because they believe that serving implies mutuality. That is, when seen as whole persons possessing a core of spirituality, even frail residents can be understood as having something to give back to their caregivers. Much like the Cloutier chapter in the Hauerwas volume talked about the "mutual dependence" (p. 259) of the terminally ill person and the community, Barton and colleagues argue that residents, their families, and the staff need to be treated as occupying a space of mutuality. They prefer to say that instead of "caring for" another person, paid and unpaid caregivers "care with" elders.
Barton, Grudzen, and Zielske contributed specific chapters to this book, all with the same organization. The chapters contain several short discussions of specific topics followed by discussion questions, and each could be the source of enough ideas for several training sessions covering subjects like spiritual well-being, caring communities, relationships with people with dementia, intimacy and sexuality, pain management, and terminal care. Two of the most intriguing chapters address "the pleasures of the table," containing thoughts on food and eating, and "recovering the self through the arts," a chapter that has a useful appendix instructing long-term care staff on how to develop relationships with the arts community.
The authors also include various exercises that involve training participants in activities like mutual care (e.g., foot washing), progressive relaxation, and journaling. Every chapter ends with action steps to promote wholistic care in the nursing facility, recommended readings, and a number of useful web sites. The abundance of information included in this book is impressive and indicative of the many years that the authors have worked to produce a new vision of hope for the institutional care of older people.
In addition to all this, every chapter also contains case studies, and the authors have been careful in presenting them to include stories of persons from many ethnic and religious backgrounds. Herein lies a wide gap between this book and that of Hauerwas and colleagues. Barton, Grudzen, and Zielske must work with residents of long-term care who represent many faith traditions. Their vision of hope for long-term care is expressed through an inclusive notion of spirituality. According to these authors, the keys to spiritual growth lie in "positive experiences with family and friends" (p. 15), and spiritual care can take the form of rituals and activities that are not grounded in any particular faith. Given the environments within which they work, this is appropriate, although the specifically Christian perspective of the authors in the Hauerwas volume would undoubtedly lead them to declare mere spirituality insufficient to provide the kind of hope that can be truly sustained in suffering.
Hope Despite Dementia
Eileen Shamy, a Methodist clergywoman, begins and ends her book on ministry to people with Alzheimer's disease with chapters about hope. In between, she presents basic information on the illness, the spiritual dimension of care, approaches to leading worship and having pastoral conversations with people with dementia, and, finally, caring for caregivers. Although much of this material has begun to appear in other publications, Shamy's approach is helpful in several ways. For example, she offers guidance for ministry that recognizes the progressive nature of the disease. Thus, worship for newly diagnosed persons may occur in a congregational setting, only later moving into the home and then perhaps to a long-term care facility. She also uses this approach when she discusses "pastoral conversations" and offers helpful suggestions as well as sample dialogues showing ways of having these conversations. In addition, her book contains a number of liturgies specifically designed for use with groups of people with dementia.
Shamy locates hope for caregivers and those with dementia in "committed action connecting with God's action-in-the-world" (p. 200). Action can take the form of compassionate care for people with dementia that affirms their retention of personhood regardless of the degree of cognitive deterioration. However, hope derives from more than individuals acting to meet the spiritual needs of people with dementia. Shamy also calls for social action to stand up to medical systems that value profits more than people and, more broadly, to critique the "idols of materialism and consumerism" (p. 31) that define a person's value. She reserves some of her most stinging criticisms for the church and its focus upon the young, stating that churches direct resources toward youth programs and then claim that a lack of funds prevents them from expanding ministry to older people, especially those whose dementia calls for specialized pastoral care. Her experiences in New Zealand and England point her to conclusions similar to those of Jones and Jones, who contributed a chapter to the Hauerwas volume. Their ministry in the United States led them to observe that too often Protestant Christians "have allowed our worship to be shaped by the very presumptions of rationality and productivity that are regnant in the wider culture" (p. 187).
Hope for the Future?
It is instructive to consider the audiences for these three books. Barton and colleagues designed and wrote their book for staff trainers at long-term care facilities, arguing that wholistic care must include attention to the spirituality of both residents and caregivers. Shamy's work is directed primarily at clergy and chaplains, although she also offers suggestions for long-term care administrators about how to provide worship and pastoral care for people with dementia. Both books speak primarily to the present situation and provide concrete suggestions for bringing hope to older adults living in institutional settings. This hope is found in the recognition of mutuality and the discovery of common bonds of humanity revealed through shared stories. The authors writing in the Hauerwas volume primarily address Christian clergy and laity; they focus on the specific narratives of Christianity that bind believers together as friends in a community that transcends time and culture. However, just because these books are addressed to specific audiences should not deter others from reading them, for all offer important insights. They also raise challenging questions.
Who will provide care in the future? Will it be people like my fearful student? If so, what kinds of decisions will they make about social policies that shape the experience of aging and the care of the infirm elderly? What will happen to societies that continue to valorize youth and to promote expensive nostrums for maintaining the illusion of youthfulness in old age? Other troubling questions arise about social justice and the separation of those who can afford a "good old age" (defined solely as the maintenance of youthful appearance, physical activity, and mental acuity) from those who cannot.
Two of the three books reviewed here (Shamy and Hauerwas et al.) call for faith communities to provide the moral leadership needed to secure hope in aging societies. Nevertheless, evidence provided by Altemeyer's (2004) research and a recent survey of Jewish Americans (Berkofsky, 2004) suggests that religious organizations are rapidly declining because people—especially middle-aged adults and their children—are abandoning faith communities despite desperate efforts by churches and synagogues to appeal to youth. On the other hand, there are a few programs developed in the last decade to train religious leaders both in ministry with older people and in speaking prophetically to a society that devalues the old.
The Center on Aging, Religion, and Spirituality at Luther Seminary in St. Paul, Minnesota, educates clergy and laity about aging, as does Hiddur: The Center for Aging and Judaism at the Reconstructionist Rabbinical College outside of Philadelphia, Pennsylvania. Barton, Grudzen, and Zielske are all associated with the Center for Gerontology, Spirituality, and Faith, which sponsors seminars on spirituality and aging for theological and medical schools in the San Francisco area. Eileen Shamy died a few years ago, but her work in New Zealand and with the Christian Council on Ageing in the United Kingdom is being continued in programs that educate clergy about ministry with people with dementia. Finally, a number of contributors to the Hauerwas volume are associated with the divinity school at Duke University where, for many years, research and scholarship has promoted a wholistic perspective on later life. These students and teachers, as well as the gerontologists who are contributing fresh perspectives on aging from their involvement with the arts and humanities, are planting the seeds for future generations to grow old with hope.
References
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