People come here to die: Winnicott and the the trauma of old age 

This essay draws on my experience with a continuing care retirement community (CCRC).  It is an essay on trauma–the trauma of old age and impending death.  The CCRC serves as what D. W. Winnicott calls a transitional object.  Only in the case of the CCRC, it’s a transitional object in reverse.  That’s good and bad.  Mostly it’s interesting, especially for me, since I live in one.  

People come here to die.  A CCRC, of which there are over 2,000 in the United States, provides independent living, assisted living, and nursing home care under one roof in the smaller communities.  The larger CCRCs often occupy a campus, but the same principle applies.  I live in one of the smaller CCRCs, with about 200 residents in independent living.

My wife died close to five years ago now.  I lived alone in a big house for about two years.  Keeping up the house and living alone became too much, and I moved to the CCRC.  I’ve lived here now for almost three years.  

The CCRC as transitional object in reverse

I’ve thought a lot about the psychology of living in a CCRC.  What set me off was the remark by my first friend here.  He said people don’t make close friendships in retirement communities because they know their friends will soon die.  My friend died about a year after I met him (he was in his 90s), and I think what he said was only partly true.  

The CCRC serves as a transitional object.   What’s unusual about the CCRC is that it’s a transitional object in reverse.  The infant and young child’s use of the transitional object serves to help him or her separate me from not-me, and so move from dependence to relative independence.  The CCRC is the opposite, helping the residents move from independence to relative dependence.

The flipper is a good example, the first step in this move.  The flipper is a little tear-drop-shaped piece of wood that swings on the outside of the independent living resident’s door.  A worker pushes it against the door late at night, and it flips to a down position when I open the door in the morning.  If the door isn’t opened by about 11am, the flipper stays up, and someone checks to see if I’m dead or seriously ill.  

The flipper is the first step in a series of events—call them care—that usually eventuate in the resident dying in the nursing facility in an adjacent building. 

A flawed transitional object 

The CCRC is a flawed, imperfect transitional object because it cannot be created by the resident.  Mine is a non-profit, but a corporate board, composed of younger men and women relatively unfamiliar with everyday life here sets policy.  More importantly, the ethic of the CCRC is one of caring for those who cannot care for themselves.  This is most obvious in the nursing home, but it all begins with the little flipper.  

Residents are remarkably constrained in their ability to influence policy and procedure.  If they could, it would be the institutional version of creating what is needed and supplied, which is the mark of the transitional object.  For the infant, the experience is an illusion meeting a corresponding reality.  The breast appears just as the infant desires to be fed,  as though the infant had created the breast.  For the adult, the experience of illusion meeting reality is making a difference when faced with the concrete institution.  Institutions of all kinds are reified and resistant to change.  To change an institution, even in a small way, is the adult version of having created what was presented as unalterably given.  An adult is aware of the process, but it remains a minor miracle.

Concentrated morbidity and mortality

Living in a CCRC, especially a small one like mine is an experience concentrated morbidity and mortality.  An ambulance comes to the front door several times a week (often accompanied by a firetruck; I have no idea why).  For some regulatory reason I don’t understand, there is no separate entrance to the wellness center (aka nursing home), but the ambulance often comes for people in independent living.  Everyone hates it; everyone is intensely curious.  Will it be someone like me, someone deemed in good health?  

Life here resembles life on a cruise ship.  Two or three movies a day in a small theater, afternoon and evening entertainment, two dining venues, and a pub.  A cruise ship to nowhere it is sometimes called.  Rarely is it called what I call it, a cruise ship across the river Styx.  

Limbo

The transitional object is neither internalized nor lost when it is no longer needed, says Winnicott.  It is relegated to limbo (“Transitional Objects,” pp. 5-6).  Here we must invert our perspective.  Imagine that the resident becomes the transitional object.  Limbo is a state of existence between life and death.  There is lots of living here, but the dominant emotional state, frequently hidden by activity, is waiting: waiting to die.  Some just wait; many consume entertainment to fill the time.  Often I see people going into the auditorium and asking what’s the entertainment tonight. As in, “I’ll listen to anything just to stay out of my apartment for another hour.”  Here it’s generally a lecture or music, mostly classical or jazz.  It’s a pretty cultured group.  But residents are still consuming entertainment while waiting.  Book clubs, populated almost exclusively by women, are a big waiting activity here.  So are dining groups, composed of residents who dine together regularly.  

Holding 

Holding is the most important function of the CCRC.   The new individual feels “infinitely exposed,” says Winnicott.  “Only if someone has her arms around the infant . . . can the I AM moment be endured.” (“Group Influences,” p 148)  

The aged individual is infinitely exposed to the universe, to nothingness, to incipient non-being.  Religion helps some, but it hardly eliminates the terror.  Jews, who make up almost 30% of the residents, are generally not oriented toward the afterlife; nor are the surprisingly large percentage of Unitarian Universalists.  Add non-believers and skeptical believers like myself, and the fear of non-being is virtually unmitigated. This “infinite exposure” to endless non-being is the most important unstated fact of life in the CCRC.  All the failures of the CCRC as a transitional object pale in comparison, although they are related.  The most important function of the CCRC as transitional object is to hold without crushing or dropping the resident.  Only unlike the infant, the goal is to hold the aging resident more tightly.   One small and only seemingly insignificant way the institution does so is through food.  

The food served here is generally closer to comfort food than healthy food.  By the time you’ve reached 80+ years, it hardly matters.  Rich desserts are especially popular, one of the few sensuous pleasures that remain.

“Psyche indwelling in soma” 

Good enough handling results in the infant’s “psyche indwelling in soma.” (“Mind and its Relationship to the Psyche-Soma,” p. 244)  The body is self.  This reality is threatened in old age, and in some ways, it’s better when the psyche doesn’t dwell in soma.  Parkinson’s disease, stroke, and other infirmities mean that psyche isn’t soma.  Or at least the sufferer wishes it weren’t.  Soma betrays psyche, and in some respects the psyche is forever young.

There are more physical conditioning classes here than any other type of class, as well as a fully outfitted gym in addition to a rehabilitation center.  Chair yoga, regular yoga, exercising to music, Zumba, stretching classes, balance classes, tap dancing, boxing bag classes (boxing is therapeutic for Parkinson’s patients), the list goes on.  The goal isn’t just to keep the body as fit as possible, though there are some remarkably fit 80+ year-olds here.  It’s to keep mind in sync with soma as much and as long as possible.  The result is an experience of mind united with soma for at least a little while.  Evidently, it works.  Most classes are fully booked.

Many residents wear step trackers and do 10,000 steps/day, about 5 miles.  Most walk around the two man-made lakes within walking distance.  Many log 20,000 or more steps per day. 

Winnicott wasn’t wrong.  For the psyche to feel united with the body is deeply satisfying.  I’m not sure whether to say that in the end, the body betrays the mind, or whether the body just dies and with it the mind.   

Conclusion

People come here to die.  But along the way, some people find fuller lives than they had known for years.  I have found a romantic partner and a degree and type of love I’ve never known.  But I’m one of the lucky ones.  Most don’t.  There is more hanky-panky here than one might expect in a retirement home, but not a lot as far as I can tell.  For some this is a result of choice; for others, it is a lack of opportunity.  

There are a few couples who seem content with friendship, but who knows what goes on behind closed doors?  There is only one lesbian couple, married for years now.  There must be other gays, given that homosexuals are roughly 10% of the population, but I don’t know who they might be.  Almost all single people here are widowed, but of course, most gays married in the era in which those who live here grew up.  

Every year there are more couples admitted than before.  Men are living longer is the simplest explanation.  Often the spouse, not always the man, is cognitively impaired, but that is why they come here.  There is a “memory care unit” in the wellness center.  

Everyone here is waiting to die.  Almost a third rarely leave their rooms.  About a third consume entertainment, and about a third are active in everything from book clubs to the residents’ association.  Almost all are better off than if they were waiting alone at home.  Even those who rarely leave their rooms venture out occasionally.   

The Todestrieb

Sometimes I’ve wondered if everyone, not just the old, is not just waiting to die.  Freud said that in the end the ego, led by the so-called death drive (Todestrieb), seeks the cessation of all stimulation, but it seeks its detour to death in its own way and its own time (Beyond the Pleasure Principle, pp 30-33).  Generally considered one of his wilder speculations, we can at least conclude that whatever our age, the real issue is how we live while waiting.  

References

Sigmund Freud, Beyond the Pleasure Principle, translated by James Strachey.  W. W. Norton, 1961.  [original 1920]

D. W. Winnicott, “Mind and its Relationship to the Psyche-Soma.”  In Collected Papers: Through Pediatrics to Psycho-Analysis, 243-254.  Basic Books, 1958.

D. W. Winnicott “Transitional Objects and Transitional Phenomena.” In Playing and Reality, 1-25.  Routledge, 1971.   

D. W.  Winnicott, “Group Influences and the Maladjusted Child: The School Aspect.” In The Family and Individual Development, 146-154.  Tavistock, 1965.