Dignity Therapy

Terminal illness often undermines a patient's sense of dignity and leads to depression, anxiety, a sense of hopelessness, and feelings of being a burden to others. One technique, however, “dignity therapy,” seems to alleviate some of these symptoms. A recent program on NPR brought it to my attention.

Dignity therapy is an intervention with the terminally ill who, in guided conversations with trained interviewers, speak of what’s most important to them. Patients are encouraged to tell their life stories and to talk about their feelings, their memories, and their hopes for their descendants. Transcriptions of their conversations are then edited and presented to the patients, who have an opportunity to correct or otherwise change them, and the patients can then bequeath the final versions to their loved ones.

The interviewers ask about the patient’s life as a whole. “Tell me a little about your life history, particularly the parts that you either remember most or think are the most important.” Responses are followed up by other questions such as “When did you feel most alive?” “Are there specific things that you would want your family to know about you and are there particular things you would want them to remember?” “What are your most important accomplishments, and what do you feel most proud of?” “What have you learned about life that you would want to pass on to others?”

The dignity therapy technique was first reported by Harvey Max Chochinov , a psychiatrist at the University of Manitoba, and his colleagues in the Journal of Clinical Oncology in 2005. The researchers, who employed the procedure with 100 terminally ill patients, half from Canada and half from Australia, found that after the therapy, a majority of patients reported a “heightened sense of dignity” and a “heightened sense of meaning,” and reported less suffering compared to the level present before the intervention.

One doesn’t need to be terminally ill in order to suffer a loss of dignity, as I’ve found in my own hospitalizations, in which I’ve often felt as though I were being processed along an assembly line of patients, an impression fortified by our being all dressed alike, in identical ill-fitting, unflattering hospital gowns. How much worse must these feelings be when, terminally ill, your strength is depleted and your dependency greater. It stands to reason that you will be bucked up when a professional shows an interest in you not as a collection of symptoms or as the host of a disease but as a person with a unique life story. And if you do not believe in an afterlife, the annihilation you face may seem not so terrible if you can leave something behind, a testament of what has been most important to you.

It struck me as I read about this technique, that one shouldn’t wait until one is terminally ill before preparing such a legacy. Not all of us will be terminally ill. We may drop dead from a heart attack or a burst aneurysm. We may be run over. We may be shot by a jealous lover. We may, in other words, die with no warning whatsoever.

I was reminded of this recently when, during a family dinner at a Chinese restaurant in Chelsea, my brother slumped in his seat, unresponsive. My quick-thinking daughter called 911, and he was taken to NYU Medical Center, where his vital signs returned to normal levels. He had suffered a “vasovagal episode” brought on by having to stand for four hours at the opening of an art show in which his wife had participated. But as I looked at him slumped in his restaurant chair, horrified at the thought that he might be dead, the brevity and uncertainty of life never seemed clearer.

So, people, if you want to leave a written legacy for your loved ones, don't wait until you’re terminally ill. But, I must admit, this is advice I won’t take myself. Since I’m not going to be hung in two weeks, to steal from one of Johnson's aphorisms, my mind is not sufficiently concentrated. Besides, I’m too busy having a good time.

2010-2011 Anchises-an Old Man's Journal All rights reserved

Inequality

The other day, while waiting at Memorial Sloan-Kettering for my medical oncologist, my wife and I sat in a row of chairs, at the end of which sat a male patient and a woman, both persons of color. Their relationship wasn’t clear. Was she his daughter? His wife? A friend? English appeared to be her native language. His English was clearly not native, although it was fluent if a bit hesitant. My nose was in a book (actually a Kindle), so I didn’t pay much attention to them, but my wife later told me what she had observed.

They had arrived three hours late for an appointment with the man’s doctor, who had already left for the day. They were late because the man had been unable to obtain transportation in time to take him to the center. He had not yet applied for the right to use the MTA’s system for disabled persons, Access-a-Ride, and therefore had to rely for transporation on the municipal shelter in which he was living. He had no means of returning to the shelter. The staff summoned a social worker, who arranged return transportation for him and explained how to apply for Access-a-Ride.

My wife told me all this as we were riding home in a taxi. Ordinarily we would have returned home by public transportation, but I had injured my foot the day before and walking was still painful. Furthermore it was pouring with an Ethiopian ferocity. So we hailed a cab.

As we rode along the East River, I couldn’t help comparing our situation with that of the man who was living in a municipal shelter, who could not pay for a long taxi ride home. It would be pleasant to assume that our good fortune was the result of our own efforts and that his misfortune was his own fault. Of course, I don’t know why he landed in a shelter. Perhaps, as my wife suggested, medical expenses bankrupted him. He was too young for Medicare and his medical insurance, if he had any, may have dropped him after he became ill.

Whatever the reason for his poverty, it’s clear that our ability to take a taxi without our having to skimp on something else had nothing to do with whatever virtues we might possess. Had we not been born to economically comfortable families that valued education and could afford to send us to elite schools, it’s doubtful that we would as privileged as we are. Life is unfair, as all the world knows, and it will ever be so. But do the inequalities have to be so great? And do they have to widen? Considering our current political gridlock, the answer to those questions, at least in the short term, is yes.

2010-2011 Anchises-an Old Man's Journal All Rights Reserved

Brain-Frying Exercises

During the past few months, my wife and I have been engaged in the most trivial of pursuits, as we've been making choices regarding the renovation of our apartment. Our contractor tells us that the work will be done in a few weeks and that we can move back before Rosh Hashanah, which falls at the end of the month. But we're still in the thick of decision-making. Recently, for example, we ordered window blinds and curtains. Last week, we bought a mattress and a bed, and this week saw us buying shower curtains and towel racks. Each of these purchases necessitated research, thought, and discussion, for the choices available are almost endless.

Barry Schwartz has written of the tyranny of choice, in his book of the same name. We were untroubled by that tyranny when we renovated our apartment in Jerusalem in 1975. The choices in finishes such as tiles and countertops were so few that we went away for the summer, while most of the work was being done, and let our architect and contractor make those decisions.

Nor were we bothered by the tyranny of choice when we furnished our home in Addis Ababa in 1968. The Ford Foundation, my employer, paid for the furniture, since subsequent employees and their families would use it, but we had to make the choices ourselves. This was easy because there was so little to choose from. There were, as I recall, only three types of upholstered chair at the town’s principal furniture store.

But the choices available today are stupefyingly numerous, even within a given price range, whether for floor tiles, wall tiles, kitchen and bathroom countertops, kitchen and bathroom cabinets, towel racks, bathroom and kitchen faucets, showerheads, bathroom vanities, door and cupboard handles, lighting fixtures, or window treatments. The head swims and the brain fries in dealing with it all.

I’m lucky in that I don’t need to look at everything before making up my mind. If it’s good enough, I’m satisfied. My wife’s doesn’t search for perfection either, but she’s more particular than I am and more fearful of making a mistake, so it usually takes her longer to decide. I tease her about this. This would be mean of me even if, as a result of her persistence, what she selects were not almost unfailingly excellent.

We look forward to moving back to our apartment and making it habitable. I worry, though, that after the brain-frying exercises in which we’ve been engaged - this tile or that tile, this color or that color - we won't ever be able to talk intelligently about anything ever again, even if we're able to find anything else to talk about.

2010-2011 Anchises-an Old Man's Journal All Rights Reserved

Self as Illusion

Last Sunday, I walked from our temporary quarters on Bridge Street to the end of Joralemon Street, at the East River, about one mile away. Paved with cobblestones for the last few blocks, the street is lined with mid-19^th century townhouses, many with splendid front gardens. As I walked down the street towards the river, I thought back to the time that I lived only a ten minute walk away, on Monroe Place, more than 50 years ago and wondered at my lack of curiosity at the time. It never occurred to me to explore the historic and remarkably beautiful area in which I was then living.

Am I the same person now that I was then? What connects me to that foolish, self-absorbed young man whose riotous living should have gotten him into far more trouble than it did? If “cigarettes and whiskey and wild, wild women will drive a man crazy,” as the old song goes, I should have landed in a locked ward at Bellevue instead of managing to return each night to Monroe Place.

My cells have been replaced several times over since then. I’m no more like that young man today than I am like Herbert Hoover. What binds me to that youth are my memories, but memories change with age, just as dispositions do. When I compare my childhood memories to those held by my brother and sister about the same events, the discrepancies are often huge, as if we had each grown up in different households. Memory is treacherous.

Perhaps the self is like a bubble floating on the ocean, its contents continually changing as the water moves under it. If so, the continuity of the self is an illusion. I hope that’s true, for I don’t much care for the young man that once I was.

2010 - 2011 Anchises-an Old Man's Journal All Rights Reserved

Very, Very Late

The other day, as I was leaving our building to take my morning walk, I held open the door for a woman who was behind me. “Thank you, sir,” she said, “I shouldn’t have said the police stopped me.” When I looked puzzled, she said that she was supposed to pick up her friend, who lives in the building, but that she was late and that to explain her tardiness, she had told her friend that she had been stopped by the police. She asked me the time. When I told her it was 10:30, she said that she was supposed to pick up her friend at 9:30. “I can’t even make up a decent excuse,” she said. “In fact, I haven’t any excuse at all.”

The woman was past her first youth, but she had beautiful blue eyes. “I’m very, very, very, very, very late,” she said. “I hope she will forgive me.” “Nobody’s perfect,” I said. “If she’s a good friend, she’ll forgive you.”

Why was that woman talking to me at all? She seemed slightly deranged. Was she flirting with me? If so, flirting with a guy a few months short of 80 would be proof of derangement. I would have been tempted to prolong the conversation – those eyes were beautiful – but it didn’t seem right somehow. “Good luck,” I said, as I turned to leave. She walked over to her parked car, the door on the driver’s side still open, and said, “Friends are so important.” She may have been slightly nuts, but she was right about that.

Hypotheses

On my morning walk the other day, I passed a woman standing near the entrance to a shop. She was talking passionately into her cellphone. “What do you care about” she asked. “You don’t care about me. You don’t care about [muffled]. What do you care about?” Totally engaged with the person to whom she was speaking, she seemed divorced from the world around her. I was intrigued, of course, by her question. To whom was she speaking? To whom or what did the muffled noun or pronoun refer?

I was tempted to stop in my tracks and eavesdrop, but that would have been rude. Besides, she might have awoken to her surroundings, noticed me listening, and moved away. As it was, she continued speaking in a loud voice, which carried for at least a block as I walked away. Alas, I could no longer make out what she was saying.

At night, when you walk past a window whose shades are not yet drawn, past a window that lets you look into a lighted room, don’t you wonder who lives there and what kind of life they lead? Through that window you can glimpse another life, just as you can glimpse a bit of the life of the people who are talking on their cellphones.

New York has eight million people and at any one time it seems that one-tenth of them are outside talking on their cellphones. If you walk the city streets, as most New Yorkers do, in any one month you can observe hundreds if not thousands of different lives through the momentary revelations that pedestrians offer in their cellphone talk. You may not learn much about them, just as you don’t learn much about the lives within the lighted room you pass, but you learn more about these people than you would have learned in the past, before cellphones became ubiquitous. And their talk provides fodder for your imagination, allowing you to construct a story around what you’ve heard.

That woman, for example, who asked so emphatically what her interlocutor cared about, was, I imagined, talking to her husband, and the muffled word I heard referred to their child. I imagined that the husband had moved out after it was discovered that he was carrying on an affair, that he had told his wife that the flame from their marriage had died out, that the thrill was gone, and that there was no use pretending any more. No wonder the woman was angry. Of course, for all I knew she was talking to her mother.

Speaking Out

The other day, when my wife boarded a bus at Grand Army Plaza, she saw an old man sitting near the driver. Chubby and cherubic, the old man seemed to be talking to himself. But his voice became louder and his face more and more mischievous. "They killed 3,000 people. Those Muslims wouldn't hurt a flea, not even a baby flea."

My wife looked around and saw, sitting near the old man, a strikingly beautiful young woman who was wearing an Islamic-style headscarf. Her face was calm as she looked straight ahead, her hands demurely in her lap. After a while she took her cellphone from her purse and photographed the old man. "How dignified she is," thought my wife.

When the bus reached the young woman's stop, she exited the bus, turned around, and shouted at her attacker, "I've got your picture on my cellphone, you fucking, racist bastard." The driver asked her to move aside, but she stood there, continuing to shout, the f-word in each breath. The driver threatened to call the police if she didn't move aside. "The police! You didn't hear what he was saying." But she did move, with a final shout, "Fascist pig!"

While the old man was abusing Muslims, my wife wondered if she ought to say something. But she concluded that the old man was deranged and that therefore there would be no point in speaking out. "The Muslims are taking the heat off the Jews," my wife thought, before remembering the saying attributed to the German pastor Martin Niemöller (1892-1984). "First they came for the communists, and I didn't speak out because I wasn't a communist. then they came for the trade unionists, and I didn't speak out because I wasn't a trade unionist. Then they came for the Jews, and I didn't speak out because I wasn't a Jew. Then they came for me, and there was no one to speak out for me."

It's not that my wife is afraid of speaking out. In a taxicab in Jerusalem, she listened to her Jewish driver abusing the Arabs. "They don't all want to kill us," she said. "I put my life in their hands every time I enter one of their cabs." This silenced her driver. But she didn't speak out this time because the old man was not, in her view, compos mentis. Had I been in her position I doubt that I would have said anything either, not because I thought the old man mentally disturbed but because I shrink from making a scene. Still, if no one says anything, if no one protests, does that lend legitimacy to the old man's vituperation? No one came to the young woman's defense, surely a failure she will not soon forget.

2010-2011 Anchises-an Old Man's Journal All rights reserved