The Journal of Long Term Home Health Care, The Pride Institute Journal, Vol. 13, No. 2, Spring 1994

Enhancing the Quality of Life for the Frail Elderly: Rx, The Poetic Prescription
Sherry Reiter, C.S. W., R.P. T., R.D. T.

Introduction

Poet Matthew Arnold asked, "What is it to grow old?"

Is it to lose the glory of the form,
The luster of the eye?...
Is it to feel each limb
Grow stiffer, every function less exact,
Each nerve more loosely strung ?...

His response was:

It is to spend long days
And not once feel that we were ever young;
It is to add, immured
In the hot prison of the present, month
To month with weary pain.1

What an anti-therapeutic poem! These words are sure to depress not only the older person, but the younger person as well. In fact, the words embody depression, speaking of fatality, imprisonment, debilitation, loss of selfhood, and no alternatives. Although Mr. Arnold's poetry may state the problem, it offers no solution.

Rainer Maria Rilke stated, "It seems to me that almost all our sadnesses are moments of... paralysis because we no longer hear our astonished emotions living." 2 When emotions are frozen, it is the therapist's task to help the paralysis give way to feeling, and to liberate feelings that have been imprisoned.

A poem by William Wordsworth speaks to this point, exalting the serendipitous joys of life when he writes:

My heart leaps up when I behold
A rainbow in the sky.
So was it when my life began;
So is it now I am a man. So be it when I shall grow old,
Or let me die...1

Poetry is a special statement about the human condition.3 To be frail and elderly presents several dilemmas: How can one trust oneself when the body is falling apart? How can one rely on others when loved ones are disappearing? How can one feel one's own strength when loss, infirmity, and death loom as certainties? How does the professional address these issues? What is better suited to the task than poetry? This art form integrates the expression of mind.

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One of my favorite poems for working with the elderly is a poem called "My Get Up and Go Has Got Up and Went."4 It deals with the problems of physical deterioration through humor. The poetic devices of rhythm and rhyme work on a subconscious level to relax the listener while presenting serious issues.

How do I know that my youth is all spent?
Well, my get up and go has got up and went.
But in spite of it all I am able to grin
When I recall where my get up has been.

Old age is golden, so I've heard it said,
But sometimes I wonder when I get into bed,
With my ears in a drawer and my teeth in a cup
My eyes on the table until I wake up...

When I was young, my slippers were red,
I could kick up my heels right over my head;
When I grew older, my slippers were blue,
But still l could dance the whole night through
But now I am old; my slippers are black
I walk to the store, and I puff my way back...
Since I have retired from life's competition,
I busy myself with complete repetition.

I get up each morning, dust off my wits,
Pick up my paper and read the "obits. "
If my name is missing, I know I'm not dead,
So I eat a good breakfast and go back to bed!

Poetry as Catalyst

Last year I received a call from a woman in my community whose mother, Millie, was extremely depressed and withdrawn. Her chief contact with the outside world was her daily trip to the mailbox. Would I go and visit and somehow help her mother to understand that her life was valuable?

I approached this task with some trepidation. If only I had some magic potion! This magical elixir of life could be administered, and once swallowed and digested would transform the consumer. That was, in fact, part of the healing ceremonies in ancient Egypt, where the physician would write healing words on papyrus, dissolve the words, and have the patient ingest the solution.5 The modern-day version of this is the poetry therapist who does not write on papyrus, but brings words to be taken in and digested on an emotional and cognitive level. However, when I went to visit Millie, the only magic I knew was in my briefcase-a stash of poems, an assortment of powerful poetry prescriptions ready to use should the occasion warrant it.

Although Millie's daughter had contacted me because she knew I was a psychiatric social worker, in this particular case, it was my skill as a biblio/poetry therapist that offered a specific treatment method.

In poetry therapy, a poem is used as a catalyst for exploring deeper thoughts and feelings. The poem may be thought of as an empathetic friend.6 In actuality, it is an embodiment of the thoughts and feelings of another human being, whether the poet is alive or long dead. This friendly "other" is nonthreatening in its reduced black-and-white form and, unlike some human friends, it is always there. Object constancy becomes very important to a person who is particularly sensitive to the issues of separation and loss.

The therapist chooses a poem that addresses the needs and concerns of a specific person. Material emerges on a cognitive and affective level. The creative process is accompanied by a sense of wonder, joy, and renewal. Sometimes the client or therapist collects the material resulting in a poem which further validates and integrates the recalled experience. Rollo May points to creativity as man's highest and healthiest activity: "The creative process is a struggle against disintegration, the struggle to bring into existence new kinds of being that give harmony and integration."7

According to Erickson, the developmental task of the last period of life is integrity, the coming together of all previous phases of the life cycle, "to clarify, deepen, and find use for what one has already obtained in a lifetime of learning and adapting.8 Accepting this theoretical base, Butler introduced the concept of "life review" or reminiscing, the return to past experiences with the purpose of ego integration and enhancing self-esteem.9

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Studies have found that recalling the past can help the older person cope with anxiety and depression both in the present and future (see the work of McMahon and Rudick,10 Liton and Olstein,11 and Fallot12). John Wheelock once wrote "A poem is what happens when a poet rediscovers, for himself, the reality we have lost sight of because ... it has been overlaid by the veil of familiarity."14 Reminiscence and poetry therefore share this commonality. It was my hope that Millie would be receptive to these creative techniques.

Millie

Millie was an 86-year-old widow who had rarely left her home since the death of her husband 4 years earlier. She had various physical ailments, including a hiatus hernia, digestive difficulties, and arthritis. Millie also suffered from an inability to control her bladder and was fearful of being embarrassed by "having an accident." One of the few times she left the house was upon the urging of her friends from the senior center who begged her to join them. Prior to her husband's illness, Millie had been popular and very active. She went to the senior center a few times a week and was part of the choral group and the drama club, but this time she just sat at the table with her friends and could not stop crying. She became withdrawn and seclusive. Friends eventually gave up trying to contact her. The only persons with whom she spoke regularly were her daughter and her older sister.

Although her daughter recognized the symptoms of depression in her mother, she was not able to convince her to see a doctor. At one point, she called the geriatric mobile crisis unit from a city hospital, and the visiting psychiatrist hospitalized Millie against her will. Millie became hysterical and was put into isolation. The antidepressant she was given aggravated her digestive difficulties, forcing her to discontinue the medication. Millie's negative experience only furthered her distrust of medical doctors, social workers, and anyone associated with the helping professions.

My relationship with Millie was not an easy one. At the end of our first session, she collapsed in my arms, crying hysterically, beating her breasts, saying that she wanted to die. Only a few moments earlier, she had been eager to show me the family pictures which were mounted on her walls: photographs of Millie as a vivacious young girl, a happy young woman, a cheerful middle-aged lady, and a smiling, fashionable woman in her seventies, arm-in-arm with her husband. The photographs revealed a very different side to the weeping, distraught woman beside me. Efforts to focus the conversation and extract a history were difficult, since Millie free-associated and cried throughout the hour.

During that first session, I kept my sheaf of poetry nearby and asked brightly, "Do you like poetry, Millie?"

"No," she replied. "Can't stand the stuff." Attempting a more traditional approach, I asked what her life had been like when her husband was alive. She rambled on and continued to cry. At that point I reached for my briefcase and said, "I have something here I'd like you to listen to, Millie." I read her the following poem:

Rough Weather Makes Good Timber
by Lee Edwin Kiser14

The house was built in '98,
prior to my arrival.
And a big maple tree at the corner of the porch
was run over and buried lots of times by wagons
moving in materials to build the house.
And the other maples what Daddy had planted,
they had no trouble at all.
But they all died and this one lived that has such rough treatment.

And there's a saying
"Rough weather makes good timber. "

It may be
that the trouble with folks today
is that they're raised like hothouse flowers,
and they don't have much to go on
at the end.

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"So Millie, are you a hothouse flower?" I asked.

For the first time in the session, Millie gave me a straight answer without rambling or digressing. "I certainly am not," she replied. "I was the strong one-always working, always good with my hands. As a young girl, I was stronger than my sister. I worked in the factory for several years before I married-then I helped my husband in his business."

Suddenly, I was in touch with the other side of Millie. She spoke with pride and dignity. I am continually amazed by the power of imagery to bypass all resistances and get straight to the heart of the matter. The image operates like an access code typed into the computer of the brain. Studies show that concrete language and imagery activate the storehouse of long-term memory images and associations.15

Of all the stories Millie told me that day, the words of one in particular echoed in my mind as it depicted her predicament and emotional state with flawless clarity. I recorded her stories, almost word for word, condensing them into a narrative poem, for although the poetry therapist utilizes his or her own skill as a poet, the source of all material is the client. It would be impossible for a client to claim or reclaim his or her experience if it were altered beyond recognition, therefore it is crucial that the therapist record the client's own words while striving to retain the authenticity and integrity of the voice struggling to be heard. A psychiatrist may view the poem as an emotional X-ray, which contains important diagnostic information within it. Here is Millie's experience:

Lost

I was four or five
in Russia
Playing with my two little friends.
We played and played, running and laughing.
We hardly noticed that we had entered
The great forest.
Suddenly I was alone
Lost in a wilderness -

I could not find my way I was running,
running, running
Alone
Until at last I found my way to a stand
where a woman held me in her arms
while I cried,
"I am lost! I am lost!"
And now, eighty years later,
I am again in the wilderness-
running, running, running...

The Second Visit

During our second session, I presented Millie with a typed version of this poem which I had recorded the previous week. She listened as I read it and cried, "Yes, yes, it's true. I am in the wilderness."

"And I am here with you," I added. I left the poem on her coffee table where I found it the following session.

On that day, my third visit, she pointed at the poem shrieking, "Oh! It makes me sick. Please; take it away."

I put the poem away. A few minutes later, she brought the poem up again and said, "Why do you want me to look at such a thing?"

I replied, "It is your emotional truth. It may be painful to look at, nevertheless, it speaks the truth."

"Well," Millie said, "You may have something there." I returned the poem to the coffee table.

Fanny

Subsequent poems focused on her relationship with her sister, Fanny- her best friend and greatest rival.

My Sister

She called
to tell me she was dying.
What can I say?
l always took care of her.
But now... what can I do?
She said, "Cry. Go ahead, I want to
hear you cry. "
I cried and screamed and hung up the
phone.
I think my sister hates me.
She has hated me for a long, long time.
From the time we were children.

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I was the prettier. I was the smarter.
People always remembered me.
They forgot her.
They paid attention to me. They
ignored her.
She will never forgive me for that.
She called
to tell me she was dying.
What can I say?

It was important for Millie to make some sense of the love-hate relationship she had with her sister. At one point, the sister called from her hospital bed, telling Millie to drop dead. Millie was able to cope with this situation because our work had helped her to understand the dynamics of her relationship with Fanny. As we explored this relationship, another poem emerged.

Ptew! Ptew!! Ptew!!! Spit Three Times

When people comment
"What a pretty girl you are! "
My mother would spit-ptew! ptew! ptew!
Lest the evil eye befall me.
But from the time I was born
There was one who watched with jealous eyes
And a little green demon sat upon her heart.

My sister Fanny hated me from the time I
was born
And taking the full advantage that older
sisters do,
I believed her threats, veiled or direct.
When we both vied to sleep near the window,
she would say,
"So, sleep near the window- someone's going to grab your tuchis!"
The joy was squelched and replaced by unseen punishment.

And in the fifth grade, I did my job as
assistant teacher so well,
"Oh, what a pretty face you have "

Spit three times-ptew! ptew! ptew!
" Were they good in my absence ? " asked the
teacher.
"All but one, " I answered.
"I will punish her," she said.
And she did.
But the punishment and shame were mine.
Does being pretty always mean that
someone else will suffer?

Ptew! Ptew! Ptew! Spit three times.

When I was twenty-five, we lived in the
country.

I was minding the store when a young man
came in and asked,
"Would you like to come to a dance?"
"Can I take my sister along ?" I asked.
That night, in long dresses, Fanny insisted
we take a detour.
"I don 't want to go to the dance. Let's go to
the movies instead."
And so we did.
That night was bedlam. Mama had called the
Hudson police and
everyone was searching for the two young
women in long dresses who never
arrived at the dance.
Daddy shook me, "What do you mean by
doing this to your mother?"
I cried, but Fanny just laughed.
She's got the devil in her.
I still cry. She still laughs.
Haven't I been punished enough?

This poem was a catalyst that prompted Millie to explore her present state of ill health, which felt to her very much like a punishment. Old guilts preyed on Millie's mind, as she sought an explanation for her suffering.

A short time after I began working with Millie, I noticed that at some sessions, she would say, "I feel good-No, not just good, but very, very good!"

But within a day or two, there was a mood swing and Millie would be deeply depressed. I felt that it was crucial for Millie to be seen by a psychiatrist and be treated for a bipolar disorder. At one point, Millie called me late one evening to say that she would see a doctor. The pain, she said, was more than she could bear. By my next visit, she had reversed her decision.

Although Millie had received some comfort from my visits, I felt that psychopharmaceutical treatment could make a real difference. As a last resort, I called a family meeting when her granddaughter was in town during her college recess. The intervention was unsuccessful and I never saw Millie again. In Millie's eye, she no longer had control over anything in her life. She would not let others tell he

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Although I deeply regretted the abrupt way the relationship ended, I do feel that the best moments in the therapeutic relationship were shared through the vehicle of poetry therapy and reminiscence-and that, for a short period of time, the words offered solace and some sense to a lonely, bewildered individual.

Conclusions

Several points of learning can be extracted from this case study.

· Just as play is natural to the child, storytelling and reminiscing are natural to the older adult. It is the practitioner's task to listen, to supply verbal cues to keep the storyteller on track, and to clarify the information by asking pertinent questions.

· Two therapeutic components are evident when using biblio/poetry therapy techniques. First, when the children find their own voice, they learn what it is that they know. Telling one's story is very powerful and many feelings are evoked. Finding one's voice reminds the older person that there is still a voice within. Second, the fact that someone will listen further validates the life of the story, and consequently, the life of the storyteller as well.

· It is the therapist's task to assess the significance of information in therapeutic terms.

We all store thousands of stories, and any story that surfaces may do so for a reason. For example, Millie's first poem, 'lost," was a replication of her present confusion. In addition, it was a cry for help. In the poem, she mentions a woman who held her in her arms as she cried, "I am lost!" After the telling of the story, Millie cried and I held her hand, reassuring her that we would work together to find a solution.

· Images, whether represented by concrete objects or "word pictures," can be used as evocative tools for eliciting feelings and associative thoughts in reminiscence work.

In poetry therapy, the image serves as a key to the floodgates of feeling and thought which otherwise may remain closed. Metaphor provides an alterative language that the therapist can use to communicate on a deep level without resistance from the client.

Millie understood the metaphor in "Rough Weather Makes Good Timber." She also readily embraced the metaphor of the hothouse flower, and was able to make comparisons between the flower and herself. Metaphoric language was a successful catalyst to meaningful discussion whereas prose was not as effective. The language of metaphor is readily understood by children, adults, and the psychiatrically disabled. All therapists should be bilingual, since common prose cannot always connect us to our clients' thoughts, particularly if they are distraught or upset. "Metaphorese" is a primary language that uses our visual inner eye, much as we do in dreams. If poetry is the royal road to the unconscious, metaphor is the drawbridge allowing us to enter a deeper realm of feeling and thought.

· Putting the story to paper and externalizing it allows the thoughts to be viewed from a different perspective, and gives the creator a sense of mastery. The black-and-white mirror of Millie's emotions was overwhelming for her at first. Nevertheless, it was a crystallization of her own thought processes and a representation of her feelings-painful, but truthful.

When possible, it is the clients themselves who write their own stories and poems. When the client cannot do this, because of physical or emotional handicaps, the therapist becomes the scribe.

The poem and the story are creative art forms that work upon the heart, mind, and spirit with a gentleness that is unsurpassed

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by traditional modes of verbal therapy. The elderly are keepers of thousands of stories and unwritten poems. The biblio/ poetry therapist is trained to listen for the story and call it into being, using other stories, poems, and objects if necessary. By recording the poems and stories, we validate their existence. The creative process breathes new life into the story, as well as the storyteller.

How can we enhance the quality of life for the frail elderly? A biblio/poetry therapist like myself will suggest that the answer lies dormant within the hearts of the elderly themselves. It is their innate creativity that offers the most natural, dignified, and life affirming solution. The poetic prescription has yet to be recognized for the powerful healing modality that it is. In the meantime, the poetic prescription sleeps, along with countless poems and stories, in the treasure chests of our elderly.

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References

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A BIBLIOGRAPHY FOR WORKING WITH OLDER ADULTS

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