Simplistic article on suicide in the elderly from Milesetones

Milestones is a tabloid type newspaper published by the Philadelphia Corporation for Aging and distributed free in Philadelphia and downloadable online. It’s the usual party line pep talk stuff.

Their November 2017 issue included an article about suicide. Here’s how I responded.

I was appalled by your article on suicide among the elderly. Milestones reaches a large, diverse audience with a tabloid type newspaper. You have a rare opportunity to share accurate information and raise concerns. Instead, you present a simplistic view of a complex subject, in a way that could actually harm the very people you are targeting for help.

(1) The article conflates suicide with depression. The truth is, not all suicidal people are depressed, and not all depressed people are suicidal. Yet following an opening paragraph on suicide, the article segues into a discussion of depression, without making this distinction.
For many people, suicide can be viewed as a rational response to a diagnosis of Alzheimers or any other condition that removes the person’s opportunity to live pain-free and with dignity. Pain is not always responsive to treatment and side effects of medications can be so horrific as to take away all quality of life. The view of all suicide decisions as irrational is based on values, not medicine or science.

Last year, the New York Times Magazine reported the suicide of Sandy Bem, a distinguished research psychologist diagnosed with Alzheimers. She was perfectly sane; she just wanted to avoid the miserable life that lay ahead. In her book Never Say Die, Susan Jacoby describes a man who could no longer live alone, after living in solitude for many years and valuing his privacy; he stole his caregiver’s car keys, drove to a bridge and jumped. She argues that he should have had easier access to death, not psychiatric treatment.

To put this in context, at one point the CIA gave cyanide tablets to spy pilots who were in danger of crashing into POW camps. For many innocent elderly people, a nursing home will resemble a POW camp, but with no possibility of rescue and no opportunity to live a good life afterward. About 1/6 of nursing home residents are subject to abuse, and that’s a conservative estimate, omitting behaviors that deprive people of their peace and dignity; tying someone to a chair in front of a television set is considered normal.

Your article totally ignores this issue, suggesting that people want to die to avoid being a burden. Some just want to live a life free of pain and misery. Think of Patrick Henry’s “Give me liberty or give me death.”

(2) In lieu of Patrick Henry, the article quotes someone named Patrick Arbore, an Ed.D. Apparently he says, “depressed older adults often respond positively to intervention,” and, “In most cases their depression can be treated.”

“Often” and “most” aren’t exactly scientific terms or precise quantifications. Often could mean 51% or even “not rare,” i.e., 10-30%. Why aren’t you quoting statistics, which are easily available on the Internet?

Anything can be treated, but not all treatments have good outcomes. The truth is that only the most severe cases of depression respond to medications. There’s a strong placebo effect. Treating depression isn’t like giving someone aspirin for a headache; you have to work with the medications, trying one and then making modifications. Talk therapy has been indicated as more desirable for sadness associated with life events, such as bereavement.

(3) The article suggests that older people avoid therapy because of the stigma. People who came of age in the sixties — who are now in their sixties and seventies — grew up with therapy. They know that therapists differ widely in skill and experience. And they can’t find the good ones, let alone pay the going rate.
The New York Times has reported that only 55% of mental health professionals accept Medicare, compared to 86% of other medical professionals. Anyone seeking treatment faces an uphill battle to find a provider, let alone someone who’s competent and experienced with the relevant age group.

Another NY Times article found that 27% of people with depression were not receiving treatment. At the same time, about 29% of those being treated for depression were not clinically depressed; they were receiving unnecessary, potentially harmful treatment.

When readers get exposed to simplistic articles like this one, they may be tempted to push healthy people into treatment that’s at best a waste of time and at worst leading to side effects that would make anyone depressed. I personally know two people who presented with physical illness, yet were misdiagnosed as mentally ill, leaving them traumatized from receiving unnecessary treatment and suffering from delayed intervention in their genuine medical conditions. And according to Steven Hatch, MD, author of Snowball In A Blizzard, psychiatric diagnoses are prone to systematic flaws that can be summarized in one word: Rosenhan.

Practical measures should include fighting to make assisted dying more widely available. We need more awareness of the difference between depression-related suicide and the desire to die with dignity. And if someone truly is depressed, they need access to competent professionals, instead of the bottom of the barrel therapists willing to accept Medicare.

Simplistic articles like this one do a lot of harm. The elderly are abused because they’re not taken seriously. Many are depressed because there’s no place for them in society; that can be cured with a pill or a year of talk therapy. Writing in a simplistic tone about a complex, challenging situation can be viewed as dismissive, exacerbating the problem. I hope you’ll reconsider your editorial policy and start to do some good.

Answer to an article

Here’s what I sent to the author of Milestones, a tabloid for “seniors.”

The story on “elder orphans” raised several questions for me.

The term “elder orphans” is deeply offensive to many people who are aging without family. An orphan is a child without parents. We’re talking about adults without children. The term is infantilizing.

Additionally, the problem of planning for end of life as well as care during illness is not limited to elders. Anyone’s spouse could die or decide to leave; I know a woman who was “dumped” in her mid-fifties. Children can be unreliable, far away, or estranged. There’s no guarantee that children will carry out your wishes; we’ve all heard stories of the grown children who fly in and start making decisions even when they haven’t seen their parents in years.

As for care, something like 90% of elder abuse comes from family.

Your story also implies that older people who live alone are lonely. Many of us would rather be dead than share our living space. In her book, Never Say Die, Susan Jacoby describes a man who’s forced to start living with a caretaker. He steals the caretaker’s car keys, drives to a bridge and jumps off. Many older people can relate.

What’s needed are three things:

1 – A way to allow the elderly to see meaningful employment — something that gets rewarded for good performance. Not every elder wants to leave a legacy Many older people are isolated because of age discrimination in the workplace. One of Trump’s lawyers is 84 years old. Nancy Pelosi is in her late 70s. Most people their age would be considered too old for any job except greeter in a big box store. Getting paid means being recognized and valued. Many older people have trouble reaching out and getting involved because they don’t have money — and because working creates bonds.

I’m older than the people you mentioned in the article. I work on the Internet; there’s no way I could get a meaningful face to face job. And when I meet people, they don’t ask what I do; they ask, “Are you retired?”

2 – Currently age discrimination is not considered politically incorrect. Older women are disrespectfully addressed as “Gramma” or referred to as “grannies.” Jokes about older people needing diapers don’t help. Think of the song, “Grandma got run over by a reindeer.” Imagine a similar song about black people or gays.

3 – Everybody – not just the elderly – needs to be able to set up advance directives for end of life care, stored in the cloud. Those who set this up could get a bracelet or tattoo with the URL holding these wishes. We need strict laws to prevent overeager medical people from violating these wishes. This is the 21st century. I did my last mortgage without touching a piece of paper. Our ability to die as we wish should not depend on a live medical proxy.

And we need assisted dying. There’s no way to maintain quality of life in most nursing homes. Without constant vigilance by a capable advocate, the inmates will be abused.

Good article here:

Tracking Aging Concepts

Back when I was doing improv, we were at the last class. One of the guys says, “It’s nice to see you playing with the kids.”
“Kids? That guy over there has white hair. He’s not a kid. Anyway, what difference does it make?

7/15 – In the Clay Studio I tell the joke about telling tourists my dog is an authentic colonial dog. Nice guy says, “They think you’re this crazy old lady.”
Me: Crazy? I’m going to come here and make a crack about gays.
Him: “I’ll probably agree with you.” OK…I’m on that one.

7/17: Image on LinkedIn: “Software so simple even a grandma could use it.” Ageist AND Sexist.

7/18 – Today I’m watching a CreativeLive video on vlogs. The charming, very young presenter (who speaks with the usual “young people’s accent”) says, “You vary your presentation for your audience. If they’re older, you might want to go slower.”

Comments on Cialdini’s Pre-Suasion

The book is generally good, though not as ground-breaking as Influence. The impact of pre-suasion has been identified elsewhere and is commonly practiced by marketers.

However, four pages in this book – 122-126, together with the related footnote, seem particularly disturbing.

“the process of growing old” is described in very negative terms, mostly physical: “erode your ability to see, hear and think clearly…dulled sense of taste…compromised digestive system…vulnerable to an array of other afflictions, such as coronary heart issue, stroke, atherosclerosis, pneumonia, arthritis and heart disease.”

These “afflictions” affect people who are quite old and often near death. Many older people suffer more from the misguided effort of the medical professional to address these conditions, although medical intervention doesn’t always extend mortality or raise quality of life. In fact, some research suggests that diagnosis of diabetes after 65 doesn’t affect mortality.

Cialdini goes on to say that, “on average elderly individuals experience significant losses…yet they don’t let the declines undermine their happiness.” He cites one set of research studies, yet refers to “seniors,” not “seniors in the study.”

In his footnote, he does note that the “positivity paradox doesn’t usually extend into the very last phases of life…” because at that point the elderly lose control of their lives.

Yet considerable research as well as evidence from practicing physicians suggests that depression is significant among the old and younger old. Reported incidence of depression varies widely, possibly due to measurement flaws and motivation of the medical provider to prescribe drugs.

The tendency to focus on the good in a marriage may be related to length of time in a marriage, or experience of being married generally.

Age discrimination takes a huge toll. Many older people are able and willing to work. While a 70-ear-old can be president of the US, a competent person over 50 will have trouble finding an ordinary responsible job; at 60, the options dwindle to jobs like greeter at big box store. Older people often are treated with rudeness and condescension. Not all have spouses or siblings who can be sources of support and advocacy. People who experience these realities have every reason to be “grumpy” — an ageist term that should not appear in the pages of a psychology book. Images of cheerful, tolerant elders are as harmful to the aging population as images of happy slaves were to the treatment of African-Americans.

I’d suggest reading Never Say Die, by Susan Jacoby, for a realistic view of the aging experience, and also Goddesses Never Age by Christiane Northrup, about the possibility of aging in good health. Northrup is optimistic but does not dismiss the realities of age discrimination and stereotypes. Read Mary Pipher’s Another Country (which has become somewhat dated due to weaker family structures in the western world).

Aging By The Numbers

Something to think about:

Paul Westhead was 68 years old when he coached the Phoenix Mercury to a WNBA championship.
Marynell Meadors coached the Atlanta Dream while she was 64 to 69 years old (including playoff appearances).
Bernie Sanders runs for president of the United States at 74.
Donald Trump and Hilly Clinton run for president at 69.
Joan Rivers won The Apprentice at 75.

Nobody would hire people of their ages for a corporate management or academic professorial job.

But it’s important to realize that in some ways these people are outliers. They benefit from a combination of genes and opportunities – seeds sown before they reached their sixties.

When looking at age, it’s about the variance, not the mean.