Book Review: Living Well and Dying Well: Tales of Counselling Older People

Living Well and Dying Well: Tales of Counselling Older People

Helen Kewell (2019). Ross-on-Wye: PCCS.

The publisher's summary on the back of this book promises a collection of case studies. I suppose this is so, but it all depends on what is meant by case study. A case study is a way of reflecting on practice. As such, it is a research method and there are many different sorts of research methods. Their value depends on the question being asked as well as the skill of the researcher. Traditionally favoured by psychoanalysis, the case study is a hybrid method, part biography, part literature review, part autobiography, part phenomenological research and part natural science. Our closest association with them is usually when we write them as part of our training and, because they are assessed, the case study itself can easily get contaminated with notions of success and failure. We cannot help asking 'What effect did I have?', 'Did my client get better?', 'Will my tutor like it?'.

The case study is where two people who previously knew nothing of each other's lives come together, meet and then part. In addition, case studies are usually only written by one person, the therapist. Those written by clients only see the light of day as novels and rarely get on to course reading lists. As therapists, we know nothing of what happens after and our knowledge of what happened before is patchy. All we really know is what happens in the meeting; even then, we do not know much about that.

When considering the case study we need to ask the question, 'What is the best way to describe a life – existentially and phenomenologically??', even imagining there is such a thing as A life, bearing in mind that we are relational and that a life is only complete on death. Moreover, life is not neat and tidy and it remains so for as long as we remain alive. It is the product of randomness, chance and opportunity, even when we try to make it seem coherent and planned. The case study has to find an ethical way to represent, to re-present in words, the spirit of the richness and uncertainty of the transience of life as well as the transience of the therapeutic relationship. A translation has to be made from the unreflected ambiguity of individual co-constituted experience into something altogether more coherent, linear and fixed – the written word. This is the tricky part, because this translation often means that what is most valuable, the experience and ambiguity, can get lost.

Thinking of the case study in this way makes it closer to fiction and, as Picasso said, "We all know that art is not truth. Art is a lie that makes us realise truth" (Fry, 1966: 165). Overall, we have nothing to prove or explain. All we have to do is describe.

One of the great strengths of this book of tales is that the subject is not the client, it is the counsellor-and-client. Or rather, Helen-and-Maggie, or Bobby, or Joan, or Kate, or Alice, or Cliff, or Susan, or Tom. In another sense, of course, the subject is Helen because she is the thread that joins all these lives up. She is the writer.

Another strength is that the author does not try to pretend to be an all-knowing expert (although at times her theoretical references do intrude on the telling of the tale). These are simply stories of what happened when she met with the people who form the focus of each chapter. She gives some hindsight reflection of the 'If I had known what effect it would have I would not have done it' variety, but fortunately not much and it does not intrude. Hindsight is a wonderful thing and the purpose of such writing is rarely very informative. Indeed, it usually makes the reader less, rather than more, engaged. This is a difference between writing existentially and writing about existentialism.

Kewell states in the introduction that she considered "pulling together some themes for the readers' consideration" but decided against it. This was a wise decision. The tales themselves say enough without the reader needing to be told what to think about them or what theoretical points the author thinks they illustrate.

So what can we make of the group the author chose to write about, older people? Very simply that this group, however it is defined, is marginalised, and homogenised. This is not just by chance. It happens, as Beauvoir (1972) writes, because old people are seen as the contingent Other and distinct from adults who are seen as transcendent Subjects. They are seen as unlikely to change, and as finished existentially. We (the adults) objectify them (the old) because we fear endings and the end. We fear death. Research from the NHS Improving Access to Psychological Therapies (IAPT) programme shows that as well as having the lowest referral rate, older people had the highest recovery rate of all age groups (HSCIC, 2015).

The old threaten our personal delusion of continuity and specialness; ageing and death happens to other people. However, ageing is not sudden, it is continuous, and starts at birth. The old are no different from the rest of us, they have just lived longer. A close relation of the old are the retired and perhaps because of the close identification between the work we do and who we are, it seems that psychotherapists also find retirement hard to acknowledge (Adams, 2019: 88), equating retiring from work with retiring from life.

Like all things that we fear, we can learn a great deal from confronting them and this is what the author of this book does. Existentially, the present moment encapsulates all that has happened and all that could happen and working with the old really teaches us what that well-worn phrase 'be with' really means. Younger therapists have a great deal to learn from the old, if they open themselves to it. What is learnt can never be predicted. As Beauvoir says:

If we do not know what we are going to be, we cannot know what we are: let us recognise ourselves in this old man or this old woman. It must be done if we are to take on the entirety of the human state.

(1972: 5)

She means that we need to be able to reflect on our whole life and the inevitability of our ageing if we are to become fully human.

Kewell's tales show that this is present in old age in a more profound way than when younger. All the people the author talks about, except herself, are aged between seventy-two and ninety-five, the span of a generation. So much for the old being homogeneous. Some are in what has become known as the third age and some are in the fourth age, the first and second ages being childhood and adulthood. The third age refers to people whom no longer work, have good health, financial means and fill their time with self-defined projects. The fourth age denotes those people whose health issues, whether chronic or terminal, mean that their lives are considerably constrained and that they probably need carers.

Another point is that, although some can travel, the writer sees all of her clients in the book in their own homes. Why not? Straightaway this disturbs the usual therapeutic boundaries and one wonders while reading her accounts if the convention of the client coming to see us in our own space is just there because it makes life easier for us as therapists to be in control of the surroundings. She is clearly not in control, how could she be, but she meets this with a sensitivity born out of humility and it clearly enriches the work.

In everything that is written, and whatever is written about, the subject is always, as Nietzsche (2006: 6) notes, the writer. So what of the reviewer of this book? I am, I was reminded, around the same age as one of the people in her tales. This sort of thing never fails to surprise; being old, feeling old and being identified by others as old, are three different things. Therefore, as I am something over three-quarters of the way through my life, I am old by any definition. How much is left remains to be seen. This makes me not so much one of the we (the adults) who talk about them (the old) any more. I am already one of them. How did this happen? Well, very slowly but also very quickly and repeatedly.

When we care for someone, what we care for is their autonomy, regardless of their chronological or existential age. Of all these tales, Tom stands out for me because he was so much not what the author was expecting and she met him with impressive openness and respect. She was not scared of his age and infirmity because she was also not afraid of meeting the inevitability of the ending of a life.

The tales ring true to me, none of the people Kewell meets with are afraid of death. This is not the same as willing it to come, or pretending that it will not. They are all keen, although there are some wobbles along the way – young people are not immune to this either – to make the most of the time left and then to die at the right time. Now that is really tricky, and it takes a lifetime's experience to know when that is.

Martin Adams

References

Adams, M. (2019). Simone de Beauvoir: Existential Philosophy and Human Development. Existential Analysis: Journal of the Society for Existential Analysis. 30.1: 80-93.

Beauvoir, S. de (1972 [1958]). The Coming of Age. Trans. O'Brian, P. New York: G.P. Putnam's.

Fry, E. (1966). Cubism. London: Thames and Hudson.

Nietzsche, F. (2006 [1886]). Beyond Good and Evil. Trans. Kaufmann, W. London: Vintage.

HSCIC (Health & Social Care Information Centre) (2015). Psychological Therapies, Annual Report on the Use of IAPT Services: England – 2014/15 Experimental Statistics. London: HSCIC. www.gov.uk/government/statistics/psychologicaltherapies [Accessed 16 June 2020].