Preserving People – Preserving Place

July 10, 2014
The Ward-Franzmann House circa 1840

The Ward-Franzmann House circa 1840

I believe there is a natural fit between the movement to create age and ability-friendly communities and historic preservation. This may have grown from my lifelong interest in all things old. My house, above, and I are growing older together, and, as it seems, both entering the winter of life. It’s a good fit. My personal passions and biases aside, nevertheless, I feel a case can be made that proponents of these two movements have much to say to each other and then much to do together.

Indiana Landmarks is one of the most highly respected and the largest private statewide preservation group in the U.S. There is another story there, of course, about leadership, vision, commitment and creativity. This last quality, I believe, helps account for its recent support of a day-long conference in Indianapolis on the subject of this old people-old place connection. Co-organized by another uniquely statewide Indiana treasure called the Indiana Philanthropy Alliance, the conference brought together preservationists and aging/disability professionals in what may have been the first meeting of its kind in the U.S.

Presenters addressed many of the technical issues surrounding accessible modifications for historic homes and commercial properties, the potential for a virtuous relationship between history and the ADA, and financial resources communities can use for historic preservation that benefits older populations, including Main Street restoration.

My contribution was to tender some thoughts about the relationship between the preservation of place and the preservation of community memory. In many ways, they are an identity. Place is the concrete expression of community memory and old people are its vessel, or, perhaps I have that backwards. It reads both ways because it is an identity. In any case, preservation of place is more likely to occur when it retains a presence in community memory. Buildings that fall into history without those personal connections to our current lives are more at risk for destruction unless, perhaps, they exude some extraordinary beauty or character, or are associated distantly with an officially recognized event or person. The position of older people in a community as holders of memory valorizes their role when other sources of status have diminished. A comment by Scott Roden in my previous blog on memory is evidence of this, “I had an elderly friend who passed away last year–he was very influential in my life. He once told me that his job now (at 85) was to remember…”

I try to avoid nostalgia; hope the Golden Age is something in the future, not the past. I am not naïve about the dark side of the places we have created. In a folklore field school we organized several years ago to study the Bloomington Town Square, we were curious about the lack of stories told about on-the-square experiences by older African-Americans. While the town square on Saturday nights in the 40’s was truly hopping, African-Americans, we were told, were not welcome. What was, and remains, a truly central and iconic feature of the place we call Bloomington was, despite the democratic image, an exclusive environment. I like to think that has changed, but it is something we should never forget.

Gerontologists often argue in favor of a policy called “aging in place”, understanding that the personal preference of most older people is to stay put. I would agree that people need the places, for the benefits to their social and physical well-being. I would add, however, that the places need the people just as much. When people stay put, the places benefit. Preserving place and preserving people is one job, not two.

And the house? Linda and I grow old together there and I am so lucky to dwell in her love as well.

Now, as a person also trying to attract valuable older people to our wonderful community, leaving their own, this presents some professional conflicts. I am working on this question and can try to pose a resolution of this paradox in another blog.

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Being and Dwelling: in praise of occupational therapists

March 20, 2014

Recently, I had the privilege of participating in a small conference on Palliative Care convened by the Center for Practical Bioethics (https://www.practicalbioethics.org/) with support from Kathy Greenlee, head of the Administration on Community Living and Asst. Secretary (HHS) of the Administration on Aging. The presentations were outstanding and gave me some new insights into the role of the health care system in communities for a lifetime. I was under the false impression that palliative care was all about end of life care when, in fact, it’s about quality of life, whether one is near death or not. While most participants came from the fields of medicine, I was invited to offer a “community” perspective on the issues. I would like to share my comments with the Phil’s Adventure audience, and solicit yours in return.

Being and Dwelling

In praise of occupational therapists

In the final days of his life, unable to dictate and suffering from immense pain of throat cancer, U.S. Grant scribbled a few final thoughts…

“I do not sleep though I sometimes doze a little. If up I am talked to and in my efforts to answer cause pain. The fact is I think I am a verb instead of a personal pronoun. A verb is anything that signifies to be; to do; or to suffer. I signify all three.”

I find the quote evocative for its relevance to an understanding of the concept of home in the lifeworld of elders. In short, if home is in any way an object, its meaning only derives from use. Hence, as outsiders, we must pay constant attention to movement in the lifeworld of elders, which is a challenge to our stereotypical view of old age as a period of stasis and rest.

Consider this beautiful passage from Wendell Berry’s The Memory of Old Jack, its description of the old farmer Jack Beechum and the identity between self and environment that is created by movement.

He had known no other place. From babyhood he had moved in the openings and foldings of the old farm as familiarly as he moved inside his clothes … Now when he walked in his fields and pastures and woodlands he was tramping into his mind the shape of the land, his thought becoming indistinguishable from it, so that when he came to die, his intelligence would subside into it like his own spirit.

When I was Director of Senior Health services at an Indiana hospital, we often asked seniors “What do you want the health care system to do for you?” Invariably, the answer would be…”to help me manage at home as long as I can”, what Marian Barnes calls “being well enough.”  Seniors saw the concepts of health and home as an identity, one unrecognized by both the health care and the housing systems I would add.

With this in mind, we undertook ethnographic research on the meaning of home for older adults in our community. A deep map of home emerged, organized around several basic elements.

First, home is a complex concept, far more significant than “house.” In our research we encountered individuals who have lived in the same house for over 75 years! It requires a virtual archaeology of memory to peel back the deep sediments of meaning of a life in such a place. These memories, good and bad, are codified in the physical contents of the place. As she walks through the house the tenant walks through her life. Photos, furniture stains, knick knacks, postcards, window vistas, even dents in the woodwork signify and embody important events and individuals in her life. How could she be expected to easily leave behind the door jamb marked by a pencil with the advancing height of her children and grandchildren?

Home is a physical support. Over time, home and body coalesce, a hand in glove. We can walk through our home with our eyes closed because we maintain its physical representation within our body. This is very comforting. Managing the home (sometimes trivialized as homemaking) anchors daily life, provides markers for our temporal experience, and provides cues and incentives to keep our body and mind active.

Home is a social base. When you are home, it’s your territory, your turf. You control who enters. When you are home you are at the node of a social network of friends, neighbors and family, where well-being is not an individual state but is generated through relationships. As Berry says, in another essay, “Community is the smallest unit of health.”

Home is an aesthetic. You design its appearance for self-satisfaction and display to others. The aesthetic reflects your own sense of self just as importantly as does your clothing and your car.

With all these things in play, the home becomes a mirror for the self. It represents you to yourself and, as such, provides a constant reminder of your uniqueness and contributions to your family, your neighborhood, your community. Is it any wonder why someone would want to stay put?

Understanding the lifeworld of older persons from the inside is an essential starting point for design, whether of environments or of services. This requires close observation and deep listening. Psychiatrist Robert Coles, trained by physician poet William Carlos Williams, spent some time with Nellie Benoit, over 90 years of age, in preparation for his book Old and On Their Own .

Nellie reports that they say she’s legally blind with glaucoma and “all I can see is ‘forms’ or ‘outlines’ of objects. But I say (to myself) that they are way, way off track. I can see a whole lifetime of scenes, people and places, all the details, in black and white and in color, even if their medical instruments say I can’t!”

For Nellie, the sun is her daily companion. “…without the sun, the whole planet would die… so when I can catch sight of that light, creeping in here, I talk to it, I say ‘Welcome and please make yourself at home… I say I know you’ve got other folks to visit, and I don’t want to get possessive, and try to hoard all your treasure, and not share it with others – but it’s so nice to have you here and I’d like you to know that.” …Now after a while, I can feel the sun getting ready to leave. Things will cool down! Things get darker! I’ll start gabbing again. I’ll talk to that fading light; it gets dimmer, saying good-bye, and I feel my heart sinking. But I try to be cheerful, and express my gratitude: ‘Thank you ever so much’, I say. ‘So long and I hope and pray I’ll be here, and see you tomorrow’. I say, ‘You’ve been kind, to visit us, and I sure wish you a safe and sound trip.’ I say. ‘What joy you’ve brought us, and we are all so grateful, ‘ I say.”

Though Nellie herself moves only so slowly through her house, she participates in a daily round and shares a path with the sun. In fact, home is the path.

Among philosophers, Martin Heidegger has spoken extensively about the identification of self and place, of dwelling and thinking. He notes that the etymological history of the word dwelling, bauen, in German, means to build, but has as its cognate the word bin, as in ich bin, I am, du bist, you are, the imperative form bis, to be:

What then does ich bin mean? The old word bauen, to which the bin belongs, answers: ich bin, du bist mean: I dwell, you dwell. The way in which you are and I am, the manner in which we humans are on the earth, is Buan, dwelling. To be human … means to dwell (1971, 147).

He proceeds to elaborate on the old definition of home to mean to remain, to stay in a place and compares it to the Old Saxon woun, which also means to be at peace. Hence, the word home comes to mean retreat, a place of safety and security – dwelling as a noun, not verb.  Heidegger misses the possibility of home as path, so beautifully enacted by Nellie.

If being and dwelling are identities, and if home and travel are not antithetical, it follows that achieving a sense of place in old age does not require “aging in place”, in its narrow sense of aging in the house. Aging with a sense of place can be accomplished in many ways. The question is not whether staying put or relocating south is the right solution. The question is… can we fill our spaces with meaning and memory? Can we attain a sense of agency, where what we do makes a difference? Can we dwell in the other? Can we transform space into a place that reflects who we imagine ourselves to be? This is why the occupational therapist, working exclusively at the fulcrum of home and health, may be the most important member of the palliative care team.

In the end, we return to the starting point – home is a verb, not a noun. Home is created by going in and out of the circles of life that surround us. I have found no better definition of this premise than one provided by a poetry group of Adult Day Care participants with dementia:

I have several homes

I know a home is a home when I can

Go there

Stay

And go out again.

Home is where the dog goes

When it gets too cold to roam

When winter’s coming on

That’s when I want to go

Home.

 

Phil Stafford, Ph.D., is a cultural anthropologist and Director of the Center on Aging and Community at the Indiana Institute on Disability and Community, Indiana University, Bloomington, IN. staffor@indiana.edu. He blogs at Phil’s Adventures in Elderburbia: https://agingindiana.wordpress.com/

 

 References and readings on the meaning of home: a brief list

Bachelard, Gaston. 1994. (trans.) The Poetics of Space. Boston: Beacon.

Barnes, Marian, Taylor, D and Ward, L (2013) ‘Being well enough in old age’, Critical Social Policy, vol.

33, no. 3, 473-493.

Berry, Wendell. 1974. The Memory of Old Jack. San Diego: Harcourt Brace.

___1995. Health is Membership, in Another Turn of the Crank. New York: Counterpoint

Csikszentmihaly, Mihaly, and Eugene Rochberg-Halton. 1981. The Meaning of Things: Domestic Symbols and the Self. Cambridge: Cambridge University Press.

Coles, Robert. 1997. Old and on Their Own. With photographs by Alex Harris and Thomas Roma. New York: Norton.

Ekerdt, David K. and Julie F. Sargent. 2006. Family Things: Attending the household disbandment of older adults. Journal of Aging Studies 20: 193-205.

Gubrium, Jaber. 1993. Speaking of Life: Horizons of Meaning for Nursing Home Residents. New York: Aldine de Gruyter.

Gubrium, Jaber F. and Andrea Sankar, eds. 1990. The Home Care Experience: Ethnography and Policy.

Newbury Park: Sage.

Heidegger,M. 1971 (orig. 1927). Building, Dwelling, Thinking. In Poetry, language, thought. A. Hofstadter, (trans.).New York: Harper and Row.

Jackson, Michael. 1995. At Home in the World. Durham, N.C.: Duke University Press.

Korosec-Serfaty, Perla 1985. Experience and Use of the Dwelling. In Home Environments. Irwin

Altman and Carol M. Werner, eds., New York: Plenum Press.

Marcus, Claire Cooper. 1995. House as a Mirror of Self: Exploring the Deeper Meaning of Home. Berkeley: Conari Press.

Sanders, Scott Russell. 1993. Staying Put: Making a Home in a Restless World. Boston: Beacon.

Snyder, Gary. 1990. The Practice of the Wild. San Francisco: North Point Press.

Stafford, Philip B.  2001. When Community Planning Becomes Community Building: Place-Based Activism and the Creation of Good Places to Grow Old. In L.F. Heumann, M.E.    McCall, D.P. Boldy, eds., Empowering Frail Elderly People. Wesport, CT: Praeger.

___2003. Homebodies: Voices of Place in a North American Community”. In Gray Areas: Ethnographic Encounters with Nursing Home Culture., Philip B. Stafford, ed., Santa Fe: SAR Press.

___2009. Aging in the Hood: Creating and Sustaining Elder Friendly Environments. In The Cultural Context of Aging: Worldwide Perspectives. Jay Sokolovsky, ed., Westport:

Praeger.

___2009. Living Large while Living Small: The Spatial Life of Aging Boomers. In Boomer Bust? Economic and Political Issues of the Graying Society. Robert B. Hudson, ed., Westport: Praeger.

___2009. Elderburbia: Aging with a Sense of Place in America. Santa Barbara: ABC-Clio.

Tuan, Yi-Fu. 1977. Space and Place: The Perspective of Experience. Minneapolis: University of Minnesota Press.

 

 

 

 

 

 


A Sticky Message: “Community is the Smallest Unit of Health”

June 26, 2009

Wendell Berry, author of the quote following the colon, would not likely have thought of his message as sticky. But it has sure stuck with me over the years and I use it often in describing the need to re-frame our understanding of aging away from the body and toward community. This week, I learned about the concept of sticky messages.

Made to Stick: Why Some Ideas Survive and Others Die, C. Heath and D. Heath, 2007, was the inspiration for a portion of a terrific workshop provided by John Beilenson, President of Strategic Communications & Planning on June 24, 2009 in Indianapolis. 35 participants from around Indiana’s expanding aging network attended.

John’s an outstanding resource, so it’s no surprise that he is working with the National Council on the Aging in a major consulting capacity. The workshop, coordinated by the Center on Aging and Community, brought together an energetic and engaged group of professionals and activists working locally to create “communities for life” – or elder-friendly communties that just happen to work well for all ages.

With gracious permission, I’m posting John’s slides with this blog. Communicating for Communities for Life

Phil


Building Community in the Nursing Home?

April 21, 2009

Gerontology students in Indiana have been participating in a week long facebook discussion to celebrate Careers in Aging week. This post elaborates on a thread related to the possibility of creating community in long term care facilities. I believe it can be done, but that many factors mitigate against it. What follows is an abstract from my forthcoming book Elderburbia: Aging with a Sense of Place in America, on this subject…

A good place, then, is also a “keeping place” – it holds people together through their common participation in its qualities. As Wendell Berry put it in another essay…”a human community, then, if it is to last, must exert a kind of centripetal force, holding local soil and local memory in place” (1990:155). Perhaps our chief criticism of the institution we call the nursing home, then, should be that it too often erases memory. Now this may be difficult to perceive at first for we are talking about noticing absences and silences – the semiotician’s zero signs. How do you notice something that’s not there? I’m suggesting that we think not about what we see, or hear, or smell, when we enter the nursing home, but what we don’t see, don’t hear when we enter into this space. In evaluating the quality of this environment then, we might ask:

Where is the memory of this place?

Where is the evidence that people have lived here?

Where are the personal traces of former residents?

Where are their pictures, their mementos, their trophies, their headlines, their

            scrapbooks?

Did they laugh? Did they cry?

Were they loved? Did they love?

 

…and where is the evidence that people died here?

Where are the memorials, the funerals, the survivors?

…and did anyone make an impact here?

as a worker?

as a volunteer?

as a family member?

 

Too often, we look and do not see. Traces have been obliterated. Death has been spirited out the back door. The room has been cleared and cleaned to receive another. Valuable possessions are bagged, tagged, and gone with a family sometimes eager to never look back.

By the same token, the good nursing home remembers its residents to us. It celebrates their presence and enables them to create place. It creates home through enabling its occupation, its dwelling, through bodily practice. It invites former residents to return (yes, they do exist). One sees previous family members returning to sustain ties with friends of the deceased. One sees memorial services to acknowledge death and graduation ceremonies to celebrate the triumph of rehabilitation (see Shield 1988: 76 ff). Yet, it is a struggle to enable the creation of place where so many factors mitigate against memory making:

 

„          the lack of temporal depth in relationships due to staff rotation, the fear of approaching the sick, and death itself

 

            At the Crescent Nursing Home, where anthropologist Nancy Foner studied the working lives of nursing assistants, the turnover rate is remarkably low (as low as 5%). She attributes this low turnover rate to the relatively high wages and job stability offered to the predominantly Caribbean and Hispanic workers in this unionized setting (as compared to most nursing homes around the U.S.). The long tenure of most nursing assistants positively reflects on the caring and enduring relationships engendered among staff and residents in this facility (Foner 1994:17). Compare this with the average turnover rates ranging from 40% to 75% annually in most nursing homes around the country and the very real problem, as I have seen, with nursing assistants coming and going so quickly that they have no real possibility of forming lasting relationships with patients and families. Foner also acknowledges that nursing assistants who spend too much time with residents may risk the ire of nursing directors or other staff who follow on the next shift and must pick up the “bed and body” work left undone. J. Neil Henderson, in his ethnography of Pecan Grove Manor, noted how superficial the interactions between nursing assistants and residents might be. In the words of his interviewee, the Director of Nursing:

All of them (CNAs) are needed for basic care, so that the emotional side is kind of left (undone)…It is hard to just sit down and have eye-to-eye contact and really feel close to the patient when you are giving them daily care…(1995,45).

Renee Shield, in her ethnography of Franklin Nursing Home, notes how peer relationships among residents are clipped by the limits put upon exchange and reciprocity. The development of horizontal relationships with potential friends is conspicuous by its absence, as residents who lack possessions, strength, and health have little to exchange with peers (1988,155). Hence, residents attempt to develop vertical relationships with staff (albeit dependency relationships) to survive. When residents do provide staff or visitors with little gifts of kindness, there is often an attempt made to refuse them, sometimes with a citation of official policy. As Shield has observed, staff and visitors often do not want to be put into the position of having to reciprocate out of guilt, nor being trapped in an escalating structure of exchange that cannot, ultimately, solve the fundamental existential problem (Shield 1988, 172-173).

Shield adds that avoidance of enduring relationships may have some self- protective, though perhaps not adaptive consequences:

Nurses remark that new residents often try to make friends after they have begun to settle into the nursing home routine. But if a friend dies or becomes ill, the new resident learns that it is dangerous to make friends. Keeping interactions to a minimum protects the self against the emotional trauma of these losses. The emotional distance that staff members keep from residents is similarly self-protective. People-work activities, shifting schedules, and frequent changes in nursing assistant-resident assignment prevent continuity. In these ways the nonenduring nature of resident-staff relationships is per­petuated (1988,166).

In the end, it may be the illusion of timelessness, the denial of aging and death, that prevents the establishment of “communitas” in the nursing home setting (following Turner 1969). In “normal” life, outside of the institution, definitional rites of passage mark time and place individuals within the context of a supportive cultural matrix. Typically, rites of separation, followed by a liminal period, are closed by conjoining rites of incorporation, wherein the initiate rejoins the cultural fold, albeit in a changed state. The nursing home, as Shield argues, is characterized by an ongoing, neverending state of liminality. The resident qua patient leaves society but neither re-enters nor fully achieves a new status.

The illusion of timelessness belies the certainty of how limited the resident’s time actually is. The time of future peril that intact residents perceive as their fate threatens the quality of resident interactions rather than intensifies them. The residents interact superficially and guardedly. There can be little chance of communitas where the present is benignly misrepresented as safe and timeless, the future is known to be uncertain and perilous, and individuals serve as reminders to one another of their present fragile security and future certain danger (1988,208).

 

„          the dementia which robs people of memory-making capacity

 

While dementia or Alzheimer’s disease may not be the primary diagnosis for most  nursing home patients, the disorder is, nevertheless, ubiquitous in the setting. A typical study (Hing 1989) estimates that 66% of the nursing home residents in the U.S. have at least one mental disorder (generally dementia). One widely recognized epidemiological study puts the rate of moderate to severe dementia among community-residing persons over 85 at 47%. As the over-85 group is the fastest growing segment of the population, it is no surprise that the condition is very common in nursing homes. While Alzheimer’s dementia is popularly thought of as memory loss (and indeed, the loss of long term memory is undeniably present in more advanced dementia) it is the inability to make new memories, which causes functional problems for the individual. Alzheimer’s disease is, in this light, a learning disorder – the patient is unable to impress events and thoughts upon the brain for later recollection and use. Events of the remote past may be recollected with pleasure. Core elements of identity may be sustained through the active support of others (as Silverman and McAllister 1995 have shown). Even the current flux of the present can provide great pleasure and meaning. The recent past, however, the anchor of new relationships, may not be sustainable in memory. Small scale environments, such as adult day care centers, have the best chance of supporting the development of new relationships and marking events ceremonially. These markers – these memories – enable participants to maintain a sense of the passage of time and the body’s participation in a web of meaningful human relationships.

 

„          the restrictions of the physical environment which prevent intimacy from developing among residents and others

 

 

Most ethnographers of the nursing home scene have commented on the difficulty of maintaining privacy in the institutional setting. Indeed, the medical model which dominates the architecture of the nursing home constitutes a virtual panopticon in which most activities of the residents are capable of being scrutinized by the powers that be (c.f. Foucault 1979, Stafford 1997). Fire and safety codes, the wishes of family members regarding sexual conduct of elderly parents, the rarity of single rooms and small private spaces, the dispensability of small modesties, and the enforced familiarities of well meaning staff and visitors, all combine to create an environment which, as Goffman (1961) and Henry (1963) mave noted for total institutions, strips the inmate of his/her individuality and important, unique markers of personhood and biography.

As Verbrugge and Jette (1994), and many subsequent observers have noted, disability, health, and aging are not located in the body so much as in the relationship between the body and the environment. Hence, our attention is turned to the more politically sensitive notion of “disabling environments” which, being poorly designed, distort sound, amplify glare, restrict mobility, and sanitize smells.

 

„          the undeniable diminishing of the body’s capacity to extend fully into space due to impairments in vision, smell, hearing, mobility, taste, and touch

 

Yi-Fu Tuan, master interpreter of the spatial experience, notes how the synesthetic experience, in which all of the senses are employed, etches itself on our memory in a way unmatched by the unidimensional memories of the “seen:”

Life is lived, not a pageant from which we stand aside and observe. The real is the familiar daily round, unobtrusive like breathing. The real involves our whole being, all our senses (1977,146).

How can the person with hearing impairment, loss of smell, loss of vision fully experience and therefore fully remember either the routine or the special events which surround one in the nursing home environment?

So it’s not only the erasure of memory but the difficulty of making new memories which works to drain the nursing home of meaning. Professionals are well-intentioned in their efforts to make institutions homelike. Yet, not understanding the bodily experience of memory, nor the role of cultural processes, the professional intervention is often misplaced. As a kind of semiotic strategy, it tries to recreate home through its symbolic representation. It uses wingback chairs, the charade of a library with books purchased by the pound, the false fireplace hearth to create a simulacrum of home. As such, it trivializes the notion of home and, indeed, may have the opposite effect on the resident. The attempt to recreate home too often draws attention to its impossibility.

Bahloul, in The Architecture of Memory, clearly demonstrates how this lived experience of place, this quotidian routine of “taking care of everything,” provides a framework for its remembrance:

Domestic memory focuses not only on images of places but also on images of concrete acts…Remembrance of socialized domestic space is thus based above all on the practice of this space as it is articulated in the repeated inter­actions of its agents…Remembrance of the house is the symbolic locus for the embodiment of social practices experienced in daily life; it constitutes a system of bodily practices (1996,136).

 

If we truly listen to the authentic voices of the residents, we can learn a great deal about the  notion of home, and the role of memory in helping to sustain and create a sense of place.  We can learn that home and self are intertwined. That home and spouse can be identities. That space is transformed into place as it supports a sense of human agency and  partakes of the qualities of the human encounter (Tuan 1977,143). But listening is not enough. An ethnography of place and memory involves us not in its representation but in its creation. As Hack and I recreate the place he calls home we make memories together. By this means do we create place and not merely recollect it. By this means does memory become more than cognition. By this means does memory become transformational in Myerhoff’s sense, a kind of sacralizing process by which the sanitized space of the nursing home becomes the experienced and meaningful place of genuine human interaction.

 

 


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