Stress Points: Play Your Own Game in Life

Elizabeth Tillinghast'93

I don't know if it's ever possible to reach middle age without shock. Accepting that other people are growing old is easy enough, but accepting that you are? Not quite the same thing. Perhaps physicians should have a relatively easy time of it. After all, we're around people struggling with aging and illness every day. But doctors dedicate themselves to fighting the inevitable slide toward death. In fact, it's been suggested some of us may have gone into medicine because of heightened anxieties about mortality and a powerful wish to deny our own vulnerability. Stories in the media pick up on this half-hidden fantasy of the immortal physician as well; they often focus on doctors who've been stricken with life-threatening illnesses, as if there's a terrible irony in that. Whether we take aging easier than others, or have a heightened anxiety about it, there is no doubt we do work that stirs the waters of mortality every day.

Now that I'm middle-aged myself, I seem to be attracting a lot of patients in the same boat. At this point, we're old enough that many of us have had a serious health scare, perhaps a bout of cancer or a life-threatening accident that left us feeling existentially shaken. We may also be taking care of elderly parents who now seem to be laying down the road to our own futures. Some of my patients are quite elderly themselves; at times I admire one person's grace and courage in facing the losses that come with old age, or another's struggle to maintain optimism, and the dignity that comes with being a good sport. All of this has come to feel more real.

It can take awhile to sink in but sooner or later, many of us may find ourselves steeped in unease as we come to accept the fragility of our lives and the certainty they will end. Let's be blunt: We will end.

Having mortality as an ever-present backdrop is unsettling, but it can also sharpen the focus. As Samuel Johnson said, "Death concentrates the mind." Faced with the reality of limits, what does the mind leap to? What matters? 

Often we're so busy sweeping away the clutter of life we lose track of what we care about most. This kind of excessive busyness is an occupational hazard in medicine. A mid-life crisis can change that. It can give us a jolt, and a chance to pause, reflect and reset our course. Ironically, a sense of the end can infuse us with life: a sense of urgency, purpose, desire. 

The mid-life crisis is often the subject of laughter, even ridicule, but I've become a big proponent of it. There's no doubt this can be a turning point. Those of us who are middle-aged have enough of a past to put things in perspective and (perhaps!) enough of a future to make meaningful changes.

Often the first surprise in looking back is in realizing how specific life has become. What the poet Matthew Arnold once described, with hazy beauty, as "a land of dreams" has by now narrowed for most of us into something much more tightly drawn. A job, a family, perhaps a dog, a location.

According to psychologist Erik Erikson, the critical developmental challenge at this point is generativity vs. despair. As a psychiatrist and psychoanalyst, I don't fight death per se but I do try to help people make the most of their lives. Sometimes the first challenge is helping people overcome a vast hopelessness as they look back, and contemplate what may lie ahead. At times,  mid-life strikes with a sickening loss of grandeur. Some of us do get the Nobel prize, of course -- but most do not. Even people with the most driving ambition do not always win their goals.

In some cases, people who have been quite successful professionally may be disappointed because they can see what is not so evident to the outside world: a recurrent tendency to undermine themselves at critical points. Without meaning to, people like this limit themselves because of fear of success. For those who self-sabotage, therapy is definitely worth a try; it can help you clear out your path psychologically, so achieving goals becomes more straightforward.

Other people may be disgusted with themselves because they cannot seem to get their acts together. Again, these may well be successful professionals -- but they know they've been limited by persistent disorganization, a tendency to miss deadlines, and trouble sustaining focus on tasks, particularly tedious tasks, which unfortunately tend to be plentiful in life. Often people like this have lots of wonderful ideas but find it nearly impossible to follow through on them. It's as if everything fizzles before it starts.

Anyone like this should consider getting an evaluation for attention deficit disorder. ADD can occur without hyperactivity. Although it has gotten a lot of press for being over-diagnosed, and over-medicated in children, ADD is often unrecognized in adults and can easily be confused, for example, with depression, which can also make it hard to stay motivated and focused. In fact, ADD can cause depression; people who don't know they have it often believe they have a serious character flaw rather than a neurological problem; they may be full of bitter self-recriminations and accuse themselves relentlessly of being lazy and failing to meet their potential. Left untreated, ADD often leaves people deeply discouraged, and demoralized, with low self-esteem. Yet medication can make a dramatic difference; some people with ADD take it and feel transformed, suddenly much more capable of sticking with things and achieving their goals.

As for goals, I've come to believe too many of us have had far too narrow a focus on achievement – and too narrow a view of what that means. Life is not a race run on a single track. It's far more complex and interesting. Early on, it seemed like what mattered was getting the best grades, so you could get into the best school, the best residency, the best fellowship. Every grade counted; you had to try to be good at everything. That's not true later. Instead what matters is knowing how to play to your strengths. Some people have managed to turn relatively narrow talents into big careers.

By now, we've all had a good deal of experience with ourselves. If you know you're not good at managing the business aspects of a practice, but you're full of intellectual curiosity and drive, get into a setting where your strengths matter and your weaknesses don't, perhaps a group practice  with like-minded colleagues who share your enjoyment of intellectual puzzles – and hire a good office manager to handle the rest. Knowing who you are, valuing it, and making the most of it: That's what counts.

Sometimes what's needed is a mental frame change. I've worked with patients who feel like failures because they can't seem to manage the business aspects of a practice effectively; with more discussion, though, it may become evident they have a certain disdain for making money. What they really love is painting; they may have just gotten a piece into a show but somehow don't let that shake the fiction of being a failure. Who says running an office well is more important?

When you're little, you're told what matters and what you need to do. Later you get to decide for yourself. You can judge yourself by standards you care about instead of by standards that you don't hold in much regard. What do you think matters? What do you care about and believe in? Should artistic endeavor, or its equivalent, count for as much as your rank in the hospital administration? It's up to you. We've reached an age where we've got the power and freedom to set the rules. You can play your own game in life, mentally speaking, instead of feeling like a loser at someone else's.

I've come to believe making this shift from external markers of achievement to internal values and goals is critical to aging well. What matters is not so much achievement as it is fulfillment -- and fulfillment is a highly personal matter. Psychoanalyst William Fairbairn has suggested people who are most afraid of dying are those who have not lived in a way that is true to their inner selves. What has mattered to you the most? What are you most proud of? What makes you feel most alive? Arrange life so you spend more time doing that.

"Death concentrates the mind." Well, yes, and the sense of wonder and pleasure in what we have. Looking behind me, and then ahead, I can feel, with a kind of concentrated sweetness, that these are precious days.

See more Stress Points columns at http://www.cumc.columbia.edu/psjournal/columns/new-stress-points

Elizabeth Tillinghast is a psychiatrist and psychoanalyst who also has a law degree. She has published articles about how lawyers and other professionals can overcome psychological impediments to success and happiness at work. She is on the faculties of Columbia and Cornell medical schools. Contact her through et41@columbia.edu