1It is well known that the parameters of the later phase of life are changing due to demographic shifts and higher life expectancy associated with improved health. The most obvious implication for the field of mental health is that the proportion of older adults will continue to rise and an increased need for psychosocial services in this group can be anticipated (Statistisches Bundesamt, 2019; World Health Organization, 2023). At the same time, these transformations also involve changes in our perception of old age and aging which may become relevant for the treatment of affective disorders, e.g. major depression, in this population. A case can be made that the prevalence and phenotype of these disorders in old age are underestimated (Maercker, 2015, p. 53; Morichi et al., 2015). For decades a systematic approach to psychotherapy with older adults had been lacking while therapeutic nihilism characterized by negative age stereotypes dominated, today an increasing amount of studies and concepts on this topic is available (Hepple, 2004). Yet, the most well-known approaches often carry an idea of optimization and share a pragmatic stance which rather impedes a thorough engagement with the existential dimension of age-specific themes and experiences.
- 1 I chose to introduce both terms in the original German, but their English translations will be use (...)
2This contribution uses an empirical reference point to study the significance of specific philosophical concepts for understanding aging and old age in a psychiatric-psychotherapeutic context. At the center is Karl Jaspers’ terminology for describing experiences of instability and the beliefs that lend a sense of security amid these experiences. His concepts of Grenzsituation (limit situation) and Gehäuse (shell) are employed to bring the existential adversities of aging and old age into one perspective and provide a more nuanced description of age-related conflicts.1 The leading question is: What significance does the concept of the limit situation hold in the context of aging or old age and the psychotherapeutic treatment of older individuals? I propose that the experience of the limit situation is intensified in the context of old age due to an accelerated erosion of the individual’s shell which can be understood as their stabilizing beliefs.
3I will first offer a brief overview of the theoretical background of my considerations. Then the methodology will be outlined. Against this backdrop, I will explicate the two key philosophical concepts – limit situation and shell – and outline their role. Finally, I will support my hypothesis by referencing specific examples from the analysis of empirical material. This material consisted of written protocols of psychotherapeutic treatment sessions with older adults. This will make clear how the application of specific philosophical concepts can be beneficial to the engagement with empirical data and therapeutic approaches in the context of geriatric psychiatry – and vice versa.
- 2 One can find attempts to conceptualize psychotherapy with older adults in all predominant schools (...)
- 3 Specifically, Baltes’ “model of selective optimization with compensation” (Baltes and Baltes, 2008 (...)
4While its efficacy has been proven, only few older adults seek out psychotherapeutic treatment (Crabb & Hunsley, 2006; Kessler, Agines, & Bowen, 2015; Wei, Sambamoorthi, Olfson, Walkup, & Crystal, 2005). There have been efforts to systematize psychotherapy with older adults and at the very least from a cognitive-behavioralist standpoint these can be deemed a success (Hepple, 2004; Maercker, 2015, p. 4). Nevertheless, most models of geriatric psychotherapy share guiding ideas which might limit their effectiveness and call for further inquiry.2 They usually rest on models that attempt to explain “normal” or “successful” aging (Maercker, 2015, pp. 124-125).3 These models provide the basis for a pragmatic approach that assumes that affective disorders in old age do not warrant a completely new psychotherapeutic program but only some modifications to existing strategies which in many cases merely amounts to a stricter selection of therapeutic goals amidst an assumedly reduced developmental potential (Maercker, 2015, p. 36). The key point is that the focus on practical modifications to proven strategies does not leave much room for themes and dimensions of experience that are specific to old age. Bringing the engagement with the existential dimension of age-related themes and experiences into the foreground could be conducive to challenging a deficit-oriented perspective on old age and allow for a wider view on affective disorders in this stage of life.
- 4 See for example Thomas Fuchs’ ideas for a psychopathology of limit situations Fuchs (2013) or Juan (...)
5Looking at relevant philosophical work, particularly from the field of phenomenology, it becomes clear that the experience of aging and old age is much more complex than what the above-mentioned models may capture. Examples can be found with Jean Améry (Améry, 1994), Simone de Beauvoir (Beauvoir & O’Brian, 1996), Norberto Bobbio (Bobbio, 2017), or Odo Marquard (Wetz & Marquard, 2013). Existentialism gives room to themes associated with finiteness and many of its proponents focus on explicating their existential relevance. Mainly, this happens without a direct connection to mental illness in old age, but this is precisely why there is room for investigations into how the role of these themes changes in this specific context. Especially Karl Jaspers’ concept of the limit situation has the potential to bring the existential adversities of aging and old age into one perspective. At the same time, reflections on how it could become practically relevant in the field of psychiatry and psychotherapy already exist while lacking systematic analysis regarding old age.4
- 5 It should be noted that the brevity of this introduction entails disregarding the nuances of these (...)
6Karl Jaspers’ concept of the limit situation is the theoretical starting point of this study. It is closely related to the second Jaspersian concept relevant in this context: shell. I will briefly introduce both and then illuminate their role in relation to the empirical data in the following section.5
7The limit situation is not a single, concrete situation humans can experience but should instead be understood as a necessary and finiteness-dependent component of human experience which is irreducible, cannot be changed but appears in different shapes, and may be alluded to through the experience of particular situations (Jaspers, 1925, p. 229). The “limit” can be broadly understood as the limit to what humans can consciously perceive, think through, and potentially understand. In his early work, Jaspers focusses on two general characteristics of the limit situation: it has the character of a crossroads, entailing suffering as well as a potential for personal growth, and in it an antinomic, i.e. fundamentally contradictory, structure of the world becomes apparent to the individual (Jaspers, 1925, pp. 232 and 247). The latter aspect is especially important: Jaspers conceives our way of consciously being in the world as being tied to an antinomic structure which becomes apparent upon entering the limit situation; a process that Jaspers equates with “existing” (Jaspers, 1973, p. 204). This experience of entering (and exiting) the limit situation is important, because according to Jaspers, Existenz cannot be grasped fully through cognition but relies on the experience of the limit situation (Jaspers, 1973, p. 204). After giving a general account of the concept, Jaspers illuminates it using different examples for ways in which the limit situation may be experienced, each pertaining to a different antinomy; the list changes over the years, early examples are death, struggle, guilt, and chance (Jaspers, 1925, pp. 256-257).
8At this point, it is useful to outline the role of the shell in Jaspers’ thinking. The German word Gehäuse is an odd term, reminiscent of a seashell in which one lives; Jaspers appropriated it from Max Weber and developed it on his own (Weber, 2007, p. 160). It stands in close relation to the limit situation because it protects individuals from experiencing this situation most of the time (Jaspers, 1925, p. 254). The shell stabilizes the individual by turning what cannot be fully grasped into something comprehensible and thus puts the individual in a position where they may create a hierarchy of values and act according to it (Jaspers, 1925, p. 304ff). Hence, it serves a desire for clear and concise prescriptions on how to act. These instructions may be found in principles, dogmas, traditional institutions, absolute and at the same time general demands (Jaspers, 1925, p. 304f).
9The relationship between limit situation and shell can be understood as a dynamic of dissolution and finding stability. Normally, the shell is unnoticeable, self-evident, and remains unquestioned. This sense of security is dissolved upon entering the limit situation when one’s shell is seen as such and called into question. The limit situation becomes apparent, one’s shell is dissolved, and needs to be rebuilt. This process of disintegration is rarely complete, since the new shell may be developed from the remnants of the old one. It is important to note that Jaspers sees this as a cyclical process necessary for self-development in which only stale and expired shells are dissolved and rebuilt. He does not assume that many or any individuals can or want to experience the limit situation all the time (Jaspers, 1925, p. 282f).
- 6 Jaspers himself notes that some forms of neurosis might be understood as resulting from failure of (...)
10The limit situation or related terms have often been employed in different contexts including old age and mental illness.6 At the same time, these reflections often have a different main subject and fall short of analyzing the connections between old age, limit situation, and mental illness in depth. Two things they have in common are the assumption that the limit situation gains importance in the context of aging and old age and the idea that engaging with it leads to a process of self-development and therefore it should be acknowledged as being inherent to life and not a deficiency.
11In order to gain a more nuanced view on the significance of the limit situation in geriatric psychiatry, an empirical point of reference was chosen. A qualitative approach appeared particularly suited because it aims to assess what is subjectively meaningful for patients and therapists. Phenomenological concepts in the tradition of Jaspers were used to construct a theoretical framework for the qualitative study. On the one hand, the phenomenon in question, i.e. the limit situation, may be understood better in a practical setting which might also allow for ethical reflections. On the other hand, insights into what a concept appears to capture in a specific setting can be of interest on a theoretical level.
- 7 The study was registered with the German Clinical Trials Register (DRKS00023139).
12The material used for analysis were written protocols of psychotherapeutic treatments of older adults. This documentation is recorded after each session by the therapist to ensure treatment quality, conserve evidence and allow for a reconstruction of the course of treatment. The absence of stylistic guidelines leads to a great variety of documents but does not impede a critical assessment of this rich material. The analyzed material amounted to 152 pages (44784 words) containing the available documentation of all sessions in each case. The 13 patients were between 60 and 80 years of age (8 female, 5 male) and consented to the use of their personal data for this purpose. All had been patients in a psychiatric clinic at one or multiple times during treatment, had been treated solely in an outpatient setting at the clinic, or both at different times. The total length of treatment differed between three months and almost ten years. The study protocol was approved by the Research Ethics Committee of the School of Medicine and Health Sciences at the University of Oldenburg (RN 2020-138) and the data protection officers of the participating institutions.7
- 8 For more information on QCA in general please see for example Schreier et al. (2019).
13In order to analyze the material, I employed qualitative content analysis (QCA) according to Kuckartz (Kuckartz & Rädiker, 2023). QCA is a well-established method in the field of qualitative social research.8 I chose this version because it allows the inclusion of the Jaspersian ideas as the theoretical framework of the study while retaining its explorative character that intends to generate new hypotheses for further studies from detailed single case materials.
14The central hypothesis – experience of the limit situation is intensified in the context of old age due to an accelerated erosion of the individual’s shell – will be explored by highlighting three aspects in the material: how aging enters into experience, which stabilizing beliefs become relevant, and what happens in therapy.
- 9 The special character of this research material entails that the patient’s inner experience and th (...)
15First, different perspectives on aging, old age, and their relationship to the destabilization of shells can be identified in the material.9 These dynamics are referred to as “age markers” since they designate the experience of aging or old age for an individual and can be ordered into types like “the dying of others”, “retirement”, “the narrowing time horizon”, “bodily complaints”, or “the age of our ancestors”. These types are not exclusive, i.e. more than one of these dynamics are usually apparent in one case. An excerpt from the case of Mr. D., who was 67 years old at the time of admission, will help to illuminate this idea. The therapist notes that the client:
- 10 All translations of excerpts from the material are my own.
[…] is bothered by statements like ‘At that age…’, especially in regard to physical limitations and forgetfulness. Is unsettled by the topic of death. He notices that others are dying with 60, 70, 80. Thereby becomes conscious of his own age (HD6, Pos. 19).10
16The example falls predominately within the category “the dying of others” but connections to “bodily complaints” can be drawn as well. The most salient point here is Mr. D. reporting his realization that other people – to what extent these are close to him remains unclear – die at his age or at an age he will soon reach. Through this realization, he becomes aware of his own aging and old age.
17More subtle aspects can be picked up as well: The therapist notes Mr. D.’s irritation with ascriptions of old age that – as the patient appears to perceive it – put changes like a diminished physical ability in a different perspective when they are not conceived as temporary and disease-associated states but as more or less permanent and irreversible changes. Also, their connection to the process of aging lends them a sense of inevitability.
18Taking other text segments of this case into consideration as well, Mr. D.’s preoccupation with his own death gains importance. This train of thought is made out to be closely associated with an injury he sustained before admission which has been limiting his physical abilities. Thus, a dynamic between new physical limitations, becoming conscious of old age, and engagement with one’s death plays a role in this case as well. So far, it should have become clear that different types of dynamics in which aging or old age enter into one’s experience can be distilled from these cases.
19Second, I want to outline the idea that some shells carry an “expiration date”, i.e. some types of stabilizing beliefs may offer less support in the context of aging and old age. In the material, these types of shells can be structured into three broad categories: work, relationships, and determination-related beliefs. While these types are useful for ordering different dynamics, they are – as with age markers or the limit situation – not entirely exclusive, i.e. shells are rarely shaped monothematically.
20To illuminate this point, I chose an example from the category of work-related stabilizing beliefs. These appear to be especially vulnerable in the context of aging and old age since in most cases societal norms exert a strong influence on the individual to retire at a certain time. The substructure of this category unfolds into ideas of a personal mission, every-day structure, being safe from loneliness, recognition by others, or wealth and social standing. In the following case, ideas of merit or achievement are prominent. The excerpt is from the case of Mr. F. who was 67 years old at the time of his stay at a psychiatric hospital:
When he hears other patients talk about how they have been in treatment before or have been suffering from their illness for a long time, this fills him with a ‘dreadful sense of hopelessness’. He also feels jealous when he ‘sees other craftsmen’, because they stand ‘in the prime of their life’. It’s that he was also a craftsman and a successful businessman but now he is asking himself ‘Who am I anymore? – Nothing!’. Mirroring that he still was a craftsman and a businessman, that these are part of his identity/self-image and that right now adaptation takes place. Patient can accept that. Says that it is still difficult to integrate the illness into his self-image (HF11, Pos. 8).
21What can be picked up from the therapist’s assertions is that she perceives Mr. F. as someone who feels he had a successful professional life. In conjunction with other parts of the material, it can be assumed that he managed his own business, and his retirement is recent. When examining this excerpt in regard to age markers, it seems clear that the confrontation with younger people practicing the same profession as he did before his retirement makes him aware of his own age. This is supported by the therapist recording some direct speech of Mr. F. claiming that these younger men “stand in the prime of their life”, while he appears to struggle with his self-image after retirement. Evidently, a feeling of having past the “prime” of life stands in close relation to one’s own process of aging and old age.
22Moving on, this form of becoming aware of aging seems to be associated with work-related stabilizing beliefs becoming unstable. These can be understood as a type of shell which has thus far facilitated avoiding confrontation with the limit situation but has now become brittle. Here, these beliefs might be condensed into an idea of merit or achievement. That this is taken up by the therapist becomes more salient in conjunction with other segments of the material; it can be grasped that Mr. F. successfully pursued rather materialistic life goals in the past and that the crisis prompting him to seek psychiatric treatment came suddenly, while he felt generally content before. Thus, the belief in stability through professional success appears to have provided a sense of security in life that fades in the context of retirement because it is tightly bound to being an active member of the workforce.
23This assertion is also supported by the importance ascribed to Mr. F.’s self-image as “craftsman and successful businessman” to his sense of identity – underlined by the therapist highlighting the quite drastic exclamation “Who am I anymore? – Nothing!” in this context. It is not surprising that strongly associating self-worth with professional achievements seems to be especially relevant in the context of retirement. Yet, what this framework provides is a deeper look at what comes under pressure in this situation: a type of shell tightly bound to work-related beliefs. This more intricate view on the structure of stabilizing beliefs and their relations to aging, old age, and the limit situation consequently allows one to imagine that engagement with the limit situation in this context could be less intense if this shell were less closely coupled with an idea of performance and reward.
24Thus far, I have argued that specific dynamics of aging and old age entering experience – age markers – could be identified in the material. Also, in association with these dynamics some forms of stabilizing beliefs – shells – can come under pressure and provide less to little security. This constellation can be understood as an engagement with the limit situation in the context of aging and old age. One aspect unmentioned so far is the presentation of the limit situation in the material. This is because it is difficult to make sense of using only one excerpt and can be better grasped when taking the entirety of the material into account – a task requiring a different format. Nevertheless, it is helpful to pay attention to the “dreadful sense of hopelessness” the therapist deems so important in a communication from Mr. F. that she marks it as direct speech. Even to the reader, a sense of urgency and despair is conveyed in these few sentences that revolve around a feeling of not knowing who one is anymore.
25It is passages like this one, often featuring references to a diffuse anxiety or feelings of impotence or groundlessness, that hint at the crisis in the background. In the material, the shapes of the limit situation can be ordered in types similar to age markers and shells: “death”, “isolation”, “contingency”, “guilt”, and “suffering”. These types are not surprising and do not stray far from Jaspers’ examples of limit situations. Yet, an interesting perspective can be gained from the analysis of the material: Across the cases, the shape of the limit situation can be very different, and it can hardly be reduced to one single theme in any of the cases. Thus, next to the isolated types mentioned above, several types encompassing more than one theme can be worked out as well. Here, multidirectional connections between all “basic” shapes become visible and appear to be context-dependent. It follows that – within the reach of the cases studied here – the limit situation is not presented and captured in the therapist’s documentation in one of five different variants but as more of a superordinate phenomenon which appears in a context-dependent shape. The dominant idea behind this phenomenon appears to be the individual’s own death or the idea of not-being-anymore to which all other facets of the limit situation seem to orient themselves without ever fully merging into it.
26I will now turn to examining one final aspect: the provision of transitory shells in therapy. Obviously, there is not just one reaction to the constellation described before. What happens cannot be boiled down to a specific set of interventions or developments. Still, as before, some dominant dynamics can be identified, but not all of them can be laid out here. The one I have chosen shines a light on one way of understanding and engaging with the limit situation in therapy. While the existential dimension of certain dynamics is rarely explicit for patients and therapists, the patient’s condition can nevertheless improve. In these cases, what seems to be helpful is a “transitory” shell, i.e. ready-made stabilizing beliefs that can quickly be developed and provide a sense of stability but are not necessarily durable.
27This will become clearer by looking at an example. The following excerpt is from the case of Mr. K. (80). From different parts of this case, it can be learned that Mr. K. sought psychiatric treatment with different bodily symptoms (like pain) without any obvious somatic correlate. During his stay a conflict arises in which he is reported to realize that he struggles with the performance of daily tasks costing him more energy and time whereas before they would have been peripheral. It is worked out by him and the therapist that at the core of this conflict lies the idea that in accepting his restrictions and the changes experienced he would have to accept that he is now of old age. The following is from the very last entry before Mr. K. is discharged:
Final session: Mr. K. reviews the past 6 weeks – the pain, which he experienced at the beginning of treatment and which had let his mood derail so extremely, is now completely gone. He has gained a new view on his symptoms and can now understand them as ‘body language’ and thus a sign for potential stress/overload. He is going home in good spirits since his mood has gotten significantly more stable or normal […] (HK12, Pos. 22).
28First of all, the mood conveyed in this paragraph is positive. Both patient and therapist appear very satisfied with the course of treatment. It is recapitulated that the symptoms leading to admission have completely vanished and with them a depressed mood on the part of Mr. K. As the main reason for this course of events, a new view on his symptoms is identified which was co-developed over the course of his stay: Mr. K. resolves to understand the troublesome symptoms as “body language” by which he seems to mean that they are a signal that he is exerting himself and should rest. While he seems content with this new belief – the mood-affecting symptoms as markers of exertion – it must also be noted that the aging-related conflict mentioned earlier, which was specifically connected to his symptoms, does not play a significant part in the end.
29Similar dynamics appear in several cases. What they have in common is an underlying idea of a biological entity, i.e. a disease and in these cases plausibly depression, being the cause for the symptoms at the heart of the individual’s crisis. This entails several assertions: i) the individual is subjected to this debilitating experience; they are not at fault and the experience does not have anything to do with them, ii) the disease can cause any kind of symptom up to a “temporary loss of meaning in life” (FP13, Pos. 70) in cases of suicidal behavior, iii) all of the symptoms may be improved through adopting certain behaviors, medication, or other ready-to-hand measures. As in the example of Mr. K., stabilizing measures seem to lead to improvement but also seem to rest on providing or co-developing a transitory shell. The potential issue with this is its dubitable stability in concert with the impression that this aspect is not taken into consideration by neither therapist nor patient. In consequence, it is conceivable that age-specific dynamics are underestimated, set aside as mere epiphenomena, and may thus continue to exert an individually unfavorable influence.
30The analysis offers a conceptualization of a dynamic of destabilization of formerly stabilizing beliefs in the context of aging and old age. Three key parts of this dynamic were explored: How aging and old age enter experience through age markers, how shells may expire with age, and the limit situation as an experience of instability in the context of aging. In addition, the provision of transitory shells in treatment was examined as one reaction to this experience.
31Overall, the analysis of the material seems capable of delivering insights into how aging as a phenomenon may become conscious, how stabilizing beliefs regarding the limit situation are structured, how these beliefs change in relation to aging, and how the relationship between aging and the limit situation may be described. Thus, the concept of the limit situation has the potential to bring the existential adversities of aging and old age into one perspective.
32A full account of the study’s results requires a much more extensive elaboration that could not be provided here. Instead, the thesis that the experience of the limit situation is intensified in the context of old age due to an accelerated erosion of the individual’s shell was argued for using a selection of examples illustrating several key aspects. Two main points to explore with regard to the study’s limitations would be the use of rather unique research material and the claim to reconstruct problematizations of certain themes and ideas from it.
- 11 Experimental philosophy is a young philosophical field that aims to connect philosophical question (...)
33One point that could not be expanded on in sufficient detail is the methodological framework of the project which can be considered an approach in experimental philosophy of psychiatry.11 This is relevant, because the pursuit of such an approach has recently been advocated for (Aftab, 2021; Faucher & Béghin, 2023), and, contrary to most studies in experimental philosophy, this project does not use quantitative data to study intuitions regarding philosophical claims but explores a theory-building approach using qualitative data. I aim to outline this approach and its implications in future publications.
- 12 The acquisition of a specific “competence” in engaging the limit situation has been argued for by (...)
34These findings offer starting points for methodological discussions concerning the role of philosophy and specifically existentialist concepts in the field of psychiatry and psychotherapy, an age-sensitive reworking of phenomenological-existentialist models, and discussions about their practical relevance for the treatment of mental illness in old age and in respect to aging. In regard to this last point, it seems adequate to advocate for greater openness towards existential dynamics in psychiatry and psychotherapy with the aim of increasing practitioners’ competency in engaging with them.12