Last updated June 2013.

Generativity and Ego Integrity:
What a boring title! How about, "The craziness of lifelong development?"
June 2013
Doug Kramer

Life Member LogoIntroduction:
As with most things human, everything important begins with a conversation1. Despite the push to understand the brain in reductionistic terms, analogous to how we understood the liver in medical school, the brain can only be understood via its interactions with other brains2,3. All that we consider to be "human" about ourselves, about our fabulous brains, evolved to mediate social interactions4. Thus, this Life Member Report began as a response to Ginger asking, "So, how goes it in Vermont?" I chided her about asking for something which she then might not have time to read, forgetting myself that talking to Ginger often leads to a subsequent assignment (always rewarding).

My wife (Patti) and I began falling in love with Vermont, for the second time, about eight years ago when we started more or less annual cross-country skiing trips to an area known as the Northeast Kingdom, and a community, Craftsbury Common. The village is named for the "Common" at its center, around which are several homes, most dating to the 1800s, the Craftsbury Academy, including both a middle school and a high school, Sterling College, a very small progressive school which focuses on sustainable agriculture, the Craftsbury Public Library, the United Church of Craftsbury, and the old parsonage where the parson and his family once resided.

We have been renting the parsonage for about a year. We found a plaque commemorating its donation to the church in 1879. A repairman told us that the timbers in the basement are hewn in a fashion that pre-dates the Civil War. From the front of our home, we often see beautiful sunrises; and from the back we see even more beautiful sunsets, as the ultimate source of life departs daily behind the Lowell Mountains. From our home, the traditional New England church we attend, one of the most photographed churches in Vermont, is shrouded each evening in the magical colors of the sunset. Most days, we enjoy seeing Morgan horses pulling a cart past our home, the cart carrying a professor and usually two students, essentially "driver education class" for sustainable agriculture students from Sterling. That's real learning! Somewhere I read that Craftsbury Common is the Shangri-La of New England.

My reply to Ginger (with a little updating):
Hi Ginger, I was thinking today that you probably know more child psychiatrists than anyone in the world. Which gives me license to give you a long answer to your six-word question. You should know better! First, everything is wonderful. Remember that as you read on.

This particular community, Craftsbury Common - the village, and Craftsbury - the town, is incredible. One hears the term "community" a lot the last few years, but I have never understood what the word meant until living here. The people and the relationship network are just wonderful. I think we know several people here better than we knew most of our neighbors in Madison - including our next door neighbor of 24 years. I think the thing I love the most is that you cannot have a short conversation. If you want to check on something, in person or by telephone, it's pretty much required that there be a ten-minute conversation first. What a way to live!

Today was 'Town Meeting Day' in Vermont. On the surface, it's like what is depicted on television, but really it's much more than that. Attendance was good, people are very conscientious to speak about issues in terms of what is good for the community, and what they care about, and everyone is caring and respectful. It is also a social gathering. Lots of conversation every time there was a paper ballot, required for all items over $5,000, as we stood in line to cast our scrap of paper, and then more conversation as we waited while the votes were tallied. A real community. It's all first names. No ID to check in. They know who you are and just check you off the list. They ask about your dog.

So, what's the News? Despite how much we love our experience in Vermont, especially the people and the relationships, we are moving back to Madison. We thought we could live in this place and travel to see the kids and grandkids, but we realized at Christmas that we want to have a more natural relationship with them, and we believe it is important that they know us as well - maybe more important in the long run. I think the emotions about this were heightened by Sandy Hook. That happened the day before we left to drive to Wisconsin. Two of our three children, and three of our five grandchildren are one to two hours from Madison.

The other issue goes something like this, "For better or worse, Madison is our home." Meaning, we have lived there three different times, med school, gone for four years, residency, gone for nine years, back for the majority of my practice and teaching life (24 years), the period during which you and I became friends. Our history is there and is connected to the history of Madison. Our timeline has geographical coordinates. Not that we're an important part of Madison, but it's our home - for better or for worse.

Even so, we are not unhappy at all that we came here. I cannot stress this too much. Despite the inconvenience and the cost, this has been one of the most important periods of our life. It has been good for us, we have made good friends, and it has been a great experience. We would not trade our year in Craftsbury Common for anything.

It was good for us to leave Madison, no matter where we went, some sort of process that has been good psychologically, relationally, and with respect to our entering the grandparent generation. We were looking for something post-retirement, came to Vermont to find it, and found it within ourselves.

Last night, we were invited to a cross-country skiing progressive dinner. So, instead of going down the block or across the street, it was four or five miles from soup to main course, through the woods, at night, on un-groomed trails, some of which were sort of exhilarating. Great group of people! Great adventure!

Six days after Sandy Hook, we were confined to the Hampton Inn in Madison by the blizzard - the Thursday before Christmas - and I started an op-ed on "guns, violence, and mental health." It was the only way I could deal with my feelings about that tragedy - deal with them by contributing to the discussion - particularly about a way to improve the condition of the seriously mentally ill. I've lost track of the number of drafts and revisions, but it got better each time. Neither the New York Times, the Wall Street Journal, the Washington Post, USA Today, JAMA, or the Archives of General Psychiatry were interested. Psychiatric Times loved it, thought it was "timely and important." I later learned that Psychiatric Times is the most widely read psychiatric publication, so I am very glad about the rejections. That's the News from Lake Wobegon! All goes well in Vermont!



A Clean Break:
A good friend of mine, also named Kramer, was fascinated by this story, and said that what Patti and I needed was "a clean break." In his formulation, with which I basically agree, in order to move on with our lives post-retirement, we needed a clean break from being a physician with a practice, and a teacher with students. We always saw retirement as being an adventure, essentially a new life, but a new life that had its origins in our old life. Neither a divorce from that life, nor a repudiation of it. We accomplished the "clean break" of Milton Kramer's formulation. This has been more than an extended vacation, more than a sabbatical. This has been a different life and a life that we dearly love.

Even though the decision was without ambivalence, the process was not easy. It actually feels pure in a way. As I think of the two weeks during which the decision was made to return, I am reminded of the scene in The Empire Strikes Back when Luke is being trained by Yoda, Luke's frustration at not being able to successfully engage the apparitions he was attempting to fight.

A few days before the drive to Wisconsin, I was looking at the late day silhouette of the mountains thinking, "I am so glad we live here (Vermont)." Arriving in Madison less than a week later, driving down the Beltline at night in the rain, I remember thinking, "Oh, I remember why we don't live here (Wisconsin)." What followed was two weeks of almost unbearable anxiety, I suppose trying to reconcile what seemed right with what was right. I think a "hyperspace" analogy might work here. What I believe I was experiencing was a developmental shift at hyperspace speed, in my own personal Millennium Falcon - not that I was a passenger by choice! Another sort of "clean break!"

Generativity and Ego Integrity:
I wonder if the cultural changes in the late 20th and 21st centuries, interacting with a much longer lifespan than even in the early 20th century, result in a substantial overlap between Erikson's Stages VII and VIII5. Erikson discussed the continuing reworking of all previous stages as one negotiates any current stage. Does the term, "60 is the new 40," imply developmental progress or developmental delay? Might 'generativity vs. stagnation' and 'ego integrity vs. despair' co-exist? Might one actually be able to actively continue with Stage VII while forging ahead with Stage VIII?

It has been speculated that what differentiated anatomically modern human beings (Homo sapiens sapiens) from other lines of Homo sapiens was long-livedness, and the accompanying ability to transmit knowledge related to adaptedness across more than two generations6-9. Someone I know once suggested this transmission of knowledge might be the adaptive function of transference.

As I sit at the kitchen table completing this Report to fellow Life Members, next to our Siberian Husky, who has now passed me in dog year equivalents, on a day that included packing a U-Haul truck to drive to Wisconsin, and delivering a six-inch hairball to his veterinarian, I feel satisfied to be newly discovering, for instance, that I care deeply about the plight of the seriously mentally ill, about their unimaginable psychic distress10, and that I am equally concerned about the loss of physician in our identity as psychiatrists11,12. I suppose dropping the true internship in 1972 eventually would lead to most doctors being doers rather than healers, but I particularly mourn this in our field - the field where relationship matters most. At the same time, I marvel at how my life is following the course Erikson described (p 268)5, "It is the acceptance of one's one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions: it thus means a new, a different love of one's parents." We would not trade our year in Craftsbury Common, Vermont, in the Northeast Kingdom, for anything! Thank you.

1. Bateson G. Steps to an ecology of mind. New York: Ballantine Books; 1972.

2. Freeman WJ. Societies of Brains: A Study in the Neuroscience of Love and Hate. Hillsdale, NJ: Lawrence Erlbaum Associates; 1995.

3. Freeman WJ. Neurodynamic models of brain in psychiatry. Neuropsychopharmacology. Jul 2003;28 Supplement 1:S54-63.

4. Cheney DL, Seyfarth RM. How monkeys see the world: Inside the mind of another species. Chicago: The University of Chicago Press; 1990.

5. Erikson EH. Eight ages of man. Childhood and society. 2 ed. New York: W. W. Norton & Company; 1963:247-274.

6. Kramer DA. Like (grand-) father, like (grand-) son: The implications of the transference relationship and developmentally sensitive periods for learning on the three-generational system. Denison Journal of Biological Science. 1988;25(1):18-35.

7. Diamond J. The great leap forward. The third chimpanzee: The evolution and future of the human animal. New York: HarperCollins; 1992:32-57.

8. Caspari R, Lee SH. Older age becomes common late in human evolution. Proc Natl Acad Sci U S A. Jul 13 2004.

9. Caspari R. The evolution of grandparents: senior citizens may have been the secret of our species' success. Scientific American. August 2011 2011;305(2):44-49.

10. Kramer DA, Verhulst J. Guns, violence, and mental health: Did we close the state mental hospitals prematurely? Psychiatric News. June 2013;30(6):34-35.

11. Kramer DA. The next patient. AACAP News. January/February 2009;40(1):26-27.

12. Kramer DA. phy-si-cian: a person who is skilled in the art of healing. AACAP News. September/October 2011;42(5):240-241.