Blooming in December: Psychodynamic Psychotherapy With Older Adults

Amy Schaffer

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000375282
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

This book covers the essentials of psychotherapeutic work with older adults, discussing how contemporary psychodynamic thought can be applied clinically to engage the older patient in psychotherapeutic work of depth and meaning, workthat not only relieves suffering but also promotes growth.

It describes the way the difficulties accompanying older age can affect psychological functioning and it examines the unique psychotherapeutic needs of this age group. Using clinical vignettes for illustrative purposes, it explores the psychotherapeutic challenges, tasks, techniques and accomplishments involved in the treatment of older adults. Topics discussed include the reemergence of earlier developmental challenges; the concurrent treatment of late life and revived early trauma; transference and countertransference; the functions of developing an enriched life narrative in restoring the self; existential issues; and mourning. Throughout, the focus is on what psychotherapy can do to help.

The demand for mental health services for older adults is growing alongside increasing life spans, but the psychodynamic literature has neglected this population. Blooming in December: Psychodynamic Psychotherapy with Older Adults fills this gap, offering a clear guide to effective work with older adults for all psychotherapists and psychoanalysts.

Chapter 1

Introduction

To work as a psychotherapist with older adults is to live with the painful reality of how little you can do. You cannot relieve arthritic pain or the agony of losing a spouse. You cannot cure cancer or fend off death. You cannot undo the wrong turns that your patient has taken earlier in life and now deeply regrets. And you cannot erase wrinkles. Yet, if you can tolerate these limitations, the work with this age group can be highly effective. It not only relieves suffering, but it can also lead to significant growth. And it can bring fulfillment and meaning to both patient and therapist.

Life’s brevity, as Freud (1916) wrote in his poignant essay on transience, can make it all the sweeter. Older adults are all too aware of the fleeting nature of existence. And for many, the later years are indeed a time to treasure what life offers. For countless others, however, older age brings true distress. It brings depression, bitterness, feelings of failure, self-loathing, and shame. How do psychodynamic clinicians help suffering elders? An examination of the psychoanalytic literature provides little in the way of answers.

I have long wondered why psychoanalysts pay such scant attention to the treatment of the old. My interest in this population stems from an early experience running a group psychotherapy service for older adults. The psychiatrist head of the agency providing this service was open about his negative countertransference toward the aged. He was pessimistic about what therapy could offer these patients and expressed grateful surprise when the groups I led seemed to work. I loved these groups. I was a psychodramatically trained group therapist then, not yet trained in psychoanalysis. At the time I had led groups in several settings: two psychiatric hospitals, a residential camp for children with special needs, an institute treating young adults, and a service for creative artists. Of these many groups, those with the older adults stood out for the depth of connection of its members, their generosity toward each other, their willingness to reveal their vulnerabilities, their resilience and courage in the face of harsh life circumstances, and – particularly gratifying to a beginning therapist – how much benefit they seemed to gain from their groups. I learned from these groups and found them rewarding, inspiring.

Because I was vocal about my enthusiasm for this population, I have over the years received many referrals of older adults – including some from fellow therapists who referred their parents. At first, these patients were twice my age; now they are age-mates. Throughout, I have been mystified by the lack of interest by my colleagues in this group of potential patients.

Psychoanalytic writing on the aged, what there is of it, is extremely interesting. However, this literature is disturbingly sparse – especially so in proportion to the size of the population that can benefit from this treatment. Recently, attention is being paid to this lack of attention. McWilliams (2017), for example, described the neglect of later life in the first edition of the Psychodynamic Diagnostic Manual – ruefully noting the advanced ages of many involved in its creation and concluding: “We were a study in denial” (p. 51). Plotkin (2014) subtitled his urgent statement of the need for more focus on this area, “It’s about time.” Schachter et al. (2014) actually counted the number of papers on this topic to document their scarcity. And Junkers (2006) commented, “many analysts have a strange aversion to working clinically with elderly people” (p. xiii). Writers have begun to examine the prejudices responsible for this inattention (e.g., Wagner, 2005). And a small (so far) group of voices have begun to call for the work necessary to redress this imbalance, to examine the psychological needs of a significant and growing segment of our population. I join this chorus of voices and hope that others will as well. Let us embrace a quest to study how we can best serve people in their later years.

Is psychotherapy of older adults different from that of the young?

One might counter these voices, asking if there is really a need to further develop our theory about treatment at this stage of life. Doesn’t existing psychodynamic theory adequately inform our work with these patients? The answer is no. Of course, older adults are prey to the same difficulties as younger adults and, of course, existing psychodynamic theory is applicable to their treatment. But this theory while necessary is insufficient. Older patients face, and present to their therapists, unique issues and complexities. To offer just one example (many more will be discussed in the chapters ahead): a major thrust of our work with younger individuals is geared to fostering the development of, and removing the obstacles to, a sense of autonomy and agency. We want our patients to be captains of their ships. How then does one work with an 80-year-old who has achieved and prizes his autonomy and whose challenge now, in the face of physical infirmity, is to retain his sense of self and equanimity while experiencing ever-increasing dependence?

One’s advanced years entail emotional challenges specific to this phase of life. The body changes in ways one cannot control and sphincters that used to work reliably no longer do. Social and familial roles are transformed. Indignities are many (Lax, 2008). Death looms and death anxiety can no longer be evaded. Losses pile up. Autonomy is diminished. Whatever was provided by the belief that one will have a future is no longer provided. And existential and spiritual questions surge to the surface. What has this all been about? Does my life have meaning? Who am I? Tested in this way, many people find their long-buried traumas and timeworn relational conflicts reemerging. Old defenses, which were once “good enough,” no longer suffice. Issues that were worked through well enough in the past arise to be worked though again. Significant psychological effort is often required to meet these challenges. This effort can make the difference between a late life of fulfillment or of despair. And this effort is often fruitfully made within the context of a therapeutic relationship. But therapists of patients in this age group often work alone, grappling with emotions and questions in the absence of the grounding which a more complete literature, which a more complete dialogue between professionals, could provide.

With advances in our field – the expansion of our clinical repertoire, the movement of our theory from its emphasis on drives to one on relationship, our greater understanding of multiple modes of therapeutic action, and evidence of the neuroplasticity of the brain extending throughout the life span (Siegel, 2020) – we now have new and better conceptual tools for engaging in this work. My goal here will be to examine the psychological tasks of older age and the ways that the clinician can engage the older patient in work of depth and meaning, work promoting significant growth.

I send a cry to my fellow psychotherapists. Let us recognize that the population of older adults is increasing rapidly, that their mental health needs will be great. Let us study the later years as life spans lengthen. And let us rise to the occasion. It is incumbent upon us to learn more about how to help older people. In this work, I will examine what I have learned about the developmental crises and needs of older patients as well as the challenges they present to the clinician. I hope that in this goal I will be joined by many others.

I now turn to the factors that have contributed to the psychoanalytic world’s striking lapse in attending to the treatment of older adults. Readers who would prefer to move directly to discussion of clinical work with this population may wish to skip this section and proceed to Chapter 2.

How is it that a field devoted to the psychological welfare of others has managed to keep its gaze from the needs of such a large sector of our human community? How is it that psychodynamic clinicians, individuals who constantly engage in self-analytic processes directed toward understanding their unconscious biases, have failed to recognize and grapple with this bias? The cumulative effect of numerous dynamics explains this glaring omission. It is imperative we face the multiple forces responsible for our lapse so that we can overcome them. I will begin with issues encountered by individual clinical practitioners which may lead to avoiding work with older patients. As significant as these may be, their effect is magnified by institutional hindrances stemming from the field of psychoanalysis. Our discipline, for all the richness and depth it offers, has been beset by biases that interfered with developing a solid foundation for treatment in the later stages of adulthood. I will, therefore, examine these institutional biases as well.

Challenges to the individual clinician in treating older patients

Psychodynamic treatment of the older patient can be extremely rewarding to the therapist but that is hardly the full story. It can also be excruciating. Some of the avoidance of this work stems from the difficulties it presents to the clinician. All of these have been made worse by the inadequacy of our theory and literature. Misery in the countertransference is not restricted to work with the old. We treat people with borderline personality disorder, we treat traumatized survivors of physical and sexual assault, and we treat addicts. We know that we will endure painful affects as we work with these populations. Gartner (2014), for example, summarizes his affective life working with sexually abused men, “However you look at it, it hurts” (p. 614). In the grip of the interpersonal field with these patients, we hurt. Fortunately, in these treatments our theory contains us. It helps us make sense of our experiences and puts words to them. Shared suffering is bearable suffering (Berzoff, 2019). This is true for our patients, and it is true for us. As the literature on working with elder patients grows and provides similar assistance to the therapist, I hope the challenges I describe below will become easier for therapists to bear.

Painful countertransference and assaults to grandiosity

The psychotherapist of the older patient must confront aging and death and must renounce the luxury of postponing this reckoning. To help these patients with their feelings and fears, we must face them ourselves. But, as Schramm (2018) comments, the elderly are sometimes (although not always) less frightened of death than are the professionals helping them. Humans are remarkably adroit at avoiding the knowledge that they will die (Becker, 1973). And in this respect, analysts are all too human. Too few create the professional wills which would ensure assistance to patients should the therapist be incapacitated. A long history of botched handling of therapist illness or death attests to this (Masur, 2018; O’Neil, 2013). Analysts such as Feinsilver (1998) and Gingold (2018), who faced terminal diagnoses and wrote about their thoughtful attempts to handle their practices therapeutically, are rare. I know of therapists who, denying their terminal illnesses, failed to inform their patients or to make provisions for their being informed – leaving these patients to learn of their therapists’ deaths from a doorman or an obituary. I know of therapists who, unable or refusing to recognize their own dementia, insisted that their patients continue with them, interpreting their desires to leave therapy as resistance. Similar denial has manifested itself in cases where patients’ expressions of reasonable fears about their infirm elderly therapists’ possible deaths were interpreted as unconscious wishes to kill the therapist (Slochower, 2019). Psychoanalysts, like other mortals, avoid facing the realities of death and decline – even when the failure to do so harms others. Working as a therapist with patients in later life pierces this denial. Is it any wonder that members of our profession dodge such encounters?

Working with the aged also cracks into the analyst’s comfortable and unacknowledged grandiosity. Under the sway of “Olympic delusions” (Pinsky, 2017), we may unconsciously believe that we can defeat death. To work with the aged, we must face that despite our ministrations, patients die; that we, too, will die. Cooper (2016) reminds analysts of their need to continually rework the depressive position, pointing out that we have difficulty accepting our limits. In addition, it is not merely personal grandiosity which must be overcome but also psychoanalysts’ idealization of psychoanalysis itself. As Gabbard (2017) observes, psychoanalysts may join their analysands in a shared unconscious fantasy of “triumph over death.” To work with patients in late life is to tolerate the pain of relinquishing this illusion. This pain adds to the other aches that attend this work, aches further described in Chapter 4 on transference and countertransference.

Altered gratification from results

Psychoanalysts pride themselves on working for deep change. Not for us simple symptom relief. We want to make an internal transformation. We may name what we’re after “structural change” or “modification of implicit memory systems” or “alteration of relational patterns” or “making the unconscious conscious” or “standing in the spaces.” Whatever our terminology or psychoanalytic orientation, we are trying to influence our patients’ inner life.

And yet, although these are our stated goals, it is striking that almost every case report in the literature describes external change as evidence of success. Our patients find mates, or blossom in their careers, or become better parents, or create art. These external gains, I believe, are described not merely because they demonstrate accomplishment but also because they are deeply gratifying to the therapist. And they should be. We work hard and long and experience joy when patients’ external lives change for the better. Is this a pleasure one is denied in treating the aged? Not necessarily. In many cases, an older patient’s external gains are highly gratifying to observe: a patient in late adulthood has his/her work shown in a gallery for the first time, makes a new friend, enjoys rather than quakes at a dinner party, confronts a financial consultant, accepts a long denied sexual orientation and has the courage to come out, or is finally able to feel and express loving feelings to a grandchild. But it is n...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Contents
• Acknowledgments
• 1 Introduction
• 2 Ghosts in later life
• 3 Trauma and trauma redux
• 4 Dramatis personae, past and present
• 5 The narration of life stories and the self
• 6 Existential anxieties
• 7 Endings
• Index