Over seven hundred psychoanalysts and other mental health professionals gathered at the National Institute of Mental Health in Washington on the weekend of November 6-7, 1982, to consider research on the interplay of personality, biology, and society in shaping adaptation to aging. The convening of this meeting, co-sponsored by the Center for Studies of the Mental Health of the Aging and the Psychosocial Treatments Research Branch, marked the first time that NIMH had sponsored a conference in which the clinical and theoretical contributions of psychoanalysis to the study of normal and pathological development had been so explicitly recognized.
The formal conference program included a Past-President of the American Psychoanalytic Association, George Pollock, and numerous other members of the American, including Drs. Robert Michels, William W. Meissner, Martin Berezin, John C. Nemiah, Otto Kernberg, Mardi Horowitz, Peter Sifneos, Stanley Cath, Stanley Greenspan, Herbert J. Schlesinger, and Robert S. Wallerstein, along with research candidates Dr. Nancy E. Miller, organizer and chair of the program, and Dr. Bertram. J. Cohler. A variety of research issues regarding human growth and development past age fifty were considered, as well as aspects of psychopathology unique to late life and special approaches to psychodynamic assessment and treatment in the elderly.
The conference began with a consideration of the vicissitudes of normal development across the second half of life. In his opening remarks, Dr. Carl Eisdorfer reviewed stereotypes of aging and noted the importance of considering the special talents as well as the particular needs of older persons, pointing to studies showing that older persons are not simply concerned with issues of loss and death but can maintain a rich inner life. Devaluation of aging, Eisdorfer cautioned, leads to a devaluation of life itself. Dr. Bertram Cohler reviewed findings from a number of longitudinal studies, suggesting that personality development may not be simply continuous across the course of life. Aspects both of personality and of the social context, associated with increased morale and life-satisfaction through mid-life, may not be those most relevant for preservation of a sense of psychological well-being later in life.
In underscoring the importance of considering psychodynamic and biologic aspects of development together, Dr. Arnold Mandell described research on brain assymmetry which suggests that more obsessional and analytic personality characteristics are associated with the left brain, while traits associated with a more hysterical, creative, and synthetic style are associated with the right brain. Individual differences in hemispheric dominance, in effective communication between hemispheres, and in the level and function of specific neuro-transmitter systems, lead to differential personality responses to advancing age and help explain discontinuous fluctuations in the organization of self.
Speaking directly from a psychoanalytic perspective, Dr. Robert Michels wondered if psychoanalysis as a discipline was ready to tackle problems of such complexity as aging. Study of the unconscious and of early memories is believed easier in younger persons, where biologic and social crises do not compete for consideration. At the same time, Michels noted that older patients may be less resistant to psychoanalytic intervention than younger persons, and he supported the request made by numerous other presenters for more sustained, systematic study of older persons from a psychoanalytic perspective.
In commenting on the psychiatric syndromes of later life, Dr. Martin Berezin stated that there is need for more detailed comparative clinical inquiry, regarding persons differing in their capacity to adapt to the unique developmental challenges of later life, and more need to better understand distinctions between so-called normal and pathological aging.
Dr. George Pollock discussed issues of mourning and depression in late life, noting that depression has adaptive characteristics, in preserving energy and supporting the increasingly inward orientation observed normatively among older persons. Mourning is important in dealing with the inevitable disappointments and losses across the life-course and need not become pathological. Restating a theme emphasized by several panelists, Pollock noted the complex relationship between psychological and biological processes, as seen in pathological mourning, where several body systems are implicated in particular psychological processes.
Drawing upon the clinical and theoretical perspectives of self-psychology, Dr. Lawrence Lazarus presented results from a study of senile dementia of the Alzheimer type (SDAT), in which the impact of illness upon feelings of self-cohesion has been studied. Lazarus found that the use of others in idealized ways may assist the patient in maintaining his sense of self during earlier phases of the illness, when awareness of loss of cognitive skills is especially acute. SDAT patients were found to use mirror and particularly idealizing transferences to a far greater extent than normals in clinical interviews.
Dr. William Meissner also discussed the internal world of the elderly, noting the function of paranoia as a means used by older persons to defend against loss and change and to preserve adaptation and narcissistic equilibrium by sustaining particular constructions of reality in ways that will be stable over time. Vulnerable persons, unable to respond in effective ways to the challenges of advancing age, often feel increasingly isolated and helpless in a world no longer understood and experience a lack of acknowledgement or confirmation of the self. Over time, these vulnerable older persons may become increasingly sensitive to the point that they become paranoid. Meissner noted the importance of further study of factors in our lives that lead to feelings of particular vulnerability in order to determine differences in the extent of narcissistic vulnerability experienced by older persons.
In his remarks on personality disorders in middle and late life, Dr. Otto Kernberg noted that little is known about the determinants of hysterical, obsessional, and depressive disorders. Though preliminary clinical evidence suggests that such disorders among older persons respond well to treatment, on the other hand, aging individuals with narcissistic or borderline character disorders present a particular challenge for the therapist and have a more guarded prognosis.
In discussing psychosomatic disorders and hypochondriasis in late life, Dr. John Nemiah commented on the surprising dearth of clinical and research data in these areas. However, he reported some evidence for an increase in alexithymia with advancing age. Dr. Mardi Horowitz extended a theme present in virtually all papers on pathology, that of threats to the self and attendant anxiety arising in late life. Recognition of a foreshortened life, together with grief resulting from important losses, leads to increased anxiety-related disorders that are not well represented in the DSM-III. Although severity of stress response declines in later life, there is a relatively greater frequency of adverse changes in older persons. Supporting the observations reported by Pollock, Kernberg, and others, Horowitz noted the effectiveness of psychotherapeutic intervention with older patients.
In keeping with this observation, Drs. George Silerschatz and John Curtis reported that psychoanalytic psychotherapy is demonstrably effective with older persons. They cautioned, however, that effort must be expended in research in order to obtain more systematic information about the treatment process, while preserving the richness of the context of the particular analyst and analysand. Their cogent criticism of the “clinical trials” methodology as an adequate research design in the study of psychoanalytic psychotherapy was affirmed both by Dr. Robert Wallerstein and Dr. Hans Strupp, on the basis of their own respective research projects. Strupp noted both that findings to date on psychotherapy outcome have been more favorable than has generally been acknowledged and that systematic study should be carried out in a context designed to preserve the actuality of the clinical situation.
In reviewing findings from a study of insurance records that show psychotherapy may actually be cost effective, Dr. Herbert Schlesinger and Emily Mumford found that patients receiving psychotherapy subsequently seek medical care for a number of chronic diseases to a lesser extent than do persons in a comparison group. They further discovered that such post-psychotherapy effects are even greater among individuals over 65.
Extending the discussion on modes of psychodynamic intervention, Dr. Peter Sifneos reported positive results from short-term psychodynamic psychotherapy with neurotic older persons who presented with specific, delimited complaints. Dr. Jerome Grunes noted that the demand for psychoanalytic forms of treatment will increase, as a generation of immigrant and rural-born elderly is replaced by a better educated, urban generation that expects high quality of mental health assistance.
Grunes also discussed particular countertransferential problems and failures of empathy in working with older persons. Supporting Meissner's observations, Grunes noted that losses, including those of cognitive skills, require particular awareness of the sensitivities of older persons and of the enhanced tendency to projective identification. Sheldon Tobin noted that such problems were particularly acute among older persons requiring long term institutional care. He described instances in which family members manifested a split transference to the consulting analyst and to the institution. In his discussion of problems in technique, Dr. Stanley Cath highlighted the importance of attending to processes which will support integration of the self among older persons and using analytic understanding in the service of maintaining a successful adaptation.
Following the conference, presenters and discussants convened for the purpose of formulating specific recommendations to NIMH, regarding substantive priorities in psychodynamic research with the aged, strategies for overcoming methodological barriers, and ways of stimulating interest in insight-oriented treatment approaches. NIMH is interested and committed to enhancing research in this area, and NIMH staff will be pleased to consult with anyone interested in applying for an NIMH research grant award. Dr. Miller can be reached at (301) 443-1185 for further information.
The papers presented at this conference will be published by International Universities Press in 1984.
Bertram J. Cohler, Ph.D., Chicago
Nancy E. Miller, Ph.D., Washington