When I was first introduced to Freud, I became fascinated by his psychosexual developmental theory, in which the complexity of our minds was rooted in the growth of our bodies. Gradually, this interest led me into an appreciation of aging as a vector for change and senescence as a unique developmental stage. Application of psychoanalytic concepts to the maturational development of the elderly has informed my practice and stimulated my future research.
While many people may think of geriatric psychiatry as aligned solely with biologically based psychiatric interventions, approaching issues of senescence as a developmental phase opens up the field to psychoanalytic work. I see elderly patients in my office as well as in long-term care settings. I have patients in independent apartments, assisted living, and nursing home care. I also consult on a specialty unit for elders with dementia. Consequently, the developmental challenges are very different even amongst the elderly cohort.
Losses are prevalent of course, yet the nature of the loss varies. Old anxieties are reawakened, but new obstacles are the most confounding. Loss of purpose, loss of independence, loss of body integrity, loss of loved ones, and loss of reason are all seen during the elder years. Executive functions and abstract thinking can give way to primary process, paranoia, and hallucinatory experiences. Conscious or unconscious fears of annihilation as well as increased dependency on others underlie many of my patients' struggles, yet their reactions to these conflicts are unique, causing as much dysfunction as any good neurosis.
In general, maintaining self-integrity in the face of these losses is a major treatment objective. I find my interventions vary depending on the level of assistance required for the elder. Within my office, my patients frequently utilize psychoanalytic psychotherapy with good success, and the literature documents psychoanalysis conducted well over retirement age.
Loss of purpose, loss of independence, loss of body integrity, loss of loved ones, and loss of reason are all seen during the elder years.
In the long-term care setting, my work can include individual psychotherapy, family therapeutic interventions or even milieu management. Issues of providing a “holding environment,” co-construction of meaning and attention to transference manifestations inform my work in every role. Transference reactions that place the physician in the role of an idealized savior or a “young whippersnapper” are quite common in the elders as well as in their caregivers. Use of the analyst for mirroring functions initially contains intense affect, yet gradually the work transforms into understanding conflict and working through.
The more elders are displaced from their roles in the community, the greater the attachment conflicts they experience. Disruptions in attachment first described by Bowlby in infants or children are strikingly similar to those in the older adults in long-term care. Bringing this information to the nursing home's attention allows for significant shifts in these communities. Typically, the nursing assistants are not familiar with psychological concepts. Enhancing their natural talents with an increased awareness of the developmental struggles of the elders allows for inter-generational bonding that transcends the institutional setting.
Displays of positive affection, empathy for another's plight, and tolerance of anger are modeled with the staff as well as the elders. Role playing interpersonal interactions and communications foster the caregivers' environment and stimulate their own creativity. Once these efforts prove fruitful, nursing home administrators begin to address management aspects that contribute to insecure or chaotic attachments. I hope to pursue further research into these dynamics and their impact on ego functioning in the elderly. Identifying characteristics that promote resiliency and maintain mentalization through senescence could enhance our work with the elderly as well as the young.
John R. Whipple, M.D., is a senior candidate and associate faculty at the Greater Kansas City Psychoanalytic Institute. He works in Lawrence, Kansas as a psychoanalyst in private practice. His current research and writing focus on maturational development and the tasks of aging.
I have noticed a change in my psychoanalytic work with younger adults through my work with the elders. The role of reminiscence, the collapse of time perspective, and the neurotic ruminations of younger adults now take on different implications. The mutative function of working with the elders is something I can appreciate because of my psychoanalytic education. I am transformed through the dialectic interactions with each relationship. My countertransference reactions to the sights, sounds, smells, and emotions I confront with the elders allow me to explore my functioning.
When visiting with a demented patient, I can feel inadequate as a therapist since language may be lost. I will start to feel restless or ponder my next inquiry. There is no yesterday or tomorrow for us. My internal search for a point of reference is gone. Many times, I simply want to leave. My own neurotic ruminations may fill the silence. Meanwhile, the elder is simply taking it all in. She'll scan the hallway, look at my face or down at the floor. She becomes the mirror and I see myself in middle age. Sometimes I can tune in to her serenity. I will focus on her face or her wrinkles or the look in her eye. I wonder about the inter-subjective world after words, and I time my glances to meet her gaze. Our game of “peek-a-boo” establishes a connection if even for the moment and like the joy of holding a newborn baby, I want to visit again and again.