In 2010, I was very pleased to be selected for the initial class of the American Psychoanalytic Association's Psychoanalytic and Psychodynamic Teachers' Academy, a one-year professional development and mentoring program for psychology, psychiatry, and social work faculty to develop expertise in psychoanalytic and psychodynamic teaching and course development. This article reflects some of how I grew as a teacher and therapist from my work with the Academy.
The chief of the Geriatrics and Extended Care Service at my facility, the VA Puget Sound Healthcare System, describes geriatric medicine as a discipline whose art is managing complexity. As geriatric mental health professionals we, too, routinely wade into cases featuring interrelated psychological and neuropsychological issues, medical and pharmacological concerns, and complex psychosocial factors, all embedded in a historical context that usually predates us. Moreover, in some cases we face the added challenge of interpreting and ameliorating psychological distress in individuals who cannot even speak for themselves, those with advanced dementias.
…in 1905 Sigmund Freud expressed his view that older adults did not make good patients for psychoanalysis.
Given this, I have increasingly come to see the value of integrating a psychodynamic understanding and approach into my work. Using contemporary psychodynamic approaches, alongside cognitive behavioral therapy, behavioral analysis, and family systems theories, allow me to best capture the complexity of the case and choose the best intervention.
Our field resists thinking about older adults through a psychodynamic lens. Many readers may recall that in 1905 Sigmund Freud expressed his view that older adults did not make good patients for psychoanalysis. Specifically, he considered anyone over the age of 50 as having lost “the elasticity of the mental processes on which treatment depends…old people are not educatable.” While decades of research, clinical work, and theoretical evolution have proven him soundly wrong, barriers to working with older adults from a psychodynamic perspective remain.
In 2005, Jolyn Wagner identified persistent ageist assumptions in the field that discourage taking a psychodynamic approach to older adults. These are that older adults develop psychic rigidity, lose their sense of investment in the future, develop an excessive attachment to the past, and undergo a weakening of life-fulfilling drive. Wagner also described the way in which such assumptions, based as they are on linear, stage models of lifespan development, become reified into unquestioned truths.
As an antidote, she cited the work of Susan Coates who advised us to conceptualize human development instead “in the context of multiple transactions between self and other across different domains with consequences that cannot be predicted a priori.” Finally, and perhaps most importantly, Wagner alluded to the unique, and sometimes daunting, countertransference issues that can arise in working with older adults. When we work from the dynamic stance which holds that fundamental human wishes, needs, and fears do not stop at a certain age, we work with the patient's transference. In turn, this can lead to powerful countertransference and our own conflicts over aging.
When we are asked to provide assistance for individuals with dementia, including those in advanced stages, we rely heavily on the treatment team. Team members look to us for insight into what might lie behind challenging behavioral issues and what strategies might help reduce them. We often employ the “ABC” method of behavioral analysis here (antecedent-behavior-consequence) and for good reason. I think it can be helpful to add our psychodynamic understanding, though, because it allows us to develop a deeper appreciation of the subjective emotional experience of dementia. This dynamic insight is helpful to other staff in truly understanding the needs of the person with dementia.
In an inpatient environment, I find that a focus on object relations is especially useful. I am using the term “object relations” to refer to our need for seminal emotional connectedness with others, and how this need is met in increasingly complex and interactive ways as we develop. Indeed, neuroscientists have confirmed that human attachment is a fundamental survival mechanism that functions throughout the life span. Such relationships give us our sense of presence and identity, and facilitate the growth and maintenance of our abilities to cope with the internal and external demands of our world. In other words, humanization is an ongoing, reciprocal process. Not surprisingly, the human brain itself has evolved to exist and thrive in a social context. We possess complex, multimodal neural networks dedicated to social cognition, “mirror neurons” being just one example.
Douglas W. Lane, Ph.D., ABPP, works in the Geriatrics and Extended Care Service of the VA Puget Sound Healthcare System in Tacoma, Washington.
This powerful need for safe relationships can remain intact for a long time, long after the higher cognition that once facilitated attachment behavior has crumbled under the weight of neurofibrillary plaques, Lewy bodies, cerebrovascular insults, and other neuropathologies. The great risk is inadvertent interpersonal and emotional abandonment of individuals with dementia by others, which has been shown to lead to premature decay. In particular, Thomas Kitwood has written extensively about the therapeutic milieu (or lack thereof) in long-term care units, and specific interpersonal strategies that staff can use on a day-by-day basis to reach out to people with dementia and try to keep them attached. Caregivers can become new “self-objects,” almost “ego prostheses.” Thus, how we interact with the person with dementia can provide support to structure their experience, including that of themselves.
This powerful need for safe relationships can remain intact for a long time, long after the higher cognition that once facilitated attachment behavior has crumbled under the weight of neurofibrillary plaques, Lewy bodies, cerebrovascular insults, and other neuropathologies.
Wagner's work on not reifying ageist assumptions brings to mind examples from my own caseload in which the very human drives for connection, safety, purpose, and resolution exert themselves, even in those with advanced dementia. The first case is that of a gentleman I worked with for many months, a resident of our dementia care unit. He regularly wrote notes, as best he could given his aphasia, and forwarded them to me through the nursing staff. They chronicled his experiences with his illness. His family has given me permission to use the quotes that follow.
In the early months of our work, this patient was focused on being a spokesman for what he and his fellow residents were enduring. He found meaning in this, a sense of continued relevance and dignity based in what he could do for us. In one of his notes he wrote (syntax/spelling corrected), “I have done everything I can think of to get more attention for dementia of all sorts. Please now give me a chance to learn all I can about this disease. My spelling and other crazy things are happening to make this far more difficult than necessary.” I used to tell him that by helping me understand his experiences with dementia he was, in turn, helping me help other caregivers do the same. In a way, he was a teacher and I was his student. My effort was to validate and support his continued sense of purpose and value for as long as possible, a palliative approach.
One of his greatest fears about having dementia was that it would ultimately lead him to be a “monster,” a frightening shell of his former self. Because of his aphasia he had trouble expressing himself at times, especially when upset. In moments of frustration he would become agitated and shout. Some staff did not know how to react to this and would instinctively disengage and move away.
After one of these incidents he wrote to me (syntax/spelling corrected), “One of the saddest things about this malady is when I speak up. When people are around everyone runs when I raise my voice or move too quick. This is really sad for me and those around me.” Confirmation of his sense of himself as devolving into a monster was coming inadvertently through interactions with those around him. My understanding of his fear that he was losing the capacity to inhibit his anger allowed me to help the staff realize that the best way to calm him down was to engage him, because when they moved away they inadvertently confirmed his fear that he would let out the monster in him.
My second example is a gentleman I met a few times, when he was admitted for a brief respite stay. I also met with his wife briefly at that time. A year later, he was readmitted for long-term care. Not long after the long-term care admission his beloved wife died. It soon became evident that he was very attached to me, to a degree that was beyond what our prior time together seemed to warrant. He regularly reminded me (and himself) that I had known his wife. Viewed through the lens of object relations, my prior experience with him and his wife, allowed me to serve as a “transitional object” for him, which facilitated my efforts to help him adjust to being on the unit again.
There are many ways in which psychodynamic ideas can be applied in working with older adults. Old age is known to be a time of great complexity, but the elderly also have many resources. Working with them from a psychodynamic perspective can be an invigorating challenge for us. I hope more of us will join the effort.
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