Looking back often sets a path to moving forward, and so this article begins with an anecdote from the 1930s when Dr. Herbert Rosenfeld took a job at a mental hospital near Oxford, England while awaiting entry into the Tavistock Clinic Training Program. In his orientation to the job, he was told he was responsible for 350 patients and that “Altogether I would work no more than one and a half hours in the morning and I would then generally be free for the rest of the morning and afternoon.” (1987)
How could he be responsible for 350 patients and work for just 10 hours a week? One can only conclude that young Rosenfeld was not expected to actually talk, listen or try to understand the psychotic patients. Rosenfeld dared to begin the experiment of talking with some of his hospital patients and became a pioneer in the modern approach to treating psychotic disorders and psychoanalytic theory on the topics of psychosis, psychotic processes, narcissism and projective identification.
Opportunity for change lies in experiences that defy accepted expectations. On the road to overcoming prejudices such as sexism, racism and ageism, these personal encounters that confound established beliefs play a special part.
In my psychiatric training in the late 1970s, expectations for treating older patients psychotherapeutically were absent. Consequently, I was practically indignant when I was assigned an inpatient caseload with an average age of 74. My expectation, supported by the team, was that I was to provide necessary service with little educational value. We were all wrong. Within a week, my preconceptions gave way as the patients proved themselves to be motivated, intensely engaged, and looking for meaning in their fantasies and lives. The therapeutic responses were also a welcome surprise.
Today, a growing network of analysts work with older patients and many share their experiences of a fortuitous initiation into this work. Late-life patients are finding their way to our consulting rooms and onto our couches in a variety of ways: direct referrals as new patients, analytic and therapy patients returning to their analysts at a later life stage, and patients and analysts aging together into late life in a long treatment.
What we are seeing in our offices reflects the dramatic age demographic shift toward late life that is shaping our current world. The U.S. Department of Health and Human Services Administration on Aging reports:
The older population—persons 65 years or older—numbered 46.2 million in 2014. They represented 14.5 percent of the U.S. population, about one in every seven Americans. They are expected to grow to be 21.7 percent of the population by 2040. By 2060, there will be about 98 million older persons, more than twice their number in 2014.
Furthermore, people are living longer and healthier. According to the U.S. Department of Health and Human Services Administration on Aging statistics:
Americans are living longer than ever before. Life expectancies at both age 65 and age 85 have increased. Under current mortality conditions, people who survive to age 65 can expect to live an average of 19.2 more years, nearly 5 years longer than people age 65 in 1960. In 2009, the life expectancy of people who survive to age 85 was 7 years for women and 5.9 years for men.
During the period of 2008–2010, 76 percent of people age 65 and over rated their health as good, very good or excellent. Older men and women reported similar levels of health.
A loud message rises from these statistics: It is time to shift our analytic attention from the question of whether to treat older patients to the question, what do we learn from the psychoanalytic treatment of late-life individuals? This is a time of opportunity for psychoanalysis to expand our knowledge and contribute to a growing field of multidisciplinary study, but in order to do so, we must make this shift in focus.
Due to its enormous growth, professional fields from banking institutions to world health organizations are actively studying the over 65-year-old demographic group. Psychoanalysis, which has always had a dual identity as a method of treatment and a research method, should follow suit. In this tradition, clinical engagement with the late-life patient, as
well as engagement with our own aging, opens a path for making unique contributions to the growing research on aging throughout the full life cycle. Our profession has much to offer and much to gain.
For many analysts, the older patients have already arrived, and we are learning from them about late life and about ourselves.
In my experience, older patients are like analytic patients of any age:
They arrive in the consulting room with various levels of insight and motivation, seeking relief from psychological difficulties.
Unconscious material is accessible through free association, dreams and from the total situation of the transference.
Enhanced engagement in life and love regardless of external limitations is characteristic of a therapeutic outcome.
Transference is not restricted to youth or middle age. (In the vignettes that follow, I have changed names and details to disguise identities.) I fondly recall Mrs. Takama, a Japanese-American widow whose obsessive worries about her family members brought her to treatment at age 86 following years of failed anti-depressant treatment. Second oldest of eight children, she was the last living child and barely remembered the birth order of the other siblings. She did remember she felt least loved by her mother and often humiliated by her siblings. For her, the central trauma of her life was the loss of a younger sibling and a deep sense of personal guilt and expectation of revenge and punishment. In treatment, gradual remodeling of her inner sense of debasement and failure was revealed in a dream in which she was leading me through a Japanese fish market and making sure I received the best quality fish despite being a non-Japanese outsider. In response to the dream, she announced, “We are sisters.” This transference configuration enabled her to reclaim a sense of inner goodness that survived despite attacks from her inner objects and her own retaliatory death wishes and sense of triumph over her deceased siblings.
Treating older patients reminds clinicians that chronological age is not particularly useful in defining “late life” or “older.” Nonetheless, there exists a grouping of characteristics that do seem to define a relatively distinct developmental period that can be labeled “late life.” As in adolescence, bodily change and consequences of those physical changes affect the inner psychological world of the individual. However, in contrast to the adolescent capacity for freedom and growth, changes of late life will largely be experienced as loss or decline. These life phase changes are numerous and broad, affecting health status, physical/mental capacities and competencies, work status, financial status, family roles and social/professional roles; they pose a challenge to narcissistic equilibrium. Late life is also a time of accumulating losses of loved ones, including life partner, family and peers.
Early conflicts are often revived as profound issues of grief, transience and mortality press upon awareness. For Mrs. Takama, being the sole survivor was both a triumph and source of unremitting guilt and anxiety. Psychoanalytic appreciation of the timeless nature of the unconscious opens up the possibility of working with the lifelong inner disturbances that are aroused in the context of directly experiencing:
Encroachment on independence and autonomy
Intrusion of end-of-life inevitability
Fantasies of death and of dying
Challenges to omnipotent desires
Mourning for aspirations never to be reached
Given these distinctive qualities, it is reasonable to ask, Is the analyst’s experience any different treating a late-life patient than his or her experience with other patients? Frieda Plotkin in “Treatment of the Older Adult: Impact on the Psychoanalyst,” (JAPA 2000) studied this question and reached some surprising conclusions. The analysts in the study reported feeling deeply impacted by their patients. The patients seemed “special,” intensely engaged and more appreciative of the analytic opportunity relative to the experience with younger patients. Rather than untreatable, the analysts described the work as especially gratifying in terms of treatment outcome. But these gratifying aspects also posed countertransference challenges. Plotkin described the analysts being more protective and nurturing in their treatments. She found at times, it was the analyst who used reality as a resistance to analyzing. And she described significant difficulties on the part of the analyst with respect to termination. She discerned that termination with a late-life patient arouses analyst contact with their own vulnerabilities and challenges ahead, including loss of loved ones, retirement, personal illness and death.
I can corroborate this finding from my own experience. Termination with a late life patient is not just an ending. With younger patients, we can defend against the pain of finality by telling ourselves that perhaps the patient will return in the future. We can defensively ease our concerns about the outcome of the treatment with the reassurance that the patient can always get more analysis later. These defenses are not available when ending the treatment of a late-life patient.
This sense of confrontation with deeply painful aspects of life with little room for defense characterizes the treatment of the older patient from the beginning. I still recall the sting of the affront, 20 years ago, from 70-year-old Mrs. Grahm in her first visit, “I do not like getting old. What are you going to do about that? Expert, ha!”
She had framed the problem in a way that instantly rendered me a failure and disappointment.
Assaulting me with a list of painful losses, physical difficulties, and a personal vision of the future as further decline and loss, she demanded to know what I was going to do about any of it. In caustically demanding from me nothing less than relief from aging, Mrs. Grahm was exposing me to the hopeless, helpless feelings overwhelming her. I could not stop the aging process, so I was destined to be the object that fails to protect her.
In my countertransference, she was becoming an object that brings out inner anxieties about omnipotent wishes and inevitable failures, failures to protect her and failures to protect my own inner objects from the facts of life and death. In the timeless nature of my unconscious, failing to protect the patient against loss, ill health and death was threatening to revive anxieties about my past, present and future experiences of being unable to protect my own inner objects.
Extracting myself from our coincident omnipotent desires for protection from the losses and assaults of aging was always a part of the work.
I look back on those angry, unrealistic demands for solutions to unsolvable problems as a panic-driven communication about the pain of facing mortality and omnipotent desires that cannot be fulfilled, hers and mine alike. I was able to proceed because I felt for her exquisite sensitivity to anything that could be perceived as loss or failure. It could be a small slight such as not being included in the post-church coffee klatch or the profound shame of a mentally ill adult child never able to live without her rescuing interventions. If she was sidelined from her weekly tennis game by a back spasm, she was ready to quit tennis forever. If she was walking slower than her walking group friends, she thought she ought to withdraw from the group in order to not hold them back. She was desperate to avoid the feeling of not measuring up, but it was inescapable. Preoccupied with inflexible competitive strivings and increasing self-imposed isolation, it appeared that her frightening fantasies of dying alone, surrounded only by her tamed feral cats, might be as likely as any ending of her life.
Extracting myself from our coincident omnipotent desires for protection from the losses and assaults of aging was always part of the work. She directly reprimanded me if she felt I was distancing myself from her and her pain with anything that could be interpreted as encouragement or reassurance. Interest in her early life was also treated as an unacceptable attempt to escape from the pain of the present and future.
In the face of these controlling, rigid defenses, she continued to find faults in my work with her. Yet over time, the analytic process supported her capacity to appreciate both of us as flawed and disappointingly human but also steady, reliable, capable and connected. The good-enough internal objects she had lived with throughout life were revived. Her identification with her father, a simple warm man who imbued her with a lifelong love of nature, brought out a new
sense of nurturing capacities for plant, wildlife, and even for grandchildren. Female friendships evolved from a focus on competitive activity to a focus on support and companionship in concert with a growing awareness of an identification with her mother’s demanding competitiveness. Friends, family, paid caregivers and ambivalently loved internal objects supported her to the end of her life. I had not protected her from illness or death, but I learned she died a death she had prepared for in the home she had designed, shaded by the trees she had planted and tended, with her children and grandchildren at her side.
Concluding thoughts: In my experience, older patients do use psychoanalytic treatment to free themselves to love and live to the very end of life if we, the analysts, can tolerate the blows to our own wishes for omnipotence, perfection and immortality.
But, given the special characteristics of late life and special countertransference challenges, can we expect more analysts to take on clinical and research responsibilities related to late-life patients and issues? I hope we can and will.
The psychoanalytic literature on late life is expanding, and yet, late life is still mostly absent from formal candidate curriculums. In 2014-2015, I undertook a database study of late-life curriculums in APsaA institutes. We searched for coursework on late-life development, senescence and treatment of late-life patients. The results demonstrate that three-quarters of APsaA institutes have no instruction in those categories. The time is ripe for including late life in psychoanalytic training and post-graduate education and study.
In many locales, the psychoanalytic community itself is a community of over 60-year-olds. APsaA membership data from September 2015 reveals that approximately 70 percent of the membership is 60 years old or older. Twenty-four percent are between 70 and 80 and 17 percent are over 80. When it comes to late-life individuals, we need only look at APsaA.
Recent psychoanalytic interest in the issues of retirement, professional wills and maintenance of competence is surfacing and reflects an awareness and commitment to our own aging.
It is my hope and expectation that broader psychoanalytic engagement with older patients and late-life issues will yield valuable knowledge concerning our patients and ourselves.