This article provides a historical perspective on psychoanalytic views on aging and on the feasibility of psychoanalytic treatment for older patients. It includes a focus on the writings of Sigmund Freud and Karl Abraham as a way to highlight different attitudes towards aging, and will provide a brief overview on relevant psychoanalytic and gerontology literature.
Sigmund Freud is famous for stating that older patients are not suitable for analysis and Karl Abraham is less well known for saying that some of his most successful cases were older. To provide some perspective on these two founding fathers of psychoanalysis, Freud’s pessimistic view that individuals older than 50 years of age would lack the “elasticity” to do psychoanalytic work was expressed in 1905, when he was nearing 50. Of course, life expectancy was significantly shorter than it is now, and it is possible Freud’s thoughts about his own aging and death colored these views. Author Peter Gay notes that Freud believed he would die at 51 years of age (and when he didn’t, he then thought he would die at 61 or 62). Perhaps Freud’s discomfort with his own aging and thoughts about death interfered with his ability to formulate theories about these important subjects (for more on analysts’ own comfort level with death, please see Salman Akhtar’s article, page 12). Ironically, Freud remained vital, productive and with seemingly intact elasticity of mental processes into his 80s (despite developing painful cancer of the mouth in his late 60s).
Karl Abraham was probably the first to suggest, in 1919, that older adults (which at the time meant those over 50) can benefit from psychoanalytic treatment, and noted that “to my surprise a considerable number of them reacted very favorably to the treatment. I might add that I count some of these cures among my most successful cases.” He went on to say:
If we survey a certain quantity of successful and unsuccessful treatments in patients of this group, the problem of their varying results is explained in a simple manner. The prognosis in cases even at an advanced age is favorable if the neurosis has set in its full severity only after a long period has elapsed since puberty, and if the patient has enjoyed for at least several years a sexual attitude approaching the normal and a period of social usefulness. The unfavorable cases are those who have already had a pronounced obsessional neurosis, etc., in childhood, and who have never attained a state approaching the normal in the respects just mentioned. These, however, are also the kind of cases in which psychoanalytic therapy can fail even if the patient is young. In other words, the age at which the neurosis breaks out is of greater importance for the success of psychoanalysis than the age at which treatment is begun. We may say that the age of the neurosis is more important than the age of the patient.
Abraham’s paper ends with a call for more research into suitability for psychoanalytic treatment.
Remarkably, Abraham’s prescient remarks anticipated current day concerns regarding suitability, indications and precision in matching interventions to conditions. One might think it would have sparked an interest in and a considerable literature on treating older adults. But this is not the case. Although reports of good psychoanalytic work with older adults have appeared in the literature for close to a century, the idea did not get much traction. To be sure, important contributions were made over the years, notably by Smith Ely Jelliffe , Carl Jung , Martin Grotjahn and Hannah Segal .
In the 1960s, the relatively new field of gerontology emerged, and social psychologists published works on adult development and offered theories of aging. William Earl Cumming and Elaine Henry offered the “disengagement theory” of aging, which stressed an inevitable withdrawal of energy and connections as people age. Followed with his “activity theory” of aging, suggesting that withdrawal is not inevitable and vitality in old age is related to staying active and socially connected. In the early 1970s, continuity theory was proposed by Robert Atchley, based on work by George Maddox. It expanded activity theory to account for the persistence of lifestyle in individuals as they age, and included aspects of individual personality and self-concept. In 1964, James Birren developed the first multidisciplinary research center devoted to aging, at the University of Southern California.
Meanwhile, Bernice Neugarten, in 1964, observed that adults become more reflective and change their orientation from outer-world to inner-world as they age, which she called “interiority.” Later, she added “by midlife, time becomes restructured in terms of time left to live instead of time since birth. It is not that 50 or 60 years have passed, but the question, how many years lie ahead? What is yet to be accomplished, and what might best be abandoned?” .
Erik Erikson (1959, 1966) extended the concept of psychological development into adulthood and even into old age. His observations led him to theorize psychological milestones applicable to old age and consistent with activity and continuity theories: “I have characterized the psychosocial gains of adult ego development with the terms intimacy, generativity, and integrity … their very alternative, isolation, self-absorption, and despair can be held in check only by the individual’s fitting participation in social endeavors.”
In the psychoanalytic world, a panel on aging was convened at the annual meeting of the American Psychoanalytic Association in 1963, summarized by Norman Zinberg , who noted “the study of aging until now has been left to fields other than psychoanalysis, but the increased index of psychoanalytic interest is exemplified by the existence of the Boston Society for Gerontologic Psychiatry with a membership predominantly of analysts.” Rich commentaries were offered by Martin Berezin, Douglas Bond, Sidney Levin, Kurt Eissler, and Stanley Cath, and Muriel Gardiner (who talked about Freud’s famous patient, the Wolf Man, then 76 years old, and whom she had been in contact with for 35 years).
In 1979, at the first Congress of the International Psychoanalytic Association to be held in the United States, Pearl King presented a paper on psychoanalysis of patients in the second half of life. During the discussion, she emphasized
points reminiscent of Abraham, that older adults “were a neglected, although a rapidly growing group of potential patients, and it was not fair to exclude them from the possibility of obtaining psychoanalytic help, purely on the criterion of age.” In 1980 the Committee on Psychoanalytic Practice of the American Psychoanalytic Association noted that one of the population groups under-served by psychoanalysis was adults over the age of 50, and recommended that efforts be made to include them.
Psychoanalysts Calvin Colarusso and Robert Nemiroff, in 1981, focused on the theme of adult development and presented a model of normal adult functioning and a psychodynamic theory of development during the second half of life. They followed it up with “The Race Against Time: Psychotherapy and Psychoanalysis in the Second Half of Life” in 1985, presenting additional theoretical concepts and clinical material from 11 different therapists. They summarized, “based on current and past research, it is our conclusion that psychodynamically oriented psychotherapy and psychoanalysis are valid clinical techniques for selected patients in the second half of life, regardless of age.”
Another panel was held in December 1982, at the annual meeting of the American Psychoanalytic Association, reported on by Stanley Cath and Nancy Miller, this time chaired by Cath, with contributions from Martin Berezin, Miller, Pearl King, Ann-Marie Sandler, Earl Simburg, and acknowledging the contributions of George Pollock. Cath and Miller noted:
Evidence is accumulating from all over the world suggesting that chronological age, contrary to Freud’s impression, is not a valid predictor of analyzability; that throughout evanescence and senescence, new assimilation, leading to modifications of psychic structure, and new enthusiasm and vitality, forged in the psychoanalytic crucible, remain possible. Aging is not a monolithic experience for all persons, and in late life, as in youth, it is just as important that potential cases for analysis be thoughtfully and appropriately selected.
Over the next decade, further momentum was generated. Martin Berezin, in reviewing a new book by Wayne Myers on psychodynamic treatment for older adults, proclaimed: “Dynamic therapy for older people is an idea whose time has finally arrived. I mean simply that in view of the recent explosion of interest in geriatric psychiatry, this information, which was known only to a few of us in the past, is now known to a very large and receptive audience. Psychoanalysis and dynamic therapy for old people has finally emerged from the closet.” Calvin Settlage reported his work with a woman in her 90s, a poet, and noted “the myth of the unsuitability of middle aged and elderly individuals for psychoanalytic treatment has been dispelled.”
But things seem to have stalled a bit, or at least taken a turn away from older patients themselves. There are still relatively few reports in the literature on psychoanalytic work with older patients, and over the last decade or so reports have focused more on the perspective of the analyst than on the older patient (as detailed by Audrey Kavka, page 8). The hesitation has been, at least in part, due to a bias against older adults. Psychoanalysts are not alone, of course, in holding biased attitudes about aging, although there is a certain irony in it, given that psychoanalytic organizations tend to comprise older individuals, and psychoanalysis has been called an old man’s game.
The term describing prejudice against older adults, “ageism,” was coined by Robert Butler , the psychoanalytic-friendly geriatric psychiatrist who was a founding father of geriatrics in this country, and the founding director of the National Institute of Aging . We live in a youth-oriented society, and it hasn’t changed much over the last few decades. While there have been substantial changes in other prejudices, involving race, gender, sexual identity/preference, and even though we still have a way to go on all of them, there has been relatively little change with regard to ageism. Indeed, we embrace “anti-aging” efforts more than we do acceptance of aging or celebration of old age (there is even a medical organization called the American Academy for Anti-Aging Medicine), and anti-aging rhetoric has become a part of the current zeitgeist (Jason Flatt 2013). When I was doing some online research about Robert Butler and ageism for this article, I was bemused to find a “sponsored link” pop up on my computer screen on how to get a flat belly.
While there have been substantial changes in other prejudices, there has been relatively little change with regard to ageism.
Indeed, it is unlikely that any of us (myself included) can escape the ageism that is so much a part of American society. Importantly, older adults themselves also hold age-biased beliefs, called self-stereotypes (Becca Levy 2003, 2009). They continue to believe they are too old to “learn new tricks” or to benefit from psychotherapy. Such beliefs turn into self-fulfilling prophecies and undoubtedly contribute to the well-documented finding that mental health services in general are vastly underutilized by older adults.
My own experiences illustrate some of these points. In the 1980s, when I was an analytic candidate and had conducted a successful analysis of a young man. I applied to have my second case be an elderly female patient I was treating with psychodynamic psychotherapy. My initial application was rejected, clearly along the lines of age bias, by a review panel composed of older adults. Fortunately, when I appealed, the panel, to their credit, changed their minds, and the resultant psychoanalysis was a very successful one.
More recently, just a few years ago, I observed that the new diagnostic manual, the Psychodynamic Diagnostic Manual (PDM), lacked almost any discussion of older adults. When I brought the issue to the authors, and ended up speaking directly with Nancy McWilliams (who was open, interested and not at all defensive about it), it became clear it was the result of some denial on the part of the largely older group of analysts who had put together the PDM. I am pleased to report the recently published second edition of PDM (PDM-2) will include a special section on older adults, for which I am a section editor, with Franco del Corno.
Returning to Freud and Abraham, perhaps we can view their stated positions as representing our own ambivalence about aging. While Abraham spoke for our open-minded and scientific selves, Freud succumbed to the biases that have only become more prevalent as our population ages. Given Freud’s remarkable critical thinking abilities in general, I suspect his seemingly dismissive attitude toward older adults was not representative of his attitude in totality. Although he didn’t write on aging, per se, his writings on death may reveal some of his attitudes about aging. Freud’s “official” position on death is often seen as reductionist and incomplete, but there is evidence to suggest he had complicated and ambivalent views on death and aging. In her 2013 book Freud, Psychoanalysis and Death, Liran Razinsky notes, “Freud actually had two significant points of view on death. The one, much more prominent, is evident throughout his work, and does not regard death as a psychic motive or death anxiety as a factor in mental life. The second point of view, less dominant and often hidden, regards death as central, and often reflects a personal belief held by Freud, rather than his ‘professional’ views.” Thus, it is not surprising to read Freud’s Our Attitude Toward Death , in which he can’t resist chastising America:
This attitude of ours towards death has a powerful effect on our lives. Life is impoverished, it loses in interest, when the highest stake in the game of living, life itself, may not be risked. It becomes as shallow and empty as, let us say, an American flirtation, in which it is understood from the first that nothing is to happen, as contrasted with a Continental love affair in which both partners must constantly bear its serious consequences in mind.
Likewise, in “On Transience” , he writes, “limitation in the possibility of an enjoyment raises the value of the enjoyment,” which is in keeping with the previously mentioned observations of Neugarten as well as more recent observational research by Laura Carstensen. Carstensen’s socioemotional selectivity theory of aging posits that older adults have a more positive emotional attitude than do younger adults, as a result of awareness of the finiteness of life.
In closing, I want to thank the American Psychoanalytic Association for asking me to chair an ongoing Discussion Group focused on older adults at the 2018 National Meeting in February in New York. I invite all those attending the meeting to join our Discussion Group and contribute to this worthwhile endeavor.