In this issue, COPS highlights Audrey Kavka's article on the relationship between understanding an analytic approach to the aging process and an analytic adaptation to the pandemic. Kavka is chair of the COPS Study Group on Psychoanalytic Education and Aging, which includes Robert Galatzer-Levy, David Joseph, Patricia Plopa, and Dan Plotkin.
From the inception of our Study Group on Psychoanalytic Education and Aging in 2016, we have advocated for the inclusion of late-life curriculum in psychoanalytic training. We hope to see a future in which psychoanalytic perspectives on aging through the entire life cycle, birth (maybe even inutero) to death, are integrated into the basic core education of psychoanalysts. It is, however, an upstream battle.
A 100-year history of neglected consideration of late-life development within psychoanalysis creates a downstream current that challenges our efforts. To make the swim a bit easier for individual psychoanalytic training centers, we have developed resources, including two overlapping yet distinctly different six- to seven-week course outlines, suggested weekly readings, and three extensive bibliographies. To access these resources, go to the DPE section in the APsaA website.
As with salmon swimming upstream, we hope to spawn new life with these resources as aging patients bring direct contact with the analyzable psychic challenges of the facts of life, as described by Roger Money-Kyrle in his 1968 article, “Cognitive Development” in IJP, 49:691-69.
When I sat down in May 2020 to reflect and write about practicing psychoanalysis during the Covid-19 pandemic, I had an uncanny experience. I kept referring to the Covid-19 pandemic as unimagined, unprecedented. But were those adjectives accurate in relation to the facts?
Epidemics and pandemics are certainly not unprecedented in history. I was a young physician in the Bay Area at the alarming start of the AIDS epidemic during which the diagnosis was a death sentence. I was never a citizen in a war zone, but through various forms of media, we all hear accounts of those who live in stark conditions, in disruption, isolation, and the threats of active war.
Familiar with the “facts” of deadly pandemics, I was unfamiliar with how the pandemic could enter my life. There was nevertheless an uncanny aura of the “known” feeling entirely unknown. A defensive combination of infantile omnipotence and denial produced an often correct but false sense of safety, a belief that deadly virus infections, like wars, happen only to other people in other places. Heralded by a sense of the uncanny, conscious recognition that the Covid-19 virus pandemic intruded into my life and psyche, threatening disruption, loss, sickness, and mortality was like discovering a previously unconscious countertransference in clinical analysis. This Covid-19 pandemic brought me directly and painfully into contact with hard-to-manage feelings of surprise, unpreparedness, loss of control, uncertainty, and fear. And, I recognize that so many of the issues now demanding external and internal adaptation are already familiar from my 40 plus years of treating aged patients.
In clinical work with older patients, minor impingements and major intrusions from external reality inevitably send ripples and tsunamis into the patient's life and mind, at both conscious and unconscious levels. In his 1919 paper, “The Uncanny,” Freud offers a humorous vignette about himself:
I was sitting alone in my wagon-lit compartment when a more than usually violent jolt of the train swung back the door of the adjoining washing-cabinet, and an elderly gentleman in a dressing-gown and a travelling cap came in. I assumed that in leaving the washing-cabinet, which lay between the two compartments, he had taken the wrong direction and come into my compartment by mistake. Jumping up with the intention of putting him right, I at once realized to my dismay that the intruder was nothing but my own reflection in the looking-glass on the open door. I can still recollect that I thoroughly disliked his appearance. Instead, therefore, of being frightened by our “doubles,” I simply failed to recognize them as such. Is it not possible, though, that our dislike of
Audrey Kavka, M.D., is supervising analyst and faculty of the San Francisco Psychoanalytic Center, working in the broad field of aging since 1979. She wrote the Psychoanalyst Assistance Casebook and currently chairs the APsaA Psychoanalytic Education and Aging Study Group.
Page 25them was a vestigial trace of the archaic reaction that feels the “double” to be something uncanny?
Charming as it is, this vignette reveals Freud's discomfort and disturbance, both superficially and deeply, with evidence of his aging. Changes of appearance are relatively minor impingements that can activate anxieties whereas life threatening illness can present a serious disrupting psychic intrusion. In late life, the impingements and intrusions of reality are numerous. From this point of view, we can see this is also true in the Covid-19 experience. In late life, changes in health, physical capacities, activity restrictions, mobility, relationships, career, finances, and feelings challenge the psyche. In the pandemic, many similar changes pose similar challenges. In both, direct or subtle threats to life are present. Such factors press for psychic adaptation to preserve the capacity for continued psychic growth and development.
In late life, the odds are no longer in your favor and unwanted changes to appearance, health, and function no longer happen to the other guy. Many of us felt relatively safe and protected at first because the virus was “over there,” far away in China. This is how the young look at the old. In later life, as with the pandemic, facts and statistics introduce the uncomfortable idea, “This could happen to me!” Denial and manic omnipotent fantasies protect us from neither age nor deadly viruses.
The pandemic and aging are certainly not the same. But what about the internal reverberations they create? How are they understood and symbolized internally? What is the role of unconscious fantasy and how do internal object relations shape and change under the influence of aging or the pandemic? What is the role of reactivation of past trauma states already survived? As analysts, we have the privilege of working with such anxieties as they're stimulated by the pandemic and by aging as briefly illustrated in the following vignettes.
Mrs. Oak,* an 80-year-old, retired academic was referred for therapy by her orthopedist because extreme weight loss, lethargy, and malaise were delaying a much needed hip replacement. The referral description stimulated the analyst's fantasies of an occult tumor slowly taking the prospective patient's life. When Mrs. Oak arrived, she appeared reduced to skin and bones. Yet, hints of a vivacious spirit and adventurous past drew my attention beyond her withered exterior. Concerns of a dying body receded as we initiated treatment with a focus on her anger, entitlement, and guilt toward her early objects. Five years post-hip replacement, she is careful and sanguine, even in the face of the current Covid pandemic.
Denial and manic omnipotent fantasies protect us from neither age nor deadly viruses.
Ms. Michaels is decades younger than Mrs. Oaks but also burdens her body with a heavy, unconscious sense of guilt toward her early objects. She struggles to make something positive out of the current pandemic restrictions and isolation, but returns to the question, “Is this life or is this limbo?” “Limbo” brings mortality and death into the hour. But limbo is also a waiting place for the Innocents. This is a moment in her ongoing analysis in which identification with a sense of innocence keeps her waiting for an idealized external figure to release her from guilt and limbo.
Whether late-life aging or pandemic, there will be heterogeneity of the external situation that confronts the individual with the facts of life, of the internal world and psychic response. Late life and pandemics bring change, exposure to inner and outer vulnerability, loss and grief, newly experienced dependencies, narcissistic destabilization, limitations, and direct contact with mortality and death.
Late life and pandemics also present opportunities for maturation through containment and exploration of the disturbing, even traumatic, nature of the experience in relation to an individual's past, present, and future. The pandemic can be more than a time of waiting for a return to normal. Late life can be much more than a time of waiting for death. They can both be times of internal growth and development.
There is much to be learned from late life about the psyche's response to collision with the facts of life. The study group plans to keep swimming upstream to bring late life into psychoanalytic focus and enrich understanding and clinical expertise. Please check out the members website, , posting and feel free to share your thoughts and interest.
* Real names of patients are not used in this article.