Common Themes and Issues in Geriatric Psychotherapy

Introduction

Like any other form of treatment, the purpose of psychotherapy is to relieve suffering, to allow normal functioning, and if possible to cure and prevent difficulties. Psychotherapy has been demonstrated to be as effective for elderly people as for younger populations, although clear superiority of one modality of psychotherapy over another has not emerged.^1–3

Psychotherapy can be used as either a primary or an adjunctive method of treatment, depending on the elderly patient and the presenting problem. There has been a gradual increase in our knowledge of the psychological characteristics of aging and elderly persons as well as in our experience of conducting geriatric psychotherapy. The following case will help illustrate some of the common themes that emerge during the psychotherapy process with elderly people, and it will also highlight some techniques and practice points that are important when performing geriatric psychotherapy.

Clinical Composite Case Presentation

Harold was a 72-year-old widower who presented with some symptoms of depression and anxiety, which started after the death of his wife a few years ago. He noted gradual worsening of his symptoms over the course of last few years that he believes are related to worsening chronic medical problems, physical limitations, and decline in sexual functioning.

The therapy began by providing a relationship in which Harold felt understood, supported, and valued. He was encouraged to outline his problems, express many feelings, and receive validation for the realistic pressures he faced. Harold's competence and experience were evident not only in his professional activities but in many of the ways in which he managed his life, and this was acknowledged by the therapist. The therapist also clarified issues that were presented in the discussion that had bearing on Harold's self esteem to help restore a positive sense of self.

Practice Point 1: Restoration of a Positive Self-Concept and Self-Esteem in the Elderly Patient

Self esteem is often a major theme during psychotherapy with elderly patients. The therapist's job is to try to understand how the patient attempts to maintain self esteem in the wake of biopsychosocial losses associated with aging, and support or build upon these coping strategies.

It is important for the psychiatrist or other mental health professional to realize that elderly patients often seek approval and support from their (sometimes much younger) therapists. They benefit from this approval because it helps them restore a more positive view of themselves as competent and masterful and helps them reestablish continuity with their positive view of themselves.⁴ The therapist is used by the patient for validation of competency and normalcy and for restoration of feelings of mastery and self-esteem.

Case Presentation, Continued

Harold had experienced some significant losses, the most important being the loss of his wife. Family contacts diminished as relatives died or moved away. Most of his friends from his previous job were dead or he had lost contact with them. Therefore, the emphasis especially during the initial stages of therapy was limited to past unresolvable losses and mourning. A “working through” of unresolved mourning (obtaining additional insight through repeated and varied examinations of the meaning of the loss) was done after establishing a therapeutic alliance.

Practice point 2: Dealing with Loss

The most common theme encountered when working with elderly patients is loss. Inevitably over the years and particularly in advanced age, one loses many things. The elderly suffer multiple actual losses of spouses, friends, relatives, roles, functions, and independence, which may occur alongside fear of anticipated future losses. Survivor guilt should also be acknowledged and worked through in therapy as most of these elderly patients have witnessed the sufferings and deaths of many of their loved ones.⁵ From a psychodynamic perspective, the losses of older age are most commonly perceived as “narcissistic injuries,” or injuries to the “self” of the patient. Individuals with an inadequately developed “self” or with a poorly functioning ego do not cope well with these narcissistic assaults, whereas those with a firm sense of self find these losses far less taxing.

According to self psychology concepts, individuals with a firm sense of self are those whose early psychological development was characterized by adequately met “narcissistic needs.” These narcissistic needs first involve a need for “mirroring,” in which an important figure upon whom the child is modeling his psychological development responds to and confirms the child's sense of “goodness,” and secondly having a figure that can be “idealized,” with whom the child can merge and feel safe.⁶ In operational terms, the developed adult with a firm sense of self displays a wide range of coping skills and multiple sources of personal meaning. If the opportunity for mirroring and idealizing were unmet early in life and continue to be chronically unmet across the life span, the elderly individual is left with an inadequately developed sense of self that is forever searching for people (“self objects” in Kohutian terms) to provide the unmet infantile psychological needs of mirroring and idealization. These opportunities are often especially unavailable in older age, leaving the elderly person especially vulnerable.

Case Presentation, Continued

Like majority of elderly (and other) patients, Harold demonstrated a conflict between the wish to be cared for and the need to be in control of his life and to feel independent. After the clinician established a rapport with Harold and provided a safe and trusting environment in which Harold felt supported and valued, he was able to express some of the feelings resulting from dependency. These feelings included overwhelming anger, humiliation, helplessness, fear of loss of control over body and environment, feelings of vulnerability, and fear of abandonment. With consistent empathic validation for these feelings, Harold started feeling supported and understood, and his self esteem was enhanced. He started experiencing the therapeutic relationship as similar to other powerful supportive relationships (parents, wife, mentors) from his past on whom he relied for support and self esteem in times of crises. Within the context of this relationship, his shame, anxiety, and depression decreased.

Practice point 3: Dealing with Aging, Illness, and Possible Dependence

For elderly patients facing the many changes and narcissistic losses of aging, including increased dependency and anticipation and fear of dependency and physical illnesses, the process of psychotherapy can offer a safe and trusting relationship in which to examine those most frightening feelings. These fears may be of being hated by or disgusting to the caretaker, or perhaps it is intolerable to be “in someone else's hands.” The experience of therapy offers the elderly person a chance to respond to these frightening feelings in a manner that is life-enhancing rather than stagnating.

Aging well depends on the ability to mourn for the self, which opens up possibilities and freedom in the years that are to come. For those with sufficient internal resources, aging, despite all its losses, may in itself be a spur to positive development of the personality.^7,8

Case Presentation, Continued

For Harold, psychotherapy moved his focus from a denial of his oncoming death to a point where he gave up his denial and was able to review and examine his life. Psychotherapy prolonged and enriched his life and facilitated his preparation for dying. Specifically, techniques of “life-review therapy”¹¹ (creative reminiscing) were applied, in which Harold was encouraged to provide a narrative of his life. This narrative was not a recitation of what happened to him in a passive sense, but rather recalling the role he played in his own history. This provided a platform from which Harold was able to find new meaning in his life, its purpose, accomplishments, and disappointments, and an acceptance and ability to live in the present.

Practice point 4: Dealing with Death and Dying

In old age, impending death becomes a reality that can no longer be denied, and facing this can be a challenge. For an old person with a poor ego function, this task can be quite overwhelming. However, death-related anxiety is more a part of early adult life than of old age because, for elderly individuals, pain and suffering related to death are more of a concern than the fear of death itself.^9,10 The concern about death itself does not end here, because for some people the thought of not existing or not being is not a possibility they can imagine. Even if they are not religious, the thought of life after death is a pressing question that should be explored, as it is clinically significant.

Case Presentation, Continued

As therapy progressed with Harold, he adopted a kindly, parental stance toward the therapist and the therapist was seen as young and inexperienced and in need of education and help (reverse transference). However, beneath the surface interaction Harold had feelings of helplessness, inferiority, and fears of decline on the part of Harold. This defensive stance (resistance) was worked through in therapy, which helped Harold become more accepting and at ease with the realities of life.

Practice Point 5: Transference and Countertransference

Transference occurs when a patient experiences the therapist as a significant figure from the past with whom he or she had a highly significant and developmentally important relationship. The therapist, empathically understanding the transference relationship, aims to respond differently from the figures of the past, which creates a more positive experience for the patient. In this way, the patient develops a more positive view of the self.^12,13 Grunes described a transference phenomenon unique to psychotherapy with the elderly in which the therapist is viewed as the child of the patient, and he termed it reverse transference.⁵ Countertransference is defined here as the therapist's experience of the elderly patient. The therapist needs to pay special attention to any positive or negative feelings he or she has toward the patient. For the therapist, a relationship with an elderly person can be anxiety-provoking because of the possible physical problems, dementing illness, apparent helplessness, and dependency that the elderly person may have. This therapist anxiety in turn can promote fear of engulfment by the patient and can lead to withdrawal from or rejection of the patient. Overidentification with the patient's problems can also invoke feelings of sadness and pity, which can block accurate empathy and realistic exploration of the possibilities of change.

Summary

Psychotherapy is an important skill for psychiatrists that can be used very effectively in treating the emotional problems of the elderly. The core principles of the therapies are similar to those of younger people in most ways. However, certain issues and themes may be unique to this population: issues of transference and countertransference related to the disparity of the ages between the patient and the therapist. A tailored, individualized, flexible approach that considers the patient's unique needs and takes into account specific developmental tasks and challenges associated with aging appears to benefit elderly patients.