Psychotherapeutic approaches for the older patient

It is not easy to come to terms with retirement, failing bodily functions, increased vulnerability, potential institutionalisation and inevitable death. For some this is a stage of life tinged with difficult memories of being cared for when they were younger. It is not uncommon to see some older adults with a past history of childhood trauma and adversity develop new onset relationship problems having lost the containment of a career or a loved one. Older people can derive huge benefit from psychotherapeutic approaches. Personal transformation may enable them to go on to enjoy meaningful and fruitful old and new relationships whether in the community or in a care home.

Somato-psychic challenges of ageing

Falls can become a devastating experience with loss of confidence and sometimes lead to institutionalisation. Falls often are significant as a reflection of change or significant shifts in the everyday. Our language uses numerous analogies to the idea of falling: People fall in and out of love, fall for each other, fall pregnant, burdens fall onto shoulders, fall into depression, we fall from grace.¹The body especially provides that ultimate boundary between self and external reality. The skin, as it ages becomes fragile both in an external sense and an internal one, revealing the fragility of the ageing body inside. Care often just focuses on the overt physical fragility. The body is there to be washed, fed and toileted. Urinary incontinence may evoke inappropriate feelings of shame. The emotional needs stemming from such changes are often neglected. The idea of emotional containment needs to be considered when rehabilitating an individual who has fallen, has fragile skin or some other physical disability.¹

There is a need to recognise the vulnerability of the person with such boundary insults. If the body fails that boundary also starts to fail. Such shifts in equilibrium cause emotional pain in the form of shame and disgust: a narcissistic injury stemming from the person’s sense of pride and independence. After all, how many times have you heard an older person say in clinic that he/she does not need help as he/she has always managed in the past. It is very easy for any perception by the patient of the need to receive care to be lost in such emotional pain.A specific fear that follows loss, whether of mental function or physical ability, is a fear of dependence. For many individuals, such need to rely on others is probably the first time in their lives since infancy they have needed support. Ageing and its vicissitudes reawaken infantile fears, brought forward to the here and now. During adulthood, such fears may have been sealed off from the conscious mind, often by mature capacities such as mastery and independence, but sometimes as well by immature mechanisms such as denial and projection. Faced with the realities of ageing, these defences can become loosened.²

Fear of death, as with fear of loss and mourning, are again factors which can haunt us at any age; but, as Erkison’s stages of man emphasise, it surely has more significance for the elderly. The fear of life ending without full resolution of goals and regrets can be motivational factors for improvement and may serve as a prompt for psychological intervention. The individual may see this time as a useful moment for recollection and reflection given the inevitability of death.

This would depend on ego strength: an ability to accept failure by allowing the good internalised relationships and experiences significant for that person’s psyche to shine through. As with mourning, those that may face difficulty are those who have poor strength of internal relationships and experiences. Indeed, the aim of a reflection on a life lived, is to accept one’s own mourning and death. The urgency of time becomes the motivator for psychological care.

The psychodynamics of caring for a person with dementia

The emotional welfare of staff and other caregivers must also be kept in mind. It is estimated there are six million carers in the UK looking after someone with illness or disability, one million of whom provide more than 50 hours of care per week.³ Studies consistently demonstrate the impact of dementia upon family members. Without adequate support carers will experience stress resulting in their own deterioration in physical and mental health.⁴

However, for the clinician such emotional reactions can be extremely useful if the clinician can manage to maintain a ‘third position’ within the consulting room. Emotional reactions to the patient give useful clues about what it is like for that person right now, and what it must be like for families and staff trying to care for that person. Always ask yourself the question: ‘if I feel like this right now, what is it like for someone living with this feeling all the time?’

Such reactions become a principle form of communication for those whose verbal communication is impaired by dementia. Dementia patients are sensitive to such changes in their carers and will quickly pick up on cues in tone and body language and yet not have enough cognition to understand the reasons why their carer might be angry, or snappy with them.⁵ Frustration can soon follow resulting in behavioural and psychological disturbance in dementia patients, breakdown in placement and sometimes the misuse of psychotropic medications.⁴

Carers must carry the burden of feelings arising suddenly and unexpectedly from the encounter with the patient without identifying with them. This is a near impossible task to carry, and without adequate support can become overwhelming. Such feelings however will often ‘hook’ onto something unresolved for a carer from the carer’s past and perhaps evoke similar feelings the carer might have towards parents or grandparents.⁶ This could be taken further as a means by which a carer could try to solve unresolved past issues. Sometimes this process can result in an extreme wish to please and not ‘let go’ leading to over-dependency and malignant regression into a highly dependent and infantile state on the part of the patient.⁷

Sometimes the feelings are the opposite and result in neglect and aggression. Such feelings as difficult as they are need to be openly acknowledged as by doing so the risk of acting inappropriately towards the patient declines. The opposite strategy of ignoring such feelings increases risk and leaves the patient misunderstood and isolated. As Garner and Ardern describe, the consequences are as follows: €œBy denying an emotional life to the elderly the imagined pain and fear of old age and life’s end can be conveniently denied for the rest of us.⁸ In other words by denying an emotional life to our older patients we serve our own needs and not the needs of those who need our help.

Sometimes feelings in carers in response to the patient (countertransference) can become particularly aggressive resulting in resentful and even hateful feelings. Winnicott’s discussions surrounding such feelings provide a model for thinking about the challenges of caring for someone with dementia when expected to hold onto the less pleasant aspects of human suffering.⁹ Although admitting to such feelings can feel shameful, they are normal and require a forum for discussion. There is a risk of such feelings interfering with the quality of care given if they are not discussed. Impatience with a patient’s slowness of movements or repetition of language may lead to angry outbursts on the part of the carer, or lead to over-compensation of the patient’s slowness or simply ignoring the patient’s repetitions. Such responses may result in added shame and humiliation for the patient, further worsening their already impaired abilities.⁷

Sometimes counter-transference to the elderly and specifically to those with dementia, can become extreme. Staff and carers can become prey to therapeutic nihilism or, conversely, embark on heroic treatments that cause pain and distress to all concerned.¹⁰ The tendency seems to be towards splitting in our attitudes, either annihilating the very existence of such people in our minds within institutions or even their own homes, or becoming grossly emotionally over-involved and emotionally over-whelmed.

The experience of the patient and carer is often of social exclusion and social embarrassment. Dementia patients are notorious for being unpredictable, particularly within social situations where the multitude of stimuli to process can become too much. Social exclusion may protect the patient from embarrassment, but it may also protect our own embarrassments.¹¹ It can be challenging to protect an often assumed need for dignity, especially when the dementia sufferer cannot communicate their own wishes, against the need to protect ourselves from unsightly eating habits, or incontinence.

Behaviours can become less socially acceptable and more disinhibited, sometimes provoking anger and aggression in those on the receiving end of such behaviours and who do not understand the illness. This need to exclude continues even after the patient has become institutionalised. We do not wish to be confronted with neither the experience of being in a nursing home, nor the state of mind of the sufferer, as it reminds us of our own possible future.

Conclusion

The applicability of psychotherapy to the elderly, both as a treatment and an approach to care, is broad and useful. There is a wealth of opportunity for psychological approaches to the changing roles and transitions of old age as well as specific mental health problems. In contrast to this there is inadequate training in understanding the psychological challenges of ageing and inadequate provision of specific services. Some clinicians do apply these principles in day-to-day work. An understanding of psychodynamic and family dynamic factors can sometimes be life-saving, for example in assessing suicide risk. Behavioural problems, particularly in people with dementia, are often a function of the interaction between the patient and those caring for them. Both psychodynamic and behavioural approaches can help family and professional carers to provide care, which is both more effective and less stressful. In continuing care facilities, the work centres around the value of meaningful relationships, the therapeutic environment and supervision of staff to explore their reactions to patients in the day-to-day work of caring for older people.

Of course ageing is not all about dementia, and many suffer the consequences of transitions, role changes and loss. Currently we have a mix of older people who have learnt to be stoical in adversity and consequently have often never worked through past difficult material with an increasing proportion of older baby-boomers with their post-1960s lifestyles and expectations. Personality disorder in older adults is being increasingly recognised particularly apparently late-onset personality disorder and its relationship to treatment resistant anxiety and depression. Taking a careful personal history in such individuals often uncovers untold stories of childhood trauma including physical and sexual violence, and of loss. Being cared for as an older adult in need can re-ignite old patterns of disturbed interpersonal relating and attachment established from childhood.

What is certain is that the elderly have their own unique anxieties and face a unique moment in life€”that moment when life will be no more. Freud wondered if the elderly should not be analysed as they carry with them too much life experience. Yet this should be considered in modern practice as a further unique and challenging attribute. The elderly carry a wealth of life-time experience and so a wealth of coping strategies and psychotherapeutic opportunity. They deserve our best efforts and we have much to learn from them. We need to make a reality of improving access to psychological treatments for older people.

Conflict of interest: none declared

References

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