Psychoanalytic Gerontology--A Contemporary View

In this paper the author explores the evolution of attitudes toward recommending psychoanalysis for patients of advanced age. Resistances to making this recommendation are explored. Clinical examples taken from psychoanalytic publications are used to illustrate transferences and countertrasferences that commonly occur in the analysis of aged patients. Issues of development in later life and facing mortality are also addressed.

Psychoanalytic Gerontology - A Contemporary View

Clinical reports have repeatedly demonstrated positive responses to psychoanalytic techniques in the treatment of the elderly. Yet some still question whether older patients are good candidates for analysis. It is my intent to explore the evolution of attitudes toward recommending traditional psychoanalysis for patients of advanced age. This exploration will address resistances to making this recommendation, the challenges to following this recommendation, and the many issues encountered in doing so. In addition I will provide examples of contributions by analytic clinicians to our understanding of development in later life. The resulting delineation of putative developmental stages have, in turn, contributed to more specific diagnoses and therapeutic choices. Excerpts from published clinical reports of colleagues provide the opportunity to describe common transferences, countertransferences, fears, and concerns that emerge during the analysis of patients in the last decades of their lives.

In the face of a burgeoning population confronting the emotional upheavals of aging and the repeated demonstrations of the effectiveness of psychoanalytic techniques in assisting this group, the reluctance to accept these potential patients for psychoanalysis is striking. The principal obstacles to recommending psychoanalysis for patients of advanced age lie in the feelings and attitudes of the individual analyst toward aging and toward the elderly. Determinants of these attitudes, which I will expand upon later, include unresolved feelings about parents and grandparents, the cultural milieu vis-a-vis aging, and fears of confronting one’s own decline and mortality. In the course of an analysis of an older patient these same issues heavily influence the transference-countertransference engagement.

The struggles by analytic pioneers to deal with these resistances can be observed and perhaps vicariously experienced by following the historical evolution from prohibition to reluctant acceptance. The slow modification of resistances and the accretion of new viewpoints resemble the experience of an individual psychoanalysis.

Historical Overview

Psychoanalytic history of the analysis of the elderly begins with Freud’s admonitions regarding attempts to analyze individuals near or above the age of fifty (Freu,1898 pp282-283); (Freud,1905, p264). King (1974) makes the interesting observation that Freud was forty nine when he [Freud] wrote that “ near or above the age of fifty the elasticity of the mental processes, on which the treatment depends, is as a rule lacking—old people are no longer educable—and, on the other hand, the mass of material to be dealt with would prolong the duration of the treatment indefinitely” . “What amazes me about Freud's comments is that he is referring to people of his own age—near or above the age of fifty—and yet his own experience of himself must have shown him that his mental processes were still elastic and he was, to some extent, able to learn from experience. Perhaps it indicates how difficult it is to accept that we ourselves grow old as well as other people.”(p.23)

Abraham (1919), while acknowledging the possible validity of Freud’s caveats, responded to the urgings of older patients who requested analytic treatment. He reported therapeutic successes in patients in their forties and fifties who maintained their gains years after treatment. He concluded that the prognosis in these cases was more favourable if “the patient had enjoyed several or more years of relative normality before the neurosis has set in in its full severity” (p316). He also suggested the value of examining failed cases.

While not rushing to place aged patients into full psychoanalysis, analysts began exploring the possible responses to employing analytic techniques in the treatment of the elderly.

Jelliffe (1925) and Kaufman (1937) each reported symptomatic relief in older patients using analytic techniques. Kaufman treated two hospitalized psychotic patients ages 56 and 60 respectively, instituting a “psychoanalytic approach”( p334). He did not claim that these were instances of psychoanalysis, but the patients developed demonstrable transferences, responded to interpretations, improved symptomatically, and were able to leave the hospital. He stated that these might be considered transference cures, but clearly “Advanced age, as such, was not in these two cases, at least, an obstacle.”.(p334)

While psychoanalytic authors spoke to the usefulness of psychoanalytic therapy in helping ageing patients, content specific to these situations was not mentioned although involution was considered as a possible etiological contributor. The patients, with some exceptions, were individuals in their 40s and 50s. Concurrently psychoanalysts also became interested in exploring the psychological impact of ageing per se e.g. biological involution, inevitable losses, sociological changes, and increased awareness of mortality.

Subsequently, analytic writers began to address specific issues encountered in the treatment of the aged. These issues include concerns not usually present in younger patients as well as particular forms of transference and countertransference to be considered. Patients referred to in these articles included those of later ages ranging into the 60s and 70s.

In 1958 (Segal, 1958) published a detailed report of her analysis of a seventy-three-year-old man who suffered from an “acute psychotic breakdown”(p178).

“His treatment with me lasted eighteen months. It was not, of course, a completed analysis, but it dealt sufficiently with the patient's outstanding problems to enable him to resume normal life and activity and to achieve for the first time in his life a feeling of stability and maturity. At the moment this paper is going to press, the patient has been back in Rhodesia for 18 months, enjoying good health and having resumed his business.

In his analysis, I came to the conclusion that the unconscious fear of death, increasing with old age, had led to his psychotic breakdown. I believe that the same problem underlies many breakdowns in old age.” (p.178) (Several authors have noted fear of death in older patients but they have not considered this an etiologic factor nor specified conscious or unconscious fears).

Beginning with or perhaps inspired by Erikson’s (1950) seminal work proposing eight developmental stages from birth to senescence, analytic writers (e.g. Grotjahn, 1955; King 1974) began to recognize the fact that adulthood was not a prolonged period of developmental stasis.

For example, Benedek (1950) proposed the climacteric as a developmental phase. As this is a universal phenomenon biologically determined, it certainly fits early descriptions of development similar to those of infancy and adolescence.

During the ensuing decades, numerous reports on the dynamic treatments of aged patients appeared in the psychiatric and psychoanalytic literature. Stages of development in later life that were hinted at by (Erikson, ibid),Grotjahn (1955), and King (1974) were described in increasing detail with the designation of various stages, descriptions of developmental tasks, enumerating internal and external determinants, and using knowledge of the aforementioned developmental stages to plan therapeutic approaches.

In their three books published between 1981,1985, and 1990 Nemiroff and Colarusso (1981,1985,1990) proposed and described specific stages in adult development demonstrating the use of these stages in formulating diagnoses as well as in planning therapy. Consideration of psychodynamic changes with ageing and relating therapeutic techniques to development, however, was not entirely new. Jung in 1929 quoted by King (1974. p26) proposed “It is natural that neurosis, resistance, repression, transference, “guiding fictions,” and so forth should have one meaning in the young person and quite another in the old, despite apparent similarities. The aims of therapy should undoubtedly be modified to meet this fact. Hence the age of the patient seems to me a most important indicium…’ (Jung, 1929 p. 41). King goes on to say “Among other important points that Jung makes is the need for a developmental conceptual frame of reference within which the healthy functioning of mental processes can be reassessed according to the stage the individual has reached in his life cycle.”(p26). These suggestions, however, were never followed up in a systematic fashion until the work of Nemiroff and Colarusso (1985).

The impact of sociological factors such as retirement(King,1974) and cultural attitudes toward the aged (Grotjahn, 1955) was becoming evident.

The state of analytic attitudes toward development and treatment of the aged is well expressed in a panel held in 1982 at the American Psychoanalytic association and reported in 1986. Cath’s introduction (Cath and Miller, 1986) included the following: “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. Ageing 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.”(p163)

In view of the great interest and multiple publications regarding the responsiveness of the elderly to psychoanalytic technique, it remains puzzling as to why there were such reservations and scepticism regarding full analysis for these patients. In the first formal presentation in the aforementioned panel, Simburg (Cath and Miller 1986, p164 )described how he had conducted an informal poll of local psychoanalysts; this poll revealed that many harbour serious doubts regarding the plausibility of successfully analyzing persons aged sixty or over. In responding to the poll, analysts questioned whether elderly patients actually worked in analysis, and they also wondered about the distance of such analysands from the thoughts and feelings of early childhood. Not only did they question the flexibility of the patient's ego, and ultimately seemed sceptical that such a patient could be analyzed, but they expressed little interest or curiosity regarding the possible determinants of the analyst's motivation for wishing to work with an older patient.

In 2000 Valenstein published the results of a four-year research study of older patients in psychoanalysis. The conclusions pertaining to the advisability of recommending analysis for patients of advanced age were optimistic. However, despite the conclusions of the previously mentioned 1982 panel and the optimistic tone of Valenstein’s study group, the paucity of case reports in the analytic literature suggests to me that strong reservations persist.

Wagner (2005) noted that accounts of psychoanalytic experiences with patients seventy and above “seem to have little effect on a persistent sense of scepticism among many analysts”.(p78) This was confirmed for her when as a candidate her Institute initially rejected a possible control case solely on the basis of the patient’s age. Plotkin ( 2000) reported that when she was considering analysis for a patient in his seventies she noted a certain reluctance in herself. Upon consulting a colleague she was advised against analysis primarily because of issues associated with age. Fortunately, a second consultant differed. As recently as 2009 Quinodoze, (2009,) reported receiving several requests from ”young psychoanalysts” to supervise the psychotherapy of elderly patients. When asked about recommending psychoanalysis they said “given the patient’s age they had quite simply not envisaged the possibility”.(p781)

At the time of this writing I could find only fourteen detailed reports of analyses of older patients: (Segal,1958; King, 1980; Myers, 1984, [4 cases]; Sandler, 1984; Simburg, 1985; Wylie & Wylie, 1987; Miller, 1987; Coltart ,1991; Settlage, 1996; (‘author’s’ name ,2002); Mi-Yu, 2007) one informative description of a successfully terminated analysis that began in the patient’s late seventies (Wagner, 2005); one excerpt from a six-year analysis begun in the patient’s late fifties (Lax, 2008); and one excerpt from a four year analysis (Quinidoze, 2009). Although the numerous reported cases of analytically informed psychotherapy (Nemiroff & Colarusso, ibid), (Sadavoy, J. & Leszcs, !987), ( Myers ,1984), (Abraham,1980), have provided a rich source of information about transference, countertransference, development, and responses to analytic techniques in the treatment of elderly patients, the limited data from so few psychoanalyses leaves a number of questions about development, analyzability, and attitudes toward the aged unanswered. I would like to summarize in some detail the cumulative knowledge that we have acquired.

Transference and Countertransference

The great variety of transferences that occur in the analytic treatment of younger patients are also experienced by elderly analytic patients. Transferences observed almost exclusively in older patients include the experience of feelings, wishes, and expectations derived from past as well as from current relations to children.

Pollock describes a “son transference “ (Sadavoy and Lesczs,1987, p24) in which the patient displaced on to the therapist expectations to fulfil special needs occurring at this time of his life, needs to which his son had not responded.

Levinson (1985) describes a woman patient 30 years his senior who for some time related to him as a “lost child, young, naive, and inexperienced, learning about the world from a wise, loving mother/grandmother.” (p183)

Laufer (2000) reports from the psychotherapy of a 90-year-old woman “ In this regard, I was playing the role of the mother-imago. But, equally important, we were both aware that in another sense she was still playing the mother and I was an idealized version of her own daughter, who had disappointed her in many ways.” (p708). This particular type of transgenerational transference, though common, did not usually persist for long periods in the cases that I reviewed.

Finally, Hinze (1987) demonstrates the evolution of a parent to child transference in his treatment of a 60-year-old woman.

A second form of transference expression reported in two cases of full psychoanalysis (the first three examples were from psychotherapies) is that of the erotic transference of an older male patient to a younger female analyst (Wagner, 2005),(Mi-Yu, 2007). (Crusey,1985, p164-165) reports a similar experience in a psychotherapy case. While erotic transferences may occur in any analysis, when it occurs in the situation of the above-mentioned age gap, it takes on additional meanings for both patient and analyst. As one might anticipate both types of transference e.g. the described erotic transference and that displaced from children generate particular countertranferences.

The aforementioned examples highlight the significance of the age difference between the two participants.

Countertransferences are much more complex. Since the term itself has lost specific meaning in the analytic literature, and for want of a better all encompassing term, I am using it to designate feelings evoked in the analyst due to the age of the patient, the analyst’s responses to patients’ transferences, analysts’ transferences to the older patient, and attitudes and feelings about aging that are part of the individual analyst’s makeup. The latter in turn are determined not only by the analyst’s personal history but also by the society and culture in which he or she has grown.

Grotjahn (1955), for example, has noted the differences in attitudes toward the aged between American and European cultures and the influence of these attitudes on therapists---”The old mother and the old wise man are subjects of veneration in the old country. They do not seem to exist in the same form in this country, which is the country of the Young, the Beautiful, the Strong and the Healthy.” (p.419).

Wayne (1953) agrees:

“People of advanced age, a constantly increasing group, represent the most neglected segment of the population in our youth-revering country. They experience an increasing isolation and exclusion in all activities. In older cultures, and even in the so-called primitive ones, the aged enjoy distinction and are appreciated for the wisdom that comes from weathering the vicissitudes of life. Our culture depreciates the “old man” and the “old woman”; it extolls the virility and virtues of youth. Rarely is the aged person accepted as a genuinely productive member, without condescending forbearance. It is as though they are being tolerated for the while until a more suitable, younger substitute can be eased in as a replacement.”(p99).

In a third example, Hinze(1987) in his report of the psychotherapy with an older man, reflected: “The treatment was characterized from the beginning by his tendency to indulge in grandiose monologues and virtually talk his interlocutor into the ground. ---- I could succeed in getting a word in edgeways only by interrupting the flow of his speech and positively cutting him short. -----. I belong to a generation that was taught to respect its elders. One does not interrupt an older person! “. (p.467)

While these particular descriptions may not apply to today's zeitgeist, current cultural attitudes likely impact one’s view of the elderly. This would also be true of what one is exposed to in one’s familial home and in the analytic community. The atmosphere in the institute where an analyst trains is especially influential.

There was a time in our institute when a training analyst reached the age of seventy he/she was prohibited from taking on additional candidates in analysis. In the decades subsequent to the rescinding of this practice, colleagues in their seventies and early eighties continued to supervise, teach classes, publish, and analyze effectively. I am able to confirm the latter from my participation in a study group where colleagues present detailed clinical notes.

Reactions to the specific transferences that arise in the course of an analysis are superimposed upon the general attitudes toward the elderly that are part of the personality of the individual analyst.

In the context of a paper emphasizing the importance of self-analysis when working with the elderly, Wylie and Wylie(1987) illustrate a type of countertransference that I suspect is quite common--one which is determined by a blending of absorbed cultural attitudes with unresolved oedipal issues. They report from the analysis of an older woman by a younger male analyst the latter’s acceptance of his patient’s claim of an absence of sexual feelings due to her age. When he ultimately understood his reaction to his patient’s defensive manoeuvre the erotic transference blossomed.

The following example illustrates the effects of a cultural attitude in combination with the analyst’s transference.

In the context of describing her analysis of a 90-year-old man at the time she was 40, Mi Yu (ibid) tells the reader that she was born in China where “great respect for and absolute authority of the elderly” (p428) were emphasized. She describes how this attitude influenced her feelings about and responses to her worldly patient. Her own grandfather was alive when she began this analysis and she apparently displaced her concern for her grandfather’s health and survival. She experienced constant fear that her patient would die at any time. Unfortunately, her grandfather died during this analysis. The loss of her beloved grandfather stirred up intense feelings that made it difficult for her to understand what she was feeling for her patient. “I was afraid that my quandary was about my emotional need to elicit some grandfatherly feelings from him”. (p442)

A male colleague reported to me his experience of a male patient thirty years his senior as an admired father figure. His transference, as one might expect, had a definite influence on the nature of his interventions.

There are, of course, many variations in transference and countertransference expressions in the analytic treatment of the elderly (see Grotjahn,1955). In this paper, I have limited myself to those expressions for which I have clinical illustrations.

Development

It is beyond the scope of this paper to explicate the evolution of developmental theory. This theory is in a state of flux. There is no agreement as to what constitutes development; there is no simple schema of stages of development in later life comparable to that described in childhood and adolescence. For some theoreticians (A. Freud et al, 1965) development is completed with the end of adolescence. Tyson and Tyson(1980) in their extensive scholarly review of developmental lines, limit development to the period of birth to young adulthood.

In contrast to this approach, clinicians working with older patients observed the inevitable psychological changes and new adaptations that occur throughout adulthood and concluded that development accompanied by structural change is a continuous lifelong process.

Exploration and discovery of the challenges faced by ageing, the means of facing these challenges, and especially the possibilities for structural changes encouraged an optimistic outlook upon the possibility for psychoanalysis in the later years. Clinical publications of successful analyses served to heighten optimism. Analytically informed psychotherapy and full analyses provided opportunities to expand our knowledge of development and to dispel certain myths about the effects of ageing. Examples of continuing myths include the lack of sexual interest and activity in the elderly, rigid thought processes, the decrease in measured intelligence with ageing, and the universal fear of death.

Conscious recognition of decline and acknowledgement of the effects of decline on capacities, mood, and self-image are considered by many as major necessary developmental achievements for the elderly. Appreciation of the implications of these changes may lead to realistic action in modifying or giving up certain activities. While these changes may be accompanied by or followed by sadness, mourning, or pangs of depression the result may be adaptation expressed in new more appropriate as well as gratifying activities. Denial or minimization can result in attempts to function beyond one’s ability and consequently, may lead to repeated frustration and disappointment as well as damage to others.

Pollock’s (1987) proposal of a universal “Mourning-Liberation Process” is another example of a discreet developmental challenge that, when successfully negotiated, leads to structural change. Pollock defines this as “The painful internal detachment from ideals, goals, objectives, and from individuals who no longer exist results in an acceptance of the reality principle of functioning.”(p16)..

Study of development throughout life and the delineation of phase-specific tasks led to conceptualizing developmental arrest. Recognition of failure to meet particular challenges became an additional tool in formulating diagnoses and planning treatment. (Nemiroff & Colarusso,1985).

Innumerable contributions to the psychoanalytic understanding of development yielded, as might be expected, divergent opinions regarding how best to conceptualize stages, phases, developmental tasks, and process as well as what phenomena constitute development. For example, should regressive shifts be considered as part of the developmental process? Some would challenge the inclusion of marriage and parenthood in a list of stages as they are not universal experiences as are the challenges of declining functions which all must encounter. Settlage et al(1988) noting the limitations of the stage model propose a model based on the developmental process. Abrams points out that there are many models of development dependent upon one’s theoretical orientation. He cites self-psychology and attachment psychology as examples. But two issues find almost universal acceptance: that development continues throughout life, and that the last stage is a confrontation with mortality.

Mortality

“It is indeed impossible to imagine our own death; and whenever we attempt to do so we can perceive that we are in fact still present as spectators. Hence the psycho-analytic school could venture on the assertion that at bottom no one believes in his own death, or, to put it in another way, that in the unconscious every one of us is convinced of his own immortality.” (Freud ,1915, p289)

“It (fear of death) presents a difficult problem to psychoanalysis, for death is an abstract concept with a negative content for which no unconscious correlative can be found.” (Freud ,1923, p58)

Biological involution and the inevitable losses that accompany advancing years ultimately pressure one to confront the reality of personal death. Psychoanalytic statements about the impact of this potential awareness are varied and not infrequently contradictory.

Sadavoy & Leszcz (1987) quote Meerloo (1955) as claiming all older patients fear death. In contrast, however, Pollock(1987) states “Unlike younger patients, the elderly do not fear death. At times, they welcome it as a relief from pain and anguish. “ (p.19)

Berezin (1987) speaks of the “myth of older people fearing death”. This is a projection “imputed to them by a younger age group. Clinical experience does not demonstrate that older people have anxiety about dying.” (p59)

Several authors ( e.g.Eissler, 1955; Segal, 1968; Feifel, 1969) suggest that fear of death is a frequent cause of neurotic and psychotic symptomatology in the aged.

Fearful fantasies associated with death and dying are not limited to the aged. Imagining not being able to breathe in a coffin, fearing not being remembered (Wagner, 2005, p89), or anticipating an assault or rape by a reified “death” (Eissler, 1955; Bulletin, 1980) can occur at any age. When such fears become manifest in the course of an analysis of an older patient, they are best treated as one does in any analysis. So the question arises as to what, if anything, is unique about these concerns in the elderly. One difference is the experience of decline that makes approaching finality more real. I think it is worth distinguishing between fear of death, fear of being dead, and fear of dying. The fear of dying, in response to actual physical and mental changes, conjures up dependency and helplessness: As Sadavoy and Leszcz (1987) put it “with the onset of physical decline in old age, the potential pain, helplessness, and infirmity which the patient imagines as a prelude to death often provokes intense fear and anxiety in the vulnerable person”. (p 195).Or as Sandler (1984) states “Yet, the anxieties and fears of becoming ill and dependent on others, the dread of losing mental and physical capacities, the inevitability of death and increasing loneliness as close friends and relatives die may cause severe disruptions in the equilibrium of some aging individuals.” (p472)

A number of authors refer to an “existential crisis” or to coming to terms with death. (Nemiroff & Colarusso, 1985, p12); Levinson (1978). Grotjahn (1985) describes his own experience--”The assignment of my age is now to achieve wisdom (an obvious reference to Erikson), which is the ability to deal with the unavoidable reality of death. That seems to be my last assignment--and it seems to escape my reach.” (p293)

As one sorts through the analytic literature it becomes apparent that we have no clear agreed upon picture as to what takes place in the “final developmental stage” (Erikson’s eighth stage). The data underlying diverse conclusions are drawn from different populations---institutionalized patients, physically ill patients, dying patients, patients in analysis, patients varying in age from 35 to 95. Frequently writers do not specify whether they are referring to conscious or unconscious fears. When specific conscious fears of death are mentioned we are often not told of the unconscious meaning to the individual; for example separation, abandonment, castration, loss of love, to name a few. On the occasion that a patient brings up preparing for death (e.g. making financial arrangements, writing a will etc.), it is incumbent upon the analyst not to immediately pursue unconscious meanings out of a personal need to deny the realities of death and dying. Are fears of death an issue for the relatively healthy aging individual confronting mortality? What is meant by “coming to terms” with personal death?

Having reviewed Freud’s early comments on death (1915, 1923,) as well as subsequent observations and speculations of others, I am left agreeing with Sadavoy & Leszcz (1987) that “it is still necessary to recognize that little is known about death anxiety in old age”. (p195.)

In working analytically with individuals of advanced age the common denominator is the ultimate impossibility of totally avoiding the reality of personal death. It is the task of the analyst to be alert to the patient’s attempt to deny death and/or repress fears, and to assist each patient in his or her various attempts to “come to terms” with the inevitable. This, in turn, requires the analyst to be comfortable with mortality. This obligatory equanimity will be influenced by the analyst’s age and personal experiences with illness and death. Obviously, any countertransference reactions will relate to the degree of resolution of the analyst’s unresolved feelings to parents and grandparents.

In summary--while concerns about mortality may be experienced early in life, an urgent awareness of personal death does not usually take on the characteristics of a universal developmental stage until very late in life. We do not yet have sufficient data to describe the variety of individual solutions or attempted solutions to this challenge. For many “coming to terms” may take place only in the context of dying. Settlage(1996) and Norton(1963) provide illuminating details from their analytic treatments of dying patients. Freud’s formulation of what I would consider disavowal and splitting, in my opinion, still obtains. We intellectually acknowledge mortality but live as if it were not.

Retirement

The previous discussion of mortality primarily involves what many refer to as the “old old” or “ older old” which terms usually refer to individuals past the age of seventy-five. (Valenstein, 2000, pp1570-1571). Forrest and Cote (2002) propose a subphase of Erikson’s eighth phase (Mature Age) which they call “The Mortal Stage Of Late Life” beginning at age eighty.

Valenstein (2000) suggests an age bracket of 55 to 68 for the “younger old”. A primary issue frequently faced by this group is retirement. Obviously, this can go significantly beyond age 68. Since retirement is not a universal phenomenon, I don’t consider it a developmental phase per se; but it is a frequent sociological event of great psychological impact. I find it convenient to consider separately two obviously related time periods---pre-retirement and the years following retirement.

The nature of the concerns that precede retirement vary somewhat depending upon whether the retirement is voluntary or obligatory. The anticipation of leisure does not infrequently stir up unrealistic expectations of play and pleasure that we imagined took place during the mythical innocence of childhood. Unattainable expectations of great creativity may also emerge.

Following her retirement from teaching voice in the public schools, M began studying music composition at a local University. Even though her work was well thought of and her innate talent was recognized, she was shocked when, at age sixty-seven, she received the first B in her college career. The thought entered her mind “I’ll never be a Mozart”. This was followed by a severe regression during which she suffered attacks of inchoate rage and destructive obsessional thoughts. A year of these painful experiences led her to seek analysis. As we slowly uncovered her long-standing expectation of ultimate greatness it became apparent that the organizing fantasy of being a boy genius (Mozart) which had sustained her for years had suddenly been shattered. Determinants of this fantasy included a need to share in her father’s presumed omnipotence, belief that her mother would love a boy genius, and her belief in the magical power of the phallus. Concomitant to understanding and working through these highly charged beliefs her musical creativity flowered. During the eighth year of analysis, at age seventy-nine she was awarded her PhD in music composition. (Lipson 2002)

Analysts recognize the relationship between one’s occupation and one’s identity (King,1980). Retirement may revive in a vulnerable individual old painful feelings of identity confusion similar to those experienced in adolescence. Since one’s employment is frequently a major source of self-esteem, retirement may precipitate depression. On the other hand, it may motivate creative endeavours. Settlage et al, (1988) suggest that the responses to retirement as well as to other life events may be part of a developmental process. Older retirees may find themselves contending with previously mentioned physical and mental decline which complicates efforts at adaptation.

Additionally, revived memories of boredom and loneliness may intensify concerns about how one will fill the empty hours during retirement. Concern about this may result in the postponement of a voluntary retirement. In the instance of unwanted obligatory retirement, the individual may feel controlled, diminished, and experience a lack of worth. The consequences may be a revival of past conflicts with authority accompanied by anger, rebellion, and feeling helpless and defeated.

How an analyst deals with these issues in the analyses of older patients will be influenced by his or her own attitudes toward retirement. The age of the analyst can be an important determinant of these attitudes. As an analysand is planning for retirement the analyst may inadvertently encourage or discourage retirement depending upon his or her own plans and views.

Sexuality

Nemirroff and Calorusso 1985) write extensively about sexuality in the elderly:

“Sexuality in later life has given rise to much myth and misunderstanding despite the ready availability of scientific information. Similar to the cultural taboos about infantile sexuality before Freud’s great discoveries, sex is thought to be something older people are finished with (biologically) or should be finished with (psychologically)”. (p311). The authors devote six pages to explicating these myths, the cultural and psychological reasons for their persistence, and the impact on both analytic therapists and the elderly.

In reviewing case reports of psychoanalyses of aged patients as well as reports of psychotherapy by experienced analysts I was impressed by the paucity of sexual references. Out of the fourteen cases of analysis that I mentioned earlier. only three of the analysts included detailed reports of sexual fantasies and activity. Several reports mentioned the emergence of sexual feelings, erotic transferences, and wishes for affairs but there was little content. Two therapeutically successful cases that demonstrated extensive analytic work made no mention whatsoever of sexuality. This is a striking contrast to the importance attributed by traditional analysts to the content of conscious and unconscious sexual phantasies. There is a peculiar disconnect between well-documented information about sexual desire and activity in the elderly and what appears in case reports. Meerloo (1955) reports a 68-year-old woman being told by her doctor that sex has to stop at 50 and that she did not have the right at her age to think about sex. Illustrative of self-consciousness young psychiatrists have with older patients is Berezin‘s (1986) observation that not only is it common to find no reference at all to the ongoing sexuality of older patients in the case reports of younger therapists, but - in fact- even on the APsaA (1986) panel devoted to the psychoanalysis of the older patient, no information was provided regarding the current sexual lives of the patients presented by Simburg, King, and Sandler. Omissions of this nature, he suggested, are rarely seen in case presentations focused on younger patients. Some 30 plus years later Wagner (2005) reported the burst of uneasy laughter that emanated from an audience of analytic clinicians when she spoke about sexual fantasies of a 79 year old patient.

There obviously exists in the professional community an inhibition in recognizing and exploring the details of sexual activities and phantasies of the elderly. Recognition of this problem and an attempt to deal with it is illustrated by a publication in the prestigious New England Journal of Medicine (Lindau et al, 2007). The article entitled A Study of Sexuality and Health among Older Adults in the United States begins with “Despite the ageing of the population, little is known about the sexual behaviours and sexual function of older people”. (p762) Following a detailed analysis of the interviews of 3005 persons, the authors state that their findings indicate that the majority of older adults are engaged in spousal or other intimate relationships and regard sexuality as an important part of life. The prevalence of sexual activity declines with age, yet a substantial number of men and women engage in vaginal intercourse, oral sex, and masturbation even in the eighth and ninth decades of life.” (p774)

Myers (1985) points out the importance of adequate sexual functioning to one’s self-esteem. Ignoring sexual life in a patient can be experienced as a condemnation of his or her desires and activities. It also results in depriving those with sexual difficulties of the help they need.

What we seem to be witnessing is a long-standing reluctance to accept and deal with sexual activity in the aged-- an inhibition that is determined by countertransferences and cultural prejudices and that persists despite the availability of information.

Termination

There was considerable variation in the nature of terminations in the psychoanalytic cases that I reviewed. Following extensive therapeutic relief, two patients moved to distant countries--one after eighteen months of intense analytic work, the other after two years. In several other cases that experienced more traditional terminations, there were varying degrees of post-termination contact. The implications of these endings vary with one’s view of termination. One might legitimately refer to the first two cases as interrupted. In response to the cases, Valenstein (2000) studied he concluded that analyses of the elderly are “not quite ‘terminable’ in the usual fashion” (p.1585). The description “an open or swinging door” ( p.1585) could easily be applied in the above-mentioned instances of post-termination contacts. On the other hand, Gabbard’s recent discussion of termination ( Gabbard, 2009) presents a more flexible or nuanced approach. Gabbard contrasts “idealized models of termination” (p580) to the variety of forms it takes in practice. He concludes with “terminations need to be tailored to the individual analysand” (p589).

One impediment to termination is the fantasy that being in analysis postpones death. This, however, is not unique to elderly patients (Schmukler, 1990). In the event that the analyst unconsciously shares this fantasy, the analysis might be interminable or result in extensive post-analytic contact. Some analysts (Coltart,1991; Valenstein, 2000) have suggested that the diminished possibilities for finding new objects combined with the experience of many losses may contribute to the presumed need for intermittent contact.

While most of the case reports that I reviewed highlighted countertransference issues related to age, ageing, and age differences, little was mentioned about the impact of these issues on termination. It was clear in many instances that post-analytic contacts were clinically indicated (Coltart, 1991) and therapeutically helpful. Subsequent to the termination of a twelve-year analysis which began when the patient was sixty-eight, she and I maintained contact through an exchange of Christmas cards. The termination phase was quite traditional in the revival of previously worked through regressive wishes as well as the emergence of new memories. However, as I began writing this section I began to wonder about whose need or desire was served by these post-analytic contacts. In other words, when an analyst working with an elderly patient decides to modify his or her customary termination procedures, is his or her decision influenced by age-related countertransference issues?

Discussion

There is more than ample evidence that elderly patients respond positively to analytic techniques. It is also apparent that age is no obstacle to full analysis as patients of very advanced age have demonstrated the capability of tolerating and utilizing the necessary intensity and depth. With so few case reports it would be difficult to list criteria for analyzability, but so far it appears that they would be the same as they are for younger patients.

Many analysts writing about development in the later years find it useful to designate two groups of the elderly--the “ younger old” and the “old old”. Some of the criteria used to determine this arbitrary division include age, position in life vis-a-vis work, general health, and especially the degree of infirmity (Plotkin, ibid). Ruth Lax (2008) suggests that “the age of sixty is sometimes considered older, but can still herald a vigorous decade.” But, she continues, “At eighty and beyond, however, the situation is often different”. (p855) When reading reports of analyses it is apparent that patients in both groups are dealing with the increasing awareness of ageing. There are, however some significant differences. In working with patients who are at the younger end of the age continuum, one is more likely to deal with problems surrounding retirement and plans for the future. Dahlberg (1980) provides the following description of the dawning awareness of ageing.

“Age comes slowly or abruptly, but one day you find that you can't quite keep up with your children. Aches you never felt before appear. It doesn't happen to you, but you notice that friends are getting paunchy, short of breath, balding, greying, and at some point, you recognize that you are on the edge of that state yourself. More dramatic is the fact that more and more friends are having heart attacks, cancer, and strokes, as well as prostatic enlargements or mastectomies and hysterectomies. A bit of bursitis pops up. Tennis doubles replace singles, and you see your internist more often. Parents become senile and/or die. You think more about conditions in nursing homes. If you're lucky, you are pleased that your children are self-supporting. You start to realize more of what your ageing patients are talking about. You may even sympathize with the secondary gains that you see in some physically ill patients”. (p.369)

While conducting an analysis of one of the “younger old” it would not be unreasonable to anticipate modifications of self-representation, expressions of narcissistic injury, and a sense of loss of what was and no longer is. With the passage of time, the increased awareness of change makes confrontation with these issues more likely if not imperative. In reading case reports of analyses that began when the patients were in their late fifties or early sixties I found them, at first, hardly distinguishable from analyses begun earlier in life. In my experience confronting retirement was a major distinguishing factor.

With so few reports available it is difficult to decide whether the evidence matches one’s expectations. In the analyses of the aged in either the “younger” or “older” group, I think the following from Quinodoz ( 2009) obtains.

“I came to realize that, in psychoanalysis, the Oedipus complex is expressed with just as much vigour at 70 years of age as it is at 20 and that mental functioning in an elderly person is not fundamentally different from that of someone younger in years. That is why the basic technique employed by the psychoanalyst is, generally speaking, the same in both cases. There are the same basic references to the unconscious, the transference, the Oedipus complex with its genital and pregenital aspects, the compulsion to repeat, defence mechanisms, etc. (p.774)

Nevertheless, while basic technique may be the same, certain concerns and events can emerge in aged analysands that test the analyst’s flexibility. Dealing with patients’ memory lapses can be problematic for an analyst. Since only forty percent of seventy-year-olds retain the memory of their mid-thirties (Kandel, 2006 p327), distinguishing repression from common attrition can be confusing. Memory difficulties can evoke dread of incipient dementia, and dementia is only one of many fears accompanying ageing. Others include the possibilities of impotence, incontinence, helplessness, inability to be a caretaker, abandonment, and death. The context in which a particular fear is expressed is determinative. What does it mean when a patient first expresses fear of dementia when reporting masturbatory activity and fantasies?

It is pretty well known that some cases of depression are mistaken for dementia. Less well known is the opposite. There is the occasional analytically sophisticated patient who seeks help for depression when the true problem is early dementia.

One of the most consistent differences in the analyses of the aged lies in the countertransferences. As noted previously, the individual analyst’s attitudes toward the elderly is often a factor. The relative ages of the two participants may have great significance. In addition to the transgenerational transferences described, the older patient may experience great envy of the youth, strength, and power attributed to a significantly younger analyst. This perception of reality may at times be derived from a reversal of unconscious early oedipal experience.

In addition to dealing with where he or she has been e.g. childhood, adolescence, young and middle adulthood the analyst is faced with where he or she is inevitably going---retirement, decline, and death. Negative attitudes toward the aged combined with an apprehensive view of one’s future may lead to “therapeutic rejection of the geriatric patient”. (Feifel, 1969, p.128).

Summary

The reciprocal relationship between lifespan developmental theory and clinical psychoanalysis becomes evident when viewed historically. Each discipline has enlightened the other. The ageing process from birth onwards includes a series of losses. This is especially cogent in advanced age. Yalom (1987) observes “The geriatric patient usually endured extraordinary loss--loss of strength, power, prestige, recognition, physical ability, beauty, friends and affiliations, material wealth, intimacy, sexual opportunities, and occupation. But the most grievous loss of all is the loss of possibility.” (p.xi)

While it is true that there is an increase in the number of elderly patients accepted for analysis, a reluctance on the part of many analysts remains. In addition to the previously noted determinants of this reluctance (negative attitudes toward the aged compounded by an apprehension of facing the future), there is an educational issue. While many psychoanalytic institutes now include courses on adult development and analytic possibilities for the aged in their curriculums, this is far from ubiquitous. The detailed attention given to the development and treatment of children does not yet exist at the other end of the spectrum.

Published clinical reports of colleagues provide data from which we can attempt to extrapolate generalizations applicable to the psychoanalytic treatment of the elderly. Additional analytic data might clarify several questions: What does it mean to come to terms with death? Are fears of death a usual or expected occurrence of advancing age? Are death fears a common etiological factor? When the inevitability of death becomes a central issue, how does it resonate unconsciously? Are early experiences and repressed fears revived?

Are the principal therapeutic instruments e.g. interpretation, analytic relationship, any difference in the analysis of the elderly? Is the relationship itself more significant in the treatment of the elderly? What might be the expectable termination experience?

It is my belief that familiarity with adult development, the challenges faced in later life and the concept of developmental arrest will make more analysts receptive to recommending psychoanalysis for people of advanced age. Furthermore, knowledge of the experience of colleagues, especially in regard to countertransferences, will prepare us for unanticipated events that arise in the course of their analytic work.

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