Older adults and psychoanalytic treatment: it's about time.

PLOTKIN OLDER ADULTS AND PSYCHOANALYTIC TREATMENT

Older Adults and Psychoanalytic Treatment: It’s About Time Daniel A. Plotkin Abstract: It has become increasingly apparent that older adults may not only benefit from psychoanalysis and psychodynamic psychotherapy but may be particularly well suited to such treatment. Clinical evidence to support this is presented, including discussion of the successful psychoanalysis of a woman in her seventies. An overview of the psychoanalytic literature indicates that psychoanalytic beliefs about the feasibility of treating older patients have always been favorable, but have had difficulty gaining traction. The modern psychoanalytic literature is compatible with extra-analytic studies of aging that provide further rationale for the potential usefulness of psychoanalytically oriented interventions in the elderly population.

CASE PRESENTATION JF*, a 73-year-old widowed Caucasian woman, was self-referred to the University of California Los Angeles Medical Center, Geriatric Psychiatry Outpatient Clinic. She waited almost a month for an appointment and expressed a preference to see a male therapist in his thirties or forties (I was in my late 30s at the time), someone with whom she would be unlikely to get too emotionally involved. She was retired, lived alone in an apartment in Beverly Hills (with two cats), and supported herself from savings and Social Security. She complained of decreased energy, “aging,” a feeling of being alone and not belonging (“where do I fit in?”), not having women friends, and a block in her cre*Names and details have been changed to protect patient privacy. Daniel A. Plotkin, M.D., M.P.H., Ph.D., is a clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine, University of California at Los Angeles. Psychodynamic Psychiatry, 42(1) 23–50, 2014 © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry

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ativity, particularly with regard to painting (which she had previously enjoyed as a leisure activity and modality of self expression). JF was initially seen in psychotherapy once a week and increased to three times a week over the course of about 18 months. She experienced some improvement, yet felt it wasn’t enough and wanted to go further. There was no use of antidepressant or other psychotropic medication during her treatment. Since she had had prior psychoanalysis and was familiar with it, she decided to pursue it again. I applied to my psychoanalytic institute for her to be a control case, but her case was initially rejected, for reasons that clearly had to do with her age. On appeal, the decision was reversed, and we were given the green light. The duration of her psychoanalysis was about three years, for a total treatment time of about four and a half years. An important piece of information is that early on in her treatment, her youngest daughter (the only one with children of her own) moved back to their family place of origin in the Midwest and invited JF to move nearby to be part of their lives, but JF had declined. In treatment, she expressed her reasons clearly: she did not feel worthy of living near them, and was sure she’d be an “imposition” on them. It was just as clear that she yearned to be near them.

Initial DSM-III-R* Diagnosis 1. Dysthymic disorder 2. Possible Cluster B traits 3. History of uterine adenocarcinoma 4. Moderate social isolation 5. GAF 70

Background JF was born and raised in the Midwest; she had one sibling, a brother approximately four years older. Her parents were not very involved in her upbringing. They divorced when she was around 5 years old, and she was raised by various family members. For a time, she lived with her father, his brother, and her paternal grandmother. This grandmother was tall, had a strong personality, was a midwife, and served as a role model for JF. The grandmother put a premium on toughness and valued intellect over emotions. *The version used at the time.

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JF’s brother died in his mid twenties of complications from a tonsillectomy. JF did not speak of him very much in her therapy. She recalled being somewhat protective of him and that he had playfully exposed himself to her when she was 10. Her relationships with her parents were fraught with difficulties. She described her mother as not being there for her physically or psychologically, and actively opposing her at times. “She never loved me very much; she loved my brother.” She recalled her mother and grandmother hugging and kissing her brother (but not her) after not seeing them for a time. She also recalled that when her mother was dying and JF had gone to see her, her mother had said, in a disappointed manner, “Oh, it’s you.” JF’s father was initially described in glowing terms as a tall, handsome Welsh man who, like his “volatile, handsome, irrational” brothers, was a “prima donna.” However, when JF was approximately 13 years old, he made some kind of sexual advance toward her that was “terrifying” and “never talked about,” but permanently changed her view of him. She later described him as “an ass” and recalls that her first memory of him is that he was “a drunk.” While there was no family history of depression, suicide, bipolar disorder, schizophrenia, or psychiatric hospitalizations, it is likely that there was a history of alcoholism. JF married in her late teens, mostly to separate from her family and achieve some degree of autonomy, but the marriage was stormy and ended in divorce after about 10 years. She recalled being afraid of her husband, who was “a thug” and critical of her. She also recalled leaving him and then being hurt that he didn’t ask her to return. They had three daughters. Approximately 2–3 years after her divorce, she remarried a distant cousin she had known and liked since childhood, thinking he would be a good father to her daughters. JF worked as a journalist in the newspaper business from her late 30s to early 50s, at a time when there were few women in that business. She became associated with feminism and with unions and causes. Later, she left the newspaper business and worked as an interior designer. All of JF’s daughters married. The oldest divorced, lived alone in New York, struggled with alcohol abuse, was diagnosed with borderline personality disorder, and had psychiatric treatment. The middle daughter, a physician, was married but widowed during the early phase of JFs treatment with me. She lived in the southern California area. The youngest daughter was married, had two young children (JF’s only grandchildren), and then moved from southern California to the Midwest. JF said that she tried to raise her daughters to “not need me” in the way that she had needed, and been hurt by, her own mother. For this reason, she “walked away” from them when they were teenagers.

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JF talked about feeling guilty for being a bad mother; she saw herself as someone who would rescue stray cats but not her own daughters. JF had psychoanalytic treatment around the time of her divorce, when she was in her late twenties, as it was “the thing to do at the time.” After two years, her analyst “fell in love” with her and seduced her. The treatment ended, but she did see him again “socially but not sexually” after her second husband’s demise, when she was lonely. She recalled that the analyst resembled her father, and she connected the seduction by her analyst with her father touching her in a way that had felt sexual as well as her brother exposing himself to her. She was left with a feeling of “what’s wrong with me—what did I do to make them think they could do that to me?” In general, JF enjoyed good medical health, but she had a hysterectomy in her sixties for uterine adenocarcinoma. At the request of her physician daughter, the doctor never told JF that she had cancer. She found out when the doctor’s staff inadvertently revealed it to her, and she was furious with both the doctor and her daughter. She did not have strong feelings about the cancer, which was essentially cured by the surgery.

Treatment In the initial psychotherapy phase, JF rather quickly developed a strong positive transference that had a prominent erotic quality to it. She alternated between being able to enjoy her intense erotic feelings, and the freedom to have such feelings, with feelings of shame and embarrassment related to her attitude that she should no longer have such feelings, that she was too old for such feelings. JF imagined that I would be “offended” or disgusted by her sexual longings. Her associations took us to memories of her father and his brothers, the handsome Welsh men for whom she harbored unwelcome feelings. She also expressed feelings related to her prior analysis and the shortlived sexual relationship that had developed. She felt “maneuvered” by her therapist and worried that I might do the same. At the same time, she felt guilt and shame related to a vague feeling that she was somehow responsible for inviting the sexual overture. In her treatment with me, she often described an image of me in a “bubble,” sometimes alone, sometimes with her, sometimes nude and sexual, and other times like “a perfect mother and child.” She brought me gifts, ranging from an apple, to a mother-child bronze paperweight, to a crystal turtle. We talked about the meaning of each. We understood


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the turtle to be a metaphor for how she felt about herself: protected in a shell, needing and yearning to be protected. She developed an understanding of the roots of her tendency to shy away from people, even though she was charismatic and had many opportunities for social interactions and relationships. She realized that she was more comfortable with her cats than with people and that she was drawn to any animal that seemed to need help. After about a year of psychoanalysis, the transference evolved: the sexualized father transference receded and an idealized mother transference became more prominent, in which I was experienced as comforting, soothing, and powerful. As JF had anticipated and feared, her strong attachment to me became problematic. When I returned from a week away, she said, “You’re too dominant in my life” and talked about her reluctance to express the depth of her feelings for me, fearing she would “invade” and impose on me if she did. Then, she surprised herself by saying, “I want to be you, to be young, and male,” which led to a rich discussion of her longing to be around men and to be like them (which she did do in some ways, as a cigar-smoking journalist), and of her difficulty relating to women. She complained about the gossipy women she was surrounded by, and she wanted to give me a book about competition and envy between women. JF described our relationship as protecting her from the pain of the world, and how my interpretation of her idealization of me “shattered the protection” and left her hurt and vulnerable. She would express a yearning for her “other”—a male companion who would fulfill her spiritually, not necessarily sexually, and make her feel whole and complete. She felt this at times with me, and she talked about a “joining” with me, and how it didn’t matter if I was her child or parent or lover, that it had to do with being close to me. She felt that the world had passed her by at this point in her life, however, and that she could not have the kind of companionship she desired; “I don’t have anybody to love.” JF then began to experience me in a different way: as cold, aloof, and uncaring. She experienced herself as “excessive, an imposition, boring, and offensive.” She was convinced that I would eventually reject her. She was embarrassed and ashamed at the intensity of these feelings, calling herself “irrational” and “ludicrous.” She began to reveal longstanding conflicts in reconciling her highly valued intellectual self with her devalued and disavowed emotional self. She regarded the emotional aspects of herself as “childish” (in a pejorative sense) and thought of her emotional self with disdain. Throughout our work, she described her inner life and her experiences with dramatic and vivid imagery, with compelling renderings that were filled with “never” and “first time ever” and a “forgetting”

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of prior similar feelings. A distinct pattern emerged in which JF would feel hurt, rejected, and angry at the beginning of a session, often because I would not return a smile or not smile enough. However, by the end of the session, after talking about her experiences and feeling understood and, on some level, “accepted” (i.e., loved), she would not want to leave; she seemed to feel that leaving would mean never seeing me again. She would also often express her appreciation to me: “You don’t treat me like I’m old; you don’t just pat me on the back.” JF would often call after a session to say she had been feeling very good, or productive, or whatever; she wanted to let me know in order to “touch” me and also in order not to lose the feeling—recognizing that she might not feel the same or even recall the feeling at our next session. Analytic work helped JF understand herself as someone with a flair for the dramatic (i.e., with elements of a histrionic style, though we did not discuss it in jargon terms), and this led to a new attitude in her, one that was noticeably more self-respectful and realistic than the previous one. She developed a deeper understanding of the tension between the different aspects of herself, all contained within one person. This led to an unblocking of her creativity, now in the form of writing rather than painting. JF wrote poems, hundreds of them. She brought in one titled “He is my agony of love,” in which she expressed her desire to have me back in the bubble, explaining that she could control me as well as herself that way. She also relayed a dream involving a dark hallway; when she turns the other way, there is brightness and a rainbow, then beautiful clouds and me, sitting, “very pure,” nude, with a crown. She does not want to be angry with me for being emotionally unavailable to her. Then a memory from when she was 7 years old: a teacher makes her say multiplications over and over in front of her classmates, which was very embarrassing. Her association was that if she opened up to me, she would be humiliated. Also, she would become just another patient of mine. She expressed her need to feel special in order to feel lovable and worthy. This related to her first analysis, and to her sense that she somehow invited the analyst’s seduction. Her associations led us to realize that her feelings involved more than the dangerous oedipal feelings toward her analyst/father, they involved feelings toward her mother. We came to understand that the idealized mother compensated for a painful relationship with a pre-oedipal mother in which she felt unwanted and unlovable; this was “solved” with the development of a competent if not “true” self that she found to be more fragile than she had believed. Sessions were often stormy. JF revealed that she wanted me to join her on the couch and that she was angry with me for not running off with her, “to a cloud.” Later, she wondered if I would “maneuver” (i.e.,


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seduce) her like her previous analyst did. Thinking about my upcoming vacation, she anticipated missing me deeply and feeling as if I’d be gone forever. “You’re everything to me, and it’s not productive or constructive to talk about it; it’s just pain.” She related her conviction that what she really needed from me was positive feedback and other signs of actual love, not just understanding. She told me she had stopped writing poetry. I said I understood that my words seemed inadequate to her and that she was responding by stopping her own words/poetry. My understanding, appreciation, and acknowledgment of her feelings and her dilemma led to insight on her part, as she was able to connect her feelings with her thoughts. She felt changed, and in a phone message after our session she informed me, “I’m writing poetry again.” Subsequently, she talked about how she felt “whole” but was having difficulty “taking authority over myself.” Further reflections allowed her to realize that she had been blaming and punishing herself for “being alone.” She revealed a dream in which some large men are walking away, her second husband being one of them; she’s behind a barricade, and then her brother is one of them, “pushy and adorable.” She then associated to her grandson, and she was able to connect her avoidance of moving to the Midwest with her sense of “badness” and unworthiness, allowing her to realize how much she missed him and his mother, her daughter. On her 78th birthday, she told me that she wanted me to say, “Happy Birthday” and to say her first name out loud; she then talked about the shame she felt related to the nature as well as the articulation of her request. In particular, her experience of me as hating her (and of herself as hating me) was directly related to her mother in a powerful transferential way. The working through of it was transformative to her on a deep emotional level. Once again she was able to connect her feelings with her thoughts, demonstrating that she was developing the capacity to “handle” her intense emotions. Once again, she felt changed, in that she had become aware of her unwelcome feelings of longing, unrequited love, and unworthiness. She talked about blaming herself for being “an unwanted child.” For the first time, she was able to formulate and express what she wanted to do now: terminate treatment and move close to her youngest daughter and family, something she had not felt worthy of doing before. JF expressed a desire to deal with losing me and our work together on a gradual basis. She initially thought she would be incapable of sustaining that loss, that she would not survive without her “other.” She also believed that termination represented a gratification of my desire to be rid of her. The sessions were characterized by an intensification of feelings, and repetition of her feelings of hurt, anger, and guilt as well

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as love and gratitude. On one occasion, JF began by telling me how angry she was that I talked to her in a different tone than the one I’d used when she overheard me talking on the phone. She also expressed anger and disgust with herself for having such intense feelings about me. Through her associations, we learned that her anger was a kind of bravado that covered up a sense of hurt and a fear that she would become debilitated by physical disease and completely dependent on others who would, of course, feel imposed upon. She expressed regret for not having been a better mother to her daughters, especially her eldest, and she was able to own her competitive, aggressive feelings toward this daughter. She went on to say that she was grateful to me because “you’re the only one I’ve ever been able to express my anguish to.” Then she related a dream in which I take her hand and she is invisible to everyone except me. Further exploration over the next several weeks revealed that her fear was not of death or dependency as much as a fear that she would be unable to bring all her efforts to completion before she died. These included “being there” for her granddaughter, counseling her, and having “heart to heart” talks with her. She also lamented that she might not be able to give full expression to her own creative poetry and painting. She worried that she no longer had anything valuable to give to society, and at times she would wax sociological about the generally poor treatment of the elderly in our society. She talked about feeling not needed by anyone. JF began to talk more and more about wanting a photograph of me to look at “and hold,” and also to paint a portrait of me. Although my initial reaction was to interpret rather than gratify, I eventually gave her a photograph, and subsequently we explored some of the aspects of the process—of my giving her the photograph as well as the content, meaning, and associations of her having the photograph. An important piece of work toward the end of treatment came about when she received a warm card from her youngest daughter’s family. It became apparent to both of us that she was finally able to accept their love, admiration, and devotion. This was in stark contrast to recently recovered memories of her father and her feeling unrecognized by him—how she “did not exist around him,” except as an object for his use. At about the same time, she expressed, more clearly than before, feelings of genuine empathy for her children with regard to their efforts to help her, especially given her reticent, passive responses to them thus far. This was in contrast to her previous compulsive and guilt-laden complaints about herself. She seemed to be able to truly distinguish, emotionally as well as intellectually, between her remote past and her current reality, saying that she had finally “found a way to make a life for myself” by moving near her youngest daughter and


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family. This, in turn, led to tender, protective, motherly, and grandmotherly feelings toward me. Such developments felt like real emotional growth, with a relinquishing of old fantasies, accompanying feelings of sadness, and an acceptance of mature, adaptive feelings “appropriate” to her stage of life. About a month before termination, after stumbling a bit in my office, she talked about herself as victim and about her “why me?” attitude, saying “I’m a good kid.” Over the next weeks, she reflected on what she meant, realizing that she’d always thought her role was to be a good little girl around me so I would feel big and powerful, and then she’d have my approval and love. She experienced genuine sadness, as we both understood that the little girl’s perspective was real and valid and still operative. The sadness signified her letting go of fantasies, and it allowed her to move forward psychologically to, as she said, “accommodate to feeling old and wrinkled and not pretty.” She saw herself as a competent grown-up who finally accepted that she was old and had physical limitations, and we discussed it frankly. She considered this the first time I’d answered her questions regarding a physical condition, and that being able to talk to me about it realistically made her “feel alive.” JF terminated on schedule. The last sessions were quite poignant, with a sense of sadness and loss as well as pride and accomplishment. She said that it was very important that I understand that not all of her feelings for me were “transference,” that she also appreciated the “real” me. “This has been the most painful and exciting adventure I’ve ever been on.” She talked specifically about how helpful it was for her to allow herself to get very angry at me and to express that anger, and see that it did not damage or destroy either of us or our relationship; instead, it actually freed her up. Understanding our relationship helped her respect and integrate the different sides of herself: “I had the experience of being myself with you.” She wondered aloud why it took so long for her to grasp that she was not a burden, not an “excessive” person, and not unlovable, when “it’s so simple.” JF then moved away, and in order to ease her transition, we had some scheduled phone sessions over the next year or so. I agreed to those sessions, perhaps as a way of dealing with my own countertransference feelings that she was correct about my wanting to get rid of her or that I wanted her to move because it would be an outcome that was right and good. As she settled into her new life, the frequency of our sessions decreased, and after several months we said goodbye. She spent the last years of her life in the company of those she loved and who loved her. I learned of her death (cause unknown) through her youngest daughter, who thanked me for helping her mother so much.

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This case was not without limitations. Some of JF’s improvement might be attributed to a “transference cure.” There were a number of enactments or parameters that may not have been fully analyzed or worked through during the treatment. Also, my sense that moving would be a good outcome for her may have been, at least in part, a countertransference reaction corresponding to her feeling that I wanted to get rid of her, just as her mother had wanted to get rid of her. Still, overall, it was a successful psychoanalytic treatment, and it is consistent with the notion that older adults can participate in, and benefit from, deep psychological work and treatment. It also attests to the ability of older adults to change in meaningful ways. Indeed, JF achieved robust results that impacted her life in a very tangible way. Although causality cannot be proven from a case study, the process and outcome here strongly suggest that the treatment produced the good results, and that psychoanalytic treatment may be just the right intervention for at least some older adults. But this is not news. Reports of good psychoanalytic work with older adults have appeared in the literature for close to a century. Karl Abraham (1919) was probably the first to suggest 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. (pp. 315–316)

We will return to this keen observation later. Over the next few decades, others made contributions, notably Smith Ely Jelliffe (1924), Carl Jung (1933), Martin Grotjahn (1955), and Hannah Segal (1958). Erik Erikson (1959, 1966) extended the concept of psychological development into adulthood and even into old age. His


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observations led him to theorize psychological milestones applicable to old age: “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” (1956, p. 108). In his theory, the last psychological developmental milestone pits integrity versus despair, with integrity defined as “the acceptance of one’s own and only life cycle and of the people who have become significant to it as something that had to be and that, by necessity, permitted of no substitutions. It thus means a new different love of one’s parents, free of the wish that they should have been different, and an acceptance of the fact that one’s life is one’s own responsibility” (1959, p. 104). In 1963, a panel was convened at the annual meeting of the American Psychoanalytic Association, summarized by Norman Zinberg (1964), 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” (p. 151). Rich commentaries were offered by Martin Berezin, Douglas Bond, 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), Sidney Levin, Kurt Eissler, and Stanley Cath. In 1979, at the first Congress of the International Psychoanalytic Association to be held in the United States, Pearl King (1980) presented a paper on psychoanalysis of patients in the second half of life. During the discussion, she emphasized that older age is not a good reason to exclude patients from doing psychoanalytic work. In 1980, the Committee on Psychoanalytic Practice of the American Psychoanalytic Association noted that one of the population groups underserved by psychoanalysis was adults over the age of 50, and recommended that efforts be made to include them. Hoffman (1979), in writing about death anxiety, took exception to Freud’s admonition about the supposed rigidity of older adults, and suggested that even if some aspects of personality are relatively fixed, other aspects may be “unsettled or fluid in the middle and later years” and “contrary to Freud’s stated position, one would expect that, in many cases, residues of early developmental conflicts would also be stirred up so that even they would become more elastic and amenable to analytic influence” (p. 263). In December 1982, another panel was held at the annual meeting of the American Psychoanalytic Association, reported on by Cath and Miller (1986), this time chaired by Stanley Cath (1986), with contributions from Martin Berezin, Nancy Miller, Pearl King, Ann-Marie Sandler, and

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Earl Simburg. They acknowledged the contributions of George Pollock in convening such a panel. Cath and Miller (1986) 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” (p. 163). Meanwhile, Colarusso and Nemiroff (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 (Nemiroff and Colarusso 1985), in which they presented 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” (p. 2). Sandler (1984) reported on the psychoanalysis of a 69-year-old woman who experienced a reasonably good outcome. Martin Berezin (1986), in reviewing a new book by Wayne Myers (1984) 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” (p. 517). Muslin and Clarke (1988) reported on the transference of the therapist in working with older adults. Coltart (1991) reported on the analysis of a 75-year-old man. Settlage (1996) reported on his work with a woman in her 90s, a poet, and he noted that, “the myth of the unsuitability of middle aged and elderly individuals for psychoanalytic treatment has been dispelled.” Valenstein (2000) provided case histories of two older men (a 65 year old and a 77 year old) in successful psychoanalytic treatment, as well as 11 case presentations and various vignettes. Lipson (2002) noted, “While analytic work with older patients has revealed much about development in later life and a good deal about the factors that may determine therapeutic possibilities, I feel that we have too few cases to arrive at definitive conclusions,” and “Significant changes and termination are achievable in some patients of advanced age” (p. 774). Morgan (2003) discussed practical aspects of providing psycho-


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dynamic psychotherapy with older adults, using clinical vignettes to illustrate issues. Interestingly, psychoanalytic reports on aging over the last two decades have focused more on the perspective of the analyst than on the older patient, per se (Chessick, 2013; Eissler, 1993; Junkers, 2013; Plotkin [no relation], 2000). The reports noted the challenges faced by aging analysts and by analysts working with older patients. Others identified the reluctance of analysts to work with patients older than 60 as “countertransference resistance” (Wylie & Wylie 1987) and to outright age bias on the part of the psychoanalyst (Wagner, 2005). Both Wylie and Wylie and Wagner noted the irony of applying time/age constraints to an analytic process dealing with the “timelessness” of the unconscious and of psychological conflicts. Indeed, even though psychoanalysis may be thought of as a progressive field, the pessimistic view about working with older adults, expressed a hundred years ago by Sigmund Freud, is still operational within the field. For example, the Psychodynamic Diagnostic Manual contains almost nothing about older adults. A recent PEP-Web search using the terms “elderly” and “children” resulted in a 50-fold difference between the two (23 citations for elderly, 1,202 citations for children). Likewise, a review of the International Journal of Psychoanalysis revealed only 20 papers on older adults in the entire history of the journal (Junkers, 2006). It seems that as life expectancy increased over the last century, psychoanalysis went younger and younger. It is said that “psychoanalysis is an old man’s game,” yet old people have been kept out of one side of the game! In some ways, this makes sense, as self-psychologist Ernest Wolf (1997) wryly observed, “As sciences go, psychoanalysis is very young. Hardly 100 years old, it is a youngster among other ancient and venerable pursuits of humankind such as religion, art, and philosophy. It is hardly surprising that not a great deal of attention has been paid by psychoanalysts to the psychology of growing old” (p. 201). Psychoanalysts are not alone, of course, in holding biased attitudes about aging. The term “ageism” was coined by Robert Butler (1969), the psychoanalytic-friendly psychiatrist who was a founding father of geriatrics in this country and the first director of the National Institute on Aging. We live in a youth-oriented society. We embrace “anti-aging” efforts more than we do acceptance of aging or celebration of old age. Indeed, anti-aging rhetoric has become a part of the current zeitgeist (Flatt, Settersten, Ponsaran, & Fishman, 2013). Our health care reimbursement system reflects the attitude that it is not considered particularly valuable to be doing slow, painstaking low-tech work with older adults. Older adults themselves hold biased beliefs called self-stereo-

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types (Levy, 2003, 2009) that can surely limit them, if they continue to believe that they are too old to benefit from psychotherapy. Of course, it would be advantageous if there were an evidence base demonstrating the effectiveness of psychodynamic psychotherapy for older adults. However, psychodynamic psychotherapy is a latecomer when it comes to randomized controlled trials. As Michael Thase (2013) has observed, psychodynamic psychotherapy is a time-honored approach that came of age in an era prior to evidence-based medicine (i.e., randomized controlled trials), and so is one of the most used but least studied of the psychotherapies. Not surprisingly, there are no studies on psychoanalysis with older adults, and there is a paucity of evidence on psychodynamic psychotherapy for older adults. Those relatively few studies on psychodynamic psychotherapy for older adults focused on depression and are limited by small numbers of patients, poor quality, and generally very modest results (Cuijpers, van Straten, & Smit, 2006; Kiosses, Leon, & Arean, 2011; Snowden, Steinman, & Frederick, 2008; Wilkinson & Izmeth, 2012; Wilson et al., 2008). Still, meta-analyses suggest that psychotherapy is as effective for older depressed adults as is pharmacotherapy (Pinquart, Duberstein, & Lyness, 2006), and that psychotherapy is as effective for older depressed adults as it is for younger depressed adults (Cuijpers, van Straten, Smit, & Andersson, 2009). In March 2007, the journal Psychology and Aging published a special section on evidence-based psychological treatments for older adults, asserting that evidence supports the effectiveness of psychotherapy for older adults, but noted a “disproportionate research attention to some psychotherapies and some mental disorders, with corresponding lack of research about other treatments and disorders” (Gatz, 2007). Relationship-based therapies such as psychoanalytic treatments belong to the latter category. Still, there have been reviews of “evidence-based therapy relationships” in general, but not focused on older adults in particular. One used a panel of experts and presented conclusions based on a series of meta-analyses conducted on the effectiveness of various relationship elements and methods of treatment adaptation (Norcross & Wampold, 2011). They found that some elements were demonstrably effective (e.g., alliance, empathy) while others (e.g., managing countertransference) lacked sufficient evidence. Recently, psychoanalytic treatment has been subjected to traditional medical/psychiatric quantitative research methods. One study compared psychoanalysis to cognitive behavioral therapy (CBT) and to psychodynamic psychotherapy, and the study design used randomization (Roose, 2012). A feasibility study has demonstrated that subjects are willing to accept assignment to one of the study treatments (Caligor et al., 2012). Meanwhile, a European group (Beutel et al., 2012) has


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undertaken a large clinical research study comparing psychoanalytic treatment with CBT, with a design containing both naturalistic and randomized elements. Both studies (Beutel et al., 2012, and Roose, 2012) exclude patients over 60 years of age. Given the lack of direct empirical evidence for psychodynamic psychiatry, its useful to review other sources of information/evidence that may bear, at least indirectly, on the question of psychodynamic treatment for older adults. One unmistakable demographic trend is that older adults comprise a large and expanding group, indeed, the fastest growing segment of our population. Older adults are a heterogeneous group, more different from each other than any other age group. Some older adults cant get out of bed, while others run marathons and lead companies and nations. Older adults enjoy an unprecedented extended period of relatively good (disability-free) health (Murabito et al., 2008) and have more discretionary time and money than their younger counterparts. Psychological well-being is generally high in old age, similar to that in young adulthood, and greater than that in middle age (Blanchflower & Oswald, 2008). An important implication is that misery and suffering should not be considered a normal aspect of aging. Another key fact is that most older adults are cognitively intact. One of the most feared conditions in middle and old age is Alzheimers disease, and because it is so feared, many think that the prevalence is greater than it is. The fact is that most older adults do not suffer from serious cognitive impairment: Alzheimer’s disease, the most common cause of dementia, occurs in only 1% at age 65, although it does increase to more than 30% for people over 80 (Fratiglioni, De Ronchi, & Agüero-Torres, 1999). Milder cognitive disorders occur in about 10% of those in their 60s (Anstey et al., 2013), but it is unknown whether such deficits interfere with psychotherapeutic processes. Although there is a decrease in major depression in old age, many older adults have mild mood and/or personality syndromes that interfere with their quality of life (Meeks et al., 2011), and there is an increase in depressive symptoms in old age that is not due solely to physical decline (Sutin et al., 2013). Dysthymic disorder and other negative affect conditions (e.g., neuroticism) are associated with disability, cognitive impairment, and poor medical outcomes (Devanand 2013; Kremen et al., 2012). There is even an association between certain personality traits and risk of Alzheimer’s disease (Terracciano, Iacono, O’Brien, Troncoso, An, Sutin et al., 2013; Terracciano, Sutin, An, O’Brien, Ferrucci, Zonderman et al., 2013). Older dysthymic patients tend to be different from younger dysthymic patients (Devanand, 2013). Most older dysthymic patients have late age of onset, do not have a high rate of family history of mood disorders, have not had bouts of major depres-

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sion, and have identifiable stressors such as loss of social support and/ or bereavement. Complicated grief is another syndrome of importance late in life (Miller, 2012), one that may share some characteristics with late onset dysthymia. Thus, demographic and epidemiologic evidence suggests that there is and will continue to be a large number of older adults who have mood syndromes that interfere with their quality of life and increase their risk for cognitive and general medical problems. Such individuals may benefit from a psychotherapeutic intervention, including psychodynamic psychotherapy, and studies have begun to explore older adults’ perspectives on seeking psychotherapy (Dakin & Arean, 2012). Still, older adults have, in general, underutilized psychotherapy of any type (Wei et al., 2005). For those who do seek, or are at least amenable, to psychotherapy, there are no data on suitability to guide the clinician. Even for general adult populations, “clinical decision-making about suitability for psychological therapies is hampered by limitations of psychotherapy research and our lack of understanding of therapeutic mechanisms” (Fonagy, 2010). Psychoanalytic suitability studies have not shed much light on this issue. Knapp (1960) reviewed 100 cases (age range 20–41) accepted for supervised analysis and rated for results, and found that contrary to expectations, the older patients did better, though it was barely statistically significant and no patients could be considered old. Still, Knapp (1960) suggested that older patients may have a “greater stake in getting more from analysis, that is, a more powerful original motivation,” and concluded that the notion that analyzability decreases with age should be challenged. Overall, though, the suitability research has yielded limited insights (Erle & Goldberg, 1979). More recently, Valbak (2004) conducted a review of papers on suitability for psychoanalytic psychotherapy (most were brief dynamic therapy) and found modest correlations of non-age-related patient characteristics associated with a good outcome: good quality of object relations, psychological mindedness, and motivation for change. Current research on suitability focuses on “treatment moderator profiles” which are combinations of selected clinical characteristics to guide clinical decision making (Wallace, Frank, & Kraemer, 2013), and have not been applied to older adults. While suitability research is limited, clinical observations suggest that characteristics of older age might overlap with those of suitability for psychoanalytic treatment. Pollock (1982) observed, “In my successful work with middle aged and older adults, I have found: the capacity for insight, for therapeutically induced transferences, for dreams and the ability to relate these dreams; the capacity for self-observation; the mobilization of motivation to change and also of libidinal and construc-


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tive aggressive energies; the institution of a mourning-liberation process” (p. 280). Coltart (1991) observed that older patients have a “nowor-never feeling which the patient brings into the analysis. There is a single-minded, often clear, sense of need, an intensity of devotion to the work, a skill in recognizing shorthand opportunities, and a reduction in shame and embarrassment (as if to say ‘Oh, I haven’t got time for all that’), which is very attractive” (p. 209). According to Gene Cohen (2005), older adults are more thoughtful, open to new ideas, open to complexity in life, and have greater respect for intuitive feelings than younger adults. Also, older adults may benefit from the engagement and structure offered by intensive psychotherapeutic work (Nemiroff & Colarusso, 1985, chapter 16). Psychiatrist Robert Butler (the same one who coined “ageism”) observed the tendency of older adults to reminisce, and developed the theory of “life review” as a normal developmental aspect of aging, a way of “putting one’s life in order,” precipitated by the realization of death and short life expectancy (Butler, 1963). Subsequent research has identified the “reminiscence bump” effect in which autobiographical memories are disproportionately recalled for events in late adolescence and early adulthood (Webster & Gould, 2007), and how emotionally laden events are associated with improved recall (Kensinger, 2009). Butler saw reminiscence and life review as characterized by the progressive return to consciousness of past experiences, particularly unresolved conflicts that can be reflected upon and reintegrated, giving new significance to one’s life and helping to prepare one for death. By 1974, Lewis and Butler suggested that life review can be used as a therapeutic intervention, one focused on meaning and purpose. Medical anthropologist Sharon Kaufman (1994) analyzed life review interviews of older adults and found that older adults create a continuity of self associated with meaning in their lives. Kaufman found that as people interpret the events, experiences, and relationships of their lives, they formulate “themes” that are repeated in their life narratives, are readily discernible for each individual, and are highly individualistic and unique. A recent review of the literature attests to the therapeutic value of life review (Bohlmeijer, Roemer, Cuijpers, & Smit, 2007). Along similar lines, the developmental social scientist/gerontologist, Bernice Neugarten, observed that adults become more reflective and change their orientation from outer world to inner world as they age, which she called “interiority” (Neugarten et al., 1964). Later, she added, “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” (Neugarten, 1979, p. 890). The tendency of

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adults to cherish the time they have left was not lost on Freud, who wrote in “On Transience” (1915) that “limitation in the possibility of an enjoyment raises the value of the enjoyment.” More recently, Laura Carstensen (2006) extended this idea with a multitude of studies comparing older to younger adults, and developed a theory of motivation and aging called “socioemotional selectivity theory”—a “lifespan theory of motivation” positing that as time horizons shrink, people become increasingly selective, investing greater resources in emotionally meaningful goals and activities and less in individual strivings or material possessions. There is increased motivation to regulate emotional states and increased competence to do so. The shift affects cognitive processing—it becomes easier to regulate emotions (Blanchard-Fields, 2009), and aging is associated with improved emotional well-being and greater emotional stability. There is also greater appreciation for complexity, that is, the co-occurrence of positive and negative emotions, with a relative preference for positive over negative information, called the “positivity effect” of aging (Carstensen et al., 2011; Mather, 2012). Thus, it might be said that emotional life improves with aging, in spite of declines in some cognitive and physical domains (Carstensen et al., 2011). It is noteworthy that socioemotional selectivity theory is compatible with the Eriksonian concepts of generativity and integrity that are associated with later life. Brain imaging studies support the notion that aging may be associated with an increased capacity for emotional control (Nashiro, Sakaki, & Mather, 2012; Opitz, Rauch, Terry, & Urry, 2012), and that at least some older brains can be more active than younger ones (Berlingeri et al., 2010, Topiwala & Ebmeier, 2012). Although the precise mechanisms are still unknown, various theories invoking neuroplasticity have been offered (Cramer et al., 2011). One of the most intriguing is the scaffolding theory (Goh & Park, 2009), which posits that the older brain is a plastic homeostatic organ, able to compensate for its deteriorating structure. Other theories also suggest a dynamic brain that recruits additional brain regions in order to compensate for age-related declines in some brain areas (hemispheric asymmetry reduction in older adults or HAROLD and compensation-related utilization of neural circuits hypothesis or CRUNCH models), depending on the task at hand (Berlingeri et al., 2010). At least one psychological theory of aging (Baltes & Baltes, 1990) invokes a similar kind of compensatory process, “selective optimization with compensation,” in which individuals compensate for declines in physical and cognitive functioning by developing themselves in other areas, and that traits such as resilience and wisdom come into play. This may underlie the concept of cognitive reserve (Tucker & Stern, 2011).


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Longitudinal studies provide further evidence that older adults continue to develop (Roberts & Mroczek, 2008; Vaillant 2002, 2012). Psychological defense mechanisms mature with age (Vaillant, 1993) and also mature with successful psychodynamic psychotherapeutic intervention (Perry & Bond, 2012). Malone and colleagues (2013) found that more adaptive defenses in midlife were associated with better physical health in later life, partially mediated by social relationships. While aging confers potential advantages (for doing psychological work) in some areas, other areas show decline. For example,, there are declines in episodic memory, which is the encoding and retrieval of personally relevant events (Friedman, 2013) and in executive functioning, which may cause impairments in financial and medical decision making (Boyle et al., 2013). Also, there are declines in those cognitive and affective mentalizing processes known as theory of mind (Cavallini et al., 2013). The impairment in mentalizing is primarily with the cognitive component; the performance of older adults on the affective component is relatively intact (Wang & Su, 2013). To summarize then, clinical evidence (i.e., case studies and longitudinal studies), experimental psychology, and neuroimaging studies suggest that older adults are capable of change, and that aging may have favorable effects on the emotional lives of older individuals. It follows that older adults should not be excluded from in-depth psychotherapeutic interventions on the basis of age. But even if old age should not disqualify an individual from consideration for psychoanalytic treatment, perhaps it should influence the kinds of goals one strives for. After all, life contexts are very different for a 75-year-old compared to a 25-year-old. Are the goals of treatment different for older compared to younger adults? In the broadest sense, the goals are probably similar: to enhance quality of life. The specific goals for each individual, however, will depend on that individual and their circumstances, and cannot be reduced to some generic template. And yet, there may be certain guiding principles that apply particularly well to older adults. There are several perspectives to consider. Psychoanalytic concepts, such as Pollock’s mourning/liberation and Erikson’s final developmental goal of integrity versus despair, stress the importance of acceptance of bittersweet or painful aspects of reality and the relinquishing of fantasies, with integration into one’s self concept. More recently, Lax (2008) suggested that successful psychoanalytic treatment of older adults results in the patient “being able to accept her/his aged self. In even more successful ones, the individual is enabled to discover and/or develop a new interest—basically, the capacity to do something narcissistically gratifying. This contributes to self-esteem” (p. 855). She also suggested that being able to mourn

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for the past will result in “a reconciliation with the present, with the change of the self state. Such individuals may be able to gather what remains of life and living” (p. 857). From the general scientific/medical/gerontological literature comes the concept of “successful aging,” first introduced by Rowe and Kahn in the 1980s, related to minimizing disease/disability, maximizing function, and having meaningful engagement with life. Their landmark article in Science (1987) noted, “Research in aging has emphasized average age-related losses and neglected the substantial heterogeneity of older persons. The effects of the aging process itself have been exaggerated, and the modifying effects of diet, exercise, personal habits, and psychosocial factors underestimated” (p. 143). Longitudinal studies such as the Harvard Grant Study (Vaillant, 2012) have provided corroborating evidence, showing that successful physical and emotional aging is associated with an adaptive coping style, a sustained loving (in most cases, marital) relationship, years of education, healthy lifestyle (maintaining a healthy weight, doing regular exercise, and avoiding tobacco and excessive alcohol). While there is still no one satisfactory definition of successful aging (Jeste, Depp, & Vahia, 2010), the framework for viewing aging has shifted from a deficiency/loss model to one emphasizing coping, adaptation, meaningfulness, and connection. Bowling and Iliffe (2011) emphasize maximizing one’s psychological resources, that is, self-efficacy and resilience. Resilience, in particular, has become a construct of interest in recent years, and evidence suggests that interventions aimed at fostering resilience may be particularly helpful for older adults (Jeste, Savla, Thompson, Vahia, Glorioso, Martin et al., 2013). A related construct is that of wisdom, defined by a panel of experts (Jeste, Ardelt, Blazer, Kraemer, Vaillant, & Meeks, 2010) as “uniquely human, a form of advanced cognitive and emotional development that is experience driven; a personal quality, albeit a rare one, which can be learned, increases with age, can be measured, and is not likely to be enhanced by taking a medication” (p. 668). Perhaps some of these constructs could be worked into a meaningful set of goals for psychoanalytic treatment for older adults. For my patient, JF, the various vantage points regarding goals allow us to see the different ways in which her treatment was successful. If viewed from the standpoint of successful aging, one thinks of adaption and meaningful engagement in her decision to move nearer to her family. From the traditional psychoanalytic and developmental points of view, she was able to mourn for her past and accept her life and her true self, to change her coping style (from a primarily histrionic one, involving repression and projection, to a more mature one, involving


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sublimation, suppression, and humor), and to recover a sense of goodness and worthiness in herself, allowing her to have a renewed sense of meaning and purpose and to reconnect with her creative self. She achieved these goals, and in so doing she also accomplished a very tangible result. SUMMARY AND CONCLUSIONS Clinical evidence supports the notion that psychoanalytic treatment can be effective for older adults. Along those lines, the case presented here was a decidedly psychoanalytic treatment of a woman in her 70s. While many issues associated with aging were encountered (widowhood, loneliness, physical decline), the general mode and arc of the treatment were characteristic of a typical successful psychoanalysis of a younger person. Development and utilization of transference was a key aspect of the treatment. JF was motivated to change. She was able to form a good working alliance, and she was able to participate in the full intense analytic experience, including having frequent sessions, tolerating frustration, and looking at herself in new and different ways. The treatment produced robust, life-changing results, suggesting that this form of treatment can yield good results for at least some older individuals. A review of the psychoanalytic literature covering almost a century reveals that there have been many reports of successful psychoanalytic work with older individuals as well as theoretical arguments favorable to the idea, yet the psychoanalytic world has not yet embraced older adults, in general. It is likely that at least some of the hesitancy is a result of age bias on the part of the medical and psychoanalytic communities as well as on the patients themselves, who believe that change is not possible in old age and so do not seek it. Yet converging trends suggest that circumstances may be ripe for expansion of psychodynamic treatment for older adults. From a demographic and epidemiologic viewpoint, it is well known that older adults comprise a large and expanding population. Currently, baby boomers have almost as many years to live as did people in their 20s and 30s 100 years ago. Most older adults are cognitively intact and do not suffer from depression or anxiety, and life satisfaction is generally high in older age, so misery should not be considered a normal aspect of aging. Still, there are many challenges and losses associated with aging, and many individuals do develop mild mood syndromes (subsyndromal depression, dysthymia) and/or personality problems (neuroticism) that interfere with their quality of life. Such individuals

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may correspond to the group so presciently described by Karl Abraham almost a century ago: older adults who have functioned well and been relatively free of significant psychological problems until they encounter problems in later life, and who will be good candidates for a psychodynamic treatment. From the perspective of extra-analytic studies of aging, selected psychological and neuroscientific studies suggest that at least some older adults are capable of therapeutic change and that aging may even confer some advantages with regard to psychoanalytic treatment. For example, older people are more competent with regard to emotional regulation than younger adults, and they are more motivated and focused on relationships and meaning than younger adults. Attributes such as wisdom and resilience, comfort with complexity and uncertainty, and ease with self-reflection may be particularly evident in the elderly and may confer enhanced capabilities to do deep psychological work. These findings bode well for treatments that value and address emotional states and emotion regulation, and are relationship-based, such as psychoanalytic treatments. On the other hand, older adults are likely to have cognitive impairments that may interfere with doing the psychological work of psychodynamic psychotherapy, such as age-associated deficits in memory, executive functioning, processing speed, and mentalizing. Clearly, aging has varying effects, and it is not known how such effects will translate regarding an older individual’s capacity to do psychodynamic work. Whatever the eventual outcome of studies on the aging brain, the various converging trends suggest that aging does not universally impair one’s ability to do psychodynamic work, and in fact may impart certain advantages. This paper presents a “proof of concept” hypothesis suggesting that not only is it feasible for older adults to benefit from psychoanalytic treatment, but that at least some older adults may be particularly well suited to such treatment. Clearly, it is time to test this hypothesis with clinical research. One straightforward research approach would be to adapt the Roose and Beutel study protocols for use with adults older than 60 years of age. Research should also focus on how to identify patients who might be most suitable for psychodynamic treatment. Currently, it is not possible to know which patients (older or younger, for that matter) will be a good match for any type of psychotherapy. For now, the type of psychotherapy used depends on therapist and patient preference, in the context of the therapeutic relationship and the particular circumstances. Of course, older patients might benefit from a variety of psychotherapeutic approaches, or from a psychotherapy combining different modalities, designed with the older patient in mind (Knight, 2004).


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It would not be surprising to find that some older adults will be suited to a cognitive behavioral or problem-solving therapy, while others will be good candidates for a psychoanalytic treatment. Whatever the approach, there is ample evidence to support the notion that psychodynamic psychotherapy should be in the mix. As the health care world becomes more fragmented and more technologically oriented, it will be especially important to have a modality that is personal, intimate, and can reach where other treatments do not go. Perhaps there can even be an expanded role for psychoanalysis. Imagine a psychoanalytically informed intervention as a way to improve brain health. If so, the elderly would surely be one of the main targets and beneficiaries of such an intervention. Wouldn’t it be ironic if the elderly, generally spurned by psychoanalysis over the years, saved psychoanalysis? Perhaps, a renaissance of psychoanalysis will be led by older adults. REFERENCES Abraham, K. (1927). The applicability of psycho-analytic treatment to patients at an advanced age. Selected papers (pp. 312-317). London: Hogarth. (Original work published 1919) Anstey, K. J., Cherbuin, N., Eramudugolla, R., Sargent-Cox, K., Easteal, S., Kumar, R., et al. (2013, March 6). Characterizing mild cognitive disorders in the young-old over 8 years: Prevalence, estimated incidence, stability of diagnosis, and impact on IADLs. Alzheimer’s and Dementia, ii, S1552-5260(12)02583-6. Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging: The model of selective optimization with compensation. In P. B. Baltes & M. M. Baltes (Eds.), Successful aging: Perspectives from the behavioral sciences (pp. 1-27). Cambridge, UK: Cambridge University Press. Berezin, M. A. (1986). Review of Dynamic therapy of the older patient by Wayne A. Meyers (1984). Psychoanalytic Quarterly, 55, 517-519. Berlingeri, M., Bottini, G., Danelli, L., Ferri, F., Traficante, D., Sacheli, L., Colombo, N., Sberna, M., Sterzi, R., Scialfa, G., & Paulesu, E. (2010). With time on our side? Task-dependent compensatory processes in graceful aging. Experimental Brain Research, 205(3), 307-324. Beutel, M. E., Leuzinger-Bohleber, M., Rüger, B., Bahrke, U., Negele, A., Haselbacher, A., et al. (2012). Psychoanalytic and cognitive-behavior therapy of chronic depression: Study protocol for a randomized controlled trial. Trials, 13, 117. Blanchard-Fields, F. (2009). Flexible and adaptive socio-emotional problem solving in adult development and aging. Restorative Neurology and Neuroscience, 27(5), 539-550. Blanchflower, D. G., & Oswald, A. J. (2008). Is well-being U-shaped over the life cycle? Social Science & Medicine, 66(8), 1733-1749. Bohlmeijer, E., Roemer, M., Cuijpers, P., & Smit, F. (2007). The effects of reminiscence on psychological well-being in older adults: A meta-analysis. Aging & Mental Health, 11(3), 291-300.

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Bowling, A., & Iliffe, S. (2011). Psychological approach to successful ageing predicts future quality of life in older adults. Health and Quality of Life Outcomes, 9, 13. Boyle, P. A., Yu, L., Wilson, R. S., Segawa, E., Buchman, A. S., & Bennett, D. A. (2013). Cognitive decline impairs financial and health literacy among communitybased older persons without dementia. Psychology and Aging, 28(3), 614-624. Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26, 65-76. Butler, R. N. (1969). Age-ism: Another form of bigotry. Gerontologist, 9(4), 243-246. Caligor, E., Hilsenroth, M. J., Devlin, M., Rutherford, B. R., Terry, M., & Roose, S. P. (2012). Will patients accept randomization to psychoanalysis? A feasibility study. Journal of the American Psychoanalytic Association, 60(2), 337-360. Carstensen, L. L. (2006). The influence of a sense of time on human development. Science, 312(5782), 1913-1915. Carstensen, L. L., Turan, B., Scheibe, S., Ram, N., Ersner-Hershfield, H., SamanezLarkin, G. R., et al. (2011). Emotional experience improves with age: Evidence based on over 10 years of experience sampling. Psychology and Aging, 26(1), 21-33. Cath, S., & Miller, N. E. (1986). The psychoanalysis of the older patient. Journal of the American Psychoanalytic Association, 34, 163-177. Cavallini, E., Lecce, S., Bottiroli, S., Palladino, P., & Pagnin, A. (2013). Beyond false belief: Theory of mind in young, young-old, and old-old adults. International Journal of Aging and Human Development, 76(3), 181-198. Chessick, R. D. (2013). Special problems for the elderly psychoanalyst in the psychoanalytic process. Journal of the American Psychoanalytic Association, 61(1), 67-94. Cohen, G. (2005). The mature mind: The positive power of the aging brain. New York: Basic Books. Colarusso, C. A., & Nemiroff, R. A. (1981). Adult development: A new dimension in psychodynamic theory and practice. New York: Plenum. Coltart, N. E. (1991). The analysis of an elderly patient. International Journal of Psychoanalysis, 72, 209-219. Cramer, S. C., Sur, M., Dobkin, B. H., O’Brien, C., Sanger, T. D., Trojanowski, J. Q., et al. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(pt. 6), 1591-1609. Cuijpers, P., van Straten, A., & Smit, F. (2006). Psychological treatment of late-life depression: A meta-analysis of randomized controlled trials. International Journal of Geriatric Psychiatry, 21(12), 1139-1149. Cuijpers, P., van Straten, A., Smit, F., & Andersson, G. (2009). Is psychotherapy for depression equally effective in younger and older adults? A meta-regression analysis. International Psychogeriatrics, 21(1), 16-24. Dakin, E. K., & Arean, P. (2012). Patient perspectives on the benefits of psychotherapy for late-life depression. American Journal of Geriatric Psychiatry, 21(2), 155163. Devanand, D. P. (2013). Dysthymic disorder in the elderly population. International Psychogeriatrics, 32, 1-10. Eissler, K. R. (1993). On possible effects of aging on the practice of psychoanalysis: An essay. Psychoanalytic Inquiry, 13, 316-332. Erikson, E. H. (1956). The problem of ego identity. Journal of the American Psychoanalytic Association, 4, 56-121. Erikson, E. (1966). Eight ages of man. International Journal of Psychoanalysis, 2, 281-300.


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Erikson, E. H. (1959). Identity and the life cycle. Madison, CT: International Universities Press. Erle, J. B., & Goldberg, D. A. (1979). Problems in the assessment of analyzability. Psychoanalytic Quarterly, 48(1), 48-84. Flatt, M. A., Settersten, R. A., Jr., Ponsaran, R., & Fishman, J. R. (2013). Are “antiaging medicine” and “successful aging” two sides of the same coin? Views of anti-aging practitioners. Journals of Gerontology, Series B, Psychological Sciences and Social Sciences, 68(6), 944-955. Fonagy, P. (2010). Psychotherapy research: Do we know what works for whom? British Journal of Psychiatry, 197(2), 83-85. Fratiglioni, L., De Ronchi, D., & Agüero-Torres, H. (1999). Worldwide prevalence and incidence of dementia. Drugs and Aging, 15(5), 365-375. Freud, S. (1916 [1915]). Vergänglichkeit. Das Land Goethes 1914–1916. [On transience, in Das Land Goethes (Goethe’s Country)] Gedenkbuch, in Berliner Goethebund: Stuttgart; G.W., 10, 358-361. On transcience. SE, 14, 305-307. Friedman, D. (2013). The cognitive aging of episodic memory: A view based on the event-related brain potential. Frontiers in Behavioral Neuroscience, 7, 111. Gatz, M. (2007). Commentary on evidence-based psychological treatments for older adults. Psychology and Aging, 22(1), 52-55. Goh, J. O., & Park, D. C. (2009). Neuroplasticity and cognitive aging: The scaffolding theory of aging and cognition. Restorative Neurology and Neuroscience, 27(5), 391-403. Grotjahn, M. (1955). Analytic psychotherapy with the elderly. Psychoanalytic Review, 42, 419-427. Hoffman, I. (1979) Death anxiety and adaptation to mortality in psychoanalytic theory. Annals of Psychoanalysis, 7, 233-267. Jelliffe, S. E. (1924). The old age factor in psychoanalytic therapy. Medical Journal and Records, 121(7), 7-12. Jeste, D. V., Ardelt, M., Blazer, D., Kraemer, H. C., Vaillant, G., & Meeks, T. W. (2010). Expert consensus on characteristics of wisdom: A Delphi method study. Gerontologist, 50(5), 668-680. Jeste, D. V., Depp, C. A., & Vahia, I. V. (2010). Successful cognitive and emotional aging. World Psychiatry, 9(2), 78-84. Jeste, D. V., Savla, G. N., Thompson, W. K., Vahia, I. V., Glorioso, D. K., Martin, A. S., et al. (2013). Association between older age and more successful aging: Critical role of resilience and depression. American Journal of Psychiatry, 170(2), 188-196. Jung, C. G. (1933). Modern man in search of a soul. New York: Harcourt, Brace & World. Junkers, G. (2006). Is it too late?: Key papers on psychoanalysis and ageing. International Journal of Psychoanalysis, Key Papers Series. London: Karnac. Junkers, G. (Ed.). (2013). The empty couch: The taboo of ageing and retirement in psychoanalysis. New York: Routledge. Kaufman, S. R. (1994). The ageless self: Sources of meaning in late life. Madison: University of Wisconsin Press. Kensinger, E. A. (2009). How emotion affects older adults’ memories for event details. Memory, 17(2), 208-219. King, P. H. (1980). The life cycle as indicated by the nature of the transference in the psychoanalysis of the middle-aged and elderly. International Journal of Psychoanalysis, 61, 153-160.

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Kiosses, D. N., Leon, A. C., & Aréan, P. A. (2011). Psychosocial interventions for latelife major depression: Evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects. Psychiatric Clinics of North America, 34(2), 377-401. Knapp, P. H. (1960). Suitability for psychoanalysis: A review of one hundred supervised analytic cases. Psychoanalytic Quarterly, 29, 459-477. Knight, B. G. (2004). Psychotherapy with older adults (3rd ed.). Thousand Oaks, CA: Sage. Kremen, W. S., Lachman, M. E., Pruessner, J. C., Sliwinski, M., & Wilson, R. S. (2012). Mechanisms of age-related cognitive change and targets for intervention: Social interactions and stress. Journal of Gerontology, Series A, Biological Sciences and Medical Sciences, 67(7), 760-765. Lax, R. F. (2008). Becoming really old: The indignities. Psychoanalytic Quarterly, 77(3), 835-857. Levy, B. (2009). Stereotype embodiment: A psychosocial approach to aging. Current Directions in Psychological Science, 18(6), 332-336. Levy, B. R. (2003). Mind matters: Cognitive and physical effects of aging self-stereotypes. Journal of Gerontology, Series B, Psychological Sciences and Social Sciences, 58(4), 203-211. Lewis, M. I., & Butler, R. N. (1974). Life-review therapy. Putting memories to work in individual and group psychotherapy. Geriatrics, 29(11), 165-173. Lipson, C.T. (2002). Psychoanalysis in later life. Psychoanalytic Quarterly, 71, 751-775. Malone, J. C., Cohen, S., Liu, S. R., Vaillant, G. E., & Waldinger, R. J. (2013). Adaptive midlife defense mechanisms and late-life health. Personality and Individual Differences, 55(2), 85-89. Mather, M. (2012). The emotion paradox in the aging brain. Annals of the New York Academy of Science, 1251, 33-49. Meeks, T., Vahia, I., et al. (2011). A tune in “A minor” can “B major”: A review of epidemiology, illness course, and public health implications of subthreshold depression in older adults. Journal of Affective Disorders, 129(1-3), 126-142. Miller, M. D. (2012). Complicated grief in late life. Dialogues in Clinical Neuroscience, 14(2), 195-202. Morgan, A. C. (2003). Practical geriatrics: Psychodynamic psychotherapy with older adults. Psychiatric Services, 54(12), 1592-1594. Murabito, J. M., Pencina, M. J., Zhu, L., Kelly-Hayes, M., Shrader, P., & D’Agostino, R. B., Sr. (2008). Temporal trends in self-reported functional limitations and physical disability among the community-dwelling elderly population: The Framingham heart study. American Journal of Public Health, 98(7), 1256-1262. Muslin, H., & Clarke, S. (1988). The transference of the therapist of the elderly. Journal of the American Academy of Psychoanalysis, 16, 295-315. Myers, W. A. (1984). Dynamic therapy of the older patient. New York: Aronson. Nashiro, K., Sakaki, M., & Mather, M. (2012). Age differences in brain activity during emotion processing: Reflections of age-related decline or increased emotion regulation? Gerontology, 58(2), 156-163. Nemiroff, R. A., & Colarusso, C. A. (1985). The race against time: Psychotherapy and psychoanalysis in the second half of life. New York: Plenum. Neugarten, B. L. (1979). Time, age, and the life cycle. American Journal of Psychiatry, 136(7), 887-894.


49

Neugarten, B. L., in collaboration with H. Berkowitz and others. (1964). Personality in middle and late life: Empirical studies. New York: Atherton Press. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy (Chic), 48(1), 98-102. Opitz, P. C., Rauch, L. C., Terry, D. P., & Urry, H. L. (2012). Prefrontal mediation of age differences in cognitive reappraisal. Neurobiology of Aging, 33(4), 645-655. PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Perry, J. C., & Bond, M. (2012). Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. American Journal of Psychiatry, 169(9), 916-925. Pinquart, M., Duberstein, P. R., & Lyness, J. F. (2006). Treatments for later-life depressive conditions: A meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry, 163(9), 1493-1501. Plotkin, F. (2000). Treatment of the older adult: The impact on the psychoanalyst. Journal of the American Psychoanalytic Association, 48, 1591-1616. Pollock, G. H. (1982). On ageing and psychopathology—discussion of Dr. Norman A. Cohen’s paper “On loneliness and the ageing process.” International Journal of Psychoanalysis, 63, 275-281. Roberts, B. W., & Mroczek, D. (2008). Personality trait change in adulthood. Current Directions in Psychological Science, 17(1), 31-35. Roose, S. P., Psychoanalytic Outcome Committee. (2012). The development of a psychoanalytic outcome study: Choices, conflicts, and consensus. Journal of the American Psychoanalytic Association, 60(2), 311-335. Rowe, J. W., & Kahn, R. L. (1987). Human aging: Usual and successful. Science, 237(4811), 143-149. Sandler, A. (1984). Problems of development and adaptation in an elderly patient. Psychoanalytic Study of the Child, 39, 471-489. Seemuller, F., Moller, H. J., Dittmann, S., & Musil, R. (2012). Is the efficacy of psychopharmacological drugs comparable to the efficacy of general medicine medication? BMC Medicine, 10(1), 17. Segal, H. (1958). Fear of death: Notes on the analysis of an old man. International Journal of Psychoanalysis, 39, 178-181. Settlage, C. F. (1996). Transcending old age: Creativity, development and psychoanalysis. International Journal of Psychoanalysis, 77, 549-564. Simburg, E. J. (1985). Psychoanalysis of the older patient. Journal of the American Psychoanalytic Association, 33, 117-132. Snowden, M., Steinman, L., & Frederick, J. (2008). Treating depression in older adults: Challenges to implementing the recommendations of an expert panel. Prevention of Chronic Disease, 5(1), A26. Sutin, A. R., Terracciano, A., Milaneschi, Y., An, Y., Ferrucci, L., & Zonderman, A. B. (2013). The trajectory of depressive symptoms across the adult life span. JAMA Psychiatry, 70(8), 803-811. Terracciano, A., Iacono, D., O’Brien, R. J., Troncoso, J. C., An, Y., Sutin, A. R., et al. (2013). Personality and resilience to Alzheimer’s disease neuropathology: A prospective autopsy study. Neurobiology of Aging, 34(4), 1045-1050. Terracciano, A., Sutin, A. R., An, Y., O’Brien, R. J., Ferrucci, L., Zonderman, A. B., et al. (2013). Personality and risk of Alzheimer’s disease: New data and metaanalysis. Alzheimer’s and Dementia, ii, S1552-5260(13)00080-0.

50

PLOTKIN

Thase, M. E. (2013). Comparative effectiveness of psychodynamic psychotherapy and cognitive-behavioral therapy: It’s about time, and what’s next? American Journal of Psychiatry, 170(9), 953-956. Topiwala, A., & Ebmeier, K. P. (2012). Vascular changes and brain plasticity: A new approach to neurodegenerative diseases. American Journal of Neurodegenerative Diseases, 1(2), 152-159. Tucker, A. M., & Stern, Y. (2011). Cognitive reserve in aging. Current Alzheimer Research, 8(4), 354-360. Vaillant, G. (1993). The wisdom of the ego. Cambridge, MA: Harvard University Press. Vaillant, G. (2002). Aging well: Surprising guideposts to a happier life from the landmark Harvard study of adult development. New York: Little, Brown. Vaillant, G. (2011). Involuntary coping mechanisms: A psychodynamic perspective. Dialogues in Clinical Neuroscience, 13, 366-370. Vaillant, G. (2012). Triumphs of experience: The men of the Harvard grant study. Cambridge, MA: Belknap. Valbak, K. (2004). Suitability for psychoanalytic psychotherapy: A review. Acta Psychiatrica Scandinavica, 109(3), 164-178. Valenstein, A. F. (2000). The older patient in psychoanalysis. Journal of the American Psychoanalytic Association, 48, 1563-1589. Wagner, J. W. (2005). Psychoanalytic bias against the elderly patient: Hiding our fears under developmental milestones. Contemporary Psychoanalysis, 41, 77-92. Wallace, M. L., Frank, E., & Kraemer, H. C. (2013). A novel approach for developing and interpreting treatment moderator profiles in randomized clinical trials. JAMA Psychiatry, 70(11), 1241-1247. Wang, Z., & Su, Y. (2013). Age-related differences in the performance of theory of mind in older adults: A dissociation of cognitive and affective components. Psychology and Aging, 28(1), 284-291. Webster, J. D., & Gould, O. (2007). Reminiscence and vivid personal memories across adulthood. International Journal of Aging and Human Development, 64(2), 149-170. Wei, W., Sambamoorthi, U., Olfson, M., et al. (2005). Use of psychotherapy for depression in older adults. American Journal of Psychiatry, 162, 711-717. Wilkinson, P., & Izmeth, Z. (2012). Continuation and maintenance treatments for depression in older people. Cochrane Database Systematic Reviews, 11, CD006727. Wilson, K. C., Mottram, P. G., & Vassilas, C. A. (2008). Psychotherapeutic treatments for older depressed people. Cochrane Database Systematic Reviews, 1, CD004853. Wolf, E. S. (1997). Self psychology and the aging self throughout the life curve. Annual of Psychoanalysis, 25, 201-215. Wylie, H. W., Jr., & Wylie, M. L. (1987). The older analysand: Countertransference issues in psychoanalysis. International Journal of Psychoanalysis, 68, 343-352. Zinberg, N. E. (1964). Psychoanalytic consideration of aging. Journal of the American Psychoanalytic Association, 12, 151-159. Presented at the annual meeting of the American Psychoanalytic Association, St. Louis, Missouri, May 1963.

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