Recent neuropsychological research and psychodynamic perspectives on aging, together with the growing percentage of high-functioning senior adults in populations throughout the Western world, have given rise to a new image of older people and challenged clinical psychologists to be adequately informed and skillful in assessing and treating them (Greenberg, 2016; Lockhart, DeCarli, & Fama, 2014). For clinical purposes, an accepted age for regarding a person as a senior adult has been 55 and above (Lingiardi & McWilliams, 2017, p. 752), although empirical studies have commonly used an age of 60 or 65 as the cutoff for including senior adults in age-based samples. Whichever age is used, contemporary senior adults increasingly include individuals who were exposed to unprecedented educational and economic opportunities in their childhood and adolescence (Barnett & Quenzel, 2017). As adults, they have additionally been faced with new developmental tasks of adapting themselves to a rapidly changing postmodern culture. Most importantly, what was once viewed as ānormalā age-related mental decline has increasingly changed to much more complex and sometimes contradictory representations of what older people are like.
As background to discussing the Rorschach assessment of senior adults, this introductory chapter addresses how the new image of older people has emerged from contemporary neuropsychological research on the relation of brain functions to observable behavior and from current psychodynamic perspectives on the inner needs, attitudes, and concerns that influence a personās behavior.
Neuropsychological Research on Aging
With the increasing percentage of older adults in the population, the study of aging has become a major focus of attention in neuropsychological research. Older adults may undergo substantial changes in their cognitive functioning, as in people with dementia or mild cognitive impairment. Research has shown that healthy adults may also experience subtle cognitive changes associated with advancing age. It therefore becomes important to distinguish between mental abilities that are likely to be preserved or even improved over the years and those that are relatively likely to decline with normal aging, and also to distinguish normal mental decline from manifestations of psychological disorder.
As a general distinction in regard to mental decline, crystallized intellectual abilities (e.g., vocabulary and learned knowledge) show stability or even improve through the sixth and seventh decades of life, whereas fluid intelligence (e.g., abilities involving attention, reasoning, and spatial orientation) normally tends to decline. However, these terms are somewhat misleading for summarizing age trends because other capacities, such as processing speed and memory, are distinguished from fluid ability, and yet are highly sensitive to age.
Much of the cognitive decline in healthy older adults appears to result from slowed processing speed (Salthouse, 2010). Age-related slowing includes performance on many neuropsychological tests, as well as memory capabilities (Harada, Love, & Triebel, 2013). Indeed, decline in memory is one of the most common cognitive complaints among older adults. In addition to diminished processing speed, age-related memory decline may be due to reduced ability to register and retrieve new information, reduced ability to ignore irrelevant information, and decreased use of strategies for improving learning and memory. For such reasons, older adults as a group generally perform less well than younger adults on numerous tests of learning and memory (Harada et al., 2013).
To be more precise, however, it is important to distinguish between declarative and nondeclarative memory. Declarative memory is an explicit process that consists of conscious retrieval of information and includes semantic memory and episodic memory. Semantic memory involves the recollection of language usage and the meaning of concepts and is relatively preserved as people age. Episodic memory is the recall of personally experienced events that occurred at a specific time and place and can also be measured by how well people can remember stories and lists of numbers or words. Unlike semantic memory, episodic memory tends to decline with aging.
Nondeclarative memory, in contrast, is an implicit process that occurs automatically, outside of a personās awareness and without conscious intent to recall anything. A familiar type of nondeclarative memory is procedural memory, which is immediate recall for such motor and cognitive skills as driving a car, using a knife and fork, and adding and subtracting numbers. Like semantic memory, procedural memory does not normally diminish as people grow older.
Research has shown further that executive functions may decline with age, including reduction in the ability to select relevant information and to inhibit irrelevant stimuli, decreased ability to perform task switching, and deficits in attentional processing. The reduction in processing speed, working memory, and other executive functions may result in subtracted cognitive resources that increasingly limit older adultsā processing capacity. Thus, aging affects the ability to modulate neural activity when a task becomes more demanding (Kennedy et al., 2015).
In addition to assessing the change in mental abilities with aging, neuroscientists have sought to identify the underlying brain mechanisms that are associated with variations in cognitive performance of senior adults. Many brain structures show reduction of brain volume, cortical thickness, and white-matter integrity, as well as depletion in dopamine receptors. In contrast to the age-related decline in cognitive functions and brain structures, functional brain activity increases with age, particularly in the frontal cortex. The Scaffolding Theory of Aging and Cognition Revised (STAC-R; Reuter-Lorenz & Park, 2014) suggests that the increase in functional activity is due to compensatory scaffolding. A key element of the model is that the aging brain has the capacity to adapt to brain degradation by developing neural scaffolds (i.e., supportive neural structures and neural activity) that minimize or compensate for some aspects of neural degradation and in turn minimize the impact of this degradation on cognition.
Furthermore, life events and developmental processes can also be important factors that either deplete or enrich neural resources. Neural enrichment may result from various factors such as intellectual engagement, higher education, and cognitive ability, as well as physical fitness. Depletion of neural resources may result from many risk factors such as lower socioeconomic status, depression, and anxiety symptoms.
The neurocognitive structural changes as well as the developmental factors are responsible for what is called the neuroplasticity of the brain in older adults (Lingiardi & McWilliams, 2017, p. 753) and might explain their capacity to function quite well in demanding personal, familial, social, and other surrounding environments. The interplay between neurological and contextual changes thus acts as a protective agent against the age-related decline in neural structures and cognitive processing efficiency.
For the readerās further information, the measures most commonly used for rapid screening of general cognitive and other areas of neuropsychological functioning in senior adults include the following: Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975); the short form of the Cambridge Mental Disorders of the Elderly Examination Revised (CAMDEX-R; Roth, Hupert, Mountjoy, & Tym, 1998); the Dementia Rating Scale (DRS; Mattis, 1988); and the Alzheimer Disease Assessment Scale (ADAS; Rosen, Mohs, & Davis, 1984), which consists of 11 cognitive performance items (ADAS Cog) and 10 noncognitive observation items (ADAS Non-Cog). In addition, some tests are used for assessing specific cognitive capacities. These include the Visual Pattern Test (VPT; Della Sala, Gray, Baddely, & Wilson, 1999), which is useful for evaluating attention and mental imagery, and the ReyāOsterrieth Complex Figure Test (CFT; Corwin & Bylsma, 1993), which was developed to assess visualāspatial constructional ability and visual memory.
Among more general measures, the Bender Gestalt Test and some Wechsler Adult Inelligence Scale-5 (WAIS-5) subtests can also be helpful for assessing neuropsychological functioning in senior adults. In addition, recent developments in brain imaging techniques indicate that the Rorschach Inkblot Method (Rorschach, 1921/1942) can prove useful in evaluating neurocognitive functioning in senior adults (Porcelli, Giromini, Parolin, Pineda, & Viglione, 2013). Moreover, as elaborated in the present text, the Rorschach brings to the clinical assessment process an evidence-based and psychodynamically oriented measure of personality functioning that provides information about a personās cognitive functioning, affective experience, interpersonal relatedness, self-perception, and inner subjective experience.
Psychodynamic Perspectives on Aging
In conjunction with innovations in neuropsychology, contemporary psychodynamic perspectives on aging have helped to modernize the image of older people by challenging entrenched stereotypes and false assumptions about the elderly. Among these stereotypes and false assumptions is the expectation that growing older causes people to become increasingly rigid and fixed in their ways, incapable of solving problems and exercising good judgment, and likely to show psychopathological manifestations. Youth-oriented societies are particularly likely to harbor such negative and unwarranted attitudes toward aging, and most people, including mental health professionals, are susceptible to adopting such attitudes. Changes in these and other traditional images of older people have been emerging, but only gradually, and there is a continuing need to counter biased attitudes toward aging with new facts and revised conceptions.
As a case in point, common attitudes in most societies consider the elderly to lack an active mind and a complex set of motivations, and the presumed rigidity and inability to change of older people has often been regarded as precluding their being responsive to psychodynamic psychotherapy or able to benefit from it. To the contrary, however, the neuroscience research mentioned earlier in this chapter has introduced the concept of neuroplasticity, according to which changes in the brain and improved cognitive capacities are possible even in old age. As reported by Lingiardi and McWilliams (2017, p. 751), moreover, accumulating clinical experience has shown that senior adults can in fact participate beneficially in psychodynamic psychotherapy.
To put these considerations in their historical context, the traditional psychodynamic image of rigidity and incapacity for change in older people traces back to the views of Freud (1904/1953), who wrote:
Over the years, this classical image of older people has given way to more positive psychoanalytic views of aging, with increasing appreciation of the poor fit that has existed between the needs and abilities of older people and the limited expectations and opportunities in their society. There has also been increasing recognition that, far from lacking an active mind and a complex set of motivations, elderly individuals are likely to be grappling with a variety of unresolved conflicts, contradictions, and tensions. As elaborated by Lomranz (1998), such conflicts, contradictions, and tensions are part of the reason why older people have proved able to engage effectively in psychodynamic psychotherapy.
With further respect to contemporary views on aging, the phrase growing old as commonly used today reflects a developmental perspective on late as well as early life. From this perspective, aging is currently viewed as a developmental process that occurs in reciprocal relationships between individuals and their contexts (Baltes, 1979, 1987; Baltes, Lindenberger, & Staudinger, 1998; Boyer, 2006; Lerner, 2015; Overton, 2015). Important developments in psychodynamic theories jointly with advances in contemporary neuroscience findings and accumulating empirical evidence support the view that personality changes with age occur within a context of surrounding environments.
Erikson (1956, 1959) was one of the first developmental psychologists to assert that some type of psychosocial development continues throughout...
