Talking Over the Years

A Handbook of Dynamic Psychotherapy with Older Adults

Sandra Evans, Jane Garner, Sandra Evans, Jane Garner

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135480912
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

this is the only handbook on this topic; it is uniquely comprehensive ageing and work with the elderly is a very hot topic across mental health professions; it has been neglected for so long.

Part I

Theoretical frameworks

Chapter 1

Old and new: Freud and others

Rachael Davenhill

Two themes run through these pages: the story of my life and the history of psychoanalysis. They are intimately interwoven. This Autobiographical Study shows how psychoanalysis came to be the whole content of my life and rightly assumes that no personal experiences of mine are of any interest in comparison to my relations with that science.

(Freud’s 1935 ‘Postscript’ to his ‘An Autobiographical Study’, 1924)

Psychoanalysis has always held fast to its radical origins, and no more so is this true than in the area of old age. Although in his early paper, ‘On Psychotherapy’ (1904), Freud was pessimistic as to the relevance of the psychoanalytic method with older people, his life and thinking, and that of post-Freudian analysts such as Segal, King, Hildebrand, Martindale and Waddell, have given us a framework for addressing those factors which can impede or support development across the lifespan, including further development right up until the end of life. Understanding factors that can support normal development can also give insight into those things which can interfere with growing up and into one’s own personality – something Waddell (1998) refers to as ‘… the extraordinarily difficult process of growing up on the inside as well as on the outside’.

The first half of this chapter will give an introduction to Freud’s life along with an overview of his key psychoanalytic concepts which, taken together, will give a framework to focus on aspects of ageing and their impact on the individual older person and those around them. The second half of the chapter will describe a particular way in which such concepts can be made accessible as a component of pre and post qualification trainings for clinicians wanting to deepen their understanding of the unconscious factors involved in the experience of old age, through a form of experience-based learning called the psychodynamic observational method.

FREUD – THE EARLY AND MIDDLE YEARS

Whilst it is not necessary to be familiar with Freud ‘the person’ to appreciate his theoretical contributions, nonetheless some familiarity with aspects of his life and death add a richness to the reading of his writings. Sigmund Freud was born in 1856 in Freiberg, Moravia, to poor Jewish parents. His father, Jacob, was 40 and had been married twice previously with two sons from his first marriage. His third wife, Amalia, was half his age, 20 years younger than himself. When Freud was 17 months old, his mother gave birth to a second baby boy, Julius, who died after only 7 months in 1858. Immediately after this, the family moved first to Leipzig, and then in 1860 to Vienna. The years from 1860 to 1866 were filled with pregnancies and births. Freud had four sisters and a young brother. As an adult he looked back with nostalgia for his early days as an infant and little boy in the countryside of Freiberg rather than the crowded city of Vienna which he always professed to hate. In his exemplary biography of Freud, however, Peter Gay (1988) points out that for

someone who hated Vienna as fiercely as Freud told everyone he did, he proved uncommonly resistant to leaving it. He had excellent English, good foreign connections, repeated invitations to settle abroad, but he stayed until he could stay no longer. ‘The feeling of triumph at liberation is mingled too strongly with mourning, ’ he wrote, a very old man, just after his arrival in London in early 1939, ‘for one had still very much loved the prison from which one has been released.’

In 1873, Freud began his study of medicine at the University of Vienna, which he completed in 1881 after which he took up a junior post in the General Hospital in Vienna. He wrote in his ‘Autobiographical Study’ that his choice of medicine was not so much that he wanted to become a doctor, either in his early or later years, but ‘Rather, I was moved by a sort of greed for knowledge.’ A year later, aged 26, he met Martha Bernays, but it was to be four years before he married her. They had six children, three daughters and three sons, in the ensuing nine years. It was during his university years that he visited England for the first time, in order to see his two older half brothers in Manchester. This visit, he wrote to Martha Bernays, had a ‘decisive influence’ on him. In another letter to his friend Eduard Silberstein he commented that he liked England better than Austria despite the ‘fog and rain, drunkenness and conservatism’! He also became interested in English writers such as Huxley and Darwin.

Throughout this time, Freud was moving towards his identity as a psychoanalyst rather than an anatomist or neuropsychologist. He threw himself into writing his ‘Project for a Scientific Psychology’ and found himself on the verge

not of a psychology for neurologists, but of a psychology for psychologists. The physiological and biological substrata of the mind never lost their importance for Freud but for several decades they faded into the background as he explored the domains of the unconscious and its manifestations in thought and act – slips, jokes, symptoms, defences, and, most intriguing of all, dreams.

(Gay, 1988)

In 1885 Freud was granted a bursary which enabled him to spend some months in Paris studying hysteria and hypnotism under Charcot. This was a formative experience in Freud’s move from the physical sciences towards a driving, lifelong investigation of the mind. On his return, he worked in the laboratory of Carl Claus, searching, inconclusively, for the gonads of eels – a search which was to sharpen his powers of patience and observation. Following this he moved to Brucke’s laboratory, where he was much happier, and it was there he made friends with Josef Breuer, whose role in Freud’s development as a psychoanalyst was critical.

Breuer was an older colleague of Freud who had made use of hypnotic suggestion in the treatment of a young woman regarded as suffering from hysteria. Hysteria at this point was thought to stem from physical trauma which had been forgotten by the patient. The idea of hypnosis and suggestion was to enable the patient to remember the traumatic event along with its accompanying emotions. Freud rapidly became dissatisfied with hypnosis as a treatment method. His eventual rejection of the use of hypnosis was decisive for the development of his new ideas as to how the mind worked – ideas which came to be referred to as psychoanalysis.

In 1896 when Freud was 40, his father died, by now an old man of 81. In his introduction to the second edition of the ‘Interpretation of Dreams’, Freud commented that the paper had in part been a response to the impact of his father’s death, which had affected him greatly. From this point on, from an external viewpoint, what is striking is the settled nature of Freud’s domestic life – living and working from the same house in Vienna until his move 47 years later to England. During these years, however, Freud was to struggle with, ripen and bring to fruition a comprehensive theory of mind which was able to take account of unconscious as well as conscious factors involved in the human ability to either develop and thrive or, conversely, undermine and destroy the capacity to love and the capacity to work which Freud saw as two of the great endeavours in life.

The notion of the unconscious was revolutionary in its time in terms of the blow such a concept gave to the narcissistic belief that men and women could take conscious control of their destiny. Freud developed the concepts of transference and countertransference as clinical phenomena naturally stemming from this central concept of the unconscious. Here Freud thought that it was not just the patient who transferred feelings from earlier primary relationships (usually with parental figures) onto current relationships (transference), but that the analyst/clinician also could bring their own unresolved feelings towards figures in their own past and transfer them onto their patient (countertransference).

Another cornerstone of the new psychoanalytic treatment depended on what Freud referred to as free association. Here, the only thing patients were required to do was to feel free to say whatever came into their mind in as unedited a way as possible. Freud was taken aback by the powerful emotional response encountered in both his patients and in himself in the course of treatment, and it was his struggle to make sense of the strength of his own, as well as his own patients’ feelings, that led him to develop a number of key concepts which are as useful and relevant clinically today as they were when he first began to put forward his ideas in the late 1800s. He quickly noticed that despite being given the freedom to speak freely about whatever was on their mind, through the method of free association, patients found this difficult. In fact the contents of the mind are often censored, not available to be spoken about at first hand, but may be accessible through, for example, dreams, or ‘slips of the tongue’. Early on Freud developed the concepts of resistance and repression, using the latter term interchangeably with defence mechanisms.

Defence mechanisms act as a kind of perimeter fence coming into force in order to protect the mind from overwhelming anxieties and conflicts which can arise from within or outside the self – often a mixture of the two. They operate from very early on in life in order to protect the infant against anxieties regarding survival itself, and include splitting, denial, identification, projection, introjection and idealisation. In later years, Anna Freud, Freud’s daughter, published a book called The Ego and the Mechanisms of Defence (1936), classifying and further developing the defence mechanisms her father had described so many years before.

FREUD – THE LATER YEARS

From 1911 onwards, Freud wrote a number of meta-psychological papers which contained his continued explorations in developing his theory of psychoanalysis. At the age of 61, he published a paper called ‘Mourning and Melancholia’ (1917) which is crucial for the understanding of the psycho-dynamics and treatment of severe depression in people who are older. The paper is important in giving an explicit account of the role of identification in the formation of the individual’s internal world. Freud thought that a world of internal object relationships came about through projection and identification which, in the case of melancholia (depressive illness) remained more alive to the individual in a quite deadly way and interfered with the possibility of the person being able to acknowledge and make use of relationships available to them in their current reality.

Clinical Illustration

Mrs Y, a 63 year old woman, went to see the practice nurse at her GP’s surgery. She said she was living a ‘shadow-life’ when she tried to describe how she felt in the initial meeting. The nurse, through listening carefully and enquiring as to what her patient meant by this, was able to establish that Mrs Y felt that she had turned into a shadow of her former self since the death of her husband when she was 50 and had not been able to fully mourn her husband or move on from his death in terms of getting on with the rest of her life. A template of the marital relationship began to emerge as Mrs Y talked – her husband was perfect, he had done everything for her, they had gone everywhere together. All competencies seemed to be lodged in her husband. When he died, instead of being able to re-acquire aspects of herself that had been lodged with him through the process of projection, Mrs Y held onto her way of relating to him as the solution, and replicated this in her relationships with her daughter, neighbours, and potentially in her contact with the nurse. She presented extremely passively – the nurse would know the answer to all of this, her daughter did all her shopping, she had a rota of neighbours calling in each day to check she was all right, etc.

The nurse, however, was able to resist the pressure to ‘do’ something at the patient’s request, and held onto her curiosity. This enabled her to explore the patient’s difficulties further over a couple more meetings. It became clear that although chronologically in her 60s, the patient had never negotiated the ordinary transitions of infancy and childhood. She still had an extremely enmeshed relationship with her own mother (who visited the patient every other day, though she herself was now in her 80s), and was only able to leave home by marrying a man who cared for her in the same way as her father had. Rather than acquiesce to the patient’s request that she, the nurse, was the solution – if she could just pop in on her every now and then, she would probably be fine – the nurse instead was able to point out how that would be replicating the exact problem Mrs Y was presenting with – everyone else getting on with things so that she did not need to. She offered to refer Mrs Y on for brief psychodynamic therapy, which Mrs Y eventually accepted, though not before an angry outburst at the nurse for her neglect and lack of caring attitude in wanting to pass her on. This explosion was a catalyst for fruitful exploration into the patient’s absolute rage, rooted in infancy, at having to separate which was taken up first in brief individual treatment and then through her joining a longer term psychoanalytic psychotherapy group.

This example of Mrs Y is a variation of the kind of depression with which GPs, old age psychiatrists, CPNs, psychologists and other mental health workers may find themselves dealing on a daily basis.

Extremely valuable work can be done in those first contact meetings when the clinician is trying to assess the situation and struggling to make sense of some of the unconscious as well as conscious pressures the patient is bringing into the consultation. In the example above of Mrs Y, the nurse was able to use her skills to assess ‘where next’ for her patient, and refer her on for a formal assessment for psychotherapy. The transitions across the later years of life involve mourning, both in connection with that which has been had and lost, as well as for those things which may never have been experienced. The capacity to cope with transition, loss and change in later life is rooted in ways of facing loss forged much earlier on in life. Whilst living in the shadow of death is a well known colloquialism, its corollary, for older people presenting with depression...