The Psychotherapy Of The Elderly Self

Hyman L. Muslin

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9781138004931
• Edition: 1
• eBook ISBN:
  9781134856176
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

People grow old. We are terrified by the fact. And this fear has translated into a pervasive neglect of the elderly across all spheres of living. Now Dr. Hyman Muslin steps forward to challenge the mental health field to reevaluate its perspective on this powerful human resource. The book is written in the effort to dispel some of the myths of aging; to highlight old age as a natural developmental phase and to delineate an effective model of observation, diagnosis and therapy for working with the elderly. Ultimately, Dr. Muslin's message is one of hope - for older individuals currently in need of psychological help and for the elderly self who awaits us all.

  1  

A Definition of the Elderly Self

Descriptions of the elderly commonly deal with them as a group of people who are affected by their altered physiology; their lack of power in social, economic, and professional spheres; and their closeness to death. Those who are viewed as elderly would perhaps add to the definition that older people are among those abhorred in almost all human cultures and in all times. Other groups who are similarly regarded are women, people who are ill or are congenitally defective, and various racial and ethnic groups (Butler, 1970; Erikson, 1982; Gutman, 1987; De Beauvoir, 1972). The abhorrence and ostracism turn on either such groups’ behavioral or physiognomic differences from the main stream, their real or putative power, or their afflictions (Sophocles, 1942).

The elderly would further add to the definition of their state that caretaking is easy to dispense but difficult to obtain. Thus Shakespeare's drama in which the aged King Lear does not receive the succor he needs from his favorite daughter, Cordelia, is replayed again and again in families in which the transition to becoming a caretaker to one's former caretaker often is not easily accomplished or is not accomplished at all (Zola, 1972; Muslin, 1981). The psychologist would note here that while changes inevitably do take place in the aging soma and psyche, there is no one elderly self—thus implying that the various structures of the self do not react to the ubiquitous alterations and stress in a simple reflexive manner. Just as no two nervous systems are alike in their resistance to aging, so no two selves are alike in their response to their changes in their roles and vigor; some selves with abundant endogenous stores of self-worth and self-calming mechanisms respond to aging quite differently than do those whose entire source of approval is linked to minute-to-minute activities representing achievement.

The following are some of the factors commonly identified with the elderly.

1. As a group, the elderly are people going through the physiological and metabolic processes of aging so that their functioning has become altered or impaired.

2. As a group, the elderly are those persons whom their cultures have designated as unable to continue as participants in the professional or business world. This definition ordinarily includes a numerical standard for aging, such as beyond age 65 or beyond age 70.

3. The elderly are those persons whose aging processes have advanced to the level of impaired functioning of various systems of the body or mind and so they are, therefore, simply awaiting their death.

4. The elderly are those persons whose physiological and metabolic aging processes have advanced to the level of diminished functioning so that they no longer are capable of living independently, and so require supervised care.

Thus the definition of the elderly requires the input of a variety of points of view: the cultural, the sociological, the economic, and the biophysiological. And most observers would hasten to add the psychological view, since there are some persons in their ninth, and even tenth decades who have just begun to demonstrate a significant negative alteration in their soma and psyche (Muslin & Epstein, 1980; Busse & Pfeiffer, 1972; Berezin & Cath, 1965).

In response to these alterations in the soma, there are, as in the adolescent, intrapsychic changes necessary for the adaptation of those undergoing the profound social and organic changes of aging. And just as in adolescence (a so-called phase of development also with physiological and cultural aspects that was unrecognized as a developmental phase before the 20th century), there are those elderly persons who will go to their deaths without ever experiencing the profound physiological changes of aging or significant intrapsychic alterations (Riesman, 1954; Zinberg & Kaufman, 1963).

What are the psychological alterations in the elderly that constitute an adaptation rather than an adjustment to the oft-present somatic and sociocultural changes? What constitutes the completed modal self of the elderly, if such exists? Is there a justification for designating the time before death as a specific phase of somato-cultural-psychological change through which all humans will pass?

Perhaps the overview pertaining to the elderly that the psychotherapist could accept includes the following: (l)The various institutions of the culture and the family for persons in the seventh decade and thereafter impose limitations on functioning. (2) The deterioration in the organs and musculoskeletal systems and the behaviors that derive from these alterations proceed at a variable, and sometimes accelerated rate in persons in their 70s and beyond. (3) There are a variety of intrapsychic reactions to the sociocultural standards and somatic changes—or expectations—imposed on aging persons, some of which constitute adaptive changes and others that do not. The fact of the psychological reactions to aging is unequivocal, but the nature of the reactions is, of course, idiosyncratic. They include affect imbalances, such as sadness or hypomanic affects, to anxiety reactions ranging from nervousness to panic and neurosis, and expressions of hostility ranging from bitterness to rage and homicidal fantasies.

From the vantage points of the foregoing observations, there is justification for describing people undergoing the aging process as belonging to a defined group, albeit one so defined by society. Deterioration—its changes and the psychological reactions to it—is a natural progression, but the “traditional” roles assigned to the elderly are not necessarily dictated by nature. These cultural impositions on aging persons also result in significant psychological reactions on the part of the victims—from adaptation to painful depression to fragmentation of the self.

THE LINES OF DEVELOPMENT OF THE ELDERLY SELF

The elderly self is a composite of the intrapsychic alterations of the different agencies (structures) of the mind. In this form, it will reflect the accents of a particular culture with regard to aging, deterioration, and death, in addition to the other variables noted previously—the rate of somatic deterioration and the capacities of a particular individual to change. Thus the elderly self must be defined in cultural and biopsychological contexts. It is, therefore, imperative that the psychotherapist be aware of what the particular surround expects of and offers its aging (the sociological input) as well as of the impact of aging on the person's capacities for action and thought (the psychological experiences).

A composite definition of the elderly self is as follows:

The elderly self is the self of aging people that has become altered in all or many of its structures and functions in reaction to a constellation of societal and biological influences that reflect a particular society's views of an aging person, as well as the individual biological givens. An elderly self is a self that has passed through specific alterations in its self structures that have evolved in reaction to the specific internal and external milieus. A cohesive elderly self is one in which the self-alterations have resulted in an adaptive self without the symptoms and signs of excessive reactions to the external world in the form of loss of worth or self-fragmentation and its vicissitudes as evidenced in neurosis or psychosis.

The crystallization of these self-changes in reaction to the sometimes malevolent, sometimes benevolent forces of nature and nurture that we are defining as the self of the aging are sufficiently prominent in all cultures that we can speak of the elderly self as an entity by which to measure one's aging patients. The entire self of the aging person undergoes these alterations in becoming an elderly self in each of its agencies: the sense of reality; the pole of ambitions; the defenses against drives; the value system (the pole of values) and, therefore, the quality and quantity of shame and guilt; the strength and quality of drives; and the attachments to other selves as either objects or selfobjects (Neugarten, Havighurst & Tobin, 1968).

The completed elderly self is a self that is adaptive to its milieu—not just as an adjustive self, implying acceptance of its inadequacy. Further, it is a self that is, depending on the surroundings not only at peace with itself, but is also a joyous self reflecting achievements that are deemed laudatory (Kohut, 1977; Muslin & Epstein, 1980).

The following chapters center on the development of the cohesive elderly self* and the psychopathological conditions in the elderly, as well as the psychotherapies that are helpful to them.

*For those readers who are interested in learning more about the findings and positions of self psychology, please refer to Psychotherapy of the Self (Muslin & Val, 1987).

2

On the Development of the Elderly Self

The completed elderly self is a self that has become transformed from the self of adulthood, the preceding era, with its unique values and programs of action consonant with an altered physiological status. The developmental period of aging, as do other developmental periods, necessitates self-transformations to effect the desired end stage. Changes in the pole of values, for example, are a major feature of the developmental task of becoming an adolescent. Each developmental phase—childhood, adolescence, adulthood, aging—involves specific self-transformations, in addition to the changes in physiology and physiognomy, in order for persons in that particular phase to complete the developmental task rendering them, for example, adolescents or adults. From this point of view, there are many 15-year-olds operating with an 8-year-old pole of values who will never be adolescents functionally. Similarly, there are 80-year-olds who will attempt to function as if they were in their 6th decade of life.

Also from this point of view, the person in a particular age period should be identified and labeled as adolescent or adult only if that person has been able to effect the self-transformations that meet the criteria for a particular developmental phase. Just as an adolescent is not only a 15-year-old person, so an elderly person is not just an aging person, but is an older person who has undergone major alterations in his or her self-structures that identify the person as an elderly self. The outcome of the developmental process, the cohesive elderly self, is a self that is in harmony within its components. In this cohesive elderly self, the transformed inner values that are held can be matched by the now-altered assertive forces of the self, assuring a cohesive shame-free self. Conversely, a person without the self-alterations required in any developmental period suffers the vicissitudes of a self in disarray with a loss of self-value and other features of a self in disequilibrium, such as the propensity to fragmentation. A person in the fourth decade of life who has not effected the required self-changes of an adult will not be able easily to perform the empathic tasks required of a parent or spouse, since the values and standards of a responsible caretaker have not been formed. Such persons will compete with their children for the ministrations of their spouses or be unavailable to the children since they cannot empathize with the needs of their wards for their input. Their self-transformations have not resulted in a self-experience as a calmer and soother of the young.

Thus in every developmental period, there are those unfortunates who have not been able to effect the changes that would afford them the gratifications of being, for example, an adolescent or an adult (cf. Chapter 3).

In their passage to becoming an elderly self, there are those throughout history who have loudly proclaimed the grief attendant on being aged without being aware that they have not been able to alter their selves in accordance with the requirements of a cohesive elderly self. Horace, Ovid, and Juvenal exemplify the description of the aged as those ancients for whom life ceases with the advancement of age. Horace wrote, “Sad age come, farewell to laughing, happy love and easy sleep” (De Beauvoir, 1972, p. 121). Ovid observed, “Time, O great destroyer and envious old age, together you bring all things to ruin” (De Beauvoir, 1972, p. 122). And Juvenal complained, “What a train of woes—and such woes—comes with a prolonged old age. To begin with, this deformed, hideous, unrecognizable face; this vile leather instead of skin; these pendulous cheeks; these wrinkles … The ancient no longer has his wits. A perpetual train of losses, incessant mourning and old age dressed in black, surrounded by everlasting sadness—that is the price of a long life” (De Beauvoir, 1972, p. 123).

In the 16th and 17th centuries, Shakespeare wrote of his fears of the ravages of time. In As You Like It, he described the aging man in this fashion:

The sixth age shifts

Into the lean and slippered

pantaloon. … and his big manly voice,

Turning again toward childish treble, pipes

And whistles in his sound. Last scene of all,

That ends this strange eventful history,

Is second childishness and mere oblivion,

Sans teeth, sans eyes, sans taste, sans everything.

(Act II, sc. VII, 1, 158-164)

And Lear, crying out against old age and disloyal children:

You see me here, you gods, a poor old man,

As full of grief as age; wretched in both,

If it be you that stir these daughters’ hearts

Against their father, fool me not so much

To bear it tamely; touch me with noble anger

And let not woman's weapons, water-drop,

Stain my man's cheeks!

(Act II, sc. IV, 1, 276-321)

In the 18th century, Swift presented an unusually despairing picture of aging in Gulliver's Travels(Chapter 10), when he described the Struldbruggs or Immortals. These were persons in the Luggnoggian kingdom who were destined to be immortal and were recognized at birth by a red spot over their left eyebrow. “When they came to fourscore years … they had not only all the follies and infirmities of other old men, but many more which arose from the dreadful prospect of never dying” (p. 127). Swift alluded to the notion of life as “perpetuity of youth, health and vigour,” and thus the awfulness, to him, of immortality as an older person (Swift, 1952).

In the 20th century, perhaps no one has captured the despair in those whose conception of old age as deterioration without any gratifications as has the playwright Samuel Beckett. The old people in End Game (Beckett, 1947), communicating from one garbage can to another, can only speak of their past as sources of empathy and tenderness, with the present (old age) likened to a garbage can and they to the garbage.

The completed elderly self—the self that has been mobilized to alter its functioning in reaction to the bio-sociological stimuli impacting on the aging throughout history—shows its differences from the adult self in its several compartments. The self, as Kohut (1959) initially redefined it, is the body of experiences of which one is aware or of which one can be made aware—one's body, one's mind, one's perception of objects and selfobjects. Moreover, it refers to experiences, hitherto unknown, of which one can be made aware now and in the past. He later added to these seminal insights into the self the organizing scheme of the self called the bipolar self. The bipolar version of the self is a model of a self in which a pole of ambitions—the assertive strivings—is conceptualized, which through its talents and skills acts to live up to its pole of values and thereby to avoid shame. The pole of values is the interiorized unconscious and conscious repository of ideals and morality codes. Some facets of this structure, which date from the first year of life, reflect the caretaker's (selfob...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• FOREWORD BY BORIS ASTRACHAN, M.D.
• INTRODUCTION BY STANLEY H. CATH, M.D.
• 1. A Definition of the Elderly Self
• 2. On the Development of the Elderly Self
• 3. Psychopathology and Psychotherapy in the Elderly
• 4. The Psychotherapies for the Elderly Self: Diagnoses and Plans
• 5. The Supportive Psychotherapies
• 6. Psychoanalytic Psychotherapy
• 7. Psychoanalysis in the Elderly
• 8. The Inner World of the Therapist of the Elderly
• 9. Epilogue
• REFERENCES
• NAME INDEX
• SUBJECT INDEX