Counselling and Psychotherapy with Older People

A Psychodynamic Approach

Paul Terry

• Publisher: Bloomsbury Academic
• Year: 2008
• Print ISBN:
  9780230506541
• Edition: 2
• eBook ISBN:
  9781350306004
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Building on the success of Working with the Elderly and their Carers, this new edition pursues an in depth understanding of therapy with older people. A wide range of clinical material and 3 new chapters draw on developments in psychodynamic theory and the author's experience to offer valuable insights for trainees and experienced practitioners.

PART I

DIRECT FACE TO FACE THERAPY

1

TO LOVE LIFE AND MOURN ITS END

Introduction

The shadow of death brings an exquisite poignancy to therapy with older people. It means the therapist and older client have to manage various tensions: to appreciate the life that has been lived whilst bearing the pain about what has not been possible, the mistakes and regrets; to hold onto and savour what remains whilst being assailed by inexorable losses; to explore and pursue the developmental and creative possibilities of this last phase of life whilst knowing it is an ending, and recognising the limits imposed by one’s history, constitution and ageing. In therapy these limits include the therapist’s training, skills and personality, and the time that is available. In essence the tension in this work is to retain a love of life whilst mourning its end.

Mourning is central to this therapeutic work because mourning involves recognition of whom and what are valued and loved, as well as recognition of their loss. The pain evoked by loss is a reflection of our love, passion, involvement, hopes and ambitions, whether for a person, career, hobby, interest or country. The work of mourning also means acknowledging our own and others’ limitations, including hatred and destructiveness, and the limits of life itself. If who and what are loved can be truly mourned then, though no longer part of our external world, they can be established in the internal world of the mind and continue to nourish and sustain our lives and our love of life. Mourning can therefore be enriching and support development and creativity in old age, as it does through all life transitions (Noonan, 1983, p. 3).

Although the theme of loss threads its way through each chapter of this book, it is important to keep in mind that the losses are reflections of the lives that have been lived, and of who and what have been cherished. Older people suffer a multitude of losses which are indicative of a multitude of experiences. They suffer loss of work and vocation because of retirement, redundancy or incapacity; and can therefore draw on histories of work, interests and hobbies, some of which they may still be able to pursue. As their bodies wear out they experience losses of physical and mental capacities, and consequent losses of independence especially when they may need others to care for them; the wrinkles, wear and tear of their bodies and minds are markers of the lives that have been lived. Children leave home. Colleagues, contemporaries, neighbours, friends, partners and pets die, and inconsolably their own children may die ahead of them. Therefore they have influenced and may continue to influence a multifarious world of interpersonal relationships, and are influenced by these relationships in their internal worlds. They face the inevitability of the ending of a long life. They have experienced, witnessed, endured and survived the joy and pain of life for a long time.

The understanding of how external losses become internal resources has come from psychoanalytic studies of mourning. The following section describes two seminal works on mourning, and introduces key theoretical concepts as they evolved in these studies and which inform much of the therapeutic work in this book.

Two seminal psychoanalytic studies of mourning

In Freud’s study of mourning and depression he understood how unconscious hatred could obstruct mourning. Klein showed how such obstacles could be overcome through bearing painful feelings of guilt and sorrow leading to reparation and the establishment of the lost loved one in an internal world.

Early in the history of psychoanalysis there were two outstanding studies of mourning and depression which led to the development of what is known as the Object Relations School of Thought in Psychoanalysis. Object Relations theory essentially reflects the recognition that from the beginnings of life we seek a loving relationship, and our early relationships play a critical part in our emotional development and our identity. (See Caper, 2000 for an excellent introduction to the development of Object Relations theory.) The two seminal papers were by Sigmund Freud, titled ‘Mourning and Melancholia’ published in 1917 and Melanie Klein’s ‘Mourning and its Relation to Manic-Depressive States’ published in 1940. Both these papers examine the similarities and differences between mourning and depression. Freud and Klein were pioneers in the study of the unconscious, and bravely drew on their own experiences to extend the frontiers of psychological knowledge. Both papers were linked with personal grief. In Freud’s case we know that he first sketched the ideas for his paper a year after the death of his father. Klein wrote her paper several years after the tragic death of her son and she even included a thinly disguised case study about her own grief in the paper. Both these seminal works were written from the heart.

Freud understood that mourning the loss of a loved one has to be worked through in minute detail; as he said ‘Each single one of the memories and expectations’ of the loved person has to be summoned up against reality to reach the verdict that the loved one is dead and lost forever. He described how ‘extra-ordinarily’ painful this process could be and puzzled over why it is so painful. Freud saw that depression, like mourning, involved an important loss but which the depressed person was unable to mourn because of strong ambivalent feelings towards the lost loved one. He recognised that in apparent self-criticisms that a depressed patient made, there were concealed criticisms against the lost one, and that these self-criticisms were in fact disguised complaints about being abandoned and left. Part of the self or ego became identified with the lost person, as Freud so memorably and poetically wrote ‘the shadow of the object (the one who was lost) fell upon the ego’. Later in his work Freud realised how any loss, especially early in life, leads to important identifications that shape the ego and the nature of our character.

An illustration of Freud’s insight can be seen underlying the problems presented by a man in his seventies who complained of breathing difficulties for which there was no physical basis, but which severely impaired his life over several years. He was constantly in a weak state and had to be accompanied to the assessment interview by his wife. He tended to lean on his wife because he was afraid of falling. Five years previously his eldest son died of asthma. He was very close to his son and was still tearful when speaking of him. He had become identified with his son in this debilitating physical symptom which replicated his son’s asthmatic condition. In a concrete identification he unconsciously denied the loss because he felt he was his son and had not lost him. He was unable to mourn and had become depressed. The shadow of his son had fallen on his ego.

In ‘Mourning and its Relation to Manic-Depressive States’ Klein agreed with Freud that the central tasks in mourning are to face the reality of the loss in the external world and establish the loved one internally. Klein discovered that, in the unconscious, experiences of bereavement revive our earliest experiences of loss first encountered in infancy in relation to the mother or primary caretaker. Furthermore, Klein developed an understanding of how in infancy and childhood the experience of loss leads to identifying with and internalising important figures like our parents and family, with the result that the child builds up an internal world which is peopled with all these figures. Klein’s work thus sheds further light on how in mourning the task of establishing the loved one internally is accomplished. Klein also went some way in explaining why mourning is so very painful and may endure for a long time. Following bereavement it is as though all the loved figures in the internal world are lost, and the internal world is in a state of devastation.

Mourning in infancy

It may seem strange in an introduction to therapy in later life to turn to infancy, but psychoanalytic and psychodynamic therapy is informed by an understanding of how early experiences of infancy and childhood crucially influence development of the personality and personal relationships. In particular the internalisation of early life experiences and relationships creates an unconscious internal world of ‘object relations’ which influences and is influenced by experiences and relationships throughout life. Later influences may include the experience of therapy, so understanding more about the internalisation contributes to insight into the therapeutic process. Infancy has particular relevance for therapy with older people because ageing often brings the need to be dependent again on the care of others and thus revives, consciously and unconsciously, our earliest experience of dependency and being in a dependent relationship. (Fears of dependency which are revived in later life are discussed in Chapter 7.)

The following is a sketch of Klein’s understanding of how the internal world is first established, and of the nature of infantile states of mind that are revived in later experiences of bereavement. Klein emphasised that for the infant or small child with little or no sense of time or continuity, a temporary absence of the mother, as well as major losses experienced such as in weaning, can be experienced as irrevocable losses, equivalent in important respects to an adult’s experience of loss and bereavement. So for the infant and child, when faced with an absence that may feel eternal, there is the mourner’s task of needing to establish the lost loved one internally in the mind. Klein saw too that just as for adults, experiences of loss and frustration for the infant and child stir powerful conflicting feelings between love and hate for the one who is missed.

Klein introduced the concept of unconscious phantasy to describe what she understood about the infant’s, child’s and adult’s unconscious experience. Klein traced different phantasies and anxieties which were linked to how external figures are established in the internal world, to the infant’s and child’s capacities and to the love and care they receive. Klein proposed that just as the infant takes in food and nourishment so in unconscious phantasy the infant internalises experiences of nurture and security of mother’s care; and just as the infant expels waste products such as faeces and urine so in unconscious phantasy the infant projects unpleasant emotional experiences into the external world. The fragmented and unintegrated state of the infant’s physical and psychological capacities mean that at first what is internalised is also fragmented, such as isolated aspects of mother’s care, like the sound of mother’s voice, or her cradling arms, rather than an identification with mother as a whole person. It is the mother or primary caretaker who by physically and mentally holding the infant gives the infant an experience of continuity and coherence, essentially by holding all the different fragments of the infant’s experience in her mind (Bick, 1968). For example the mother helps the infant to know that the infant, who was crying at one moment, is the same infant who smiles at the next. Gradually the infant becomes able to recognise a sense of continuity and wholeness in his or her own identity and recognise the mother as a whole person.

From the start of life there is a complex interaction between the internal and external world, especially between the ambivalence of loving and hating feelings and good and bad experiences. The infant does not have the capacity to manage the conjunction of opposite feelings and experiences, and at first needs to keep them as separate as possible, out of fear that the bad will spoil the good. Thus the infant splits feelings and experiences into either good or bad, and is inclined to exaggerate the differences, idealising the good as a necessary source of strength and inner security against the bad. Moreover, these very opposite feelings are projected into what becomes polarised loved or hated external figures who are then established as such figures in the internal world. Klein described this state of mind and the accompanying anxieties and defences as the ‘paranoid-schizoid position’, indicating that it is a state of mind to which we can return throughout life especially when under conditions of extreme stress.

Klein’s child patients sometimes revealed harsh and cruel internal parental figures in contrast to their actual parents. Klein soon appreciated that as a result of projection of feelings there was not a direct correspondence between the external figures in reality and how they were internalised which she described as ‘internal objects’. She thus developed Freud’s understanding of projective processes into the concept of projective identification in which in unconscious phantasy parts of the self are split off and denied and projected into the other who is then identified with those aspects of the self (Klein, 1946). Projective identification has been widely recognised as perhaps Klein’s most influential contribution to psychoanalytic understanding and has had far-reaching consequences in contemporary psychoanalytic schools of thought. Although projective identification refers to an unconscious phantasy, Klein’s followers have discovered that it can actually have an effect on the recipient of the projection who through subtle influences of verbal and non-verbal behaviour, can come to actually feel what is projected into them. This discovery led to understanding more about the crucial role of the mother or primary carer.

Wilfrid Bion, one of Klein’s most influential protégés, described the mother’s capacity to contain the infant’s projected emotional states as an essential contribution to the infant’s development (Bion, 1962). So, by virtue of her capacity to hold together the fragments of the infant’s experience, as well as her receptiveness to the infant’s emotional states, particularly being able to take in his or her distress and transform it with love and understanding, the mother eventually enables the infant, then child, to bear difficult feelings. Thus along with the infant’s developing physical and cognitive capacities, there is less splitting, less need to project, and a growing sense of being more emotionally integrated, whole and able to relate to whole people. Consequently the internal world becomes inhabited with whole figures.

However, these developments towards integration usher in new depressive anxieties which come from the realisation that the nurturing mother is the same mother who is sometimes absent, a mother who is both loved and hated, and that the self who loves is also the self who hates. Thus the experience of loss of the whole mother presents the infant or child with much pain, because in phantasy the mother is felt to be irretrievably lost and the infant or child feels responsible for the loss because of hatred and aggression. The infant or child is therefore faced with painful feelings of guilt and sorrow, pining for the lost mother and for him- or herself who has lost the mother. These are at first very difficult feelings for the infant or child to manage without recourse to the early defences of splitting, denial and projective identification and what Klein described as manic defences which are characterised by control, contempt and triumph. However with repeated experiences of mother’s love and care, and with developing emotional resources there develops a capacity to bear the tragedy of the loss, guilt and sorrow which leads to reparation, a desire to make good the damage and the establishment of the lost loved one internally.

Although Klein emphasised unconscious phantasy and the internal world, she also understood the importance of external reality in establishing the loved one internally. It is the reality of the presence of the mother or primary carer, her reliability and consistency, and most of all her love that assuages the infant’s and child’s fears and worst phantasies stirred by her absences. The mother’s loving presence brings hope in the face of devastation and ultimately enables a sense of duration and permanence in the internal world (Likierman, 2001), so that, as Freud understood, eventually as an adult mourning we can face the reality of loss of our loved ones and our own death. However, in order for this to be achieved the absences and losses in infancy and childhood have to be overcome by working through again and again the suffering and need for reparation, in order to restore and reestablish our loved ones in the internal world.

Adult mourning

The appreciation of infant experiences of mourning is especially important because these states of mind are revived in adult experiences of loss and grief. Following a bereavement the internal world is in a state of devastation, not only the loved one is felt to be lost but all the loved and loving internal figures, particularly important early primary figures like mother and father, are felt to be lost as well. The self can then feel at the mercy of hated and hating internal figures which may lead to frightening or even persecutory internal states. Thus the bereaved may feel in pieces, in a fragmented state and unable to manage other than by extremely polarised and split feelings, making a sharp divide between loving and hating feelings.

A woman was brought into hospital in a weak and malnourished condition, convinced her neighbours were plotting to have her evicted from her home. She had worked conscientiously in a commercial business that was like an extended family to her. She was devoted to her work, it was the centre of her world, and when she retired a few years previously she came to feel that she had lost everything. She then believed that anything good she had left would be taken away from her.

Klein understood that the mourner’s task is ‘with anguish’ to rebuild the internal world, to reinstate the lost loved ones. In the unconscious the mourner feels responsible for the death and destruction, helpless to repair or restore the lost one, terrified he or she will not survive without the lo...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• Acknowledgements
• Preface to the Second Edition
• Part I: Direct Face to Face Therapy
• Part II: Indirect Therapeutic Consultations
• References
• Index