Category: Neuroscience/Brain-Based

I am a geriatric clinical psychologist. I love working with older adults. I have often wondered, though, why there are so few of us around. Ten thousand people in America turn 65 every single day now. There is an accelerating rate of this already underserved segment of our society, and there is a huge and growing but untapped market of potential revenue for psychotherapists wanting to expand their practices. Why, then, are there so few psychotherapists actively working with older adults? While it is estimated that 70% of psychotherapists see adults on their caseload, only 3% of them have had formal training in working with older adults. What has stopped clinicians from getting training that could be so valuable in their professional development? Despite the general finding that the motivation and attitude of the older adult toward psychotherapy is as positive as it is in other age groups, many clinicians doubt this nevertheless. As I began working with older adults, I confronted these issues, and as I did, I found new joy in my work. What I discovered was this: I have as much to learn from my older clients as they may have to learn from me.

Many clinicians prefer not to work with older adults, and I have a great deal of respect for those preferences. In my own practice, I'm not inclined to work with children or adolescents. Oftentimes, though, the therapist’s preference is based on a view of older adulthood that is grounded less in fact and more in myth. When I first started seeing people in nursing homes, I felt like a fish out of water. I was trained in two of the best graduate psychology programs around, but when I was in a nursing home, I was consumed with doubt and fear.

It was 1999. I had just become licensed as a psychologist, and I was offered a job with a firm that brokered psychological services to nursing home residents. I was excited about making a living as a psychologist, energized about venturing into this new application of my skills, and eager to ply my trade—that is, up until the first week I actually saw clients! It was then that the reality of working with older adults eclipsed my fantasies of doing so. It was then that I confronted my awareness that this was incredibly challenging work for which I felt ill prepared.

My main fear: could my cognitively compromised clients even benefit from psychotherapy? I asked myself, How much of my work with them could they actually comprehend? How capable were they of working through their emotional struggles and inner conflicts? To what end would our psychotherapy serve if their lives would soon come to a close? I was overwhelmed with confusion, uncertain of my effectiveness, and scared I might be practicing outside my area of competence. Out of an amalgam of fear, guilt, and good sense came a series of consultations with a wise geropsychologist, and it was there that I began my schooling about the cognitive, emotional, and functional eccentricities of the older adult.

I am here to tell you, though, that 13 years later, I have come full circle. My acquired knowledge and experience in geriatrics have been invaluable, but I see now that, with respect to the essence of effective psychotherapy, it turned out that I had been sufficiently trained to do the work all along. Becoming technically proficient as a gerontologist has taken me on an invaluable path, but I see now that my former fears about conducting psychotherapy with older adults were driven almost entirely by my own introjects from the social stigma of aging. That’s what this article is about—to describe my own journey as a clinician framed within the cultural mythology around aging.

Myth #1: Psychotherapy with the elderly is time wasted, because the elderly client has so little time to enjoy any gains that might be made.

There is a film released in 2011 entitled Beginners, for which Christopher Plummer won the Oscar for Best Supporting Actor. The story involves a widower who, at age 75, joyously begins living a sexually authentic life as a gay man. To justify such a change, how many years should this man have left to live? Is the length of time he would have to enjoy his newfound emotional freedom really the issue? I am reminded of the elderly client who responded to her therapist’s query why she wanted psychotherapy by saying, “It’s simple; all I have left is my future.” At age 49, Freud is well known for having contended that anyone over 50 was uneducable, and I wonder if some of our biases working with older adults might stem from this overstated assertion.

Due to a very severe stroke, Estelle had for some four years been living in a nursing home. At 75, this was her home now. She was referred to me because she could not stop getting into heated arguments with other residents, and she was sad a lot. She had a history of drinking moonshine; she had been an ironworker and a barmaid, drove a semi, and had graduated high school with honors.

As with most nursing home residents, she was on a ton of meds, including an antidepressant, two anxiolytics, and an antipsychotic. When I first met her, she told me she had multiple personality disorder (which wasn’t the case), but due to her stroke, she did have memory problems and severe aphasia (difficulty expressing herself with language). In fact, her aphasia was so pronounced that it took her as long as a minute to express a complete sentence. She grinded out each word—one by one—with persistent determination. Her desire to communicate was relentless, and this was what allowed her to stay connected to others.

My psychotherapy with Estelle lasted two years, and I learned a great deal from her. I learned about the incredible courage and fortitude it takes to cope with an abusive upbringing, the loneliness and isolation that can accompany nursing home life, and the debilitating physical ravages of vascular dementia. I also learned about the connection that occurs between two souls—where words are often not needed.

More than her aggravated depression, though, Estelle wanted to work on emotional abuse issues from her childhood and the disparaging way her mother and father had treated her. She was open to the idea that those images—and the ways she coped with them—were influencing how she related to others and to herself. And this was how we approached her psychotherapy.

I am tempted to say that Estelle was a wonderful psychotherapy client, but the temptation to do so implies that it was Estelle’s characteristics that made the therapy meaningful. It was not. What made the psychotherapy beautiful—even reverent—evolved from the exceptionally meaningful way the two of us found to communicate with each other. And not unlike Victor Frankl’s odyssey through Auschwitz, what was most meaningful to me was to witness Estelle’s search for meaning in the limitations of her own life.

In the beginning, our therapy focused on relieving her depressive and angry feelings, and Estelle made comments like,

I have been fighting lately—it’s enjoyable … and it’s not enjoyable. It relieves tension, but I am crying all the time. If I told you all that is going on inside of me now we would have to meet all day!

Take a minute and think about her, though—grinding out each sentence—me wondering where in the world it was going to go—waiting almost interminably for each idea to unveil itself—and to eventually experience just how wondrous it was to witness such life-revealing self-reflection. How could a therapist not marvel at the human capability that was co-existing with such daunting a physical disability!

As our therapy progressed, the emotional work Estelle and I did together chronicled her evolution in becoming a more whole person. She created a process where she found her inner self in a way she had never done—developing her own autonomy and independence by resolving longstanding introjects that, for the first time in her life, she was now ready to expel. Toward the end of our work together, she proclaimed,

I’ve overlooked myself … but I can discover me … I can see the good inside me now. That surprises me to hear myself say that, but I see I will make it … and I know now who I’ve been angry at, and I see that I don’t need to be angry at everybody anymore. I’m not quite proud yet, but I do like being alone with me now … I really do enjoy my company. I’m on my way.

When I began doing psychotherapy with older adults, I didn’t realize that the kind of emotional and spiritual trek that Estelle would make was more similar than different from the journey I made with clients in other age groups. This is my joy of working with older adults—to see them unveil to themselves and to me their indomitable wisdom. For me, this is a revelation perhaps most profound in those who have lived with their darkness for so long.

Myth #2: The grief, loss, and somatic and socioeconomic burdens of the elderly are too excessive to warrant believing they could get better.

There is a great deal of pessimism about doing effective psychotherapy with older adults. Many of these clients have limited resources to face unimaginable social, medical, and economic struggles, and many clinicians tacitly believe that the elderly’s frustration, deprivation, fear, and dependence are so emotionally injurious that no amount of psychotherapy could really help them. When I began my psychotherapy career with the elderly, I wondered about these things too. With experience, though, what I learned was that it was not my clients’ deprivation and burden that was too excessive—it was my own. It was my inability to cope with my fears and frustrations working with excessively burdened people, and I was projecting these issues into my elder clients.

Marge was a ten-year resident of her nursing home. Legally blind, she had a longstanding diagnosis of mild mental retardation and had been institutionalized with paranoid schizophrenia for much of her life. When her mobility began to fail and her dementia and other medical conditions became too much for her family caretakers to manage, she was admitted to a skilled nursing facility. In order to address issues of depression and to help her manage her psychotic symptoms, for almost three years I saw Marge weekly for psychotherapy. I wondered if the odds of Marge overcoming her burdens were too great. I wondered if she could fight the good fight. What I came to learn, though, was that I was actually asking that of myself.

Like many people with schizophrenia, Marge was an isolationist, and this often exacerbated her psychotic symptoms. The structure and consistency of our weekly visits, though, allowed her to quell many of her paranoid thoughts, and she made remarkable progress. For the first time in many years, she was successfully managing most of her troubling and longstanding paranoid symptoms. Her solitary lifestyle, however, unintentionally reinforced her chronic feelings of loneliness.

As does happen sometimes, changes in my own life forced me to turn her psychological care over to another clinician, and we spent two months planning for the transfer. As you might imagine, my concern was that my departure would lead her to regress into further isolation. As it turned out, though, my underestimation of her strengths and concerns about her succumbing to her fears were a projection of my own issues.

In the waning weeks before my departure, Marge began to voice her sadness with our impending termination, and this was clinically therapeutic for her. She also began to tell me about the new and pleasant experience she was having on "the boat," so asked her about it.

Marge: "I will miss you."
Dr. Kraus: "Yes. It's sad that our therapy together is going to end. You have made great progress, and I am proud of you. I know you will continue your good work with Dr. Hamilton. … You had mentioned to me about a boat. Can you tell me more about it?”
Marge: "Oh, yes! We travel around."
Dr. Kraus: "Do you, now! Where have you been?"
Marge: "Well, we're going to France."
Dr. Kraus: "Really! How nice! It sounds like a cruise ship."
Marge: "Not really.{whispering} It's a submarine, but you can't tell anyone."
Dr. Kraus: {with curiosity} "How come?"
Marge: "Because they might throw me off!"
Dr. Kraus: "I see. What's it like for you traveling to all these places?"
Marge: "There's a group of us … my roommate … and a few more … and Nancy {one of her nursing assistants} … I like it."
Dr. Kraus: "That's terrific. It sounds like you're seeing that while you are sad our therapy is ending, you also see that you will have some good friends here with you after I am gone."
Marge: {Smiling and in a very calm and self-assured voice} "Yes, I will." ¹

And so it was with Marge that I learned two very important lessons: 1) even with a mentally retarded, schizophrenic, aging nursing home patient with dementia, extraordinary things can be accomplished, and 2) the fears and discounting of her strengths that I imagined within her were really projections of my own.

Myth #3: Old people are staid in their ways; they are too stubborn to change.

In some of my geriatric workshops, I ask the audience what the four essential signs of aging are. Invariably, they will say things like grey hair, illness, and memory loss. Then I tell them my four: wisdom, confidence, character, and strength! I tell them that I threw them a little curve-ball, but they get the point that we often ignore or minimize the tremendous assets and capacities possessed by older adults. We overfocus on their liabilities and underrecognize their strengths. We miss how many competencies increase with age: appreciation, authenticity, desire to help, maturity, patience. Being stubborn can imply having mettle to take a stand and stick to it, and it is often quite effective for a psychotherapist to run with a resistance than to try to overcome it. It also occurs to me that to say that the elderly are staid may again say more about the patience, optimism, and confidence of those who serve them than anything else.

In Psychotherapy with the Elderly, psychologist George Bouklas offers an extraordinary account of a conversation with Errol, an 82-year-old patient of his with mild dementia, who entered a nursing facility for rehab following a colostomy. Errol never accepted his surgery, was constantly angry and agitated, and would routinely resist medical care. He was referred to Bouklas for ripping off his colostomy bag and spreading its contents across the room. He then would ask the staff what the fuss was all about! Here’s a powerful and provocative excerpt from their therapy:

Errol: (in an angry tone) "I stopped spreading shit on the floor.”
Bouklas: (silence)
Errol: "I told you, I stopped spreading shit on the floor! You act like that doesn’t matter! Well, does it matter to you?”
Bouklas: "Should it matter to me?”
Errol: "I thought you might be proud. The room doesn’t smell like shit anymore.”
Bouklas: "What’s wrong with the smell of shit?”
Errol: "You mean you liked it?”
Bouklas: “I like everything about you, no matter what it looks like, what it sounds like, or what it smells like.”
Errol: (now weeping) “You son of a bitch, if you’re lying to me I’ll kill you.”
Bouklas: “If I was lying to you I would deserve it.”²

Errol is typical of most elderly clients in that their stubbornness is a defense, albeit maladaptive—an indication that something more loathsome, more unacceptable, more humiliating may lie beneath. From my point of view, the word “staid” is an exemplar to some extent characterizing every psychotherapy client.

All clients resist—they all hold on to old patterns of thought and action. Resistance is the sin qua non of all psychotherapy, and it is no less true of the elderly. But when clients are unblocked, when resistance evaporates, psychotherapy with the elderly is an amazing thing. When we can help our clients abandon their defenses—even for just a moment—we create in the therapy a transcendent experience that elevates and inspires. It takes something special to really dare to live, and I feel privileged to witness them doing it. If we are open to our undeniable emotional connection to our clients, we can truly witness their transcendence—and it then emphatically becomes our own. With the elderly client, the metamorphosis is no less exalting, no less divine.

Growing old changes the way people relate to themselves and to others. The aged are often dealing with three principal issues: (1) how to adapt to the biggest transition of their lives—their changing health, the idea of getting older, and their changing family and work roles, (2) how to cope with the grief and loss that accompany their advancing age and decreasing abilities, and (3) how to manage their interpersonal relationships with others. As people advance in age, they go through an immense life transition—their role in their family changes, their view of themselves as a healthy person changes, and their sense of their own longevity and mortality changes. If kept silent or hidden, the feelings underlying these transitions often get acted out in disguised forms. Listening to and being there for the elderly client is invaluable to them not only because it makes available a problem-solving process that may ameliorate their distress, but also because it brings a heightened sense of connectedness and bonding with you. When this happens, they are not alone, and in that moment, neither are you.

Grief over family that's passed on, sadness over their sense of lost usefulness, loss of their former and more active pursuits that once gave them so much pleasure all make it more difficult for aging people to emotionally cope with their circumstances. Simply listening with supportive understanding and making meaningful emotional contact can bring them a sense of calm and solace. More than that, though, most of my older clients have the capacity for and can benefit from deeper emotional work. Not always are they aware they are engaged in such work, but my experience has been that it doesn’t really matter whether they are aware of it or not. It can go on, and they can reap the benefits of it nevertheless. Although the person's memory for recent events may be lacking, long-term memory, especially for well-learned actions, events, and knowledge, is one of the last cognitive abilities to decline. By helping them share something important and meaningful about their own lives, you bring into your here-and-now relationship with them the feelings of closeness they have experienced or longed to experience with others. In my view, this is so important in facilitating the growth process.

Geraldine was one of my depressed nursing home patients. Her Alzheimer's was at a moderate stage, and she could not remember my name to save her life. I met with her every week for months, and at every session she had trouble recognizing me. "Its Dr. Sparky," I would say. The social worker at the nursing home who introduced me to each of the residents there liked telling them my nickname, and that's how everybody soon started knowing me. When she would hear this, Geraldine's brow and eyelids would rise ever so slightly. "I'm your psychologist," I would say. I would prompt her recall with a verbal sketch of my role and why we were meeting. With this, you could begin to see her recognition building and she began feeling more at ease with me. I never really knew for sure that she actually was recognizing me, but it really didn’t matter, because she felt more comfortable with me.

As a rule, Geraldine's mood was irritable, she had a cynical view of the world, and she isolated herself excessively. Keeping to herself was a real problem for her, because she had begun to develop sores on her backside from lying in bed so much. When she wasn't in her bed, she was lying in her recliner. Her sores were becoming so severe that the medical staff felt they would soon threaten her life. Despite forgetting who I was and what we had talked about the week before, after a number of sessions together she began to learn that she could trust me. This is not learning that is taking place in the cerebral cortex but learning that new neuroscience research explains is occurring at a subcortical level. One thing was true—I enjoyed her sarcasm, and she could see that. I encouraged her to socialize more with others, to give others a second chance, but it was not my expertise or even my words that made a difference—it was her trust in me that eventually allowed her to risk taking my suggestions to heart.

You see, underneath her rough exterior, Geraldine really was a sweetheart. As she allowed herself to trust me, she learned that she just might be able to trust others as well. As she allowed others to know her, they began to see her sweetness, too, and as she socialized more, her depression began to lift, she spent less time in her bed and chair, and her sores began to heal.

Along with her physical healing, Geraldine experienced a significant emotional healing. Just how emotional healing occurs in therapy is still quite a mystery, but for Geraldine, it seemed to occur at a level that went well beyond what she could articulate in words or what she could remember. In this sense, her Alzheimer's did not prevent her emotional recovery. Her learning seemed to take place not within her cognitive self but as a consequence of how she felt about her relationship with me and, later, with others. Communication with her took place beyond words, beyond logic, beyond conscious thought.

“What I learned from Geraldine was that in psychotherapy, words are overrated—I learned that it is the relationship that can heal.” I have often mused about how insightful my interpretations were in a session and believed how it may have been my pithy comment that was a turning point in the therapy. That seems almost never to have been the case. When my clients recall their own turning points in therapy, it almost never has to do with anything I have said but almost always relates to something I have done or been for them. Being with them in their “staidness” may be the most effective thing I do with my older clients.

This type of healing occurs because an emotional reconciliation is reached within the aging client that has more to do with restored faith, with renewed hope, and with enhanced trust in the world, in themselves, and in their relationships with others than it has to do with cognitive functioning per se. Granted, cognitive decline generates fear, anger, suspiciousness, loss, and any number of other difficult and challenging emotional experiences—but the aging process impairs emotional functioning on a biological level only in its final stages. And that's why many people with Alzheimer's can be comforted and counseled, can feel support from others, and can reach a greater sense of peace with their experience. It's your empathy that eases their suffering. It's your empathy that cultivates their sense of joy in the life they might see they are blessed to be living and can give thanks to have lived.

How Clinicians Get Stuck: Some Emotional Risks in Working with the Aged

For several years, I led a biweekly consultation group with psychologists and master’s-level clinicians interested in learning from their own experience with their elderly clients. Some of what we discussed had to do with gerontology, cognition, testing, contracting, and the like, but much of what we discussed related to the emotional lives of the clinicians when they were with their clients.

Despite the growing evidence on the effectiveness of psychotherapy with the elderly—even with those who have dementia—psychotherapists underserve this population of clients. One of the reasons for this stems from how clinicians defend against the knowledge of their own physical and emotional mortality and the terror of their own vulnerability and dependency. I believe that this is especially true in psychotherapy with the dementia patient, where, in some form, the death of the cognitive self is confronted.

Another reason psychotherapists shy from involvement with older adults arises from the necessity for therapists to manage their own unresolved internal representations of parental and grandparental figures. Much has been written about how the older client sees a younger therapist as a younger (adult) child. When this occurs, the client needs to work through issues within the therapeutic relationship that mirror unresolved issues in the client’s relationship with his or her own children. Younger therapists, especially, can have a difficult time addressing an older client’s provocative comments like “You’re just a kid. What do you think you know about what I am going through?” In the reality of older adulthood—where the older client is increasingly dependent on younger caretakers—the unjustified but prejudicial attitude that older clients can develop toward their younger therapists can be exceptionally challenging.

It is generally understood that psychotherapy occurs within an intersubjective field—where the therapist and the client affects and is affected by the other. At some level, the therapist is always experiencing what is emanating from the client, and the client is always projecting into the therapist his or her needs, fantasies, and stereotypes. And the therapist cannot help but do the same. When skillfully observed, this can lay the groundwork for significant therapeutic gains. The therapy progresses when the therapist is aware of these processes and can use them to move the therapy forward. The less therapists are trained to do so, or the more they are hampered by their own complete internal resolution, the more likely that these processes will be acted out within the therapeutic relationship, and the less likely these processes will be therapeutically worked through. The less therapists are aware of their own projections, the more their idealized and devalued stereotypes of “old age” will unknowingly creep into the therapy, and the meaning they unknowingly assign to “old age” will color their relationships with their clients. Signifiers that should alert therapists that they may be developing distorted attitudes toward their clients are:

• the assumption that an elderly client would not benefit from therapy,
• the assumption that medication would be preferable to psychotherapy,
• the attitude that a client may be too old, too stubborn, or too burdened to benefit from psychotherapy, and
• prominent feelings of boredom, anxiety, or frustration when with a client.

In America, we honor the young for their beauty, strength, and vitality. However, in other places on the globe, old men and women are objects of veneration. This leads to a curious consequence: the less we acknowledge what can be respected, admired, or even venerated in the parents and grandparents of the world, the more we make ourselves orphans who lose a piece of our faith, security, and connection to a past that we risk repeating. This has been part of my joy in working with older adults: I am able to honor them, to sit at their feet, marvel, and learn. As their therapist, I have become their faithful student, their privileged witness, and my life is ever richer because of it.

Footnotes

1 Kraus, G. (2006). At wit's end: plain talk on Alzheimer's for families and clinicians. West Lafayette, IN: Purdue University Press.

2 Bouklas, G. (1997). Psychotherapy with the elderly: Becoming Methuselah’s echo.Lanham, MD: Rowman and Littlefield.