Psychodynamic Perspectives on Aging and Illness

Psychodynamic Perspectives on Aging and Illness Tamara McClintock Greenberg Psychodynamic Perspectives on Aging and ...

Author: Tamara McClintock Greenberg

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Psychodynamic Perspectives on Aging and Illness

Tamara McClintock Greenberg

Psychodynamic Perspectives on Aging and Illness

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Tamara McClintock Greenberg Department of Psychiatry University of California, San Francisco San Francisco, CA USA [email protected]

ISBN 978-1-4419-0285-6 e-ISBN 978-1-4419-0286-3 DOI 10.1007/978-1-4419-0286-3 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2009926038 c Springer Science+Business Media, LLC 2009 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

This book is the culmination of the teaching and writing that I have done over the last several years in which I try to speak about the value of a psychodynamic approach from a practical perspective. Although, when I was a health psychology student, I was trained as a cognitive behavioral therapist, I felt that these approaches were limited in terms of treating patients who struggle with bodily limitations. I was fortunate enough to discover psychodynamic theory in my last year of graduate school, but then had the chance to learn more from my supervisors while in internship about a more nuanced and sophisticated way of understanding the mind. It was not until I landed in San Francisco for my post-doc year, however, that I began to fully appreciate the value of a psychodynamic approach. The teachers here in the San Francisco Bay Area represent not only diverse views of contemporary thought, but also a community of talented and committed clinicians who are striving to understand the ways that they can help their patients to get better. Yet, given my training with medically ill adults, I found that some applications of psychodynamic theory, especially those that represented more traditional forms of thought, did not quite speak about the experiences of my patients who were struggling with the devastating effects of illness as well as the blows of aging. It is these gaps in the theory that have informed my writing and teaching most recently. Although contemporary theories offer the student of psychodynamic perspectives a glimpse into the incredible minds of the authors/clinicians, a common complaint is that much of this writing does not provide access to or understanding of the theory in a way that most people can comprehend. Currently, data show the limits of short-term approaches for complicated patients, which create a need for psychodynamic clinicians to make our work and our ideas more accessible, transparent, and readable. This book attempts to bridge the best of contemporary psychodynamic theory with what I have found to be true for the patients I have treated over the years who have acute and chronic illnesses and who have wrestled with the bodily declines associated with aging. Psychoanalytic and psychodynamic theorists have been hesitant to apply their concepts to people who are aging and/or medically ill. This history will be briefly described in Chapter 1, as well as the real challenges medically ill patients and older adults face, which require us to use a different kind of approach

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that sensitively and flexibly meets the needs of patients. Chapter 2 describes the dilemmas of the modern medical patient in the fast-paced culture of medicine in which technology plays an ever-increasing role in the provision of patient care. The following chapters address the common dynamics of the medically ill and aging, including the normative narcissistic injuries that occur in patients when their bodies stop working, as well as the trauma associated with being a patient with severe medical disease. I will also discuss contemporary ideas of transference and countertransference as well as the curious, but common scenario of people who do not take care of their bodies as manifested through nonadherence and lifestyle behaviors. As working with older adults with cognitive impairment is a new application of psychotherapy, a separate chapter is devoted to this issue and addresses some of the common questions that arise when working with adults with dementia. There are currently a number of competing theories in psychodynamic psychology and modern psychoanalysis. These competing schools have made it difficult for the public to know what we have to offer. Although many forces exist which have made psychodynamic theory a less desirable approach, arguments among experts in the field itself have further plagued its ability to be accepted as a mainstream theory. In other words, if experts in the field cannot agree on what contemporary psychodynamic theory is, how can we expect anyone else to know what we are actually doing with patients? The fact that arguments occur between psychodynamic theorists is in my mind, only somewhat related to the narcissism inherent in all of us. I think that since psychoanalysis and psychodynamic therapy have been threatened, this has led to a sense of loss among many clinicians in the field. The losses are multiple, including but not limited to managed care, desires for quick fixes, and perhaps a newer generation of patients who may want to avoid the complex character understandings we can provide. I see the infighting that occurs as akin to what often results in siblings who are neglected by parents. In the face of absent parents, siblings look for intense emotional stimulation, and this is often expressed aggressively. In other words, if parents are not around, and they are being and feeling neglected, then siblings feel that they have no option but to beat each other up. My aim in this work is to advocate pluralism within the field, as all ideas in the history of psychoanalysis have much to offer as we try to understand and help our patients. And though my stance is more modern, I see great utility in Freudian ideas, as well as ego psychology, even though these theories may not necessarily translate into the technique I use on a day-to-day basis. I am fond of the object relations theorists, self-psychologists and their predecessors who have expanded the psychodynamic literature to encompass a truer and more profound explanation of what actually happens in the psychodynamic relationships we have with our patients. That being said, my intention for this book is that I include many aspects of the rich and varied history of psychoanalysis and psychodynamic theory, as all schools can teach us how to understand and enrich the lives of our patients. Although I argue that more contemporary theories are helpful, there are a number of traditional ideas that have made their way into current ideas, even if in disguised form. Therefore, the reader will find that some chapters embrace Freud while simultaneously critique his limit in scope. Other chapters emphasize self-psychology and its great

Preface

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benefits to understanding the importance of the sense of self in aging and illness, while focusing on the interpretive nature of therapy in the work of Klein and other modern clinicians. Nearly all chapters focus on the importance of the therapeutic relationship, the impact of the here-and-now aspects of relational functioning, and provide suggestions for how to talk with patients using the concepts described. This book is geared toward therapists who are interested in psychodynamic theory, but may have encountered difficulties in graduate school in learning a more nuanced psychodynamic approach. Experienced clinicians will also find this book useful as it strives to provide an applied understanding of many concepts in psychodynamic theory, which have not yet comprehensively focused these concepts on older adults and medical patients. Additionally, patients with illnesses may also find solace in this book, as I strive to make the ideas in the field accessible and transparent to people who want to understand themselves in relation to their bodies. My work in the field has evolved over the years, but has included the privilege of being on the faculty of the University of California, San Francisco, in the Department of Psychiatry. This position has allowed me to learn from medical students and psychiatry residents as well as the cutting-edge aspects of medical education that UCSF offers. Much of the time, however, I am in private practice and I also visit a number of nursing homes each week to see patients. I am grateful and fortunate to have a large number of talented colleagues in the Bay Area who have generously donated their time and energy to comment on ideas in this book as well as to critique specific chapters. Thanks to Heather Bornfeld, Ph.D., Peter Carnochan, Ph.D., Holly Gordon, D.M.H., Scott Lines, Ph.D., Bart Magee, Ph.D., Anne O’Crowley, Ph.D., Steve Purcell, M.D., Owen Renik, M.D., Robert Wallerstein, M.D., and Deborah Weisinger, Psy.D. for generously taking the time to comment on aspects of this work. I also owe a debt of gratitude to the volunteers I spoke to who offered their experiences regarding their ongoing challenges with medical illness. As many of these volunteers were themselves therapists, they helped me to understand how far the field has come from the days of blaming patients for their illnesses, but also how much farther we have to go in order to create a respectful understanding of those who are beleaguered by bodies that do not function as they should. I am also indebted to my teachers and mentors, who over the years influenced my thinking and understanding of how the mind and body work. These people have affected me in ways that they are likely unaware of, but without them I would be unable to integrate the many ideas I have learned. These clinicians include Victor Bonfillio, Ph.D., Marilyn Jacobs, Ph.D., Mary-Joan Gerson, Ph.D., Toni Vaughn Heineman, D.M.H., Maureen Murphy, Ph.D., Wendy Stern, D.M.H., and Steve Purcell, M.D. Also, a special thanks to Michael Zimmerman, Ph.D., who is responsible for my falling in love with the poetry of T.S. Elliot. The young poet as reflected in the imagined (and likely felt) experience of the old man, Prufrock, has spoken to me in ways that surpass any brilliant psychoanalytic paper. Zimmerman’s teaching serves to acknowledge that psychoanalytic theory is one of many ways of understanding human suffering and the unconscious, as literature and poetry has been

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trying to teach us all along about the vicissitudes of aging and human suffering in relation to the sadness in life and the inevitability of death. I am especially grateful for the help of Stephen Brown, my psychology editor, who patiently and competently made my writing more readable. Stephen was an invaluable asset to this project and it was a pleasure to work with him and to gain from his knowledge and expertise. Also Sharon Panulla, my Executive Editor at Springer has not only been a delight to work with, but has bestowed trust in myself as a writer and a clinician. I feel privileged again to be authoring a book with Springer, as I respect their standards and their commitment to publishing works that can enable the furthering of solid academic ideas. Also, my husband, Andrew McClintock Greenberg, M.D., Ph.D., has been a great source of support and has been patient with the demands that writing a book requires. Finally, it is the patients I have treated who are the principal inspiration for this work. My love of work is reflected in their ongoing abilities to educate me regarding the multiple ways in which the mind and the body interact. For this reason and to protect their confidentiality, all cases as reported in this work are based on actual encounters but are disguised, often in composite form, to protect identity. San Francisco, CA

Tamara McClintock Greenberg

Contents

1

When the Body Intrudes: Psychotherapy with Older and Medically Ill Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 1 Psychoanalytic Theory and the Body . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 3 Applying Psychodynamic Concepts to Aging and Medically Ill Patients.. . 6 Aging and the Medically Ill: An Increasing Population .. . . . . . . . . . . . . . . . . . . . 14 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 16 References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 17

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Technology, Idealization, and Unconscious Dynamics in the Culture of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . The Hypomanic Culture of Medicine .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Patient Expectations in Medicine . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Technology and Idealization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Looking for Love (and a Cure): Medical Relationships .. . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

19 21 24 26 30 33 34

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The Trauma of Medical Illness . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . The Mental Health Clinician and Medical Patients . . . . . .. . . . . . . . . . . . . . . . . . . . Medical Illness as Adult-Onset Trauma . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Past Trauma in the Context of Aging and Illness. . . . . . . . .. . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

37 38 45 52 55 56

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Narcissistic Aspects of Aging and Illness. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . The Concept of Narcissism Within Psychodynamic Theory.. . . . . . . . . . . . . . . . The “Midlife Crisis” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

59 60 68 72 73

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Contents

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Transference and Countertransference in Aging and Illness . . . . . . . . . . . . Transference and Implications for Older and Medically Ill Patients . . . . . . . . Countertransference Feelings in Working with Medical Patients . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

75 76 86 92 92

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Self-Destructive Behaviors, Masochistic Dynamics, and Illness . . . . . . . . . Psychodynamic Ideas on Masochism .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Masochism and the Body .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

95 96 98 105 106

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Cognitive Changes and Implications for the Therapeutic Encounter . . Cognitive Impairment in the Elderly .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Normal Physical Changes Related to Aging.. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Psychotherapy with Cognitively Impaired Adults. . . . . . . .. . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

107 108 109 113 117 117

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What We Know and What We Don’t: The Influence of Psychological Factors on Medical Illness . . . . . . . . . . . . . . Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Cancer . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . The Meaning of the Research on Psychological Factors and Medical Risk . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

128 130 131

Hope and Grief: The Introduction of an Emotional Language.. . . . . . . . . Alexithymia: Adaptive Aspects of Psychic Detachment .. . . . . . . . . . . . . . . . . . . . Alexithymia and Hysteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Trauma, the Sense of Self, and Therapeutic Action . . . . . .. . . . . . . . . . . . . . . . . . . . Hope and Grief: Advanced Understandings of Therapeutic Action .. . . . . . . . (Epilogue) Resilience in the Elderly and Medically Ill . .. . . . . . . . . . . . . . . . . . . . References .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .

135 135 138 140 142 144 145

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121 123 126 126 127

Index . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 147

Chapter 1

When the Body Intrudes: Psychotherapy with Older and Medically Ill Adults

In this extraordinary age of advances in medical technology, people live longer than any other time in history. As mental health clinicians, we are now treating a greater number of older and medically ill patients than ever before. These populations: aging adults, medically ill adults, and those who are both older and medically ill, are the subjects of this book. Aging and illness are not always mutually exclusive. Although aging does not necessarily imply the presence of illness, it is an independent risk factor in the development of disease. Additionally, bodily changes that accompany aging are inevitable, and as we age, we are all confronted with the limits of physical abilities. However, naturally occurring physiological effects of aging, emotional reactions to the aging process, and the impact of medical illness vary widely from person to person. Therefore, some sections of this book will address aspects of aging that are distinct from medical illness. As psychodynamic clinicians, we are not only in the position to reduce the psychological distress that accompanies aging or illness, but also we have the unique ability to make sense of the complicated and sometimes confusing emotional states that can result in response to bodily changes and limitations. Consider the following example: Betty is a 79-year-old female who has no cognitive difficulties beyond what would be expected of someone her age. She is in good health, though her vision has declined slightly due to mild macular degeneration. She has no history of mental health problems. However, around the same time that her vision changed, she began having anxiety and depressive symptoms, and her primary care physician observed increasingly guarded behavior. Eventually, Betty began to suspect and then complain that others were entering her apartment while she was gone and stealing her furniture. She spent increasing amounts of time “checking” her furniture to make sure it was not missing. As it was evident that no one was really breaking into her apartment, she developed stories to explain how her furniture had been moved or stolen and then moved back to its original position.

Although Betty’s case sounds dramatic, it is not uncommon for older adults (and sometimes younger adults in cases of serious illness) to present with paranoid ideation in the context of medical problems, aging, or both. Although sometimes paranoia can be a prodrome to age-related cognitive decline and dementia, in some cases paranoia and other regressed states represent a psychological collapse in

T. McClintock Greenberg, Psychodynamic Perspectives on Aging and Illness, c Springer Science+Business Media LLC 2009 DOI 10.1007/978-1-4419-0286-3 1,

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1 When the Body Intrudes: Psychotherapy with Older and Medically Ill Adults

response to illness, aging, awareness of mortality, and/or the fear about and realization of bodily limitations. In many patients, the presence of illness as well as the impact of aging in those who are psychologically vulnerable creates technical challenges for mental health clinicians who at times may expect that patients are easily able to describe emotions and thoughts related to their experience. In Betty’s case, she could not articulate her fear of deteriorating vision (or other losses that eventually made themselves apparent in treatment), but began to imagine that others were stealing from her. Within traditional psychoanalytic (Freudian) theory, it was thought that patients who cannot communicate symbolically are not good candidates for psychotherapy or psychoanalysis. Although many theorists since Freud have addressed some of the challenges in working with less symbolic patients, there are a number of conceptual, technical, and practical difficulties related to medical and aging patients. Though anyone who has difficulty with symbolization can make psychotherapy challenging, patients who are ill and some aging populations present unique challenges. Later in the chapter we will return to Betty’s case as an illustration of how to deal with individuals who have reduced symbolic capacity. This chapter will introduce psychotherapeutic work with medical patients, older adults, and those who are both ill and aging. First, I will briefly discuss some of the problems that have beset traditional psychoanalytic theory and its application to patients in these populations. Next, I will present some of the basic technical and conceptual challenges of working with medically ill and older patients, and introduce some of the major dynamics we find in treating these individuals. Finally, I will suggest that working with ill and aging patients requires us to retain some of the original ideas within traditional psychoanalysis. However, by using a more flexible and modern approach, we can increase the chances of successfully engaging these populations in long-term therapy. Although other therapeutic approaches (outside psychodynamic therapy) have been suggested for working with older and medically ill patients, these methods have limitations that do not fully address many important aspects of psychological functioning, including the influence of the unconscious. Therefore, I will briefly highlight some of the shortcomings of other theoretical approaches to make a case that, despite some of the historical problems with traditional psychoanalytic theory, a modern psychodynamic orientation can be the most comprehensive approach for appreciating the complexities of medical and aging patient populations. The chapter will conclude with the changing demographics of older and medically ill adults and will highlight the emerging need for clinicians to be prepared to deal with both chronic illness and other facets of aging in their patients.

Psychoanalytic Theory and the Body

3

Psychoanalytic Theory and the Body Psychoanalysis1 started out as a theory of the mind that emphasized bodily reactions (hysterical illnesses) that occurred due to psychological conflicts. Freud’s (1927/1961) comment relatively late in his career that “the ego is first and foremost a body ego” (p. 31) illustrates the interrelated relationship of the mind and the body. Freud’s introduction of the theory began with a focus on physical symptoms in women that had psychological causes. Historically, attention to bodily symptoms and illness within the theory has concentrated on psychosomatic illnesses. An illness that is “psychosomatic” suggests that psychological conflicts within patients are complicit in the origin of illness. There are many facets of the history of psychoanalysis and the body that do not bear repeating here, though the historical assumptions about physical illness have left a residue of conflict as well as concern about using psychoanalytic approaches for treating illness. I will review a few key theorists to outline how traditional theory has treated bodily symptoms. Many of the ideas about how psychoanalysis views illness stem not just from Freud, but from research and writing that took place in the 1930s, 1940s, and 1950s. The diseases studied at this time were medical diseases, meaning those with organic physical causes. However, these illnesses were referred to as “psychosomatic illnesses,” and psychological factors and character traits were considered underlying factors in the development of these diseases. For example, Deutsch (1939) described the term organ neurosis as the necessary expression of a neurotic conflict in which a specific organ is recruited to express psychological conflicts. He described a case of a woman with bladder problems as representing her “rebellion against punishment.” Fenichel (1945) stated that unconscious aggression is related to heart and circulatory diseases, whereas Dunbar (1938) claimed that dependency issues were complicit in asthma. Dunbar (1943) and Alexander (1950), who were both studying psychological factors and illness around the same time, were interested in the ability to predict the development of certain medical disorders based on personality profiles. The attempt to correlate specific psychological conflicts with illness was referred to as specificity theory, which postulated that certain physical symptoms are recruited to mange emotional conflicts. Alexander (1950) studied seven types of diseases and concluded that the development of many medical disorders results from repressed conflicts. These diseases included asthma, hypertension, peptic ulcer disease, and rheumatoid arthritis. Alexander developed very specific psychological pathways in which these diseases could develop. Many of these pathways suggested the influence of dependency issues. 1

For ease in delineating traditional versus contemporary thinking within the broad field of psychoanalysis, I will use the term “psychodynamic” to mean the more contemporary practice of psychoanalytic psychology and an acknowledgment of the use of any of a large number of theories that stem from this tradition by a number of contemporary clinicians, including nonanalysts. Throughout the book I will use the terms “traditional theory,” “classical theory,” and “psychoanalysis” to refer to traditional and older theories.

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Specificity theory was ultimately discredited on the grounds of being too absolute (e.g., Paulley, 1991) and because research findings did not support its claims. Other psychoanalytic theorists continued to emphasize emotional difficulties as complicit in medical illness. The term alexithymia, introduced by Sifneos (1973) and Nemiah (1973) in two separate papers the same year, refers to individuals who are unable to use words to describe emotions. The main qualities in those who are alexithymic include difficulties identifying and describing feelings, differentiating between emotional and physical sensations, and those who have a concrete and externally oriented cognitive style (Zackheim, 2007). People who are considered alexithymic tend to present as emotionally flat; it is difficult for others to know what they are experiencing, presumably because they themselves do not know what they are feeling. Alexithymia was originally conceptualized as a predisposing factor for psychosomatic illnesses based on the notion that if one is unable to access feelings and emotions, then these feelings and emotions would be expressed in the body through physical symptoms. Although it is true that some medical patients have trouble accessing feelings (which is often the result of an illness, not the cause), the implication that people who are prone to physical illness are expressing some kind of psychic conflict remains today as a stereotype of psychoanalytic approaches to illness. For example, for this book I interviewed a number of highly educated people with medical illnesses. A constant barrier in these interviews was that when the individuals I interviewed were told that I was writing a book on psychodynamic approaches to illness, they assumed that since I identified myself as a psychodynamic clinician, I must assume that their illnesses were not real. Many of these people said that they understood both traditional and contemporary psychoanalytic/psychodynamic theory to presume that illness is “all in one’s head.” The persistence of these ideas has made a psychodynamic influence in modern medicine difficult and seemingly incompatible. In general, many clinicians and scientists today look upon psychodynamic approaches to illness as “vague, unnecessarily mentalistic, and therefore inimical to scientific investigation” (Duberstein & Masling, 2000, p. xv). Classical psychoanalysis was also initially not considered a useful therapeutic intervention for older adults. Freud (1905) considered the analysis of people over 50 as inappropriate due to a lack in what he referred to as “elasticity of the mental processes” (p. 258). There are exceptions to this exclusion within psychoanalysis, however. As early as 1924, Abraham described the application of psychoanalytic work to older adults. Erikson (1950) characterized self-development occurring throughout the lifespan and discussed important conflicts that need to be resolved well into old age. More recently, there appears to be an attempt to integrate psychoanalysis and psychodynamic principles with older patients. For example, Muslin (1992) and Settlage (1996) wrote on the psychoanalytic treatments of elderly women. Cohler (1998) described the benefits and limitations of working with older adults from a psychoanalytic perspective. Sobel (1980) discussed countertransference issues with elderly patients. Additionally, a new book addresses psychodynamic approaches to both late-life depression and dementia. (Davenhill,

Psychoanalytic Theory and the Body

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2007). In general, however, until recently there has been little psychoanalytic or psychodynamic literature on work with older adults. The field of geropsychology often emphasizes the use of life reviews and narrative therapy as recommended therapeutic interventions with aging populations (e.g., Haber, 2006), as opposed to contemporary psychodynamic approaches. Although Freud discovered how psychic conflicts create physical symptoms, the patients being treated at that time were thought to have physical problems without an organic cause. Very little has been said in the literature about therapeutic approaches with patients with medical problems that are not psychosomatic – those with real illnesses. Traditional psychoanalysis has a long and complicated relationship with its valuation of the reality of external circumstances in a patient’s life, as its theoretical approach has tended to privilege meaning via fantasies over real concerns. Conceptually, the “problem” of reality was never fully resolved within the psychoanalytic school of thought (Renik, 1998), and traditional analysts have been concerned that talking about reality in the sense of actual, concrete events and situations diminishes a patient’s ability to understand their psychic life. Thus, psychoanalysis has de-emphasized real events (Goldschmidt, 1986). The persistence within psychoanalytic theory that many medical disorders are caused by psychological and neurotic conflicts is one example of how reality has not been integrated very well into the theory. Simply put, psychoanalysis has been resistant to considering external phenomena as real, including bodily events, especially illness. Though many events relating to illness and aging are experienced as part of a lifelong history and through a dynamic unconscious, it seems reckless to say that the events, feelings, and experiences that go along with illness and physiological changes do not have an a priori impact, and that there are no universal consequences to aging, illness, and the meaning of death experienced by all people. For example, research suggests that regardless of character type and prior psychopathology, a specific set of symptoms arises in many adults in response to life-threatening trauma (Boulanger, 2002). I include many serious medical illnesses in the category of adult trauma, but I also suspect that universal experiences of illness can be extended to some aspects of aging as well as nonlife-threatening illnesses. When we consider the impact of adult-onset events and take them on as important, independent (of the unconscious) facts, we venture into a different area of psychoanalytic theory. Fortunately, a modern psychodynamic approach to illness allows us to use helpful aspects of traditional theory (concepts such as transference, the process of loss and mourning, and aggression) while integrating newer and more flexible approaches to illness and aging. These approaches will be introduced in the next section and will be addressed throughout the remainder of the book.

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Applying Psychodynamic Concepts to Aging and Medically Ill Patients Classical psychoanalytic theory has avoided in-depth theoretical and technical involvement regarding medically ill and aging patients, which is understandable to some extent. Ageism, the fear of growing older, and the vulnerability associated with illness and dying are likely contributors, as all of us tend to avoid what makes us uncomfortable, a dynamic that affects both patients and clinicians. Additionally, the problem of applying psychoanalytic theory to “nontraditional” patient populations has plagued the field since its inception. Historically, psychoanalysts have treated young, white, middle- to upper-middle class adults who are most often physically healthy. Such patients, it was thought, have ample psychological resources (ego strength) to tolerate the therapeutic process and sufficient capacity for symbolization. Although within the last 50 years or so, psychoanalytic theory has addressed working with patients who are more concrete and lack symbolic capacity, these approaches have not been widely applied to work with patients who have medical problems or who are struggling due to the demands of aging. Many patients who are fraught with bodily demands present with difficulties accessing thoughts and feelings. The body is a concrete arena and individuals experiencing bodily decline tend to be more focused on the physical, rather than the psychological aspects of functioning. This can make it difficult for us to connect with them. As an example, several years ago I was talking with a colleague about working psychotherapeutically with medically hospitalized patients. We were discussing the difficulty of engaging these patients in the psychotherapeutic process. As my colleague put it, “It seems at times if the patients weren’t chained to the bed they wouldn’t talk to you.”2 The point to be made is that for hospitalized medical patients, their relative captivity in the hospital makes it difficult for them to refuse a consultation with a mental health clinician. Additionally, this comment reflects the fact that many medical patients get mental health treatment at the urging of their physicians. Making this situation more difficult, patients often interpret such a referral to mean that there is something psychologically wrong with them or that their physician is concerned about some aspect of their coping or adherence to treatment. These patients are often not being overly suspicious. As I have previously described, because our mental health system is not more integrated and accessible, “difficult” patients are often overrepresented among referrals for psychological treatment in medical settings (Greenberg, 2007). When the body stops working, the individual becomes more concrete. The term concrete has negative connotations within both psychiatric and psychodynamic literature. Here, however, I am using it in a more neutral way. I will discuss in further detail the ideas related to this concept in Chapter 3, particularly how trauma, 2

I am indebted to Bram Fridhandler, Ph.D., for this portrayal of work in medical settings. Many students over the years have benefited from his apt description of the challenges of working with medical patients.

Applying Psychodynamic Concepts to Aging and Medically Ill Patients

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illness, and the long-held notion that traumatic events impact the ability to think abstractly. However, what I mean by concrete is that the focus on the body (in illness) pulls attention away from psychological factors. When attention is removed from the psychological, all of us become more physically oriented and, thus, psychologically concrete. We have less access to our mind’s capacity for reasoning, reflection, and symbolic thought. Simply put, intense bodily demands make it difficult to think. One need only remember the last serious flu they had to recognize this issue. When the body is malfunctioning and one is suffering, it is hard to reflect in a psychological way. Attention is directed toward the body. Additionally, this somatic distraction can affect not only attention, but also concentration and other necessary neuropsychological skills, which makes access to emotional functioning difficult (Duffy, personal communication, August 13th, 2008). This can also result in normative regression in which access to thoughts and feelings is reduced. In some cases regression can become extreme, as in the case of Betty, who could not access her feelings since they were externalized through her paranoia. In other patients, however, regression may mean difficulties in working with doctors, what some physicians perceive as excessive emotionality, or difficulty following a physician’s advice. Although the term regression carries some of the same risks as concrete, I also mean to use regression in a neutral way. We all depend on our physical body for day-to-day support of our normal daily living and activity, so most of us take the healthy functioning of our body for granted. When our body stops working or the use of our body is threatened, this can be “world shattering” (Gordon, personal communication, August 1st, 2008). The shattering of this world, the world of physical liveliness and ability, is threatening because we realize that without a body, there is nothing else. We all are dependent on our body to live. This dependency is a normal one that we all take for granted, as most of us are accustomed to an efficiently functioning body. However, those who lose this dependency are thrown into a world where nothing can be trusted and nothing can be depended upon. Of course this is more pronounced with people who have serious and life-threatening illnesses, but this can also be true of psychologically vulnerable individuals, even if illness is not severe. As I will discuss, these issues create a sense of an inherent lack of safety; it is this lack of safety and security that presents challenges to us as mental health clinicians. Some of these difficulties may explain the apparent popularity of cognitivebehavioral therapy (CBT). Although in my opinion the CBT approach does not fully address the range of concerns and issues present in medical patients, I can understand the reasons why CBT is seemingly compelling. The first refers to the idea that “difficult” or noncompliant patients often get referred for medical treatment within health care facilities. Since noncompliance is estimated to be a problem in half of all medical patients (DiMatteo, Lepper, & Crogan, 2000), these behavioral concerns naturally are often the focus of treatment by mental health clinicians who work in medical settings. When a physician refers a patient for mental health treatment, in many cases it is for the purpose of getting a patient do something (or stop doing something). For example, a clinician might receive a referral for a patient who has fibromyalgia; the physician may suggest that the patient needs to

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“cope better” which often includes a recommendation to exercise more. In such cases CBT may seem compatible; at least the approach makes intuitive sense. CBT uses techniques that encourage not only thinking differently but also addresses health-related behaviors. Ideally, for the referral described, a patient may come in with the expressed desire to exercise more and is asking us to help with that process. However, this is not often the case. The patient may not be willing to exercise and may not take the advice that a CBT approach can offer to help change their behavior and thinking about exercise, even if we (and the physician) think that this is good for them. As mental health clinicians, approaching a consultation with such an agenda risks neglecting what the patient may actually want. I am using this simple example to illustrate that if a patient is willing, a CBT approach may be useful in such a situation. However, many people who have these sorts of issues and problems often do not come to us for therapeutic intervention, even though it would greatly benefit them to do so. Instead, they use other resources in their lives to make changes related to these straightforward goals. This is not to say that we should not talk to patients about health behaviors (and as we will see in that case of Robert in Chapter 2, I will argue that not doing so can be detrimental); however, many medical patients present with very complex issues that go well beyond what a CBT approach can achieve. This may explain why there are no compelling data in the literature to suggest that CBT is more helpful than other kinds of treatment for patients with complex psychological issues. An important paper by Ronald Levant (2004) succinctly describes the problems with CBT research: Many CBT studies include patients with only one Axis I disorder (and in some studies, those with any psychiatric disorder are excluded). Patients with only one Axis I disorder comprise less than 20% of the population; comorbidity excludes more than twothirds of the general mental health patient population. Comorbidity is a major issue when we consider one of the most common mental disorders in clinical practice. Major depression is a common disorder among medical patients and is also subject to comorbidity. For example, over 50% of all depressed patients have at least one coexisting anxiety disorder (Culpepper, 2003). This does not address the number of medical patients who have Axis II issues or disorders; nor does it begin to address the effects of regression, which can result in more concrete thinking. Although CBT approaches are concrete, it is my experience that some patients who have trouble coping due to illness or aging do not have the internal resources or willingness to benefit from CBT. This type of therapy requires a great deal of motivation and energy, which is not often available to people who are overwhelmed with physical problems. My point here is that medical patients present with unique challenges that require a complex approach sensitive to the issue of normative regression. While I am sympathetic to the notion that CBT may be useful for some medical patients, psychodynamic theory offers a needed approach that can help us to understand the complex feelings and reactions that are often observed in medical and aging patients. Let us return our attention to Betty: Betty was very likable initially, though when I tried to ask her questions about her previous life before her vision began to deteriorate, I was met with a strong sense of impatience. She said, “Your questions have nothing to do with my current problem. People are stealing from


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me.” This was followed by long discussions of what her furniture had looked like before it had gone missing. I quickly realized that if I was to keep Betty in therapy, I had to endure long discussions of what her furniture looked like, who the designer was, what period the particular piece of furniture was from, and so on. To my surprise, these discussions proved very fruitful. Over time, Betty told me that not only was her furniture stolen, that it had been defaced, by some “evildoer” who came into her apartment when she wasn’t home. I could then question how her furniture had been altered. Eventually she told me that her roommate and best friend of over 60 years had bought the furniture with her. Betty’s roommate/friend had died only a few months before she began therapy with me. Although she initially resisted my asking about her friend, it eventually became clear that this woman had been the one person Betty could count on in her life. She had no romantic relationships and few friends, so her roommate was her sole emotional connection and source of support. (Several years later in therapy, Betty wondered if had she been raised in a different time if this woman might have been a romantic partner). With some changes to the framework of her therapy (described later), Betty remained in counseling for over a decade, significantly improved her condition, and took several trips abroad. After her paranoia subsided, she was able to use the therapy to discuss her disappointment in how her life had turned out, including her sadness that she had not developed other more meaningful interpersonal relationships.

This vignette illustrates several points about the use of a contemporary psychodynamic approach. Conceptually, the loss of her roommate, as well as the threat of declining vision, had become too much for Betty to tolerate. Her paranoia was a way not only to organize the intensely overwhelming feelings of loss and grief, but also was a way for her to project the anger about these losses into the greedy “evildoers” who were stealing and destroying her furniture. And of course, the loss and vandalizing of her furniture served as an apt metaphor for how she felt at times that her life had been stolen from her. Working with Betty required me to tolerate a number of concrete discussions; at times, the details regarding her furniture seemed meaningless, and I wondered if I could ever be useful to her. Along with this concern was the problem that 50-minute sessions were intolerable to Betty, so we met for only 25 minute though she eventually agreed to attend sessions twice a week, and this continued for many years. Although it may sound as if Betty “bought in” to the idea of therapy, she did not feel that therapy was useful to her for a long time. In fact, she often complained that I was not helping her, that I could not prevent people from stealing from her, and that therapy was a “waste of time.” She frequently cancelled sessions at the last minute. Unlike many so-called neurotic patients, these behaviors were not available to interpretation. In other words, we could not look at these behaviors in way that helped to symbolically understand them, and even after many years of therapy we did not pursue the meaning of these behaviors any further. An issue I have not addressed regarding my treatment with Betty is the familiar psychoanalytic idea of transference. Often considered the bedrock of any classical or even contemporary treatment, transference essentially refers to the dynamic that occurs when we impose our wishes and feelings toward some other person in our adult lives, the feelings originally related to those who were our primary caretakers when we were young. Although I agree about the importance of this concept (which will be discussed in detail in subsequent chapters), I have encountered a number of difficulties in making use of this concept for patients who appear psychologically regressed in the face of severe illness or even for some who are having difficulty with

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the impact of aging. Even in cases when I surmise what kind of transference reaction a patient might have (e.g., in Betty’s case, alternating between idealizing and devaluing me as her therapist), in general, I have not found transference interpretations useful for many older and medically ill patients. Though conceptualizing the transference can be useful, I have found that talking with patients about it, even in the context of a long-term therapeutic relationship, sometimes is not helpful or meaningful to them. I suspect this is because the concrete aspects of aging and illness, and their demands on the body, prevent these kinds of interpretations from being more instructive. In my experience, the therapeutic action for some of my patients and what has seemed to make them better is what Alexander and French (1946) referred to as the “corrective emotional experience.” These authors hint at a process that needs to occur before a transference cure can take place: The principal curative powers of this treatment, however, lie in the fact that [the patient] can express his aggressiveness toward the therapist without being punished, and can assert himself without being censured. This actual experience is needed before the patient gains the emotional perception that he is no longer a child facing an omnipotent father. This type of emotional experience as it occurs during treatment, we call ‘corrective emotional experience’ and we consider it the most important factor in all uncovering types of therapy. (p. 22)

What these authors seem to suggest is that patients need to come to terms with a basic sense of safety before other levels of interpretive experience can take place in therapy. The corrective aspect of treatment is in realizing that close relationships can develop without further trauma. Though this idea is prevalent in many modern-day psychodynamic treatments, I think that the requirement for safety in a person with a failing body makes a basic sense of security difficult to attain. Since this fundamental feeling of well-being may never really be achieved in someone who has a serious and life-threatening illness, we need to employ more patience and time for meanings and themes to occur while simultaneously participating in concrete discussions. In some cases, issues of transference may not get addressed at all. Additionally, it is worth mentioning the impact of dissociation (elaborated further in Chapter 3). Dissociation is a common dynamic of both traumatic illness, and as some authors argue, certain aspects of normal experience. The defense of dissociation is common among medical patients. Though it is true that many patients externalize their feelings when in the midst of coping with aging and illness (as we saw with Betty and her paranoia), Bromberg (1994) explains that what we may be tempted to diagnose as externalizing is often the “presence of dissociated self-state that cannot yet experience intrapsychic conflict” (p. 533). Therefore, while participating in concrete discussions we are helping to facilitate a more cohesive self-state that can help people begin to know what they are thinking and feeling. As Bromberg states, language does not merely carry meaning, but it also serves the purpose of constructing a relational process, which lays the foundation for meanings to emerge. But in the process of talking about things that may seem unrelated to thoughts and emotions, we must tolerate the ambiguity of not knowing when other kinds of meaning and feelings may emerge. Although Betty’s case suggests that these meanings eventually do emerge and can result in significant understanding and healing, as we will


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see in the next case example of Thomas, sometimes they are not fully addressed. So, we need to understand how ambiguity and uncertainty in concrete discussions can be of use. In extreme cases such as Betty’s, access to symbolic thought becomes so truncated that paranoid thoughts (an extreme in concrete thinking) can take over. However, there are other more subtle forms of concrete thinking and regression that affect medical patients. Psychic and physical demands are placed on all of us when our bodies change or stop working effectively. Another challenge in working with medically ill patients who are older is that the current cohort of geriatric patients did not grow up with a normalized idea of psychotherapy. Older adults often feel that seeking therapy indicates some failure in coping or ability to manage “on their own,” and a sense of shame and embarrassment is often associated with this. As a result, many older patients are encouraged to participate in psychotherapy at the urging of family (often adult children) and/or physicians. Though it is true that all kinds of patients are encouraged to seek mental health treatment (such as when a spouse suggests their anxious and depressed partner seeks help), it is my experience that many older patients have trouble both knowing what to expect in therapy and what help we can provide to them. Again, this may not be much different than it is with other kinds of patients. However, many older adults have to work through the shame in needing psychological help, which is related to cohort-based stigma regarding the need for mental health treatment. In order to successfully work with some of these patients, we need to not only allow for a great deal of time and energy describing the process of therapy, but also to be more willing to talk about what is on our minds. Many older patients I see ask me frequently, “So what do you think?” Being prepared to answer this question with a straightforward, sensitive, and honest evaluation of their situation is often required. In some cases this is a discussion that happens in every session during the early phases of treatment. The following example will help to elaborate some of these points: Thomas is a 76-year-old retired policeman who had a successful career and had never received therapy or had mental health problems before. He was referred for therapy at the urging of his son following the death of his wife. Thomas had a number of medical problems, including renal disease and diabetes, both of which were exacerbated following his wife’s death. At times he was noncompliant with his medications. He initially saw a psychoanalyst for psychotherapy. They met a number of times, but the analyst concluded that he was unsuitable for therapy. I met with Thomas shortly thereafter, as his son felt strongly that his father needed “someone to talk to.” He was pleasant and kind, and initially in our first session, denied both psychological symptoms and the need for therapy. I then asked him where he was from. He answered my question, but was more curious to know the same about me, and I replied that I came from the same region. I then asked about his hobbies, and he told me of an active life involving a certain sport. Since I was especially familiar with the sport, I talked with him about my own experience and briefly discussed how my father had pursued similar sports-related interests. We talked for nearly 30 minutes about these topics when he spontaneously became tearful and talked all about his wife. He described his disabling depression and told me he had been considering suicide, and that he had an imminent plan for carrying this out.

My interventions in the first session with Thomas were based entirely on a psychodynamic assessment of him and the issues he was struggling with. Because

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Thomas was used to being “in charge” of many different situations, it seemed crucial that I could provide an environment that allowed him to maintain control. At the same time, it was also vital that I convey a sense of confidence and authority that would match his sense of control in order for him to feel safe and assured of my expertise and ability to be of help to him. I needed to offer an environment where I could be flexible with my use of self-disclosure and could talk about seemingly unrelated or concrete (nonemotional) topics. Although I felt hesitant in discussing aspects of my personal experience, it became clear that this disclosure was essential to his feeling comfortable with me. Though to some extent I feel that I took a risk (as is always the case with self-disclosure), I could tell by Thomas’s reluctance to talk with me that if I did not participate in a concrete conversation, and one that acknowledged some shared interest, I would have not seen him a second time. An additional factor was not what we talked about but rather the fact that I was willing to discuss something other than the obvious topics, his grief and his severe medical illnesses. Thomas’s life ended within 2 years of my meeting him, and it was no secret to either of us in that first meeting that he had relatively little time to live. Yet I did not require that he discuss this with me. As I came to know Thomas and his perception of why his first experience in therapy did not work, it seemed as if his previous therapist wanted Thomas to address narcissistic aspects of his illness and the loss of his wife. Thomas explained that his therapist had made interpretations about his anger and his feelings of unfairness about being left by his wife, as well as having to endure his medical problems and limitations.3 Although I take narcissistic injury seriously (a chapter of this volume is related to this issue), the losses associated with the death of Thomas’s wife as well as his illness were not topics he could tolerate discussing at the time. Although Thomas referred to these issues in therapy (after many hours of discussions related to unrelated topics), anger about his medical condition and his wife’s death, what would be referred to as a full mourning of these losses did not happen in his therapy. And I am not sure that they needed to. Thomas eagerly participated in therapy and his death was not something he had to control through suicide. The last years of his life were spent enjoying time with his family, even though his health increasingly deteriorated. Returning to the therapeutic and technical aspects of Thomas’s treatment, ironically, though I felt that I was very active in his therapy and engaged him in dialog often (even introducing topics for discussion), he continued throughout his treatment to complain that I did not “talk enough.” This was his way of letting me know how difficult it was for him to access his thoughts and his wish that I could extract them from him in order to make therapy easier. In the first several sessions Thomas often said to me, “So, doctor, what do you think?” I answered him as best as I could in terms of what I thought was going on in the moment. For example, I would say something like, “I think you are not feeling physically well today and that maybe that bad feeling is in your mind also.” I did not ever directly interpret the fact that he 3

I am aware of the multiple risks in evaluating a past treatment based on a one-sided account provided by a patient. However, over time I believed that Thomas’s first treatment was not helpful due to the fact that a traditional approach had been utilized with him.


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might want to get away from these distressing feelings, but instead I acknowledged that growing old and being ill is hard and involves many changes. As for conversations about sports and other topics, Thomas’s need for this in therapy waxed and waned, but when he wanted to discuss concrete, external events, I followed his lead without interpreting his preference for these kinds of conversations. In fact, part of Thomas’s therapy involved his need to talk about and imagine himself as the young and successful person he was earlier in life. It was important that I imagined with him that he was the important and vibrant person of his past. This is different than a life review, which is a common therapeutic technique with older adults. What I am describing is not a review of life events as much as it is an intentional collusion of his psychological need (conceptualized as a defense) in which Thomas could pretend that he was still a young, successful athlete. These sessions were a way that he could begin to grieve the loss of his life. This was not an easy process for him. At times Thomas talked as if he had a choice to go back to work. Over time, I was able to say to him, “I think that part of your life is past. I don’t think you will be able to return to work.” These interpretations eventually allowed him to acknowledge that he was no longer this person of his memory, that he was now old, ill, and near death. I was also flexible in terms of the timing of sessions. We always began on time, but Thomas would sometimes request to have shorter sessions; in general we met for 40 minutes, though some days he wanted to end therapy after a half hour. Again, I did not express to him what I thought was the actual meaning of his wanting to end sessions early, which I often construed as his need to escape from painful feelings. A flexible psychodynamic approach helps to address more concrete needs of our patients, as well as dealing with the fact that there are less emotional resources available to many medically ill and some older patients. Individuals such as Thomas do not require that the therapist be available as a “transference object” in the traditional psychoanalytic sense. Rather, our role as therapists is to facilitate a conversation that eventually gets to the core of the emotions within the patient, in a way that they can control, as opposed to their illnesses, which the patient has no control over. In this way we are giving something unique to the patient that they have most likely not received before. Additionally, I am emphasizing the difference between using psychodynamic ideas to conceptualize what issues are salient for a patient, versus interpretive and technical considerations in how I talk to a patient. It is often these interpretive issues that require more adaptation. One way that we can achieve more flexibility is through issues related to the therapeutic frame. By frame, I include issues such as the amount of time spent in sessions, payment, and financial concerns, overt behavior on the part of the therapist, contact with family members and other collateral contacts, in addition to referral process. As we saw with Betty and Thomas, one example of an issue concerning the frame is that some older patients who are preoccupied with bodily change and/or illness are typically not used to a therapy hour in which the therapist is quiet and allows room for reflection. Though a 50-minutes session is the classical therapy hour, many patients cannot tolerate this amount of time to talk about what is on their mind. Additionally, many patients simply cannot bear the idea of a therapist not talking and allowing space for the patient to guide the session. The analytic idea of abstinence, in which the therapist does not

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offer up material for discussion or disclose their own thoughts, creates a very untenable, and at times, intolerable situation for patients. As a clinician myself, as well as many therapists I have supervised over the years, I have tried the traditional (though stereotypical) technique of explaining to patients that it is important for them to talk about what is on their minds, not that of the therapist. This does little to soothe an older or medically ill patient who is uncertain of the therapy process and who might be terrified of emotional thoughts. Patients who are overwhelmed with emotion, unable to access thoughts and feelings due to their physical condition, need a more flexible approach in order to encourage access to symbolic thought. We saw with Betty that allowing for concrete discussions created space for the therapist to get a better understanding of what she needed as well as what losses were responsible for her symptoms. For Thomas, although many more issues could have been explored in his therapy, being flexible and more concrete allowed him to receive much needed support in the last years of his life. With patients who are more concretely organized, I sometimes find that discussing medical symptoms (e.g., focusing on the concrete aspects of the body) can be an avenue for dialog. Surprisingly, though, even getting some medical patients to talk about their physical symptoms can be difficult. Many therapists believe that a lack of willingness to talk about “symptoms” is a contraindication of therapy. However, it is often the case that these patients cannot describe their symptoms because they have difficulty accessing their thoughts in general, and for some who are seriously ill, talking about the body is limited to not much more than vague descriptions. The demands of illness, or in some older people, reactions to bodily changes and loss (including bereavement, common among surviving older adults) make it difficult to focus on their thoughts. This does not mean that these patients cannot focus on their mind, they often just need the right environment for doing so.

Aging and the Medically Ill: An Increasing Population We all are accustomed to hearing that the aging population is increasing and that “baby boomers” will soon comprise a large elderly population. The following summary outlines Aldwin and Gilmer’s findings (2004, pp. 16–19) on these changing demographics: • • • • • •

In 1905 a very small percentage of the population was over 65. By 2010 many more people will survive into their 70s and 80s. By 2030 70 million people will be 65 or older. The fastest growing segment of the population is 85 and older. The 2000 census reported over 50,000 centenarians. People born in 1980 have a 1 in 87 chance of living to the age of 100.

As these statistics suggest, one of the great advantages of living in an industrialized country with the benefits of improved nutrition, access to healthcare, and medical technology is the potential to live longer and healthier lives. Although many

Aging and the Medically Ill: An Increasing Population

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adults are likely to live well into old age with minimal medical problems, many will develop medical conditions and chronic illnesses. However, Aldwin and Gilmer’s research does not reflect that while certain individuals may live longer with multiple medical problems, quality of life may be a necessary sacrifice. Additionally, the sheer number of people with chronic medical conditions is likely to multiply due to the fact that increasing numbers of people are surviving life-threatening illnesses. The Summary Health Statistics for U.S. Adults, National Health Interview Survey for the Year 2005 (U.S. Department of Health and Human Services, 2006) present these dizzying statistics based on the self-reports of Americans for a number of health problems (percentages are based on the number of Americans reporting the condition): Heart disease Diabetes Cancer Emphysema Ulcers Liver disease

11.8% 7.5% 7.4% 7.2% 6.9% 1.4%

Kidney disease Chronic joint symptoms Migraines Hearing problems Vision problems Pain in neck, low back, or jaw

1.7% 27.1% 15.1% 16.8% 9.3% 47.8%

As would be expected, individuals 65 and over are more likely to have reported major medical conditions, though some exceptions to this exist, most likely due to high mortality rates (e.g., the highest rate of people reporting liver disease were those in the 45–64 age group). Overall, however, aging increases susceptibility to illness. For example, in the case of heart disease, incidence of the illness was reported as follows: 4.3% of adults aged 18–44; 13.6% of adults, 45–64; 26.8% of respondents, 65–74; and 75 and older, 36.6% (p. 112). It is prudent to not overgeneralize from these statistics, however, remembering that the effects of illness and their resulting limitations vary widely, based on severity of disease as well as individual responses to the illness and pre-existing conditions. For example, some people with migraines are severely restricted in their activities, yet others function quite well. Furthermore, health behaviors certainly play a role in how individuals manage illness. Again, using heart disease as an example, people who make dietary changes, exercise, and stop smoking (if they are smokers) are likely to have a better prognosis as well as an enhanced quality of life. Alternatively, we must be careful not to overgeneralize about health behaviors, as the role of genetic “bad luck” also influences disease outcomes – we all have heard stories of people who “do everything right” in living a healthy lifestyle who still develop serious and disabling illnesses. The point is that there is tremendous variability in who gets sick and why, as well as how disabled they may become. These issues demonstrate just how complicated it is to treat people who are older and those with medical illnesses. One of the great advantages of an informed psychodynamic therapy is that the therapist can hold on to all these complexities and over time, in the context of a good therapeutic relationship, help patients grasp some of or all these complex ideas.

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Conclusion As clinicians, we will be faced with treating increasing numbers of older and medically ill patients as the population ages and medical technology allows many people to live longer lives. Traditional psychoanalytic theory and treatment have proven to be incompatible with these populations, especially given the current cultural context and views of mental health treatment. However, there are aspects to this theory, as well as a number of contemporary clinical perspectives, that can make the use of a psychodynamic approach valuable for individuals experiencing physical changes and limitations. With such an approach, we can consider adult-onset events, such as illness, as unique factors that can cause particular psychological stresses and reactions. Illness, especially of a severe nature, can make people more concrete in their thinking. This is due to the fact that we depend on our bodies to work well. When a body stops functioning normally, it creates an untenable situation for our natural dependency on it. Without being able to depend on a body to provide the necessary functions that we all expect, regression is a normal and expected result. These reactions require therapeutic interventions that encompass a more active therapist who can use flexibility and tolerance for concrete dynamics that emerge when the body changes or fails. In this kind of endeavor, success in therapy is achieved when a patient can come to understand their own disturbing emotions. Therefore, interpretation (especially of transference) is seen as less useful, as opposed to subtle and nonverbal interventions that encourage the slow acknowledgment of overwhelming and intense feelings. We can do this by intervening through self-disclosure and/or by giving the patient a stronger sense of who we are as therapists, by speaking our thoughts more directly. Establishing a sense of commonality through our conversations in therapy can help to provide a feeling of safety. Interpreting defenses (meaning the ways in which a patient may want to move away from emotional material) is also not as useful for some medically ill and aging populations. Rather, it is more important that the therapist can help to symbolize that which cannot be immediately be symbolized by the patient, the feelings associated with a declining body. In embarking on a psychodynamic approach to illness, it is important to keep in mind that historically, psychoanalytic theory implied that patients are to blame for their illnesses. Of course, this is not the case, but aspects of early psychoanalysis are responsible for the perception that a psychodynamic approach does not appreciate “real” aspects of medical illness. However, given the alternatives, it is hard to imagine a theory better suited to working with this population. Psychodynamic theory creates an environment in which patients can access multiple facets of emotional functioning, with the aim of increased understanding and tolerance of emotions, and an appreciation of how unconscious dynamics may inform experience. Although unconscious motives are always at play, a more contemporary approach involves taking seriously that adult-onset events, such as medical illness, have unique aspects. Regarding the implication in psychoanalytic theory (either explicitly or implicitly) that patients are to blame for their illnesses, it is also important to mention that concerns about how illnesses are caused and the role of individual responsibility is often on the minds of medical patients. This issue is complicated, as blaming

References

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oneself for illness has many psychological meanings, which will be discussed in subsequent chapters. Adding to this complexity, as we will see in Chapter 8, medical research has demonstrated that there are psychological factors that influence the course and in some cases the development of illness. This is due to the fact that certain psychological states have physiological consequences and can create additional risk factors for disease. The research in this area is ever expanding, and we will undoubtedly discover much more about the physiological mechanisms that explain these associations in the future. In light of this research, it is even more important that we use psychodynamic approaches without causing patients to feel blame. Our job as therapists is to help patients feel safe enough to know their thoughts and feelings about aging, bodily change, illness, and whatever other issues they bring to psychotherapy. The rest of this volume will address the ways in which we might think about patients from a psychodynamic perspective that address the complicated psychological issues that arise when one’s body changes or stops working, with the hope that the psychodynamic perspective can enrich the lives of patients and their loved ones.

References Abraham, K. (1924). The applicability of psychoanalytic treatment to patients at an advancing age. In Selected papers on psychoanalysis (pp. 312–317). London: Hogarth. Aldwin, C. M., & Gilmer, D. F. (2004). Health, illness, and optimal aging: Biological and psychosocial perspectives. Thousand Oaks, CA: Sage. Alexander, F. (1950). Psychosomatic medicine. New York: Norton. Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principals and Applications. New York: The Ronald. Boulanger, G. (2002). The cost of survival: Psychoanalysis and adult onset trauma. Contemporary Psychoanalysis, 38, 17–44. Bromberg, P. (1994). “Speak! That I may see you”: Some reflections of dissociation, reality, and psychoanalytic listening. Psychoanalytic Dialogues, 4, 517–547. Cohler, B. J. (1998). Psychoanalysis and the life course: Development and intervention. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.) Clinical geropsychology (pp. 61–78). Washington, DC: American Psychological Association. Culpepper, L. (2003). Use of algorithms to treat anxiety in primary care. Journal of Clinical Psychiatry, 64(Suppl. 2), 30–33. Davenhill, R. (2007). Looking into later life: A psychoanalytic approach to depression and dementia in old age. London: Karnac. Deutsch, F. (1939). The choice of organ in organ neurosis. International Journal of Psychoanalysis, 20, 252–262. DiMatteo, M. R., Lepper, H. S., & Crogan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment. Archives of Internal Medicine, 160(14), 2101–2107. Duberstein, P. R., & Masling, J. M. (Eds.). (2000). Psychodynamic perspectives on sickness and health. Washington, DC: American Psychological Association. Dunbar, F. (1938). Psychoanalytic notes relating to syndromes of asthma and hay fever. Psychoanalytic Quarterly, 7, 25–68. Dunbar, F. (1943). Psychosomatic diagnosis. New York: Hoeber. Erikson, E. H. (1950). Childhood and society. New York: Norton. Fenichel, O. (1945). The psychoanalytic theory of neurosis. New York: Norton.

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Freud, S. (1905). On psychotherapy. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 265–268). London: Hogarth. Freud, S. (1961). The future of an illusion. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 21, pp. 3–56). London: Hogarth. (Original work published 1927). Goldschmidt, O. (1986). A contribution of the subject of “psychic trauma” based on a course of a psychoanalytic short therapy. International Review of Psychoanalysis, 13, 181–199. Greenberg, T. M. (2007). The psychological impact of acute and chronic illness: A practical guide for primary care physicians. New York: Springer. Haber, D. (2006). Life review: Implementation, theory, research and therapy. International Journal of Aging and Human Development, 63(2), 153–171. Levant, R. F. (2004). The empirically validated treatments movement: A practitioner/educator perspective. Clinical Psychology: Science and Practice, 11(2), 219–224. Muslin, H. L. (1992). The psychotherapy of the elderly self. New York: Brunner/Mazel. Nemiah, J. C. (1973). Psychology and psychosomatic illness: Reflections on theory and research methodology. Psychotherapy and Psychosomatics, 22, 106–111. Paulley, J. W. (1991). Specificity revisited and updated. Psychotherapy and Psychosomatics, 55, 42–46. Renik, O. (1998). Getting real in analysis. Psychoanalytic Quarterly, 67, 566–593. Settlage, C. F. (1996) Transcending old age: Creativity, development, and psychoanalysis in the life of a centenarian. International Journal of Psychoanalysis, 77, 549–564. Sifneos, P. E. (1973). The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22(2), 255–262. Sobel, E. F. (1980). Countertransference issues with the later life patient. Contemporary Psychoanalysis, 16, 211–222. U.S. Department of Health and Human Services. (2006). Summary Health Statistics for U.S. Adults, National Health Interview Survey, 2005 (Series 10, No. 232). Hyattsville, MD: Author. Zackheim, L. (2007). Alexithymia: The expanding realm of research. Journal of Psychosomatic Research, 63, 345–347.

Chapter 2

Technology, Idealization, and Unconscious Dynamics in the Culture of Medicine

If I’d known I was going to live so long, I’d have taken better care of myself. Leon Eldred

The miracles of modern medicine seem endless. Diseases that were once debilitating or life threatening can now be prevented or cured through antibiotics, surgical procedures, and advanced medical technology. The growing population of older adults can serve as a reminder of how much medicine has changed. For example, those over 70 remember a time when people commonly died of infectious diseases, as antibiotics have only been widely used since the 1940s. Not only are many illnesses now curable, but also the ability to prolong life has changed dramatically. Intubation, advanced resuscitation, and medications used to control blood pressure in intensive care units, which literally keep people alive, have not only saved lives but have also dramatically changed the way people live in the weeks and days before dying. Although some of these life-extending mechanisms do not actually improve quality of life (medical ethicists continually debate the acceptable use of life-extending measures), overall, medical advances combined with improved nutrition and enhanced quality of life have led to longer and healthier lives for many.1 However, advances in medical science and technology raise a number of important and unique issues that will undoubtedly require increased attention, as our patients get older. Consider the following case example: Betsy is a 97-year-old woman living in an independent apartment within a long-term care facility. She was referred for psychological treatment because she mentioned to her physician that she was considering killing herself and wondered if her physician could provide her with information about how to go to Oregon to receive assisted suicide. Betsy was in good health with normal to above average cognitive abilities. When we met, she told me that she was “stunned” to still be alive. Although she was aware of longevity in her family,

1

Better medical care unfortunately has not meant better access to medical care, especially for the over 40 million Americans without medical insurance. I am also not addressing the fact some marginalized populations (e.g., Latino/Hispanic, African-American, Native American) receive inadequate medical care. An in-depth discussion of these issues is beyond the scope of this volume, but will be addressed less directly in subsequent chapters.


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2 Technology, Idealization, and Unconscious Dynamics in the Culture of Medicine she commented that, in her generation, it was never expected that one would live well into their 90s. When asked if she was able to take any pleasure in her good health she replied: “I look around and see what is ahead of me, and I don’t want to be disabled. What if I have a stroke or something, then what? If I kill myself, I am quitting while I am ahead.”

Betsy’s situation is illustrative of one kind of suffering in older adults. Living a longer life carries with it a number of complications and risks for the development of new conflicts, as well as the re-emergence of psychological issues that are related to emotional functioning and attachment. Although Betsy’s story has many more facets to it, including a deep fear of dependency, her situation raises a number of familiar issues that affect those who live into their 80s, 90s, and those who live to be 100 or more. The first is the genuine shock of living so long. At the time of Betsy’s birth in 1911, the average life expectancy for both men and women was 51.49 years (National Center for Health Statistics, 1999). Today’s average life expectancy is 77.8 years (National Center for Health Statistics, 2007). As we saw in Chapter 1, it is now more common for people to live well into their 80s, with an increased likelihood of living longer. As suggested earlier, people in this generation have often had the experience of losing loved ones to common disease. Second, although it might be easy for those of us who are younger to speculate that people such as Betsy should be happy to be alive and in good health, it is not uncommon for patients to express a feeling of cruel irony associated with such a long life: Some people who are healthy and cognitively intact well into old age are fully aware of the potential ills that could happen to them, as they have seen countless friends and family succumb to dementias, cardiovascular diseases, and other ailments. Many of my older adult patients have talked about wishing they would die quickly, to avoid the fate of people they know who have strokes or dementias, as they have seen these others live on in a state of limbo, hovering between life and death. One only has to visit any skilled nursing facility where there are a number of incapacitated adults who are solely dependent on others’ care to appreciate and understand this fear. However, the greatest apprehension expressed by many of my own patients is that they will remain cognitively intact in the face of severe physical impairment. They worry intensely about being aware of their own impairment, while powerless to do anything about it. Their peers who are demented and confused suffer a great deal, but their suffering can be muted by episodic confusion.2 Those with mild cognitive impairment, or even normal agerelated changes, can be especially worried about losing even more of their cognitive and physical abilities. This is a realistic fear. The longer people live, the more likely they are to develop medical illness. The ability of medical technology to prolong life, as well as the ever-increasing aging population, creates a number of issues that are new to many of us as mental health clinicians. 2

I am risking overstating the case by suggesting that people who experience confusion associated with dementias do not suffer psychologically. This is not true; those with dementia do suffer, are aware of their confusion, and can benefit from psychotherapeutic interventions to help address this suffering. I have found however, that patients who do not experience confusion and are aware of their physical and cognitive impairment can be more vulnerable to fear of disability as they often experience constant reminders of far worse scenarios.

The Hypomanic Culture of Medicine

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This chapter will address aspects of an increased lifespan as well as medical technology in the current landscape of contemporary healthcare. In particular, I will address hypomania and idealization in the culture of medicine, how these dynamics are both fueled by and the consequence of technological advances, and how they affect both doctors and patients. Conversely, I will also discuss the related issue of the devaluing of medicine and medical practitioners. Changes in modern medicine, including the emergence of advanced medical technology, exacerbate expectations from patients and reactions to physicians. Given the changes in both life expectancy and medical technology, it is also easier to expect more from physicians and to devalue them and the medical system. Increased pressure is felt by all who are involved in the modern medical encounter. These dynamics as well as the idiosyncrasies inherent in the culture of Western medicine create conditions for both patients and physicians that eventually lead to disappointment, frustration, and a sense of helplessness. There are also increasingly unique challenges for mental health clinicians in talking to patients about the difficult feelings associated with a long life, feelings about their relationships with physicians, as well as their feelings associated with bodily failure. Indeed, many patients present as expecting definite and clear answers to complicated questions.

The Hypomanic Culture of Medicine The fast-paced, energetic, aspects of medicine in this country can be characterized as being “hypomanic.” Although referring loosely to the familiar Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria of hypomania, my approach is more akin to the ideas of Melanie Klein and what she called “manic” defenses. Briefly, Klein described manic defenses as when idealization, feelings of being powerful, and hyperactivity are employed to ward off sadness, worries about aggression, and ambivalence (Klein, 1940). In other words, manic defenses are used to avoid difficult feelings. Although Klein construed manic defenses in a developmental context and felt that some people who have particular difficulties rely on these defenses extensively, here I am referring to the common and sometimes adaptive use of manic defenses, hence the use of the term hypomanic. Even minimal experience in the medical profession inevitably leads one to appreciate the consequences of a hypomanic culture. Particularly in hospitals, people talk fast, move fast, and think fast. Many people who work in healthcare are constantly engaged in goal-directed activity. Even in outpatient settings, patients remark that they spend only 5–15 minutes with their physician and commonly complain that doctors are rushed and pressed for time. This kind of pressure and a speed-driven culture has a rational component; when a patient is critically ill, physicians and medical staff need to move quickly in order to administer urgent care, which could be life saving. Additionally, many physicians, especially those who work in inpatient settings, are chronically sleep-deprived due to the demands inherent to call schedules, long work hours, and other personal and

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2 Technology, Idealization, and Unconscious Dynamics in the Culture of Medicine

professional responsibilities. In the outpatient setting, physicians are often tightly scheduled with the obligation to see a large number of patients in a limited amount of time. Medicine has changed dramatically because modern physicians can offer a higher quality of treatment and care to patients than in the past. One hundred years ago, physicians had little to offer patients in the way of a cure, so instead they provided comforting words and a personal rapport. As medicine has advanced, the kinds of interpersonal connections within medicine have changed as well. Winnicott (1966) described the way he experienced changes as a result of a more modern medical practice: It is a sad result of the advances in modern medicine that there is no personal clash between patient and doctor as whole persons; there is a visit to the doctor, a disease process found, treatment is given, and the disease is cured, but no one has met anyone, no one person has bumped into another person. (p. 183)

Many people experience lack of interpersonal connection in the present-day medical encounter. Medicine demands a great deal from its practitioners and a hypomanic style in the personalities of medical professionals can be viewed as a kind of acculturation to seemingly endless demands. On the other hand, the perpetually fast pace in medical facilities also reflects a tendency and desire to not engage with patients in an emotional way. The tendency to act vs. think was articulated in this way by Linsk (1993): “The dominant response to a presenting illness is to do something ‘don’t just stand there, do something’” (p. 174). Doing something (i.e., acting in a concrete way to solve a problem) is the dominant response to medical issues in this country. One way that this is manifested in medicine is through the prescription of medications to alleviate or manage disease. Although medications are very important and in some cases life saving, it is also evident that behavioral interventions can diminish the impact of certain illnesses and can reduce the need for the use of medications, especially for conditions such as hypertension, Type II diabetes and high cholesterol, to name but a few. Interestingly, it seems that physicians in the U.S. are less likely than doctors in other parts of the world to spend time talking with patients about certain nonpharmacological aspects of medical care. For example, research suggests that American and British physicians diagnose illness in the same fashion, but American doctors are more likely to prescribe medications, and less likely to suggest lifestyle and behavior changes (McKinlay et al., 2006). Additionally, a recent study suggests that discussions about lifestyle and behavioral change comprise about 10% of the encounter between patients and physicians (Ory, Peck, Browning, & Forjuoh, 2007), and another study found that patients are insufficiently counseled or provided with educational information about diet, exercise, and smoking cessation (Heaton & Frede, 2006). Why American physicians may be less likely to discuss behavioral changes with patients is a complicated matter that involves the psychology of both patients and physicians, as well as systemic aspects of our medical system. However, it is likely that the high rates of noncompliance (not following the advice of one’s physician) play a role in the provision of medications in medical practice. Noncompliance, now often referred to as “nonadherence” in an attempt to sound less pejorative, is

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a common phenomenon. Some estimates suggest that almost half of all medical patients in the U.S. do not adhere to medical advice regarding the prevention or treatment of disease (DiMatteo, 1994). One can imagine how difficult it must be to be a physician who spends most of their day advising patients on treatment and knowing that some patients will not follow medical and behavioral guidance. If a physician suspects that about half of their patients may not listen to their advice, perhaps the benefit of behavioral counseling may not seem to outweigh the time it takes to talk with patients about changes to their lifestyle and health behaviors. It may seem easier and more efficient to simply write a prescription. For example, in the case of high blood pressure, prescribing an antihypertensive medication takes less effort than providing behavioral counseling about exercise, weight loss, and reducing salt intake, which are all factors that can lower blood pressure. Research supports this idea. A recent study concluded that most Americans have decreased adherence to the dietary approaches to stop hypertension (DASH) diet, which has been found to reduce systolic blood pressure (Mellen, Gao, Vitolins, & Goff, 2008). However, it is unclear how many people receive counseling regarding the DASH diet. Another study reported that among physicians, counseling patients with hypertension regarding lifestyle habits was limited (Bell & Kravitz, 2008). Although one can appreciate the reluctance of physicians to counsel patients on behaviors that they suspect will not be followed through on, the practice of solely prescribing medication is one of many ways that physicians and patients alike become dissatisfied with the quality of medical care. And though it is true that many patients do not comply with lifestyle recommendations, the tacit message when physicians do not try to explain that patients can control some medical problems through behavioral changes is one of skepticism, doubt, and perhaps even cynicism. This creates a scenario in which patients may feel infantilized, devalued and that they cannot be trusted to take responsibility for their health. For physicians, however, talking with patients takes a lot of time. Both medical research and popular literature frequently remark that doctors feel they are under increased pressure for demands on their time and that practicing medicine is not as gratifying as it used to be.3 However, the behavior of prescribing versus talking also reflects the hypomanic style that is present in contemporary healthcare. Moving quickly from one patient to another, solving one problem and moving on to the next, quickly coming up with a plan to treat an illness, and then attend to more severely ill patients is the current practice in modern medicine. Current medical practice in America often has the result of patients feeling objectified, that their problems do 3

There are a number of changes in medicine that have dramatically affected the culture of medical practice and eroded away the feelings of emotional and financial security physicians once considered integral to their profession. Although these changes are important to the present discussion, I have previously described how these changes affect physicians and result in increased pressure for both doctors and patients (Greenberg, 2007). I am also refraining from elaborating on how the medical financing system in this country (and the urgent need for healthcare reform) has added to the burden. These issues have been documented elsewhere in detail in the popular medical literature. For example, Cohn (2007) describes our current health care crisis though the eyes of patient experiences.

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not warrant appropriate time and attention, and that their provider should simply fill their prescription and leave them be. Although physician variables and the culture of medicine play a role in how patients feel about the medical encounter, it is also useful to consider ways in which patient variables affect interactions with physicians. Although our medical system is plagued by problems related to reduced access to quality care (especially for the disadvantaged), less time for interpersonally meaningful interactions with their doctors, the increasing intrusiveness from insurance companies that affects both physicians’ decision making and the treatment patients receive, there are also issues that patients bring to the encounter. Many people get caught up in the hypomanic components of medicine for varied and complicated reasons. Again returning to the idea of medication prescribing, it is the case that a number of patients expect to be cured through pharmacological interventions and do not want to have to do the work of changing health behaviors. This is one way that medicine is idealized. The idea that one can simply take a pill to treat a problem can feel like an easy solution and that responsibility for one’s health is in the hands of an all-powerful physician. However, for many medical conditions, even pills do not offer cures unless health behaviors are addressed. Expectations among patients complicate medical relationships further.

Patient Expectations in Medicine The issues around prescribing medications serve as an apt metaphor for the ways in which individual psychology interacts with the culture of medicine. We all expect our doctors to make us feel better. Many people are accustomed to expecting a prescription when ill. Taking a pill can be a soothing and concrete experience, which can make us feel that we are actively doing something to help ourselves “get better.” This is an understandable response and is akin to when a parent puts a band-aid on a young child to help their child feel better, even when it is not necessary. When a doctor counsels a patient to change their dietary habits, engage in an exercise routine, quit smoking, or make other behavioral or lifestyle changes, this requires much more effort than simply taking a pill. The issue of behavioral change in medicine is complex and historically has not been described in the psychodynamic literature. In fact, within traditional psychoanalysis, discussing issues and events “outside” the analytic setting was discouraged and thought to be merely a tactic to avoid important unconscious dynamics (e.g., Gray, 1973). Clearly, this is erroneous, for modern psychodynamic theory does not hold such a rigid stance about discussing “outside” concerns. Health behaviors such as smoking, drinking excessively, physical inactivity, and diet are important aspects of the psychodynamic encounter and factors that we should not only be informed about, but should consider actively discussing with our patients. An example of how I failed to address these issues early in my career and the consequences may serve to illustrate this point.

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Robert was a 49-year-old man who came to see me for chronic pain and depression related to a number of failed back surgeries. He was difficult to engage in treatment and found the “space” afforded to him in a 50-minute session to be difficult. He wasn’t sure what to discuss and attempts to engage him in talking about his current family or relational life were strained and awkward; talking about his early family life was even more problematic. Despite this, he remained in therapy for many years and eventually achieved a measure of control over his pain, though he remained on disability leave due to the extent to his injuries. I noticed that over the course of about a year, Robert gained about 15 pounds. Although I was aware of this weight gain and made vague references about exercising (as this was part of his regimen for managing his pain), I never addressed the issue of his weight directly, and I never asked about his diet. Although through modern-day transference interpretations, I tried to discuss his difficulties in feeling responsible for his health, these interpretations were not meaningful to Robert. For example, I tried to address his sense of “waiting” for a cure and his feeling that others should be responsible for his health. Robert reported one day that he was urinating excessively and was planning to see his physician. Following that visit, Robert told me that his blood sugar was extremely elevated and that he was diagnosed with Type II diabetes. He told me that his physician informed him he was consuming too much sugar; for example, he drank three cups of coffee a day with five teaspoons of sugar in each cup.

Although it is likely that had I been more proactive in addressing Robert’s health behaviors the outcome would have been no different (as he later demonstrated that he did not want to proactively address his health), I use this example to illustrate the difficulties of addressing health behaviors in treatments that may have more of a psychodynamic influence. Since his health had become relatively “stable,” and the focus of therapy was on his on-going depression, I was unclear about whether or not I should make his weight an issue of treatment. As I had begun a more psychodynamic treatment with him I had been loosely following the “rule” of free association, the idea that what gets discussed in therapy is what the patient brings forth, what is on the patient’s mind, rather than that of the therapist. This idea, which is rooted in traditional psychoanalytic theory, is meant to allow space for transference to develop. Although the concept of transference will be described further at the end of this chapter as well as Chapter 5, for more concretely oriented patients such as Robert transference interpretations are not particularly useful, especially in the absence of patient-reported anxiety. Robert was not aware of anxiety. His focus tended to be more external. And although he dutifully came to therapy, Robert frequently “reported” to me the events of the previous week and there was little room for me to intervene. My passivity in Robert’s situation did not allow confrontation for what turned out to be an emerging health problem and overall difficulties in taking care of his body. Though my “miss” regarding his weight was a way that I could understand more about how Robert avoided thinking about his health. It seems likely that my not addressing his weight was in effect in collusion with his own defensive system. Robert struggled with a deep denial of his own responsibility for his health. He felt angry and cheated by the surgeons who performed his back surgeries and that these procedures did not result in more symptomatic relief. It is often anecdotally noted that some people who seek out multiple back surgeries are looking for cures that may not exist. Millions of people suffer with back pain and not all of them ask for surgical treatment. The fact that Robert had several back surgeries does not prove

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that he did not want to take responsibility for his own health. However, it added credibility to the hypothesis that Robert wanted an external cure to relieve his back pain. Throughout his treatment he struggled to take care of himself in a number of ways. Over the next several years, Robert had other health problems that were not addressed and he was very noncompliant with many forms of treatment. He seemed to be caught in an unending cycle of seeking out physicians for medical problems and then refusing to cooperate with treatment, feeling that the treatment options were not suitable for him because he was not well understood by his medical clinicians, whether or not treatment involved major behavioral changes. This was one reason his pain had persisted; less intrusive options than surgery were offered to him, but he refused, expressing that he did not want to feel any pain or discomfort from the procedure. Over time, it became clear that Robert wanted to be taken care of and that he wanted the responsibility for his health to be a problem that others would address. He wanted to be taken care of, but his anger about this desire was externally oriented in his medical and mental health caretakers, who were never able to help him to his satisfaction with his pain and suffering. Robert idealized the potential for help within modern medicine, but when he did not get the cure he hoped for, he devalued this potential, which he ultimately used to justify his noncompliance. Since medical patients often present with more concrete issues, which are reinforced by a materialist medical system, it can be hard for psychodynamic clinicians to know how to interpret physical and psychological suffering and the impact of this suffering on health behaviors. Traditional psychoanalytic approaches have focused on addressing transference, yet with patients such as Robert, we need to develop a new approach and integrating ideas related to health and health behaviors can be one way to participate in conversations about the body, with an aim toward understanding the workings of the mind. Perhaps in part due to the sometimes over aggressiveness in medicine, we feel the pull of not wanting to be overly assertive with our own agendas and wanting to focus on what the patient feels is important to discuss. For Robert and I, once we were able to discuss in more detail his thoughts about needing to take care of himself we were able to identify feelings of anger about having to be responsible for his health and his wish that others could do this for him. In terms of transference interpretations, the last case in this chapter should help with understanding when transference interpretations are useful, as the presence of anxiety is often a key for knowing how and when to interpret the muddy and complicated transference issues patients present.

Technology and Idealization Considering his specific issues, one might surmise that the negative and hypomanic aspects of the medical system in this country would be a perfect complement for someone like Robert. For people who are focused on the body, hope for more concrete solutions, and expect to be frustrated and disappointed by others, the medical system can be a perfect fit. Modern medicine offers cures, and even in cases in

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which treatments are not good enough, many patients (and physicians) never have a real discussion about the limits of medicine and where personal responsibility should override medical interventions. The illusion of unlimited capacity for cures is one component of a hypomanic medical system (e.g., physicians who have trouble admitting to patients the limits of medicine) and can be reflected in those patients who want a cure, but cannot really imagine how to navigate the difficult sacrifices and frustrations that involve the work toward better physical health. Hypomania is seductive; whether we employ hypomanic defenses ourselves or get drawn into a hypomanic system, we are putting ourselves at risk of avoiding our emotions and denying our limits and responsibilities. Denial and related noncompliance are aspects of how a hypomanic medical culture can interact with patient dynamics, especially when patients have difficulties taking care of themselves. Some physicians may feel so frustrated with noncompliant patients that they themselves may rely more on relatively easy, concrete solutions such as prescribing medication as a way to treat a large number of patients who may not be able to change behaviors in order to manage common medical conditions. Of course, one would not expect that a physician would ignore a patient’s high blood pressure when they cannot make behavioral changes; medication is needed in order to prevent more serious medical consequences. In addition to the development of sophisticated medications, other kinds of technological innovations have dramatically changed the landscape of the medical encounter. Although there are many legal, ethical, and psychological implications to the phenomenal advances in medical technology, an important psychodynamic issue is how technology has taken a role in the provision of patient care. To use the example of heart disease (the current leading cause of death in men and women in industrialized nations), in the past, a physician might have spent considerable time talking to a patient about their health behaviors. Today, highly sophisticated technological equipment has dramatically changed the field of cardiology, in that procedures are now rapidly employed for patients with acute cardiac events. For example, cardiac catheterization, in which a cardiologist places a catheter into the arteries that supply blood flow to the heart in order to identify significant narrowing of the arteries, now has a central place in the treatment of heart disease. Though some cardiologists still talk with patients about health behaviors, they now also engage in more physically aggressive treatments to deal with the symptoms of heart ailments. This puts cardiologists in a different position than in the past. For example a recent patient received a cardiac stent to prevent further narrowing of an artery. He reported that his cardiologist did not discuss needed dietary changes that will help prevent the worsening of his heart disease. Although this patient is compliant with his medications, he was unaware (until he and I discussed it) what kind of diet is optimal for someone with heart disease. As this example suggests, procedures such as cardiac catherization may replace the priority of talking with patients who have heart disease about their health behaviors. In an ideal world, cardiologists and other physicians who deal with patients with heart disease and other serious illnesses might also be available to talk with patients not only about diet and health behaviors, but also about the emotional distress associated with their disease. Sadly though, with the advent of modern medical technologies,

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extensive consultations with patients are less likely to occur. It is more common that the increasing role of technology makes physicians less able to act in a talking role. This is different than other times in the history of medicine when the doctor–patient relationship was primary. Advances in technology have not only changed the role physicians play in the lives of patients, but have also changed the expectations of patients. Many people feel that medications and technology can treat most medical problems, and of course this is true. However, this too often leads to the assumption and desire that medical problems can be easily solved through medications and medical technology. This is not necessarily true. Cancer patients may be able to be cured, but they have to undergo painful surgeries and treatments such as chemotherapy and radiation, which have very unpleasant side effects. Patients can receive solid organ and bone marrow transplants, but the side effects of these procedures as well as the often drastic behavioral modifications some people have to make serve as a reminder that technology and medical treatments are still difficult, painful, and require an active effort on the part of patients. Modern medicine has increased the capacity to extend life; however, many patients expect even when ill quality of life will not be sacrificed. Though it is true that many patients can have a long life despite severe illness, the following case demonstrates in more detail how patients feel regarding quality of life limitations: Joan is a 78-year-old woman who was transported out of Germany in the early days of the Nazi occupation. Several of her family members perished in concentration camps. Though she had a good life in the United States, she developed severe kidney and heart disease in her early 70s. She had a number of “close calls” and almost died several times in intensive care units. Many advanced life-saving methods were used to keep her alive. Though living, Joan had a number of physical limitations that included dietary restrictions, difficulties socializing with friends (as many days she could not get out of bed), and intense physical pain and discomfort. As a highly self-sufficient woman, being limited due to her disease was demoralizing: She hated dialysis treatments, she disliked having to limit her diet, and most of all she resented the physical effects of her disease, which included painful swelling in her hands and feet as well as frequent nausea. She needed a caretaker to help her get dressed as well as bathe and to use the bathroom. When I spoke with her physician about her case, and remarked that Joan felt burdened and depressed by her disabilities, her doctor told me about all of Joan’s close calls while hospitalized and suggested that Joan was expecting too much. He then said, “We saved her life, what does she want?” Joan’s feelings were much different, however. She wanted to feel better. She felt angry to be alive in such an impaired state and felt especially cheated that she could not enjoy the foods (particularly those that were high in sodium) that she had previously preferred. In the context of her traumatic background, Joan felt that her kidney failure and heart disease was an unceremonious end to a life in which she had survived seemingly far worse trauma.

Joan felt that although she was alive, the life she led was not really “living,” and of course, these feelings are valid and understandable. Her life, compared with how she knew it before, had been extremely comprised. Not that long ago, Joan would have died from her illness. Medicine prolonged her life and the extension of Joan’s life is an example of a new generation of older patients. Not only is there shock and dismay for people like Joan in living with reduced physical abilities, Joan’s limitations allowed her the unwanted space of grieving the multiple losses in her life,

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including family members who had died in the Holocaust, as well as other aspects of a painful and unjust life. However, her perception was that she was surviving these traumas quite well until her illness took over. For many trauma survivors, the use of hypomanic defenses such as distraction, continually moving and not thinking in an emotional way, are key factors in the prevention of severe depression, and will be further considered in the next chapter. However, in terms of the present discussion, for Joan, the advances in medical technology that had made it possible for her to physically survive, meant little. Though the comment from her physician sounds harsh, his point of view is understandable. He likely felt devalued in the face of Joan’s complaints. Medical technology, which at times is capable of prolonging life, requires the presence and expertise of a physician. It is the interwoven relationship between medical professionals and technology that complicates expectations of doctors. The idea is that physicians should “cure,” not simply prolong life in a compromised state. This dynamic was articulated by a doctor who reflects on his own as well as his father’s career in medical practice: “My father’s patients regarded him as a god. Now patients treat you as one and demand miracles. You know it all (or ought to) and you cannot let a patient die no matter what” (Bhargava, 2001). This fascinating quote reveals many aspects of the dilemmas of both modern medicine and the idealization of both physicians and technology. Regarding the physician as a “god” suggests that in a time when technology was less central in the provision of medical services, patients could more easily have the fantasy that the physician is superhuman and can bestow omnipotent benevolence and cure all, as the character of the physician and the medical relationship was primary. It also reflects the problems that often occur when fantasies are enacted in reality. The ominous nature of the following sentence, “Now patients treat you as one and demand miracles” suggests how dangerous it is to really believe that one’s physician is more than a caring human being well trained in their field of expertise. The contemporary overvaluation of technology suggests that the tools physicians have at their disposal give them god-like powers to miraculously cure their patients all the time. Finally, Bhargava’s remark suggests what can happen to physicians in the face of expectations to always heal, no matter what. The idea that doctors “can’t let anyone die” feeds the illusion among patients and physicians alike that patients can be kept alive under any circumstances with the aid of technology. The wish that technology can “take care” of any medical problem is closely associated with the concept of denial. Many patients wish that their physicians were omnipotent healers who can cure the most serious of diseases. When physicians are perceived this way, it is less likely that patients will have space to think about their own mortality, or for some people, the even more uncomfortable thought that they could have taken better care of themselves. This belief is reinforced by the reality that doctors can now do more than ever before to help patients with severe diseases. It is easier to focus on doctors abilities or lack thereof, than to think about the idea of limitations in medicine and of the body. Complicating matters even more is that physicians are themselves vulnerable to the feeling of omniscience. Medical professionals often go into medicine with the conscious idea that their careers will involve the saving of lives as well as the promotion of good health. Although it is true that

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with the help of medications and technology, physicians can help people live quality lives even with serious illness, diseases are still the cause of death and severe disabilities in many people. And while some illnesses are caused by health behaviors (such as when a heavy smoker contracts lung cancer) many ailments and injuries occur randomly. Genetic predisposition and unfortunate timing explain a number of negative outcomes. For example, hematological disorders such as leukemia strike children and adults of all ages and yet the cause is unknown. Random accidents are responsible for many trauma cases and can be due to unpredictable circumstances, such as when a person gets hit by a car in a crosswalk. These realities are difficult for many young adults who enter the field of medicine to integrate into their understanding of what it means to provide care to their patients. If one were to stop and take in the emotional aspects of the everyday traumas in healthcare, it could be difficult to bring oneself to practice medicine everyday with confidence and optimism. For physicians, feeling more powerful than they actually are (i.e., perceptions of omnipotence) may be one way to manage the intense feelings associated with the traumatic situations they see every day. On the other hand, avoidance of feelings can be brought to extremes, as when physicians and medical staff often go to great lengths to avoid painful emotions and the difficult aspects of vulnerability encountered in the medical setting. An unsettling dynamic I have personally observed in both medical and mental health professionals (especially mental health professionals who work with medical patients) is the tendency to blame patients for their illness. This emotionally defensive strategy puts the vulnerability in the “other” (the patient) and removes the emotion of fear from the medical clinician. While it is true that many poor health behaviors cause illness and that noncompliance is a common problem in medicine, assigning blame to a patient does little to ease the reality of the situation, for both patients and clinicians. Assigning blame to patients is one way to gain a sense of control regarding the uncertainty and randomness of many illnesses. So, while some patients may soothe themselves with ideas and fantasies that technology can “take care” of disease, physicians and other professionals who work with medical patients may adopt the perspective that if their patients had treated their bodies better in the first place, the disease may have been prevented. Unfortunately, neither stance is completely true nor serves to resolve the feelings about the realities and unfairness of illness and human suffering.

Looking for Love (and a Cure): Medical Relationships Although faith in technology perpetuates the illusion that physicians are omnipotent healers and that with the help of modern medical equipment, many, if not all ills, can be cured, this dynamic is not solely due to the use of technology. From a psychodynamic perspective, we can easily understand how physicians could be subject to intense idealization and devaluation based on the ways that we understand human development and psychology. In other words, despite the influence of technology in contemporary healthcare, the relationship between doctors and patients remains

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primary, and as such, is associated with the common dynamics one would expect in any relational encounter. When people are ill, they expect to be healed, the normal wish we all have as children. Good parents provide nurturing care for their children when they are sick and ease their discomfort. Likewise, it is understandable that we would all wish that our physicians serve a role as sympathetic healers. For many, though, when this does not happen in our adult lives, we can turn to our friends and families for this kind of support. In such cases in which a physician is not as comforting as we would like them to be, we can choose to not take it personally, and understand that although we wish for more from our physicians, that we may simply not get it. This is a disappointment most of us can bear, and we move on. For some patients, however, the disappointment is too much to take, and the feelings (often related to past disappointments) get re-experienced with their attending physician. Consider the example of Denise: Denise was a woman in her 30s who required the implant of a defibrillator (a device placed in the wall of the chest to deliver an electrical shock for people who have life-threatening problems with the electrical conducting system of the heart). She was well liked by her cardiologist and was noted during her frequent hospitalizations to be a “good patient.” This outward behavior, however, was masking intense feelings of mistrust and hatred that Denise felt toward her cardiologist. When she entered therapy with me, Denise was troubled by intense anxiety, initially thought to be due to a problem with her defibrillator firing unexpectedly, which causes a great deal of anxiety for most patients. However, eventually it became clear that she felt intense anger toward her cardiologist, though the reasons for her feelings were unclear to both Denise and myself. Denise understood rationally that her cardiologist had helped her a great deal, yet found herself feeling extremely anxious before her follow-up appointments; eventually we related this to her angry feelings toward her cardiologist. She felt that her cardiologist did not care about her and admitted that she tried to “drag out” her questions to see if she could get her doctor to spend more time with her. She left her appointments feeling angry and empty, even though her health had improved dramatically.

Denise’s example, not uncommon among many patients who manage aggressive feelings though being overly “nice,” illustrates the common dynamic of transference as it often occurs in medical settings. Freud (1893–1895) initially described transference in as a “forbidden wish” (p. 303) and a “false connection” (p. 304) that others will meet needs that have not been met previously. Freud (1900) expanded the concept of transference in when he described it as a “displacement of psychical intensities” (p. 307). The idea then is that transference is in action when we impose our wishes and feelings toward some other person in our adult lives to the feelings related to those who were our primary caretakers when we were young. In my experience with medical patients, transference dynamics are at their height in those who are unaware of ambivalent or difficult feelings toward their parents. When I initially met Denise, she told me that her family situation had been good and that she enjoyed amiable relationships with both parents. Over the course of long-term therapy, however, I discovered that Denise did not feel so positive toward her mother and that she felt that her mother was intrusive and overbearing. Although Denise did not like the intrusive nature of her interactions with her mother, she found that in the absence of this dynamic, there was little her mother could offer her in terms of emotional intimacy. She was very conflicted about her relationship with her mother, as she

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associated closeness with intrusiveness, but knew on some level that a caring, nurturing relationship between a mother and daughter had to involve more than intense, overbearing interactions. While this was eventually sorted out more in the context of her therapy, it became clear that part of her problem with her cardiologist was that her doctor was not engaged enough with her, and like many specialized physicians, was somewhat detached. Denise felt the detachment from her cardiologist meant that she did not care about her. However, her cardiologist was quite fond of Denise and spoke very highly of her. It became clear that Denise felt that interactions with pronounced boundaries indicated dislike or worse, the threat of a lack of love. Though Denise’s individual psychology explained a great deal of how we eventually understood her feelings about her cardiologist, and by discussing these feelings we were eventually able to get a better sense of her experience of her parents and how these experiences impacted her present day relationship with her cardiologist, it is understandable that many patients find physician detachment uncomfortable. Although it would be ideal for doctors to be emotionally available as most of us long for our doctors to be caring and sympathetic, it may be unrealistic to expect them to always be emotionally present. Though one hopes that physicians are able to be present “enough” to not blame patients for their illness and to treat them with kindness and respect, some detachment could be viewed as adaptive. As previously discussed, the many demands on physicians, including the large numbers of patients doctors must attend to (many with traumatic medical conditions), and the fact that some specialty and procedurally oriented physicians need to be detached to some extent in order to successfully carry out their work, creates a scenario in which doctors need some measure of detachment in order to bring the integrity and professionalism to the practice of medicine we expect from them every day. Especially for those physicians who regularly perform highly sophisticated procedures, such as surgery, a degree of detachment could actually be considered ideal. This perspective on detachment and the way it creates room for our work as mental health clinicians was well articulated by Core and Pugh (2001): The nature of the need for medical and surgical intervention often requires the organization to operate in such a way that feelings are denied, and the use of the defenses of splitting and projection dominate. Counsellors in medical settings may, therefore, allow the health carers to continue to do their tasks that require this ‘process of detachment’ while providing the listening and response required by the patient. (p. 9)

These British authors take a very different stance on physician detachment. They provide a normalizing context for physician detachment and also point out that mental health professionals can serve in the role of helping patients deal with emotions, as our jobs do not require the kind of emotional detachment asked of physicians. In fact, being emotionally present is needed in order for us to do our jobs well. Core and Pugh seem to be speaking of the desire implicit in transference that physicians can “do it all.” These authors remind us that in reality, we cannot ask physicians to be all things at once. This does not mean that our patients are not entitled to disappointment when they find shortcomings with the limits of emotional availability in medical care; rather, it means that being sympathetic to both patients and physicians might be an effective and humane way to approach the complicated dynamics

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in medicine. Labeling transference feelings regarding physician attachment can be useful to some patients; on the other hand, it is important to validate the reality that many physicians are detached in their patient relationships. And as noted regarding Robert, transference interpretations are simply not useful for some patients. For example, Denise was anxious enough that she could benefit from a more nuanced understanding of her reaction to her physician. Her anxiety caused Denise to question the intensity of her reactions. However, it was also crucial that I validated Denise’s feelings that her physician was not as emotionally available as she might have liked. This allowed Denise the space to consider whether her expectations of her cardiologist were realistic. Holding both realities in mind – the interpersonal problems that occur in medicine, and that unfulfilled wishes of patients may be linked to past disappointments – allows space for patients to understand more about their own feelings of loss and the realities of limitations that occur in the body and in the culture of medicine.

Conclusion As people in the twenty-first century live longer than ever before, we are subject to increasing medical problems as well as the disappointment of failures related to reduced physical functioning. In this context, idealization and hypomania serve many purposes. They prevent devastating aspects of bodily decline, yet allow people to hold on to the hope that their healthcare needs will be met, as well as receiving “cures” from a powerful authority. The hypomanic culture of medicine is the perfect scenario for transference feelings to emerge, and the idealized wish that physicians can cure all and be sympathetic healers. Technology plays into idealization in that there is seductive hope for curable treatment when in actuality a cure may not exist. Physicians are vulnerable to the dynamics of being omnipotent healers, as they themselves experience vicarious trauma on a day-to-day basis with often little emotional resources of support, as least within the fast-paced and emotionally avoidant field of contemporary medicine. Without support and help in dealing with the traumas physicians face, grandiosity and omnipotence can take over and result in physicians feeling that they can offer more than they can, which makes the dialog about the realities and limits of medicine difficult. In this scenario, both patients and physicians suffer from a loss of real human connection. The complicated dynamics inherent in human psychology suggest that idealization and devaluation are intrinsic and are to be expected to some extent in many encounters in which vulnerable and sick people seek out professional help for healing. As people age and experience more acute and chronic illnesses, we are faced with unprecedented numbers of patients for whom we need to be able to interpret and understand powerful emotional reactions. The interrelationships in medicine are complex, and it is tempting to blame physicians for getting caught up in omnipotent ideas regarding their role as healers. Conversely, it is easy to blame patients for their own culpability in their illnesses.

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Neither stance is completely true. The reality is that there is an uneasy tension between the problems of modern medicine and patient responsibility. The medical community is confronted with overwhelming expectations from patients to cure any health issue, from relatively benign conditions to serious diseases. Patients want to be cured and physicians want to heal. This scenario often works out well until a patient cannot be completely cured or attain full recovery. Then, a place is needed in the patient’s psyche and emotional landscape for feelings of sadness, anger, loss, and disappointment; it is easy for these feelings to become attached to doctors and the limitations within the field of medicine. As mental health clinicians, we can offer help with the management and expression of these intense feelings, while easing the blow of reality for many patients that there are limits with technology, medicine, and our bodies.

References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Bell, R. A., & Kravitz, R. L. (2008). Physician counseling for hypertension: What do doctors really do? Patient Education and Counseling, 72(1), 115–121. doi:10.1016/j.pec.2008.01.021. Bhargava, R. (2001). What happened. Rapid responses to survey: Why are doctors unhappy? BMJ. Retrieved March 14, 2008 from http://www.bmj.com/cgi/eletters/322/7294/DC2#14377. Cohn, J. (2007). Sick. New York: HarperCollins. Core, E., & Pugh, K. (2001). A review. In P. Thomas, S. Davison, & C. Rance (Eds.), Clinical counselling in medical settings (pp. 5–23). East Sussex, United Kingdom: Brunner-Routledge. DiMatteo, M. R. (1994). Enhancing patient adherence to medical recommendations. Journal of the American Medical Association, 271, 79–83. Freud, S. (1893–1895). The psychotherapy of hysteria. Studies on hysteria. (trans: Strachey, J.). In The standard edition of the complete psychological works of Sigmund Freud (vol. 2, pp. 253–305). London: Hogarth. Freud, S. (1900). The interpretation of dreams. (trans: Strachey, J.) In The standard edition of the complete psychological works of Sigmund Freud (vol. 4, pp. ix–627). London: Hogarth. Gray, P. (1973). Psychoanalytic technique and the ego capacity for intrapsychic activity. Journal of the American Psychoanalytic Association, 21, 474–494. Greenberg, T. M. (2007). The psychological impact of acute and chronic illness: A practical guide for primary care physicians. New York: Springer. Heaton, D. C., & Frede, S. M. (2006). Patients need for more counseling on diet, exercise, and smoking cessation: Results from the national medical care survey. Journal of the American Pharmacists Association, 46(3), 364–369. Klein, M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis, 21, 125–153. Linsk, J. A. (1993). American medical culture and the health care crisis. American Journal of Medical Quality, 8(4), 174–180. McKinlay, J., Link, C., Arber, S., Marceau, L., ODonnell, K., & Adams, A. (2006). How do doctors in different countries manage the same patient? Results of a factorial experiment. Health Services Research, 41(6), 2182–2200. Mellen, P. B., Gao, S. K., Vitolins, M. Z., & Goff, D. C., Jr. (2008). Deteriorating dietary habits among adults with hypertension: DASH dietary accordance, NHANES 1988–1994 and 1999–2004. Archives of Internal Medicine, 168(3), 308–314.

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National Center for Health Statistics. (1999). U.S. decennial life tables for 1989–1991. Some trends and comparisons of United States life table data: 1900–1991 (vol. 1, No. 3). Hyattsville, MD: Author. National Center for Health Statistics. (2007). National vital statistic report, Deaths: Final data for 2004 (vol. 55, No. 19). Hyattsville, MD: Author. Ory, M. G., Peck, B. M., Browning, C., & Forjuoh, S. N. (2007). Lifestyle discussions during doctor–older patient interactions: The role of time in the medical encounter. Medscape General Medicine, 9(4), 48. Retrieved July 3, 2008 from http://www.medscape.com/viewarticle/ 565280 1. Winnicott, D. W. (1996). On cardiac neurosis in children: 1966. In R. Shepherd, J. Johns, & H. T. Robinson (Eds.), Thinking about children. New York: Addison-Wesley.

Chapter 3

The Trauma of Medical Illness

You are living in a land you no longer recognize. You don’t know the language. Martin Amis

Severe and life-threatening illnesses are traumatic events. Although this remark may not sound novel, the idea of illness as traumatic has not been given much attention in the psychodynamic literature or in general psychological and psychiatric literature. It was only as recently as 1994 that the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) referred to life-threatening illness as a traumatic event for consideration in the diagnosis of Posttraumatic Stress Disorder (PTSD). Additionally, as mentioned in Chapter 1, within classical psychoanalysis, there has been relatively little emphasis on “real events,” including the effects of adult-onset trauma. However, modern psychodynamics recognizes that reactions to adult-onset traumatic events are different and unique, with the power to shape adult development, potentially as forcefully as childhood events. Patients experiencing major medical illnesses may have reduced capacity for symbolic thought due to the physical demands of their illness and stress associated with mortality. In the first part of this chapter I will address clinical work with patients who present with less access to symbolic thought and concrete thinking. Second, I will discuss additional sequelae of traumatic illnesses. Traumatic events such as severe life-threatening illness can cause PTSD or its symptoms in many people, though the diagnostic criterion of PTSD does not fully convey the extent of feelings or suffering in those who have experienced traumatic medical illnesses. Physicians refer many patients with major illness for therapy, yet the fundamental premise of therapy, thinking about one’s experience, can feel overwhelming. Avoidance, a primary symptom of PTSD, makes reflection difficult. I will provide suggestions for clinical management, followed by observations on the interaction of past traumatic experiences in the presence of traumatic illnesses, nonlife-threatening illnesses, and age-related bodily changes. Finally, I will discuss the ways in which physical slowing down related to illness and aging, which are experienced by many as a type of loss and its associated disappointment, can be a stimulus for psychological symptoms in those with traumatic histories. For people


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3 The Trauma of Medical Illness

who use their bodies to avoid thinking and feeling, aging and illness mean the end of physical and mental distractions. Patients who use hypomanic defenses, which can also include ways of thinking which create distractions to avoid feelings of guilt and sadness, or who are excessively active to keep troubling thoughts and feelings at bay, can develop disturbing psychological symptoms. Additionally, for some patients who have relied excessively on somatic modes of functioning (often present in those who have experienced early trauma), being more somatically focused takes place because adequate access to thoughts is not possible. Illness and aging can end a relationship with the body that has served a soothing function, and loss of the body as a soothing object has serious consequences. Especially for patients with traumatic histories, this can result in intrusive memories of past trauma, which creates intense psychological distress. I will discuss these dynamics further and implications for therapeutic interventions.

The Mental Health Clinician and Medical Patients I was recently teaching a class on psychodynamic perspectives of medical illness and mentioned a common phenomenon with cancer patients: Many cancer patients who engage in therapy do so when they are in the active stages of their medical treatment (e.g., chemotherapy or radiation), and once the active phase of medical treatment is finished, many of these patients leave therapy. Those therapists in the class who have worked with cancer patients laughed and seemed relieved to know that this is a common experience and not one that is necessarily based on the therapist’s individual psychotherapeutic style or practice. While it is true that many medical patients (not just those who have cancer) present for medical treatment in the more acute phases of illness and then leave when illness becomes chronic, is in remission, or in the best of circumstances, is cured, it raises the question of why this happens and how it affects the psychological health of patients. One possibility is that those who are acutely ill and undergoing intensive kinds of treatment need acute and intensive psychological support, and once that phase of medical treatment is finished, they may feel less intensive psychological treatment is needed. Although this rationale may appear to make sense, I have been surprised over the years at the number of people who have left psychotherapy after the acute phases of medical treatment, as some of these patients have clearly had issues that would have benefited from longer-term psychotherapy. And even though it is true that some people, particularly those who have had psychotherapy in the past, might be inclined to continue with therapy after the acute phases of treatment, how are we to understand those who do not? And are there things we can do to increase the chance of engaging some of these people in a more meaningful and helpful therapeutic relationship? Medical patients are hesitant to engage in longer-term treatment with mental health clinicians for a number of reasons. As mentioned in the previous chapter on the culture of medicine, modern healthcare reflects a hypomanic culture in which “cures” are provided in a quick and often rushed manner. The practice

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of psychology within medicine, though valuable, offers a culturally inconsistent approach for medical patients. Even with the approaches often advocated within health psychology and medical care (specifically, cognitive-behavioral approaches), the integration of psychology in medicine remains largely difficult. Integration of psychological approaches and applications in healthcare has improved dramatically over recent years, yet psychological services are largely viewed as an “elective” treatment within the medical system. To some extent this makes sense. From a practical standpoint, many patients are overwhelmed with medical appointments, as well as the financial expenses involved in receiving care for an illness. Time and money spent on psychotherapy may not seem to be a priority. Physicians may not consider referrals to mental health professionals for those patients who seem to be “coping well,” even though therapy could be of great benefit. However, even for people who have financial resources and time for it, therapy is often construed as not only elective, but also a burden. Psychotherapy involves a tremendous amount of resources, both internal and external. Patients with severe illnesses are often taxed with the impact of bodily changes and decline, physical pain, and fear of death. For such patients surviving from day to day involves tremendous physical energy, and as a result, psychological energy that might be employed to address emotional issues is reduced. This relates to the idea that medical patients often present as being more psychologically “concrete.” Although introduced in Chapter 1, this term warrants additional elaboration. The term concrete has been associated with thinking in patients who are more severely disturbed, such as those who are psychotic or those with personality disorders. One way this has been described was by Frosch (1995) when he referred to the presence of “preconceptually organized emotion” (p. 437), related to rigid belief structures, resulting in a pronounced disparity between distinguishing internal reality from the external world. Original conceptualizations of psychosomatic illness and alexithymia also emphasized that patients with psychosomatic illnesses contend with their conditions in a concrete manner, as emotional issues “land” in the concrete domain of the body and thus are resistant to traditional notions of interpretation. Although these definitions of concrete thinking have some useful value (and for some patients with diagnoses of Somatization Disorder these ideas aptly apply), a more modern way to view concrete thinking is that we are all capable of reduced access to symbolic thought, and under times of stress we all can regress to a more concrete way of operating; some theorists have described this as “primitive” thinking. In such states, we feel more sensitive to intrusions, more focused on pragmatic aspects of functioning, with less emotional space for reflection. Trauma researchers have long known that traumatic events make it difficult for patients to think in a symbolic way (e.g., van der Kolk, Hostetler, Herron, & Fisler, 1994; van der Kolk, 2003). Some clinicians have also argued that unique aspects of adult-onset trauma make it difficult to think abstractly because the defense of dissociation leaves the survivor in a state of confusion. Boulanger (2007) distinguishes between the effects of childhood trauma and adult trauma: “Childhood trauma becomes a part of self-experience. In adulthood, it causes the collapse of the self.” (p. 29). Traumatic events that occur in adulthood present a number of threats to psychological integrity and are the result of a basic lack of selfhood security

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that is present when life is threatened. The state of confusion that results creates a unique and difficult situation for both therapists and patients. Patients understandably (and for reasons inherent to psychological survival) try to avoid the confusion that is associated with traumatic aspects of illness and the threat to bodily integrity. Such patients can present as difficult to engage in a lively way. As we will see in the case of Sara, being overly focused on concrete details is an attempt to achieve psychological homeostasis through avoiding feelings of terror and confusion. The need to avoid the confusing aspects of dissociation, which is experienced as an internal sense of feeling terribly alone, detached, and not “whole,” suggests that such patients may present in therapy as wanting help, but are terrified of confronting more confusing aspects of their internal experience. This has implications when we talk to patients and manage the time spent in psychotherapy. Part of this management and need for a specific therapeutic technique relates to the previously mentioned idea of concrete thinking. Holly Gordon (personal communication, August 1, 2008) provided an apt description of this dilemma. She said, “When one’s house burns down, interventions aimed at psychological meaning of events seem less relevant, as one is caught up in the urgency and immediacy of the distressing external and real events: ‘My house just burned down!’ ” The implication is that if someone has had a traumatic loss, such as a fire that destroys their home (a fitting metaphor for a body that stops working and is threatened by death), what remains available for discussion is related to basic survival, or in some cases only expressions of panic can be described. As Gordon’s analogy, “My house just burnt down!” suggests, the state of panic that ensues following a devastating threat of livelihood makes it difficult for some people to become organized enough to think about basic survival (e.g., Who can be called to see if they can provide shelter? Will insurance cover this damage? Are there still things in the home that can be salvaged, etc.). Our job when helping someone who is panicked is to help begin the process of organization. This often means initiating concrete discussions. One caveat regarding this approach, however, is that although we may engage in concrete dialog with patients and even have a sense of what the meaning of the concrete material is, this does not mean that we immediately begin to understand our patients and their emotional world. In other words, although we may sense the meaning of concrete topics, it often takes a long time to fully appreciate and understand the complex internal and unconscious worlds of our patients (Joseph, 1983). However, concrete thinking can be a window to other forms of thinking, feeling, and relating. A present threat to the self results in less access to symbolic thought and then the “default position” of concrete thinking takes over. The following example will help illustrate the kind of dialog we can expect from someone who has no “home,” or a body that is being ravaged by illness. Sara is a 30 year-old doctorate level professional who was recently diagnosed with leukemia. After a routine doctor visit, her physician told her that she could not go back to work that day, but needed to be hospitalized immediately for dangerously low blood cell counts. I met her a few days later in the hospital. She was referred for what her nurses described as almost nonstop crying as well as what was perceived as excessive controlling behaviors, such as continually asking the nurses to verify the accuracy of her medications, even when they had already told her what they were giving her and confirmed that the dosages were correct.


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When I met with Sara, she was guarded and extremely anxious. Although she felt that she wanted help by talking with me, she appeared in genuine shock (as would be expected), but also appeared panicked. When I suggested that she might feel overwhelmingly anxious, and that perhaps even thought that the feelings she was having would cause her to die immediately, she agreed. She said that at times she felt that she could just “die right there” even though she knew she was getting treated for her disease. The panicked feelings made it difficult for Sara to cope in the hospital. Staff became increasingly concerned because she often asked for higher levels of anxiolytics and pain medications, presumably to manage her anxiety. Sara acknowledged that she just wanted to feel “numb.” Although I had suggested an antidepressant, which might provide longer-term and more consistent relief from her symptoms, she refused, objecting that she did not want to feel “controlled” through medication. As for my role while she was in the hospital, Sara was able to talk to some extent about her anxiety. However, discussions tended to focus on aspects of her life that needed to be managed and taken care of, such as who was paying her bills, what was happening in a recent financial transaction, how others were managing her projects at work, etc. And although I willingly discussed these topics with her, I felt as if there was little I could do to help ease her tremendous anxiety.

Sara’s situation illustrates that when someone is overwhelmingly terrified in response to a serious and life-threatening illness, their ability to think about meaning is reduced. Feelings of hopelessness in patients are also present and can be detected by a feeling of helplessness in the therapist. Sara attempted to manage her anxiety through becoming more watchful of her environment, including frequently checking that the nurses would not make any mistakes. Not only was Sara terrified and attempting to manage her terror, I understood that underneath her need to be more in control of her environment was a sense of profound confusion regarding what was happening to her. Attempts at control were a way to reduce the confusion she felt. In her conversations with me, Sara felt the need to “go over” events in her life that she could not currently control as a way to try to maintain control. She was stuck in this way of thinking and needed me to give ample attention to these external events. Talking about the more real issue of what she could not control (her body) was not possible, as it made her unbearably anxious and confused. Sara was completely caught off guard by this diagnosis. As a relatively young woman she had little experience with major illnesses or death. She had no risk factors for malignancies, something she eventually told me she often thought about. Not knowing why or how this had happened to her was a tremendous source of confusion and anxiety. The level of her confusion was so intense that at times it felt as if it would overwhelm her. This is one meaning of panic attacks that sometimes occur in patients. Anxiety, confusion, and feeling out of control become so powerful that people sometimes feel as if they will die imminently. Although it is understandable that many people experiencing a life-threatening illness would be terrified, the kind of terror I am describing is the kind where one cannot find refuge in a logical reminder that they are not dying at that moment or that others are helping to keep them living (meaning, in these cases, medical treatment). This is because the confusion and disorienting nature of feelings in reaction to a traumatic illness can become overpowering. Many psychodynamic clinicians have discussed this phenomenon. One of the more notable is Melanie Klein (introduced in the previous chapter on the topic of manic defenses), who described intense anxiety associated with fears of

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annihilation which originate in childhood, when young children have intense fear of death related to overwhelming affect (Klein, 1948). Other clinicians have referred to a feeling of falling forever (Winnicott, 1965), or a “collapse of the self” (Sullivan, 1956) to describe the sense of overwhelming terror and confusion that impact people who have had an extensive experiences of terror and fear of death. One need not be ill to experience these kinds of feelings. However, being confronted with the real possibility of death transforms ideas of death into something actual. Although death is the ultimate outcome of life for all of us, some people respond to ideas and fantasies about death with intensely distressing images, which are akin to torture. Jaques (1998) described these phenomena when he applied the idea of annihilation anxiety to the idea of death: It is not in fact death in the sense in which we consciously think about it, but an unconscious fantasy of immobilization and helplessness in which the self is subject to violent fragmentation, while yet retaining the capacity to experience the persecution and torment to which it is being subjected. (p. 507)

Jaques describes that in order to accept the reality of death, intense feelings of loss and anger have to be dealt with. For some people, the inability to manage these feelings can become so overwhelming that they can get turned inward on oneself through ideas of being persecuted. In other words, the feelings related to loss and aggression, instead of being expressed outwardly, become turned inward on the self. Although aggressive feelings have a part in the kinds of terrifying death fantasies Jaques describes, it is also the case that the confusing and dissociative aspects of traumatic illness create the environment for a disturbing and terrifying emotional life, which manifests in persecutory images. The kind of panic experienced by Sara illustrates this association of fear with death. Sara could not find solace in the fact that she was being treated for a disease. Although ambiguities existed in terms of her overall prognosis and were in reality a terrifying situation, Sara was so tortured by her feelings that she feared others. However, in actuality, others were desperately trying to help her. In her situation, I knew that the nurses and doctors caring for her at the time were extremely sympathetic. Yet Sara could not absorb sympathy, as her fears had rendered her helpless to a kind of condition in which she felt paralyzed and tortured. In this state, no one can really be trusted. Additionally, in this state of mind, the act of thinking as well as having ideas can feel like torture. In other words, the process of thinking as we understand it can feel persecuting. The feeling that Jaques describes, in which one has the idea that death is a kind of persecutory paralysis while being alive, captures Sara’s fears at the time. Although this may be how she conceptualized death, when we met, this was Sara’s actual experience of her current life. As a person who was used to having extraordinary control in her day-to-day life and needed control for her psychological homeostasis, having to relinquish this control rendered her terrified, helpless, and unsure of how to organize herself. This explains the difficulty she had in talking with me. Although Sara expressed that she “liked” me, she refused to see me more frequently. Fortunately, she was willing to talk with me, which was a start. But her terror and feeling of being out of control made it difficult for her to respond to the usual things one might get from a psychotherapeutic encounter, such as sympathy or understanding.


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This phenomenon, that patients seek psychotherapy for understanding but then act in ways that prevent understanding, was articulated by Betty Joseph (1983), who observed that the traditional notion of interpreting “in the transference” (a common technique within psychoanalysis) is less important with concrete patients. As she and other modern psychoanalytic clinicians point out, especially for people experiencing more concrete mental states, interpretation should take place in whatever seems most emotionally salient for the patient at the time. The premise for this idea is that experientially, the transference is always being lived; therefore, one need not become overly attached to only interpreting when there is “evidence” of transference material. I interpret these ideas to mean that one needs to engage in whatever concrete discussions need to take place, while trying to understand other aspects of functioning. For Sara, although I did engage in concrete discussions with her, I constantly held the idea in mind that she felt trapped and tortured and was attempting to avoid disorganizing states of confusion. Since I knew she felt tortured, I also knew that any interpretations and interventions I might make carried the risk of feeling like another assault. In Sara’s case (similar to Robert in the previous chapter), any kind of interpretation related to transference not only would not have been useful, but would have indicated that I did not understand her situation at all. So I focused on waiting for moments to discuss her current, lived emotional experience. Eventually, I was able to comment that she felt trapped in the hospital or wary of whom she could trust, which let her know that I understood her feelings. Over time she was able to benefit from my acknowledging that although her anxiety made her feel at times that she would be overwhelmed or die, she did in fact continue to live and her body, though compromised, was still intact. Once Sara got out of the hospital, however, she did not follow up for additional therapy, even though she called me several times, indicating that she wanted to see me. She scheduled appointments but did not come to them. When we spoke after her missing a session, she was very apologetic, but always had an excuse for why she did not show up. Although a part of Sara knew she needed follow-up care, the actual idea of knowing more about how confused she was would have been intolerable, at least at the time. I surmise that her missing sessions was a reflection of her inability to organize herself in a very fundamental way. Since my office is off-campus from the hospital, there was no way she could meet me close to the same time she needed to see her medical doctors (and unlike some beneficial health psychology primary care models, I could not see her in her physician’s office while she was waiting to be seen by her doctor). For these kinds of patients, being in a healthcare facility where they can be seen by a mental health clinician provides the kind of organized structure that is often needed to have potentially “dangerous” conversations about overwhelming thoughts and feelings. Because illness demands so much from the body and bodily failure causes a distrust of the internal workings of the self, it is hard to know who and how to trust people on the “outside.” I am referring to the idea that we all have an internal sense and experience of our body as an inside process which operates separately from the outside world. As children, we learn by about the age of 4 or 5 that not only are the mind and the body separate, but that just because we feel ill does not mean that others in our family will feel ill (Inagaki & Hatano, 1993). We learn that our bodies

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are separate from others and that our relationship with our body is a private affair that outsiders are not generally involved in. For most of us who are born without chronic illnesses, we take that functioning of the body for granted. When the body stops working in adulthood, this causes a jarring to one’s sense of self and can lead a person to question the internal workings of their own body. In describing trauma in general terms, Bromberg (2003) described the cause of what gets experienced as “trauma”: Trauma, in these terms, is caused by “the shock of strangeness” in an interpersonal field on which security of selfhood depends and is relative to the developmental threshold at which a person can accommodate the “strangeness” at that point in time. (p. 690)

Though Bromberg is suggesting that traumatic events are damaging because of the developmental limitations that are often present in young children when trauma occurs, I think his point also applies to cases of adult-onset trauma. Especially with medical illness, the feeling of “strangeness” that he describes is suggestive of the surreal feeling of a body that has stopped working. In autoimmune diseases (in which a part of the body is attacking oneself), this has even more resonance. For example, many cancer patients talk about the “eerie” feeling that cancer cells have been growing in their body without them knowing it. This may be related to both ideas and fears of cancer in our culture. Although heart disease is the number one cause of death in industrialized countries, many people verbalize not a fear of heart disease, but of cancer. This is most likely because the imagery associated with cancer, in which bad cells insidiously destroy good cells, resonates with the fear of the internal workings of the body being attacked by itself. This attack can result in disorientation and mistrust of people in the “outside” world. In other words, if one cannot trust the inside to work properly and protect itself from attacks, how can one know what to trust the outside? This is akin to what Anna Freud (1952) said regarding working with medically ill children when they cannot “distinguish suffering caused by the disease inside the body and suffering imposed on him from outside for the sake of curing the disease” (p. 70). As we saw in the case of Betty in Chapter 1, she did not know what or who to trust. She could not trust her body, her mind (as it was filled with anxious thoughts of persecution), or others. Although the fear of others is closely associated with hypervigilance, I am referring to the general sense of distrust that emerges when one cannot trust their own body. A general sense of bodily integrity is eroded when the body breaks down. For some, this results in confusion, collapse, and as a result, a feeling that nothing can be trusted either internally or externally. Sara tried to remedy these disorganized, helpless, and out of control feelings by managing the nurses’ behaviors with an attempt to control, in a literal way, what was being put into her body. Such patients need to be able to feel that they can control what we, as mental health clinicians, put “into” them as well. In these situations, we need to tolerate the fact that due to a patient’s suspicions and sense of terror, it may feel at times that we have little to offer. However, just being able to engage with patients such as Sara goes a long way, as language sets the stage for a meaningful and relational encounter (Bromberg, 1994). Concrete kinds of treatment interventions can help to “offer something” to patients, but even

Medical Illness as Adult-Onset Trauma

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concrete approaches may not always be useful. Although I offered Sara more concrete interventions (such as medication and even behavioral strategies to manage her symptoms), she declined. These refusals did not necessarily mean that she did not want help, but that such help had to be titrated in a form that she could both tolerate and control. It was extremely important that Sara felt that I could interact with her without telling her what to do (in the form of interventions or other recommendations). So I met her where she was at, I interpreted her mistrust in a more distant way and addressed the extreme terror she was feeling. For example, at one point I told her, “I think you are not sure what or who you can trust right now.” This offered Sara some relief as I was assuring her I understood that she could not really “take anyone in.” In essence, I was attempting to provide some sense of containment for her experience. Though the idea of containment is complicated and has been elaborated on by multiple theorists, here I am referring to Bion’s (1965) concept, in which emotions are absorbed and held by an understanding person. As is often the case for those who have experienced traumatic events, developing a sense of containment in the treatment relationship is a crucial first step to achieving a basic sense of safety.

Medical Illness as Adult-Onset Trauma Trauma is often associated with child abuse, cumulative losses, overstimulation, fear of abandonment, and feelings of helplessness. Herman (1992) described traumatic events as those that “overwhelm the ordinary systems of care that give people a sense of control, connection and meaning” (p. 33). Yet thinking about adults who experience adult-onset trauma is relatively new to the field of contemporary psychodynamic theory. Boulanger (2007) takes up this problem directly and states that adults who experience trauma are difficult to categorize, especially given the metapsychology of traditional psychoanalysis, which has historically privileged meaning as being related to early childhood events, with less of an impact of adultonset events. Although traditional psychoanalysis has had a difficult time addressing issues related to adult-onset trauma, there are also patient variables that have likely created some of the difficulties for psychoanalytic clinicians who might have wanted to study this population. When we consider the symptoms of PTSD and how prevalent this condition is in many medical patients, it suggests that while psychoanalysis has failed to understand some aspects of adult trauma, this may be because the very symptoms of PTSD make it unlikely that a large percentage of these patients will come into therapy in the first place. Before I describe in more detail some of these dynamics in more detail, let us consider the case of Frank: Frank is a 69-year-old single male who had successful careers in a number of areas, most of which involved various aspects of public speaking. About a year before we met, Frank was diagnosed with head and neck cancer, and surgery was performed to remove the malignancy. Frank’s surgery was deemed to be successful. Yet following surgery, because of damage to both his larynx and esophagus, he was unable to talk above a whisper or eat solid food. His primary care physician referred him for therapy after she suspected that Frank had suicidal ideation. When Frank and I met, it was clear that he had suicidal thoughts, though had no

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3 The Trauma of Medical Illness intention of acting on these feelings because of religious beliefs. Nevertheless, Frank felt “hopeless and lost.” First, he was stunned and confused that he had contracted throat cancer as he had never been a smoker and he understood that this form of cancer was more likely to occur in smokers. Second, his difficulty speaking and eating had dramatically altered his social life, not to mention the public speaking aspects of his career, which he had (before his illness) no intention of retiring from for at least five more years. Though Frank was able to tell me these things and was pleasant enough in talking with me, he appeared flat in his conversations and did not know what to say. Unlike some medical patients, Frank did not appear to want me to direct him and did not expect me to solve concrete problems, rather; he appeared stunned. Labeling this stunned state felt true to Frank, but understanding did little to help him feel less lost.

Frank’s situation illustrates many of the kinds of concerns medical patients present with. Frank left therapy after a few sessions in which he articulated to both his physician and myself that he was “fine” and no longer had suicidal thoughts. Though this may have been true, I do not really know if he was less suicidal when he ended his therapy with me. Frank and others who experience a traumatic illness are beset by a number of threats to self, fear of death, and inexplicable losses. The conceptualization of PTSD and PTSD symptoms can help us begin to make sense of the kinds of experiences people with medical illnesses have. The diagnosis of PTSD is common in medical patients. The DSM IV-TR (4th ed., American Psychiatric Association, text revision, 2000) requires the following criteria for PTSD: (a) a traumatic event that involves actual or threatened death, or the threat of physical integrity to self or others and the person’s response to that event was intense fear, helplessness, or horror; (b) at least one symptom of re-experiencing of the event, such as intrusive memories, nightmares, a sense of reliving the event, and/or psychological distress when reminded of the event; (c) three or more symptoms of avoidance, such as avoidance of thoughts, feelings, or reminders of the event, inability to recall aspects of the event, withdrawal from others, emotional numbing, sense of a foreshortened future; and (d) two or more symptoms of increased arousal, such as insomnia, irritability, concentration difficulties, hypervigilance, and exaggerated startle response. Roughly one-third of medical patients with cancer and heart disease meet criteria for PTSD (Bankier, Januzzi, & Littman, 2004; Doerfler & Paraskos, 2005; Kangas, Henry, & Bryant, 2002, 2005). Though these statistics describe a large number of medical patients, they do not capture the extent of patients who have PTSD symptoms without meeting criteria for the disorder. Many medical patients, including Frank, have PTSD symptoms that make the utilization of psychotherapy difficult. Frank was not only avoidant in terms of not wanting to talk about his traumatic illness and dramatically impaired post-treatment quality of life problems, but also he was so numb with regard to his emotional experience he could not imagine how to engage with me or the therapeutic process. Although his numbness was likely masking intense and profound confusion as we saw with Sara, Frank did not have sufficient energy to begin to try to manage his fear and confusion. He was stunned, suicidal, and devastated. He spent his days watching television. He refused to see his friends and had stopped working in any capacity. In such cases, our ability to help may be limited unless we can find a way to connect with such patients on any level that is tolerable to them. One caveat regarding this suggestion, however, is that


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although I have argued that we need to be flexible in our willingness to engage in more concrete discussions and even consider the use of our own self-disclosure (as we saw with John in Chapter 1), we also need to be careful using time spent in therapy to discuss our own thoughts and feelings. Self-disclosure, if it is initiated by patients, can be used to provide an organizing structure for patients. In others, such as Frank, self-disclosure is less advisable, not only because he did not initiate these conversations, but because the nature of his numbness, dissociation, and confusion would have made self-disclosure an intrusive experience for him. Although for some patients self-disclosure in the therapist can create space, in others it can collapse therapeutic and psychic space and feel intrusive. Medical patients with symptoms of avoidance often present for psychotherapy at the urging of spouses, family members, or physicians. Presumably their symptoms worry someone in the patient’s life and they present for therapy out of a sense of compliance to the persuasion of someone close to them. That being said, such patients are often extremely conflicted about whether or not they should receive help, and it is often the “side” of ambivalence that wins in the decision to present for therapy. However, once in the therapist’s office, such patients do not necessarily buy into the idea that therapy can offer help. They present with some hope of feeling better, yet talking about the very things that bring them into therapy makes working in treatment difficult. I am reminded of a woman, whom I will call “Evelyn.” She had finished several months of treatment for severe cancer and came to see me at the recommendation of her oncologist. She told me when we met that she had hidden her cancer from her children and her friends. When I asked how this could be possible given that she had long hospital stays and had lost all of her hair, she said that she “just never said anything” and that she wore wigs to conceal her hair loss. She had trouble telling me anything other than vague details about her illness. She was similarly vague about her professional or family life. I did not experience her opaqueness as intentionally withholding; rather, Evelyn genuinely felt she had little to say. As one could imagine, her denial about her cancer ran very deep, so talking with me about most anything posed tremendous challenges, as there was no topic we could discuss that did not in some way connect with her life-altering cancer diagnosis. She claimed that she felt “just fine” and the main worry which emerged in her therapy was that others would find out she had cancer and this would diminish her social standing in her community. Before moving on to discussing denial and dissociation in more detail, it is important to mention the impact of shame in medical patients. Many patients who have been diagnosed with a disease often feel extremely shameful. This complicated dynamic will be addressed in detail in the next chapter, but here it is important to introduce the dynamic of shame when treating patients who have an idea that in some way they have caused their illness. Lewis (1984) described shame as “a family of affective-cognitive states which humiliation, mortification, embarrassment and chagrin are among the variants. Guilt is also a family of affective-cognitive states, such as responsibility, obligation, fault, and blame” (pp. 8–9). Shame and related guilt are often prevalent in smokers when they believe that their illness has been caused by smoking or other unhealthy behaviors. However, shame is also present

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in many other cases when people perceive that they have contributed to their disease in a real or imagined way. Although shame is a prevailing dynamic, we do not often hear about the shameful feelings that patients carry, especially if we only see them briefly. Shame is associated with feelings of having caused an illness, and often patients feel so badly about what they perceive to have done to cause their illness that these feelings can barely be discussed. I am reminded of work I did a number of years ago with lung cancer patients. A number of people I saw had long histories of smoking and felt ashamed about the influence of their smoking habit in the development of their disease. Most of them had trouble making eye contact, and often denied the fact that they were still smoking, even though I could smell cigarette smoke when I was in the same room. In this day and age, to continue smoking excessively requires some level of denial and dissociation, as the warnings regarding the risks of smoking are an important part not only of health education, but of popular press coverage on health-related issues. In order to rationalize smoking, a person needs to have access to a part of themselves that can ignore these warnings and feel that they are not related to them personally. Although dissociation and denial have a place in the functioning of such people, they are “caught” through diagnosis of cancer or heart disease, and then feelings of shame can take over. It is as if the part of the person who felt that they could “get away” with an unhealthy behavior gets exposed. The part of the self that knows certain behaviors are dangerous and self-destructive is revealed. The feeling of being caught that such people have is often related to enormous amounts of shame and embarrassment. This issue is complicated. As I have described (Greenberg, 2007), smoking cigarettes may be a cause of many diseases, though it is not always the case that smoking causes lung cancer. Unfortunately, lung cancer increasingly occurs in people who have not been smokers. For our purposes, we need to be able to think about what patients view as the cause of disease and start from there. Personal attributions of illness may be real, but they also may be imagined. I remember one patient who had blood cancer, who told me he believed that a conflict with his neighbor in the last year was related to his development of cancer. Another told me that he got cancer because he painted his house in the previous year. Obviously, these ideas of causation are not true. But shame manifests itself in a variety of ways that may or may not make sense to us. Evelyn clearly felt ashamed about her diagnosis of cancer, and though she had never been a smoker or engaged in any behaviors that one might consider risky, somehow she seemed to have felt culpable for her disease. She appeared to feel embarrassed and shameful, which was evident in her telling me that her biggest fear was that others would find out about her disease. She had poor eye contact when discussing her illness and she often looked down when discussing her disease. Yet, Evelyn’s rare cancer was the result of bad luck. It is the surrender to this idea that people are subject to bad luck in illness that can ignite a reaction of shame. Sometimes feeling responsible for a disease is an easier choice than feeling that one has been the victim of bad luck. Ironically, feeling responsible for one’s illness, even when it does not make sense is sometimes a better “compromise” than feeling out of control and at the whim of bad circumstances. This is part and parcel of the experience of trauma for many people. Trauma often occurs randomly, yet the idea of being the victim of


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random circumstances is terrifying and causes people to question their own sense of meaning. Feeling responsible and taking blame, even when it is not warranted, is often a far better scenario than feeling like bad things can happen for no reason. Of course, bad things do happen when no reason or explanation is involved. Denial and dissociation can help to defend against the overwhelming feelings that are associated with this kind of devastating blow, and are common among traumatized medical populations. These two responses are related and often occur together. Both denial and dissociation can be seen as protective against overwhelming affect. Dorpat (1987) defined denial as “the unconscious repudiation of some or all of the meanings of an event to allay anxiety or other unpleasurable affect” (p. 2). Regarding dissociation, Putnam (1992) described dissociation as the “escape when there is no escape” that “kicks in when all is lost” (p. 104). Putnam’s description of dissociation indicates the extreme nature of this defense, and implies that dissociation is a last resort and one that is needed when all other defenses fail. We can see the influence of denial and dissociation when we consider Evelyn. She not only was in denial of her serious illness by attempting to convince herself and others that she was not ill, but the extent to which she could escape (in her perception, successfully) from her illness also suggested the presence of dissociation. When Evelyn presented for therapy she genuinely felt that her life was fine, though her children and other family members had found out about her cancer and felt otherwise. They demanded that she receive psychotherapy. Evelyn’s perception that things were “fine” suggests that the psychic escape afforded by dissociation works to some degree. However, as Putnam goes on to say, dissociation does not come without a cost, which includes: (1) discontinuity of sense of self; (2) a detachment or depersonalization from the physical self that permits or even fosters self-mutilation; (3) An array of amnesias and gaps in the continuity of memory; (4) inability to transfer basic conceptual information across dissociative states, leading to a failure to learn from experience and erratic access to knowledge and skills; and (5) inner conflicts and self-sabotage. (p. 105)

This description of the consequences of dissociation illuminates a number of issues related to engaging these patients in the therapeutic process. Traumatized medical patients who use dissociation are difficult to engage in therapy not simply because of the need to not think about aspects of medical illness, but because of the susceptibility to dissociation. In particular, the discontinuous sense of self that results from dissociation makes it difficult to think, and as Putnam suggests, to cognitively process information. Thus, for some medical patients, the cognitive abilities required to benefit from psychotherapy are simply less available. This explains why we need to work differently to engage patients in the therapeutic process as well as how patients such as Evelyn and Frank can seem lost and without access to their rational faculties. A further complication is that dissociative experiences become an important part of self-experience. As therapists, we threaten to disrupt the very aspects of experience that have helped people survive traumatic events. As Bromberg (1991) puts it, people who use dissociation try to stay the same without changing. This is because the help afforded by psychotherapy results in overwhelming confusion and feelings. Not having a cohesive sense of self, that is, not knowing about confusing and terrifying feelings, serves the purpose of feeling connected and

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whole. Awareness of these feelings threatens to disrupt important dynamics of a cohesive self. Not knowing about something too painful to know serves the function of a basic level of protection. Such people are difficult to help, as our attempts to intervene can be experienced as hostile or simply inept. Take the example of the common technique of normalizing feelings and behaviors. Although it may seem to us that in most cases, normalizing feelings as a therapeutic intervention is helpful for people who use dissociation and denial, normalizing can have a negative effect. This is because such an intervention threatens the presence of these defenses. Indeed, the very reminder that they have experienced something in reality that is traumatic or even unpleasant can be met with incredible anger. Consider the case of Barrett: Barrett was 44 years old when he was diagnosed with a rare form of cancer. He presented for therapy at the urging of his wife and hematologist. He had developed classic PTSD symptoms due to the impact of his disease, which included several life-threatening events during multiple hospitalizations throughout his medical treatment. He had nightmares, intrusive recollections, insomnia, and hypervigilance. He had been experiencing acute anxiety regarding these symptoms and said that he constantly worried about what was wrong with him. When I told him that I felt that his symptoms were normal given the extreme amount of distress he had gone through, he reacted not with relief, but with a sense of rage. He said to me, “I don’t think you know what you are talking about and I wonder if you have any experience at all with cancer patients.” I responded to this remark by telling him that I did have experience in working not only with cancer patients, but with those who had the same kind of cancer he had. This made his rage worse, when he declared, “What I am going through is very unusual and there is no way that you could even begin to understand the special and specific aspects of. . . ” and he began to list a number of medical issues related to his disease.

Barrett’s case describes the bind that we can all find ourselves in when trying to help people who use dissociation and denial to cope with illness. Though the familiar technique of normalizing works for some patients, it backfires with others. Barrett felt that I was not acknowledging the experience of his illness and how unique and special it was to him. Although I think it is true that Barrett generally tended to view himself as unique and special, I do not think that these issues (related to premorbid narcissism) fully explained his rage when I attempted to normalize his symptoms. Rather, my speaking to his experience suggested that his illness was real, thus challenging his use of dissociation and denial. Although intervening the way I did was a threat to Barrett’s use of these two defenses, what seemed even more threatening was that by initiating this shift in perspective (through normalizing and suggesting that I knew about his illness) to Barrett, I was threatening a powerful perception; that he and I were the same. Over the course of his therapy, it became clear that Barrett’s difficulties stemmed from his view that he and I were separate individuals. Normalizing his experience was my attempt to offer him something, which carries the implicit assumption that we were separate people. The idea of separateness and differentiation goes further in explaining why some patients present as concrete. Bass (1997) describes how concrete patients are desperately attempting to defend against the idea of differentiation. The desire to be the same as others, especially the therapist, results in the kind of concrete thinking we can see in some patients. Bass describes concrete thinking as a “defensive conflation” between reality and fantasy (p. 647). For patients who need denial and dissociative


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defenses, offering something, whether it be knowledge, advice, and interpretation, or sometimes even a simple observation, threatens the fantasy that the therapist and the patient have the same mind. Of course, it is not a conscious or rational idea that patients hold when they believe that they are the one and the same as the therapist. However, this idea is important because merging one’s identity with that of the therapist wards off overwhelming emotions. Though these dynamics are common in patients with narcissistic personalities (which will be described further in the following chapter), they are also common in people who are overwhelmed and using narcissistic defenses. These people are attempting to avoid feelings such as intense sadness, loss, disappointment, and anger over aspects of life that have been affected by illness. I also suspect that feelings of envy toward the therapist contribute to these emotions. The apparent wellness of the therapist is an important and often neglected aspect of treatment with medical patients, likely in part, because of the difficulties in talking about this issue. Nevertheless, the very idea that the therapist is well and the patient is not also threatens to undermine the idea that some patients may have of similarity. With Barrett, it took me some time to realize that by my knowing something different than what he knows, I was expressing a kind of differentiation that he was unable to bear. This latter aspect of his functioning was left out and missed in my simply normalizing his feelings. Fortunately, Barrett continued in therapy and I had a chance to change my technique. It took a long time before I could describe that I had any idea of his disease. Although he continually said that he wanted to work with someone who he felt was an “expert” regarding his disease, he also needed to feel that he knew more than I did, because he had to feel that we shared the same level of knowledge. The kind of technical shift I needed to make was easy from the standpoint that I could easily withhold my comments about what I knew of the difficulties of his disease. However, working with Barrett became more difficult, in that I had to assume something that was not true, that he and I were the same. In order for Barrett to connect with me I had to join him in the idea that we were the same. In subsequent hours with him, it was necessary to suspend ideas of our differences, even though I knew otherwise. Although for some patients it can feel pleasurable to deny differences (such as when we feel merged with a patient who idealizes us), the feeling of connecting with Barrett was not at all pleasurable. For patients such as Barrett, we need to tolerate the feelings that arise when we are not afforded the luxury of our own separate minds. On a superficial level, this means we cannot provide much in the way of normalizing interpretations regarding reactions to illness and offer our expertise about illness. On a more substantial level, it means allowing a kind of loss (though hopefully temporary) to our psychological integrity. We need to be able to tolerate the feeling that what we are offering may be different than what we are used to, and at times, it may feel that we are offering little help. Though some clinicians might experience this as a feeling related to being devalued, I think this feeling is more of a reflection of what patients are experiencing in terms of their own diminished self-state and loss of access to normal cognitive functioning because of the use of dissociative defenses. Feeling the same as others prevents devastating disappointment, overwhelming sadness, and fear. Although

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tolerating these feelings can be difficult, doing so provides the opportunity to get to know patients such as Barrett and to eventually be able to provide more in terms of therapeutic interventions. For many patients like Barrett, I have found that by being able to access sympathetic feelings within myself regarding the pressures of dissociative defenses, I have been able to weather the indeterminate period of a particular patient’s disavowal of my separateness and not only encourage them to stay in therapy, but also provide help in a way that they may not have received before. Not only did Barrett eventually become more comfortable accepting that I knew something about his cancer, these insights were helpful to him and in general he became more willing to hear my interpretations. Though it never seemed useful for Barrett to return to the meaning of his initially not feeling that I had much to offer him, it was more useful to him that I could manage the complex juxtaposition of his needing help, yet wanting to resist my influence in providing this help.

Past Trauma in the Context of Aging and Illness Although I have discussed the traumatic aspects of illness that can affect adults who become seriously ill, I want to turn our attention to another kind of trauma that impacts adults; not those with life-threatening illnesses per se, but those with less severe illnesses and those related to aging. Although this topic, at first blush, might appear to be out of place in this chapter, it seems to be perfectly fitting from the standpoint that some patients who experience literal bodily slowing can also experience a reawakening of feelings and memories from the past. When these feelings are related to earlier traumatic events, they can cause significant psychological distress. These memories and feelings are often suggestive of the reawakening of PTSD symptoms. They are commonly related to the fact that past experiences have not been thought through and that feelings regarding past trauma have been negated, due to the fact that previous defenses have proved successful in avoiding of memories of traumatic events. Although such people often have a long history of avoidance and dissociation, what seems to have been especially successful in staving off thoughts and feelings related to past trauma are manic defenses. As I described previously, manic defenses are activated when idealization, feelings of being powerful, and hyperactivity are employed to ward off sadness, worries about aggression, and ambivalence (Klein, 1940). Manic defenses are used to avoid difficult and devastating feelings. However, like dissociation, manic defenses have a cost. Consider the case of Louise: Louise is a cognitively intact 75-year-old married woman who lives in an independent seniors’ residence with her husband, who is physically healthy. She has mild osteoarthritis and laments not being able to play tennis anymore, as she did so well into her sixties. Although highly educated, Louise never worked and was supported by her husband while raising their children. She denied symptoms of a psychiatric disorder. Yet, she presented for therapy saying that she “just wanted someone to talk to.” After a number of interviews and in the absence any psychological complaints, I was confused as to why she sought therapy. I also found sessions with Louise to be strained and uncomfortable, as she frequently

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complained about how the long sessions were. She eagerly agreed to meet for 30 minutes instead of the standard 50-minute session. This reduced session time allowed her to feel more comfortable and she seemed less guarded. She finally told me that she was experiencing intense anxiety related to the fact that she had been masturbating. Her husband was no longer interested in sex and she reported that she felt fine with this, but masturbating made her extremely uncomfortable. I initially understood Louise’s anxiety as being related to the common prohibition of her generation against masturbation, especially for women. My attempts to talk with her about this and to provide reassurance through interpretations related to her cohort proved unsuccessful. Her anxiety remained and she was unconvinced that masturbating was anything less than “evil.” Eventually, Louise told me that an older brother had molested her when she was about 12-years old. Although her brother stopped abusing her by the time she was 13, Louise reported that throughout her adult life and often during times when they were vacationing together with their respective spouses, her brother made sexual advances toward her. As in her childhood, Louise never told anyone about these violations. She told me that I was the first person she has ever talked to about these traumatic events.

Although Louise’s experience in therapy represents one kind of presentation related to past trauma, her situation does not reflect the dynamic of adult trauma as the result of an illness. However, experiences such as those expressed by Louise are common in older adults who have had childhood incidences of trauma and who develop limitations related to aging and nonlife-threatening bodily illness. And as we saw in Louise, the traumatic events of childhood were re-enacted in her adulthood, which likely served the purpose of helping avoid her feelings about these events, as they were being enacted in the present. Chu (1991) describes how trauma that has been dissociated gets re-experienced in the present as a way to avoid thinking in a meaningful way about the past. Until Louise and I met, she had never questioned the reasons why she would continue to see her brother when she clearly felt uncomfortable with his behavior. Louise’s brother had died many years before we met, and she later told me that his death had been a great relief because she did not have to see him anymore. Like many survivors of incest, Louise thought that her brother’s death would also be the end to her need to ward off feelings about this relationship. This was not true, but as long as Louise had been able to use her body to “stay busy,” she was able to avoid the memory of his presence in her life. Louise had avoided thoughts about the sexual molestation by her brother and her parents’ inability to protect her through excessive activity in her adult life. Although manic defenses can and do involve use of the mind, it often involves the body. For many patients, excessive physical activity by exercising or manual work allows needed distance from thoughts of past trauma. As I got to know Louise more, it was clear that the loss of her physical functioning due to her arthritis was the beginning of her not being able to avoid intrusive thoughts about the problems with her brother. Additionally, it seemed that once her husband began to become more detached (he eventually developed dementia, a fact that Louise had suspected when we first met), Louise felt, for the first time in her life, alone. This aloneness combined with the loss of the use of her body for physical activity made it impossible to avoid remembering past experiences with her brother. As we saw with Louise, as well as Joan in the previous chapter, illness and aging not only brings on new challenges, in that one has to accept the reality of physical

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limitations, but also changes in the ability to use one’s body can open a door to recalling traumatic events. For people with trauma in their past, illness and bodily changes mean the end of defenses used to avoid painful memories. As mental health clinicians, we may assume that patients with traumatic experiences might present for therapy earlier in life; however, it is often the case that people who have suffered from trauma avoid therapy, because it presents an opportunity to think about past experiences. My experience with a number of people who are Holocaust survivors and had never been in psychotherapy until they are beset with physical limitations, supports this idea. Avoiding therapy and not thinking about past traumatic events can “work” when one is not inhibited from using the body as a distraction. Additionally, the ways that the mind literally slows down in aging makes it harder to avoid painful thoughts and memories. Older adults often comment to me about the increased amount of time it takes to process thoughts and complete tasks. For those who use their mind to avoid painful thoughts, the relative slowness of an older brain (which will be discussed more in Chapter 8) makes it more difficult to use quick thinking as a distraction. Therefore, it may be that the literal slowing of both the mind and the body changes the way older people can make use of distraction. As I learned from Louise, she had been an avid tennis player and engaged in a number of other athletic activities, which kept her from thinking about her past. Although acknowledging that at times “thoughts would creep in,” she was able to avoid these thoughts by using her mind and her body to “move along” as she put it, in an attempt to “put the past behind.” This kind of “moving forward” mentality is common among trauma survivors who on some level seem to carry on and lead successful, asymptomatic lives. However, the past can catch up with the present when such individuals are forced to utilize different coping strategies. Such people present to therapy with a number of psychological symptoms that include depression and anxiety. Louise put these issues into clear focus by articulating, “As long as I keep busy I am fine, but if I am not distracted I feel awful.” For Louise, “awful” meant enduring panic attacks in the mornings as well as intermittent anxiety throughout the day. In my experience, these individuals are apprehensive to accept what therapy can offer, since they have been able to cope for many years without the help of a therapist. However, these patients can actually be more open to psychotherapy because of an awareness (even vaguely so) that something has changed. Louise was hesitant about talking with me, but she stayed in therapy for many years, in part because she wanted to tell her story, although she frequently asked me how therapy could help her. As with John in Chapter 1, Louise not only wanted shorter sessions, but at times she left therapy before our 30-minute session was finished. I understood her behavior as a desire to have some control over not only herself and the issues she presented in therapy, but also to some extent, control over me. Being able to influence her therapy was a means of replacement for the control she previously had achieved through the use of her body. Louise frequently asked me what I thought of her situation and was quite demanding (though pleasantly so) in this regard. This question, which was repeated many times in the first couple of years of her therapy, was an invitation to help structure her thoughts and a way for her to understand how I was conceptualizing her situation, and I willingly shared my thoughts with her.

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My patience and understanding about how difficult the sessions were for her, and acknowledging her need to have access to my own thoughts about our therapeutic relationship conveyed that I would allow her to have some control over our interactions. I often said to Louise, “I know this is hard for you, talking about yourself in this way.” She frequently responded by describing how her children often asked her how therapy was going. She smiled as she recounted these interactions and said that she told her children, “I know you think that I talk about you when I see Dr. Greenberg, but believe it or not, I actually don’t talk about you at all. I talk about me.” Louise was letting me know that although a part of her felt embarrassed by her need to talk about herself, she was grateful for the opportunity to do so. She eventually began to describe many aspects of her early family history that had left her feeling very uncertain about her power and sense of control as a person, and it became clear to both of us that Louise had led much of her adult life feeling terrified of setting limits with people because of worries about her own angry feelings. These insights led to more meaningful interpersonal relationships with friends and family in which she could interact with others without worrying about being taken advantage of. Improved interactions with others as well as a more confident and cohesive sense of self-led to decreased anxiety and panic attacks. Louise eventually stopped taking psychotropic medications and was able to engage in her life with a feeling that she could manage her anxiety. Although it was evident that throughout her life Louise had used denial, dissociation, and manic defenses, she retained enough internal selfstructure to eventually allow therapy to have an influence on her in a nonintrusive and meaningful way.

Conclusion The loss of manic defenses is particularly difficult for those who have had traumatic experiences in childhood, as aging and illness can bring an end to these former ways of coping. Psychotherapy can be successful for such persons if we can use psychodynamic theory in a flexible way and alter the framework, based on what patients may need in the present without pressuring ourselves and our patients to interpret the meaning of this flexibility. Additionally, as therapists working with aging and medically ill populations, we need to be less judgmental and transform our understanding of what is meaningful in the therapeutic encounter. As we saw with the very different patients in this chapter, meaning in a therapeutic moment is highly individual and changeable, based on the severity of illness, the sense of self-continuity, and the presence of emotions. As we saw with Louise, although she initially challenged the idea of psychotherapy, she conveyed a sense of wanting to know herself in a deeper, more complete way. Although suffering psychologically, she was sufficiently confident in her desire to connect with others in a meaningful way. And even though she had experienced childhood trauma, there had been enough positive, enriching experiences in her life to foster the belief, and the faith, that under the right circumstances she could be adequately taken care of. Perhaps

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more importantly, Louise did not have to contend with a life-threatening illness. As we saw with Sara, Evelyn, and Frank, who were coping with potentially terminal diseases, patients who have experienced these kinds of traumatic events are more difficult to engage in the therapeutic process. The imposing threat to the integrity and cohesion of the self, as well as the distressing fear of death result in reduced access to symbolic thought, which require different therapeutic approaches in order to provide a basic level of security. Avoidance, dissociation, and denial keep such people trapped in an internal world that we need to cautiously enter with sensitivity and compassion. We can attempt to reach these individuals by meeting them where they are in their lives, and by discussing the issues they can feel safe talking about, while knowing that language is merely a window into more meaningful ways of relating and understanding. This way of viewing the therapeutic relationship creates a more conducive atmosphere for ourselves as clinicians and for our patients. For it is not what we talk about that is of paramount importance, but in providing an environment in which we can communicate to those who come to us for therapy an understanding of the confusion and mixed emotions related to the ways that their bodies have failed.

References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, DC: Author. Bankier, B., Januzzi, J. L., & Littman, A. B. (2004). The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease. Psychosomatic Medicine, 66, 645–650. Bass, A. (1997). The problem of “concreteness.” Psychoanalytic Quarterly, 66, 642–682. Bion, W. R. (1965). Transformations: Change from learning to growth. London: Tavistock. Retrieved September 5, 2008, from http://www.pep-web.org/document.php?id=zbk.005.0001a. Boungler, G. (2007). Wounded by reality: Understanding and treating adult onset trauma. Mahwah, New Jersey: The Analytic Press. Bromberg, P. (1991). On knowing one’s patient inside out: The aesthetics of unconscious communication. Psychoanalytic Dialogues, 1, 399–422. Bromberg, P. (1994). “Speak! That I may see you”: Some reflections of dissociation, reality, and psychoanalytic listening. Psychoanalytic Dialogues, 4, 517–547. Bromberg, P. (2003). One need not be a house to be haunted: On enactment dissociation and the dread of “not me” – A case study. Psychoanalytic Dialogues, 13, 689–709. Chu, J. A. (1991). The repetition compulsion revisited: Reliving dissociated trauma. Psychotherapy, 28(2), 327–332. Doerfler, L., & Paraskos, J. A. (2005). Posttraumatic stress disorder in patients with coronary artery disease: Screening and management implications. Canadian Journal of Cardiology, 21, 689–697. Dorpat, T. L. (1987). A new look at denial and defense. Annual of Psychoanalysis, 15, 23–47. Freud, A. (1952). The role of bodily illness in the mental life of children. Psychoanalytic Study of the Child, 7, 69–81. Frosch, A. (1995). The preconceptual organization of emotion. Journal of the American Psychoanalytic Association, 43, 423–447.

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Greenberg, T. M. (2007). The psychological impact of acute and chronic illness: A practical guide for primary care physicians. New York: Springer. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Inagaki, K., & Hatano, G. (1993). Young children’s understanding of the mind-body distinction. Child Development, 64(5), 1534–1549. Jaques, E. (1998). Death and the mid-life crisis. In E. B. Spillus (Ed.), Melanie Klein today: Developments in theory and practice (vol. 2, pp. 226–248). London: Routledge. Joseph, B. (1983). On understanding and not understanding: Some technical issues. International Journal of Psycho-Analysis, 64, 291–298. Kangas, M., Henry, J. L., & Bryant, R. A. (2002). Posttraumatic stress disorders following cancer: A conceptual and empirical review. Clinical Psychology Review, 22, 499–524. Kangas, M., Henry, J. L., & Bryant, R. A. (2005). The relationship of acute stress disorder and posttraumatic stress disorder following cancer. Journal of Consulting and Clinical Psychology, 73, 360–364. Klein, M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis, 21, 125–153. Klein, M. (1948). A contribution to the theory of anxiety and guilt. International Journal of Psychoanalysis, 29, 114–123. Lewis, H. B. (1984). Freud and modern psychology: The social nature of humanity. Psychoanalytic Review, 71, 7–26. Putnam, F. W. (1992). Discussion: Are alter personalities fragments or figments? Psychoanalytic Inquiry, 12, 95–111. Sullivan, H. S. (1956). Clinical studies in psychiatry. New York: Norton. van der Kolk, B. A. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatry Clinics of North America, 12(2), 293–317. van der Kolk, B. A., Hostetler, A., Herron, N., & Fisler, R. E. (1994). Trauma and the development of borderline personality disorder. Psychiatry Clinics of North America. 17(4), 715–730. Winnicott, D. W. (1965). Maturational processes and the facilitating environment: Studies in the theory of emotional development. New York: International Universities Press.

Chapter 4

Narcissistic Aspects of Aging and Illness

Whereas in my youth I succeeded daily and under all circumstances, I now succeed only periodically and under favorable circumstances. Goethe (at age 79)

Although people can flourish as they get older, aging is difficult and requires us to manage a number of blows regarding the ways that the body changes and lets us down. Growing older presents a number of challenges and involves adjustments to changes in physical abilities, the time required to complete tasks and activities, alterations in appearance, and an awareness of the inevitability of death. Although some people manage the passing of time with only minor ailments, aging increases possibilities for the development of various illnesses, a reality that serves as a disquieting threat for those who allow themselves to become conscious of this fact. A further complication of aging is that aspects of self-care and adherence to medical treatment become increasingly important to ward off health problems or to manage existing illness. Regarding self-care, this can be an enormous challenge for people who struggle to refrain from behaviors that put them at risk. As an introduction to these issues, and the topic of narcissism in aging, consider the following case example: Mary is a 63-year-old woman who had a stroke that left her with significant weakness on her left side. She left acute rehabilitation in a wheelchair and then came to me for psychotherapy for 2 years. Mary had been a beautiful woman who had worked in the entertainment industry, where her attractiveness worked in her favor, as she frequently had contact with actors and television professionals. Perhaps linked with the culture of the entertainment business, she had also been a heavy smoker and drinker, and frequently engaged in illegal drug use. Her stroke left her unable to partake in these activities, since she initially lived in an assisted living facility where she was under frequent care and supervision. Although Mary reported that she was aware of risk factors for a stroke (she had suffered a heart attack a few years earlier and had continued to smoke and drink heavily) she experienced her stroke and subsequent limitations as a “shock.” And though she came to see me for help, it was never really clear what she wanted from therapy, except to “feel better.” Mary informed me that she was most distressed about the changes in her appearance following her stroke, as her ability to care for herself had been drastically compromised. Though she previously had plastic surgery in an attempt to maintain a youthful appearance, she felt that she now


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4 Narcissistic Aspects of Aging and Illness looked “old and tired.” Mary maintained a focus on the external aspects of herself in our meetings together, as she felt that if she could regain a youthful appearance, then she would feel better about herself. Attempts to talk about internal aspects of her functioning proved difficult and Mary eventually moved out of her supervised setting, back into her home with a caretaker. She then began smoking, drinking, and using drugs, and eventually stopped seeing me.

This chapter will address aspects of narcissistic injury in aging and illness. Mary illustrates an extreme example of someone whose focus on the external aspects of herself, denial of the impact of unhealthy behaviors, and subsequent illness can lead to self-destructive behavior. In the face of illness and aging, Mary could no longer rely on her outer appearance and the relative ease and privilege it provided. Without these sources of self-esteem, her sense of self collapsed. Facing the reality of her health situation was devastating because Mary had invested her self-worth in these external qualities, rather than developing an intact inner life, which would sustain her and connect her to others in a more meaningful way. Changing her behavior to promote better health required a capacity to tolerate sadness, emptiness, and loneliness. Instead, she denied her medical condition, focusing on external aspects of her life, in an effort to restore the only sense of self and internal structure she knew. Mary’s denial put her at risk for further medical complications, as she continued to indulge in temporarily relieving, but long-term injurious substance abuse. Self-destructive behavior is one kind of collapse when narcissistic defenses fail and all hope is lost for gaining an internal sense of self and self-structure. Although aging and illness often coexist, this chapter will offer a framework for thinking about the adult patient struggling with the aging process, including the loss of physical abilities, the reality of bodily limitations, and how psychic functioning is impacted. The onset of physical difficulties can be the final prompt to come to terms with narcissistic issues. With the crutch of perfection kicked away, new modes of functioning and relating with others can result. I also will discuss the concept of the “midlife crisis” and how this stage of life can be a time when narcissistic injuries and disappointments can lead to hopelessness and self-destruction. Alternatively, midlife can be a great time of creativity and insight if certain issues are resolved. In the absence of the resolution of conflicts, however, this can be a tumultuous time, when unaddressed narcissism interacts with the ability to take care of oneself. The likelihood of engaging in health-promoting behaviors or not is often related to the ability to accept reality and mourn previous losses.

The Concept of Narcissism Within Psychodynamic Theory Narcissism is perhaps one of the most well-known ideas within psychodynamic theory. Christopher Lasch’s best-selling book, The Culture of Narcissism (1978), provides an extensive sociocultural discussion of narcissism in contemporary Western culture, suggesting its societal prevalence and familiarity. Many aspects of the concept of narcissism have been elaborated on in great detail in psychoanalytic

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and psychodynamic literature. Therefore, only key aspects of the concept will be reviewed here. Freud (1914) described narcissism as a kind of “sexual perversion” in which narcissistic persons are overly focused on themselves, and this focus is in the aim of self-pleasure and gratification. However, Freud described normal and primary forms of narcissism. In Mourning and Melancholia (1917a), he observed that narcissism is present in children (implying its developmental underpinnings) and the “universal narcissism of men.” He also said that it is, “excessive narcissism of primitive man that we ascribe his belief in the omnipotence of his thoughts and his consequent attempts to influence the course of events in the external world by the technique of magic” (p. 139). This description serves as an initial foundation for what we see in people who are especially narcissistic. For example, ideas of omnipotence and magical thinking explain a number of Mary’s behaviors. Omnipotent thoughts involve the idea that one is more powerful than they actually are, and magical thinking and denial serve to reinforce this belief. Mary had long been in denial about her excessive drinking, smoking, and drug use, and the severity of her cardiovascular disease. Her focus on her external appearance and the idea that “fixing” her outer self would magically solve her problems illustrates the ways that narcissism affects people who are struggling with aging and illness. Contemporary psychodynamic theory emphasizes the normative aspects of omnipotence, meaning that we can all get confused regarding the extent of our power and control over others. Additionally, magical thinking and denial are common ways people avoid coming to terms with the meaning of aging. This is true especially as it relates to common perceptions of the body. Our relationship with our bodies is inherently narcissistic and we expect it to be capable of providing pleasure, mobility, and to serve us on command. Developmentally, discovery of our physical capacities is associated with the idea that our bodies are limitless in their capacity to do great things. Further, in the early stages of illness, denial can be used to fight disease and mobilize coping resources. Indeed, narcissism has normal and adaptive elements. Kohut was among the first to question the assumption that narcissism is fundamentally pathological (Morrison, 1986). In fact, Kohut makes the assertion that it is not narcissism that is the problem per se, but the way it has been pathologized by clinicians. Regarding the tendency to look at narcissism negatively, Kohut (1986) explains: Where such a prejudice exists it is undoubtedly based on a comparison between narcissism and object love, and it is justified by the assertion that it is the more primitive and the less adaptive of the two forms of libido distribution. I believe, however, that these views do no stem primarily from an objective assessment either of the developmental position or of the adaptive value of narcissism, but that they are due to the improper intrusion of the altruistic value system of Western civilization. Whatever the reasons for them, these value judgments exert a narrowing effect on clinical practice. They tend to lead to a wish from the side of the therapist to replace the patient’s narcissistic position with object love, while often the more appropriate goal of a transformed narcissism (i.e., a redistribution of the patient’s narcissistic libido and the integration of the primitive psychological structures into the mature personality) is neglected. (p. 61)

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4 Narcissistic Aspects of Aging and Illness

Here, Kohut is not only disputing the pathologizing of narcissism, but he also points out that for many therapists, narcissism in our patients results in an unsympathetic response to their needs. Therapists often feel annoyed, bored, and irritated in the presence of patients who seem to have narcissistic defenses or character traits. Although I think there are many good reasons for this, Kohut’s comments suggest that our frustration with narcissistic patients is in fact a narcissistic defense that occurs in us, as therapists. Narcissistic patients tend not to “take us in,” and they consciously or unconsciously attempt to control both the therapist and the treatment we provide. As therapists, we often do not feel appropriately recognized as healthcare professionals who have something valuable to offer, especially in the early stages of treatment. Additionally, and perhaps more importantly, narcissism in medically ill and aging patients often reflects that these patients are attempting to avoid thinking about their own vulnerability, an issue that is also likely common in us as therapists. Perhaps our dismay with these patients has something to do with our own sense of vulnerability and fear. In other words, none of us want to grow old, and none of us want to become ill, yet some of the narcissistic defenses that occur in our patients are likely those that would occur in us, if we were to become the patient. Perhaps our need to feel recognized is related to a desire to avoid our own fears and vulnerability. Part of navigating the terrain of aging and illness for ourselves and our patients is to come to terms with the reality that our bodies are finite, that as we age, our bodies will disappoint us, and that we will not live forever. Although authors in both psychology and popular literature have discussed common aspects of the denial of death, more often than not, problems related to aging (and the narcissistic injuries associated with aging) are what we encounter in people who have trouble coping with aging and illness. Though many people are knowledgeable about the eventuality of dying, many are not prepared for the effects of aging and its subsequent limitations. In other words, for some, death is not so hard to accept, but living with reduced physical capacities is much more difficult, if not unimaginable. One of my patients in her 60s recently put this idea into clear focus by confiding, Dying is easy. Then it is over. It is the living that is hard. I grow old and I worry what could happen to me next. A stroke, a heart attack, dementia. If these things happen and I die, that is fine. But what if I don’t (die), what if I have to live being impaired like that? I can’t even think about it.

Although I described in the previous chapter that some people perceive death as being paralyzed and subject to torture, others who have relied extensively on narcissism seem to be relatively less concerned with thoughts of dying, but more concerned with being reduced to a state of dependency in the context of bodily limitations. Narcissism in an excessive form is an attempt to avoid feelings of dependency, which is a common issue for aging and medically ill persons. Lasch (1978) notes, “In its pathological form, narcissism originates as a defense against feelings of helplessness in early life, which it tries to counter with ‘blind optimism’ and grandiose illusions of personal self-sufficiency” (p. 231). Aging and associated bodily limitations increase the need for help from others, and it is this issue that I constantly find to be salient, in a conscious way for many of my patients.


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Dependency and loss that accompany aging and illness can render some people to feeling helpless and empty. Consider the case of Edward: Edward is a 78-year-old man who enjoyed good health most of his life. He had been extremely physically active and enjoyed a number of competitive sports. He thrived on the challenge of competition, which he found most gratifying in his work as an attorney. As a litigator, he achieved success and status, and financially supported a large family. He and his wife entered an independent living facility when they reached the age of 75, as they were too weary to maintain their large home. Shortly after entering the facility, Edward’s wife died suddenly. However, despite this loss, he maintained relatively good health and spirits, and within a year began dating a single woman in the retirement community. I met Edward following an injury in which he fractured his femur. He had been placed in a skilled nursing facility and was referred to me because he became extremely depressed. He admitted that although he realized he was in a “good” facility, he felt embarrassed and devastated that he needed help with aspects of basic care. As I got to know Edward, he told me that he felt as if his injury had left him “empty.” At times he experienced this empty feeling so intensely that he felt as if he was “nothing.”

Since narcissistic aspects of a person’s character involve a tremendous sense of self-sufficiency, loss of the ability to “do it all” alone poses tremendous challenges (see Almond, 2004, for an illustrative clinical example of this issue). As we saw with Edward, his ability to not be an “in-charge” man, who could take care of himself without help, left him bereft. Although, as I got to know him, Edward told me that he felt a sense of emptiness and nothingness much of the time, these feelings made him feel terrified. Therefore, he somehow had to keep these emotions at bay. One way he did this was to find fault in his caregivers. Although he told me that he felt he was being well cared for, his attitude with staff was much different. He often yelled at them when they did not meet his needs immediately, and at times he was not only impatient, but was particularly livid when he felt embarrassed (such as when he needed help using the bathroom). Edward had the tendency to belittle his caretakers and on many occasions made comments related to the personal appearance of the staff caring for him. He also frequently told staff they were “stupid,” and he openly mocked those who did not speak English well. Though most clinicians are familiar with the concept of “narcissistic rage” which often results from feelings of humiliation and shame (often in the context of reduced personal control), it seems important to highlight this particular brand of humiliation and rage, because it results from feelings of dependency and emptiness. Further, individuals such as Edward also experience a great deal of anger and contempt toward themselves, as well as anger toward the unjustness of circumstances, which have left them feeling helpless. Edward’s contempt toward himself was evident in his apparent antipathy toward his caretakers. Patients like Edward are enraged that they need the help of others, which can result in animosity toward caretakers and loved ones. However, hatred and rage have an organizing function and thus can avert the aforementioned feelings of emptiness and nothingness that patients who have been extremely self-sufficient often experience. In other words, in moments of hatred and rage, the dilemma is clear; the other has done something unjust or wrong. In these states, anger makes sense: the other is to blame, and the fault of one’s life is due to

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the incompetence of the other. I met with this aspect of Edward’s functioning when I returned from a vacation. Let us consider this exchange: I arrived in Edward’s room after a long vacation. He had been helped out of bed and he had just had breakfast. He glanced at me briefly and then returned his gaze to the floor. “Oh, you’re back,” he said. I responded, “Yes, I am.” “Did you have a good time?” he wanted to know. “Yes, I did, thanks,” I responded. “Good, good. Well, you just run off whenever you want to and shit is still the same here. I can’t get these people to do anything I want them to do and I still can’t walk. Who knows where they get these idiots to work in this place.” Since I understood myself to be included among the “idiots” he was referring to, I said, “I was gone a long time. It must be hard to have people you count on be able to come and go while you stay here with a broken leg. How are you supposed to know who you can count on when people can just get up and leave? Edward then made eye contact. “Yes, I used to travel all over the world and now I do nothing.” I responded to this by saying, “At times you also have these empty feelings.” Edward said, “Yes, well, I am not doing much here, am I?”

Given our previous conversations and the narcissistic aspects of his character, I understood Edward’s comment “and now I do nothing,” to mean that he felt like nothing. My being able to leave him and go on vacation exacerbated his sense of dependency and was a harsh reminder of not only my health, but my separateness from him. As therapists we often provide a crucial lifeline for patients who cannot access their thoughts. We provide the function of not only mirroring and witnessing of the experiences associated with aging and illness we can provide the emotional language that is often needed for patients to metabolize and understand these experiences. Our separations from patients leave them without an external conduit which can help with understanding and metabolizing of their lived experiences. This loss through my vacation was difficult for Edward as he lacked the capacity at the time to feel the sadness and disappointment that resulted from my being absent from him. Another serious blow, however, was that his leg was not getting better; other health problems had emerged, and it was looking like Edward was going to need a higher level of care. Although the rage and the anger at his loss of control were palpable, I often feel in these situations that focusing on rage and need for control do not address extreme aspects of helplessness and sense of loss that accompanies the narcissistic injury associated with aging, illness, and the relative nearness of death. Edward had become more depressed. His depression was viewed as a realistic response to the fact that he had less control over his circumstances and that he was becoming increasingly ill. However, his depression also reflected a “collapse” of his usual narcissistic coping mechanisms. Although Edward was angry with me, he had been more cooperative with his caretakers, as the emergence of his depression had left him with fewer resources and energy to fight with staff. Kernberg (1975) described depression in people with narcissistic characters as a temporary state that results from the collapse that occurs when one realizes they have denied the reality of their situation and its accompanying physical limitations. Though I find this concept to be true in many of the older people I see who have excessive narcissistic aspects to their character, depressive states often persist. In younger patients with narcissistic characters, depression can lift if they can realize aspects of previous functioning. The stereotypical example of this is a patient who presents with narcissistic depression after the ending of a relationship. Often in these cases, once an


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individual can build up sufficient inner resources or by finding a new person who is interested in them (often a potential romantic partner), their depression improves and they can resort to previous levels of emotional functioning. In older adults and medically ill adults, however, previous levels of physical functioning often do not return. An additional complication is that depression itself is a common physical consequence of aging, especially among patients who have hypertension and vascular dysfunction, which are common illnesses in older adults (Vicario, 2008). Therefore, patients such as Edward are at increased risk for ongoing depression, especially if the underlying emotional causes of depression are not addressed. Many aging people are likely experiencing symptoms of age-related cognitive changes. Although I will address this issue in more detail in Chapter 7, it is important to mention here that the kind of disinhibition that can occur in medical and aging patients can often be the result of frontal lobe disinhibition that occurs in patients who have vascular or cardiac illnesses and those with dementia. Therefore we can understand both Edward’s and Mary’s difficulties as stemming in part from the neurological impact of vascular disease, in that they likely had neurological changes which left them susceptible to “acting out.” Although such acting out may have a neurological component, psychological influences both contribute to and can help curb these behaviors. Regarding psychological influences, I find that many patients who have trouble inhibiting themselves when aging and ill also have histories of expressing anger in an inappropriate way. Like many patients with brain injuries, personality changes are often an exacerbation of premorbid functioning. Even if aggression and acting out in aging patients is in part a result of age-related cognitive changes, psychological interventions can effectively not only reduce aggressive behavior, but can also provide a sense of soothing care, understanding, and help with the development of an internal self-structure in which patients can eventually rely more on internal resources for comfort, even when feeling threatened by dependency and fear. For Edward, meeting regularly helped to calm his anger. As noted earlier, however, interpreting his anger did little to help him. For example, if I said, “I can see you are angry,” this was often met with him saying, “Of course I am, wouldn’t you be!?” Tolerating his anger, on the other hand, and having him think about what else he might be feeling seemed a better avenue to help him adjust to the fact that he was now dependent, and allowing for a measure of ambiguity about whether or not he would eventually be able to return to his previous level of functioning. Therefore, I listened to his complaints about his caregivers, and although at times I referenced the common struggles of any skilled nursing facility, I kept the focus on his feelings of emptiness. Over time, this seemed to help him have a clearer focus on his internal life. He began to cope better and his aggression toward staff decreased. In a much later session, while we were talking about his adjustment to becoming a permanent resident in the skilled nursing facility, as his health did not improve, he said, “Well, you know, I am here and I still hate it. And I am just going on in this way. But I have to say; I do feel okay about being alive. I mean, I am not dead, yet, right? The staff, well, they do help me, and at least I can still do some things on my own.”

The moment was poignant. When I met Edward, his life was filled with anger and aggression toward people who cared for him, which was not only a reflection

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of his own self-contempt, but his rage at needing others. When we had this conversation, Edward had become somewhat less depressed, although like many people in his situation, he remained on antidepressant medication. Yet, his attitude had shifted considerably. He had found pleasure in aspects of his life and reportedly had more meaningful interactions with family members, even though at this point he was fairly ill. I find that a main treatment goal for people who have experienced narcissistic collapse and depression is to be able to gain a sense of a functioning self in which they can genuinely feel that life has something to offer, even if one is compromised medically. This is not to say that one should adopt a Pollyannaish attitude, but rather, that some aspect of mourning has taken place, in that the losses of aging and illness can become integrated into a healthy sense of self. Mourning, a concept identified by Freud (1917b) in which he ties in aspects of narcissism and mourning, is an essential component of working through the narcissistic losses associated with aging and illness. In narcissism, others are idealized as a way to avoid mourning and reality. Idealization explains the common experience that narcissistic patients often initially perceive us as perfect. But for the astute therapist, idealization carries a false feeling. This is because idealization is a way to avoid the ambiguous nature of relationships and prevents the mourning of losses of the past, present and future. This lack of ambiguity regarding relationships takes place relationally, but also intrapersonally. People who avoid mourning related to aging and illness are also denying the very real nature of the ambiguity of health and the precarious nature of life. In order to mourn, one needs to acknowledge the limitations of one’s body and of one’s life. Although idealization may be a necessary component of treatment for some patients (as Kohut suggested), over time patients need to relinquish the need for idealized others and an idealized body. Mourning takes shape in many ways. As we saw with Edward, mourning the loss of his health allowed him to realize that he was well enough to find pleasure in his family visits and even the fact that he was still alive. June represents a different facet of the mourning experience: I met June when she lived in an assisted living facility. She was referred for depression and suspiciousness. She had been a self-described “loner” and never felt the need to develop close relationships with others. Through the course of therapy with her, she began to question her assumption that relationships were not worth her energy. Over the course of my knowing her she developed normal pressure hydrocephalus, which eventually required her to be cared for in a 24-hour locked facility. She presented with extreme paranoia and often felt that the staff was attempting to poison her, though she continued to actively engage in therapy when I arrived to see her. Like many patients in such a facility, she expressed to me that her living situation was temporary, that she intended to return to her home, and that she did not need help. She held these beliefs even though she had been conserved and her conservator had sold her apartment and all her belongings. Eventually, however, June began to realize that she would live out the rest of her life in the facility. She said to me one day, “You know, I think I might die here.” I said, “Yes, that is likely the case.” This was followed by many sessions in which June wrestled with the realization that she would not be able to be discharged from the facility to her former life. For the first time she expressed extreme anger at me for allowing her to remain in such a facility. In one particularly memorable session, as June was crying she said, “I can’t believe that after all we have been through that you would just let me die here. I am going to die here.” I said, “It is so sad, as you


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have told me many times that your life had not been what you wanted. You wanted closer relationships and you did not have them. I think that is really, if not unbearably, sad.” June said, “Yes, my life was not what I wanted. I wanted more friends. I wanted to feel more that I was a part of things.”

This vignette illustrates many important points. Regarding the issue of mourning, June illustrates the painful aspects of mourning and sadness when people are able to finally come to terms with their own mortality and limitations. Despite her neurological condition, June was incredibly responsive to psychotherapy and over the course of my talking with her, she was able to see that in fact, she was never going to be discharged from the facility where she lived. This led to tremendous grief for June, which she expressed not only through sadness but through her anger with me; if I were a better “caretaker,” I would release her from the facility and bring her back to her home. Eventually, however, she began to understand that this was not a realistic idea. I could not save her, as she had hoped. This situation illustrates the issue of idealization, as well as the anger and rage that can result when we as therapists are not able to meet all the demands imposed on us through a patient’s idealization of us. Kernberg (1986) described that narcissistic idealization feels uncomfortable to clinicians because aspects of idealization involve a desire for control and that idealization can switch on and off. He goes on to say that people who tend to idealize often do not view others as separate and independent people. June held a belief that she would get better and she tended to experience me as an ideal person who could help her get out of the facility where she now resided. The confrontation with reality, however, that she was not going to leave the locked facility she lived in to resume a normal life, led her to become very angry with me. Not only is this a common dynamic when a person realizes that the people they idealize cannot save them, it is also an essential part of mourning. A major part of this psychic shift is the recognition and acceptance that others are actually separate people. For both June and Edward, part of realizing separateness created a needed pathway for ideas of loss to emerge. For Edward, this separateness was realized through my vacations and my ability to leave. For June, she realized our separateness through allowing herself to know that I would not rescue her from the place where she would likely live out the remainder of her life. Mourning involves the acceptance of reality. Others cannot save us and ultimately we are responsible for our own lives. This difficult reality is one that many people struggle with, especially when aging and ill. Although I have described that narcissism involves difficulties in feeling separate from others, an inherent dynamic in narcissism is that people feel separate and alienated from themselves. Mitchell (1986), described the ways that narcissism results in a sense of a fractured self, as one has substituted ideas of “perfection” (in themselves and others) for true relational meaning and connection. It is often in midlife when the losses of relatedness start to hit home. Patients describe that they feel “alone” and often comment on thoughts related to how they might die. This often unbearable feeling and the idea of “dying alone” is what brings patients into treatment in midlife. In the middle years of life, accepting reality takes on new meaning, and for many this offers the first opportunity to experience mourning. People who find it

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difficult to accept the realities of aging and death, and those who hold out hope for others to make their lives better are very emotionally vulnerable at this time.

The “Midlife Crisis” Midlife is commonly defined as being roughly between the ages of 40 and 60. It is difficult to approach the topic of midlife without risking the common stereotypes associated with the idea of the “midlife crisis.” Nevertheless, the conflicts that arise when people become aware of aging and the threat of death (whether this awareness is conscious or unconscious) are important to consider, as this realization often occurs when people are in middle age. Patients I have worked with who seek treatment because of the difficulties with aging during midlife have resulted in some of the most gratifying treatments I have provided. When people have enough internal and external resources to become involved in therapy due to midlife conflicts, they can be highly motivated to participate in therapies that are meaningful as well as efficient. However, there is tremendous variability regarding the levels of awareness of physical changes associated with midlife, as well as the real limitations one might confront. We all age differently. Different genetics, psychological resources and defenses, as well as economic status and class impact the way we approach midlife. Conflicts related to narcissism are especially important in midlife because for many people who have not had medical problems, this time of life serves as the first “blow” regarding limitations in the body and mind, especially for people who have enjoyed previously good health and working bodies. Roose and Pardes (1989) provided the following remarks on the aging body: As the middle years begin, one becomes aware of subtle, often disquieting changes in the body: our reflexes are a little slower, our muscle tone seems harder to maintain and weight distressingly easier to accumulate, our hair takes leave, our eyes focus with less acuity. In sum, it is as if one feels a chill from a fall wind, inexplicitly blowing on an August day. (p. 179)

For most of us, aging bodies are unsettling. Awareness of this takes many forms. For athletes, sports injuries signal that performance will eventually decline. For some, the minor pains and aches that can begin to develop signal change. And yet for others, it is the mandates of primary care physicians that remind people of aging: cholesterol checks beginning in their 30s, mammograms starting at 40, and colonoscopies at 50. Aging and its reminders seem to “creep up.” And if people allow themselves to think about this, it can feel like the “fall wind” that Roose and Pardes describe, the ominous threat that life is finite. For many people, thinking consciously about the idea of death is uncomfortable. Spirituality and religious beliefs may serve as a buffer from the fear of death, as when one believes that there is a heaven, or life after death. Interestingly, when I was involved in seeing acutely hospitalized medical patients, I noticed that a striking number of people who asked for psychological help were atheists or agnostic. This suggests that in the absence of strong religious or spiritual ties, existential concerns are more troubling, and existential anxiety is a

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more conscious and distressing dynamic. Another aspect of coming to terms with death is the realization of lost opportunities and related regrets. However, midlife can be a time of life-affirming change: To achieve a desired goal, such as when a person in middle age goes to graduate school, changes careers, or develops new creative interests. For some people, the increasing independence of their children allows for additional time to be spent with partners and/or to travel and explore new hobbies or avocations. However, in order to really pursue new interests and opportunities in midlife, one need not only have the financial resources available to them, one also needs to be able to integrate and acknowledge what has not and likely will not ever be achieved. For example, a patient I treated in her 50s, whom I will call Meredith, became conscious of these limitations after about 3 years in therapy. She had been very successful in her chosen career, both professionally and financially, but struggled with a vague sense of uneasiness and inertia, which kept her from having a fulfilling life outside work. Eventually, it became clear that she always thought she would be “rich and famous.” Though she could not really say what this meant to her (in terms of whether she imagined herself as a famous actor or politician, etc.), it became evident to both of us that this unfulfilled wish left her with considerable anger and competitiveness, which made it difficult for her to engage in fulfilling hobbies and activities, since she felt that she had to outdo everyone around her in any undertaking she participated in. She also had trouble establishing meaningful relationships due to her highly competitive nature and her need to feel better than others. Intrapsychically, she suffered tremendously. If she was not better than others, she felt like a total failure and was wrought with self-doubt and anger toward herself for not being good enough. In one session, we were discussing these emotional dynamics and how they had thus far prevented her from getting more out of life. Tearfully she revealed, “I always thought I would be someone else, that things would be different. Is this all there is?” “Is this all there is” is a familiar refrain among many people who have struggled with expectations that life should offer more. Often, such patients have had very disappointing childhoods in which they did not receive the attention they needed and coped with this through a fantasy life where they receive love and admiration from everyone. Adult relationships are often difficult because intense competitiveness ensues when one finds that they are relegated to the same playing field as others. In other words, not being acknowledged as special and having to compete in the same arena as everyone else forces one to recognize that they are not necessarily defined by their uniqueness. The overly competitive attitude of always outdoing others, being the best at everything, becoming rich and famous, are ways that one can imagine that they were given what they deserved in terms of love, attention, and fair treatment. It is often in midlife when the realities of childhood losses begin to press into conscious awareness. If people can accept what they missed out on as well as what they have prevented themselves from getting, it can help to create space for a renewed creative (and not manic) energy, which can allow midlife to be gratifying. Ironically, however, it is sometimes the success attained by midlife which triggers depression and despair, even in the midst of what externally appear to be impressive accomplishments. Consider the case of Janice:

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4 Narcissistic Aspects of Aging and Illness Janice was a 45-year-old woman who had achieved remarkable financial success in the early years of the Internet business. She had been able to retire early and was straightforward when she told me that she never had to worry about money again. The problem was, she said, that she “did not know what to do with herself.” She was married and without children by choice, and her husband continued to work, as he had several career aspirations. She said she was involved with some charity organizations as well as philanthropy, but that these activities were “meaningless” to her. When she wasn’t involved with charity events, she said that her days were spent exercising with a trainer and at times she exercised up to 3 hours a day. She found the afternoons excruciating, however, as she felt she had “nothing” to do. Although having used marijuana recreationally in the past, she now admitted that she started smoking pot in the afternoons on most days. She disclosed that she felt worried about this, and thought it contributed to her “lack of motivation,” but was uncertain how she could quit, and eventually acknowledged that she was not sure “what the point” would be in quitting or reducing her marijuana use.

In 1916, Freud described the “Exceptions,” people who defied common sense. In this group, he described those who are “wrecked by success.” Blum (2001) further described this dynamic by saying that such people feel so guilty that they “snatch defeat from the jaws of victory” (Blum, 2001, p. 124). For some people, thinking about or acknowledging success is accompanied by intense ideas of punishment and guilt. These feelings may be conscious, but are often unconscious, and distracting activities (such as substance use or excessive activity) are frequently employed to manage them. Success, whether it has been achieved or not, is often a facet of midlife. For people with traumatic early relationships, success can carry unrelenting feelings of guilt as well and intense feelings of anger. Guilt and associated feelings are not just related to career and financial success. Many parents I have spoken to who appear to be raising their children well, report the confusing feelings associated with providing their children with a good upbringing, when they did not have it themselves. One mother of two who was neglected by her parents said to me, “I don’t think parenting is that hard. I mean, it is hard, but not hard enough that you need to neglect your children.” Clearly this woman’s conscious relationship with her past and her disappointments regarding her parents allowed her to tolerate her feelings regarding the meaning of giving her children a better life. Such is the case as well with those who can come to terms with a traumatic past and give themselves a better life. Janice reported that she had a difficult childhood and vaguely expressed that her father was “harsh” and her mother “depressed.” However, it was clear that she had not really thought much about her parents. She continued to see them frequently, including traveling with them on vacations several times a year. She described her current relationship with her parents as “good,” though these descriptions were ambiguous, and I constantly had the feeling that she did not feel like she had conscious control of her obligations to her parents. The idea of giving oneself a better life than one had as a child seems, at first blush, like an easy task. However, a curious paradox exists in some who manage to become more successful than their parents, or even equally as successful. Though Oedipal issues are surely at play, especially when one feels guilty about surpassing their parents (and often have had unresolved experiences related to feeling excluded from the parental couple), a more nuanced understanding regarding these issues has

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been articulated by contemporary psychodynamic theorists. López-Corvo (1999) suggests that people such as Janice are envious of the capacity for creativity and harmonious relationships – but that this envy occurs within themselves. The idea is based on the Kleinian idea that a part of the self can envy another part of the self (Klein, 1975). Envy in this context has to do with the idea that early trauma makes it difficult to integrate aspects of the self, so certain parts of the self are “split off.” The split off aspect includes a particular kind of aggression, one in which feelings of hostility are employed in response to need. Segal (1973) translates Klein’s ideas about envy by saying that one can envy another for some possession or quality. When one envies others in this context, it is for the ability of the other to provide love and other needed support. When one envies the self, as is suggested by López-Corvo, it envies its creative and independent capacities. Why would this be the case? Coming to terms with envy means that one can come to terms with the loss of an ideal parent or parenting situation. This ideal situation, however, can be experienced in the capacity for the self. As we saw in the case of Meredith, she had placed the highest expectations in herself, that she would be “rich and famous.” Meredith’s fantasy was that being rich and famous would somehow allow her to avoid the feelings of having felt “less than” in her childhood. She constantly spoke of having come from a poor background in which everything from food to love was scarce. Coming to terms with her fantasy/wish of a better life, and having this remain conscious, were crucial for Meredith to begin the process of thinking about how to get more from her life. In terms of technique, I often said to Meredith, “It is difficult for you to have now what you did not have when you were young. Maybe it is hard for you to have a good life.” This created an avenue for her to be open to understand the intensity of her anger toward others, her difficulty in feeling dependent, and the sadness that she had not received more from her parents. Those who cannot come to terms with these feelings and losses are at risk for a turbulent and stormy middle age. Even in the context of what appears to be a successful life, the sense of loss, anger, and disappointment can lead to potentially dangerous behaviors, as we saw with Janice and her daily marijuana use. Failure to come to terms with loss and limitations in oneself and others, past and present, can lead to self-destructive behaviors. It is estimated that half of all fatalities in the United States from the leading causes of death are linked to lifestyle behaviors, including poor diet, inactivity, smoking, drug abuse, and risky sexual practices (McGinnis & Foege, 1996). Although optimal health would ideally be considered throughout one’s lifespan, it is commonly the case that in midlife, many people choose to discontinue unhealthy behaviors in favor of those that support healthy living and longevity. For example, some elderly adults I work with stopped smoking in their 40s, and other middleaged individuals I see begin exercise regimens and paying attention to dietary issues. Additionally, it is often in midlife when many people become concerned about alcohol consumption, especially if it is excessive. At this stage of life, behaviors that cause or exacerbate illness can suddenly offer a “wake-up call,” in that lifestyle choices that once seemed benign are now perceived as potentially dangerous. In the 20s and early 30s, many individuals feel that they can “get away with”

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potentially unhealthy behaviors, if they even think about such matters at all. This can be attributed to forms of developmental narcissism that occur in younger people who luxuriously feel (if they have not experienced illness) that a long life is still ahead of them. And if there are no evident symptoms from problematic behaviors, then they may feel that habits such as excessive drinking, smoking, physical inactivity, and a poor diet are not harming them. For those whose lifestyles involve such behaviors, it is often the onset of symptoms that raises their awareness about the potential danger of these activities. For example, a 26-year-old patient of mine was not feeling well. I suggested that she see her physician, who told her that she had very high blood pressure. Later, this patient informed me that she ate “fast food” at almost every meal. Since she had grown up eating fast food, it had not occurred to her that such poor dietary habits could have health risks. Although such scenarios are more common given the obesity epidemic in our country, it is often later, in midlife that people experience adverse consequences related to health behaviors. This young woman was an exception rather than the rule, in that her symptoms led to a proper diagnosis, so she may be fortunate enough to have received much needed health education and support to change her dietary habits. Doing so allowed her to quickly lose weight and to achieve normal blood pressure without the need for medication. For most, however, the midlife years require a commitment to giving up unhealthy behaviors and to acknowledge that some lifestyle choices can contribute to the development of illness. As adults, we alone are responsible for our health and the quality of our lives. When self-destructive behaviors prevail, it is often the result of failure to mourn past losses, and acceptance of the reality, as difficult as it may be, that life has not been as good as it might have been. A kind of “toxic” anger that turns inward on the self can take over. It is as if people such as Janice are saying, “If my past can’t be better, I will ruin the future,” though of course, this is not a conscious thought. For some, the impulse to be self-destructive with their body can signal the presence of masochistic tendencies, issues that will be discussed in Chapter 6. However, anger and hopelessness in our patients can be attended to, and hopefully alleviated, if we as therapists can find effective ways to help individuals come to terms with these problems by identifying with and acknowledging the reality of their feelings regarding the fact that we alone are responsible for our health. If people wish for an ultimate caretaker to come along and save them, midlife serves as the pan-ultimate reminder that, no one else but us can take care of our bodies.

Conclusion Narcissistic issues in aging and illness are thought to be represented on a continuum of normative to pathological. We all experience, at some point, the narcissistic blows associated with growing older. Aging results in bodily changes, that if integrated successfully into an evolving adult-self character, can allow space for the development of new interests and motivations, or at the very least an ability to appreciate,

References

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in a genuine way, the pleasurable aspects of living a long life. Mourning, accepting loss, and acknowledging the actual conditions of one’s life are essential to a more fully developed and meaningful later life. This ideally involves an awareness of the inevitability of life’s finiteness, and with it the ability to disengage from the defenses of denial, magical thinking, and omnipotence. These are not easy tasks, as the vicissitudes of aging and its consequences are difficult to accept and live with. For those with traumatic backgrounds, these dynamics are even more complicated, as relying on fantasies for comfort and support can become problematic when seeking support for issues of aging and illness. At some point, we all have to come to terms with the fact that as humans we are dependent on others. For people who have narcissistic characters or who have relied extensively on narcissistic defenses, this can be a daunting endeavor. As therapists we have the privilege and the responsibility to help such individuals develop a more structured and supportive internal world so that they can rely on others in their later years, without the terror that can be associated with dependence.

References Almond, R. (2004). “I can do it (all) myself ”: Clinical technique with defensive narcissistic self sufficiency. Psychoanalytic Psychology, 21, 371–384. Blum, H. P. (2001). The “Exceptions” reviewed: The formation and deformation of the privileged character. Psychoanalytic Study of the Child, 56, 123–136. Freud, S. (1914). On Narcissism: An introduction. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud, (1914–1916): On the history of the psychoanalytic movement, papers on metapsychology and other works (Vol. 14, pp. 67–102). London: Hogarth. Freud, S. (1916). Some character-types met with in psychoanalytic work. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud, (1914–1916): On the history of the psychoanalytic movement, papers on metapsychology and other works (Vol. 14, pp. 309–333). London: Hogarth. Freud, S. (1917a). Mourning and melancholia. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud, (1914–1916): On the history of the psychoanalytic movement, papers on metapsychology and other works (Vol. 14, pp. 237–258). London: Hogarth. Freud, S. (1917b). A difficulty in the path of psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud, (1917–1919): An infantile neurosis and other works (Vol. 17, pp. 135–144). London: Hogarth. Kernberg, O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson. Kernberg, O. (1986). Further contributions to treatment. In A. P. Morrison (Ed.), Essential papers on narcissism (pp. 245–292). New York: New York University Press. Klein, M. (1975). Envy and gratitude and other works 1946–1963 (M. Masud & R. Khan, Eds.). London: Hogarth. Kohut, H. (1986). Forms and transformations of narcissism. In A. P. Morrison (Ed.), Essential papers on narcissism (pp. 61–88). New York: New York University Press. Lasch, C. (1978). The culture of narcissism. New York: Norton. López-Corvo, R. (1999). Self-envy and intrapsychic interpretation. Psychoanalytic Quarterly, 68, 209–219.

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McGinnis, J., & Foege, W. (1996). Actual causes of death in the United States. Journal of the American Medical Association, 270(18), 2207–2212. Mitchell, S. A. (1986). The wings of Icarus: Illusion and the problem of narcissism. Contemporary Psychoanalysis, 22, 107–132. Morrison, A. P. (1986). Landmark contributions. In A. P. Morrison (Ed.), Essential papers on narcissism (pp. 13–16). New York: New York University Press. Roose, S. P., & Pardes, H. (1989). Biological considerations in the middle years. In J. M. Oldham & R. S. Liebert (Eds.), The middle years (pp. 179–190). New Haven, CT: Yale University Press. Segal, H. (1973). Introduction to the work of Melanie Klein. New York: Basic Books. Vicario, A. (2008, July). Hypertension, memory and frontal lobe disability. Paper presented at The International Neuropsychological Society, Sociedad de Neuropsicologia de Argentina, Symposium 2: Cognitive Disorders in Vascular Patients: A Multidisciplinary Approach, Buenos Aires, Argentina.

Chapter 5

Transference and Countertransference in Aging and Illness

Scars have the strange power to remind us that our past is real. Cormac McCarthy

The concept of transference is a central idea in classical and contemporary psychodynamic theories. Often thought to be the bedrock of traditional psychoanalysis, to what extent transference interpretations function as the therapeutic action of the modern psychodynamic therapy encounter, especially with medically ill and aging patients, remains an open question. At the heart of the distinction between traditional and contemporary theory is the nature of involvement of the therapist. At its extremes, proponents of the traditional school hold that a therapist is a “blank screen” on which patient projections and ideas of transference occur; contemporary theorists on the other hand have recently been advocating that emotional involvement by the therapist is an essential and unavoidable factor in all treatment modalities. The idea among many contemporary clinicians is that the emotions of both the patient and the therapist create a unique and intersubjective world between the two parties. Despite different perspectives about transference, there is perhaps no idea more fundamental to psychodynamic theory. This chapter will explore methods for applying ideas related to transference in working with medically ill and aging patients, particularly how we can most effectively be attuned to a patient’s emotional states, as well as understanding how transference can inform the way we talk with patients. Since transference theory has received considerable attention in psychoanalytic and psychodynamic writings, I will not attempt detailed discussion on this vast literature. Rather, following a discussion of some of the limitations of traditional ideas of transference and transference interpretations, we will focus on aspects of transference that are useful for medical and aging populations. Ideas regarding transference have been expanded in contemporary theory, beyond the level of traditional “genetic interpretations” which suggest that one views a situation based solely on an understanding of reported early childhood experiences. Modern ideas of transference are more complex and take multiple aspects of emotions as felt in the present into consideration. However, we will also consider the various ways that our patient population can be vulnerable to inaccurate interpretations, since bodily issues that affect these patients, especially


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pain, can elicit irrational ideas and beliefs which may not be related to past experiences or even unconscious fantasy. Finally, I will briefly discuss the difficulties encountered in working with aging and medically ill patients from the perspective of countertransference. Contemporary psychodynamic theory has magnified the importance and clinical utility of our own emotional reactions and thoughts when we are with patients; some of the pertinent challenges in dealing with our own emotional responses when working with this vulnerable population will be described.

Transference and Implications for Older and Medically Ill Patients Interpreting transference may not always be a realistic option for some of the medical and aging patients we treat. In addition to variables such as concrete thinking, physical limitations, and proximity to the end of life, taking up in-depth transference in therapy may simply not be possible. The concrete demands of bodily illness and the lack of emotional language available to some patients make it difficult to say or even know what their thoughts are. In addition, the lack of conscious awareness of anxiety in our patients, or so-called neurotic suffering, limits the scope of transference interpretations. When patients are anxious about their interactions with others, as Denise (in Chapter 2) was with her cardiologist, there is a window of opportunity for insight into the ways that the past may be impacting the present, and we may decide to address these issues. Though it is often not realistic to verbally link the past with the present with our patients, the conceptualization of transference and the discussion of lived emotional experience in the present are important and useful therapeutic points of departure. The basic of definition of transference remains unchanged, typically described as feelings from early childhood that get imposed on present-day situations, emotions relived in the here and now, even though they are reflective of experiences with parental figures. In a panel at the American Psychoanalytic Association meeting in 1998 (Abend & Shaw 1991), current concepts of transference were reviewed. Sandler Abend explained that Freud expanded his idea of transference in a series of papers from 1912–1917: At that time, Freud understood neurotic illness to be the consequence of repressed instinctual illnesses. The transference neurosis was seen as both giving expression to these instinctual wishes and serving as resistance to remembering and understanding their historical origins and infantile nature. Transference interpretation thus provided unique access to the core of the patient’s difficulties and, through the lifting of repression the only means to achieving a truly psychoanalytic cure. (p. 227)

Traditional transference interpretations can be difficult for patients to hear from the standpoint that people typically perceive that the issue they bring into therapy as a complaint or problem is rooted in “reality,” so an interpretation calls into question the nature of the complaint. For example, when a woman complains about

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her husband in treatment focused on uncovering transference, the therapist might suggest that the patient’s feelings have a resonance from the past. In other words, her feelings may not be solely related (or at all related, depending on the therapist) to her husband. The idea is that the emotional weight of the patient’s complaints is rooted in the past, not the present. She is re-experiencing emotions related to her past as channeled through her current feelings about her husband. As described in Chapter 1, traditional psychoanalysis has had difficulties integrating its emphasis on unconscious fantasies to a patient’s adulthood experience and their current perception of reality. Although “genetic interpretations” are less common than they used to be, the traditional approach toward transference has limitations, as some people feel invalidated by focusing on the past, as if the present does not matter. The idea that traditional psychoanalysis could determine and define reality was a concern expressed time and time again by people I interviewed for this book, many of whom had received psychodynamic therapy as well as psychoanalysis. Those with medical problems remarked that it was crucial that their therapists “believed them” about their illness, a strong statement about the problems with and possibly the misuses of (or at the very least misunderstandings about) interpretations designating a particular reality. Although bodily problems presumed to be psychosomatic in nature do not necessarily imply problems with the concept of transference per se, it is a residue of conflict in a theory that has historically valued fantasy and the past as the sole determinants of psychic reality. Many authors have voiced concerns regarding these issues in general (e.g., Chused & Raphling, 1992; Pizer, 1996; Renik, 1995), and as they relate to trauma and the understanding of “clinical facts” (Blum, 1994, p. 872). The voices of the people I interviewed sum up a major quandary in the field as a whole; transference does indeed occur and unconscious fantasies impact perceptions of adult experience, but in the course of long-term dynamic treatments, some patients are given the message that reality is somehow less important. For our patients who are aging and or ill, an acknowledgement of reality is vital for them to feel understood by us. More modern approaches can help us think about the past in a way that validates a patient’s present reality and need not send the message that facets of current experience and bodily limitations are less important. As mentioned in Chapter 3, with patients who present with more concrete dynamics, transference interpretations may interrupt other needed aspects of emotional functioning and relational connecting which may need to be prioritized before interpretations can successfully take place. These aspects of emotional functioning include a sense of a coherent self, a sense of personal safety, and an experience that others, including the therapist, can provide a caring and stable environment for difficult feelings to emerge without retribution. However, people with serious illnesses, the very elderly, and others who have a predominant bodily focus, which causes them to be oriented in a more concrete way, may never achieve a sense of safety. Therefore, we are reliant on some aspects of what Alexander and French (1946) described as the “corrective emotional cure” for treatment to be helpful, at least in a psychodynamic way. However, the corrective aspect of therapy with patients is only a small part of what we can offer, and need not, and should not, be superficial. Indeed, some contemporary theorists are making

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a case that there is much more to treatment than transference. As the field has placed increasing importance on the therapeutic relationship, ideas regarding the nature of the transference have shifted, such as the question of whether transference reactions in patients are formed, coformed, and impacted by the personality of the therapist, as well as whether or not there are realistic elements to transference experiences. Newer theories, intersubjective ideas, and a two-person psychoanalytic psychology (e.g., Aron, 1990) suggest that despite the powerful impact of transference, the therapist’s behavior might impact the experience of transference in patients. For example, Levenson (1981) suggests that more contemporary theorists could first look at their own behavior as a way to understand what material a patient might discuss, an acknowledgement of the real impact of the therapist. Although transference happens in all relationships, contemporary theory offers up additional ideas of therapeutic action. The concept of mentalization, the reflective functioning of the therapist, has received considerable attention, especially in relation to working with more difficult patients (Fonagy, 2000). The ability of the therapist to think about and organize emotional material is thought to be a source of therapeutic action; others have expanded on these ideas, initially described in depth by Wilfred Bion (Ferro, 2002). The focus in this research is that what we do with our minds as therapists has a tremendous impact on our patients. Hopefully, in the right kind of treatment environment, our ability to emotionally organize our patients’ material helps the patient to eventually develop their own symbolic capacity, as well as tolerance for their emotions. Though the literature referred to above begins the discussion of newer ways of understanding therapeutic action (which will be discussed further in Chapter 9), transference still takes shape in most human interactions. The question then becomes, what do we do in treatment, and how do we treat transference ideas that emerge? One response to this question was articulated in a poignant article written by Mayer (1994) in which she described her analysis of a patient who was dying of breast cancer. Mayer makes the case that even in this situation, transference themes not only emerged, but also were aggressively addressed by the analyst. It should be noted, however, that the patient she described had been in analysis with her for 2-years before the development of her terminal illness, and was therefore someone who was already accustomed to the ideas of both an intensive treatment and transference interpretations. A contrasting view was offered by Norton (1963), who described the case of psychotherapy with a woman who was also terminally ill with breast cancer. Norton uses ideas of transference as a primary conceptualization tool, but focuses her interpretations on the present, even though she understood that her patient’s behaviors came from both the past and the present: . . . the first obvious regression, and from this point there was no question she was repeating with me aspects of her earlier relationship with her mother. She perceived this regression and was briefly apologetic “for being such a baby,” but as I explained this as an expected part of her illness, she became less ashamed. (p. 550)

Norton demonstrates that one can surmise that a particular behavior or emotional response is based on a transference regression, but that the real issues in the present


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can also explain reactions in the patient. Norton’s intervention chose to address the present, which was most useful for the patient in the particular moment of treatment. In yet another case example of a woman who had terminal cancer, Adams-Sullivan (1994) described her approach in a way similar to Norton. Through a detailed understanding of this woman’s character, Adams-Sullivan used these issues to provide supportive interventions (e.g., pointing out the courage it took to endure her illness) with the aim of improving this woman’s ability to have a stronger sense of herself and of her mind, and to limit externalization. Through these interventions, Adams-Sullivan was able to comment on transference material that emerged, related to issues with the patient’s parents being intolerable of her vulnerability. However, though these issues were addressed to some extent, the focus of the therapy was on the importance of flexibility and the adherence to dynamics of the clinical situation and the patient’s medical crisis. According to Adams-Sullivan, the treatment helped mobilize healthy narcissistic defenses that would facilitate selfesteem, as her patient felt ashamed about her illness. All three of the articles referred to focus on the issue of transference in the conceptualization of treatment. The latter two articles, which involved patients treated in psychotherapy after the diagnosis of a terminal illness, emphasize caution in moving too quickly with transference interpretations. These authors focus on here and now interventions, with the background of a patient’s history firmly in mind. All three authors emphasize the importance on flexibility of the therapeutic frame and as well as the need for a more active, engaged approach to treatment. Traditional ideas within psychoanalytic theory have pointed out that regression needs to occur for a transference neurosis to take place. In a rare and interesting article about psychodynamic work in a hospital-based consultation liaison setting, Viederman (1986) suggests that the regression taking place in physical illness creates a scenario in which patients can be treated and achieve a “transference cure,” though curiously, interpretations were focused on character patterns and the meaning of these patterns in the present, with mere hints at unconscious motivation. For example, Viederman (1986) cites the following interpretation at the end of a second session for a patient who had developed a severe medical complication that rendered him unable to walk and thus go to work: It seems pretty clear why you are depressed. For most of your life you have worked to give your children all the support and love your father gave to you. As long as you could work, you could see yourself as a good father. Even when you got sick and needed dialysis and then a transplant, you kept your spirits up because you could work – but now this difficulty with your legs has hit you. Just when you want to give your teenage children a good image to look up to, you find yourself sick, frustrated, and angry at your kids, who are going through a stage when they need to rebel and put their father down. And yet, as I listen to you describe your life, it is certain that if this leg problem had not occurred, you would be at work this very moment. Your children know you better than I, so I am sure they realize what a good provider you can be and how much you are about them. (p. 134)

Though Viederman suggests that the patient has strong paternal transference toward him and credits this transference as being responsible for a notable decrease in this man’s depression, the data indicate otherwise. The intervention succinctly summoned up this patient’s character and defenses, and speaks to the overwhelming

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impact of the loss of his mobility and how this was experienced by the patient through an inability to provide for his family. Though alluding to the patient’s unconscious motivation, the weight of the interpretation focuses on the patient’s past success. In this intervention the therapist encouraged this patient to mobilize his previous defenses, by pointing out that the patient’s ego syntonic ideal of being a good provider, was in fact true, despite his current limitations. These interpretations were based on a thoughtful psychodynamic conceptualization of the patient’s character, which was quickly understood after only two sessions. As this case demonstrates, someone experiencing a medical crisis or distress related to aging is not likely available for transference interpretations in the way that traditional analysis has implied. However, conscious and unconscious motivations can be discussed using the here and now aspects of character functioning, which can often be understood even without extensive familiarity with the patient’s history. Through the therapeutic relationship, as well as observations of patients in the present, we can learn a great deal about character, motivations, defenses, and coping. Many modern psychodynamic therapists focus on the feelings patients may have about the therapist as a way to gain access into the window of transference. However, this too can have pitfalls. Some contemporary theorists have argued that overly focusing on listening for transference impedes the ability to listen to patients (Arlow, 2002). This cautions us to avoid looking for transference when other important issues, indeed those that may be closer to experience and affectively available to the patient, need to be addressed. A recent clinical example comes to mind, which highlights this dilemma. Jed had a number of medical issues growing up and as a result he had several iatrogenic medical problems as an adult, though he dealt with these quite well. At times, it seemed he coped almost too well with what were unfair consequences of the medical treatment he underwent in his childhood. I frequently thought that anyone who had endured what he had been through would be enraged. However, Jed never expressed anger about his health problems, only a sense of even-keeled acceptance at whatever he faced medically. He came to see me three times a week for psychotherapy with the hope of addressing “relationship issues,” as his anger had found its way into his interpersonal relationships, making his marriage and relationships with work colleagues more tumultuous than they needed to be. I was a few weeks away from taking a month-long vacation, which I had informed Jed of several weeks beforehand. Jed was not at all reticent about expressing his attachment to me, and the therapy, and he worried about how the break would be for him. Yet, he never expressed any negative feelings toward me. In the weeks before I left, however, Jed began to make subtle complaints about my office, especially my waiting room. The lights were too bright, I did not have a garbage can in the waiting room, and once, when a magazine had shed its marketing mail-in form, Jed brought this in for me to see, mentioning that he was just trying to “help me out by keeping my waiting room clean.” These behaviors, as well as his uncharacteristic lateness, led me to believe that there were feelings about my vacation that he had been unable to express directly. When I brought up the possibility that he may feel disappointed, angry, even that I am leaving him for several weeks, he responded by saying, “But I knew you were leaving. You told me at the beginning (of the treatment) what your vacation schedule was, I am prepared for this. It would be better if you were here, but you are not and you told me that from the beginning.” Other attempts at interpreting his feelings about the vacation were met with similar comments.


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The example with Jed is not an uncommon occurrence. Especially in the beginning phases of therapy, many patients simply cannot approach ideas of being angry at or disappointed with the therapist, which are common feelings that occur when the therapist is unavailable due to vacations or disruptions in meetings. For many, over time, denial of aggressive feelings diminishes and conversations related to the disruptions in therapy caused by vacations or other common issues can be discussed with a more authentic inclusion of feelings. However, this is often the case when I am working with patients other than those who are medically ill. Jed was a younger patient, in his 40s; however, he had recently undergone medical treatment for one of his iatrogenic conditions, and he had other ongoing medical issues, including pain management. In addition, he was dealing with unpleasant and frightening side effects of a new medication. It is these current medical issues that I want to highlight here, as they had a major role in Jed not being able to think about his disappointment and anger about my vacation. Jed had had a number of major disruptions involving his parents’ availability during his childhood. I assumed that these feelings were being expressed in the transference through his complaints about my office. Jed had been in therapy with me for a long time, with sessions three times a week. This had proven to be helpful to him in a number of ways, as he had been able to gain considerable improvement in his ability to be aware of and articulate his feelings in his marriage as well as with his colleagues at work, without feeling or acting overly enraged. In the context of his medical problems, however, my leaving was the loss of his psychological (and likely unconsciously physical) lifeline. I understand this feeling as being related to both the past and the present. Regarding the present, Jed had continued to feel that my leaving might cause him to “regress” (Jed’s word) to his pretreatment state in which many of his relationships were strained because of his anger. My evaluation of his behavior regarding his past was this: Since his parents had been profoundly unavailable for him, the feelings of separation around my leaving might be an emotionally charged issue for him. Further, since I knew Jed had been extensively hospitalized as a child, I saw that his behavior was like that of a child dealing with medical caretakers on whom he was solely dependent, in the context of his parents being allowed limited visitation, as was the trend in hospitals 30 years ago. I imagined his behavior as reflecting how he dealt with a nurse or a doctor who was disappointing him, yet on whom he was totally dependent. Jed’s resilience in dealing with his illnesses had been due to precisely the behavior I saw in my office having to do with my leaving for vacation. He tried to be a good patient. He cleaned my waiting room; he tolerated bright, intrusive lights. He was left without a place to put his garbage and prepared to hold on to it instead. Facing the injustice of all of this, he told himself, and me, that he expected this absence. Knowing what to expect, and managing expectations are common coping strategies among ill children in the hospital, and he had this down to a science. The ability to split off his angry feelings and manage expectations had allowed him to survive psychologically. Being upset with me, or allowing these feelings to be expressed, especially in light of his current medical condition, would have been too terrifying. He was not protecting me by restraining his anger per se, he was protecting himself and his need for bodily help by assuring that I would come back from vacation, if

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he were a good patient. It was this interpretation, when I was able to make it, which was most useful to Jed. Focusing on the anger and my fairly dogmatic attempts to do what I thought I should be doing (looking for the transference and focusing on anger, and not listening to Jed), caused me to initially miss the important emotions that he was feeling and allow both of us access to them. One technical question arises for working with someone like Jed related to anger. Different theoretical schools and their emphases in particular regions of the United States, Europe, and South America have different stances related to anger. Proponents of Melanie Klein emphasize interpretations of anger and envy. Some current object relations theorists, however, especially those informed by the newer intersubjective school of thought, value this approach to a much lesser degree; their interpretations are much closer to what I eventually came to identify with when I was able to develop a more nuanced understanding of Jed’s feelings. Of course, the most guiding answer to how one addresses anger is what the patient can tolerate and what makes sense to those we are treating. What I learned with Jed was that he needed me to be present, as my presence allows him to deal with all the intense feelings he faces on a day-to-day basis. Fortunately, he let me know that interpreting his anger about my leaving missed the mark. Had Jed simply accepted that interpretation, we would have missed an important opportunity to understand another aspect of transference. If I am the caretaker who goes away, he has to protect the relationship by being positive. That way he can assure that I will return to take care of him and unconsciously, this is a way for him to make sure that his body is intact. Our ability to listen and meet patients where they are, is the most crucial thing we can offer. However, anger in medical and aging patients is not uncommon, and there are times when understanding not only anger, but also intense fear, can be very useful to patients. Again, simply identifying anger (even if a patient acts in a way suggesting it) in a direct way may miss the point. This is especially the case when a patient harbors anger or other strong feelings toward a physician and acts in a way that potentially threatens their medical care. The following example is one I have discussed previously in another publication, albeit in more condensed form (Greenberg, 2007): Jessica is a 35-year-old woman who injured her spine while rock climbing. She needed surgery to repair damaged disks and consulted a reputable spine surgeon, after many failures with nonallopathic clinicians. The surgeon met with Jessica a couple of times to discuss the surgery, and a surgery date was soon scheduled. Jessica cancelled the surgery 1 day before the procedure, saying that she had changed her mind. She then went to see the doctor again, now informing him that she wanted the surgery after all. Her surgeon, puzzled and irritated, referred Jessica to me for an opinion of her psychological state before scheduling another date for the surgery. Jessica told me that she liked her surgeon, who had spent a lot of time with her. Yet, Jessica was convinced that her surgeon “didn’t care enough about her.” When I asked her what this meant, Jessica said that since she was allowing the surgeon to “cut her open” that it was crucial that she felt connected to him. Thus far this surgeon had spent more time on Jessica’s case than he usually did with other patients, including a phone call with me in the evening to talk about her. It turned out that while growing up, Jessica’s parents were very unavailable and as she told me about her formative background, she described series of incidents in which she felt extremely vulnerable, but without any support from


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authority figures to help her feel safe. Although she had evidence that her surgeon did care about her, she needed almost constant reassurance from him that he indeed cared about her and her well-being.

Jessica’s feeling that others will not help her when she is vulnerable was played out with her surgeon. While fear of a major surgery is normal, Jessica’s worries were excessive; her need for constant reassurance and anger that she did not get sufficient support from her surgeon was based more on the past than the present. However, in intervening with her, I did not make references to the past. Rather, I focused on the present while suspecting that the past played a role in her irrational fears and behavior, in the sense that Jessica had acute anxiety about her surgery which was related to intense fears of being out of control, a feeling she was likely very familiar with in her childhood., In talking with her about the surgery, it was clear that Jessica felt that she would be awake but immobilized during the surgery, and at the mercy of her surgeon’s “aggression,” as she perceived it. This is akin to the persecutory anxiety described by Jaques (1998). Jessica imagined her surgeon to be someone who would subject her to torture, and she would be paralyzed and helpless to protect herself. One current understanding of transference interpretations is that Jessica’s feeling of being tortured was not due to a past similar external experience, but feelings similar to those experienced as a young child. As Joseph (1985) explains, transference is not necessarily the true transfer of feelings from the past, but rather, the feelings that one may have internalized as a younger person, most often as an infant. These younger emotions are often those characterized by terror and anger that some “other” is out to hurt oneself. It seemed most useful to Jessica to identify the magnitude of her fears. I told her that I thought she imagined herself to be awake during surgery and at the mercy of her surgeon, whom she felt did not care whether she lived or died. This made tremendous sense to Jessica, and once this was articulated out loud, she could begin to question it, and when she could think about her real experiences with her surgeon, it did not seem possible to be true, in reality. The other major intervention in this brief treatment was that I suggested that her surgeon schedule another long appointment with Jessica to talk further about the procedure itself, so she could feel more in control. Jessica then went on to have the surgery and recovered well, without physical or psychological postoperative complications. Understanding transference is often just the beginning of conducting work with patients. With Jessica, by being able to articulate the here and now aspects of her feelings of terror, we were able to allow her to complete a surgery that was medically necessary and that was threatened by the extent of her irrational fears. Talking about her past would have been contraindicated in this situation because Jessica had very little conscious awareness of her feelings about earlier disappointments with her parents. Further, we could get to the heart of her anxiety by what she was presenting clinically in the present, though I had a firm hypothesis in mind regarding the origins of her fear. Despite the reality of transference and its clinical implications, there are times when patients develop complex reactions to situations, which can create irrational ideas. Yet, these irrational ideas may not have roots in childhood. They may stem from adult experiences as well as be the result of physiological responses to

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distressing stimuli. I am referring here to the simple but often overlooked aspects of pain and fear, and the way that these two powerful emotions can create irrational ideas, which in turn influence perceptions. The most common example of what I am referring to is frequently seen in many chronic pain patients. However, before I explain more about these patients and the ways that some of them are often pathologized, I want to illustrate this point with a personal example: My husband and I were traveling in the South Pacific. We had taken a boat to a remote village with the intention of going on a hike to a waterfall. We arrived at a local village and a villager met us, accompanied by three dogs. Although island dogs are often strays, which are malnourished and mistreated, these dogs appeared, initially to be guarded, but friendly. As my husband and I are both animal lovers, we asked the guide to tell us the names of the dogs. He responded by telling us that their names were Rikki, Hunter, and Benny. Upon hearing his name called, Hunter, a gentle yellow dog with jubilant eyes ran over to me. I reached out my hand, so he could get a sense of my smell. Though Hunter appeared thrilled by the attention and eagerly began to lick my hand, within an instant, Rikki, a territorial female (who likely felt protective of Hunter) ran over to me and promptly wrapped her teeth around my wrist, biting hard enough to let me know she was serious, though not enough to cause more than a few scratches. I felt shocked and afraid, but rationally knew that since my skin was not broken beyond a superficial level, I was more than likely not seriously injured. The hike then got underway, with these events having happened in the span of less than a minute. The terrain was a bit more challenging than we had thought, as we proceeded to climb up several steep hills, then scaling up several boulders to get to the waterfall. Although the hike was demanding, it was not unlike those I had done before and was certainly less challenging than other hikes I have taken. Yet, I found that I was overly cautious. I felt afraid of where I might place my feet, as the rocks and angularity of the hill we were climbing felt ominous. I was strangely and irrationally worried about falling. Even minor hills or changes in landscape caused me to feel that my feet were not firmly planted on the ground. I tried to understand my fears, as I knew they were irrational. At first, I became focused on my shoes; perhaps they were not tight enough, or perhaps they were not right for this kind of hike. After ruling out this possibility, I considered that perhaps my own narcissism regarding the age-related decline in my athletic abilities had led me to conclude that I could manage a hike of this magnitude, when in fact, I simply no longer have the same physical abilities I once had. As I considered these explanations, and nothing made sense to explain my fear, I experienced increasing anxiety. Every hill seemed too steep; every rock I gingerly approached seemed evidence of my ineptitude. At one point I thought that I might not make it back to the boat. I envisioned a helicopter rescue, though I was not seriously injured, and there was no reason I could not hike back down the hill we had climbed. By the time we made it to the waterfall, I was in a full state of panic. Reminders that I exercise regularly, that I have done many hikes more difficult than this, offered no relief for my panicked state of mind. I momentarily felt I was doomed. Once in the presence of the waterfall and safely situated on a firm rock, I recalled the dog bite. I had been terrified and I was in pain, though again I did not feel that I was in any physical danger (and had been reassured by my husband, a physician). As I thought about it I felt that I had been the victim of bad luck, but also disconcerted that I courted the attention of dogs in a foreign country with a preponderance of strays, who are known to act unpredictably. These ideas, which fully took shape at the waterfall, led me to conclude that the hike had not been that difficult, and that my fear and physical pain regarding the dog bite had led to a psychological and physiological state of fear, which impacted my perception of danger (the difficulty of the hike) as well as my confidence that I could trust my body enough to allow me to finish the hike. Able to integrate these ideas, I completed the hike back to the boat, without anxiety. This included scaling down a steep series of rocks, using a rope, and other physical challenges, which I felt then to be fine and relatively benign.


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This experience was striking to me for a number of reasons. First, I was struck at the way many of us, as psychodynamic therapists often feel tempted to pathologize ourselves in the face of irrational anxiety. I concluded, as many of us do, that there was something wrong with me, and looked to faults in my character to explain the situation. Although there is nothing wrong with looking inward to try and understand character traits that might explain an irrational response to situations, this tendency can overlook physiology, which can provide a simpler and more straightforward explanation. Looking back in terms of potential seeds of transference, there is nothing useful I could conjure up related to this experience that explained my fears, even regarding the dog bite. I was raised with dogs, currently own two dogs, and have many fond memories of dogs while growing up. I have also been around dogs that have behaved aggressively, including island dogs. What I believe I experienced was a classic example of an operant fear response that was related to the fact that I had been bitten by a dog in a setting that was especially scary, a remote area in foreign country. I felt afraid and foolish (as I could have been more cautious), and though had not had a serious injury from the dog bite, I was scared by the reality of what did happen as well as the knowledge of what could have happened. Given that we continued the hike so quickly after the incident, I did not have time to emotionally understand and develop a definite meaning regarding these events during the first part of the hike. The pain I was experiencing most likely compounded my fears, as pain and fear have similar physiological pathways. I had spun myself into a cycle of fear and panic in which I felt helpless. The cure to this, however, was in allowing myself to understand my emotions and the impact of pain related to this unfortunate event. This example from my own life experience represents the common but often overlooked aspect of pain and fear that occurs in many of our patients. Pain sparks a physiological response, known as the autonomic nervous system response. More commonly known as the fight/flight response, this mechanism results in fear and anxiety, which are often present in both acute and chronic pain. My brief experience with acute pain and fear sheds light on this complex dynamic, because I was able to link the dog bite and subsequent fear and pain to my irrational fears. Since I was able to understand my emotions, I achieved a “cure,” as it were. However, many patients who have complex pain conditions can be subject to problems with coping because of these fears, which unattended, tend to spiral out of control. Pain initiates an anxiety response, yet anxiety heightens the perception of pain (Esteve & Camacho, 2008). I do not mean to oversimplify the issue. Although pain and anxiety are physiologically linked, there are those for whom psychosomatic complaints are a primary focus of treatment. Some people with chronic pain are hypervigilantly attentive to their bodies, thus elevating their perception of pain, and there are complex psychological factors associated with some pain conditions that prevent adequate coping. Indeed, considerable research has linked child abuse with benign chronic pain (e.g., Sachs-Ericsson, Kendall-Tackett, & Hernandez, 2007). These factors interact with physiological responses to pain and subsequent anxiety, and create a difficult and at times untenable situation for patients and their clinicians.

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Combined with a cumbersome and inefficient system in the United States of disability status and payments, such circumstances make it difficult for people to feel that they can recover from an injury without losing much-needed financial benefits they receive from being ill. In such cases, an approach that affirms the patient’s experience as well as education about how pain, fear, and physiology affect perceptions can be a good starting point in treatment. Given the right amount of time in therapy and allowing emotional themes to occur can help patients develop an increased awareness of mind–body interactions as well as enhancing an internal, emotional focus. It is important to mention a potential, noteworthy exception. The work in the popular press of John Sarno (1991), a rehabilitation physician, takes a very opposite stance of what I am describing. And, given the nature of his reported successes, his opinion is worth considering. Sarno, in multiple publications, has translated the work of earlier psychoanalytic researchers and has made this information accessible to a number of relatively high-functioning individuals who suffer from chronic pain and who seek out nonallopathic cures. Sarno points out that much of chronic pain is related to psychological factors, particularly unconscious anger. He basically takes drive theory of traditional psychoanalysis, which focuses on aggression and sex (though he limits his focus to aggression) and makes these ideas accessible in a modern way. He offers “prescriptions” of writing about childhood issues as well as feelings in order to help patients get in touch with unconscious motivations. Many patients have experienced relief from this approach, which should cause one to pause regarding the opinion that more concretely or physically oriented patients will resist an immediate link to unconscious factors as well as childhood experiences. Yet, most patients I see benefit from acknowledging physical pain as well as a straightforward explanation of how physiological factors can exacerbate and prolong pain. Following this physiological explanation, the emergence of emotional themes can be built on in the context of a good therapeutic relationship. The main point I wish to impart regarding acute and chronic pain, however, is that many patients may spiral into an extreme state of irrational fear. Often, by explaining the interaction of pain and emotional factors, we can acknowledge the often-needed porthole of reality that can help people settle into a psychodynamic treatment which eventually helps to address unexplored emotional reactions to illness.

Countertransference Feelings in Working with Medical Patients Countertransference is a complicated concept, and like transference, its meaning has been expanded as contemporary theorists have explored the concept and its clinical applications. Many facets of this term have been addressed and debated in the literature. Additionally, many cases throughout this book describe countertransference experiences when I describe my emotional reactions to patients and the way these reactions have guided my conceptual understanding of the case and my comments.

Countertransference Feelings in Working with Medical Patients

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Therefore, I am going to keep comments about this topic relatively brief and will focus on common feelings and dynamics that arise in our work with medical and aging patients. Countertransference applies to the feelings we have as therapists in response to the dynamics present in our patients. One definition of countertransference refers to early conflicts in our patients, which get stirred up in the therapist. These feelings are thought to be an identification with the patient’s unconscious fantasies or wishes, or with a patient’s internal self-representation (Kernberg, 1988). Our reactions when we are with patients matter because our thoughts and feelings not only lie at the heart of a relational and meaningful encounter, but can also provide important clues as to what our patients are experiencing emotionally. In other words, our emotional responses to patients help identify what they are experiencing, consciously and unconsciously. As a simple example of this, I might find myself feeling angry with a patient while listening to her. One hypothesis regarding this feeling of anger is that, in fact the patient is angry, but is unable to be aware of it. The notion of projective identification is one way to explain this. Klein (1975) postulates that unconscious anger gets located in the therapist as an early form of communication. Far from being a magical process in which emotions “get put into” the other, Gabbard (2000) has described this process as a “nudge,” in which patients unconsciously urge the therapist to be cast in a role of some important person from their past. In the case of my patient, my anger may not only have been reflective of her anger toward myself, but also an expression that she expects that others will be angry with her. The value in contemporary ideas on countertransference is an increased appreciation of the multiple forms of communication that we are all capable of. Countertransference feelings are particularly useful in patients who have difficulty symbolizing. Especially in more vulnerable populations, which include the older and medically ill, our emotional responses can help us to acknowledge the extent of vulnerability and fear often present in these patients but which cannot always be verbalized. Working with medical and aging patients causes us to face our own vulnerability. In order to not defensively distance ourselves from our patients, we need a heightened awareness of our emotional responses to patients, as well as an awareness of our own fears regarding illness, and our feelings about the inevitability of death. This is not easy to do. As we will see, it has been argued that countertransference within the field has led to hesitation of treating these patients from a psychodynamic perspective. Psychoanalysis has historically found it challenging to include older adults (and medically ill adults in a way that takes seriously their illnesses) in consideration for treatment. Countertransference with older patients has been described, albeit scantly, in the literature. Sobel (1980), using a broad definition of the term, referred to countertransference in aging patients as being manifested in two ways. The first has to do with what Sobel calls “professional ageism”: Fear and prejudice lead to a tendency to not provide therapy for people of an advanced age because of “therapist’s anxiety aroused by the loneliness, helplessness and death imagery that these patients provoke” (p. 211). The second difficulty has to do with the nature and modifications

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of technique that need to occur for treating the older patient. She refers to the idea that transference often cannot be interpreted with older patients, especially in the beginning of treatment. Again, we return to the problem of traditional notions of method and ideas of flexibility in therapeutic technique. As an illustration of this, Sobel goes on to say that treatments in which the transference is not addressed are often judged by others to be “merely supportive.” However, she says these perceptions by some other therapists are simply a “cover-up for the range of anxieties that are aroused when the therapist is called upon to function in this way” (p. 212). As this article was written in 1980, it may be that some of the aforementioned judgments have waned among contemporary clinicians, though Sobel’s ideas still apply given the history of challenges treating older adults using psychodynamic approaches. Perhaps more than any other kind of patient, treating medically ill and older adults stirs up a range of complex and intense emotions. Treating older adults can be difficult especially if the therapist is new to the field, and particularly those who are young. Younger therapists may feel “self conscious and apologetic” (p. 422) in response to working with older adults Grotjahn (1955). Grotjahn describes the normal tendency, especially among young therapists, to idealize older patients. This is a defense against hostility that some patients can evoke. Although Grotjan goes on to say that idealizing elderly patients is related to unanalyzed material in the therapist regarding their parents, I have not found this to be necessarily true in many younger therapists I have supervised. Surely some younger therapists feel hostility toward their patients and ward it off through idealization. However, I see hostility as a common countertransference feeling associated with unrealistic demands some patients tend to make on younger therapists. Some older patients prefer to have younger therapists so they can maintain the image they long for in themselves – that they are young and virile. This, of course, is a kind of transference in which the patient is secretly identifying with the therapist, as a means of dealing with feelings of envy, in which denial of aging and death is ever present. The countertransference risk with such patients is a tendency to counteridentify with the wishes of the older patient. Younger therapists may wish, through counteridentification, or what Kleinians call projective identification, to be the young and sexualized person that the patient can possess, as a manifestation of the patient’s unconscious wish of being young again. This thought is most often unconscious on the part of the therapist and is frequently associated with shame, once recognized. However, such feelings are normal, and supervision that can aid younger colleagues in understanding the wishes of the patient as well as the unconscious desire to grant patients this wish, with the goal to help the therapist direct the treatment in a way that is ultimately helpful, is what we should strive for. In the following case described, an intern dealt with a challenging case, but was able to successfully maintain a focus on the patient’s internal world, even though she experienced great transference and countertransference obstacles in doing so. An attractive female intern in her late 20s treated a 75-year-old male in therapy once a week. The patient had a number of serious medical problems, which he tended to avoid thinking about. What he did think about in therapy was the attractiveness of his therapist.


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He frequently commented on her appearance, which the intern dealt with though trying to steer the conversation toward the patient’s internal experience about his illness and his life, as well as aspects of the separateness of the intern and the patient. The therapist acknowledged the importance of his feelings toward her and she set appropriate limits and reminders regarding the realistic scope of the treatment. Yet, the patient persisted with what was obviously his need to compliment the therapist, though not surprisingly, these remarks often had a pejorative quality. Although initially feeling flattered by the patient’s compliments, the therapist eventually began to feel that these comments were not respectful, as they increasingly began to be linked in the sessions with dialogue about pornography and prostitutes, both of which the patient was a frequent consumer. At this point in the supervision an important shift took place. The intern felt safe enough in supervision to express that she felt disgusted by the patient and his attempts to win her over, whereas she previously felt it important to convey her respect of this patient to me and all ways in which he had suffered. I normalized her feeling of disgust and expressed that I thought that this was a good shift for her developmentally, and that I thought it would help the patient. I also suggested that perhaps the feeling of disgust was related to the patient’s tendency to be intrusive toward her. In a candid session following this supervision, this therapeutically savvy patient described his understanding of transference, in which he expressed “falling in love with the therapist.” He spoke about what might be different about his current treatment: “I guess I just know you better. Well actually, I don’t really know you at all. I don’t know much about you at all. You are probably the most private (therapist) of them all. You don’t talk about yourself. Other therapists would do that. They would tell me something about themselves. But you don’t give anything and that is good I suppose.” The therapist then commented that the relationship is not all that he might like it to be, yet it is really important to him. The patient then continued, “Oh, it’s what makes it work. I can’t describe it but I feel so much better after coming here, and I leave feeling good, and that lasts me for the week and I then need to come back in again. And I am telling you, I was really depressed when I started coming here and I feel better now. I am not suicidal.”

Although this example illustrates many difficult aspects of this patient’s character, it also sheds light on what is needed to manage countertransference feelings resulting from erotic transferences, in a patient’s attempt to control the treatment. Additionally, this intern successfully dealt with what was a real suicidal wish in this older man. Though this intern was by all objective standards, gifted in her work as a therapist, it seemed crucial that she could come to terms with the feelings of disgust she felt for her patient, as she struggled with the sense that an older man should be sweet and charming, or at the very least, thought she should be able to feel more empathy toward him. The feeling of disgust in a therapist is often associated with some kind of boundary violation in the patient’s past or present, and in this case it was both. This patient attempted to express his anger and envy, and likely his wish/fear that she would not adhere to the boundaries of the therapeutic relationship through his constant focus on her appearance. However, the intern kept the focus on the patient’s internal life. Though the therapist initially felt flattered by the compliments the patient gave her, she eventually understood that these sentiments were empty. Yet, in that this therapist could tolerate and even appreciate such compliments in the beginning of the treatment helped to solidify the therapeutic relationship. In essence, she could provide a holding of the patient’s admiration, which likely was needed so a more genuine attachment could take place. By acknowledging the disgust she felt by the compliments, a doorway was opened for she and her patient to have a greater understanding of what motivated this behavior. As the

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treatment progressed, the patient was able to achieve a greater understanding of his mortality as well as his limits in the present. Countertransference is a complicated and slippery slope. For example, the increasing reliance on enactments in some psychodynamic circles as evidence of unconscious motivations in patients is one such overuse and extension of the concept. We must all recognize the intense feelings we have about our patients, yet we must not act on them in a way that will be further traumatizing to those who come to us for treatment. In the case cited, the therapist could hold on to and manage her own feelings about the patient’s behavior. Although she was initially flattered by the comments from her patient, she did not act seductively toward him. In allowing these feelings to arise, she could come to know other, uncomfortable feelings in herself, that were more deeply indicative of her patient’s experience. By reflecting on the feelings that the patient evoked in her, over time these feelings became more nuanced and clearer. This allowed her to have a deeper understanding of the limits of this patient’s interpersonal world, and also created a way for her to develop genuine empathy toward him. As the patient’s feelings became more clear, the therapist’s burden of managing these feelings eased. What was eventually recognized as disgust was transformed quickly into an understanding of the ways that this patient was desperate for attention in the face of the current deterioration of his body as well as a history of boundary violations. Erotic transference and resultant countertransference is a common issue that occurs in (especially younger) therapists and some characterlogically disturbed older patients. Other feelings that can occur, particularly with older narcissistic patients, are boredom and irritation. Cohen (1982) observes that therapists can feel tortured by a constant sense of futility in work with older patients. Though this feeling is often thought to be reflective of the helplessness and futility within the patient, it is difficult for the therapist to stay engaged and authentically involved with such patients. As I will describe in Chapter 9, some patients who feel futile often present with symptoms of alexithymia, or the lack of an emotional language. It is this lack of emotional relating that is increasingly common in the older and medical patients we treat. When patients present for therapy not knowing what they want (except to “feel better”), it places additional demands on us to explain what therapy can offer and to try to relate to them. Although I advocate for explaining any requests for explicating what therapy has to offer, on a level more sensitive to unconscious dynamics, we need to be able to acknowledge to ourselves the unpleasant feelings we may have toward our patients. We may feel a pull to view our patients, especially the elderly as “sweet and charming” (C. Evenden, personal communication, November 12, 2008) when what patients may need is our ability to hold and know about the less pleasant aspects of their character and feelings. Identifying the negative feelings that patients evoke in us is a way to increase a sense of authentic connection, which then creates a window for a truly emphatic (rather than merely socially appropriate) relationship to emerge. An even more difficult, but common, situation concerns issues of illness, decline in functioning, acknowledging one’s mortality, and our own relationship to the unavoidable and inevitable facts of life. Ellman (1996), noting the paucity of


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literature on countertransference with older adults, addressed the commonplace therapeutic dyad of both therapist and patient being in midlife. In this article, Ellman describes ways in which both therapist and patients can be negotiating aspects of the midlife crisis. He states that a common countertransference reaction in such cases is overidentifying with patients. A further complication is that patients often assume that as therapists, we have successfully navigated the emotional terrain that is a response to aging in midlife, when in fact, we may have not. However, awareness of our own emotional limitations can help in understanding our patients, as long as our own feelings do not remain unconscious. Much of medicine and psychology are plagued with difficulties with regard to how to think about death and serious illness. I recall the first time someone I worked with died, someone I will call “Anne,” a pleasant and motivated 70 year old, who was being treated for mild depression. I had known her only briefly, as she was an elderly woman I had been seeing in my outpatient practice. I was not yet 30 years old and had been in private practice only a couple of years. She had missed an appointment and I had been unable to get in touch with her. The next day, while at a busy nurse’s station in the cardiology unit of the hospital I worked in, I saw her primary care physician, who had referred Anne to me. Upon seeing me, the physician said, “Oh, Tamara, your patient, the older lady, she died 2 days ago. She had a heart attack.” He then walked away as I stood at the nurse’s station both stunned and tearful. I felt more emotionally vulnerable regarding death and serious illness in my patients when I was younger. Especially then, I had a hard time knowing how to manage the feelings that death and severe illness stirred up. This was probably exacerbated by the difficulties with mourning that are present in medicine, as I had little support in a culture in which people simply move on to the next task, even after someone dies. My experience with many mental health clinicians over the years suggests similar kinds of manic defenses and anxiety. One manifestation of my intense anxiety at the time was that I went through phases of thinking that I would develop the same diseases my patients had. Especially when I worked with people who had been subject to random or mysterious illnesses (often those thought not to have links to lifestyle behaviors), I worried that I too would be subject to the same bad luck. At times, when I was seeing large numbers of patients in the hospital, it seemed unbelievable to me that anyone could be in good health, and not sick with some terrible illness! People I have supervised in intense hospital settings have echoed similar sentiments. These feelings and anxieties seem especially prevalent in younger clinicians and those who have not experienced illness or death in their personal life. However, all of us, in working with this patient population, need to come to terms with the intense anxieties and overstimulation that is associated with treating very ill and/or elderly patients. Though our feelings and experiences are filtered through our own psychology, there are many common reactions to working with these patients. Intense fear, anxiety, and thoughts and images of our own death are common reactions not necessarily related to problems with “primitive” psychological states. Rather, serious illness and death are primitive and concrete, and inherently involve intense and disorganizing emotions that are felt by us as therapists when we are with very ill patients. Since many people experience considerable

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shame in confronting these emotions, reinforced by a cultural mandate of “moving on,” one needs to create and internal and external space for these intense feelings.

Conclusion Transference is a useful organizing concept that can help ground us in our work with older adults. Conceptualizations of the modern psychodynamic encounter involve much more than transference and countertransference-based interpretations. Being able to hold, contain, and metabolize intense patient emotions, as well as the healing aspects of a thoughtful emotional relationship with patients gives us a variety of ways to understand the therapeutic action of our work. Illness does, however, make certain scars of the past resurface. For these individuals, as we saw with Jessica, we can work to create a meaningful understanding of intense fears, while addressing the reality of here and now concerns. It is prudent not to forget the important role of physiological functions and how it impacts some patients experiencing acute and chronic pain. The over-reliance on the concept of transference in psychodynamic theory has made it difficult for some to think about and consider this important aspect of our work. While the field of modern psychodynamic psychology seems to be questioning what I would call an over-reliance on the theory of transference, there is much work to be done in articulating and understanding the ways that we can move beyond transference interpretations for a more engaged and emotionally based psychotherapy. Similarly, regarding countertransference, much more needs to be discussed applying this concept to our work with older and medically ill patients. I have provided a mere introduction to this topic, but clearly the intensity of feelings that get stirred up in reaction to this work implores us to have constant awareness of our own emotional reactions. By doing so, we can avoid distancing ourselves from our patients and getting caught up in overidentification. Ideally, we need to come to terms with the potential and prevalence of illness, and the reality of death, in order to be optimally helpful to our patients. While this may not be always realistic, as therapists, most of us are constantly striving to better understand and accept the realities of the world. By honestly, and courageously appraising our strengths and weaknesses as well as our emotional limitations, we can help our patients understand the intensity of their own emotions in the face of terrifying life events.

References Abend, S. M., & Shaw R. R. (1991). Concepts and controversies about the transference neurosis. Journal of the American Psychoanalytic Association, 39, 227–239. Adams-Sullivan, A. (1994). That darkness is about to pass: The treatment of a dying patient. Psychoanalytic Study of the Child, 49, 328–348. Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principals and Applications. New York: The Ronald.

References

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Arlow, J. (2002). Transference as a defense. Journal of the American Psychoanalytic Association, 50, 1139–1150. Aron, L. (1990). One person and two person psychologies and the method of psychoanalysis. Psychoanalytic Psychology, 7, 475–485. Blum, H. P. (1994). The confusion of tongues and psychic trauma. International Journal of Psychoanalysis, 75, 871–882. Chused, J. F., & Raphling, D. L. (1992). The analyst’s mistakes. Journal of the American Psychoanalytic Association, 40, 89–116. Cohen, N. A. (1982). On loneliness and that aging process. International Journal of Psychoanalysis, 63, 149–155. Ellman, J. P. (1996). Analyst and patient at midlife. Psychoanalytic Quarterly, 65, 353–371. Esteve, M. R., & Camacho, L. (2008). Anxiety sensitivity, body vigilance and fear of pain. Behaviour Research and Therapy, 46, 715–727. Ferro, A. (2002). In the analyst’s consulting room (trans: Slotkin, P.). New York: Taylor & Francis. Fonagy, P. (2000). Attachment and borderline personality disorder. Journal of the American Psychoanalysis Association, 48, 1129–1146. Gabbard, G. (2000). The integration of psychoanalytic and neuroscientific thought in the realm of personality. In J. Sandler, R. Michels, & P. Fonagy (Eds.), Changing ideas in a changing world: The revolution in psychoanalysis (pp. 155–162). London: Karnac. Greenberg, T. M. (2007). The psychological impact of acute and chronic illness. New York: Springer. Grotjahn, M. (1955). Analytic psychotherapy with the elderly. Psychoanalytic Review, 42, 419–427. Jaques, E. (1998). Death and the mid-life crisis. In E. B. Spillus (Ed.), Melanie Klein today: Developments in theory and practice (pp. 502–514). London: Routledge. Joseph, B. (1985). Transference: The total situation. International Journal of Psychoanalysis, 66, 447–454. Kernberg, O. F. (1988). Object relations theory in clinical practice. Psychoanalytic Quarterly, 57, 481–504. Klein, M. (1975). In M. Masud & R. Khan (Eds.). Envy and gratitude and other works 1946–1963. London: The Hogarth. Levenson, (1981). Facts or fantasies: The nature of psychoanalytic data. Contemporary Psychoanalysis, 17, 486–500. Mayer, E. L. (1994). Some implications for psychoanalytic technique drawn from analysis of a dying patient. Psychoanalytic Quarterly, 113, 1–19. Norton, J. (1963). Treatment of a dying patient. Psychoanalytic Study of the Child, 18, 541–560. Pizer, S. A. (1996). Negotiating potential space: Illusion, play, metaphor, and the subjunctive. Psychoanalytic Dialogues, 6, 689–712. Renik, O. (1995). The ideal of the anonymous analyst and the problem of self-disclosure. Psychoanalytic Quarterly, 64, 466–495. Sachs-Ericsson, N., Kendall-Tackett, K., & Hernandez, A. (2007). Childhood abuse, chronic pain, and depression in the National Comorbidity Survey. Child Abuse and Neglect, 31(5), 531–547. Sarno, J. (1991). Healing back pain. The mind-body connection. New York: Warner Books. Sobel, E. F. (1980). Countertransference issues with the later life patient. Contemporary Psychoanalysis, 16, 211–222. Viederman, M. (1986). The psychodynamic life narrative: Its implications as a transference cure. In H. Meyers (Ed.), Between analyst and patient: New dimensions in countertransference and transference (pp. 129–149). New Jersey: The Analytic.

Chapter 6

Self-Destructive Behaviors, Masochistic Dynamics, and Illness

Do I dare Disturb the universe? T.S. Elliot

Medical illness, and to some extent, physical decline associated with aging, are linked with the dynamics of power and control. When illness strikes, people become aware of the limits of their bodies. Once sickness sets in, we cannot change the fact that we are ill. On the other hand, illness can cause us to seize control by following medical regimens, improving self-care, and changing lifestyle behaviors that increase the risk of disease. This chapter will focus on parameters of self-care and how they relate to control over illness. I will begin by exploring this issue through the lens of the paradoxical situation when people with medical illness engage in behaviors that put themselves at further risk. These cases illustrate an extreme scenario in which feelings about oneself are physically manifested through unhealthy and self-destructive behaviors. At times such behaviors are often conducted with a specific aim of provoking a response in another person, and also represent complicated internal dynamics related to rage, confusion, and feelings of powerlessness. Although some people behave with habitual self-destructive behaviors in illness, I will also address the common occurrence of those who engage in risky behaviors outside the context of being ill. Given the high degree of noncompliance in the United States pertaining to lifestyle factors and illness, I will suggest that there are common components of a self-destructive instinct in many people. Though selfdestructive behaviors can be differentiated from calculated risks (since we are all subject to activities, behaviors, and environmental influences that could be harmful and yet cannot avoid), I will make a case that certain psychological states related to fear of illness and death, and the resulting issues related to power, control, and omnipotence can be covered loosely under the heading “masochism.”


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6 Self-Destructive Behaviors, Masochistic Dynamics, and Illness

Psychodynamic Ideas on Masochism Although I set out to write this chapter on masochism and its relationship to illness, once I started to think about how such behavior is related to the body in illness, I realized that although I have read a great deal about it, I did not know what the concept of masochism really means. My ideas about masochistic behavior quickly became conflated, especially once I looked at more of the psychodynamic literature on the topic. This is likely due to the fact that the term masochism is confusing within the psychodynamic literature itself, as multiple definitions are used in the field. Theories about this perplexing and fascinating topic have shifted dramatically over the years, and there are many valid ways to view masochism. In this discussion, we will view masochism through the narrow lens that it has components that are developmental and normal, and that it is linked with omnipotence. This should be distinguished from the sense of masochism as a sexual perversion, which I will briefly review. Though masochism as a perversion certainly exists, I am going to focus on the ways we might understand the varying aspects of self-destructive behaviors that we see in many people. Additionally, since the idea of punishment in response to successes was described in Chapter 4, I am going to limit that aspect of masochistic and self-destructive phenomena in the present discussion. Traditional psychodynamic theory offers a conceptualization of masochism, which is closely related to what Freud called the death instinct. Freud (1915/1964) connected his idea of a primary self-destructive instinct with masochism, in that strong self-destructive impulses are turned inward on the self. In other writings, Freud (1919/1955) ties in abuse and sadism in the parents as being linked with masochistic character development. Sadism is the flip side of masochism – these two phenomena coexist. Sadistic impulses are expressed through masochistic fantasies and behaviors. Freud and traditional theorists felt that masochism was a problem related to sexual perversion, in which pleasure and pain, dominance and submission need to co-occur. Though Freud and many others felt that aggressive impulses can be sublimated through creative energy (and not enacted as sadism), Anna Freud (1949) offered the view that masochism should be “regarded as normal components of the human mind” (p. 205). Bergler (1949) argued that masochism is a normal part of development and connects this with the developmental problem and difficulty of giving up omnipotence. Related to the consequences of losing the illusion of omnipotent power, Stolorow & Lachman (1980) suggest that masochistic activities are efforts to restore and maintain self-cohesion and stability in the face of a “crumbling self-representation” (p. 30). Other authors have also pointed out the ways that self-destruction, through the creation of disappointing experiences, can be a powerful way people try to manage their view of reality. Ghent (1990), through making a distinction between submission and surrender, describes how repetitive masochistic behaviors express both the wish and the dread of knowing the truth. Such behaviors become a pattern in which people attempt to take in the truth of an unpleasant situation, while not wanting to know the truth at all. Ghent explains: In effect, I am suggesting that some instances of masochism may be rooted in a deep quest for understanding, for undoing the isolation. It is as if with one mind the person is setting

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up situations in which he is “done in” or caused pain by the other, an authority, friend, lover, and with the other, is struggling with the inner question that remains tantalizingly unanswered: What happened? How did it happen? A loved one could not have done that to me! That is inconceivable. Then how did it happen? He did it! . . . but somehow I cannot “take it in.” It just cannot be. Maybe next time I can create a situation that’s more clear. . . . Then I will be able to “take it in, perceive, conceive it.” (p. 127)

Reality can be a bitter pill to swallow. In illness and bodily failure, the world can feel taunting and cruel. Particularly when patients are forced to acknowledge the limits of omnipotent control over their bodies, masochistic “solutions” allow people to avoid the reality of their condition. The most striking example of this took place in young man I saw many years ago who struggled with this issue: John was 26 years old, when after years of chronic illness he received a solid organ transplant. We met during his hospitalization and he came to me for follow-up treatment for several years. John developed a very close attachment to his doctors and nurses during his long hospital stay. Though his family came to visit often, he never spoke of them. And if I came to see him when a family member was in the room, he often “forgot” to introduce me. Once he was out of the hospital and recovered from his surgery, he began to skip follow-up appointments with his doctors. Additionally, he was noncompliant with nearly all aspects of his medical care, which had a rather defiant tone. For example, one of his medications carried warnings of excessive sun exposure. John frequently had a dark tan from many hours of being in the sun. He took his medications infrequently and avoided going to the hospital when he had complications that were potentially life-threatening. Though his doctors became angry with him, my reaction was more complicated. I felt concerned about his health, but also curious, and at times amused at his defiance. A couple of years after his transplant, John saw me following a hospitalization which was not due to his noncompliance, but rather a medical problem related to his beleaguered immune system. It was in this session that John expressed for the first time, intense anger at the doctors who performed the transplant. The thought occurred to me that he felt his doctors were responsible for his original illness. I then asked John if he thought he was noncompliant with his care as a way of “getting back” at his doctors. He said, “Well yeah, I am rebelling against them. I am mad about what they did to me. They should pay for it.”

John’s neglect in taking care of himself was a way to express anger about his medical situation and his difficult relationship with his family. In this way, his behavior is similar to traditional ideas of masochism. His anger about his illness was turned inward, resulting in mistreatment of his body. However, a more contemporary view sheds light on other aspects of John’s behavior. John was also struggling with surrendering (as Ghent suggests) to the truth that he had been unfairly and unjustly burdened with a life-threatening illness as a teenager. Illness is a blow for anyone, but especially for a teen at the height of developmental omnipotence, disease itself can feel like a sadistic attack from within. At the peak of omnipotent feelings in development, teens and young adults they feel invincible. When illness hits, it threatens this view and can make them feel as if their “power” has been contorted in some bizarre way and has been turned inward. The experience of such an attack on the body is not only confusing, but also intolerable. Therefore, others are often the brunt of these feelings, as John’s doctors were. Being noncompliant and focused on anger at his doctors also served the purpose of organizing this confusion, as his focus became externalized. Ironically, once John received his transplant, a cure for his disease, he began to behave in a noncompliant manner, although he had no prior

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history of this kind of behavior. His transplant had been deemed successful, and so it was in the context of setting out to develop a proper adult life for himself that he struggled with the truth about his illness. By being continually noncompliant, John could test the reality of his situation. Was he “better?” Yes, but his noncompliance made him ill again. Through being ill again, John could move away from his feelings about having survived a life-threatening illness and this unjust situation could be avoided by focusing on the doctors who ruined his life. Once his anger had been uncovered, John began to experience intense anxiety and fear over the limitations of his body. His omnipotence had taken on a different shape; he now worried about his own body’s power to cause harm to himself. Even though at this point he had become completely compliant with his post-transplant treatment and was taking excellent care of himself, he feared complications from his transplant. His fear is understandable: Self-destruction helps one thwart anxiety and confusion. By becoming self-destructive, John avoided overwhelming and confusing feelings related to his illness. Self-defeating behavior paradoxically suppresses worries about power and omnipotence. John was both “better” and ill. It is these kinds of paradoxical ideas and behaviors that Ghent describes so well. In another article, Ghent (1992) talks about the ways people who have experienced trauma and deprivation attempt to ward off need, though in doing so, they act and appear excessively needy. John’s behaviors resulted in medical complications that in fact caused him to see his doctors even more. However, his conscious experience was that more interaction with his doctors was the very thing he did not want. I eventually came to understand that John needed both his doctors and me to help him take better care of himself, as he could not get that at home because of a chaotic, and at times, violent environment. Becoming aware of his needs, however, made him feel both needy and enraged at others who potentially had the ability to meet these deficiencies. In addition to the revelation that he wanted his doctors to “pay for” what they did to him, this moment in his therapy created space for us to discuss just how angry he felt when he needed others. This became an ongoing theme in his treatment, which lasted nearly a decade. Perhaps my mild amusement at his brazen rebellion was a means of identifying with John’s intense anger. I also was genuinely amazed at how his body continued to survive in spite of attempts to kill himself through his masochistic tendencies. I am aware that in those early years, I was championing his ability to “get away with” not taking care of himself. I mention this because although John and I were able to get at the root of these dynamics, the aspect of getting away with things is an important part of masochistic and self-destructive dynamics. As I will describe, there is psychic necessity, and a secondary feeling of pleasure, in not doing the right thing as it relates to the body.

Masochism and the Body In the mid-1980s, I had a volunteer job in a residential treatment center in rural Minnesota. Many of my colleagues and supervisors were heavy smokers. As was the case in those days, smoking was typically allowed at work and people often

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smoked when they were with clients. When the issue of smoking came up (as it often does for those aware of its health risks), many people would say, often when lighting up a cigarette, “I know I should not (smoke) but something’s got to kill me!” Over many years I have wondered about these kinds of statements that I think serve as an apt example of a common enough (though no longer socially acceptable) behavior. Smoking allows us to look at a clearly dangerous behavior, which many people continue to engage in despite the risks1 . While smoking can be understood in terms of the various kinds of self-destructive behaviors that people might partake in, another comment that took place about 10 years later that put my thoughts about smoking into clearer focus came from a senior colleague2 who mentioned that oncologists tend to smoke cigarettes. This statement was striking from the standpoint that once I heard it, I knew it to be true. I have known from experience that many health care professionals tend to smoke, though often in private, and in current times, with a great deal of shame. In terms of objective (and not just clinical) data, smoking rates in medical professionals are hard to measure, as one can imagine the motivation to hide such a fact. However, despite problems with accurate figures, the issue has been studied worldwide. Research suggests that in countries where preventative education lags behind, physicians take up smoking earlier and to a greater extent than the general population; however, once awareness about the risks increases in a particular country, doctors do tend to quit earlier than the general population (Davis, 1993). However, a recent review of the literature on physicians and smoking (most of which published since 1990) found that although smoking rates among doctors have declined in the last 30 years, these figures are “not uniformly low when viewed from an international perspective” (Smith & Leggat, 2007, p. 1). This study also found that nurses tend to smoke more than medical doctors, and that in some countries dentists smoke more than physicians. This research, as well as clinical observations, suggests that in fact, a subset of medical professionals tend to be smokers. The question is why a subgroup of professionals, who know the risk of smoking better than any other professionals, would smoke, and what can this tell us about the fact that a large number of people engage in behaviors that they know are harmful? As I have thought about this issue over the years, the anxious justification I heard from my senior colleagues in Minnesota explains a great deal. The notion of “something has to kill me” could be supplanted with the sentence, “I don’t know what is going to kill me, and this unknown fact terrifies me, but if I smoke at least I know what will.” This, I think, is the allure of smoking and other unhealthy behaviors among some people, especially those who we might suspect “know better.” To take the example of health professionals further, people in this profession see a tremendous amount of trauma, much of which encompasses illnesses that are 1

Though I am aware that cigarettes are highly physically addictive, I am going to focus on the psychological factors of this behavior, as I think it captures something important about the ways people can mistreat their bodies, while maintaining an ongoing psychological awareness of the risk. 2 I am appreciative to Toni Heineman, DMH, for her thoughts and comments related to smoking among physicians.

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“random”: lung cancer in nonsmokers, cardiac disease in those who do everything right in terms of medical compliance and regimens, childbirth complications in women with normal pregnancies, leukemia and lymphoma in those not at risk for any illness, to name just a few. These traumatic events cause a tremendous amount of fear. For example, the recent death of Tim Russert, noted television journalist, who was reportedly medically stable, yet died of a heart attack at the age of 58. Russert had been diagnosed with coronary artery disease, but this was reportedly well controlled with medication, and he did well on a stress test that took place less than 3 months before his death (Johnson, 2008). Although people who are not in the world of medicine may find this unfortunate event unusual, medical professionals see such incidents as commonplace. As psychological clinicians, we may not realize it (unless we work in acute medial settings), but the incidence of people who have diseases and do “everything right” and still die is more common than often recognized. People who work in medical settings have more exposure to these unfortunate cases. It is this issue I want highlight to address why some health care professionals might be more prone to smoking and other negative health behaviors. In my work with numerous medical professionals, traumatic aspects of working with patients are intense and severe, resulting in vicarious trauma, in which medical practitioners develop some of the same symptoms of post-traumatic stress disorder as their patients. In this kind of traumatic work, medical professionals face the reality that there are aspects of illness that cannot be controlled. In a field in which illusions of control abound and manic defenses prevail, this realization is difficult at best and devastating for some. Perhaps this explains why, although modern medicine offers many cures and success stories, it is the tales of people who do not do well that stay in the minds of many medical clinicians. The lack of control and feeling of powerlessness in practitioners who see traumatic events day in and day out might explain aspects of smoking and other self-destructive behaviors. Control is being seized through these activities; yet of course, this control is destructive. However, this destructive control may be preferable to the feeling of no control at all (“At least I know what will kill me”). Especially when it comes to thinking about death and illness, one has to come to terms with the reality that our actual control may be limited. This realization is difficult to tolerate and challenges normal developmental ideas of omnipotence. For any addictive behavior, denial and idealization must exist (Johnson, 2003). Denial wards off feelings about the dangers associated with self-destructive behavior. Idealization manifests in the form of elevating the human body’s capacity to avoid harm, that the body (which is thought to be perfect in the unconscious) is indestructible. Perhaps this explains why many people tend to stop smoking in their late 30s and 40s. If one is plugged into reality well enough, they are reminded that the body is not perfect; normal aging reminds us of that, if we pay attention. Not paying attention to this fact, however, is indicative of an omnipotent mindset and the reluctance to give up this facet of human development. Aspects of denial and idealization (omnipotence) explain a great deal about poor health behaviors and noncompliance in general. As mentioned in Chapter 3, some estimates suggest that about half of all medical patients in the U.S. do not adhere to


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medical advice regarding the prevention or treatment of disease (DiMatteo, 1994). Although smoking and other addictive behaviors offer one view of self-destruction in a significant portion of the population, there are many other examples of selfdestructive behaviors among people educated about health risks and behaviors. Examples include people with type 2 diabetes or heart disease who will not exercise, people who have unprotected sex, people who refuse mammograms and colonoscopies, those with sleep apnea who will not use C-PAP machines, persons with severe obesity who will not try to lose weight, to name only a few. Such individuals are often resentful about what is required to take care of themselves. However, anger is often a silent partner in crime. Most people who have difficulty adjusting their lifestyles to accommodate health problems or preventative care are not aware of unconscious anger. Rather, some people respond to requests about their health behaviors with self-deprecating remarks. People who do not exercise refer to themselves as “lazy.” Others externalize the anger such as when people say they work too much to make different food choices or that C-PAP machines are uncomfortable. However, we should acknowledge the slippery slope regarding the parameters of health and lifestyle behaviors. Though the examples illustrate certain difficulties with self-care, where do we draw the line? If people do not eat five servings of fruits and vegetables every day, are they really self-destructive? What about alcohol? Many people drink alcohol in excess, like having an extra cocktail at a party to overcome social anxiety. These latter examples point out just how blurry the line can be between self-care, self-medication, and self-destruction. After all, what is the harm in having an extra drink at a party or not eating fruits and vegetables at every meal? Moreover, guidelines regarding food and alcohol consumption seem to constantly change and experts do not necessarily agree. For example, some health experts suggest minimal alcohol use to prevent certain cancers, while others suggest moderate drinking to prevent heart disease. We are all constantly barraged with health information, some of which is confusing or even contradictory. Even the most well-intended, well-educated person may not be able to always live according to “optimal” health behaviors. Despite the complexities in identifying the boundaries of self-care and self-destruction, it is clear that there is something common in our society involving the difficulty of taking care of oneself that is reflected in smoking, other substance use, excessive fast food consumption, as well as other (perhaps lesser) forms of not behaving in optimal ways toward the body. Normative aspects of omnipotence can explain the psychological instinct to deny risky behaviors and to tempt fate, by seeing if one can be an exception to the rules of health. The desire to control our bodies is normal and the impulse to avoid death is natural. However, something goes awry with the system of denial and omnipotence when people excessively engage in risky behaviors. Smoking, substance abuse, unsafe sexual practices and other potentially harmful behaviors reflect an unconscious desire to control factors that might lead to death, so that omnipotent control and power can be maintained. To return to the problem of noncompliance among patients, in addition to risky health behaviors, another common clinical issue is that of not adhering to physician directives, especially medication use. Many patients do not take medication

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as prescribed by their physicians; some patients take more than prescribed, and others less. Some people simply choose not to take the medications that are prescribed for their illness. In the absence of a belief system that justifies treatment with nonallopathic medicine (such as when people choose equally beneficial alternative approaches), noncompliance often reflects Ghent’s idea of surrender. When we do as we are supposed to, we surrender to the higher authority of a physician. For some people, this is very difficult to accept. Following a physician’s advice feels like a form of masochistic submission, as opposed to the decision to consciously pursue self-care, in which the physician is a trusted authority. A patient of mine who unilaterally decides which medications he will take for his medical problems expressed the following in response to my asking him why he does not take his medications as prescribed. In a session with him, I was trying to understand why he decided to take only one of his two prescribed diabetes medications. He said, “I don’t like it. I don’t like the way it makes me feel.” I then asked how he knew it was medication “A” rather than medication “B” that was making him feel bad. He said, with a slight smile, “I don’t know. I just don’t want to take too much medicine. Dr. C just writes a prescription for this stuff and I don’t know why I have to take it.” Though one could argue that patient education about medication may have been an issue in this case, it was not, as I was able to explain the purpose of his medicine, and his physician had assured me that he had done so as well. This patient clearly had a desire to control, which made interactions with his physicians difficult. But as much as he wanted to be in control and found pleasure in it (hence his smile when I challenged him), his attempts at control were self-destructive. Some patients become very anxious when they become aware of the realistic ways that they can take control of their bodies. Krystal (1978) described how patients in psychoanalysis with him who were simultaneously undergoing biofeedback, thus achieving mastery over aspects of bodily functioning previously thought to be out of their control (respiration rate, muscle tension, etc.), would become extremely anxious. The patients he described did not act with relief over this awareness of control; rather, they became terrified of some terrible danger. Anxiety is associated with increased control in that it involves knowing the ways in which we do not have control. Knowledge of control and knowledge of lack of control occur together. A balanced realization of what we can and cannot control requires letting go of omnipotent notions. In another publication, Krystal (2005) described how those in active military combat, who confront death on a regular basis, function at a higher level when they can maintain a state of omnipotence and denial of death. Here Krystal links omnipotence with short-term adjustment in people exposed to the imminent risk of death. In the long term, however, there is a cost for this form of denial. As we know, people who cope with threat of death during war have trouble coping when they return home to a “normal life.” As we see in smokers and others who engage in dangerous behaviors, denial places the body at unnecessary risk for illness. In other words, omnipotent ideas of control are a short-term solution. In the long run, there is a high price for excessive omnipotence. People who live with such denial about their body often do so because it serves the purpose of warding off fear and terror associated with the existential


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confrontation of death. However, such behaviors are used to actively manage fear and anxiety, quite often related to problems with maintaining a coherent sense of self, especially as described in Chapter 3. Certainly, smoking and other types of substance abuse serve a physiological purpose. Smoking improves concentration, alcohol decreases anxiety, other drugs have psychoactive effects which people describe as pleasurable. Additionally, people use foods high in carbohydrates for energy and sugar “highs.” Obviously, moderation is key. However, we all know people who take the risks associated with noncompliance and risky behaviors to an extreme. Paradoxically, realizing the limits of one’s control can also mean “taking” control as a way to preserve and maintain a sense of power that helps ease the burden of terrifying anxiety. As a final anecdote on this topic, in the beginning of my career I worked with a large number of smokers who eventually developed lung cancer. I was struck at how many of these patients did not appear guilty about their smoking habits. Many of them commented, “Well I knew the risks, but I did it anyway.” This suggests that a level of insight endures even in people who, over decades, take tremendous risks. “But I did it anyway,” suggests being aware of their need for this unhealthy behavior, despite its risks. Given the extensive literature on masochism and its varying definitions, the attention given to this issue is indicative of its perplexing nature as well as the common aspects of self-destruction. Freud himself was fond of nicotine and cocaine, the latter purportedly used to help ease social anxiety (Johnson, 2003). Johnson points out that Freud’s own denial about his questionable health behaviors might explain some of the difficulties the field has had in developing a fuller understanding of these kinds of addictive behaviors from a psychodynamic perspective. In the mid-1890s Freud suffered from severe cardiac symptoms, which he realized was made worse by his cigar smoking (Schur, 1972), and although he tried to quit at times, he continued to smoke throughout his life. Interestingly, in Schur’s account of Freud, including several previously unpublished letters, it is clear that Freud questioned whether or not his symptoms were “real” or due to psychosomatization. Schur recounts the following letter to his physician at the time: “It is painful for a medical man, who spends every hour of the day struggling to achieve an understanding of the neuroses, not to know whether he himself is suffering from a reasonable or hypochondriacal depression.” (p. 43). Schur goes on to say that Freud was in fact experiencing tachycardia and arrhythmias, which were quite painful. Here we see another common aspect of omnipotence related to control. Facing loss of control, it is common for some patients to worry and unconsciously wish that they are “making up” their illness, especially with those patients in whom control and omnipotence are important dynamics. Wishing for an illness can be thought of as a way to feel that one is in constant control of the body. This can be thought of as the other end of the continuum of omnipotence. A patient of mine who was having a heart attack made this mistake. Having a long history of psychosomatic illnesses, she assumed that the chest pain and stomach pain she was having were related to anxiety. Fortunately, at the urging of her children, she went to

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the hospital and received proper treatment. However, even after her hospitalization, she continued to question whether or not her heart disease was “real.” The idea that one is manufacturing symptoms in order to deal with anxieties about death and dying are, ironically, common in people who have experienced traumatic losses and who defend against disorganizing confusion and the threat to omnipotence through psychosomatic symptoms. Consider the following case example: Jackie was a woman in her 20s who sought psychotherapy after the unexpected and traumatic death of her mother, who perished in a motor vehicle accident. Though such an incident would be traumatic for anyone, Jackie’s situation was all the more agonizing because her last conversation with her mother was a quarrel. In the heat of this argument, Jackie told her mother that she “wished she were dead”; these were the last words she said to her mother. Although initially responsive to the idea of therapy, Jackie had a hard time attending sessions on a regular basis. She reported having abdominal pain, which she thought may be the sign of a serious illness. However, after appointments with several physicians, no evidence of a serious medical problem was found. So, Jackie came to see me for therapy more regularly, but still worried excessively about having various medical conditions, even though she was young and had no risk factors. She was concerned about developing breast cancer, HIV, as well as lung cancer, even though she was not a smoker. It eventually became clear that Jackie struggled with and worried about intense aggressive feelings within herself for much of her life. As a result, she found herself in relationships with people who mistreated her, as is commonly the case with those who adopt a masochistic stance. She felt that her mother was an intrusive person who demanded frequent attention, insisting that they speak several times a day. Jackie eventually admitted with considerable shame that her mother’s dying meant that she did not have to endure her mother’s need for excessive attention. Yet this reality was difficult for her to deal with, and expressed only momentarily in therapy. She continued to be preoccupied with somatic troubles even though her physicians had confirmed that her health was fine.

Jackie’s case illustrates the difficulties, traumatic in and of themselves, that occur when omnipotence is put to the test in actual, lived experience. Similar to the scenario when someone with a history of psychosomatic problems develops a real illness, what is feared and wished for actually happens in reality. Jackie had a secret wish that her mother would die. Such a desire is not unusual, except that in this case it happened to come true; her mother really did die, after a contentious argument. Winnicott (1965) described the importance of omnipotence being allowed full psychic expression in early childhood and the devastating effects when the intrusion of reality interferes. In Jackie’s mind, reality mirrored her aggressive and omnipotent ideas in the worst possible way. Unable to bear thinking about this desire, a psychosomatic preoccupation served to organize her profound confusion, in an attempt toward integration as Winnicott (1966) elucidated. Psychosomatic symptoms sometimes manage fears regarding the power of aggression. Omnipotent fears of aggression take over the body (in Jackie’s case that her aggression killed her mother). A person has the power to make themselves sick – to bring about serious disease in themselves. The paradox is this: Fear of one’s own power becomes the power to make oneself suffer. In treating these aspects of omnipotence tied to self-defeating behaviors, an eventual goal of treatment is to allow the patient to get in touch with facets of their

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aggressive thoughts. However, as discussed throughout this volume, this is not necessarily curative. People who are terrified of their own aggression are attempting to gain control through self-destructive behaviors, noncompliance, or psychosomatic symptoms, yet they are also trying to reach a state of self-cohesion. Additionally, people who are psychically organized around anger, as we saw with John and Jackie, are attempting to define parameters of feelings and confusing self-states, to avoid what Peter Carnochan calls the almost nonself experience of ease and relaxation (P. Carnochan, personal communication, January 8, 2009). Identifying these states of confusion and disorganization is often a good start. The reality, however, is that many behaviors people engage in that we, and they, want to change are met with deep internal resistance, frequently due to the threat of loss of self-cohesion. It is this aspect of modern psychodynamic theory that has offered insight into these disturbing and overwhelming feelings in our patients. As discussed in previous chapters, focusing patients on the present with an ear to the past allows us to help people begin to find their own emotional language. In the context of a safe-enough therapeutic relationship patients can get help with understanding the motivations that underlie many self-destructive behaviors.

Conclusion Self-destructive behaviors, although more prevalent in some, are seen on a continuum of normative to extreme. Especially in this era of advances in medical technology, the understanding of what we can all do to promote optimal health is ever-increasing. This raises a number of important issues regarding the reality and illusion of the control we have over illness. At times, it seems that new research can tell us how to avoid sickness as new risk factors are increasingly emerging (recent research on periodontal disease and cardiac illness come to mind). Though it is beneficial for all of us to recognize the ways we can have more control over our bodies, the painful truth is that there are many things we cannot regulate ourselves. Coming to terms with this is reality is essential to avoid the helpless states that some people experience when they try to take control of their bodies in unhealthy ways. Engaging in risky lifestyle behaviors, not following advice from physicians, especially as it concerns matters they are expert in, and even emphasizing psychosomatic symptoms are all ways that people can try to grasp at a feeling of control – not only to manage anger, but also to gain a sense of self-cohesion. Though I am not opposed to behavioral interventions for lifestyle behaviors, the kinds of patients and dynamics described in this chapter are reflective of those for whom behavioral interventions are unlikely to be effective, as unconscious motivations and intense feelings of fear, confusion, and resentment are “managed” through these activities. Moreover, there is a normative component of a self-destructive instinct that many people encounter when they think about the inevitability of death. It is as if some people think, “If I am going to die anyway, then what does it matter how I treat my body?” Of course it matters, because despite the inevitability of death, changing behaviors and taking better care of one’s body allow one to be able to suffer less in life. Though this

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is a simple concept, experience has shown me that it takes a long time to get this idea across to patients, because letting go of omnipotence can feel worse than the consequences of not taking care of oneself.

References Bergler, E. (1949). The basic neurosis, oral regression and psychic masochism. New York: Grune & Stratton. Davis, R. M. (1993). When doctors smoke. Tobacco Control, 2, 187–188. DiMatteo, M. R. (1994). Enhancing patient adherence to medical recommendations. Journal of the American Medical Association, 271, 79–83. Freud, A. (1949). Report on the sixteenth international psycho-analytical congress. Bulletin of the International Psycho-Analytical Association, 30, 178–208. Freud, S. (1955). A child is being beaten. A contribution to the study of the origin of sexual perversions. In J. Strachey (Ed. & trans.), The standard edition of the complete psychological works of Sigmund Freud (vol. 14, pp. 175–204). London: Hogarth. (Original work published 1919). Freud, S. (1964). Instincts and their vicissitudes. In J. Strachey (Ed. & trans.), The standard edition of the complete psychological works of Sigmund Freud (vol. 14, pp. 109–40). London: Hogarth. (Original work published 1915). Ghent, E. (1990). Masochism, submission, surrender: Masochism as a perversion of surrender. Contemporary Psychoanalysis, 26, 108–136. Ghent, E. (1992). Paradox and process. Psychoanalytic Dialogues, 2, 135–159. Johnson, B. (2003). Psychological addiction, physical addiction, addictive character, and addictive personality disorder: A nosology of addictive disorders. Canadian Journal of Psychoanalysis, 11, 135–160. Johnson, A., Yang, J., & Strickland, K. (2008). NBC’s Tim Russert dies of heart attack at 58. http://www.msnbc.msn.com/id/25145431/. Accessed 2 Jan 2009. Krystal, H. (1978). Trauma and affect. Psychoanalytic Study of the Child, 33, 81–118. Krystal, H. (2005). The trauma of confronting one’s vulnerability and death. In C. Ellman & J. Reppen (Eds.), Omnipotent fantasies and the vulnerable self (pp. 149–193). Oxford: Rowman & Littlefield. Schur, M. (1972). Freud: Living and dying. New York: International Universities Press. Smith, D. R., & Leggat, P. A. (2007). An international review of tobacco smoking in the medical profession: 1974–2004. BMC Public Health, 7, 115. http://www.ncbi.nlm.nih.gov/pubmed/ 17578582. Accessed 5 Jan 2009. Stolorow, R. D., & Lachman, F. M. (1980). Psychoanalysis of developmental arrests. New York: International Universities Press. Winnicott, D. W. (1965). The maturational process and the facilitating environment. New York: International Universities Press. Winnicott, D. W. (1966). Psycho-somatic illness in its positive and negative aspects. International Journal of Psychoanalysis, 47, 510–516.

Chapter 7

Cognitive Changes and Implications for the Therapeutic Encounter

The advantage of a bad memory is that, several times over, one enjoys the same good things for the first time. Freidrich Nietzsche

Traditional psychoanalysis held the view that due to cognitive constraints (“lack of elasticity”) elderly people were not appropriate for psychoanalysis. This led to a resistance to treating older patients until relatively recently. Now, however, there is little doubt that treating older adults with psychotherapy is appropriate and effective. As discussed in Chapter 1, psychodynamic approaches are increasingly being applied to work with aging adults. However, for some older people and the very elderly, cognitive changes impact the therapeutic encounter. Emerging research and clinical insights suggest that despite cognitive decline, psychotherapeutic and psychodynamic approaches are useful. Nevertheless, the presence of impaired cognitive abilities raises questions among clinicians who conduct psychotherapy with this population. For example, people often wonder about the ethics of practicing psychotherapy with adults who have memory problems. This chapter will address this controversy as well as other considerations in treating adults with cognitive difficulties. I will discuss some of the main cognitive issues that arise in treating older adults as well as exciting research within contemporary psychodynamics, which pertain to cognitively impaired populations. First, I will provide a context for this discussion by describing common presentations of dementia. I will also delineate some of the medical issues typical in older adults, as these symptoms, though not disabling for many, inevitably change aspects of the therapeutic encounter and are a focus of clinical attention. Finally I will detail the ways that psychodynamic interventions can be helpful, as well as the limits of these interventions for people with more advanced cognitive decline.


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7 Cognitive Changes and Implications for the Therapeutic Encounter

Cognitive Impairment in the Elderly As most clinicians are undoubtedly aware, cognitive impairment in the elderly is not uncommon. While it is beyond the scope of this chapter to provide an exhaustive survey of all neuropsychological disorders that we might encounter in our elderly patients, we will begin by looking at some of the primary clinical symptoms in the most common diseases we encounter. First, I will describe the most common forms of dementia, as well as related cognitive sequelae of heart disease and diabetes. These disorders are so prevalent in clinical practice that we may forget to pay attention to how these illnesses affect cognitive functioning. Although there are a number of diseases we will not cover here, the references at the end of this chapter provide an excellent review of many of the major illnesses confronting older adults. Dementia is a broad term used to identify impairments in memory, learning, language, visuospatial, and executive abilities (American Psychiatric Association, 2000). The most common dementias are Alzheimer’s disease (AD), vascular dementia, which may or may not be subcategorized as poststroke dementia. These disorders are considered to be those most commonly encountered in aging populations (Fillit, Nash, Rundek, & Zuckerman, 2008). These authors say that at present there are 24.3 million cases of dementia worldwide, and this number is expected to double every twenty years, reaching 81.1 million by 2040. Dementia can be mild, moderate, or severe, and clinical symptoms of dementia vary widely. For example, some patients with dementia have severe expressive language difficulties and others maintain speaking abilities until relatively late in their illness. Dementia should be distinguished from mild cognitive impairment (MCI), which refers to memory impairment in excess of what might be expected given someone’s age, but not severe enough to cause clinical impairment (Werner & Korczyn, 2008). Some authors have described MCI as a transitional phase between normal aging and development of dementia and often reflects one specific domain of impairment in the absence of other neurological problems (Rosenberg & Lyketsos, 2008). Normal aging, however, is also associated with forgetfulness, in that details of an event can be forgotten without easy recall (Crook et al., 1986). Some have also suggested that a diagnosis of MCI can reflect a state of uncertainty in the medical clinician regarding diagnostic classification of symptoms (i.e., dementia or not dementia) rather than an actual clinical syndrome in the patient (Heather Bornfeld, personal communication, January 28, 2009). Controversy exists currently in the field of neurology regarding understandings of dementia diagnoses. Some experts question the definition of MCI and feel that the focus of research and diagnoses should be on the detection of early Alzheimer’s dementia (AD) as well as early treatment (Allegri, Glaser, Taragano, & Buschke, 2008). One reason for this is that recent data (described later) suggest that AD is more common in people with heart disease and heart disease risk factors. The reason why this is important is that earlier views associated only vascular dementia and risk factors of heart disease. The current research raises questions regarding what is “vascular dementia,” in that other types of dementia may also have vascular causes.

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Whatever researchers and experts in the field decide to call it, heart disease risk factors cause changes in cognitive functioning in older adults. Many traditional heart disease risk factors include (as described in the now famous Framingham study) high levels of low-density lipoproteins (“bad cholesterol”), low levels of highdensity lipoproteins (“good cholesterol”), diabetes, gender (male), hypertension, smoking, and family history (Kannel, Dawber, Kagan, Revotskie, & Stokes, 1961). Women are at greater risk of heart disease following menopause (Flegal, Carroll, Ogden, & Johnson, 2002), and lack of exercise and obesity in both women and men comprise additional risk factors for heart disease. A recent review on the topic by Fillit, Nash, Rundek, and Zuckerman (2008) suggests that lifestyle factors associated with heart disease, including obesity, lack of physical activity, and possibly smoking are associated with cognitive impairment in the elderly, including AD. Uncontrolled hypertension is associated with mild cognitive deterioration in both older (65–80) and younger (18–40) adults (Vicario, 2008; Vicario, Martinez, Baretto, Diaz Casale, & Nicolosi, 2005). A further implication of the aforementioned research described by Vicario (2008) is that depression is on the spectrum of systemic disorders impacted by vascular disturbances stemming from hypertension. This partially explains the frequency of depression in older patients as well as its resistance to treatment, even when medication and psychotherapy are combined. That is not to say that depression cannot be successfully treated in the elderly with psychotherapy, but it is important to be aware of the difficulties that we may encounter and to realize that neurological factors make depression, as well as affective blunting more complex to treat. Since physiological factors contribute to mood, we can be realistic about the levels of improvement some patients may experience, particularly when associated with cognitive decline. Although this research is unsettling to think about, it is also helpful to be aware that AD, which was thought at one time to be a random illness, may not be as arbitrary as previously thought; however, like any disease, it can be expected that genetic factors also play a role. This underscores how important lifestyle behaviors are and should be grist for the psychotherapeutic mill. If heart disease risk factors are associated with both vascular and AD, we will all be confronted with the impact of cognitive changes in our patients. It is vital that mental health clinicians are aware of cognitive impairment as well as other aspects of aging patients, as we shall see next.

Normal Physical Changes Related to Aging Anyone who has treated older adults is familiar with the subjective complaints of aging. Patients complain that they forget things easily. They lament not remembering where they put their car keys or that they need to write things down, when they have never needed to do so before. Among the very elderly, people complain about how bright lighting has become, or how cold it seems in rooms that should be better heated. These examples illustrate a few of the physiological changes associated

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with aging. Interestingly, patients rarely seem educated about the fact that these complaints are normal and reflect physical aspects of growing older. In this section I highlight a few changes associated with aging that are often mentioned by older patients. Again, this is not an exhaustive review. For the interested reader, references at the end of the chapter provide more in-depth information. In terms of thinking, aging brains tend to work differently than younger brains. Older brains tend to hang on to acquired knowledge (thus explaining how some people even with moderate dementia can remember details of the past), but tend to have difficulty solving novel problems with reduced flexibility in thinking (Salthouse, 2007). This explains why patients complain that it “takes longer” to solve problems. When flexibility is reduced, the process of making decisions in novel situations takes longer. This influences how we talk with our patients. I notice that with my older patients it simply takes more time for them to register interpretations. A longer pause might be required in conversation, which is not due to resistance on the patient’s part, but to physiological slowing of cognitive processing. Moreover, I often find that in talking with older patients I need to literally slow down when talking with them. Although with some younger and more manically inclined patients, I might incorporate a number of themes into an interpretation, with older adults, I find it best if I pick one main theme to focus on. For example, the other day I was talking with a 98-year-old woman who does not have any cognitive problems, considering her age. We were talking about her feelings related to one of her caretakers who is known to be somewhat gruff and irritable with patients in her assisted living facility. I made a comment which underscored the reality of the situation but that also reflected her ongoing difficulty and awareness of her having to be dependent on others for aspects of her daily care. She paused and seemed to get “lost,” and could only focus on the first part of my remark, but not what followed. I did not see her focus as a resistance to my statement about her concerns involving dependency. In fact, she is quite aware of and familiar with her issues of being dependent, as they have been a focus of her therapy for some time. Rather, I said too much and spoke too quickly for her to register what I was saying. Looking back, I should have taken one facet of my comment and remark on it alone, not both. Older adults simply need more time, with fewer words, to register what is being said to them. I find (often with pleasure) that there is a slower pace to sessions with older adults. The pressure often experienced with younger people is simply not present. Although it seems ironic that older adults may feel less pressured regarding moving quickly in therapy (as they do not have as much time for treatment as younger people do), I think this is not only due to neurological slowing in old age, but also the refreshing realization among some older adults that things need to take more time. As I will describe later, older adults do many things slower than younger people and for those who have been able to integrate this fact, simply adapt to a slower pace of life. This is one of the many ways that wisdom in our older patients can be viewed. They have lived a long life and paradoxically do not feel pressed for time. Although I have described the detriments of manic defenses when people cannot relinquish them, for some people who have felt pressured by manic energy, the “excuse” to slow down because of an aging body can provide the first permission in life to take things at a slower pace. Such

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people often have accepted the fact that things in life take more time in the later years. Another major change in the physical functioning of older adults is related to mobility. Moving around becomes difficult and painful. I have observed many elderly patients watch helplessly as the phone rings on the other side of the room, knowing that they cannot get up to answer it in time. As we all are aware of, the risk of falling increases with age; some elderly people become especially anxious about falling, but this anxiety renders them less able to prevent a fall (Whitbourne, 2001). The issue of falling is often a major focus of clinical attention. Older patients who have fallen often report this at the beginning of a session. There is often a great deal of shame and embarrassment associated with falling and needing help from others. For people who live alone and fall, they may wait long periods of time before receiving help; these events can have traumatic physical and psychological consequences. For example, when doing acute hospital work, I saw a number of elderly people who fell in their homes and waited, sometimes for days, before someone was able to get them to the hospital. These individuals had complications such as dehydration or even kidney failure due to being left alone for extended periods of time without being able to move. These experiences left the patients terrified of ever falling again, but they were also confronted with their physical limitations and their need for help. These concerns about dependency, as well as the trauma of being left alone for hours or days at a time were often the focus of clinical attention. Such patients often needed help with dealing with the terrifying emotions that these incidents caused. In attempting to understand how older people react to changes related to aging, some authors suggest that it is changes associated with vision and hearing which cause more difficulties than impairments with mobility (Whitbourne, 2007). As adults age, visual acuity decreases dramatically. Increasing lighting helps, but older adults are sensitive to glare from bright light (Whitbourne, 2005). Many elderly people wear sunglasses to help with glare. Vision changes in older adults are commonly articulated as being especially frightening. Common diseases such as cataracts and macular degeneration alter vision. Treatment for the former condition can involve laser surgery, and many of my patients have had extreme anxiety before these procedures. Regarding quality of life, many patients comment on difficulties with reading, more often in patients who are avid readers. As I visit a number of nursing homes it has been surprising to me how few of these facilities have large-print reading material for patients. Additionally, many people I talk to who are not in long-term care facilities are not aware of large-print materials or the option of digital reading and auditory materials. Suggesting these options is a simple way to impact quality of life and develop rapport with our elderly patients. However, this kind of concrete intervention should be made mindfully, as for some patients acknowledging that they need other sources of reading material, can be met with a deep sense of shame regarding alterations in vision. Problems with the ear create not only compromise hearing but affect balance as well (Aldwin & Gilmer, 2004). Hearing impairment makes talking with patients difficult, as we often need to speak louder. However, not all elderly adults have hearing deficiencies, and some who have relatively good hearing complain that because they

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are old, people assume they cannot hear very well. This recurring situation has led me to asking my patients when I greet them if they can hear me at the level I am speaking at or if I should talk louder or softer. This approach acknowledges that not all older people are hard of hearing, but also allows these patients to determine the volume at which I speak, allowing them more control. Additionally, hearing problems in the elderly do not just affect volume, but in the ability to discriminate sounds, especially in areas in which there is background noise. Patients often describe how they cannot dine in a loud restaurant any longer and be able to hear the conversations they themselves are a part of. Falling is another complication of ear problems in older adults, due to balance being affected and raises the issue of falling in our offices, which is not necessarily uncommon. For example, a healthy 79-year-old woman who was a patient of mine recently fell getting out of a waiting room chair. This woman uses a cane for support, but simply lost her balance when attempting to stand up. She needed my help in getting up from the floor, as she could not do this on her own. She was incredibly embarrassed about this situation and my touching her to help her get up was a departure from the normal psychotherapeutic situation. This was her focus of attention in her therapy for a number of sessions, specifically the issue of needing help, the embarrassment of needing me to help her in such a fundamental way, as well as her intense fear of falling again. This woman lived independently, and so falling while alone was something she could express being especially fearful of. Moreover, needing me to help her get up was especially humiliating since she tried to present herself to me as a capable woman who did not need help from others. Clinically, the fall, a concrete occurrence which happened in “real time” for both of us to experience, allowed us a more direct way to discuss this woman’s concerns about needing others and her general fears of growing older and eventually needing more help. Another common and embarrassing issue in older adults is that of incontinence. Urinary incontinence is very prevalent with older people and affects over 30% of those over age 60 and more than 50% of people living in nursing homes (Diokno, Brock, Herzog, & Bromberg, 1990). Fecal incontinence is much less common, though this can be a complication from colon or prostate surgeries. Although it sometimes takes a great deal of time for patients to discuss incontinence, this issue causes a great deal of shame and embarrassment, even in people who are moderately demented. Many of my patients express their dismay of needing a caretaker to help them in using the bathroom (e.g., people who have had strokes cannot wipe themselves alone) or to empty their bedpans. Another issue involves those who do not have incontinence problems, but because of mobility problems, need help getting out of bed to get to the bathroom. In nursing homes, a patient may ring the call light in order to get a staff person to take them to the bathroom. If someone does not come to help them, they are then left to eliminate in their bed. Many patients I see in nursing homes have spoke of this frustrating dilemma. Understandably, it leads to a great deal of anger, shame, and embarrassment. Again, this underscores the need for us to be able to help our patients deal with issues of increased dependency, especially when they are institutionalized and their caretakers may or may not be available to meet their needs when required.

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Psychotherapy with Cognitively Impaired Adults Although some authors have described psychotherapeutic work with older adults from a psychodynamic perspective (e.g., Muslin, 1992; Nordhus, Nielsen, & Kvale, 2007), literature pertaining to working with older adults who have memory impairment and dementia is lacking. However, particularly in Europe, research on working with both individuals and groups of older adults with dementia is growing, especially related to working with mild to moderately impaired people (e.g., Cheston, Jones, & Gilliard, 2003; Sinason, 1992). Though the most frequent intervention for working with people with dementia has been described in group psychotherapeutic work (Watkins, Cheston, Jones, & Gilliard, 2006), there is exciting research in the field of psychodynamic theory on brain impairment as well as dementia, and its applications to individual work. First, a rare volume has been dedicated to both dementia and depression in the elderly from a psychodynamic perspective (Davenhill, 2007). These European authors address the importance of traditional psychoanalytic concepts such as transference and countertransference, and more contemporary concepts such as containment in their work with depressed and demented older adults. Second, the field of neuropsychoanalysis attempts to bridge psychoanalytic theory and current neuropsychological research. A particularly fascinating aspect of this research involves the presence of emotional relatedness, even in cases of severe brain injury. For example, a recent article discusses how a man with amnesia had an emotional memory as well as a transference reaction in his psychotherapeutic relationship (Turnbull, Zois, Kaplan-Solms, & Solms, 2006). Balfour (2006) has also addressed the importance of the unconscious in dementia. Of special interest in Balfour’s work is his finding (consistent with my own) that many older adults with dementia are aware of their impairment. Though some authors have described this insight occurring only in mild dementia, a number of patients I have seen have exhibited moments of insight, even those who are moderately to severely impaired; this has also been observed by family members of patients with more advanced dementia. Although memory impairment that occurs in dementia might render many things unavailable for new learning, I think that the pathways of emotional learning and emotional connections remain in stronger force, even in people who have more advanced dementias. For example, A severely demented woman who I had not seen in several weeks wheeled her wheelchair in to a room while I was talking with another patient. I have known this woman for years, as she was a weekly psychotherapy patient before a hip fracture and cognitive decline rendered her too cognitively impaired to benefit from weekly psychotherapy. When she interrupted the session, I greeted her and she said, “Hello, I have been meaning to see you.” I then told her I would be delighted to talk with her but that I was talking with someone else, and perhaps she could wait for me. She then left the room, but was waiting for me when I finished with the patient I was with. When we spoke, she asked me how I was, and I told her I had been fine, though had been away and so had not been around. She said, “Yes, I noticed that.” She paused and looked at me. I asked her how she had been and she said, “Well you know, it has been hard.” She then paused again, and I asked her if she knew or could tell me how it has been hard. She said, “I don’t know, but I see that you are well and it is good to see you. I imagine you were away in a trip to a faraway place or something.” “Yes, I was,” I told her. “And I imagine without seeing me around, it must have been a strange interruption.”

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She replied, “Yes! Things are not the way they often are. I um, I don’t think people know what to do.”

This was a striking conversation from the standpoint that this woman has severe dementia with moderate to severe language difficulties. Yet, she remembered me, remembered that I was important to her. She later asked, “I know you are a doctor. What is your name again?” She could not remember my name or even that I was a psychologist, but rather that I was some important person she wanted to see. Perhaps even relating more to the power of emotional memory, she remembered that I took a lot of vacations and traveled to faraway places (something I often disclose to my nursing home patients if they ask). Given her cognitive impairments, it was remarkable that she could retain this fact about me. Many people who have a family member tell similar stories. These patients may not remember what they had for breakfast, or who helped them get out of bed in the morning, but they do have transient memories of people who are important to them interpersonally. This is not to say that severely demented patients can benefit from psychotherapy in the way that we are used to. As a rule (in part informed by insurance regulations and also my own individual ethical guidelines), I do not provide weekly psychotherapy for patients who have severe dementia. This decision is not merely a pandering to fears of the omnipotence of insurance companies who feel that they can determine the scope of my work; rather, this is based on the fact that patients with severe dementia simply do not require as much interaction. Although the patient illustrated earlier clearly seeks me out (and she only does so about once a month) some people with severe dementia are too detached to benefit from therapy. In the absence of behavioral problems or medication concerns, I often terminate treatment with more severely impaired patients. From what I understand in the state where I practice (California), this approach is in accordance with insurance guidelines for treatment of older and cognitively impaired adults. However, a large number of patients who have mild to moderate dementia can benefit from more active help. As a field, continued research may need to take place in order to justify our work with patients who have more than mild dementia. My experience has demonstrated that many patients benefit from the affective regulation and soothing that long-term psychotherapeutic relationships can provide. Memory impairment, whether due to normal changes in aging or to dementia, is often a focus of clinical attention. Patients often describe their thoughts about memory loss. For example, a patient recently said to me: “I can remember my army registration number and I can remember my social security number. But I can’t remember my own damn phone number. Can you believe that?”

Many older adults feel ashamed and frightened about not being able to remember things. We can address these feelings by allowing our patients to talk about them. Sometimes it is also helpful to educate our older patients about why they may be able to remember information stored in long-term memory (such as an army registration number), but newer information (such as a recent telephone number) may not be stored as successfully in memory.

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It is also common that older adults have trouble acknowledging their memory problems. Such people often rely on over learned information as well as good social skills to get by, even when they may be demented. It can be extremely difficult for these patients to talk about memory problems, though over time and with therapeutic support, it gets easier. Additionally, although some authors have reported that denial, lack of awareness, or anosognosia is a symptom of dementia, others have pointed out that that denial is not necessarily a part of dementing illnesses (Balfour, 2007). Previous chapters in this volume have examined the ways that this kind of denial can be dealt with. In my experience, however, a large number of mildly to moderately impaired adults are painfully (even if only episodically) aware of memory impairment. These patients may initially deny that they are aware of memory problems, but in the context of a safe therapeutic relationship they can begin to discuss their feelings about this issue. Consider the following case example: Eli was an 85 year-old man who was seen for therapy following the death of his wife, who had a long battle with dementia. I met Eli and his wife several years ago when her dementia had begun to compromise her functioning. I saw the couple in their room at an independent living facility. Eli was resistant to treatment then, claiming that his wife was fine, though when I was in their apartment I noticed that (at Eli’s urging) they started drinking gin around 11:00 in the morning. At the time, Eli felt that neither he nor his wife would benefit from seeing me. Independent evaluations of his wife led to her being admitted to a skilled nursing facility due to advancing dementia. After his wife died about a year later, Eli was advised to see me again by his primary care physician, so I went to see Eli still in his apartment. He said that he was doing fine, but that he had no memory of having met me before. As is often the case for people such as Eli, I did not give him a formal mental status examination during our first meeting, as I was concerned that he would find it too intrusive and that he would be unwilling to see me again. This proved to be a good decision. In subsequent sessions, Eli told me he had been worried about his memory impairment, that he could not remember the names of friends in the facility where he lived, that he could not even remember the names of his family members who he had recently seen. Eli asked me, “Have you ever had the experience of going into a room and not knowing what you had gone in there for?” As he continued to stare at me, I realized this was not a rhetorical question. “I responded, No, I do not.” He said, “Well you will. It is not pretty.”

Eli was obviously revealing the intense depths of shame and embarrassment he felt in disclosing the impact of his memory impairment. By telling me that I too would experience the same fate as he had, he was attempting to level the playing field. If I were to undergo the same fate as Eli, then perhaps he could talk with me about his experience. Eli had suspected for some time that his memory impairment might signal dementia, though when I asked him directly if he had worried he might end up in a similar situation as his wife, he adamantly denied it. Eli’s situation is illustrative of someone who is both aware and unaware of memory impairment. His ability to talk with me about his deficits reflects a desire to communicate his worries to me. By telling me that I would experience the same thing he has been through, as well as his denial of worrying that he would end up as impaired as his wife, were both ways to reinforce the part of him that had to deny, but externalize these fears. These dynamics are common in adults who are experiencing cognitive changes. The fear and the terror associated with “losing one’s mind” are too much to bear thinking about. Therapy helped Eli realize that although his memory had faltered,

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that did not mean he would become incapacitated; however, the possibility that he would become as deteriorated as his wife was also a reality. It was important for Eli to recognize that since his memory had been faltering, he needed to get whatever medical help he could to prevent further deterioration. He eventually told his doctor about his memory impairment and took medication to help slow the progression of memory loss. Doing this, however, meant that Eli could recognize come to terms with the reality, that in fact, he could become demented. It was this awareness that led him to take steps to take better care of himself and to do what he could to prevent further memory problems and the onset of dementia. Despite the fact that we can treat patients with dementia from a psychodynamic perspective well into moderate stages of illness, there are a number of considerations to mention as many of our patients with histories of heart disease, which are risk factors for dementia, can alter the way patients present to us. I mention this because although it is tempting to attribute psychological mechanisms to some affective behaviors, it is often the case that patient presentations have a neurological basis. Though a neurological basis to behavior does not mean that psychotherapy cannot have an impact, it is also crucial to recognize the role that physiology plays in some patients who are older and at risk for cognitive changes due to vascular disease. First, many older adults experience a change in response time and appear to have slower emotional responses. As described earlier, the majority of these patients are simply trying to register what has been said to them and take longer to digest material that we might present in our interpretations. Second, it is also the case that some patients might appear affectively blunted or apathetic as the result of cognitive impairment. It is easy to attribute affective blunting or apathy to depression, yet the appearance of being detached or withdrawn may be due to symptoms of cognitive decline and AD (Benoit, Clairet, Koulibaly, Darcourt, & Robert, 2004). Another common issue is that of executive functioning problems or frontal lobe impairment in those who have dementia. Such people have difficulties with planning, organization, and awareness of impairment and may be prone to acting out or verbal behaviors, which may have previously been censored when the patient was well (Davis & Tremont, 2007). Indeed, some patients with dementia are prone to behavioral disinhibition, which make them more prone to acting out, which may previously have been expressed in more subtle ways. For example, a patient in a long-term care facility with dementia recently responded to his primary care physician asking, “Can I do anything else for you?” by saying, “Yes, you can get me a young boy.” Since this patient was known to masturbate frequently and in public, we had questions about his ability to censor his thoughts. Yet, the patient’s experience of the question reflected an honest response. As he was someone who frequently dated younger men, and had brief sexual encounters with young men, often, to reduce anxiety, his answer to the question was truthful, though not filtered by the normal social constraints which might preclude him asking to see a young man for sex (not to mention that such a request was inappropriate in that his primary care physician could not grant such a request!). Such behaviors are not uncommon among patients who have frontal lobe impairment due to dementia. They are unable to censor thoughts which previously may have been suppressed. In some ways these

References

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behaviors make such patients more amenable to psychotherapy since they are quite willing to talk about what is on their mind! On the other hand, we can be helpful to these patients by reminding them that their comments may potentially offend others in their environment. In this last case example, when I pointed out that his comments made some of the staff uncomfortable, this man was able to curtail these discussions and did not require medication to help him with his “acting out.” I am so aware of neurological difficulties in older patients that in order to diagnose depression in my patients, I always make sure the criteria for depression are met through cognitive symptoms of depression such as feelings of guilt, worthlessness, hopelessness, anxious rumination, irritability, suicidality, and so on. With this approach, some of the potentially confusing variables of neurological impairment (as well as the neurovegetative signs) of dementia do not impact my diagnosis.

Conclusion Being aware of cognitive impairment helps us to be more sympathetic and sensitive to the cognitive sequelae of dementia and vascular illnesses. Although research has not caught up with clinical practice in terms of guidelines for working with dementia patients, my clinical experience suggests that this work can be useful, even once a week for people who have mild to moderate impairments. In those with severe impairments, I tend to see them once a month. The fact of the matter is that many people with dementia are transiently aware of their impairments and that for some, despite profound memory failure, they retain the ability to develop new emotional relationships and meaning. This neurological pathway, which allows us to connect with older patients, even those with severe impairments, suggests that our work with these individuals can make a difference. Although behavioral and medication treatment is sometimes necessary, a psychodynamic approach, which emphasizes the profound “blow” of dependency as well as acknowledging the impact of shame, is tremendously helpful to many older adults with cognitive impairments. An appreciation of the actual physiological and neurological changes in aging and dementia, however, allows for a more informed approach. The very elderly and cognitively impaired patients who we treat need skillful clinicians who are knowledgeable about the mind and the body, and how the two interact with illness in later life.

References Aldwin, C. M., & Gilmer, D. F. (2004). Health, illness, and optimal aging: Biological and psychosocial perspectives. Thousand Oaks, CA: Sage. Allegri, R. F., Glaser, F. B., Taragano, F. E., & Buschke, H. (2008). Mild cognitive impairment, believe it or not? International Review of Psychiatry, 20(4), 357–363. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

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Balfour, A. (2006). Thinking about the experience of dementia: The importance of the unconscious. Journal of Social Work Practice, 20(3), 329–346. Balfour, A. (2007). Facts, phenomenology, and psychoanalytic contributions to dementia care. In R. Davenhill (Ed.), Looking into later life: A psychoanalytic approach to depression and dementia in old age (pp. 222–247). London: Karnac. Benoit, M., Clairet, S., Koulibaly, P. M., Darcourt, J., & Robert, P. H. (2004). Brain perfusion correlates of the apathy inventory dimensions of Alzheimer’s disease. International Journal of Geriatric Psychiatry, 19(9), 864–869. Cheston, R., Jones, K., & Gilliard, J. (2003). Group psychotherapy and people with dementia. Aging and Mental Health, 7(6), 452–461. Crook, T., Bartus, R. T., Ferris, S. H., Whitehouse, P., Cohen, G. D., & Gershon, S. (1986). Age associated memory impairment: Proposed diagnostic criteria and measures of clinical change. Report of a National Institute of Mental Health work group. Developmental Neuropsychology, 2, 261–276. Davenhill, R. (2007). Looking into later life: A psychoanalytic approach to depression and dementia in old age. London: Karnac. Davis, J. D., & Tremont, G. (2007). Impact of frontal systems behavioral functioning in dementia on caregiver burden. Journal of Neuropsychiatry and Clinical Neuroscience, 19, 43–49. Diokno, A. C., Brock, B. M., Herzog, A. R., & Bromberg, J. (1990). Medical correlates of urinary incontinence in the elderly. Urology, 36, 129–138. Fillit, H., Nash, D. T., Rundek, T., & Zuckerman, A. (2008). Cardiovascular risk factors and dementia. The American Journal of Geriatric Pharmacology, 6(2), 100–118. Retrieved January 6, 2009, from doi:10.1016/j.amjopharm.2008.06.004. Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and trends in obesity among U.S. adults, 1999–2000. Journal of the American Medical Association, 288, 1723–1727. Kannel, W. B., Dawber, T. R., Kagan, A., Revotskie, N., & Stokes, J. (1961). Factors of risk in the development of coronary heart disease: Six year follow-up experience. The Framingham Study. Annals of Internal Medicine, 55, 33–50. Muslin, H. L. (1992). The psychotherapy of the elderly self. New York: Brunner/Mazel. Nordhus, I. H., Nielsen, G. H., & Kvale, G. (2007). Psychotherapy with older adults. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp. 289–311). Washington, DC: American Psychological Association. Rosenberg, P. B., & Lyketsos, C. (2008). Mild cognitive impairment: Searching for the prodome of Alzheimer’s disease. World Psychiatry, 7(2), 72–78. Salthouse, T. A. (2007). Cognitive and information-processing perspectives on aging. Psychotherapy with older adults. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp. 49–59). Washington, DC: American Psychological Association. Sinason, V. (1992). Mental handicap and the human condition. London: Free Association. Turnbull, O. H., Zois, E., Kaplan-Solms, K., & Solms, M. (2006). The developing transference in amnesia: Changes in interpersonal relationship, despite profound memory loss. Neuro-psychoanalysis, 8(2), 199–204. Vicario, A. (2008, July). Hypertension, memory and frontal lobe disability. Paper presented at The International Neuropsychological Society, Sociedad de Neuropsicologia de Argentina, Symposium 2: Cognitive Disorders in Vascular Patients: A Multidisciplinary Approach, Buenos Aires, Argentina. Vicario, A., Martinez, C. D., Baretto, D., Diaz Casale, A., & Nicolosi, L. (2005). Hypertension and cognitive function: Impact on executive function. Journal of Clinical Hypertension, 7(10), 598–604. Watkins, R., Cheston, R., Jones, K., & Gilliard, J. (2006). “Coming out” with Alzheimer’s disease: Changes in awareness during a psychotherapy group for people with dementia. Aging and Mental Health, 10(2), 166–176. Werner, P., & Korczyn, A. (2008). Mild cognitive impairment: Conceptual assessment. Clinical Interventions in Aging, 3(3), 413–420.

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Whitbourne, S. K. (2001). Physiological aspects of aging: Relation to identity and clinical implications. In B. Edelstein (Ed.), Clinical geropsychology (pp. 1–24). Oxford: Elsevier Science. Whitbourne, S. K. (Ed.). (2005). Adult development and aging: Biopsychosocial perspectives. Hoboken, NJ: Wiley. Whitbourne, S. K. (2007). Physical changes in the aging individual: Clinical implications. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp. 79–108). Washington, DC: American Psychological Association.

Chapter 8

What We Know and What We Don’t: The Influence of Psychological Factors on Medical Illness

Science is no illusion. But it would be an illusion to suppose that we could not get anywhere else what it cannot give us. Sigmund Freud

Early psychoanalytic researchers attempted, with varying degrees of success, to prove that psychological conflicts are complicit in medical illness. Ironically, current medical research indicates that psychological issues do, in fact, play a role in the development or exacerbation of illness. The relationship between psychology and illness exists not because of the nature or symbolism of neurotic conflicts per se, though it is certainly possible that someone with a number of unconscious conflicts might be more vulnerable to the psychological states that are linked with disease. Current research suggests that it is actual physiological consequences of psychological disorders that explain the findings that some emotional factors are associated with disease. Although many questions remain about these associations, there are at least two pathways thought to partially explain the influence of emotional functioning on the body. The first is that certain psychological disorders and personality traits affect the likelihood of engaging in high-risk health behaviors. Second, certain psychological states, when they persist over time, cause physical changes that increase the risk of disease. This research has uncovered additional risk factors for illness and many of these psychological factors are now understood to be additional independent risk factors for disease. For example, in the case of depression, we know that it is a risk factor for heart disease, even when traditional factors such as smoking and cholesterol levels are controlled. The ability of depression to predict heart disease often causes a great deal of anxiety in people, since depressed mood is a very common experience and major depression is a common diagnosis. However, it is important to remember that depression is one of many psychological, biological, and behavioral risk factors for heart disease. Not every depressed person develops heart disease and multiple risk factors often need to be present in order to develop an illness. Additionally, as we think about the research, it is important to do so cautiously, as it can be tempting to make one-to-one correlations between psychological states and illness that may not,


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in fact, be valid. In the case of depression and heart disease, it might be easy for a mental health clinician to speculate that depression is symbolic of a “broken heart,” which might mirror itself as heart disease. As we saw in Chapter 1, cause-and-effect relationships are oversimplified and do not fully appreciate the impact of physiology, genetic predispositions, and health behaviors. It makes sense on some level that as psychological clinicians, we would wish that psychological factors carry more weight in their responsibility for disease: If psychology were solely responsible for illness, then there may be hope that with enough psychological treatment illness can be cured. Such generalizations are unfortunately not true. Though it is the case that some symptoms of medical disorders can improve through addressing psychological and behavioral/lifestyle issues, it is important to avoid an omnipotent trap in which we believe that we can control all aspects of our bodies. This can be a disservice to both patients and clinicians, as there are many things people can do psychologically and behaviorally to prevent illness, but the notion that illness is completely influenced by psychology neglects important biological contributions and factors that are beyond our control. In other words, it is both the mind and the body, and the interaction of the two that contribute to illness. I will highlight relevant literature that describes psychological influences on illness. It is assumed that this research will be familiar to some readers, as much of the findings from recent studies have been making their way into the popular press. Nevertheless it is important to review some of the literature because while recent medical findings are illuminating and fascinating, such studies raise many more questions than answers. Knowing what the research says and does not say about psychological factors and illness keeps us from having to rely on intuition when working with our patients. There are decades of research on psychological factors and illness; I will highlight four areas of research. The first is heart disease, which has a large number of studies to date that implicate a number of psychological factors as independent risk factors for the disease. Next, I will discuss osteoporosis, which as the population ages will become an increasing health concern. Third, I will discuss the literature on cancer. Cancer has been extensively studied and many researchers suspect that there is a connection between psychological issues and the development and outcome of various forms of cancer. Fourth, I will present research on child abuse and its relationship to the development of adult medical illness. Since my focus here is on psychological disorders, personality traits, and illness, there are a number of areas of research that will not be discussed. These include the majority of research on coping and illness (which includes factors such as optimism, benefit finding, religious beliefs), and racial and socioeconomic variables and illness. Although coping variables have been shown to influence health and medical outcomes, coping factors have not been found to independently predict disease. Racial and socioeconomic factors affect illness outcomes in a variety of ways, but this vast body of research is beyond the scope of this chapter. A more complete review of the literature on these and other psychological factors and illness is available in other publications (e.g., Greenberg, 2007).

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Heart Disease Heart disease is the number one cause of death for both men and women in the United States and thus, a major focus of medical and psychological research. Obviously, behavioral factors are implicated in the risk of the disease and include activity level, smoking, and dietary factors, as well as compliance with medications designed to lower cholesterol and blood pressure. However, the influence of psychological and personality factors has been of interest to physicians for a number of years. The concept of type A personality (Friedman & Rosenman, 1972) became a popular way of conceptualizing heart disease in men. Impatience, aggression, and competitiveness in achievement-oriented men were thought to contribute to the development of the disease. As it turns out, some aspects of type A behavior and personality are more associated with heart disease than others. Before I address these personality characteristics and their links to heart disease, I will describe the most prominent and repeated findings in the literature, the links between depression and anxiety and heart disease. Depression is a risk factor for the development of heart disease, and depressed patients who already have heart disease have an increased risk of morbidity and mortality. Some of the early research in this field initially found that depression predicted a subsequent heart attack and increased mortality in persons who had already had a heart attack (Frasure-Smith, Lesperance, & Talajic, 1993). Since this 1993 study, similar findings have emerged, including that the risk of a first heart attack in individuals who are depressed (Greenberg, 1998; Pratt et al., 1996). Depression predicts poorer survival in patients who have coronary artery disease, a form of heart disease that is also a risk factor for heart attacks, and congestive heart failure, a form of heart disease which results in increased fluid to the lungs and impairs breathing (Barefoot et al., 2000; Jiang et al., 2001). Although some of the earlier research in this area did not include women, more recent studies have found that depression is a risk factor for the development of heart disease in women as well (Rutledge et al., 2006). While many studies have found links between moderate and severe depression and heart disease, it has also been found that even minimal symptoms of depression (as measured by a Beck Depression Inventory Scale of 10 points or more) are predictive of worse outcomes for those with heart disease (Bush et al., 2001). Anxiety is another risk factor for the development of heart disease, and emerging research in this area suggests that anxiety may be an equally powerful predictor of heart disease as depression. Although depressed persons often experience anxiety, particular types of anxiety have been found to be associated with heart disease than others. Men and women who have panic disorder and panic disorder symptoms (often referred to a “phobic anxiety” in the medical literature) are more likely to have coronary artery disease as well as increased likelihood of death due to sudden cardiac arrest (Kubzansky, Kawachi, Weiss, & Sparrow, 1998; Kawachi et al., 1994; Albert, Chae, Rexrode, Manson, & Kawachi, 2005). A recent study found that anxiety, specifically the diagnosis of generalized anxiety disorder, is a predictor of major cardiac events (such as a heart attack) in persons with stable coronary artery disease (Frasure-Smith & Lespérance, 2008). Additionally, another recent study that used

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a variety of well-validated measures of anxiety found that in older men moderate anxiety is associated with a modest increase in heart attack risk and severe anxiety represents a more substantial risk (Shen et al., 2008). It appears as well that a diagnosis of PTSD is associated with early death from heart disease. A study of over 4,000 Vietnam veterans found that those who met diagnostic criteria for PTSD were twice as likely to die from heart disease as those without PTSD (Boscarino, 2008). Additionally, veterans with PTSD were more likely to have metabolic syndrome, which is a risk factor for heart disease and diabetes (Heppner et al., 2009). In addition to depression and anxiety, the personality traits of hostility and cynical mistrust are also predictive of heart disease. These are the traits that were part of the original conceptualization of type A personality. A number of studies indicate that persons who have high levels of these traits are at more risk of developing heart disease (Myrtek, 2001; Smith, Glaser, Ruiz, & Gallo, 2004). There is also evidence that a tendency to express anger is a potential trigger for a heart attack (Möller et al., 1999) and that those with heart disease, angry outbursts are associated with having a heart attack (Strike, Perkins-Porras, Whitehead, McEwan, & Steptoe, 2006). Additionally, even in young adults, individuals who were high in hostility and mistrust were more likely to develop coronary calcification, which is a precursor to coronary artery disease (Iribarren et al., 2000). Further, although the results need to be replicated, a recent study found that persons high in hostility were more likely to have reduced pulmonary function, which results in reduced airflow to the lungs (Jackson, Kubzansky, Cohen, Jacobs & Wright, 2007). The literature on psychological factors and heart disease is overwhelmingly clear: Depression, chronic and intense anxiety, and hostility are linked with the development and exacerbation of heart disease. It may also be clear to some that these factors are often overlapping and intercorrelated, especially in patients who have long-standing characterlogical issues. Depression and anger are related; depression can result when angry feelings get turned in on oneself; likewise anger can result as a defense against disorganizing feelings of loss and sadness. One study that looked at anger, depression, and hostility in men found that they are correlated and not surprisingly, men who were prone to intense feelings of anger as well as depression had increases in C3, which is a protein thought to be connected to the development of heart disease (Boyle, Jackson, & Suarez, 2007). As mental health clinicians, we are all aware of the protective aspect that relationships can have on the impact of psychological symptoms. Social support is protective against the development of depression, and social support is protective against the development of heart disease, but the quality of relationships does matter, especially those of persons closest to us. Marital cohesion is associated with lower systolic blood pressure (Tobe et al., 2007) and persons in poor marriages have an increased risk of periodontal disease, which is thought to increase risk of coronary artery disease (Kiecolt-Glaser & Newton, 2001; Amabile et al., 2008). A recent study found that adverse marital relationships were associated with an increase in heart disease, especially among men and women in lower socioeconomic groups (De Vogli, Chandola, & Marmot, 2007). In general, marriage is protective against heart disease, especially in men. Even in men who are anxious, marriage has been

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found to serve as a protective factor against heart attacks (Shen et al., 2008). Consistent with the research on the importance of relationships, social isolation is also associated with poorer medical outcomes in persons with heart disease. For example, social isolation independently predicts mortality in persons who have had a heart attack (Mookadam & Arthur, 2004). One final factor that deserves to be mentioned is that of stress. Many people assume that stress is a risk factor for heart disease as well as multiple forms of illness. Even the research literature is misleading in this regard, primarily because the concept of stress is poorly defined. In general terms, we could say that “stress” has an impact on the development or exacerbation of heart disease. However, the caveat to this is that when I refer to stress, I am largely referencing the data in existence on anxiety, depression, and heart disease. In other words, stress is very difficult to define and the research that exists on stress and heart disease often refers to anxious and depressed states. Of course, chronic stress (and, probably more importantly, difficulty coping with normal everyday aspects of a stress-filled life) results in the development of anxiety and depression. There is one kind of stress, however, that has been relatively well defined in the literature, which is referred to as “job strain.” This type of stress is typically characterized by high psychological demands and low decision-making capacity, and has been found in some studies to increase the risk of the development of heart disease (Aboa-Eboulé et al., 2007). Other studies have found that work stress is associated with an increased chance of a heart attack (Brotman, Golden & Wittstein, 2007). Using similar criteria regarding job strain, another study found that this doubled the risk of stroke in Japanese men after controlling for traditional risk factors (Tsutsumi, Kayaba, Kario, & Ishikawa, 2009). The previously mentioned psychological variables that contribute to heart disease have been replicated a number of times in both the medical and psychological literature, and little disagreement exists regarding the importance of psychological factors in the development and exacerbation of heart disease. However, the physiological and psychological mechanisms that are responsible for emotional factors and heart disease are not so clearly understood, though a number of factors have been suggested. One of the most straightforward ways to understand the impact of these psychological factors is that they impact health behaviors. For example, depressed persons with heart disease are less likely to adhere to treatment advice (Steptoe & Whitehead, 2005) and persons high on measures of hostility are more likely to smoke cigarettes than those who are less hostile (Allen, Markovitz, Jacobs, & Knox et al., 2001; Lapkus, Barefoot, Williams, & Siegler et al., 1994). Although these findings are important and certainly make sense to us who use psychodynamic theory, health behaviors do not fully explain the findings. Medical researchers are also investigating a number of possible physiological mechanisms to explain why psychological variables impact heart disease. Although the physical effects of psychological variables remain poorly understood, a number of physiological mechanisms are hypothesized to be involved. These include endothelial dysfunction/vasoconstriction, neuroendocrine effects, immune activation, inflammation, hypercoagulation, cardiac rhythm disturbances, and metabolic disturbances (Parissis et al., 2007). Given the many ways in which psychological states can affect

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the body, it will likely take time for researchers to find the physiological pathways that explain the relationship between psychological issues and heart disease.

Osteoporosis Osteoporosis causes increased fragility in bones, which in turn, increases fracture risk. Fractures among the elderly can have serious medical consequences and as such, prevention of osteoporosis is rapidly becoming a public health concern as the population ages. The role of psychological factors in affecting bone density may not seem intuitive, but research has found associations between depression and osteoporosis. Specifically, in perimenopausal women, depression is associated with an increased risk of osteoporosis (Jacka et al., 2005) In young women both depression and borderline personality disorder are risk factors for low bone mineral density, which is a precursor to osteoporosis (Eskandari et al., 2007; Kahl et al., 2005). Although a majority of research has looked at osteoporosis risk factors in women, depression as a risk factor for bone loss has been found in men as well (Cizza, Ravn, Chrousos, & Gold, 2001). Although depression is now considered an additional risk factor for osteoporosis (along with smoking cigarettes and low calcium intake) the reasons are unclear. It has been suggested that selective serotonin reuptake inhibitors (SSRIs) may be to blame, and research has found that that SSRI use was associated with bone loss in older women, compared with older women who were depressed and not using SSRIs (Diem et al., 2007). However, like much of the research on psychological factors and illness, there are many more questions than answers and the influence of SSRIs is suspect to some medical researchers (Schulte-Herbrüggen & Anghelescu, 2008). Many researchers speculate that like heart disease, depression causes physiological changes, which affects bone density.

Cancer Research on the influence of psychological factors and cancer has been of interest to physicians and patients alike for decades. Many people believe that there is a link between stress and cancer, and many mental health clinicians often suspect that depression, repressed emotions, and repressed hostility are linked with cancer. Cancer is a terrifying disease; the desire to find an influence of psychological factors on the disease is understandable, as then there would be hope that cancer could be prevented or alleviated through addressing these issues. In contrast to the data on heart disease, findings on psychological variables and the development of cancer have not yielded strong or even moderate associations, and much of the research is contradictory and suffers from poor methodology and a lack of randomized controlled trials. However, one source of motivation for continued research in this area is that patients with similar tumor presentations (in breast cancer, for example) can

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have very different outcomes, which can mean that more factors than just medical issues are determinate of outcome (Falagas et al., 2007). A problem with research on psychological factors in cancer, however, is that people with cancer may be more susceptible to anxiety and depression as a result of endocrine changes from the disease itself as well as the effects of chemotherapy, which makes psychological issues difficult to study. Despite problems with the research, there are weak associations between chronic depression and the development of cancer, especially in older persons (Penninx et al., 1998). Once someone already has cancer, there is slightly stronger evidence that depression may shorten survival time (Spiegel & Giese-Davis, 2003), though research in this area has been inconsistent. In terms of other coping measures (such as social support, minimization, and denial) there has, again, been inconsistent findings in the literature. Interestingly, a recent major study with head and neck cancer patients found that there was no conclusive relationship between emotional well-being and survival (Coyne et al., 2007).

Child Abuse As psychodynamic clinicians, we are obviously interested in developmental issues and family backgrounds that impacted our patients when they were children. Many of us see in our work that people who have histories of childhood maltreatment struggle with a variety of emotional and psychological difficulties. Not surprisingly, research has found that there is an increase in the prevalence of depression and anxiety disorders in those who have histories of abuse or neglect as children (Springer, Sheridan, Kuo, & Carnes, 2007). Given what we know about the risks of anxiety and depression, we could predict that individuals who have abusive histories might be more susceptible to health problems. And this is indeed the case. Childhood abuse (especially sexual abuse and overt neglect) predicts medically unexplained symptoms (Fiddler, Jackson, Kapur, Wells, & Creed, 2004). Although adults who experienced childhood maltreatment are more likely to have so-called psychosomatic disturbances, it is also the case that childhood abuse and neglect is associated with the development of “real” medical problems1. Felitti et al. (1998) found in a large sample of adults that adverse childhood experiences (which included physical, psychological, sexual abuse, violence in the home, a mentally ill or suicidal family 1

The problem of what are real illnesses vs. psychosomatic illnesses is extremely complicated. Medical science has historically had difficulty with dealing with patients who have physical symptoms without demonstrated illness patterns, which easily lead to diagnosis. The risk in describing illness as merely psychological or physical is that certain patient populations can be marginalized. For example, more recent research in patients with fibromyalgia indicates that autoimmune forces may be an influence in this disease (e.g., Staud, 2006). This group of patients (mostly women) has been subject to accusations that their illness is purely “psychosomatic,” because of a lack of research that explained their symptoms. An appreciation for a combined influence of both psychological and biological factors in disease would better serve patients, as illness is a complex interaction of biological factors and psychological influences.

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member, or someone in the household abusing substances) were associated with not only an increase in psychological problems, but also increased health risk behaviors and medical illness. The more adverse events respondents reported, the more likely they were to have medical problems that included heart disease, cancer, chronic bronchitis, chronic obstructive pulmonary disease, liver disease, and skeletal fractures. Regarding the relationship between increased incidence of liver disease and adverse childhood experiences, a follow-up publication to the Felitti et al. study found that high-risk behaviors (such as substance use, intravenous drug use, over 50 sexual partners and other high-risk sexual behaviors) were associated with an increase in liver disease, and that the more adverse childhood experiences reported the more risky behaviors were reported (Dong, Dube, Felitti, Giles, & Anda, 2003). While in the case of liver disease, risky behaviors explain how persons with experiences of childhood maltreatment become ill, it is less clear what explains the relationship between childhood difficulties and the increased incidence in heart disease in persons who report traumatic childhood experiences. In another follow-up study, it was found that health behaviors, depression, and anger were associated with the development of heart disease (Dong et al., 2004). However, these authors note that there are likely other pathways to explain the association between child maltreatment and heart disease that have not yet been described, and caution that depression, anger, and health behaviors do not tell the whole story. In support of this hypothesis, researchers at Yale University found that women who reported abuse or neglect as children had an almost ninefold increase in cardiovascular disease; however, depression did not explain the increased prevalence of heart disease in these women (Batten, Aslan, Maciejewski, & Mazure, 2004). Although the possibilities are numerous as to what might further explain the relationship of child abuse and heart disease, a recent study found that childhood maltreatment predicts adult multiorgan inflammation, which is thought to be connected to a variety of diseases, including heart disease (Danese, Pariante, Caspi, Taylor, & Poulton, 2007). Again, more research is needed to elucidate the meanings of these findings.

The Meaning of the Research on Psychological Factors and Medical Risk As is clear from the preceding discussion of the research, some aspects of what early psychoanalytic researchers claimed are valid. Psychology does impact health. The mechanisms to explain these associations, however, do not lie in what some researchers declared about neurotic conflicts. Rather, these findings partially indicate the influence of health behaviors, which includes increased nonadherence to treatment advice as well as increases in risky behaviors. For example, persons high in hostility are more likely to smoke cigarettes and persons who have been abused as children are more likely to abuse substances and engage in high-risk sexual behavior, both of which can contribute to a number of illnesses.

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However, health behaviors only partially explain the associations between psychology and illness, especially since even when factors such as smoking are accounted for in research studies on heart disease, for example, mood and personality factors still independently predict its development. Though at this point much is unknown about how physiological changes influence illness, there are a number of possible explanations that shed light on the above research findings. Depression may impact immune functioning (as might be hypothesized by the cancer research), and over time a weakened body might be more susceptible to disease. Chronic anxiety, essentially the “fight/flight” response, likely results in a number of physical changes as a result of the mobilization of stress hormones. Eventually these stress hormones may cause physical damage as neuroendocrine responses are designed (from an evolutionary standpoint) to be used in crisis situations. For someone who is chronically anxious, these hormones may affect the body in deleterious ways over a period of time. This seems to be one implication of the current research (and popular press coverage) on the impact of inflammation and is one hypothesis regarding the psychological links in heart disease. A similar situation might be present in individuals who have been abused or neglected as children, as the need to protect oneself vs. fleeing in stressful situations an ongoing conflict. For such people the fight/flight response is exaggerated and thus they act with excessive fear and or anger in situations where such responses seem irrational. We know as clinicians that these children do not often have the opportunity to flee from troubled families. Fighting and the development of anger and hostility is one option, and a spiral into helpless despair is another. When we see these people as adults, they are often troubled by varying aspects of the fight/flight spectrum; they struggle with worries about their aggression as well as states of terrifying, yet familiar aspects of helplessness. These clinical situations are well known to those of us who do long-term psychodynamic work with patients, and they sadly elucidate the real-life stories of the research I have addressed. Given the aging population of our culture, we will likely see more number of older adults in our clinical work, so we need to have an increased awareness of what physiological vulnerabilities our patients have, based on their psychological conflicts and personal histories. Yet, this situation raises the important question of what these physiological vulnerabilities mean when patients are in psychological treatment with us. In the case of depressed or anxious patients, do we tell them that their symptoms put them at risk for heart disease or other illnesses? It is hard to know what this would accomplish and also risks causing a depressed or anxious patient more harm. At this point, I am not aware of any research suggesting that certain interventions for treating depression or anxiety prevent the eventual onset of heart disease or other illness. We are left then to hold on to the uncertainty and ambiguity of the implications of current research. This, of course, is what we often do as psychodynamic clinicians. We accept ambiguity, we can tolerate not knowing and we encourage our patients to do the same. The research on psychology and illness raises a number of questions regarding how we think of our work. We have data to suggest that health behaviors are one pathway that explain how psychological issues influence illness, especially in

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patients with depression and some who have been mistreated as children. Though neutrality and abstinence were valued by traditional psychoanalytic clinicians, as I have argued throughout this volume, these areas might need to be re-evaluated in order to more effectively serve our patients. Do we really want to abstain from having an opinion when a patient tells us she is not taking her blood pressure medication? A more contemporary approach might be to aggressively question such a statement and to communicate concern regarding behavior that is potentially life threatening as well as trying to get to the cause (in an efficient way) of nonadherence to the medication treatment. Of course, thinking about the meaning of such a disclosure is important, but to take an active stance while such self-destructive issues get worked out has become a more common approach among psychodynamic clinicians. The implications of the research described in this chapter implore us to reconsider some aspects of our approach. A major challenge with patients who are older and medically ill is that of balancing acute needs in the context of personality factors and issues that require time to resolve.

Conclusion Psychodynamic theory teaches us how to hold two (or more) different ideas and not to leap to conclusion about their “truth.” The research described in this chapter requires us to do just that. We are aware that psychological factors play a role in the development or exacerbation of illness. This does not mean, however, that psychology alone causes illness. We need to hold both to the important role psychology and health behaviors play, as well as the role of biology, genetics, and environmental factors beyond our control (e.g., pesticides, problematic food sources, other environmental toxins, etc.) The reality is that there is much more to be learned about what causes many of the diseases that harm us. Additionally, there is no conclusive research at this time that helps us to understand what interventions might be most useful for patients who are at risk for illness based on psychological issues. However, as psychodynamic clinicians we are aware of the important aspects of attachment that occur in long-term therapies as these kinds of attachments may have beneficial and restorative effects. We have seen in the research that close interpersonal relationships can be protective against illness. This is one of many factors that justify the long-term work we do with patients. It seems important, however, that our work can incorporate a flexible technique in helping patients to work on their emotional issues while simultaneously addressing important aspects of health.

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Falagas, M. E., Zarkadoulia, E. A., N loannidou, E., Peppas, G., Christodoulou, C., & Rafaildis, P. I. (2007). The effect of psychological variables on breast cancer outcome: A systematic review. Breast Cancer Research, 9(4), R44. http://breast-cancer-research.com/content/9/4/R44. Accessed 10 Feb 2008. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of child abuse and household dysfunction to many leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245–258. Fiddler, M., Jackson, J., Kapur, N., Wells, A., & Creed, F. (2004). Childhood adversity and frequent medical consultations. General Hospital Psychiatry, 26(5), 367–377. Frasure-Smith, N., & Lespérance, F. (2008). Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Archives of General Psychiatry, 65(1), 62–71. Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). Depression following myocardial infarction: Impact on 6-month survival. Journal of the American Medical Association, 270, 1819–1824. Friedman, M., & Rosenman, R. H. (1972). Type A behavior and your heart. New York: Knopf. Glassman, A. H., & Shapiro, P. A. (1998). Depression and the course of coronary artery disease. American Journal of Psychiatry, 155, 4–11. Greenberg, T. M. (2007). The psychological impact of acute and chronic illness. New York: Springer. Heppner, P. F., Crawford, E. F., Haji, U. A., Afari, N., Hauger, R. L., Dashevsky, B. et al. (2009). The association of posttraumatic stress disorder and metabolic syndrome: A study of increased health risk in veterans. BMC Medicine, 7, 1. Iribarren, C., Sidney, S., Bild, D. E., Liu, K., Markovitz, J. H., Roseman, J. M., et al. (2000). Association of hostility with coronary artery calcification in young adults: The CARDIA study. Coronary artery risk development in young adults. Journal of the American Medical Association, 283(19), 2546–2551. Jacka, F. N., Pasco, J. A., Henry, M. J., Kotowicz, M. A., Dodd, S., Nicholson, G. C., et al. (2005). Depression and bone mineral density in a community sample of perimenopausal women: Geelong osteoporosis study. Menopause, 12(1), 88–91. Jackson, B., Kubzansky, L. D., Cohen, S., Jacobs, D. R., & Wright, R. W. (2007). Does harboring hostility hurt? Associations between hostility and pulmonary function in the coronary artery risk development in (young) adults (CARDIA) study. Health Psychology, 26(3), 333–340. Jiang, W., Alexander, J., Christopher, E., Kuchibhatla, M., Gaulden, L. H., Cuffe, M. S., et al. (2001). Relationship of depression to increased mortality and rehospitalization in patients with congestive heart failures. Archives of Internal Medicine, 161, 1849–1856. Kahl, K. G., Rudolf, S., Stoeckelhuber, B. M., Dibbelt, L., Gehl, H. B., Markof, K., et al. (2005). Bone mineral density, markers of bone turnover, and cytokines in young women with borderline personality disorder with and without comorbid major depressive disorder. American Journal of Psychiatry, 162(1), 168–174. Kawachi, I., Colditz, G. A., Ascherio, A., Rimm, E. D., Giovannucci, E., Stapfer, M. J., et al. (1994). Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation, 89(5), 1992–1997. Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472–503. Kubzansky, L. D., Kawachi, I., Weiss, S. T., & Sparrow, D. (1998). Anxiety and coronary heart disease: A synthesis of epidemiological, psychological, and experimental evidence. Annals of Behavioral Medicine, 20, 47–58. Lapkus, I. M., Barefoot, J. C., Williams, R. B., & Siegler, I. C. (1994). Personality measures as predictors of smoking initiation and cessation in the UNC alumni heart study. Health Psychology, 13(2), 149–155. Möller, J., Hallqvist, J., Diderichsen, F., Theorell, T., Reuterwall, C., & Ahlbam, A. (1999). Do episodes of anger trigger myocardial infarction? A case crossover analysis in the Stockholm heart epidemiology program (SHEEP). Psychosomatic Medicine, 61, 842–849.

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Mookadam, F., & Arthur, H. M. (2004). Social support and its relationship to morbidity and mortality after acute myocardial infarction: systematic overview. Archives of Internal Medicine, 164, 1514–1518. Myrtek, M. (2001). Meta-analysis of prospective studies on coronary heart disease, type A personality and hostility. International Journal of Cardiology, 79(2–3), 245–251. Parissis, J. T., Fountoulaki, K., Filippatos, G., Adamopoulos, S., Paraskevaidis, I., & Kremastinos, D. (2007). Depression in coronary artery disease: Novel pathophysiological mechanisms and therapeutic implications. International Journal of Cardiology, 116, 153–160. Penninx, B. W., Guralnik, J. M., Pahor, M., Ferucci, L., Carhan, J. R., Wallace, R. B., et al. (1998). Chronically depressed mood and cancer risk in older persons. Journal of the National Cancer Institute, 90(24), 1888–1893. Pratt, L. A., Ford, D. E., Crum, R. M., Armenian, H. K., Gallo, J. J., & Eaton, W. W. (1996). Depression, psychotropic medication, and risk of myocardial infarction. Circulation, 94, 3123–3129. Rutledge, T., Reis, S. E., Olson, M., Owens, J., Kelsey, S. E., Pepine, C. J., et al. (2006). Depression is associated with cardiac symptoms and hospitalization among women with suspected coronary heart disease: The NHLBI-sponsored WISE study. Psychosomatic Medicine, 68, 217–223. Schulte-Herbrüggen, O., & Anghelescu, I. (2008). Selective serotonin reuptake inhibitors and osteoporosis: Pathomechanism and clinical relevance to be established. Archives of Internal Medicine, 168(1), 110. Shen, B. J., Avivi, Y. E., Todaro, J. F., Spiro, A., Laurenceau, J. P., Ward, K. D., et al. (2008). Anxiety characteristics independently and prospectively predict myocardial infarction in men: The unique contribution of anxiety among psychologic factors. Journal of the American College of Cardiology, 51(2), 113–119. Smith, T. W., Glaser, K., Ruiz, J. M., & Gallo, L. C. (2004). Hostility, anger, aggressiveness, and coronary heart disease: an interpersonal perspective in personality, emotion, and health. Journal of Personality, 72(6), 1217–1270. Springer, K. W., Sheridan, J., Kuo, D., & Carnes, M. (2007). Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse and Neglect, 31, 517–530. Spiegel, D., & Giese-Davis, J. (2003). Depression and cancer: Mechanisms and disease progression. Biological Psychiatry, 54, 751–758. Steptoe, A., & Whitehead, D. L. (2005). Depression, stress, and coronary heart disease: The need for more complex models. Heart, 91, 419–420. Straud, R. (2006). Are patients with systemic lupus erthematosus at increased risk of fibromyalgia? Current Rheumatology Reports, 8(6), 430–436. Strike, P. C., Perkins-Porras, L., Whitehead, D. L., McEwan, J., & Steptoe, A. (2006). Triggering of acute coronary syndrome by physical exertion and anger: Clinical and sociodemographic characteristics. Heart, 92(8), 1035–1040. Tobe, S. W., Kiss, A., Sainsbury, S., Jeslin, M., Geerts, R., & Baker, B. (2007). The impact of job strain and marital cohesion on ambulatory blood pressure during 1 year: The double exposure study. American Journal of Hypertension, 20, 148–153. Tsutsumi, A., Kayaba, K., Kario, K., & Ishikawa, S. (2009). Prospective study of occupational stress and risk of stroke. Archives of Internal Medicine, 169(1), 56–61.

Chapter 9

Hope and Grief: The Introduction of an Emotional Language

Emotion: The human spirit experienced in the flesh. Jerry Tucker

Throughout this book, I have attempted to describe various aspects of emotional experience related to the process of aging and illness. Although the patients whose case histories I have discussed portray varied levels of psychological functioning, different personalities, character structures, and defenses, there is one major theme that is common to all of them: the difficulty in accessing an emotional language due to the concrete demands of bodily illness or concrete focus on the body. While I have described how ageism, and the fear of illness or death on the part of therapists may explain the hesitation of traditional psychoanalysts in addressing the needs of medically ill and older patients, the challenges that these patients bring to the therapeutic setting in talking about their internal and mental experiences create unique difficulties for working with this population. In this chapter, we will revisit the concept of alexithymia; I will suggest that this idea can be expanded and applied to our work as clinicians, but without the pejorative connotations that are often associated with the dilemma of lacking the right words to describe feelings, or the assumption that illness is psychosomatic. I have argued that traditional approaches are not useful for many medical and aging patients; I will also describe how we might understand aspects of the therapeutic encounter with this population. Finally, I will contextualize the hope and grief our patients face, with a focus on the resilience of the elderly and medical patients, as these individuals often want to learn ways they can expand their emotional landscape toward a more nuanced and developed internal dialog. The quest for meaning and insight in these patients implores us to continue to find ways to connect with and help this growing population.

Alexithymia: Adaptive Aspects of Psychic Detachment Alexithymia has historically been attributed to people who have physical complaints in the absence of demonstrable organic disease. There is no doubt that some people have more trouble than others describing affect and accessing their emotions. Only T. McClintock Greenberg, Psychodynamic Perspectives on Aging and Illness, c Springer Science+Business Media LLC 2009 DOI 10.1007/978-1-4419-0286-3 9,

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some of these individuals have psychosomatic complaints. A case can be made that the demands of organic illness pull attention away from the mind, as a bodily focus takes over. And since the arena of the body is concrete, such people present with concrete concerns, with less access to their minds. Such patients may seem initially hard to engage in the therapeutic process and may present as lacking symbolic capacity, but it is our job to introduce, explain – and I would add – model, how one can have an expanded relationship with their own mental life. Sifneos (1973) and Nemiah (1973) characterized alexithymia as occurring in individuals who lack an emotional language to describe internal mental experiences and states. The main qualities in those who are alexithymic include difficulties identifying and describing feelings, differentiating between emotional and physical sensations, and exhibiting a concrete and externally oriented cognitive style (Zackheim, 2007). Some authors have described alexithymia as defensive, in which denial, repression, and externalization operate, while others have focused on aspects of affective regulation as being primary (Glucksman, 2000). Joyce McDougall is perhaps the most well-known author within contemporary psychoanalysis to explain the ways people with psychosomatic disorders have a distanced relationship with their bodies. For example, she points out that people who are not aware of their emotions and cannot distinguish one emotion from another, typically have both alexithymia and character types which make them prone to addiction (McDougall, 1984). Regarding psychotherapy, such people have trouble making much progress, as they are in “fierce opposition to analyzing anything to do with their inner psychic reality” (p. 387). McDougall also describes the ways that early development and relationships with caretakers can predispose people to the kinds of physical problems she describes (McDougall, 1989). Though McDougall tends to focus on the psychological aspects of illness, even those which might be considered more organic in nature (e.g., McDougall, 1980), her work has led others to conclude that alexithymia is associated with a disorder of the self, in that the language of these patients often avoids awareness of the body. For example, a patient might refer to “the hands” and “the pain” as opposed to a more emotionally close relationship to the body, which might express “my hands” and “my pain” (Rickles, 1986, p. 215). The fact that alexithymic presentations have been relegated to illnesses that are “not real” should be challenged. First, since psychosomatic illnesses studied in the history of psychoanalysis are now known to have physiological correlates, the patients who were thought to be somaticizing their illnesses were in fact coping with real medical conditions. This suggests that people who are alexithymic can have all types of illnesses. In my experience, the kinds of emotionally distancing comments people make in relation to their physical suffering can be a consequence of severe life-threatening illness, suggesting that a kind of alexithymic dynamic might be a coping mechanism in those who are overwhelmed with emotions related to illness. The second point is that the term alexithymia encompasses those with illnesses who are sensitive to the psychological effects of stress. But the theory of alexithymia has suggested that these people are recruiting their illness as a defensive strategy. This is simply not true; as we saw in the previous chapter, many illnesses once thought

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to be independent of physiological factors are, in fact, impacted by psychological states. The mind is a part of the body, so psychological issues will naturally manifest there – through physiological mechanisms. This does not mean, as early researchers suggested, that people “make up” physical illnesses. Research clearly suggests a physiological consequence of certain prolonged emotional states. Additionally, even for people whose bodies are sensitive, or who have conditions especially thought to be exacerbated by psychological issues, illness is not necessarily the function of defensive psychological recruitment. Rather, people prone to physical problems under stress (backaches, headaches, hypertension, asthma, etc.) are experiencing real symptoms, and their bodies are more “stress and emotional sensitive” than others. In some cases I think this is simply due to physiological differences, though early development probably also contributes to this kind of sensitivity for physically vulnerable individuals. I am suggesting that relationships between mind and body are bidirectional. Although authors like McDougall tend to emphasize that the psyche affects soma, I think there is ample evidence that the body impacts the mind as powerfully as the mind affects the body, and that what may appear to be alexithymic may be an adaptable coping strategy, especially in persons who lack a temporary or chronic loss of sense of self. The use of the language, as noted earlier by Rickles, in which he comments on the presence of distancing psychological language in alexithymia, was common when I was seeing severely ill cancer patients and is thought to be a sign of adaptive dissociation. These people were so shocked and stunned by the behavior of their bodies that they would often distance themselves in a way to make their suffering more palatable. One example that comes to mind is the reaction to the side effect of mucositis, which is common in people undergoing high-dose chemotherapy or bone marrow transplants. This condition causes very painful sores in the mouth and throat, to such an extent that many people need potent narcotics to manage their pain. When I would talk with patients who had this symptom, many of them would remark that “the pain” (not “my pain”) was overwhelming. Such people seemed to be engaging in an adaptive defense in which they were trying to make the pain they were experiencing separate from their sense of self. I would argue that in these extreme situations, that these individuals could talk at all about pain was a visible demonstration of their ability to acknowledge and integrate the experience. When someone has a life-threatening disease and is undergoing painful treatment, perhaps much more painful than could be imagined, coping through distancing seems like an adaptive defense and not one that should be pathologized. The ability to detach is not only a good strategy for managing pain in the short term, but it helps to provide necessary resources for coping with the traumatic aspects of treatment. For people who are suffering from acute illness and pain, the focus of therapy should be on the ways they are trying to manage their physical maladies. In terms of therapeutic technique, pointing out to patients that they are being detached is not generally helpful. I might even try to harness this coping strategy as a short-term approach. For example, I might say to someone in pain, “It’s good that you know how to separate yourself from your pain.” This helps to acknowledge the need to distance oneself while increasing insight into how the patient is coping. Once I get to know

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someone better, I might try to comment on the emotions connected with such coping. For example, I might say to someone who is experiencing intense pain as a side effect of treatment, “Is it scary that your ‘cure’ is causing you such pain and suffering? Perhaps you didn’t expect this.” Some patients might respond to such a remark with denial and immediately dismiss such a suggestion. Then, I would back off and return to recognizing the ways they are coping as best as they can with their pain. However, others do respond by acknowledging that they did not know what they were “signing up for” when they agreed to go through high-dose chemotherapy or a bone marrow transplant. Regardless of how someone responds to the question/interpretation, I attempt to foster their awareness of the impact of emotional suffering and the ways that the mind is behaving in response to something physical. This creates connections between the body and the mind, which is the beginning of an emotional language. For those who cannot articulate fear (and in my experience, many cannot, especially those with acute illnesses), I understand this as the need to be detached from fear and to have this, and other intense emotions, remain at a distance. Given today’s understanding of how the mind and body interact (and this research is expanding almost daily), it seems dubious to state that any illness is “purely” physical or “purely” psychological in origin or to assume that only the mind affects the body or vice versa. Of course it is difficult for us to ignore our understanding of Cartesian Dualism, in that it is natural to try to compartmentalize physical and psychological occurrences. To think in such an integrated way is challenging for most of us, and more so for those confronted with illness or age-related decline.

Alexithymia and Hysteria People who have alexithymic presentations use repression to manage overwhelming affect. This is similar to what is seen in hysteria. Although hysteria and alexithymia differ in a number of ways, the use of repression is common in people who employ both these defensive operations. Some people who seek therapy for physical problems have hysterical aspects of their character. For Breuer and Freud (1895/1957), hysteria was associated with denial, repression, and the emergence of physical symptoms without a known physical cause in women with backgrounds of trauma. Defenses of denial and repression are also typical in alexithymia. Our understanding of hysteria has evolved considerably over the years and now emphasizes excessive use of fantasy and an externalized approach to the world in which one molds themselves into what they imagine the other wants them to be (Guttman, 2006). This also explains the common behavior of the excessive overmonitoring of and “caretaking” of others that people with hysterical characters engage in. Patients who have hysterical aspects of their character are externally focused on others, particularly in relation to the needs of others. People with hysterical dynamics can do well in life if they can sublimate these issues through the helping professions. It is not uncommon to find people in psychology, medicine, and law who devote their lives to helping

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others who have hysterical aspects of their character. However, there is a cost to overly focusing on others and not on oneself. People who have hysterical tendencies are externally focused in this way, so have fewer resources to manage their own emotions in times of crisis and often lack an emotional language to describe their experience, as they tend to develop vague sense impressions of people and events in the external world. Although I think that alexithymia has normal and adaptive elements for many people with illness, it may also be the case that those with hysterical tendencies are more prone to the presenting symptoms of alexithymia, especially when confronted with bodily illness or failure. People with hysterical defenses are often stunned and speechless in response to illness and often do not take much time to think about their feelings and experiences of illness. For example, Jed, who was discussed in Chapter 5, did not think much about his illnesses. He just became very good at coping, and his illness and feelings about it were repressed and fragmented. However, the cost of this for Jed was that he did not know how manage his own internal life, as he was constantly focusing on others. Jed was coming to therapy three times a week for relationship issues in the context of medical problems, as previously described. He was very detached from both his emotions and his body. For example, he told me that his wife made a comment about a scar from a childhood surgery, and this shocked him; he said he does not feel that the scar “belongs” to him, but that it “belongs to someone else.” This realization surprised him, since he did not understand how something so intimately a part of his body could feel so unknown and disconnected. This signaled the beginning of Jed’s readiness to consciously know more about how he spent much of his emotional life, and the tension with his wife acted as a catalyst towards this understanding. Jed realized that no matter what he did, his wife would not make changes to behaviors he perceived as problematic until she herself was ready to do so. I was not only focused on helping Jed with his omnipotence (meaning his idea that if he behaved in a certain way, that he could get his wife to change), but also on the more important issue: Jed’s overdeveloped ability to attend to and notice the behavior of others. In some ways, Jed felt that he was helpful to others by noticing their every need, but he was also constantly “in the minds” of others as a way to avert his feelings of disappointment and sadness when his wife did not behave as he wanted. This overdeveloped skill was likely honed when he was ill in the hospital as a child. Concerning himself with the thoughts of others was a strategy not only to escape his own physical and mental pain, but to gain “control” over his circumstances. For example, if he could tune in to the mood of a nurse taking care of him, he would believe that by behaving like she wanted him to and being who he imagined she wanted him to be (a happy, cheerful boy), he could be sure of getting better care while in the hospital and at home by trying to make his caretakers more “alive” and attentive to his needs (a similar dynamic took place with his depressed mother.) This strategy made sense when Jed was a child, but now it worked against him, as he was almost always trying to figure out what others were thinking. This also left him confused and stunned when aspects of his current illnesses became complicated or difficult, as he had few internal resources to know how he felt about the ongoing struggles and disappointments he faced with his illnesses.

Jed’s lack of relationship with his own mind, when he could tolerate thinking about this problem, made him very sad. This sadness was accompanied with grief, as he had to become aware of how much of his life he had spent out of touch with his thoughts while his attention was on the minds of others. Jed was genuinely unaware of having felt (consciously) sad about the disappointments over his ailing body and in his environment growing up. His ability to understand the ways that he had to

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become detached from himself in order to manage his physical struggles as a child, especially in the face of parents who were less available than he needed, was the true beginning of developing an emotional language and an improved sense of self and identity. This was a painful period for Jed, but such grief is often part of cultivating an emotional language. In order to change, we all need to come to terms with what we do not know and what we have missed out on. Although some theorists (e.g., Klein, 1940) focus on aspects of aggression in grief and mourning, my experience with medical patients is more similar to what trauma researchers have described as self-integration (e.g., Alpert, 1994; Krystal, 1988). Reflecting on past experiences and how we could have done things differently or better serve to point out the ways we could have gotten more out of life, and also constructs a story of how things came to be the way they are. The case example described with Jed, as well as many people who have battled illness as children, represents how aspects of alexithymia and hysteria share commonalities. Although in terms of outward personalities, people with hysterical traits are thought to be more gregarious and outgoing, in my experience outward behavior is less important than the internal use of repression, denial, and a sense of emptiness or blankness when being expected to offer an authentic, rather than a false self-presentation (as articulated in Winnicott’s study on the true and false self, 1965 pp. 140–152) and mode of connecting. This is why therapy is so hard for these individuals. One may assume that a patient can have a “real conversation” at the beginning of therapy. This is often not the case, as traumatic aspects of bodily loss make thinking and talking in an organic way risky and overwhelming.

Trauma, the Sense of Self, and Therapeutic Action On the other hand, trauma in childhood, particularly that which feels overstimulating, can have an impact on bodily development. For example, Schwartz and Stolorow (2001) describe the case of a woman who experienced early trauma and apparent “sensorimotor dysregulation” (p. 383). These authors described how this patient was frequently cold, even when the weather was warm outside, that she was sensitive to light and easily distracted. Infant researchers have long known that early attachment impacts psychological and somatic experiences, but these ideas are just now becoming more integrated into psychodynamic psychology (Fonagy & Target, 2000; Seligman, 2000). As young children, our experiences are not separated into compartments of physical vs. mental. When a baby cries or is frightened, their whole body is involved in the emotional experience. This analogy serves as the idea for understanding the ways our bodies experience emotion when we are young; and in the case of trauma and trouble relating with caretakers, our minds may develop in such a way that emotions are processed somatically. Krystal (1997) states that alexithymia is present to some degree in people who have experienced trauma, particularly traumatic events that involve confrontation with death. Of course, serious illness would qualify as a confrontation with death,

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as does being at an advanced age and approaching the end of one’s life. Illness of any kind reminds people of the limits of the body as well as the finite nature of life. Although aging itself is not traumatic per se, confronting death is scary and stirs up intense, complicated, and primitive feelings. In other words, aging can feel traumatic, especially for those who have used denial extensively, have not been able to pay attention to an aging body, and are unprepared for this phase of life. For many, this dilemma makes it difficult to talk about facets of emotional experience, at least in a way that suggests the presence of “symbolic” emotional functioning and relating. Krystal points out the difficulties in expecting people who have experienced traumatic confrontations with death to be able to explain these emotional experiences to us. In his words, We cannot expect the patients to translate these problems for us into the neurotic type verbal and symbolic productions, but must continue to learn to develop sensitivities, observational strategies, and new techniques to deal with these types of problems. (p. 61)

Krystal’s comments apply to several of our patients. Illness itself can be traumatic, but many aspects of modern medical treatment are also harrowing. ICU care, painful procedures, delirium, and surgeries are just a few of the possible events that are traumatic to patients. Some undergo these experiences with little support. And the hypomanic environment of medicine can feel like a cold place in which to suffer. Krystal’s comments suggest the importance of listening for material that can be most useful to our patients, and suggest that what one might in expect in a neurotic patient, a verbal articulation of symptoms and emotional suffering, does not always occur, at least initially in treatment. Getting to know oneself and having an expanded emotional language can offer hope, even in calamitous circumstances and at the end of life. Though traditional psychoanalysis felt that people in treatment should have a long future ahead of them, it is also the case that even if a patient does not have many years left in life, knowing more about one’s experiences by being able to bear and tolerate feelings, especially in the context of an empathic, attuned other, creates a sense of hope or relief through emotional relatedness. I am reminded of one of the first patients I worked with during the dying process. She was a woman in her 70s with uterine cancer. I met her in the hospital and when she was transferred to hospice care, she asked if I would continue to see her. She had been alone throughout much of her life and as someone with a fair amount of hysterical defenses, had merely superficial relationships with others. Her work with me while dying was remarkable. She felt the need to tell the story of her life: her disappointments, failed relationships, and unsuccessful career aspirations. Since she currently had little support, our contact seemed important for her to have a final chance at developing a deeper meaning about facets of her life. Additionally, it seemed that part of her attachment to me was so that I could witness and reflect her experience. The pain from her cancer was intolerable and traumatic, and in order not to feel alone, she allowed me access to her thoughts and feelings throughout the final stage of her life. My presence gave her comfort as well as a chance for someone to know about her life, as I was actively invested in her emotional life until just days before she died.

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Hope can manifest itself in many ways. And while it is hard to imagine this kind of engagement in the dying process, some people prefer to think about what has been missed out on in life. I do not mean to suggest that at the end of life many people make dramatic transformations. Some people prefer to spend the end of their lives with loved ones they are currently attached to, and the need for new relationships (especially with a therapist) is not necessary. For others who have been loners, they may prefer to spend the end of their life alone. However, if given the chance, some people do feel motivated to try to emotionally understand themselves better, as the end of life serves as the last chance for this kind of self-awareness.

Hope and Grief: Advanced Understandings of Therapeutic Action In situations where a patient may not be able to adequately use words to describe their emotions, our conceptualization of the patient’s emotional state and our ability to manage the intense feelings that arise in us when working with such patients, constitute the true nature of empathic understanding and healing in therapy. Modern research in psychodynamic theory and other therapeutic approaches have emphasized that it may not be what we say as therapists that is most important, but the affective exchange between therapist and patient that is most curative in treatment. An implicit acknowledgment that the therapist’s emotions play a role and contribute to the meanings developed between the therapeutic pair ensues (Miller, 2008), and that the therapist and patient’s emotional and empathic engagement is crucial for the patient to get better (Mitchell, 1993; Renik, 1996). Additionally, attempts to integrate neuroscience with psychodynamic ideas have led to an increased understanding of the ways that human attachment and relatedness provide a sense of self-regulation (Schore, 1994) and has implications for how therapy can be helpful through the therapist’s ability to resonate with patients’ emotions (Schore, 2002). I have described the ways in which medically ill and some elderly patients can present as concrete with less access to emotional functioning. This is expected, as the energy that is expended toward the body takes away from the ability to focus on the mind. Contemporary theory has developed a greater appreciation of treating patients who are concretely oriented and has attempted to go beyond the standard definitions of working with so-called neurotic patients. With this in mind, a more nuanced understanding is possible that levels of confused and even disorganized thinking can occur in all of us. The idea is this: As young children our thinking is not linear and that we are all prone to feeling fearful of our own emotional experiences; moreover, the responses we receive from our caregivers help to shape and form our ability to manage emotions. Mentalization is a newer concept which explains the process of human relational functioning, self and emotional regulation, as well as how attachment in early relationships is informed by a caregiver’s mindfulness of a young person’s needs (Bouchard et al., 2008). Wilfred Bion has also greatly added to the field of contemporary psychodynamic theory through his ideas

Hope and Grief: Advanced Understandings of Therapeutic Action

143

of primitive emotions and the containing function of the therapist (Bion, 1962) as well as a normalization of the primitive aspects of functioning that we are all capable of (Bion, 1970). The idea of understanding and normalizing regressed or primitive emotions is of inherent value, as bodily demands and failures, as well as fear of death, strike up disorganized feelings in all of us. Additionally, clinicians are now recognizing the value of working with patients in the here and now, even when making interpretations about transference. Other recent theorists expand the concept of transference and highlight ways that therapists can access the intense emotions of transference without necessarily resorting to the technique of reconstructing the entirety of a patient’s past (e.g., Gill, 1984; Joseph, 1983). Though these authors emphasize the importance of the transference, they focus on how transference is experienced in the present moment. And, I would add, the lived experienced of the here and now, although related to transference, offers a window through which we can gain better insight into how our patients interact in the world of relationships, and in relationship to their body. Contemporary theory has extended the ways we can gain an enhanced understanding of more concrete-oriented patients who have a reduced capacity for symbolization and emphasize the importance of the therapist’s mind as a mechanism of therapeutic action. One contemporary theorist suggests that the purpose of working in the here and now is not simply that the therapist interprets what is happening in the present situation, but that symbolization should take place in the session while we are present with our patients (Ferro, 2002). This is the act of searching and waiting for authentic moments, for feelings that are present in the moment during a session, and then being able to help our patients connect what they happen to be discussing with what they are feeling. This is the foundation of the bridge building between the mind and the body. Although the work of contemporary psychodynamic clinicians and theorists is exciting and offers more in terms of thinking about how to work with patients who are more concrete, many authors have not discussed applications of their work to the type of concrete thinking we see in medical and aging patients. Although I have generalized from these writings, the issue of reality again becomes one we cannot neglect to consider. In the types of concrete patients I have described, much of what they worry about is real and really happening, such as the actual failing of the body, the nearness of death, as well as the real limitations and physical pain that illness causes. This is much different than a patient who comes in with intense anxiety associated to relationship problems, interpersonal conflicts with others, and other issues. Many people think about aging and illness on some level, but when was has been thought about theoretically (“when I get old” or “if I get sick”) has actually happened. In Chapter 3, I described how Jaques (1998) characterized a particular kind of intense anxiety. This type of persecutory anxiety causes people to feel as if they are being tortured while alive and they imagine death to feel the same way, yet they are immobilized. Though Jaques argues that this terrifying state is common among people who are more primitively organized (based on the Kleinian idea of the paranoid schizoid position), disorganizing states of terror are common among many who

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are faced with death. When confronted with physical illness, these patients can feel that what was most feared has come true, and the idea of being persecuted is in fact taking place in one’s own body and possibly being externally mirrored in medical procedures and treatments. This explains the intense panic we sometimes see in patients who are diagnosed with a serious illness; they feel that their body is really under attack and that nothing can be trusted. Conversely, some people with these primitive anxieties feel relieved in the presence of illness, as they finally know what is causing their distress. This idea pertains to the situation of someone who has feared an illness (involving primitive anxieties) but has not had medical problems that could be considered a precursor of the illness. Such people can mobilize around the “reality” of an actual illness, as they then have a “bad guy” to fight. This is similar to what I heard from some of my students after the 9/11 attack. Several students told me that in the days and weeks following the attacks that their paranoid patients suddenly seemed calm and more organized. The “bad guys” had been identified and the need to worry about internal feelings of torture and some kind of unexpected threat was replaced by the external reality that there was something equally horrendous to fear. Internal worries of torture and fear of some unknown danger get supplanted by the reality when there is something external of which to be frightened. This juxtaposition of managing internal primitive feelings (which exist in all of us) vs. what actually happens in external reality is complicated, and I have attempted to introduce some of the dilemmas we clinicians face with this dynamic in our work. Further research and writing on this topic is needed, not only to continue demonstrating the value of long-term treatments, but also to be able to offer more effective treatment to patients as they age and develop illness. Though I have tried to articulate what seems salient in my work, this kind of inquiry is still in its infancy. Despite over 100 years of psychoanalytic thought, the validity and understanding of what we have to offer is still unfolding.

(Epilogue) Resilience in the Elderly and Medically Ill I have described a number of issues in this book that impact older adults, which focus on the negative aspects of aging, such as narcissistic injuries associated with growing older and the awareness of relative proximity to death; yet the elderly are often remarkably resilient. More so than younger patients, older adults can be willing and eager for help. Defenses that are often present in younger patients have waned with age, and for some there is an increased ability of attaching to the therapist more quickly. These ideas were discussed in a panel at the American Psychoanalytic Association in 1963. Clearly ahead of its time, the speakers at this meeting described psychodynamic treatments with older adults (Zinberg, 1964). In particular, Douglas Bond and Sidney Levin commented on the relative ease of working with older adults due to the weakening of repression and alterations in the defensive system. This is consistent with my own experience of working with older

References

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patients. I suspect that cognitive changes play a role in the ability to keep thoughts and memories at bay, and also elicit a desire in some people to develop a more meaningful understanding of their histories in their later years. Nevertheless, the impingement of memories is what brings some people to therapy. As we saw with some of the patients I have described throughout this volume, they were defensive but ready to have someone help them realize the limitations of these defenses. The individuals whose case histories were presented throughout this book were all aware of some kind of suffering. Many of these patients, however, could not really verbally convey the true nature of their emotional experience. Many had feelings of emptiness, of depressed mood (though not related to sadness as much as a collapse of psychological resources), or vague experiences of unease that could not be easily named. These patients had to learn how to talk and think about their minds in a new way that would relieve their pain but would not overwhelm them. The capacity to offer this potential to our patients is the true value of the psychodynamic approach. We teach, but we also learn. We talk, and we absorb and hold intense emotions as well. Above all, we foster the hope that our ideas can provide better lives for the people we meet every day in therapy. We are continually striving to do what we do better and to offer more nuanced understandings of the workings of the human mind and body.

References Alpert, J. L. (1994). Analytic reconstruction in the treatment of an incest survivor. Psychoanalytic Review, 81, 217–235. Bion, W. R. (1962). Learning from experience. London: Tavistock. Bion, W. R. (1970). Attention and interpretation: A scientific approach to insight in psychoanalysis and groups. London: Tavistock. Bouchard, M. A, Lecours, S., Tremblay, L. M., Target, M., Fonagy, P., Schachter, A., et al. (2008). Mentalization in adult attachment narratives: Reflective functioning, mental states and affect. Psychoanalytic Psychology, 25(1), 47–66. Breuer, J., & Freud, S. (1957). Studies on hysteria (J. Strachey, Ed. & Trans.). London: Hogarth Press. (Original work published in 1895). Ferro, A. (2002). In the analyst’s consulting room (P. Slotkin, Trans.). New York: Taylor & Francis. Fonagy, P., & Target, M. (2000). Playing with reality III: The persistence of dual psychic reality in borderline patients. International Journal of Psychoanalysis, 81, 853–873. Glucksman, M. L. (2000). Affect dysregulation: Defense or deficit? Journal of the American Academy of Psychoanalysis, 28, 263–273. Gill, M. M. (1984). Transference: A change in conception or only in emphasis? A response. Psychoanalytic Inquiry, 4, 489–524. Guttman, S. R. (2006). Hysteria as a concept: A survey of its history in the psychoanalytic literature. Modern Psychoanalysis, 31, 182–228. Jaques, E. (1998). Death and the mid-life crisis. In E. B. Spillus (Ed.), Melanie Klein today: Developments in theory and practice (Vol. 2, pp. 226–248). London/New York: Routledge. Joseph, B. (1983). On understanding and not understanding: Some technical issues. International Journal of Psychoanalysis, 64, 291–298. Klein, M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis, 21, 125–153.

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Krystal, H. (1988). Integration and self-healing: Affect-trauma-alexithymia. Hillsdale, NJ: The Analytic Press. Krystal, H. (1997). The trauma of confronting one’s vulnerability and death. In C. Ellman & J. Reppen (Eds.), Omnipotent fantasies and the vulnerable self (149–185). Northvale, NJ: Jason Aronson. McDougall, J. (1980). A child is being eaten, I: Psychosomatic states anxiety neurosis, and hysteria. Theoretical approach II: The abysmal mother and the cork child – A clinical illustration. Contemporary Psychoanalysis, 16, 417–459. McDougall, J. (1984). The “dis-affected” patient: Reflections of affect pathology. Psychoanalytic Quarterly, 53, 386–409. McDougall, J. (1989). Theaters of the body. New York: Norton. Miller, M. L. (2008). The emotionally engaged analyst I: Theories of affect and their influence on therapeutic action. Psychoanalytic Psychology, 25(1), 3–25. Mitchell, S. A. (1993). Hope and dread in psychoanalysis. Cambridge: Harvard University Press. Nemiah, J. C. (1973). Psychology and psychosomatic illness: Reflections on theory and research methodology. Psychotherapy and Psychosomatics, 22, 106–111. Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 65, 495–517. Rickles, W. H. (1986). Self psychology and somatization: An integration with alexithymia. Progress in Self Psychology, 2, 212–226. Schore, A. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale: Erlbaum. Schore, A. (2002). Advances in neuropsychoanalysis, attachment theory, and trauma research: Implications for self psychology. Psychoanalytic Inquiry, 22, 433–484. Schwartz, J. M., & Stolorow, R. D. (2001) Trauma in a presymbolic world. Psychoanalytic Psychology, 18, 380–387. Seligman, S. (2000). Clinical implications of current attachment theory. Journal of the American Psychoanalytic Association, 48, 1189–1194. Sifneos, P. E. (1973). The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22(2), 255–262. Winnicott, D. W. (1965). The maturational process and the facilitating environment. New York: International Universities Press. Zackheim, L. (2007). Alexithymia: Expanding the realm of research. Journal of Psychosomatic Research, 63, 345–347. Zinberg, N. E. (1964). Psychoanalytic consideration of aging. Journal of the American Psychoanalytic Association, 12, 151–159.

Index

Adams-Sullivan, A., 79 Adult-onset trauma cigarette smoking, 48 denial and dissociation, 49 dissociative defenses, 51 normalizing feelings, 50 PTSD symptoms, 46–47 shame impact, 47 therapeutic interventions, 50, 52 Alexander, F., 3, 10, 77 Alexithymia hysteria grief, 140 repression, 138 psychic detachment coping strategy, 137 psychosomatic disorders, 136 psychoanalytic theory, 4 Alzheimer’s disease (AD), 108 American Psychiatric Association, 21, 37 Balfour, A., 113 Bergler, E., 96 Bion, W.R., 45 Blum, H.P., 70 Body intrusion, psychotherapy aging population, 14–15 cognitive behavioral therapy (CBT), 7–8 concrete, 6–7 paranoia, 1 psychoanalytic theory alexithymia, 4 classical psychoanalysis, 4–5 geropsychology, 5 mental process elasticity, 4 patient symptoms, 14 psychosomatic illness, 3 traditional psychoanalysis, 5 traditional technique, 14 transference, 9–10

psychological distress reduction, 1 regression, 7 symbolization, 2, 6 Boulanger, G., 39, 45 Breuer, J., 138 Bromberg, P., 10 Chu, J.A., 53 Clinician and patients anxious thought, 41 concrete thinking, 39 confusion aspects, 40 death inevitability, 42 psychotherapy, 39 transference, 43 Cognitive behavioral therapy (CBT), 7–8 Cognitive impairment dementia, 108 depression, 113 heart disease risk factors, 109 memory impairment, 114–115 neurological changes, 116 Cohen, N.A., 90 Cohler, B.J., 4 Cohn, J., 23 Core, E., 32 Countertransference, medical patients definition and emotional responses, 87 erotic transferences, 89, 90 futility, 90 idealization and hostility, 88 nature and modifications, 87–88 professional ageism, 87 projective identification, 88 Culture of medicine. See also Hypomanic culture interpersonal connections, 22 medical relationships contemporary healthcare, 30 transference dynamics, 31

147

148 Culture of medicine. See also Hypomanic culture (cont.) patient expectations health behaviors, 25 modern medicine, 26 technology and idealization behavioral changes, 27 cardiac catherization, 27 counseling, 23 doctor-patient relationship, 28 hematological disorders, 30 medical system, 26 noncompliance, 22–23 Dementia, 108 Deutsch, F., 3 Dietary approaches to stop hypertension (DASH), 23 Dorpat, T.L., 49 Dunbar, F., 3 Ellman, J.P., 90 Emotional language alexithymia, 136–138 hope and grief contemporary theory, 143 therapist’s emotions, 142 transference, 143 hysteria, 138–140 resilience, 144–145 trauma and therapeutic action, 140–142 Erikson, E., 4 Felitti, V.J., 127 Fenichel, O., 3 Fillit, H., 109 French, T.M., 10, 77 Freud, A., 44, 96 Freud, S., 3, 4, 31, 61, 66, 138 Frosch, A., 39 Gabbard, G., 87 Geropsychology, 5 Ghent, E., 96, 98 Grotjahn, M., 88 Heart disease anxiety and depression, 123 martial relationship and hostility, 124 stress, 125

Index Herman, J.L., 45 Hope and grief contemporary theory, 143 therapist’s emotions, 142 transference, 143 Hypomanic culture antihypertensive medication, 23 behavioral interventions, 22 lifestyle habits, 23 manic defenses, 21 medical encounter, 24 noncompliance, 22 pharmacological interventions, 24 prescribing vs. talking, 23 Hysteria grief, 140 repression, 138

Jaques, E., 42, 83, 143 Joseph, B., 40, 43, 83

Kernberg, O., 64, 67 Klein, M., 87 Kohut, H., 61 Krystal, H., 102, 140

Lachman, F.M., 96 Lasch, C., 62 Levant, R.F., 8 Levenson, 78 Lewis, H.B., 47 Linsk, J.A., 22 López-Corvo, R., 71

Masochism addictive behaviors, 103 anger, 97 anxiousness, 102 cigarette smoking, 99 conceptualization, 96 death denial, 102 food and alcohol consumption, 101 idealization, 100 medications, 102 noncompliance, 98 omnipotence, 101, 102 psychosomatic symptoms, 104 sadism, 96 self-care, 95 self-cohesion, 105

Index traumatic events, 100 unhealthy behaviors, 101 Mayer, E.L., 78 Midlife crisis competitiveness, 69 conflicts, 68 guilty feeling, 70 split off aspects, 71 unhealthy behaviour, 72 Mild cognitive impairment (MCI), 108 Mitchell, S.A., 67 Muslin, H.L., 4

Narcissism, aging and illness concept death denial, 62 dependency, 62–63 depression, 64 humiliation and rage, 63 idealization, 67 mourning, 66 omnipotence and magical thinking, 61 pathologizing, 62 psychological interventions, 65 midlife crisis competitiveness, 69 conflicts, 68 guilty feeling, 70 split off aspects, 71 unhealthy behavior, 72 self-destructive behavior, 60 Nash, D.T., 109 National Center for Health Statistics, 20 Nemiah, J.C., 4, 136 Norton, J., 78

Organ neurosis, 3 Osteoporosis, 126

Pardes, H., 68 Posttraumatic stress disorder (PTSD), 37, 124 Psychoanalytic theory alexithymia, 4 classical psychoanalysis, 4–5 cognitive impairment, 20 geropsychology, 5 mental process elasticity, 4 patient symptoms, 14 psychosomatic illness, 3 traditional psychoanalysis, 5 traditional technique, 14

149 transference, 9–10, 26 treatment, 25 Psychological factors, medical illness cancer, 126–127 child abuse, 127–128 dementias, 20 heart disease anxiety and depression, 123 martial relationship and hostility, 124 stress, 125 medical risk, research depression and chronic anxiety, 129 health behaviour, 128 modern medical encounter, 21 osteoporosis, 126 Pugh, K., 32 Putnam, F.W., 49

Roose, S.P., 68 Rundek, T., 109

Sarno, J., 86 Schwartz, J.M., 140 Segal, H., 71 Selective serotonin reuptake inhibitors (SSRIs), 126 Self-destructive behaviors. See Masochism Settlage, C.F., 4 Sifneos, P.E., 4, 136 Sobel, E.F., 4, 87 Specificity theory, 3 Stolorow, R.D., 96, 140

Therapeutic encounter cognitive impairment dementia, 108 depression, 113 heart disease risk factors, 109 memory impairment, 114–115 neurological changes, 116 physical changes dependency, 111 hearing problem, 112 mobility, 111 physiological slow thinking, 110 urinary incontinence, 112 Transference anger, 82 conceptualization tool, 78, 79 conscious and unconscious motivation, 80 definition, 76

150 Transference (cont.) emotional functioning, 77 expectations, 81 fears, 83, 85 flight/flight response, 85 irrational ideas, 83–84 mentalization, 78 pain, 85 reality, 77 regression, 79 traditional interpretations, 76–77 Trauma adult-onset trauma cigarette smoking, 48 denial and dissociation, 49 dissociative defenses, 51 normalizing feelings, 50 PTSD symptoms, 46–47 shame impact, 47 therapeutic interventions, 50, 52 life-threatening, 5 mental health clinician and medical patients anxious thought, 41

Index concrete thinking, 39 confusion aspects, 40 death fear, 42 psychotherapy, 39 transference, 43 past traumatic events interpersonal relationship, 55 physical activity, 53

U.S. Department of Health and Human Services, 15

Vicario, A., 109 Viederman, M., 79

Winnicott, D.W., 22, 104

Zuckerman, A., 109

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