group-analytic psychotherapy with the elderly

Group Therapy

GROUP-ANALYTIC PSYCHOTHERAPY WITH THE ELDERLY

Maria Canete, Fiona Stormont and Arturo Ezquerro

ABSTRACT Orthodox psychoanalysis offered the view that mental processes in the elderly are toorigidly established for favourable treatment results. Group psychotherapy with the elderly ingeneral has received little attention, mostly concentrating on inpatient groups. The main focus hasbeen on supportive techniques, often in institutional settings.

Two of the authors (Maria Canete and Fiona Stormont) co-conducted a weekly slow-openanalytic group for elderly people, in a London outpatient NHS clinic. This paper presents clinicalmaterial that illustrates some age-specific issues, as they appear in the group process. For example,issues of competitiveness, rivalry and aggression, which are generally present in the beginning ofgroups with younger people, tend to be absent, or manifest themselves differently, in the elderlygroup. Denial of age becomes impossible, which helps these patients to accept approaching deathand the process of dying itself. Psychoanalytic group psychotherapy can be especially indicated forthis age population.

Introduction

People over 65 constitute the fastest growing age group in the western world. They have thehighest prevalence of physical and mental disturbance of any age group. Their health needsgenerate the highest per capita medical expenses in the population. Specialist geriatricservices began to develop in Britain from the late 1940s, and psychogeriatric services fromthe late 1960s. Old age psychiatry became a recognized speciality in 1989.

In the nineteenth century, Charcot had denounced the fact that `senile pathology' was aneglected area of medicine (Howell 1988). Freud (1905) did not follow his mentor on this,and considered that people aged around 50 lack the mental elasticity required forpsychoanalytic treatment. Besides, he thought that the mass of material to be dealt withwould prolong the treatment indefinitely. As a consequence, the entire old age field withinpsychoanalysis and group analysis was largely ignored. Those who tried to employpsychodynamic psychotherapy with this age group were only a tiny minority. Until 1986,the British Psycho-Analytical Society refused to accept patients over the age of 40, and theTavistock Clinic was also routinely rejecting patients over 45.

The Literature

The influence of early psychoanalytic beliefs or prejudices (?) was so widespread that,during the first three quarters of the twentieth century, only a few papers referred to thepsychoanalysis of older patients. Abraham (1919) wondered about the applicability ofpsychoanalytic treatment to patients at an advanced age, and he drew an important

MARIA CANETE is a psychiatrist and group analyst working with the elderly. FIONA STORMONT isa senior registrar in Old Age Psychiatry. ARTURO EZQUERRO is a consultant psychotherapist.Address for correspondence: 57 Hamlet Square, London NW2 1SR.

British Journal of Psychotherapy, Vol 17(1), 2000© The author

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO 95

distinction between the `age of the neurosis' and the chronological age of the patient. Segal (1958) reported an impressive account of a successful analysis of a 73-year-old man, whomshe treated for 18 months following his psychotic breakdown. At a conceptual level, therewere few but important psychoanalytic contributions. Jacques's (1965) seminal paper onmid-life crisis refers to the need to come to terms with our own mortality and, therefore, theacceptance that the time available is finite. Erikson (1966) suggests that the fundamentalconflicts faced by older people centre on generativity versus stagnated self-absorption, andego-integrity versus despair.

The first comprehensive breakthrough in the UK came with King's (1974) landmarkpaper, `Notes on the psychoanalysis of older patients'. King quoted Freud and Erikson,described a number of successful analyses of elderly patients, and provided a pioneeringpsychoanalytic theory of old age. She formulated some late-life developmental issues andage-specific sources of anxiety. In the next few years, King (1980) developed her ideasfurther. She suggested that the disturbance of some elderly people relates to thereawakening of unresolved childhood conflicts, and the activation of new developmentalchallenges - some of which are similar to those of adolescence but in reverse.

We also found it very helpful to read Sandler's (1978, 1984) analyses of some of herelderly patients. She warned about potentially dangerous narcissistic ambitions in thetherapist's aims. She did not attempt a full reconstruction of the past or a complete characteranalysis, but concentrated on age-specific developmental issues. Her deeply humane andhumble attitude was a source of inspiration to us. Both King and Sandler continue towonder, to search and to produce ideas. It is as if they had decided to demonstrate in theirown life that creative growth is an open-ended task. They have been very influential andhave changed the attitude of many psychoanalytic clinicians world-wide (for example,Cohen 1982; Limentani 1995).

Like King and Sandler, Hildebrand (1982, 1986, 1995) has also written profusely on thesubject. In the late 1970s, he set up an individual psychotherapy workshop for older patientsat the Tavistock Clinic, where people aged between 60 and 85 were assessed and treated ona one-to-one basis. By the late 1980s a long waiting list had been generated. At this time,one of us (Arturo Ezquerro) was invited to join the late Naomi Stern, herself already in hersixties, to negotiate with Dr Hildebrand a one-year-long analytic group for nine patientsawaiting individual psychotherapy on his elderly workshop waiting list. This experiment ingroup-analytic psychotherapy with the pre-elderly had a positive outcome (Ezquerro 1989).

Before the 1980s, most groups were designed for physically and cognitively impairedgeriatric inpatients, concentrating on sensory retraining, reality orientation and remotivationtherapy. Other group approaches used such techniques as music and movement, which weretherapeutic in their own right, but had little to do with analytic work. Since the late 1980s,there has been an increasing number of publications showing that psychoanalytic groupapproaches are a growing therapeutic and cost effective form of treatment for older people (Grotjahm 1989; MacLennan et al. 1989; Leszcz 1990; Porter 1991; Vardi & Buchholz1994; Martindale 1995). The annotated bibliography for psychoanalytic psychotherapy (Milton 1996) reports that group psychotherapy improved both life expectancy and quality oflife in older patients suffering from terminal cancer. It was also reassuring to read thatpsychotherapy and old age psychiatry are coming closer together (Ardern et al. 1998;Garner 1999; Murphy 2000).

96 BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 17(1)

The Group

We inherited a long-term group project which was originally set up in the early 1990s. Oneof us (Maria Canete) became the group conductor in 1996, and the other cotherapist (FionaStormont) joined the project in 1998. This is a slow-open group, run weekly for 90 minutesin an NHS outpatients clinic, where people join and leave as ready. The age range has been65 to 89 years. We do not have a rigid exclusion criteria but we are reluctant to offer a placeto people suffering from active psychosis, especially paranoia. We also think that our groupis not suitable for people with dementia. We may accept patients with deeply ingrainedpersonality disorders, major depression, disabling chronic anxiety or addiction problems;these conditions usually necessitate combined treatments. We have no facilities yet forpeople who are too physically ill to attend the group.

From our experience of treating elderly people in this group, we anticipate a betterprognosis when patients have a good level of verbal communication and social skills. Thisusually means that they will be able to recall the past, to work through their losses withoutresorting to somatization or physical illness, and to overcome non-voluntary social isolation.A history of prior successful psychotherapy, whether group or individual, can be anindicator of positive outcome. While there was little psychotherapy provision for thispopulation in the past, elderly people are becoming better educated and morepsychologically sophisticated. Their demand on psychotherapeutic services has alsoincreased.

Some Developmental Tasks of Old Age

We found it useful to differentiate between the 'young-old' and the 'old-old'. This does notnecessarily coincide with chronological age. The 'young-old' need to adjust to a differentplace and role in society, usually following retirement. They may take up new activities andderive much satisfaction in developing a new, creative, perhaps until then dormant, part ofthemselves. The 'old-old' must also adapt to the increasingly unpleasant bodily and mentalchanges of ageing, to dependence on others, and to the imminence and inevitability ofdeath. The very old may not fear death in the way the young-old do, but they tend to fearmore the actual process of dying.

The aim of group-analytic psychotherapy with older people is to help with these age-specific adaptations through the understanding of the individual's internal world, in a widerrelational context. In this way, emotional development can continue until death. Our groupgave us some moving examples of their struggle to face these tasks. (In the clinicalvignettes that follow, names and circumstances are disguised to preserve confidentiality.)

The Main Themes in Our Group

We anticipated that group members would readily discuss ageing, physical and emotionalcare, and review their own lives in the context of an increasingly stronger sense of loss.Elderly people have sustained many losses during their lives (parents, spouses, siblings,other close relatives and friends). Bodily changes can lead to loss of mobility, speech,hearing and sight. They might also be troubled by short term


memory impairment, shortness of breath, loss of sexual potency, social status andindependence, and, ultimately, loss of life itself.

We initially had four members, three from the existing group and one newcomer. As thegroup had been running for six years, we expected to find an established culture. However,we appeared to start a process that in many ways resembled the formation of some brand-new groups. For several months, they predominantly discussed practicalities about thegroup and tried to look for things in common. We wondered if this was a defence - perhapsthey were avoiding differences and envious feelings, but dared not say it. Later, as newmembers came and there was a `core' of seven, talk became more personal. Maybe the `superficial' discussion of the group itself was necessary for becoming its own `secure base',from which to explore.

In these `initial' stages, we allowed them to use the group as a life-line - a 'non-rejectinggood object', as they were especially vulnerable to feelings of being let down andabandoned. We interpreted that they seemed to be feeling cautious with us, the newtherapists, and wondered if they were anxious about being rejected by us. We added that wehad arrived soon after the departure of the previous therapists, which perhaps was perceivedby them as a form of rejection. Our interpretation made sense to them and opened theprocess of deeper exploration.

Reflecting on the Group's Anxieties

History has a bearing on the ongoing group behaviour in the 'here-and-now'. This canmanifest itself at conscious and unconscious levels. In the psychoanalytic and group-analytic fields, this has been described as `group culture' or `group matrix'. Before wejoined the project, our group had survived many changes, including the departure of fivetherapists and a number of patients. Some of these patients left when they were ready,contributing to the therapeutic group culture. Others dropped out or died, which generated ahigh level of anxiety about what they perceived as a threat to the survival of the group andtheir own survival.

Thinking about the group's history helped us understand the sense of uncertainty andfragility we encountered. The initial `suspiciousness' gradually gave way to the developmentof a basic sense of trust, which enabled members to face some of the obvious differencesbetween them. We hope this will become clearer with the following clinical vignette.Brenda, a 69-year-old woman of mixed parentage, had experienced racial discrimination.She was the only coloured person and, often, a 'barometer' for the group regarding feelingsof unlikeness or rejection. In an age homogeneous group, she also represented `heterogeneity'.

Brenda had initially felt suspicious and angry in the group. She later commented that she wasunable to trust the group for a while. However, she was now beginning to experience it differently,after the realization that the group did not persecute her but became consistently available everyweek. At one point, Brenda felt safe to disclose details of her first psychotic breakdown, which shehad felt was caused by her husband's extra-marital affair. She added that he had tried to exploit hervulnerability and demanded her inpatient psychiatric admission, in order to take advantage of herthrough the divorce proceedings.

Most group members, especially the women, commented on Brenda's sense of betrayal byher ex-husband. We also interpreted the possible `betrayal' of her and other people in thegroup by the previous therapists, and the fear that we might do the


same. Brenda and other members recognized that they had felt anxious about the continuityof the group.

Brenda's material was followed by other people sharing their own experiences ofseparating and breaking down. This new dynamic of more open exchange helped Brenda totrust the members and the therapists. The group became more cohesive and the presence ofeveryone almost a matter of `life and death'. If a member was missing they always askedabout them and became reassured to know that they were àlive and kicking'. When themissing member next returned to the group, they were usually welcomed back with: 'Wewere anxious that you might have kicked the bucket'. This comment helped us to understandtheir anxiety about `disengagement', which often reflected a reaction to real or imaginedthreats to the individual's sense of self. Accordingly, the group had to be a non-failureexperience for each member.

They showed particular interest in language and meaning. They looked for the origin ofsome idiomatic phrases. They also showed curiosity about foreign accents and the òrigin'of the therapists. We interpreted the transference, which this time seemed to bring to theforeground the age gap between them and the therapists. Sometimes, they directly askedwhether we were familiar with some of the old-fashioned expressions they used. Thisacquired special significance in one member's words: Ìn a few years time, we all could bepushing up daisies'.

We said that the comment, which on the surface èxcluded' the therapists, could refer tothe hope of being survived by younger generations. Some of them found our thoughtcomforting - a way of ensuring continuity of life in the future. All were born in the first threedecades of the twentieth century. We felt prompted to read books on the history of thisperiod, which helped us to gain context and understanding into their stories. We were alsotrying to learn the membership's primary language.

The group-analytic concept of `cohesion' denotes a rather undifferentiated form ofgetting together. In contrast to it, `coherency' is the result of a more advanced group-therapeutic process in which disagreements and conflicts are faced with the aim of beingworked through (Pines 1986). In our group, members tended to fluctuate in a pendular-likemovement, from fragmentation, through cohesion, to coherency. The circularity' of thismovement reminded us of the life-long fluctuations between the paranoid-schizoid' and the `depressive' positions.

The initial period described above was an example of fears of fragmentation andparanoid' anxieties, characterized by suspiciousness and lack of trust. They graduallyovercame these difficulties by emphasizing their similarities and achieving a sense oftogetherness or `cohesion', but without dealing with differences openly. Brenda offered agood opportunity to transcend this phase and use their wider range of personalities andpsychopathologies. We hoped that this process of ùncovering' the `hidden' heterogeneity ofthe group would bring about the `coherency' needed to maximize its therapeutic potential.The following material is another example of this struggle.

The arrival of Ellen in the group, a 79-year-old woman with a diagnosis of schizo-affectivepsychosis, initially revealed concern and strong objections. In the first few sessions, she fell asleepand snored noticeably, after having introduced herself to the group saying: 'I am a schizophrenic'.This `presentation' of the newcomer reactivated the old fears of fragmentation. Later, we learnedthat she had been over-medicated. When her medication was reduced, she participated in the groupmore constructively. Rose, a youthful 68-year-old lady with a diagnosis of manic-depressivepsychosis, left the group shortly after Ellen joined.


Rose's mother had had a psychotic breakdown soon after she was born. We interpreted that Rosewas finding it very difficult to tolerate the fact that Ellen's vulnerability reminded her of her ownmother's, but in spite of our efforts she left.

At first we thought that it was not possible to achieve a more mature level of sharing or`coherency', where differences and conflict could be tolerated without resorting tofragmentation or escape. However, after the initial hostility towards Ellen's arrival andRose's departure, the group shifted to a more `depressive' form of anxiety. They missedRose, her enthusiasm and liveliness. They also accepted Ellen as a full member. Somepeople commented that she might have suffered from prejudice towards the elderly and theseverely mentally ill, as portrayed in the media with the collusion of society at large.

Jean added to the group's acceptance of Ellen with a comment: `You don't look or act like aschizophrenic, to me'. Then, Ellen brought photographs showing that she had been a beautifulactress, prior to her psychotic breakdown. She wanted to reassure the group that what she hadshared about her past was not a grandiose psychotic fantasy, but a real and healthy side of herselfthat she needed to rediscover. The group appreciated her need for a newly found sense ofbelonging and identity.

Relationships with their Children

The group went through a period in which members mainly focused on the negative aspectsof the relationships with their children and grandchildren. This seemed to reflect somethingabout their own difficult experiences during childhood and adolescence. We tried to provideopportunities for them to explore these difficulties and to improve their familyrelationships. Most of them struggled with the fact that their children had left home, gotmarried and made them grandparents, about which they had mixed feelings. In spite of thejoy of becoming grandparents, the new `transgenerational' realities were also painful andoften perceived as yet another form of rejection. The in-law families became `natural'recipients of their hostile projections and, of course, the group. However, members usually`protected' us, the group conductors, from their destructive anger. They seemed to need amore diluted form of negative transference towards one another.

Brenda accused Eddie of upsetting her with his chauvinistic and patronizing attitude. This led toan impasse until Tom commented that she had previously described her eldest son as a patronizingand chauvinistic person. Then, Brenda was able to recognize that Eddie reminded her of her eldestson.

We thought that this material was therapeutically more mature and closer to `coherency', asthey were able to deal with conflict, survive it and relate with one another in a moreconstructive fashion. They were beginning to disentangle what belonged to them and whatto the transference distortions of the past. Brenda's insight into her own transference toanother group member helped her to move on.

Then, she reflected on the impact that her psychotic breakdown had had on herchildren. She felt that she became unavailable to them, in much the same way that she hadexperienced her own mother. In addition, she felt cut off from one of her sons following hismarriage. This was aggravated by the fact that the only child towards whom she felt closeemigrated to Australia, which enhanced her feelings of being abandoned.


Several group members elaborated on their fears of rejection and being seen as useless by others orby themselves. June participated actively in the discussion and reported that, after the death of herdaughter-in-law, she went to live with her son to help with the children. Her first breakdownoccurred when her son's new partner moved in with them. June was accused by her son of takingover and not allowing him to be the 'parent in charge', about which she felt deeply hurt andexcluded. Tom had not experienced physical separation from his children in the way Brenda andJune did, because his children still lived at home, but in his view they behaved like 'lodgers'. Incontrast to the experience of the parents in the group, those members who were childless tended tohave an idealized image of parenthood. Jean, who had no children, stated that it was difficult forher to understand Tom's feelings of loneliness, because he lived with his own children; in her view,they should give Tom good companionship. Then, Ellen referred to the fact that her first episode ofpsychotic depression coincided with the realization that she was too old to become pregnant.

In our group, the patients who had children and grandchildren experienced life asdifficult and conflictive; but the childless members tended to talk more often about feelingsof emptiness. We commented that the group was providing opportunities to exploredifferent or even opposite viewpoints. For example, children could either be idealized orbecome a source of pain and problems. This intervention promoted a process, throughwhich extreme and 'polarized' views were gradually transformed or 'translated' into moremeaningful and less hostile communication.

This move was a therapeutic exercise in its own right. It developed greater awareness ineach individual of himself and others, increasing the capacity for insight and integration ineach person. This has been described in group-analytic terms as `ego training in action' (Foulkes 1964). Childless members could appreciate other creative aspects of their lives,which helped them gain a sense of fulfilment and 'transcendence' into posterity.

Ageing, Death and Dying

Ageing is a natural process, not a pathological one, but it is physically and emotionallytaxing. Some people seemed more able to accept growing old than others. In our group, thistheme usually came up in relation to physical symptoms and decline. Members oftencomplained of being discriminated against in our Western society. They resented theportrayal of the elderly in our media, whilst in other cultures elderly people are valued asexperienced and wise members of the community. This theme had a strong 'resonance' forEddie who was struggling with his loss of status following his retirement - his son hadtaken over the family business.

Eddie tried to dominate the group and talked about the possibility of going back to work. Onlywhen he was able to 'retire' from his role of 'Mr Chairman' in the group, could he be accepted by theothers as a full member. Rose, who identified herself with younger people, did not join in whenthere was a discussion about ageing. We became concerned when she decided to leave the group toattend a course in sociology. However, we could also appreciate that she had developed anintellectual curiosity about groups and was trying to use her remaining years creatively. In contrastto her, Tom was more able to discuss his decline; but he said with resignation that he was markingtime until he 'popped off.

Group members did not usually discuss death openly. They seemed more interested incomparing the actual quality of their lives. However, disabling physical symptoms anddying were matters of concern for them.


Tom and Brenda often said that they would prefer to `drop down dead suddenly' whilst still healthy,because they would not like to be a burden to their children. Paul could not agree with them.Already in his late eighties, he was physically very frail and had lost contact with his family. Hismain fear was dying alone at home and being dead for days before anyone noticed. He was a veryreliable member of the group. Even during his sudden final illness he managed to let us know thathe had been admitted to hospital. At the beginning of a session, following a holiday break, thegroup intuitively knew that something was wrong when he was missing, even before we broke thesad news of his death. His fellow group members expressed sadness, but they were relieved that hehad not died alone. Jean commented that the group had become a `replacement family' for Paul.

Some Ideas on Group-Analytic Technique with the Elderly

The elderly have a long history behind them and the expectation of a shorter time to live.They experience reduced rather than expanded capabilities. Western civilization is lesslikely to offer the elderly new opportunities for achievement. Therapeutic tasks frequentlyare to adjust to the present and create the most favourable conditions for the future. Incontrast to this, the young have most of their lives still in front of them; they are more likelyto spend time fantasizing and planning for the future. We reflected on some of thesedifferences in our group of elderly patients; they gained more satisfaction fromreminiscence about the past and sharing common values with people of their owngeneration. We will expand on this at the next section.

Differences with the younger population became clear from the early stages of ourgroup. For example, issues of competitiveness, rivalry and aggression, which are generallypresent in the beginning of groups with younger people, tended to be absent or manifestedthemselves differently in our elderly group. They did not struggle for power and controlopenly like the young but concentrated more on the identification of common problems - aprocess of 'cohesion-formation'. The Western world, in particular Anglo-American culture,is generally considered to stress values associated with individualism, such as self-confidence, individual achievement and independence. Often, attachment needs arewrongly seen as child-like or weaknesses.

In contrast to the increased `dependency' in the elderly, and the resultant role reversalwith their children, younger patients in groups try to develop the `independent' self, whosegoal is to be unique and expressive in the external or public roles. Elderly patients graduallybecome more preoccupied with belonging and maintaining internal harmony.

Another difference in our findings relates to the group defensive process of `pairing'. Ina younger people's group this would be viewed as a subgroup with a potential detrimentaleffect. However, in a group of elderly patients the same defence might be tolerated or evenaccepted in the light of its self-restorative function, and its contribution to the long-termdevelopment of the group. The multiplicity of the therapeutic mechanisms accessible in thegroup-analytic setting (for example, the mobilization of diverse individual transferences,family transferences and mirroring among group members) eases the process for an old agegroup to become `all generations'. Experiencing oneself in a 'life-cycle process' becomesmore imaginable, as does the resolution of intergenerational problems. Age differencesbetween patients and therapists, with their implicit `generational role reversal', have to berecognized in the transference and countertransference. However, the age gaps


are not insurmountable; they can be creatively used to help elderly people overcome someof their difficulties, in a youth-orientated society.

In our project, this was particularly important during personal and group crises. Whensecurity and trust were restored, members became more able to explore differences andconfrontation. This, in turn, promoted a more mature expression of negative feelingstowards one another and towards us, the therapists. When they were able to resolve thistension, the atmosphere in the group became more heterogeneous, flexible and a greaterpotential for change emerged. Overall, however, our elderly patients appeared to make moreprogress when treatment was carried out within a predominantly positive transference. Wedid not find that this was so important in groups with younger patients. Grouppsychotherapists working with the elderly need to understand their attitudes, both consciousand unconscious, to ageing and death. They especially need to guard againstcountertransferences resulting from their own unresolved conflicts about ageing, declininghealth, or about relationships with their own parental figures.

Countertransference

We did not know what we were letting ourselves in for, but found that our elderly patientsaccepted death better than we were able to. We felt privileged to share their sadness andstimulated by their wisdom. Sometimes, we were used as recipients of their envy of `idealized' younger people - a possible expression of a difficulty they had in letting go of theyouth inside themselves? We wondered about the possibility of their unconscious wish forus, the therapists, to become the idealized child who can guarantee their permanence, andpass on to posterity the good aspects of themselves that they wanted to see preserved. Wealso recognized our own `envy' of them for having survived so long and for their ownachievements.

At first, we were `suspicious' of their help-seeking attitude, manifested by almostperfect attendance rates. We feared that their demands would put a heavy burden upon ourshoulders. Gradually, we realized that they were also trying to maximize responsibly theuse of our time limits and their own limited life-span. We learned from it. Our anxietiesabout their initial demands for `total' care, progressively, gave way to the acceptance of ourown limitations in the understanding of their problems, which they appreciated. We realizedthat we can write about them but we cannot own the history they themselves made, becauseit belongs to them and not even death can take it away from them. Life ends but historyremains.

Discussion

The group-analytic approach meets a wide variety of needs for elderly people, as theystruggle with internal and external needs. It provides a self-sustaining matrix in which thenarcissistic injuries to the self can be addressed, through the provision of thinking andrelationships that may serve necessary self-object functions. Some of the basic features ofold age can be better explored in a group (for example, dependency, helplessness and socialisolation). Experiencing feelings of interdependency and belonging stimulates olderpatients to make a better use of the social context in their own lives. In ourcountertransference we identified that caring for the elderly can be taxing and get in theway of our wishes for `greater' achievements or ambitions.


We later recognized that caring for them was also an achievement in its own right. Wecame to this conclusion as we realized that older patients in the past have not alwaysreceived early or adequate care from public, or even private, health services. Elderly peoplehave often been institutionalized in mental hospitals, nursing homes and other residentialfacilities. They tended to suffer disproportionately within the established health system,which was (and in many ways still is) characterized by insufficient financing and thefragmented delivery of services. Our group patients hoped that, in the future, care of elderlypeople with mental illness will continue to gain not just independence but also respect.

Intimacy and sexuality were difficult for our older patients. While their attachmentneeds were reactivated they also tended to `disengage', as they realized that they could notsustain the level of productivity and involvement of their earlier working life. In spite ofloss of potency and sexual drive, sexual functions and needs persisted. Their sexualitybecame less a matter of physical urge and more an expression of tenderness, affection andtrust. They felt comfortable discussing this in a group with people of the same age.

In our group, we needed to employ a `binocular' vision to link up different time scales,such as their chronological restrictions and their unconscious processes - which areparadoxically timeless. We found that reminiscence helped them recognize the child, theadolescent and the mature adult still present internally. Remembering and staying in contactwith the past promoted a sense of internal self-constancy and integrity, for them to givevalue to their own life experiences and, therefore, to themselves. At times, the continuitywith the past became an antidote against overwhelming despair. We will elaborate on this.

Grievous loss is part of the ageing process. The individual's failure to negotiate thenarcissistic losses ageing brings (losses of personal capacities, relationships, functions androles) may result in an impoverished sense of self with feelings of depletion, worthlessness,depression and despair. Reminiscence can be conceptualized as a developmentallyappropriate and natural process of review, organization and evaluation of one's life. In thissense, it may be utilized to promote reintegration of the individual's identity, of who theyare, by having them re-connect with who they were. It may become a mainstay ofpsychoanalytic group psychotherapy.

At its best, the reminiscence process fleshes out individuals within the group and makesthem three-dimensional people, rather than one-dimensional objects of projections or bi-dimensional units of projective identification. Reminiscence restores feelings of worth,stature and competence through the articulation of past successes and the recollection ofprior credentials. The group adds an important dimension to the use of reminiscence. Whathas been of significant subjective importance to any individual can be confirmed by a morecollectively objective valuation. In a psychotherapy group, appropriate grieving and lettinggo of the past may be facilitated, promoting better engagement with the currentenvironment. The reminiscence of previous challenges mastered can also help soothe theapprehension facing future uncertainties.

A sense of continuity with the future was also crucial. They sometimes considered thecontinuing existence of a world, in which some part of themselves could be left. They couldlive on in their children and grandchildren, in the memory of others or in their own works,written words, painting or music. Quite simple objects, like photographs and videos, couldalso provide this sense of continuity; but the greater


the damage the more difficult this task became. At its worst, the reminiscence process mayresult in a fixation with the past, guilt over irreparable errors, and a heightened, morbidself-absorption that results in social alienation.

It is debatable whether treatment with the old may or may not be as `open-ended' aswith the young. In our group, we observed that the flexibility of having `thinking space',without being pressurized, was beneficial for most of the members. Approaching death wasoften a challenge that some were able to use constructively to be more selective, and tofocus on what mattered most for them: the consolidation and affirmation of their existence.On occasions, shortness of time generated overwhelming anxieties, which prevented themfrom getting on with the therapeutic task. On other occasions, time restrictions were anincentive to work in therapy rather than the opposite - a real 'deadline' may serve tocreatively concentrate the mind.

Conclusion

Group-analytic psychotherapy can be especially beneficial for the elderly. Some of the basicfeatures of old age (for example, dependency, loneliness, social discrimination,helplessness and despair) might be better explored in a group therapeutic situation of thiskind. Such a group provides ample opportunities to experience, and re-experience, truefeelings of interdependency and belonging. They can also help one another to acceptwithout shame the reactivation of their needs for reliable attachment figures, as well asmutually stimulate themselves to use the social context in their own lives. It is important forpractitioners working with groups for this age population not to underestimate the richresources that elderly patients may bring to the therapeutic context. Ignoring their wealth ofwisdom and experience unduly fosters dependency.

We would like those colleagues who are interested in this population to continue towrite and exchange ideas, without being discouraged by what seems a divide in theliterature between individual psychotherapy and group psychotherapy. Although individualand group psychotherapies for the elderly are steadily growing, they still are a challenge formany practitioners. We hope this paper will go some way in overcoming the hesitations ofthose not already working with this population.

For those already working with the elderly, we hope that some of our ideas will havebeen delivered in a stimulating form, maybe to add to their treatment repertoire. Facing thepotentially fragmenting pressures in our society at the turn of the Millennium, we need tocooperate in a joint venture that breaks some of the prejudices and discrimination againstolder people, with the aim of developing a more coherent life-long perspective of ourexistence, from the cradle to the grave.

Acknowledgements

To Mark Ardern and Brian Martindale, who initiated this Group Psychotherapy Project inthe early 1990s.


Note

This paper was presented in a Clinical Workshop at the Second Conference of the EuropeanFederation of Psychoanalytic Psychotherapy in the Public Sector (EFPP), Group Section ('From Fragmentation to Cohesion'), Barcelona, Spain, May 1999. An abridged version of thepaper was presented at the EFPP Millennium Conference ('Changing Times, ChangingRelationships'), Oxford, England, April 2000.

References

Abraham, K. (1919) The applicability of psychoanalytic treatment to patients at an advanced age. InSelected Papers on Psychoanalysis (Eds. D. Bryan and A. Strachey). London: Karnac, 1988.

Ardern, M., Garner, J. & Porter, R. (1998) Curious bedfellows: psychoanalytic understanding and oldage psychiatry. Psychoanalytic Psychotherapy 12: 47-56.

Cohen, N. (1982) On loneliness and the ageing process. Int. J. Psychoanal. 63: 149-155.Erikson, E. (1966) Eight ages of man. Int. J. Psychoanal. 47: 281-300.Ezquerro, A. (1989) Group psychotherapy with the pre-elderly. Group Analysis 22: 299-308.Foulkes, S.H. (1964) Therapeutic Group Analysis. London: Allen & Unwin.Freud, S. (1905) On psychotherapy. In Standard Edition of the Complete Works of Sigmund Freud.

London: Hogarth Press.Garner, J. (1999) Psychotherapy and old age psychiatry. Psychiatric Bulletin 23: 149-153.Grotjahm, M. (1989) Group analysis in old age. Group Analysis 22: 109-111.Hildebrand, P. (1982) Psychotherapy with older patients. Brit. J. Med. Psychol. 55: 19-28.Hildebrand, P. (1986) Dynamic psychotherapy with the elderly. In Psychological Therapies for the

Elderly (Eds. I. Hanley and M. Gilhooly), pp. 22-40. London: Croom Helm.Hildebrand, P. (1995) Beyond the Mid-Life Crisis. London: Sheldon Press.Howell, T.H. (1988) Charcot's lectures on senile dementia. Age and Ageing 17: 61-62.Jacques, E. (1965) Death and the mid-life crisis. Int. J. Psychoanal. 46: 502-514.King, P. (1974) Notes on the psychoanalysis of older patients. J. Anal. Psychol. 55: 22-37.King, P. (1980) The life cycle as indicated by the nature of the transference in the psychoanalysis of the

middle-aged and elderly. Int. J. Psychoanal. 61: 153-160.Leszcz, M. (1990) Towards an integrated model of group psychotherapy with the elderly. Int. J. Group

Psychother. 40: 379-399.Limentani, A. (1995) Creativity and the third age. Int. J. Psychoanal. 76: 825-833.Maclennan, B.W., Saul, S. & Weiner, M.B. (Eds.) (1989) Group Psychotherapies for the Elderly.Madison, CT: International University Press.Martindale, B. (1995) Psychological treatments II: Psychodynamic approaches. In Neurotic Disorders

in the Elderly (Ed. J. Lindesay) pp. 114-137. Oxford: Oxford University Press.Milton, J. (1996) Presenting the Case for Psychoanalytic Psychotherapy Services: An Annotated

Bibliography. London: Tavistock Centre.Murphy, S. (2000) Provision of psychotherapy services for older people. Psychiatric Bulletin 24: 181-

184.Pines, M. (1986) Coherency and its disruption in the development of the self. British J. Psychotherapy

2(2): 180-185.Porter, R. (1991) Psychotherapy with the elderly. In Textbook of Psychotherapy in Psychiatric Practice

(Ed. J. Holmes), pp. 469-487. London: Churchill Livingstone.Sandler, A.M. (1978) Problems in the psychoanalysis of an ageing narcissistic patient. J. of Geriatric

Psychiatry 11: 5-16.Sandler, A.M. (1984) Problems of development and adaptation in an elderly patient. Psychoanal. Study

Child. 39: 471-489.Segal, H. (1958) Fear of death: notes on the analysis of an old man. Int. J. Psychoanal. 39: 178181.Vardi, D.J. & Buchholz, E.S. (1994) Group psychotherapy with inner-city grandmothers raising their

grandchildren. Int. J. Group Psychother. 44: 101-122.

group-analytic psychotherapy with the elderly

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