Treating the Elderly with Psychotherapy

Treating the Elderly with Psychotherapy: The Scope for Change in Later Life

Edited by Joel Sadavoy and Molyn Leszcz

Madison, CT, International Universities Press, Inc., 1987. 366 pp.

As emphasized early in this book, the elderly will represent nearly 20 percent of the U.S. population in the twenty-first century. This fact underscores the importance of a work for physicians, therapists, and health workers which focuses on issues specific to clients who are 65 and older. Editors Sadavoy and Leszcz have put together a series of essays by some of the pioneers in geriatric psychiatry (e.g., George Pollack, Jerome Grunes, Martin Berezin, Ralph Kahana, and others), each of whom has brought an expertise to different aspects of psychotherapeutic care. The essays are well-written, interesting, and full of eye-opening clinical vignettes, and the book as a whole has met its challenge of encouraging “hopefulness” in geriatric care. One problem, however, is that in presenting essays largely from a psychodynamic perspective, it lacks coherent underlying theories. Several essays, moreover, fail to distinguish the elderly patient from any other client. The overall collection, however, is pioneering and should encourage more specific studies.

The book is divided into three parts. Part I, entitled “General Psychodynamic Perspectives,” comprises essays by Pollack, Grunes, and Berezin, respectively. Each focuses on a general theme: Pollack emphasizes the wealth of psychodynamic material in therapy with the elderly and presents his own notion of a mourning-liberation process in bereavement. Grunes writes about the unique features of transference between an older client and a younger therapist and provides the concept of reverse empathy to account for the elder’s regard for the therapist. Berezin presents a wonderful introduction to clinical work, stressing the depth and vitality of the elderly. Taken together, these three essays break many stereotypes of the older client and provide a much deeper sense of age-specific therapeutic needs.

Part II, entitled “Manifestations of Psychopathology,” is the most theoretical section of the book and, as a result, the weakest. Its essays, which cover such topics as paranoia in the aged, the impact of massive psychic trauma, and character disorders, are well-organized and yet tangential to the stated goals of the general collection. The flaw seems to lie in the dearth of relevant psychodynamic theories; each essay provides concise theoretical introductions, yet never adequately adapts them for a geriatric population. In addition, no essay attempts to define the elderly. Are clients in their 60s similar to others in their 80-s and 90-s? One is left with little regard for the life cycle as a viable force past adulthood. Several of the cases presented raise interesting issues but, again, do not place them within a meaningful context. One exception in Part II is an essay by Lawrence Breslau on the Exaggerated Helplessness Syndrome. This syndrome, in which elderly patients become maladjusted to their disabilities, highlights their passivity and serves to maintain the support of primary caregivers. The psychodynamic issues here are ripe for intervention, and Breslau provides good clinical examples.

Part III, entitled “Specific Psychotherapeutic Modalities,” picks up many issues from Part I and ends with a real gem: an essay entitled “The Whole Grandfather: An Intergenerational Approach to Family Therapy” by Etta Ginsberg McEwan. The other essays focus on crisis management and short-term and group geriatric psychotherapy, and the information provided here is perhaps the most practical for readers, since it addresses the appropriate structure of therapeutic intervention. For example, Kahana’s chapter on crisis management presents a crucial skill for the intake of elderly clients. He provides a working definition for geriatric crisis, along with many useful clinical pieces. Ginsberg McEwan’s essay, coming second to last, is poignant and informative, presenting an entire case study within the context of family and intergenerational therapy. It speaks to the very intent of the book in tying together the therapeutic goals of the elderly with those of children and grandchildren. By juxtaposing these issues, Ginsberg McEwan illustrates points of common interest as well as age-specific ones.

Sadavoy and Leszcz’s collection of essays will, it is hoped, serve to encourage study along the lines of its distinguished contributors. Although several essays are a bit incongruous with the book’s focus on treating the elderly, one should not be discouraged. There has simply not been enough longitudinal work on the elderly, and the very concept, both before and after reading the book, remains a diffuse notion of “people 65 years and older.” What emerges from the book, then, is not a specific definition, but a well-rounded appreciation for the complex issues facing the elderly and the enormous potential for therapeutic intervention.