From uncertainty to understanding: Can psychodynamic theories improve our care of older adults?

Dr Juliette Brown is a locum consultant psychiatrist in CMHT for Older Adults in Newham and in liaison psychiatry at Newham University Hospital, and is a member of the Association for Psychoanalytic Psychotherapy in the NHS. 

Dr Cate Bailey is a Specialist Registrar in Psychiatry working in Liaison Psychiatry at Homerton University Hospital, and is a member of the Association for Psychoanalytic Psychotherapy in the NHS.

‘Psycho-analysis is not a child of speculation, but the outcome of experience; and for that reason, like every new product of science, is unfinished. It is open to anyone to convince himself by his own investigations of the correctness of the theses embodied in it, and to help in the further development of the study’ Sigmund Freud, On Psycho-analysis (1)

Can psychodynamic theory improve our care of older adults? A century of psychoanalytic thought and a half century of work by old age psychiatrists and psychotherapists suggest that it can (2-3). Psychodynamic approaches help in making sense of complex, bewildering and frustrating clinical encounters through the recognition and observation of unconscious communication (4). By becoming aware of the inner and outer worlds of ourselves and our patients we can provide more thoughtful and effective care.

In a podcast with geriatricians Iain Wilkinson and Jo Preston this month, we explained the approach a liaison psychiatrist might take to a more complex case utilising insights from psychodynamic thought.

We described how psychodynamic theory is premised on the hypothesis that there is an unconscious part of the mind that influences action, thought and feeling. This unconscious mind is in dynamic relationship with the external world, both past and present. Within the unconscious, early relationships with important figures provide a template for our approach and experience of relationships throughout life (known as object relations)(4). The mind operates defences to protect us from conflicting desires and from being overwhelmed by painful realities. Defences such as repression, regression, sublimation, displacement, projection and rationalisation are unconscious processes which we all make more or less adaptive use of on a daily basis (4). Examples of these defences are further described in the podcast notes . Understanding and identifying when defence mechanisms are operating can help us to be aware that things are not always what they seem.

In caring for older adults, we are working with a patient group who may be facing death, debility and decline, multiple actual and anticipated losses, and all the complicated, associated emotions. Responses to such stresses include shame, disgust, anger, hate and fear which can often manifest as a difficulty in accepting treatment or care. We are called upon constantly, as caregivers, to register these emotional communications and process them, to reflect and think. Ageing and illness are stress tests of the unconscious mind and internalised early relationships, our resilience to loss, our capacity to trust, and to tolerate interdependency (2-3). Our first experiences of reliance on others, namely the care we received as infants, will affect our ability to accept care later in life and negotiate the challenges of ageing.

It’s important to note that we too, as professionals, also come to work with an unconscious mind. There are some remarkable insights on the unconscious motivations of people choosing healthcare as profession (5-7). We know that positive feelings such as compassion, sadness and concern are all acceptable and encouraged in health care professionals. However, the more negative feelings may be disavowed and deemed incompatible with our professional identifies, often to the detriment of ourselves and our patients (5-7). Burying hate and dislike only makes it more destructive (5-7). Our unconscious motivations to work with older adults sometimes lie in a desire to repair a relationship (chronologically past, psychically present) (5). When these motivations are not well understood, and our unconscious fantasy differs wildly from the reality, we can become increasingly driven and burn out or become depressed as a consequence (6).

Freud’s challenge was to convince ourselves of the value of analytic work on the parts of our minds we conceal from ourselves. In the podcast with Jo and Iain we suggested that to begin to think psychodynamically, with and about patients and ourselves we might ask:

  • How does it feel to be with this patient? And what might this tell me about their experience?
  • What is not being said?
  • How are past patterns of behaviour or relating being repeated?
  • How might this person’s early life shape their experience of caring or being cared for?
  • How might thinking about these things help me to better care for them?

Those who are interested in exploring these ideas further may decide to undertake personal analysis (Institute of Psychoanalysis have a list of qualified therapists). As psychiatrists we often make use of personal supervision and Balint groups to think about unconscious communications. Schwartz rounds and reflective practice also represent opportunities to think about our interactions with patients and families (ask your liaison psychiatry team if to find out what happens locally). Other resources include:

Attending to unconscious communications from ourselves, patients and families can help to anticipate problems, resolve conflict and create a better and more thoughtful environment for caring, and indeed a better experience for patients and staff.

References:

  1. Freud, S. (1913). On Psycho-Analysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 205-212
  2. Garner, J. (2002). Psychodynamic work and older adults. Advances in Psychiatric Treatment, 8(2), 128-135. doi:10.1192/apt.8.2.128 (Available here:)
  3. Evans, S., & Garner, J. (2004). Talking over the years: A handbook of dynamic psychotherapy with older adults (Vol. 1). Hove and New York: Brunner-Routledge.
  4. Milton, J., Polmear, C., & Fabricius, J. (2011). A short introduction to psychoanalysis (Vol. 2). London: Sage.
  5. Ballatt, J., & Campling, P. (2011). Intelligent Kindness: reforming the culture of healthcare (Vol. 4). London: RCPsych Publications.
  6. Zigmond, D. (1984). Physician heal thyself: The paradox of the wounded healer. British Journal of Holistic Medicine, 1, 63-71 )
  7. Winnicott, D. (1949). Hate in the Counter-Transference. The International Journal of Psychoanalysis, 30, 69-74. )

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