Psychodynamic Perspectives on Aging and Illness PDF
Preview Psychodynamic Perspectives on Aging and Illness
Psychodynamic Perspectives on Aging and Illness Tamara McClintock Greenberg Psychodynamic Perspectives on Aging and Illness Tamara McClintock Greenberg Psychodynamic Perspectives on Aging and Illness 123 TamaraMcClintockGreenberg DepartmentofPsychiatry UniversityofCalifornia,SanFrancisco SanFrancisco,CA USA [email protected] ISBN978-1-4419-0285-6 e-ISBN978-1-4419-0286-3 DOI10.1007/978-1-4419-0286-3 SpringerDordrechtHeidelbergLondonNewYork LibraryofCongressControlNumber:2009926038 (cid:2)c SpringerScience+BusinessMedia,LLC2009 Allrightsreserved.Thisworkmaynotbetranslatedorcopiedinwholeorinpartwithoutthewritten permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY10013, USA),except forbrief excerpts inconnection with reviews orscholarly analysis. Usein connectionwithanyformofinformationstorageandretrieval,electronicadaptation,computersoftware, orbysimilarordissimilarmethodologynowknownorhereafterdevelopedisforbidden. Theuseinthispublicationoftradenames,trademarks,servicemarks,andsimilarterms,eveniftheyare notidentifiedassuch,isnottobetakenasanexpressionofopinionastowhetherornottheyaresubject toproprietaryrights. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) Preface ThisbookistheculminationoftheteachingandwritingthatIhavedoneoverthelast severalyearsinwhichItrytospeakaboutthevalueofapsychodynamicapproach from a practical perspective. Although, when I was a health psychology student, I was trained as a cognitivebehavioraltherapist, I felt that these approacheswere limitedintermsoftreatingpatientswhostrugglewithbodilylimitations.Iwasfor- tunateenoughtodiscoverpsychodynamictheoryinmylastyearofgraduateschool, butthenhadthechancetolearnmorefrommysupervisorswhileininternshipabout amorenuancedandsophisticatedwayofunderstandingthemind.ItwasnotuntilI landedinSanFranciscoformypost-docyear,however,thatIbegantofullyappreci- atethevalueofapsychodynamicapproach.TheteachershereintheSanFrancisco BayArearepresentnotonlydiverseviewsofcontemporarythought,butalsoacom- munityoftalentedandcommittedclinicianswhoarestrivingtounderstandtheways thattheycanhelptheirpatientstogetbetter.Yet,givenmytrainingwithmedically illadults,Ifoundthatsomeapplicationsofpsychodynamictheory,especiallythose that represented more traditional forms of thought, did not quite speak about the experiencesofmypatientswhowerestrugglingwiththedevastatingeffectsofill- nessaswellastheblowsofaging.Itisthesegapsinthetheorythathaveinformed my writing and teaching most recently. Although contemporarytheories offer the studentof psychodynamicperspectivesa glimpse into the incredibleminds of the authors/clinicians,acommoncomplaintisthatmuchofthiswritingdoesnotprovide accesstoorunderstandingofthetheoryinawaythatmostpeoplecancomprehend. Currently,data show the limits ofshort-termapproachesfor complicatedpatients, whichcreateaneedforpsychodynamicclinicianstomakeourworkandourideas moreaccessible,transparent,andreadable. This book attempts to bridge the best of contemporary psychodynamic theory withwhatIhavefoundtobetrueforthepatientsIhavetreatedovertheyearswho have acute and chronic illnesses and who have wrestled with the bodily declines associatedwithaging.Psychoanalyticandpsychodynamictheoristshavebeenhesi- tanttoapplytheirconceptstopeoplewhoareagingand/ormedicallyill.Thishistory will be briefly described in Chapter 1, as well as the real challengesmedically ill patientsandolderadultsface,whichrequireustouseadifferentkindofapproach v vi Preface 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 whichtechnologyplaysanever-increasingroleintheprovisionofpatientcare.The following chapters address the common dynamics of the medically ill and aging, includingthe normativenarcissistic injuriesthatoccurin patientswhen theirbod- iesstopworking,aswellasthetraumaassociatedwithbeingapatientwithsevere medicaldisease. I will also discuss contemporaryideas of transference and coun- tertransferenceas wellasthe curious,butcommonscenarioofpeoplewhodo not take care of their bodiesas manifestedthroughnonadherenceand lifestyle behav- iors.Asworkingwith olderadultswith cognitiveimpairmentis anew application ofpsychotherapy,aseparatechapterisdevotedtothisissueandaddressessomeof thecommonquestionsthatarisewhenworkingwithadultswithdementia. Therearecurrentlyanumberofcompetingtheoriesinpsychodynamicpsychol- ogyandmodernpsychoanalysis.Thesecompetingschoolshavemadeitdifficultfor thepublictoknowwhatwehavetooffer.Althoughmanyforcesexistwhichhave madepsychodynamictheoryalessdesirableapproach,argumentsamongexpertsin thefielditselfhavefurtherplagueditsabilitytobeacceptedasamainstreamtheory. Inotherwords,if expertsin the field cannotagreeon whatcontemporarypsycho- dynamic theory is, how can we expectanyone else to know what we are actually doingwith patients? The factthatargumentsoccurbetweenpsychodynamictheo- ristsisinmymind,onlysomewhatrelatedtothenarcissisminherentinallofus.I thinkthatsince psychoanalysisandpsychodynamictherapyhavebeenthreatened, this has led to a sense of loss among many clinicians in the field. The losses are multiple,includingbutnotlimitedtomanagedcare,desiresforquickfixes,andper- hapsanewergenerationofpatientswhomaywanttoavoidthecomplexcharacter understandingswecanprovide.Iseetheinfightingthatoccursasakintowhatoften resultsinsiblingswhoareneglectedbyparents.Inthefaceofabsentparents,sib- lingslookforintenseemotionalstimulation,andthisisoftenexpressedaggressively. Inotherwords,ifparentsarenotaround,andtheyarebeingandfeelingneglected, thensiblingsfeelthattheyhavenooptionbuttobeateachotherup. Myaiminthisworkistoadvocatepluralismwithinthefield,asallideasinthe historyofpsychoanalysishavemuchtoofferaswetrytounderstandandhelpour patients.Andthoughmystanceismoremodern,IseegreatutilityinFreudianideas, aswellasegopsychology,eventhoughthesetheoriesmaynotnecessarilytranslate into the technique I use on a day-to-day basis. I am fond of the object relations theorists,self-psychologistsandtheirpredecessorswhohaveexpandedthepsycho- dynamic 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 richandvariedhistoryofpsychoanalysisandpsychodynamictheory,asallschools can teach us how to understand and enrich the lives of our patients. Although I arguethatmorecontemporarytheoriesarehelpful,thereareanumberoftraditional ideasthathavemadetheirwayintocurrentideas,evenifindisguisedform.There- fore, the reader will find that some chapters embrace Freud while simultaneously critiquehislimitinscope.Otherchaptersemphasizeself-psychologyanditsgreat Preface vii benefits to understandingthe importanceof the sense of self in aging and illness, whilefocusingontheinterpretivenatureoftherapyintheworkofKleinandother modern clinicians. Nearly all chapters focus on the importance of the therapeutic relationship,the impactofthe here-and-nowaspectsofrelationalfunctioning,and providesuggestionsforhowtotalkwithpatientsusingtheconceptsdescribed. Thisbookisgearedtowardtherapistswhoareinterestedinpsychodynamicthe- ory, but may have encountered difficulties in graduate school in learning a more nuancedpsychodynamicapproach.Experiencedclinicianswill also find this book useful as it strives to provide an applied understanding of many concepts in psy- chodynamic theory, which have not yet comprehensively focused these concepts onolderadultsandmedicalpatients.Additionally,patientswithillnessesmayalso find solace in this book, as I strive to make the ideas in the field accessible and transparenttopeoplewhowanttounderstandthemselvesinrelationtotheirbodies. Myworkinthefieldhasevolvedovertheyears,buthasincludedtheprivilegeof beingon the facultyof the UniversityofCalifornia,San Francisco,in the Depart- ment 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 visitanumberofnursinghomeseachweektoseepatients. Iamgratefulandfortunatetohavealargenumberoftalentedcolleaguesinthe BayAreawhohavegenerouslydonatedtheirtimeandenergytocommentonideas 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., RobertWallerstein,M.D.,andDeborahWeisinger,Psy.D.forgenerouslytakingthe timetocommentonaspectsofthiswork.Ialsooweadebtofgratitudetothevol- unteersIspoketowhoofferedtheirexperiencesregardingtheirongoingchallenges withmedicalillness.Asmanyofthesevolunteerswerethemselvestherapists,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 understandingof those who are beleaguered by bodies that do notfunctionastheyshould. I am also indebted to my teachers and mentors, who over the years influenced mythinkingandunderstandingofhowthemindandbodywork.Thesepeoplehave affected me in ways that they are likely unawareof, but without them I would be unable to integrate the manyideas I have learned. These cliniciansinclude Victor Bonfillio, Ph.D., Marilyn Jacobs, Ph.D., Mary-Joan Gerson, Ph.D., Toni Vaughn Heineman,D.M.H.,MaureenMurphy,Ph.D.,WendyStern,D.M.H.,andStevePur- cell,M.D.Also,aspecialthankstoMichaelZimmerman,Ph.D.,whoisresponsible formyfallinginlovewiththepoetryofT.S.Elliot.Theyoungpoetasreflectedin the imagined (and likely felt) experience of the old man, Prufrock, has spoken to meinwaysthatsurpassanybrilliantpsychoanalyticpaper.Zimmerman’steaching serves to acknowledge that psychoanalytic theory is one of many ways of under- standing human suffering and the unconscious, as literature and poetry has been viii Preface tryingto teachusallalongaboutthe vicissitudesofagingandhumansufferingin relationtothesadnessinlifeandtheinevitabilityofdeath. I am especially gratefulfor the help of Stephen Brown, my psychologyeditor, who patiently and competently made my writing more readable. Stephen was an invaluableasset tothisprojectanditwas apleasureto workwithhimandto gain from his knowledge and expertise. Also Sharon Panulla, my Executive Editor at Springerhasnotonlybeenadelighttoworkwith,buthasbestowedtrustinmyself 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 thatcanenablethefurtheringofsolidacademicideas.Also,myhusband,Andrew McClintock Greenberg, M.D., Ph.D., has been a great source of support and has beenpatientwiththedemandsthatwritingabookrequires. Finally,itisthepatientsIhavetreatedwhoaretheprincipalinspirationforthis work.Myloveofworkisreflectedintheirongoingabilitiestoeducatemeregarding the multipleways in whichthe mind andthe bodyinteract.For thisreason andto protect their confidentiality, all cases as reported in this work are based on actual encountersbutaredisguised,oftenincompositeform,toprotectidentity. SanFrancisco,CA TamaraMcClintockGreenberg Contents 1 When the Body Intrudes: Psychotherapywith Older andMedicallyIllAdults ..................................................... 1 PsychoanalyticTheoryandtheBody......................................... 3 ApplyingPsychodynamicConceptstoAgingandMedicallyIllPatients... 6 AgingandtheMedicallyIll:AnIncreasingPopulation ..................... 14 Conclusion ..................................................................... 16 References...................................................................... 17 2 Technology, Idealization,and UnconsciousDynamics intheCultureofMedicine................................................... 19 TheHypomanicCultureofMedicine......................................... 21 PatientExpectationsinMedicine ............................................. 24 TechnologyandIdealization .................................................. 26 LookingforLove(andaCure):MedicalRelationships ..................... 30 Conclusion ..................................................................... 33 References...................................................................... 34 3 TheTraumaofMedicalIllness.............................................. 37 TheMentalHealthClinicianandMedicalPatients .......................... 38 MedicalIllnessasAdult-OnsetTrauma ...................................... 45 PastTraumaintheContextofAgingandIllness............................. 52 Conclusion ..................................................................... 55 References...................................................................... 56 4 NarcissisticAspectsofAgingandIllness................................... 59 TheConceptofNarcissismWithinPsychodynamicTheory................. 60 The“MidlifeCrisis”........................................................... 68 Conclusion ..................................................................... 72 References...................................................................... 73 ix x Contents 5 TransferenceandCountertransferenceinAgingandIllness............ 75 TransferenceandImplicationsforOlderandMedicallyIllPatients ........ 76 CountertransferenceFeelingsinWorkingwithMedicalPatients ........... 86 Conclusion ..................................................................... 92 References...................................................................... 92 6 Self-DestructiveBehaviors,MasochisticDynamics,andIllness......... 95 PsychodynamicIdeasonMasochism......................................... 96 MasochismandtheBody...................................................... 98 Conclusion ..................................................................... 105 References...................................................................... 106 7 CognitiveChangesandImplicationsfortheTherapeuticEncounter .. 107 CognitiveImpairmentintheElderly.......................................... 108 NormalPhysicalChangesRelatedtoAging.................................. 109 PsychotherapywithCognitivelyImpairedAdults............................ 113 Conclusion ..................................................................... 117 References...................................................................... 117 8 What We Know and What We Don’t: TheInfluenceofPsychologicalFactorsonMedicalIllness .............. 121 HeartDisease .................................................................. 123 Osteoporosis ................................................................... 126 Cancer.......................................................................... 126 ChildAbuse.................................................................... 127 The Meaning of the Research on Psychological FactorsandMedicalRisk ............................................... 128 Conclusion ..................................................................... 130 References...................................................................... 131 9 HopeandGrief:TheIntroductionofanEmotionalLanguage.......... 135 Alexithymia:AdaptiveAspectsofPsychicDetachment..................... 135 AlexithymiaandHysteria ..................................................... 138 Trauma,theSenseofSelf,andTherapeuticAction.......................... 140 HopeandGrief:AdvancedUnderstandingsofTherapeuticAction......... 142 (Epilogue)ResilienceintheElderlyandMedicallyIll ...................... 144 References...................................................................... 145 Index................................................................................ 147
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