Cognitive Changes and Implications for the Therapeutic Encounter

Abstract

Early proponents of 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 not only appropriate but 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 these questions, as well as other considerations in treating adults with cognitive difficulties. 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 I 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. In addition to discussing some of the main cognitive issues that arise in treating older adults, I will discuss the common problem of delirium. Delirium is a relatively sudden change in cognitive abilities, caused most often by medical problems: frequently infections, medication interactions, and difficulties in metabolizing medications (which becomes more challenging for all of us as we grow older). As psychoanalytic clinicians, we may initially perceive changes in cognition as related to normative regression that can occur in therapies that emphasize dealing with unconscious conflicts, and we may miss when biological forces cause changes in the mental status of our patients. From my own experience, it is helpful to know when delirium might be present so that I can refer to or coordinate with psychiatrists and primary care physicians. I’ll discuss the limited (though insightful) psychodynamic writing that has taken place on the topic of working with older adults. 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.

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

Freidrich Nietzsche