A Dynamic Psychotherapy Group for the Elderly

Sandra Evans, Paul Chisholm and John Walshe

This paper describes a dynamic group for elderly chronically mentally ill patients within a day hospital setting. It highlights some of the difculties of working psychodynamically with older people, but also suggests that psychological mindedness can be learnt as part of the process. Dependency issues can be confronted, facilitating increased autonomy and self-esteem. Key words: day hospitals, depressed elderly, group psychotherapy, psychotherapy

Freud (1905) held a pessimistic view of the ability of the overforties to change in the analytic setting. C.G Jung (1931) suggested a more positive role for the second half of life, when people may adopt a different role from that of earlier years. The extrovert may become more thoughtful and the masculine take on more feminine attributes. Indeed, there may be some biological basis for the latter state of a hormonal nature. Erikson (1966) maintained that there was still a developmental task to be tackled in old age, that of completing ones affairs and achieving some understanding and acceptance of ones self. The alternative is despair. There is an increasing body of evidence of the efcacy of using psychotherapeutic models in the treatment of elderly people with mental health problems. Some studies have considered cost benets (Mumford et al., 1984) while others have concentrated on reducing the readmission rates (Ong et al., 1987). Steuer et al. (1984) have
Group Analysis. Copyright 2001 The Group-Analytic Society (London). SAGE Publications (London, Thousand Oaks, CA and New Delhi), 0533-3164(200106)34:2;287298;017316

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compared dynamic psychotherapy with cognitive behavioural therapy and have found them to be of equal efcacy. Both treatments are found to be superior to placebo but were found to be less effective than antidepressant medication. Woods and Roth (1996) concur with the 1996 NHS Executive review that there is no evidence to suggest that psychotherapy is less effective in this age group than in others. All authors agree that there should be more research in this area, although the usual difculties with research exist; including the lack of an adequate control group (Altshuler, 1989; Luborsky et al., 1975). Psychotherapy has also been found to be useful in the treatment of major depression. Psychotherapy combined with antidepressant treatment produces better results than when either is used alone and may result in fewer relapses (APA, 1989; Reynolds et al., 1999). Old age psychiatry practitioners are often concerned with the risks associated with inducing dependence in patients: any work that might reduce the loss of condence and personal integrity should be encouraged.

General Issues on Psychotherapy with the Elderly Age in itself may be less important than the generational or cohort effect when regarding the special issues affecting elderly people. One needs to be aware of the different historical backgrounds and value systems. These differentiate older from younger people or even older from younger elderly. Older people are likely to differ from one another on a variety of different measures. Their increasing age arguably makes for increasing individuality (Eisdorfer and Faun, 1973). Elderly peoples problems do not necessarily stem from their chronological age, but adverse physical effects of ageing complicate and worsen other difculties. In the therapeutic setting one may have to take these into consideration. The aged may not consider themselves to be old and may resent being placed in environments exclusively for the elderly (Thompson, 1993). Anticipation of difculties and diminished expectations of quality of life in advancing years may be unnecessary, and lead to low mood and despair (Butler, 1975). There appears to be a commonly held belief that the elderly often talk of death, especially their own. Knight (1986) reminds us that negotiating death is a task of late middle age, and that older people have often come to terms with their own mortality. It may be that

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some need to renegotiate life. Many of our patients have experienced major losses and may need help in retrieving meaning in their lives; possibly by establishing new emotional links with other individuals. A group provides that opportunity by offering a safe environment in which people who have been emotionally isolated for many years may take the risk of engaging with others once more (Evans, 1998). Transference issues may be complicated; in addition to the more traditional parental gure, the therapist may represent the patients children or grandchildren (Colarusso and Nemiroff, 1991). Patterns of conict that have repeated over generations may become evident. Patients may renegotiate any number of developmental tasks. The tendency towards dependence may in itself be a manifestation of early infantile needs, rekindled and terrifying; particularly if they were not sympathetically attended to originally (Martindale, 1989). The demands for the therapists time and attention may feel more burdensome if the therapist is concurrently experiencing similar demands from his or her own ageing parents. If this is illunderstood or infected with too much guilt, it may be poorly dealt with in the therapeutic setting. The issue of terminating therapy or of discharging patients who are old may be fraught with anxieties and ambivalences. Unease with ending treatment might be related to the unconscious intertwining of the therapy with the patients own life. The patients and staff may at some level feel the group is keeping them alive; with odious consequences were it to discontinue (King, 1980).

Aims In this article, we describe a dynamically oriented psychotherapy group which consisted of clients attending the functional days of a day hospital for the elderly. People with frank dementia were not included. In offering a dynamic psychotherapy group, we were hoping to explore some of the issues around what had made them ill initially, and what factors maintained their vulnerability. We wondered whether this group of quite dependent people would assume personal responsibility around group attendance, and whether they would become anxious in unstructured time. Finally, since many of the patients referred to us had been attending for many months, if not years, we were hoping to explore their dependence on the day hospital itself (Adshead, 1997).

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Setting Up Referrals came from the day hospital staff. We interviewed each individual for suitability. During the assessment, closer attention was paid in the history to early experiences and current social circumstances and a dynamic formulation was made. Any mild cognitive impairment was not tested. Each patient was told that we were starting a new group with a closed membership. It would require a substantial degree of commitment, but they were given time to decide whether to accept. All those assessed appeared interested, and seemed to enjoy the chance to talk thoughtfully and in depth about their problems. The group commenced when there was an adequate membership and met on a weekly basis for one hour. Supervision was provided on a fortnightly basis by JW, a group analyst. The group was limited to eight months in order to negotiate an ending, and because of the reality of the training placement of one of the authors.1 The Demographics The group started with nine members, six women and three men, reecting the gender ratio of the day hospital patient population. Their ages ran from 75 to 84. They had a range of psychiatric diagnoses. None had suffered a psychotic illness. Two group members had signicant hearing impairment. Another two suffered from severe physical disorders which impaired mobility. All were retired and all but three lived alone. Membership A aged 82; long-term history of anxiety and depression. On antidepressants and benzodiazepines. Had ECT in the past. Mental state currently stable but requiring regular respite care to give his wife a break from his chronic dysthymia. B aged 76; long-standing alcohol and relationship difculties. Been on withdrawal programmes before but always relapsed. C aged 79; anxiety neurosis. No depressive symptoms; withdrawn from chronic benzodiazepine use. Essentially well but discharge plans always made him relapse. D aged 81; long history of anxiety and depression. Relapsed again when her second husband retired. On antidepressants: successfully withdrawn from benzodiazepines.

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E aged 82; widowed. Daughter lived far away. Sister and husband both died shortly after E and her husband had moved to be near her sister. Depressed. F aged 75; left her husband when in her sixties. Still ambivalent about it now, as is alone. Cared for her elderly mother unstintingly but nding no one to do the same for her. Chronic benzodiazepine misuse. Dysthymic. G aged 82; wife is dementing. Lost both sons. Persisting grief. H aged 77; widowed. Idealized husband but poor relationship with her daughter. Bitterly complains of loneliness and physical ill health although well preserved. Very depressed. J aged 84; severe arthritis, needing Zimmer frame to walk. Lives with oppressive blind husband. Unable to talk about how that makes her feel, because of loyalty towards him. The Group The Beginning Initially, members had to be reminded of the times and venue. This immediately contradicted our group philosophy. The facilitators managed to resist offering help, and found that members did attend and helped each other after a few weeks. After the introductions, and a few comments on the exploratory nature of the group, we sat back in silence. Predictably the group became uneasy, but the anxiety never became overwhelming. They looked for leaders (Bion, 1961). They voiced concerns about what was expected of them as they were used to being provided with highly organized classes. We noted the similarity to beginnings of many dynamic groups, with existential questions such as Why are we here? and What are we meant to be doing? Other familiar issues that emerged were those of condentiality whether or not we as a group could be trusted. The manner in which people were talking was beginning to change by about the fth or sixth meeting. We were seeing a subtle change in the way in which the individuals expressed themselves. That is, they were able to appreciate content that was being articulated on different levels. They were able to abstract and generalize from the specic. For example, if one member complained about how little they saw of their children, others might join in with similar complaints, while yet others might suggest that their expectations were too high, or that they only felt

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that way because they could not easily go out and make new friends themselves. It was then accepted that some of the disgruntlement about younger people was that they could never replace the people that they had lost; and that some of the disaffection came from the complainers themselves. Just because everybody had lost someone of importance to them, didnt mean it hurt or mattered less. Although they would sometimes retreat into small talk if the topic became too painful, they would also recognize that that is what had happened; some people would acknowledge their part in it. Others would use platitudes rather than acknowledge painful areas. It would then require the facilitators to comment and attempt to retrieve the topic so that the speaker could be allowed their feelings. They had, overall, begun to develop a more sophisticated way of communicating whilst in the group. They appeared to do this quite rapidly. Hunter (1989) describes a similar businesslike attitude to group work with older people, who vigorously grasp the opportunity. The patients seemed to be learning by modelling, how to be reexive and to use metaphor. This was highlighted when one group member who earlier on had been sick for two months returned. She stood out from the group, not only as an outsider in the sense that she had missed many sessions but in the rather concrete manner in which she dealt with others communications. She physically removed herself from the group by twisting in her chair and looking out of the window. She communicated hurt and anger and needed to be invited back in, an experience with which others resonated individually. The facilitators commented on it from a group and from a societal level (Foulkes, 1964). Other major issues dealt with in the course of these sessions were those of bereavement and loss. The enormity of this subject often led to expressions of despair and much envy which was aimed at the two group facilitators who were notably youthful by comparison. Much of this was expressed initially by attacking doctors in general and as the theme progressed, psychiatrists in particular. The prescribed drugs never worked and the doctors did not listen and were not interested. The facilitators felt invisible and useless. Through supervision it was understood that this was how the group felt, and were conveying their feelings through projective identication. Our reection of what they were saying, seemed to help them feel heard and understood. This appeared to be the case because subsequently, as the mood and content shifted to another

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level, as in Malans (1979) deepening of rapport, the constant barrage of attacks abated. Loneliness was frequently expressed and was felt much more acutely over the Christmas break. Prior to the ending of the rst term, a lot of anger was expressed towards the facilitators and various assumptions were made about their lifestyles, as though they were both going to enjoy a family Christmas with friends in abundance. Disappointment and bitterness were often expressed in somatic terms. There were always a number of physical complaints. Exchanges would occur that were an almost grotesque parody in the accounts of who had the worst pains, the least sleep and the most medication to take. This was indeed what our patients were feeling and our task was to stay with them, although there were times when that felt very uncomfortable and occasionally unrelenting. Our tolerance of these feelings was gratefully received, but concern was expressed about our own welfare at this time, as if the burden of their collective miseries might somehow damage us.

Spring Term Ageism was apparent throughout the group. Our own ageism was perhaps most profoundly expressed in our surprise at the ease with which people took up this way of working, and how far they took it. Our own feeling about the individuals in the group had changed and we no longer saw them just as elderly patients but as people with full lives behind them and the potential for some quality of life yet. Sometimes the patients took on a very youthful quality. Once they had got over some of their original anxiety about the more negative aspects of the group, such as fear of the unknown, they became palpably excited at the prospect of trying something new. The reverse side of fear of the unknown is the excitement of the new and the prospect of a voyage of discovery in which anything could happen. The children that they had once been became more apparent and a playfulness pervaded some of the sessions. This was different from the manic quality the group sometimes took on when difcult issues were being addressed. For example, when it was suggested that H should go to a day centre in order to relieve some of her loneliness, she refused to go on the grounds that it was full of old people and the ridiculousness

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of the statement was playfully received with Well, that puts the pot on it then, doesnt it?

The Ending Throughout the groups eight-month existence there remained a confusion in everyones mind about the ending, when or indeed if it would be. The group had taken on an importance for all concerned, not least for the facilitators who were reluctant to kill it off. The group members themselves resisted the ending by putting us under pressure to continue. It was not resolved until the last few sessions. The membership of the group had changed only a little. Attendance had been good. Most sessions had 6070 percent of members. Two people left. Mrs F demanded lots of individual attention and left for the safety of other groups in the day hospital. Her need for constant attention was reminiscent of a hungry baby in its unremitting nature, and in her inability to tolerate the frustration of having to share nourishment with others. Mrs B was alcoholic and had difculty relating to other group members. She had been unable to stay with any intervention in the past. As the end approached, the members reected on what the group had meant. They reminded themselves of how they had been at the outset: their main comments were about their expectations which now seemed more realistic. We concurred and had noticed that their demands were less infantile and that we had begun to experience their needs in a less persecuted manner. Mrs E thanked us for reminding her how good it felt to help someone. She had been so wrapped up in her misery that she experienced the world in a paranoid manner; even young children in her street were experienced as hostile. She was able to see that she had closed herself off to the world, but now distressed people opened up to her, she felt it was lovely. Deafness had sometimes been a problem, both in the real sense and in our inability at times to appreciate what was said. It was remarked on that Mrs D and Mr A had both been able to hear things better when they were more relaxed. This was taken as a metaphor for feeling comfortable with oneself. From a position of greater personal strength one could be more open to other people. In the last few sessions a feeling of time running out descended upon us. Application to work intensied. The obvious parallel to

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draw was with the individuals own lives and the need to capture any opportunity, particularly as some were able to acknowledge that they had missed opportunities in the past. The group had started to recognize its own value. Mrs J said she had started to work when she saw the group coming to an end. She had nally shared her problems and the group had begun to matter to her. The facilitators wondered if the group had to end in order for people to value it. During the last session there was more denial of ending, in that people were already moving on to the next group. Mr G spoke of not feeling well and was unsure that he would be there for that future. Someone cut across him. Ending group/life is painful to hear. They spoke once more of the facilitators youth, and asked themselves how we tolerated them for so long, re-invoking their internalized ageism; or perhaps feeling that we were abandoning them after all. The content then became irtatious, with comments that made us feel that they were adolescents and we were the parents. Mr A who had been under psychiatric services for years and had received over 60 ECT treatments, had maintained an understandably jaundiced view of the proceedings. He had not engaged in any obvious way, until latterly when he had identied with others through his symptoms of anxiety and depression. He spoke of going away for respite which would have caused him to miss the group ending. He maintained until the last that he could see no reason to return. There was none except that the group wanted him to be there; and so he came.

Summary What we have described is important from several perspectives. We achieved what we had set out to do to see if a psychodynamic group could be run in a day hospital setting, taking referrals mainly from within the existing clientele. The patients were old. Most had chronic conditions which were refractory to drug treatments alone and had physical conditions which complicated the picture. Most patients showed personality traits which may have potentiated their psychiatric conditions (Abrams, 1995). None of the patients had been in this form of psychotherapy before and although they were used to being in groups, these had been of a highly structured nature. Patients were representative of

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an elderly day hospital population. The weekly attendance was good and a high proportion of patients remained in treatment until the end. During the eight months, the individuals quickly learnt the group protocol and could appreciate interpretations made on different levels without ever using therapy jargon. No assessment had been made during selection of psychological mindedness; but this appears to be something that people can learn. The stages of a therapy group as described by Yalom (1985) were evident and worked through appropriately. Perhaps because the group life was short, it was focused. Psychological work was done efciently and with great intensity, particularly as the ending drew near. The individuals did indeed take responsibility for their own attendance. We did not have to remind them of group times, as was the culture in the rest of the day hospital. With some initial hesitation, they appreciated bringing their own agenda to the group rather than relying on us to choose topics. We did not formally test psychological distress pre- and post-group as this was never our intention, but we know from patient feedback that it was valued. We would consider using this group as a template for future research groups to study process and outcome. The facilitators had no formal qualications in psychotherapy,2 but had above average experience and training. They were supervised by a consultant psychotherapist who was a group analyst. Supervision was essential in helping to maintain a thinking distance when the feelings from the group were very powerful and hard to bear.

Notes
The authors would like to thank the patients who participated in this group for trusting the group and allowing us to witness some of their struggles. We would also like to thank the staff of the day hospital for their welcome and their support. 1. The group took place during Sandra Evanss higher training in psychiatry. This involved spending up to one year in a training placement and then moving to another post. 2. Sandra Evans subsequently trained as a group analyst.

References
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Reynolds, C.F., Frank, E., Perel, J.M. et al. (1999) Nortryptiline and IPT as Maintenance Therapies for Recurrent Major Depression: A Randomised Controlled Trial in Patients Older than 59 Years, Journal of the American Medical Association 281(1): 834. Steuer, J.L. (1982) Psychotherapy with the Elderly, Psychiatric Clinics of North America 5(1): 199213. Steuer, I.L., Mintz, I., Hammen, C.I., Hill, M.A., Jarvik, L.F., McCarley, T., Motoike, P., Rosen, R. et al. (1984) Cognitive-Behavioural and Psychodynamic Group Therapy in the Treatment of Geriatric Depression, Journal of Consult & Clin Psychol. 52(2):1809. Thompson, P. (1993) I Dont Feel Old: The Signicance of the Search for Meaning in Later Life, International Journal of Geriatric Psychiatry 8: 68592. Woods, R. and Roth, A. (1996) Effectiveness of Psychological Interventions with Older People, in A. Roth and P. Fonagy (eds) What Works for Whom? London: Guilford Press. Yalom, I.D. (1985) The Theory and Practice of Group Psychotherapy. New York: Basic Books.

Sandra Evans is a Consultant Psychiatrist and Senior Lecturer at St Bartholomews and Homerton Hospitals, William Harvey House, London EC1A 7BE, UK. Paul Chisholm is Charge Nurse employed by the North East Essex Mental Health Trust at Clacton-on-Sea, Essex, UK. John Walshe is a Consultant Psychotherapist, employed by the North East Essex Mental Health Trust at Colchester, Essex, UK. Authors address: c/o Sandra Evans, 1st Floor, East Wing, Homerton Hospital, Homerton Row, London E9 6SR, UK.