The interaction of existential concerns and psychoanalytic insights in the treatment of contemporary patients

Middle-aged and elderly patients have been shown to respond to psychoanalytic treatment, but they present certain characteristic problems not typical of young patients. I discuss these and offer a brief case presentation followed by a general discussion of the role of existential concerns and of their intertwining with psychoanalytic insights and interpretations in the treatment of older patients from our contemporary culture. The particular case of a relatively mild narcissistic personality disorder is used as an example of the kinds of difficulties contemporary psychoanalysts and psychodynamic psychiatrists run into in the current treatment of the aging patient population. The analyst's beliefs and personality are seen as more important than in classical Freudian psychoanalysis, and deliberate attention to the patient's existential concerns and cultural milieu cannot be avoided. A great deal of correction of what Gedo called "apraxias" is necessary, but I argue that in this situation each person must develop one's self in one's own way and without education and intrusion by the analyst. This self development in the face of one's inevitable future is seen as a vital aspect of contemporary psychoanalytic treatment of aging patients, regardless of which of the five orientation channels (that I have discussed elsewhere) are employed. The patient is seen as dealing both with his or her own infantile neurosis that is interfering with adult functioning and at the same time with universal existential human problems that become increasingly pressing as one ages. I contend that the current biological orientation of psychiatry is insufficient to address these difficulties, regardless of what advances we make in psychopharmacology and neurobiology. An exclusive neurobiological orientation can represent what existentialists label an "inauthentic choice" and a retreat from the spirit of humanism.