Neuroses and character disorders

This paper emphasizes the importance of understanding and treating the aged with neuroses and character disorders. Although they are often neglected by mental health workers, the aged with these emotional problems form a far larger group than the psychotic aged who receive a greater share of attention. Stereotyped attitudes and commonly accepted myths regarding the aged encourage an attitude of therapeutic nihilism and pessimism. The unconscious motivation for ignoring the obvious distress of older people is discussed. Certain specific myths, such as the "rigidity" of the aged and the tendency to "wastebasket" and to view all pathology as organic or caused by aging alone, are discussed. The fear of the devouring older person is also explored, as well as the myth of "family rejection." A number of clinical examples are given of the types of emotional problems frequently seen among the noninstitutionalized older population. Each case is described from the standpoint of dynamic understanding and management. A trial of observation and psychotherapy is recommended in all situations, since even "organic" signs may be reversed. Generalizations concerning the aged as a group are avoided in the belief that they lead to further stereotyping and the discouragement of scientific investigation. Individual assessment and understanding are emphasized. The persistence of unconscious attitudes, fantasies, and wishes from childhood is pointed out, but it is emphasized that they may not always carry the same value and meaning throughout life. Certain patients achieve insight through treatment, along with a greater capacity to enjoy life than they had before. Others are comforted by the relationship with the therapist for both its "real" and unconscious meanings. Some require assistance in accepting and tolerating more regressive behavior, while others need help in accepting and assimilating their changing feelings about their goals, objects, and sexuality in old age. Reminiscences are emphasized as important sources of elevating self-esteem. Concerns about death and common countertransference problems in work with the aged are examined. The need to be flexible but not to "lean over backward" is emphasized. Patients understand a genuine offer of involvement and concern as the most precious gift.