Group-analytic approaches for the elderly

Dr Kalliopi Panagiotopoulou

A version of this paper was presented at the 11th Hellenic Congress of Alzheimer Disease (PICAD) & the 3rd Mediterranean Congress of Neurodegenerative Disorders (MeCoND), 14-17 February 2019, Thessaloniki, Greece.

Abstract

Recent epidemiological studies demonstrate a shift in the upcoming years towards the growth in the number of older people as a percentage of the population. This is due to a combination of low birth rates and rising life expectancy. As healthy people age, neuropsychological evidence points to a progressive increase in cognitive function deterioration and in depression rates, this being worse if different types of dementia occur. Various supportive therapeutic groups (such as art therapy, yoga, existential, etc.) have been shown to be helpful in alleviating these symptoms. Group-analytic psychotherapy has been applied in homogeneous groups to members suffering from mild dementia as well as to healthy older people. It has also been applied in heterogeneous groups with members of different ages. This challenging procedure is difficult but fruitful and will hopefully become even more effective in the future. With the following characteristics, many among the elderly are able to benefit from a group-analytic group: a willingness to change; an ability to show empathy; a desire for interpersonal engagement; a curiosity about the unconscious; and a capacity to learn from transferential role relationships in the therapeutic group. There is a long standing stereotype inhibiting the elderly from being accepted in a group-analytic group, which is related to: the likely arousal of the fear and anxiety of death within the group; the possibility of negative transference occurrence; the regression to archaic defenses such as splitting and preverbal psychotic reactions, ultimately leading to the drop-out of some members. Nevertheless, evidence suggests that the working process in a group-analytic group can be effective in inducing here-and-now changes for people of all ages. Moreover, the preventive use of group analysis in the middle-aged population may contribute to a reduction in the dementia onset rate in the elderly while providing, at the same time, significant value and importance to old age, through investing senility with meaning.

Key Words: group analysis for the elderly, dementia, prevention.

Introduction

Literature Search Results

Various supportive therapeutic groups (such as art therapy, yoga, existential, etc.) have been helpful in alleviating these symptoms (Rusted et al., 2006). Group-analytic psychotherapy has been applied in homogeneous groups to members suffering from mild dementia as well as to healthy older people. It has also been applied in heterogeneous groups with members of different ages (Anderson, 2011; Hadar, 2017; Moss, 2017).

Dignity in old age and the social perspective of ageing

Old people want and deserve to be treated with dignity. Alternative approaches to the care of old people need to be provided. Dignity appears to have as a concept a broad utility in expressing a shared social understanding of the status of old people (Agich, 2007). Recently, a remarkable shift in thinking about old age has gradually occurred. Contradictory messages about how ageing is viewed in contemporary society are enunciated. Structured dependency theory suggests that ageing mostly arises from social practices rather than physiological parameters. There is a contradiction between the desire for rejuvenation – promoted by people’s lately increasing tendency to reward only appearance – and the acceptance of finitude. The need for restoration of a social meaning to the final stage of life through social networks and social support emerges (Gilleard and Higgs, 1998). Intergenerational programs for improving young people’s personalized attitudes toward old people ameliorated their acceptance of old people (Couper et al., 1991). Old people, as culture bearers, can contribute to society and to the education of youngsters by writing about and presenting their life experience in schools, thus adding to a bridging of the generation gap (Beverfelt, 1984). In order to achieve successful and resourceful ageing, strategies to combat stereotypes and negative images of ageing are needed (Angus and Reeve, 2006).

Attachment capacity in the elderly and its impact on depression; Correlation between depression and dementia.

Epidemiological data support the hypothesis that oxytocin may have an attenuating effect on perceived stress to adverse life events in old age. Among 952 participants, 65-90 years old, who reported minimal suffering, insecure individuals had lower oxytocin than securely attached individuals (Emeny et al., 2015). Depression in older adults is associated with increased risk of suicide, physical illness and disability, life events, anxiety, social isolation, loneliness, death wishes, depressed mood, loss of interest, pessimism, cognitive and functional impairment and dementia (Rodda et al., 2011; Anderson, 2001; Belvederi et al., 2018). A generalized intersecting type of chronic inflammation seems to describe the pathological background of depression and cognitive deterioration.

Age-associated cognitive decline; Cognitive reserve in ageing and implications for intervention.

A population heterogeneity exists as far as it concerns cognitive decline in the elderly. Factors affecting general bodily ageing also influence cognitive functions in old age. Biological processes such as inflammation, neurobiological changes, diet and lifestyle, as well as genetics contribute to individual differentiation in cognitive decline (Hayden et al., 2011; Deary et al., 2009). The cognitive reserve hypothesis states that individual differences in how tasks are processed provide reserves against brain pathology; this continues to evolve across the lifespan, thus allowing promising interventions (Tucker and Stern, 2011). In further corroboration, ‘the whole nervous network emerges according to the model of the group matrix that is in a continuing situation of changing process called plasticity (brain plasticity, cellular and neuronal plasticity) according to the internal and external stimuli of the environment (social brain)’ (Mela, 2009). Moreover, it has been shown that in old patients who underwent combined individual and group psychotherapy a reduction in the blood cytokine levels occurred, leading to a regulation of IL-1, to the reduction of the CRP blood levels and to the amelioration of the levels of cortisol, resulting in better regulation of brain inflammation (Mela, 2019).

Focus group

A focus group was held with the objective of studying the therapists’ views of the role of inpatient analytic psychotherapy groups for older people with dementia. The four group facilitators interviewed described the intra-, inter- and extra- personal impacts of the groups. The group increased the capacity and desire to communicate and belong through enabling and enhancing communication, emphasizing common humanity, facilitating the expression of emotion and combatting isolation by promoting a sense of belonging: everybody needs a group (Perren and Richardson, 2018).

Group Analysis in old age

The World Health Organization (WHO) determines elderliness as the reduction in the competency to accommodate environmental factors (WHO, 1992). There is growing evidence that an integrated model of group analytic psychotherapy may prove valuable and effective in alleviating the difficulties encountered by the elderly. The main objectives of an incorporated approach include: stabilization of the individual’s sense of self; establishment of interpersonal competence; and enhanced mastery over the affects of depression and demoralization (Leszcz, 1990). Late middle age (55-67 years) is a critical period suitable for group psychotherapy, as the loss of important sustaining figures often creates a state of true isolation, so the group provides mental activity and meets a wide variety of needs (Ezquerro, 1989).

A psychodynamic-supportive group therapy model was introduced for elderly Holocaust survivors, who confronted the problems of old age combined with those of the experienced trauma, aiming at the improvement of the patients’ homeostasis as well as enhancement of their ego functions and adaptation to inner and outer worlds (Müller and Barash-Kishon, 1998). Group psychotherapy of a population of men, aged 70-95 years, resident in a home for the aged, addressed social isolation, depression, and demoralization. Technical modifications, like high therapist activity and support, therapeutic transparency, translation and integration, were adapted by the leader so as to facilitate the process. The following psychodynamic aspects of ageing were elaborated: living in an institution; the role of the life review; narcissism; the efforts to maintain self-esteem and a sense of self (Leszcz et al., 1985). An older adults group established on a short-term psychiatric unit helped the aged patients to make restitution for losses and regain self-esteem through renewed engagement with their environment. Cohesion and inclusion in the group were important (Sorensen, 1986).

A dynamic group for elderly chronically mentally ill patients ran within a day hospital setting. The authors concluded that psychological mindedness can be learnt as part of the process, whereas dependency issues can be confronted through facilitation of increased autonomy and self-esteem (Evans et al., 2001). An older adults group established on a short-term psychiatric unit aimed at helping the aged patients to restitute their losses and regain self-esteem through renewed engagement with their environment (Settlage, 1996). A one-hour weekly closed group for those in mild stages of dementia, experiencing psychological difficulties as a result, was held in an outpatient psychotherapy department setting, between the end of 2009 and the start of 2010. According to the author, the skill of the conductor is being able to hold a therapeutic frame and to balance it alongside psychiatric, nursing, social and medical needs (Anderson, 2011).

A group analytic group for people over sixty, that started in 2010, exemplifies that there is hope and ability for change at any age (Hadar, 2017). A case study of an elderly person successfully joining a group analytic group with younger members shows that often age stereotyping and prejudice deprive older people from dynamic psychotherapy (Moss, 2017). The suitability and ability of elderly individuals for psychoanalytic treatment has been shown (Quinodoz, 2009; Grotjahn, 1978).

The above data confirms the effectiveness of group analytic groups – either homogeneous or heterogeneous – both in the prevention and management of the psychological needs of the elderly, whether they are healthy or suffering from depression, mild dementia, and other mental diseases.

Discussion

‘When is a patient too old for therapy?’ According to Martin Grotjahn, ‘a patient is never too old for therapy, especially for group analysis – assuming no organic condition makes communication impossible’. Inclusion in the group is imperative for the restoration of the narcissistic trauma engendered by the losses inherent in the ageing process. Many issues (loneliness, despair, depression, sickness, the feeling of being deserted by loved ones, dissatisfaction with doctors and nurses, dealing with acquaintances, the death of friends, fear of death) are addressed in the group analytic group, leading to insight, correction, integration of past-life experience into final identity formation and a new start. Providing group analytic psychotherapy to the elderly represents also a challenge for the therapist, as he should either be old himself or understand countertransference (Grotjahn, 1989; Schramm, 2018). Attention must also be drawn to the ageing of group therapists themselves and the need for processing this issue. Becoming older enhances wisdom through experience, while, at the same time, decline is inherent in elderliness. Changes in parent-adult-child relationships as the parent ages can be examined in groups. Countertransference is a significant topic to be addressed, in order to achieve better therapeutic results. The conductor who has worked through his own concerns and fears about ageing and better comprehends his own counter-transference towards old people while acknowledging his attitude towards his own grandparents or ageing parents – dead or alive – can use the strong personal reactions occurring on both sides – younger and older members of the group – to move the group and individual members forward in their efforts to grow (Moss, 2017; Quinodoz, 2009; Schramm, 2018; Koukis, 2016).

The manner of conducting group analytic groups with elderly members also constitutes a significantly important theme. There are times when it may be more effective for the therapist to act as a leader, particularly given that groups including the elderly can often be regressed to the primordial level, revealing archaic anxieties and fear, calls upon the therapist initially to be a more directive guiding authority, representing the imago of the primal father – worthy of admiration and satisfying the dependency needs of members – whereas at other times he needs to be more of a conductor, as the most experienced member of the group (Koukis, 2016). It is ultimately through this attitude, that cohesion in the group will be enhanced, redounding in the working process and an elaboration requisite for the here-and-now resolution of the challenges confronted.

Many among the elderly are able to benefit from a group-analytic group, particularly when equipped with a willingness for change; an ability to show empathy; a desire for interpersonal engagement; a curiosity about the unconscious and the role of transferential relationships in the therapeutic group. The group provides the opportunity: to complete developmental tasks; to address unresolved conflicts of the past; to elaborate anxieties about ageing, physical deterioration, retirement, the empty nest syndrome, dependence, fragility and death; to explore new possibilities of accomplishing dreams and wishes unrecognized or unrealized beforehand. Moreover, the presence of an elderly member in the group is rewarding for younger members, as they take advantage of understanding and processing issues of life and death, in relating their present problems with earlier stages of an elderly person’s life with regard to interpersonal engagement with others and involvement with groups, in clarifying matters of intimacy with their own family, in working through negative themes characteristic of their own parents (Anderson, 2011; Hadar, 2017; Moss, 2017; Schramm, 2018, Valenstein, 2000).

Psychodynamic approach

There is a longstanding stereotype and prejudice inhibiting the elderly from being accepted in a group-analytic group. It relates to: the likely arousal of fear and anxiety of death within the group; the possibility of negative transference occurrence; the regression to archaic defenses such as splitting and preverbal psychotic reactions, ultimately leading to the drop out of some members. (Anderson, 2011; Hadar, 2017; Moss, 2017; Sorensen, 1986; Settlage, 1996; Schramm, 2018; Koukis, 2016; Valenstein, 2000).

In therapeutic groups for psychotic patients a psychotic transference often arises, leading members to withdrawal tendencies, expressed as exclusion or undifferentiated engagement of themselves. A group where an old member is included might similarly provoke a psychotic-like transference, due to narcissistic loss and injury, regression and activation of archaic defenses, such as splitting, projective identification, scapegoating phenomena, sub-grouping, anti-group situation, thunderous silence (Moss, 2017; Settlage, 1996; Koukis, 2016; Wheelock, 1997; Mitchell, 2018).

Unfamiliar questions emerge when dealing with the elderly. Adequate functioning and adaptation subsides, allowing ineffective defense structures to predominate and primordial patterns to emerge. Object loss and bereavement may be overwhelming, resulting in grief, depression, anxiety, leading to deprivation of the individual from attachment, thus culminating in loneliness. Undesired changes in family structure, role expectations, living situations, for instance, parent-child relationships, are difficult to tackle. The fear of dependency alters all interpersonal relationships. Narcissistic losses, such as lower physical strength and potency, changes in appearance, cognitive deterioration, and loss of professional identity, all affect one’s sense of self, lowering self-esteem and contributing to depression and anxiety. Memory disruption in particular, evokes in the aged the feeling of helplessness in the face of the definitive deletion of crucial life-events from their mind, as if they were never lived (Wheelock, 1997).

Visible physical disability causes discrimination and shame, via projection and splitting, mobilizing mechanisms registered in the social unconscious (Mitchell, 2018). In a parallel way, visible ageing may provoke shame in the individual, simultaneously diverting all the projections of the group towards the old person. This is due to deeply primitive feelings and defensive denial, frequently of a primordial, psychotic nature (Clarisse et al., 2018; Wheelock, 1997; Mitchell, 2018). The group mirrors negative societal attitudes towards old age. It is the working process of the group, enabled by the leader that will shed light on the location of the disturbance, mainly in the group, not in the member, gradually promoting cohesion and containment, acceptance of difference and of individuality, as well as enrichment of the communication network and maturation of the matrix.

The challenging procedure of group-analytic psychotherapy with the elderly is difficult but fruitful and will hopefully become even more effective in the future. It is desirable for more group analysts to be engaged in such groups, offering their experience and wisdom, so as to evolve our technique in order for it to be more beneficial for elderly members. Without ignoring the therapeutic impact of homogeneous groups, it seems that the participation of an elderly member in a heterogeneous group – composed of members of different ages, genders and diagnosis, as a reflection of society – may enrich the network of communications, mirrors, relationships and transferences, thus provoking therapeutic insight, emotional ripening and change.

Prevention

Middle age has been identified as a period of critical importance for health in later life. Especially as far as brain health is concerned, a precursory period seems to exist, possibly up to twenty years before the onset of neurodegenerative diseases. It is assumed that the age of onset depends upon pathophysiological alterations and cognitive decline, which may occur during middle age (Schubert et al., 2019). It seems that chronic systematic inflammation during middle age, via its early pathogenic role, may trigger cognitive decline in the next decades of life (Walker et al., 2019). Stress increases the cortisol levels circulating in the blood and is linked to negatively influencing total brain volume and memory during middle age (Echouffo-Tcheugui et al., 2018). Psychological distress in middle age is a risk factor for the later development of dementia (Islamoska et al., 2019). Loneliness is associated with an increased risk of the occurrence of dementia due to higher chronic inflammation, secondary harmful behaviours (alcohol intake, sedentary life), and the lack of meaningful social interaction (Sutin et al., 2018). The feeling that life is worthwhile and full of beneficial activities (healthy lifestyle choices, such as natural exercise, consummation of fruits and vegetables, sleep quality, smoking and alcohol avoidance, etc.) enhances healthy ageing and preserves the important social relationships and the optimal exploitation of time during old age (Ezquerro, 1989; Steptoe and Fancourt, 2018).

The preventive inclusion of middle-aged people in group-analytic psychotherapy groups would be helpful and effective as far as it concerns the processing of issues correlated to stress, depression, loneliness and isolation, thus protecting brain function and mental health in old age. Certainly, more prospective studies are needed in order to prove this reasoning and to use group analytic psychotherapy as a preventive therapeutic tool for protection from dementia.

Clinical vignette

Menelaos, a sixty-nine-year-old medical doctor, entered a heterogeneous outpatient group-analytic group conducted by the author, at the 79^th session, complaining about his recently diagnosed Parkinson’s disease that resulted in major life changes with subsequent mild dementia expressed mainly as memory decline, anxiety and depression. His wife and three adult sons were unable to understand his problem and regretted him not looking after them anymore as he did before. His realization that his friends sometimes avoided him was painful and his attempt to seek out empathy from childhood companions in his small island of origin, on the Aegean Sea, was not very successful. His entrance in the group was marked by hesitation, reserve and suspicion from the other members. Initially they felt haunted by his visible disability and old age; they projected negative parts of themselves towards him and the fear of death was palpable. Some identified with their own parents, long dead from the same disease; others saw an unwanted future before their eyes. Instead of returning the hostility he engaged his humour and sharp tongue in the group’s interactions, opening thus a new refreshing way of looking into things. As time went by the other members started to ask him more personal questions. He declared the loss of his professional identity as the most painful event he was obliged to deal with. From that moment on they tried to offer him new tasks asking for his opinion and guidance for different problems, which he happily assumed, even with a tone of absolutism deriving from his life experience, which interestingly triggered lively confrontations that were therapeutically effective. When he announced becoming seventy years old the group asked for a life narrative where the difficulties of the past were unfurled in a touching, simple and sincere manner. A kind of historicity and factuality was brought in the group and the members felt emotionally nearer to the obstacles that their ancestors – frequently blamed for every problem the members confronted – had to overcome. The group realized that there was time enough for them to deal with their life issues but, at the same time, this working through could not wait forever, since a visible end of lifespan exists. Interestingly, the other members internalized and embraced his pain and traumatic experiences altering them to their own and deploying them for their evolution. This processing strengthened the group emotionally, leading to its maturation and adulthood on the one hand and on the other, offering Menelaos insight and a recourse in order to compromise and seek comfort to whatever was now manageable and feasible. The group-as-a-whole was now – 104^th session – functioning as an extended family, resulting in useful psychic movement, change and life decisions for all its members.

Conclusions

Accumulative research evidence suggests that the working process in a group-analytic group can be effective in inducing here-and-now changes for people of all ages. The effectiveness of group analysis in the management of the challenges and mental difficulties emerging in the elderly population is described in various studies. Heterogeneous groups are preferable since they reflect society and its diversity. Moreover, it is considered that group analysis is helpful in preventing the manifestation of psychological symptoms in old people, should it be implemented in advance in middle-age. The role of the leader is essential in group-analytic groups including aged members – he must become an actively energetic, directive, guiding figure, in order to promote coherence and facilitate communication.

The concept of ageing is consistent with the sense of time, often fleeting from a precise description. Time can be a connector. A human life of whatever length may be seen as a period of time complete in itself (Maratos, 2003). And insight outreached: we, humans, thrive in groups.

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Dr Kalliopi Panagiotopoulou, MD PhD
Allergist & Clinical Immunologist, Group Psychotherapist, Trainee in Group Analysis, Student Member of IAGP, Voluntary Conductor of Groups of People suffering from Mental Disease
panagiotopouloukp@gmail.com