Cognitive Changes and Implications for the Therapeutic Encounter

Abstract

Traditional 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 appropriate, and 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 this controversy as well as other considerations in treating adults with cognitive difficulties. I will discuss some of the main cognitive issues that arise in treating older adults as well as exciting research within contemporary psychodynamics, which pertain to cognitively impaired populations. First, I will provide a context for this discussion by describing common presentations of dementia. I will also delineate some of the medical issues typical in older adults, as these symptoms, though not disabling for many, inevitably change aspects of the therapeutic encounter and are a focus of clinical attention. Finally 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.