Cognitive Changes and Implications for the Therapeutic Encounter



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.


Memory Impairment Vascular Dementia Severe Dementia Memory Problem Therapeutic Encounter 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Aldwin, C. M., & Gilmer, D. F. (2004). Health, illness, and optimal aging: Biological and psychosocial perspectives. Thousand Oaks, CA: Sage.Google Scholar
  2. Allegri, R. F., Glaser, F. B., Taragano, F. E., & Buschke, H. (2008). Mild cognitive impairment, believe it or not? International Review of Psychiatry, 20(4) 357 – 363.PubMedCrossRefGoogle Scholar
  3. American Psychiatric Association, (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington DC: Author.Google Scholar
  4. Balfour, A. (2006). Thinking about the experience of dementia: The importance of the unconscious. Journal of Social Work Practice, 20(3), 329–346.CrossRefGoogle Scholar
  5. Balfour, A. (2007). Facts, phenomenology, and psychoanalytic contributions to dementia care. In R. Davenhill (Ed.), Looking into later life: A psychoanalytic approach to depression and dementia in old age (pp. 222- 247). London: Karnac.Google Scholar
  6. Benoit, M., Clairet, S., Koulibaly, P. M., Darcourt, J., & Robert, P. H. (2004). Brain perfusion correlates of the apathy inventory dimensions of Alzheimer's disease. International Journal of Geriatric Psychiatry, 19(9) 864–869.PubMedCrossRefGoogle Scholar
  7. Cheston, R., Jones, K., & Gilliard, J. (2003). Group psychotherapy and people with dementia. Aging and Mental Health, 7(6), 452–461.PubMedCrossRefGoogle Scholar
  8. Crook, T., Bartus, R. T., Ferris, S. H., Whitehouse, P., Cohen, G. D., & Gershon, S. (1986). Age associated memory impairment: Proposed diagnostic criteria and measures of clinical change. Report of a National Institute of Mental Health work group. Developmental Neuropsychology, 2, 261–276.CrossRefGoogle Scholar
  9. Davenhill, R. (2007). Looking into later life: A psychoanalytic approach to depression and dementia in old age. London: Karnac.Google Scholar
  10. Davis, J. D., & Tremont, G. (2007). Impact of frontal systems behavioral functioning in dementia on caregiver burden. Journal of Neuropsychiatry and Clinical Neuroscience, 19, 43–49.CrossRefGoogle Scholar
  11. Diokno, A. C., Brock, B. M., Herzog, A. R., & Bromberg, J. (1990). Medical correlates of urinary incontinence in the elderly. Urology, 36, 129–138.PubMedCrossRefGoogle Scholar
  12. Fillit, H., Nash, D. T., Rundek, T., & Zuckerman, A. (2008). Cardiovascular risk factors and dementia. The American Journal of Geriatric Pharmacology, 6(2), 100–118. Retrieved January 6, 2009, from doi:10.1016/j.amjopharm.2008.06.004CrossRefGoogle Scholar
  13. Flegal, K. M., Carroll M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and trends in obesity among U.S. adults, 1999–2000. Journal of the American Medical Association, 288, 1723–1727.PubMedCrossRefGoogle Scholar
  14. Kannel, W. B., Dawber, T. R., Kagan, A., Revotskie, N., & Stokes, J. (1961). Factors of risk in the development of coronary heart disease: Six year follow-up experience. The Framingham Study. Annals of Internal Medicine, 55, 33–50.PubMedGoogle Scholar
  15. Muslin, H. L. (1992). The psychotherapy of the elderly self. New York: Brunner/Mazel.Google Scholar
  16. Nordhus, I. H., Nielsen, G. H., & Kvale, G. (2007). Psychotherapy with older adults. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp. 289–311). Washington DC: American Psychological Association.Google Scholar
  17. Rosenberg, P. B., & Lyketsos, C. (2008). Mild cognitive impairment: Searching for the prodome of Alzheimer's disease. World Psychiatry, 7(2), 72–78.PubMedGoogle Scholar
  18. Salthouse, T. A. (2007). Cognitive and information-processing perspectives on aging. Psychotherapy with older adults. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp.49–59). Washington DC: American Psychological Association.Google Scholar
  19. Sinason, V. (1992). Mental handicap and the human condition. London: Free Association.Google Scholar
  20. Turnbull, O.H., Zois, E., Kaplan-Solms, K., & Solms, M. (2006). The developing transference in amnesia: Changes in interpersonal relationship, despite profound memory loss. Neuro-psychoanalysis, 8(2), 199–204.Google Scholar
  21. Vicario, A. (2008, July). Hypertension, memory and frontal lobe disability. Paper presented at The International Neuropsychological Society, Sociedad de Neuropsicologia de Argentina, Symposium 2: Cognitive Disorders in Vascular Patients: A Multidisciplinary Approach, Buenos Aires, Argentina.Google Scholar
  22. Vicario, A., Martinez, C.D., Baretto, D., Diaz Casale, A., & Nicolosi, L. (2005). Hypertension and cognitive function: Impact on executive function. Journal of Clinical Hypertension, 7(10) 598–604.PubMedCrossRefGoogle Scholar
  23. Watkins, R., Cheston, R., Jones, K., & Gilliard, J. (2006). “Coming out” with Alzheimer's disease: Changes in awareness during a psychotherapy group for people with dementia. Aging and Mental Health, 10(2), 166–176.PubMedCrossRefGoogle Scholar
  24. Werner, P., & Korczyn A. (2008) Mild cognitive impairment: Conceptual assessment. Clinical Interventions in Aging, 3(3), 413–420.PubMedGoogle Scholar
  25. Whitbourne, S. K. (2001). Physiological aspects of aging: Relation to identity and clinical implications. In B. Edelstein (Ed.), Clinical Geropsychology (pp. 1–24). Oxford: Elsevier Science.Google Scholar
  26. Whitbourne, S. K. (Ed.). (2005). Adult development and aging: Biopsychosocial perspectives. New Jersey: John Wiley & Sons.Google Scholar
  27. Whitbourne, S. K. (2007). Physical changes in the aging individual: Clinical implications. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical geropsychology (pp. 79–108). Washington DC: American Psychological Association.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of CaliforniaSan FranciscoUSA

Personalised recommendations