Approaches of psychoanalysis in the care of the elderly: an integrative review

Santos, Álvaro da Silva; Albino, Araceli; Santos, Vitória de Ávila; Granero, Gabriela Souza; Barros, Maria Teresa Mendonça de; Farinelli, Marta Regina

doi:10.1590/1981-22562018021.180149

Abstract

Objective:

to map publications about the clinical psychoanalytical care of the elderly and describe their characteristics.

Method:

an integrative review was carried out, considering the period 2008 to 2017 using the following databases: Index-Psychology, LILACS, MedLine, PubMED, SciELO and RedALyC, irrespective of language. The terms Elderly (Idoso), Aging (Envelhecimento) and Psychoanalysis (Psicanálise) were used. The guiding question was: what scientific literature exists about the elderly and psychoanalytical clinical care? A total of 33 articles were considered.

Results:

five categories were constructed: "Elderly clinical care with a psychoanalytical approach" (15), "Psychoanalytical Approaches in old age” (9), "Psychoanalytical Interventions in long-term care facilities" (6), "Representations of old age for health professionals in the light of psychoanalysis" (2) and "Generationality and psyche" (1). The concern of psychoanalysis for the elderly is incipient and precedes epistemological issues, meaning that production regarding clinical practice is greater; in turn, there are fewer research studies, as most of the articles are reflective in nature.

Conclusion:

the published studies indicate the possibility of employing psychoanalysis with the elderly, as the unconscious does not age and symptoms are continuously updated. The timidity of psychoanalysis in contrast to the increase in the numbers of elderly persons may be criticized. It is also emphasized that the losses, the effects on the body and the reduction of social ties require adjustments in clinical care, such as the inclusion of group activities and activities beyond the analytical setting, especially hospitals, homes and LTCFs.

Keywords:
Aged; Psychoanalysis; Health of the Elderly; Old Age

[1] Correspondence
Álvaro da Silva Santos alvaroenf@hotmail.com

Title	Proposal of Study	Synopsis
Care of the elderly as an intersubjective field: ethical reflections ⁸8 Cherix K, Coelho Júnior NE. O cuidado de idosos como um campo intersubjetivo: reflexões éticas. Interface. 2017;21(62):579-88..	Reflection on the care of the elderly with a basis in intersubjectivity.	Four types of intersubjectivities were described: transobjective (difference between the Self and the Other), traumatic (the other in a constitutive and traumatic relationship), interpersonal (symmetrical/horizontal relationship between the Self and the Other) and intrapsychic (based on psychoanalytic theory - the relationship between the Self and its introjected psychic objects). The ethics of caring is described in the sense that the elderly should assume self-care as much as possible.
Clinical Considerations The psychoanalysis of aging in the SUS: the CRI-Norte⁹9 Genaro Junior F. Considerações sobre a clínica psicanalítica do envelhecimento no SUS: o CRI-Norte. Mais 60. 2016;27(66):20-45..	Experience Report on the management of a Winnicottian psychoanalytic clinic in the SUS.	The use of brief psychodiagnosis and individual and group psychotherapy and thematic therapeutic groups. The dependence of humans themselves is described. The valorization of feeling oneself in the cycle of real life, and being alive (in Winnicotti), which is beyond the determinism of diseases.
Aesthetics and poetics of old age in autobiographical narratives: a study in the light of psychoanalysis ⁵5 Lima PMR, Viana TC, Lima SC. Estética e poética da velhice em narrativas autobiográficas: um estudo a luz da psicanálise. Estud Pesqui Psicol. 2015;15(1):58-78..	Reflection on autobiographical writing as a technique.	Autobiography is defended as a technique for proposing sublimation, desexualization, and the use of written words to give vent to the drives of the elderly. The use of group workshops in which the elderly recall facts for the resignification of identity and the remaking of their social place and relations is described.
Directing clinical treatment of the elderly¹⁰10 Mucida A. Direção do tratamento na clínica com idosos. Rev Bras Ciênc Envelhec Hum. 2015;12(3):245-55..	A reflection on psychoanalytical care for the elderly, focusing on the symptom.	Analysis is performed with the unconscious which does not age and not with the aged body and, as such, the symptom brings up to date the inscribed marks. There are no symptoms of the old but rather old symptoms, which are primary marks. Many elderly people have many bodily symptoms that are a form of pleasure, of weaving a bond with the "other”.
Psychoanalysis and aging: clinical considerations¹¹11 Silva JM, Moreira JO. Psicanálise e velhice: considerações clínicas. Ciênc Téc Vitiv. 2015;30(2):238-56..	Case study with elderly woman in panic syndrome and "delicate surgery”.	After surgery, the elderly woman requested medical care, since she now has an "artificial organ". This "signifier" referred to existential questions. The analytical work allowed resignification and the search for activities to give meaning to her life.
Older Adults and psychoanalytic treatment: it’s about time¹²12 Plotkin DA. Older adults and psychoanalytic treatment: it's about time. Psychodyn Psychiatr. 2014;42(1):23-50..	Case study with elderly woman hospitalized in a Geriatric Psychiatry Clinic.	Analysis sessions three times a week for 18 months in the hospital and then for three further years after discharge. Transfer was observed with the patient feeling herself motivated to change, tolerant towards her frustrations and searching for new meanings in life.
Winnicotti and the challenge of care for elderly patients in a confused state¹³13 Fontoni MR, Oliveira WL, Kaneta CN. Winnicotti e o desafio do atendimento a pacientes idosos em estado confusional. Psicol Saúde Doenças. 2014;15(3):816-27..	Qualitative research with categorization performed with four elderly women in a confused state, in an orthopedic hospital.	Two categories were elucidated: "characterization of the clinical picture" and "performances of the Psychotherapist". In the former the patients suffered attention and consciousness disturbances, memory loss and confusion. In the second category, the condition of the patients prevented traditional analysis using holding, from the perspective of reception and support. Like with the care of the psychotic, listening, reception, guidance for the family and team had an effect.
Special problems for the elderly psychoanalyst in the psychoanalytic process¹⁴14 Chessick RD. Special problems for the elderly psychoanalyst in the psychoanalytic process. J Am Psychoanal Assoc. 2013;61(1):67-93..	Reflection on the special conditions of elderly psychoanalysts in the therapeutic process.	The condition of the elderly psychoanalyst as a context requires awareness of his or her existence and continuous monitoring of transference and countertransference, avoiding silent, dangerous and unconscious interaction with his or her patients.
Psychoanalysis and old age: are the elderly obsolete¹⁵15 Castilho G. Psicanálise e velhice: o idoso é obsoleto? Trivium. 2012;4(2):48-58..	Psychoanalytical reflection on the elderly in a University hospital outpatient clinic.	The patient gives authenticity to his or her illness as much as he or she can, and the doctor contributes to this antidepressants that instead of "elaborating his or her context" makes the patient numb. In the analytic perspective, pain, recurrent falls, forgetfulness should be seen in the elderly in the subjective dimension.
Pour une approche intégrative de la maladie d’Alzheimer: pertinence et limites¹⁶16 Pierron-Robinet G. Pour une approche intégrative de la maladie d'Alzheimer: pertinence et limites. Geriatr Psychol Neuropsychiatr Vieil. 2012;10(1):73-81..	Reflection of the need to combat Alzheimer's beyond neurological issues.	The concept of a memory trait from psychoanalytic and neuropsychological theories is described. Forgetfulness in Alzheimer's disease may be a defense mechanism that is rooted in a "desire for forgetfulness" associated with traumatic loss, leading to real psychic suicide.
Aging in the light of psychoanalysis⁴4 Altman M. O envelhecimento à luz da psicanálise. J Psicanál. 2011;44(80):193-206..	Reflection on losses experienced by the elderly.	Argues that the age of neurosis is more important than chronological age, necessitating the elaboration of loss, mourning, and reinventing life.
The aging of Anna Freud's diagnostic profile: a re-examination and re-application of the psychoanalytic assessment for older adults¹⁷17 Chase C. The aging of Anna Freud's diagnostic profile: a re-examination and re-application of the psychoanalytic assessment for older adults. Psychoanal Study Child. 2011;65:245-74..	Case study of the applicability of the Anna Freud diagnostic profile in the elderly	Case study of a 70-year-old woman using Ana Freud's diagnostic profile technique for greater clarity, intrapsychic diagnosis or understanding.
The workshop of letters, photographs and souvenirs as a group psychotherapeutic intervention with the elderly¹⁸18 Gil CA, Tardivo LSPC. A oficina de cartas, fotografias e lembranças como intervenção psicoterapêutica grupal com idosos. Mudanças. 2011;19(1-2):19-30..	Winnicottian psychoanalytic research, developed in a group of six elderly people.	The mediating materiality was used. Patients were invited to bring letters, photographs, or other souvenirs. There were 16 weekly meetings of 90 minutes each. The objects were placed on a magnetic board and the group talked about what they brought up. They were then photographed and recorded for a new memory. The socialization of the meanings of the objects allowed affective exchanges and projection of the future.
Clinical observations on the value of reminiscences in the aging process¹⁹19 Santos SS, Carlos AS. Observações clínicas sobre o valor das reminiscências no processo de envelhecimento. Barbarói. 2011;35:128-40..	Case study with a 89-year-old woman on historical reminiscences that broke the barrier of repression .	The children (50 years old or older) ask the elderly woman to reveal past love stories that involved guilt caused by religious values. She has a "blackout" and a spell of anger and crying. In the past, her husband died and she was left with five small children, experiencing moments of depression and suicide attempts. The analysis took around two months with two sessions per week, and conflicts over the forbidden themes emerged, giving way to a reconciliation with herself, showing that there is no time limit for the return of repressed memories.
Psychoanalytical diagnostic²⁰20 Bodni O. Diagnóstico psicoanalítico. Subj Procesos Cogn. 2010;14(2):1-14..	Case study with David Libermam Algorithm (DLA) psychoanalytic diagnosis.	The case presented is of an elderly writer, and relates to fragments from an interview about a dream and a literary work, with drive stagnation and various physical (respiratory) symptoms. Phallic genital eroticism and intra-somatic libido fixation is demonstrated in a poem. In the dream there is a smaller and dramatic intra-somatic component. The interview focuses on economic issues, the will to live and breathe the air on a ranch. The DLA is cited as an instrument that orders words, phrases, rhetoric, narratives, intonations and provides the semiological ordering of discourse.

Títle	Study Proposal	Synopsis
The silencing of old age: social erasure and processes of subjectivation²¹21 Rosa MC. Vilhena J. O Silenciamento da velhice: apagamento social e processos de subjetivação. Rev Subj. 2016;16(2):9-19..	Reflection on subjectivities of the aged body and social imaginary.	Prejudice as everyday attitudes: social exclusion, subjective erasure, disinterest in life history and fear of contact with old age due to link to death. Terms like "the best age" mask the difficulty of accepting this cycle. The passage of the "ideal of the self" regulates the subject with marks of the insignias of the "other", in the hope of recognition.
The “third age”, subjectification and biopolitics²²22 Birman J. Terceira idade, subjetivação e biopolítica. História Ciênc Saúde. 2015;22(4):1267-82..	Reflection of the concept of the third age as significant in the reading of biopower and biopolitics.	The significant "third age" brings new modalities of subjectivation in the field of old age - such as the "end of life" for a "new time of life". In the figure of biopower and biopolitics and the control of vital processes, there is the medicalization of social space, the prevention of diseases and the promotion of health.
Body and aging: a psychoanalytic perspective²³23 Cherix K. Corpo e envelhecimento: uma perspectiva psicanalítica. Rev SBPH. 2015;18(1):39-51..	Reflection on the body, aging and psychoanalysis.	An unconscious body image is created, with identity, despite the changes of the body over time. It is the phase of the "negative mirror". There are losses in subjectivation, the reduction of the libidinal flow, the search for ways out (diseases, therapeutics, use of medication); ways of re-creating links and contacts with the "other".
The shadow of a body that declares itself: body, image and aging²⁴24 Vilhena J, Novaes JV, Rosa CM. A sombra de um corpo, imagem e envelhecimento. Rev Latinoam Psicopatol Fundam. 2014;17(2):251-64..	Reflection on old age and impacts on the subject from the psychoanalytic gaze.	There is a mismatch between the timeless unconscious and the body, within the scope of temporality. The reduction or loss of libido causes the elderly to seek a certain narcissism, focusing on memories, fantasies and pain.
Symptoms of the elderly?²⁵25 Mucida A, Pinto JM. Sintomas de velhos? Cad Psicanal (CPRJ). 2014;36(30):45-60..	Reflection about symptoms in the elderly.	The symptom in psychoanalysis contrasts with the biological and cultural view of aging. The symptom may be old but not specific to the elderly. Psychoanalysis does not deal with pathologies, but with the subjectivated symptoms, in which the subjects are implicated. There are no "symptoms of the old" and in the real and symbolic the symptom can also be "enjoyed".
"Old age? I think it's great considering the alternative ": reflections on old age and humor²⁶26 Lima PMR, Viana TC, Lazzarini ER. "Velhice? Acho ótima, considerando a alternativa": reflexões sobre velhice e humor. Rev Mal-estar e Subj. 2011;11(4):1597-618..	Reflection on humor and old age, from the starting point of psychoanalysis.	Old age is seen and lived through in a negative way and there is an incessant search for happiness and a denial of suffering and death. Examples of Freud's life are presented with the use of humor for the relief of suffering and tolerance towards the ambiguities of life.
Old Age and Death: Reflections on the Grieving Process²⁷27 Concentino JMB, Viana TC. A Velhice e a morte: reflexões sobre o processo de luto. Rev Bras Geriatr Gerontol. 2011;14(3):591-600..	Reflection on death and aging in the light of psychoanalysis.	Death of friends and companions, loss of work, family and social relations refer to real and symbolic losses. Death is not accepted as natural, and religious ideas and beliefs are born out of the need to make helplessness bearable. In suppressing the loved object, the libido needs to be directed, a somewhat painful and slow process.
Vieillir en terre étrangère: une nouvelle épreuve de l’exil²⁸28 Sittou R. Vieillir en terre étrangère: une nouvelle épreuve de l'exil. Psychol NeuroPsychiatr Vieil. 2008;6(1):23-31..	Reflection on aging in the LTCF* and migratory situation.	Being old and outside the cultural context can generate suffering of the social and psychic order. Foreign elderly people in the LTCF experience psychic suffering because of the proximity of death and because they do not see possibilities for the reformulation of life. Listening spaces that see uniqueness as a conscious or unconscious investment in culture are necessary, considering the symbolic resources.
Encounters and solitudes of our time²⁹29 Corbella S. Encontros e solidões do nosso tempo. Rev Bras Psicanal. 2008;42(3):149-67..	Reflection on the relationship between Psychoanalysis and modern Philosophy, highlighting: adolescence, the elderly and love.	Adolescence, aging and love are described as moments of transition, which are difficult to live through. With analytical work, it is possible to assume "responsibility" for one's own destiny, which allows the emancipation of the lived past, opening up the future through human freedom, which is however limited.

Title	Study Proposal	Synopsis
Too much love: institutional care for old age³⁰30 Barbieri NA, Sarti C. Amor demais: o cuidado institucional à velhice. Vibrant 2015;13(1):71-88..	An ethnographic case study, based on a psychoanalytic study of an LTCF* on representations of old age.	Love, care and attention were understood by the professionals as requirements for the proper exercise of the task, conceived as a gift (talent) and independent of technical knowledge. The idea of this talent as a disinterested action evidences care in a relationship of "charity" and power.
L'apport de la psychanalyse aux soins en institution gériatrique³¹31 Charazac PM. L'apport de la psychanalyse aux soins en institution gériatrique. Geriatr Psychol Neuropsychiatr. 2014;12(2):193-8..	Reflection on contributions of psychoanalysis to caregivers.	There is transference and countertransference from the professional in relation to the elderly; in addition, the same experience frustrations in the constant losses of autonomy and death. Psychoanalysis can contribute to the understanding of the care practice for both the elderly and the caregiver.
The foreign relative: the care of the other in the geriatric institution³²32 Carrano I, Grifo P. Estrangeiro, familiar: o cuidado do outro na instituição geriátrica. Rev Inter Mob Hum. 2012;20(38):163-79..	Quantitative-qualitative research, based on psychoanalysis and on cultural representations.	The foreign workers in the LTCF* were women, with a mean age 39, from South America and Eastern Europe, had more than 13 years of schooling, had resided in Italy for 10 years, were mostly nurses or nursing technicians, 25% had already suffered discrimination. In interviews with 13 nursing directors, three categories emerged: "safety for us" (aspects that unite and reassure), "familiar but threatening" (fear of relatives and family members) and "radically strange" (leaving one place and arriving in another). The group activities showed that through the symbolic one can reduce the sensation of strangeness to “ourselves”, elaborating it, without living in the denial of this "other".
Institutionalization of old age and regression: a psychoanalytic view of old people's homes³³33 Rozendo AS, Justo JS. Institucionalização da velhice e regressão: um olhar psicanalítico sobre os asilos de velhos. Rev Kairós. 2012;15(8):25-51..	Reflection of practical reality in two LTCFs in partnership with universities, with use of "Psychology workshops", and trips.	The infantilization (speech, type of care) and psychological regression of the elderly was observed through prostration, apathy towards a routine; and also among caregivers, because only basic needs were valued, the stimulus to self-care was non-existent. There is a mortification of the 'Self' through the loss of subjectivity and the notion of territory. The departure from the institution (trips) sought re-signification, contact with the external world.
Old age as a brand today: a psychoanalytic view³⁴34 Silva BR, Finocchio AL. A velhice como marca da atualidade: uma visão psicanalítica. Vínculo. 2011;8(2):22-8..	Report of experience of working in a group in a LTCF*.	Activity carried out with four to six elderly women in four meetings of a total of 16 residents. The narratives revealed the silence of the institution regarding symptoms, an attempt to protect desires, in contrast to the drivers of life and death. There was a devaluation of the knowledge of the elderly; a feeling of abandonment and helplessness; communication that was not tolerated by the LTCF*; deletion of individual traits; and, repetition of stories.
The unveiling of old age: the contributions of psychoanalysis in the search for meanings for the experience of aging³⁵35 Abrahão ES. O desvelar da velhice: as contribuições da psicanálise na busca de sentidos para a experiência do envelhecer. Rev SPAGESP. 2008;9(1):57-65..	Experience report of the relationship of psychoanalysis, aging and old age, with six elderly persons.	Experience has shown that there is an emotional, psychic life, and the existence of unconscious processes that govern the behaviors, actions and symptoms of very old people.

Title	Study Proposal	Synopsis
Collective imaginary of mental health professionals regarding aging³⁶36 Simões CHD, Ferreira-Teixeira MC, Aiello-Vaisberg TMJ. Imaginário coletivo de profissionais de saúde mental sobre envelhecimento. Bol Psicol. 2014;64(140):65-77..	Qualitative survey on the collective imaginary of mental health workers.	Two fields of affective-emotional meaning emerged: "suffering and loneliness" and "age does not matter". This shows that being old is seen as sad and lonely, but few professionals see the possibility of creative and healthy lifestyles.
Death from the view of a cleaning team³⁷37 Silva DPG, Kiyan L, Wanderley KS. O óbito sob a ótica da equipe de limpeza. Saúde Debate. 2009;33(81):140-7..	Survey of views of cleaning workers in a geriatric nursing ward on death.	Four categories were observed: perception about death (repetition, fear of fragility); death and religion (religious practice for managing helplessness); death of the elderly (acceptance in this age cycle, penalty); space offered to participants (reflection of finitude).

Títle	Study Proposal	Synopsis
Transmission of the psyche between generations ³⁸38 Hartmann IB, Schestatsky S. Transmissão do psiquismo entre as gerações. Rev Bras Psicoter. 2011;13(2):992-1114..	Reflection on a case in the transmission of the psyche.	Elderly woman with a history of generational repetitions including events such as: incest, denial and hiding facts, showing that unprocessed psychic traumas can pass to future generations.