Many practitioners are applying psychodynamic principles to the work they do, even when treatment doesn't conform to the traditional frame. This month Melissa Anderson, M.A., Elder Abuse Specialist, and Tom Cicciarelli, Psy.D., Director of Clinical Training at the Institute on Aging, take on the difficult topic of psychodynamic therapy with long-term elder abuse patients.

Elder abuse patients present with complex issues related to mental health, grief, impaired cognition, and social stressors such as isolation and poverty. A patient with mild dementia and longstanding bipolar disorder negotiates the stresses of physical and financial abuse by a drug-addicted child returning home from jail. Another patient considers the multigenerational legacy of mental illness and criminality in her family while working to create physical safety and an emotional container for painful feelings of regret.

We deal daily with the insidious nature of abuse. Research shows that the primary predictor of abuse is a prior history of abuse (Sengstock-Hwaleck, 1987). One interpretation of longstanding abusive relationships is that they are somehow familiar and comfortable. This doesn't make sense — abuse is painful. At the same time, attention and predictability in relationship enable an individual to maintain a sense of interpersonal contact and recognition (Gottman & Notarius, 2000). Abuse can be experienced as a form of connection. The immediate and intimate nature of abuse presents an alternative to the confusion and isolation of mental illness and social marginalization.

Our therapists learn to sit with, comprehend, and contain the relational ambiguities and conflicts patients bring to treatment. We work as long as needed in the aftermath of trauma. The rate by which a patient begins to recognize her story — and form internal representations of hurt — is crucial. Removing outmoded defenses too soon can be as detrimental as staying in denial. We work from an experience-near psychodynamic theoretical base, emphasizing the relationship as key to working through trauma, and as a place to experience emotional support, and, in best cases, a deeper sense of self. 

Sengstock-Hwaleck, M. 1987. "A Review and Analysis of Measures for the Identification of Elder Abuse." Journal of Gerontological Social Work 10 (3/4):21-36.

Gottman, J. M., & Notarius, C. I. (2000). Decade review: Observing marital interaction. Journal of Marriage and the Family, 62, 927-947. 

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