Full text of DOI:10.1111/j.1752-0118.2000.tb00563.x

Group Therapy
GROUP-ANALYTIC PSYCHOTHERAPY WITH THE ELDERLY
Maria Canete, Fiona Stormont and Arturo Ezquerro
ABSTRACT Orthodox psychoanalysis offered the view that mental processes in the elderly are too
rigidly established for favourable treatment results. Group psychotherapy with the elderly in
general has received little attention, mostly concentrating on inpatient groups. The main focus has
been on supportive techniques, often in institutional settings.
Two of the authors (Maria Canete and Fiona Stormont) co-conducted a weekly slow-open
analytic group for elderly people, in a London outpatient NHS clinic. This paper presents clinical
material that illustrates some age-specific issues, as they appear in the group process. For example,
issues of competitiveness, rivalry and aggression, which are generally present in the beginning of
groups with younger people, tend to be absent, or manifest themselves differently, in the elderly
group. Denial of age becomes impossible, which helps these patients to accept approaching death
and the process of dying itself. Psychoanalytic group psychotherapy can be especially indicated for
this age population.
Introduction
People over 65 constitute the fastest growing age group in the western world. They have the
highest prevalence of physical and mental disturbance of any age group. Their health needs
generate the highest per capita medical expenses in the population. Specialist geriatric
services began to develop in Britain from the late 1940s, and psychogeriatric services from
the late 1960s. Old age psychiatry became a recognized speciality in 1989.
In the nineteenth century, Charcot had denounced the fact that `senile pathology' was a
neglected area of medicine (Howell 1988). Freud (1905) did not follow his mentor on this,
and considered that people aged around 50 lack the mental elasticity required for
psychoanalytic treatment. Besides, he thought that the mass of material to be dealt with
would prolong the treatment indefinitely. As a consequence, the entire old age field within
psychoanalysis and group analysis was largely ignored. Those who tried to employ
psychodynamic psychotherapy with this age group were only a tiny minority. Until 1986,
the British Psycho-Analytical Society refused to accept patients over the age of 40, and the
Tavistock Clinic was also routinely rejecting patients over 45.
The Literature
The influence of early psychoanalytic beliefs or prejudices (?) was so widespread that,
during the first three quarters of the twentieth century, only a few papers referred to the
psychoanalysis of older patients. Abraham (1919) wondered about the applicability of
psychoanalytic treatment to patients at an advanced age, and he drew an important
MARIA CANETE is a psychiatrist and group analyst working with the elderly. FIONA STORMONT is
a senior registrar in Old Age Psychiatry. ARTURO EZQUERRO is a consultant psychotherapist.
Address for correspondence: 57 Hamlet Square, London NW2 1SR.
British Journal of Psychotherapy, Vol 17(1), 2000
© The author

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO
95
distinction between the `age of the neurosis' and the chronological age of the patient. Segal (
1958) reported an impressive account of a successful analysis of a 73-year-old man, whom
she treated for 18 months following his psychotic breakdown. At a conceptual level, there
were few but important psychoanalytic contributions. Jacques's (1965) seminal paper on
mid-life crisis refers to the need to come to terms with our own mortality and, therefore, the
acceptance that the time available is finite. Erikson (1966) suggests that the fundamental
conflicts faced by older people centre on generativity versus stagnated self-absorption, and
ego-integrity versus despair.
The first comprehensive breakthrough in the UK came with King's (1974) landmark
paper, `Notes on the psychoanalysis of older patients'. King quoted Freud and Erikson,
described a number of successful analyses of elderly patients, and provided a pioneering
psychoanalytic theory of old age. She formulated some late-life developmental issues and
age-specific sources of anxiety. In the next few years, King (1980) developed her ideas
further. She suggested that the disturbance of some elderly people relates to the
reawakening of unresolved childhood conflicts, and the activation of new developmental
challenges - some of which are similar to those of adolescence but in reverse.
We also found it very helpful to read Sandler's (1978, 1984) analyses of some of her
elderly patients. She warned about potentially dangerous narcissistic ambitions in the
therapist's aims. She did not attempt a full reconstruction of the past or a complete character
analysis, but concentrated on age-specific developmental issues. Her deeply humane and
humble attitude was a source of inspiration to us. Both King and Sandler continue to
wonder, to search and to produce ideas. It is as if they had decided to demonstrate in their
own life that creative growth is an open-ended task. They have been very influential and
have changed the attitude of many psychoanalytic clinicians world-wide (for example,
Cohen 1982; Limentani 1995).
Like King and Sandler, Hildebrand (1982, 1986, 1995) has also written profusely on the
subject. In the late 1970s, he set up an individual psychotherapy workshop for older patients
at the Tavistock Clinic, where people aged between 60 and 85 were assessed and treated on
a one-to-one basis. By the late 1980s a long waiting list had been generated. At this time,
one of us (Arturo Ezquerro) was invited to join the late Naomi Stern, herself already in her
sixties, to negotiate with Dr Hildebrand a one-year-long analytic group for nine patients
awaiting individual psychotherapy on his elderly workshop waiting list. This experiment in
group-analytic psychotherapy with the pre-elderly had a positive outcome (Ezquerro 1989).
Before the 1980s, most groups were designed for physically and cognitively impaired
geriatric inpatients, concentrating on sensory retraining, reality orientation and remotivation
therapy. Other group approaches used such techniques as music and movement, which were
therapeutic in their own right, but had little to do with analytic work. Since the late 1980s,
there has been an increasing number of publications showing that psychoanalytic group
approaches are a growing therapeutic and cost effective form of treatment for older people (
Grotjahm 1989; MacLennan et al. 1989; Leszcz 1990; Porter 1991; Vardi & Buchholz
1994; Martindale 1995). The annotated bibliography for psychoanalytic psychotherapy (
Milton 1996) reports that group psychotherapy improved both life expectancy and quality of
life in older patients suffering from terminal cancer. It was also reassuring to read that
psychotherapy and old age psychiatry are coming closer together (Ardern et al. 1998;
Garner 1999; Murphy 2000).

96
BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 17(1)
The Group
We inherited a long-term group project which was originally set up in the early 1990s. One
of us (Maria Canete) became the group conductor in 1996, and the other cotherapist (Fiona
Stormont) joined the project in 1998. This is a slow-open group, run weekly for 90 minutes
in an NHS outpatients clinic, where people join and leave as ready. The age range has been
65 to 89 years. We do not have a rigid exclusion criteria but we are reluctant to offer a place
to people suffering from active psychosis, especially paranoia. We also think that our group
is not suitable for people with dementia. We may accept patients with deeply ingrained
personality disorders, major depression, disabling chronic anxiety or addiction problems;
these conditions usually necessitate combined treatments. We have no facilities yet for
people who are too physically ill to attend the group.
From our experience of treating elderly people in this group, we anticipate a better
prognosis when patients have a good level of verbal communication and social skills. This
usually means that they will be able to recall the past, to work through their losses without
resorting to somatization or physical illness, and to overcome non-voluntary social isolation.
A history of prior successful psychotherapy, whether group or individual, can be an
indicator of positive outcome. While there was little psychotherapy provision for this
population in the past, elderly people are becoming better educated and more
psychologically sophisticated. Their demand on psychotherapeutic services has also
increased.
Some Developmental Tasks of Old Age
We found it useful to differentiate between the 'young-old' and the 'old-old'. This does not
necessarily coincide with chronological age. The 'young-old' need to adjust to a different
place and role in society, usually following retirement. They may take up new activities and
derive much satisfaction in developing a new, creative, perhaps until then dormant, part of
themselves. The 'old-old' must also adapt to the increasingly unpleasant bodily and mental
changes of ageing, to dependence on others, and to the imminence and inevitability of
death. The very old may not fear death in the way the young-old do, but they tend to fear
more the actual process of dying.
The aim of group-analytic psychotherapy with older people is to help with these age-
specific adaptations through the understanding of the individual's internal world, in a wider
relational context. In this way, emotional development can continue until death. Our group
gave us some moving examples of their struggle to face these tasks. (In the clinical
vignettes that follow, names and circumstances are disguised to preserve confidentiality.)
The Main Themes in Our Group
We anticipated that group members would readily discuss ageing, physical and emotional
care, and review their own lives in the context of an increasingly stronger sense of loss.
Elderly people have sustained many losses during their lives (parents, spouses, siblings,
other close relatives and friends). Bodily changes can lead to loss of mobility, speech,
hearing and sight. They might also be troubled by short term

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO
97
memory impairment, shortness of breath, loss of sexual potency, social status and
independence, and, ultimately, loss of life itself.
We initially had four members, three from the existing group and one newcomer. As the
group had been running for six years, we expected to find an established culture. However,
we appeared to start a process that in many ways resembled the formation of some brand-
new groups. For several months, they predominantly discussed practicalities about the
group and tried to look for things in common. We wondered if this was a defence - perhaps
they were avoiding differences and envious feelings, but dared not say it. Later, as new
members came and there was a `core' of seven, talk became more personal. Maybe the `
superficial' discussion of the group itself was necessary for becoming its own `secure base',
from which to explore.
In these `initial' stages, we allowed them to use the group as a life-line - a 'non-rejecting
good object', as they were especially vulnerable to feelings of being let down and
abandoned. We interpreted that they seemed to be feeling cautious with us, the new
therapists, and wondered if they were anxious about being rejected by us. We added that we
had arrived soon after the departure of the previous therapists, which perhaps was perceived
by them as a form of rejection. Our interpretation made sense to them and opened the
process of deeper exploration.
Reflecting on the Group's Anxieties
History has a bearing on the ongoing group behaviour in the 'here-and-now'. This can
manifest itself at conscious and unconscious levels. In the psychoanalytic and group-
analytic fields, this has been described as `group culture' or `group matrix'. Before we
joined the project, our group had survived many changes, including the departure of five
therapists and a number of patients. Some of these patients left when they were ready,
contributing to the therapeutic group culture. Others dropped out or died, which generated a
high level of anxiety about what they perceived as a threat to the survival of the group and
their own survival.
Thinking about the group's history helped us understand the sense of uncertainty and
fragility we encountered. The initial `suspiciousness' gradually gave way to the development
of a basic sense of trust, which enabled members to face some of the obvious differences
between them. We hope this will become clearer with the following clinical vignette.
Brenda, a 69-year-old woman of mixed parentage, had experienced racial discrimination.
She was the only coloured person and, often, a 'barometer' for the group regarding feelings
of unlikeness or rejection. In an age homogeneous group, she also represented `
heterogeneity'.
Brenda had initially felt suspicious and angry in the group. She later commented that she was
unable to trust the group for a while. However, she was now beginning to experience it differently,
after the realization that the group did not persecute her but became consistently available every
week. At one point, Brenda felt safe to disclose details of her first psychotic breakdown, which she
had felt was caused by her husband's extra-marital affair. She added that he had tried to exploit her
vulnerability and demanded her inpatient psychiatric admission, in order to take advantage of her
through the divorce proceedings.
Most group members, especially the women, commented on Brenda's sense of betrayal by
her ex-husband. We also interpreted the possible `betrayal' of her and other people in the
group by the previous therapists, and the fear that we might do the

98
BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 17(1)
same. Brenda and other members recognized that they had felt anxious about the continuity
of the group.
Brenda's material was followed by other people sharing their own experiences of
separating and breaking down. This new dynamic of more open exchange helped Brenda to
trust the members and the therapists. The group became more cohesive and the presence of
everyone almost a matter of `life and death'. If a member was missing they always asked
about them and became reassured to know that they were `alive and kicking'. When the
missing member next returned to the group, they were usually welcomed back with: 'We
were anxious that you might have kicked the bucket'. This comment helped us to understand
their anxiety about `disengagement', which often reflected a reaction to real or imagined
threats to the individual's sense of self. Accordingly, the group had to be a non-failure
experience for each member.
They showed particular interest in language and meaning. They looked for the origin of
some idiomatic phrases. They also showed curiosity about foreign accents and the `origin'
of the therapists. We interpreted the transference, which this time seemed to bring to the
foreground the age gap between them and the therapists. Sometimes, they directly asked
whether we were familiar with some of the old-fashioned expressions they used. This
acquired special significance in one member's words: `In a few years time, we all could be
pushing up daisies'.
We said that the comment, which on the surface `excluded' the therapists, could refer to
the hope of being survived by younger generations. Some of them found our thought
comforting - a way of ensuring continuity of life in the future. All were born in the first three
decades of the twentieth century. We felt prompted to read books on the history of this
period, which helped us to gain context and understanding into their stories. We were also
trying to learn the membership's primary language.
The group-analytic concept of `cohesion' denotes a rather undifferentiated form of
getting together. In contrast to it, `coherency' is the result of a more advanced group-
therapeutic process in which disagreements and conflicts are faced with the aim of being
worked through (Pines 1986). In our group, members tended to fluctuate in a pendular-like
movement, from fragmentation, through cohesion, to coherency. The circularity' of this
movement reminded us of the life-long fluctuations between the paranoid-schizoid' and the `
depressive' positions.
The initial period described above was an example of fears of fragmentation and
paranoid' anxieties, characterized by suspiciousness and lack of trust. They gradually
overcame these difficulties by emphasizing their similarities and achieving a sense of
togetherness or `cohesion', but without dealing with differences openly. Brenda offered a
good opportunity to transcend this phase and use their wider range of personalities and
psychopathologies. We hoped that this process of `uncovering' the `hidden' heterogeneity of
the group would bring about the `coherency' needed to maximize its therapeutic potential.
The following material is another example of this struggle.
The arrival of Ellen in the group, a 79-year-old woman with a diagnosis of schizo-affective
psychosis, initially revealed concern and strong objections. In the first few sessions, she fell asleep
and snored noticeably, after having introduced herself to the group saying: 'I am a schizophrenic'.
This `presentation' of the newcomer reactivated the old fears of fragmentation. Later, we learned
that she had been over-medicated. When her medication was reduced, she participated in the group
more constructively. Rose, a youthful 68-year-old lady with a diagnosis of manic-depressive
psychosis, left the group shortly after Ellen joined.

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO
99
Rose's mother had had a psychotic breakdown soon after she was born. We interpreted that Rose
was finding it very difficult to tolerate the fact that Ellen's vulnerability reminded her of her own
mother's, but in spite of our efforts she left.
At first we thought that it was not possible to achieve a more mature level of sharing or
`coherency', where differences and conflict could be tolerated without resorting to
fragmentation or escape. However, after the initial hostility towards Ellen's arrival and
Rose's departure, the group shifted to a more `depressive' form of anxiety. They missed
Rose, her enthusiasm and liveliness. They also accepted Ellen as a full member. Some
people commented that she might have suffered from prejudice towards the elderly and the
severely mentally ill, as portrayed in the media with the collusion of society at large.
Jean added to the group's acceptance of Ellen with a comment: `You don't look or act like a
schizophrenic, to me'. Then, Ellen brought photographs showing that she had been a beautiful
actress, prior to her psychotic breakdown. She wanted to reassure the group that what she had
shared about her past was not a grandiose psychotic fantasy, but a real and healthy side of herself
that she needed to rediscover. The group appreciated her need for a newly found sense of
belonging and identity.
Relationships with their Children
The group went through a period in which members mainly focused on the negative aspects
of the relationships with their children and grandchildren. This seemed to reflect something
about their own difficult experiences during childhood and adolescence. We tried to provide
opportunities for them to explore these difficulties and to improve their family
relationships. Most of them struggled with the fact that their children had left home, got
married and made them grandparents, about which they had mixed feelings. In spite of the
joy of becoming grandparents, the new `transgenerational' realities were also painful and
often perceived as yet another form of rejection. The in-law families became `natural'
recipients of their hostile projections and, of course, the group. However, members usually
`protected' us, the group conductors, from their destructive anger. They seemed to need a
more diluted form of negative transference towards one another.
Brenda accused Eddie of upsetting her with his chauvinistic and patronizing attitude. This led to
an impasse until Tom commented that she had previously described her eldest son as a patronizing
and chauvinistic person. Then, Brenda was able to recognize that Eddie reminded her of her eldest
son.
We thought that this material was therapeutically more mature and closer to `coherency', as
they were able to deal with conflict, survive it and relate with one another in a more
constructive fashion. They were beginning to disentangle what belonged to them and what
to the transference distortions of the past. Brenda's insight into her own transference to
another group member helped her to move on.
Then, she reflected on the impact that her psychotic breakdown had had on her
children. She felt that she became unavailable to them, in much the same way that she had
experienced her own mother. In addition, she felt cut off from one of her sons following his
marriage. This was aggravated by the fact that the only child towards whom she felt close
emigrated to Australia, which enhanced her feelings of being abandoned.

100
BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 17(1)
Several group members elaborated on their fears of rejection and being seen as useless by others or
by themselves. June participated actively in the discussion and reported that, after the death of her
daughter-in-law, she went to live with her son to help with the children. Her first breakdown
occurred when her son's new partner moved in with them. June was accused by her son of taking
over and not allowing him to be the 'parent in charge', about which she felt deeply hurt and
excluded. Tom had not experienced physical separation from his children in the way Brenda and
June did, because his children still lived at home, but in his view they behaved like 'lodgers'. In
contrast to the experience of the parents in the group, those members who were childless tended to
have an idealized image of parenthood. Jean, who had no children, stated that it was difficult for
her to understand Tom's feelings of loneliness, because he lived with his own children; in her view,
they should give Tom good companionship. Then, Ellen referred to the fact that her first episode of
psychotic depression coincided with the realization that she was too old to become pregnant.
In our group, the patients who had children and grandchildren experienced life as
difficult and conflictive; but the childless members tended to talk more often about feelings
of emptiness. We commented that the group was providing opportunities to explore
different or even opposite viewpoints. For example, children could either be idealized or
become a source of pain and problems. This intervention promoted a process, through
which extreme and 'polarized' views were gradually transformed or 'translated' into more
meaningful and less hostile communication.
This move was a therapeutic exercise in its own right. It developed greater awareness in
each individual of himself and others, increasing the capacity for insight and integration in
each person. This has been described in group-analytic terms as `ego training in action' (
Foulkes 1964). Childless members could appreciate other creative aspects of their lives,
which helped them gain a sense of fulfilment and 'transcendence' into posterity.
Ageing, Death and Dying
Ageing is a natural process, not a pathological one, but it is physically and emotionally
taxing. Some people seemed more able to accept growing old than others. In our group, this
theme usually came up in relation to physical symptoms and decline. Members often
complained of being discriminated against in our Western society. They resented the
portrayal of the elderly in our media, whilst in other cultures elderly people are valued as
experienced and wise members of the community. This theme had a strong 'resonance' for
Eddie who was struggling with his loss of status following his retirement - his son had
taken over the family business.
Eddie tried to dominate the group and talked about the possibility of going back to work. Only
when he was able to 'retire' from his role of 'Mr Chairman' in the group, could he be accepted by the
others as a full member. Rose, who identified herself with younger people, did not join in when
there was a discussion about ageing. We became concerned when she decided to leave the group to
attend a course in sociology. However, we could also appreciate that she had developed an
intellectual curiosity about groups and was trying to use her remaining years creatively. In contrast
to her, Tom was more able to discuss his decline; but he said with resignation that he was marking
time until he 'popped off.
Group members did not usually discuss death openly. They seemed more interested in
comparing the actual quality of their lives. However, disabling physical symptoms and
dying were matters of concern for them.

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO
101
Tom and Brenda often said that they would prefer to `drop down dead suddenly' whilst still healthy,
because they would not like to be a burden to their children. Paul could not agree with them.
Already in his late eighties, he was physically very frail and had lost contact with his family. His
main fear was dying alone at home and being dead for days before anyone noticed. He was a very
reliable member of the group. Even during his sudden final illness he managed to let us know that
he had been admitted to hospital. At the beginning of a session, following a holiday break, the
group intuitively knew that something was wrong when he was missing, even before we broke the
sad news of his death. His fellow group members expressed sadness, but they were relieved that he
had not died alone. Jean commented that the group had become a `replacement family' for Paul.
Some Ideas on Group-Analytic Technique with the Elderly
The elderly have a long history behind them and the expectation of a shorter time to live.
They experience reduced rather than expanded capabilities. Western civilization is less
likely to offer the elderly new opportunities for achievement. Therapeutic tasks frequently
are to adjust to the present and create the most favourable conditions for the future. In
contrast to this, the young have most of their lives still in front of them; they are more likely
to spend time fantasizing and planning for the future. We reflected on some of these
differences in our group of elderly patients; they gained more satisfaction from
reminiscence about the past and sharing common values with people of their own
generation. We will expand on this at the next section.
Differences with the younger population became clear from the early stages of our
group. For example, issues of competitiveness, rivalry and aggression, which are generally
present in the beginning of groups with younger people, tended to be absent or manifested
themselves differently in our elderly group. They did not struggle for power and control
openly like the young but concentrated more on the identification of common problems - a
process of 'cohesion-formation'. The Western world, in particular Anglo-American culture,
is generally considered to stress values associated with individualism, such as self-
confidence, individual achievement and independence. Often, attachment needs are
wrongly seen as child-like or weaknesses.
In contrast to the increased `dependency' in the elderly, and the resultant role reversal
with their children, younger patients in groups try to develop the `independent' self, whose
goal is to be unique and expressive in the external or public roles. Elderly patients gradually
become more preoccupied with belonging and maintaining internal harmony.
Another difference in our findings relates to the group defensive process of `pairing'. In
a younger people's group this would be viewed as a subgroup with a potential detrimental
effect. However, in a group of elderly patients the same defence might be tolerated or even
accepted in the light of its self-restorative function, and its contribution to the long-term
development of the group. The multiplicity of the therapeutic mechanisms accessible in the
group-analytic setting (for example, the mobilization of diverse individual transferences,
family transferences and mirroring among group members) eases the process for an old age
group to become `all generations'. Experiencing oneself in a 'life-cycle process' becomes
more imaginable, as does the resolution of intergenerational problems. Age differences
between patients and therapists, with their implicit `generational role reversal', have to be
recognized in the transference and countertransference. However, the age gaps

102
BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 17(1)
are not insurmountable; they can be creatively used to help elderly people overcome some
of their difficulties, in a youth-orientated society.
In our project, this was particularly important during personal and group crises. When
security and trust were restored, members became more able to explore differences and
confrontation. This, in turn, promoted a more mature expression of negative feelings
towards one another and towards us, the therapists. When they were able to resolve this
tension, the atmosphere in the group became more heterogeneous, flexible and a greater
potential for change emerged. Overall, however, our elderly patients appeared to make more
progress when treatment was carried out within a predominantly positive transference. We
did not find that this was so important in groups with younger patients. Group
psychotherapists working with the elderly need to understand their attitudes, both conscious
and unconscious, to ageing and death. They especially need to guard against
countertransferences resulting from their own unresolved conflicts about ageing, declining
health, or about relationships with their own parental figures.
Countertransference
We did not know what we were letting ourselves in for, but found that our elderly patients
accepted death better than we were able to. We felt privileged to share their sadness and
stimulated by their wisdom. Sometimes, we were used as recipients of their envy of `
idealized' younger people - a possible expression of a difficulty they had in letting go of the
youth inside themselves? We wondered about the possibility of their unconscious wish for
us, the therapists, to become the idealized child who can guarantee their permanence, and
pass on to posterity the good aspects of themselves that they wanted to see preserved. We
also recognized our own `envy' of them for having survived so long and for their own
achievements.
At first, we were `suspicious' of their help-seeking attitude, manifested by almost
perfect attendance rates. We feared that their demands would put a heavy burden upon our
shoulders. Gradually, we realized that they were also trying to maximize responsibly the
use of our time limits and their own limited life-span. We learned from it. Our anxieties
about their initial demands for `total' care, progressively, gave way to the acceptance of our
own limitations in the understanding of their problems, which they appreciated. We realized
that we can write about them but we cannot own the history they themselves made, because
it belongs to them and not even death can take it away from them. Life ends but history
remains.
Discussion
The group-analytic approach meets a wide variety of needs for elderly people, as they
struggle with internal and external needs. It provides a self-sustaining matrix in which the
narcissistic injuries to the self can be addressed, through the provision of thinking and
relationships that may serve necessary self-object functions. Some of the basic features of
old age can be better explored in a group (for example, dependency, helplessness and social
isolation). Experiencing feelings of interdependency and belonging stimulates older
patients to make a better use of the social context in their own lives. In our
countertransference we identified that caring for the elderly can be taxing and get in the
way of our wishes for `greater' achievements or ambitions.

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO
103
We later recognized that caring for them was also an achievement in its own right. We
came to this conclusion as we realized that older patients in the past have not always
received early or adequate care from public, or even private, health services. Elderly people
have often been institutionalized in mental hospitals, nursing homes and other residential
facilities. They tended to suffer disproportionately within the established health system,
which was (and in many ways still is) characterized by insufficient financing and the
fragmented delivery of services. Our group patients hoped that, in the future, care of elderly
people with mental illness will continue to gain not just independence but also respect.
Intimacy and sexuality were difficult for our older patients. While their attachment
needs were reactivated they also tended to `disengage', as they realized that they could not
sustain the level of productivity and involvement of their earlier working life. In spite of
loss of potency and sexual drive, sexual functions and needs persisted. Their sexuality
became less a matter of physical urge and more an expression of tenderness, affection and
trust. They felt comfortable discussing this in a group with people of the same age.
In our group, we needed to employ a `binocular' vision to link up different time scales,
such as their chronological restrictions and their unconscious processes - which are
paradoxically timeless. We found that reminiscence helped them recognize the child, the
adolescent and the mature adult still present internally. Remembering and staying in contact
with the past promoted a sense of internal self-constancy and integrity, for them to give
value to their own life experiences and, therefore, to themselves. At times, the continuity
with the past became an antidote against overwhelming despair. We will elaborate on this.
Grievous loss is part of the ageing process. The individual's failure to negotiate the
narcissistic losses ageing brings (losses of personal capacities, relationships, functions and
roles) may result in an impoverished sense of self with feelings of depletion, worthlessness,
depression and despair. Reminiscence can be conceptualized as a developmentally
appropriate and natural process of review, organization and evaluation of one's life. In this
sense, it may be utilized to promote reintegration of the individual's identity, of who they
are, by having them re-connect with who they were. It may become a mainstay of
psychoanalytic group psychotherapy.
At its best, the reminiscence process fleshes out individuals within the group and makes
them three-dimensional people, rather than one-dimensional objects of projections or bi-
dimensional units of projective identification. Reminiscence restores feelings of worth,
stature and competence through the articulation of past successes and the recollection of
prior credentials. The group adds an important dimension to the use of reminiscence. What
has been of significant subjective importance to any individual can be confirmed by a more
collectively objective valuation. In a psychotherapy group, appropriate grieving and letting
go of the past may be facilitated, promoting better engagement with the current
environment. The reminiscence of previous challenges mastered can also help soothe the
apprehension facing future uncertainties.
A sense of continuity with the future was also crucial. They sometimes considered the
continuing existence of a world, in which some part of themselves could be left. They could
live on in their children and grandchildren, in the memory of others or in their own works,
written words, painting or music. Quite simple objects, like photographs and videos, could
also provide this sense of continuity; but the greater

104
BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 17(1)
the damage the more difficult this task became. At its worst, the reminiscence process may
result in a fixation with the past, guilt over irreparable errors, and a heightened, morbid
self-absorption that results in social alienation.
It is debatable whether treatment with the old may or may not be as `open-ended' as
with the young. In our group, we observed that the flexibility of having `thinking space',
without being pressurized, was beneficial for most of the members. Approaching death was
often a challenge that some were able to use constructively to be more selective, and to
focus on what mattered most for them: the consolidation and affirmation of their existence.
On occasions, shortness of time generated overwhelming anxieties, which prevented them
from getting on with the therapeutic task. On other occasions, time restrictions were an
incentive to work in therapy rather than the opposite - a real 'deadline' may serve to
creatively concentrate the mind.
Conclusion
Group-analytic psychotherapy can be especially beneficial for the elderly. Some of the basic
features of old age (for example, dependency, loneliness, social discrimination,
helplessness and despair) might be better explored in a group therapeutic situation of this
kind. Such a group provides ample opportunities to experience, and re-experience, true
feelings of interdependency and belonging. They can also help one another to accept
without shame the reactivation of their needs for reliable attachment figures, as well as
mutually stimulate themselves to use the social context in their own lives. It is important for
practitioners working with groups for this age population not to underestimate the rich
resources that elderly patients may bring to the therapeutic context. Ignoring their wealth of
wisdom and experience unduly fosters dependency.
We would like those colleagues who are interested in this population to continue to
write and exchange ideas, without being discouraged by what seems a divide in the
literature between individual psychotherapy and group psychotherapy. Although individual
and group psychotherapies for the elderly are steadily growing, they still are a challenge for
many practitioners. We hope this paper will go some way in overcoming the hesitations of
those not already working with this population.
For those already working with the elderly, we hope that some of our ideas will have
been delivered in a stimulating form, maybe to add to their treatment repertoire. Facing the
potentially fragmenting pressures in our society at the turn of the Millennium, we need to
cooperate in a joint venture that breaks some of the prejudices and discrimination against
older people, with the aim of developing a more coherent life-long perspective of our
existence, from the cradle to the grave.
Acknowledgements
To Mark Ardern and Brian Martindale, who initiated this Group Psychotherapy Project in
the early 1990s.

MARIA CANETE, FIONA STORMONT AND ARTURO EZQUERRO
105
Note
This paper was presented in a Clinical Workshop at the Second Conference of the European
Federation of Psychoanalytic Psychotherapy in the Public Sector (EFPP), Group Section ('
From Fragmentation to Cohesion'), Barcelona, Spain, May 1999. An abridged version of the
paper was presented at the EFPP Millennium Conference ('Changing Times, Changing
Relationships'), Oxford, England, April 2000.
References
Abraham, K. (1919) The applicability of psychoanalytic treatment to patients at an advanced age. In
Selected Papers on Psychoanalysis (Eds. D. Bryan and A. Strachey). London: Karnac, 1988.
Ardern, M., Garner, J. & Porter, R. (1998) Curious bedfellows: psychoanalytic understanding and old
age psychiatry. Psychoanalytic Psychotherapy 12: 47-56.
Cohen, N. (1982) On loneliness and the ageing process. Int. J. Psychoanal. 63: 149-155.
Erikson, E. (1966) Eight ages of man. Int. J. Psychoanal. 47: 281-300.
Ezquerro, A. (1989) Group psychotherapy with the pre-elderly. Group Analysis 22: 299-308.
Foulkes, S.H. (1964) Therapeutic Group Analysis. London: Allen & Unwin.
Freud, S. (1905) On psychotherapy. In Standard Edition of the Complete Works of Sigmund Freud.
London: Hogarth Press.
Garner, J. (1999) Psychotherapy and old age psychiatry. Psychiatric Bulletin 23: 149-153.
Grotjahm, M. (1989) Group analysis in old age. Group Analysis 22: 109-111.
Hildebrand, P. (1982) Psychotherapy with older patients. Brit. J. Med. Psychol. 55: 19-28.
Hildebrand, P. (1986) Dynamic psychotherapy with the elderly. In Psychological Therapies for the
Elderly (Eds. I. Hanley and M. Gilhooly), pp. 22-40. London: Croom Helm.
Hildebrand, P. (1995) Beyond the Mid-Life Crisis. London: Sheldon Press.
Howell, T.H. (1988) Charcot's lectures on senile dementia. Age and Ageing 17: 61-62.
Jacques, E. (1965) Death and the mid-life crisis. Int. J. Psychoanal. 46: 502-514.
King, P. (1974) Notes on the psychoanalysis of older patients. J. Anal. Psychol. 55: 22-37.
King, P. (1980) The life cycle as indicated by the nature of the transference in the psychoanalysis of the
middle-aged and elderly. Int. J. Psychoanal. 61: 153-160.
Leszcz, M. (1990) Towards an integrated model of group psychotherapy with the elderly. Int. J. Group
Psychother. 40: 379-399.
Limentani, A. (1995) Creativity and the third age. Int. J. Psychoanal. 76: 825-833.
Maclennan, B.W., Saul, S. & Weiner, M.B. (Eds.) (1989) Group Psychotherapies for the Elderly.
Madison, CT: International University Press.
Martindale, B. (1995) Psychological treatments II: Psychodynamic approaches. In Neurotic Disorders
in the Elderly (Ed. J. Lindesay) pp. 114-137. Oxford: Oxford University Press.
Milton, J. (1996) Presenting the Case for Psychoanalytic Psychotherapy Services: An Annotated
Bibliography. London: Tavistock Centre.
Murphy, S. (2000) Provision of psychotherapy services for older people. Psychiatric Bulletin 24: 181-
184.
Pines, M. (1986) Coherency and its disruption in the development of the self. British J. Psychotherapy
2(2): 180-185.
Porter, R. (1991) Psychotherapy with the elderly. In Textbook of Psychotherapy in Psychiatric Practice
(Ed. J. Holmes), pp. 469-487. London: Churchill Livingstone.
Sandler, A.M. (1978) Problems in the psychoanalysis of an ageing narcissistic patient. J. of Geriatric
Psychiatry 11: 5-16.
Sandler, A.M. (1984) Problems of development and adaptation in an elderly patient. Psychoanal. Study
Child. 39: 471-489.
Segal, H. (1958) Fear of death: notes on the analysis of an old man. Int. J. Psychoanal. 39: 178181.
Vardi, D.J. & Buchholz, E.S. (1994) Group psychotherapy with inner-city grandmothers raising their
grandchildren. Int. J. Group Psychother. 44: 101-122.