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Book Reviews |
This seventh and final volume of the series The Course of Life is a revised and expanded version of an earlier work subtitled Psychoanalytical Contributions Toward Understanding Personality Development.
Although the author of the important first chapter cites the by now well-accepted view that neurobiology will increasingly influence psychoanalysis, this volume does not set out to achieve meaningful integration between those two disciplines. Rather, the reader is presented with a different synthesis, that between psychoanalytic understanding and epidemiology. The balance here is between insight and statistics; careful perusal of this book's twelve chapters will reward the reader both by clarifying the extent of some of the developmental and mental health problems of the elderly and by providing an especially rich and humane understanding of those problems.
This blend of insight and statistics is especially characteristic of the first chapter, "Old Age." We learn that 5.3 percent of the older population is institutionalized; that 20 percent will enter a nursing home before dying; that 86 percent have some form of chronic disease; that 60 percent of the institutionalized elderly suffer from psychiatric illness and most importantly, that 80 percent of the mental health problems of older persons are being neglected. A master of his subject, the author goes on to discuss personality theory in old age, psychological theories, social theories, psychoanalytic contributions to mental illness in later life, and much more. A minor irritant is the frequent reference to DSM-III, which in 1998 gives a somewhat dated flavor to the chapter.
The chapter "Aging or Aged," clearly the product of years of clinical experience and thinking, succeeds in broadening the reader's understanding of this period of the life cycle. The author shares many valuable clinical insights. He states his view that symbiosis is a general term that describes particular relationships throughout the course of life and is therefore just as applicable in old age as in childhood. Earlier work on the mourning-liberation process is also discussed and merits serious attention. The author's reminder that the viewpoint that "everything can be explained by early life" is outdated struck me as unnecessary and outdated itself. His warning that the preoccupation with the theme of death and dying may have done us a disservice if it has diverted attention from life and living is controversial. (This view may have influenced the editorial stance, since nowhere in the book does this theme receive the attention it surely deserves.)
For those readers who are grandfathers, the chapter "Grandfatherhood" is a rare pearl and not to be missed. For those who enjoy the careful use of language, the chapter "Reminiscence and Nostalgia" will be welcome. Do we all appreciate that the former is a process and the latter an affect? Erudition is always appealing, and the literary-minded will also enjoy the timely reference to the work of Marcel Proust.
The work of Erik Erikson is revisited in a particularly dynamic and engaging manner in the chapter "Psychosocial Thoughts on Old Age." An accompanying case history of a 76-year-old physician is poignant and illuminating. This chapter closes by clarifying the final developmental challenge: an inner struggle in which integrity may win out over despair, even in the face of the certainty of sudden interruption. (Here then is a hint of that last hurdle, which is correctly labeled but not fully addressed.)
The chapters "Transitions in Asian American Elderly" and "The African American Elder" widen the appeal of the book. All mental health professionals should be aware of the high suicide rate among Chinese and Japanese elderly women. All health professionals should ponder the fact that 30 percent of African American individuals live below the poverty line, as do 39 percent of African American households. (Comparable figures for whites are 15 and 12 percent, respectively).
Although a brief review cannot do them full justice, the remaining chapters merit attention. "Psychoanalytic Contributions to Geriatric Psychiatry" closes with the statement that "the study of self-esteem maintenance has become a central focus of psychoanalytic inquiry about aging." "Attachment Behavior in Dementia" is noteworthy for its success in capturing the inner world of dementia sufferers and for reminding us that the illness has great meaning for both patients and family members as all grapple with the obvious inherent loss. The chapter "Dynamisms of Depression Among Older Women" helps refine our empathy for that group. "Depression and Anxiety in the Elderly" does justice to this common syndrome. The final chapter, "Development and Treatment in Late Adulthood," emphasizes that significant intrapsychic change continues to occur in late adulthood and is clinically useful when the author turns to treatment issues. Although there is a subsection entitled "Preparing for Death," it is only one page long. I think the editors would have done well to have devoted an entire chapter to that subject.
Anyone working in the field of geriatric psychiatry would do well to read this rich, psychoanalytically informed work. I would be surprised if a reader completed the book without feeling that he or she had received at least one special gift. In my case, that gift was my belated introduction to some early work of Stanley Cath,1 who believes that throughout life, a psychic balance is struck between external and internal depleting and restorative forces. The life-affirming quality of this book may be regarded as a restorative force—one that should energize professionals involved in the psychiatry of old age.
Footnotes
Dr. Johnson is Professor and Vice Chairman, Department of Psychiatry and Behavioral Sciences, University of Nevada School of Medicine, Reno, NV.
References
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