Extended Psychotherapies

To the Editor: We would like to comment on the Introspection by Michael W. Kahn in the September issue (1). We recently conducted a study of older therapists and their practices with particular emphasis on those patients being seen for a very long time. We interviewed 11 psychotherapists between 70 and 90 years old who had between two and five patients. This totaled a group of 35 patients whom the therapists had seen for periods of 10 to 50 years. Dr. Kahn's patient is similar to these patients who are still seen “after years of therapy” (MW Kahn, personal communication, 2012). The therapists were surprised to learn that those in their age group were seeing similar patients. The patients either were self-payers or had flexible insurance, and most, although working, were socially isolated. The patients were mostly well educated, and about two-thirds were men. Two-thirds were married or had a live-in partner, and about half had adult children, some estranged. However, less than half of the sample had friends, and of these, just six had a confidante. As one therapist commented, “These patients have few or no friends, and not one has what I would consider an intimate trustworthy other in their lives. None has a confidante other than me.”

How did these therapists view their work with these patients, what Dr. Kahn has called “palliative psychotherapy”? They mostly came to view their role as that of a trusted adviser, counselor, or coach. As one therapist said, “Although I am trained as a dynamic psychotherapist, very little of my work with these people would be recognizable as anything resembling insight oriented.… In short, I have acted as a guide and mentor.” Several therapists commented that they missed the intellectual challenge of more interpretive therapies. They all felt that they were being useful to the patient, and many acknowledged that they were also benefiting from the relationship. Sessions had the flavor of a regular meeting with an old friend who gradually had come to know a fair bit about the therapist's life. For the oldest therapists in the sample, there was some suggestion that continuing to see a few patients enabled them to feel that they were still working and productive.

We believe that there is a group of patients who, instead of forming a diagnostic group (as none of our cases had serious mental disorders), form a functional group arising out of the patients' need for social support and their ability to afford continuing psychotherapy. Younger therapists begin with such patients, but only gradually does it become clear that the patients are members of this group.

Apfel and Grondahl (2) called the relationship an “abiding friendship” and observed that “therapists acknowledge these lifelong connections reluctantly,” perhaps out of shame. None of the therapists in our sample expressed any shame about their work but rather, like Dr. Kahn, felt that they were helping some patients get through life. What to call therapy with this group of patients remains a question. Perhaps a relationship—simply by virtue of being “extended”—is transformed into a real-world attachment to both therapists and clients and takes the form engendered by that particular dyad and their historical context.