By Daniel A. Plotkin, MD, MPH, PhD
Here’s a thought experiment: What if old age actually meant having enhanced potential for change — but since few realized it, it remained a kind of secret?
Unleashing this secret could go a long way toward liberating souls, if people would realize that change is not only possible, but within reach.
Instead, the great majority of people believe, consciously or unconsciously, that change in old age is not possible.
But that turns out not to be true.
Granted, this claim goes against conventional wisdom, but let me explain how I, as a physician who specializes in adult and geriatric psychiatry, know that aging actually enhances our capacity for change. And, full disclosure, I am 72 years old myself, so you could say I speak from a certain bias.
Also worth knowing is that older adults are the fastest-growing segment of our population, and older individuals are more diverse than any other age group. So beware of attempts (by me or anyone else) to talk about older adults as monolithic.
Too late for therapy?
Meditation, coaching, clergy and family connections are all well-known ways to help facilitate personal growth. Yet, often it’s assumed that past a certain age, there’s no point in trying talk therapy, otherwise known as psychotherapy.
It is still not clear what type of therapy works best for whom. What is clear, though, is that there are some crucial factors common to all therapies. For any therapy to go well, it generally requires a well-motivated patient who has the ability to connect with the therapist, as well as the ability to think about one’s behavior and one’s life. So, three key factors:
- Ability to reflect
- Be motivated
- Form a well-functioning therapeutic relationship
A moment of reflection
It turns out that older adults have a natural tendency to reflect. And reflecting and reminiscing is a normal, healthy developmental aspect of aging.
Robert Butler, the physician who started the field of geriatrics in the U.S., described the natural tendency to reminisce as “life review.” Over the last decades, life review, or reminiscence therapy, has been used to facilitate this process in older adults, leading to rich discussions and realizations about how one has lived life.
Erik Erikson, the pioneering psychologist who described the psychological development of a person’s sense of identity over the life cycle, identified the stage in late life when the individual, by virtue of life review, comes to terms with their life, and clarifies the themes, meaning and purpose of that life.
Feeling motivated
It makes sense intuitively, and is borne out in practice, that therapy works best when the patient is motivated. Older adults tend to be motivated because they are keenly aware they’re not going to live forever, and have a sense that it’s now or never.
At the same time, people are living longer than they ever have, and there is a lot of life left to live when you’re, say, 65 or 70 years old. People who are in unhappy marriages, for example, are more likely these days to get divorced in order to make the most of their remaining years. In fact, they’re driving a so-called “gray divorce” demographic trend.
The realization that time is marching on and that there is usually still enough time to make it worthwhile to change makes the motivation to change doubly strong in older people.
There’s even a theory, called the socioemotional selectivity theory (developed by Stanford psychologist Laura L. Carstensen), that posits that older adults become increasingly selective about how they spend their time and other resources as they age. And what they tend to focus on are emotionally meaningful goals and activities.
Building relationships
Talk therapy is one way to identify and pursue emotionally important goals. Therapy works via a relationship, the so-called therapeutic relationship. Exploring a therapeutic relationship often provides rich insight into yourself that might otherwise be difficult to achieve.
Most therapies benefit from a relationship, so the patient’s capacity to relate to others is extremely important.
Once again, older adults, having honed their relationship skills over a lifetime and tending to value relationships over material objects, are generally good at forming a relationship that then facilitates change. As the long-term Harvard Study of Adult Development found, the most important characteristic associated with successful aging is not intelligence or money, it’s the quality of relationships.
Memory serves
Memory, and other cognitive processes — such as how we think, how we process information, and how we make decisions — are important to consider when thinking about a person’s capacity for growth and change.
As usual in our society, we associate age with loss: Age is associated with a slowing of processes, whether it’s running the 100-yard dash or solving math problems. It’s also common for older adults to have difficulty recalling names, words and even recent events.
The truth is, while this short-term memory impairment is frustrating, it’s usually not a significant problem. And long-term memory is usually well preserved, even in individuals who have some type of diagnosable memory impairment.
In therapy, especially the type of therapy that involves reflecting on one’s life and connecting the dots from one’s earliest memories, long-term memory is key. There’s even a “reminiscence bump” in which older adults recall early life events especially well. So short-term memory impairment, though frustrating, is not necessarily a non-starter for therapy.
While older adults may have slower processing speed, they’re usually better than younger adults at organizing and synthesizing information. An important type of intelligence, called “crystallized intelligence,” emerges in midlife and grows. It’s based on experience, and helps older adults to identify and prioritize what’s important, and to make good judgments and good decisions.
It’s involved in what is called wisdom, which is the ability to use knowledge and experience to achieve a deeper understanding of human nature, inner lives, and what makes people tick. It also helps the wise person to understand what motivates people, to have what is called a “theory of mind” about humans.
Some of the intangibles that enhance the ability to change include wisdom, perspective, being more comfortable with who we are, and less afraid of saying what’s really on our minds.
Older adults also seem to be better at what’s called emotional regulation, which is the ability to respond to situations with a range of emotions, and to not over-respond or respond too quickly. It involves conscious as well as unconscious thinking, and is considered an important part of well-being and mental health. Psychotherapy is one good way to improve one’s emotional regulation, which improves one’s quality of life.
Research on personality has shown that older adults can still change. Biological research has identified “neuroplasticity” in older adults, meaning the older brain is still capable of change. (Remember the line from the film “The Graduate” about plastics? “There’s a great future in plastics. Think about it. Will you think about it?” That guy knew something.)
The barrier: Ageism
For more than a century, case reports and scholarly overviews have reported positive experiences for older adults in talk therapy, showing them as good candidates.
So, with all the things going for us, why don’t older adults utilize therapy to change and improve the quality of our lives? The answer: We are brainwashed into thinking we can’t do it.
It’s called ageism. The term was coined by the same Robert Butler who started the field of geriatrics in the U.S. and who identified life review as a normal part of aging.
Almost all of us who were raised in typical Western culture, myself included, are bombarded with the message that old people are stuck in their ways, and too cognitively impaired to partake of change-making. The general message is that old equals bad, and it’s so much a part of our zeitgeist that we rarely question it.
For example, almost everyone is pleased to hear that they look young for their age. What if someone said to an older adult: “You look great, so old!” I’ve tried it, and I can attest to the fact that it doesn’t go over very well!
Ageism can be relatively subtle, such as the patronizing appreciation of “cuteness” in old people, or giving dumb-downed explanations to older adults, as if the older adult were a child. Most of us have felt what it’s like to be invisible in a grocery or retail store. Even sympathetic authors encourage older adults to think of themselves as “elders” and not elderly or old. An entire anti-aging industry is built around “turning back the clock.”
More pernicious are the effects of having lowered expectations for older adults. Remember when President George W. Bush talked about the “soft bigotry of low expectations” in the context of racism? That same dynamic can easily be applied to older adults, and perpetuates a kind of self-fulfilling prophecy in which people don’t reach for things they feel incapable of achieving. If you don’t think you can do something, you are less likely to even try.
So it’s no surprise that older adults are less likely to seek or obtain mental health services compared to other age groups. With ageism in mind, it is easy to see how this comes about. Looking at the Covid pandemic, with its emphasis on the isolation experienced by younger populations, and some smoldering attitudes about prioritizing younger adults over older ones, provides fresh evidence.
Win for losing
By owning our own feelings, we reclaim important parts of ourselves, and actually liberate ourselves to pursue our better selves. Instead of spending psychic energy on self-criticism, we can think about more realistic alternatives, and make sure we are doing the best we can, which is usually comforting.
Getting back to the emphasis on loss, it has been observed by many therapists, poets, writers, musicians and philosophers that loss is associated with personal growth. Seen from this vantage point, old age presents a wealth of growth opportunities.
Losses come in many forms: there are relationship losses such as the loss of a spouse, medical losses such as loss of energy or even loss of a limb due to a stroke, and losses of independence. The latter is especially important in our country, with its emphasis on being “strong” and independent. Shameful feelings about dependency often connect directly to one’s own upbringing, past relationships, and cultural context.
One of my patients, whom I’ll call G.D., is a retired, successful businessman in his 80s. He immigrated to the U.S. at a young age, lived the American dream, and has a close-knit family of kids, grandkids and great-grandkids. He came to therapy for help with depression and burnout caused by caring for his wife with dementia. We identified and acknowledged his losses: the loss of his wife as he knew her, and also the loss of a part of himself that is confident, able to master difficult challenges, able to experience joy with a sense of humor.
He realized that he was responding to his stressful situation by trying to control and manage the care for his wife, similar to what he had done all his life. It left him feeling sad, guilty and frustrated. In therapy, he was able to see how his coping mechanisms that had served him well in his life now brought him despair. In therapy, he was able to let go of some of his heroic efforts, to accept his circumstances, and to know that he was doing the best he could. This left him feeling “sadder but wiser” (per the song from “Music Man”), and considerably more at peace with himself.
Another patient, S.U., a woman in her 70s, struggled with guilt, anger and sadness connected to the on-and-off relationship with her adopted daughter. In therapy, she was able to add a level of understanding and acceptance that was previously not possible. Her usual attitude was a harsh, blaming one, related to her feelings of regret and remorse over what she had done, and not done, with her daughter.
In therapy, she was able to develop newer, softer and more nuanced attitudes that take into account her own background and upbringing. She came to understand and appreciate the complex psychological contributions behind her actions, leaving her with more compassion and comforting thoughts about herself.
Importantly, she realized that she could not excise the old harsh attitude, but she could relegate it to a less influential place in her psyche, with the more mature and adaptive parts of herself assuming a more prominent place.
How to find help
Perhaps older adults are “designed” to be adaptable because so much happens to them!
While I hope this leads to greater opportunities for older adults, I realize that the supply of experienced therapists who have advanced training in working with older adults is woefully inadequate. I hope those few of us who have the expertise will inspire and train a new generation of therapists.
Meanwhile, the best plan is to ask your primary care physician to make a referral. Many psychotherapists work well with older adults, even if they don’t have formal training in geriatrics.
Also, most (general adult) psychotherapists have older adults in their practices. And since older adults make up the largest percent of most primary care physician practices, the physician will likely have faced this challenge before, and will be able to make a good referral.
Daniel A. Plotkin is a physician who specializes in adult and geriatric psychiatry.
