Mohammed T. Abou-Saleh

THEORETICAL AND MANAGEMENT ISSUES 597PsychotherapyUnless there is a co-morbid Axis I disorder that requirespsychopharmacological intervention, the treatment of geriatricpersonality disorders is largely a psychotherapeutic endeavor. Asdescribed by Sadavoy 27 , a major difference between the psychotherapyof older and younger patients is the time framecovered. Transference issues continue to be directed from childhoodsources and early 8 parental relationships, but they will oftencontain an overlay from experience later in life. Usually the initialfocus should be on the patient’s present reality and presentingproblems, secondarily on historical material and on the relationshipwith the therapist. Then, as it unfolds, more time and effortcan be devoted to clarifying and perhaps analyzing distortions inthe patient’s attitudes and behaviors toward the therapist. Somepatients, not necessarily the highest-functioning ones, will be ableto focus usefully on the relationship with the therapist to a greaterdegree than others. In either case, special attention must be paidto the potential for transference issues to become painful andparalyzing for both patient and therapist. Ideally, discussion ofthe therapeutic relationship can provide a point of shared reality,which patient and therapist can examine together. Issues from thepast then emerge more naturally, in an unforced and relevantfashion. Patients probably do have a need to mourn past losses, aprocess that can be fostered in psychotherapy, but it should beremembered that such mourning is not done globally or in apredictable sequence 27 .Another factor complicating psychotherapy in the elderly isthat overall treatment plans often involve family, caregivers orinstitutional representatives. Important persons in the patient’ssocial sphere must be engaged in treatment strategies because ofthe interpersonal field in which personality psychopathology,especially the Cluster B disorders, is expressed; also, older peoplewith disabilities may function less autonomously. This createspotential boundary problems for the therapist, as well as concernsabout confidentiality; these must be spelled out to the patient andan understanding reached between the patient and therapist onexactly what information may be transmitted to others and underwhat circumstances this will be done. Once this is accomplished,creative use can be made of family and institutional supports.Whatever the approach taken in psychotherapy, limited andrealistic goals should be set, based upon a collaterally informedpicture of the patient’s long-term functioning. A psychotherapyrelationship cannot reasonably be expected to resolve thepsychological deficits, and the consequences of those deficits ofthe elderly personality disorder patient—a lifetime of failedrelationships, missed opportunities and unused talents. Nevertheless,it can be hoped that for some individuals, the loss ofnarcissistic gratifications associated with physical beauty andvocational competence can actually foster psychotherapeuticwork. Patients may find themselves in old age to be motivatedfor self-examination as never before. The impetus provided byaging and the press of reality may render the older patientamenable to a process of growth and change.REFERENCES1. American Psychiatric Association. Diagnostic and Statistical Manual ofMental Disorders, 3rd edn. Washington, DC: APA, 1980.2. Widiger TA, Frances A. The DSM-III personality disorders:perspectives from psychology. Arch Gen Psychiat 1985; 42: 615–23.3. Cloninger CR. 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