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The Psychotherapy of the
Elderly Self
By Hyman L. Muslin, M.D.
New York, Brunner/Mazel, 1992
220 pages, ISBN 0-87630-657-1
$27.50
Reuieuied by Ruth EVel11S Netscher; M.D.
T his is a delightful book. I can recorn-
mend it wholeheartedly for anyone who
has an interest in either aging or psychother-
apy. For those whose interest is in aging, the
book offers a concise review of the psychol-
ogy of normal aging. Well-written and con-
cise, The Psychotherapy qf the Elderly Self
flows easily, fulfilling with ease its stated
purpose. Written to encourage therapists to
accept aging patients, this book achieves
more: Dr. Muslin's case reviews are quite
unique in that his emphasis is on how, not
just why, to help an older patient.
The language is accessible to nonpro-
fessionals, so that even relatively unsophis-
ticated audiences, like medical students and
caregivers in retirement facilities, 111 a y ben-
efit. The review of self-psychology con-
forms to all the conventions, but Blakes the
complex philosophies of Kohut available to
a lay reader in a 1110st refreshing manner,
The review of how psychological mat-
uration occurs after middle-life is in accord
with mainstream teaching, but it is made
particularly poignant by such thought-pro-
voking examples as how it feels when a
cinema cashier automatically gives a senior-
citizen's discount without asking for identi-
fication. Even a seemingly trivial event like
this can result in narcissistic losses severe
enough to fragment the self if they are not
assimilated in a supportive environment,
How does a therapist help an elderly patient
accept that he or she is aging and adapt to
that process?
S0111e of the losses of aging are narcis-
sistic losses, like those brought on by the
loss of identity when an aging person re-
tires. Using as an example the case history
THE AMERICAN JOURNALOF GERIATIUC PSYCHIATRY
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of a lawyer who is balking at the prospect
of retiring, Dr. Muslin points out that a
patient may become depressed at the
thought of a life filled with cruises and trips
to Florida if retirement 111eanS the loss of
identity that such a patient derives from his
or her professional identity. Dr. Muslin
demonstrates with clarity and empathy how
to manage this kind of loss. For him, the
emergent management of such a patient is
in providing a bond that will calm him or
her by leading with firm direction. Dr. Mus-
lin also points out that such a patient will
eventually need to understand why he/she
experiences the pending loss of mirrors for
professional identity as enfeebling. Here, a
genetic interpretation emerges as the pa-
tient recognizes the lifelong need to aCC0111-
modate to the needs of others. Whenever
his/her own needs become prominent,
he/she is overwhelmed by anxiety.
Classical psychoanalysis has always at-
tempted to help patients accept that which
cannot be changed, and Dr. Muslin's pur-
pose in writing 771e Psychotherapy of the
Elderly Se{(is to "lower the age barrier" for
the psychotherapy patient. So, how does he
see the role of classical therapy, or analysis?
Certainly, Dr. Muslin feels that some pa-
tients require psychoanalysis, and the case
he presents is the kind COll11TIOnly seen in
outpatient practice, although the patient is
older. Dr. Muslin's requirements for such
analysands are the usual ones: they should
be motivated (of course); they should be
capable of self-observation; and they
should be able to form a therapeutic alli-
ance. However, for an older patient, ques-
tions also include whether the patient is
physically able to make several visits each
week. The need for a transformed self must
be weighed against the patient's projected
life span to justify the cost.
Expanding the modlfications in tech-
nique, Dr. Muslin recognizes how elderly
patients become frustrated with traditional
nondirective therapy. His solution is to offer
the positive transference as a bond, using
his influence to direct the patient to do what
175
Book Reuieus
the patient clearly needs and wants to do.
In summary, this book is useful for
self-psychologists extending their own
range, but is equally useful for those who
deal with the aging or those who are inter-
ested in a guide to psychological prepara-
tion for their own aging. (As a member of
the "sandwich generation" I found it of
value in dealing with my in-laws.) Patients
in therapy of any kind will do better with a
therapist who has had the benefit of study-
ing cases handled with the capability that
Dr. Muslin demonstrates,
Ruth Evans Netscher, lvl.D., is a Clinical As-
slstant Professor in the Department of PS)'-
chiatry at the University of Texas Health
Sciences Center at Houston.
Mortality Patterns and
Trends in the United States
By Paul E. Zopf
Westport, CT, Greenwood Press, 1992
281 pages, ISBN 0..313-26769-3, $59.95
Reuieuied by Steven Seuush, M'D.
T his VOlUt11e is a single-author work that
addresses the subject of mortality pat-
terns on multiple levels. The author goes
beyond simple reporting of raw data, offer-
ing interpretation and teaching in each
chapter. I-Ie describes his book as being
"about an American revolution comprising
lower general death rates, dramatically re-
duced infant mortality rates, increased life
expectancy, changes in the relative i111POl1-
ance of various causes of death, shifting
mortality differentials, and even the pros-
pect of increases in the ,~ 'fixed lifespan.' "
The book is organized into seven chap-
ters. The first examines the general issues of
life expectancy and mortallty and provides
a useful discussion of methods of measure-
ment, the concept of death rate, and the use
of life tables. In a manner typical of ensuing
chapters, the author treats his subject ere-
176
atively and incisively, looking, in some
depth, at the complex of social, environ-
mental, genetic, and technological factors
that interact with mortality variables. The
discussions proceed conservatively, render-
ing the interpretations compelling,
Chapters Two through Six comprehen-
sively review mortality differentials, 1110rt'1l-
ity trends, and life expectancy. Chapter Two
specifically examines mortality differentials
by age, gender, race, ethnicity, marital sta-
tus, socioeconomic status, and geography,
including a discussion of international COIU-
parisons. Chapter Three explores variations
in infant 111011ality, which is first examined
from an international perspective, featuring
comparisons of patterns in developed vs.
developing countries. Patterns within the
United States are then compared with re-
spect to age, gender, race, ethnicity, and
geography. The chapter concludes with a
discussion of temporal trends.
Chapter Four focuses on causes of
death, identifying the ten leading causes of
death in the United States and examining
HIV/ AIDS, drugs, alcohol, and Alzheimer's
disease as factors in mortality patterns. Vari-
ations in cause by age, gender, race, and
ethnicity are examined, The chapter con-
cludes with an inspection of the geographic
distribution of deaths from heart disease
and cancer. Chapter Five concentrates on
trends in cause of death, with particular
focus on infectious diseases, cardiovascular
diseases, stroke, cancer, diabetes, accidents,
suicide, and homicide. The effects of gender
ancl race on trends in mortality ratios are
also examined.
Chapter Six analyzes life expectancy. It
develops the concept of life expectancy ancl
examines differentials by age, gender, race,
geographic location, and marital status, It
examines the relationship between life ex-
pectancy and cause of death and addresses
national health goals from the perspective
of life expectancy. The final chapter pro-
vides a summary analysis of the book's
principal conclusions about mortality pat-
terns and trends in the United States.
VOLUME 2 NU~IBER 2 SPRING 1994