Freud, Psychoanalysis, and Dementia

Sigismund Freud’s name is instantly recognisable by large swathes of the population some three quarters of a century after his death.The phrase ‘Freudian slip’ has even entered the language, as has the phrase ‘oh, very Freudian’ to describe something that is sexually suggestive.Such is the way clever people are perhaps remembered by the general mass of us.But, Freud is clearly a great deal more than slips of speech or views on sex.

However, if one was to ask a sociologist or psychologist what is important about Freud they would instantly answer psychoanalysis.  Freud’s impact on modern thought has been enormous although today the details of his work are often open to academic criticism.  If thinking has moved on since Freud’s death in 1939 then that is the natural progress of any academic study.  We shouldn’t be surprised by that.  Yet he changed our thinking about the nature of human beings.

Yet what is interesting and enduring about Freud and his work is that succeeding generations do return to the texts and draw something new and useful from them.

So who was this remarkable man?

He was born in 1856 in Moravia, now part of The Czech Republic, to Jewish parents.  This being the reason of course that he fled his adopted city of Vienna in 1938 and came to London.  Vienna was no longer a safe place for Jews following The Anschluss.  He died in London the following year.

Freud’s academic fame rests upon his work on psychoanalysis.

Freud first used the term as analyse physique in a 1894 paper, which he wrote in French and entitled ‘Obsessions et Phobies”.  The word translated into German as ‘psychoanalysis’ first appeared in print two years later.

The theory advanced by Freud was developed from the practical ‘talking cure’ pioneered by Dr Josef Breuer a decade or more earlier, and with whom Freud worked.

Towards the end of his life Freud defined the term psychoanalysis in ‘Some Elementary Lessons in Psychoanalysis’ thus : “Psychoanalysis is part of the mental science of psychology.  It is also described as ‘depth psychology’.  If someone asks what ‘the psychical’ really means, it is easy to reply by enumerating its constituents; our perceptions, ideas, memories, feelings and acts of volition – all these form part of what is psychical.”

And this gives us an insight as to why psychoanalysis is a technique used today to deal with people suffering from dementia.

Freud’s emphasis in psychoanalysis was to observe and identify how the subconscious affects action.  But the clue for the link between this and the treatment of dementia is the method of talking therapy.

All forms of dementia, including the two most frequent – Alzheimer’s and vascular dementia – involve loss in significant areas such as memory, language, reasoning, spatial awareness, and even physical movement.  Dementia can also be associated with mental symptoms, such as delusions, anxiety, depression, and even changes to an individual’s personality.

As regards cognitive losses then cognitive behavioural therapy can be used to good effect, enabling the patient to concentrate on the present and learn coping skills that will help with the position they find themselves in.  A simple example would be the posting of reminders such as the milk is in the fridge and so forth, and the use of a large calendar/diary in which to note tasks for the week ahead.

Memory loss is usually related to issues of short term memory, such as what did you eat for breakfast this morning, whereas long term memory, such as where did you take shelter during The Blitz, remarkably survive.  Psychoanalytical techniques of taking the patient back in time, by the use of photographs, music, even sounds and smells, can help to bring the patient ‘back to life’ and provide a sense of connection for them.

Such psychoanalytical approaches can be facilitated either on a one to one basis or within a group.  Many Care Homes provide such reminiscence sessions, a technique originally pioneered by adult educators working with older people in this country, and not necessarily those suffering from dementia.  In addition, there is the developing specific area of life story therapy, where the patient produces an autobiography, usually drawing on photographs supplied by relatives.

Of course one important distinction of using such techniques with dementia patients is that there can be no end to the therapy – there can, because of the very nature of the illness, be no cure.  Rather the patient will become, over time, progressively worse.  But this is precisely the point.  Society should not give up on such people but continue to stimulate, support, and calm them.  As The Alzheimer’s Society has written in a Paper on ‘Talking Therapies’, “People find it understandably hard to make sense of what is happening to them and how their life is changing.  Some feel angry, confused, frightened or anxious.  Talking therapies may offer someone with dementia the opportunity to speak openly about their feelings and help them to live with their condition more successfully.”

Not all carers of the elderly suffering from dementia employ such techniques, and there is a strong case to be made for better qualifications for those tasked with either the medical or social care of this group so as a far better quality of life can be achieved.  Nothing is as depressing as a patient suffering from such illnesses to be observed slumped in a chair in their own home or sat in a circle in a Care Home.  We need to do far more than keep such people clean, fed, and medicated.  Freud’s approach with talking therapies provides us with one important way into this problem.

Recently the media got very excited about the Government’s plan to pay GPs £55 for every dementia patient they identify.

Dementia is becoming a political issue for the reason that the number of people suffering from it is growing exponentially.  According to last year’s Government Policy Paper, “Improving Care for People with Dementia” there are 800,000 people suffering from the condition today and that by 2040 that number is expected to double.  The same Paper claimed that in England the diagnosis rate was only 45%, hence the recent announcement.

In that 2013 Paper the Government said quite categorically, “To get across the message that people with dementia can be helped, we’re raising awareness …”

This recent announcement is but the most recent in a number of Government initiatives including significantly The National Dementia Strategy launched in 2009 and The Dementia Challenge, thrown down by The Prime Minister in 2012.

Before I move to my next point, concerning carers, I should like to add in some further statistics to those already quoted.There are 40,000 younger people suffering from dementia.  It isn’t only an old person’s condition.80% of people living in Care Homes, however, are suffering with dementia.

There are 67,000 carers of people suffering from dementia in the UK, and many of these are themselves elderly.

Shah and Wadoo in a Paper called “Free NHS Talking Therapy” write, “The majority of patients are cared for by family caregivers and these individuals are placed in a situation of escalating personal demands.  Caring for an elderly person with dementia is a major life challenge and it entails emotional, physical, social and financial burden.  It also has been described as one of the most difficult situations encountered by caregivers.”

Freud wrote, “We are never so defenceless against suffering as when we love”.

Now I want to turn to a quite different area where talking therapies can prove of enormous benefit, and that is with the carers.  Here there is no problem of the patient on an irreversible decline.  Here the client can hope to show progress as in the case of any adult undergoing therapy.  In our society we have many elderly carers of dementia patients who feel trapped by their loved one’s disease – literally trapped in their own home, and trapped by the impossibility of holding a normal conversation with them as in the past.  The sense of guilt felt by the carer if the patent is left even for a short time, or if the patient hurts themselves, or even a desire by the carer to ‘hit out’, both metaphorically and literally. The Alzheimer’s Society’s Paper says, “Being close to someone with dementia can feel overwhelming and lonely.  Many carers experience feelings of sadness, grief, guilt or anger, as well as high levels of anxiety and depression.  Talking therapies may help people to explore these feelings in confidence, as well as providing extra support outside their network of friends and family.  This can be especially important at times when decisions are being made how to look after a person with dementia.”

My personal family experience of dealing with a nonagenarian relative suffering from both vascular dementia and Alzheimer’s has re-confirmed my view that progress in the care of such patients comes down to training; yet the level of that training does not have to be in enormous depth it just has to make people more aware of the issues and the ways in which they can be alleviated both for the patient and the carer.  Freud’s approach teaches us that for talking therapies to work they must be conducted in a relaxed atmosphere where the patient feels at ease to say whatever they wish to say.  Even where such therapies are on offer this basic requirement is often missing.  The patient should not be corrected but allowed to express themselves in whatever way seems to them appropriate.  This is most important when many of the patients may be elderly and many of the carers young.  A long time ago, in the 1970s, when I was an education Inspector for Adult Education I visited a group of older students, who were suffering from dementia in one form or another.  They were in a soft toy making class being run by a young tutor.  I have never forgotten the look of horror on one male student’s face when he was asked to stuff a soft toy with ladies tights.  He was genuinely shocked and embarrassed to be asked to perform such a task.  He turned out to have been a GP.  I was mortified on his behalf, and fortunately was in a position to do something about it.

Those employing the therapies must be able to judge from the patient’s reactions when the talk strays into areas which makes them feel uneasy.

The NHS, to give it credit, has launched an e learning programme to improve professionals understanding of dementia.  “The dementia e learning sessions have been designed to familiarise health and social care staff with recognising, understanding, assessing and managing dementia, and with providing high quality dementia care.”

And so as I come to the end of this short paper can I summarise what on a personal level seems to me important?

• Spread awareness of dementia wherever we can and to whomever we can, in accordance with the Government’s own initiatives in this field.
• Encourage wherever we can and whomever we can to put in place therapies, including most importantly the talking therapies I’ve mentioned, although there are a myriad of others which also prove useful.  There is no one answer or one solution.
• But above all wherever we can and with whomever we can argue the case for better training of the health and social care professionals, and in the case of social care professionals, especially carers in the private sector, whether working in the community or in Care Homes, this will need a radical upgrading in their pay and conditions.

We should also act as advocates for those suffering from dementia.  They have earned the right to demand that from us; as Freud wrote, “The first request of civilisation ….is justice.”

This is too important a subject to leave to politicians.

“Civilisation began the first time an angry person cast a word instead of a rock”, said Sigismund Freud.  I urge all of us to start casting words in support of better understanding for dementia patients and their carers.

William Tyler, MBE, MA (Oxon), MA, MPhil

Consultant to The Galatea Trust.