Book Essay: Perspectives on Aging: Countering Ageism in Psychoanalytic Thought

Midlife: Humanity’s Secret Weapon

In Midlife: Humanity’s Secret Weapon, Andrew Jamieson (2022) sets out to make the case for midlife as a time of necessary psychic crisis and potential growth through resolution of crisis. The central thesis of Jamieson’s book is that the psychological issues confronted and overcome in midlife can lead to a form of wisdom or perspective useful to humanity as a whole. Relying extensively on Carl Jung’s theory of individuation, Jamieson offers biographical discussions of numerous well-known figures to demonstrate the transformative impact of midlife breakdowns on these individuals’ future capacities and functioning. It is worth noting, however, that such midlife breakdowns are neither commonplace nor expectable: The concept of a “midlife crisis” based on work by Elliott Jaques (1965) and popularized by Gail Sheehy (1976) in Passages and by Daniel Levinson (1978) in The Seasons of a Man’s Life, may be more a popular myth than a reality.

Contemporary studies and popular works characterize midlife not as a crisis but as

a time when you shift gears—a temporary pause, yes, but not a prolonged stall. In fact, you are moving forward to a new place in life. This moment can be exhilarating rather than terrifying, informed by the experiences of your past and shaped by the promise of your future. (Hagerty, 2016, p. 5)

Contemporary understandings of midlife echo Bernice Neugarten’s (1972) notion of “increased interiority” (p. 10) and reflection during the middle years.

Though Jamieson’s definition of the midlife crisis is somewhat elastic—it can happen, he says, at any age—its essential elements are clear. When human nature faces an existential threat, patients’ usual defenses “become ramshackled and far less effective” (Jamieson, 2022, p. 55), and the person undergoes much turmoil. Yet this is far from a despairing book. For Jamieson, as for Jung, the midlife crisis has within it the potential for much creative growth:

As I have traversed this challenging emotional rockface with client after client, I am, time and again, impressed with how these periods of inner turmoil provide us with an unmatched opportunity to review our loves and explore our personalities. We can then attempt to adapt and reshape those aspects of our nature which construct our development, that hold back our true potential and impede our sense of well-being. (p. 1)

Jung’s fascination with confronting demons and misfortunes and his insistence that doing so can lead to transformative results serve as the model for Jamieson’s buoyant presentation. We follow Jamieson as he traces recurrences of his themes through religion, literature, politics, and Jung’s own midlife crisis, which was intertwined with his separation from Freud and Jung’s development of the idea of archetypes. And we begin to feel inspired with Jamieson.

Jamieson places a high value on the importance of creative struggle and explores many examples from history and the arts, including Michelangelo’s heroic work on the ceiling of the Sistine Chapel, Tolstoy’s (1869/2017) epic effort to finish War and Peace, Marie Curie’s discovery of radioactivity under adverse circumstances, as well as Beethoven, Abraham Lincoln, and Franklin D. Roosevelt. We are ambivalent about the value of these brief biographical studies of well-known figures, all tending to show the transformative impact of a midlife breakdown on future capacities and functioning, and all framed for a popular audience. The most striking material here, on the Cuban missile crisis of 1962, portrays John F. Kennedy’s firm resistance to pressure from military leadership to use force, including a nuclear strike, against Cuba. Recently revealed documents show that Adlai Stevenson, United States ambassador to the United Nations, stepped in to counsel Kennedy, ultimately convincing him to take a course of negotiation and compromise that avoided a possible nuclear disaster. Jamieson believes that, as a person beyond midlife, Stevenson had the reserve, perspective, and judgment characteristic of an elder statesman to guide a younger colleague even in the face of strong forces in the military urging a destructive course of action (Stern, 2012). Many of the non-Kennedy vignettes may already be familiar to the general public; all involve individuals of remarkable achievement who successfully resolved their midlife crises. While the vignettes illustrate his theory and are often inspiring, Jamieson’s focus on great achievement limits their value as evidence for the more normative psychology of aging or resilience.

Jung himself, though he did stress the creative opportunity represented by crisis and by the reordering of leading traits within a personality, what Jamieson (2022) terms “ego deconstruction” (p. 57), was not always as buoyant on the matter as Jamieson. In “The Structure and Dynamics of the Psyche,” Jung (1930/1972) took the fact that depression is more common after age 40 as a sign of an unconscious change, in which the leading traits previously established in a personality are either weakened and replaced, or hardened to the point of rigidity, even “fanaticism” (p. 395). “The wine of youth,” Jung said, “does not always clear with advancing years; sometimes it grows turbid” (p. 396). As life necessarily contracts in scope in its second half, Jung believed, a crisis is more likely in “one-sided people” (p. 396) and neurotics.

Jamieson accepts the Freudian postulate of repetition compulsion as an accurate diagnosis of humanity’s trouble and acknowledges that its burden can be alleviated to an extent, but he claims that in the Freudian system of endless repetition there is fundamentally “no way out” (p. 31). Jung, says Jamieson (2022), differentiated himself from his mentor, offering hope “by suggesting that the very purpose of life is for us to move beyond the endless wheel of repetition into a state of being that takes us into a whole new realm of experience” (pp. 30–31). The key to reaching this new state of experience is to grapple with the disavowed “ominous shadow” that is part and parcel of the “febrile energy” (p. 142) that carries people into midlife. Can the “wisdom, empathy, and altruism” (p. 142) of later life, if developed adequately, succeed in controlling the shadow? Jamieson thinks so, or is at least hopeful about the prospects. Careful readers of Freud might view the working through of repetitions and rigid defenses as having more potential for transformation than Jamieson asserts here, though it is certainly true that in his chastened moods Freud tended to see “common unhappiness” (Breuer & Freud, 1893–1895/1955, p. 305) as the best that humanity could achieve, even with psychoanalysis.

Close scrutiny of Jamieson’s ideas would require some grappling with the fact noted above that recent empirical work has discounted the notion that a midlife crisis even exists as a general phenomenon. Only 10% to 20% of people experience one, and there is certainly no firm evidence that it is a necessary part of growth (Infurna et al., 2020). Axelrod (2024) disputes the idea that a midlife crisis is an expectable event for the majority of people. Does a midlife crisis belong to life at large, only to the clinic, or only to selected patients? We never learn from Jamieson, because the questions are never raised. Perhaps this book’s greatest value lies in its buoyant spirit and its much needed reminder to therapists and analysts of the positive creative potential of therapy with older adults.

Psychoanalysis of Aging and Maturity

The Italian psychoanalyst Guillermo Julio Montero’s (2020) Psychoanalysis of Aging and Maturity provides a more theoretical, scholarly, and original psychoanalytic view of the middle years. Wary of the simplistic notion of a midlife crisis and stating, “Up to this moment, the concept of mid-life remains tied to the concept of crisis as if they were just one” (Montero, 2020, p. 3), Montero hypothesizes a period of involution of reproductive and sexual function that occurs in both men and women and that is associated with a decline of reproductive hormones and sexual drive. He bestows the neologism maturescence, a term deliberately designed to echo the notion of adolescence, on this period and its psychic work. Montero is moved to eloquence and a certain amount of whimsy as he explores the limits of the midlife crisis concept and expands his thinking in different directions. The author believes that the “power and pregnancy of the concept of mid-life crisis comes from the inner and mysterious uncanny place where all human beings remain tied to biology” (p. 3). Montero, in his expansive, if often elusive, reconsideration, emphasizes that the human species is the only one that “endeavors to go on living as long as possible” (p. 11) after female menopause and after the end of male fertility. Humans’ search for meaning is, in this context, both a creative act and a form of denial. Maturescence, inclusive of the midlife transition and by no means limited to a crisis, is the psychic work involved in answering the somatic stimuli of biological change, “the psychic outcome related to the true beginning of biological aging” (p. 27).

In this emphasis on the biological drives, Montero remains true to Freud. Diverse chapters explore topics under the big tent of psychic work related to universal biological aging. A chapter is devoted entirely to deriving a metapsychology of maturescence from Freud’s work alone, including the concept of the drive to death in Freud. A lucid exposition of Nabokov’s (1958) novel Lolita is presented to document Humbert Humbert’s sexual longing as a search for immortality and his inability to accept his own impotence and approaching death; Virginia Woolf’s (1925) novel Mrs. Dalloway is also explored as an example of working through maturescence. Montero’s theory clearly conforms to the Freudian postulate of the opposition between life forces (Eros) and forces of death or destruction (Thanatos).

For Montero, it is crucial to differentiate between direct and indirect understandings of maturescence. An indirect understanding considers manifest events (parental death, empty nest, retirement) which reflect a latent or implicit meaning of loss and sorrow; a direct understanding “considers what is happening with the psychic expression of somatic phenomena” (Montero, 2020, p. 83), and the “revolt against biology” (p. 83) as evident in the latent content of a patient’s associations, symptoms and dreams. Montero joins Freud in insisting upon the truth that humans are animals, fundamentally part of nature, and cannot avoid this biological fact. He elaborates several “deviants of thought” (p. 85), psychic elements that “force humans to deny their belonging to nature,” most particularly the avoidance of the present moment. Montero argues for “living the actual moment” (p. 88).

Montero lays out the difference between avoidance and confrontation. Confrontation requires that the individual not resort to avoidant patterns of thought (euphemisms, relying on past habits, or common sense) to reduce the authentic moment. He is indeed arguing for the enormous potential of aging when one accepts aging and death and their psychic challenges. This requires a commitment to genuinely experiencing the changes of aging both in soma and psyche, and finding one’s own understanding and meaning. “Maturescence is a great opportunity to let go of common sense in order to obtain one’s own individual sense . . . to transform common places into one’s own individual place” (Montero, 2020, p. 97). This formulation expresses well the nature of the growth that is possible, the growth we have observed in our older patients. We recommend Chapter 6, “Different Understandings of Maturescence,” which offers helpful and illuminating variations on the book’s overall theme.

In an earlier exposition of his theory of maturescence, Montero (2015) postulated a mid-life shift from the dominance of Eros in younger adult life to the insistence of Thanatos in the second half of life. Montero sees later life anxieties as the underpinnings of human efforts to deny aging, with its loss of reproductive capacity and ultimately the awareness of death, that is, the effort to remain youthful, or, perhaps too-hopefully, to anticipate or seek an ever-longer lifespan even as one is aging.

It should be said that Montero’s steady emphasis on the postclimacteric in males and the psychic work it requires seems at odds with much masculine experience and arguably at variance with the research literature. Based on a reading of the endocrinology literature, one could question how clear the relationship actually is between age and hormonal levels in men (McKinlay, Longcope, & Gray, 1989).

In grounding his theory in biology, Montero seeks to remain true to the fundamental Freudian assumptions of a unified psyche-soma. He asserts that maturescence represents a chance for well-being, because well-being is “the result of a working-through of drive increase confronted with the background of the underlying aphanisis [loss of sexual desire] and the multiple variables that include the life history and subjectivity of the individual” (Montero, 2020, p. 133). Each person, that is, will work through and process maturescence “with his own psychic resources” (p. 27), making for a multiplicity of personal developmental journeys and resolutions, all of which have in common an “acknowledgment of and confrontation with uncertainty and paradox” (p. 47) and, importantly, the acceptance of personal mortality.

However, biological perspectives must take into account the evolutionary needs of the species (to reproduce, to nurture offspring, to transmit knowledge to the next generation, etc.). Margaret Mead observed that the older members of many Indigenous human groups were indispensable for their cultural knowledge. Mead (1970) asserted, “the continuity of all cultures depends on the living presence of at least three generations” (p. 2). This perspective is quite consistent with an Eriksonian emphasis on the tasks of midlife and beyond—ego integrity versus despair and generativity versus stagnation—emphasizing ongoing psychological dilemmas and also the potential contributions of elders. Montero’s theorizing, however, does not take into account contemporary sociological or evolutionary thought. Evolutionary biologists have explored the question of human female survival well beyond reproductive capacity. Female elephants are very long-lived, and the elephant herd relies on these matriarchs to hold historical knowledge for the herd, a form of cultural knowledge.

The only other known examples of mammalian menopause are whales, specifically four distinct species of toothed whales, in which this phenomenon has evolved independently in four separate evolutionary lines. The hypothesized evolutionary advantages for the toothed whale species include having the aging females available to support their daughters with the extended demands of rearing their young, having the experienced elder females’ knowledge to guide the pod in potential crises such as insufficient food in expectable hunting grounds (a form of cultural knowledge), and the elimination of additional offspring of more senior females who would compete with the offspring of the whale daughters for resources (Ellis, Franks, Kronberg Neilsen, Weiss, & Croft, 2024). A truly biological perspective must take into account not merely innate individual drives but also a more sociological perspective, such as the needs of the human species.

Blooming in December

Amy Schaffer’s (2021) Blooming in December presents, in a well-organized, well-informed, and yet fundamentally modest way, the clinical terrain of working with older adults. Saddened over past psychoanalytic views, and convinced based on her own extensive experience that older adults have much potential for change in therapy, Schaffer disagrees with the pessimistic views of Freud. She movingly relates her own discovery of the power of working with older adults:

a major thrust of our work with younger individuals is geared to fostering the development of, and removing the obstacles to, a sense of autonomy and agency. We want our patients to be captains of their ships. How then does one work with an 80-year-old who has achieved and prizes his autonomy and whose challenge now, in the face of physical infirmity, is to retain his sense of self and equanimity while experiencing ever-increasing dependence? (p. 3)

Erik Erikson’s influence is clear here and indeed is felt throughout the book. Skeptical about the neat linear progression of stages Erikson proposed, Schaffer nonetheless accepts the developmental tasks Erikson identified and sees them as clinically important. She views later life as a time when earlier relational conflicts, perhaps insufficiently resolved in early life, such as those around trust and autonomy, may resurface and present a challenge once again. Building on Selma Fraiberg’s notion of “ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975, p. 387), as well as Loewald’s (1960) idea that the ghosts of the unconscious may, with work, become transformed into ancestors, she frames her theme as “ghosts in later life” (Schaffer, 2021, p. 19).

Later life, for Schaffer (2021), is a time when the body’s forward development slows and when “physical capacities decline” (p. 25). The failure of a patient’s manic defenses may join with the therapist’s uneasy countertransference in the face of aging and death to create an assault on the grandiose expectations that mental health professionals may have for therapeutic work with older individuals. Even Erikson (1984), decades after publishing his stage theory, acknowledged that “the demand to develop Integrity and Wisdom in old age seems to be somewhat unfair, especially when made by middle-aged theorists—as, indeed, we then were” (p. 159). In this way Schaffer’s concept of work with older adults bears a family resemblance to the Jungian idea that under existential challenge, defenses may fail and clinical turmoil may result (Jamieson, 2022). For her, “the sad fact is that the problematic experiences of one’s early years often gain greater disruptive power later, as the hardships that accompany older age and the facing of the end of one’s existence revive long-buried troubles” (p. 20).

But Schaffer’s carefully observed dilemmas and realistic ways of working, elaborated throughout the book, make a striking contrast to the expansive spirit that animates Jamieson. For example, Schaffer relates the following vignette: Sadie, a widow nearing age 70 who worried about becoming “’a burdensome old lady’” (p. 19) complained to her psychotherapy group that “’I can’t open my bedroom window’” (p. 19). “’What should I do? Should I ask my super to help? If I ask him, should I tip him?’” (p. 19). Shaffer, the group’s leader, silently consulted her own countertransference and recognized a dread that this particular group session would turn out to be boring and superficial. (What else could a stuck window portend?) Yet to her surprise, the group took up the issue of humiliation, the experience of needing help, and the presumably early and now recurrent theme of “loss of self-sufficiency” (p. 19) with genuine gusto. The drama here, of late-life struggles capably addressed through psychotherapy, attention to development, and introspection, is in fact central to the book; it is heightened by Schaffer’s confiding to the reader that the group session happened more than 4 decades earlier. Once an anxious and self-divided young therapist, Shaffer developed over time into an eloquent advocate for psychotherapy and its potential to foster meaningful growth in elders. She remembers how her view of older clients was transformed, and she is eager to share.

Blooming in December defines its subject lucidly, illustrates its generalizations wisely, and knows the limits of its scope. It will likely be of enormous help to clinicians in their daily work with middle-aged and late-life adults, and to psychotherapists who are new to this kind of work.

Breaking the Age Code

In the fourth book, Breaking the Age Code: How Your Beliefs About Aging Determine How Long and Well You Live by Becca Levy (2022), the author has carefully documented the impact of ageism and beliefs about aging on the length and quality of life for elders—and has done so in a reader-friendly style that is both responsible and inspiring. As a professor of epidemiology and psychology at Yale University, Levy specializes in the comparative study of attitudes about aging. She herself published influential work in 2016 by analyzing data from the Ohio Longitudinal Study on Aging and Retirement. As she relates the story,

Since there was so much information collected about these Ohioans, I was able to determine that age beliefs were determining their life spans above and beyond the influence of gender, race, socioeconomic status, loneliness, and health. Age beliefs stole or added almost eight years to their lives, conferring an even better survival advantage than low cholesterol or low blood pressure (both of which added an extra four years of life) or low body mass index (one extra year) or avoiding smoking (three extra years). (p. 93)

The graph on page 93 illustrating Levy’s findings conveys the essence of her work in dramatic form. The vigorous line of the “Positive-Age Belief Group” gently slopes downward over the 22.5-year interval since initial interviews were conducted, while the broken line of the “Negative-Age Belief Group” plunges downward at a faster pace, finally resulting in a 7.5-year survival advantage for those with positive beliefs about aging. With these findings in hand, Levy came to view socially accepted negative beliefs about aging as the equivalent of a disease, and she made a vigorous case for social action against denigrating views of elders. In so doing, she gained much attention in the press and in public forums, including a hearing on ageism before the U.S. Senate.

In Breaking the Age Code, Levy (2022) uses a very wide lens to help the reader see (and feel the impact of) the way such beliefs work as protective factors, as well as the urgent need for change. She draws not only on her own and others’ published medical and developmental science but on interviews with elders; examples of successful aging; anecdotes about famous and creative people (reminiscent of Jamieson’s anecdotes in some respects, but more fully integrated with other sources); thought experiments about how society might change its ways; mnemonics and talking points on how to effect change; her own memories of her experience of antisemitism (as a reflection on how beliefs change); and perhaps most intensely and hopefully, on the history of successful social movements. For her, an “age liberation movement” (p. 175) is critically needed. It is, she firmly believes, very possible to create such a movement if the lessons of past social movements are heeded. Levy offers detailed guidelines for creating such a movement. And she notes with optimism that some encouraging signs of change have already emerged, such as antiageism campaigns by the World Health Organization and policy changes at the National Institutes of Health that aim at including older participants in clinical trials. Her overarching mission, which she calls cultural redefinition, involves the aim to make aging beautiful, in much the way the civil rights movement aimed to shift culture.

The hope in Levy’s book is infectious, and her goals self-evidently worthy. Yet at times her hope, and/or her strong belief in the importance of positive beliefs, seems to crowd out acknowledgment of real problems and barriers to change. For example, while acknowledging the importance of her deep empirical work on determinants of longevity, one may view with some skepticism her claim to have discovered a town where ageism does not exist, Greensboro, Vermont. In a more sober turn of phrase, Levy (2022) calls this town a place where “older people and their surrounding society are harmonized in a productive way” (p. 201). This Eriksonian formulation—she was friends with the older Erik and Joan Erikson during her graduate school years and was inspired by them—comes across as a shining ideal rather than a lived reality. Freud appears here only briefly, as the holder of unfortunate ageist stereotypes about the rigidity of older patients. His biased thinking, Levy suggests, likely “came from his ageist Austrian upbringing” (p. 79), including his mother’s, Amalia Freud’s, resistance to seeing herself as old. Levy counters with a clinical anecdote reported by a psychiatrist who finds older people to be, contra Freud, quite flexible in treatment.

From an epidemiological point of view, of course, unconscious forces are hard to quantify and may be elusive in comparison with data like cholesterol levels, pack-years of smoking, and years of life. (Vaillant and Mukamal, 2001, however, have been able to do just this in their study of defenses and successful aging.) Studying the data and anecdotes that Levy amasses about positive beliefs and longevity leads us to speculate that analysts still have much to learn from the empirical study of social cognition. The embodied way negative beliefs hold patients back from living richer lives is familiar to analysts in the consulting room, where considerations of early history, repetition, transference/countertransference, and affect tend to dominate. Levy’s findings in the social-cognitive vein could be reconceptualized as potentially showing the effects of psychoanalytic concepts like self-division, internalized bias, or unconscious resistance to change. But for that imaginative possibility to be confirmed, more analysts would need to enter fully into a longitudinal research role.

Life Reimagined

The final book we will discuss is Life Reimagined: The Science, Art, and Opportunity of Midlife, by Barbara Bradley Hagerty (2016). Hagerty, a former journalist at National Public Radio, chronicles her personal journey, beginning with an episode of chest pain in her 50s, the death of her father, and the health decline of her mother. Hagerty was inspired by her own crisis, in a turn that Jamieson and Jung would appreciate, to spend 2 years interviewing researchers on aging, to listen closely to their descriptions of their work, and to integrate current findings not only with her own story, but with interviews and stories of people in midlife, many of whom responded to an invitation posted on an NPR website.

As a reporter rather than a scientist by training, Hagerty has approached her investigation diligently and thoroughly, looking to as many perspectives as she could imagine, including cognitive science, neuroscience, psychology, genetics, and sociology. The book is carefully referenced yet highly readable, warm, and witty. The overarching conclusion is that the overall quality of a life in terms of satisfaction, relationships, and mental health is not foretold by genetics, education, socioeconomic status, or professional achievement. Instead, she derives pearls such as research psychiatrist and psychoanalyst George Vaillant’s lesson that “Happiness is love. Full stop” (Hagerty, 2016, p. 38). That is, warm relationships, especially those formed after age 30, predict flourishing in late life. It is gratifying for a psychoanalyst to read that the quality of relationships, both in early life and subsequently, is a major predictor of a good life. From a clinical point of view, some of the outcomes may, of course, depend on choices made in middle life, a time when patients commonly come into treatment. The relationship/affective focus explored by Hagerty is intriguingly congruent with the way Levy frames her cognitive/belief findings and with Vaillant and Mukamal’s (2001) longitudinal finding that mature defenses and stable, satisfying relationships are critical to successful aging.

Hagerty’s moving description of her own journey involves a new midlife awareness of both the potential for and the reality of parental loss and the inevitability of personal mortality.

Similar psychological territory was framed by John Oldham (1989) as representing a “third individuation” (p. 89), following the first separation from parents in infancy (growth into normal autonomy) and the second in adolescence, defined by Peter Blos (1967) as a psychic restructuring and a disengagement not only from parents but “from internalized infantile objects” (Oldham, 1989, p. 90). Where ego psychology once equated “maturation with autonomy” (Modell, 1989, p. 19), current thinking emphasizes, as research psychiatrist-psychoanalyst Robert Waldinger does in his interview with Hagerty, that even as developing humans separate in these ways, much of the meaning in life remains in connection. Such meaning may come from an emotional appreciation that the “isolated, separate self” (Hagerty, 2016, p. 41) is less meaningful than the “vast continuum of life” (p. 41) that surrounds it, from the discovery of new relationships in late-life reflecting the decline of the power of old internalized objects to shape life, the reworking of past loves and traumas in psychotherapy and psychoanalysis, or what Heinz Kohut (1977) saw as a normative, lifelong self-psychological need for appreciation and mirroring from others.

Concurrently much focus has shifted away from overt death anxiety in midlife to the notion of death awareness, which leaves room for much noncrisis thinking, reevaluating, and planning. As Seneca (2005) taught, “learning how to live takes a whole life, and, which may surprise you more, it takes a whole life to learn how to die” (p. 10). Our elders can help us live in the present and also accept dying.

Discussion

Jamieson’s book seems designed to inspire; Montero’s to provoke thought; Schaffer’s to offer specific, practical guidance to the techniques, potentials, and limits of clinical work; Levy’s to raise important concerns about devastating social impacts of ageism on individuals and communities (even psychoanalytic communities) and to define a path forward for meaningful social change; and Hagerty’s to offer realistic optimism and insight. Each perspective has a valuable place in the big tent of clinical work with older adults. The models—of expansive possibility, of theoretical reworking, of psychosocial integration, and of optimism for psychoanalytic therapies as the art of the possible—are all likely to play a role in the consulting room over the relatively large periods of time that are distinctively available in analytically informed dynamic work. Perhaps the most accessible and encouraging book for individuals is that by Hagerty, which George Vaillant described as “arguably the best book on middle life ever written” (Hagerty, 2016, dust jacket).

In the wider world of empirical study, where few analysts dare to tread, what is known about the second half of life? Jamieson and Montero show little interest in what the empirical literature may have to say about the topics they explore. Erikson (1968/1987) himself thought that there was little point in “measuring what by its nature cannot be measured” (p. 595)—that is, he believed that dynamic concepts are just too subtle to pin down and measure with numbers. But there is now a large and growing body of empirical work that is readily available on the psychological changes that accompany adulthood and aging, both in life and through treatment.

To take an example that is centrally relevant to the claims made in three of the books discussed, the role of defenses (or coping styles) in life and in therapy has been an area of intense study for decades, using sophisticated empirical methods (Vaillant, 1992b). Since the 1970s, analytically trained researchers have established that “choice of defensive style” (Vaillant, 1976, p. 542) is measurable; that use of more adaptive (mature) defenses or coping styles increases in the period from adolescence to midlife (Vaillant, 1977/1995); and that use of mature defenses is positively correlated with midlife mental health, including adult adjustment, successful marriage, and successful parenting (Vaillant, 1976, 1978). More recently, as noted above, Vaillant and Waldinger’s over 70-year longitudinal studies of male psychological health in college men and inner-city men have demonstrated that defenses are an important facet of successful aging in the years after midlife (Vaillant & Mukamal, 2001) and that men who endured adverse childhood experiences nonetheless show late-life resilience, in the form of maturation of their defenses, after age 50 (Martin-Joy et al., 2017). Diehl et al.’s (2014) stratified study of European-American men and women confirmed that the use of adaptive defenses increases from midlife to late middle age and early old age, though this study found some signals to suggest some possible decline in coping in very old age, consistent with the reemergence of early conflicts and less mature defensive styles as observed by Levy (2022).

Studies of higher risk populations often show more mixed findings over time: high-risk pregnant women followed for 2 years after delivery, for example, showed declines in the use of adaptive defenses (Porcerelli, Richardson, Smith, & Huth-Bocks, 2022). A recent effort (Jacob et al., 2022) to remedy the chronic neglect of Black participants in studies of coping reviewed 26 studies of emotion regulation and coping in Black people who deal with pervasive racism. Frequently used means of coping included spiritual strategies, seeking social and community support, and problem-solving, including directly addressing the stressor. The identified coping strategies, more distinctive for Black women than for Black men, are highly suggestive for clinical work. There is a parallel literature on changes in defenses, generally in an adaptive direction, in the course of psychodynamic psychotherapy (Bond & Perry, 2004). The clinical literature on changes in defensive structures and outcomes in various conditions maps well onto recent empirical literature showing that dynamic therapy is effective for a range of psychiatric and life conditions (Henkel et al., 2025). It is unfortunate and in many ways puzzling that psychoanalytic theorists and writers like those discussed above are not engaging robustly with this literature, despite the central role each gives to changes in defenses in late-life analysis and dynamic therapy.

How, if at all, can a clinician make use of the range of sophisticated studies of the capacity for change in life and in psychoanalytic and psychodynamic work? Empirical studies prize reliability in their methods and reproducibility in their findings. Yet a psychoanalyst or individual psychodynamic clinician can only take one patient at a time and immerse themselves in the experience of the case. Psychodynamic patterns, countertransference data, Eriksonian stages, the relevant relationships in a life, and the changes that do or do not emerge unfold in time and in the context of the treatment relationship. One listens first, begins to consider an insight, a developmental theory, or a clinical approach in time, and then talks to one’s patient in his or her own idiom as ideas begin to coalesce in a flexible rather than rigid pattern of work (Axelrod, 2024).

Using the empirical data, one can learn to identify and work with specific defenses (Vaillant, 1992a, 1992b), including the omnipotent defenses that are the common barriers to acceptance of aging, and one can work at softening them by interpretation, by empathy, by relational being-with, and by attention to one’s own moment-to-moment countertransference and reverie. Where studies suggest the possibility of positive change in defenses and movement toward more positive outcomes, empirical work can provide hope. One may also draw on the now well-developed resilience literature and aim to become skilled at what Hauser, Allen, and Golden (2026) call “seeing in the dark” (p. 260). Patients are likely to present to us at their most difficult times, when it is hard to see grounds for hope or even for a useful clinical approach. In the Hauser et al. study, the patients were teens hospitalized for serious depression, self-injury, and assault. Yet if one follows those patients for 10 to 15 years, long after the index event and the hospitalization, some manage to right themselves. Why? Are there factors present at the time of crisis that predict a good outcome? Hauser et al. identified several predictors of a relatively positive outcome: agency, capacity for reflection, interest in relationships, and mental coherence. All of these qualities were identifiably present in the narratives of the troubled teens at the time of hospitalization. Adaptive defenses themselves, present in selected domains even in the presence of much trouble, may also predict good outcome (Billings, Hauser, & Allen, 2008; Martin-Joy & Vaillant, 2010; Rutter, 2013).

Clinical Example

With all this groundwork in mind, we wish to offer the following clinical example. Consider Mrs. H, a patient who came to one of us (J.M.B.) in her early 70s. ² She was flooded with rage and guilt toward her husband, who was suffering from Alzheimer’s disease and whose needs had forced the couple’s move to a retirement community. She had been a highly esteemed artist with rich friendships in a vibrant community of artists and feminists in a major city. She let me know that she felt she had never loved her husband, though she was grateful for all his support, and she recognized that he had loved her and their two children very deeply. But she now felt “trapped.” She recalled having similar feelings when on the lap of her overprotective and somewhat needy mother as a young child, or when staying home with her own first-born child. Her shame and guilt were heartbreaking to sit with. Mrs. H had been in multiple psychotherapies over most of her life; she stated that these had been “lifesaving.” In our first meeting, she shared many insights and offered a rather formulaic description of her current situation. As we ended that meeting, I suggested that I wasn’t sure I could help her because she seemed to have already done the work and to “have it all figured out.”

Mrs. H left crushed and angry, but she called back several days later to schedule another meeting, and so we began. Much of our therapy process centered on a series of her drawings, which she brought in, as each was completed, to explore with me. She described her artistic process as quite involuntary and unplanned, simply letting the drawings “happen.” Yet over the next decade, as we talked about each of these drawings, she gained increasing access to their unconscious meanings, and her emotional life was gradually transformed. When her treatment ended, she had “fallen in love” with her husband and took great pleasure in simply sitting in silence with him, taking in his generous love. When she would ask what he would like to do, he invariably answered, “Whatever you would like to do.” Over time, her drawings shifted dramatically from the first, a wretched, despondent bird trapped on a nest and screeching in rage, to a witch-like bird attempting to fly free on a broomstick, to, finally, a serene barn owl with a heart-shaped face echoed by a vibrant red heart in the image. She told me that she had now realized that “love isn’t something one feels, but something one does.”

I continue hearing from Mrs. H every few months. Now 95, she has grieved her husband’s death, confronted and managed her own substantial medical issues, and lost many friends, but she expresses equanimity and deep satisfaction with her own life. She remains deeply connected to her children and grandchildren. She has been a major contributor to her remarkably energetic and caring retirement community, starting a nationally recognized on-site gallery that recently hosted an exhibit of work by an artist now in his nineties. She believes that the present therapy opened her to be able to experience intimacy and to love. Her personal vision of aging has been radically revised as she has recognized the wisdom and perspective she has accrued over a lifetime. She accepts that her own death is imminent and feels her life has been “more than fulfilling.”

This case well illustrates several of our themes. First, individuals in middle to late life can, under fortunate circumstances, be profoundly receptive to psychoanalytic work and can achieve deep change. As Schaffer (2021) and others document, clinicians who have focused on psychoanalytic work with persons in either middle or late life describe the power and poignancy of this work. Even at the end of life, meaningful growth is possible, potentially representing a shift from “existential anxiety” (Slavin, 2013, p. 298) to “existential maturity” (Emanuel, Reddy, Hauser, & Sonnenfeld, 2017, p. 318), as elaborated by Linda Emanuel and her colleagues. Emanuel et al. (2017), who are researchers working in palliative care, consider existential maturity to develop when the individual is able to accept the finality of death and to find individual and interpersonal meaning in the face of the end of life. A similar development is part of the Eriksons’ eighth stage of adult development, integrity vs. despair (Erikson & Erikson, 1997). Second, we observe from the work with Mrs. H how one’s aging is profoundly shaped by internalized societal and personal experiences and prevalent attitudes concerning aging. Initially, her depression was strongly influenced by her sense that she was now removed from her gratifying life to live with old people. However, she discovered many intelligent and active members of the community and was able to join them as a contributing and engaged member. Third, we observe that early developmental issues may reemerge in late life when they become accessible to therapeutic intervention (Schaffer, 2021). Mrs. H felt despair, in part, because she had been constricted in her early life in her efforts toward separation and individuation. In addition, her deep anxiety about being taken over by the other created an internal defensive barrier in her capacity to love her husband. The kind of growth Mrs. H experienced involved transforming early unconscious fantasies about relationships and associated avoidant and omnipotent defenses in favor of more mature capacities for love and for tolerating vulnerability in relationships, especially in the therapeutic relationship and with her husband. Thus in growth one can trace a shift from denial to acceptance, especially of the task of mourning that Freud in “On Transience” (1916/1957) identified as central to a well-integrated human life.

Conclusion

Informed and inspired by the theory and practice embodied in Jamieson, Montero, Schaffer, and Hagerty, by the effect of social biases documented by Levy, and by the empirical knowledge that defenses can and do mature both over the course of lifespan and in the course of treatment, perhaps psychoanalysts and psychotherapists can come to see cases like that of Mrs. H in a different light—not as aberrations or even as exceptional outcomes, but as well within the range of what can be expected over time when analysts and therapists dedicate ourselves to work with people who are in the second half of life. In future research documenting development over the lifespan, and in our field’s clinical literature, psychoanalytic clinicians can aim to become more sensitive to the potentials and struggles of our older patients.

On a policy level, while the social movement envisioned by Levy is potentially taking shape, those within the psychological and psychoanalytic community can advocate for including material on the psychological dimensions of healthy aging in our clinical training curricula. As we age and undergo our own midlife and late-life transitions, we might reflect on what views, evidence, and lingering biases we may be passing along to the eager, sensitive, and ambivalent learners looking to us for guidance.