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Psychotherapy Casebook


Dean Schuyler, MD

Published: July 21, 2016


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Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist and a member of the palliative care team at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord 2016;18(4):doi:10.4088/PCC.16f02007

Published online: July 21, 2016.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (

Funding/support: None.

Potential conflicts of interest: None.

I have been reading Old Age: A Beginner’s Guide by Michael Kinsley,1 and it got me thinking. I have worked in geriatrics at the Veterans Affairs Hospital in Charleston, South Carolina, since March 2010 and have interacted with many aging men. In the process, I have become familiar with some of the problems inherent in aging.

Getting up in years often means contracting a serious medical illness, and thinking about that illness and its possible consequences often produces anxiety. Aging typically entails experiencing losses at a rate greater than one is used to at an earlier age. Several 80- and 90-year-old men told me that they were the only remaining people among their peer group of friends—all had died.

Another feature of aging is loss of control. The aged often walk slower, are less open to change, and are unable to do what they did at an earlier time in their lives. When an older man’s license to drive a car is taken away, for example, his world is often diminished markedly. Some aging men no longer go outside, do little around the house, and may have their activity level reduced to zero.

In an effort to preserve a sense of who they are, some men cling to an identity established when they were much younger. When discussing that identity, they talk of work they may have accomplished many years before. Only a minority seem to rework identity to fit this new life stage. Retirement, for many, doesn’ t seem to fulfill them and is not what they thought it would be.

Some are concerned with reputation: how they are seen by others. Many, however, don’ t seem to care. Anticipation seems to focus on what the serious disease state might bring, rather than the activities that might enable one to escape domination by the thoughts of illness.

Loss, control, and activity seem to be key variables in understanding this latter stage in the life of some individuals. When a life partner of many decades dies, some men seem lost. The division of labor that defines many couples is reduced to one person left to "do it all." That was the problem faced by Mr A.


Mr A is an 85-year-old man with lung cancer. He consulted me at an oncology clinic several months ago. Born in Washington, DC, he grew up in neighboring Bethesda, Maryland. The oldest of 5 children in his family, he was independent at an early age. He graduated high school and then attended the University of Virginia in Charlottesville.

After 2 years in the Army, he worked as a traveling salesman for over 40 years. He married while in college, and he and his wife had 4 sons. His wife raised their 4 boys and managed the home while he worked on the road. The diagnosis of cancer was the start of his first serious illness.

Mr A was now retired. Suddenly, his wife died. They had been married for nearly 60 years. Mr A’s vision and hearing deteriorated, and the many hobbies he had undertaken were now impossible to pursue. He stayed at home, grief-stricken, and wondered how he would manage the life that had been run expertly for him by his wife.


When he first consulted me, Mr A spoke about his son’s financial habit, which had cost him considerable money. He noted that I was the first person he had told about this. He seemed quite relieved. Shortly thereafter, when his wife suddenly died, we took on, together, the problem of reworking a life that could no longer be managed as it was.

Many of the problems inherent in aging were commingled with the need to figure out how to deal with this new life stage. In our first session after his wife’s death, I encouraged Mr A to tell me about her final days. When he returned, he spoke about how difficult it was for him to live alone after so many years of having a partner. Having been so long "independent," it was hard for him to put together a life of "dependency" on others. We spoke in detail about preparing food, taking medicines, and shopping, as well as continuing some of his hobbies—now much more difficult because of his visual difficulties. "I’ ll find a way, I promise you," he said. When he returned for our next session, he said, "The quiet is deafening." He was making an effort to stay active. Activity and eating were major issues for him.

"Sometimes I let my thoughts run away with me," he said at the start of our next meeting. We spoke about his concern with what others thought of him. He needed, he said, to be less concerned with this. We spoke about decisions he had made in business and how the same process now needed to be applied to running a home.

In our next meeting, he wondered whether his wife’s death should be attributed to "God’s will." I responded by reminding him about bad things happening to good people. The active ingredient now seemed to be his responsibility, not that of God. He needed to practice delegating some tasks and setting some priorities. He needed to be able to say, "I’ m not ready for some things yet." People were likely to understand that. He didn’ t want to be a recluse; however, he also didn’ t want to be a "pain to others."

This exercise will most likely continue. He will try out ways to deal with this life stage, and I will respond with encouragement and then detail the likely consequences. Aging for many men and women poses problems they haven’ t had to face before. Many people cannot continue to do what has been successful in the past. There is a need to think about this life stage and then to adopt ways to deal with it. A trusting relationship with a counselor can be helpful in this task.


1. Kinsley M. Old Age: A Beginner’s Guide. New York, NY: Random House; 2016.

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