Narcissus Also Has Gray Hair Narcissism in the Second Half of Life: Treatment from a Psychodynamic Perspective

Introduction

The issue of narcissism is broad and intricate. It encompasses many of the challenges we, as therapists, encounter in treatment - and in life more generally. We all face painful aspects of reality: fear of illness, the loss of control over our fate, multiple losses, the fact of our mortality, and the death that awaits us all. It is therefore understandable that many cling to a system of defensive - imagined - narcissistic beliefs that protect us from these upheavals and provide a familiar sense of security, stability, control, and meaning to our existence. The cost is a degree of detachment from reality, leaving one vulnerable to crisis [1]. In his writings on narcissism, Freud discusses the complexity of the phenomenon [2]. On the one hand, he views narcissism as a necessary developmental stage, a form of self-love that never ceases, one that enables self- esteem and satisfaction - even if fundamentally illusory. On the other hand, he defines it as a libidinal investment in the self at the expense of connections to reality and the other, thereby risking pathology. Freud notes that one must love in order to live. We require recognition of the object - the other as separate - in order to live with reality. Following him, some theorists see narcissism as a distinct system, vital to mental health and quality of life, reciprocally influencing other psychic systems [3-5].

Others regard narcissism as a pathological phenomenon, a manifestation of the death drive and a defense against it, as well as against envy and destructiveness entwined with it [6-9]. Beyond these premises, Freud points to the withdrawal of libido and its turning inward to the self in response to disappointment in objects in reality and to the pains that reality imposes. This is the defensive aspect of narcissism; an aspect challenged in everyone throughout the life cycle. My clinical experience with adults has taught me that older adults repeatedly attempt to cope with losses, vulnerabilities, and dependency, recruiting many and varied defenses for this purpose. Beyond individual differences, I have found that narcissism - and the ability to overcome injuries to it - are decisive in meeting the challenges of aging. Klein notes that a person who has firmly established the “good object” in childhood can also find compensation for later losses in adulthood [10].

Even in the treatment of younger people, narcissism is critical to whether the patient can make use of therapy to encounter themselves and the surrounding reality - or whether the therapeutic encounter will evoke resistance, vulnerability, and humiliation, perhaps even regression and a strengthening of narcissistic defenses and a refusal to face reality. Symington writes: “Narcissus will live to a ripe old age unless he meets himself” (p. 6) [6]. Through a clinical description, I consider the idea that movement along the life cycle and the losses of old age constitute a complex crossroads for the narcissistic structure. The injuries inflicted by reality destabilize familiar defenses - those that form a kind of narcissistic immune system described by Solan- and sometimes even shatter them [5]. On the one hand, regression and an intensification of disconnection may occur, alongside desperate attempts to restore what was destroyed; on the other, fracture and injury may promote increased flexibility and even a greater willingness to regard reality soberly. When mourning processes become possible in the encounter with reality, psychic growth and personal development occur, accompanied by a transformation in both personal and archaic narcissism [3,7].

Clinical Case

I will describe the treatment ofYosef (a pseudonym) to illustrate these reflections. Yosef is 86 and faces two options: the intensification and amplification of his narcissistic patterns, or the softening and thawing of his defenses, and with it the capacity for introspection. I begin with an episode from the end. When, at our parting, Yosef was asked whether he would agree that I speak or write about our shared treatment, I was surprised by his response. Yosef beamed with joy and said: “Of course - gladly!” Yosef was pleased to have a “stage,” emphasizing that there was no need to disguise his details (which I, of course, did). In retrospect, I understood that Yosef derived narcissistic gratification from commemoration itself - from the possibility of focusing the spotlight solely on him. Alongside this, he felt a sense of meaning in transmitting his life experience and wisdom to future generations.

The Treatment with Yosef

Yosef arrived to the first session tall and erect, projecting confidence and control, despite a somewhat hesitant gait. He sat down and, in a vigorous voice, announced: “I am here only because my daughter and son-in-law think I should see a psychologist. I comply with them, but I see no need.” When I asked what led his children to think so, he explained that his wife had cancer (an advanced stage), which he described in a matter-of-fact manner. Two years later, he understood how disconnected he had been during that period. He had not recognized her prolonged deterioration and the approach of death, which came upon him as a shock and a surprise. He busied himself with caregiving roles; he estimated the duration of her illness at one or two years, when in fact she had been ill for eight.

After three sessions in which he described, comprehensively and matter-of-factly, the course of his life and achievements, Yosef informed me that he did not wish to continue. He enjoyed our conversations, but he knew himself, was aware of his condition, was satisfied with his achievements and his lovely family, and felt no need for help. This was later borne out by the revelation of his deep aversion to emotional closeness and to contact with others beyond his daughter and grandchildren. His aversion to being vulnerable and needing help emerged, and even more so his aversion to inner self-examination. This aversion highlighted the array of defenses he had built - defenses of self-satisfaction and contentment - alongside an inability to face cracks in this edifice when confronted with changing reality, his own limitations, and the need for others. I told Yosef that I fully respected his stance; that it was important to me that the decision to seek treatment be his - out of need and choice - and not at his children’s behest. Even if his family’s concerns were justified and gave voice to feelings he dared not express, experience had taught me that one who is “sent” to therapy without defining the need for themselves will not take responsibility for the exacting challenge posed by dynamic treatment.

I was therefore very surprised when, a year later, his daughter called to ask on his behalf to resume therapy. When he arrived, a completely different man sat across from me. Yosef used a walker, reported that his wife had died three months prior, that he was living with a caregiver, and that he suffered from severe bodily pains. Medications did not help at all, and the physician suspected psychological stress and recommended treatment. Yosef burst into tears several times during the session; it was evident that he was struggling, yet he also enjoyed the release and catharsis. Beneath the confident man who lorded over his surroundings, childlike parts were revealed - anxieties, fear of being alone, fear of pain and death. Yosef faced the limitations of his age and said: “I don’t understand what is happening to me... I don’t recognize myself; I feel lost and frightened.” The transference also shifted entirely. I became an authority figure - a knowing, even maternal, therapist. He leaned on me and was deeply reliant on my presence. Yosef calmed significantly with me and said: “Strangely, the pains are hardly noticeable when I’m here.” We began the therapeutic work.

Phase I The Crisis

Yosef experienced a kind of regression to the frightened child he had been in infancy and childhood. He was a child whose name was taken and replaced with a Hebrew name upon immigrating to Israel with his parents from Europe. He described humiliating adjustment difficulties in the new country, together with severe narcissistic injuries: from being very established in Europe, they became refugees, with most of their family having perished. They endured poverty and deprivation, awkwardness, and a lack of social, occupational, and cultural integration. Yosef went on to describe his mother’s anxieties and bitterness alongside the cruelty and violence of his wounded and frustrated father. His sisters, perceived as more talented and successful than he, flooded him with feelings of insecurity, social anxiety, and aversion to native- born “sabra” children. He also described academic difficulties.

The material Yosef brought evoked in me empathy and pain. I reflected on how poignant is the condition of older adults who regress to childhood states of distress - severe fears, loneliness, need for attention - without the captivating sweetness of toddlers who mobilize their environment to respond, even if only partially, to their needs. Our meetings included detailed accounts of Yosef’s somatic complaints. A severe and understandable narcissistic regression was evident in light of his difficulties, with immense and almost exclusive preoccupation with his body and pains. His environment became increasingly instrumental, with minimal regard for others’ subjectivity. On a cold, rainy day, when I suggested that his caregiver wait inside, Yosef replied curtly: “She’s fine, sitting in the car - no need.” I gently tried to render others more present in his life: his daughter’s stance, the caregiver’s, my own…

A more fruitful channel during this period was Yosef’s willingness to “listen to the body as it narrates its distress.” The body became a narrator of the events he had experienced as a child and adolescent. Hesitantly, Yosef also began to speak about present distress and fears - his anxieties, pains, and dread of imminent death. A melancholic hue was evident, grieving the good life taken from him. He also expressed a kind of “sulk” - not wanting to live like this. During this period, there was very little reference to his widowhood. Another concern was his daughter’s wish that he move to a nursing home. This proposal reawakened his social anxieties, which had been masked during his marriage to a warm and sociable woman. His distress subsided only after we articulated his legitimate right to decide what is good and right for him, as well as his responsibility to bear the costs of such a decision. Yosef realized how important it was to make decisions about his own life, thus slightly stirring him out of regressive dependency.

He informed his daughter of his decision to remain at home. He also consulted a psychogeriatric Ian who prescribed anxiolytics. In the following session, he began to speak about his father, who had forced him to begin academic studies the day after his army discharge. He also spoke about the need always to be busy and in a “role,” a pattern that had accompanied him throughout his wife’s illness. He always created roles for himself. Now, the loneliness - the inner emptiness - was difficult. “In the place of emptiness, pain enters,” he said, pointing to his body. I spoke about the servitude to “role,” to the active persona, and even suggested, as an option, an aging style of the “rocking chair” - one that emphasizes relaxation and rest, a freedom he had never allowed himself, the experience of being. Yosef reacted with surprise but also interest and curiosity. He left more at ease.

From that session onward, Yosef spoke of the vast space for pleasure and enjoyment that had opened before him once he stopped tormenting himself for not taking on “tasks.” He gradually loosened the persecutory active image that had hounded him for years. He now enjoyed reading, watching television, or simply resting. The “rocking chair” image generated creative ideas for writing, documenting, and organizing at home. His bodily sensations improved, his anxieties diminished, and his reliance on his daughter nearly vanished. He asked to reduce the meetings to once weekly and began to use therapy in an exploratory and creative mode.

Phase II – Psychic Archaeology

Freud teaches that a person in acute crisis is not available for analytic work. Indeed, in the first phase, Yosef primarily needed supportive therapy. In the second phase, as his anxieties waned, he began to pose inquisitive questions about his life choices, relationships, and identifications. He even referred to our sessions as “psychic archaeology.” I felt some discomfort regarding my prior assumptions about analytic work in old age. I was surprised by Yosef’s questions about himself, which indeed opened the possibility for analysis. Another development emerged: Yosef began to dream - after years of not remembering his dreams. I understood this as an increased connection to his inner world, a softening of defenses, and an expanding self-awareness. He showed a certain delight when presenting his “productions” [11]. The dream contents raised topics he had not dared to touch: his relationship with his wife; difficulties as a child, adolescent, provider, and career man; and references to his aging and helplessness. His dreams began to depict highly complex narratives. I illustrate Yosef’s encounter between narcissism and aging through several themes that arose.

Yosef recounts: “After our last session I felt on cloud nine for two days”; “I felt understood”; “The pains disappeared and then returned. I told my daughter you’re a magician”; “I slept like a baby after our session.” The powerful transference - the need for idealization, for being understood in a place where he is listened to, can focus on himself, and feel protected and cared for - evoked intense, sometimes dramatic responses in both body and mind. The regression to more childlike lines made contact with the “child” within surprisingly accessible, and difficult as well as pleasant experiences flowed from him into the analytic space. His language also became more childlike; his talk about his body was open in a way that would embarrass a more defended adult. This accessibility of a revivified past enabled connections and interpretations that were received with surprising speed. For example, his mother’s fear of immigrating to Israel, his parents’ acculturation struggles, and their social isolation helped explain his frightened reaction to the possibility of moving to assisted living today - as if there were an emerging understanding of his inner child’s fear of further mockery, alienation, and strangeness in a new environment.

Yosef adds: “When I’m in the ‘rocking chair,’ endless plans arise. For example, to write about my grandfather, who used to play with us as children, made us laugh - I loved him so much”; “I grieved his death so deeply”; “I want to sort photographs thrown into the attic, assuming they would wait for retirement”; “To read letters my parents wrote to me”; “I find it interesting to write about myself and my past; I actually love myself.” Much has been written about turning inward in old age - the need to order, search for, and find meaning along the life course [12]. During this period, Yosef fully calmed and no longer feared solitude. He found a quiet space for being and even enjoyed it. Looking back, a partial revivification of good internal objects led him to weave plans whose execution afforded great pleasure and satisfaction. There was a sense of meaning and care for documenting the past for future generations - engagement with beloved objects, commemorating them, and reviving childlike and playful aspects of life. There was also narcissistic pleasure in our meetings - both from the focus on himself and from the attention to his past [4].

Yosef spoke of the pain he felt that his daughter did not agree to his request to move in with her family. Gradually, he realized that he too had distanced himself from his parents, visiting only out of obligation, essentially building his life separately and at a remove from them. He came to see that his demand of his daughter reflected a wish based on present needs rather than the relationship he had actually built with her. Their relationship did reflect greater closeness than with his parents, yet it retained an element of distance with which he identified and unconsciously transmitted. In a subsequent session, Yosef suddenly asked: “Am I selfish?. People don’t interest me much; conversation is usually boring. I’m fine by myself, in the armchair, reading, watching TV.” His pains had receded, his anxieties disappeared, and he noted he could not recall such a happy time. “I always aspired not to exert myself, to rest - and suddenly now it’s legitimate.”

I was taken aback by this lively display. Perhaps it reflected a surge of energy after a period of depression and decline; perhaps the closeness between us; perhaps the antidepressants. His question surprised me: the simplicity with which he confronted his self- focus, without defenses or shame. Yosef spoke very little about significant objects in his life, or even about his losses. I decided to take up the challenge and move cautiously to more focused interpretive work, attending to the transference. It felt as if a door had opened to review his object relations, traumas, humiliations, emotional deprivations, low self-esteem, and more.

Yosef asked: “What do you think - is it possible that because of my feelings of inferiority I had to strive to charm and win favor, and that was an enormous effort, and still, it makes me keep my distance from people?” This insight emerged in the transference as he insisted on arriving with a list of topics, expressing fear of boring me. The bridge - reflecting on the past through our relationship - became surprisingly accessible. It felt as if Yosef was now willing to relinquish considerations of “how I appear or am evaluated,” which previously dominated him. Fear of a nursing home took on further meanings as we illuminated his lifelong need to succeed in the eyes of the world, alongside the relief he felt in isolation. The toddler who had been deemed “sweet” next to his impressive and intelligent sisters; the immigrant child who felt alien in a new reality; the factory manager who constantly felt his product was never good enough and compensated by charming clients - these experiences were linked, interpreted, and shaded anew. This introspective work unfolded alongside narcissistic nourishment he experienced in our sessions. Yosef now brought writings from different periods of his life - descriptions of various situations - while I listened and bore witness. When he spoke about a special, dignified, and carefully planned event he held for relatives on his birthday, he expressed deep satisfaction with his achievements and repeated: “I really love myself.” In that moment, the link between feelings of inferiority and a narcissistic defensive organization crystallized vividly.

The therapeutic experience was not always easy for Yosef. At times he felt dizzy, found it hard to stand, or arrived unwell. We spoke about the betraying body, rising dependency, functional decline, and the anxiety that those upon whom he depends will vanish. Reality penetrated more and more, and it was hard for him to digest. Difficult themes surfaced in his dreams - losing his way, inability to board the bus, inability to get home or to work, failing a math test alongside a sister among the top performers, his factory collapsing, and all his clients disappearing. During this period, Yosef confronted performance anxiety, inferiority, and loss of direction. The encounter with the reality of aging and loss - the finitude of life - destabilized him and activated narcissistic defenses sometimes with a hypomanic hue. When I tried linking associations from his dreams to possible present experiences, he rejected my remarks vigorously. A deep hurt was evident in Yosef in the face of loss of control and the inevitability of his approaching death. His writing about prior generations and about his past more generally he framed as a “contribution to future generations so they may know and value their roots.” Gradually, Yosef acknowledged - to himself and to me - that this was also his way of remaining present after death, to commemorate himself forever.

After a year and a bit, Yosef decided to pause treatment, saying his daily routine satisfied him and he had no need to keep “digging.” Part of his decision stemmed from feeling he was “no longer interesting to me.” Despite extended therapeutic work on letting go and meeting himself as he is - his more and less admirable human parts - his internal need to charm and impress grew stronger. Yosef left, this time with deep appreciation for the process we had undergone, for the help he had received through our relationship, and with the statement that he would return if he felt the need. Perhaps the seeds sown - especially regarding help to accept himself as he is - will indeed enable such a return.

Discussion: Old Age and Narcissism

Much has been written about the humiliation associated with aging, particularly in cultures that idolize youth, youthfulness, and power. Freud raised the possibility that developmental biological processes might disrupt psychic equilibria and even produce neurotic breakdowns at life-cycle junctions. In “On Narcissism”, he describes how, due to organic illness or persistent pain, a person ceases to take interest in the world, and egotism and self- preservation intensify [2]. Hypochondriasis, too, is an example of narcissistic preoccupation: interest and libido are invested in a body part, with libido withdrawn from disappointing objects. He also discusses narcissistic object choice: focusing on what one is, was, or wishes to be, and relating to future generations as a revival of the self’s immortality against reality. For Freud, self-image is always tied to the narcissistic component. Everything one has been and achieved, feelings of omnipotence confirmed by experience, elevate self-esteem, which is reduced by the recognition of impotence and by the inability to love due to mental or physical disturbance. Repressed libido that finds no satisfaction fosters narcissistic withdrawal.

Yosef sought treatment due to personal life crises - primarily somatic distress, weakness, and heavy dependency. These led to narcissistic withdrawal with a diminished and injured self-image. He felt “null and fading from the world.” In attempting to restore his world and his narcissistic collapse, he initially focused on his achievements, wealth, and his children’s success. Only later, as defenses collapsed under distress, did Yosef dare to engage in ongoing psychological work - to meet his inner world and painful feelings. Klein’s thinking resonates here. She presents mourning processes around loss, whereby early mourning is rekindled in each later loss [10]. Those who struggle to mourn, she argues, are limited and even impoverished in their inner life. The notion that one can be built by difficulties and trauma is also noted elsewhere [12]. In my view, these theories relate to the capacity - especially in old age - to relinquish rigid narcissistic self-images and grandiose positions, and to reconcile more with reality. Yosef appears to have undertaken such a journey. It enabled him to mourn, accept himself and his surroundings, and come to terms more with the life cycle and reality, while his creativity grew in his relations with others and with himself.

In “On the Sense of Loneliness”, Klein, in her own old age, describes factors that alleviate loneliness: softening and flexibilizing narcissism; secure internalization of a good, benevolent object; a reduction in omnipotence; tolerance for the shortcomings of self and others; less resentment regarding past frustrations; discovering new sources of pleasure; gratitude; the capacity to receive and to give; creative activity; and enjoyment of what exists [10]. As defenses that intensify loneliness, she notes: hardening of narcissism and retreat into it; flight to an internal object to avoid dependency on external objects; rejection of human company; a drive for independence; idealization of the past; and attempts to avoid the frustrations of the present. Erikson posits polarized options for potential positioning in midlife and old age [13]. In old age, an integration is required between mourning for inevitable losses and changes and the need to adapt to a new reality. Vaillant offers his own poles [14]. In the healthy state, there is capacity for intimacy, sharing, receiving help, and a transformation toward self-engagement and commitment to hobbies; in the less healthy state, there is sinking into the self and intense preoccupation with individual pains and distress. The literature contains a notable dichotomy regarding the encounter between narcissism and old age: on the one hand, a breach in defenses and in felt competence, control, and wholeness that allows sober modesty and a depressive position internally and externally; on the other, a severe threat to defensiveness - together with pain and regression - that may lead to a hardening and exacerbation of narcissistic mechanisms.

Narcissism and the Therapeutic Encounter with Older Patients

Freud is known for the dictum that psychoanalysis is inaccessible after age fifty, due to rigidity and fixation, adaptation to circumstances, and too great a burden of life experience demanding analysis. Abraham opposed this claim, describing deep treatments with adults and older adults and emphasizing the “age of the neurosis” as the determinant of analytic accessibility, rather than chronological age [11]. In this way, Abraham paved the way for a psychological view of later life and for understanding to what extent those in this age group can cope with the challenges before them. In reports of analyses in old age, Segal discerns paranoid– schizoid states in which aging and death are experienced as threat, punishment, and persecution [8]. In her view, analyses at this age can move toward greater ambivalence, reactivating the infantile depressive position, rebuilding good internal objects, achieving a more mature view of old age and death, and enabling what she calls an “emergence from narcissism” [15]. Coltart describes “now or never” feelings in work with the elderly, writing about intense therapeutic investment, an ability to recognize missed opportunities, and decreased shame and embarrassment in this population [16]. She argues that it is possible to reconstruct past experiences at this age, alongside the understanding that goals will be more limited.

King argues that the unconscious is “timeless,” alongside separate scales of time - chronological, psychological, and biological [17]. As in adolescence, old age requires adjustment to bodily and sexual changes that arouse anxiety. Changes also occur in socioeconomic standing and in feelings of security. Many patients experience the shattering of old defenses, identity crises, altered self- and object- perception, and wounded self-esteem. Yet, King contends, a sense of “last chance” emerges, denials regarding paranoid and depressive anxieties diminish, and mourning, sadness, and forgiveness rise. All of this creates a sense of urgency in adapting to losses and can even enable a more effective and fruitful therapeutic alliance than with younger patients. In my treatment of Yosef, I also heard echoes of Cohen’s writing about narcissistic patients who avoided treatment earlier as part of their disturbance and who now, due to losses and regressions, seek help [18]. Common in these ages are feelings of urgency, failure, shame, and humiliation. Patients at this age often seek relief more than real change. In his understanding, heightened awareness of dependency and the separateness of the object intensify narcissistic defenses, increase loneliness, and hinder the ability to mourn and adapt. In discussing Cohen’s paper, Pollock describes a process of mourning and release, pointing to acceptance of death as relief from pain and suffering - acceptance and freedom [19].

Valenstein dwells on Freud’s conceptualization of the pull to return to the initial, an-organic, non-integrative, lifeless state - a tendency that grows in late old age [20]. This trend must also be considered in work with an aging population. Self-psychology speaks to the need to relinquish “archaic narcissism.” Treatment should ease and aid the regulation of self-esteem so that, through empathic, sensitive attunement, the patient feels understood. Baruch asks, “How to lose without getting lost”, suggesting the use of ironic humor and a fertile creative space for processing painful, unbearable matters [21]. The difficulty of ending therapy, she argues, stems from the narcissistic needs of both parties to keep the patient alive - never to grow older, lose, or die. Baruch proposes a human partnership between therapist and patient at this age. Quinodoz, in a similar spirit, describes work with older adults struggling with a “frozen time” conflict: the narcissistic illusion of pushing death away versus acceptance of temporality and the flavor of real life [22]. She proposes goals less burdened with the prestige of competition and power and more imbued with inner freedom.

Conclusion: The Transformations of Narcissism in Old Age

Through Yosef’s story and the accompanying theoretical review, we see the injury that comes with nearing the end of the life cycle - with its losses and regressions. The injury intertwines with the narcissistic system and self-image. A harsh reality penetrates sharply within, no longer deniable or ignorable. Such injuries may prompt several trajectories: idealization of the “golden years,” denigration of old age, generalized collapse, or acceptance of age and its limitations. In our work with adults and older adults, we are required to encounter our own aging, the losses it entails, and our own death. These challenges stir complex transference and countertransference, which may threaten our own narcissism, paralleling our patients’ experiences. Will we manage in treatment to enable a gentle, reality-mediating encounter - or will we bolster narcissistic defenses as we are pushed into our own defensiveness?. The literature also discusses the potential opening for inner growth: release from conventions, from a self-organizing image that, on the one hand, structures, and, on the other, binds. It is a matter of pain over what is not, but also of considerable appreciation for what is.

Yosef’s story illustrates collapse, but also recovery - together with narcissistic comforts and gains. Yosef also takes steps toward releasing a successful, competent image, moving toward acknowledgment of vulnerabilities that a rigid image had blocked. He finds a capacity - absent in his youth - for creativity, a more realistic self-acceptance, and enjoyment of the present despite its limitations. In his words, he could not have brought himself to such an introspective journey in his younger years when “everything was working.” Such statements often arise in therapeutic encounters with older adults.

The basic, and in my view difficult, analytic stance - “to meet the lack,” to meet inner and outer truth - enables and even encourages potentials for growth and development in work with older patients. Here too, the therapist’s stance toward lack affects their capacity to accompany patients through harsh realities. Even when reality is painful, even when we meet declines and regressions, reversals, insights, and the release from illusions form a crucial stratum in the inner and outer encounter each person conducts with themselves. Narcissism, in its permutations, remains ever-present at some level, but perhaps we can approach it with more humor, forgiveness, and less servitude to its dictates.

References