At the age of 75, Jenny was dealing with more than
  her fair share of grief. She had recently lost both her son and her husband of 50 years to cancer. She was also terminally ill with cancer herself.

“Jenny was dealing with complicated grief — the loss of her husband and son, plus her own diagnosis,” says Christine Moll, associate professor in the Department of Counseling and Human Services at Canisius College in Buffalo, N.Y. “She felt genuine sorrow for her remaining family members and the tremendous loss they were feeling.”

At a time when Jenny had perhaps her greatest need for counseling, there was yet one more hurdle to face — she was unable to travel to a clinician’s office. So instead, Moll went to her.

Earlier in her career, Moll, a past president of the Association for Adult Development and Aging, a division of the American Counseling Association, worked with Catholic Charities of Buffalo in a group known as the Geriatric Outreach Treatment Team. The team focused solely on conducting at-home visits with people over the age of 60 who could not travel.

“Over the course of about three months, Jenny and I worked on her accepting her diagnosis as part of her life journey and her anticipation of meeting her husband, son and other family members on the ‘other side,’” Moll says. “Jenny shared her life story, her own early childhood and how her family of origin managed during the Great Depression. We discussed the strengths and gifts that she and her family possessed to live through those hardships. How might those strengths serve her now?”

As Jenny’s health weakened, her daughter and daughter-in-law were often there when Moll made her visits. “We spoke of Jenny as a mother and grandmother, her love for her family and how that love would be carried on in her absence,” Moll says. “What legacies would continue with family meals, celebrations and in life, especially as her grandchildren grew into adults themselves?”

“My last visit with Jenny was about 12 hours before her death,” Moll continues. “She was peaceful and ready to move on to what she believed to be eternal life with her God and her family who had predeceased her. Interestingly enough, as they witnessed Jenny’s peace, her daughter and daughter-in-law were able to let go of their anger and ‘let her go’ in peace.”

Similar to Jenny’s experience with loss and her own mortality, challenges can mount for people as they age, says Larry Golden, an associate professor in the University of Texas at San Antonio Department of Counseling. The challenge for counselors, he says, is helping these clients to cope.

Golden, an ACA member who ran a private practice for 25 years, divides older adults into two categories: “old-old” and “young-old.” He categorizes the first group as those in their 80s and 90s who are becoming physically frail and possibly struggling with dementia. Clients in this group may be struggling with a decision over whether to move to an assisted living center or enter hospice care, he says. Many different entities may have an interest in the person’s decision, from the health care industry to family members, Golden says, adding that the counselor has the opportunity to serve as an advocate for the client. “Our primary concern as counselors is advocacy,” he says. “(But) the individual, depending on their mental competence, should have the last word.”

Golden defines the young-old as people in their 60s and 70s who are in good health. Although their counseling needs don’t differ much from any other age group, he says their commitment and openness to the counseling process is generally greater. The same person who had alcohol problems in his 20s might seek counseling in his later years more ready to embrace change and see life differently, Golden explains. Likewise, someone with a history of failed relationships might meet a partner in her later years and become invested in ensuring the relationship’s success. “This group takes counseling very, very seriously,” Golden says, and in his opinion, that’s what makes them such rewarding clients. “We usually meet people in counseling when they’re in trouble. I would just as soon meet them when they’re serious about the work.”

Bumps in the road of life

While people often say that they dream of retiring, the realities can prove nightmarish for many individuals. “People leaving their profession is like a death,” Golden says. “My identity doesn’t exist anymore at the point I retire.” That struggle is an opening for counselors, however. “Group counseling can be very effective because it helps normalize the kinds of anxiety people feel,” he says. Finances are another stressor related to retirement, so Golden suggests counselors who want to specialize in retirement issues consider collaborating with a financial expert or learning more about finances themselves.

Chronic health problems can pose another uphill battle for people as they age, says Summer M. Reiner, an assistant professor at the College at Brockport in New York and incoming president of AADA. They experience discomfort on a constant basis and mourn the ability to do things as quickly as they used to, she says. It’s important for counselors to focus on what it means to that client to be going through those struggles. “The bottom line is acknowledging that the person is experiencing that condition,” Reiner says.

It’s also imperative for counselors to know about clients’ illnesses and what medications they are taking, Moll adds Being knowledgeable of the side effects of an illness or medication can help the counselor better understand the client’s situation. As an example, Moll cites a client who has suffered a stroke, leaving that person more labile or teary. If counselors aren’t paying attention to that, Moll says, they might misinterpret the frequency of the tears and conclude that it’s something more serious, such as depression.

Loss and grief go hand in hand and can weigh heavily on people as they go through life. People lose spouses and partners, family members and friends. With a country at war and violence on the streets, Moll adds, that loss can come in the form of younger family members as well. “Loss is a ‘change’ that we cannot change, and we are often left feeling ‘orphanated,’ eviscerated and just plain sad,” she says. “Loss for an older adult can be more challenging because our losses sometimes accumulate, so that with each loss we feel as if a surgical wound, well-healed, has reopened. Loss may remind us of our own mortality.”

“Grief is a normal emotional reaction,” she continues. “A counselor can assist the grieving client to come to terms with the separation from their loved one and how life has changed with the absence of loved ones and to live life in its new form.”

For many people, religious faith can be of crucial assistance when dealing with grief, and Reiner points to studies showing that spirituality increases as people age. Attempting to incorporate that spirituality into counseling is important, says Reiner, who suggests counselors review the Association for Spiritual, Ethical and Religious Values in Counseling’s competencies and then talk to clients about what they believe and if spirituality could be a means of support to them. “The client is the best person to educate the counselor about their beliefs,” she says.

All three counselors agree that finances can be a significant barrier in getting counseling for older adults on a fixed income. The client might not have insurance or be able to afford the copay. “We better get effective at getting Medicare coverage for LPCs (licensed professional counselors),” Golden says. “We will continue to be shut out of opportunities to work with older adults until we get Medicare coverage.” In the meantime, Moll notes, social service agencies often provide counseling on a sliding scale where the fee is dependent on the client’s income or ability to pay. Worship communities and community centers might also provide counseling services to members.

Like Moll’s client Jenny experienced, simply getting to a practitioner’s office may offer another challenge for older adult clients. Moll and her colleagues solved the problem by visiting their clients at home. For those counselors for whom making house calls isn’t feasible, Reiner suggests helping clients navigate options such as local van service or public transportation.

This is your life

As the years pass by, emotional baggage can build up. That’s when “life review” can help, Golden says. Life review is a counseling intervention that Golden says he uses mostly with old-old people, as long as they’re not struggling with dementia. “There’s a tendency in old people to want to reminisce, to talk about the good old days,” he says. “There’s a serious side to that that counselors can capitalize on.”

In the process of the counselor asking questions about the client’s life comes talk about the good, the bad and the unresolved. “One of the reasons older people reminisce is because they are trying to get some resolution to issues in their lives,” Golden says. “The questions could be everything from tell me about your first friend to tell me about your first romantic relationship to what are some of your memories of your children? You don’t get very far before people get into some issues.”

“(Life review) provides one last chance to make sense of your life,” he continues. “It can even lead to decisions to reconcile or to reframe an issue in a way that lends itself to acceptance rather than bitterness. These are some of the tasks of the old-old.”

In addition to life review, counselors say there are other do’s and don’ts when working with older adult clients. Among their best tips:

• DO coordinate with physicians. Clients are oftentimes seeing multiple physicians, Reiner says, and it’s helpful for a counselor to know what treatments clients are receiving and what medications they may be taking.
• DON’T be shocked. “Many of us think (sexual) intimacy stops at a particular age,” Moll says. “It doesn’t.”
• DO address the client’s needs and barriers, then attend to the emotional strain that could come with those needs or experiences. For instance, Reiner says, if a client uses a wheelchair and the ramp is inconvenient or nonexistent, address how to make it easier for the client to access the counselor’s services. Then address the client’s feelings about how frustrating it might be to experience barriers due to physical limitations.
• DO be attentive. Speak clearly and audibly, Moll says. Pay close attention to the client’s ability to hear, see and move. “Make sure they’re comfortable,” she says.
• DON’T make assumptions. Don’t assume that clients aren’t concerned with their sexuality, their leisure time or their family needs just because they’re older, Reiner advises. Likewise, don’t assume that a client is distraught, grieving or even sad if a spouse or partner has died, she says. “Don’t jump to conclusions about what things can mean to a person. Remember that although they’re aging and they have a lot to deal with, they’re still full people.”
• DO enjoy older clients. “Working with older adults is as much of a journey as working with any other age group,” Moll says. “I genuinely enjoy the person and the uniqueness of the person.”

Connecting with clients

Counselors who are passionate about working with older adults and would like to build their client base can start by networking with local doctors. Try internists, heart specialists or other doctors likely to have a larger elderly patient base, Moll suggests. Build relationships with them and then ask them to refer clients whom they think might benefit from counseling. Reiner agrees that doctors can be a great resource, pointing out that older adults might make more doctor’s appointments if they’re lonely and in need of interaction. Physicians might pick up on that and be able to refer the client.

Reiner also recommends that counselors visit the local library or senior center to meet older adults and put out pamphlets. Pamphlets are effective at helping to spread the word, she says, because even if someone who picks it up doesn’t need counseling, that person might think of a friend or family member to refer. Hospice is another good resource, Reiner adds. Even if the person receiving hospice care doesn’t want counseling, a spouse or elderly sibling might benefit from it.

When you connect with older adult clients and begin working with them, Moll says, it’s important to remember that the length of one’s life story is what makes it even more powerful. “These clients’ stories are rich and powerful and historical and full of wisdom,” she says. “There’s much to be learned.”

What has Moll learned from Jenny and her other clients? Above all, resiliency. “What each (client) has taught me is that there’s something to be said for resiliency, there’s something to be said for seeing the glass half full.”

Moll’s own father, who passed away about six years ago, exemplified resiliency, she says. In his younger years, he loved to golf, and he didn’t let the aging process stop him. Instead, he adapted the game to fit his stage in life. Out on the green, someone would help him tee the ball up, then after a short swing, he’d move the ball to within chipping distance and finish out the hole. “He played practically up to the end,” Moll says. “He simply went with what he could do.”

That idea of the glass being half full isn’t lost on Moll, and it’s a philosophy she tries to share with her clients. “It’s how we transcend our limitations,” she says, “to find quality in what we have in front of us.”

Lynne Shallcross is a staff writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org.

Lonnie Rowell knows all about the benefits of evidence-based counseling practice, a subject that has consumed much of his life for the past 10 years. Not everyone, however, is quite so enthusiastic.

“I was told by a counselor educator yesterday that she didn’t want anybody to look too closely at what she does,” says Rowell, an associate professor and codirector of the counseling program at the University of San Diego and a member of the American Counseling Association. “’We know what we’re doing is effective, and we don’t want administrators looking at our results,’ she told me. It’s an extreme example, but it is an example of counselors being pushed out of their comfort zones.”

ACA member Patricia Kyle recognizes the merits of evidence-based practice — using therapy that is tested, scrutinized and then applied in clinical settings. However, she questions local agencies that rely almost exclusively on certain types of evidence-based practice primarily because their bills are paid by federal and state agencies that accept those modalities and require the use of evidence-based practice.

“I had a student in my family counseling class who chose a theoretical model and made choices based on that model. The student did an excellent job,” says Kyle, an assistant professor of psychology at Southern Oregon University. “She went out, interviewed for a job and was told, ’We can’t hire you because this isn’t an evidence-based practice.”

The model chosen by the student?

“I’m not sure,” Kyle says. “But it wasn’t cognitive behavioral. That much I know.”

Trying to answer an enduring question

Evidence-based practice is not a new concept, with the Federal Action Agenda providing the impetus for it a decade ago. But evidence-based practice has picked up steam in recent years as counselors and other mental health workers seek to improve their efficacy, insurance companies look for quantifiable results and the people who control governmental funding attempt to determine where monies can best be apportioned.

Then there is that age-old question still looming in the public’s mind: Does therapy really work? Evidence-based practice and the testing of the efficacy of counseling modalities is a response to that question. Testing whether a particular practice meets client needs may also help to change the public’s perception of psychotherapy as a “soft” science.

“There is no perfect test out there,” says ACA member Paul West, an assistant professor of counseling education at Alvernia University. “But I can do my best with what we have. That is a whole lot better than doing no outcomes research at all.”

John Murphy, a professor of psychology and counseling at the University of Central Arkansas, agrees. “Sometimes, I’ll hear people say, ’I just know intuitively how my client is doing.’ That scares me,” says Murphy, a member of ACA. “Without denying the part that art and experience play in this profession, I think it would be arrogant for someone to rely solely on their judgment — and not some sort of testing — to determine whether counseling is effective.”

What should counselors do in the age of evidence-based practice? That has been the subject of much talk and a number of presentations at ACA conferences in recent years.

Kyle, along with Lani Fujitsubo and Paul Murray, both professors of psychology at Southern Oregon, presented on “Counselors Dealing With the Impact of Evidence-Based Practice” at the 2009 ACA Conference in Charlotte, N.C. She cited the American Psychological Association’s definition of evidence-based practice in her presentation: “Practice is evidence-based which utilizes scientific research findings and/or methods of assessing therapy process and outcome in some way to inform clinical practice.” Kyle also noted some of the attributes of evidence-based practice, including transparency, standardization, research, replication and attaining meaningful outcomes.

However, Kyle still isn’t a true believer in evidence-based practice, at least not in the way it’s being utilized today. “We all support the underlying concept that counselors should be accountable to their clients and use strategies that have an evidence base,” she says, “but we (her copresenters and other critics) have concerns about how evidence-based practice is being implemented on the federal and state levels.”

Specifically, Kyle is concerned that agencies receiving federal and state funding will end up relying solely on approved programs, which, she points out, haven’t necessarily cornered the market on effectiveness. In many cases, she says, other interventions (“non-approved programs”) simply haven’t been reviewed according to the standards required by the Substance Abuse and Mental Health Services Administration (SAMHSA) at the federal level or other agencies at the state level.

According to Kyle, humanistic, gestalt, existential, Jungian and Adlerian approaches largely have not been reviewed. At this writing, SAMHSA’s National Registry of Evidence-based Programs and Practices (nrepp.samhsa.gov) included 137 interventions. Plug in the word “gestalt” in SAMHSA’S search engine, and nothing comes up. Insert “existential” and, again, nothing appears. Insert “cognitive behavioral,” however, and 19 interventions appear.

“Existentialists don’t even like the label ’existentialists,’ much less going out and finding data,” Kyle says.

Compiling that data, doing research and submitting the findings to federal and state agencies is exactly what Kyle advocates though. “The list of approved practices is narrow,” she says. “But it doesn’t have to be so narrow.”

Kyle mentions other problems she thinks are endemic with tests that lead to the approval of certain practices, including a lack of research on the impact of the therapeutic alliance and what she sees as the process of science squeezing art out of therapy.

In spite of those reservations, however, she comes down on the side of evidence-based practice overall. “Any ethical counselor wants to make sure they are using strategies that have positive outcomes,” Kyle says.

Quality control

The way West looks at it, all counseling is evidence based. What’s in question is the quality of the evidence.

“You have your client satisfaction surveys,” West says, “but we don’t know if they are just evidence of the strength of the client-counselor relationship. A client may say you’re the best thing since soft butter, but it might not be evidence of the effectiveness of counseling.”

OK, so why not ask the therapist if counseling has been effective?

“It’s a question of bias,” says West, who presented on “The Role of Evidence-Based Therapy Programs in the Determination of Treatment Effectiveness” at the 2009 ACA Conference. “Say I’ve developed this treatment plan, and the client has completed this and this and this. Who’s to say the treatment plan helped bring about change? And if it doesn’t work, do I look at myself, or do I say the client screwed up?”

Then why not go by a book that outlines the best practice for particular situations?

“Yes, there is evidence that certain treatment approaches work for certain problems,” West says. “An example of that is in substance abuse. Everybody does a type of 12-step program that is supposed to be effective. But we know that only 16 to 17 percent respond to substance abuse treatment. Is that really best practice?”

For West, empirical evidence with pre- and post-tests that are tied to clinical results should be the foundation of counseling. “If I’m doing therapy correctly, the test I use should have good reliability and validity and should include a broad range of issues. If I let this guide my assessment, I should be able to tell whether there is change at the finish.”

West concedes, however, that the use of testing and evidence-based practice has encountered resistance. “And not just in counseling, but with human services across the board,” he says. “First of all, there is no mandate for it. One, the insurance companies don’t all require people to prove that their efforts work. Even in the ACA Code of Ethics , there is nothing that says you have to do outcomes research.”

Additional reasons for resistance are that many counselors simply do not like research or are not offered adequate training in school, West says. “If you only have one research course in school, is that really enough?” he asks.

Fear of failure also comes into play, West says. Some counselors are worried that outcomes research will show that what they’ve been doing all along isn’t working. For these counselors, engaging in evidence-based practice may be akin to “slitting (their own) throat and possibly losing their job,” he says.

How should counselors measure success then? According to West, it isn’t about measuring the outcome of Program A versus Program B. Likewise, it isn’t about theoretical models. “Because we really haven’t found that one theory is better than another,” he says.

It is, however, about the quality of the research, West says. “Does Program A do valid research and follow guidelines based on the population it treats? The idea of a client getting well has to be defined. It might not be about making a behavioral change, say, for someone suffering from chronic mental illness. It might just be about whether the client is taking his medication.”

Action research

West suggests that mental health agencies could and should make better use of colleges and universities to formulate evidence-based practices.

Rowell, who presented on “Action Research in Counseling: Closing the Gap Between Research and Practice” at the 2008 ACA Conference in Honolulu, agrees. He is a proponent of “collaborative action research” and sends his students out into real-world clinical settings to work hand-in-hand with practitioners.

Why action research? In part because of public skepticism of the effectiveness of counseling, Rowell says, and in part because of the lack of adequate graduate school training programs. “And within the field itself, practitioners often don’t use research correctly,” Rowell says. “It’s a well-established fact within school counseling, but it also happens within clinical mental health settings. (Mental health professionals) read journals, but they don’t read them carefully.”

Rowell’s students help school counselors formulate questions, do the research, test whether interventions are working and, if not, determine what may work instead. Rowell believes action research also could help underfunded, overburdened community mental health settings.

The goal is twofold, he says: to help students learn the value of research and to help practitioners come up with successful, empirically tested counseling methods. “Psychology, as a profession, needs to hold itself accountable,” Rowell says.

Client feedback

For Murphy, all the evidence needed in formulating evidence-based practice is sitting in the chair across from the counselor during therapy sessions. “Who better to ask about the effectiveness of treatment than the client himself? The consumer should be the primary measure, if not the sole measure,” contends Murphy, who presented on “Client Feedback Tools: A Fast Track to Better Outcomes in Counseling” at the 2009 ACA Conference.

Murphy advocates starting off each session with a short question-and-answer period. During this time, clients relate how they are doing individually, interpersonally, socially and overall and then tell the counselor what they want to work on. This introduction, he says, should last about five minutes.

The counselor concludes each session by asking the client to fill out a form explaining how the session went. This takes about one minute, he says. “I tell them to be honest. If I’m not connecting with them, I sincerely want to know about it,” Murphy says.

Murphy points to studies showing the client’s perception of the client-therapist relationship as the most reliable predictor of the success of therapy. So Murphy wants to know about those perceptions early and often. “It allows you to create a conversation around areas the client is concerned with,” he says. “It’s an ongoing thing. If things are going well, great. If things aren’t going well, you talk about what you can do differently.”

Aside from the efficacy of therapy, Murphy sees another reason for having the client take the lead. “If you’re blaming the client when things aren’t going well, it’s not only counterproductive,” he says, “it’s downright bad manners.”

ACA member Chris Morkides is a psychoterapist in private practice in Swarthmore, Pa. Contact him at cmorkides@aol.com.

Letters to the editor: ct@counseling.org.