Our experience working with students and professionals in training and research suggests the necessity of re-examining the issues affecting older adults. This population, defined for the purposes of this article as individuals age 65 and older, is quickly increasing in number and will need our services in multiple ways, including assisting them in adapting to the natural changes associated with the aging process, encouraging them to embrace activities that increase wellness and vibrancy, and reducing the myths associated with this developmental stage.
This is underscored by the misconception that sadness must accompany aging. Our research revealed insights quite contrary to commonly held beliefs. Recent epidemiological studies have found that adults ages 40-59 exhibit higher rates of depression than do older adults. Subsequently, older adults develop a sense of integrity and achieve a level of happiness and life satisfaction that in some cases surpasses the happiness of their younger counterparts.
As counselors, we must dispel myths associated with aging, advocate for the needs of older adults and help this population adapt, thrive and maintain a sense of life satisfaction and achievement as they go through the multiple changes associated with reaching the last stages of adulthood.
Myth 1: Various mental disorders are inherent to the process of aging. The potential of experiencing a reduction in physical and mental abilities as we grow older leads many people to believe that feeling sad and depressed is an inherent part of the aging process. Depression and anxiety are not mandatory to aging, however. In fact, in many cases, aging is associated with resilience and happiness. An example of this resilience was illustrated during the recent economic crisis when this age group weathered the storm better than others. In 2011, a Pew Research Center survey found that 54 percent of older adults gave their personal financial situations a “high” rating, compared with roughly one-third of younger and middle-aged adults. This was a noticeable increase from the 50 percent of older adults who applied that rating in 2004.
Of course, aging does bring on well-documented changes such as decline in physical, perceptual and mental functions, with subsequent slower reaction times and limited or impaired memory. But many older adults deal successfully with these challenges. They learn to cope, modify their activities, change roles and wisely apply their resources and capabilities to newer goals and objectives that are age appropriate. Role modification may be demonstrated in the shift from parent to grandparent or by modifying lifestyle.
Highlighting successful older adults may aid in dispelling this myth, while simultaneously encouraging other older adults to increase social interaction, expand their social networks and continue to contribute to society. Furthermore, social interaction may serve as a promoter of mental and physical health.
Braulio Alonso exemplifies the ability of older persons to continue leading a full, meaningful life after age 65. The city of Tampa, Fla., named Alonso “best Tampanian” because he embodied the morals and values held most dear by its residents. At age 70, Alonso had a high school named after him, provided math tutoring once a week to high school students, served as a driver and delivery person for Meals on Wheels and participated on many community boards. Additionally, Alonso continued to be a contributing member of society and earned many accomplishments later in life.
Myth 2: Older adults should feel down and blue as they age. Two important issues are worth mentioning here. First, the belief that aging inevitably brings sadness should be questioned. In 2012, the Centers for Disease Control and Prevention reported rates of depression to be lower among adults ages 60 and older than among adults in all other age groups. Second, negative stereotypical views can have detrimental effects on our understanding of and service to older adult clients. The commonly held belief that older adults should feel “blue” because of aging can mask symptoms of clinical depression.
We have previously reported on the “invisibility” of depression among older adults due to misdiagnosis by mental health professionals. Symptoms of clinical depression were often overlooked because these symptoms were assumed to be part of aging, indicating that feeling blue is inevitable and chronic. It is true that disorders such as depression tend to acquire chronicity, especially if left untreated. However, the issue of treatment leads to our discussion of Myth 3.
Myth 3: There are no treatments for what older adults are experiencing. This myth, which complements the first two myths, suggests we lack effective treatments to help older adults with the problems they are experiencing, such as symptoms of depression. Contrary to this belief, a number of treatments are currently available to serve this age group. Some treatments, such as cognitive therapy (a la Beck) and interpersonal therapy, have enough research evidence to describe them as efficacious. These psychosocial models of counseling interventions have been shown to be as successful as medication in the treatment of depression and work better than medication in the prevention of recidivism among older adults. Modifications of these therapeutic approaches, by integrating spirituality and religion, have demonstrated significant effectiveness in the treatment of older adults. Additionally, counselors should consider using strength-based approaches to counseling such as developmental counseling and therapy and interventions such as Therapeutic Lifestyle Changes. These psychosocial interventions may aid in highlighting the positive aspects of aging and decrease the “problem” focus of traditional psychotherapy.
Myth 4: There is only one age bracket of “older adults.” Ordinarily, we define 65 as the beginning of the older adult stage and assume this stage spans from 65-75, a calculation based on life expectancy. However, the number of individuals joining the 75-100 age group is rising. Today, more than 53,300 individuals have reached 100 years of age or older in the United States alone. This group is known as the centenarians or the “very old,” but a sizable number could be described as the “very old in good spirits” group. Many of the characterizing issues, tasks and challenges facing this group are largely unknown, which presents a key opportunity for further research. We will benefit from gaining a better understanding of the very old and investigating what helps this group continue to grow and thrive.
Myth 5: A significant number of agencies, support networks, events and activities are available for older populations. The assumption is that a sufficient number of shelters, nursing homes and facilities exist for older adults. However, restrictions in Medicaid and Medicare, threats to Supplemental Security Income, and issues with insurance and coverage have reduced the number of outlets available. Some of the current resources deny admission to older adults with psychological, social or mental disorders. There is also a shortage of long-term hospitalization beds, leading some older adults with mental disorders to become homeless or incarcerated. This is a major issue, as illustrated by the fact that many nursing homes and assisted living facilities are not equipped to handle older adults in the mid to late stages of Alzheimer’s disease if they are ambulatory.
Myth 6: Older adults are gender homogeneous. The number of older adults by gender is not similar. The male-to-female ratio falls rapidly as individuals move into the older and very old age brackets, with women outnumbering men. According to statistics provided by the U.S. Census Bureau, by the time individuals reach the age group 80 and older, the male-to-female ratio reaches 38.1 to 61.9; by 90 and older, the male-to-female ratio reaches 27.8 to 72.2; and by 100 and older, the male-to-female ratio reaches 17.2 to 82.8. This predominance of women should lead to increased focus on issues such as poverty, health care, social security and housing from a woman’s perspective.
Dispelling the myths of counseling older adults may help to reduce ageism and improve the effectiveness of services. On the other hand, identifying the real issues that affect older adults will aid in providing services. This is important because failing to recognize their issues is a helping opportunity lost. In the absence of adequate services and care, older adults’ quality of life may be significantly affected and can deteriorate quickly. In turn, the ensuing conditions can further debilitate the bodies, abilities and cognitive functioning of older adults, reducing their quality of life and accelerating the aging process.
Meet Grandmother Tita
The following example provides an illustration of the challenges involved in transitional situations for older adults and provides some evidence of the preventative nature of intervening during the transitional period. This example also demonstrates how a cognitive behavior therapy (CBT) approach can be applied in a modified form to counsel an older adult in her transition to a nursing home, which is often characterized by significant anxiety and sadness. Embracing a more accurate perspective and strengths-based approach should lead practitioners to include evidence-based practices (see examples under Myth 3) to help older adults improve their physical and mental health and wellness. A comprehensive counseling and therapeutic approach should work with older adult clients to make life changes known to positively affect the aging process, such as appropriate diet, exercise, cognitive training and social engagements, to name a few.
In this section, we discuss the use of CBT with an older adult suffering from generalized anxiety disorder due to her impending transition into an assisted living facility. This transition has the capacity to produce a mood disorder or anxiety due to the issues she may face as her ability to live independently becomes severely challenged or limited.
Grandmother Tita is a 74-year-old Bahamian woman. Her daughter, Natalie, has brought her to therapy at the urging of Grandmother Tita’s pastor. Grandmother Tita immigrated to the United States approximately 30 years ago. She recently broke her hip and found out from her primary care physician that she will have to be transitioned into long-term care. Grandmother Tita would like to live with one of her children (she has two sons and one daughter). However, none of her children are able to provide the care she needs.
Grandmother Tita reports feeling worried about leaving her home permanently. She is afraid of long-term care because of what she has heard about the associated conditions from some of her friends. She has experienced problems sleeping due to nightmares about living in the assisted living facility. In addition, she complains about neck and back pain and shortness of breath. She says that when she thinks about moving, her heart beats fast, she breaks into a cold sweat and she experiences dizzy spells.
When asked if she has received previous treatment, Grandmother Tita reports seeing her pastor on a weekly basis. In fact, she has spent many hours with her pastor as she tried to make a decision concerning her transition. When Grandmother Tita started complaining about issues related to anxiety, her pastor recommended that she see a counselor. She is skeptical of the therapeutic process. However, she has come to therapy after her children encouraged her to attend.
Developing rapport and incorporating a strengths-based approach
Developing rapport with Grandmother Tita is central during the initial session because multicultural clients may be less likely to return to therapy if they do not feel a connection or common understanding with the therapist. Establishing rapport may be difficult if you do not understand some of the issues common to older people that may require some modifications to the CBT process. Integrating effective modifications can increase positive therapeutic outcomes by ensuring homework completion and adherence to treatment. Consider the following tips in the early stages of the case conceptualization process:
- Consider the belief systems, values and healing practices of the older adult client.
- Ensure you are knowledgeable of the services available within the client’s community.
- Be knowledgeable of indigenous healing practices.
- Understand that immigrants face multiple stressors, some of which may include the incongruence of belief systems between first-generation and second-generation immigrants.
- Consider environmental factors during assessment and diagnosis.
- Acclimate your client to the process of receiving mental health services.
During the case conceptualization process, it is important to consider integrating various techniques while you are developing your problem list and treatment plan. Consider focusing on the client’s strengths and integrating language that highlights the possibility of overcoming issues. An example would be changing the word problem to challenge (as suggested by Allen Ivey). To strengthen your working hypothesis, it is important to discuss the working hypothesis with the client.
Guidelines and summary
Although CBT has been found to be effective in treating generalized anxiety disorder in older adults, it is important to consider the way this disorder may present. In some cases, older adults’ symptoms of anxiety and/or depression may not meet criteria from the Diagnostic and Statistical Manual of Mental Disorders. This does not mean, however, that these clients’ symptoms should be ignored. In the case study of Grandmother Tita, she might have declined into depression or suffered from significant symptoms of anxiety if her family and community had not intervened.
Furthermore, it has been suggested that in the absence of treatment, generalized anxiety disorder can develop into major depressive disorder. Preventative measures such as helping older adults manage daily tasks, including doctors’ appointments and medication regimens, can be effectively integrated into problem-solving-based counseling techniques. These techniques can help older adults organize daily activities that were seen as trivial in their younger years. Failing to master these simple tasks can exacerbate the older client’s symptoms of anxiety, depression and anger.
The practical tips that follow can help counselors provide evidence-based interventions for older adults.
Tip 1: Tackle cognitive changes: Mild to moderate cognitive changes are common in older adult populations. To improve therapeutic outcomes, a counselor should present information in the session in multiple modalities. Additionally, a counselor should repeat and summarize as often as necessary and use folders and notebooks to aid in organization. Finally, consider offering memory training or additional activities to improve cognitive functioning.
Tip 2: Tackle sensory impairment: Older adults may experience sensory impairment that can hinder the counseling process. A culturally sensitive office environment should include informational material, pamphlets and handouts in bold print. Encourage clients to use tape recorders and assistive devices. Maintain a list of community resources, including optometrists and audiologists, that specialize in older adult populations.
Tip 3: Tackle issues of physical health: Many older adults experience a decline in physical health. This decline can adversely affect an individual’s mental health and ability to access social services. Ensure that your client has had a recent physical, especially if increased physical activity may be considered as part of the treatment plan. Develop a treatment plan that includes realistic goals, challenges dysfunctional thinking that may hinder physical activity and includes input from other health care professionals, if needed.
Tip 4: Develop a culturally sensitive therapeutic environment: Although a percentage of older adult populations reside in assisted living facilities, the majority of older adults reside in their own homes, in senior living communities or in partial assisted living facilities. A counselor may consider offering outreach services such as providing in-home therapeutic services. Your office environment should provide materials in multiple modalities as well as multiple entrances or office areas that are accessible to individuals who may have mobility issues. You might ask your office assistant to go into the lobby to help older clients with the sign-in or intake process. Also ensure that you are aware of your client’s perception of the aging process. There are varying perceptions of aging from culture to culture. Counselors should not assume all mental health issues are related to the aging process.
Tip 5: Consider successfully aging older adults a great resource for younger generations: In The Longevity Project, a 2011 book by Howard S. Friedman and Leslie R. Martin, it was reported that individuals who were sociable, helped others, stayed physically active and associated with other healthy individuals were more likely to lead long, healthy lives. Many individuals in this research study who exhibited these traits lived to be 100 or older. As Braulio Alonso demonstrated, older adults can be significant resources, provide assistance and become positive role models for younger generations. Encouraging your older adult clients to develop a social circle and connect with their communities can be mutually beneficial.
In summary, we need to be more optimistic about aging and develop a more accurate picture of this population if we are to provide effective help. As counselors, we can be advocates and aid in the process to change common myths and widely held assumptions regarding older adults and the aging process.
As the baby boomer generation approaches retirement age, the need for augmented mental health services will continue to rise. It will become essential for mental health professionals to be aware of and have working knowledge of best practices when providing services for the older adult population.
“Knowledge Share” articles are adapted from sessions presented at American Counseling Association conferences.
SeriaShia Chatters is an assistant professor in the psychology and human services program in the Department of Natural Sciences and Public Health at Zayed University in Dubai, United Arab Emirates. Her research interests include preparing mental health professionals and mental health counseling programs in schools. Contact her at firstname.lastname@example.org.
Carlos Zalaquett is a professor in the Department of Psychological and Social Foundations at the University of South Florida, where he is the coordinator of the clinical mental health counseling specialization and the graduate certificate in mental health counseling. He is an internationally recognized expert on mental health, diversity and education.
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