Americans live in a youth-obsessed society. Advertisers, the media and even the job market send the message that it pays to be young — or at least look young. But looking beyond the airbrushing and the nip/tucking, there is a stark reality: The population of adults 65 and older in the United States is increasing rapidly.
According to Stanford University’s Center on Longevity, during the next 30 years, the U.S. population of those 65 and older will double from 40 million to 80 million. By the time the last baby boomer turns 65 in 2029, one in five Americans will be 65 or older. By 2032, there will be more people 65 and older than the total number of children under the age of 15.
These numbers are more than just statistics; they represent actual people who will be going through major life changes. These potential transitions and challenges could include a second career (whether by choice or out of necessity), the need to give care or be cared for, reduced income, personal loss, physical illness or pain, depression or other mental illness, cognitive decline, terminal disease, facing one’s own mortality and confronting ageism.
It is not hard to connect the dots then that as the aging population increases, so does the need for counselors who can help clients with these transitions. “Professional counseling is focused on healthy development over the life span,” says Suzanne Degges-White, president of the Association for Adult Development and Aging (AADA), a division of the American Counseling Association. “This includes working with older adults as they move through both the normal transitions in life and with unexpected difficulties. As adults move into each new developmental stage — and development doesn’t just stop at 18 — they may experience a need for support, guidance and normalization of the emotional responses to each stage. Personal and professional transitions are important at any age.”
Despite the demonstrable need for help throughout this transitional period, many counselors do not focus on engaging with this population. Catherine Roland, AADA’s representative to the ACA Governing Council and editor of Adultspan Journal, says it can be very uncomfortable for some counselors to explore late-in-life issues with older adult clients because it forces counselors to confront their own mortality, which can be a difficult process. “It’s like looking in a mirror,” Roland says.
However, counselors should be aware that working with aging adults is not all doom and gloom. Surveys and research have found that life satisfaction and happiness increase for many people as they approach their 60s. Older adults also possess more life experience and in many instances have accumulated more wisdom and confidence that contribute to greater overall well-being.
When considering aging adults, counselors need to remember that they are not one homogenous population, says Christine Moll, an ACA member and professor of counselor education at Canisius University in Buffalo, N.Y. “There are several generations. We have the boomers, the youngest of whom just turned 50 and the oldest are 68 or 69, and then we have Depression-era and World War II babies, people over 69 and up to 100,” she says. “It’s probably the widest range within the life span of development. We’ve got 40-plus years of people that we call ‘older adults.’”
What do I do with the rest of my life?
One of the first — and sometimes most challenging — life changes this group faces is change in job status. Older adults between the ages of 60 and 70 — or, as Moll likes to call them, the “new aged” — may be considering retirement, transitioning to part-time work, embarking on a new career altogether or trying to remain in their current position.
Their decisions may be driven not just by personal preference, but also by economic circumstances related to the recession and a changing global economy, Roland says. “Whenever the economy goes bad, people at or later than retirement age are really harmed [financially],” she points out. “They don’t have the ability to go back and make up savings.”
In many cases, even when these older adults developed a plan for setting aside money for retirement, the rules changed on them, notes Tom Christensen, a licensed mental health counselor and doctoral candidate at the Warner School of Education at the University of Rochester. As an example, he points to employer-funded pensions shrinking or being taken away entirely. “After a lifetime of planning, how do you rearrange things to account for sudden changes in retirement accounts?” he asks.
Aging adults who are still in the workforce also face the dual realities of downsizing and evolving job requirements. And when their jobs are outsourced, Christensen says, older adults often have less flexibility and fewer options. “It’s harder to just up and relocate to where the jobs are because you have a house or obligations and family ties. Maybe you are even needed to provide child care for your grandchildren,” he says. “And how easy is it really to bear the cost of going back for retraining?”
“In the past, a person’s age matched their wage and worker loyalty garnered longer tenure,” adds Rich Feller, a past president of the National Career Development Association, a division of ACA. “Globalization, technology and a winner-take-all performance system have imploded later-life expectations. Fewer opportunities exist to transfer older skills, dated habits or traditional and repetitive performance skills that pay livable wages.”
However, the situation is not hopeless, emphasizes Feller, an author and professor of counseling and career development at Colorado State University’s Institute for Learning and Teaching. Many employers do still appreciate the professionalism and experience that older workers offer, he says. One important task for career counselors is to show older adult clients how to reframe their experiences and work histories to match available positions, Feller says. He asserts that older workers can overcome the biases they sometimes face by highlighting their demonstrable skills.
Simply applying to positions in response to postings on job boards is not enough, he says. Instead, aging adults need to work with their professional and personal networks to connect with hiring managers. Meeting decision-makers face to face gives aging adults the opportunity to transcend being simply an “older résumé” by demonstrating their maturity and accumulated wisdom in person, Feller says.
On the flip side, even when aging adults are ready to retire, the transition can pack more of a punch than most people realize. “Work provides structure, relationships and relevancy,” Feller says. “Without work, finding purpose is hard. Seeking meaning, contributing and mattering is especially important in the new adult phase where we live 30 years longer than our parents.”
Degges-White delves into this life transition further. “Older adults experience this passage with such a diverse range of responses,” she says. “Some individuals embrace the new freedoms of retirement with great ease, while others may see their transition out of the workplace as a huge blow to self-esteem and identity. Counselors are able to help individuals make sense of these types of transitions and help clients develop a new sense of self and purpose in their lives.”
Feller says aging adults need to know they are not alone in their experience — that others have gone through this transition and regained a sense of meaning in their lives. Counselors can help these clients see that they have other talents and are more than the sum of their careers. Retiring can bring time to “redefine” their lives by exploring new interests, developing new hobbies or spending more time with their family members.
Retirement is not the only challenge aging adults will begin — or continue — to face. The “new aged” group in particular may find themselves confronting family issues such as the need to provide some level of care to grandchildren or even coping with an adult child who has returned home, Moll notes.
Degges-White recounts the story of a female client who was 70-plus and suddenly found herself raising a grandchild. “This woman was trying to figure out the best way to handle her responsibilities as primary caregiver to her 7-year-old granddaughter,” Degges-White says. “This young girl was diagnosed with an assortment of learning disorders, behavior disorders and emotional challenges. The young girl’s mother, who was the daughter of the older woman, had been a drug addict and ‘lost soul,’ but her mother recognized that the granddaughter should not be lost in the system. When our country’s older adults are coping with raising the children of their own children, they have a difficult time facing their own concerns. Counselors of children and adolescents may need to intervene when these kids are being cared for by already overwhelmed or vulnerable older adults.”
Aging adults may also be the primary caregivers for a parent or spouse. Counselors need to remain aware of how much stress these caregivers are under and intervene by helping them find strategies to cope.
ACA member Rebecca Cowan, a counselor and instructor at Eastern Virginia Medical School, provides counseling to caregivers at a weekly senior clinic that takes place at the medical school’s Portsmouth Family Medicine. “We often ask caregivers to come in with the elder to their visit. The geriatrician, nurse practitioner or medical resident will complete a physical exam on the elder, while I talk in a separate room to the caregiver,” she explains. “We spend the majority of our time discussing caregiver burnout. If a caregiver is feeling particularly stressed and strained, we brainstorm ways to increase support, whether it be contacting other family members for respite or exploring community supports. We also do some very brief relaxation exercises such as diaphragmatic breathing or guided visualization.”
Older adult clients may not currently be facing caregiving issues or having trouble transitioning into retirement, but there is one experience that everyone must eventually face: loss. Although that experience is certainly not restricted to the older adult population, it does become more common as people age.
“One big thing that counselors can help clients with is loss,” Roland says. “Even if you’re healthy and have enough money to age comfortably, people around you are passing — spouses, friends and, in some cases, even children, and that is devastating. It’s not something that you are prepared for.”
As adults move through the “new aged” stage, they share similar challenges, but in certain circumstances, Moll says, the aging path really starts to diverge. Although most people who reach older adulthood have some kind of health complaint, the “well-aged” (as Moll terms them) generally have minor or manageable conditions. They may have arthritis and other wear and tear, she explains, but they are as healthy as can be expected for their age group.
On the other hand, aging adults in poor health are starting to reach the point — if they are not there already — of becoming seriously disabled. In many cases, these aging adults have a “biological” age that is older than their chronological age, Moll says. She adds that counselors should be cognizant of these differences and watch for the depression and anxiety that often accompany a loss of ability.
Some counselors, such as Cowan, are working with other health professionals to meet the needs of the ill and aging. In concert with a geriatrician, nurse practitioner and family medicine physician resident, Cowan helps aging adults with complex health issues. Primary care providers send aging adults with common geriatric issues such as dementia, depression, frequent falls and poor nutrition occurring with comorbid chronic illnesses such as obstructive pulmonary disease, heart failure or diabetes to the medical school’s senior clinic for assessment.
“The purpose of our clinic is not to follow these elders long term,” Cowan explains. “We see them for one-hour appointments once or twice or, in some cases, three times to develop a comprehensive management plan which we give to their primary care provider.”
Cowan’s principal role is to screen these aging adults for mental health issues such as cognitive decline, depression and anxiety. “When elders present with anxiety or depression, having me right there in the clinic during their medical visit reduces the stigma of seeking therapy,” she says. “Many elders are resistant to therapy because they fear they will be labeled with having a ‘mental illness’ and, therefore, do not seek mental health treatment. They are usually more comfortable with the idea of engaging in a therapeutic relationship right there in their physician’s office. I often administer brief assessments such as the Geriatric Depression Scale, which gives us a nice starting point to discuss these difficult topics.”
Cowan also contributes to the team’s overall treatment assessment. One common issue is aging adults who take numerous medications and are confused about when and how to take them. “It is imperative that their medications are taken correctly,” Cowan says. “Taking too much or too little can significantly impact health outcomes. This is often a primary focus, and I use motivational interviewing techniques to encourage medication adherence.”
Sometimes, however, the team decides it would be better for a patient’s family member or caregiver to manage the medication schedule. “The team may use me to deliver the news in a sensitive way,” Cowan says. “I have found that the use of empathy is imperative. Most of the time, elders are concerned about losing their independence and autonomy. With motivational interviewing techniques, the elders often open up about these fears, and we can process them together. … For instance, I might say, ‘It must be terrifying to feel like you are losing your independence, and I’m wondering how I can help you feel more in control.’”
Cowan also assists in delivering upsetting medical information to patients and then helps them to deal with the news. She has the flexibility to remain with patients beyond their scheduled 10- to 15-minute medical visits at the senior clinic, and she is also available to provide additional counseling outside of the senior clinic to help patients process and cope with their diagnoses. Cowan believes the integrated structure of the senior clinic provides patients a level and breadth of physical, mental and emotional care that would be difficult to find elsewhere.
Cowan recalls an 85-year-old female patient with a history of breast cancer who came to the clinic with swelling in her upper arm. “Her daughter and son often accompanied her to her senior care clinic appointments, and I was able to begin to develop a relationship with both the patient and her children during that very first visit,” she says. “At a subsequent visit, she was diagnosed with breast cancer, and I was able to provide counseling to both the patient and her family members. This is something that may not take place in a typical medical clinic, as there is often a rush to move on to the next patient.” Cowan notes that patients and caregivers genuinely seem to appreciate this additional support during their medical visits.
Aging and marginalized
Health and wealth aren’t the only factors that affect how people age, says Karen Mackie, an ACA member and assistant professor of counseling and human development at the Warner School of Education at Rochester University. She contends that elements such as race, gender, ethnicity, sexual orientation and even historical context — being born in a time of war versus a time of peace, for instance — color the aging process.
“Over time, people tend to accumulate advantage or disadvantage,” Mackie says. “Over the life course, people who are advantaged seem to become more advantaged, and those who are disadvantaged become more disadvantaged. If you think of life as a kind of V shape, we start closer together, but throughout life we diverge, and the greatest disparity gap appears toward the end of life.”
For instance, older adults who are lesbian, gay, bisexual or transgender (LGBT) can face difficulties that their heterosexual counterparts are, in a sense, protected from.
“This [issue] reminds me of a story that a woman shared with me many years ago,” Degges-White says. “She mentioned that she and her best friend envied lesbians because they were less likely to become widows as early as a straight woman might. Therefore, she and her best friend were already making plans to set up house together if they outlived their husbands.”
“True, straight women tend to outlive their male partners, but they also are often more socially integrated into their communities, churches and other support networks,” Degges-White continues. “Depending on age and communities, some lesbian couples may still be living relatively isolated lives. This sense of isolation can present significant challenges when one partner or the other is dealing with health-related concerns or when a partner dies. Without a healthy support system — no matter what your sexual orientation might be — older adulthood is much more difficult.”
“There are other vital issues and needs that can present difficulties, such as shared retirement accounts and Social Security, that straight couples — due to the advantages conferred by being legally married — are not likely to face,” she adds.
Because of that reality, LGBT older adults need to put financial plans in place for any future needs. At the same time, Degges-White says, counselors should be aware of these issues and encourage their clients to consult a financial planner to organize estate planning.
All aging adults should seek connection with others, she says, but it is especially important for clients from marginalized populations to solidify or build networks with their extended families, close friends, community organizations or faith-based institutions so they will have supports in place to help them face later-life difficulties.
Faith-based, family and community connections are essential to meeting the mental health needs of older adult persons of color and other diverse ethnicities, says SeriaShia Chatters, an ACA member and assistant professor of counselor education at Penn State’s College of Education. “Many older adults from diverse populations may be skeptical of the therapeutic process and are more likely to divulge their personal issues to someone in their religious community or neighborhood,” she observes. Oftentimes, it is a suggestion from someone in the aging adult’s religious community or other personal network that encourages the person to visit a counselor’s office, Chatters says.
Counselors must also keep in mind that context is crucial, especially with older adult clients from diverse populations, Chatters says. “I think counselors should be aware of indigenous healing practices and their impact on their client’s culture and belief system,” she says. “I also think counselors need to be aware of and open to various belief systems and understand how to incorporate these beliefs into the therapeutic process if they are helpful and positively impact mental health.”
Chatters notes it is also important for counselors to understand the acculturation process and the divisions it can cause within different generations of the same family. Family therapy can be very useful in these situations if it is something with which the older adult is comfortable, she says.
Still a story to tell
An ageist society tends to stop seeing older adults as individuals, regardless of whether those adults are advantaged or disadvantaged, asserts Mackie, who references the idea of a “mask of aging.”
“People get related to on the basis of their appearance,” she explains. “But, actually, they carry internally multiple stories and identities and senses of who they are. Part of training counselors to work with aging [adults] is to understand what new developmental aspects aging might bring to people.”
“For instance,” Mackie continues, “they may never have had a physical illness before, or they may not have been as isolated before or as economically unstable, so aging brings assaults and crises for them, but at the same time, they are who they have always been. They have this rich background that we have to tap into in order to find those resources to help people cope.”
It is essential for counselors to recognize that aging people still have a story to tell, Mackie emphasizes.
Donald Redmond, an ACA member and assistant professor of counseling at Mercer University in Atlanta, agrees. He proposes narrative therapy as a particularly useful technique for working with aging adults.
“Narrative approaches to counseling center people as the experts in their own lives and view problems as separate from people,” Redmond explains. “This technique assumes that people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to reduce the influence of problems in their lives. ‘Narrative’ refers to the emphasis that is placed upon the stories of people’s lives and the differences that can be made through reauthoring these stories in collaboration with a counselor.”
Redmond notes he has found that many people — aging adults in particular — are more likely to be open to discussing their lives if the term narrative is used rather than counseling or therapy. “We all have a desire to make sense of our lives,” he says, “and with older adults or others facing mortality, this means integrating the different parts of our life — finding ‘integrity.’ In my opinion, this need makes a narrative approach particularly useful for older adults.”
Simply having someone listen to the older adult’s story can be a kind of therapy in and of itself, Redmond asserts.
Christensen’s years of experience counseling nursing home residents has taught him that it’s hard to overestimate the difference that listening and understanding can make. “I had one female patient who had been a refugee during World War II, and during her stay at the nursing home, she had to change rooms,” he recounts. “She reacted to that room change as if she had been abducted against her will at knifepoint. She was so terrified that she was constantly talking about war-related things such as the danger of the communists coming at night. People really had trouble relating to her because they couldn’t see what she was experiencing.”
“I talked with her and listened to her story,” Christensen continues. “And we then tried to build on that experience based on her strengths. We would talk about things like her needlework, and she would tell me about how back in her native country, her grandmother taught her needlework, and this helped her remember that bond. She would also tell me about the meanings of the pattern’s colors. For example, how the black thread was like the very rich soil they used to grow their food, and the reds and yellows were the colors of the wildflowers, and how the green represented hope. Bringing all of that life back helped her let go of a lot of those fears and … some of the war themes and really expand the range of her conversation.”
The resulting change was so dramatic that the woman’s daughter called the nursing home wondering what had happened to her mother. She was suddenly, once again, the mother she remembered, says Christensen.
There is a small concentration in gerontological counseling at the Warner School of Education, but Christensen and Mackie see an urgent need for more programs that focus on meeting the needs of older adults.
“It’s really important that counselor education programs have faculty that identify as gerontology specialists, that they have specialized course work and are performing research,” Christensen says, “because without those sustaining resources, I don’t know how effective an education program can be in this area. So many gerontological counseling programs have withered for lack of student interest. What example is being set?”
As it relates to counselors advocating for, supporting and providing services to the older adult population, Mackie draws one last conclusion: “There is a huge social justice need.”
Medicare: Advocates needed
As the population ages, so does the counseling profession’s client (or potential client) base. And that poses a significant issue. Unless they have private resources, most adults over 65 are on Medicare and depend on this coverage when seeking physical and mental health care. However, Medicare does not currently cover licensed professional counselors (LPCs).
The American Counseling Association and its division, the Association for Adult Development and Aging (AADA), are leading advocacy efforts for the inclusion of counselors under Medicare, which is the nation’s largest health insurance program. According to numbers compiled from the 2010 U.S. Census, Medicare covers roughly 40 million older Americans (ages 65 and older) and approximately 8 million Americans with disabilities. The program was established in 1965.
As an ACA position paper explains: “Medicare has covered psychologists and clinical social workers since 1989, but does not cover licensed professional counselors. Many Medicare beneficiaries live in mental health professional shortage areas, and there are more than 120,000 licensed professional counselors across the country ready to provide needed treatment. Lack of access to outpatient mental health treatment harms beneficiaries and contributes to overutilization of more expensive inpatient care. It also increases the costs of treating chronic medical conditions such as diabetes or congestive heart failure, since many individuals with these conditions have a comorbid depressive disorder.”
Art Terrazas, the director of government affairs for ACA, emphasizes that Medicare reimbursement for LPCs is unlikely to be achieved without a significant amount of advocacy from individual counselors in the field. Terrazas encourages all ACA members to contact their congressional representatives to urge legislative action on behalf of older adults.
“Not only do we need to have counselors call their congressional members, but we need their friends and families to call as well,” Terrazas says. “Many times representatives don’t know about these issues, and it’s up to their constituents to educate them. With the rapid growth in the older population, we are going to see a serious increase in the need for mental health providers, and Medicare is sidelining 40 percent of the providers at a time when we need them the most.”
For more information on ACA’s efforts regarding Medicare coverage of LPCs, contact Terrazas at firstname.lastname@example.org, and read Washington Update on page 10 of the April issue of Counseling Today.
To learn about AADA’s “Day on the Hill” event taking place in July, contact AADA President-Elect Bob Dobmeier at email@example.com.
Approaches to counseling older adults
Because older adults often are on tight budgets and because counselors aren’t currently covered under Medicare (see sidebar, above), SeriaShia Chatters, an assistant professor of counselor education at Penn State, says it is essential for counselors to provide treatment that is effective and that can produce results in a relatively short period of time.
She believes cognitive behavior therapy (CBT) should be at the core of care for these clients. “CBT offers techniques that, when used properly, can effectively reduce symptoms of depression and anxiety in many clients in fewer sessions than some other therapeutic techniques,” she says.
Chatters also thinks strengths-based counseling is important. “In the older adult populations, some of our clients may be faced with declining physical health and/or cognitive ability,” she says. “It is important to focus on their strengths and abilities and draw from their ability to overcome previous challenges. [I] also advocate for the use of the word challenge in place of the word problem. Changing the terms we use in therapy can also provide hope.”
In addition, Chatters says it is important for counselors to challenge some of the myths of aging. Although it is true that some cognitive decline is common among older adult populations, she says advances in neuroscience indicate that older adults “can still change their brains and maintain healthy cognitive function.”
To help preserve cognitive function in older clients, counselors need to discuss exercise, nutrition and the importance of sleep with these clients, she says.
To contact individuals interviewed for this article, email:
Christine Moll at firstname.lastname@example.org
Catherine Roland at email@example.com
Tom Christensen at firstname.lastname@example.org
Karen Mackie at email@example.com
Rich Feller at firstname.lastname@example.org
Suzanne Degges-White at email@example.com
Rebecca Cowan at firstname.lastname@example.org
SeriaShia Chatters at email@example.com
Laurie Meyers is a staff writer for Counseling Today. Contact her at LMeyers@counseling.org
Letters to the editor: firstname.lastname@example.org