Picture a grandson trying to help his grandfather adjust the tracking on his VCR. In the corner, the grandson’s friend jokes that they are ignoring the larger issue — that no one uses VCRs anymore. When the grandfather starts talking about his life, the young men make up an excuse to leave, but the grandfather captures their attention with a story about his experience during the war. By the end, the young men are eager to spend more time with him.
This is the opening scene from an episode of the Netflix comedy series Master of None. The episode, titled “Old People,” effectively exposes and challenges ageist stereotypes.
For some people, even the phrase older adult conjures up negative images of physical and cognitive impairment. But ageist stereotypes, such as older people being out of touch, do not reflect the typical experiences of older adults. Aging is a natural part of life, and many people age well. In fact, only approximately 5 percent of older Americans live in nursing homes at any given time, according to the American Psychological Association.
AARP is attempting to reverse this negative narrative with its #DisruptAging campaign, which provides a space for changing the story about aging and embracing life throughout the life span. In a recent post, AARP used the phrase gray-cial profiling to call out companies guilty of age discrimination. These offenses range from identifying older adults as potential shoplifters to excluding older adults from certain career opportunities.
Unfortunately, the issue of thinking negatively about aging often extends to health care professionals, many of whom view aging as a problem to be solved rather than a normal part of the life span. In addition, they often focus on the physiological aspects of aging rather than the psychological, social and spiritual needs of older adults.
Many interventions across disciplines focus on deficits, observes Sara Bailey, a doctoral candidate at the University of North Carolina at Greensboro (UNCG). For example, some gerontology, nursing and medical programs use an aging suit — a suit that simulates the physical impairments of older adults, such as strength and sensory loss — to expose students to the impairments of older people. “That basically conditions the student to understand that age and impairment are the same thing,” argues Bailey, a member of the American Counseling Association.
In his work in long-term care facilities, Matthew Fullen, an assistant professor of counselor education at Virginia Tech, noticed that conversations between older adults and health care providers often focused on physiological deficits. From his perspective, this scenario contributes to the medicalization of aging and tells only a narrow piece of the overall story. “If we assume that [physiological changes] are only going to be moving in a deficit direction, then we sort of get the self-fulfilling prophecy where we see those problems and we don’t see the rest of the person in front of us,” Fullen explains.
Most older adults don’t develop dementia or lose their ability to walk, be funny or engage with others, so “it’s important to expose [counseling] students to the reality of [aging] instead of pathologizing it,” Bailey says. To assist with this process of introspection, she challenges counseling students to find a birthday card for someone beyond the age of 18 that doesn’t rely on disparagement humor. Bailey refers to this type of humor as future-focused self-loathing: “When we laugh at getting older, we’re really laughing at ourselves, and we’re not laughing in a kind and loving way. We’re laughing in a way that others our future selves, and that’s not OK.”
The forgotten population
The level of importance placed on gerontology in counseling has not been clear or consistent. In 1975 in the Personnel and Guidance Journal, Richard Blake called attention to counseling older adults, a population he deemed “forgotten and ignored.” Then, gerontological counseling gained forward momentum. In 1986, the Association for Adult Development and Aging (AADA) became a division of ACA. Between 1990 and 1992, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) adopted gerontological counseling standards for community counseling programs, and the National Board for Certified Counselors (NBCC) created a specialty certification in gerontological counseling. However, because of declining interest, NBCC retired this certification by 1999 and CACREP removed the gerontological counseling standards by 2009.
This de-emphasis on later adulthood in counseling education motivated Bailey to pursue a doctorate in counseling and become part of the solution by specializing in later adulthood. At her first counseling education and supervision conference, she discovered that the gerontological counseling certification no longer existed. She says this led her to wonder, “What does this say about the focus of counselor educators? What does it say about the value of our clients and who we value more?”
In the United States, the older adult population is projected to more than double from 46 million to over 98 million by 2060, according to the Population Reference Bureau, and the Institute of Medicine notes that nearly 1 in 5 older adults has one or more mental health or substance use disorders. This raises a question: Why isn’t the counseling profession doing more to prepare counselors to care for this rapidly growing and vulnerable population?
Fullen, an ACA member who also serves as secretary of AADA, argues that counselors lack awareness about aging issues. This lack of awareness may stem from a range of factors, including the fact that older adults are a segmented part of the population, he says. Fullen also posits terror management theory as a possible explanation: Counselors fear the aging process because it reminds them of their own mortality.
In a course on life span development, Amber Randolph, an assistant professor and program director of the clinical mental health counseling program at Judson University in Illinois, discovered that her entire class of 25 students was terrified to discuss the end of life. “We’re turning out counselors who are going to be dealing with grief and loss issues who are very uncomfortable with the idea of death and, in particular, the idea that they too will age and die,” notes Randolph, a member of ACA.
This anxiety over aging can lead to the avoidance of older adults’ needs. Humans are the only species aware of their own mortality, so avoiding working with older adults is often not a conscious decision but rather an aversion to fear, Bailey adds.
Bailey is directly addressing counselors’ resistance to incorporating later adulthood within counselor education. Her research focuses on reintegrating gerontological competencies into existing coursework, which she believes will be a less objectionable approach. “I think it’s going to take a sea change in the way we view culture to start to include age in our developmental courses, in our career courses, in our theories courses, in our diversity courses,” she says. That might mean really integrating “the competencies that used to exist … in a subtle, gentle, very fluid … way so that every counseling course covers the age span,” she adds.
Bailey thinks that emotionally connecting counselors with aging issues is key. “You can talk about issues of late adulthood, but until you connect emotionally with the student around those issues … it just doesn’t click.”
To improve empathy and attitudes toward older adults, Bailey developed a perspective-taking intervention that includes three parts. First, in a journaling activity, counseling students describe their future 75-year-old selves. The second part is a game in which the students read prompts describing ageist events and then immediately reflect on the emotional reactions they would have if they were the older adult. In the third part (a reflective journaling activity), the counseling students consider their feelings and reactions toward counseling a 90-year-old client who shows symptoms of depression.
Age as an intersecting identity
Intersectionality is often discussed in terms of the interconnections between a person’s identities of race/ethnicity, gender, sexual orientation and class, but age typically gets overlooked. “Age is the only one of these marginalized identities that every single person will experience granted that they live long enough,” Fullen says. Even so, he points out that little research exists within the counseling profession on intersectionality that includes aging. “The client’s age just becomes another intersection piece that fits in very appropriately with all of those other constructs. So I’m more concerned with the ability of counselors to consider age as another intersection.”
Christian Chan, an assistant professor of counseling at Idaho State University and an ACA member, also encourages counselors to discuss intersectional identity with clients. “There are microaggressions that exist because of those intersections,” he says. For example, an older adult may refuse to socialize with someone who is gay. Thus, diversity exists between and within identity categories, and the way people navigate their overlapping forms of privilege and oppression provides them with their unique experience, he explains. By putting these identities into conversation, counselors can help clients understand what is happening to them.
This conversation about intersectionality is crucial because the growing population of older adults is also becoming more diverse. According to the Centers for Disease Control and Prevention, between 2014 and 2060, the percentage of adults age 65 and older who identify as white non-Hispanic is expected to drop from 78 percent to 55 percent. In addition, according to the University of Washington’s School of Social Work, approximately 2.7 million U.S. adults age 50 and older identify as lesbian, gay, bisexual or transgender, but that number is expected to increase to more than 5 million by 2060.
Counselors should avoid speaking about diversity in a broad sense, cautions Chan, who serves on the AADA executive board. He explains that when counselors focus on the centrality of one type of identity, they lose sight of the other identities and the way these intersections affect experiences, which can lead to the rank order of identities. For example, counselors often talk about LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning and others) communities and older adult communities in isolation rather than discussing the overlap between these identities.
Instead of asking broad questions (e.g., “How do you identify culturally?”), Chan advises counselors to use specific questions (e.g., “How would you identify in terms of your racial/ethnic identity?”) to engage in a richer conversation with clients. The simple act of including open-ended space for identity on preliminary assessments and intake interviews — for instance, by replacing check boxes with fill in the blanks — can help counselors understand a client’s multiple identities and possible intersections, he adds.
Mijin Chung, an ACA member and licensed professional counselor (LPC) with a private practice in the greater Atlanta area, also sees a danger in discussing diversity broadly. When working with older adult immigrants, for example, counselors should examine the home country and family culture of clients and avoid making broad generalizations based on age or culture, she says, because a significant number of within-group differences exist. Therefore, it is crucial for counselors to understand the environmental context of older adult clients. For example, immigrant older adults who came to the United States when they were young may have a different view of aging and U.S. culture compared with immigrant older adults who recently came to the country and perhaps live with their adult children.
Chung finds the narrative approach helpful when working with older adults, and especially with older adult immigrants, to uncover clients’ unique experiences. Often, Chung says, this population does not receive many opportunities to share their life or immigrant stories. With a narrative approach, counselors can glean the obstacles and challenges older adults have overcome, and clients’ stories can provide counselors with a frame of reference for how to proceed in session.
Counselors must also remember that intersectionality is more than just multiple identities, Chan says. “You can’t have intersectionality if you’re not talking about power; you can’t have intersectionality if you’re not talking about social context; you can’t have intersectionality if you’re not talking about social justice,” he explains.
Fullen agrees that intersectionality is about the way that multiple identities lead to power differences or marginalization. In fact, disparities often emerge when marginalized identities such as race and sexual orientation are combined with an older adult experience. For example, an older LGBTQ+ individual may face barriers to finding safe housing options, such as denial from entry or a higher probability of eviction. These barriers are further complicated if this older individual has a disability that limits mobility or a lower income because of decreased access to income opportunities, Chan says.
Counselors should think about how they can help to make systemic changes to ensure that multiple marginalized communities are visible and have rights and access to opportunities and basic care, Chan argues.
A hidden reserve of resilience
Resilience — an individual’s ability to recover from adversity — is often a coping skill that we attempt to teach to children, but research shows that resilience can have a positive effect in later adulthood as well. According to an article by Tara Parker-Pope in The New York Times this past summer, scientists claim that resilience operates like an emotional muscle that can and should be strengthened with techniques such as being optimistic, reframing your personal narrative and remembering challenges that you have overcome.
Of course, building resilience isn’t easy and takes practice. To further complicate matters, resilience is a contested term among gerontological scholars, who debate whether it is something that only certain people possess. Fullen rejects this all-or-nothing view and instead assumes that every person possesses some degree of resilience.
With this core assumption, Fullen and Sean Gorby, a doctoral candidate in counselor education at Ohio State University, piloted a Resilient Aging program, which they believe holds the potential to enhance participants’ perceptions of resilience and wellness. In their pilot study, Fullen and Gorby helped marginalized older adults identify connections between their histories and the ways they had already shown resilience throughout their lives, with the hope that participants could apply this resilience to their present situations.
After Fullen and Gorby introduced the term resilience and allowed the participants to generate their own definitions, the older adults easily identified moments of resilience in their own stories or the lives of others. “Those resilience examples became … counternarratives to the larger societal narratives about aging being only a time of decay and decrement,” Fullen says.
In his prior research, Fullen had noticed that people who are marginalized seemed to possess a hidden reserve of resilience. The pilot study for the Resilient Aging program served as a lightbulb moment for him because he was able to see it in action. “It was a chance for us to better understand the way that people who have been overlooked at various points throughout their lives develop this sort of reserve of resilience that perhaps better equips them to handle some of the challenges associated with aging because this isn’t the first time the deck had been stacked against them,” he explains.
Thus, rather than discussing a marginalized identity such as age only in terms of oppression and deficits, counselors also need to highlight resilience and make it a part of the conversation, says Chan, a past president of the Maryland Counseling Association. “What is so beautiful about working with older adults is that they have such rich narratives [in] their lives. … They have found ways to navigate and make sense of not only their identities but their experiences,” he points out.
Empathizing and reframing clients’ stories
Fullen realizes that using a resilience-based approach requires counselors to walk a tightrope between empathizing with clients’ lived experiences of the difficulties of aging and pointing out an alternative viewpoint. “It’s important not to lose [the] client by jumping too quickly into strength and resilience,” he warns. “[Counselors should] spend some time … building rapport in regard to their grief or their sense of lament related to the aging process but then start to integrate this alternative narrative, alternative conceptualization, that is more strengths oriented or resilience orientated.”
Fullen provides an example of how counselors can navigate this delicate balance in a counseling session. Suppose a client says, “I’m just fed up with this friction between me and my kids. I remember when I was the one calling the shots for them, and now all of a sudden, the tables have turned and I’m not happy about that.” First, the counselor needs to be empathetic, Fullen says. For example, the counselor could say, “Wow, that must be really difficult. It can’t be easy to spend so much of your life being the one who’s providing and now all of a sudden having your kids try to provide for you.” This is not the time to correct the client’s perception of what he or she is going through; instead, the counselor should join the client in understanding how difficult the transition is for the individual, Fullen advises.
As the session unfolds, the counselor can begin a more formal assessment of the client’s perception of how he or she is doing across the wellness domains (emotional, physical, occupational, social, spiritual and intellectual wellness) and how the client views the aging process, which will elicit any age-related bias that the client has internalized, Fullen notes. This is also the time to ask broad questions about resilience, he advises. For example, the counselor could say, “It sounds like things are so challenging right now. I can’t imagine this is the first time that you’ve been through a really challenging situation. So, tell me about how you have shown resilience over the course of your life when it comes to facing really difficult situations like the one you are talking about.”
Fullen notes a broad question that is particularly helpful for counselors to ask when working with marginalized clients: “How have you survived? You’ve been through so much. You continue to go through so much.” This question allows clients to talk about resilience — even if they don’t use that language, Fullen says. Then the counselor can introduce the term resilience by saying, “That is so fascinating to hear about all the ways that you have survived over the years. In my profession, we have a word for that, and the word is resilience. Are you familiar with that concept? What do you make of that concept?” This process subtly introduces a counternarrative to the dominant ageism narrative for both the client and counselor, Fullen says.
If clients begin talking about their history of resilience, then the counselor can incorporate resilience language and help them reframe their stories as resilient ones, Fullen suggests. However, if a client pushes back and says, “I don’t know what resilience has to do with anything,” that indicates the client needs more time to unpack the situation and vent, he says.
The future of gerontological counseling
Despite the obvious need to work with older adults, the counseling profession has slowly de-emphasized gerontology. This has left Fullen to wonder whether gerontology and Medicare reimbursement are priorities for the counseling profession or whether gerontological counseling will survive only as a niche in the future. Currently, Medicare, the federal health care insurance program for people 65 and older, does not cover LPCs.
There seems to be a sense that once Medicare reimbursement for LPCs is achieved, counselors will make gerontological counseling a priority, but that is problematic, Fullen says. He questions whether counselors would be as complacent if an insurance issue hindered their ability to work with another population group, such as children. “We would find ways to innovate. We would find ways to bang that door down,” he asserts.
Fullen points out that although approximately half of older adults’ mental health services are paid for by Medicare, that leaves another 50 percent of mental health care dollars tied to this client population that the counseling profession isn’t tapping into regularly. Counselors need to explore alternative strategies such as private pay, grant opportunities and supplemental insurance, which haven’t received as much attention, he says.
Bailey has heard similar arguments indicating that the counseling profession’s relative lack of interest in serving the older adult population stems from the lack of progress in securing Medicare reimbursement. From her perspective, that makes gerontological counseling a social justice issue. “If we are simply discounting an entire population of people because we can’t make money off of them, that’s a problem that goes well beyond counselor education and CACREP Standards,” she says. “That goes to the heart of the counseling profession.”
“Across the entirety of the profession, there have been inconsistent commitments to the needs of this population,” Fullen asserts. This inconsistency directly affects counseling students, who may struggle to find gerontology-related courses and internships or even counseling professors who are truly knowledgeable in that area.
With the discontinuation of both NBCC’s specialty certification for gerontological counseling and CACREP’s gerontological counseling standards, counselors often must go outside the profession and counseling education departments to receive gerontological training. After developing an interest in working with older adults during her master’s program, Randolph noticed the lack of a gerontology specialization or certification within the counseling profession when she was applying for doctoral programs. To address this, she earned a certificate in gerontology through the continuing education department at the University of Wisconsin–La Crosse.
Bailey is also taking an interdisciplinary approach to gerontological training. She is in the process of finishing a post-baccalaureate certificate in gerontology from the gerontology program at UNCG.
There is a silver lining, however. Namely, the counseling profession already teaches and embraces qualities essential to working with older adults. For instance, counselors focus on using wellness and strength-based approaches, being client oriented and building meaningful relationships. The fact that wellness is vital to the work that counselors do is significant, Fullen says, because wellness can be the antidote against the tendency to view aging through a medicalized lens.
In addition, AADA provides resources and support for counselors who want to work with older adults but do not feel adequately trained. “[AADA’s] overarching goal is to make sure that there are counselors out there who feel prepared to meet the needs of our rapidly aging population,” says Randolph, who serves on AADA’s executive board. In addition, the AADA Older Adult Task Force is focused on expanding and promoting research, advocacy and practice related to older adulthood so that full-time practitioners do not feel alone in working with the older adult population, Fullen says.
Avoiding gray-cial profiling
Earlier this year, Allure magazine made a bold move to stop using the word anti-aging. Acknowledging that language about aging matters, editor-in-chief Michelle Lee challenged readers to consider how the simple act of removing the qualifier “for her age” from a statement such as “She looks great for her age” changes the meaning. Jo Ann Jenkins, CEO of AARP, praised the decision and stated that AARP would follow suit and avoid falling prey to the “anti-aging” trap.
This action highlights the power and danger of ageist language. Counselors steeped in societal ageism and ageist language may incorrectly assume that counseling won’t work with older adult clients, or they may focus only on the physiological aspects of aging. However, as Bailey points out, all people, regardless of age, are still developing. “People can learn throughout the life span. … People can develop new habits and change old habits. … As long as there is air in the lungs, there is potential for change.”
Even though the counseling profession is well-positioned to serve the growing, diverse population of older adults, it often leaves them out of the conversation, committing its own gray-cial profiling. “It’s an open question of whether or not [counselors] will rise to the occasion and start to think in a more sophisticated way about these issues,” Fullen says, “or whether [they’ll] want to continue to keep [their] heads in the sand.”
Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at firstname.lastname@example.org or through her website at lindseynphillips.com.
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