Tag Archives: Adult Development & Aging

Counseling clients with cancer

By Lynne Shallcross February 24, 2015

As of Jan. 1, there is official recognition that a cancer diagnosis can, and often does, affect a patient’s mental health. At the beginning of the year, a requirement was put in place for cancer programs to screen all patients for psychosocial distress in order to receive accreditation through the Branding-Box-CancerAmerican College of Surgeons Commission on Cancer. The centers accredited by the commission treat almost 70 percent of newly diagnosed cancer patients in the United States every year.

The new guideline represents a step forward in terms of acknowledging the link between mind and body when it comes to cancer. But for Gary Patton, this “new” emphasis is really nothing new at all.

Patton has worked as a counselor in the cancer center at St. Mary’s Medical Center in Huntington, West Virginia, since 2008. Working at the time as the director of St. Mary’s employee assistance program, the hospital reached out to him after medical professionals there took note of increased mental health concerns among oncology patients.

St. Mary’s ultimately decided to establish a Department of Mental Health Counseling and Employee Assistance Program, which Patton directs. The main purpose for creating the department, he says, was to bring a counselor to the bedsides of patients, primarily in the oncology center. In addition to Patton, the mental health counseling department employs another full-time counselor and one part-time counselor. It also runs a medical-based counseling internship program for counseling students.

“The thing that St. Mary’s was looking at in 2008, [hospitals are] looking at across the nation now: What psychologically happens to patients when they hear ‘You have pancreatic cancer’ or ‘You have lung cancer’? You know, what’s happening to these patients and these families? If we’re not going to assess their distress levels with that, then we’re leaving a piece of their care unattended,” says Patton, a member of the American Counseling Association.

Patton says the new accreditation requirement means that hospitals “can’t just assume, ‘Oh, that patient looks like they’re OK. They’ll let us know if they need something.’ So just like [with] every patient, you check their vitals, you check their blood levels … but every patient needs to be assessed for the psychological reaction to cancer.”

According to the World Health Organization, the number of new cancer cases is expected to rise globally by about 70 percent over the next two decades. The news is better in the United States, where the cancer death risk is actually decreasing. But the numbers are still staggering. According to the American Cancer Society, an estimated 1,658,000-plus new cancer cases will be diagnosed in the United States this year. And if the vast majority of the country’s new cancer cases are treated in centers now required to screen for psychological distress going forward, a growing need may soon exist for mental health practitioners to work with these patients.

“Historically, psychologists and social workers are the most commonly found mental health providers in medical systems,” says Mary Jones, a counselor in private practice in Sioux Falls, South Dakota, who also teaches in Capella University’s mental health counseling graduate program. “I think we [counselors] need to be more involved in getting in on that turf.”

Jones’ background includes previously serving as a counselor in the oncology clinic at a hospital in Sioux Falls, where she worked with cancer patients, their family members and their caregivers as well as the health care providers treating those patients. To illustrate how well suited counselors are for this area of work, Jones points to recommended practices that she says were given to hospitals by the National Cancer Institute Community Cancer Centers Program a little less than a decade ago. The recommendations included facilitating communication between patients and health care providers, identifying the psychosocial needs of patients and engaging patients in the management of their care.

“All of those things are things that mental health counselors do,” says Jones, an ACA member who presented on the topic of working with cancer patients at the ACA 2014 Conference & Expo in Honolulu. “We work on communication, we work on coordination, we work on getting clients invested in their wellness journey, so it just seems to me like this is such a natural fit.”

The gamut of emotions

A man recently took a bad fall on his construction job, so he came to St. Mary’s Medical Center to get checked out. The doctors took X-rays and scans, but instead of finding an issue related to the fall, Patton says they discovered a cancerous mass.

People often get blindsided by a cancer diagnosis, Patton says, even when they sense that something is wrong. “Sometimes we find with these patients that their symptoms don’t seem to add up to the severity of something like cancer,” he says. “Many of our patients will say, ‘I’ve been tired, I haven’t had much of an appetite, I’ve lost a little bit of weight and my back’s been hurting.’ That could be the flu. [But] they come here and find out that it’s cancer.” Understandably, he says, they leave in total shock.

Patton describes other instances in which patients receive a cancer diagnosis and, instead of shock, immediately adopt a defeated attitude. “So on the one hand you have crisis and shock, and on the other hand, as soon as they hear it, [certain patients think], ‘Well, I’m not surprised. Most of my family members had cancer, and I’m going to die too.’ I think those are two unique dimensions of treating people who have cancer from a psychological perspective,” Patton says. “Because on the one hand, you’re doing crisis counseling. And on the other side, you’re talking about the will to live and trying to help people mobilize some resources.”

Jones says several clients told her that they prayed to God and tried to bargain even before a formal cancer diagnosis was made. “If you don’t give me cancer,” they’d pray, “I’ll do this or that in exchange.”

It may come as a surprise to learn that once those patients actually received a diagnosis and treatment plan, they often experienced some decrease in their anxiety and depression, Jones says. “Now they had a plan. Now they had knowledge. It [was no longer] scary, unknowable stuff that was happening,” she says.

But once treatments such as chemotherapy and radiation were set to begin, Jones says the patients’ fear tended to spike back up because they didn’t know what to expect. “Once they got through the first two sessions, there was again a lessening of anxiety because they knew what to anticipate,” she says.

When cancer clients have a history of severe mental illness, the cancer diagnosis has the potential to exacerbate that illness, so counselors should be on the lookout for increasing symptoms, Patton says. Along those same lines, he says counselors should be aware of what psychotropic medications the person is taking and what impacts the cancer treatments could have on those medications, and vice versa.

Patton worked with a client being treated for cancer who also had a history of schizophrenia. The client was on a medication for the schizophrenia that wouldn’t cooperate well with chemotherapy treatments. Patton, the pharmacist and the oncologist worked together to gradually move the patient to a different schizophrenia medication so she could safely begin the chemotherapy for her cancer.

ACA member Sejal Barden, an assistant professor of counselor education and coordinator of the marriage, couples and family therapy program at the University of Central Florida, says clients with cancer can also feel isolated. Although friends and loved ones often provide plenty of support right after a diagnosis is made, as time passes, they often don’t know what to say, explains Barden, who previously worked in a cancer center for two years and currently researches the impact of breast cancer on Latino couples. In cases in which a client feels isolated or abandoned, support groups for cancer patients can provide a good forum to vent and to feel less alone, she says.

Questions of a spiritual or religious nature are also common when patients are dealing with a cancer diagnosis and treatment, Jones says. “There was a lot of discussion in sessions over ‘What’s going to happen to me when I die? Where do I go? Where does my spirit go?’” she says. “Difficulties for me [definitely included] seeing them die but also trying to help them say goodbye to family members and trying to make meaning out of what was going on.”

In cases in which clients are unable to beat cancer, Jones says, counselors might be tasked with helping them consider end-of-life decisions or quality-of-life issues in their remaining time. Jones tried to connect clients in such circumstances with a variety of resources depending on their concerns, including helping them meet with a hospital chaplain or reach out to hospice care.

Predictably, Jones says that feelings of fear, depression and anxiety are quite common in clients throughout the cancer diagnosis and treatment process. Other issues she encountered regularly with her clients included changes in appetite, difficulties sleeping, financial concerns related to paying for the treatments and concerns about changes in sexuality due to the cancer or medication. “And then, almost without exception, somebody with cancer worries about it recurring,” she says.

Patton agrees. Even patients who get through cancer treatment and seem to be recovering well become very anxious again whenever the time comes for a regularly scheduled checkup scan, he says.

In the script of a television commercial Patton did for St. Mary’s about how counseling helps clients with cancer, he said, “Once that word cancer is used in the same sentence with your name, your life will never be the same again.”

That change can take two forms, he explains. “It could put a cloud over this person that never fully goes away, or it could show them a vitality and resilience for life they never had before because they know how close maybe they came to death or how close they came to chronic suffering. And they’re past that now, and they’re enjoying life more than ever because they’ve had that critical experience,” Patton says.

Taking a systemic approach

Although cancer traditionally has been conceptualized as an individual diagnosis, research has begun conceptualizing it as a couple’s or family’s disease, Barden says. The impact of cancer on loved ones became apparent to Barden in her work with a cancer survivor support group in North Carolina.

“What kept coming up for those women was how much the cancer had impacted their relationships, their marriages, their partners, but how there were no supports for their partners,” says Barden, who spent a month last summer as a fellow at the National Cancer Institute. “The cancer survivors felt there were adequate psychosocial groups, counselors, etc. [for them], but there was really nothing for their partners to be able to talk about how they were experiencing [it].”

“Sometimes the loved ones are actually more distressed than the patient is,” observes Patton, who also teaches in the online counseling program at the University of the Cumberlands in Williamsburg, Kentucky. “I’ve had patients tell me, ‘My family needs to settle down. … It’s like they’re more worried about me than I am about me.’”

Burnout can be a huge issue for loved ones and caregivers of a client with cancer, Jones says. “The thing I heard over and over again in my support group for caregivers was they needed a break, they needed to get away from it,” she says. “These are things we’d work on in our group sessions — being able to say to people around them, ‘I don’t want to talk about cancer today. I don’t want to think about cancer today. Can we just talk about anything else?’”

Jones says she would remind her caregiver clients that if they didn’t take good care of themselves, then they wouldn’t be able to adequately care for their loved ones with cancer over the long term. Caregivers and loved ones can also experience feelings of anger for bearing the heavy burden of caregiving, Jones says, and, oftentimes, they then feel a sense of guilt for having such feelings.

Additionally, Jones says, there are often concerns around parenting, especially related to deciding what to tell children about the cancer diagnosis and when. Jones recalls one client and his wife choosing to wait to tell their college-age children about his cancer diagnosis until he was in his third session of chemotherapy, primarily because that was when their children would be finished with their final exams.

The hospital where Jones worked had a program in place for parents with younger children. Jones would fill a backpack with age-appropriate information about cancer as well as toys and games to send home to the children.

When taking a systemic approach, counselors should also pay attention to how the actions of loved ones might be affecting the cancer patient now and what the dynamics of the family system were prior to the diagnosis, Patton says. “Maybe there have been disruptions of some kind — divorce or alienation from family,” he says. “Once that diagnosis of cancer comes, it can be a resurgence of all that. Either people try to overcompensate for the harm or the damage or the disruption that they’ve had in the past, or it can take those problems and make them worse.”

At times, Patton and his colleagues will notice loved ones hovering over the patient and drawing a negative reaction from the person. “Sometimes you’ll find that this [involves] family members who haven’t spoken for seven years, and now they’ve heard cancer and they’ve rushed in to be the rescuers. And it’s really irritating the patient.”

Helping the patient and his or her loved ones communicate about the realities of the diagnosis and treatment can also be a critical role for the counselor, Patton says. He has witnessed situations in which both the patient and the patient’s family thought the other didn’t truly understand how bad the cancer diagnosis was. Therefore, they completely avoided talking about it with each other.

Patton says he tries to “expedite a different type of conversation,” reminding the patient and the patient’s loved ones that “truth does not have to be projectile.” Meaning, he says, that they don’t need to share everything they know in one encounter but can instead slowly open up the lines of communication.

From theoretical to practical

Patton says that in his experience, cognitive behavior therapy (CBT), mindfulness and group work can be especially productive when working with clients who are dealing with cancer.

CBT allows clients to explore their emotions and feelings without allowing those emotions and feelings to control everything, Patton says. Behaviors and emotions are determined by thought processes, he points out. So while CBT gives emotions respect, it also enables clients to look at their individual situations again and think about them differently when tackling questions such as “Am I going to be compliant with treatments?” or “How will I live my last days?” says Patton.

A colleague of Patton’s practices mindfulness with clients at St Mary’s cancer center. Patton says this helps clients bypass some of the associated distress and experience some physiologic comfort and relief. Mindfulness can also help clients to reconnect with their bodies and their existence as a person, he says. For example, “I’m not just a cancer patient. I’m a patient who has cancer, but I’m also a patient tomorrow who’s going to see my grandchildren,” Patton says.

Group work can also be beneficial for these clients because it offers them a place to feel support, a sense of belonging and camaraderie. One of the support groups at Patton’s hospital is for cancer clients under the age of 40. One of the topics the group has addressed is being confronted by mortality at such a young age and how to respond to clichés from other people, such as “You’re young; you’ll be fine.”

Judy Green is an ACA member who teaches in the Walden University School of Counseling and co-presented with Jones at the 2014 ACA Conference in Honolulu. She says counselors must be aware of grief issues when working with clients with cancer and their loved ones. For example, Green says, even clients who have survived cancer go through a grief process. Counselors can help those clients validate their feelings of having survived cancer and navigate a new normal now that their life has changed. They might grieve the loss of what they thought their future would be or the loss of their self-identity as a healthy person, Jones adds.

When working with clients who have lost a loved one to cancer, Green says she gravitates toward William Worden’s “tasks of mourning,” which consist of accepting the loss, working through the pain, adjusting to the new reality without the person and finding an enduring connection with the person who died. Green adds that grief counseling groups can be therapeutic both for those who have received a cancer diagnosis and those who have lost a loved one to cancer.

Though each counselor may lean on his or her own preferred counseling approach or framework when working with cancer clients and their loved ones, Barden reiterates that counselors must not conceptualize cancer as an individual diagnosis. “Really understand how the whole system — the family and the couple — has been impacted, and [know] that while your cancer survivor might come to you an hour a week, they’re really going home to their family each day and every day.” Counselors should strive to educate and work with the whole system, Barden emphasizes. “Taking some kind of family, systemic, couples approach is probably what I would say is best practice,” she says.

Patton also supports taking a systemic approaching and says the family must be included in the counseling work. But he also advises counselors who might be treating cancer patients at bedside to recognize when these patients want and need family there with them and when they need to talk alone with the counselor.

Providing these clients with practical and educational information and resources is also a key element to counseling in this area. Jones points out that cancer patients are typically given a substantial amount of educational information before they begin treatment, but they may be in shock and have difficulty absorbing it all at that point. “In many cases, though they had been given that information, it was kind of my job to synthesize it in a more palatable way for them,” she says.

In addition to screening the oncology patients she worked with for psychological stress, Jones also screened them for the types of services they might need. She connected her clients with available resources such as a nutritionist to discuss what to eat when nothing appealed and the financial services representative at the hospital to discuss how they might afford all the treatments. She also gave out free cancer cookbooks to her clients at the hospital.

At St. Mary’s, Patton provides substantial psychoeducation and cancer education to patients, aiming to “simplify this complex, scary thing called cancer.” Patton often stays behind after the oncologist leaves so he can try to explain anything the patient didn’t understand. He says counselors should focus on simplifying the answers and information without resorting to clichés. “Don’t say, ‘Just hang in there. We’ll take care of things,’” he advises.

An opportunity for counselors to emerge

Even if providing mental health treatment to clients with cancer isn’t a specialty for counselors, Patton suggests that they become educated about it because it is highly likely that cancer will affect one of their clients to some degree. For instance, the client a counselor is treating for bipolar disorder might come to session one week and announce that his dad has cancer. “Well, that counselor needs to be able to understand that concept without becoming so alarmed or so anxious that they give the easy answers or give the clichés,” Patton says.

Because cancer can be a scary word, Patton says counselors should start by becoming comfortable with it themselves. They can take steps toward that by educating themselves about different cancers and treatment processes as well as increasing their awareness of cancer resources in their communities, including other mental health providers who may specialize in this area.

“Because it is so prevalent in our society, I think every counselor needs to become more proficient in understanding what this disease process is, who are the people involved in the treatment of it, what are the various kinds of cancer, how does one begin to understand the treatments available for it and [get] acquainted with the treatment process,” Patton says.

Jones says having education and experience in grief work is helpful for counselors who might like to work in this area, as is the willingness to be at the end of life with clients. She suggests checking the website for the American Psychosocial Oncology Society (apos-society.org) for free resources or even signing up for a membership and taking advantage of workshops and continuing education opportunities.

Barden recommends that counselors visit the National Cancer Institute website (cancer.gov) for resources and read the journal Psycho-Oncology.

Counselors interested in working with cancer patients should reach out to the human resources departments at local hospitals and cancer centers and keep an eye on job openings, Jones says. If there aren’t any current openings, she adds, counselors can explain the kinds of services they provide and investigate doing the work on a contract basis.

When a counselor successfully secures work in a cancer center setting, Jones suggests forming an alliance with the resident doctors and nurses as quickly as possible. Jones says that in her experience at the hospital, oncologists were often open to prescribing sleep and anxiety medications to patients. But oftentimes, she says, neither the doctors nor the patients thought to ask the other about this possibility. When counselors can make those connections and work collaboratively with doctors, nurses and other health care providers, patients will see that everyone is working together on the same team for their benefit, Jones says.

With the new accreditation requirements regarding psychological distress screening for cancer patients, Patton expects to see growth in the resources and continuing education opportunities surrounding this topic. And with that, he sees an opening for counselors, and ACA, to fill the new demand.

“What an opportunity for counselors to emerge here,” he says. “What an opportunity for the American Counseling Association to take a step forward and say, ‘Let’s start looking at this, look at resources, make resources available and become the leader in this field of medical-based counseling.’”


To contact the individuals interviewed for this article, email:


Lynne Shallcross is a former writer and editor at Counseling Today. She is currently pursuing her master’s degree in journalism at the University of California, Berkeley. Contact her at lshallcross@berkeley.edu.

Letters to the editor: ct@counseling.org

Interventions with nursing home residents

By Georgia A. Ellis October 2, 2014

In an article written for the Journal of Counseling & Development in 2006, titled “Baby Boomers Mature and Gerontological Counseling Comes of Age,” Mary Maples and Paul Abney suggested that professional counseling would become more complex as the baby boomers continued to age. They said that the increasing number of older adults would create a greater need for professional counselors who possessed the expertise and skills to work with that population, and particularly those older adults who reside in nursing homes or long-term care facilities.

I have had the pleasure and privilege of working with members of this population as a counselor for more than a year. My venture at the nursing facility began as part of a requirement in my doctoral program to choose a specialty area in which to practice counseling. I have always had an affinity for NursingHomeolder students as a teacher, and this afforded me the opportunity to work with older adults in this phase of my profession. After a few weeks of individual and group counseling with the geriatric patients, I knew that my specialty had found me.

As I made my rounds through the hallways and entered into patient rooms at their request, several counseling interventions emerged that I was able to use effectively with individual patients. The interventions, which I am developing as an integrated model of “personal activities” for counseling adults in nursing homes, were equally effective with groups. These techniques provide clinical flexibility and may be used for clients’ general wellness or to address specific problems such as dementia, depression or problems associated with terminal illness.

Music Matters allows me to use my passion as a gospel singer to reach out to the residents and engage them in song. Life Journey helps clients to open up and review the paths they have traveled through life. Story Time increases client concentration, communication and well-being in a group reading activity.


Music Matters

I started singing during my adolescent years. I always listened to my mother singing with her beautiful high-pitched voice, and she let me sing along at an early age. My voice was a combination of soprano, alto and tenor. Little did I know that I would need all of those pitches to delight my clients and make a difference at the nursing facility.

I had been working with the elderly residents for several weeks and was enjoying every visit, every client, every interaction, but none so much as when I started singing with them. Carrying music in my toolbox allows me to use my gift as a gospel singer to reach out to clients, touch their memories and engage them with musical selections.

It started with me singing a few songs to clients who seemed depressed. This evolved into a “sing-along with Georgia” activity and ended with me singing with them rather than to them. Now, whenever I visit the nursing facility, the residents ask me to sing, whether it is during a group session or individually with a client who just needs to hear a melody.

Although I am a gospel singer, song selections can range from “Amazing Grace” to “Old MacDonald Had a Farm.” One resident loves to sing “R-E-S-P-E-C-T” right along with me, and afterward, she tells me what a great singer she was in her day. This opens the door to conversations within the group and leads to more meaningful interactive communication among the residents.

Thus, this activity is much more than just singing for fun. After every song, we pause to reminisce and discuss the thoughts that a particular song brings to mind. Clients who fail to respond at any other time will start moving their lips, clapping their hands or tapping their feet to the tune. One of the clients will sometimes ask to lead a song and I, along with the other residents, will sing backup, taking everybody back to another place and time.

Singing together often opens the door to discuss contemporary issues that may be of concern to the residents such as money, health or family problems. After singing “Amazing Grace,” one of the residents wanted to talk about loved ones she had lost, which in turn revealed her concern about her own health and thoughts of death. The other members of the group entered the conversation, demonstrating that there is a calming and healing power in knowing others share your concerns.

Before we know it, the time for the group is up, and the clients are asking, “When will you come again?” During time, regardless of their ills or ailments, they experience a period of rejuvenation and, often, peace.


Life Journey

Sometimes the help given to a resident is provided on an individual basis. When you are asked to talk to an individual in a nursing home, the approach has to be respectful and carefully planned because you will be entering into an older person’s home. Even though it is a nursing facility, for the resident, it is home. Almost all of the residents have a huge array of pictures. Sometimes these photos are hanging on the wall or sitting on the dresser; other times, they are gathering dust in a drawer.

The activity starts with my entering a room respectfully and thanking the client for allowing me to come into his or her home. I then talk about the weather outside, the program on TV or some other insignificant observation. While standing there, I ask about one of the pictures, such as, “Who is this pretty little girl?” or “Tell me about this handsome gentleman.” That is all it takes for the journey to begin.

During our session, clients are encouraged to share the story behind their pictures. The clients start by identifying the individuals in each picture and telling stories about them. The clients are often surprised at the things they remember. They may start laughing or crying as they share their story. They are sometimes sad and, occasionally, they get mad. Even though the process is sometimes painful, it allows me to grasp an additional piece of the client’s life and to gain insight without appearing to pry or be “nosy.”

With those clients who don’t have pictures in their room, the Life Journey technique can still be engaged in through guided conversation and without calling attention to the lack of photographs. I ask these clients to tell me about their childhood, family members or hobbies, looking for something they would like to share that might start a conversation.

It is often surprising how much conversation and enjoyment are generated as the older adult takes a stroll down memory lane and tells bits and pieces of his or her life story. During the conversation, the counselor is gently guiding the journey, listening attentively and searching for those nuggets of information that can be used to benefit the client and add to his or her quality of life. Nuggets of information shared in the life journey, such as abuse, trauma, fear of dying, loneliness and feelings of neglect, are golden because they help the counselor to process the event with the client and gain information about issues that may be troubling. Once the client shares this information — without feeling pressured or intimidated — the counselor-client relationship begins. The counselor can then embark on the journey with the client, letting the individual know that he or she is not alone.


Story Time

Another technique that is beneficial is a group reading activity that I call Story Time. Many of the residents had fulfilling lives and successful careers prior to entering the nursing home. They were members of community and church organizations and attended various retreats and events. Story Time is a good way to bring a group together and encourage conversation among residents who don’t always interact with one another or have a lot to say.

The counselor must read clearly, with emotion and with volume, to ensure that everyone can hear and understand the story. Many of the clients may at one time have been enthusiastic readers, belonged to book clubs or had magazine subscriptions that were abandoned when they had to leave their homes and enter the nursing home. Much of this information can be elicited during the conversations. Many of the residents are delighted to come to a book reading at which they may be served tea and cookies, listen to a short story or article, and then spend time talking about what that story means.

The selection of a book should be based on the members of the group and their collective interests. The book should invoke thought pictures that encourage the residents to tap into and then talk about their memories. Articles from favorite magazines are also good for bringing back memories, in part because they provide a visual aid. Asking the residents for suggestions about reading material has garnered enlightening information and led to unique reading selections.

Each reading is followed by a discussion of the chosen book or article. I have been most successful with stories that featured a distinct beginning, middle and ending. The answers to the questions or the thoughts to be explored should be projected throughout the reading so that most of the group will understand and be able to answer the questions. A major benefit of Story Time is that it connects the residents socially and emotionally. It allows them to participate in an activity that encourages good conversation and brings back pleasant memories.



Music Matters, Life Journey and Story Time are effective integrated intervention techniques that I have developed in working with geriatric patients, especially those who reside in nursing homes. I have found the techniques to be positive interactive tools that engage the clients, involve the families and open up lines of communication in the therapeutic process.




Georgia A. Ellis is a licensed professional clinical counselor and the regional enrollment director at Lindsey Wilson College in Kentucky. She is also in the doctoral program at Argosy University in Nashville, Tennessee. Contact her at ellisg@lindsey.edu.

Midcourse corrections

By Stacy Notaras Murphy September 24, 2014

Picture a female client facing a bleak employment market, stressing out about finding a new living space and struggling to find a boyfriend who wants the same things she does. She also suffers from low self-esteem and has been dabbling in some disordered eating.

Based on that description, perhaps you are envisioning a millennial in her mid-20s. In fact, this client could just as easily be 60 years old and confronting the same complicated issues that we typically Lady-Smallassign to younger people. Women in “midlife,” defined for our purposes as age 45 and beyond, may face career issues, changes in their primary coupling, challenges parenting adult children and becoming caregivers to their own parents — all at a time of life when Hollywood tells us they should either be enjoying complete success or be thoroughly ignored as popular culture trains its spotlight on ever younger role models.

Counselors serving this population can help put today’s struggles in the context of the woman’s entire life, assisting her with making sense of the past and deciding whether a new lens could be used to process her current circumstances. These counselors must be capable of navigating a variety of topics, from sexuality to career development, often while bumping into lifelong stereotypes about women’s self-worth and poor boundary-setting skills. The rewards are manifold for counselors who can work in this space, and the experience can enrich their own understanding of development across the life span.

Carolyn Greer, a longtime American Counseling Association member and an adjunct professor at Texas A&M University-Central Texas, was inspired by the major transitions women in midlife often face, including moves, divorce, the death of loved ones and new family arrangements. She and a counseling colleague developed a workshop to help women facing these circumstances explore some of the new pathways before them, while also considering the mental, physical and social changes associated with these changes. Greer highlights her own personal interest in an evolving approach to adult development.

“As I have aged and dealt with many personal situations, I have gained better insight into what Erik Erikson proposed with his stages of adult development, a theoretical approach I learned in my counselor training and have continued to teach in my counseling courses,” says Greer, who adds that her membership in other organizations studying adult development deepened her interest in questioning old thinking about aging.

“As life expectancy extends, the expected ideas about what individuals will look like, feel like and be doing by middle age continue to be questioned,” she says. “Erikson called ages 35 to 60 middle age, with an expectation that the adult would be at a point midway of having many accomplishments that lead to the personal life dream. However, what once was midlife, with all the preconceived thoughts, no longer fits the picture.”

“The life expectancy in 1900 was 47 years, but in 2000, it was 77 years. So, what is middle age?” Greer asks. “Adding to changes in this picture, what one looks like as an aging adult is [changing] as more and more effects from improved medicine, exercise and environment tend to lead to a more youthful life and outlook. There is an accepted premise that the current 50-year-old is the previous 40-year-old, and the changing age concept continues upward. Adding to these phenomena, the fastest-growing population group in our country is 85-plus, with an ever-increasing number of adults living to 100 and above.”

Changing relationships

With such a wide definition of midlife, counselors must be able to walk with these women through an array of topics that can have an impact on mental health. Jean Dixon, a licensed professional counselor with private practices in Houston and The Woodlands, Texas, leads several groups that help empower women facing life transitions. Noting that at age 42, she also is experiencing transitions unlike those earlier in her life, Dixon says she understands the immense change and growth occurring in midlife.

“It’s like adolescence all over again but with the added advantage of wisdom,” she says. “[Women at midlife] are often experiencing emotions that are deeper than they have experienced in the past. Due to increased awareness of themselves, others [and having more] experience, this new stage of life can be trying but also very exciting. It’s a lot for them to take in and process.”

For some women, midlife becomes a time to consider past unresolved issues that they did not have the time or energy to address previously. Dixon says these clients often feel that they need direction and a dedicated space to process their feelings. In her experience, empowerment is a very popular topic for this population.

“These women are often successful in life but continue to feel a sense of low self-worth,” she says. “Many … are wanting to work after being at home with children [but] are facing self-esteem and self-worth issues related to being out of the workforce, feeling inferior to younger women and sometimes even to their own [adult] female children who are not always supportive. … These younger women can be critical, as they have their own self-centered desire to keep mom as mom.” 

Dixon mentions a client who attended one of her women’s empowerment groups. “She talked about how her grown girls would comment to her, ‘Why do you need that group, Mom? You don’t struggle with empowerment.’ Their concept of her as ‘Mom’ was that she was in charge, and she was of them, but they did not see what she felt about herself.”

Carol Boyer, an ACA member in private practice in Montclair, New Jersey, mainly works with women ages 25 to 60. She advises counselors to be on the lookout for relationships as a key component of many of the struggles women face in midlife. For example, she recalls one of her clients who ended a romantic relationship.

“It was her choice to end it, but now she feels like she lopped off her arm and is having trouble moving forward,” Boyer says. “One of the things she brought up was, ‘I’m 60, and I don’t want to start with someone new.’ As we get older, if we’re not in a stable, continuing relationship, I think it can hit us harder when we break up. We are not as resilient as we were in our 20s. The stakes are higher. We aren’t as comfortable in looking for the next one. Meanwhile, we are bringing more baggage to the situation.”

Dixon has found that her clients in midlife possess great interest in discussing their sexuality, often for the first time in their lives. Some are struggling with the way their bodies are changing, while others have accepted those changes but are noticing that sex has a different meaning for them at this stage.

“They often come to therapy asking for help being more open-minded with sex or wanting to help their partners develop a healthier and mature relationship with sex,” Dixon says. She notes that often these women are with partners whose sex drive has decreased, while their own libido is stronger than it was at earlier stages of their life. Dixon works with these women to adjust to the changes and helps them develop the communication skills to address the shifts with their partners.

The women’s husbands or partners often have difficulty adjusting to the changes, at least initially, Dixon says. “I have heard my clients comment that at first, their partners did not really like hearing them speak [up] or share their opinion, and that this would create power struggles,” she says. “But in time, most of them come to appreciate it and can see that the power equality feels more intimate and increases their enjoyment of each other. The intimacy actually encourages other types of intimacy as well and can rekindle old flames.”

Continued career development

With longer life expectancy comes the desire or need to continue investing in a career. As such, career development issues often work their way into therapeutic discussions of life satisfaction and meaning-making. But the career development needs of women in midlife may be quite different from what career counselors typically see.

Jill Dustin, an ACA member and assistant professor in the Department of Counseling and Human Services at Old Dominion University in Norfolk, Virginia, specializes in career development. She has found that women in midlife often exhibit a strong desire to embark on new career-related adventures, such as tackling long-held goals or changing careers entirely. But at the same time, they also have financial concerns and struggle with work-life balance, just like younger workers often do. She notes that women in midlife also struggle with barriers to career success that may be structural or even related to their physical and mental health changes at this stage. Finally, women in midlife may be recognizing career dissatisfaction and a loss of self-identity.

Boyer has witnessed this struggle in her own office. “Some people at this midlife point say to themselves, ‘This is the best I’m ever going to feel, ever going to do. This is the most money I’m going to make.’ People get stuck when thinking that forward motion is not an option anymore,” she explains. “There’s a loss when we believe we’ve reached the end of our promotional ability. People find themselves a little depressed that life is kind of over and that things are just going to start getting worse. It can become a self-fulfilling prophecy.”

Boyer could cite herself as an example of why that line of thinking is too limiting. “For me, I went to grad school at 45, and I’m about to turn 57,” she says. “My career is still on the ascendancy. While chronologically I’ve reached midlife, professionally, I consider myself quite young in the profession. It’s all relative.”

When teaching counseling students how to help women with midlife career development issues, Dustin emphasizes that each woman is unique and comes to the process with diverse experiences and challenges. “It is very important that counselors working with women in midlife do not stereotype their clients,” she advises. “For example, counselors should not assume that since their client is in midlife, she is experiencing a ‘crisis.’ This certainly is not the case. Many women experience midlife as an exciting time of transition in which they can redesign their lives and explore careers that hold greater meaning for them.”

Career development is often viewed as a separate entity from personal counseling, but in reality, Dustin says, it is very personal and can be transformative. For that reason, she encourages counselors to include career development as part of their work with female clients in midlife.

“I would urge [counselors] to actively engage their clients in their career development,” she says. “This can be achieved by supporting, encouraging and empowering women throughout their journeys and assisting them in discovering and uncovering their strengths, barriers, types of support, goals, fears, abilities, values and desires.”

Methods in midlife

While the counseling methods applied to working with midlife women may not be too different from those used with other populations, the enthusiasm these clients show for trying new things can be inspiring. From empowerment workshops to psychoeducational book groups, psychodynamic analysis to mindfulness, women in midlife are often accepting of diverse approaches.

Greer has witnessed this herself. She explains that her workshop for midlife women in transition was not designed to be a clinical experience. But the end result is that many of the participants evaluate their own lives and set out in new directions that were mostly unknown to them at the beginning of the class.

Boyer also agrees, noting that she has used mindfulness techniques to help women connect with their bodies and become more aware of how they experience stress — something many women go through life never truly understanding. She recalls a 51-year-old client whose menopausal symptoms brought her into counseling. But the client’s mother was also in a nursing home, and on top of that, she was managing the stress of a change in her workplace review process and a complicated issue in her marriage.

“She is managing the aging aspect while she’s in a situation caring for her mother because she is an only child. Meanwhile, she’s trying to do an impossible job professionally and trying to save a marriage at the same time,” Boyer reflects. “She’s feeling misunderstood and it’s overwhelming to have to deal with these things all at the same time. Her energy level is different than it has been in the past, her moods are more labile [and] she doesn’t have the same kind of resources to bring to the other issues in her life.” Working with clients to simply name the stressors can be a major turning point for those who have spent decades ignoring their own needs, Boyer says.

Assertiveness training and building decision-making skills are other common techniques used with these clients. Dixon adds that basic decision-making can be a challenge for women in midlife who have rarely felt heard by their families or communities. She explains that they struggle with saying “no” without feeling guilty, often viewing themselves as one-dimensional beings: mothers, wives, workers or children of aging parents.

“Long-standing roles as ‘doers’ and caretakers take a toll,” Dixon says. “These women often report feeling depressed and lonely and very often just not knowing who they are or what they want. For example, often these women even struggle with deciding where they want to go to dinner. They are afraid to make the wrong decision. Having someone angry or disappointed with them is a big deal and creates such anxiety that they would rather just leave decisions to others.”

Dixon also finds that many of these women are afraid of being alone or being left by a partner. “Their sense of self and self-confidence is so low that we work on basic skills and communication, as well as self-talk and self-acceptance, for quite awhile,” she says.

She advises counselors to be sensitive to the client’s past experiences when working with current struggles, noting that understanding how the client managed transitions in her past can offer good direction today. She also suggests asking the client about current resources and supports, as well as what supports she may have possessed in the past. Then ask how her life is similar or different as she transitions through this current stage or challenge. For example, Dixon notes that women in midlife may suffer from anxiety or depression as their bodies age and they face new medical challenges. Being able to connect current frustrations to old struggles that they may have overcome — an eating disorder, for instance — can be transformative, Dixon says.

Dixon’s love of working with women in midlife comes from the joy she finds in helping them finally release their inner voices. “To help someone value and learn to listen and respond to themselves is the greatest gift I receive from my work, and these women have it in them so strongly it can’t be stopped,” she says.

However, Dixon acknowledges, fear of change is the main obstacle to making progress. “Change is hard, and the work it asks of us can often seem insurmountable,” she says. “That is why I spend so very long sometimes just working on the value of the person, improving and uplifting [the women’s] belief in themselves as they ready for the work it will take to change. But many times, luckily, the beauty of working with these women … [is that] they are ready for the work. They actually love the work because it is so very self-satisfying and serves their confidence, and they see their worth increase steadily. It is very satisfying work.”


Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org

Ages and stages

By Laurie Meyers March 24, 2014

ForrestAmericans 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.

Giving care

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.”

Health effects

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 aterrazas@counseling.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 rdobmeie@brockport.edu.




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 moll@canisius.edu

Catherine Roland at caroland@gru.edu

Tom Christensen at thomas.christensen@warner.rochester.edu

Karen Mackie at kmackie@warner.rochester.edu

Rich Feller at rich.feller@colostate.edu

Suzanne Degges-White at sdeggeswhite@niu.edu

Rebecca Cowan at cowanrg@evms.edu

SeriaShia Chatters at sjc25@psu.edu


Laurie Meyers is a staff writer for Counseling Today. Contact her at LMeyers@counseling.org

Letters to the editor: ct@counseling.org

The impact of community on postnatal depression

Heather Rudow February 13, 2013

CCU_MeAttendees of next month’s 2013 American Counseling Association Conference & Expo in Cincinnati will be treated to a new series of conference sessions aimed at shedding light on research gathered by ACA members on topics that uniquely benefit clients. 

Called the Client-Focused Research Series, these 30-minute presentations aim to increase awareness of research that focuses on improving the services that professional counselors provide to clients. 

In the weeks leading up to the conference, Counseling Today is speaking with some of the presenters about their research and why they believe it enhances the work of the profession. Next up is counseling student and public health advocate David Jones, who will be presenting on “Advocacy Outside the Box: A Multilevel Spatial Analysis of First-Time Mothers With Postpartum Depression.”

What would you like attendees to take away from your session? 

A greater knowledge of individual and community risk factors associated with postnatal depression (PND). Additionally, they will have an expanded conceptualization and tools for working with their clients and community.

Why is it important for counselors to learn the difference between community and individual risk factors associated with postpartum depression?

From an ecological perspective or other social models, there is a conjugal dance between individual and community risk factors. To effect lasting change, the counselor needs to see within but also beyond the individual risk factors toward the context: community. This context is a powerful influence on the individual’s affect, mood, cognition and behavior. Further, the individual’s choices have collateral. This collateral affects the family, which impacts neighborhood, which influences the community and vice versa.

How did you get involved with this subject?

My career is in public health, but I am also a counseling student. Through my work at Cincinnati Children’s Hospital and Medical Center and my studies emerged a passion around improving the outcomes of children.

Further, counseling and public health have a natural marriage: prevention. Therefore, through the lens of life course theory, the best approach is to intervene before the birth of the child to change the trajectory of lifelong outcomes for the child. Hence, a counselor seeks interventions before womb, secondarily when the child is in the womb and, tertiary, postpartum.

What inspired you to present this session at the conference?

It is a desire to bring about awareness and advancing the field of counseling. I believe that research is imperative for improving the health of our clients and their communities. Furthermore, there is a call for the counseling profession to get more serious about research. By doing so, it will advance our identity as counselors. 

Did anything surprise you as you were compiling information for your session?

The sample was drawn from a home visiting program for first-time mothers. The program contracts with seven agencies within Hamilton County, Ohio, to conduct their services. Each agency provides services in a specific catchment based on ZIP code. What was of particular interest was the severity of these rates and that the majority had rates higher than the national averages [of] 10 to 15 percent. Yet, conversely, the Hamilton County rate was high as well.

When looking at the individual risk factors, several became salient. For example, race and ethnicity were significantly different between those at risk for PND  (EPDS score < 10) than those not at risk. Another risk factor associated with the risk of PND was years of education.

Besides these finding above, what was remarkable was the many risk factors that were not found to be significant. This study linked the home visitation client record data with hospital discharge data, Ohio birth certificate data and 2010 Census tract data. After the linkage, there were over 300 variables associated with each case. Through analysis, no significant association was found for preterm birth and infant loss among others.

When examining the area level (Census tract) variables, it was a surprise that median home value was not significant. Yet, other area level variables did have an association such as percent of vacant housing units, percent on SNAP and GINI Index score.

This is the initial step in our investigation. Our study group plans on digging deeper into the data and looks forward to seeing what we will find.

Who do you feel is the best audience for this session?

This is important for a variety of audiences. One is the counselor who works with this specific population. Others that become prominent are counselors who take prevention and community outreach to heart, such as those who are passionate about social justice. It is relevant for counselors-in-training to expand their conceptualization of their profession. Finally, based on ACA’s call, it is imperative for all counselors [to take part] in a concerted effort to advance the counseling profession’s presence in research.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.