Tag Archives: Medicare

ACA hosts webinar on navigating Medicare reimbursement

By Lisa R. Rhodes   May 16, 2023

Colorful bubbles shaped paper with the a megaphone icon and the word "Medicare"

Jerome.Romme/Shutterstock.com

On April 19, the American Counseling Association hosted a webinar discussing the Mental Health Access Improvement Act. This law, which was passed by Congress in December 2022 and goes into effect in January 1, 2024, allows licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) to be reimbursed by Medicare for providing mental health treatment and services to adults age 65 and older as well as some people under the age of 65 who are disabled or have permanent kidney failure.  

Matthew Fullen, an associate professor of counselor education at Virginia Tech whose research focuses on the mental health of older adults, began the discussion by recalling the decadelong effort to pass the law. He noted the partnership between the ACA, the Medicare Mental Health Workforce Coalition, Arnold & Porter, and other professional and grassroots organizations in lobbying Congress to update Medicare’s mental health provider regulations and close the gap in federal law that historically excluded LPCs and LMFTs. The last time Medicare’s mental health provider regulations were updated was 1989.   

The new law enables LPCs and LMFTs to expand their reach to new clients and in new health care settings, such as federally qualified health centers, rural health clinics, Medicare hospice interdisciplinary teams and Medicare integrated behavioral health and primary care programs.  

“Counselors are now officially at the table in how Medicare thinks about mental health care,” said Fullen, past co-chair of the ACA Public Policy and Legislation Committee.  

Under the new law, LPCs and LMFTs will be known as “non-physician practitioners,” which refers to any Medicare provider other than a physician (e.g., social worker, psychiatric nurse). To enroll in Medicare as a mental health care provider, counselors must have earned a master’s or doctorate degree that qualifies them to work as a licensed mental health counselor, professional counselor or clinical professional counselor in their state. They must have also completed two years of postgraduate supervised clinical experience in mental health counseling and have licensure in the state where they intend to provide services.   

Monique Nolan, an attorney at Arnold & Porter with 20 years of health regulatory experience, told the audience that early this summer, the Centers for Medicare and Medicaid Services (CMS) will issue a proposed rule to address how the agency plans to enroll LPCs and LMFTs into the Medicare program, and how payment rates, which are adjusted every year, will be established. ACA will provide written public comments after the proposed rule is released.  

“We expect that the agency will, as the months go on, begin to provide more information around implementation and the steps that you will need to go through to join the [Medicare] program as well as to generally orient you to Medicare,” Nolan added.  

Kristine Blackwood, who serves as counsel at Arnold & Porter’s legislative and public policy practice, provided the audience with an overview of the Medicare program, which was signed into law in 1965. The program provides federal health care insurance for people aged 65 and older, eligible younger people with disabilities and individuals with end-stage renal disease.  

“Traditional” Medicare is a fee-for-service health insurance program offered through the federal government. Traditional Medicare is divided into two parts: Part A provides hospital coverage and includes inpatient care in hospitals, skilled nursing facilities, hospice care and some home health care. Part B provides medical coverage and includes certain physician services, outpatient care, durable medical equipment and preventive services. Blackwood said LPCs and LMFTs will provide mental health treatment and services as nonphysician practitioners under the provisions for Part B.  

Medicare Advantage, also known as Part C, allows people to get Medicare coverage from a private health plan that contracts with the federal government. This plan covers all the same services under Part A and Part B and provides care through physicians who are in-network, Blackwood said. Unlike the fee-for-service program, Part C may also provide coverage for vision, hearing and dental services. After the new law goes into effect on Jan. 1, 2024, LPCs and LMFTs can also be reimbursed for mental health treatment and services provided through Medicare Advantage, Blackwood noted.  

“This is going to be a whole new market [to] access new clients,” she said.  The new law will “open up a lot of opportunities for LPCs.”  

LPCs may also benefit from the provisions in the Counseling Compact, which allow for reciprocal licensure in states that are a part of the compact, Blackwood said. ACA is keeping a close eye on the proposed rule to ensure that the CMS understands and will work to accommodate the compact.  

We will not know what is in the proposed rule until it is released, but Nolan said that questions regarding diagnostic (psychological) testing, telehealth services and the use of current procedural technology codes may also be addressed.  

Fullen acknowledged that the passage of this law was thanks to the persistence of ACA’s alliance with other professional partners and the advocacy of counseling professionals who sent emails, wrote letters and attended meetings with lawmakers to let their voice be heard.  

“We see through this legislative victory [a] real contribution to equity and social justice in a way that provides more access to care for people who really need it,” Fullen said.  

////  

Learn more 

 


Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Mental Health Access Improvement Act poised to pass in Congress

By Lisa R. Rhodes December 20, 2022

the Capitol building

Image by JamesDeMers from Pixabay

The American Counseling Association’s lobbying efforts for Congress to pass the Mental Health Access Improvement Act (H.R. 432) may garner success before the new year.

As of this morning, the House version of H.R. 432 has been included in Section 4121 of the Omnibus released by the Senate, says Brian D. Banks, ACA’s chief government affairs and public policy officer. “This means the House and Senate have worked together to include our bill in the final vote to become law,” he explains. “Both the House and Senate have to vote yes for the bill to pass and make its way to the President’s desk for signature. We can expect a vote by the 23rd of this [week].”

If passed, H.R. 432 and S. 828, its companion bill, will allow licensed professional counselors and licensed marriage and family therapists to get reimbursed for providing mental health services to adults age 65 and older who access their health care through Medicare. This includes clients who are disabled and veterans.

This latest development is proof of ACA’s ongoing progress to make the bill a law. Earlier in the month, ACA was successful in its work with the Centers for Medicare and Medicaid Services (CMS) to help lower the cost of the bill to $902 million over a 10-year period.

“This is a big deal. Many Republicans were hesitant to support [the bill] because of the $1 billion plus price tag,” Banks says. “This gives us more momentum, right when we need it.”

Banks also notes that mental health is a “hot topic on the Hill.” ACA was competing for a vote on Congress’ legislative calendar, which is scheduled to end on December 21. Now it appears the House and Senate will vote on the bill before the start of the new 118th Congress in January.

The decadelong push of ACA and its stakeholders to bring a Medicare reimbursement bill this far on the Hill is bearing fruit, says Banks, who has focused on the effort for three years.

“This bill passing is a hand up to people in need, and that is bigger and better than any impact on the Hill,” he continues. “I will share this. Congress will look to ACA more when this bill passes because we will become equals with our needed colleagues in the social work and psychology professions.”

According to the national study ““Counselors’ Interest in Working With Medicare Beneficiaries: A Survey of Licensed Professional Mental Health Counselors,” conducted by ACA in April, an estimated 115,000 current licensed professional counselors would enroll in the Medicare program with the passage of this legislation, including counselors in the CMS Medicare Program. The ability for licensed professional counselors to treat Medicare clients also provides them with a way to earn additional income.

Danielle Monroe, a licensed mental health counselor at Southwestern Behavioral Healthcare in Indiana, has been helping with lobbying efforts in her state. “There is a lot of excitement and anticipation amongst counselors to finally have access to this population and to provide services to meet their needs,” she says.

The passage of the bill is necessary because licensed professional counselors and licensed marriage and family therapists can only provide mental health services to clients up to age 65, when they become eligible to enroll in Medicare. Older Americans on Medicare who are working with these counseling professionals must then find a new provider who accepts Medicare so they can continue their treatment.

According to Banks, passage of the Mental Health Access Improvement Act will help older adults who must often wait as long as three to four months for an appointment with other mental health providers who accept Medicare, such as social workers or psychologists.

As of now, Monroe explains, older adults must decide whether to pay out of pocket for care, which is an added burden since many live on a fixed income, or to discontinue treatment because they don’t want to start over with a new provider who takes Medicare.

“Passage of this legislation means that older Americans will be able to keep working with providers that they connect with and trust regardless of their age,” notes Monroe, an ACA member. “This seamlessness of treatment makes completion of treatment more likely.” Making it possible for older adults to continue mental health services with licensed professional counselors is an important preventative measure against future negative outcomes.

If older clients don’t receive consistent clinical help, they may begin to rely on medication to treat their mental health symptoms, Banks adds. “Some of the medications contain opioids, which can be addictive and lead to substance use issues, or worse,” he says. This includes suicide attempts, thoughts of suicide and self-harm. Many psychologists and social workers are not accepting Medicare, which, as Banks notes, gives licensed professional counselors the opportunity to treat these clients.

Monroe says that there is an important lesson to be learned in the dedicated effort to pass the Mental Health Access Improvement Act. “We have to continue to be organized and to have our voices heard,” she stresses.

 


Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counselor participates in White House conference call, task force

Compiled by Bethany Bray June 26, 2020

American Counseling Association member Laura Shannonhouse added a professional counselor’s voice to two recent events organized by the White House.

Shannonhouse, an assistant professor in the Counseling and Psychological Services department at Georgia State University, is part of a cohort of researchers working on a grant-funded project on suicide and aging adults. A recent conference call brought this issue to the attention of some of the highest leaders in the country. In April, Shannonhouse participated in a call on COVID-19 pandemic’s effect on mental health that included U.S. President Donald Trump, Vice President Mike Pence and other senior administration officials as well as leaders from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Earlier, Shannonhouse also traveled to Washington D.C. to participate in the White House Summit on Transforming Mental Health Treatment to Combat Homelessness, Violence, and Substance Abuse, held in December 2019.

In addition to Shannonhouse, the grant team includes ACA members Mary Chase Mize, Matthew Fullen and Casey Barrio-Minton. Funded by the U.S. Department of Health and Human Services’ Administration for Community Living (ACL), the project focuses on training home-delivered meals workers in suicide intervention and mental health basics.

According to the Centers for Disease Control and Prevention (CDC), suicide is the 10th-leading cause of death in the United States. For many age groups, however, it ranks much higher, including as the eighth-leading cause of death among those ages 55-64.

ACA Member Laura Shannonhouse participated in the White House Summit on Transforming Mental Health Treatment to Combat Homelessness, Violence, and Substance Abuse in December 2019. Photo via Georgia State University.

Q+A: CT Online sent Shannonhouse, Mize, Fullen and Barrio-Minton some questions via email, to learn more about the White House events, their grant work and related issues.

What do you hope comes out of the White House task force meeting and conference call?

These meetings were convened with the purpose of creating awareness about key mental health issues, sharing information about innovative practices and connecting with national leaders who are charged with addressing many of these issues from a federal perspective. In light of these meetings, we hope that federal programs and policies will prioritize the mental health of Americans of all ages. By attending on behalf of our federal grant, we hope to raise awareness about suicide risk among older adults, as well as the Medicare mental health coverage gap that interferes with many of these people from accessing care.

From your perspective, what do our government leaders need to know. What are the needs right now?

There are many pressing issues that affect the mental health of Americans. One such issue is the lack of access to licensed professional counselors (LPCs) for Medicare recipients. Regulations governing which mental health providers are reimbursed through Medicare were last updated in 1989. Since that time, the mental health marketplace has changed dramatically. Current Medicare policy is not aligned with the realities of mental health practice in 2020.

For example, when we reviewed the Psychology Today provider database, a popular tool for locating mental health providers, only 12.49% of providers in this database accepted Medicare. This means that 60 million Medicare recipients are left without access to a significant number of eligible providers, including LPCs.

How has your grant work on suicide prevention for older adults changed with the COVID-19 pandemic?

We have several partnerships with local agencies dedicated to meeting the needs of older adults. Due to the pandemic, many of these agencies are having to reconfigure entire programs to ensure that physical distancing measures are enacted. This means that many programs that previously met in person have to shift rapidly.

Even the best efforts to do this have, unfortunately, resulted in greater social isolation and loneliness among older adults. Our team is hoping to collect data on how the pandemic is impacting vulnerable older adults who rely on home-delivered meals programs. We want to illuminate how to best address socialization needs while nutrition needs are also met.

Looking ahead, what do you see as long-term needs in this realm, as the pandemic continues?

As the pandemic continues we anticipate that social isolation and loneliness will become increasingly greater issues, especially for older adults. In a recent study by the John A. Hartford Foundation and the SCAN Foundation, 83% of adults ages 70 and older stated that they were prepared to self-isolate for several months. Notably, after only one month of self-isolation, 33% reported increased feelings of loneliness since the pandemic became widespread. Therefore, efforts to connect with this population and ensure that their mental health needs are addressed is vitally important.

Tell us more about the connection between your work and the need for Medicare reimbursement for LPCs.

Our work focuses on identifying and assisting older adults who may be experiencing psychological distress or suicide risk. A major question, then, is what happens after they are identified and referred for counseling and other mental health services? The vast majority of these older adults use Medicare to access the health care system, including mental health, and as the counseling profession knows all too well, counselors are not currently eligible to be reimbursed through the Medicare program, something we have been calling the Medicare mental health coverage gap (MMHCG).

Although this is an issue that the majority of practicing counselors have experienced firsthand, most aging and health care advocates are not aware that it is a problem. They are generally aware of the behavioral health needs of older adults, but not aware that the exclusion of LPCs makes it more difficult to address these needs.

What are some challenges and bright spots that you would want counselors to know about the Medicare issue?

There has been a great deal of progress made in regard to Medicare advocacy for counselors. When lawmakers, federal agency leaders and the public hear about the outdated Medicare mental health provider policy, they are largely sympathetic and want to determine how they can help.

For example, there are two congressional bills that focus on adding LPCs to Medicare. These are both bipartisan bills with a high degree of support. House Bill 945 has 116 co-sponsors and Senate Bill 286 has 31 co-sponsors, and both of these numbers represent forward movement (Find out more from the American Counseling Association Government Affairs team at counseling.org/government-affairs).

In January of this year, the Center for Medicare and Medicaid Services (CMS; part of the U.S. Department of Health and Human Services) determined that LPCs are viewed as Medicare-eligible when they provide services within opioid treatment programs. This represented a major victory.

Then, in early May of this year, CMS made a similar determination within rural health centers/federally qualified health centers, as long as counselors are working in a manner that is consistent with their scope of practice. ACA and other members of the Medicare Mental Health Workforce Coalition are now advocating that LPCs be included in any future COVID-19 stimulus bills that Congress considers. These are all exciting developments that reflect years of hard advocacy work.

What do you suggest counselors who are passionate about these issues do to get involved and/or advocate?

COVID-19 has outsized effects on older adults, which means that our collective response to what our “new normal” looks like must be done with their needs in mind. What makes this pandemic particularly insidious is the way that physical distancing elevates health risks associated with social isolation and loneliness.

Local agencies that focus on aging are keenly aware of this, but may not have the infrastructure in place to fully address older adults’ mental health needs. Counselors should consider the many ways that their gifts can be invested in community efforts to keep older adults connected. At the local level, this might look like working alongside other colleagues to pool some pro bono hours that could be donated to your local area agency on aging so tele-counseling can be shared with at-risk older adults.

At the national level, it means responding to Medicare advocacy alerts so that policies can be modernized to address older adults’ mental health needs.

Whether you are a full-time counselor, student or counselor educator, making a difference also means combating ageism whenever it creeps up, whether it occurs in conversations with friends or family, on social media, or within healthcare or counseling professions. By asserting that older adults are every bit as deserving of mental health services as people of other ages, members of the counseling profession combat ageism, strengthen the case for Medicare reimbursement and improve the lives of socially isolated older adults. 

 

***** 

Learn more:

  • Matthew Fullen participated in ACA’s recent Government Affairs and Public Policy Town Hall, and spoke about the Medicare issue: youtube.com/watch?v=liXnCVlGomM

*****

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

***** 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Changing the conversation about aging

By Lindsey Phillips January 10, 2018

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 lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

****

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

ACA advocates for Medicare bill on Capitol Hill

By Bethany Bray July 20, 2017

ACA leaders gather for a day of advocacy on Capitol Hill on July 18. (Photo by Paul Sakuma)

A bill that would allow professional counselors to be reimbursed for the treatment of clients under Medicare has been introduced in the House of Representatives, and more than 100 counseling professionals added to its momentum by advocating in person on Capitol Hill earlier this week in an event organized by the American Counseling Association (ACA).

Currently, Medicare does not reimburse licensed professional counselors (LPCs) for the treatment they provide for older adults who carry this federal insurance coverage. However, ACA is advocating for a bill that would add LPCs to the list of providers who can be reimbursed under Medicare – a list that already includes clinical social workers and marriage and family therapists. H.R. 3032 was introduced last month by Rep. John Katko (R-N.Y.) in the House of Representatives, and a companion Senate bill is expected to be introduced shortly by Sen. John Barrasso (R-Wyo.) and co-sponsored by Sen. Debbie Stabenow (D-Mich.).

H.R. 3032 currently has three co-sponsors: Reps. Mike Thompson (D-Calif.), Elise Stefanik (R-N.Y.) and Zoe Lofgren (D-Calif.). If passed, the measure would add an estimated 165,000 mental health providers to the Medicare network, providing much-needed access to care for older adults in the United States.

On July 18, 125 ACA members from across the United States visited the Capitol Hill offices of their senators and House representatives to ask for support for the Medicare bill. The counselors were gathered in Washington, D.C., for ACA’s annual Institute for Leadership Training (ILT), a four-day conference of education sessions, trainings and business meetings for leaders in the counseling profession.

“In the United States, exercising our First Amendment rights under the Constitution is vitally important to ensure that we have a strong and responsive government,” said ACA Director of Government Affairs Art Terrazas. “I am so happy that we were able to help ACA leaders from across the country meet and speak with their federal lawmakers about the needs of the counseling profession.”

Amanda DeDiego, an ACA member from Casper, Wyoming, talks with Sen. John Barrasso (R-Wyo.) in his Capitol Hill office. (Photo by Bethany Bray)

Amanda DeDiego, an ACA member from Casper, Wyoming, met with Sen. Barrasso to thank him for his upcoming sponsorship of the Medicare bill. Barrasso expressed his support for the issue, saying “the needs are great” in Wyoming. For example, the average life expectancy on Native American reservations is 47 years – decades below that of Wyoming’s general population – and issues related to mental health are part of the cause, Barrasso said.

A delegation from the American Counseling Association of New York (ACA-NY) met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for co-sponsorship of the bill that Barrasso soon will introduce in the Senate.

ACA-NY leaders Summer Reiner, Allison Parry-Gurak and Tiphanie Gonzalez (ACA-NY president) explained that LPCs have training and graduate coursework that is equal to or exceeding that of the social workers and other mental health practitioners currently covered under Medicare. In the rural parts of New York, a dearth of mental health providers already exists, and that number shrinks further for people who rely on Medicare coverage for treatment, Reiner explained.

“There’s a huge need,” said Reiner, an associate professor at the State University of New York (SUNY) in Brockport and ACA-NY past president. “There are more than enough clients to go around, and we all have a different perspective for a reason.”

“We’re very much cousins in the exact same family, with different specialties,” agreed Gonzalez, an assistant professor at SUNY Oswego.

ACA members who visited legislative offices on July 18 also advocated for full funding of the Title Four block grant as part of the Every Student Succeeds Act (ESSA). The grants, some of which goes to support school counseling programs, were funded at $400 million, or just 25 percent of the $1.6 billion that was authorized this year. President Trump’s proposed budget for 2018 recommends no funding for the block grant at all.

Terrazas, in a training session held prior to the Day on the Hill event, urged the assembled ACA leaders to follow up with their legislators, stay informed and continue pushing for issues that are vital to the counseling profession.

“Advocacy doesn’t start and end with just this day [on Capitol Hill] tomorrow; it is year-round,” said Terrazas.

 

ACA members from Louisiana speak with staff in the office of Congressman Steve Scalise (R-La.) on July 18. (Photo by Bethany Bray)

 

****

 

By the numbers: ACA Day on the Hill 2017

125 ACA members from 37 states, plus the District of Columbia, U.S. Virgin Islands and Puerto Rico, visited 74 Senate offices and 95 House offices

ACA President Gerard Lawson also met with

  • James Paluskiewicz, staff, House Committee on Energy and Commerce
  • Nick Uehlecke, staff, House Committee on Ways and Means
  • Allison Steil, deputy chief of staff, U.S. House Speaker Paul Ryan (R-Wis.)
  • Wendell Primus, office of House Minority Leader Nancy Pelosi (D-Calif.)

 

Cynthia Goehring and Sarah Shortbull, ACA members from South Dakota, met with Sen. John Thune (R-S.D.) on July 18. (Photo by Paul Sakuma)

 

****

 

ACA awards Murray, Lieu

ACA has recognized Rep. Ted Lieu (D-Calif.) and Sen. Patty Murray (D-Wash.) with an Illumination Award for their work against harmful conversion therapy. Lieu and Murray have introduced bills in the House and Senate, respectively, that would classify commercial conversion therapy and advertising that claims to change sexual orientation and gender identity as fraud.

An ACA delegation met Murray on July 18 to recognize her on Capitol Hill; Lieu was previously honored at last month’s Illuminate symposium, a three-day conference in Washington, D.C., focused on the intersection of counseling and lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) issues.

Sen. Patty Murray (center left, in grey suit) is given an ACA Illumination Award on July 18 by ACA Past President Catherine Roland, current ACA President Gerard Lawson and ACA President-elect Simone Lambert, along with ACA members from Washington state. (Photo by Paul Sakuma)

 

****

 

To stay up-to-date on the Medicare bill and other current issues, sign up for updates from ACA Government Affairs at counseling.org/news/aca-blogs/aca-government-affairs-blog

 

Search for the hashtag #ACAILT2017 for social media posts from ILT and the Day on the Hill

 

See more photos on the ACA flickr page: flickr.com/photos/23682700@N04/albums/72157686345016025

 

A delegation from the American Counseling Association of New York (left to right) Tiphanie Gonzalez (ACA-NY president), Summer Reiner and Allison Parry-Gurak met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for cosponsorship of the Medicare bill that Sen. Barrasso will soon introduce in the Senate. (Photo by Bethany Bray)

 

****

 

 

Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday