Tag Archives: Adult Development & Aging

Adult Development & Aging

Preparing for retirement goes beyond a good 401(k)

By Laurie Meyers November 29, 2017

Thou shalt contribute to thy 401(k) — or 403(b) or individual retirement account, etc. It is the first commandment of retirement planning. Contribute early and often, perch on that nest egg and make sure that it’s big enough for you to live on after you retire.

That’s sound advice. After all, you will need lots of money to support yourself once you’re unwilling or unable to work any longer.

But then what? After your financial future is secure, are there really any questions left to answer or obstacles to overcome? Well, yes. As it turns out, there’s a lot more to sound retirement planning than saving money. Consider: What are you going to do with the rest of your life? Where will you get your social interaction now that you’re not gathered around the coffee pot with your co-workers? What will you do with your time? What happens when you and your partner are together all day, every day? Who are you without your job?

Professional counselors may not be experts in financial planning, but they can certainly help clients explore what they want their lives to look like after retirement and take steps to make that vision a reality.

Exit ahead?

As a society, our definition of retiring is changing. Largely gone are the days of people walking out the door at age 65, gold watch and pension in hand. The majority of Americans today either need or want to work beyond what once was considered “full retirement age.” Working past retirement age could mean spending a few extra years at an existing job, cutting back to part time or even trying out a new career entirely. There’s no “right” or predetermined path. Clients need to consider what would work best for them.

“Start by thinking about if you like what you’re doing. Do you want to do it until you retire?” asks Christine Moll, a past president of the Association for Adult Development and Aging (AADA), a division of the American Counseling Association.

Deciding whether to stay in a job isn’t just a matter of willingness, adds Moll, a licensed professional counselor (LPC) who practices in the Buffalo, New York, area. People also need to consider whether they will be physically able to stay at their current job as they are approaching retirement age.

Wendy Killam, an ACA member and co-editor of the book Career Counseling Interventions: Practice With Diverse Clients, agrees. “Our physical decline really starts in our 40s, so it’s incumbent upon people to start thinking about what they are going to be able to handle physically,” she stresses. “Can I do this job forever, or do I need to think about doing something less strenuous?”

Killam, also a former president of AADA, adds that if clients are considering changing jobs in anticipation of retirement, the earlier they do it the better. She recommends that clients make this kind of move, if possible, in their 50s rather than in their 60s.

“As people get older, they face more ageism,” explains Killam, a professor in the Department of Human Services at Stephen F. Austin State University in Texas. “Someone may say, ‘Hmm, this person is 60. How long could they really be useful?’” She notes that although U.S. workers are protected against age discrimination, cases can be tough to prove.

Even entertaining the idea of changing jobs can be scary, and figuring out what that next job will be can be terrifying. That’s where career counseling comes in for people who are looking toward retirement but still need or want to work for several more years, says Killam. “Counselors can offer career guidance, testing and career exploration. They can give a wide number of [assessment and aptitude] tests that can help clients consider opportunities that they might not otherwise have thought of.”

Counselors can also help these clients research what jobs are available and in which markets. Clients may find that some positions aren’t very prevalent in their local job market. “I may decide I want to be a marine biologist, but I don’t want to move from Texas,” Killam says. In those cases, clients casting an eye toward retirement need to decide whether they are willing to relocate.

As a kind of trial run for retirement, Killam sometimes encourages her clients to take a minivacation at home for a minimum of one to two weeks. “Stay at home, stay totally disconnected, and see what that’s like,” she urges. “It gives you an idea: ‘Is this something I can really do?’”

Some clients may find that rather than abruptly retiring, they would prefer to transition to part-time employment. In fact, Killam adds, as society seemingly embraces an expectation of remaining in the workforce longer, that kind of arrangement may become more common.

Taking time to process

There is no magic age or plan for retirement, and regardless of when it happens, it marks a significant time of transition and loss, Killam emphasizes.

However, proper preparation can make going through the loss less painful, says Nancy Rhine, a licensed marriage and family therapist with a private practice in the San Francisco Bay area.

When people decide to retire, “there’s a lot of anticipatory anxiety,” she says. “We tend to focus on … the process of retirement: When do I tell my boss? Am I going to have enough money? How will I pay my bills?”

In the flurry of planning and questioning, the emotional element of retiring can get lost, says Rhine, who specializes in gerontological counseling. She advises clients to take a few months, at minimum, to go through the steps of exiting their jobs so that they have time to process all of the attendant emotions. For clients feeling anxious or uncertain, Rhine recommends that they ask about the experiences of friends or colleagues who have been through the retirement process already, talking their fears and questions over with others and keeping a journal. She finds that when clients write down their thoughts, it prevents them from “spinning their wheels” by obsessing, ruminating and overthinking.

When the final month of work arrives, the mood often becomes celebratory, Rhine says. Clients typically are looking forward to giving up the daily grind. Flash-forward to the final week, and there are often farewell lunches with co-workers and maybe even a party. And then the party is over. What then?

“Now you’re thinking, ‘I don’t have to get up early, I don’t have any set schedule.  … This is great! I’m going to call my friend and go to lunch with her, watch the news …’ That tends to last about a month,” Rhine says.

Moll agrees, explaining that although the newly retired do typically feel a sense of freedom, there is usually a point at which people sit up and ask themselves, “Is this all there is?”

“Then,” says Rhine, “you tend to start thinking, ‘A lot of my friends were at the office. That’s who I was talking to every day.’” Clients may then decide to reach out to retired friends for inspiration, only to find that some are busier than ever, serving on every committee and constantly on the move, while others are sitting on the couch, bored out of their minds. Neither option necessarily speaks to the way these newly retired clients want to live their own retirement years.

Clients frequently fall into the trap of comparing themselves with others who have retired and thinking, “I’m not doing this right. What’s wrong with me?’” Rhine says. “There’s a tendency [for clients] to want to rush through and figure out the answer really quickly. You don’t know who you are in retirement yet. Give yourself time. There is no one way to do it; no one-size-fits-all.”

Moll adds that part of the transition is letting the pendulum swing from doing nothing to beginning to find structure.

“I advise people to take their time,” Rhine says. “Don’t sign up for a lot of responsibilities, such as volunteering or joining committees, right away.” Overscheduling and trying to figure everything out all at once can lead to clients feeling overwhelmed and depressed, she says. Instead, she encourages recently retired clients to let the dust settle before sticking a toe in the “after” pool. “Then go try things,” Rhine says. “Go to a book club one time and check it out, volunteer for one shift someplace, join the gym.”

To further help these clients stave off anxiety and depression after retiring, Rhine also urges them to be committed about getting exercise any way they can, getting outside every day and eating well.

Rhine says it can take as long as three to six months for retirees to get their “sea legs.” She adds that people who have been working in high-stress jobs in particular are going to feel exhausted and will need to take time to rest and decompress.

In search of

Because many people do a substantial portion of their socializing through work, retirement may require a search for a new social circle, and that isn’t always easy, Moll says. Although clients have to do the work and open themselves up to these new relationships, counselors can help them identify potential social networks.

For instance, if clients have a place of worship, Moll urges them to think about how they might make connections there. If clients aren’t spiritual or religious, she asks about hobbies that might give them opportunities to meet others with similar interests.

Moll has even suggested that retired clients invite their neighbors from down the street for a backyard cookout. “Know your neighbors,” she advises. “You don’t have to adopt them. You don’t have to give them holiday gifts. Just talk.”

Moll notes that clients who are retired need to be open to meeting new people. She shares that her father was “adopted” by a bunch of younger golfing buddies whom he met while hanging out at the local bar.

Many people, but men in particular, equate their work with who they are. “Your identity may be your career or your job, but you are more than that,” Moll tells these clients. “You need to look at what the other components are that define you.”

For instance, she might ask, “Do you have areas of interest that you want to spend more time on or make money off of? Do you have extended family that you moved away from that you now want to move closer to?”

Moll says she knows many retirees who have full and busy lives that revolve around babysitting grandchildren, volunteering, working part time or traveling. “I think you need to find rhythm and passion,” she says. “You need to find a passion that you’ve dreamed of doing, being [and] having, and a rhythm that’s appropriate for you today, and just go with it.”

Rhine and Moll say that retirees’ hobbies and interests may even turn into business opportunities, part-time jobs or simply a way to earn a little money on the side. Moll had one client who had spent most of his career in retail. After retiring, he needed to supplement his income, but he didn’t want to remain in the retail field. Looking for other ideas, he and Moll talked about his interests.

“He and his wife enjoyed traveling but did not have the funds to [as he put it] ‘follow life beyond the AAA TripTik,’” Moll says. Moll and the client talked about how he might turn his interest in traveling into a job opportunity, and in a few weeks, the client arrived at his counseling appointment with big news. He had found a part-time job delivering small buses and ambulances around the United States and into Canada. The company would pay for him to fly home once the delivery was completed. The client not only turned his hobby into a money-making opportunity but was also able to share his journeys with his wife, who often went along for the ride.

“Together, they traveled throughout the Southwest, along the California coast and to Calgary, Canada,” Moll says. The client’s wife died before he did, and Moll says the memories from those trips were a source of comfort and joyous remembrance for the remainder of his life.

Crowded house

In 1991, a Japanese physician, Nobuo Kurokawa, coined the phrase “retired husband syndrome” in a presentation to the Japanese Society of Psychosomatic Medicine. For years, Kurokawa and other Japanese physicians had been seeing scores of older women with serious health problems such as ulcers, rashes, polyps, slurred speech and other ailments that were seemingly without cause. However, the women’s mysterious physical complaints appeared to have a common starting point: the retirement of their husbands. Accustomed to having the house to themselves, these Japanese wives were now confronted with spending the bulk of their time with their formerly high-powered and frequently demanding husbands — and Kurokawa theorized that it was making them sick.

Spousal tensions triggered by retirement aren’t exclusive to Japan, and they aren’t caused solely by husbands. Retirement of either or both partners can cause significant relationship strain. Even so, Rhine notes that the home is often still traditionally the woman’s bailiwick, and many of the problems she sees with clients do start when the husband retires.

“Here’s the wife — her husband is home all the time, and she’s thinking, ‘Get out!’” Rhine says. Meanwhile, the husband is trying to adjust to retirement and is unsure about what his wife needs.

“She may need to get out of the house more to be with her friends and commiserate,” Rhine says. But the same may hold true for the husband, she adds. After all, he is also dealing with the loss of his regular schedule and personal space. One possible solution is for the wife and husband to set up a schedule in which one of them goes out while the other stays home a couple of mornings each week.

Rhine also stresses communication skills — particularly the “I” statement — with her retired clients. “‘I feel this.’ ‘I need this.’ It requires you to think, ‘What is it that I feel? What is it that I need?’” she explains. These basic skills make it easier for each partner to say things such as “I feel like I need more space,” “I feel pressured” or “I feel criticized,” Rhine says.

In fact, couples need to sit down and have a conversation about retirement well before either person stops working, Moll says. Otherwise, they risk running into scenarios such as a husband working hard to map out all of his post-retirement activities, while the wife harbors plans of her own to return to school, Moll says.

“He’s retiring thinking they’re going to travel, and she’s picking up where she left off,” Moll says. “There has to be some conversation about each other’s dreams and goals and how to get those met, while also finding time to be with and enjoy each other’s company.”

Both Rhine and Moll say it is never too early to start planning for retirement.

Rhine tells clients to dream about what they want to do and to think about where they see themselves in five, 10, 15 or more years. “Allow yourself to have dreams. Hope is a big part of emotional health,” she says. “There’s going to be a lot of good chapters opening up. Will there be hard times? Yes, life has hard things, but odds are there are going to be a lot of good times [too]. Stay open to possibilities.”

Says Moll in conclusion: “We retire from work; we don’t retire from life.”




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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.

Understanding elder financial abuse

By Joanne Cohen April 27, 2017


“All forms of elder abuse are acts of violence” — Margaret Hudson (1991)




With the aging of the baby boomers and advances in medicine and technology, more people are living into old age, and more elders are experiencing abuse. According to the National Center for Elder Abuse, at least 1 in 10 elders report some form of abuse. And according to the National Elder Maltreatment Study of more than 6,000 elders and proxies, the most prevalent form of elder abuse is financial in nature, eclipsing both elder emotional abuse and elder neglect.

Financial offending is behavior that targets and takes advantage of elders for personal financial gain. Financial offenders (aka fraudsters, scammers and con artists) lack empathy for their victims. They groom victims by promising rewards for financial giving. They may promise products, services, time, money or even social-emotional needs fulfillment, including safety, security, belongingness, love and self-esteem.


Profiling fraud

Fraud by strangers mostly takes the form of marketing and mail fraud. From the fraudster’s perspective, it is “a business.” Fraudsters use psychological manipulation of emotion to evoke giving. They use catchwords and phrases designed to arouse feelings of pride and good will for giving, and guilt and fear for not giving. They say things such as, “Her life is in your hands”; “Save Social Security”; “Secure our borders from illegal immigrants”; and “The cure is just around the corner.”

Fraud conveys the appearance of legitimacy with words that sound credible (e.g., “official postal notice”) and names that sound familiar (e.g., Children’s Wish Foundation). It often taps into patriotic duty and religious value, using symbols such as flags, eagles, crosses and stars. It may evoke a sense of urgency with expressions such as “last chance offer.” Fraudsters produce hopes of financial reward by implying that their targeted victims have already won. Elders who respond to fraudulent pitches are placed on a “sucker list” that is sold again and again.


Profiling exploitation

Family member caregivers commit the majority of financial exploitation of elders. Family caregivers exploit as a function of personal burden rather than as a result of the burden of caregiving. Compared with burdened caregivers who do not exploit, exploiters are more likely to be occupationally, financially and mentally unstable; are more apt to have an addiction; and are more likely to be financially dependent on the elder.

Family caregiver exploiters are seen to use avoidance more than acceptance strategies to manage conflict, and they equally isolate victims and threaten abandonment if a report is made. Exploiters use intimate knowledge of the elders’ vulnerabilities to portray victims as weak and dependent. Although they may feign interest in receiving help, caregivers who exploit elder family members should not be included in counseling except in post-adjudication restorative justice.


Risk factors

Elder cognitive impairment is the single greatest risk factor for all forms of elder abuse. It is strongly associated with various forms of financial abuse, including money mismanagement, negligence, fraud and exploitation. In addition to being a risk factor for financial abuse, cognitive impairment can be exacerbated by financial abuse. Financial abuse disturbs the elder’s capacity to know what is real and whom to trust. The victim may feel confused and disoriented, as though he or she is going crazy.

Other risk factors for all forms of elder abuse include elder mobility problems, being homebound, medical and psychiatric conditions, substance abuse and social isolation. Although social isolation can be a symptom of mental illness, it can also indicate a fear of retaliation for seeking help.

Financial worries and fear of losing financial control are very common in old age. Elders worry about the cost of living, health care, long-term care and the financial struggles of adult children. In a 2014 Pew Research Center survey, about half of adult children reported financial dependence on aging parents to meet the cost of living. Economists explain that today’s generation of adults is the first to not surpass their parents’ financial success. Because elder financial worry is associated with financial risk-taking, such as falling prey to scams and risky investments, it is considered a risk factor for abuse.

Finally, there is a particularly high risk for elder financial abuse during times of crisis and transition, such as after the death of a spouse or during recovery from a fall. At these times, elders are more vulnerable to others gaining financial control under the guise of helping.


Reactions to financial abuse

The reactions of elders to financial abuse parallel the reactions of victims of all ages to various types of abuse. These reactions include denial, avoidance, confusion, hurt, betrayal, anger, embarrassment, shame, guilt, helplessness, hopelessness, mistrust, dissociation, hypervigilance and paranoia. Symptoms of elder financial abuse mimic those of depression, anxiety, posttraumatic stress disorder, dementia and even psychosis. Helplessness, hopelessness, diminished self-worth and social withdrawal are so common among victims of elder financial abuse that their presence should always signal the need for an abuse assessment.

Elders are often reluctant to acknowledge being the victims of financial abuse. This reluctance to report is associated with a host of fears, including the fear that:

  • Nothing will be done
  • The victim won’t be believed
  • The victim will be blamed or shown to have personal flaws
  • The perpetrator will be harmed
  • The family will be broken
  • The report will incite retaliation, abandonment or institutionalization

Reluctance to report financial abuse is also due to the emotional, physical and financial toll that abuse investigations take on victims. It is much simpler not to deal with an investigator who needs to examine financial records, review changes in assets, and create timelines of transactions and who was involved. Elders are typically discouraged from filing reports; only about 1 in 5 cases of family exploitation and 1 in 25 cases of stranger fraud are reported.

In addition, prosecution rates of financial abuse are low because family members are seen to have tacit consent to access elders’ finances and because strangers are hard to identify. Even in successfully adjudicated cases, no remuneration is afforded. When one elder called her state attorney general’s office to ask for help with mail fraud, the spokesperson said, “The magnitude of the problem is so great that we simply cannot investigate every case.”


Counseling principles and practices

Principles that guide counseling for child abuse can also be applied to counseling for elders who have suffered financial abuse because the dynamics are very similar. Many of the risk factors are the same (cognitive limitations, mobility problems, social isolation). Symptoms are the same (fear, confusion, hopelessness, hypervigilance). Reasons behind the reluctance to report are the same (fears of not being believed, facing retaliation, breaking up the family, being institutionalized). Threats and intimidation for reporting are the same (isolation, withdrawal of help, exposing inadequacy). And social position is the same (dependent, protected).

Referring financial abuse victims to financial experts who can confirm assault is an important part of counseling. Expert verification decreases cognitive confusion and provides emotional relief for victims. One mail fraud victim finally acknowledged being scammed when his bank manager said, “This unfortunately happens a lot. At least you caught it early.”

Financial abuse stresses an already stressed system, and victim allies may need to help produce financial records, close accounts, set up online payments, vet the mail, provide emotional support and so forth.

The passage of three laws in 2010 laid the foundation for developing integrated elder abuse services. First, by mandating states to develop adult protective service laws, the Elder Justice Act produced a common language to talk about elder abuse problems. Second, by requiring states to develop adult protective service systems, the reauthorized Adult Protective Service Law expanded state and national elder abuse detection, investigation and reporting. Finally, by funding elder mental health screening under Medicare and elder mental health counseling under Medicaid (for states opting in), the Affordable Care Act elevated the provision of elder mental health services.

In 2015, the White House Conference on Aging asserted that best practices in elder abuse prevention are multidisciplinary. This means that counselors will be called on to detect, investigate and report elder abuse in collaboration with diverse professionals. Multidisciplinary prevention of elder abuse will work much like the National Children’s Advocacy Center (NCAC) model, but instead of aiming to prevent child abuse one child at a time, its aim is to prevent elder abuse one elder at a time.




Joanne Cohen is a professor and coordinator of the marriage, couple and family counseling program in the Department of Counselor Education at Kutztown University. She is a national certified counselor and licensed marriage and family therapist. Cohen specializes in trauma and addictions counseling, prolonged exposure counseling and client-centered counseling process and supervision. She serves as a volunteer assistant ombudsperson for a county office of aging and adult services. She is trained in the NCAC multidisciplinary treatment approach to child abuse prevention. Contact her at cohen@kutztown.edu.




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.


Have you gone gray?

By Matthew Fullen June 27, 2016

The United States is going through a rapid demographic shift unlike anything it has ever experienced. Approximately 10,000 Americans are turning 65 every day. Meanwhile, the average life span in the United States has increased to approximately 81 years for women and 76 years for men, with a significant number of people living well beyond those ages.

By 2030, demographers project that 70 million people, or about 20 percent of the U.S. population, will be 65 or older. Industries ranging from health care to technology to real estate have taken note of this emerging trend and are identifying how best to respond to the needs of an older population. Although a great deal has been written about how an aging population will affect the need for biomedical services, the story of how older people maintain optimal mental health throughout the life span has received far less attention.

First, the good news. Research indicates that older adults report the highest levels of life satisfaction when compared with young and middle-aged adults. Older adults are more likely to report a satisfying marriage, and they outperform younger individuals when it comes to remaining calm during times of stress. Subjective well-being is particularly high when older people perceive that they have adequate social support; have a sense of control and mastery, opportunities to derive meaning through paid or unpaid work and a positive perception of their age; and when they participate in spiritual or religious practices. Therefore, for many people, older adulthood can be a very fulfilling phase of life.

On the other hand, a large number of people 65 and older need mental health care but do not have adequate access to it. Approximately 20 percent of adults 65 and older meet the criteria for a mental disorder. Older adults with mental disorders experience higher rates of functional disability than those with a physical illness alone. They also experience poorer overall health outcomes and higher rates of hospitalization. Economically, these factors result in medical costs that are 47 percent to 200 percent higher for older adults with a mental disorder than for other older adults. Furthermore, older Americans are disproportionately likely to die by suicide, with older white males in particular having one of the highest rates of suicide.

Access to mental health services

Why is there such a discrepancy between the preponderance of older adults who experience increased life satisfaction in old age versus those who are at risk for depression, anxiety and suicide? One factor often cited in the research is older adults’ lack of access to mental health care.

In a recent study of older Americans, only 3 percent reported seeing a mental health professional, the smallest percentage of any age group. It is likely that stigma related to aging and mental health is at least partially to blame. For instance, previous cohorts of older adults came of age in an era when mental health services were far more stigmatized. Instead of seeking services from mental health professionals, older people are more likely to share their complaints with primary care providers, family members or friends. It is worth noting, however, that the current generation of individuals turning 65, known as the boomer generation, is likely to be more open to discussions about mental health.

Stigma also exists in the form of cultural myths about aging that create barriers to older adults seeking help for mental health concerns. For instance, despite the previously cited research about older adults’ high levels of life satisfaction, many people mistakenly believe that depression is a normal feature of growing older. A myth that may influence clinicians is the notion that certain problems associated with aging — including the increased likelihood of one or more chronic health conditions, the loss of a loved one and existential concerns related to meaning and life purpose — will not be responsive to counseling treatment.

Practical skills for counseling older adults

In reality, older adults are excellent candidates for counseling services. They respond to treatment as well as or better than members of other age groups. The counseling profession is particularly well-situated to provide effective services to older adults because of its emphasis on life span development, wellness and attention to diversity. Three practical strategies can promote the work of counselors with this population.

First, it is important for counselors to consider the developmental needs of older adults. Historically, human development theorists, including Sigmund Freud, suggested that development stopped around age 40. Although this seems laughable today, the assumption that most growth and change occurs early in life is still reflected in sayings such as “You can’t teach an old dog new tricks.”

In fact, in a 2000 study, Paula Danzinger and Elizabeth Welfel found that despite identical symptom profiles, mental health professionals rated older clients as having a more negative prognosis when compared with younger clients. Therefore, when working with older clients, it is imperative for counselors to challenge this myth, first in their own minds, but also potentially with clients who do not believe in their capacity to make changes at this point in their lives. For instance, recent findings in neuroplasticity suggest that humans are capable of making changes to their attitudes and behaviors across the life span. When counselors reflect this viewpoint in session, they provide hope to clients who may have otherwise resigned themselves to a particular problem or mindset.

Next, counselors should consider the use of a wellness perspective when assessing and treating older adults. Although the wellness paradigm is increasing in popularity, its use with older adults has lagged behind, both in research and clinical applications. However, older adults are prime candidates for the use of a wellness approach for multiple reasons.

First, a great deal of research indicates that a broad range of variables influence older adults’ longevity and quality of life. These variables include strong mental and emotional health, reciprocal social relationships that are perceived as supportive, participation in preferred spiritual or religious practices that provide meaning and purpose, a belief that one has at least some control over circumstances and a positive perception of aging. A recent example of the multidimensionality of older adults’ needs was demonstrated in a 2015 study by Kelley Strout and Elizabeth Howard. The researchers found that emotional wellness was the highest predictor of cognitive health, followed by physical and spiritual wellness as additional significant variables. Therefore, counseling interventions that bolster emotional wellness may influence brain health in later life.

Similarly, there is growing interest in the concept of resilience among older people. Given the wide range of challenges that may accompany older adulthood, some gerontologists suggest that resilience should be used as a primary measure of what it means to age well.

In research supported by the Association for Adult Development and Aging (AADA), a division of the American Counseling Association, Sean Gorby and I recently piloted a program in which older adults participated in a counseling group focused on how participants had demonstrated resilience in various domains over the course of their lives. Group members identified adversities they had experienced, including physical and functional setbacks, emotional distress, changes in social relationships and spiritual and existential hardships. Participants then shared personal stories about resilience, either in their own lives or in the lives of others, and discussed how this could be manifested once again with the current challenges they were facing.

At the conclusion of the group, we found that participants perceived themselves as more resilient. This indicates that counselors may be able to tap into the reserves of resilience that older clients possess, using discussions of resilience to help these clients restructure their self-concepts around adversity and their ability to bounce back.

Finally, in spite of cultural assumptions to the contrary, older adulthood is an extremely heterogeneous phase of life. Cultural diversity and vast individual differences related to the aging process shape how older adulthood is experienced. For instance, a person’s chronological age, by itself, does not communicate a great deal of information about how one perceives life, nor does it directly correlate with overall health and wellness.

Most broad definitions of older adulthood use age 65 and up; however, there have been efforts within gerontological research to subdivide older adulthood into two segments, with the “young-old” representing individuals 65–80, and the “old-old” reflecting those who are older than 80. Although some research supports differing health and life experiences for individuals in these two groups, the division is still limited by the assumption that chronological age is aBranding-Images_gone-gray helpful descriptor. For instance, one’s health, holistic wellness and functional status may provide better information about what life is like than simply stating how many years one has lived. For this reason, some have argued for the use of biological or functional age as a more descriptive demographic than chronological age.

How one perceives his or her age can also be a telling indicator for quality of life and longevity. In fact, research by Becca Levy shows that older people with a positive age perception live significantly longer than those older adults who have a negative perception of their age, even after controlling for other health and demographic variables.

The older adult population is also rapidly becoming more diverse. In fact, ethnic minorities, particularly Latino and Asian/Pacific Islander elders, make up the fastest-growing subset of the older adult population. Furthermore, more than 2 million American older adults currently identify as lesbian, gay or bisexual.

In terms of socioeconomic diversity, a wide gap exists between older adults who have accumulated sufficient financial resources and the vast number of older adults who have either experienced poverty throughout their lifetimes or who are now on the edge of poverty because of recent changes to their health, relationships or work status. Therefore, counselors interested in working with older adults should anticipate that their clients will possess a diverse range of backgrounds and perspectives, and differing levels of health, wellness and functional abilities. Some counselors may encounter older adult clients who can afford to pay out of pocket for mental health services, whereas other counselors are likely to interact with older adults whose low income levels qualify them for subsidized housing or health care.

Counselors should recognize that growing older in America is not a monolithic experience. In fact, the diversity of perspectives related to the aging process is one of the most compelling features of working with older adults. Rather than older adults all being alike and resistant to change — as the cultural myth might suggest — older people possess a diversity of backgrounds and life experiences that can make the counseling experience particularly invigorating for client and counselor alike.

Strategies for including older adults in your practice

Counselors interested in working with older adults should be proactive about seeking opportunities to market their services to these clients. Counselors cannot currently bill Medicare. However, there are other ways to make a difference in the lives of older adults.

For instance, a 2012 report by the Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine) found that 47.5 percent of older adults’ mental health services were not paid for through Medicare. Non-Medicare payment sources included paying out of pocket (18.3 percent), supplemental private insurance (11.7 percent), Medicaid (11.4 percent) and other state and community programs (6.1 percent). Therefore, in addition to offering services directly to older clients, counselors can also market their services to local agencies on aging, community and neighborhood clinics with local service grants and capitated health service providers.

For some older people, seeking mental health treatment within a private practice or standalone mental health clinic may be appealing. However, I have found that linking mental health services to older adults’ housing, medical care and social services is an excellent strategy for providing integrated care and making mental health services more accessible to older clients. For instance, forming partnerships with primary care providers who view mental health treatment as a necessary and value-added component of integrated treatment can be an effective strategy for connecting with older clients. Counselors accustomed to the use of a wellness paradigm are familiar with the challenges of providing prevention and holistic wellness services to clients in a world of managed care and disjointed services. Therefore, instead of focusing solely on the need for Medicare reimbursement, entrepreneurial counselors may wish to consider how to extend the integrated wellness work that is already being done with younger clients to an older population.

Ongoing education and training are helpful to ensure that your counseling services are well-suited for older clients. Members of the counseling profession should look for continuing education or postgraduate training opportunities that will expand their understanding of the impacts that adult development and aging have on their clients. This could include:

  • Attending educational sessions at state or national counseling conferences
  • Joining AADA
  • Networking with other professionals in the aging sector by getting involved with a local area agency on aging
  • Seeking formal education in the form of a certificate program in gerontology at a local university

Counselor advocacy 

Given the rapid growth of the older adult population in the United States, there is a need for more mental health professionals who are both willing and able to work effectively with these clients. Although it is not the only means of access for mental health services, Medicare covers the majority of these services (52.5 percent) for older adults. Recently, there have been several critiques of the Medicare program for not doing more to address the growing number of older adults who need mental health treatment. According to the 2012 Institute of Medicine report, only 1 percent of the total Medicare budget was spent on mental health services (with a total budget estimated at $505 billion in 2014).

Advocacy for Medicare reimbursement of counselors is vital to expanding the mental health workforce. Two bills were introduced in Congress in 2015 calling for mental health counselors to be included as recognized Medicare providers: the Seniors Mental Health Access Improvement Act of 2015 (S. 1830) and the Mental Health Access Improvement Act of 2015 (H.R. 2759). Both bills have received bipartisan support in the past. However, it is common for legislative efforts to go through many iterations before becoming law.

Due in large part to the advocacy efforts of the counseling profession, there are currently numerous bipartisan co-sponsors for both of these bills. Recently, counselor advocacy efforts resulted in AARP writing a letter that supported passage of congressional bills calling for inclusion of counselors as Medicare providers.

To continue this momentum, it is imperative for all members of the counseling profession to raise awareness of Medicare’s lack of attention to mental health and the current restrictions that deny older adults the freedom to choose their mental health providers. Counselors should consider contacting their congressional representatives to provide awareness about the counseling profession and how it is uniquely situated to provide mental health care to older adults that is grounded in wellness, life span development and awareness of the diversity of older adults. Please consider contacting your senators and representative with a brief statement that advocates for S. 1830 and H.R. 2759. Contact information can be found at congress.gov/members, where you can sort by state to locate your senators or search by ZIP code to find your representative. (If you are interested in learning more about specific Medicare advocacy strategies, consider reading my April 2016 article in Adultspan Journal on this topic.)

Members of the counseling profession must also consider whether the current state of counselor training provides adequate exposure to the possibility of working with older adults. A 2009 study by Thomas Foster, Val Kreider and Jennifer Waugh found that counseling students had a high degree of interest in topics related to older adulthood, including the transition to retirement, helping families navigate the aging of a family member, providing support to caregivers and discussing issues such as dying and grief with clients. However, the authors suggest that counselors and counseling students lack opportunities to follow through with these interests.

At the programmatic level, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) specialization in gerontological counseling was discontinued in 2008 because of a lack of counselor training programs applying for accreditation in this area. Although the lack of Medicare reimbursement for counselors may influence the viability of a gerontology specialization, it is worth asking whether more could be done to promote work with older adults within counselor education programs. For instance, in reviewing the 2016 CACREP Standards, I found zero references to the words older, age or ageism, and only one reference to the word aging.

Anecdotally, I have had numerous conversations with counselors and students who express a great deal of interest in focusing more of their work on older adulthood but do not think they have adequate opportunities or knowledge to do so. Therefore, it is important for counselor training programs to assess their students’ interest level in working with older adults, identify practicum and internship sites that provide access to these individuals and participate in professional advocacy efforts to expand the role of counselors to meet the mental health needs of older adults. In addition, members of the counseling profession should work with their state counseling associations to coordinate state and local efforts to raise awareness within the community, as well as within the political arena, about the current state of older adults’ mental health access and the need for Medicare reform.


In summary, the “graying” of America is making its mark across a wide range of industries, including mental health. As more attention and public dollars shift toward the national challenge of promoting the health and wellness of an older population, members of the counseling profession will find themselves impacted in myriad ways.

Families will be affected by the growing number of older people living with chronic health conditions. Paid and unpaid caregivers will have greater responsibility for providing support to older adults. Topics such as retirement and lifelong vocation will be reconsidered as individuals work longer to make ends meet and spend their post-retirement years continuing to seek avenues for purpose and meaning.

In spite of the hurdles that remain, members of the counseling profession can support the growing number of older adults by providing mental health services that are developmentally appropriate, grounded in wellness and suited for a diverse range of older individuals. With that in mind, why don’t you go gray?




Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

FullenMatthew Fullen is a licensed professional clinical counselor in Ohio. He has worked with older adults in a variety of contexts since 2005. He currently serves on the board of the Association for Adult Development and Aging and is completing a doctorate in counselor education with a specialization in aging at Ohio State University. Contact him at fullen.33@osu.edu.

Letters to the editor: ct@counseling.org




Behind the Book: Counseling Older People: Opportunities and Challenges

By Bethany Bray January 11, 2016

Older adults are the fastest-growing segment of the U.S. population. The number of people age 65 and older is expected to nearly double by the year 2050.

From helping with family dynamics and end-of-life issues to working on a client’s coping and communication skills after hearing loss, counselors are uniquely skilled to help the older adult Branding-Box-Older-Peoplepopulation, says Charlene Kampfe, a retired counseling professor, nationally certified gerontological counselor and national certified rehabilitation counselor.

“With the growth of the older population, we counselors will have the exciting opportunity to carve a place for our profession in those systems that serve older people,” Kampfe writes in the preface of her book, Counseling Older People: Opportunities and Challenges. “Although some counselors may not have worked with older consumers in the past, they already have many of the skills necessary to do so. Counselors understand and support the concept of empowerment. They know how to provide a safe, respectful and challenging environment in which individuals can explore their thoughts, feelings and behaviors. They have also been trained to be good listeners, advocates, problem solvers and case managers.”



Q+A with Charlene M. Kampfe


In your book, I notice that you use the phrase “older population” instead of other terms (senior citizen, geriatric, elder, etc.) Why?

An excellent question. One of the primary reasons that I chose to use the phrase “older population” is that some of the other terms seem to have taken on a negative connotation. “Senior citizens,” “geriatric” and even the word “elder” may now be terms that have been viewed by our current society with a negative perspective — e.g., age prejudice. Another phrase that I use is “people who are older” rather than older people. I did this in order to focus first on the person/s and then on one of their qualities — i.e., people who are older, people with disabilities, people who have visual impairment, people who are age 65 or older, etc.).


From your perspective, how are counselors a good fit to work with the aging/older population?

I could say so much about this, but will keep this answer at a minimum. Throughout my book, I describe the reasons that counselors are a good fit for working with the older population. Counselors have the ability to listen — to really listen. One of the issues often faced by older people in our current society is that they are not listened to. Therefore, the listening skills of the counselor are vital to this population.

Counselors also have the ability to empower their clients. By empowerment, I do not mean they give the power to the person; I mean they recognize and acknowledge the power of the person they are counseling. In our current society, many older people are no longer given the opportunity for choice and decisions about their own or their families’ lives. Therefore, the counselor’s ability to encourage client power is vital for this population.

Furthermore, counselors have the ability to advocate, both individually and systemically, for clients. Advocacy is vital for people who are older because many of the systems that serve them do not serve them well or are disempowering. Counselors have the ability to do creative problem solving. Therefore, they can support consumers as they negotiate the many transitions and issues they face as they age. Counselors know that each person is unique and does not fit a mold. Counselors can use this understanding to avoid putting all older people into a single category with the same skills, wants, needs, issues, etc.


In your book’s preface, you say the systems that serve older people often leave seniors “disempowered.” Can you elaborate? How could counselors help in this area?

Many of the systems or service providers that serve older people assume that all older people are the same or similar. They may assume that older people are no longer able to make their own decisions. It is likely that children or service providers who think they are “helping” older people are actually taking away the opportunity to make decisions for themselves, doing things for them that they can do, ignoring their desires or disempowering them.

Counselors can help by counseling family members to … recognize how their behaviors may be disempowering and to find new ways of interacting with their older family members or friends, advocating for systemic change within institutions that are disempowering, modeling behaviors that are empowering rather than disempowering and serving on boards of or acting as consultants to service providers. Counselors can act as staff trainers to challenge disempowering attitudes and practices. See my book for a reference to a training package that is available to counselors.


What are some main takeaways you want counselors of all types and specialties to know about working with the older population, especially considering this population is one of the fastest-growing demographics in the U.S.?

One important point is that this group is not homogeneous. Some scholars have suggested that it is the most diverse of all groups today. Simply by virtue of the definition of “older,” this group can span 40-plus years — 65 to 105 or older. Each generation — those who are age 65 versus those who are 75, 85, 95, 100 or 105 — has experienced unique life experiences based on the year they were born. Furthermore, within the older population, there is diversity in race, culture, location of birth, education, health status, life experiences, family perspectives, mental status, etc. Counselors can, therefore, not lump this group into one category. Each person will be unique, and that uniqueness should be recognized and honored.


What would you want a newly graduated counselor to know about working with the older population? What might not have been covered in their studies?

New counselors can use all the counseling strategies they have learned in their graduate studies. Perhaps the most important things that they will now need to do are:

1) Examine their own attitudes toward aging and older people. This is discussed in detail in my book, [and] exercises to challenge one’s own attitudes toward aging are included.

2) Learn about the multitude of transitions that older people may be experiencing, and learn ways to support these people as they make these transitions. Learn problem-focused counseling skills, and learn about the specific transitions that older people may experience.

3) Learn about the various systems that serve older people — e.g., Medicare, Social Security, nursing homes and other residential options, health care systems, mental health programs, recreation programs, social service programs, etc. Know the ways these systems can be of assistance to older people, and know the problems associated with these systems. Keep current about changes in such systems. Learn about the legal issues associated with being old. In nearly every chapter of my book, I provide resources for each topic. These are very valuable resources that can be of great help to counselors and the consumers they serve.

4) Recognize that the older population is one of the most diverse populations in the United States and that older people cannot be placed in any specific category. Learn about the various issues faced by people from specific cultures.

5) Learn how to advocate for the older population and for individuals who are older. This can be systemic advocacy and individual advocacy.

6) Learn about the issues of people who are caregivers to older people. Learn how to work with these people in order to help them with their own personal issues. Learn how to show caregivers the importance of dignity versus dehumanization and personal choice of the people they serve.


From your perspective, how can the counseling profession as a whole become more involved in the care of the older population?

The counseling profession, as a whole, can be especially watchful of legislation that is being considered regarding the older population and become activists when the legislation seems to create negative issues for that population.

The counseling profession, as a whole, can:

  • Focus on its own attitudes toward aging
  • Consider the concepts of positive aging
  • Advocate for better and more empowering living conditions for older people
  • Advocate for more positive societal and service workers’ attitudes toward aging
  • Advocate for employment opportunities for older people
  • Reinstate the national gerontological counselor certification (a specialty the National Board for Certified Counselors retired in 1999)
  • Develop program guidelines for gerontological counseling specialties


The book as originally written was almost twice as long as the resultant book. There is so much for people to know. I would suggest taking a class in gerontology, aging, etc., in order to get more details. Also, counselors can use the many resources that are listed in my book to learn more about each specific topic.


What inspired you to write this book?

I was blessed as a child and young woman to know and love three of my great-grandparents. I was also very fortunate to have and to know my four grandparents. All of them taught me many important life lessons from their various perspectives. Likewise, my parents and other family members were wonderful mentors and supporters. In other words, I learned the value of people who were older as a young person.

Over the years, I began to find that one of my professional foci was aging. I was influenced by various people who were counselor educators and leaders who were interested in the older NursingHomepopulation — e.g., Mae Smith, Jane Myers — and who taught me much about attitudes toward aging and about specific issues associated with aging. These mentors had great influence on my path.

Over the past 30 years, I have engaged in a great deal of research and writing about the older population. I also became heavily involved in the Association for Adult Development and Aging (AADA), a division of the American Counseling Association. As a member of AADA, I served as president, chair of many committees and as an ACA Governing Council representative of this wonderful, family-like professional organization.

Another inspiration has been my lifelong work as a rehabilitation counselor and rehabilitation educator. I have been guided by rehabilitation principles such as dignity versus dehumanization, personal power, personal choice versus being told what to do, appropriate language when speaking of and to different populations — i.e., person-first language — advocacy for and by consumers themselves, respect for consumers, etc.

In summary then, my book Counseling Older People: Opportunities and Challenges, is the culmination of my personal and professional interest in people who are older, the issues they face, the strengths they may display and the role of counselors in their lives. At my own retirement, I desired to continue to serve the counseling community and the aging community by writing this book. It has been a fantastic journey.





Counseling Older People: Opportunities and Challenges is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222.





About the author

Charlene M. Kampfe is professor emeritus of rehabilitation counseling at the University of Arizona, Tucson, a nationally certified gerontological counselor and national certified rehabilitation counselor. She is a past representative to the American Counseling Association Governing Council and has held leadership positions in two ACA divisions: the Association for Adult Development and Aging (past president) and the American Rehabilitation Counseling Association.

She is also a member of the International Association for Creative Dance and dances regularly at the Tucson Creative Dance Center.




Related reading

For more on counseling and the older population, see Counseling Today’s 2014 cover story, “Ages and stages





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

Multiple stressors take a bite out of the sandwich generation

By Lynne Shallcross October 20, 2015

Merriam-Webster defines the term sandwich generation as a “generation of people who are caring for their aging parents while supporting their own children.”

Estimates vary concerning how many Americans belong to this sandwich generation, but a recent poll from the Associated Press-NORC Center for Public Affairs Research puts the number at nearly 1 in 10 Americans age 40 and older, with another roughly 8 percent who may become “sandwiched” caregivers in the next five years.

Caretaker_brandingNot all sandwiches are alike, however. Some sandwich generation caregivers have aging parents living with them, while others care remotely for aging parents who still live on their own or in assisted living facilities, sometimes in another state.

As for the “children” that sandwich generation caregivers are looking after? Traditionally, the assumed reference would have been to those younger than 18 who are still living at home. But many sandwich generation caregivers have young adult children who no longer live in the home yet still rely on their parents for financial support. Still others have adult “boomerang” children who have moved back into the house.

There’s also the “club” sandwich, which includes more than three generations. For example, a 55-year-old woman might be caring for her aging parents, while her 30-year-old son and daughter-in-law, along with their young children, live at home with her. “It’s not just a regular peanut butter and jelly sandwich, it’s a club sandwich of family members looking behind and ahead in multiple generations,” says E. Christine Moll, an associate professor and chair of the Department of Counseling and Human Services at Canisius College in Buffalo, New York. Moll is also a past president of the Association for Adult Development and Aging, a division of the American Counseling Association.

Ten years ago, Phillip Rumrill found himself in a variation of the sandwich generation. Rumrill, a professor of rehabilitation counseling and director of the Center for Disability Studies at Kent State University, was helping to care for his grandmother, who had cancer and dementia. He was also raising young children of his own and holding down a full-time job as a counselor educator.

Rumrill says there weren’t many good resources at the time for sandwich generation caregivers like himself. He and the other family members helping with his grandmother’s care “had to learn a lot on the fly.” A few years later, two rehabilitation counseling colleagues approached Rumrill. The women — one of whom had cared for her mother-in-law and the other of whom had cared for her father, both while raising their own children — were interested in writing a book on the topic.

Rumrill, Kimberly McCrone Wickert and Danielle Schultz Dresden co-authored The Sandwich Generation’s Guide to Eldercare: Concrete Advice to Simultaneously Care for Your Kids and Your Parents in 2013. Their aim was to provide the kind of practical guide they wished had been available for them.

Among other things, Rumrill says the book addresses the inherent tension and conflict involved in caring for an aging family member, especially when the tables in the relationship are turned and adult children are telling their aging parents what to do.

For Rumrill, that point is exemplified by one memory of his grandmother. He was explaining something to his grandmother when she interrupted him. “Apparently I was saying it in too much of an advisory way,” Rumrill says, “and she stopped me for a minute. And she said, ‘I want to ask you a question. … When did the change happen where you started telling me what to do?’”

Career plus caregiving 

As a life span services manager in the Office of Work, Life and Engagement at Johns Hopkins University, Meg Stoltzfus helps university staff and faculty members navigate all kinds of caregiving challenges. The biggest stressors she sees with sandwich generation caregivers are related to finances and career.

“Many caregivers, if they are working, have to cut back hours at work, or they can’t accept promotions if that would involve more travel or more hours, because they have so many commitments that they have to fulfill with their children and their parents,” says Stoltzfus, an ACA member. “Then they start to deal with their own financial difficulties if they’re not able to save as much for retirement, if they’ve cut back their hours or if they’re spending all their discretionary income on providing care and assistance for their parents.”

The impact on a sandwich generation caregiver’s career compounds the problem. “This sandwich situation happens really at the prime time in your career,” Stoltzfus explains. “And that’s the time when you have the most competence, when you’re making the most money, when you’re really on a roll — and then it kind of brings that to a screeching halt for many people.”

As it relates to taking care of aging parents, sandwich generation caregivers may also experience less understanding, collegiality and encouragement in the workplace. When someone is expecting a baby, co-workers often throw an in-office baby shower to show their excitement and support, complete with gifts and good wishes. “You do not have a similar party when you’re taking care of your dad or you have to move dad into the house,” Stoltzfus points out. “There’s still a real taboo in the workplace generally about talking about eldercare.”

In fact, Stoltzfus says, some people go to great lengths to hide their caregiving responsibilities for aging parents. They worry that it might cause supervisors to pass them over for promotions or that colleagues may think less of them for having to miss an office happy hour to go home and care for a parent, she explains.

Although some progressive employers are beginning to support workers faced with these kinds of caregiving responsibilities, Stoltzfus says it remains challenging to balance work with caregiving. She recommends that counselors working with sandwich generation clients encourage those clients to familiarize themselves with their companies’ employee policies and meet with a human resources manager to discuss supportive options with which they might not be familiar.

Stoltzfus’ employer, Johns Hopkins University, has a program that pays part of the cost of backup care. For example, if the aging parent of a university employee needs surgery and then needs an in-home nurse afterward, the university will pay part of the cost of that care, Stoltzfus says. “Employees need to see what their employer covers and what benefits they have in place for caregivers because it may be a big help to them [and] they may be able to be more successful at work if they can take advantage of those,” she says.

Rumrill suggests that clients set up a contingency plan at work concerning what will happen should they need to be absent at the last minute because of caregiving responsibilities. Clients shouldn’t assume that employers haven’t had to deal with those kinds of caregiving challenges before because, odds are, they have. “It’s a really pervasive issue,” he says.

To help clients tackle the financial stresses that accompany caregiving in the sandwich generation, Stoltzfus says counselors should be equipped to make referrals to local experts who can help. One overall referral that Stoltzfus recommends is to an “aging life care professional,” also known as a geriatric care manager. Those professionals can connect caregivers with various kinds of eldercare resources in their communities, she says.

Both Stoltzfus and Rumrill also recommend that counselors be ready with referrals to qualified elder-law attorneys and financial planners. Those professionals can help clients navigate government benefits for which the aging parent may qualify, help create wills or trusts and provide assistance with other financial and legal issues.

For everyday practical needs, such as finding transportation or adult day care for aging parents, Rumrill often suggests the Eldercare Locator (eldercare.gov), provided by the U.S. Department of Health and Human Services Administration on Aging, or connecting with a local Area Agency on Aging.

A balancing act

Another major challenge for those in the sandwich generation is meeting the caregiving needs of their children and their aging parents simultaneously, Rumrill says.

“Sometimes, those needs compete with one another,” he says. “Meeting your parents’ needs may mean that you aren’t meeting your children’s needs in the way you would like to. In many cases, members of the sandwich generation find that the skills they employ in raising children help them in providing eldercare, but being responsible for multiple generations of people can be daunting and exhausting in terms of physical energy, time and financial resources.”

And children — especially young children — often don’t possess the perspective needed to understand the situation. Sometimes children will express frustration, resentment and even anger that their parents are taking time away from them to care for their grandparents or other older relatives, Rumrill says.

Guilt is a common reaction, Rumrill adds. “The caregiver feels that he or she is letting everyone down when, in fact, he or she is keeping everyone moving along.”

Rumrill suggests that parents communicate openly and honestly with their children about the health of older loved ones. “Find ways for children to take part in the care if that is possible, encourage children to maintain a good relationship with the elderly loved one as he or she declines and maintain as much continuity as possible in terms of family customs and traditions,” he advises.

Many parents find creative ways to involve children in the caregiving, Rumrill says. “One mother assigned her 12-year-old son to go to his grandmother’s home every Saturday to mow her lawn,” he says. “While he was mowing the lawn, grandma made him lemonade, baked cookies for him and, after he finished the lawn, they visited for several hours in the afternoon, she telling him stories about her life and her memories of her family. So by helping out with a needed task, the boy was also making a value-added connection with his grandmother. Plus, his presence provided her with companionship to combat the loneliness that often accompanies aging.”

Counselors can help sandwich generation caregivers and their children in a number of ways, Rumrill says, including giving children a safe space to share their feelings about the situation. They can also help parents and children deal with feelings of grief over the changes happening to their older loved one and help them prepare for the eventual death of that person, Rumrill says. Counselors might also try to help children and parents clarify and possibly revise the expectations they have of one another considering the changes taking place in the family due to caregiving responsibilities.

Friction in the family

Caring for an aging family member can create or exacerbate interfamily conflicts among adult siblings, Stoltzfus says. “It brings up a lot of family-of-origin issues,” she says. For example, one adult sibling might tell another adult sibling, “Mom always liked you best” or “You’ve never helped; you’ve always been selfish.”

“It really taxes the family structure to get everybody on the same page about what kind of care is needed and how that care is going to be provided because many times, the siblings all have different opinions about how this should be handled,” Stoltzfus says.

Moll, who specializes in working with older adults and runs a small private practice in a suburb of Buffalo, agrees. The stress and complexities involved in family caregiving can dredge up unresolved family issues that may have germinated years, or even decades, ago. It is often important for counselors to peer beyond the issues at hand, Moll says, and instead identify and follow the roots underlying those issues to their source.

Sandwich generation caregiving can also put stress on the relationship between partners. For example, if one partner or spouse is devoting a significant amount of time to caring for an aging parent, the other partner or spouse can be left to handle the lion’s share of the household and child care duties, Stoltzfus says.

Then there is the issue of clients balancing their new roles as the son or daughter of an aging parent, Rumrill says. Part of the time, that person is still the child of a parent, while at other times, that person has to step in as the adult caregiver and tell the aging parent what to do, just as Rumrill experienced with his grandmother.

Rumrill suggests that individuals who find themselves in that situation remain as open and honest as the circumstances allow. If they have safety concerns about an aging parent, for example, they should express those concerns, while at the same time respecting and honoring the lifelong relationship they have had with that parent. Adult caregivers should also continue to honor whatever resources and capabilities that aging loved one still possesses, he adds.

“Our parents and grandparents also have the right to know exactly what it is that we’re thinking and feeling and observing,” Rumrill says. “And if it’s a good relationship, it won’t be permanently undermined by that.” In the meantime, however, clients may have to deal with the conflict and resistance that result from those honest conversations, he says.

Some sandwich generation caregivers help to care for an aging parent from afar. That circumstance often ushers in feelings of guilt among caregivers, Rumrill says. One remedy he suggests is exploring how to use technologies such as Skype to stay as connected as possible. But that can be challenging, Rumrill admits, especially if aging parents aren’t tech savvy.

Rumrill also points out that issues of grief and loss can be present among caregivers even as an aging parent is still alive. Especially in cases of dementia, caregivers might mourn the loss of that parent’s former self. “Your mother as you knew her is never going to be the way she was,” says Rumrill, citing an example.

‘We need to ask that question’

The majority of unpaid caregivers in the United States are female, according to research published earlier this year from the National Alliance for Caregiving and the AARP Public Policy Institute. But Jacqueline Smith, director of the master’s counseling program at Regent University in Virginia Beach, Virginia, says that counselors can easily overlook caregiver-related stresses among female clients if they aren’t watching carefully.

“We teach our students to ask about domestic violence, we teach them to ask about sexual assault, we even teach them to ask about trauma in [clients’] backgrounds,” says Smith, a member of ACA. “But we’re not asking [clients], ‘Are you taking care of children and parents?’ We’re not asking that question, and we need to ask that question.”

A few years ago, Smith and two graduate students from Northern Kentucky University, where Smith was working at the time as director of the counseling and human services program, conducted a pilot study with nine women who were sandwich generation caregivers. One of the things those women expressed was a sense of isolation, Smith says. They talked about feeling alone and lacking others with whom they could share their experiences. Many of the women told Smith that they would like to go to counseling but didn’t have time to spend on their own needs because they had so many other people’s needs to meet.

Smith and the graduate students provided a support group as part of the study, and it received rave reviews from the participants. “This is the type of thing that we need — a place where we can be validated and share resources and experiences with one another,” Smith says the women told her.

Research has shown that caregivers have a higher incidence of depression, Smith says. “While we as counselors and as behavioral health care practitioners may be diagnosing depression, I think the depression may look different for individuals who are caught in this sandwich generation syndrome because they can’t get out of it,” Smith says. “This is not acute; this is long term, this is ongoing. This is a long-term, life-altering, everyday stressor. And I think it’s something that needs to be addressed and not medicated.”

In addition to support groups, Smith recommends resilience-building techniques as being particularly helpful to sandwich generation caregivers. “I believe that many sandwich generation women could handle their circumstances with a supportive, optimistic, hope-filled counselor who was looking to build upon the women’s strengths,” Smith says.

Among the ways Smith says counselors can foster resilience among these female caregivers include giving them a place to express strong emotions, helping them identify their strengths and encouraging them to advocate for themselves within their families.

Women who are caring for aging parents may also need help managing boundaries. “It’s definitely a balancing act between being [both] a daughter and caregiver to an aging parent,” Smith says. Beyond helping the individual caregiver client work on boundary setting in session, Smith says that in some cases, family counseling sessions can be helpful so that the caregiver can clarify changing roles and boundaries with her family members.

Another area in which counselors can offer assistance is helping these women to reaffirm their own personal identities. Between outside employment and their caregiving responsibilities to children
and parents, Smith says, women can easily lose a sense of their own identities as individuals.

Especially among African American women, Smith suggests that counselors take note of the importance of spirituality, both as a way to support these clients during the counseling process and in reaching out to them in the first place. Smith calls the church the center of the African American community and says that counselors might be able to connect with many sandwich generation caregivers by partnering with local churches.

Smith says support groups are “vitally important” to female caregivers as a whole because the groups offer women a place to be heard and validated as they share resources. Smith suggests that counselors consider partnering with either adult day care providers or child care providers when creating support groups for caregivers so that clients can participate in the groups without having to find alternative care for aging parents or young children.

Smith says counselors should be careful not to pathologize women who are facing challenges and stressors related to their caregiving responsibilities. Sometimes, there can be a tendency among mental health practitioners to “slap a diagnosis” on everything, she says. “As opposed to looking at what it is they’re doing right and how they can do more of [it].” Counselors must support resilience among these women instead, Smith emphasizes.

No one can do it alone

If caregivers are approaching burnout, Rumrill says, counselors might start hearing them say things such as “This is more than I can handle” or “I just can’t do this.” Other hints of burnout can include conflicts with other family members and signs of strain at work, he says. Ideally, counselors would encourage clients to seek help from their support networks to avoid burning out, Rumrill says.

Family caregivers can balk at seeking and accepting help, however, and their hesitancy isn’t necessarily connected to financial worries. Sometimes, Stoltzfus says, sandwich generation caregivers think they should be able to handle all the family’s needs on their own. In other instances, an aging parent may accept help only from certain people, such as a spouse or adult child. In the latter case, Stoltzfus suggests that counselors attempt to brainstorm other options with clients, such as identifying a friend the aging parent is comfortable with who is willing to pitch in and help.

In addition, there are services that can organize volunteer help from friends, Stoltzfus says. Lotsa Helping Hands (lotsahelpinghands.com) is one example. It offers a calendar at which people can post requests for help with anything from the provision of meals to being transported to medical appointments.

Counselors can also encourage caregivers to look within the family for additional assistance, Stoltzfus says. Sometimes caregivers make themselves feel responsible for seeing that everything gets done or, alternately, feel that everything has been dumped in their lap. It can be difficult to get clients to zero in on other family members who can help, but Stoltzfus says counselors should help caregivers see that no single person can manage everything on his or her own. Delegation is key, she says.

The counselor and client can work together on setting boundaries and being more assertive, Stoltzfus says. For example, if the caregiver works full time but the caregiver’s aging parent calls often during work hours, Stoltzfus might suggest setting one specific time to talk every day that fits within the caregiver’s work schedule.

Settings boundaries with other family members such as adult siblings can be challenging as well. Counselors can work with clients on assertiveness training, encouraging them to clearly communicate to family members what roles they are able to fill and what roles other family members need to step up and take on. In some cases, Stoltzfus coaches clients about how to discuss the financial responsibilities of caregiving with family members. For instance, in some circumstances, families have money available to pay for caregiving but prefer for that care to be provided by a family member. Although Stoltzfus acknowledges that it is a tricky conversation to have, she says that the designated family caregiver might consider talking with other family members about being compensated for the work that he or she is doing.

Caring for the caregiver

Caring for children and aging parents can leave little time for anything else, including self-care. Stoltzfus heard recently of something called the “bobblehead effect,” which she says applies to the topic of self-care. A counselor might suggest that the client take time out for self-care, and the client might nod and smile, just as a bobblehead would do. “But in their mind, they’re really saying, ‘How on earth am I going to do that? I have absolutely no time left in my day and no energy,’” Stoltzfus says.

Embracing self-care is something that clients have to do in their own time and in their own way, Stoltzfus says. Counselors should still bring up the concept of self-care in sessions, she says, but they need to understand that the solution isn’t as easy as the client simply agreeing with what they said.

For instance, she might suggest that clients overburdened by caregiving responsibilities should take one night per week to go out with friends, go to the gym or take the dog for a walk. “I’m going to say these things, and they’re going to be looking at me like I have no idea what their life is really like,” Stoltzfus says. “But over time, they realize that there’s absolutely no way they can make it without it.”

Stoltzfus will ask clients to rate their readiness for self-care activities on a scale from 1 to 10. “If they’re a 2, I say, ‘What would it take to get you to a 4?’” She’ll then check in with clients during sessions and help them set attainable goals. For example, Stoltzfus might ask clients to name one self-care action they can follow through on in the upcoming week. “Don’t impress me, don’t try to bite off more than you can chew,” she’ll tell them. “But, realistically, is it just lunch with a friend one day?”

At times, success comes when counselors appeal to the selfless side of caregivers, even as a way of nudging them toward caring for themselves. “Sometimes people won’t do it just for their own sake,” Rumrill says. “But those same people will resonate with the fact that if you don’t take care of yourself, then you’re compromising the care you’re providing to your children or your grandchildren or to your mom or to your grandma.”

Counselors can frame self-care as a necessity for being the best caregiver a person can be for other family members, Rumrill says. “Sometimes that works for people who are [otherwise] like, ‘Well, I wouldn’t do this just for me.’”




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Want to work with sandwich generation families? 

If you are interested in working with sandwich generation caregivers, there are many ways to increase your level of expertise and find clients.

Educational opportunities for counselors are all around, says Meg Stoltzfus, a life span services manager in the Office of Work, Life and Engagement at Johns Hopkins University. For example, she says, the local Department of Motor Vehicles office might offer a seminar on how to talk to older drivers about when it is time to give up their driver’s license. A local Area Agency on Aging will often sponsor seminars on aging and caregiving topics as well.

Phillip Rumrill, a professor of rehabilitation counseling and director of the Center for Disability Studies at Kent State University, suggests checking out continuing education classes at a local university. Classes in human development or gerontology, as well as classes on grief and loss, can be particularly helpful, he says.

Connecting with eldercare lawyers, financial planners who specialize in estate planning and physicians who specialize in treating older adults can be beneficial to counselors in different ways. First, being familiar with these kinds of professionals will allow counselors to provide informed referral options when they’re needed by clients, Stoltzfus says. In addition, she says, those connections can result in new client referrals for the counselor.

— Lynne Shallcross



Lynne Shallcross is a contributing writer to Counseling Today. She recently graduated with a master’s degree in journalism from the University of California, Berkeley, where she won a 2015 Online Journalism Award for best work in the small student projects category from the Online News Association. Her winning project was a master’s thesis titled “Mobile Health: Apps for Every Age and Ouch.” Contact her at lshallcross@gmail.com.

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