Tag Archives: Human Development Across the Lifespan

Human Development Across the Lifespan

LGBTQ issues across the life span

By Laurie Meyers March 24, 2017

The specific biological mechanisms that underpin how people develop as lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) are still undiscovered, but what many researchers have determined is that neither sexual/affectional orientation nor gender identity is a choice. Rather, they are innate, unchangeable parts of who a person is, much like skin color.

And like people of color, LGBTQ individuals regularly encounter significant prejudice throughout their lives. This stigma can make life’s typical slings and arrows all the more painful. Although tremendous progress has been made in LGBTQ rights in the past few decades, counselors must still work to understand the barriers that these clients face across all stages of the life span.

“Growing up in any marginalized group can cause issues surrounding identity,” says Misty Ginicola, the lead editor of the new book Affirmative Counseling With LGBTQI+ People, published by the American Counseling Association. “For LGBTQI+ persons” — referring to individuals who identify as lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, ally, pansexual/polysexual or two-spirited — “the unique identity surrounds not only who they bond with and are attracted to, but very often also their own gender identity and expression. Rather than having their differences be celebrated, unfortunately, LGBTQI+ people commonly grow up in an environment where they internalize very early on that their differences are taboo or undesirable, particularly if they grow up in a disaffirming religious context. Being marginalized also puts a person at greater risk of experiences of trauma and bias incidents, which impacts how safe a person is in any given context.”

Growing up LGBTQ

In general, experts are finding that children and adolescents are growing more comfortable with coming out at an early age, according to Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counselor program at Southern Connecticut State University. If this coming-out process transpires in a supportive and affirmative environment, it can help LGBTQ students to form a strong sense of self and establish healthy relationships, she notes. However, in many cases, these individuals face significant stigma from an early age.

“Being LGBTQ in school requires continuous negotiations between authenticity, connection, safety and health,” explains Colton Brown, a member of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of ACA. “Students may find themselves in unsupportive or even hostile environments.”

ALGBTIC President Tonya Hammer notes that physical, emotional and verbal bullying of LGBTQ students begins as early as elementary school or even prekindergarten. “While physical bullying, particularly that which results in injury and at times death, is prevalent and probably the most talked about since it makes the news sometimes, the cyberbullying and the emotional and mental bullying that take place can often be just as harmful … if at times not more so,” she says.

LGBTQ individuals may be subject to bullying across the life span, but the experience of being bullied can be particularly devastating when it occurs early in a person’s life, says Hammer, an assistant professor of counseling and coordinator of the counseling program at Oklahoma State University. “The power of language and words to inflict damage — especially on children — is often dismissed,” she says.

Insults and taunts — long a staple of playgrounds and classrooms — have found an additional and often particularly vicious arena in cyberspace, warns Hammer, whose research focus includes both bullying and the intersection of gender and sexual/affectional orientation. “Cyberbullying — from Instagram to Snapchat — is only growing and, unfortunately, much harder to address and remedy,” she says. “If physical bullying takes place on school grounds, counselors, teachers and administrators have the capability to take action. However, much of cyberbullying takes place outside of their purview, as well as that of parents, and often goes unnoticed by adults.”

Transgender students are particularly at risk for bullying, stigma and rejection, says Brown, a counselor in the college clinic at the University of Central Oklahoma and a doctoral student in counseling psychology at Oklahoma State University. “Transgender students often face difficulty with coming out because their authentic selves are typically much more visible than [that of] LGBQ students,” he notes. “These students face bathroom and locker room barriers that may come from peers, teachers, administrators and even state policies.” Transgender students also may be excluded from participating in many extracurricular activities such as sports teams because of their gendered nature, he says.

Brown points out that these painful exclusions are happening during a crucial developmental period when adolescents are typically learning how to form various emotional bonds. Transgender and other LGBQ adolescents “may be looking for friendship or romance but can be met with rejection [instead],” he says.

Further complicating matters for many transgender adolescents is that they may not be able to fully establish their personal identities. Those who wish to transition medically need parental support until they are 18, Brown explains.

But transgender students are not the only members of the LGBTQ community who face unique barriers in coming out and finding community, Brown says. Bisexual youth also often find themselves struggling for acceptance and a sense of belonging, not just among heterosexual, cisgender students, but also within the greater LGBTQ community, he says.

“Bisexual people are generally defined by who they are dating at a given time,” Brown explains. “For example, if a male student is dating a female student, then [he is] assumed to be heterosexual. If that same male student is dating a male student, the script flips, and he is now considered gay. Students do not often consider that this student may actually be bisexual. These perceptions can result in these students not feeling ‘straight enough’ for the heterosexual kids or ‘gay enough’ for the gay kids.”

“Bisexual students are in this middle ground in which they may be left without a close-knit group unless they find other bisexual students,” Brown continues. “These students may also struggle more with coming out due to the continued pressure to define themselves outside of who they are or are not dating. Other students also internalize monosexist messages from adults, media and culture and may harass or discriminate against bisexual students. These factors can result in bisexual students feeling shame and may result in internalized biphobia.”

The potential rejection and lack of support may lead LGBTQ children and youth as a whole to be wary of being their authentic selves with friends, teachers, parents and counselors, Ginicola says. “They may also attempt to hide this identity from romantic partners before they have accepted their affectional orientation or come out to others,” she continues. “In this context, identity development in adolescence is disturbed, particularly if they experience rejection.”

A safe space

The good news is that counselors can help bridge the acceptance gap for LGBTQ youth.

“Counselors can create a safe space by a variety of means,” Hammer says. “It can be as simple as displaying an HRC [Human Rights Campaign] ‘equal’ sign in their office or a small rainbow flag somewhere. I know that sounds minor, but small symbols can signify something to students.”

“It is also a matter of having resources available,” she says. “GLSEN [formerly the Gay, Lesbian and Straight Education Network] has a resource called Safe Space Kit that provides curriculum, activities and also stickers that can be displayed which indicate that your office is a safe space. Additionally, counselors can provide programming that is LGBT inclusive or sponsor organizations like a Gay-Straight Alliance. There are activities or weeks that counselors can help organize, such as No Name-Calling Week, Ally Week and Day of Silence.”

When meeting with students, school counselors can create supportive environments by using language that does not assume a student is attracted to any particular sex, Brown says. “This can let students know that you are open to them sharing that information when they are ready,” he says. “School counselors can also be sure to have pamphlets and information sources that include LGBTQ issues and use these examples if they present to classes. Counselors can also include LGBTQ sensitivity training in any presentation they may give to faculty and staff so that the supportive environment may be spread.”

GLSEN has been tracking the school experience of LGBTQ students since 1999 through its National School Climate Survey. Although the survey has shown an improvement in awareness and acceptance of LGBTQ students in schools, significant harassment and discrimination still exist, particularly in relation to transgender students. The 2015 survey found that 85.7 percent of LGBTQ students heard negative remarks from their peers specifically about transgender people, whereas 65.3 percent heard negative remarks from teachers and other school staff members. The survey also found that 22.2 percent of transgender students had been prevented from wearing clothing considered inappropriate based on their legal sex, while 60 percent of transgender students had been required to use a bathroom or locker room of their legal sex.

In late February, President Trump rescinded a 2016 directive issued by President Obama that ordered schools to allow transgender students the use of bathrooms that match their gender identity. The battle reached the Supreme Court with G.G. v. Gloucester County School Board, in which Gavin Grimm, a transgender boy, filed suit against the Virginia school board alleging that it violated Title IX of the Education Amendments of 1972 by denying him the use of the boys’ restroom. On March 2, in a development indicative of growing support for transgender individuals, 53 major businesses signed on to a “friend of the court” brief in support of Grimm. However, the case ultimately was sent back to a lower court.

School counselors can play a critical role in supporting the rights of transgender students, Brown says. “School counselors can help advocate for and with transgender students through engaging in school policy discussions and promoting fair bathroom, locker room and athletic policies,” he urges. “They can also be outspoken against bullying of transgender students and assist other school professionals with stopping bullying. Importantly, school counselors can also support transgender students simply by using [these students’] identified names and gender pronouns. Although this seems small, many students are not supported in this way, and acknowledging [their] true selves can help foster their development.”

Brown also encourages school counselors to educate themselves about the multiple identities that fall under the transgender umbrella, such as gender-queer (individuals who do not identify with conventional gender distinctions, such as solely male or female, but instead identify with both or neither) and gender-fluid (individuals whose gender identification fluctuates over time).

Hammer adds that the Southern Poverty Law Center and its Teaching Tolerance program provides materials for schools that focus not only on LGBTQ identity issues but also ethnicity and racism. “It is important to remember that our cultural identity, no matter what our affectional/sexual orientation, is made up of so much more,” she says. “The intersection of our ethnicity, age, religious and/or spiritual orientation, gender, affectional/sexual orientation, where we live, etc., are all important factors to consider when working with a client. As a counselor, you should not ignore any aspect of a client’s culture. For example, the intersection of affectional/sexual orientation with a person’s religious and/or spiritual identity can either be a source of support and comfort for someone, or possibly a source of rejection and trauma.”

As always, Hammer says, the most important thing to focus on when working with LGBTQ students is the counselor-client relationship. “Listen to them with respect and treat them with dignity and not as if they are abnormal,” she says. “Let them know that they matter — to you, to their families and to the world.”

Working for a living

One of the hallmarks of adulthood is the ability to support oneself, which typically means going to work, notes ACA member Larry Burlew, whose research specialties include issues around adult development, gay men and career development. However, work can be an uncertain and sometimes hostile place for LGBTQ individuals, Burlew says.

For instance, those who are LGBTQ often have no legal protections against discrimination in the workplace, says Burlew, a counselor educator who is retired from full-time teaching and is currently an affiliate professor at the Chicago School of Professional Psychology in Washington, D.C. There is no federal anti-discrimination protection for LGBTQ individuals, and only 20 states and the District of Columbia prohibit discrimination on the basis of sexual orientation or gender identity.

“It’s easy for them to be dismissed from work without necessarily a good reason,” says Burlew, who was also a licensed professional counselor with a small private practice for almost 30 years.

Even if a workplace is not actively hostile, there may be what Burlew calls a “lavender ceiling” — an environment of subtle but pervasive anti-LGBTQ discrimination. So when LGBTQ individuals first enter the workplace or start a new job elsewhere, they are often dealing with a lot of unknowns, he says. As a result, some LGBTQ individuals decide not to come out or be out at work, choosing instead to keep that part of their identities very private, Burlew says. For LGBTQ individuals, this can require a delicate balancing act between developing and keeping social workplace connections and not fully revealing who they are, he continues.

Even those individuals who are fully out at work often still find themselves managing perceptions, Burlew says. “I think that LGBTQ workers get very creative about how to be successful. When you get to an organization, you get creative about how to present who you are in a way that is acceptable to fellow workers,” he says. “[The question becomes], how do you introduce it in conversation?”

LGBTQ workers also have to determine how they will handle microaggressions, Burlew says. He adds that he has been in situations in which he had to decide whether it was safe to address certain comments and jokes that disparaged the LGBTQ community.

Concerns about how they might be perceived can even influence professional choice for LGBTQ individuals. “I’ve had [clients] throughout the years such as gay men who wanted to go into, say, construction and had fears about that,” Burlew says. He would have these clients visualize going to work in the environment that they feared and imagine how they would be received. Then he would talk with these clients about their fears and explore possible scenarios to help them build skills for dealing with problematic situations.

Burlew uses the example of a gay man working in project management at a construction site who hears that some of the workers have been making fun of him when he isn’t around. What are this man’s options? He has to decide whether he feels safe trying to change the environment (a process called an active adjustment) or if he will choose to change himself instead (a reactive adjustment).

In the case of an active adjustment, Burlew and the client would discuss the potential consequences of trying to change the workplace. They would then work on how to use assertive communication to address the problem. This might include having a conversation with the men making the jokes and saying something such as, “I’ve heard that you don’t want to work with me, and I was just wondering if it has anything to do with me being gay?” Burlew would help the client develop assertive communication skills through role-play and practicing what he wanted to say. Burlew and the client would repeat these techniques until the client felt comfortable addressing the problem on his own.

In the case of a reactive adjustment, Burlew would help the client reduce his stress level through systematic desensitization. He would do this by having the client talk about the incident in which he experienced the most stress. They would continue to “practice” the incident until the client could imagine the situation without feeling an undue level of stress.

Burlew and the client would also talk about avoiding work scenarios, if possible, that caused the client the most stress. If avoiding these situations was not possible, Burlew would help the client evaluate how to move forward by asking questions. Did the client need to stay in the position for his career? If so, for how long? Were other alternatives possible, such as pursuing additional education or staying with the company but taking another position?

Relationships and family

Life isn’t just about work, of course, but also about personal connections and family.

Young adults can sometimes struggle to establish intimacy, and Burlew says this can be even more of a challenge for LGBTQ individuals because they are often still trying to sort out who they are. They may not be fully out, even to themselves, he explains, which can delay establishing relationships. Then, as these young adults begin making connections in the LGBTQ community and start dating as LGBTQ individuals, additional challenges can arise.

“In addition to the bountiful issues that face heterosexual, cisgender couples, LGBTQI+ couples face [other] stressors from being marginalized,” Ginicola says. “Experiencing bias incidents, trauma and rejection from loved ones can add incredible stress to a relationship. It can be particularly traumatic to have people who are supposed to unconditionally love you — parents, family and your closest friends — disapprove of or reject your partnership while celebrating heterosexual relationships with showers, weddings and family pride.”

Problems can also arise if partners have different degrees of “outness.” As Ginicola explains, “If one person in the relationship is fully out to others, and one partner is not, this can cause additional struggles within the relationship, where one person may feel invalidated.”

In such cases, it is important for counselors to explore the reasons that one partner prefers to remain in the closet or less out, she says, paying particular attention to how each partner’s coming-out experience may have differed. The partner who fears being fully out may have come from a culture in which being LGBTQ was not just taboo but also put the individual at high risk for violence. Or the person may have grown up in a religious background that stridently disapproved of LGBTQ individuals, Ginicola explains. Counselors should also encourage the out partner to talk about how it feels for the relationship to be “hidden,” Ginicola says. By improving communication, counselors can often help these couples resolve their conflict in a way that works for each partner, she says.

Another area in which LGBTQ individuals and couples face significant barriers is family planning. “In some states and in most international adoptions, same-sex couples cannot adopt,” Ginicola points out. “Therefore, they may have to utilize expensive alternatives, such as artificial insemination or IVF [in vitro fertilization] or surrogacy.”

“Again, counselors should employ affirmative counseling techniques to support these individuals and partnerships,” she says. “Acknowledging the realities and struggles of being an LGBTQI+ couple or relationship is important, as is providing nonjudgmental support and connecting clients to resources that can help them with family planning that is specific to LGBTQI+ couples.”

Taking a toll

As individuals face the various struggles that are unique to being LGBTQ throughout childhood and into adulthood, it can take a significant toll on the body.

“The LGBTQI+ person is under much greater stress than is typical for a heterosexual, cisgender person,” Ginicola says. “If the person has intersectional identities that are also marginalized — ethnic minority, immigrant, differently abled — this stress will be exponentially increased. Although anxiety, depression and suicidal ideation are common as a result of this increased stress across the LGBTQI+ spectrum, the research indicates that each subpopulation experiences different physical and mental health problems.”

“For example,” she continues, “lesbian and bisexual women are more likely to be obese and are more likely to smoke. Gay men are more likely to experience eating disorders, including anorexia, drink excessively and use substances to cope, which impact their physical health.”

In addition to all of this, medical doctors aren’t always cognizant of how LGBTQ health needs might be different from the needs of their other patients, says ACA member Jane Rheineck, a past president of ALGBTIC. For example, she notes, gynecologists often offer lesbians — even out lesbians — birth control.

In addition, LGBTQ individuals often feel uncomfortable or unsafe disclosing in doctors’ offices, Rheineck says, which means that they may delay or even altogether avoid seeking health care. Counselors can help by educating LGBTQ clients about some of the unique risks that they face, but also by providing them with validation, support and empathy for these difficulties, she says.

“Psychoeducation surrounding minority stress, understanding why these negative coping factors are there, [and] recognizing and validating the stress that they experience is crucially important,” Ginicola says. “Cognitive behavior therapy can be helpful in this regard. [It involves looking] at how their inner self-talk and coping skills are moving them more toward their goals or further away.”

Ginicola says counselors can also help clients find LGBTQ-friendly health care through resources such as the Gay and Lesbian Medical Association’s website (glma.org), which has a provider finder.

Being older in a youth-obsessed society is not always easy, but being older and LGBTQ can be even more difficult, Ginicola asserts. Older LGBTQ adults are not only discriminated against in general society but can often find themselves marginalized within the LGBTQ community, she explains. “Therefore, they may experience bias incidents both inside and outside of their community,” she says.

Older LGBTQ adults were more likely to have come out in a hostile societal environment, says Christian Chan, a former family counselor and current doctoral candidate in counseling at George Washington University in Washington, D.C. This history of intense stigma and marginalization puts older LGBTQ adults at even greater risk for mental health issues such as depression and substance abuse, he notes. In addition, at a stage in life when health care issues may necessitate the need for long-term care, older LGBTQ adults are more likely to have a difficult time securing it because retirement communities and nursing homes often discriminate against those who are LGBTQ, Chan and Ginicola say.

Counselors can help this client population, but only if they are aware of the issues, says Chan, who serves as the student trustee for ALGBTIC and the member at large for outreach and advocacy for the Association for Adult Development and Aging, a division of ACA. He emphasizes the need for further training in counselor educator programs and beyond.

“[We should] focus on extending training on how to discuss sexuality, affectional [orientation] and gender identity in conversations and meaning-making around self-disclosure and coming out,” says Chan, who is also president of the Maryland Counseling Association. “It appears to me that many counselors are unsure about how to navigate these questions at large in counseling, which makes the counseling less culturally responsive to older LGBTQ adults.”

Chan urges individual counselors to help their LGBTQ clients build social support networks. “This is especially important in the sphere of redefining family for older LGBTQ adults,” notes Chan, who adds that the concept of family may need to be extended beyond the traditional definition for these clients.

Chan also points counselors toward organizations such as Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (sageusa.org) and the National Resource Center on LGBT Aging (lgbtagingcenter.org) that specialize in helping older LGBTQ adults. AARP’s website (aarp.org) also contains a significant amount of information on LGBTQ issues.

Transgender individuals walk a particularly difficult and dangerous road throughout the life span, confronting widespread misunderstanding and discrimination and an extremely high likelihood of becoming victims of violence, Ginicola says.

“Trans persons, particularly trans women of color, face incredible bias both inside and outside of the LGBTQI+ community,” she says. “When a person transitions, their family and partner must transition with them, which may not always be possible. For example, a trans male, designated as female at birth, may have been in a relationship with a lesbian. When he transitions to male, his partner may experience identity issues and  difficulty in accepting a male as her partner. Transitioning can bring a transgender person such relief in terms of finally being able to be their authentic self, but at the same time, they are likely to experience rejection, bias incidents and discrimination within their personal and professional lives. This is why trans persons are also at the highest risk for suicide.”

Ginicola says that affirmative counseling is crucial to transgender — and, indeed, all LGBTQ — clients. “Affirmative counseling is truly about validating an identity,” she says, “while understanding the realities of being marginalized, building coping skills, connecting clients to affirming communities and making cultural accommodations.”

 

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ACA Illuminate

The American Counseling Association will be holding Illuminate, an innovative counseling symposium focused on serving the needs of the LGBTQ community and those who work with members of this community, from June 8 to 10 in Washington, D.C.

Illuminate is a passion project for ACA President Catherine B. Roland, who has made LGBTQ issues one of her presidential initiatives. “The inspiration [for Illuminate] occurred many years ago and became real right after I was elected ACA president,” Roland says. “I knew that the marginalized population of the LGBTQ community, and the diversity and multiple identities within it, should be a focus of mental health treatment.”

Roland’s goal for Illuminate is to help more counselors and counselor educators gain a greater awareness of the needs of the LGBTQ community and learn how to offer the best care. She also hopes that the symposium will generate additional specific strategies for working with the population, families and career aspirations of LGBTQ adults across the life span.

For more information, visit counseling.org/illuminate. The deadline for early bird registration is April 7.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Journal articles (counseling.org/publications/counseling-journals)

  • “Long-Term Outcomes of Lesbian, Gay, Bisexual and Transgender Recalled School Victimization” by Darrell C. Green, Paula J. Britton and Brian Fitts, Journal of Counseling & Development, December 2014
  • “I Am My Own Gender: Resilience Strategies of Trans Youth” by Anneliese A. Singh, Sarah E. Meng and Anthony W. Hansen, Journal of Counseling & Development, April 2014

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling People Living with HIV/AIDS” by Brandon Hunt
  • “LGBTQQ-Affirmative Counseling” by Anneliese Singh and Maru Gonzalez

Books & DVDs (counseling.org/publications/bookstore)

  • Affirmative Counseling With LGBTQI+ People edited by Misty M. Ginicola, Cheri Smith and Joel M. Filmore
  • Group Counseling With LGBTQI Persons by Kristopher M. Goodrich and Melissa Luke

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Queer People of Color” with Adrienne N. Erby and Christian D. Chan
  • “Group Counseling With LGBTQI Persons” with Kristopher M. Goodrich and Melissa Luke
  • “Living Straight: Coming Out After 40” with Loren Olsen
  • “Counseling Queer* (LGBT) Youth” with Anneliese Singh

ACA divisions 

  • Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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

Letters to the editor: ct@counseling.org

 

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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.

Walking with clients through their final days

By Laurie Meyers October 31, 2016

During the time that Kerin Groves spent by her dying client’s hospital bed, she could tell that he felt conflicted. “I sensed he kept hanging on because his adult children were unable to cope with him dying,” she recalls. “The son kept urging him to fight and get better, even though the patient was in his 90s and ready to go.”

When the man’s children left his room for the day, he visibly relaxed. Groves, a licensed professional counselor (LPC), gently pointed out the difference in his tension level.

“[I] let him know it was OK to go whenever he was ready, and I assured him that I would be there to help his son get through it,” Groves says. “He looked right at me, held my gaze for a time and then closed his eyes for the last time. Given permission and support, he was able to go in peace.”

Groves, an American Counseling Association member who has worked with older adults in retirement communities, assisted living, nursing homes and home care settings, is among a select number of counselors who routinely help individuals and their families cope with the process of dying.

Acceptance and denial

Receiving a terminal diagnosis, or having a loved one receive it, is almost too much to comprehend initially, says Mary Jones, an LPC who spent 20 years counseling patients and their families in an oncology center. “People go into shock, and there is an inability to wrap their minds around what they are hearing,” she says.

Loved ones who are in the room when the terminal diagnosis is given often go through a secondary trauma — shock at what they are hearing and concern for their loved one’s feelings, Jones says. In fact, she adds, these loved ones may initially experience more anxiety than the person receiving the diagnosis.

branding-images_final-daysJones counseled patients with varying prognoses, including those who would go on to live long lives after treatment, but in her role, she often saw people at the very end, when they had been told they had only months or weeks to live. “Once they know that treatment isn’t working and there are no more options, it seems like people hit a fork in the road emotionally,” she says.

One path certain patients chose was accepting their impending deaths but also determining to answer a weighty question: What do I do next? In her role as a counselor, Jones would talk to these clients about their legacies — what they wanted to say to or leave behind for their loved ones.

One of her clients was a father with a young son. He made a video that talked about the things he wanted his son to know but wouldn’t be there in person to tell him. The video included subjects such as what the son should know about middle school, about girls and about sex.

The other fork in the path that Jones commonly witnessed was complete denial of the terminal diagnosis. She heard patients make statements such as “This isn’t happening” or “I’m not going to die.”

As a counselor, her role was to try to guide these patients toward acceptance. She acknowledges that the task was difficult. “It so goes against our belief and training and experience [as counselors] to have to say to someone, ‘But your end is near,’” she says.

Jones would sit with these patients and encourage them to talk about their feelings regardless of what they were: fear, anger, sadness, disbelief, etc. After validating what they were feeling, she would circle back around to acceptance and the importance of deciding what they wanted to do or say before they died.

Groves, currently a private practitioner in Denton, Texas, often used existential and person-centered therapy when working with individuals in denial about their impending death. “Person-centered therapy gives the patient the lead in directing the conversation in the way they feel it needs to go, at their own pace,” she says. “We talk about denial openly and how it helps or serves a purpose, as well as how it might work against them. Helping a client make a cost-benefit analysis regarding denial is empowering and respectful of [his or her] needs.”

Of course, it isn’t uncommon for family members to be dealing with denial too. Jones, who would also provide family therapy in her role, says this can create tension between family members and the person who is dying, just when that person needs more support than ever.

Seeking support

Emotional support from family members is important, but the principal source of support for many clients is their husband, wife or partner. If discord is already present in the couple’s relationship, these problems will only be exacerbated by the stress of serious or terminal illness, says ACA member Nicole Stargell, who has used emotionally focused therapy (EFT) with couples facing breast cancer diagnoses. EFT operates on the premise that to feel “attached” (safe and secure) in a relationship, couples must be able to manage and share their emotions, she explains.

When certain people experience conflict or distress, they withdraw — sometimes physically — and don’t want to talk about the problem or issue, Stargell says. Other people are “pursuers,” she continues, and their desire is to talk about what is wrong. Pursuers will actively seek responses from their partners.

Anytime that either partner displays withdrawing or pursuing behaviors, implicit assumptions are being made, says Stargell, an assistant professor of counseling and the field placement and testing coordinator at the University of North Carolina at Pembroke. For instance, partners who withdraw often do so because they perceive themselves not to be strong enough to cope or view themselves as being deficient in some other way. When pursuers try to talk to withdrawers about what is wrong, this just reinforces the withdrawers’ feelings of deficiency, Stargell explains. Meanwhile, pursuers are thinking that withdrawers don’t regard them as being important enough to try to talk things through with them. As a result, both partners end up feeling alone and unsupported, which isn’t good for either individual’s mental or physical health, she says.

Using EFT, Stargell would identify the cycle of misunderstanding that plays out repeatedly between the couple but make it clear that neither partner is to blame. Next she would help the couple start to reframe their interactions by asking them to talk about a conflict and actually say out loud what they were thinking in response to their partner’s behavior.

Stargell would then help the couple see that their reactions had more to do with self-blame than with the other person’s actions. In other words, there was no implicit message attached. She would also have the couple role-play, taking turns presenting a problem and practicing reacting differently to what the other person said or did.

Stargell also works with couples to identify triggers or recurring situations that tend to set off the negative cycles. For instance, in the week following chemotherapy, the partner who is a withdrawer and is undergoing treatment might retreat emotionally, in part because he or she is sick and feels like a failure for not being able to perform his or her normal role, such as being the one who washes the dishes. Because the withdrawing partner is sick, the pursuer doesn’t want to push for interaction. However, Stargell says, it’s not uncommon for the pursuer to feel some anger or resentment about the things the partner with cancer — or the couple together — can no longer do. The withdrawer can typically sense the underlying tension, which makes him or her withdraw even more. Together, Stargell and the couple would talk about what the couple could do differently the next time the withdrawing partner has chemotherapy.

Approaching the end 

There are many ways that counselors can support and assist clients who know that they are dying. “I have helped clients find meaning in their personal [histories] and accept suffering during the dying process by engaging in life review and reminiscence, with both laughter and tears, allowing them to say what they haven’t been allowed to, reconciling unfinished business from the past [and] helping them connect with and share their true feelings with their loved ones,” Groves says. But sometimes, the most significant role is “just sitting with them in silence as a companion,” she adds.

Groves has also helped clients facing death to work through their fears and concerns. These have included issues such as feeling guilt about being ready to die when family members beg them to keep fighting; fear of more pain or agony; weariness from long medical treatments; spiritual doubts or fears; and anger over family conflicts erupting or being exacerbated during the medical crisis.

Jones would sometimes take on a sort of facilitator role with these patients, making sure they received what they wanted or needed in their final weeks or days of life. But counselors can also advocate for patients in other ways, Jones says. Especially toward the end, patients with terminal illnesses can experience a significant amount of pain but may not want to take yet another medication. She recommends that counselors working with this population educate themselves about alternative methods of pain relief and relaxation techniques.

As the end approaches, some individuals find it easier to accept that they are going to die, whereas loved ones often have the opposite reaction, Groves notes. “Curiously, people who are near death may be more calm … because they have accepted their prognosis, while their loved ones struggle with denial and avoidance because they are not ready to let them go,” she says. “When a person dies, the opportunity to make peace with them is over, so at least when the person is still hanging on, the belief or hope that it can be reconciled is still there. They may fear letting that person die with unfinished business still between them but struggle to vocalize those unsaid things because they don’t feel it’s appropriate or acceptable.”

Groves says counselors can also play an important role in preparing family members for what to expect in the dying process. “If hospice is involved, their nursing staff may make an extra effort to help counselors explain to the family what is happening biologically, the signs of impending death and other medical information,” she says. “A counselor can also be of help with active listening, reflecting feelings, normalizing emotional responses, addressing spiritual and existential concerns, and [exuding] warmth. Many people do not know what to do or say, so they do or say nothing at all, leaving the family members stranded in their grief. Counselors are equipped to sit with people in pain and be present with them.”

Groves also believes that being present when a loved one dies can be very healing for family members. “It’s very hard to witness a death and, frankly, most people fear and avoid that experience,” she says. “They are typically afraid they will be overwhelmed with their feelings and be unable to cope. But if one is willing and able to tolerate the discomfort, with the support of the counselor, being with a dying person in their final moments allows one to genuinely embrace the natural process of death and confront its reality, which is important for healthy grieving.”

 

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Related reading: See Counseling Today‘s November cover story, “Grief: Going beyond death and stages

 

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

Letters to the editorct@counseling.org

 

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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.

 

 

Growing up: An allegory

By Shawn Patrick September 15, 2016

When I turned 39, I had a midlife crisis. I wasn’t home on my 39th birthday. I was on another continent, sitting in a hotel lobby at stupid early o’clock, jet-lagged and writing because I couldn’t sleep. I looked up, saw the date and realized my birthday had occurred while I had been traveling, the day lost somewhere in the time vortex that opens up when flying overseas. Technically, then, it was the day after my 39th birthday when The Voice screamed at me, “What have you been doing with your life???!”

Granted, I had earned a doctorate, had achieved tenure, had published manuscripts. I had two lovely children, and I had managed to stay married to the same person longer than any other person in his or my family history. These are not small accomplishments. But this is not what occurred to me in that panic-inducing moment. Rather, The Voice pummeled:

“Why aren’t you on The New York Times’ best-seller list yet? What happened to the blockbuster movie? Where is the Fields Medal? Why haven’t you played Carnegie Hall yet? You haven’t even photo-1458175049065-aefb15b1b58bbothered to figure out the grand unification theory bringing together quantum mechanics and the theory of relativity — you’ve been sitting back letting Stephen Hawking do all the work. What the &$@# is wrong with you?”

Part of the problem for those like me is that we still cling to our childhood fantasies of success. We grew up imagining ourselves getting discovered simply because Hollywood Movie Mogul in a red convertible Mercedes screeches to a halt while we’re walking down the street and shouts, “There, there is the person I’ve been waiting for!” And the other part is because we were given some remarkably confusing aspirational advice.

In grade school, I was in the first group of identified “gifted” children. I didn’t know what it meant, and no one else understood it either. But to the dozen of us who were selected, it meant that we could leave class a few hours each week and play games. This was a good deal in our opinion, so we didn’t question anything. Yet without our knowing, we were already receiving those sneaky messages about where our lives were supposed to end up.

The social strata are well-established by high school, telling us who is and is not supposed to be a productive member of society. We instinctively knew there were no real differences between these arbitrary groups; the “achieving” group could simply get away with more because no one expected us to do anything illicit. The “remedial” group included plenty of individuals who were extremely smart and capable, but for reasons well outside themselves, no one paid attention to them anymore. This stratification persisted due to factors outside our control and taught us about the many forms of privilege and its consequences.

Many of us slowly go insane from pressure to climb to the top of the mountain, to win, to be the best at whatever is deemed successful. If we don’t accomplish it, then we have let the whole of civilized society down, our ancestors are forever shamed, and our future offspring will only hope to dream about peeking through the window of a good school. Include the discourses bombarding teenagers about being “Someone” — e.g., a doctor is better than a nurse, a scientist is better than an artist, a rich person is better than a poor person. So often our legacies make no sense to us. We are pushed by unexplained, invisible forces, but if we make a mistake, we will ultimately carry all the blame for what goes wrong. Everyone loves to claim the credit when someone succeeds, but if that person fails, it’s all on you, baby.

I never knew what I wanted to do. When I graduated high school, I had one very well-meaning teacher give me the kiss of death. I experienced heart-palpitating conflict over choosing a college major. Enter this literature teacher who took great interest in my writing. At the end of the term, I asked him to sign my yearbook. He wrote:

“Good luck to you in all you do. I know you’ll go far. Keep writing because it’s clearly what you were meant to do. Of course the last person I said that to now only writes grocery lists. Best wishes, B.”

He had a genuine interest in my future, and I suspect he thought he was being funny. But he had no idea how this gong resonated throughout my core, highlighting the double bind I lived with: You can do anything you want, but what you want might not amount to anything.

When I turned 39 in a hotel lobby, all I’d really figured out was that in one year I’d be 40. What did I have to show for myself? Had I even come close to approaching some of the lofty aspirations I held for myself, or did I too end up writing grocery lists?

Part of maturity is realizing that the frenetic pace of youth cannot be maintained. Eventually, we have to abandon the immature need for immediate gratification. Recognizing our mortality means catching on to the idea that one is not interested in dying due to blowing out your own candle; death will come in its own time, so why not learn to live? These are the chronic existential conversations that infiltrated my head as an adult who had to concern herself with things like paying bills. And the appearance of children completely redesigns the landscape — a total home renovation that leaves you forever wondering where you left your keys. So pacing becomes a necessity. Priorities must occur because we are forced to write our own instruction manuals for adulthood.

But the adult dilemma becomes, did I pace myself too much? Did I slow down to the point of stopping? Specialization is an ironic creature. It is comforting to think you actually know something. However, the danger in such comfort is that it can easily lull you into complacency. Did I avoid the new thing because I didn’t have the time, or because it would mean stepping outside of what was familiar? In the guise of developing “expertise,” did I actually limit myself from gaining knowledge?

“How have you made your mark on the world?” Regardless of how far-fetched, lofty, idealistic or fantastic my earlier aspirations were, they were there to tell me to make more of myself. Not in the sense of being the best, biggest, brightest or richest, but in the way of being more than just what was prescribed for me. Have I challenged myself? Have I at least tried to take a risk, or do I still play it safe? Did I keep listening to what everyone else demanded for my life, or did I speak up and say, “Here I am, like it or lump it.”

Disturbingly, my answer at age 39 was, “Well, sort of.” In examining how I had established myself, I found that even though I wasn’t writing grocery lists, I hadn’t exactly written sonnets either. Perhaps I felt like something was missing because something was, indeed, missing. Perhaps I was being told it was time to take the next step. I had allowed myself to live with a list of “what if” questions — What if I’d done this? What if I had gone there? What if I were like that? — and I’d fallen into the trap of constant speculation. Everyone wants to be Yoda, but I was at risk of turning into nothing more than Super Grover stuck in a tree.

I didn’t know what my mark would look like, but I decided I could live as though I had made one and see what happens. I stopped saying “no” and started saying “yes.” That’s not to say that I suddenly started agreeing indiscriminately with some “you can do anything” illusion. Instead, I decided that fear or social disapproval would no longer be enough of a reason to prevent me from trying the new thing. “It’s the way it has always been done” was no longer a good enough reason to stay the same. Not knowing became the reason for acting.

Experiments in living can have curious effects. All kinds of wild ideas entered my mind. Not all were viable, but the energy that comes from rediscovering one’s creative power is intoxicating. It flows into every part of work and life.

If this were a fairy tale, I would stop at this “happy ending.” But I’m not trying to wrap my experience up in a neat bow, nor am I trying to say that this is just my story. I’m not 39 anymore. I’ve had a few years to live with my experiment, and I prefer living this way. But it has not made life easier. In fact, living as though the “what if” has already been answered makes life more challenging. But it’s a challenge I put to others — and especially to a counseling profession that also seem to have gotten stalled in its own internal-gazing.

Twenty years ago during my master’s program, my professors said that counseling was in its adolescence. Today, we are still struggling with questions of identity. Who are we? What are we about? What do we believe in and stand for?

We have gone through several fast-paced movements, some which have enhanced us and some of which have diminished us. Like so many tumultuous progressions, we regularly take three steps forward and two steps back. Yet we also seem to have lulled ourselves into a strange quietude, the kind where we exude certainty until we are asked to define what it means to carry this mantle. In our quest for legitimacy, we could very well have sold ourselves out, making us into a caricature of the professions we seem to think we should be. Are there lessons we can borrow from fields such as psychology, social work or psychiatry? Certainly. But at what point do we stop saying, “This is who we are not” and instead assert, “This is who we are?”

The “what ifs” have caught us for far too long. How many debates, circular arguments really, do we get into about which theory is the “best,” which specialty is the most important, who is the most moral or just? At what point will we admit to ourselves and the rest of the public how many of our choices have been profit driven — claims staked to promote our own brand of job security? What do our politics really say about us — not an individual’s personal views, but the fact that we as a profession still argue amongst ourselves about who is granted personhood.

What if instead of fighting over limited crumbs, we acted like a profession with a unified vision, not of what each counselor should do but of who our profession is meant to serve? What if we stopped proving our legitimacy through purely Cartesian lenses and instead recognized that the totality of our work cannot be reduced to widgets and Facebook memes but must also encompass a marvelous, mysterious human interaction? What if instead of resting on our certainties, we asked ourselves in what ways our insecurities have seduced us into believing that the illusions we cling to are the realities that everyone must follow? What if instead of being afraid of our differences, we took a chance to allow ourselves to be influenced by each other in the ways in which we arrogantly expect our clients to be influenced by us?

Prepare to grow up, Counseling. What have you been doing with your life?

 

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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.

 

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Shawn Patrick is an associate professor in the counseling and guidance program at California State University, San Bernardino. Contact her at shawn.patrick@csusb.edu.

 

 

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.

Conclusion

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?

 

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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

 

 

 

Validating the quarter-life crisis

By Lynne Shallcross April 22, 2016

More than a decade ago in the song “Why Georgia,” musician John Mayer put words to a phenomenon that many 20-somethings sense all too well.

“I rent a room and I fill the spaces with/ Wood in places to make it feel like home/ But all I feel’s alone/ It might be a quarter-life crisis/ Or just the stirring in my soul/ Either way I wonder sometimes/ About the outcome/ Of a still verdictless life/ Am I living it right?”

Despite its inclusion in a hit pop song, the quarter-life crisis isn’t always taken seriously by society at large. “Nobody questions the midlife crisis,” points out Cyrus Williams, an associate professor in the Branding-Images_quarter-lifeSchool of Psychology and Counseling at Regent University, but the same isn’t always true of the quarter-life crisis, which Williams defines as a period of significant life and career transitions for young adults between the ages of roughly 22 and 30.

“As a culture, we all think that age 25 is the best stage of your life — these folks are happy, they’re doing everything they want and it’s a great time of life,” says Williams, an American Counseling Association member who has been studying and speaking about the quarter-life crisis for more than five years.

In the counseling session, however, the quarter-life crisis — a developmental time period of potentially high anxiety — needs to be given the same level of respect and attention as the midlife crisis rather than being dismissed out of hand, Williams says. “We really need to acknowledge and not minimize this time period,” he emphasizes.

Decisions, decisions, decisions

In their early 20s, many young adults are graduating from college and find themselves faced with a deluge of life transitions, Williams explains. There are choices and changes swirling around them in almost every major area of life.

They are deciding where to live, whether moving to their own apartment (or a shared living space) in a new city or back into their parents’ home. They want to pursue a career but sometimes find themselves stuck in entry-level jobs that don’t pay their bills or student loans. They wonder whether they should already be in a committed relationship headed toward marriage and a family. They question whether and how they will develop new friendships while hanging on to old ones from their high school or college days.

All of those issues can lead to feelings of anxiety, fear, instability and an existential crisis of “Who am I?” Williams says. “There are too many choices, too many decisions to make, and it’s scary,” he says.

This time in life can also dredge up self-doubt, says Melissa Nelson, a doctoral candidate in counselor education and supervision at Regent University who has been researching the quarter-life crisis with Williams. For example, some young adults might see that a peer has landed a successful job and become financially stable and start wondering why they haven’t been able to follow the same timetable. This can make young adults question themselves, their decisions and their abilities, says Nelson, a member of ACA. “Did I major in the right thing? Is there something wrong with me?”

It isn’t uncommon for clients in their 20s to present in the counseling session with feelings of depression and anxiety, says Katherine Hermann, an assistant professor in the Department of Counselor Education at the University of Louisiana at Lafayette. The idea of leaving a close-knit community, whether the town where someone grew up or the circle of friends an individual developed at college, can be isolating, says Hermann, who has presented on transitions in adulthood. The search for a romantic partner can also feel isolating and provoke anxiety, she points out.

Young adults in this stage may also feel a sense of betrayal, Williams says. Many of these individuals have grown up being told by parents, teachers and others that if they follow the rules and check all the boxes they’re instructed to, life will work out as it is supposed to. When things don’t fall into place that seamlessly, Williams says, these young adults feel lied to.

In such cases, Williams says, it can be helpful if counselors talk through those feelings of betrayal with clients, allowing them to express why things feel unfair and then working together to move forward past those feelings.

All of the anxious feelings that are normally experienced at this time of life can be exacerbated by social media, Williams adds. For instance, on Facebook and Instagram, people tend to post messages and photos documenting only their best experiences, which doesn’t translate to a realistic account of life. “That is one of the things that other generations didn’t have to deal with,” Williams says. “They [didn’t] have to have this in their face every day of ‘Wow, my friend is having a great life and I’m not.’”

Nelson agrees. It is easy for people in this stage of life to get caught up in comparing themselves to peers who post photos or messages related to career success, romantic adventures or starting a family. “What does that mean for an individual who doesn’t have those things yet?” Nelson asks.

One key is for counselors to talk with these clients about how social media rarely shows the day-to-day reality of people’s lives, Williams says. That simple action can help young adults begin to put things in the proper perspective, he adds.

Keep your ‘therapeutic antennae up’

With all those choices and transitions hurtling toward young adults in rapid succession, how can counselors help most? “I wish there was a magic answer,” says Hermann, a member of ACA. Short of that, developing a strong therapeutic relationship is perhaps most important, she says, along with gathering and attempting to understand the perspective of the client as much as possible.

“I think having your therapeutic antennae up is one of the most important things,” says Hermann, who adds that the client’s presenting problem isn’t always the real problem. Get to know these clients and work on the issues they present with, she says, but also be open and attentive to exploring other issues of which they may not even be aware.

Counselors should also know that these clients aren’t afraid to walk through your door, Williams says. “This generation is not like generations in the past,” he explains. “There’s not a stigma involved in mental health issues [with them]. They’ll come in to your office and they’re like, ‘Listen, I’m stressed out, I’m anxious. I need some help.’”

In return, Williams says that he stands ready to help these clients identify what they are experiencing. He specifically uses the term quarter-life crisis with young adult clients because he says it is empowering for them to hear a phrase that defines their experience. “It’s liberating for them,” Williams says. “They’re like, ‘Holy crap. OK. I get it. This is what I’m going through right now.’ So normalizing this is very important.”

Nelson agrees, adding that 20-somethings are reading magazine articles and self-help books on this topic as a way of finding support and normalizing their experience. “If we as counselors and therapists don’t do the same in normalizing this and recognizing this,” Nelson says, “then we’re not providing the comprehensive services that we need [to].”

Even if career counseling is not a counselor’s specialty, being well-versed in career counseling topics is imperative when working with these clients, Nelson says, because career issues are intricately tied to many other areas of life, from identity to finances to relationships. For example, Nelson says, paying for a house or paying for child care is tied to family and partner relationships, but it is also dependent on career decisions. That means that even if a counselor doesn’t specialize in career or academic counseling, it is critical to have a basic understanding of those areas of counseling, she says.

On the flip side, Nelson says, career counselors might have young adult clients come in for help writing résumés, only to discover that their parents are pressuring them to create the “perfect” résumé in order to find the “perfect” job. Or perhaps a counselor working with a couple in premarital counseling might find that one member of the couple is struggling with career and financial worries. Nelson suggests that counselors try to look holistically at everything going on in these clients’ lives.

Williams points out that, of course, not every 20-something is going to experience a full-blown “crisis.” But the potential is there for these various life transitions to lead to crisis if young adults don’t have the coping skills and supports in place to weather changes in a healthy way, he says.

Counselors would be wise to do assessments with these clients at the outset of counseling, Williams says, especially to help determine whether they might be experiencing clinical depression or anxiety. Then, he says, counselors should hear these clients out and try to understand where they’re coming from.

Williams often explores existential questions such as “Who am I?” and “What do I want to do with my life?” with clients in this age group. He also reminds these clients that the answer to what they want to do with their lives doesn’t necessarily have to be related to their jobs; a job can pay the bills without necessarily “satisfying” or defining every aspect of the person. Williams prefers a holistic perspective, asking clients to think about what things in life make them happy, bring them meaning and help them make sense of the world.

No one right approach

When working with clients on quarter-life crisis issues, Williams suggests that practitioners remember to keep the counseling brief. Although these clients tend to be more willing than generations past to seek out counseling, they also generally want a faster route to a solution, not years of sessions, he observes.

“They come to counseling, but they don’t stay in counseling,” Williams says. Brief, solution-focused and existential approaches are often the best alternatives with these clients, he says. At the same time, many young adult clients aren’t afraid of doing work toward arriving at the solution, he adds, so counselors shouldn’t hesitate to suggest books for them to read, questions for them to ponder or other homework for them to do between sessions.

When deciding which interventions to use with these clients, Nelson suggests that counselors familiarize themselves with the literature on evidence-based practices related to life transitions, such as the school-to-work transition or the transition of becoming a family. Because the quarter-life crisis is a newer area of study that hasn’t yet been extensively researched, Nelson says it is hard to pronounce whether one counseling approach would be more effective than another. She believes almost any evidence-based approach can be effective with these clients, although she tends to lean toward existential-based approaches.

Williams came up with an intervention that he calls the “NEEDS” approach. The “N” stands for normalize, which all three counselors interviewed for this article highly recommend trying to do with clients confronting a quarter-life crisis.

The first “E” stands for empower. Williams says counselors can do this by arming these clients with anything from books to YouTube videos that will help them feel less alone and more confident that what they are experiencing is real.

The second “E” stands for taking an existentially focused approach. Williams says this involves helping clients explore who they are, what their calling is and the “why” behind it. For example, if young adult clients are focused on landing a particular job or moving out of their parents’ house, Williams will ask them to examine the “why” behind those desires.

The “D” stands for a developmental approach, in which Williams encourages clients to explore the “long continuum” of their lives, and also the decision-making skills that are required at this time in life. The decisions that 20-somethings make can have consequences that extend into their later years, he points out. For example, some young adults make the decision to run up their credit card debt so they can rush to move out of their parents’ home, while others decide to get married and have children before they are truly ready.

The “S” stands for screening and assessment, which Williams says is a must in determining whether clients are experiencing a normal transition or if their experience has crossed over into crisis mode.

Prevention where possible

Although counselors must be prepared to help 20-somethings who already find themselves in the midst of a quarter-life crisis, Nelson says practitioners should be thinking with a preventive mindset whenever possible. For example, she says, counselors who work with college students can help those students better prepare for what lies ahead by engaging them in exercises to build their self-esteem and raising their awareness of the challenging decisions and transitions that might pop up in the near future.

University counseling centers might be able to offer graduating students continued career counseling services until they land jobs, Nelson says. If such services aren’t feasible, she suggests that college counselors ensure that their clients who are graduating leave the school equipped with referral sources. She encourages college counselors to add website resources for recent graduates “who are feeling the heat of the quarter-life crisis.”

Nelson says counselors must do what they can to arm graduating students with the tools they need before they actually need them. “Getting the information out there and the resources out there before it becomes a problem is really important,” she says.

In preparing to work with clients on issues related to the quarter-life crisis, Nelson says it is crucial for counselors to be aware of changing cultural dynamics. For example, she says, counselors should understand how social media can further complicate life transitions for young adults and how changes in unemployment rates and student loan rates can have “very real implications” during an already frightening time period for 20-somethings.

Counselors who desire to work with young adult clients should read more about this generation, Williams says. Understand what makes them culturally unique, what is significant to them and what has shaped their lives. Among the resources that Williams suggests is the 2001 book Quarterlife Crisis: The Unique Challenges of Life in Your Twenties by Alexandra Robbins and Abby Wilner.

“Cultural shifts of parenting style and expectations are one of the greatest mitigating factors in understanding millennials,” Williams says. “Concepts such as positive reinforcement rather than punishment, or self-esteem building rather than tough love, became popular during the millennials’ formative years. Millennials were revered by parents and sheltered from the world, developing unrealistic expectations of self and never learning skills necessary for survival in the ‘real world.’ Often they have been sheltered so much that they have not been allowed to learn to survive on
their own.”

“In addition to the confounding dynamics such as parental influence, millennials have come to age during a period of significant corporate downsizing, unemployment, underemployment and outsourcing,” Williams continues. “The estimated unemployment rates for young adults are more than double that of overall unemployment rates. As a result, young adults face increased financial stressors, often resulting in an inability to pay student loans, save for retirement or maintain independent living. It is estimated that approximately 44 percent of recent college graduates are currently experiencing underemployment, working in fields and positions in which they are overqualified. Like many other generations, work is a crucial aspect of one’s identity and expression of self. Consequently, when employment aspirations and ideals are not met, crises of personal identity may result.”

Hermann agrees. “Understanding the culture of this population will be important to sustained treatment success,” she says. “I think a systemic perspective is very important, and understanding the individual within [his or her] environment, especially as it pertains to relationships — family of origin, intimate, social, professional — is imperative to treatment.”

Hermann recommends two journals published by ACA divisions to counselors who might be working with this population. One is Adultspan Journal (published by the Association for Adult Development and Aging), which includes topics relevant to young adults. The other is the Journal of Creativity in Mental Health (published by the Association for Creativity in Counseling) “because of the innovative, therapeutic applications that engage and challenge clients to think differently,” she says.

Expert wisdom

To help counselors better prepare to work with clients undergoing a quarter-life crisis, Counseling Today asked these experts to weigh in with their best advice and guidance. Here are their top tips.

  • Don’t minimize the quarter-life crisis, Nelson says. “Far too often, that’s one of the reasons that an individual is there [in counseling] in the first place.” In many cases, parents, peers or co-workers have minimized what these 20-somethings are experiencing, which only ends up increasing the pressure on them, Nelson says.
  • Do focus on wellness, decision-making and the future, Williams says, not pathology.
  • Don’t make assumptions, Hermann says. “Every client has a different past and goals for the future. Focus on the individual,” she says. Although counselors develop models and frameworks to understand patterns, “every person is a unique human,” Hermann reminds her colleagues.
  • Do your research, Nelson says. Become aware of factors outside of your counseling specialty or area of practice that may be affecting young adults. “Awareness is half the battle,” she says.
  • Do make it clear to these clients that this is short-term counseling, Williams says, “because you lose Generation Y if you are going to ask them to come back for 15 sessions. They really need to see the end from the beginning.”
  • Don’t rely solely on clinical intuition, Williams adds. “I love the fact that we are intuitive, but we have instruments and science out there that can help us,” he says.
  • Do consider group therapy. “If you are working in a setting that has the ability to utilize group therapy and group counseling interventions, I would say go for it,” Nelson says. “I think that group counseling can really help that process of normalizing the crisis [and] developing a support network for individuals beyond their counselors.”
  • Do take the time to explore the individual’s relationships, including family relationships, intimate relationships, friendships and work relationships, Hermann says. “This exploration will give counselors an understanding of the individual and also the depth and capacity of [his or her] support group. In addition, so many of the changes that occur during this developmental period are connected to changes in relationships, so having a complete understanding of the relational aspects of an individual can be helpful in understanding and focusing a treatment plan.”
  • Do encourage these clients to address their relationship with their parents, Williams says. It is a relationship that has likely changed now that these young adults are in their 20s, but it is a relationship and an influence that has long been paramount to them, he says.
  • Do normalize the crisis, Nelson says. Point clients toward books or other resources to help them recognize that they are not alone in experiencing these struggles and challenges.
  • Do explore identity development with clients, Hermann says. What is meaningful to them, and how do they create meaning?
  • Do give these clients resources, books to read and homework to do, Williams says. They are typically used to being on the computer and doing research, so they are likely to engage in the homework related to their own counseling, he says.
  • Do ask questions and then address any issues that become apparent from the answers, Nelson says. “Is it stressful to pay your student loans each month? Is it stressful to be pressured by your parents to be married and to have children, and how are you dealing with that?” Nelson suggests asking. “I don’t think that counselors need to be afraid and shy away from addressing the quarter-life crisis.”

 

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To contact the individuals interviewed for this article, email:

 

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Lynne Shallcross, a former associate editor and senior writer at Counseling Today, works for Kaiser Health News as a web producer. Contact her at lshallcross@gmail.com.

Letters to the editor: ct@counseling.org