Tag Archives: Human Development Across the Lifespan

Human Development Across the Lifespan

Culturally competent end-of-life counseling

By Ashley C. Overman-Goldsmith May 1, 2019

End-of-life counseling is an important area of our profession. Unfortunately, it is also an area of the profession that is underdeveloped and seldom researched. Consequently, few resources are available to professional counselors that specifically address multicultural competence in end-of-life counseling.

I first became interested in end-of-life counseling while working as a bereavement program manager and counselor in a private hospice setting. As a bereavement counselor, I worked not only with the families of patients receiving hospice services but also with higher risk patients (those who struggled with psychological and physical pain). The private hospice organization provided social services for patients, but our social workers had large caseloads and found it difficult to meet the emotional and psychological needs of patients and family members who required ongoing therapeutic intervention. To meet those needs, I developed an end-of-life counseling program in which I personally worked with patients and family members deemed medium to high risk.

I currently practice counseling at Sea Change Therapy PLLC, where I help individuals who are struggling with life transitions, including the end of life. In addition to my clinical practice, I am conducting research in end-of-life counseling under the advisement of my dissertation committee at North Carolina State University.

The list of reasons for counseling at the end of life can be similar to the reasons that individuals seek out counseling earlier in life. The largest difference, of course, is that with end-of-life counseling, the client is facing his or her death. This makes this area of counseling all the more challenging. Because these clients die at the end of counseling, counselors are responsible for so much more than just helping clients pursue improvements in a relationship or changes to an existing issue. Counselors are helping these clients achieve goals that may improve the possibility of them experiencing peace before they die. This is a major undertaking.

As an end-of-life counselor, I have witnessed the impact that clients’ lived experiences and aspects of their identity have on their end-of-life experiences. These experiences are personal, unique events that require counselors to be skilled in addressing a multitude of issues regarding both a client’s identity and the dying process. Multicultural and social justice competence is key to counselors being able to provide effective end-of-life counseling and help clients navigate end-of-life experiences successfully.

The Multicultural and Social Justice Counseling Competencies (MSJCC) endorsed by the American Counseling Association are a set of guidelines for developing and maintaining multicultural and social justice competence as counselors. The MSJCC framework aids in understanding the complexities of the counseling relationship, specifically with counselor–client interactions. The MSJCC support counselors in addressing issues that are often not well-recognized but that have a significant impact on the client. These issues include power dynamics, privilege and oppression. The MSJCC are well-supported by our profession and are a very useful tool for promoting cultural competence for counselors.

The Handbook of Thanatology, a resource created for practitioners by the Association for Death Education and Counseling, provides detailed, thought-provoking suggestions on how to be culturally competent when working with clients at the end of life. The handbook includes a combination of research findings, practical implications and recommendations for end-of-life practice.

Using the MSJCC and suggestions from the Handbook of Thanatology, counselors can ensure that they are providing culturally competent and effective end-of-life counseling services to their clients. Using these references, along with information from my professional experience as an end-of-life counselor, I have developed a simple framework for culturally competent end-of-life counseling practice.

Education

Education is an important component of culturally competent practice. Continuing our education beyond the completion of the master’s degree requirement is necessary for growth and effective practice in this field.

As professional counselors, we are required to complete a specific number of continuing education credits yearly to maintain state and national licenses. For many of us, a certain number of these continuing education credits are required in the area of multicultural competence. Continuing education in end-of-life practice is increasingly available, and there are many opportunities for growth across disciplines in this specialty area. For example, there are distance learning programs that provide thanatology coursework, including multicultural competence in end-of-life care. During my personal search for continuing education, I have come across numerous courses or sessions that are outside of the university setting. Professional memberships, local funeral homes, palliative care programs and medical facilities all offer continuing education opportunities, sometimes at little to no cost.

In addition to the more formal avenues for advancing your education, there are ways to learn and grow in the understanding of other cultures through observation, immersion and self-education. The Handbook of Thanatology says that if we want to better understand the beliefs and practices of a particular cultural group, immersing ourselves in that group can aid in this quest. Obviously, that approach is time-consuming and not feasible for all counselors. However, I would recommend, at minimum, that counselors observe and investigate the beliefs and practices of the clients (and clients’ family members) with whom they are working. Don’t fear asking questions that will improve your knowledge.

We are encouraged as counselors to be well-informed about what is going on in the world around us and to consider the ways in which events may affect our clients. For example, changes in health care coverage and policies can impact terminally ill clients and their families. Seeking out details on these changes and working to stay informed not only can help us to prepare for what our clients may be facing but can also provide us with information that could be important to pass along to our clients. Social, cultural and political developments may also influence our clients’ emotional and psychological states. It is important that we maintain an awareness of how these developments could affect clients from varying groups in different ways.

Possessing knowledge of both historical and current events — particularly those resulting in the oppression of a group of individuals due to their race, ethnicity, socioeconomic status, gender or sexual orientation — can help us better understand the lived experiences of our clients. Linking historical and current events can provide us with a clearer perspective on the adversities that our clients and their families continue to face. These adversities are woven into their personal narratives and are often revisited at the end of life. Our clients may want to remember the happy experiences they have had, but they may also recall the adversities they have confronted. Our clients’ worldviews, values, beliefs, and marginalized or privileged statuses (lived experiences) all have an impact on their perceptions of death and dying. In turn, their perceptions of death and dying have an impact on their end-of-life experiences.

Education is the foundation of culturally competent end-of-life counseling. Developing knowledge of the impact of history, events, culture, religion/spirituality and other influencers on our clients’ lived experiences can help us reach a better understanding of their end-of-life experiences. Possessing a solid knowledge base — and continuing to expand that base by seeking out educational opportunities — has a direct impact on the effectiveness of our practice as counselors.

Practice

This section of the framework is designed to be used in addition to the approaches and interventions that end-of-life counselors are already trained in and currently practicing. Like other areas of the counseling profession, end-of-life counseling is not limited to one single approach or a specific set of interventions.

Culturally competent end-of-life counselors embrace the fact that multiculturalism and social justice are central to end-of-life counseling. In culturally competent end-of-life counseling, counselors work to be aware of the many identities that counselors and clients possess, as well as their privileged and marginalized statuses. These identities and privileged or marginalized statuses enter into and influence how each individual will experience interactions that occur during the counseling relationship. Culturally competent end-of-life counselors skillfully facilitate discussions about these identities and statuses. They share information about their own identities, allow clients to explore their personal identities, and work to identify and overcome any barriers that may arise in the counseling relationship.

The knowledge that culturally competent end-of-life counselors possess and continue to build upon (addressed in the education portion of the framework) aids them in better understanding clients’ identities. Open dialogue about these identities can help counselors gain insight into an individual’s unique background. Through this work, clients may even come to recognize their diagnosis or terminal illness as a new identity or way in which they see themselves. When this happens, counselors can help clients examine this new identity and use interventions that are helpful in exploring clients’ perceptions of what this new identity means to them.

Occasionally during this time in the counseling process, clients will discuss experiences that led to their understanding of these identities. These experiences and others that are shared during counseling are the clients’ lived experiences, which may influence how they view themselves and their end-of-life experience. Making space for these discussions (or even initiating them) and asking questions to better understand our clients helps us to become more culturally competent counselors. As a result, trust is built between the counselor and the client, and the counseling relationship is enhanced.

In end-of-life counseling, these discussions usually take place early on in the counseling relationship. In fact, faster development of the counseling relationship can be more critical in end-of-life counseling than in other areas of counseling practice. Allowing opportunities for these discussions early on may greatly enhance the client’s comfort in sharing with the counselor and may aid in achieving the goals of counseling in the limited time available.

The ultimate goal of end-of-life counseling is to facilitate psychological and emotional healing that will allow clients to experience peace. Counselors and clients work together to identify sources of stress or any psychological disturbances (e.g., depression, anxiety) that are preventing the client from achieving peace. Reasons behind the presence of disturbances such as depression or anxiety may vary. Clients might express fear of death, a sense of isolation, a loss of purpose or meaning, struggles with feelings of guilt, conflict in relationships or other concerns. Occasionally, struggles in relationships, personal regrets, feelings around a loss of independence, feelings of loneliness, or emotions connected to experiences with racism, sexism, religious oppression or other forms of oppression may also surface at the end of life.

Culturally competent end-of-life counselors understand that clients’ lived experiences (inclusive of issues such as oppression and discrimination) are unique and personal and should be handled delicately. Providing a safe space for clients to express their feelings surrounding these experiences is an important step in helping them achieve peace at the end of life. This safe space is created early on in the counseling relationship through structure, support, encouragement and unconditional positive regard. It is enhanced when counselors effectively and openly discuss identities, privileged or marginalized statuses, and issues such as oppression and discrimination. Allowing space for the anger, frustration, sadness and other feelings that clients may feel when sharing about these experiences is very important.

The MSJCC emphasize the need for counselors to work outside of the office, meeting directly with the client’s family members and friends (with permission from the client) to determine what relationships exist that will either support the client’s progress in counseling or present barriers to change. With end-of-life counseling, counselors are more likely to work with the client outside of the office. This might include meeting in hospice facilities, nursing facilities, assisted living facilities, hospitals or clients’ homes. As a result, end-of-life counselors are occasionally afforded opportunities to observe interactions that clients have with their family members and friends. If clients have identified resolution of conflict in a relationship as a goal of end-of-life counseling, then counselors are able to intervene.

By facilitating these discussions early on in the counseling relationship, counselors can create the solid foundation necessary for various counseling approaches and interventions. Counselors should ensure that they are using approaches and interventions that are culturally appropriate and that empower clients.

Advocacy

Advocacy at the end of life can be complicated, but it is important that we make sure our clients’ voices are heard. End-of-life counselors often are responsible for updating the interdisciplinary team about the client’s emotional and psychological well-being and the progress being made in counseling.

The interdisciplinary team (sometimes referred to as the multidisciplinary team) generally consists of medical professionals (doctors and nurses) and a group of supportive services professionals that can include some combination of social workers, counselors, psychologists, and clergy or spiritual care counselors. These teams are usually organized and assigned through hospitals and palliative care/hospice organizations. Team members work together to ensure that they are meeting the needs of individuals enrolled in services. Team meetings can vary in approach, but in my experience, each team member is asked to provide an update on the services for which they are responsible, along with any concerns they have about the needs of the individual who is facing end of life.

As counselors, we are often uniquely cognizant of the emotional and psychological needs of our clients. This gives us the ability to identify additional issues that are affecting our clients’ well-being. We can share these concerns and challenges with the interdisciplinary team in many ways. For example, we can relay information about the progress our clients are making in sessions by tracking their levels of depression or distress via simple assessments and then presenting our data during team meetings. We can also bring up any concerns that our clients have voiced during sessions regarding their care or interactions with other team members.

Our role on the team also gives us opportunities to educate the other team members on cultural considerations. The cultural insights we provide may influence discussions that these other team members have with our clients and their family members. Because of our greater level of understanding of the lived experiences of our clients and the impact these have on our clients’ end-of-life experiences, we can provide guidance to the team on how best to provide individualized care to clients.

In our role as advocates, we can also give voice to our clients’ end-of-life wishes. This may sometimes require us to relay difficult and sensitive information (again, with the client’s permission) to family members, team members and caregivers. This might involve the client’s desire concerning the presence or absence of certain individuals during the end-of-life experience, the environment in which the person wishes to die, requests for final meals, the kind of medical care or interventions the person would like to receive, and so on. As advocates, it is important that we relay this information in ways that are sensitive while also being true to our clients’ voices.

In addition to our responsibility to give our clients voice, it is also important that we work to improve the understanding of the attitudes, beliefs, biases and prejudices that exist in our communities, not just in our places of work. Among the ways we can do this are advocating for policies and procedures that rectify existing inequities, offering additional support to marginalized clients, and collaborating with others to address issues of power, privilege and oppression in advanced care settings. Some examples of how these issues arise in advanced care settings include the ways in which information is relayed to marginalized clients and assumptions that all clients have strong support systems, the same knowledge of or experience in health care settings, and similar perspectives on the end of life. Providing education on culturally competent practice to others who work in end-of-life care can also serve as advocacy. Advocacy is a part of cultural competence, and it is an important role that end-of-life counselors can play for clients.

Summary recommendations

Key considerations for providing effective, culturally competent end-of-life counseling are as follows:

  • Seek out educational opportunities that challenge and expand your understanding of multicultural and social justice issues in end-of-life counseling settings.
  • Treat the “whole” client and not just the parts of the client with which you are comfortable.
  • Integrate discussion of both the client’s and counselor’s worldviews, beliefs, attitudes, and marginalized or privileged statuses.
  • Help clients explore their lived experiences and the impact these have on their end-of-life experiences.
  • Advocate for clients by giving them a voice and pursuing social justice in end-of-life policies and practices.

Conclusion

Counselors should continue to strive to be culturally competent to provide the best services possible to our clients. Being culturally competent involves not just our professional selves but also our personal beliefs, values and worldviews. As we become more culturally competent and actively engage in multicultural and social justice advocacy, we will become more well-rounded, effective counselors.

 

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Ashley C. Overman-Goldsmith is a licensed professional counselor, a national certified counselor, and a doctoral student at North Carolina State University. She is the owner and lead therapist at Sea Change Therapy PLLC. Her current research centers on honoring the lived experiences of terminally ill clients while helping these clients resolve issues that affect their end-of-life experience. Contact her at seatherapychange@gmail.com or through her website at ashleyoverman-goldsmith.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.

 

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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.

 

Changing the conversation about aging

By Lindsey Phillips January 10, 2018

Picture a grandson trying to help his grandfather adjust the tracking on his VCR. In the corner, the grandson’s friend jokes that they are ignoring the larger issue — that no one uses VCRs anymore. When the grandfather starts talking about his life, the young men make up an excuse to leave, but the grandfather captures their attention with a story about his experience during the war. By the end, the young men are eager to spend more time with him.

This is the opening scene from an episode of the Netflix comedy series Master of None. The episode, titled “Old People,” effectively exposes and challenges ageist stereotypes.

For some people, even the phrase older adult conjures up negative images of physical and cognitive impairment. But ageist stereotypes, such as older people being out of touch, do not reflect the typical experiences of older adults. Aging is a natural part of life, and many people age well. In fact, only approximately 5 percent of older Americans live in nursing homes at any given time, according to the American Psychological Association.

AARP is attempting to reverse this negative narrative with its #DisruptAging campaign, which provides a space for changing the story about aging and embracing life throughout the life span. In a recent post, AARP used the phrase gray-cial profiling to call out companies guilty of age discrimination. These offenses range from identifying older adults as potential shoplifters to excluding older adults from certain career opportunities.

Unfortunately, the issue of thinking negatively about aging often extends to health care professionals, many of whom view aging as a problem to be solved rather than a normal part of the life span. In addition, they often focus on the physiological aspects of aging rather than the psychological, social and spiritual needs of older adults.

Many interventions across disciplines focus on deficits, observes Sara Bailey, a doctoral candidate at the University of North Carolina at Greensboro (UNCG). For example, some gerontology, nursing and medical programs use an aging suit — a suit that simulates the physical impairments of older adults, such as strength and sensory loss — to expose students to the impairments of older people. “That basically conditions the student to understand that age and impairment are the same thing,” argues Bailey, a member of the American Counseling Association.

In his work in long-term care facilities, Matthew Fullen, an assistant professor of counselor education at Virginia Tech, noticed that conversations between older adults and health care providers often focused on physiological deficits. From his perspective, this scenario contributes to the medicalization of aging and tells only a narrow piece of the overall story. “If we assume that [physiological changes] are only going to be moving in a deficit direction, then we sort of get the self-fulfilling prophecy where we see those problems and we don’t see the rest of the person in front of us,” Fullen explains.

Most older adults don’t develop dementia or lose their ability to walk, be funny or engage with others, so “it’s important to expose [counseling] students to the reality of [aging] instead of pathologizing it,” Bailey says. To assist with this process of introspection, she challenges counseling students to find a birthday card for someone beyond the age of 18 that doesn’t rely on disparagement humor. Bailey refers to this type of humor as future-focused self-loathing: “When we laugh at getting older, we’re really laughing at ourselves, and we’re not laughing in a kind and loving way. We’re laughing in a way that others our future selves, and that’s not OK.”

The forgotten population

The level of importance placed on gerontology in counseling has not been clear or consistent. In 1975 in the Personnel and Guidance Journal, Richard Blake called attention to counseling older adults, a population he deemed “forgotten and ignored.” Then, gerontological counseling gained forward momentum. In 1986, the Association for Adult Development and Aging (AADA) became a division of ACA. Between 1990 and 1992, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) adopted gerontological counseling standards for community counseling programs, and the National Board for Certified Counselors (NBCC) created a specialty certification in gerontological counseling. However, because of declining interest, NBCC retired this certification by 1999 and CACREP removed the gerontological counseling standards by 2009.

This de-emphasis on later adulthood in counseling education motivated Bailey to pursue a doctorate in counseling and become part of the solution by specializing in later adulthood. At her first counseling education and supervision conference, she discovered that the gerontological counseling certification no longer existed. She says this led her to wonder, “What does this say about the focus of counselor educators? What does it say about the value of our clients and who we value more?”

In the United States, the older adult population is projected to more than double from 46 million to over 98 million by 2060, according to the Population Reference Bureau, and the Institute of Medicine notes that nearly 1 in 5 older adults has one or more mental health or substance use disorders. This raises a question: Why isn’t the counseling profession doing more to prepare counselors to care for this rapidly growing and vulnerable population?

Fullen, an ACA member who also serves as secretary of AADA, argues that counselors lack awareness about aging issues. This lack of awareness may stem from a range of factors, including the fact that older adults are a segmented part of the population, he says. Fullen also posits terror management theory as a possible explanation: Counselors fear the aging process because it reminds them of their own mortality.

In a course on life span development, Amber Randolph, an assistant professor and program director of the clinical mental health counseling program at Judson University in Illinois, discovered that her entire class of 25 students was terrified to discuss the end of life. “We’re turning out counselors who are going to be dealing with grief and loss issues who are very uncomfortable with the idea of death and, in particular, the idea that they too will age and die,” notes Randolph, a member of ACA.

This anxiety over aging can lead to the avoidance of older adults’ needs. Humans are the only species aware of their own mortality, so avoiding working with older adults is often not a conscious decision but rather an aversion to fear, Bailey adds.

Bailey is directly addressing counselors’ resistance to incorporating later adulthood within counselor education. Her research focuses on reintegrating gerontological competencies into existing coursework, which she believes will be a less objectionable approach. “I think it’s going to take a sea change in the way we view culture to start to include age in our developmental courses, in our career courses, in our theories courses, in our diversity courses,” she says. That might mean really integrating “the competencies that used to exist … in a subtle, gentle, very fluid … way so that every counseling course covers the age span,” she adds.

Bailey thinks that emotionally connecting counselors with aging issues is key. “You can talk about issues of late adulthood, but until you connect emotionally with the student around those issues … it just doesn’t click.”

To improve empathy and attitudes toward older adults, Bailey developed a perspective-taking intervention that includes three parts. First, in a journaling activity, counseling students describe their future 75-year-old selves. The second part is a game in which the students read prompts describing ageist events and then immediately reflect on the emotional reactions they would have if they were the older adult. In the third part (a reflective journaling activity), the counseling students consider their feelings and reactions toward counseling a 90-year-old client who shows symptoms of depression.

Age as an intersecting identity

Intersectionality is often discussed in terms of the interconnections between a person’s identities of race/ethnicity, gender, sexual orientation and class, but age typically gets overlooked. “Age is the only one of these marginalized identities that every single person will experience granted that they live long enough,” Fullen says. Even so, he points out that little research exists within the counseling profession on intersectionality that includes aging. “The client’s age just becomes another intersection piece that fits in very appropriately with all of those other constructs. So I’m more concerned with the ability of counselors to consider age as another intersection.”

Christian Chan, an assistant professor of counseling at Idaho State University and an ACA member, also encourages counselors to discuss intersectional identity with clients. “There are microaggressions that exist because of those intersections,” he says. For example, an older adult may refuse to socialize with someone who is gay. Thus, diversity exists between and within identity categories, and the way people navigate their overlapping forms of privilege and oppression provides them with their unique experience, he explains. By putting these identities into conversation, counselors can help clients understand what is happening to them.

This conversation about intersectionality is crucial because the growing population of older adults is also becoming more diverse. According to the Centers for Disease Control and Prevention, between 2014 and 2060, the percentage of adults age 65 and older who identify as white non-Hispanic is expected to drop from 78 percent to 55 percent. In addition, according to the University of Washington’s School of Social Work, approximately 2.7 million U.S. adults age 50 and older identify as lesbian, gay, bisexual or transgender, but that number is expected to increase to more than 5 million by 2060.

Counselors should avoid speaking about diversity in a broad sense, cautions Chan, who serves on the AADA executive board. He explains that when counselors focus on the centrality of one type of identity, they lose sight of the other identities and the way these intersections affect experiences, which can lead to the rank order of identities. For example, counselors often talk about LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning and others) communities and older adult communities in isolation rather than discussing the overlap between these identities.

Instead of asking broad questions (e.g., “How do you identify culturally?”), Chan advises counselors to use specific questions (e.g., “How would you identify in terms of your racial/ethnic identity?”) to engage in a richer conversation with clients. The simple act of including open-ended space for identity on preliminary assessments and intake interviews — for instance, by replacing check boxes with fill in the blanks — can help counselors understand a client’s multiple identities and possible intersections, he adds.

Mijin Chung, an ACA member and licensed professional counselor (LPC) with a private practice in the greater Atlanta area, also sees a danger in discussing diversity broadly. When working with older adult immigrants, for example, counselors should examine the home country and family culture of clients and avoid making broad generalizations based on age or culture, she says, because a significant number of within-group differences exist. Therefore, it is crucial for counselors to understand the environmental context of older adult clients. For example, immigrant older adults who came to the United States when they were young may have a different view of aging and U.S. culture compared with immigrant older adults who recently came to the country and perhaps live with their adult children.

Chung finds the narrative approach helpful when working with older adults, and especially with older adult immigrants, to uncover clients’ unique experiences. Often, Chung says, this population does not receive many opportunities to share their life or immigrant stories. With a narrative approach, counselors can glean the obstacles and challenges older adults have overcome, and clients’ stories can provide counselors with a frame of reference for how to proceed in session.

Counselors must also remember that intersectionality is more than just multiple identities, Chan says. “You can’t have intersectionality if you’re not talking about power; you can’t have intersectionality if you’re not talking about social context; you can’t have intersectionality if you’re not talking about social justice,” he explains.

Fullen agrees that intersectionality is about the way that multiple identities lead to power differences or marginalization. In fact, disparities often emerge when marginalized identities such as race and sexual orientation are combined with an older adult experience. For example, an older LGBTQ+ individual may face barriers to finding safe housing options, such as denial from entry or a higher probability of eviction. These barriers are further complicated if this older individual has a disability that limits mobility or a lower income because of decreased access to income opportunities, Chan says.

Counselors should think about how they can help to make systemic changes to ensure that multiple marginalized communities are visible and have rights and access to opportunities and basic care, Chan argues.

A hidden reserve of resilience

Resilience — an individual’s ability to recover from adversity — is often a coping skill that we attempt to teach to children, but research shows that resilience can have a positive effect in later adulthood as well. According to an article by Tara Parker-Pope in The New York Times this past summer, scientists claim that resilience operates like an emotional muscle that can and should be strengthened with techniques such as being optimistic, reframing your personal narrative and remembering challenges that you have overcome.

Of course, building resilience isn’t easy and takes practice. To further complicate matters, resilience is a contested term among gerontological scholars, who debate whether it is something that only certain people possess. Fullen rejects this all-or-nothing view and instead assumes that every person possesses some degree of resilience.

With this core assumption, Fullen and Sean Gorby, a doctoral candidate in counselor education at Ohio State University, piloted a Resilient Aging program, which they believe holds the potential to enhance participants’ perceptions of resilience and wellness. In their pilot study, Fullen and Gorby helped marginalized older adults identify connections between their histories and the ways they had already shown resilience throughout their lives, with the hope that participants could apply this resilience to their present situations.

After Fullen and Gorby introduced the term resilience and allowed the participants to generate their own definitions, the older adults easily identified moments of resilience in their own stories or the lives of others. “Those resilience examples became … counternarratives to the larger societal narratives about aging being only a time of decay and decrement,” Fullen says.

In his prior research, Fullen had noticed that people who are marginalized seemed to possess a hidden reserve of resilience. The pilot study for the Resilient Aging program served as a lightbulb moment for him because he was able to see it in action. “It was a chance for us to better understand the way that people who have been overlooked at various points throughout their lives develop this sort of reserve of resilience that perhaps better equips them to handle some of the challenges associated with aging because this isn’t the first time the deck had been stacked against them,” he explains.

Thus, rather than discussing a marginalized identity such as age only in terms of oppression and deficits, counselors also need to highlight resilience and make it a part of the conversation, says Chan, a past president of the Maryland Counseling Association. “What is so beautiful about working with older adults is that they have such rich narratives [in] their lives. … They have found ways to navigate and make sense of not only their identities but their experiences,” he points out.

Empathizing and reframing clients’ stories

Fullen realizes that using a resilience-based approach requires counselors to walk a tightrope between empathizing with clients’ lived experiences of the difficulties of aging and pointing out an alternative viewpoint. “It’s important not to lose [the] client by jumping too quickly into strength and resilience,” he warns. “[Counselors should] spend some time … building rapport in regard to their grief or their sense of lament related to the aging process but then start to integrate this alternative narrative, alternative conceptualization, that is more strengths oriented or resilience orientated.”

Fullen provides an example of how counselors can navigate this delicate balance in a counseling session. Suppose a client says, “I’m just fed up with this friction between me and my kids. I remember when I was the one calling the shots for them, and now all of a sudden, the tables have turned and I’m not happy about that.” First, the counselor needs to be empathetic, Fullen says. For example, the counselor could say, “Wow, that must be really difficult. It can’t be easy to spend so much of your life being the one who’s providing and now all of a sudden having your kids try to provide for you.” This is not the time to correct the client’s perception of what he or she is going through; instead, the counselor should join the client in understanding how difficult the transition is for the individual, Fullen advises.

As the session unfolds, the counselor can begin a more formal assessment of the client’s perception of how he or she is doing across the wellness domains (emotional, physical, occupational, social, spiritual and intellectual wellness) and how the client views the aging process, which will elicit any age-related bias that the client has internalized, Fullen notes. This is also the time to ask broad questions about resilience, he advises. For example, the counselor could say, “It sounds like things are so challenging right now. I can’t imagine this is the first time that you’ve been through a really challenging situation. So, tell me about how you have shown resilience over the course of your life when it comes to facing really difficult situations like the one you are talking about.”

Fullen notes a broad question that is particularly helpful for counselors to ask when working with marginalized clients: “How have you survived? You’ve been through so much. You continue to go through so much.” This question allows clients to talk about resilience — even if they don’t use that language, Fullen says. Then the counselor can introduce the term resilience by saying, “That is so fascinating to hear about all the ways that you have survived over the years. In my profession, we have a word for that, and the word is resilience. Are you familiar with that concept? What do you make of that concept?” This process subtly introduces a counternarrative to the dominant ageism narrative for both the client and counselor, Fullen says.

If clients begin talking about their history of resilience, then the counselor can incorporate resilience language and help them reframe their stories as resilient ones, Fullen suggests. However, if a client pushes back and says, “I don’t know what resilience has to do with anything,” that indicates the client needs more time to unpack the situation and vent, he says.

The future of gerontological counseling

Despite the obvious need to work with older adults, the counseling profession has slowly de-emphasized gerontology. This has left Fullen to wonder whether gerontology and Medicare reimbursement are priorities for the counseling profession or whether gerontological counseling will survive only as a niche in the future. Currently, Medicare, the federal health care insurance program for people 65 and older, does not cover LPCs.

There seems to be a sense that once Medicare reimbursement for LPCs is achieved, counselors will make gerontological counseling a priority, but that is problematic, Fullen says. He questions whether counselors would be as complacent if an insurance issue hindered their ability to work with another population group, such as children. “We would find ways to innovate. We would find ways to bang that door down,” he asserts.

Fullen points out that although approximately half of older adults’ mental health services are paid for by Medicare, that leaves another 50 percent of mental health care dollars tied to this client population that the counseling profession isn’t tapping into regularly. Counselors need to explore alternative strategies such as private pay, grant opportunities and supplemental insurance, which haven’t received as much attention, he says.

Bailey has heard similar arguments indicating that the counseling profession’s relative lack of interest in serving the older adult population stems from the lack of progress in securing Medicare reimbursement. From her perspective, that makes gerontological counseling a social justice issue. “If we are simply discounting an entire population of people because we can’t make money off of them, that’s a problem that goes well beyond counselor education and CACREP Standards,” she says. “That goes to the heart of the counseling profession.”

“Across the entirety of the profession, there have been inconsistent commitments to the needs of this population,” Fullen asserts. This inconsistency directly affects counseling students, who may struggle to find gerontology-related courses and internships or even counseling professors who are truly knowledgeable in that area.

With the discontinuation of both NBCC’s specialty certification for gerontological counseling and CACREP’s gerontological counseling standards, counselors often must go outside the profession and counseling education departments to receive gerontological training. After developing an interest in working with older adults during her master’s program, Randolph noticed the lack of a gerontology specialization or certification within the counseling profession when she was applying for doctoral programs. To address this, she earned a certificate in gerontology through the continuing education department at the University of Wisconsin–La Crosse.

Bailey is also taking an interdisciplinary approach to gerontological training. She is in the process of finishing a post-baccalaureate certificate in gerontology from the gerontology program at UNCG.

There is a silver lining, however. Namely, the counseling profession already teaches and embraces qualities essential to working with older adults. For instance, counselors focus on using wellness and strength-based approaches, being client oriented and building meaningful relationships. The fact that wellness is vital to the work that counselors do is significant, Fullen says, because wellness can be the antidote against the tendency to view aging through a medicalized lens.

In addition, AADA provides resources and support for counselors who want to work with older adults but do not feel adequately trained. “[AADA’s] overarching goal is to make sure that there are counselors out there who feel prepared to meet the needs of our rapidly aging population,” says Randolph, who serves on AADA’s executive board. In addition, the AADA Older Adult Task Force is focused on expanding and promoting research, advocacy and practice related to older adulthood so that full-time practitioners do not feel alone in working with the older adult population, Fullen says.

Avoiding gray-cial profiling

Earlier this year, Allure magazine made a bold move to stop using the word anti-aging. Acknowledging that language about aging matters, editor-in-chief Michelle Lee challenged readers to consider how the simple act of removing the qualifier “for her age” from a statement such as “She looks great for her age” changes the meaning. Jo Ann Jenkins, CEO of AARP, praised the decision and stated that AARP would follow suit and avoid falling prey to the “anti-aging” trap.

This action highlights the power and danger of ageist language. Counselors steeped in societal ageism and ageist language may incorrectly assume that counseling won’t work with older adult clients, or they may focus only on the physiological aspects of aging. However, as Bailey points out, all people, regardless of age, are still developing. “People can learn throughout the life span. … People can develop new habits and change old habits. … As long as there is air in the lungs, there is potential for change.”

Even though the counseling profession is well-positioned to serve the growing, diverse population of older adults, it often leaves them out of the conversation, committing its own gray-cial profiling. “It’s an open question of whether or not [counselors] will rise to the occasion and start to think in a more sophisticated way about these issues,” Fullen says, “or whether [they’ll] want to continue to keep [their] heads in the sand.”

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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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.

Preparing for retirement goes beyond a good 401(k)

By Laurie Meyers November 29, 2017

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

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

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

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

Exit ahead?

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

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

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

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

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

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

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

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

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

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

Taking time to process

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

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

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

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

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

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

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

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

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

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

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

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

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

In search of

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

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

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

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

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

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

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

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

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

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

Crowded house

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

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

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

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

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

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

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

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

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

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

 

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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.

Examining our assumptions about emerging adulthood

By Peter Allen June 12, 2017

For many counselors and educators, the term failure to launch is a familiar part of the American lexicon. Some have referred to this phenomenon as an “epidemic,” and a few prominent clinicians have even described it as a “syndrome.”

This classification is problematic for a number of reasons, including that it fails to consider the longer arc of human history and development. Referring to our clients as having “failed to launch” begins the relationship with judgments and disconnection rather than a sincere desire to understand and help. When we commence our helping relationships by adopting a judgmental and comparative stance, we start off on the wrong foot with our clients and communicate to them that we have little to learn. This is, in effect, very poor modeling of the skills and traits that we hope to instill in them.

The problem

What do we mean by failure to launch? Usually this language is used to describe young adults, typically between the ages of 18 to 25 or so, who have not met the traditional benchmarks of adulthood in some fashion. The stereotype usually depicts young 20-somethings who are living in their parents’ basements, playing video games and generally not contributing to the household in a meaningful way.

In general, we observe a lack of motivation and a delay in the acquisition of skills and traits that we typically associate with adulthood: financial autonomy, independence, stable relationships, responsibility and some sense of obligation to society or the collective. We want our adolescents to grow into mature, productive adults. Because numerous examples of these adults are readily available for view, the contrast between them and the so-called failure-to-launch crowd becomes striking.

The English word adolescence comes from the Latin word adolescere, which means “to ripen” or “to grow up.” This is important because young adults, despite some thinking to the contrary, are very much still in adolescence. They are in the period between childhood and adulthood, with a foot in both worlds, so they exhibit characteristics of both stages. This presents unique challenges for those of us who encounter them in this in-between stage.

Although we basically understand what adolescence is, when it ends depends on the culture in which we were raised. For example, in Mexican culture, the quinceañera is held for young women at age 15. This coming-of-age celebration marks the beginning of adulthood in that culture. The Jewish faith marks this moment at age 13 with the tradition of the bar mitzvah and the bat mitzvah. In Japan, an event called Seijin no Hi (Coming of Age Day) occurs at age 20 and marks the passage into adulthood. The Chambri people of Papua New Guinea, sometimes called the “Crocodile People,” use ritual scarification to mark the passage of young males from childhood to adulthood. This ceremony can take place anytime between the ages of 11 and 30.

It is interesting to note the difference in timing for these cultures. I am particularly struck by the range of ages in the Chambri custom. They have perhaps come closest to identifying the actual biological range within which adolescence occurs.

Taking a cognitive behavior approach

Young adults are sometimes just beginning to evaluate the power of their own thinking to positively or negatively shape their world experience. There can be some confusion about the difference between thoughts and beliefs. In my own evaluation, a belief is simply a persistent thought that has become true or seems real to the person. For instance, if I have the thought that God exists, and if I think this way for long enough, it becomes a belief.

I like to use a story that I call “A Tale of Two Apple Trees” to teach this concept. In this story, I have an apple tree on my property. I have a lot of thoughts and beliefs about this apple tree. This apple tree is my property. I bought it, I watered it and I fertilized it. So when a stranger walks by and picks one of my apples, how do I feel? I feel angry. What am I likely to do with my anger? I am likely to have a confrontation with this person. My beliefs led to my emotion, and my emotion led to a behavior.

My neighbor also has an apple tree in her yard. Like me, she has a number of thoughts and beliefs about the apple tree, but they are quite different from mine. She believes that everyone deserves to have food. She also thinks that because she has many dozens of apples on her tree, she can certainly spare a few for someone who wants them. So when someone walks by her property and picks an apple to eat, how does she feel? Most likely she feels happy. What is she likely to do? It is likely she will approach this person and have a positive interaction. Her thoughts led her to certain feelings, and those feelings precipitated specific behaviors.

The point here is not about determining the true nature of apples and apple trees in the world. The point is that, objectively, the same thing happened to both of us: Someone picked an apple off of a tree in our yard. But our respective experiences of that event were drastically different. Based on my beliefs, I experienced anger and then behaved in a confrontational manner. My neighbor experienced happiness and then behaved in a friendly manner. We all must choose what to believe based on our life experiences and what makes the most sense to each of us.

As clinicians and educators, I think we have collectively failed to monitor our own thinking about this population. We know that thoughts lead to feelings, and feelings can lead to actions. Are we applying this knowledge to ourselves in our work with young adults? We should acknowledge that we have chosen certain beliefs about young adults and, as such, these cognitive structures are negatively influencing our experience of working with this population. One of my goals is to bring those structures into our awareness so that we can nobly wrestle with them and make more assertive decisions regarding how we are going to show up in relationships with our clients.

When we use the term “failure to launch,” we clearly display our belief that the young adult has failed in some capacity. I have also heard this called prolonged adolescence; in other words, this particular period of adolescence is taking longer than normal. Who determines what is normal? Struggling is a word often used with this population. They are certainly not thriving and not succeeding like their counterparts, who have not been labeled as “struggling.” Even the term late bloomer, which on the surface seems gentler, indicates that these individuals are not on time in their development.

Let’s assume that you came to see me, a counselor, to help you work through some issue. Perhaps you and your partner come in for couples counseling to work on better communication. How would you feel if I said to you, “Sure, I can help you with your failure to communicate”? My guess is that you would experience an immediate disconnection from me because you may not perceive yourself in that way. I am starting out from the position that you have failed. Or maybe you want to become more assertive with your parent, and I respond by saying, “I would be happy to help you while you struggle to assert yourself with your parent.” Wanting to work on something is not the same thing as struggling with it. This language betrays my internal dialogue about you.

We know that we cannot think ill of our clients, even unintentionally, and then hope to show up with compassion and warmth for them in session. There is a discipline involved in thinking well of clients, actively, so that their best interests are always at the forefront of our efforts. If we begin our work with young adults from a judgmental place, then our feelings and behaviors will follow accordingly.

That is why I advocate for a term I encountered while researching this subject: emerging adulthood. I believe this is a judgment-free term and one that is actually more accurate. Then our primary cognitive framework can begin from an understanding that these people are emerging as adults, in their own individual way, and there may be some issues or difficulty for them during this period.

Around the world

Many factors contribute to the belief that emerging adults have failed in some capacity, but one factor in particular has a very powerful influence on our perceptions of how young adults are developing — whether they leave their parents’ homes within the “proper” time frame. According to the Pew Research Center, in 2014, 32 percent of young adults ages 18-34 were living at home with their parents in the United States. This number is likely higher than most readers might have guessed.

As I thought more about this, I wondered how the rest of the world views this issue. Fortunately, the Pew Research Center has collected extensive data about young adults living at home in Europe. According to this research, Denmark is at the lowest end of the spectrum in Europe, with about 19 percent of young adults ages 18-34 living at home. At the high end of the spectrum is Macedonia, where about 73 percent of young adults in the same age range live at home with their parents. Most of Eastern Europe is in the 50 to 60 percent range. Most of the Scandinavian countries are in the 20 to 30 percent range. Why is there no failure to launch “epidemic” there?

In much of Latin America, including Central and South America, it is common for young people to live at home with their parents until they have completed school, partnered with someone in a long-term romantic relationship or begun their career. In an article from 2007, psychologist and researcher Alicia Facio and her team found that 71 percent of Argentinean emerging adults lived with their parents or other relatives.

Let’s turn to Asia for a final example. A 2014 Huffington Post article titled “Here’s Why It’s Not Weird for Indian Men to Live at Home With Mom and Dad” stated: “Typically, in the Indian culture, returning home after high school or college is not only encouraged, but expected. Even living in America, parents who have migrated here from India have instilled in their children the idea that living with their parents is how Indian ‘joint-families’ work. Most children will stay with their parents up until marriage and some even after marriage, and the Indian ‘society’ accepts this as the norm. There is no taboo, no judgment, and there is no shame — from the male or female perspective. Children are meant to stay with their parents to be taken care of, and as the parents grow older, the children are expected to take care of their parents in their home.”

The key part of this passage for me is the part that states there is no taboo, no judgment and no shame. Unfortunately, the American approach has plenty of all three.

There are actually numerous benefits to young adults staying at home beyond the age of 18 or 19. These benefits are not discussed much in the United States but are well-known to many other cultures around the world.

One thing young adults can do with greater success when they stay at home longer is save money. And nothing helps someone “launch” like having some money saved. In addition, with some healthy boundaries in place, the increased contact between young adults and their parents can actually lead to better long-term familial relationships. As the example about Indian families shows us, young adults who live at home longer are more likely to take care of their parents down the road when the parents may need support. The stability of this living arrangement also reduces anxiety for the young adult, and that readily lends itself to healthier development.

My assertion is that the American cultural emphasis on independence and autonomy is the driving force behind the current so-called failure-to-launch phenomenon. We want our young folks to be independent, but when they are actually capable of this varies widely from a developmental perspective. It is clear that Indian culture places a greater value on family connectivity than on independence. Therefore, there is much less pressure to get young adults out of the home, and thus they have more time to develop in a more stable environment — and with less shame. If American cultural beliefs are in conflict with the biological reality of human development, then perhaps it is our culture that should change.

If a young man is 25 and living at home in Argentina, his family is most likely accepting of this. It is normal for them. They do not see it as a problem provided that this young man is contributing to the household in some way. But a 25-year-old young man living at home in the United States is very likely to be viewed as being delayed somehow or, worse yet, considered lazy. This may be true even if he is contributing to the household, like his Argentinean counterpart. The same exact thing is happening in both situations (just like in my story of the apple trees), but our opinions of these young men depend on our beliefs about what is normal and healthy.

Integration of knowledge

This phenomenon is partly because of a failure to integrate knowledge from a variety of sources and disciplines. Practitioners in our field often draw on knowledge from psychology, but by also integrating information from anthropology, biology and sociology, we can develop a more accurate picture of what healthy human development looks like.

By now I hope I have demonstrated that the accepted timing of the path to adulthood depends entirely upon the culture in which one is raised. Biology tells us that the adolescent brain finishes developing in a person’s mid-20s. This piece of information alone should cause us to rethink our expectations of the average American 18-year-old. This neuroscience is widely known but seldom applied in day-to-day interactions with young adults.

Anthropology demonstrates to us that it is normal human behavior to live at home with one’s parents into one’s 20s. This is happening at very high rates all over the world. This discredits the idea that these other countries are all raising their young adults incorrectly and have been for millennia. This is not an “epidemic”; it is well within the range of normal human behavior. Sociology tells us that societies organized around principles such as family connectivity are sustainable over long periods of time.

When we put the knowledge from all of these disciplines together, it is fairly easy to see where we are going astray in the United States. When I presented this information to a group of clinicians, it was suggested to me that perhaps American culture is itself in adolescence. If that is true, then we should view ourselves as developing rather than as having arrived.

The counterarguments 

The principal argument I have heard repeated in many circles is that by letting our young adults live at home for a longer period of time, we will be raising a generation of infantilized people who will then be ill-equipped to manage their own lives. This is a valid concern, but I would respond by saying that the countries I have mentioned don’t seem to be creating generation after generation of incapable young people.

These cultures have been operating for centuries, continuously, and despite some current economic challenges, they seem to be making it work. If they were raising such incapable young adults, we probably would have seen their societies collapse decades or even centuries ago.

Having pointed that out, I am not suggesting that all young adults should get a free pass until age 25. On the contrary, we run the risk of enabling them by assuming, without testing them, that they are incapable of certain things. At the same time, we should rethink our basic position that a “healthy” person leaves the home at age 18 or 19 and should sail into adulthood with minimal disruptions from that point. What is healthy in the vast majority of the world appears to be leaving the parents’ home closer to a person’s early to mid-20s.

Both maturity and ability fall on a spectrum, so what I advocate for is the middle path. Some 18-year-olds are going to be very responsible and autonomous, while some 30-year-olds are going to need extra supports. We do not serve our clients well as counselors by comparing them all to the high-performing 18-year-olds. I acknowledge that in many cases young adults are experiencing significant gaps in their skills, engagement or motivation and need intervention to create healthy lives for themselves. In those instances, clinical and educational interventions are indicated.

Part of what we need to do better as counselors is ascertain exactly what the problem is before we intervene. Learning disabilities can play a large role in difficulties related to healthy development. If learning differences are a main cause of a young adult client’s stresses and problems, then it is we who have failed to adequately assess those challenges and make reasonable accommodations.

It has been mentioned to me several times that the difference between the other countries I have named and the United States is that young adults who live at home in those other countries are expected to contribute to the household. All of the clinicians I have asked about this have told me that they have worked with so-called failure-to-launch cases in which they discovered that the primary intervention was actually to coach the parents to communicate their expectations more clearly and to establish better boundaries.

My experience of young adults is that they will take a good deal — every time. So if parents offer full financial support and a free place to live with few or no obligations attached, young adults will gladly accept. This does not indicate pathology in them, however. Instead it indicates intelligence and shrewd negotiating skills, both of which transfer quite well to the real world.

The parents of young adults are often used to parenting children. After all, they have done this for most of their parenting lives when we encounter them as counselors. It requires a deliberate and skillful shift for them to begin parenting their new young adults effectively. Our job as counselors is to help them facilitate a smooth and supportive transition, not to judge them for perceived mistakes that we likely would make were we in their shoes.

In addition, when we encounter young adults and their families in our work, we should take very thorough histories so that we can understand the family’s unique culture and context and what is normal for them. From there, we can more effectively intervene for everyone’s benefit. For example, if the parents need to establish better boundaries, why would we offer intensive therapy to the young adult? If the parents have wonderful communication and boundaries, why would we presume to “teach” them something when we could be offering the young adult coaching and therapy services? The intervention must always flow from a careful and proper assessment of the situation and presenting problems.

The one-size-fits-all approach dictates that if someone uses the term “failure to launch,” then we assume the young adult is to blame for whatever is going on. This is an incredibly simplistic model for an astonishingly complicated developmental process. In short, our task as counselors is to separate legitimate clinical issues from normal, developmental ones.

Conclusion

As clinicians and educators, we need to actively monitor our thinking about young adults and choose a set of cognitions aligned with biology and normal human development. Our schools, clinics and programs need to be free of judgment-laden language that disconnects us from our clients and students.

We need to also recognize the wisdom that comes from a variety of cultures, countries and research-based science. We should acknowledge that we might have some cultural beliefs that, although deeply held, are incongruent with healthy human development. When we encounter these beliefs, we need to work publicly and privately to change them. The result will be better education and treatment for our emerging adults — and a better society as a whole.

 

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Peter Allen is a licensed professional counselor and the program director at College Excel (collegeexcel.com) in Bend, Oregon. The company helps college-bound young adults who have attention-deficit/hyperactivity disorder, depression, anxiety and executive functioning deficits to succeed academically. Contact him at petercallen@gmail.com.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

 

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Related reading on emerging adulthood from the Counseling Today archives: Validating the quarter-life crisis

 

 

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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.