The continued growth of the elderly population in society has placed renewed focus on providing older adults with quality mental health care. The aging of the baby boomers in combination with research indicating that psychotherapy is effective with an older population highlights the need for those with expertise in counseling the elderly.
Providing therapeutic services to an older adult population has not historically been considered an option, as age and developmental status were thought to be key determinants of psychological appropriateness. This negativistic view of counseling for the elderly appears rooted in the Freudian tradition, with the assumption that older adults were too rigid in their character structures for therapeutic change to occur. Newer theories have extended the idea of psychological mindedness into the later years of life, with counseling as a useful option for providing therapeutic support and intervention for those nearing the end of the life span.
There are no single characteristics that accurately describe “older adults,” as this cohort encompasses an array of different life experiences, personality traits, and goals for counseling. Thus, counseling the elderly must begin with basic knowledge of the aging process, such as normal versus pathological aging, fact versus fiction, and stereotypes. Counselors should be versed in the physical, mental, and emotional aspects of older clients and adept at clinical diagnoses specifically applicable to this population, such as differentiation between depression and dementia.
The majority of counseling approaches build upon a foundation of respect, empathy, and support. Creating a culture where mentally healthy older adults are considered “normal” is paramount to the field of geriatric counseling. Counselors must promote the idea that old age in itself is not pathological and does not necessarily require counseling. However, when symptoms increase beyond the level of the older adult’s ability to function, counseling should be an option, regardless of age.
Common Presenting Concerns and Psychological Disorders
Although advanced age is not equated with psychological problems, the elderly in this society experience common areas of concern during later life. Misdiagnosis often occurs due to the belief that all older adults are depressed and that negative thoughts and feelings are normal for someone in this stage of life.
Many older adults experience grief and loss, whether it be in their occupation (e.g., retirement), mobility (e.g., becoming reliant on a walker), independence (e.g., not being able to drive), or interpersonal relationships (e.g., death of spouse or friends). By definition, elderly clients have experienced the loss of youth and therefore all too often their own perceived value in today’s youth-focused society. Issues of loss, death and dying, physical and mental health changes, chronic illness and disability, and debilitating pain are often intertwined for the older client.
The fear of cognitive decline or “losing one’s mind” often becomes increasingly prevalent with age. Older adults are often more susceptible to delirium (a disturbance of consciousness and a change in thought process that develops over a short period of time) due to infections, medication interactions, or dehydration. Dementias (multiple deficits in thought, including impairment in memory) are varied; they may be Alzheimer’s type, vascular, or the result of other disease processes. When cognitive decline occurs, counselors must be not only astute in detection and differentiation of cause but also aware of the client’s capacity to participate in the decision-making process—including participation in counseling.
As many older adults are likely to visit their primary care physician first when experiencing problems, psychological problems may be reported in somatic terms. Elderly clients may express concerns about sleep disturbance, headaches, loss of appetite, or weight change rather than identifying anxiety, feelings of hopelessness, or depression. Counselors will gain increased understanding by assessing to what extent client symptoms are due to psychological factors and to what extent they are due to biochemical disturbance.
The most common psychological disorders in the elderly population include anxiety, depression, insomnia, cognitive impairment, and adjustment disorder. If an older adult is living in an assisted living facility or nursing home, the chance of experiencing these disorders increases. Each disorder has various levels of severity. For example, depression can range from a reactive sadness (stemming from minor occurrences) to grief (a normal response to painful loss) and to clinical depression with symptoms causing impairment in daily functioning. Risk for suicidal ideation increases with depressive symptoms, and it should not be overlooked in an elderly population. Older White men are one of the fastest growing groups at risk for suicide. In general, older adults complete 20% of all suicides, although they make up only 13% of the population. In assessment for suicide risk, the counselor must be savvy in regard to identification of suicidal ideation and the possibility of taking action to cause death in contrast to verbalization of “wanting” or “being ready” to die.
In addition to the above disorders, the counselor should be aware of the possibility for substance use, including abuse of alcohol and prescription medications. Substance abuse or dependence is often overlooked within this population because of their reduced social and occupational functioning. Signs may more often present as poor self-care, unexplained falls, malnutrition, and medial illnesses.
Counselors should also be able to identify chronic mental illness and personality disorders when they occur in elderly clients. As young people with a chronic mental illness age, they become older adults with a chronic mental illness. Although the severity of behaviors associated with personality disorders is often thought to diminish with age, the severity may increase under stress or as individuals experience a loss of control, such as a change in living situation.
Types of Counseling
Counseling has been found to be effective for older adults experiencing distress, and it’s clearly superior to medication because of the increased risk of pharmacological side effects in the elderly. When indicated, a combination of medication and counseling can be a successful intervention for psychological symptoms.
Both individual and group counseling are available for older adults seeking mental health treatment. Individual counseling provides older clients the time and privacy to discuss thoughts and feelings they may be experiencing. Group counseling has also been shown to be efficacious with an elderly population, and it provides an additional benefit of decreased isolation through interaction among members. Common types of groups include reminiscence (integrating past memories into present-day functioning), interpersonal (exploring personal interactions and relationships), current events (encouraging attention to current news), and adjustment (focusing on transitions).
Regardless of the type of counseling intervention, a thorough assessment of the client’s needs is required. A clinical interview is often sufficient, but additional age-sensitive instruments (e.g., Geriatric Depression Inventory) can be used when further assessment is needed. In addition, counselors should be knowledgeable of when to refer (e.g., to a primary care physician to rule out medical concerns, to a specialist such as a neuropsychologist for cognitive testing, or to a nutritionist for further exploration of diet) as well as aware of appropriate community resources.
Adaptations to the Counseling Process
Once an elderly client accesses mental health care, several adaptations to the traditional format allow the counseling experience to be of maximum benefit. Counselors need to be aware of the social context in which their older adult clients exist and the challenges of navigating an ageist world. For many older adults, entering into counseling is a new and possibly intimidating experience. Education about the counseling process may assist with rapport building and setting appropriate expectations. By outlining the logistics of the sessions (e.g., how long each meeting will last, the cost, and duration of therapy) and describing the process of therapy, the counselor can potentially alleviate concerns, allowing older clients to be active participants in the course of treatment.
Counselors may allow for additional time to explain the progression of counseling, describing their theoretical orientation and therapeutic approach in a jargon-free manner, using concrete terms and examples when possible. Choice of terminology is significant, as counselors may wish to refrain from using more informal language (e.g., “that’s cool” or “I get it”). Counselors should also be cautious of using terms with potential negative meaning too quickly, as older clients may not identify with being “depressed” but may instead more readily agree to “feeling blue,” “being down in the dumps,” or “having low spirits.” Older clients may indicate anxiety by noting they are “climbing the walls” or stating something such as, “I don’t feel right in my skin.” Other aging clients may be more comfortable beginning the conversation about symptoms by sharing, “I just haven’t felt like myself.”
The development of rapport and client conceptualization is also assisted when the counselor understands the broad historical timeline of events that may have influenced an elderly person’s perspective on life. A general awareness of the social impact of wars, the Great Depression, and other historical events may help clients to feel that the counselor is interested in understanding their stage in life. Although each person will experience events in a unique way, a basic understanding about major events this cohort has survived may facilitate the therapeutic process.
Older clients may exhibit physical declines that affect the course of therapy. They may have difficulty hearing, and provisions can be made to ease the frustrations of both parties to the counseling relationship. This may mean that the counselor must enunciate more clearly, speak louder, speak in a deeper voice, and possibly speak more slowly, or it may mean that the client requires assistive devices such as hearing aids or an amplification set. Because some clients may have decreased eyesight, counselors may wish to have written materials in large print. They should be prepared if older clients experience physical limitations preventing them from completing paperwork or providing a signature.
In addition, counselors may want to decrease the pace of therapy; this may be an effective method of ensuring client understanding. Clinicians should be prepared for clients that have overall changes in memory functioning; clinicians may need to use more repetition, provide hands-on material, and focus on events and emotions that are more easily recalled. Complex and jargon-filled interpretations will likely not be successful, as many older adults may be more receptive to pragmatic and problem-solving techniques.
In addition, modifications to therapy may be necessary due to caregiving issues or living situation. As a person ceases working outside the home, becomes less able to participate in the community, or experiences family and friends passing away, the potential to become isolated intensifies. Focus is often placed on a spouse or family members, but this is accompanied by conflicting feelings, as many older adults worry about becoming a burden to their family. On occasion, caregivers might be included in the counseling process to explore such concerns.
Unique issues also arise given various living environments, as older adults who live independently in the community experience different challenges than those living with family, those with the help of a caregiver, or those living in an assisted living facility or long-term care facility. Counselors need to understand the system in which the client lives, so they can better recognize and appreciate the corresponding challenges that may arise. For instance, if a client living in a long-term care facility complains of clothes that are missing and being worn by someone else, the counselor must determine if the client is demonstrating signs of paranoia or memory deficits, describing a thief that is employed in the building, or describing a situation that the facility must address within their laundry department.
Transference and Countertransference
As both client and counselor learn more about societal perceptions of older adulthood, they must be aware of the potential dynamics that may develop. Transference involves the attribution of characteristics, traits, or behaviors to a person based on ideas about who the person is reminiscent of or who he or she represents. Thus, older clients may look at a younger therapist and reflect on their own mortality, their loss of relationships or independence, or their physical impairments. They may think it impossible that someone so much younger could understand their thoughts and feelings at the later stage in life. A younger therapist may focus too much on illness or death, or may treat an older client as “grouchy” or “fragile,” or may think of the client as a “kind grandparent-like” individual. When appropriate, talking about the possibility for misperceptions can lead to fertile conversations about age and the counseling process.
Although it is rarely mentioned, a potential challenge of working with older clients is the increased likelihood of experiencing a client’s death. Counselors may be aware of their reaction to client death as being a double-level experience. As humans, they may face grief, guilt, and loss similar to others who have lost a close relationship. But counselors may also be cognizant of the client’s death in terms of their special role in that person’s life. This can have the potential to be confusing, emotionally draining, and isolating for counselors working with the elderly.
Reducing Barriers to Counseling Services
Older adults often face multiple challenges in obtaining counseling services due to physical, financial, and cultural obstacles. Limited physical mobility and restricted access to transportation can make attending appointments difficult. For those coping with such a loss of independence, “nonessential” activities such as therapy may quickly be cut from the list of priorities. Similarly, for those on a limited financial budget, interventions that are not quickly determined to be useful may likely be discontinued. Some clients may also need assistance navigating the tricky waters of Medicare benefits. This leads to the need for therapy to be accessible, financially feasible, and most important, something that is valued by the client as helpful. In an older population that may view counseling as something for those only with severe psychological problems, overcoming the stigma of therapy can be a challenge in itself.
In addition to reducing possible barriers, counselors working with the elderly are encouraged to operate within a multidisciplinary approach, working closely with other care providers involved, such as the primary care physician, a case manager, or a concerned family member. Creating a trusting relationship with the client may be more easily facilitated if the person has confidence in the network of those providing care.
There are endless events and experiences to recall in counseling for those who are nearing a century of life. Older adulthood, although not synonymous with psychological health, does symbolize a certain resiliency. Helping those older adults experiencing distress to remember the strengths they have utilized throughout their lives and discussing ways to enhance these personal resources has the potential to be a rewarding experience for those counseling the elderly.
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