The United States is going through a rapid demographic shift unlike anything it has ever experienced. Approximately 10,000 Americans are turning 65 every day. Meanwhile, the average life span in the United States has increased to approximately 81 years for women and 76 years for men, with a significant number of people living well beyond those ages.
By 2030, demographers project that 70 million people, or about 20 percent of the U.S. population, will be 65 or older. Industries ranging from health care to technology to real estate have taken note of this emerging trend and are identifying how best to respond to the needs of an older population. Although a great deal has been written about how an aging population will affect the need for biomedical services, the story of how older people maintain optimal mental health throughout the life span has received far less attention.
First, the good news. Research indicates that older adults report the highest levels of life satisfaction when compared with young and middle-aged adults. Older adults are more likely to report a satisfying marriage, and they outperform younger individuals when it comes to remaining calm during times of stress. Subjective well-being is particularly high when older people perceive that they have adequate social support; have a sense of control and mastery, opportunities to derive meaning through paid or unpaid work and a positive perception of their age; and when they participate in spiritual or religious practices. Therefore, for many people, older adulthood can be a very fulfilling phase of life.
On the other hand, a large number of people 65 and older need mental health care but do not have adequate access to it. Approximately 20 percent of adults 65 and older meet the criteria for a mental disorder. Older adults with mental disorders experience higher rates of functional disability than those with a physical illness alone. They also experience poorer overall health outcomes and higher rates of hospitalization. Economically, these factors result in medical costs that are 47 percent to 200 percent higher for older adults with a mental disorder than for other older adults. Furthermore, older Americans are disproportionately likely to die by suicide, with older white males in particular having one of the highest rates of suicide.
Access to mental health services
Why is there such a discrepancy between the preponderance of older adults who experience increased life satisfaction in old age versus those who are at risk for depression, anxiety and suicide? One factor often cited in the research is older adults’ lack of access to mental health care.
In a recent study of older Americans, only 3 percent reported seeing a mental health professional, the smallest percentage of any age group. It is likely that stigma related to aging and mental health is at least partially to blame. For instance, previous cohorts of older adults came of age in an era when mental health services were far more stigmatized. Instead of seeking services from mental health professionals, older people are more likely to share their complaints with primary care providers, family members or friends. It is worth noting, however, that the current generation of individuals turning 65, known as the boomer generation, is likely to be more open to discussions about mental health.
Stigma also exists in the form of cultural myths about aging that create barriers to older adults seeking help for mental health concerns. For instance, despite the previously cited research about older adults’ high levels of life satisfaction, many people mistakenly believe that depression is a normal feature of growing older. A myth that may influence clinicians is the notion that certain problems associated with aging — including the increased likelihood of one or more chronic health conditions, the loss of a loved one and existential concerns related to meaning and life purpose — will not be responsive to counseling treatment.
Practical skills for counseling older adults
In reality, older adults are excellent candidates for counseling services. They respond to treatment as well as or better than members of other age groups. The counseling profession is particularly well-situated to provide effective services to older adults because of its emphasis on life span development, wellness and attention to diversity. Three practical strategies can promote the work of counselors with this population.
First, it is important for counselors to consider the developmental needs of older adults. Historically, human development theorists, including Sigmund Freud, suggested that development stopped around age 40. Although this seems laughable today, the assumption that most growth and change occurs early in life is still reflected in sayings such as “You can’t teach an old dog new tricks.”
In fact, in a 2000 study, Paula Danzinger and Elizabeth Welfel found that despite identical symptom profiles, mental health professionals rated older clients as having a more negative prognosis when compared with younger clients. Therefore, when working with older clients, it is imperative for counselors to challenge this myth, first in their own minds, but also potentially with clients who do not believe in their capacity to make changes at this point in their lives. For instance, recent findings in neuroplasticity suggest that humans are capable of making changes to their attitudes and behaviors across the life span. When counselors reflect this viewpoint in session, they provide hope to clients who may have otherwise resigned themselves to a particular problem or mindset.
Next, counselors should consider the use of a wellness perspective when assessing and treating older adults. Although the wellness paradigm is increasing in popularity, its use with older adults has lagged behind, both in research and clinical applications. However, older adults are prime candidates for the use of a wellness approach for multiple reasons.
First, a great deal of research indicates that a broad range of variables influence older adults’ longevity and quality of life. These variables include strong mental and emotional health, reciprocal social relationships that are perceived as supportive, participation in preferred spiritual or religious practices that provide meaning and purpose, a belief that one has at least some control over circumstances and a positive perception of aging. A recent example of the multidimensionality of older adults’ needs was demonstrated in a 2015 study by Kelley Strout and Elizabeth Howard. The researchers found that emotional wellness was the highest predictor of cognitive health, followed by physical and spiritual wellness as additional significant variables. Therefore, counseling interventions that bolster emotional wellness may influence brain health in later life.
Similarly, there is growing interest in the concept of resilience among older people. Given the wide range of challenges that may accompany older adulthood, some gerontologists suggest that resilience should be used as a primary measure of what it means to age well.
In research supported by the Association for Adult Development and Aging (AADA), a division of the American Counseling Association, Sean Gorby and I recently piloted a program in which older adults participated in a counseling group focused on how participants had demonstrated resilience in various domains over the course of their lives. Group members identified adversities they had experienced, including physical and functional setbacks, emotional distress, changes in social relationships and spiritual and existential hardships. Participants then shared personal stories about resilience, either in their own lives or in the lives of others, and discussed how this could be manifested once again with the current challenges they were facing.
At the conclusion of the group, we found that participants perceived themselves as more resilient. This indicates that counselors may be able to tap into the reserves of resilience that older clients possess, using discussions of resilience to help these clients restructure their self-concepts around adversity and their ability to bounce back.
Finally, in spite of cultural assumptions to the contrary, older adulthood is an extremely heterogeneous phase of life. Cultural diversity and vast individual differences related to the aging process shape how older adulthood is experienced. For instance, a person’s chronological age, by itself, does not communicate a great deal of information about how one perceives life, nor does it directly correlate with overall health and wellness.
Most broad definitions of older adulthood use age 65 and up; however, there have been efforts within gerontological research to subdivide older adulthood into two segments, with the “young-old” representing individuals 65–80, and the “old-old” reflecting those who are older than 80. Although some research supports differing health and life experiences for individuals in these two groups, the division is still limited by the assumption that chronological age is a helpful descriptor. For instance, one’s health, holistic wellness and functional status may provide better information about what life is like than simply stating how many years one has lived. For this reason, some have argued for the use of biological or functional age as a more descriptive demographic than chronological age.
How one perceives his or her age can also be a telling indicator for quality of life and longevity. In fact, research by Becca Levy shows that older people with a positive age perception live significantly longer than those older adults who have a negative perception of their age, even after controlling for other health and demographic variables.
The older adult population is also rapidly becoming more diverse. In fact, ethnic minorities, particularly Latino and Asian/Pacific Islander elders, make up the fastest-growing subset of the older adult population. Furthermore, more than 2 million American older adults currently identify as lesbian, gay or bisexual.
In terms of socioeconomic diversity, a wide gap exists between older adults who have accumulated sufficient financial resources and the vast number of older adults who have either experienced poverty throughout their lifetimes or who are now on the edge of poverty because of recent changes to their health, relationships or work status. Therefore, counselors interested in working with older adults should anticipate that their clients will possess a diverse range of backgrounds and perspectives, and differing levels of health, wellness and functional abilities. Some counselors may encounter older adult clients who can afford to pay out of pocket for mental health services, whereas other counselors are likely to interact with older adults whose low income levels qualify them for subsidized housing or health care.
Counselors should recognize that growing older in America is not a monolithic experience. In fact, the diversity of perspectives related to the aging process is one of the most compelling features of working with older adults. Rather than older adults all being alike and resistant to change — as the cultural myth might suggest — older people possess a diversity of backgrounds and life experiences that can make the counseling experience particularly invigorating for client and counselor alike.
Strategies for including older adults in your practice
Counselors interested in working with older adults should be proactive about seeking opportunities to market their services to these clients. Counselors cannot currently bill Medicare. However, there are other ways to make a difference in the lives of older adults.
For instance, a 2012 report by the Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine) found that 47.5 percent of older adults’ mental health services were not paid for through Medicare. Non-Medicare payment sources included paying out of pocket (18.3 percent), supplemental private insurance (11.7 percent), Medicaid (11.4 percent) and other state and community programs (6.1 percent). Therefore, in addition to offering services directly to older clients, counselors can also market their services to local agencies on aging, community and neighborhood clinics with local service grants and capitated health service providers.
For some older people, seeking mental health treatment within a private practice or standalone mental health clinic may be appealing. However, I have found that linking mental health services to older adults’ housing, medical care and social services is an excellent strategy for providing integrated care and making mental health services more accessible to older clients. For instance, forming partnerships with primary care providers who view mental health treatment as a necessary and value-added component of integrated treatment can be an effective strategy for connecting with older clients. Counselors accustomed to the use of a wellness paradigm are familiar with the challenges of providing prevention and holistic wellness services to clients in a world of managed care and disjointed services. Therefore, instead of focusing solely on the need for Medicare reimbursement, entrepreneurial counselors may wish to consider how to extend the integrated wellness work that is already being done with younger clients to an older population.
Ongoing education and training are helpful to ensure that your counseling services are well-suited for older clients. Members of the counseling profession should look for continuing education or postgraduate training opportunities that will expand their understanding of the impacts that adult development and aging have on their clients. This could include:
- Attending educational sessions at state or national counseling conferences
- Joining AADA
- Networking with other professionals in the aging sector by getting involved with a local area agency on aging
- Seeking formal education in the form of a certificate program in gerontology at a local university
Given the rapid growth of the older adult population in the United States, there is a need for more mental health professionals who are both willing and able to work effectively with these clients. Although it is not the only means of access for mental health services, Medicare covers the majority of these services (52.5 percent) for older adults. Recently, there have been several critiques of the Medicare program for not doing more to address the growing number of older adults who need mental health treatment. According to the 2012 Institute of Medicine report, only 1 percent of the total Medicare budget was spent on mental health services (with a total budget estimated at $505 billion in 2014).
Advocacy for Medicare reimbursement of counselors is vital to expanding the mental health workforce. Two bills were introduced in Congress in 2015 calling for mental health counselors to be included as recognized Medicare providers: the Seniors Mental Health Access Improvement Act of 2015 (S. 1830) and the Mental Health Access Improvement Act of 2015 (H.R. 2759). Both bills have received bipartisan support in the past. However, it is common for legislative efforts to go through many iterations before becoming law.
Due in large part to the advocacy efforts of the counseling profession, there are currently numerous bipartisan co-sponsors for both of these bills. Recently, counselor advocacy efforts resulted in AARP writing a letter that supported passage of congressional bills calling for inclusion of counselors as Medicare providers.
To continue this momentum, it is imperative for all members of the counseling profession to raise awareness of Medicare’s lack of attention to mental health and the current restrictions that deny older adults the freedom to choose their mental health providers. Counselors should consider contacting their congressional representatives to provide awareness about the counseling profession and how it is uniquely situated to provide mental health care to older adults that is grounded in wellness, life span development and awareness of the diversity of older adults. Please consider contacting your senators and representative with a brief statement that advocates for S. 1830 and H.R. 2759. Contact information can be found at congress.gov/members, where you can sort by state to locate your senators or search by ZIP code to find your representative. (If you are interested in learning more about specific Medicare advocacy strategies, consider reading my April 2016 article in Adultspan Journal on this topic.)
Members of the counseling profession must also consider whether the current state of counselor training provides adequate exposure to the possibility of working with older adults. A 2009 study by Thomas Foster, Val Kreider and Jennifer Waugh found that counseling students had a high degree of interest in topics related to older adulthood, including the transition to retirement, helping families navigate the aging of a family member, providing support to caregivers and discussing issues such as dying and grief with clients. However, the authors suggest that counselors and counseling students lack opportunities to follow through with these interests.
At the programmatic level, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) specialization in gerontological counseling was discontinued in 2008 because of a lack of counselor training programs applying for accreditation in this area. Although the lack of Medicare reimbursement for counselors may influence the viability of a gerontology specialization, it is worth asking whether more could be done to promote work with older adults within counselor education programs. For instance, in reviewing the 2016 CACREP Standards, I found zero references to the words older, age or ageism, and only one reference to the word aging.
Anecdotally, I have had numerous conversations with counselors and students who express a great deal of interest in focusing more of their work on older adulthood but do not think they have adequate opportunities or knowledge to do so. Therefore, it is important for counselor training programs to assess their students’ interest level in working with older adults, identify practicum and internship sites that provide access to these individuals and participate in professional advocacy efforts to expand the role of counselors to meet the mental health needs of older adults. In addition, members of the counseling profession should work with their state counseling associations to coordinate state and local efforts to raise awareness within the community, as well as within the political arena, about the current state of older adults’ mental health access and the need for Medicare reform.
In summary, the “graying” of America is making its mark across a wide range of industries, including mental health. As more attention and public dollars shift toward the national challenge of promoting the health and wellness of an older population, members of the counseling profession will find themselves impacted in myriad ways.
Families will be affected by the growing number of older people living with chronic health conditions. Paid and unpaid caregivers will have greater responsibility for providing support to older adults. Topics such as retirement and lifelong vocation will be reconsidered as individuals work longer to make ends meet and spend their post-retirement years continuing to seek avenues for purpose and meaning.
In spite of the hurdles that remain, members of the counseling profession can support the growing number of older adults by providing mental health services that are developmentally appropriate, grounded in wellness and suited for a diverse range of older individuals. With that in mind, why don’t you go gray?
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Matthew Fullen is a licensed professional clinical counselor in Ohio. He has worked with older adults in a variety of contexts since 2005. He currently serves on the board of the Association for Adult Development and Aging and is completing a doctorate in counselor education with a specialization in aging at Ohio State University. Contact him at firstname.lastname@example.org.
Letters to the editor: email@example.com