At the age of 75, Jenny was dealing with more than
  her fair share of grief. She had recently lost both her son and her husband of 50 years to cancer. She was also terminally ill with cancer herself.

“Jenny was dealing with complicated grief — the loss of her husband and son, plus her own diagnosis,” says Christine Moll, associate professor in the Department of Counseling and Human Services at Canisius College in Buffalo, N.Y. “She felt genuine sorrow for her remaining family members and the tremendous loss they were feeling.”

At a time when Jenny had perhaps her greatest need for counseling, there was yet one more hurdle to face — she was unable to travel to a clinician’s office. So instead, Moll went to her.

Earlier in her career, Moll, a past president of the Association for Adult Development and Aging, a division of the American Counseling Association, worked with Catholic Charities of Buffalo in a group known as the Geriatric Outreach Treatment Team. The team focused solely on conducting at-home visits with people over the age of 60 who could not travel.

“Over the course of about three months, Jenny and I worked on her accepting her diagnosis as part of her life journey and her anticipation of meeting her husband, son and other family members on the ‘other side,’” Moll says. “Jenny shared her life story, her own early childhood and how her family of origin managed during the Great Depression. We discussed the strengths and gifts that she and her family possessed to live through those hardships. How might those strengths serve her now?”

As Jenny’s health weakened, her daughter and daughter-in-law were often there when Moll made her visits. “We spoke of Jenny as a mother and grandmother, her love for her family and how that love would be carried on in her absence,” Moll says. “What legacies would continue with family meals, celebrations and in life, especially as her grandchildren grew into adults themselves?”

“My last visit with Jenny was about 12 hours before her death,” Moll continues. “She was peaceful and ready to move on to what she believed to be eternal life with her God and her family who had predeceased her. Interestingly enough, as they witnessed Jenny’s peace, her daughter and daughter-in-law were able to let go of their anger and ‘let her go’ in peace.”

Similar to Jenny’s experience with loss and her own mortality, challenges can mount for people as they age, says Larry Golden, an associate professor in the University of Texas at San Antonio Department of Counseling. The challenge for counselors, he says, is helping these clients to cope.

Golden, an ACA member who ran a private practice for 25 years, divides older adults into two categories: “old-old” and “young-old.” He categorizes the first group as those in their 80s and 90s who are becoming physically frail and possibly struggling with dementia. Clients in this group may be struggling with a decision over whether to move to an assisted living center or enter hospice care, he says. Many different entities may have an interest in the person’s decision, from the health care industry to family members, Golden says, adding that the counselor has the opportunity to serve as an advocate for the client. “Our primary concern as counselors is advocacy,” he says. “(But) the individual, depending on their mental competence, should have the last word.”

Golden defines the young-old as people in their 60s and 70s who are in good health. Although their counseling needs don’t differ much from any other age group, he says their commitment and openness to the counseling process is generally greater. The same person who had alcohol problems in his 20s might seek counseling in his later years more ready to embrace change and see life differently, Golden explains. Likewise, someone with a history of failed relationships might meet a partner in her later years and become invested in ensuring the relationship’s success. “This group takes counseling very, very seriously,” Golden says, and in his opinion, that’s what makes them such rewarding clients. “We usually meet people in counseling when they’re in trouble. I would just as soon meet them when they’re serious about the work.”

Bumps in the road of life

While people often say that they dream of retiring, the realities can prove nightmarish for many individuals. “People leaving their profession is like a death,” Golden says. “My identity doesn’t exist anymore at the point I retire.” That struggle is an opening for counselors, however. “Group counseling can be very effective because it helps normalize the kinds of anxiety people feel,” he says. Finances are another stressor related to retirement, so Golden suggests counselors who want to specialize in retirement issues consider collaborating with a financial expert or learning more about finances themselves.

Chronic health problems can pose another uphill battle for people as they age, says Summer M. Reiner, an assistant professor at the College at Brockport in New York and incoming president of AADA. They experience discomfort on a constant basis and mourn the ability to do things as quickly as they used to, she says. It’s important for counselors to focus on what it means to that client to be going through those struggles. “The bottom line is acknowledging that the person is experiencing that condition,” Reiner says.

It’s also imperative for counselors to know about clients’ illnesses and what medications they are taking, Moll adds Being knowledgeable of the side effects of an illness or medication can help the counselor better understand the client’s situation. As an example, Moll cites a client who has suffered a stroke, leaving that person more labile or teary. If counselors aren’t paying attention to that, Moll says, they might misinterpret the frequency of the tears and conclude that it’s something more serious, such as depression.

Loss and grief go hand in hand and can weigh heavily on people as they go through life. People lose spouses and partners, family members and friends. With a country at war and violence on the streets, Moll adds, that loss can come in the form of younger family members as well. “Loss is a ‘change’ that we cannot change, and we are often left feeling ‘orphanated,’ eviscerated and just plain sad,” she says. “Loss for an older adult can be more challenging because our losses sometimes accumulate, so that with each loss we feel as if a surgical wound, well-healed, has reopened. Loss may remind us of our own mortality.”

“Grief is a normal emotional reaction,” she continues. “A counselor can assist the grieving client to come to terms with the separation from their loved one and how life has changed with the absence of loved ones and to live life in its new form.”

For many people, religious faith can be of crucial assistance when dealing with grief, and Reiner points to studies showing that spirituality increases as people age. Attempting to incorporate that spirituality into counseling is important, says Reiner, who suggests counselors review the Association for Spiritual, Ethical and Religious Values in Counseling’s competencies and then talk to clients about what they believe and if spirituality could be a means of support to them. “The client is the best person to educate the counselor about their beliefs,” she says.

All three counselors agree that finances can be a significant barrier in getting counseling for older adults on a fixed income. The client might not have insurance or be able to afford the copay. “We better get effective at getting Medicare coverage for LPCs (licensed professional counselors),” Golden says. “We will continue to be shut out of opportunities to work with older adults until we get Medicare coverage.” In the meantime, Moll notes, social service agencies often provide counseling on a sliding scale where the fee is dependent on the client’s income or ability to pay. Worship communities and community centers might also provide counseling services to members.

Like Moll’s client Jenny experienced, simply getting to a practitioner’s office may offer another challenge for older adult clients. Moll and her colleagues solved the problem by visiting their clients at home. For those counselors for whom making house calls isn’t feasible, Reiner suggests helping clients navigate options such as local van service or public transportation.

This is your life

As the years pass by, emotional baggage can build up. That’s when “life review” can help, Golden says. Life review is a counseling intervention that Golden says he uses mostly with old-old people, as long as they’re not struggling with dementia. “There’s a tendency in old people to want to reminisce, to talk about the good old days,” he says. “There’s a serious side to that that counselors can capitalize on.”

In the process of the counselor asking questions about the client’s life comes talk about the good, the bad and the unresolved. “One of the reasons older people reminisce is because they are trying to get some resolution to issues in their lives,” Golden says. “The questions could be everything from tell me about your first friend to tell me about your first romantic relationship to what are some of your memories of your children? You don’t get very far before people get into some issues.”

“(Life review) provides one last chance to make sense of your life,” he continues. “It can even lead to decisions to reconcile or to reframe an issue in a way that lends itself to acceptance rather than bitterness. These are some of the tasks of the old-old.”

In addition to life review, counselors say there are other do’s and don’ts when working with older adult clients. Among their best tips:

• DO coordinate with physicians. Clients are oftentimes seeing multiple physicians, Reiner says, and it’s helpful for a counselor to know what treatments clients are receiving and what medications they may be taking.
• DON’T be shocked. “Many of us think (sexual) intimacy stops at a particular age,” Moll says. “It doesn’t.”
• DO address the client’s needs and barriers, then attend to the emotional strain that could come with those needs or experiences. For instance, Reiner says, if a client uses a wheelchair and the ramp is inconvenient or nonexistent, address how to make it easier for the client to access the counselor’s services. Then address the client’s feelings about how frustrating it might be to experience barriers due to physical limitations.
• DO be attentive. Speak clearly and audibly, Moll says. Pay close attention to the client’s ability to hear, see and move. “Make sure they’re comfortable,” she says.
• DON’T make assumptions. Don’t assume that clients aren’t concerned with their sexuality, their leisure time or their family needs just because they’re older, Reiner advises. Likewise, don’t assume that a client is distraught, grieving or even sad if a spouse or partner has died, she says. “Don’t jump to conclusions about what things can mean to a person. Remember that although they’re aging and they have a lot to deal with, they’re still full people.”
• DO enjoy older clients. “Working with older adults is as much of a journey as working with any other age group,” Moll says. “I genuinely enjoy the person and the uniqueness of the person.”

Connecting with clients

Counselors who are passionate about working with older adults and would like to build their client base can start by networking with local doctors. Try internists, heart specialists or other doctors likely to have a larger elderly patient base, Moll suggests. Build relationships with them and then ask them to refer clients whom they think might benefit from counseling. Reiner agrees that doctors can be a great resource, pointing out that older adults might make more doctor’s appointments if they’re lonely and in need of interaction. Physicians might pick up on that and be able to refer the client.

Reiner also recommends that counselors visit the local library or senior center to meet older adults and put out pamphlets. Pamphlets are effective at helping to spread the word, she says, because even if someone who picks it up doesn’t need counseling, that person might think of a friend or family member to refer. Hospice is another good resource, Reiner adds. Even if the person receiving hospice care doesn’t want counseling, a spouse or elderly sibling might benefit from it.

When you connect with older adult clients and begin working with them, Moll says, it’s important to remember that the length of one’s life story is what makes it even more powerful. “These clients’ stories are rich and powerful and historical and full of wisdom,” she says. “There’s much to be learned.”

What has Moll learned from Jenny and her other clients? Above all, resiliency. “What each (client) has taught me is that there’s something to be said for resiliency, there’s something to be said for seeing the glass half full.”

Moll’s own father, who passed away about six years ago, exemplified resiliency, she says. In his younger years, he loved to golf, and he didn’t let the aging process stop him. Instead, he adapted the game to fit his stage in life. Out on the green, someone would help him tee the ball up, then after a short swing, he’d move the ball to within chipping distance and finish out the hole. “He played practically up to the end,” Moll says. “He simply went with what he could do.”

That idea of the glass being half full isn’t lost on Moll, and it’s a philosophy she tries to share with her clients. “It’s how we transcend our limitations,” she says, “to find quality in what we have in front of us.”

Lynne Shallcross is a staff writer for Counseling Today. Contact her at lshallcross@counseling.org.

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