The graying of the baby boom generation is a good news-bad news proposition for the counseling profession.

The good news? Numerous mental health experts believe baby boomers have largely come to disregard the stigma that their parents once so strongly attached to mental health services. As a result, many professionals anticipate that baby boomers will readily partake of counseling services as they deal with issues of aging.

That should make counselors stand up and take notice, especially considering that the 78 million members of the baby boom generation will begin turning 65 in 2011. According to statistics from the Institute of Medicine (IOM), the number of adults age 65 and older in the United States will almost double between 2005 and 2030 to more than 70 million, constituting almost 20 percent of the population.

American Counseling Association member Chris Johnson, a professor of gerontology and sociology at the University of Louisiana-Monroe (ULM) Institute of Gerontology, believes aging baby boomers could do much in the coming years to move counseling — and particularly gerontological counseling — even more securely into the mainstream.

The bad news? Johnson and other counselors worry the profession isn’t truly prepared to fully seize this opportunity.

“Are we ready for the number of Americans age 65 and older to almost double?” asks Johnson. “Are counselors readily equipped to handle that? Do they understand the biology of aging and the multiple changes that seniors go through? The baby boomers present us with a demographic imperative, but when you look at the sheer numbers, it’s amazing that many counselor education programs ignore gerontology courses — especially gerontology counseling courses. The baby boomers are going to be more willing to see counselors than their parents, and I think gerontological counselors are going to be in high demand.”

Carolyn Greer, president of the Association for Adult Development and Aging, a division of ACA, agrees with that assessment. “Anytime you’re looking at such a large segment of the population, you better be paying attention. More and more counselors are going to be faced with this person who is older and who is confronting concerns about aging,” she says. “But from the AADA perspective, there are not as many gerontological counselors as there need to be, and gerontology has not been given as much attention in counselor education programs as perhaps it should.”

The newly revised standards of the Council for Accreditation of Counseling and Related Educational Programs (CACREP), which were officially adopted last July and will go into effect July 2009, reflect this seeming lack of enthusiasm for gerontology among counselor education programs. In a column for the August 2008 issue of Counseling Today, CACREP Executive Director Carol L. Bobby and CACREP Director of Accreditation Robert I. Urofsky noted, “The 2009 Standards delete the program area for Gerontological Counseling because few counselor education departments have sought accreditation for this specialization.”

While the 2008 IOM report Retooling for an Aging America: Building the Health Care Workforce doesn’t focus on counseling, it predicts that as baby boomers age, “they will face a health care workforce that is too small and critically unprepared to meet their health needs.” The report urges initiatives to boost recruitment and retention of geriatric specialists and emphasizes that more health care providers need to be trained in the basics of geriatric care. The same report says about 4 percent of social workers specialize in gerontology — roughly one-third of the estimated need.

Mary Finn Maples, a past president of ACA who has written and presented extensively on baby boomers and gerontological counseling, says counselors across the spectrum — from mental health and couples counselors to career and addictions counselors — should anticipate that aging baby boomers will impact their work. “But gerontological counselors who are prepared to work with the aging and their special needs will be of optimum necessity,” says Maples, professor emerita of counseling and educational psychology at the University of Nevada, Reno. She adds that she wants “potential gero-counselors to understand the urgency that exists in helping this ‘silver tsunami’ that is headed our way. … I would like to encourage skilled and experienced counselors to consider receiving training and preparation in working with this unique and very special population.”

In that vein, Johnson invites interested counselors to learn about the 18-hour online gerontology certificate offered through the ULM Institute of Gerontology by calling him at 318.342.1467 or visiting ulm.edu/~gero/.

Climbing the Medicare mountain

Beyond questions of whether most counselors are properly prepared to help baby boomers address issues of aging is the problem of Medicare reimbursement.

“Medicare is the nation’s largest health insurance program, covering more than 40 million beneficiaries — mostly senior citizens. Obviously, with the graying of the baby boom generation, there are going to be millions more Medicare beneficiaries over the coming years,” explains ACA Director of Public Policy and Legislation Scott Barstow. “Medicare covers the services of psychologists and clinical social workers, in addition to psychiatrists and other physicians, but it doesn’t cover counselors. Consequently, with the graying of the baby boomers, this is going to mean there are millions and millions of people counselors can’t get reimbursed for seeing. That’s a big problem.”

If the situation remains status quo, Barstow says, when baby boomers turn 65, they will have the following choice: paying out of their own pockets to see a Licensed Professional Counselor or having their visits to psychologists, psychiatrists or social workers covered by Medicare. For counselors in group practice, there are some ways around the Medicare reimbursement lockout, he says, “but if you’re in private practice, that’s a huge segment of the population that you’re going to be missing out on at some point.”

Barstow is optimistic that LPCs can achieve Medicare reimbursement, but not until they grasp the seriousness of the situation and start to consistently and energetically advocate for themselves in large numbers. ACA is currently lobbying congressional offices and urging all state counseling branches to get their members engaged in grassroots work in support of Medicare reimbursement of counselors (see Washington Update, p. 12).

“We’re very, very close, and I think we’ve got a good chance of getting in next year,” Barstow says, “but it’s not going to happen if counselors don’t get upset about it and take action. Other people — related professions — aren’t going to do the work for us.”

To achieve this goal, Barstow urges counselors to call their senators and representatives and ask them to cosponsor S. 921 and H.R. 1588, respectively (both pieces of legislation are known as the Seniors Mental Health Access Improvement Act). For more information, visit the ACA website ( counseling.org) and click on “Public Policy,” then “Current Issues” and read the position paper on “Medicare Coverage of Licensed Professional Counselors.”

“I think Medicare reimbursement is a major concern to professional counselors,” says Jim Cook, assistant professor and director of the professional counseling program at McKendree University and a member of ACA, the Association for Specialists in Group Work and the Association for Counselor Education and Supervision. “As an educator, I fear that some very talented students will avoid counseling older adults because of a concern that their interests and skills will not translate into jobs as private practitioners. I also believe that Medicare reimbursement is important to our sense of identity and morale as professional counselors who work with aging populations. For professional counselors who work in situations in which they must bill under other mental health professionals, I think it sends a message that a counseling degree is a less valuable degree. Gaining Medicare coverage would help level the field with our mental health colleagues, while also expanding employment opportunities for counseling graduates.”

“One of the greatest things that could happen would be for counselors to be recognized by Medicare,” Greer confirms. “Counselors are at risk of being shut off from baby boomers, and that’s not a good thing. That’s a fifth of your possible population. But beyond reimbursement, we also ought to look at it from a societal standpoint. What are the implications? What impact might that have on our society if these aging baby boomers can’t readily access counseling?”

While Greer says much of the stigma surrounding mental health services has dissipated during the baby boomers’ lifetime, she thinks some stigma still remains concerning seeing psychiatrists, who are covered under Medicare. More important, she says, counselors are generally more accessible than other mental health professionals currently covered under Medicare, such as psychologists and clinical social workers, especially in rural areas. Greer hopes politicians will give weight to the issue of accessibility when considering legislation that would include counselors under Medicare. “If you have such a large portion of your population that is aging, why wouldn’t you want to ensure that they have some access to mental health care?” she says.

Johnson, who maintains a part-time private practice in which he works with middle aged and older couples and individuals, doesn’t see Medicare reimbursement of counselors as a critical issue. Generally, he says, baby boomers will enter their later years better off financially than previous generations and will likely carry private insurance rather than relying solely on Medicare. In addition, Johnson believes baby boomers are what he terms “better shoppers for health services,” in part because of their generally higher levels of education. Instead of automatically accepting the cheapest alternative, he says, they search for higher quality services that will meet their needs and pay close attention to credentials when choosing service providers. Johnson thinks this generational mind-set will steer many baby boomers toward professional counseling services, even if those services aren’t covered under Medicare.

Still, Johnson is a proponent of counselors and marriage and family therapists attaining coverage under Medicare. “And with the number of counselors and MFTs out there, we have the potential to change the current situation,” he says.

Johnson says many baby boomers have also indicated a preference not to have their mental and emotional issues treated with drugs. This is to the advantage of counselors, he says, not only in earning the trust and business of baby boomers, but also as another justification of why Medicare should cover LPCs. “Many psychiatrists are treating with drugs, not therapy,” he says. “This is costly for the government and also puts this population at risk of overmedication, especially as their metabolism slows down. So you have both a biological argument and a financial argument for including counselors.”

Opportunity comes knocking

Despite the obstacles, those who work with baby boomers and older adults are energized by the opportunities this population presents to the counseling profession. “It’s really an exciting time for counselors right now as we transition to this huge demographic change,” Johnson says.

The baby boomers’ sheer numbers, their openness to counseling and the fact that they are entering a new and challenging stage of life have some professionals anticipating that an unprecedented demand for counseling services could be just around the corner. In other words, the opportunity may exist for counselors to make themselves indispensable in helping aging baby boomers confront a wide spectrum of issues — and perhaps increase awareness of counseling as a valuable service for succeeding generations in the process.

Greer believes the graying of the baby boom generation offers real opportunities for counselors to prove their effectiveness, not only as practitioners, but also as advocates. She points out that numerous studies have forewarned of the burden aging baby boomers will place on the U.S. health system, while mostly ignoring or glossing over the issue of mental health care. “That’s a major place where counselors can come in, looking at and raising awareness of the mental health angle,” she says. “We also need to work with other groups, such as AARP, for example, to make sure they recognize that counselors are a valuable resource for the aging population.”

In addition, while Greer serves as president of AADA, the division is creating downloadable brochures on topics related to aging that counselors, doctors and other service providers can display in their offices for clients. The hope is to reach aging clients while simultaneously educating other service providers about the unique needs of baby boomers and older adults. “We need to get doctors to recognize that healthy aging is not just about the physical, but also the mental and emotional,” Greer says.

Of course, for the counseling profession, awareness needs to be raised on the home front as well. “With this population … there is a need for trained professionals to assist older adults and an opportunity for counselors to expand their current practices,” says ACA member Wendy K. Killam, associate professor and director of the community counseling program at Stephen F. Austin State University. “The opportunities include not only providing mental health counseling services, but also career counseling and consultation services.”

But taking full advantage of these opportunities will require the counseling profession to make some adjustments, according to Maples. “The unique characteristics of this group will cause paradigm shifts in both training and practice of counselors who work with baby boomers,” she says. “Often, counselors do not realize the uniqueness of this population. We will never be effective or successful if we look at counseling as ‘one size fits all.’ Each client or group of clients brings specific characteristics to the counseling relationship.”

“Likewise,” she continues, “as in any counseling relationship, cultural and ethnic considerations must be uppermost in the counselor’s mind — and actions — when working with baby boomers. If counselors do not possess and demonstrate multicultural competencies and applications, they will not be effective with their clientele. All clients come from unique cultures, and it is (incumbent) upon the effective counselor to practice this knowledge in all counseling relationships. As a colleague of mine says to all of his students, ‘All counseling is multicultural!’”

Major baby boomer issues

You don’t have to specialize in working with baby boomers to guess that issues surrounding retirement loom large for this age group. Often chief among their concerns is how they will survive financially.

According to a March 2007 United Nations study, life expectancy in the United States is expected to increase from 78.5 years in 2007 to 84.5 years in 2050 (for comparison, U.S. life expectancy was 70.8 years in 1970). “So one issue baby boomers are facing is can they actually afford it financially to live longer,” Greer says. “Some of them are reaching 60, 65 and realizing, ‘Social Security is not even going to begin to pay my bills.’ They may not have prepared for their retirement adequately, particularly for living 20 to 30 years past retirement age. They can really experience a lot of stress from that. They’re saying, ‘Retirement is upon me, but it doesn’t look like the pie in the sky I was expecting.’”

On the basis of the statistics, many baby boomers will either delay retirement or reenter the workforce in some capacity after retiring. According to the U.S. Census Bureau’s 2008 Statistical Abstract of the United States, 5.5 million individuals 65 and older were in the workforce in 2006; that number is projected to reach 10.1 million by 2016.

“There are a number of baby boomers who are going through career transitions,” Killam says. “It is not uncommon for a person to retire, only to then return to the workforce in a different position to help supplement retirement income. The reasons for this are multifaceted. Some people need the extra income, while others find that retirement does not provide meaning in their lives.”

“It can be very difficult for an experienced worker to have to take orders from a young person,” she continues. “Counselors can assist older adults in coping with making transitions and with exploring career options in terms of transferability of skills. … This age group has job skills that, even if the job has changed, the skills are transferable to other jobs. The key for the counselor is helping the client to understand how to apply the skills in a new environment.”

In many instances, Johnson says, finances aren’t the only shock to the system baby boomers experience upon retiring. “The question is also how couples prepare for the married part of retirement,” he says. “Are they well prepared to live together 24 hours a day? That can create havoc in a home.”

Many men, in particular, aren’t truly ready to retire, he says. They haven’t developed many hobbies outside of work, and, other than their wife, most of their friendships were based at or around work as well. “So the husband tends to rely on his wife for all of his intimacy and friendship needs,” Johnson says, “and she can become overloaded.”

In addition, he says, retired males often experience a lack of purpose. “The husband may suddenly want to rearrange everything in the kitchen when he has never shown any interest previously,” Johnson says. “Again, this can cause tension and fights.” In his practice, Johnson often sees older male clients who, in the winter when they can’t get out and work in the yard, become depressed, in large part because their level of social engagement is decreased. In some cases, he says, this leads to chronic TV watching or even a dependence on alcohol, gambling addiction or other pathologies.

Cook likewise contends that social interaction is a vital cog in healthy aging. “I think it is important for professional counselors to understand the unique needs of the aging person. For example, physical limitations often affect social functioning and vice versa,” Cook says. As baby boomers age, he explains, they encounter a number of social transitions (the death of a spouse, retirement) and physical transitions (problems with walking, hearing loss, vision difficulties) that make life more challenging. “Subsequently, our world sometimes gets smaller and smaller,” he says. “For example, after a man’s spouse dies, he may no longer think it is important to walk downstairs to watch TV or visit the local park on weekends, physically limiting his world. Or a woman stops having dinner with her family because she cannot hear the conversations around her, socially limiting her world. Interventions that examine the interplay of the aging person’s physical/social world are needed to fully understand and treat the problems of the aging person. From our research (conducted by Cook and his colleagues), we believe that counseling groups are such an intervention.”

Depression is another common problem for older adults, and Greer wonders whether baby boomers might struggle with this even more. “This group never thought they were going to grow old,” she says. “They picked up on the concept of exercise and fought to stay young, as evidenced by the rise in plastic surgery. They said to themselves, ‘I am just not going to get old like my parents.’ But now, they’re having to accept that reality.” Counselors will need to take a different approach with the baby boom generation, she adds. “Counselors should recognize that this is a different stage of depression than they have seen in younger clients,” she explains. “It’s related to the baby boomers’ acceptance of their own mortality and the aging process.”

But counselors also need to look for other issues that may be triggering depression and stress among baby boomers. In many instances, Greer says, this involves evaluating what is happening in the rest of the baby boomers’ family system. For example, she says, many baby boomers are helping to raise their grandchildren because their adult children have either returned home or are not responsible parents. In the years ahead, Greer also suspects that counselors will see many baby boomers trying to serve as caregivers for their spouses who have Alzheimer’s. Maples adds that some baby boomers feel the squeeze on both sides, not only trying to assist their adult children or grandchildren, but also trying to provide care to their own elderly parents.

Then there are issues that might not readily spring to mind. For instance, Maples says, because of growing health problems as they age and the ease of obtaining prescription drugs, many baby boomers struggle with alcohol and drug abuse.

“And believe it or not,” Johnson says, “many baby boomers need some sex education.” As a cohort, he says, baby boomers have been more sexually active than their parents and desire to remain sexually active in their later years. With drugs such as Viagra helping to make this desire a reality, health professionals have witnessed a steady increase in the number of sexually transmitted diseases among middle aged and elderly populations over the past decade or so, Johnson says. He attributes this to many baby boomers having outdated views of sex and protection from STDs. For example, with the risk of pregnancy gone after menopause, many baby boomers don’t think there is any reason to practice safe sex with different partners, never considering the possibility of picking up an STD, he says. “But in these leisure communities, do you think all those single people are abstinent?”

Working with baby boomers

In Maples’ opinion, spirituality is one consideration that doesn’t receive enough attention in connection with the baby boom generation. Maples believes, based on studies she has conducted since 2005, that “baby boomers are seeking a greater sense of meaning in life than any group before them.” She is quick to point out that “spirituality,” in this case, “should not be equated with religion, except as an individual chooses to include it.” With some exceptions, she says, baby boomers are not turning toward organized religion for answers to life’s questions or challenges, yet this group does identify their quest for meaning and purpose as being spiritual in nature. “Baby boomers seek fulfillment in more creative and unique ways,” Maples says, “such as through nature, maintaining physical health, reading, having spiritual mentors, seeking resolution to life’s problems within themselves, but not necessarily solving them — thereby leading them to seek counselor assistance.”

Interestingly, she says, this search for meaning doesn’t seem to be limited to baby boomers in the United States. In 2003, while teaching counselor education in Guatemala, Maples found that her students, the majority of whom were baby boomers, and their baby boomer clients often “spoke of being rootless and purposeless in their lives.” In fact, she says, many of them described themselves as “existing” rather than “living.” And when Maples presented a Learning Institute on spirituality and wellness in baby boomers at the 2008 ACA Conference in Hawaii, she says the session attracted baby boomer attendees from 12 different countries.

Yet Maples has also found that even counselors who care deeply about helping their clients resolve issues related to spirituality and meaning are often unprepared to do so. “Hence my plea for more effective training of counselor education graduate students and professors to work with those searching for life, career and relationship fulfillment,” she says.

But Maples has also observed that baby boomers often tend to be in a hurry. Perhaps for that reason, she says, life coaching is becoming more attractive to this age group, as are online delivery models. “I find that my certification as a distance counselor has been extremely helpful in working with these clients,” she says.

In large part to address the unique needs of baby boomers, Maples and two other colleagues recently started a new business called TLC Inc., which stands for Transition Life Coaching. One of the women is a certified financial planner and will handle financial coaching for baby boomer clients. Another colleague who has a doctorate in counselor education and is the assistant dean of a medical school will handle the wellness aspects of life coaching. And Maples says she will “deal with clients making transitions — in their careers, in their geographic locations, to retirement, experiencing the empty nest syndrome, seeing loved ones die, seeking meaning in life and having to make life changes. … Baby boomers, because of their great numbers, are ideal candidates for this type of assistance.”

Ideally, counselors would undertake some preventive work with baby boomers, but the reality is that counselors will most often find themselves helping these clients with “how can you get through this?” Greer says. “Generally, people don’t pay attention until they’re in the problem. So baby boomers are going to need more aftercare from counselors.”

One exercise Greer finds effective is to have baby boomers and mature clients draw an “age line” so they can review significant points from throughout the course of their life. She has them talk about the challenges they faced along the way and discuss how they overcame them. “I try to help them see the positives that emerged from those challenges,” she says. “This gives them insight into their coping skills.”

“The counselor needs to be equipped with and knowledgeable of brief therapy and also understand family structural issues,” says Johnson, who likes to use genograms with baby boomers and mature clients. He says a repertoire of cognitive and behavioral therapies and family systems therapy are very useful. In marriage therapy with this population, he acknowledges using some of John Gottman’s ideas (such as the “four horsemen of the apocalypse” — four key problems that lead to divorce) blended with transactional analysis and rational emotive therapy.

Based on research that he and his colleagues have conducted, Cook recommends counseling groups as particularly effective interventions in working with baby boomers and older adults. “I believe that groups with an emotional element are able to move the client to process life experiences,” he says. “Counseling groups in particular are perfect interventions because they can be used as a vehicle to tap the emotional aspects of the aging person’s physical and social experience. These groups can be used as a platform to promote a connection between the knowledge of living a healthy lifestyle with the behavior of living a healthy lifestyle.”

Counselors also need to be aware of their own attitudes in working with baby boomers and aging adults, Killam adds. “It is important for the counselor to be sensitive to the needs of the client and to not impose his or her values on the client,” she says. “Too often, people — including counselors — have an image in their mind of what older adults are capable of doing and, if not careful, one’s biases may negatively impact the counseling process.”

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.

Letters to the editor: ct@counseling.org