Growing old isn’t what it used to be. Gone are the days when the best thing about turning 60 was collecting your free bus pass. Today’s 60-somethings grew up in the Swinging Sixties, invented punk, embraced personal growth and rebelled against the idea that being an adult meant turning into carbon copies of your parents. Now at retirement age, they are reframing the Third Act as a time for new possibilities and forming think-tanks such as The Age of No Retirement to campaign for ‘a world where age does not define us’, because, ‘the linear life model is shattered, the retirement line has blurred, and people resent being treated like a number in an age-band bucket’.1

In the shadow of this vibrant, vocal generation is the less comfortable face of ageing – the plight of the very old, who are treated by society as a ‘different species’ and experience their old age by internalising other people’s reactions to them.2 While happiness and life satisfaction peaks in adults aged 65 to 79, according to an ONS report on wellbeing, it dips again after the age of 80, with adults aged 90-plus least likely to feel living is worthwhile.3 They are a growing section of society – every day, 200 more people reach the age of 85. In 2016, 1.6 million people, or 2.4% of the UK population, were aged 85 or above, and this figure is forecast to double in just 25 years, to 3.2 million (4.4% of the population) by 2041.4

This is the cohort that grew up with parents traumatised by war, in a society that turned a blind eye to sexual, emotional and physical abuse, that discriminated against those who didn’t conform to gender and sexual norms and was still largely unaccepting of the attachment implications of separation for young children. ‘It’s people who at age three would spend two weeks in hospital having their tonsils out and their parents would be discouraged from visiting. Or they would be sent away to school at eight and shamed for being homesick,’ says Sarah Baker, a member of BACP’s Older People Expert Reference Group and an integrative and creative counsellor specialising in working with older people. ‘Many have been dealing with undiagnosed trauma for years.’

Long-term trauma

Such trauma can often come to a head in later life, says Baker, when resilience is reduced through loss, not only in the form of bereavement, as family members and friends die, but in the profound change in identity that comes with losing mobility, health and independence. A report from the King’s Fund suggests that, by 2026, ageing will be the key driver for increasing incidences of mental illness in the population as a whole.5 There is also growing awareness of the link between good mental health and the ability to manage frailty, defined as ‘a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves’,6 which affects around 50% of those aged over 85.7

Yet the older people get, the less likely they are to seek support for their mental wellbeing. Only one in six say they would talk to their GP about their mental health.8 According to a recent study, two in five people aged over 75 have some signs of depression, but people aged 85 and over are five times less likely to be referred for therapy than those in their late 50s.9 This research shows that older people who go to their GP with symptoms of common mental health problems are a third more likely than younger people to be prescribed medication rather than talking therapies. Says Jeremy Bacon, BACP’s Older People Lead: ‘The reasons cited by clinicians include beliefs that therapy isn’t effective for older people, that it isn’t wanted, or that services aren’t available. The research also indicates that healthcare professionals feel that later-life depression is mainly attributable to social isolation and functional decline; in other words, that depression is, for some, an inevitable part of getting old. As part of our Older People Strategy we’re challenging these attitudes with the evidence that counselling changes lives, irrespective of age.’

But talking therapy outcomes in older people are as good as those in younger populations, according to a 2016 BACP systematic review of relevant research,10 and older people who do make it into the IAPT programme have better recovery rates than younger patients.11 Yet currently only 6.1% of IAPT clients are over 65, despite a target set for 12% in 2011.12,13

Age discrimination

A generic approach to adult mental health services has resulted in direct and indirect age discrimination, according to a 2018 report from the Royal Society of Psychiatrists:14 direct in that older people are less likely to be referred for talking therapy, and indirect in that the services currently on offer don’t meet their needs. ‘Ageing is not embraced or celebrated in our youth-focused society,’ says Danuta Lipinksa, a counsellor, supervisor and trainer with a special interest in working with older people. ‘We are often told how much it costs to care for older adults now and in the future, and what a burden they are to society. And yet without the lives and work of our ageing citizens, what kind of world would we have?’

Meanwhile, therapists themselves, being human, are not immune to ageism, and few of us choose the elderly as a specialism. ‘It’s not seen as the sexy end of therapy,’ says humanistic counsellor Helen Kewell, author of the book Living Well and Dying Well: tales of counselling older people.15 ‘We have been socially programmed to think about the main task of ageing as “coping” – an inherently passive, defensive position.’

And we might not like to admit it, but we are as likely as anyone else to experience a reflex response of ‘urgh’ to older people, says Felicity Chapman, author of Counselling and Psychotherapy with Older People in Care.16 ‘I think this inner recoil is often less about the older person before us and more about how difficult it can be to face the truth of ageing as our destiny. But if we do not try to make peace with this in some form, not only are we discriminating against the current cohort of advanced seniors, we are also discriminating against our future selves.’

Chapman has also identified what she calls a ‘Mickey Mouse mindset’ among those who work with older people. ‘It is a form of internalised ageism that feeds into the mostly Western experience of not having high regard for our elders,’ she says. ‘It’s the tendency for therapists themselves to belittle what they do when they work with older people. They feel discriminated against and have internalised that sense of unworthiness.’ But, far from being ‘a chat about the weather over a cup of tea’, working with this client group is complex and demanding, she says. ‘For me, it’s therapy at its most interesting. When working with older people I draw predominately on narrative therapy, acceptance and commitment therapy, life review models, trauma-informed care and grief therapy. But, to be honest, the real efficacy in working with this group lies with the therapeutic alliance and transcends any particular modality, because, when you are navigating a range of challenging presentations or disabilities, it is more powerful to stay focused on holding the therapeutic space for the client.’

Baker admits to having deep reservations before specialising in working with clients with dementia. ‘I got into it because I was offered an opportunity to do a funded MPhil at postgraduate medical school. But my initial reaction was, would it be boring? What would I have in common with these people? Dementia care can seem frightening at first; clients may appear to behave unpredictably and sometimes quite violently. But I very quickly became absolutely hooked. I soon learned that all behaviour has meaning and that becoming skilled in responding to the need and the person behind the behaviour not only increased the client’s sense of wellbeing but was immensely satisfying and fulfilling for me.’

What’s particularly rewarding is the opportunity to help clients retell their personal narratives, says Kewell. ‘Many of this client group grew up with fixed views formed by a world that simply did not change in the way it does now. Therapists can offer older people the opportunity to release themselves from beliefs they have held all their lives, such as “I’m not good with feelings” or “I can’t cope”. It can be powerful – the shift can affect all their personal relationships.’

Kewell, whose approach is existentially informed, initially felt deskilled; she wondered ‘How can I possibly help this person?’ when she was allocated her first very old client, when volunteering for Cruse Bereavement Care. ‘But I loved it, and so the older clients began to be sent my way,’ she says. ‘It has helped me connect on a deeper level with people in my life who are a similar age to my clients and has changed my relationship with my parents. I now think of them as young and engage with them in a different way.’

For Chapman, working with older clients has brought a sense of gratitude. ‘I think overall I am much more grateful for what I can do and much more at peace with the idea that one day I might not be able to do those things,’ she says. ‘I have an appreciation that we are more than the sum of what we can do or can’t do. It is who we are on the inside and what we hold as important that matters. And this “core self” is something that can exist in all of us, right up until the very end.’ As a bonus, working with this age group will appeal to therapists who ‘love a good novel’, she says – ‘so many stories of drama and intrigue!’

Therapeutic barriers

As counsellors, we aim to meet every client ‘where they are’ and treat them as an individual. But there are some considerations that are unique to working with older clients experiencing impaired short-term memory, such as regular contracting, says Lipinska. ‘I may recontract with clients at the beginning and end of each session to ensure we are both aware of the nature of the relationship,’ she says. Kewell agrees: ‘I verbally contract with a client at each session, to remind them why I am there. At the end of each session, I ask if it’s OK for me to come next week.’

Other challenges come in the form of unpredictability. ‘My learning from working with older adults is that the unexpected and unplanned tend to happen quite regularly,’ says Kewell. ‘If you are visiting someone in their home, you have to expect friends or family members and health workers to drop by, or drugs to be delivered, or a ring-back from the doctor.’

Working with clients who are living in residential care homes can be equally unpredictable, she says. ‘As a general rule, I let the service manager know when I will be visiting a client and I also ring ahead on the day of the session. But I have more than once arrived to find the person I am due to be seeing is having their hair done or watching a musical performance, or they’ve gone out on a day trip or to see the GP. In one case, my client had died, and no one had let me know. There is also a high likelihood that, even if you have requested privacy, care staff will come into the room to offer tea, give medicine or ask how things are going. You have to be patient, creative and flexible about this and try to hold onto your sense of humour. Supervision is a wonderful place to vent any frustration and find workarounds to this.’

Chapman suggests asking the client’s permission to put a ‘Do not disturb’ sign on their door during the session, but also points out that ‘in a long-term care situation, or in any type of supported care arrangement, your relationship with staff and how you navigate different situations is vitally important’.

Reaching out

Counselling older generations became part of BACP’s strategic plan in 2016, with the aims of increasing the availability and provision of counselling to older people and the numbers of older people accessing therapy.17 ‘We know that the GP remains a deeply trusted source for this cohort, as the much older generation are less likely to turn to Google and do their own research. So a key piece of work is getting the core messages to the GPs, making them aware of research that counselling works for older people,’ says Jeremy Bacon.

Sarah Baker agrees: ‘I think this age group is much more likely to present to a GP, but they are more likely to bring a series of ongoing physical issues. Unless the GP is awake to somatisation, they become labelled as “heart-sink” patients because their problems are psychological, not physical.’

That said, despite the indisputable challenges that come with living in an ageing body in a society primarily designed to meet the needs of a younger, working population, many 80- and 90-somethings are not only surviving, they are thriving. A famous longitudinal study carried out by Laura Carstensen found that older people experience just as many positive emotions as when we are younger.18

‘We should be careful not to associate old age with suffering lest we create even more unnecessary fear about ageing,’ says Chapman. We also need to be mindful that the over-80s are a resilient group, ‘proud of what they have weathered’, she points out. ‘They deserve attention from us because the chances of experiences of loss occurring and of this creating internal distress are highest for this sub-set than any other. Yet they are the ones most unfamiliar with therapy and the ones least likely to demand help. Obviously not all are suffering, but when they are, they might feel silenced by our ageist society or impose that silence on themselves via internalised ageism.’

And when they do access counselling, they are very motivated, Lipinska says. ‘They miss few appointments, pay their way and are committed to the process and the relationship.’

But when you are working in private practice, reaching this client group can be difficult. ‘I am now in private practice and, despite making it clear that working with old and profoundly old people is my specialism, only 20% of my clients are over 75,’ says Kewell. ‘It’s partly because many have moved into assisted living or to a care home, which can be a closed shop to counsellors coming in. There is often a philosophical approach of not “upsetting people” and resisting anything that might make people less compliant with the care home routine. It’s a case of “don’t upset the apple cart”.’

A more effective route may be through the third sector. ‘Many over the age of 75 and their carers are more comfortable accessing support through a charity such as Age UK, Cruse or Alzheimer’s Society,’ says Baker, who has recently set up a counselling service attached to Age Concern North Dorset’s befriending service. ‘Relatives and carers are more likely to call a service and say, “This person is isolated, they could do with some company.” We then assess whether they would also benefit from counselling and offer it as an option.’

But if programmes and services are to be truly generationally sensitive, says Chapman, they need to steer away from clinical assessment protocols that rely on admitting to a ‘mental health problem’, and not assume motivation toward or familiarity with the counselling process. ‘In my experience, adult programmes tend to have a “one size fits all” approach. We adapt for younger populations, so why not for advanced senior populations? Therapy for this group must also be marketed to relate to dignity, to offset a common fear that it relates to being “weak” or “mad”,’ she says.

For Kewell, the role of counselling with older people is very simple and uses the most fundamental of counselling skills: ‘As we age, we face almost constant change, logistically, biologically, neurologically and psychologically. Retelling our life stories is one way of protecting and also continuing to evolve our own identity. A powerful way to honour and comfort someone is to listen to their story.’

Resources

For further information and CPD, see Access to Therapy for Older Adults, Working with People with Dementia and Bereavement in Later Life, all by Danuta Lipinska and available online on the BACP CPD Hub.

Find out more about BACP’s work promoting therapy for older people.

Sally Brown is a counsellor and coach in private practice (www.sallybrowntherapy.com), a freelance journalist and Deputy Chair of BACP Coaching.

References

1. www.ageofnoretirement.org/about
2. De Beauvoir S. Old age. London: HarperCollins; 1972.
3. Office for National Statistics. Measuring national well-being: at what age is personal well-being the highest? London: ONS; 2016. bit.ly/2wpL9Wf
4. Office for National Statistics. National population projections: 2016-based statistical bulletin. London: ONS. bit.ly/294abhQ
5. McCrone P, Dhanasiri S, Patel A et al. Paying the price: the cost of mental health care in England to 2026. London: King’s Fund; 2008.
6. British Geriatrics Society. Briefing: introduction to frailty. London: British Geriatrics Society; 2014.
7. Age UK. Briefing: health and care of older people in England. London: Age UK; 2017.
8. NHS England. MindEd for older people. [Online.] bit.ly/2GU6MkY
9. Frost R, Beattie A, Bhanu C et al. Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies. British Journal of General Practice 2019; 69(680): e171-e181.
10. Hill A, Bretton A. Counselling older people: a systematic review. Lutterworth: BACP; 2004.
11. NHS England. Older people. [Online.] bit.ly/2hwg4bz
12. Department of Health. No health without mental health. London: DH; 2011.
13. Perfect D, Jackson C, Pybis J, Hill A. Choice of therapies in IAPT. Lutterworth: BACP; 2016. bit.ly/2YXm8OC
14. Royal College of Psychiatrists. Suffering in silence: age inequality in older people’s mental health care. London: RCPsych; 2018. bit.ly/2Xc496h
15. Kewell H. Living Well and dying well – tales of counselling older people. Monmouth: PCCS Books; 2019.16. Chapman F. Counselling and psychotherapy with older people in care: a support guide. London: Jessica Kingsley Publishers; 2017.
17. BACP. Older people: BACP strategic priorities. [Online.] bit.ly/2AI6XS7
18. Carstensen LL, Turan B, Scheibe S et al. Emotional experience improves with age: evidence based on over 10 years of experience sampling. Psychology and Aging 2011: 26(1): 21–33.