Clinician's Quandary

Elderly Clients, Hidden Gifts

Best Practices for Working with Older Populations

Elderly woman strong

Quandary: I’ve been working with adults for most of my career, but I think it’s important not to neglect the mental health of our elderly population. What are some issues and interventions I should focus on if I expand my practice to work with elderly clients?

1) A Two-Way Street

Doing psychotherapy with elderly clients usually means helping them face and process their sense of vulnerability to disability and death, their struggle to accept what they might not have accomplished in their lives, their frustration with family or friend relationships, their stress from caregiving or care-receiving, their loneliness, their sexual concerns, and their increased risk of despair and suicidality. The elderly are a vibrant and stimulating population who often feel increased pressure to find relief and peace because of the nearness of death. From my work with them, I’ve gained perspective on life and learned what a good death can look like.

I’d been working with my client Dawn for seven years before she passed away a year ago from cancer. She’d begun therapy in her mid-seventies to improve her relationships and find more meaning and peace in her life. Together, we discovered that she’d spent much of her life accommodating others and ignoring her own needs. We delved into her childhood relationships and found patterns that she’d carried throughout her life. Although these insights brought pain and grief, Dawn was also eager to grow. She had goals, longings, and feelings that needed expressing. As she found her voice, she began to confront and connect more authentically with her adult children. She became a leader in her church, a support for others, and she embraced her role as a wise elder. She forged new relationships that were more satisfying. She offered guidance back to me as well, recommending books and documentaries and describing her satisfaction in helping others.

When she received her cancer diagnosis and was moved to hospice care shortly thereafter, we continued therapy remotely. She described how grateful she was to have improved her relationships with her children and grandchildren. She’d developed a sense of peace and acceptance about her condition, but her family was devastated. She told me she was worried about their grief and sad that she wouldn’t be around to help them through it. I told her that she’d already given them so much that would support them after she was gone, and told her how honored I felt to have been involved in the work she’d done to make her life more satisfying and meaningful. I told her I was honored to have had the chance to get to know such a loving, caring person. I told her that I would miss her. And I do.

I was grateful to play a supportive role in Dawn’s life. Working with her was a meaningful therapeutic experience for me, and despite having to grieve her loss, I’m grateful to have known her.

Julia Mayer, PsyD
Swarthmore, PA

2) Hidden Wisdom

There are many reasons why I enjoy working with elderly clients. First, they’ve had a wealth of experiences, good and bad, which also means they’ve also had time to discover helpful solutions to common problems. Solution-oriented therapy teaches us that the more time a person has, the likelier they are to have a wide array of solutions to choose from. This often means that if one possible solution fails, the client has another they’re ready to try out.

Sadly, elderly clients are at a point in their lives where they’re losing significant others. I had one elderly client who was very socially inclined but had lost many friends and siblings. For many of these clients, I’ve found there’s a silver lining: these losses teach them the value of relationships and the importance of strengthening those they have left. I’ve had clients reconnect with estranged family members and become more flexible in making concessions and repairing relationships than they might’ve been earlier in life. They’ve taught me the value of improving relationships too.

Third, I find myself constantly amazed by the stories elderly clients bring to sessions. Many of my clients have been through a lot. They’ve had wealth of rich, full emotional experiences that I find fascinating. Although the purpose of therapy isn’t to entertain the therapist, I find myself deeply engrossed in what these elderly clients have to say.

Finally, my elderly clients have taught me to pace myself in therapy. With some of them, I need to speak slower or repeat myself. Whether you’re working with elderly clients or younger ones, it’s helpful to learn patience.

I’d encourage any therapist to see elderly clients. There’s a richness to the work we don’t often see, not to mention it’s both ethical and practical to see clients who aren’t just young or middle-aged.  I hope anyone out there who decides to work with elderly clients finds as much benefit in working with them as I have. It’s a special population.

David Mensink, PhD, RPsych
Victoria, BC, Canada

3) Needs and Values

I’ve spent the last 10 years of my therapy practice working with several older adults in their sixties and seventies. I tend to get lots of questions about purpose and meaning, relationships with adult children and grandchildren, and unresolved trauma from earlier in life.

For older folks who’ve spent most of their lives in a career, stepping down from work can come as a shock. There’s often fear and anxiety about their financial security. After all, living on savings and a fixed income can bring a significant amount of uncertainty. I sometimes see a crisis of identity in retirees, since many feel they’ve been defined by their career for decades. Together, these clients and I look back at their many strengths and accomplishments, as well as at interests they’ve not fully explored, as a way of creating a new identity they can move forward with.

I’ve also found it helpful to have these clients reassess their emotional needs and values at this stage of life. This involves determining what needs are currently being met and which aren’t, and which values are being embodied and which aren’t. Then, we brainstorm ways to fill in the gaps. It might be volunteer work, joining groups, taking classes, or mentoring others in fields they worked in. These are all ways of creating structure and connection in their lives, particularly if they feel they’ve lost them in the move to retirement.

A specific exercise I like to use with elderly clients is having them write a letter to their younger selves. Some of my older clients find it hard to be vulnerable, particularly if they’re new to therapy. Given the opportunity to express themselves in their own space and time, they often come forward with some great material. I recently gave this assignment to a client who brought in multiple pages full of feelings, regrets, fears, and existential questions. His inner critic also showed up throughout the letter, which hadn’t made much of an appearance in our therapy so far. The letter gave me several ideas about how we could do deeper work, and underscored his need for self-forgiveness and self-compassion.

For elders who struggle with the deaths of those who were close to them, I’ve found empty chair work to be invaluable. It gives clients an opportunity to voice their regret, pain, anger, and hurt. I’ve found it’s not only cathartic for them, but often bestows insights that wouldn’t have come otherwise.

Rachael Chatham, MA, LCMHC
Asheville, NC

4) Check Your Biases

In America, we honor the young for their beauty, strength, and vitality. But in other parts of the world, older generations are the objects of veneration. Overlooking what this population has to offer has unintended consequences: the less we acknowledge the gifts of our parents and grandparents, the more we lose pieces of hope, security, and connection to our past. Working with older adults has been one of my greatest joys. To have watched older clients reveal their indomitable wisdom and spirit—to themselves and to me—has been profound.

Twenty years ago, when I was a newly licensed clinician, I was offered a job to at a nursing facility where I’d be working with older adults. I thought I knew something about psychotherapy, and was itching to put my skills to use. But I soon found out I still had a lot to learn, especially about working with older adults. Even though I’m now a geriatric clinical psychologist, I’m still learning about this population. While it’s estimated that 70 percent of psychotherapists have older adults on their caseload, only three percent of them have had formal training in working with them.

There’s a widespread cultural mythology around aging. Early in my career, I wondered if psychotherapy with “old people” was worth it to them. After all, it would leave them with much less time to enjoy life. I also wondered if the grief, loss, and physical and social burdens they experienced were too advanced to allow them to believe that psychotherapy could help. After all, many of these clients have limited resources to deal with social, medical, and economic struggles. What I learned, though, is that it wasn’t these clients who were burdened, but myself, with my own inability to cope with my fears and frustrations.

I believed another myth, that “old people” are stuck in their ways and too rigid to change. I’ve asked audiences to name the four essential signs of aging. Invariably, they’ll say things like gray hair, illness, and memory loss. Then I tell them my four: wisdom, confidence, character, and strength. We’re overly focused on the liabilities of the elderly, and underrecognize their tremendous assets and capacities. We miss the fact that competency can increase with age. There’s often more appreciation for others, more authenticity, more compassion, more maturity, and more patience.

Many psychotherapists shy away from working with older adults, but I’ve seen that, quite often, this stems from the therapist’s inability to manage their own unresolved internal representations of parental and grandparental figures. The more we’re hampered by these beliefs, the more likely we are to act them out in the therapeutic relationship and the less effective we’ll be.

George Kraus, PhD, ABPP, CGP, SEP, ISP
Pleasant Hill, CA

5) Look for Resources

Working with older adults can mean considering things that psychotherapists typically don’t need to when working with younger clients. Older adults’ medical conditions and overall health can impact their mood and functioning more than with younger folks. Hearing can affect auditory processing and engagement in therapy, so we need to speak more clearly, in lower registers, and look directly at the client when speaking. It’s also helpful to have the client repeat back to us what they’ve heard from us in their own words. Many medical conditions can contribute to depression, anxiety, and a sense of having lost not only full functionality, but footing in the world they thought they knew. When working with older clients, we might also include family members to assist.

Many older adult clients come to therapy for perfectly reasonable reasons, and often experience depression or anxiety as a result of losses: of loved ones, roles, authority, social respect, living situations, autonomy, social communities, or independence. Helping these clients navigate an environment that seems to have has less regard for them often means helping them find resources that support their effective functioning and autonomy. One helpful resource is the national Eldercare Locator line. Most state governments include an area agency on aging or an office of elder affairs, and many local governments have town councils on aging. For our older clients, having these types of resources can make a huge difference in improving their mood and outlook.

That said, working with older adults can be extremely rewarding. Older adults bring a lifetime of experience and resilience to therapy, and, in my experience, they often respond very well to CBT, as well as to narrative and life review therapy. They also tend to be open to positive outlooks and able to hold multiple—even contradictory—emotions, and are able to understand, acknowledge, and process well.

One of my own older clients was finally able to get through her depression when, with my help, she found a conservator to help stop her children from financially exploiting her while still maintaining a relationship with them. Another one of my older clients, 80 years old, was able to overcome her anxiety and panic to the point where she finally fulfilled a lifelong dream and went to college. These achievements have been wonderful to behold.

Brenda King, PsyD
Worcester, MA



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