Christian D. Chan, Camille D. Frank, Melisa DeMeyer, Aishwarya Joshi, Edson Andrade Vargas, Nicole Silverio
Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities have faced a history of discriminatory incidents with deleterious effects on mental health and wellness. Compounded with other historically marginalized identities, LGBTQ+ people of color continue to experience disenfranchisement, inequities, and invisibility, leading to complex experiences of oppression and resilience. Moving into later stages of life span development, older adults of color in LGBTQ+ communities navigate unique nuances within their transitions. The article addresses the following goals to connect relational–cultural theory (RCT) as a relevant theoretical framework for counseling with older LGBTQ+ adults of color: (a) explication of conceptual and empirical research related to older LGBTQ+ adults of color; (b) outline of key principles involved in the RCT approach; and (c) RCT applications in practice and research for older LGBTQ+ adults of color.
Keywords: relational–cultural theory, theoretical framework, older adults, LGBTQ+, people of color
Multiple forms of oppression have been historically documented across conceptual and empirical literature for the broad spectrum of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities across the life span (Chan, 2018; Chan & Erby, 2018; Meyer, 2014, 2016; Singh, 2013). Further, Black, indigenous, and people of color (BIPOC) have experienced multiplicative deleterious effects combined with psychosocial factors that culminate in racial discrimination and marginalization (David et al., 2019; Sue et al., 2019). Oppression for BIPOC communities and LGBTQ+ communities often cascades across the life span and culminates in a number of health disparities (Choi & Meyer, 2016; Fredriksen-Goldsen et al., 2015, 2017). Given these complex dimensions with social identities, researchers have expanded their focus to examine social conditions, such as education and health care, to accentuate the needs of older LGBTQ+ adults of color (Howard et al., 2019; Kim et al., 2017). Although researchers have given more attention to LGBTQ+ BIPOC (e.g., Jackson et al., 2020; Velez et al., 2019), older adults within these communities are typically omitted in practice, advocacy, and policy (Kimmel, 2014; Porter et al., 2016; Seelman et al., 2017; South, 2017). Combined with this pattern of exclusion, older LGBTQ+ adults of color are forced to navigate a dearth of resources and complicated climates that fail to properly recognize multiple overlapping forms of racism, heterosexism, genderism, and ageism (Kim et al., 2017; Woody, 2014). Within the counseling profession, gaps in culturally responsive services and advocacy combine with alarming rates of barriers, health disparities, and underutilization of mental health services (Chan & Silverio, in press; Kim et al., 2017; Lecompte et al., 2021).
Relational–cultural theory (RCT) operates as a cohesive and modern theoretical approach founded on values of feminism, equity, empowerment, and social justice (see Comstock et al., 2008; Duffey & Trepal, 2016; Hammer et al., 2016; Kress et al., 2018). Instances of disconnection can be prominent at older adult stages of life (Seelman et al., 2017), and RCT offers a purposeful framework for increasing relational awareness (Hammer et al., 2016), relational growth (Kress et al., 2018), and investment in professional counseling relationships (Fullen et al., 2020). Given developmental concerns and life span transitions, older LGBTQ+ adults of color can remain disconnected from family, society, institutional resources, and professional counselors (Jones et al., 2018; Mereish & Poteat, 2015; Seelman et al., 2017). Using an RCT approach accounts for these factors and increases the awareness of disconnections between people and others in their environment (Hammer et al., 2016; Singh & Moss, 2016). Because of its emphasis on relationships, RCT’s focus on mutually fostering growth and dismantling oppression provides a platform for professional counselors to integrate the themes of equity, social justice, and feminism into counseling practice with older LGBTQ+ adults of color (Rausch & Wikoff, 2017; Singh et al., 2020). RCT demonstrates that intersections of social identities mirror several overlapping forms of oppression and hierarchies of power (Addison & Coolhart, 2015; Chan & Erby, 2018; Hammer et al., 2016).
Within this conceptual framework, we intentionally use LGBTQ+ communities to inclusively highlight communities featured across the spectrum of sexuality, affectional identity, and gender identity (Griffith et al., 2017). As counselors address the intersections among social identities, applying philosophical underpinnings of RCT equips them to tackle cultural, social, and contextual barriers that disconnect older LGBTQ+ people of color from society, resources, and health care access. Consequently, this article entails a three-pronged approach: (a) an overview of extant conceptual and empirical research relevant for older LGBTQ+ adults of color; (b) in-depth illustration of key principles within the RCT approach; and (c) RCT applications for counseling practice and research to support older LGBTQ+ adults of color.
Intersections of Older Adults, LGBTQ+ Communities, and Communities of Color
Scholars across disciplines (e.g., psychology, social work, counseling, sociology, education) continue to explore intersections of racial and ethnic identities in confluence with sexuality, affection, and gender identity (Chan & Erby, 2018; Jackson et al., 2020; Van Sluytman & Torres, 2014). Researchers can ostensibly benefit from a gerontological focus to critically examine social conditions and structures sustained by ageism (Chaney & Whitman, 2020; Kim et al., 2017). The lack of attention to gerontology, ageism, or older adults within LGBTQ+, racial, and ethnic identity research has further underscored the impact of health disparities and social determinants of health (e.g., education, economic resources, career, income) that precipitate an underutilization of mental health services and health care, specifically among LGBTQ+ people of color (Choi & Meyer, 2016; Du & Xu, 2016; Fredriksen-Goldsen, 2014; Rowan & Giunta, 2016; Seelman et al., 2017). Kim and colleagues (2017) specifically observed that race and ethnicity have been historically excluded as variables and outcomes in LGBTQ+ older adult research. Building further on this gap, Woody’s (2014) study of African American LGBT elders exemplified the need to address these intersections of identities. In the study, Woody noted that African American LGBT elders consistently faced conflicts in negotiating ethnic and spiritual values together with sexual and gender identities. Outside of oppressive circumstances, older adults already face realities associated with the aging process, health concerns, maintaining an economic standard of living, retirement, and housing barriers related to developmental life tasks and the stages of older adulthood (Brennan-Ing et al., 2014; Choi & Meyer, 2016; Porter et al., 2016). Several of these concerns coincide with a consistent gap in culturally responsive counseling practices focused on older adults (Chan & Silverio, in press; Fullen, 2018) and the call to action by Fullen and colleagues (2019) to broaden research evidence in gerontological counseling.
As gerontological and health researchers attempt to shed light on the experiences of older LGBTQ+ adults of color, overall trends continue to reveal cultural, social, psychological, and physical implications of intersecting forms of oppression. In fact, a study by Kim et al. (2017) documented that African American LGBT elders faced higher rates of lifetime discrimination, which adversely affected their physical and mental health. Similarly, incidents that contribute to the lack of identity affirmation, community networks, and social support exacerbate a number of health disparities and adverse outcomes of mental health (Fredriksen-Goldsen et al., 2013; Seelman et al., 2017; Woody, 2014, 2015). Consistent with patterns in health disparities research, oppression tends to serve as a catalyst for higher prevalence of suicidality among older LGBTQ+ adults of color (Choi & Meyer, 2016; Meyer, 2014, 2016). In fact, Fullen and colleagues (2018) noted that internalized ageism can predispose older adults to a myriad of mental health issues, symptoms, and increased rates of suicidal ideation. According to Seelman (2019), the combination of responding to discrimination along with barriers to access can significantly increase the mortality rate for older LGBTQ+ adults of color. Conversely, the preservation of cultural identity (Fullen, 2016) and identity affirmation (Fredriksen-Goldsen et al., 2017; Howard et al., 2019; Kim et al., 2017) buffers the effects of oppression and encourages older LGBTQ+ adults of color to seek help and health care.
Older LGBTQ+ adults of color also face disproportionate access to resources, especially adequate and LGBTQ-affirming health care services (Hinrichs & Donaldson, 2017; Kimmel, 2014). Among the variety of health conditions tied to the aging process, the risk of HIV increases for older LGBTQ+ adults of color as a result of psychosocial factors, such as poverty, stigma, marginalization, and lack of education (Bower et al., 2021; Jones et al., 2018; Karpiak & Brennan-Ing, 2016; Yarns et al., 2016). Many of these barriers can be traced to the marginalization attached to ageism, classism, racism, genderism, and heterosexism (Brennan-Ing et al., 2014; Robinson-Wood & Weber, 2016). During this stage, older LGBTQ+ adults of color face drastic changes to mental health based on cumulative interactions with societal stigma and internalized heterosexism and genderism (Correro & Nielson, 2020; Yarns et al., 2016). Consistently responding to discrimination can eventually culminate in a variety of mental health symptoms (e.g., anxiety, depression) or mental exhaustion (Fredriksen-Goldsen, 2014; Fredriksen-Goldsen et al., 2013).
Social Isolation, Grief, and Loss
Compounded with multiple overlapping forms of oppression, older LGBTQ+ adults of color can have a multifaceted experience of social isolation and loss as they transition into the stages of older adulthood (Dzierzewski, 2014). Although older adults generally experience grief and loss as part of the transition in aging (Chaney & Whitman, 2020; Kampfe, 2015), these experiences are heightened for older LGBTQ+ adults of color as an outcome of navigating racism, heterosexism, and genderism (Bockting et al., 2016; Woody, 2014, 2015). The loss of family, friends, social networks, and intimate partners for older LGBTQ+ adults of color can converge with an overall lack of affirmation and heighten experiences of racial, sexual, and gender discrimination (Seelman et al., 2017). Instances of isolation and loss are pervasive because of the confluence of racism and heterosexism converging in this stage of the life span (Woody, 2015). Woody’s (2015) study noted that older African American lesbian women cited the proliferation of racism as a more prominent issue than their experiences with other forms of oppression (e.g., heterosexism). Compounding these losses, barriers to housing and the likelihood of eviction for older LGBTQ+ adults of color can amplify feelings of displacement from communities and society (Brennan-Ing et al., 2014; Robinson-Wood & Weber, 2016).
Additionally, older LGBTQ+ adults of color consistently contend with coming out across the life span (Hinrichs & Donaldson, 2017; Mabey, 2011). Experiences of coming out and self-disclosure of these social identities can be complex because of the loss of connections, fear of rejection, and incivility from trusted communities of support (Dzierzewski, 2014; Woody, 2014; Yarns et al., 2016). Complicating the range of concerns within the older adult stages, the chronic effects of marginalization can increase risk factors for substance use and addictions as coping mechanisms for older LGBTQ+ adults of color (Bryan et al., 2017; Veldhuis et al., 2017). Substance use and addictions have become a more visible crisis facing these communities, and they can combine with the risks of displacement from social supports and vital community resources (Brennan-Ing et al., 2014; Cloyes, 2016; Rowan & Giunta, 2016).
The Model of Relational–Cultural Theory (RCT)
RCT can be used by counselors to reflect experiences with societal forces of oppression (Singh & Moss, 2016) and social determinants tied to health, connection, and wellness (Hammer et al., 2016). RCT has surfaced as an applicable theoretical approach for older LGBTQ+ adults of color with the most recent uptick of research and scholarship (Mereish & Poteat, 2015; Singh et al., 2020). Given the core values of RCT generated with social context, authenticity, connection, and social justice, the approach addresses needs, social conditions, barriers, and marginalization experiences for older LGBTQ+ adults of color (Chan & Erby, 2018; Rausch & Wikoff, 2017; Singh & Moss, 2016). The history of RCT provides context for current practice and underscores the foundation of a relationally centered paradigm. The concepts of relational images, growth-fostering relationships, and the central relational paradox inform counseling with clients experiencing such positions of resilience and oppression (Duffey & Trepal, 2016). The relevance of an RCT approach to a number of client concerns has gained traction as counseling professionals are charged with implementing more culturally responsive approaches (Flores & Sheely-Moore, 2020; Haskins & Appling, 2017; Singh et al., 2020). To support RCT’s utility, a recent review from Lenz (2016) concluded that empirical research has consistently supported RCT constructs and its use as a framework for understanding client experiences.
Originally positioned within Miller’s (1976) Five Good Things, the principles of RCT in counseling practice have imminently evolved into a robust theoretical framework centered in (a) clarity of self and others, (b) creativity, (c) zest, (d) empowerment, and (e) connection. As Jordan (2000) provided in an influential comprehensive overview of RCT, the main themes for the framework can be summarized in four distinct areas. The first principle posits that people are generally oriented toward growing individually and collectively within their relationships across the life span (Jordan, 2010, 2017), which results in growth-fostering relationships (Miller, 1976; Miller & Stiver, 1997). Secondly, growth-fostering relationships require mutuality, which is defined as mutual empathy and mutual empowerment (Jordan, 2010; Kress et al., 2018). Because of mutuality in growth-fostering relationships, assessing growth of individuals and relationships is contingent on authenticity, or individual genuineness, as the third component (Duffey & Trepal, 2016; Jordan, 2000, 2017). Individuals’ abilities to represent themselves authentically in their relationships can be a function of this growth (Duffey & Somody, 2011; Hammer et al., 2016). Because authenticity underpins mutuality and growth-fostering relationships, the fourth area of RCT involves the central relational paradox. The central relational paradox illustrates how the fear of vulnerability reduces authentic expression and maintains disconnections, despite a proclivity for connection with others (Miller & Stiver, 1997). When mutuality and authenticity are prioritized, professional counselors using RCT assume that conflict can be a normal dynamic in the relationship, in which high-level growth in the relationship involves the ability to actively address this relational difference (Comstock et al., 2008; Duffey, 2007; Jordan & Carlson, 2013). The primary function of RCT in counseling then focuses on building relational competence (Kress et al., 2018; Singh & Moss, 2016).
To build further on these constructs, several researchers have provided a foundation for using RCT with older LGBTQ+ adults of color (Flores & Sheely-Moore, 2020; Mereish & Poteat, 2015; Singh & Moss, 2016). There are cultural, social, and political implications underlying the connection between RCT and older LGBTQ+ adults of color. For example, older LGBTQ+ adults of color are forced to contend with multiple points of disconnection from society through histories of racism, genderism, heterosexism, and ageism. Although multiple forms of oppression can disconnect historically marginalized communities, ageism is distinct because it focuses on marginalizing life transitions (Chaney & Whitman, 2020; Fullen, 2018). Consequently, older LGBTQ+ adults of color experience a heightened sense of disconnection due to grief and loss, isolation, and lack of social support. Older LGBTQ+ adults of color may likely encounter disconnections from a society that fails to affirm their identities, which precipitates a disconnection to self and underutilization of community resources (Kim et al., 2017; Seelman et al., 2017). Older LGBTQ+ adults of color may face a hierarchy of power and privilege that would impair an authentic connection and movement toward mutuality (Duffey & Somody, 2011; Hammer et al., 2016; Jordan, 2010). One outcome of this hierarchy is the notion of relational images, in which historically marginalized individuals feel forced to conform to a privileged identity. For instance, an older lesbian woman of color as a client may hold controlling relational images of help-seeking when interacting with a White male counselor possessing multiple privileged identities. In this instance, the client might internalize stereotypes and biases imposed by the counselor. Using RCT explicitly addresses these controlling relational images to challenge the dominant discourse, increase authenticity, and empower connection (Hammer et al., 2016; Haskins & Appling, 2017).
RCT as a Lens for Conceptualization and Intervention
The following hypothetical case example underscores the theoretical underpinnings of RCT and illustrates applications of RCT in clinical practice. This case example illustrates a variety of RCT principles to help counselors connect potential experiences of older LGBTQ+ adults of color and the complexity of intersecting forms of oppression. With the overall case study presented, Table 1 synthesizes key principles and applications, supplemental literature, and relevant portions of the case example.
Chris, 72 years old, and Hector, 71 years old, have been partnered for 27 years. Chris is a Mexican American bisexual male born in the United States with the pronouns he, him, and his. Hector is a multi-heritage Asian American gay man of Filipino, Norwegian, and Colombian descent with the pronouns he, him, and his. Both Chris and Hector are Catholic and living without disabilities. Chris retired as a social worker when he reached 65 years of age while Hector chose to continue working as a university professor until the previous year at age 70. Chris and Hector recently relocated to live with Chris’s daughter from a previous marriage, Ella. Ella welcomed both Chris and Hector into her home as family. Upon the transition to their retirement phase, Chris and Hector began spending most of their time at home, and Ella has checked in with them regularly. They took on new hobbies, including painting, and focused more of their time on relaxation and leisure. Recently, Chris became increasingly concerned with Hector’s forgetfulness. Chris became worried about bringing him to social events, as Hector was “absentminded.” Although initially excited about the move, Chris realized Hector was struggling with all of the new issues that emerged from the transition. Chris thought about discussing the concerns with his daughter, but he did not want to worry her or embarrass Hector. Chris has felt conflicted about his own internal and external responses. Over the past few months, Chris has felt increasingly isolated and disconnected with Hector while recognizing a decreased lack of enjoyment.
RCT Applications to Case Example
||Relevance to Case Example
|Connection is essential to existence.
||Duffey & Somody, 2011; Lenz, 2016; Walker & Rosen, 2004
||Practitioners can identify the possible connections Chris and Hector have with each other and with their family. In addition, practitioners can also cite the connection they have with the clients Chris and Hector. Practitioners can particularly note the disconnect they have experienced as society has emerged with transitions and multiple overlapping forms of oppression.
|Growth-fostering relationships result in the Five Good Things: clarity of self and others, creativity, zest, empowerment, and connection.
|Miller, 1976; Miller & Stiver, 1997; Duffey, 2007; Duffey et al., 2009; Duffey & Somody, 2011; Hammer et al., 2014
|Practitioners can work with Chris and Hector to search for strengths and reinvigorate their energy in each other during this transition and stage of their lives. Although Chris and Hector initially struggled with the transition, practitioners can ascertain new types of hobbies and activities they can create together. Such creative activities might elicit more nuanced meaning. Practitioners can also highlight the methods and actions in which Chris and Hector have been resilient in the face of adversity in association with societal and interpersonal discrimination.
|The central relational paradox centers around the idea that people long deeply for relationships, but fear of what will happen after engaging in the vulnerability needed for connection provokes people to keep aspects of themselves out of connection.
||Jordan, 2010; Jordan & Carlson, 2013; Miller & Stiver, 1997; Walker & Rosen, 2004
||Practitioners can focus on how the transition affected Chris and Hector’s connection to each other. It is possible that the transition altered their interpretation of connection, given that they are now living with Chris’s daughter, Ella. Hector could have also felt a sense of loss with his retirement, which led to new ways of thinking and loss of connection. In fact, his job could have created meaning for him. Additionally, Hector had also faced instances of discrimination, which decreases the possibility of a climate of safety.
|Central to RCT is the idea that systems of power and privilege, which are pillars in our current society, result in damage to psychological health.
|Hammer et al., 2014, 2016; Haskins & Appling, 2017;
Trepal et al., 2012
|Practitioners can discuss with Chris and Hector the implications of discrimination toward their health. Practitioners can highlight factors and social determinants involved in explicit and implicit effects of discrimination on wellness and domains of health (e.g., physical, financial, social). Practitioners can also highlight instances of subordination, where Chris and Hector may have been subjugated to another person’s harmful comments.
|Exploring relational connection and equity must include an analysis of social context and mechanisms responsible for giving root to oppression.
||Hammer et al., 2014, 2016; Mereish & Poteat, 2015
||Practitioners can accentuate the manner in which Chris and Hector bring their own responses to stigma from affectional, sexual, and racial discrimination on individual and intimate partner levels. Similarly, practitioners can highlight how their own social identities play a role in power differentials with Chris and Hector together as a couple and as individuals. Practitioners can also understand their own responses to oppression and how they might transfer the experience to professional counseling relationships (e.g., internalized oppression). In some cases, practitioners might eschew from broaching cultural factors and discriminatory experiences due to internalized oppression. Practitioners can also use themselves as a model or tool when considering power differentials or uneven tensions of privilege and oppression.
Note. Table 1 demonstrates applications of RCT principles supplemented by conceptual and empirical literature. The principles are directly linked to potential avenues in the case example.
As demonstrated in the case example and Table 1, professional counselors can use RCT to strengthen an awareness of structural and interpersonal forms of oppression affecting older LGBTQ+ adults of color. With the combination of life transitions and convergent forms of oppression, Chris and Hector may become more disconnected from each other, society, or other personal relationships. The effects of oppression can culminate in a longstanding experience of disconnection. Under the RCT lens, professional counselors can identify how oppression (e.g., racism, heterosexism) exacerbates feelings of disconnection and impacts the overall health of relationships (Singh et al., 2020; Singh & Moss, 2016). It is possible that Chris might be contending with prior experiences of relational images that potentially invoke stigma and familial histories with discrimination. Consistent with Table 1, professional counselors can demonstrate how prior interpersonal experiences of marginalization can result in feelings of isolation within Chris and Hector’s relationship and silence around their concerns.
As Chris and Hector navigate life transitions and aging, professional counselors can illustrate how physical and mental health draw upon the strength of relationships, especially for communities facing social isolation (Mereish & Poteat, 2015; Woody, 2014, 2015). Tenets of RCT also focus on relational growth and resilience, which reflect how professional counselors can use strengths, growth, and creativity to ameliorate the cumulative effects of marginalization (Comstock et al., 2008; Hammer et al., 2014, 2016). By infusing these elements in practice, professional counselors invoke the Five Good Things (Miller, 1976; Miller & Stiver, 1997), which can apply to Chris and Hector’s relationship and transfer to other personal relationships. Although professional counselors can contextualize the experience of oppression, focusing on the strengths of Chris and Hector’s relationship can highlight how they have historically relied on each other and other community members for support. Reflecting on experiences of resilience and oppression can elicit more nuanced meaning in their relationship and identify possibilities for growth.
Future Research Directions for RCT With Older LGBTQ+ Adults of Color
Considering the overall framework of RCT in application to older LGBTQ+ adults of color, gerontological counseling researchers can explore a variety of avenues to advance research agendas and bridge the gap across these intersecting social identities. Counseling researchers can employ quantitative and qualitative analyses pertaining to older LGBTQ+ adults of color to challenge relational images perpetuated by society (Duffey & Somody, 2011; Hammer et al., 2016). More importantly, research framed within principles of RCT can also yield more in-depth understanding of how older LGBTQ+ adults of color navigate resilience, empowerment, and incidents of oppression, which are foundational to intersectionality and the RCT approach (Duffey & Trepal, 2016; Haskins & Appling, 2017; Singh et al., 2020). This emphasis is especially critical for older LGBTQ+ adults of color who are less likely to seek counseling that fails to affirm their identity (Kim et al., 2017; Singh & Moss, 2016). As researchers have continued to emphasize a stronger focus on resilience with multiply marginalized communities (Bostwick et al., 2014; Bower et al., 2021; Singh, 2013), RCT presents a useful framework for identity affirmation because of its focus on authenticity and growth-fostering connections (Flores & Sheely-Moore, 2020; Mereish & Poteat, 2015). As several gerontological and health equity researchers have documented, identity affirmation and culturally responsive care are crucial for buffering negative health care experiences that prevent historically marginalized clients from seeking help (Flynn et al., 2020; Fredriksen-Goldsen et al., 2017; Howard et al., 2019; Kim et al., 2017). Associated with advances of research in intersectionality, RCT continues to demonstrate promising opportunities for the critical examination of linked social identities that mirror multiple overlapping forms of oppression (Addison & Coolhart, 2015; Chan & Erby, 2018; Singh & Moss, 2016). As a theoretical framework, RCT can contextualize how structural forms of oppression (e.g., racism, ageism, heterosexism) converge for older LGBTQ+ adults of color, given RCT’s underpinnings in equity, social context, action, and a social justice agenda (Singh et al., 2020). As researchers have noted, oppression relates to physical and mental health disparities, covers a number of social experiences (e.g., social isolation, help-seeking, caregiving), and is connected to relational well-being (Correro & Nielson, 2020; Jones et al., 2018; Kim et al., 2017; Seelman et al., 2017).
Infusing RCT Constructs in Research
Gerontological counseling researchers can apply many of the RCT constructs to foster research questions to expand RCT’s applicability beyond a theoretical framework, such as feelings of empowerment and attitudes toward relationships and growth. Additionally, research has not predominantly involved RCT for empirical use, although RCT is consistently taken up through theoretical applications in practice (Haskins & Appling, 2017; Jordan & Carlson, 2013; Kress et al., 2018), education (Hammer et al., 2014), supervision (Lenz, 2014), and advising (Purgason et al., 2016). It has been used particularly as a rich theoretical framework to reform critical thinking in practice. However, the implementation of RCT can immensely benefit from furthering an empirical base to create more accessibility with applying such methods in counseling practice (Lenz, 2016). If counseling practitioners implement RCT as part of their clinical approaches, research studies would be particularly useful if research questions targeted how RCT is successful specifically with older LGBTQ+ adults of color. Because RCT is relationally driven, researchers can integrate measures on relationships as outcome variables that might explain a moderated effect, particularly if identity disaffirmation or specific forms of oppression (e.g., racism, ageism) are contributing to lower outcomes of wellness. In this case, the strength of relational outcomes may weaken the relationship between multiple measures of oppression and wellness. This information would continue to highlight which RCT factors need further intervention and effectiveness research to inform its utility as a culturally responsive practice model.
RCT in Quantitative Design
Regarding methodological frameworks, researchers can illustrate connections with RCT principles across multiple types of modalities and methods of research (e.g., quantitative, qualitative, mixed-methods). Components of RCT can more heavily exhibit factors and variables involved in the RCT lens, such as relational capacity and growth. This premise is especially vital for researchers concerned with building measurements to advance clinical practice and knowledge. Aside from the work of Liang and colleagues (2002), measures of RCT factors are virtually nonexistent, and they have not been normed for a myriad of samples connected to older LGBTQ+ adults of color. Thus, researchers can incorporate RCT into applied research with older LGBTQ+ adults of color and underscore its applicability and empirical relevance for gerontological practice. Considering Lenz’s (2016) argument for the relevance of RCT as a useful approach within practice and intervention research, it is necessary to expand research studies that observe how counseling practitioners can implement the approach of RCT with older LGBTQ+ adults of color.
RCT in Qualitative Design
Vital for research designs grounded in qualitative research, RCT can be used as a framework aligned with certain paradigms (Creswell & Poth, 2018; Guba & Lincoln, 1994; Merriam & Tisdell, 2016). The use of RCT is its own phenomenon, but it can also serve as a vehicle integrated into the paradigm of a particular qualitative research study, such as exploring grief and loss with older LGBTQ+ adults of color. Qualitative research can function from interpretivist, feminist, critical, and intersectional paradigms (Chan & Erby, 2018). Although the integration of RCT with feminist and critical paradigms are more likely due to explicit ties to social justice, the RCT approach can also be useful with interpretivist paradigms to examine how RCT reflects the lens of samples including older LGBTQ+ adults of color. Since the purpose, methodological decisions, and strategies for data analysis would follow an interpretivist approach, RCT can operate as the theoretical framework, especially to inform tools for data collection and procedures involved in data analysis. Reflecting on the lived experiences of older LGBTQ+ adults of color, counseling researchers can explore a multitude of research questions. For instance, qualitative researchers can examine the lived experiences of disconnection with access to health care providers in rural settings for older LGBTQ+ adults of color. Fundamental to RCT, another potential research question can highlight how older LGBTQ+ adults of color discover social supports and networks in older adulthood. Given the overlap in experiences with oppression, researchers can generate qualitative research that addresses how older LGBTQ+ adults of color have utilized their social supports to ameliorate racism, genderism, ageism, and heterosexism across the life span.
Given the history of discriminatory acts against LGBTQ+ communities, which can be compounded by the challenges individuals face as they age, RCT serves as an approach that acknowledges the various levels of oppression and serves as a strength-based framework to employ in a clinical setting (Comstock et al., 2008). This approach, in particular, highlights both contextual and systemic factors contributing to deepened levels of disconnection for older LGBTQ+ adults of color (Haskins & Appling, 2017; Jordan & Carlson, 2013; Singh & Moss, 2016). Using components of RCT highlights the manner in which older LGBTQ+ adults of color have been disconnected from practitioners, social relationships, institutions, and society. Implementing the RCT approach brings forth new forms of critical thinking to emphasize interpersonal and contextual factors contributing to relational growth, equity, and connection. As counseling practitioners continue to broaden their perspectives through an RCT framework, the application of RCT must serve as a driving force for further empirical research showing the developmental connection between theory and practice with older LGBTQ+ adults of color.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Christian D. Chan, PhD, NCC, is an assistant professor at the University of North Carolina at Greensboro. Camille D. Frank, PhD, NCC, LPC, is a lecturer at Eastern Washington University. Melisa DeMeyer, PhD, NCC, LPC, is an assistant professor and program coordinator at Oregon State University-Cascades. Aishwarya Joshi, MA, NCC, LPC, is a doctoral candidate at Idaho State University. Edson Andrade Vargas, PhD, is a visiting assistant professor at Palo Alto University. Nicole Silverio, MA, NCC, LMHC, LMFT, is a doctoral student at the University of North Carolina at Greensboro. Correspondence may be addressed to Christian D. Chan, 228 Curry Building, Department of Counseling and Educational Development, The University of North Carolina at Greensboro, P.O. Box 26170, Greensboro, NC 27402, email@example.com.
Matthew C. Fullen
As the number of older adults increases, it is important to understand how attitudes toward aging influence society, the aging process, and the counseling profession. Ageism—defined as social stigma associated with old age or older people—has deleterious effects on older adults’ physical health, psychological well-being, and self-perception. In spite of research indicating that the pervasiveness of ageism is growing, there are few studies, whether conceptual or empirical, related to the impact of ageism within the practice of counseling. This article includes an overview of existing literature on the prevalence and impact of ageism, systemic and practitioner-level consequences of ageism, and specific implications for the counseling profession. Discussion of how members of the counseling profession can resist ageism within the contexts of counselor education, gerontological counseling, advocacy, and future research will be addressed.
Keywords: ageism, aging, older adults, gerontological counseling, advocacy
Currently, there are approximately 47.8 million adults age 65 and over living in the United States, and this number is expected to grow to 98 million—or more than one in five Americans—by 2060 (Administration on Aging, 2017). Much of this growth can be attributed to the aging of the boomer generation, the age cohort born between 1946 and 1964. Approximately 10,000 boomers turn 65 every day (Short, 2016). Increases to the average life span also have expanded the number of older Americans, with a person age 65 now living an average of 19.4 additional years, and many living well beyond that age (Administration on Aging, 2017). Nonetheless, many misconceptions remain about the aging process, and recent research demonstrates that the prevalence of ageism is growing (Ng, Allore, Trentalange, Monin, & Levy, 2015). Ageism—defined here as social stigma related to old age or older people (Widrick & Raskin, 2010)—is associated with the lack of mental health services available to older adults (Bartels & Naslund, 2013), and when negative attitudes toward aging are internalized by older adults, significant consequences to health and well-being may occur (Levy, 2009).
Within the counseling literature, there appears to be a lack of research on ageism and its impact on older adulthood. A keyword search of leading counseling journals dating back to 1992 results in a single publication on the topic of ageism within the American Counseling Association’s Journal of Counseling & Development (Saucier, 2004), as well as a single empirical study in Adultspan Journal (McBride & Hays, 2012). Therefore, to elucidate the effects of ageism, as well as its role within the field of professional counseling, this article will provide a review of existing literature on the prevalence of ageism, its consequences among mental health professionals, and the impact of internalized ageism on older adults. The article concludes with recommendations for how counselors, counselor educators, and counseling students can mitigate the effects of ageism and promote positive perceptions of aging.
Prevalence and Impact of Ageism
Prevalence of Ageism
The term “ageism” was first used in the late 1960s to describe discriminatory beliefs or practices that are predicated on the age of a person or group (Butler, 1969). Like racism or sexism, prejudice associated with age is both pernicious and challenging to quantify. Many myths about aging are assumed to be true without additional consideration, leading to a “commonsense reality” about old age or older people that is then perpetuated throughout a society (Angus & Reeve, 2006, p. 141). Moreover, scholars argue that ageism is currently met with less disapproval than racism or sexism (Cuddy & Fiske, 2002; Nelson, 2016; Palmore, 2005), although more recent empirical research is needed to substantiate this hypothesis. Nevertheless, research indicates that views about aging are becoming more negative (Ng et al., 2015). Dominant myths include the notion that older adults are: (a) lonely and depressed; (b) increasingly similar as they grow old; (c) sick, frail, and dependent; (d) cognitively and psychologically impaired; (e) sexless and boring; and (f) unable to learn or change (Thornton, 2002; Whitbourne & Sneed, 2002). These myths persist in spite of research that demonstrates that older adults are heterogeneous, possess many psychosocial resources, frequently have high levels of self-rated and objectively measured health, and mostly do not experience dementia or other forms of cognitive impairment (Whitbourne & Sneed, 2002).
Stereotypes about older adulthood are transmitted throughout society and may lead to detrimental consequences for the health and well-being of older people. For example, media representations of older adults are likely to reinforce negative views about older adulthood. Television shows, movies, and advertising depict older people according to stereotypes about aging—or omit them altogether (North & Fiske, 2012)—and older people who watch more television over the course of their lives tend to view aging in a more negative light (Donlon, Ashman, & Levy, 2005). Ageism is transmitted through social media as well. References to older adults on Facebook are commonly comprised of references to cognitive or physical debilitation, the infantilization of older people, or suggestions that older adults be banned from public activities like driving or shopping (Levy, Chung, Bedford, & Navrazhina, 2014).
Negative stereotypes may lead to age-based discrimination, a phenomenon that experts describe as both “understudied” and “surprisingly pervasive” (North & Fiske, 2012, p. 983). For example, Posthuma and Campion (2009) described several workplace-based stereotypes that exist, in spite of a lack of supporting evidence. These include the notion that older workers have lower levels of ability and motivation, lower productivity, and greater resistance to change. Within the realm of health care, physicians may be less likely to offer particular medical treatments to older patients because of a belief that certain ailments are the inevitable consequences of natural aging (Bowling, 2007). Ageism may result in elder abuse, both within care facilities and among family members; however, it is underreported because of a lack of awareness among health and social service providers (Nelson, 2005).
Negative stereotypes about aging develop in a manner that parallels stereotypes like racism or sexism. Levy’s (2009) stereotype embodiment theory suggests that ageist views may be transmitted culturally and internalized by older adults, leading to significant changes to health and functioning. Older adults are first exposed to negative stereotypes about aging when they are young. As individuals age into older adulthood, their negative beliefs about aging become increasingly salient and self-directed. On the other hand, if an individual is socialized to hold more positive views toward aging, these viewpoints may serve as a buffer against internalized ageism (Levy, 2009).
Furthermore, stereotype embodiment theory (Levy, 2009) suggests that when stereotypes are assimilated from the surrounding culture, they eventually become self-definitions that influence a person’s functioning and health. Stereotype embodiment theory concludes that: (a) stereotypes are internalized throughout the life span; (b) they are likely to operate unconsciously; (c) as views of older age become increasingly relevant to a person’s identity, the age stereotypes become more salient; and (d) self-referential views on aging are developed via pathways that may be both top-down (i.e., societal perspectives are passed on to the individual) and longitudinal (i.e., views on old age begin in childhood).
Cuddy, Norton, and Fiske (2005) argued that groups within a society are often categorized based on two traits—warmth and competence—and the authors found that most participants rated older adults as warm, but incompetent. Contrary to the belief that ageism is only a concern in Western countries, Cuddy et al. reviewed a large-scale international study that included college students in Belgium, Costa Rica, Hong Kong, Japan, and South Korea. Across samples, participants viewed older adults as significantly more warm than competent, non-competitive, and having lower social status. Within their study, this trend persisted even when looking at cultures and countries that are typically described as more collectivist (i.e., Hong Kong, Japan, and South Korea).
Research indicates that ageism is prevalent within environments where older adults receive housing and health care services. In an ethnographic study on the impact of age and illness within a residential care setting, Dobbs et al. (2008) found that some family members, staff, and residents held negative attitudes about aging that resulted in an environment affected by ageism. In their study, examples of negative age bias included neglecting to gather resident input prior to making decisions, using infantilizing speech with older people, and stigmatizing residents because of dementia or physical disability. In a similar study completed within a multi-level care setting, Zimmerman et al. (2016) found that the use of multi-level, stepped care (i.e., adults with differing independence levels residing within the same setting) reinforced stigma related to age and health, with older adults differentiating among themselves based on which levels of care were required.
Impact of Social Forces
Scholars posit a wide range of hypotheses to explain the prevalence of ageism, but two systemic processes—modernization and medicalization—are identified in the literature as the most likely catalysts of negative attitudes toward aging (Cuddy & Fiske, 2002; Ng et al., 2015). In regard to modernization theory, Cuddy and Fiske (2002) explained that views of older adulthood have changed as a result of the shift from an agrarian society to an industrial society. Technological advances, increased literacy rates among young people, and a trend toward urbanization resulted in greater competition between young and old generations, as well as weakened intergenerational social ties between young people and their families of origin. The sum of these social changes led to decreased status for older people, resulting in the “warm, but incompetent” stereotype that is now associated with them (Cuddy et al., 2005).
Relatedly, improvements in health care have extended the life span and increased the ratio of older to younger people. Previous research shows that as the ratio of older adults to younger adults increases, views about older adulthood become increasingly negative (Ng et al., 2015). Given that the number of older people will increase markedly in coming years, it is possible that negative attitudes toward older people will continue to grow unless intervention occurs.
The second major social force described in the literature is the medicalization of aging, which refers to associating old age with a person’s physical health or illness, to the detriment of other aspects of well-being (Ng et al., 2015). The dominance of medical conceptualizations of old age is described as one of the “master narratives” associated with the modern study of aging (Biggs & Powell, 2001, p. 97). Although the causes of medicalization are many and complex, they can be summarized by the shift from viewing old age as a natural part of the life span to the viewpoint that old age, and even death itself, are problems that modern medicine may be able to solve (Ng et al., 2015). Past research indicates that the medicalization of aging predicts negative attitudes toward aging and consequentially leads to “the objectification of older adults as patients rather than as individuals with interesting life experiences” (Ng et al., 2015, p. 2).
Consequences of Ageism
Impact on Older Adults’ Health and Well-Being
There is a substantial body of research indicating that age stereotypes influence older adults’ health and well-being. For instance, older adults’ perceptions of aging are associated with memory performance (Levy, Zonderman, Slade, & Ferrucci, 2011), hearing decline (Levy, Slade, & Gill, 2006), developing Alzheimer’s symptoms (Levy et al., 2016), and dying from respiratory or cardiovascular illnesses (Levy & Myers, 2005). In fact, Levy, Slade, Kunkel, and Kasl (2002) found that even after controlling for age, gender, socioeconomic status, loneliness, and functional health, older adults with more positive self-perceptions of aging lived 7.5 years longer than those with less positive self-perceptions of aging.
Conversely, research indicates that positive perceptions of aging may provide a salutatory effect on health and well-being. Older adults with positive age stereotypes are 44% more likely to fully recover from severe disability compared to those with negative age stereotypes (Levy, Slade, Murphy, & Gill, 2012), and older military veterans who resisted negative age stereotypes had significantly lower rates of mental illness compared to those who fully accepted them (Levy, Pilver, & Pietrzak, 2014). These positive differences were found for suicidal ideation (5.0% vs. 30.1%), anxiety (3.6% vs. 34.9%), and PTSD (2.0% vs. 18.5%), even after controlling for age, combat experience, personality, and physical health. In regard to variables that may influence older adults’ self-perceptions of aging, Fullen, Granello, Richardson, and Granello (in press) found that resilience—the ability to bounce back from adversity—and multidimensional wellness were significant predictors of positive age perception, whereas increased age and decreased physical wellness predicted internalized ageism. Furthermore, resilience appeared to buffer older adults from experiencing internalized ageism as they grew older. However, older adults may not be exposed to interventions to promote resilience and well-being because of ageism’s impact on the availability of mental health services among older adults.
Impact on Mental Health Professionals
The gap between the mental health needs of older adults and the number of mental health professionals with specific training in working with older adults is on the verge of a “crisis” (Institute of Medicine, 2012, p. ix). Scholars provide a variety of explanations to account for this, including systemic factors—such as inadequate funding and a lack of training opportunities within academic programs (Bartels & Naslund, 2013; Gross & Eshbaugh, 2011; Robb, Chen, & Haley, 2002)—and personal factors, including low interest in working with older adults (Tomko, 2008) and therapeutic pessimism (Danzinger & Welfel, 2000; Helmes & Gee, 2003).
Systemic ageism. Although older adults consistently report higher life satisfaction than younger or middle-aged adults (George, 2010), approximately 26% of all Medicare beneficiaries, or more than 13 million Americans, meet the criteria for a mental disorder (Center for Medicare Advocacy, 2013). Yet, mental health services currently account for only 1% of Medicare expenditures (Bartels & Naslund, 2013). Systemic barriers may be partially responsible for the lack of access to mental health services among older adults. For example, inadequate reimbursement rates is cited as one reason for the 19.5% decline in psychiatrists accepting Medicare between 2005–2006 and 2009–2010 (Bishop, Press, Keyhani, & Pincus, 2014). Similarly, Medicare payments to psychologists for psychotherapy decreased by 35% since 2001, after adjusting for inflation (American Psychological Association, 2014). Older adults are currently unable to use Medicare to access services provided by licensed professional counselors (LPCs) or marriage and family therapists (MFTs; Fullen, 2016b). This translates to an estimate of 175,000 mental health professionals who are unavailable to serve as Medicare-eligible providers (American Counseling Association, n.d.). Clients who age into Medicare coverage after working with these professionals face discontinuity of care caused by having to change providers.
Professional training barriers among the helping and health professions also may reflect systemic ageism. Half of the fellowship positions in geriatric medicine and geriatric psychiatry are unfilled each year, and only 4.2% of psychologists focus on geriatric care in clinical practice (Bartels & Naslund, 2013). Institutional barriers that inhibit student interest in careers related to work with older adults include a lack of visibility for multidisciplinary gerontology programs, the absence of gerontological content within textbooks, few faculty who are trained in gerontology, misconceptions about employment opportunities (i.e., the assumption that the only aging sector jobs available are in nursing homes), and a primary focus on the problems associated with old age when later life is discussed within the classroom (Gross & Eshbaugh, 2011).
Within the counseling profession, scholars describe a mixed commitment to gerontological counseling. Going back to 1975, Salisbury (1975) and Blake and Kaplan (1975) described counseling with older adults as an overlooked domain within professional counseling. Twenty years later, Myers (1995) argued that gerontological counseling had evolved from “forgotten and ignored” (p. 143) to a sub-discipline within the profession complete with standards and certification. However, the gerontological counseling specialization that existed between 1992 and 2008 was discontinued in 2009 when only two institutions had applied for accreditation (Bobby, 2013). Perhaps more telling, the 2016 Standards of the Council for Accreditation of Counseling & Related Educational Programs (CACREP) include zero references to the words old, older, older adults, or ageism; only one reference each to the words age and aging; and four references to the phrase life span (CACREP, 2015). Nonetheless, Foster, Kreider, and Waugh (2009) found that many counseling students have interest in topics related to gerontological counseling, including grief counseling (70%), retirement counseling (43%), family counseling with aging parents (64%), and counseling caregivers (55%). The same study found that many respondents were interested in working in a hospice setting (39%), a hospital geriatric unit (29%), a nursing home (25%), private practice with older adults (43%), and a community setting with older adults (45%). However, it is unclear whether students who are interested in working with older adults receive training and employment opportunities within these contexts.
Individual ageism. Research regarding the prevalence of ageism among individual mental health professionals is equivocal. When mental health professionals’ perceptions of clients based on age, gender, and health variables were studied, some researchers found health bias, but not age bias (Robb et al., 2002). Others reported that participants rated older clients as having a greater number of diagnostic problems (Helmes & Gee, 2003) and a worse prognosis than younger clients, in spite of all relevant information being matched across age groups (Danzinger & Welfel, 2000). Helmes and Gee (2003) found large differences in how older people were rated on key therapeutic variables. Older clients were viewed as less able to develop an adequate therapeutic relationship, less appropriate for therapy, and less likely to recover. Respondents in their study also felt less competent in treating older people, and they were less willing to accept older people as clients.
To counteract the potential influence of negative age bias on counseling treatment, McBride and Hays (2012) described the importance of linking work with older adults to multicultural competence. The authors surveyed 360 counselors and counselor trainees and found a significant, negative correlation (r = -.41) between multicultural competence and negative attitude toward aging. Tomko (2008) found that multicultural competence was associated with improved clinical judgment when working with older adults; however, it did not predict global attitudes toward aging. In sum, considerations of both the systemic and individual aspects of ageism have important implications for the counseling profession.
Implications for the Counseling Profession
The rapid growth of the older adult population will impact members of the counseling profession in a variety of ways. Shifting age demographics make it imperative that counselors understand how the pervasiveness of ageism impacts key professional values like diversity, social justice, and client advocacy. Four domains are outlined in which counselors may dedicate their attention to generating positive views of aging. These domains include counselor education, advocacy, research, and counseling practice.
Counteracting Ageism Within Counselor Education
Within counselor training programs, resistance to ageism begins with incorporating discussions about aging and older adulthood into the counselor education curriculum. Therefore, it is important that professional accreditation standards like CACREP adequately reflect the mental health needs of older adults and their families. In its current form, the omission of keywords like aging, older adulthood, and ageism from these standards may send a mixed signal to counselor training programs and their students about social justice and multicultural competencies as they relate to older adults.
Once ageism is identified by a counselor education program as a priority, counselor educators need to develop strategies for incorporating this focus in the existing curriculum. For instance, a life span development course provides ample opportunities to discuss issues such as shifting population demographics, multigenerational families, and how an aging population will impact the counseling profession. Assessing students’ current thoughts about the aging process, including both their own aging and that of family members, may create greater empathy for the needs of older adults. Similarly, when instructing social and cultural diversity courses, counselor educators should consider introducing topics such as ageism and age privilege and juxtaposing these constructs alongside dialogue about diversity and intersectionality (Black & Stone, 2005). Furthermore, when developing practicum or internship sites, counselor educators could make a point of developing placements in which older clients will be served. Identifying potential site supervisors who have experience in working with older adults is an important step, as it ensures that trainees are given adequate opportunities to reflect on their own perspectives on aging, disability, advocacy, and related issues.
Counteracting Ageism Through Advocacy
In regard to advocacy, counselors should resist ageism at national, state, and local levels. At the national level, the omission of counselors as approved Medicare providers limits the availability of mental health services for older adults and reflects the assumption that older adults’ needs are primarily physiological. This issue creates challenges for members of the counseling profession who are interested in providing services across the life span. Mental health advocacy on behalf of older adults includes educating lawmakers about the importance of Medicare reimbursement as a means of creating mental health service access (Fullen, 2016b). Professional organizations continue to support grassroots advocacy, as well as lobbying efforts, to influence Medicare policy on behalf of counselors. In fact, as of this writing there are bills in each chamber of the United States Congress (i.e., S. 1879; H.R. 3032), and a federal advisory group (i.e., the President’s Interdepartmental Serious Mental Illness Coordinating Committee; ISMICC) recently recommended inclusion of counselors within Medicare (National Board for Certified Counselors, n.d.).
At the state and local level, members of the counseling profession should forge partnerships with gerontology professionals. For example, advocacy occurs when professional counselors and counselor educators make connections with members of the local area agency on aging, directors of local assisted living or skilled nursing facilities, or state policymakers who are responsible for budgetary and policy decisions related to aging. These partnerships are mutually beneficial; they provide members of the counseling profession with increased exposure to the diverse needs of older adults in their communities, and they educate local gerontology professionals about the range of mental health services that counselors provide. Additionally, building interprofessional connections may lead to research opportunities that can improve the care received by older adults.
Counteracting Ageism Through Research
In spite of the numerous studies indicating that ageism has detrimental effects on older adults, there are currently very few studies that demonstrate the prevalence and impact of ageism within the counseling profession. For instance, research on in-session dynamics between counselors and much older clients could shed light on the ways in which age is broached in a counseling session. Additionally, research could focus on the benefits of professional counseling for older adult clients, as well as the effectiveness of novel interventions that are grounded in counseling theories or wellness (Fullen & Gorby, 2016; Fullen et al., in press). For instance, the development and validation of a wellness-based approach to counseling older adults might mitigate mental health issues or internalized ageism among older clients (Myers & Sweeney, 2005), and it would serve as additional evidence for the necessity of adding counselors as Medicare providers.
At the institutional level, more research is needed to understand the extent to which counselor training programs address ageism, and in which curricular contexts. It is important to understand which pedagogical strategies are most effective, whether these impacts persist over time, and how well training programs make inroads with local agencies that work with older adults. Research into advocacy efforts related to Medicare reimbursement may also advance the profession. Although Medicare reimbursement is described as a priority for the counseling profession, there is currently little research on counselors’ knowledge about Medicare or participation in Medicare advocacy.
Counteracting Ageism Through Counseling Practice
Finally, it is important to consider how counselors might resist ageism within their counseling practice. Because of the heterogeneity of older adults, counseling services should be tailored to the unique needs of each client. Given that ageism has the potential to influence how older clients are conceptualized by counselors, it is important for counselors to reflect on their own beliefs about aging as well as their assumptions about the ability of older clients to grow and change. Many counselors are not familiar with the wide range of mental health interventions that have been empirically validated with older adults (Myers & Harper, 2004). For example, the SAMHSA-HRSA Center for Integrated Health Solutions (n.d.) provides numerous resources related to providing behavioral health services to older adults. These resources address issues such as evidence-based treatments for late life depression, preventing suicide in older adults, screening for substance misuse, and assessing cognitive functioning.
Given the growing interest in wellness-oriented services for older adults, SAMHSA also provides evidence-based resources related to health promotion and integrated care. Programs that focus on cultivating holistic wellness or resilience are relatively new, but they also may be worth considering as a means of countering ageism within the practice of counseling. Because the wellness approach incorporates multiple dimensions of functioning, older clients who are experiencing deficits in a particular domain (e.g., limited mobility influencing ability to drive) may find that they can use alternative domains as a means of compensating (e.g., greater reliance on social network to carpool to events; Fullen, 2016a). Similarly, discussion of how older clients have used strengths to navigate loss, overcome adversity, and resist ageism in their own lives may prove to be key ingredients in the therapeutic process. Furthermore, incorporating resilience into an older client’s treatment plan may create a buffer against internalized ageism (Fullen et al., in press), as well as an opportunity to highlight older adults’ abilities to adapt in the face of adversity (Fullen & Gorby, 2016).
As the number of older adults grows, members of the counseling profession are increasingly likely to encounter older people who seek to benefit from counseling services. A review of existing research demonstrates that there are numerous causes of ageism, detrimental consequences associated with internalizing negative age stereotypes, and gaps in research related to how the counseling profession should respond. In light of the counseling profession’s commitment to diversity, social justice, and advocacy, it is important to better understand the broad impact of ageism. By combating ageism in the domains of public policy, research, teaching, and direct service with clients, members of the counseling profession have the opportunity to counteract ageism’s deleterious effects and promote more positive perceptions of growing older.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
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John E. Mabey
Consideration of older adult lesbian, gay, bisexual, and transgender (LGBT) persons in gerontological research is lacking, leaving professional counselors without a substantive bridge with which to connect resources with treatment planning when working with sexual minorities. Therefore, presented here is an overview of aging research related to older adult LGBT individuals. The importance of individuality among LGBT individuals and suggestions for professional counselors who work with both individuals and couples in these populations also are presented.
Keywords: LGBT, older adults, gerontology, aging research, individuality
Multidisciplinary in nature, gerontology encompasses the study of dynamic processes of aging as experienced on the social, psychological, and biological levels (Hooyman & Kiyak, 2008). Knowledge of gerontology therefore enables professional counselors to work more effectively with older clients by facilitating understanding of their worldview. Professional counselors thus are better able to contextualize how aging itself is not the pathology, but rather the context that influences other aspects of the client’s life.
Due to advances in medical care and quality of life, the average lifespan in the U.S. is being prolonged and the percentage of those reaching old age is increasing dramatically (Dobrof, 2001). According to recent U.S. Census data (2008), the number of Americans aged 85 years and older will increase from 5.4 million in 2008 to 19 million by the year 2050. In addition, about 1 in 5 U.S. residents will be age 65 or older by 2030. It is not uncommon in professional literature and research to differentiate old age into categories, such as the young old, typically between 60 to 79, and the old old, typically 80 and above, to capture more accurate developmental data at different stages of the life cycle (Grossman, 2008; McFarland & Sanders, 2003; Quam, 1993; Quam, 2004; Quam & Whitford, 2007). Although relatively arbitrary, such categories do point to the fact that there are developmental differences even among older adults.
Older adult sexual minorities have been relatively ignored in gerontological research (Apuzzo, 2001; Cook-Daniels, 1997; Grossman, 2008; Kimmel, 1979; Orel, 2004; Quam, 2004). It is estimated that there are between 1 and 3 million individuals in the U.S. over age 65 who identify as lesbian, gay, bisexual, or transgender (LGBT) (Jackson, Johnson, & Roberts, 2008; McFarland & Sanders, 2003), and that number is expected to increase substantially in the next 15 years (Penn, 2004). Unfortunately, whether because of discriminatory bias against LGBT individuals or the invisibility of sexual identity within older adult populations in the larger society, most professional counselors find themselves lacking in general knowledge about this growing population and therefore ill-equipped to provide professional services for them.
Older adults, whether heterosexual or part of the LGBT community, confront many concerns about aging, including financial matters, health, companionship, independence (Quam & Whitford, 1992), loss, and residence concerns (MetLife, 2006). All older adults also face issues and stereotypes surrounding ageism (Wright & Canetto, 2009), including discriminatory attitudes and behaviors against older persons (Hooyman & Kiyak, 2008). However, ageism as experienced in LGBT communities has the additional impact of making a stigmatized group feel even more of a minority (Brown, Alley, Sarosy, Quarto, & Cook, 2001; Drumm, 2005; Jones, 2001; Jones & Pugh, 2005; Kimmel, Rose, Orel, & Greene, 2006; Meris, 2001) .
Additional concerns unique to older adult LGBT individuals include the ability to make legal decisions for each other as couples/partners, lack of support from family who might not recognize or respect their sexuality, and homophobic discrimination in healthcare and other services. Older adult LGBT persons often face unparalleled discrimination and harassment in residential care facilities (Johnson, Jackson, Arnette, & Koffman, 2005; Phillips & Marks, 2008). While elder abuse is recognized as a significant problem among older adults in general, unfortunately there is a deficiency of specific knowledge about abuse for older adult LGBT persons (Moore, 2000). Thus, in the vast majority of situations, mainstream services for older adults are not meeting the specific and unique needs of the older adult LGBT population (Slusher, Mayer, & Dunkle, 1996).
Older adult LGBT individuals have lived through distinctively oppressive social climates for sexual minorities compared to more recent generations. Their early developmental years were marked by a typically homophobic culture in which homosexuality was overtly and profoundly admonished, and included messages from national and local leaders that their sexuality was immoral, pathological, and often illegal. For example, the old old grew up in an era during which President Eisenhower ordered all homosexuals to be fired from government jobs and Senator McCarthy sought to ‘expose’ communists and homosexuals (Kimmel, 2002). Without a more organized movement in place in that era to combat the rampant homophobia and negative stereotyping, blatant fear and dislike of homosexuality was seen in nearly all political, educational, and religious institutions. Indeed, the general lack of support for LGBT individuals in religious institutions continues today, leaving many in the position of a forced choice between two fundamental components of their sense of self: spirituality and sexuality. “In turn, this conflict can manifest itself through internalized disorders, such as depression, or through externalized disorders, such as risky or suicidal behavior” (Mabey, 2007, p. 226). However, it is important for professional counselors to be aware of the distinction many older adult LGBT persons make between spirituality and religiosity; religious dogma against homosexuality does not prevent many LGBT individuals from maintaining a strong spiritual identity (Mabey, 2007; Orel, 2004).
The young old, though, became adults during a time of more relatively progressive changes in society. The Stonewall riots in Greenwich Village in 1969, in which gay and transgender individuals physically fought back against unjust police harassment, marked a milestone in what would eventually become the modern gay rights movement. In the mid-1970s, homosexuality was finally declassified as a mental disorder within both the American psychiatric and psychological professional communities (but only after decades of miseducating medical and mental health professionals about the pathologic nature of sexual minorities).
As professional counselors work with an aging LGBT population, it is important to consider this historically negative climate which shaped an individual’s experiences with, and impressions of, her or his own sexual identity (Berger, 1982). For the older adult LGBT individual, consequently, there might exist a sense of internalized homophobia (D’Augelli, Grossman, Hershberger, & O’Connell, 2001; Heaphy, 2007; Porter, Russell, & Sullivan, 2004) that contributes to nonparticipation in LGBT-supportive services and associated diminished overall mental health. These individuals also are less likely to seek any general health services for fear of having to disclose their sexual orientation to a possibly homophobic provider (Brotman, Ryan, & Cormier, R., 2003; Grossman, D’Augelli, & Dragowski, 2007; Sussman-Skalka, 2001). For example, refer to Zodikoff (2006) for vignettes that highlight unique aspects of social work practice with a diverse and aging LGBT population.
Aging and Individuality
Professional counselors should recognize that an older adult LGBT individual does not belong to one homogenous group within the LGBT acronym. For example, a gay youth living in New York City at the time of the Stonewall Riots will have experienced the movement in vastly different ways than, say, a gay youth then living in the rural Midwest. Similarly, a transgender individual involved in the Stonewall Riots will have faced different experiences than a gay male in those same riots because of the greater concealment of transgender individuals. Cook-Daniels (1997) wrote, “Lesbian and Gay male elders have been called an ‘invisible’ population (Cruikshank, 1991). If they are invisible, then transgendered elders have been inconceivable” (p. 35).
Transgender older adults also face unique challenges apart from those who are lesbian, gay, or bisexual (Cook-Daniels, 2006). For example, health concerns for those transitioning from male to female (MTF) or female to male (FTM) are greater because surgeries become more complicated with age. However, there has been a significant increase in the number of those willing to face the risk of transitioning in later life because of vastly improved methods of electronic communication about options, new research, and medical procedures (Cook-Daniels, 2006).
Another challenge to older adult transgender individuals is that most older adults in society, including gay and lesbian older adults, have well-established social roles and relationships. Thus, MTF or FTM transitioning becomes more difficult with age because of the need for changed manners of speech and gesticulations. Legal issues include additional unique challenges as a change in gender is often associated with changed governmental benefits. For example, a formerly heterosexual marriage might be seen as an illegal same-sex marriage after one spouse transitions, and then formerly anticipated benefits, such as Social Security, might be revoked.
As professional counselors work with the older adult transgender population, there are several important aspects about this community to be considered in treatment planning (Cook-Daniels, 2006). First, although transphobia in the medical community and healthcare facilities has not been adequately researched, it is well-documented (Donovan, 2001). Therefore, making effective referrals necessitates that the new service provider be familiar and comfortable with the transgender population. Professional counselors also should understand the roadmap for individuals who are transitioning, and in particular how they need to be declared mentally fit as well as diagnosed with Gender Identity Disorder before any treatment for transitioning may commence. Professional counselors also should understand that persons in MTF or FTM are often perceived to be, “…mentally ill until proven otherwise, and they are fearful and angry that—to a degree that is rivaled perhaps only by prisoners and the severely domestically abused—their life choices are under someone else’s control” (Cook-Daniels, 2006, p. 25). To the extent that a transgender person holds this perspective, it might interfere with his or her level of comfort in seeking the services of a mental health professional at all.
Transgendered individuals also cannot control the coming-out process of their gender identity because visual or auditory cues may expose their status, and therefore they are left open to the opinions and reactions of others they encounter. Thus, it is important for professional counselors to assess their own comfort levels, and meeting transgender individuals or volunteering in an organization that serves this population is a great way to increase familiarity with and knowledge about this group. It also is important to recognize that transgendered individuals face financial constraints that are usually greater than those typically encountered by other gay, lesbian, or bisexual elders due to hormone medication or surgical procedures that are usually not covered by insurance. Therefore, as with other clients experiencing financial constraints, professional counselors might employ a sliding-fee scale depending on their client’s stage of transition and/or individual circumstances.
Bisexual individuals also experience a sense of invisibility within the LGBT community. As another underrepresented group in professional research literature, the needs and experiences of bisexual older adults also are often misunderstood. Professional counselors likely will work with bisexual clients during their careers, and should approach treatment without the erroneous assumption that sexuality is necessarily dichotomous (Dworkin, 2006).
Ageism typically precludes recognizing the sexuality of older adults (Hooyman & Kiyak, 2008). However, it is an important element. Consider a professional counselor who meets an older adult client who is happily married to a member of the opposite sex. That counselor likely will not consider that the client may in fact be bisexual—but it may be the case. Indeed, coming out as bisexual during a heretofore heterosexual marriage is the point at which a professional counselor might most be needed as issues of intimacy and restructuring of familial dynamics are addressed.
There also is the myth of the impossibility of monogamous relationships for bisexual individuals that should be considered by professional counselors (Dworkin, 2006). Simply because a person has the capacity for attraction and/or commitment to both males and females does not mean that the individual is unfulfilled with a monogamous relationship or that polyamorous relationships are necessarily seen as negative.
Aging Research and Identity
Differences among individuals within the “LGBT” acronym highlight the necessity for a professional counselor to understand the complex nature of identity. Through a shared history, current activism, and support networks, individuals within the LGBT community have much in common with one another. However, they also have differences. In building rapport with an older adult client, a professional counselor should recognize these differences (beyond commonly understood stereotypes). For an older adult LGBT client, having a well-informed professional counselor is essential to relationship-building and establishing trust, i.e., a comfortable environment in which LGBT history can be addressed and acknowledged.
Comprised of persons of every nationality, socioeconomic status, gender, ability level, race and ethnicity, the older adult LGBT population cannot be grouped or treated as one cohesive category. Unfortunately, research about LGBT elders is still underrepresented in gerontological literature, and representative samples of populations within that body of research are even more limited (Berger & Kelly, 2001; Butler, 2006; Grossman, D’Augelli & Hershberger, 2000; Jackson, et al., 2008; Kimmel, 2002; Quam & Whitford, 1992). Indeed, because of a variety of factors, such as “closeted” older adults and the lack of organized LGBT communities in some areas, no economically feasible method is available to generate a random sample of older LGB(T) individuals (Grossman, et al., 2000). Professional counselors must also consider this limitation when reviewing research, and how a significant number of studies have been conducted with LGBT individuals with limited sample sizes (and who primarily were Caucasian, highly educated, affluent, self-identified, younger, male individuals living in urban areas) (Dworkin, 2006; Grossman, D’Augelli, & O’Connell, 2001; Hash, 2006; McFarland, & Sanders, 2003; Porter, et al., 2004). Within the professional research and literature on older adult LGBT individuals, there exists a substantial gap in representation of people of color, the old old, and those living in rural areas.
Professional counselors should inquire of each older adult LGBT client about level of identification with an LGBT identity or community. Indeed, a professional counselor may be better educated about LGBT history and circumstances than the client, and therefore may be able to facilitate the older adult LGBT client’s identity development. Indeed, it is rare for an older adult LGBT individual to have had LGBT parents, and therefore they are not necessarily taught this cultural history or coping strategies for overcoming homophobia, biphobia, or transphobia in the traditional family setting. Regardless, the ability of a professional counselor to access such information during a session is an important skill for relationship-building and even for educating the client regarding homework or making referrals.
As professional counselors consider the impact of an LGBT identity for the older adult individual, it also is important to not view that identity as necessarily problematic (Berger, 1982). In fact, researchers point to the idea of “crisis competence,” in which the coming-out process enables the individual to develop a competency for dealing with other crises in the lifespan, including difficulties associated with the adjustment to aging (Heaphy, 2007; Kimmel, 2002; McFarland & Sanders, 2003; MetLife, 2006; Morrow, 2001; Quam, 1993).
Additional Skills for Professional Counselors
Sometimes an older adult individual in the LGBT community has difficulty coping with the stressors of homophobia and coming-out, and professional counselors might witness psychological distress or unhealthy behaviors. Kimmel (2002) outlines suggestions that can be adapted by mental health professionals to enhance the development of crisis competency and combat maladaptive thoughts and behaviors with this population. The suggestions include to:
• Aid the client to discover any familial or peer support.
• Identify positive role models locally or nationally that embody characteristics to which the client would aspire.
• Practice the use of effective coping skills.
• Assist in managing the integration of their multiple identities to enhance their sense of self.
Because the number of older adult individuals in the U.S. is expected to increase dramatically in the next 20 to 50 years, the number of older adult LGBT individuals will continue to grow as well. Professional counselors, working with these often misunderstood populations, face the additional challenge of treating LGBT elders with limited research or experience. Quam, Knochel, Dziengel, and Whitford, (2008) offer practical suggestions for working with same-sex couples that are adapted for work with older adult LGBT individuals:
• Your older adult client may define “family” as close friends who have assumed the role of absent families of origin. These fictive kin must be treated with the same respect as other family members.
• Because of anti-LGBT attitudes, your older adult client’s biological or adoptive family may not be providing elder care. This care might instead be provided by fictive kin or not at all.
• Your older adult client might also be a caregiver for another elderly individual, especially as fictive kin play an important role in LGBT communities and caregiving.
• Your older adult client may have biological or adoptive children.
• Be knowledgeable about legal protections such as a will, power of attorney and a health care directive, as there are limited benefits for same sex couples (being denied visitation rights in a hospital when their partner is injured or gravely ill is a possibility).
• Confidentiality is essential when working with an older adult LGBT individual, specifically because of realistic fears about anti-LGBT attitudes in the medical field or treatment facilities. Therefore, disclosing your client’s sexual orientation without permission, even to another LGBT individual, should be strictly avoided.
• Familiarize yourself with older adult LGBT services and communities. An example is SAGE (Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders), a comprehensive social service agency with chapters across the country (http://www.sageusa.org).
As professional counselors continue to balance a scholar-practitioner role, increased research and experience with LGBT older adults and their aging will promote and elevate the counseling profession. It also will serve to enrich the lives of millions of LGBT older adults and their supporters. Both historically and in contemporary times, the counseling profession thrives as a fertile ground for pioneering and ground-breaking research; LGBT aging represents a generally underexplored but vital new challenge. Indeed, the dynamic and diverse nature of older adult LGBT communities provides opportunity for expanding academic inquiry and new and innovative treatment modalities in the counseling profession.
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John E. Mabey, NCC, is Editor and Facilitator at University-Community Partnership for Social Action Research Network (UCP-SARnet). Correspondence can be addressed to John E. Mabey, University-Community Partnership for Social Action Research Network, Arizona State University, P.O. Box 871104, Tempe, AZ, 85287, firstname.lastname@example.org.