Aging in the 21st Century, by T.W. Arnold
“O wonder!
How many goodly creatures are there here!
How beauteous mankind is!
O brave new world! That has such people
in't!”
Shakespeare, The Tempest, Act V, Scene 1
Introduction
An aging wave of souls as no era has
known before is about to break onto the shore of our cultural, economic,
social, and institutional landscapes.
On January 1, 2011, the youngest of the American “Baby Boomers,” born
between 1946 and 1964, achieves the age of 65. Following them are 76 million more persons – the largest generation
in the history of the United States.
This sea of “later lifers” will wash over our society and challenge its
increasingly limited resources for decades to come. That challenge will include competition for resources between
young and old. A Baby Boomer born in
1964 who lives to be 100 will die in 2064, 55 years hence.
The mental health community is inextricably
poised to serve as mid-wives to this gigantic transition. Opportunities not merely to make a
dignified living but also to serve this rising tide of humanity and so to help set
the course for the generations that trail will soon be abundant and enormously
fulfilling for clinicians with vision. Yet biases, discomforts, the relative lack of investigation
and research into the aging process and aging families as compared with other
phases of the individual and family life cycles, together with the reluctance
of this generation themselves to utilize such resources, leaves some mental
health professionals inadequately prepared to greet this new world.
I.
Who Are These “Later Lifers”?
Although the “graying of America” (Lemme,
2006, p. 6) is much heralded, its implications
are not being sufficiently addressed.
These human beings are our grandparents, aunts and uncles, fathers,
mothers, brothers and sisters, blended, half and step relatives, families of
choice, mentors, teachers, leaders, the poor and underprivileged, our friends,
and – inevitably – one day our very selves. This “disconnect” is fascinating since each of us will never
experience being a child again but each of us will intimately experience
aging. The success of younger
individuals and families is linked to the success of this older population as
it journeys through the life cycle.
A.
By the Numbers
The “aging” are generally considered to be 65 years or older. The Older Americans Act of
1964 applies to persons 60 and older (Greenberg, 2005). Walsh (2005) notes “[l]ater life is being redefined in terms of the ‘young
old,’ persons age 60 to 85 …, and the ‘old old’ or ‘fourth age’ of elders over
85” (p. 307). Blacker (2005)
describes the preceding age period of “midlife” as “spanning the ages of
roughly 45 to 65,…” She predicts
that “[b]ecause of better health and increasing longevity, [the mid-life characterization]
may get expanded even more in the future” (p. 288).
Changes in population demographics in the past 110 years are
astounding. In 1900 an average
male born in the United States could expect to live to 48 years of age and the
average female to 51. Males born
in this country in 2003 can expect to achieve the age of 75 years and females
to the age of 80 (Yorgason et al., 2009).
Compounding this transformation are the decreasing fertility rates over
the same period that have radically increased the proportion of older adults
within the population. In 1900,
4.1 percent of the population was over the age of 65. In 2000 this number had increased to 12.4 percent (Yorgason
et al., 2009, p. 29). According to
the U.S. Department of Health and Human Services, Administration on Aging (2008),
as of 2010 thirteen percent of the population, or 40,228,712 persons, will be
age 65 or older. Over the coming
decade these numbers will increase to sixteen percent and by 2030 to almost
twenty percent, leaving more Americans over the age of 65 (72,091,915) than
under the age of twenty-five.
These relative percentages are expected to stabilize through 2050, when
88,546,973 adults will be 65 or older.
Contrast these numbers with 2000, when 12.5 % of the United States
population was over 65, comprising 34,991,751 persons.
B.
Characterizations of Aging Persons in the Popular Culture
Popular culture reflects existential, cultural, and other biases
about the aging that are reflected
in the nomenclature and characterizations of this group. For instance, the aging are variously
characterized with such pejoratives as “geezers,” “crones,” “grey-backs”, “grey-beards,”
“silver-hairs,” “silverbacks,” “blue-hairs,” “raisins,” “grannies,” “old
fogeys,” “the twilight generation”, “golden ponders,” “curmudgeons,”
“centenarians,” “dodderers,” “fossils,” “dotards,” “antediluvians,”
“has-beens,” “oldsters,” “cougars,” “the senile,” “old-fashioned,” and “senior
citizens.”
This “ageism” extends to MHP’s. Even the mental health research isn’t
sure what to appropriately call “elders,” describing them as “the aging,” “age
disadvantaged,” “widows,” “widowers,” “late lifers,” “the old,” and the “age
challenged.” Butler (1989) defines
“ageism” as “negative attitudes and practices that lead to discrimination
against the aged” (p. 139).
C.
Historical Lack of Interest Towards Aging
Hence, there is a need in the mental
health sciences to improve the quality of later life and to support elder
relationship. Allen, Blieszner,
and Roberto (2000) observe that “[r]esearch on families in the middle and later
years [only] came into its own in the 1990s…. In the 1990s, a shift occurred in describing the complexity,
malleability, and variety of family connections in the second half of life,…”
(p. 911). They explain that “[n]ew
areas of investigation turned the study of aging families from a monolithic
conception of the ‘aging individual within “The Family”’ to greater awareness
of the challenges and innovations associated with variability in later family
life” (p. 920). While they
anticipated rich investigation into later life families during the first decade
of 2000 it is not clear that that promise has been met.
Yorgason,
Miller, and White (2009) note that there remain a number of barriers that block
needed services from reaching this population. These include the lack of payment/-insurance resources (and
unavailability of Medicare reimbursement), negative attitudes towards
psychotherapy among the older generation, restricted mobility of the elders
themselves, myths and stereotypes about the aged, therapist discomfort with
their own aging, lack of therapist training, lack of interest in aging issues,
and a belief that older persons cannot change (pps. 29-30). Moreover the field of marriage and
family therapy has historically focused on the problems of the young.
I
performed a search within the Journal of
Marriage and Family from 2000 to 2009 and found four articles that included
the word “aging” in their titles.
I had the same result within the Journal
of Family Relations. Nothing
appeared in the year old Journal of
Family Therapy and Review.
Other than as listed in these periodicals there is a single NCFR (2005)
Family Focus publication on issues involving the aging that contains about
fifteen brief articles. By way of
contrast, within the Journal of Marriage
and Family 112 titles contained the word “children” between 2000 and 2009
and similarly 58 articles within the Journal
of Family Relations.
II.
Common Experiences of Aging
A.
Cognitively
Impaired Older Persons
Older people react more slowly, both
psychologically and physiologically.
Short-term memory
and problem solving abilities diminish with age, and most people in later life
have lowered stamina and recover from trauma more slowly (DeMuth, 2004). Severe cognitive impairment affects almost five percent of
community residing adults over age 65 years, and between 15.8 to 30% of those
over age 85 (Qualls, 2000). These
numbers are higher in acute medical and institutional settings.
Cognitive decline impacts the entire family
unit. Qualls (2000) notes “[t]he
degree of adjustment required of the individual with cognitive impairment is
profound” (p. 193). She argues for
a family systems approach to therapy with aging families. “The simplest rationale for considering
family level interventions for older persons is that families are highly
salient social relationships for them” (p. 191). The developmental task includes significant renegotiation of
family structures. When family
structures prevent a family from meeting members’ needs, a family level
intervention is required to restore stasis. This is frequently the case with dementia sufferers, where a
‘dawning of awareness’ for the problem produces ambiguities for other member’s
responses to the elder person in transition.
B. Non-Cognitively
Impaired Older Persons/Successful Aging
The
concept of “successful aging” has been addressed in the mental health
literature for almost 50 years.
Phelan and Larson (2002) report that it means different things to
different clinicians. Key elements
include concepts of “life satisfaction,” “longevity,” “freedom from
disability,” “mastery/growth,” “active engagement with life,” “high
independent functioning, and “positive adaptation.” Predictors of successful aging include high educational
levels, regular physical activity, high self-efficacy, social contacts and supports,
and freedom from chronic illnesses.
Studies
of the attitudes of older adults themselves suggest that their definition of
successful aging is multi-dimensional, encompassing physical, functional,
psychological, and social health.
(Phelan, Anderson, LaCroix, and Larson, 2004, p. 211). Yet, Phelan et al. (2004) note that the
published work doesn’t typically describe these attributes as all being
included within the definitions of successful aging.
Non-cognitively impaired older adults may
develop compensatory tactics to deal with these changes. Schulz and Heckhausen (1996) have
theorized that a life span theory of control allows for a model of
“developmental regulation” (p. 708) that applies to the elderly. They distinguish between “primary control”
which targets the external world and attempts to achieve results in the
immediate environment outside the individual and “secondary control” which
deals with self-regulation responses within the individual. In their view, primary control holds
functional primacy over secondary control because “it enables individuals to
explore and shape their environment to fit their particular needs and optimize developmental
potential” (Schulz et al., 1996, p. 708).
A compensatory response to old age where
an individual’s capacity to affect outcomes within the environment is
negatively implicated results in a decrease in available choices when primary
control is employed. For instance,
there is less time to master the guitar or to play the piano as one’s mind and
hands slow. Therefore Schulz et
al. (1996) reason that “[i]ncreasing age-related biological and social
challenges to primary control put a premium on secondary control strategies as
means for maintaining the potential for primary control. As the ratio of gains to losses in
primary control becomes less and less favorable, the individual increasingly
resorts to secondary control processes” (p. 709). Secondary control increases and primary control wanes.
C. Resilience Theory
Resilience is an attribute of successful
aging. “Resilience has been
defined as the capacity
to remain well, recover, or even thrive in the face of adversity” (Hardy,
Concato, and Gill,
2004, p. 257). It was first
described by researchers in childhood and adolescent development as a factor
enabling children in adverse circumstances to develop into well-adjusted,
successful adults. For instance,
Windle, Markland, and Woods (2008) trace resilience from a theoretical
perspective to Erickson’s theory of the life cycle. This postulates “that the continuing developments of the
self across the life span and the ultimate achievement of wisdom provide a
basis for the resilient self” (p. 289).
Baltes and Baltes (1990) extended it to later lifers.
Similar to findings in crisis
intervention, resilience is a measure of coping responses to stress. It examines “the process by which
individuals survive or even thrive under adversity, incorporating internal
traits, such as hardiness or high self-efficacy, and external factors, such as
social support, that promote coping” (Windle et al., 2008, p. 289). The importance of assessing resilience
for the aging includes the possibility that clinicians may learn to distinguish
older persons who are more likely to “bounce back” after illness or injury from
those who may have a more difficult course and therefore need a more customized
intervention. Resilience in older adults has been
linked to spirituality (Atchley, 2008).
Concato
et al. (2004) examined resilience among a cohort of community dwelling older
persons – meaning they were nondisabled and living with others - and found “a
wide range of resilience, as assessed by response to a stressful life event”
(p. 260). They define a resilient
response as a small initial decremental effect of a stressful event, a rapid
recovery, minimal long-term negative consequences, and positive long-term
consequences of the event. A
limitation of the study was that no real stressful events were imposed;
instead, participants were asked about their memories of stressful events and
they were asked to rate them. This
information was used to generate a six-item resilience scale. Another limitation is that the authors
provide very little information on the living contexts of their participants.
In
comparison Hawkley and Cacioppo (2007) summarize studies of age differences in
associations between loneliness (social isolation) and individual differences
in health behaviors, stress exposure, physiological stress responses, appraisal
and coping, and restorative processes.
They note that repeated research that has shown that a lack of social
ties increases risk for poor health, and comment that “[i]n light of this
research, sociodemographic changes in American society indicate a disturbing
trend toward increased social isolation” (p. 187).
D. Emotional Functioning
According to Samanez-Larkin, Robertson,
Mikels, Carstensen and Gotlib (2009), “[a]
growing
body of research suggests that the ability to regulate emotion remains stable
or even improves across the adult life span” (p. 519). In comparison to their younger
counterparts, older adults recover more quickly from negative emotional states,
are more positive, report superior emotional control, and exhibit less
physiological arousal when experiencing negative emotions. This is a ‘paradox of aging.’
Despite age-related losses in function,
well-being remains surprisingly high in old age. Socioemotional
selectivity theory proposes that people prioritize well-being as their life
time horizons shorten. Thus aging
is associated with increased motivation to maintain emotional balance and as a
consequence more cognitive and social resources are allocated to the regulation
of emotion. Indeed, Samanez-Larkin
et al. (2009) cite recent studies that have found that older adults selectively
attend to positive stimuli and are more likely to retrieve positive memories than
negative ones. They call this the
“positivity effect” (p. 519), which they describe as a motivated shift from a
preference for negative information in younger adults to a preference for
positive information at older ages.
At the same time it has been suggested while older people appear to
deploy resources in favor of positive material, when cognitive load becomes too
great or requires the processing of both positive and negative stimulation the
positivity effect disappears.
To explore these theories within the
context of neural functioning, they devised a study utilizing
neuroimaging to examine selective attention to emotional stimuli in older
adults as they were exposed to lexical, or associated word, tasks. The goal was to use both behavioral and
neural measures of interference to examine age differences in the ability to
apply selective attention. A
primary task included making an emotional categorical judgment as a control,
which was then modified to supply interference that was imposed by
incongruent (positive-negative)
word juxtapositions. The subjects
were scanned during these tasks by an MRI of the prefrontal region of the
brain.
The
results suggested that older adults are at least as able as younger adults to
selectively process and successfully inhibit both negative and positive stimuli
when the task demanded it. Older
adults had more difficulty with nonemotional tasks where interference was applied
than younger adults had. The
findings for younger adults were reversed.
III. Roles of Therapists/Treatment Modalities
Yorgason
et al. (2009) recently undertook a study of therapists’ training in later life
issues, and their knowledge and attitudes towards aging. While there are indications in the
literature that specific training in elder issues is appropriate to treating
that population, training about aging issues in MFT graduate programs is
typically optional. Students are
required by accredited institutions to take course work in the areas of “’human
development, family dynamics, systemic thinking, interactional theories,
traditional and contemporary marriage and family therapy theories, research,
and the cultural context in which they are embedded’ [citation omitted], yet
students may still earn graduate degrees without having taken classes specific
to later life ” (Yorgason et al., 2009, pps. 30-31). Marriage and family therapists do not receive training in
this subspecialty unless by coincidence or choice they take optional courses. This reflects “ageism” within the
profession (Butler, 1989). In order
to dispel it, Butler proposes that MHP’s must gain an experiential and not just
an intellectual knowledge of the circumstances of these older persons.
Yorgason
et al. (2009) conducted a web based interview by questionnaire of 191 clinicians. Since participation was voluntary, those
already having some sensitivity and interest in aging were more likely to be
respondents. Their findings
suggest the following:
·
40%
reported that they agreed or agreed strongly that their training had prepared
them to work with older adults and their families, but 60 % reported they were
neutral or disagreed or strongly disagreed that their training had prepared
them very well. The majority
reported having at least some training in aging issues, but they did not feel
that training had prepared them well to work with older adults.
·
Those
who reported taking four or more courses (in or after school) felt
significantly more competent than those who had taken fewer than four. This training appeared linked to the
perceived competence and the interest levels of those working with older
adults.
·
Generally
the respondents seemed to be informed about sexuality norms, work and volunteer
involvement, disability/activity levels, and general physical health declines
in later life.
·
A
bias score coupled with a knowledge score suggested some knowledge by
clinicians of age related issues and a positive bias of older adults in the
aging process.
·
Attitudes
revealed in examining responses to two vignettes suggested that all respondents
felt neutral to comfortable in working with older adults, with 60 percent
feeling “very comfortable.”
However, comfort levels were significantly higher in working with
younger clients, and scores indicated less comfort in working with an aging
mother as opposed to an older father.
Contrary
to what is most commonly reported in the literature in terms of the common
theoretical approaches to treating elderly clients (family life cycle;
contextual family therapy; and the strength-vulnerability model), Yorgason et
al. (2009) noted that the respondents in this study reported utilizing the
following techniques:
·
Solution
focused therapy
·
The
lengthened engagement or joining process
·
Psychoeducation
·
Listening,
life review and reminiscence
They
list differences between older and younger clients that provide some insight
into working with older adults.
First, older and younger persons face different developmental challenges;
second, wisdom that comes with age can be beneficial in solving practical life
problems; third, a slower joining process might be appropriate with older
adults; fourth, older adults may be more invested than younger adults in the
therapeutic process; and five, the therapeutic process may be of shorter
duration than for younger adults.
The authors conclude, “[t] hese tendencies may be due to a limited sense
of time left in left, and in being selective in how resources are employed” (p.
42).
Weiss
(1995) discusses life review as a therapy that is particularly useful to
therapists treating aging clients.
Its purpose is to provide the individual with a means for the successful
integration of experiences, which offers the possibility of adaptive change
that “injects new meaning into an individual’s life” (p. 170). It involves reminiscence and has the
advantage that it is more appealing and less threatening for many older adults
than conventional counseling interventions. Weiss (1995) proposes it together with cognitive therapy.
Conclusion
Given
current demographics aging is bound to become an issue that MHP’s will live
with, no pun intended, on a regular basis in their practices. Yet aging has received underwhelming
attention by way of the literature and studies relative to other stages of the
lifecycle. A number of approaches
have been developed that are relevant to these individuals and the family system responses to these
transitions. It is an area that
requires training and desensitization in terms of the existential and other
biases that sometimes impact the attitudes of clinicians and others.
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