Working relationally with clients living with a neurodegenerative disorder

Dr. Helen Nicholas

Dr. Helen Nicholas

The book, Ageing with Grace, by David Snowdon was an inspiration for me when I began research with older adults diagnosed with a neurodegenerative disorder.  The question, Why do some people go on to develop dementia, whilst others don’t?, is one that many researchers have attempted to answer over the years. Despite all the findings so far, and vast amounts of research into biomarkers and genetics, the answers or potential causes remain unclear. When thinking about potential factors, some psychologists, like myself, turn to personality and to levels of social activity. Personality is fairly stable over the life time so studying what individuals were like in their 40s – before the onset of the disease – can give us a clue to these potential protective factors. By identifying certain key personality features that are associated with Alzheimer’s disease (AD) may identify clients for whom early intervention is appropriate. This could include premorbid information on social variables, such as the number of close friends and levels of social, and physical engagement. Preventative measures are key to tackling this progressive, degenerative disease. Indeed, much of the work carried out by counselling psychologists with people living with a neurodegenerative disorder ranges over the progression of the disease, from preventative measures to diagnosis and life after diagnosis.

Reflecting on my work as a young psychologist within a memory clinic and older adult service, I seem to recall the brevity of the assessment sessions. After the initial history taking, I conducted a battery of psychometric tests to confirm the suspected diagnosis of AD. The psychiatrist would then talk to the client and carer about the future and appropriate medication that could slow the progression down. The client and carer, their suspicions also unfortunately confirmed, would look puzzled, confused and worried. This was one of the difficult parts of my clinical work. I now advocate for follow up sessions, where counselling psychologists work closely with the client and carer providing therapeutic interventions to help them both cope and come to terms with their future, and to focus more on quality of life rather than the progression of the disease.

Within counselling psychology, the therapeutic relationship and relational focus is a key part of our training and professional work. We are highly skilled to understand the biological/neurological, cognitive and interpersonal/relational aspects of human functioning. A strong relational element when discussing memory difficulties, the progression of the disease and what the future may hold is important and necessary. The relational dimension is not often explored in the current mainstream literature on AD. Focus tends to be on the assessment and diagnosis, some focusing on behaviour that challenges and the psychological and behavioural symptoms of AD. As well as offering practical support, counselling psychologists can use empathy to engage with the world of the client. A skill that requires the psychologist to be with the client rather than to do to and it requires the psychologist to enter into the world of the client with a neurodegenerative disorder on the basis of their understanding and experience. This may help the client and carer to elucidate their own experience as valid and valuable, thus promoting a non-judgmental, and non-pathologising stance. Alongside the appropriate assessment(s) and battery of psychometric test, it is important to think about alternative or co-existing explanations to support individuals with their behaviour. I will present a clinical case to illustrate how the therapeutic relationship and understanding of the historic, and personal background of the client was essential in reducing his negative reactions to staff.

Mr. Davies, a 73-year-old gentleman diagnosed with an intellectual disability, was referred to the psychology department as he became more agitated on the hospital ward. The ward staff were concerned that he was developing dementia and requested a formal assessment. A holistic assessment was conducted, by supporting Mr. Davies to tell his story, understanding how important his independence was for him, and helping him come up with solutions on how he can express his needs more appropriately, was key to the success of him regulating his emotions more effectively.

Working relationally with Mr. Davies was crucial in engaging in his narrative and life story. We worked collaboratively to identify some particular situations that seemed to trigger his anger and irritation at staff and other clients on the ward. Our work incorporated educating staff about his needs, wishes and values. For example, when staff locked the cupboard where the tea bags were stored, Mr. Davies worried that he would not be able to make himself a cup of tea. These thoughts lead him to believe that he needed to hoard the tea bags. He became skilled at knowing when the cupboard was unlocked, and when caught was reprimanded by staff causing him to become defensive, angry and verbally abusive.

The team agreed to provide Mr. Davies with tea making facilities in his own room. By understanding his deprived background through the life and social story work we completed, the ward staff were better able to carry out their roles in a more supportive and person-centred way with Mr. Davies. The incidents of agitation reduced significantly and he was able to relate better to the staff by learning more appropriate ways of communicating his needs. Mr. Davies and I worked on a variety of social stories over the years, supporting him in personal hygiene difficulties and establishing routines that he felt more comfortable with. We formed a strong therapeutic relationship. I believe that without the relational element, Mr. Davies would not have felt comfortable with some of the work that we did together and this foundation supported him in forming further meaningful relationships with ward staff and friendships with clients on the ward. 

Typically, counselling psychologists work closely with teams and professional colleagues such as, occupational therapists, physiotherapists, dieticians, speech and language therapists and social workers to ensure the needs of clients are met. Working collaboratively, carrying out a comprehensive psychological assessment, often including psychometric testing and formulating a treatment plan for each client provides a clear and concise person-centred pathway to wellbeing and recovery. Counselling psychologists are well suited to providing useful and valuable in-house training on a variety of topics and through consultation are able to contribute to care plans. Multi-disciplinary team working provides unique opportunities for all staff to discuss the client’s difficulties and to express their views on how to help make the client’s experience and quality of life better. We are also uniquely skilled in working relationally with clients with neurodegenerative diseases, as well as carrying out the more diagnosis-based assessments. I think a combination of the two is important to fully understand the client and the impact of the disease on their quality of life.


About the author:

Dr. Helen Nicholas is an HCPC registered practitioner psychologist, BPS chartered psychologist, and senior lecturer at the University of Worcester, United Kingdom. Helen holds a Doctorate (PsychD) in psychotherapeutic and counselling psychology from the University of Surrey and works in academia, as well as a independent practice. She is the current chair of the British Psychological Society (BPS), Division of Counselling Psychology (DCoP) and has held a variety of voluntary positions in the BPS and DCoP over the years. Helen specialises in working over the lifespan with adolescents, adults and older adults and has a particular interest in depression, anxiety, trauma (EMDR) and neurodegenerative diseases. Helen has published in the field of Alzheimer’s disease, Dementia, Personality traits, work-life balance and counselling psychology, and is committed to the discipline as both researcher and a practitioner. Helen has a wide range of experience working in settings such as the NHS, Adult mental health, Old age psychiatry, research, the voluntary sector, in private hospitals, and in academia.

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The Intersection of Ageism and Health Status

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Shannon Patterson, M.Ed.

By Shannon Patterson, M.Ed.

Dr. Robert Butler first used the term “ageism” in 1969 to describe a type of bigotry displayed by middle-aged adults toward older adults in a public housing setting; later, it was defined as “a process of systematic stereotyping of and discrimination against people because they are old” (Butler, 1975). Ageism is referred to as the third great ism within the United States, following racism and sexism. It differs from the other “isms” in that: 1) everyone may become a target of ageism if they live long enough, and 2) people often deny, or are unaware of their ageist attitudes because it is a newer and more subtle concept (Palmore, 2004). Further, the multiple dimensions of ageism make it easier for us to unknowingly engage in behaviors that may threaten the autonomy of the older adults with whom we work.

We are largely familiar with the concept of ageism and research demonstrating the detrimental influence it has on both the mental and physical health of older adults. However, fewer of us may be aware of the ways in which our clients’ health statuses may interact with their age to produce bias in the counseling relationship. “Healthism” (Gekoski & Knox, 1990) is a term used to describe negative attitudes and stereotypes toward individuals in poor health or with visible chronic health conditions. Research indicates that bias toward an individual’s visible health status may accompany and even amplify ageism to produce ageist attitudes and behaviors toward older adults within the context of a counseling relationship (Messier, 1998; Patterson & Caskie, 2015). As clinicians who are taught to conceptualize our clients using a multicultural framework, we would label this as intersectionality.

The early introduction of the concept of intersectionality within my graduate program contributed to my understanding of the unique ways in which older adults may be oppressed by their visible health status and gender. For instance, I learned that older women are more likely to be the target of patronizing talk in long-term care settings, and that this may be further exacerbated by a visible chronic health condition or “frailty” (Nussbaum, Pitts, Huber, Krieger, & Ohs, 2005). My experience working as a certified nursing assistant (CNA) prior to my graduate training exposed me to this communication style. As my self-awareness grew during my time as a counseling psychology trainee in a nursing home, I noticed my own communication tendencies. For example, my voice became louder and slower when interacting with older adults, regardless of whether or not I knew they were hearing impaired. I also observed the language and voice intonation that nursing home employees used when talking to residents with severe visible health conditions.Why hello there, young lady; hi sweetie!” I began to realize that the actions in which I engaged without hesitation as a CNA—such as, offering to do tasks for my clients with visible chronic health conditions to save time for both of us—maintained the efficiency of my previous routine, but inadvertently decreased my respect for their autonomy. Further, as a novice trainee, my positive ageist attitudes (i.e., “They’re older, so they’re wiser—who am I to question their belief?”) often prevented me from challenging my clients.

Those of us who have served older adults in other capacities must be aware of the ways that these experiences may shape our own negative and positive biases in addition to influencing the way we conduct psychotherapy.  As professionals who choose to work with older adults, we are not likely offenders for traditional displays of negative ageist attitudes and behaviors; however, the intersection our clients’ physical health vulnerabilities and advancing age may increase the likelihood of us displaying more subtle behaviors that hinder our clients’ self-efficacy, self-esteem, and personal growth.  As counseling psychologists, we are uniquely prepared to address this dynamic in our psychotherapy sessions and at the systemic level within the organizations in which we work and study.  Our age and, quite possibly, our health statuses are demographic variables that change over our lifetime. We are fortunate to be members of a profession that encourages us to reflect on the ways in which our changing demographics can positively influence the therapeutic process and our clinical presence.


References

  • Butler, R.N (1969). Ageism: Another form of bigotry. The Gerontologist, 9, 243-246.
  • Butler R.N. (1975). Why survive? Being old in America. Harper & Row, New York.
  • Gekoski, W.L., & Knox, J. (1990). Ageism or Healthism? Perceptions based on age and health status. Journal of Aging and Health, 2(1), 15-27.
  • Messier, S.H. (1998). Ageism and healthism in diagnosis and prognosis by practicing psychologists: An analogue study. Dissertation Abstracts International: Section B: The Sciences and Engineering, 58(9-B).
  • Nussbaum, J. F., Pitts, M. J., Huber, F. N., Krieger, J. L. R., & Ohs, J. E. (2005). Ageism and ageist language across the life span: Intimate relationships and non-intimate interactions. Journal of Social Issues, 61(2), 287–305. doi:10.1111/j.1540-4560.2005.00406.x
  • Palmore, E.B. (2004). Research note: Ageism in Canada and the United States. Journal of Cross-Cultural Gerontology, 19, 41-46.
  • Patterson, S., & Caskie, G. (2015). Client Health Status as a Moderator of Relations between Trainee Personal Characteristics, Ageism, and Clinical Bias.  Paper presented at the 2015 Gerontological Society of America’s Annual Scientific Meeting, Orlando, FL.

About the Author

Shannon Patterson is a counseling psychology doctoral candidate at Lehigh University and alumna of University of Wisconsin-Madison.  She will be completing her pre-doctoral internship in Health Psychology at the Phoenix VA Health Care System during the 2016-2017 training year. Shannon currently serves as the student representative for Psychologists in Long-Term Care (PLTC), and looks forward to continuing to unite her interests in Geropsychology and Health Psychology in professional practice.

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Counseling psychology, culturally-sensitive practice, and the unique variable of aging

By Abby N. Altman, Ph.D.Altman.Picture.2.16

When interviewing for graduate school I frequently answered the question, “Why counseling psychology and not clinical psychology?” Given my doubts about what the interviewers were looking for in a response, and uncertainty about my interests and fit within the field of psychology, I struggled with a reply.

In my graduate program, I was unique among my peers in that I desired hospital placements and older adult experiences (vs. college counseling centers). Due to this distinctiveness, the “why counseling psychology?” question emerged again during internship interviews.  At this time, I felt more prepared and confident with my reply. My appreciation had grown for what counseling psychology had to offer, including its tenants of practicing cultural sensitivity and facilitating personal and interpersonal functioning across the life span. This fully resonated with my conceptualization of individuals and their struggles.

I appreciate counseling psychology for its encouragement of critical thinking, including thinking about how multiculturalism is understood and identified. During my diversity training, I found age to be a unique variable; this was something I explored clinically and in my research.  What always stood out was how we are not born into being “old”, but we grow into it. Aging is universally experienced, but in many ways not fully understood. At times, people avoid the topic of aging in discussion or self-reflection, given some of the negative impressions they have about it.  As Kelly Martincin stated in her blog entry about greeting cards as potential microaggressions, jokes about getting old are a regular part of conversation.  Also, they represent one way we relate to aging milestones.  Similar to last month’s blog entry, also penned by Kelly Martincin, how could we be culturally sensitive to a variable that is inconsistently included in personal and clinical conceptualizations of multiculturalism?

People no longer ask me, “Why counseling psychology?” Rather, people now ask, “Why older adults?” When answering, I frequently reflect on my journey. I see geropsychology as the “little engine that could.” It is growing in speed, but it has not quite arrived. More programs have Geropsychology tracks; and, there are graduate programs and fellowships in Geropsychology. There are also opportunities for re-specialization and mentorship, including the Division 17 OA-SIG mentorship program. For more information about the traditional mentorship program that links students with mentors, contact Aarika White at draarikawhite@gmail.com. For more information about the mentorship program focused on professionals who are re-specializing in Geropsychology, contact me at analtman@partners.org.

I do not mind people asking questions about my career choices, including the sub-field and the population with whom I choose to work. By asking these questions, it tells me that people are curious about what they do not know. And, they want to learn more about working with folks across the lifespan. I am excited by that- it helps “the little geropsychology engine that could” travel a bit closer to the station.


About the Author

Dr. Abby Altman is a licensed psychologist and geropsychologist currently working as an Associate Psychologist and Associate Director of Psychology Education at Brigham and Women’s Hospital- Department of Psychiatry. She is a full-time clinician in the Cognitive Behavioral Therapy (CBT) program and is the co-director of the Brigham Psychiatric Specialties’ Geriatric clinic. She is appointed at the level of Instructor at Harvard Medical School.

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My grandfather’s stories and lessons in multiculturalism

Martincin-Kelly      By Kelly Martincin, M.A.

Over the holidays, I visited my grandparents and had the opportunity to give my grandfather a ride in my new car. I’m putting the finishing touches on my PhD and earning a livable wage for the first time in my life. So, by “new” I mean used, but unlike my old car, this one has its original transmission and an odometer reading that won’t give my grandfather heart palpitations. As I proudly showed Grandpa all the nice features, he “oohed” and “aahed” attentively, but the conversation quickly turned from gas mileage and horsepower to his earliest memories of being a young boy in a time when cars were still somewhat novel. He was a child in the late 1920s and early 1930s. In his small, farming community, many of the more well-off families had cars, but some of the more hard-pressed families did not even have running water. He fondly reflected on becoming a young man and finally having a vehicle of his own, and told me about various cars he’d owned over the years, noting how each improved the quality of life for the family or prosperity of the farm.

I’ve always enjoyed my grandfather’s stories, primarily because each tends to make me reflect on my own in life in a profoundly different way, and his stories of cars and trucks over the years were no different. He and I clearly have different views about transportation and the meaning of cars in our lives, and we grew up in very different environments. I began to reflect on age as a facet of multiculturalism. The man sitting next to me enjoying my new heated seats provided a significant portion of my DNA and was an integral part of my upbringing. Despite these commonalities, we have dramatically different worldviews. When one considers the definition of multiculturalism, most would define the terms as “relating to or of many cultures“, and “culture” as “the beliefs and customs of a particular group.” Despite being direct relatives and having so much in common, our beliefs and customs related to many things are vastly different, and when considered in that light, age is clearly an aspect of multiculturalism.

When one peruses a search engine for scholarly literature on age as a facet of multiculturalism, it’s hard to find any articles. Why is age less commonly studied than other aspects of multiculturalism? Perhaps it is because many different people will become old, and with the nation’s largest age cohort crossing into older adulthood, many do not consider older adults to be special or different in any way. I clearly argue otherwise, and would encourage others to acknowledge age as ubiquitous diversity factor, one that demands our attention.

First, older adults are included in every other category of diversity – ethnicity, sexual preference, religious preference, disability status, and more. Growing up in age that was, in many ways, less accepting of differences, they have unique experiences and worldviews from people who face similar challenges related to diversity today. Intersectionality of age and other diversity factors (e.g. ethnicity or sexual preference) can have profound impact on the lives of many people, and should be more thoroughly addressed in scholarly literature.

Another point to consider is that older adults are an at-risk population for many reasons. They are more likely to have complex medical problems, and more likely than any other group to be experiencing cognitive decline. In the United States alone, 13 to 15 million people have conditions that impair cognitive function (Whitlatch, 2008), and most of these people are older adults.   Alzheimer’s disease (AD), which is the most common kind of dementia, affects approximately 5.2 million Americans. By 2050, this number is estimated to be 13.8 million Americans. Currently, 11% of people over the age of 65 and up to 32% of people who are over the age of 85 suffer from AD (Alzheimer’s Association, 2014). While AD is the most common form of dementia, it is still only one kind, so there are millions more individuals suffering from other forms of dementia. There is evidence that the rates of dementia will double every five years once an individual reaches age 60 (Krishnan et al., 2005). Also of concern, many elderly individuals live on a very limited income. Without Social Security, 43.6% of older adults would live in poverty. Even with this assistance, 8.7% still live below the poverty line, putting them at risk for hunger, homelessness, and limited access to adequate healthcare (Center for Budget and Policy Priorities, 2012). All of these considerations make the lack of available literature on this topic alarming.

With these concerns in mind, it is easy to make the argument that insufficient attention is paid to older adults when it comes to better understanding their experiences and worldviews. Age should be considered as an equal aspect of diversity and receive the same academic consideration as other facets. My grandfather would agree that he and I have formed our worldviews and personalities in very different time periods. Despite the many commonalities we share, we are not the same, and these differences should be respected and better understood. He’d also be happy to tell you stories about his cars over the years, should you want to stop by.

 

References

Alzheimer’s Association (2014). 2014 Alzheimer’s Disease Facts and Figures. Retrieved from http://www.alz.org/downloads/Facts_Figures_2014.pdf

Van de Water, P. N. & Sherman, A. (2012). Social Security Keeps 21 Million Americans Out of Poverty: A State-By-State Analysis. Center for Budget and Policy Priorities. Retrieved from http://www.cbpp.org//sites/default/files/atoms/files/10-16-12ss.pdf.

Krishnan, L. L., Petersen, N. J., Snow, A. L., Cully, J. A., Schultz, P. E., Graham, D. P., … Kunik, M. E. (2005). Prevalence of dementia among Veterans Affairs medical care system users. Dementia and Geriatric Cognitive Disorders, 20, 245-253. doi: 10.1159/000087345

Whitlatch, C. (2008). Informal caregivers: Communication and decision making. American Journal of Nursing, 108, 73-77.


About the Author: 

Kelly Martincin is a post-doctoral fellow at the Cleveland Clinic’s Chronic Pain Rehabilitation Program. She received her master’s and doctoral training at Cleveland State University, and her undergraduate education from Ohio Dominican University. She currently serves as the Div. 17 OA SIG Membership Coordinator, and previously served as student representative for this group.

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You Want to Work Where? Becoming a Counseling Psychologist in Long-Term Care

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Mary Lewis, Ph.D., ABPP

In the late 80’s, my first job in high school was washing dishes in the kitchen of a long-term care facility in rural Kansas. My mother worked at the facility at a STNA, and often told stories about the residents — stories that made me smile and laugh, and stories that made me incredibly sad. When I went to the facility for my job, I saw so much sadness, loneliness, and isolation, but also moments of joy between residents and staff.

A younger resident named Kenny (not his real name) befriended me and often came into the lunch room for coffee. He talked to me while I was on break and shared stories from his life “before” the nursing home. During this time I realized what amazing stories were within each person at the facility, and that if I only had the time to sit down with each resident, I could learn so much. Although Kenny died while I was an undergraduate, I will never forget his stories and wisdom. The more time I spent with him and the other residents of the facility, the more I realized how great the need was for emotional and social services. I already knew that I was going to become a psychologist, but Kenny (and the other residents) solidified my decision that working with older adults in long-term care settings would be the place that my passion and career would find the most impact and joy.

Unfortunately, when I went to graduate school, most of my colleagues were puzzled by my choice of practice location. Most Counseling Psychology students that I knew wanted to work in clinical practice were choosing college counseling centers or private practice with adults or children. I often heard – not just from colleagues, but also from friends and family – “You want to work where? Isn’t that depressing?” There was little understanding about work with older adults in the counseling psychology field, and even less understanding about the long-term care setting.

Less than 4% of older adults live in long-term care settings, which sounds like a very small number of older adults. However, when broken down by age, this is 1.1% for those aged 65-74, 3% for those aged 75-84 and 11% for those over the age of 85 (Administration on Aging U.S. Department of Health and Human Services, 2012). These numbers do not include the 2.7% of older adults living in senior housing that has at least one type of supportive service available (Administration on Aging U.S. Department of Health and Human Services, 2012). Statistics indicate that large numbers of long-term care residents struggle with a mental illness such as dementia (58%; Seitz, Purandare, & Conn, 2010) and depression (10% with major depressive disorder and 29% with depressive symptoms; CDC, 2013; Seitz et al., 2010). Anxiety disorders, bipolar disorder, personality disorders, and other mental health conditions are also frequently seen in long term care settings. Despite these numbers and the fact that close to 90% (86.6%; CDC, 2013) of nursing homes offer mental health or counseling services, few psychologists choose to practice in long-term care settings. Of those who do practice, the majority are from clinical psychology programs.

Why should Counseling Psychologists work in long-term care settings? Although in the licensure world there is no distinction made between counseling and clinical psychology, and the differences between the fields have shrunk, the history and training in the two programs have differences. The two notable differences are adaptation across the life-span approach and the focus on strength-based interventions (APA Division 17; http://www.div17.org/about-cp/counseling-vs-clinical-psychology/). These two pieces of Counseling Psychology fit quite well with Geropsychology, as a robust number of older adults are healthy and focused on adaptive coping to late-life concerns, such as grief, retirement, grandparenting, and aging in place.

In my own work in long-term care, a place where it could be easy to solely focus on loss and sadness (e.g., the stereotype that work in nursing homes is “depressing”), I appreciated the training that helped me focus on client strengths, adaptations over the life-span, and coping strategies that allow them to navigate the challenges within the long-term care setting. My counseling background prepared me to work with the family systems that function within the LTC setting (both biological families and the family systems that staff form), as well as the multiple diverse identities, roles and concerns with older clients. The field of Geropsychology in long-term care settings is rapidly growing, and we are facing a workforce shortage – one that Counseling Psychologists could fill. The long-term care work setting is a varied setting that can include work with younger residents who face chronic emotional or physical disabilities, neuropsychological assessment, health and behavior interventions, and staff training/in-services, to name a few.

My work is not depressing, although it can be challenging. I learn so much from my clients; life-long wisdom, profound resiliency and strength, hope and joy. I am truly humbled by the trust and life stories that they share with me, as well as the fact that my clients are willing to let me in a space where they have lost almost everything. The change I can engender with my clients is profound, particularly given the challenging environment and situation. Rather than asking, “Why would you work in long-term care?” the question should be, “Why wouldn’t you work in long-term care?” If you enjoy a challenge, have a passion for social advocacy and systems work, and love meaningful engagement with underserved populations, then the long-term care setting is for you!

For more information, visit these websites:

Gerocentral

Psychologists in Long Term Care (PLTC)

APA Office on Aging


 

About the Author

Mary M. Lewis, Ph.D., ABPP is a tenure-track instructor in the Psychology Department at Columbus State Community College, and leads their Service-Learning Program for the Human Growth and Development Across the Life-Span course. She also is a licensed psychologist and provides counseling and assessments to long-term care and nursing home residents with Senior Life Consultants, Inc. Dr. Lewis is the chair of the Ohio Psychological Association Science Committee, Past-President of Psychologists in Long-Term Care (2011-2013) and a member of the American Psychological Association, APA Divisions 17, 12/II, 20, and 31. Her professional and research interests include social responsibility and social justice issues, end-of-life concerns for individuals with dementia, mental health and aging, and spirituality. You can contact her at marylewisphd@gmail.com

The Sounds of Silence: How My Listening Improved After My Hearing Declined

By Frederick Lopez, Ph.D.

I came of age in the 1960s, so it is with some nostalgia that I borrow from a then-popular album by Paul Simon and Art Garfunkel – the Sounds of Silence — to help title my blog. Although I will not “officially” enter the ranks of older adults until later this academic year when I celebrate my 65th birthday, over the past few years, the reality of my own aging has become increasingly self-evident. In particular, during this time, I became painfully aware that my hearing had substantially declined. Losing that capacity is difficult for anyone, but especially so, if your work, like mine, requires regular and sustained conversations with others. I already knew from my professional reading that 1 in 4 Americans between 65 and 74 years of age has a significant and disabling hearing impairment … but I didn’t want to be part of that statistic…was I already an older adult?

During the early stages of my hearing loss, I learned to compensate by paying more careful attention to others’ non-verbal behaviors, such as their lip and eye movements, as well as to those fragments of their sounds that I could discern, in order to determine if they had just asked me a question or made a declarative statement, and then to make my best guess as to what it was. More times than not, I found myself hoping that what I had just heard was a simple declarative comment that, even if completely undecipherable to my failing ears, would require no more than an “approving” head nod response (followed by some rapid private cognition as to how I could gracefully exit the conversation as soon as possible). In short, my listening became more deliberate and effortful, and I got pretty good at often correctly surmising the gist of what I was hearing; however, I also knew that, with each new conversation, with each new utterance, the odds of my misreading someone’s communication were increasing. Family members had already made repeated note of my hearing deficit and urged me to get hearing aids, but I resisted, unwilling (or, perhaps better said, unready) to accept my loss. Yet, slowly, the growing sounds of silence in my daily life began redirecting my effortful listening, not to others, but inwardly, to the voice of my own ambivalence…

The turning point occurred this past summer when I visited my daughter, son-in-law, and my two grandchildren at their home in Florida. Toward the end of that visit, my four-year-old grandson, Isaac, excitedly rushed up to me while I was relaxing on the living room sofa. He looked very intent on telling me something important, and, at first, he positioned his face only a few inches from my own. But then, just as quickly, he broke eye contact (depriving me of my visual cues) and he began making low, soft sounds while fixing this gaze on a small toy he held in his hands. I couldn’t make out a single word he was saying. After a few more seconds, he stopped and looked up expectantly to me for some kind of response. My heart sank as I had no idea how to respond. I tried the “approving head nod” strategy in the hopes of keeping him engaged, but it didn’t work … Isaac looked momentarily puzzled and then scampered off to start a conversation with someone else. And then it hit me … unless I accepted my loss and my need for hearing aids, I was jeopardizing my relationship with my grandson … I would not be able to understand him … and he would not come to know me as someone who did.


About the Author

Frederick G. Lopez is a Professor in the Counseling Psychology Program at the University of Houston.  His research has generally focused on the study of how attachment relationships (i.e., relationships with parents and intimate peers) influence the psychosocial adjustment and development of adolescents and young adults.  However, more recently, he is extending attachment theory to the study of older adults and working with one of his former students to develop and validate a self-report measure of attachment security that is appropriate for this population.

Research with Korean Immigrant Elders

Na-Yeun Choi

Na-Yeun Choi

By Na-Yeun Choi, M.A.

2015 APA Division 17 Older Adult Special Interest Group (OASIG) Student Award Winner

My experiences of living in the U.S. have shaped who I am as a first-generation, Korean immigrant woman. Since moving here, I have explored and negotiated identities from two countries with different cultural values. My experiences living and working in a second language and culture have also influenced me. My unique identity in-between cultures provided me with a unique lens to empathize with people who feel voiceless, especially the Korean immigrant older adult population.

My experience as an ethnic minority led to my strong interest in raising awareness around health and mental health disparities among different racial/ethnic and age groups. This interest guided my clinical practice in outreach seminars for Korean elders at the Korean Senior Center of Ellicott City, MD. I developed three-day workshops to normalize experiences of cultural and social difficulties facing Korean elders (e.g., family conflict, isolation, loneliness, loss and grief, difficulty speaking in English, and discrimination) and provided culturally appropriate, CBT-based coping strategies. This project was meaningful, but heartbreaking at the same time. I saw the elders’ nodding heads and tearful eyes while we talked about how they didn’t want to burden their children due to concern that their immigrant lives were already challenging enough. Also, I recognized my privilege that I don’t have to worry about getting a ride from one place to the other, finding cultural entertainment that I can enjoy, and communicating with doctors about my symptoms.

My research has involved understanding racial and ethnic minority elders’ experience and providing them with culturally sensitive/adaptive treatment. At the University of Maryland, I am conducting a qualitative research project investigating: 1) Korean elders’ adjustment process to the U.S., and 2) Korean elders’ physical and mental health care utilization, conducted in a community-based adult day care center in Columbia, MD. I was struck by their need for mental health care in the face of the limited resources available to them. Interviewing Korean grandmothers and grandfathers was a humbling experience. The elders were thankful to our research team just for providing them a space to talk about their immigrant life stories and health-related concerns. At the end of the interviews, it was difficult to face our failure to address ongoing needs related to their cultural and aging experiences and not having adequate mental health referrals when requested.

Based on identified community needs, our research team believed that developing video interventions in Korean might be the best way to reach Korean elders in the U.S. I am currently working with colleagues at the Culture, Race and Health Lab at the University of Maryland, led by Dr. Matthew J. Miller, in developing a culturally and ecologically valid intervention for Korean elders. I played the role of mental health expert by providing information about depression in Korean, normalizing culturally specific experiences in the video recording. Also, I interviewed community leaders and Koran elders in Korean, so their voice can be heard by the larger U.S. community. As a future counseling psychologist, I feel personal responsibility to increase access to health and mental health care for Korean elders. In the future, I plan to continue developing interventions that address their needs in a culturally and ecologically valid way, and hope to examine the efficacy of these interventions.


About the Author

Na-Yeun Choi is a doctoral candidate in counseling psychology at the University of Maryland and a pre-doctoral intern at the University of Maryland Counseling Center. Her research includes the investigation of three key areas: (a) exploring the impact of cultural racial factors on individuals’ mental health and their decision to utilize mental health services; (b) examining understanding multicultural counseling and measuring multicultural supervision; and (c) developing and providing culturally adaptive and sensitive treatment to racial and ethnic minorities in underserved communities. Currently, she is interested in understanding the Korean Elders’ acculturation experiences and their attitudes about seeking medical and mental health services.

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