This briefing identifies and explores barriers to older people accessing talking therapies, considers the value of therapy through later life transitions, the importance of autonomy and choice in making talking therapy accessible to older adults and includes contributions from clients at the counselling services at Sheffield Mind and Life Link in Glasgow.

Background

Increases in life expectancy, and patterns in birth rates over time are contributing to a rise in the average age of the UK population. By the year 2066, the proportion of the population aged 65 and over is predicted to rise to 26%, compared to just 15.8% in the early 1990s1.

The baby boomer generation, born after the Second World War, has been identified as reshaping the life-stages they move through. Credited with inventing the teenager, redefining middle-age and now re-shaping the retirement years2, this generation brings expectations and experiences that differ enormously from those of their parents and grandparents when they were in later life.

Definitions of old are contentious. As a social rather than biological construct, it is fraught with contradictions, exceptions and risks of stereotyping and reducing the challenge of understanding complex circumstances and experiences into a simple chronological marker.

For the purpose of its older people workstream, BACP focuses on the role of counselling in supporting people through the life events which happen more commonly around the age of 50 and beyond, while recognising that there are enormous variations and diversity within this significant proportion of the UK population.

Later life brings distinct challenges that can test resilience and contribute to the onset of distress or mental health problems or may trigger recurrence of existing or previous problems. These are events and transitions that can happen at any age but are more common from age 50 onwards and can be disruptive.

Ageing matters

Across our lifespan we adapt to changes and life transitions that shape our identity and our roles in family, work and wider society. Some of these are the result of our choices, while others are beyond our control.

Increasing numbers of older workers are providing care, juggling the demands of work with meeting the physical, emotional and financial needs of elderly parents. One in four female workers and one in eight male workers have caring responsibilities3.

Awareness is also increasing of the numbers of people who are ageing without children and the impact that this has on the levels of informal care available, as well as the impact that the absence of this familial contact and support has on mental health and wellbeing.

It is estimated there are more than one million people in the UK over the age of 65 without children, and that this number is set to double by the year 20304. Behind these numbers lies a demographic with diverse experiences, including people who have chosen not to have children, those who wanted children but whose circumstances prevented them, those predeceased by children and others who have become estranged.

Retiring from work may bring a significant shift in our sense of purpose, particularly for people whose work is central to their sense of identity. Viewing retirement as a process rather than an event provides opportunity for planning and preparing.

A retiring client who has been valued and respected in their employment, who has found a place for themselves within an organisation or role, built a network of colleagues, felt competent and needed, who has perhaps risen through the ranks of their workplace over many years, is likely to feel that an enormous part of their identity is being stripped away from them. They may feel exposed, lost and unsure what meaning their life now has. If external forces such as ill-health or redundancies have led to retirement, feelings of anger and resentment may also be present in a client’s process.5

The prevalence of long-term conditions rises with age, affecting about 50% of people aged 50, and 80% of those aged 656. The majority of people over the age of 75 live with two or more long term conditions7.

There is evidence to suggest that more people with physical health conditions recover more quickly and are better able to manage their disabilities and symptoms if they have good mental health and wellbeing8, and that mental wellbeing confers protection from infection and disease (Faculty of Public Health, 2010).

As we age, our proximity to death and dying grows. People of any age can suffer from grief and it should not be assumed that bereaved older people require less support than those bereaved at a younger age. Intense loneliness can come from a bereavement and lead to increased isolation and, in time, chronic loneliness.

Our own mortality comes into sharper focus with age. The idea of a ‘good death’, one in which the wishes and preferences of the dying person are known and those bereaved have confidence and find comfort in knowing what to do, relies on a willingness to talk about death and dying. In her book Living Well and Dying Well - Tales of counselling older people, Helen Kewell relates how existential concerns can be brought into the therapy room by clients and that acceptance and exploration of death can be held gently and navigated by tracking and reflecting the individual’s lived experience9.

Older people are at increased risk of loneliness following bereavement, with the loss of a long-term partner presenting a particular risk. In its 2020 report, the Campaign to End Loneliness reviews evidence of psychological interventions and suggests that people with chronic loneliness, which may be part of a complex set of problems or due to difficult life events such as bereavement, can be helped by one-to-one support directly focused on helping them alleviate loneliness using psychological techniques10.

There is growing use of illicit drugs among older adults, with older men at greater risk of developing alcohol and illicit substance use problems than older women. However, older women have a higher risk of developing problems related to the misuse of prescribed and over-the-counter medications11. Only 6 to 7% of high-risk people with substance misuse problems over 60 years of age receive the treatment that they require12.

Counselling and dementia

The number of people living with dementia in the UK is increasing as life expectancy grows. Living with dementia commonly gives rise to feelings of depression, anxiety and loss, as people struggle to adjust to changes in their cognition, behaviour and personality. Studies suggest that prevalence of depression for people with vascular dementia may be 30%, with dementia associated with other conditions increasing the risk of depression to over 40%13.

Counselling has been shown to help people living with dementia to make sense of living with the condition. Author, counsellor and supervisor Danuta Lipinska, who has worked with clients with dementia for many years in the USA and UK, explains how the empathy and positive regard at the core of her person-centred therapy work enables clients with dementia to tell their story with "no pressure on the client to say the right words in the right order or to be smart, logical or even understandable"14. 

Counselling in care homes

There are an estimated 400,000 older people living in care homes in the UK15. Although many people live well within care homes, it is estimated that 60% of those living in residential care have poor mental health16, with an estimated 40% of care home residents living with depression17. Evidence from Australia during the 2020 Covid-19 pandemic found that use of telehealth to access counselling was acceptable to care home residents, contrary to general assumptions about older people being willing and able to use technology18. Further work is needed to increase understanding about how counselling can be made accessible to care home residents.

Accessing therapy in later life

BACP believes that the aim of counselling is to provide opportunity for a person to tell their story, help them to understand themselves better and make positive changes in their life.

The BACP Ethical Framework requires therapists to endeavour to demonstrate equality, value diversity and ensure inclusion for all clients, as well as making reasonable adjustments to overcome barriers to accessibility for any clients wishing to engage with a service19. This is as relevant for age as for any other aspect of the client’s identity.

Research and data analysis indicate that, despite significant prevalence of depression among people aged 65 and over, they are less likely to recognise symptoms of common mental health problems, and those that do are less likely to seek help from family, friends or a healthcare professional20.

Data from the Improving Access to Psychological Therapies (IAPT) programme in England have consistently shown that, despite better average completion and recovery rates for those who receive therapy, uptake of the service is low among older people, with referral rates falling well below the target of 12% of all referrals being for people aged 65 and older21.

BACP analysis of data from a small sample of third sector counselling services across the UK shows that, in services open to all adult ages, service use decreases with age, with only 4.1% of clients being aged 65 and older.

Barriers to counselling

Each client’s route into therapy and expectation of how it will work for them is different. It may come from their own initiative and research, a referral by GP or other healthcare professional, recommendation from a trusted source, or through availability of community or work-based programmes.

Barriers to older people accessing therapy can be attitudinal, structural and practical and will include varying knowledge, familiarity and understanding of what therapy is, attitudes to the concepts and language of mental health, and the willingness of others to suggest or recommend therapy.

The stigma of mental health generally, and reluctance to talk about personal issues that are painful or troubling, can impact on older people of all backgrounds and may have particular resonance in some communities. In her exploration of attitudes towards talking therapies among older African Caribbean women, Helen George found both a deep-rooted cultural norm to "don’t talk your business to people" as well as a fear and distrust of health services and the consequences of being labelled ‘mentally ill’22.

Despite age being a protected characteristic in the Equality Act (2010), ageist attitudes and views remain common in daily life. Advertising promoting anti-ageing products and negative portrayals of older people across all media reinforce the idea that old age is a time of decline and depression and that older people are out of touch and separate from the mainstream. The Royal Society for Public Health reports that one quarter of young adults (18-34 years) believe that it is normal to be unhappy and depressed in old age23.

Counsellors across the UK report a common experience of self-stigma being evident in some older clients. Often sessions begin with a client being apologetic for taking up therapy time that could be given to somebody else, someone more deserving.

The role of GPs is critical in responding to the mental health needs of older adults and in improving access to support services and therapy. But physical health is often prioritised over mental health and the management of depression has been shown to depend on the skills and interest of healthcare professionals rather than on structured approaches24.

Clients' perspectives

I wish I had known more about counselling earlier. I’ve actually got to look at things differently now. I try to get out and mix with other people, try to join clubs and things to take my mind off it, as well. Just to move on.

Rose

Coming to counselling has given me much confidence within myself. In general, I am a much happier person. The counsellor actually made me feel that I was able to cope with my anxiety, giving me coping strategies. Problems with self-confidence came from my childhood, I now look at things in a more clinical way.

Sheila, 74

After two or three sessions, I chose a couple of areas of the things I thought I wanted to talk about that I felt would help me. It was a very reflective time of my life. I consider things more – especially the use of language. I began to self-reflect and look at where I am with my life.

Stuart, 61

Therapy and healthy ageing

BACP's belief that counselling provides opportunity for a person to tell their story and helps them to better understand themselves and make positive changes in their life is not limited by age.

How we view ageing impacts not only the quality of life experienced but alarmingly also its quantity, with those with a positive attitude to ageing estimated to live an average of seven and half years longer than people who view ageing negatively25.

“Human beings are works in progress that mistakenly think they’re finished” says psychologist Daniel Gilbert, whose research has demonstrated that people of all ages consistently underestimate the extent to which their preferences, personalities and circumstances will change in the future26. This suggests that the life transitions we anticipate as we age – the empty nest for those in their 50s with adult children and retirement from work a decade later - will be experienced very differently without fitting with the expectations of our younger selves.

For Helen Kewell, author of Living Well and Dying Well – Tales of counselling older people27 belief in capacity for change underpins her work with clients in their 70s, 80s and 90s. Among the learning from her work, Helen recommends that we resist a wholly medical model in our view of ageing and be prepared to talk about death and enable stories to be told, enabling growth and change as we approach the end of life.

Recommendations

  1. Research is needed to further understand the role of therapy in supporting healthy ageing. Routine data collection and reporting of age profiles by counselling services will contribute to efforts to improve access to talking therapies by people of all ages.

  2. Campaigning and awareness raising of later life emotional wellbeing are needed to reduce barriers to support and to increase later life mental health as a public health priority. Reducing stigma and prejudice of ageing by organisations and services is critical to this aim.

  3. Outreach by third sector counselling providers to older adults can be supported by delivery of age-specific services and through ensuring that advertising and promotion of all-adult services includes messages and imagery inclusive of older adults and does not rely on the language of mental health or assume familiarity with therapy.

  4. Counsellors and psychotherapists are encouraged to explore the value of work with older clients and to ensure that continuous professional development includes knowledge and learning on working with older adults and understanding the challenges and opportunities of later life.

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References

1. Office for National Statistics (2018) Living longer: how our population is ageing and why it matters
2. Fox M (2014) Older people and transitions. BACP Healthcare Counselling and Psychotherapy Journal. Vol 14, No 1.
3. Office for National Statistics (2019) Living Longer: Caring in later working life
4. McNeil C and Hunter J (2014) The Generation Strain. Collective solutions to care in an ageing society. IPPR.
5. BACP (2018) Life transitions in later life. Recapturing meaning (Online) https://bit.ly/2GpfA7M
6. Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition
7. British Medical Association (2016) Growing Older in the UK
8. Naylor C, Parsonage M et al (2012) Long-term conditions and mental health – the cost of co-morbidities. Kings Fund.
9. Kewell H (2019) Living Well and Dying Well. Tales of counselling older people. PCCS Books Ltd.
10. The Campaign to End Loneliness (2020) The Psychology of Loneliness. Why it matters and what we can do.
11. The Royal College of Psychiatrists (2018) Our Invisible Addicts. College Report CR211
12. The Royal College of Psychiatrists (2015) Substance misuse in Older People: an information guide.
13. Enache D, Winblad B, Aarsland D. Depression in dementia: epidemiology, mechanisms, and treatment. Curr Opin Psychiatry 2011;24:461-72.
14. Lipinska D (2009) Making Sense of Self – Person centred counselling for people with dementia. Jessica Kingsley Publishers
15. NICE (2018) Improving quality of care in residential care and nursing homes.
16. Age Concern and the Mental Health Foundation (2006). Promoting mental health and wellbeing in later life: A first report from the UK Inquiry into Mental Health and Well Being in Later Life.
17. The Royal College of General Practitioners (2011) Management of Depression in Older People: Why this is Important in Primary Care
18. Bhar S, Silver M, Collins R et al (2020) Establishing Telehealth Counselling for the Age Care Community in Australia. Beck Institute.
19. BACP (2018) Ethical Framework for the Counselling Professions
20. Age UK (2016) Hidden in Plain Sight
21. http://digital.nhs.uk/iaptreports
22. George, H (2015) “You Don’t Talk Your Business to People” The barriers that prevent African Caribbean older women from seeking counselling. BACP Therapy Today, November 2015 Volume 26 Issue 9
23. The Royal Society for Public Health (2018) That Age Old Question – How attitudes to ageing affect our health and wellbeing.
24. Frost R, Beattie A, Bhanu C, Walters K, Ben-Shlomo Y. Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies. Br J Gen Pract. 2019;69(680):e171-e181. doi:10.3399/bjgp19X701297
25. Levy, B., Slade, Martin D., Kasl, S. V., Kunkel, S. R., (2002), Longevity increased by positive self-perceptions of ageing, Journal of Personality and Social Psychology, 83, no.2, 261-270
26. Gilbert D (2014) The Psychology of your future self and how your present illusions hinder your future happiness’.
27. Kewell H (2019)ibid.