By Helen Kewell – Humanistic Counsellor (MBACP)
Working therapeutically with those in later life is not often seen as the cutting edge of the counselling world and it is researched and written about relatively infrequently.
For those of us that do, we find out how to navigate the clinical dilemmas of this work often the hard way, via thinking on our feet and returning to instinct, calling supervisors to check-in where needed of course. I thought it might be useful to share some of my experiences in the absence of any robust, specific published ethical guidelines.
I found myself working in this area by chance and was immediately, and almost unaccountably, hooked. In my opinion it deserves as much airtime as working with children and young people, especially considering the statistics on longevity. The Office of National Statistics predict that the number of people aged 80 and over will double and the number of people over the age of 90 will triple by 2037. We all need to care about this work as elderly mental health will become vital to the economy and to the wellness debate in the not too distant future. What specific issues might it throw up for a counsellor and how might they be approached?
1. Be flexible on location
I offer to visit clients at their home or care home. As a minimum I think it is essential to be prepared to do this if you engage in working with those in later life. Many of my clients don’t drive in inclement conditions or in the dark and many don’t drive at all. Others may be house or care-home bound in some way. It is worth checking that your professional insurance covers this. It is also essential to ensure you are aware of your organisation’s lone working policy or to take steps to ensure your safety if you work alone. As a minimum I make an anonymised version of my diary available to someone close to me, check exits when I enter a property and keep my phone accessible. I should say, however, that I have never felt unsafe, but it is important to have this all in place.
Within the house/home I usually ask clients where they’d us both to sit. Sometimes this can result in sitting on the bed or next to clients on the sofa. You often have to get over your professional etiquette to get around this and you might need to get creative (one client was so hunched over that I sat on a footstool by her feet so we could find eye contact!). With all of this, a sense of humour and a commitment to be open, honest and phenomenological about what is happening really helps get over the awkwardness.
2. Hold elastic boundaries and a sense of humour
On many occasions I have arrived to find the client not at home or in their room (at hospital, having their hair done, on a day trip and, one two occasions, having died). ON other occasions we are mid sentence when a concerned neighbour/family member/pharmacy delivery/carer arrives unannounced through the back door. At these points it is important to be accepting, flexible and retain a sense of humour, but it is also important to be firm and to respect the counselling space. If possible, ask politely if the person can come back later, or at the very least wait in another room or space until the session finishes. I also actively engage the client on how it is for them and how they’d like to handle the situation, as we are usually in their space I find it important to put the choice and autonomy in their hands.
3. Carefully navigate confidentiality and consent
As with working with children, often it is other people that instigate the counselling work on behalf of the client and there is often a variety of people around the individual you are working with who are invested in the outcome: carers, GPs, district nurses, family members, even sympathetic receptionists in care settings. It is essential to review and re-establish issues of confidentiality and consent on an ongoing basis, with those around your client and with the client themselves. I try to tune out of the ‘noise’ around the person I am working with, but it is not always possible.
If I can, I ask for contact details for the individual concerned as early in the process as I can and if it possible, depending on their level of independence and cognition, I have ongoing contact with them. If family members are paying for the service, I discuss up front how I will let them know a session has taken place and set expectations that we will NOT be discussing the content of the sessions. I also discuss how we should communicate if I visit the client and find them unwell or unable to access counselling that day, or if they themselves are concerned or worried. It is important to acknowledge the feelings of family members whilst keeping client confidentiality water-tight. With other professionals I am firm and clear, no details can be discussed unless in the service of the client and with their explicit instruction or consent.
With the individual concerned, I always check that they are happy for me to be there, that they understand what it is we are doing and that they would like me to return next week, regardless of what I have been told by others. This often feels repetitive, but I think it is vital, particularly if I am visiting someone in their own home as they are not in control of when or if I visit.
4. Actively work with contact impairment
One of my first clients was suffering with dementia and was significantly contact-impaired, often drifting into fantasy or old, sometimes confused memories. In working with him, and many other since, I made it my commitment to always walk with him in his world, which was often rich in imagery which we could work with therapeutically. It is frightening when others don’t validate our experiences and I personally believe it deepens the therapeutic bond to explore the reality of the person you are working with, rather than try to root them into ‘truth’ or ‘reality’.
So, if someone announces, at the age of 95 that they are getting married next week you ask who with and where and how do they feel about it, you don’t question the validity of the claim. Within this exploration you might stumble upon feelings of connection, love, forgiveness, loss. One of the clients I worked with was always standing in the corridor of his nursing home waiting for the bus to take him out of there, he became anxious when he couldn’t see down the corridor so we moved our chairs nearer his door for our sessions. With patience and creativity these ‘impairments’ become powerful vehicles for connection and healing.
5. Balance vulnerability and challenge
Don’t be blindsided by visual signs of vulnerability, working with those who appear frail physically doesn’t always mean they are frail emotionally. Whenever I have made that mistake it has usually backfired on me, in terms of the therapeutic bond, as we don’t get down to meeting their authentic self. Engaging in the life stories of the person you are with, being curious about photos of their younger self, noticing tiny inflections, gestures, uses of language usually grounds me in that unique person, rather than a construct of ‘old’ from the media or literature that I might have swallowed whole. And once we meet the true self and the trust builds up it is possible to challenge beliefs or narratives that might be fixed or holding them back, just as it might feel safer to go into traumatic memories eventually. To do these things you have to push yourself beyond seeing an archetype and meet the real person.
As an aside, it is worth undergoing specific vulnerable adult training and ensuring you are aware of the signs of abuse and the appropriate methods of raising concerns if you have any. In the same way as we might when working with CYP. Vulnerability must of course be acknowledged and respected.
6. Engage in specialist and/or robust supervision
Finally, working with elderly and profoundly old clients will, naturally, bring up our own beliefs on ageing and later life. It may trigger memories of our grandparents, fears of our own mortality, concerns about our parents. I have found that working with supervisors who understand this area and will challenge me on these blind spots and engage in talk about death and dying and who can connect with my inner geriatric helps keep me grounded enough to do this work. I encourage others to choose someone either with experience in this area or who can at least do the same.
If you are interested in this area and want to read more here are some recommendations:
- Atul Gawande ‘Being Mortal’
- Laura Carstensen ‘A Long Bright Future’
- Erikson and Erikson ‘Vital Involvement in Old Age’
- Robert Slater ‘The Psychology of Growing Old’
- Linda Viney ‘Life Stories’
- Danuta Lipinska ‘Person-Centred Counselling for people with Dementia’
- Helen Kewell ‘Living Well and Dying Well: Tales of Counselling Older People’
© Helen Kewell 2019
Helen Kewell is a humanistic counsellor with a private counselling practice in Sussex, and volunteers as a counsellor and supervisor for Cruse Bereavement Care. She specialises in working with older clients and her book ‘Living Well and Dying Well: Tales of counselling older people’ is out now: https://www.pccs-books.co.uk/products/living-well-and-dying-well