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A Behavioral Health Workforce for An Aging America

As efforts are made to improve America’s inadequate behavioral health workforce, the needs of older adults should be a central concern.

By 2030, Americans over the age of 65 will become as large a portion of the population as children under the age of 18. But there is far more interest in meeting the mental health needs of children than of older adults.

One of the reasons for this is the sense that older adults are not the future of America; children are. Obviously, children have more years of life ahead of them than older adults do, but a person who has lived to be 65 will, on average, make it to about 85; half will live longer.

Older adults do have a future. Not only will they survive for many years; they also will have many years in which they can enjoy life and contribute to the American society. Making the most of old age should be a major social goal and is a key challenge for America’s behavioral health systems.

The current behavioral health workforce is neither large enough nor adequately prepared to respond effectively to the specific needs of older adults.

It is important to understand that old people are not just adults who are older than younger adults. They are in a different developmental stage and experiencing significant changes both physically and psychologically.

The behavioral health workforce in an aging America needs to understand these developmental changes. It needs to be “generationally” as well as clinically and culturally competent.

Key characteristics of a generationally competent behavioral health workforce include:

Geriatric Clinical Competence: Behavioral health professionals and paraprofessionals need to make adaptations to clinical practice for older adults in a variety of ways. For example, psychiatric medications have greater risks for older adults. These include increased rates of serious physical side effects and especially of falls, which are the greatest cause of disability among old people. In addition, older adults are likely to have chronic physical conditions as well as mental and/or substance use disorders. This makes integrated treatment critical for older adults. Of particular concern is physical pain, which can contribute to misuse and abuse of alcohol and painkillers.

Generational Competence in Multiple Fields of Practice: Although mental health and substance abuse professionals are obviously central to a behavioral health workforce for older people, they are far from the sole important practitioners. For example, primary health care professionals currently provide most treatment for mental disorders, relying heavily on the use of psychiatric medications. In general, they are poorly prepared to identify mental and/or substance use disorders or to provide appropriate treatment even when medication is the treatment of choice. Preparing primary care professionals is a critical challenge in developing a competent geriatric behavioral health workforce.

In addition, older adults with psychological problems seek and get help in a variety of settings that are not designed to provide psychological or substance abuse treatment, including senior centers, houses of worship, senior housing, and naturally occurring retirement communities (NORCs). People who work in these settings also need to be far better prepared to identify and respond to mental and substance use disorders.

A Developmental Perspective: In our culture many of the physical, mental, and social changes associated with old age are regarded as pathological rather than as normal human development. A developmental perspective includes an appreciation of both the challenges and opportunities of aging. Role changes—such as retirement and changes in parental responsibilities, diminished physical and mental capacities, chronic ailments often with increased pain, losses of friends and family, and ultimately facing death can make aging difficult. But it is also possible for old age to be a time of fulfillment. Eric Erickson, for example, noted that old age could result either in a sense of “despair” or in the achievement of “integrity,” a complex state that includes pride, meaning, authenticity, and hope despite approaching the end of life. A generationally competent behavioral health workforce needs to have a developmental perspective along Ericksonian lines.

The Spiritual Dimension of Life: For most people regardless of age, religious or spiritual experience is an important and valued part of life. For many older adults, the spiritual dimension of life becomes more and more important as they come closer and closer to death. Most behavioral health professionals are not trained to understand or relate to their clients’ spirituality. In fact, many shy away from it because the spiritual seems unscientific. This limits their ability to help the people they serve to achieve integrity in old age. A generationally competent behavioral health workforce needs to be able to help those for whom spirituality matters to have a positive spiritual experience and especially to help people nearing death to make peace with mortality.

Living with Disability: Obviously, older adults are more likely to experience disabilities than younger people. But this is far from the end of their potential to get satisfaction out of life.

In the field of psychiatric rehabilitation, a concept of recovery has emerged that does not mean that people with long-term psychiatric disabilities eventually get over their mental illnesses fully. Some do; but many continue to experience the symptoms and psychological struggles of severe, long-term mental disorders. “Recovery” for them means that they can nevertheless discover ways of living that they find satisfying and meaningful.

Geriatric behavioral health professionals need a similar concept for people who develop disabilities as they age, including those who develop dementia.

Successful Aging: “Successful aging” is one such concept. Recent literature on this concept borrows from the concept of recovery and distinguishes between objective and subjective successful aging. Emphasis on objective successful aging leads to various anti-aging initiatives and the hope that decline and death can be defeated. Emphasis on subjective successful aging emphasizes that success, like beauty, is in the eye of the beholder. In fact, many older adults experiencing the challenges of aging, even those with extensive losses of prior capabilities, can nevertheless feel that their lives are satisfying. Instead of trying to defeat old age, the concept of subjective successful aging leads to efforts to help older adults to maintain and develop relationships, to participate in activities they find pleasurable and meaningful, and to maintain a positive attitude despite the typical trials and tribulations of aging.

A generationally competent workforce needs to understand the opportunities of old age and work to promote successful aging as well as to prevent and treat mental illness.

Rejection of Ageism: In our culture, age is associated with decline, disability, and death. Aging well strikes most people as an oxymoron. In fact, however, most people over the age of 65 are not disabled and dependent, not decrepit, not finished, not over the hill, not on the edge of death. Yes, old age has its difficulties. But, surprisingly, mood and anxiety disorders are less common among older than younger adults, and suicide rates are lower than those of working age adults except for white men over 85. Yes, cognitive impairment becomes more common with age, and by 85 nearly half of older adults will have significant impairment. But that’s 20 years of potentially satisfying, independent living for the majority of older adults. It is a time when older adults can—if they want—make substantial social contributions by continuing to work for pay, by volunteering, by being grandparents, etc. Failure to recognize this fact is fundamentally ageist.

In addition, it is possible for people with physical, mental, and cognitive impairments to have satisfying lives. Failure to recognize this fact is also ageist.

Hopefully, the geriatric behavioral health workforce of the future will reject ageism and will work to fulfill the opportunities of old age. This should include not only efforts to prevent and treat mental and/or substance use disorders using interventions that are specifically adapted to the needs of older adults. It should also emphasize efforts to promote “positive mental health”—i.e. well-being in old age.

Michael Friedman is retired but continues to teach at Columbia University and to write about behavioral health and about aging. He is the founder and former director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City and co-founder of the Geriatric Mental Health Alliance. He can be reached at mf395@columbia.edu.

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