Two major demographic trends will unfold in America during the first half of the 21st century. Minorities will grow from 29% to 47% of the American population, and older adults (65+) will increase from 13% to 20%, becoming roughly as large as the population of children and adolescents under 18 for the first time in history. The concept of cultural competence has emerged as a central organizing principle in response to the growing multi-cultural character of the American society. But there is no comparable organizing concept regarding the aging of America. It strikes me that “generational competence”1 could serve as a useful counterpart to “cultural competence.”
Of course, “generational competence” suggests not just competence serving older adults, but competence serving people in all stages of human life—from birth through working age—as well as older adults. Here I will focus only on generational competence regarding older adults, but it seems to me that much work could usefully be done to conceptualize and develop systems of health and mental health promotion and intervention for all ages.
By “generational competence” I have in mind not just the use of age-appropriate clinical practices. I am referring to generationally competent systems. The general idea is twofold—to bring (1) a developmental perspective and (2) knowledge of differences among age cohorts2,3 to the design of health, mental health, and human service systems.
I do not have nearly enough space in this column to explore each of the components of a generationally competent mental health system for older adults. Suffice it to say, as I frequently have before, that a sound geriatric mental health system would include efforts to overcome ageism and stigma; mental health promotion; outreach and engagement; better identification of mental and substance use disorders; improved access to treatment in the community, including treatment in the home and in natural community settings; an emphasis on aging in the community rather than in institutions; more housing alternatives; enhanced family support; improved quality of care, including better translation of research findings into practice; greater integration of aging, health, and mental health services; extensive efforts to develop a clinically and culturally competent workforce, including the use of older adults themselves in helping roles; restructured financing mechanisms that will support a generationally competent system; and equal attention to the mental health needs older adults as to those of younger people.
In this column, I will touch on just a few of the key themes of a generationally competent mental health system for older adults.
Overcoming Ageism: Just as overcoming racism and cultural stereotypes is a critical dimension of meaningful cultural competence, so overcoming ageism is a critical component of generational competence. In our culture, age is associated with decline, disability, and death. Commonly, calling someone “old” implies that they are decrepit, “over the hill,” or “done for.” So people evade the fact of old age. “You’re as old as you feel,” they say. Nonsense! You are as old as you are. But, if you are over 65, the chances are excellent that you can get great satisfaction out of life. You can be old and good. Strange thought? That’s because of ageist expectations. Think about this: major depressive disorder actually declines in old age. Hard to believe, perhaps, but that has been the finding of all epidemiological studies for more than a quarter of a century. Yes, mood and anxiety disorders are serious problems for some older adults. Yes, suicide rates are extremely high. Yes, cognitive impairment becomes more common as we age, and by 85 nearly half of older adults will have significant impairment. But that’s 20 years of potentially good, independent living for the majority of older adults and—hard as it is for younger people to believe—it is possible for people with cognitive impairment to continue to have satisfying lives. In the field of mental health, we use the term “recovery” to refer to the potential for people with severe, prolonged psychiatric disabilities to lead lives they find satisfying and meaningful. We need a similar concept for old people with cognitive impairment. (More below.)
Aging Well: Because there is so much opportunity to live well in old age despite the challenges of role changes, diminished physical and mental capacity, loss of family and friends, and the inevitability of death, a generationally competent mental health system would emphasize and facilitate successful aging. The key to aging well is remaining active and involved. Obviously, creating opportunities for satisfying and meaningful relationships and activities is not primarily the responsibility of a mental health system. But the mental health system can help. For example, the concept of “age-friendly” communities is catching on as a way to organize the our cities and towns so that older people can have, and take advantage of, opportunities not to be isolated, to pursue personal interests, and to maintain or develop significant, even sexually intimate, relationships. There are important mental health dimensions of age-friendly communities.4
In addition, outreach into the settings where older adults live or go—such as senior centers, houses of worship, senior housing, and naturally occurring retirement communities (NORCs) can help older adults (1) to learn about how to maintain their mental health (without which they cannot age well)5 , (2) to identify mental and/or substance use disorders, and (3) to get access to good treatment (which, unfortunately, is difficult to find.) All of these mental health services and more are part of a generationally competent mental health system for older adults.
Boomers Will Be Different
Age groups from different periods of time are developmentally similar but have important differences in experiences, expectations, and values. There is little doubt that elder boomers will be different from the generation of people who are already old. The boomers are physically healthier than the generation before them and, generally, will be able to work and live independently longer. In addition, they are from the generation of “drugs, sex, and rock and roll” and have attitudes and expectations different from their parents, including greater expectations of happiness. What this means for the mental health system is not clear. For example, it is possible that the prevalence of depression will be greater among boomers. It is now. Will it decline as they age, as it did for their parents’ generation? We don’t know yet. Boomers may also experience less stigma about getting treatment. Indeed, they may be more inclined to understand their fears and sorrows as mental disorders than just as unavoidable aspects of human life. A generationally competent mental health system would try to anticipate “cohort effects” like these and adjust accordingly.
Living with Disability – Recovery and Integrity
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 schizophrenia, bi-polar disorders, treatment refractory depressions, or disabling anxiety disorders such as obsessive-compulsive disorder. “Recovery” means that many can nevertheless discover ways of living that they find satisfying and meaningful.
We need, as I said before, a similar concept for people who develop cognitive impairments or continue to have psychiatric disabilities as they age. Here’s the twist. Virtually all of the most eloquent spokespeople for recovery—people who are in recovery themselves—note the importance of hope to their finding meaning and satisfaction in their lives. Hope, however, suggests a desire for future outcomes that may not be open to very old adults. Erik Erikson, the originator of the idea that each stage of life has its pitfalls and potentials and that each has its own goal, maintains that the goal of very old age is not hope but integrity. In part this is a sense of a life well-lived—a challenge for anyone who had great disappointments along the way. But in part integrity refers to a sense of personal authenticity. Many older adults with cognitive impairment have much “to look backward to with pride,” to steal a phrase from Robert Frost, and many people with long-term psychiatric disabilities can take pride in the hard routes they traveled to reach a point of self-acceptance and peace with themselves. This state of being is different from the state of hope that is at the heart of recovery as it is usually conceived. A generationally competent mental health system would adjust its expectations accordingly.
Coming to Terms with Death
Integrity in very old age also means accepting the inevitability of death and coming to terms with it in one’s own way. This is extremely hard in a culture which assumes that we should fight death to the bitter end. “Do not go gentle into that good night. Old age should burn and rave at close of day. Rage, rage against the dying of the light.” This is what the poet Dylan Thomas said to his dying father. Cruel, it seems to me. Journalists assume much the same thing when they report about virtually everyone who dies after a protracted illness that they lost a long “battle” with their disease. Apparently, no one ever makes peace with death in our culture.
A generationally competent mental health system would help adults nearing death to make their peace with it, particularly by helping those who are believers to connect with spiritual communities. In addition, a generationally competent mental health system would not abandon and let die alone in hospitals and nursing homes those for whom mental health programs have become virtual family.
My goal in this column has been to suggest that because America is aging as well as becoming increasingly culturally diverse, we need an organizing concept such as “generational competence” as a counterpart to “cultural competence.” Here I have applied the concept in a very limited way to meeting the mental health needs of older adults. Far more needs to be done to flesh out a generationally competent mental health system for older adults as well as for other age groups. I want to emphasize again that the concept of generational competence is not the same as age-appropriate mental health treatment. The challenge is to describe a generationally competent system. It is, I think, a challenge worth taking on.
- Mike Hogan, Commissioner of Mental Health in New York State, is the first person I heard use the expression “generational competence.” At a meeting regarding the geriatric mental health needs of Latinos, he suggested that there was a need for both generational and cultural competence.
- The Ceridian Corporation uses the concept of ‘generational competence” to refer to different age groups of working people—“matures,” “baby boomers,” “generation x,” and “generation y,” each of which has different characteristics both as workers and as markets. See “Changing the World of Work,” 2005.
- Peggy Gleeson has used the concept of “generational competence” to suggest that an effective professional workplace needs to take into account the “values, work characteristics, and customs” of different age groups. See “Understanding Generational Competence Related to Professionalism,” Journal of Physical Therapy Education, Winter 2007.
- Williams, K and Friedman, M. Addressing the Mental Health Needs of Older Adults in Age-Friendly Communities. The Geriatric Mental Health Alliance of New York. 2010. http://www.mha-nyc.org/media/1251/agefriendly.pdf
- Friedman, M and Williams K., “You Cannot Age Well Without Mental Health,” Huffington Post, December 23, 2010.
Michael Friedman is an Adjunct Associate Professor at Columbia University’s schools of social work and public health. He can be reached at firstname.lastname@example.org.