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Article 15

Living Well into Later Years

A Psychoeducational Support Group

Rebecca L. Koltz, Dawn S. Tarabochia, Cristen C. Wathen, Daniel J. Koltz, Amy Foote, Nicolais Cuyle, & Aimee Volkman

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Paper based on a program that will be presented at the 2016 American Counseling Association Conference, March, 2016, Montreal, Canada.

Wellness is a “way of life oriented toward optimal health and well-being, in which body, mind, and spirit are integrated by the individual to live life more fully…” (Myers, Sweeney, & Whitmer, 2000, p. 252). One way to conceptualize wellness is through the use of the Indivisible Self Model (Myers & Sweeney, 2004). The U.S. Census Bureau predicts that between now and 2050, the United States will see exponential growth in the aging population (age 65 and older; Ortman, Velkoff, & Hogan, 2014). Reports estimate the aging population will double by the year 2050, with a projected population of 83.7 million. This growth is due largely in part to the Baby Boom generation, which, aside from the millennial generation, is the largest generation in the United States. Given this exponential growth in population, challenges will likely emerge for policymakers and programs with regard to family, business, and health care levels (Johnson, 1996; Ortman et al., 2014). Exploring ways to discover and address the experience of wellness in an aging population seems important. The authors will review factors related to wellness in the aging, describe each domain of the Indivisible Self Model (Myers, & Sweeney, 2004), and introduce Living Well into Later Years, a group counseling format that was used to promote well-being with a group of 8 women from an assisted-living center. Recommendations for group leaders working with the aging population are provided based upon lessons learned from the authors’ experiences utilizing this counseling modality.

Wellness in an Aging Population

Erikson’s (1950) theory described the final psychological life task in aging as one of integrity versus despair. Aging adults who reach this stage of life experiencing integrity have likely learned to adapt to the successes and trials normal to life. Additionally, they see this final stage of life as meaningful. Aging adults who struggle with this final stage tend to lack an ability to view their life as a chain of meaningful events and, subsequently, experience despair and lower levels of well-being. Research has shown that lower levels of subjective well-being in the aging population are directly correlated with increased illness and death (Maier & Smith, 1999). Peck (2008) asserted that an aging person’s subjective experience of well-being is directly influenced by their cognitive appraisal of their life experiences. Subjective well-being can be defined by how positively people appraise the sum total of their life experiences. The appraisal process is often influenced by the physical and cognitive limitations and challenges that emerge as adults grow older. Dissonance between new information and existing information emerges as a choice for aging individuals to either accept the discrepancies or reduce discrepancies through changes (Peck, 2008). Aging individuals experience these dissonances on a regular basis as their physical bodies are aging. If these individuals are able to resolve cognitive dissonance that emerges as a result of aging, then they will likely experience greater levels of subjective well-being. Additionally, the lack of cognitive stimulation can potentially lead to dementia (Tesky, Theil, Banzer, & Pantel, 2011). Levy, Slade, Kunkel, and Kasl (2002) found that individuals who have a positive self-perception of aging were predicted to live 7.6 years longer than those who displayed a negative self-perception. Psychological effects have a greater influence on longer lifespan than physiological effects (Levy, et al., 2002). When aging individual’s needs are satisfied, they are more likely to have a positive perception of themselves and display higher levels of well-being (Ferrand, Martinent, & Durmaz, 2014).

Demiris, Thompson, Boquet, Shomir, and Chung (2013) found that older adults want to understand their own subjective experience of wellness. Models of wellness provide a structured means to address the subjective experience of well-being, particularly in individuals experiencing disabling medical conditions (Shannonhouse et al., 2014). For the aging population, the Indivisible Self Model provides a theoretical framework to assess client behaviors and choices within the five domains of self: physical, social, essential, creative, and coping. Additionally, integrating a wellness model like the Indivisible Self within a group counseling format has been shown to increase levels of subjective well-being with clients (Myers & Sweeney, 2008; Shannonhouse et al., 2014).

Nemers (2004) stated “in order to develop successful and comprehensive wellness programs for the elderly population, an adequate knowledge of the various types of stereotypes and discrimination they may experience is needed” (p. 11). Stereotypes and discrimination often perpetuate the experience of loneliness for this population. Johnson (1996) asserted that use of a group counseling format tended to offset the loneliness. Group counseling provides ample opportunities to increase social well-being which may prevent mood disorders like depression (Myers & Degges-White, 2007). Therefore, a framework of services promoting health and well-being during the aging process is critical (Angus & Reeve, 2006) to increase overall levels of well-being (Peck, 2008). Groups provide opportunities for social interaction which in turn improves individual experiences of belonging and connectedness (Myers & Degges-White, 2007). The Indivisible Self Model operates on the premise that change in one of the five domains of wellness will elicit a cascade of changes in other areas. For aging individuals, increasing their experience of belonging and connectedness through a group counseling modality may increase their experience of well-being in other areas of wellness that they may not have worked on otherwise.

Description of the Indivisible Self Model

The Indivisible Self Model incorporates five domains: creative, coping, physical, essential, and social (Myers & Sweeney, 2004). Creative Self comprises five components (thinking, emotion, control, positive humor, and work) and forms the characteristics making individuals unique in their interactions with others. Coping Self encompasses four components (realistic beliefs, stress management, self-worth, and leisure), which help individuals regulate responses to both normal and unexpected life events. Physical Self contains two components (exercise and nutrition) and recognizes the role that nutrition and physical activity play in a well lifestyle. Essential Self includes four components (spirituality, self-care, gender identity, and cultural identity) and incorporates the “meaning-making processes in relationship to life, self, and others.” (Myers & Sweeney, 2004, p. 237). Finally, Social Self incorporates two components (friendship and love) and recognizes that friendship and romantic relationships enhance life quality.

The five domains of the Indivisible Self Model were used as a framework to design a psychoeducational support group for aging individuals in a local assisted-living home. The group, Living Well into Later Years (LWLY), was designed to increase belonging and connectedness as well as educate this population on their own experience of subjective well-being. For the remainder of the article, the authors will describe the group and provide recommendations for group counseling work with older adults, implications for counselors, and recommendation for future research.

Living Well into Later Years: Psychoeducational Support Group

The main goal of LWLY is to improve the subjective experience of well-being in the aging population (age 65 and older) as well as provide psychoeducation about wellness practices. Johnson (1996) reported that the combination of education and therapeutic components into a group modality for older adults is particular effective. LWLY was designed as a 6-week group meeting weekly for 90 minutes. The group was led by counseling student interns in a counseling program in the western United States. The group was originally developed for a group of eight adults (65 and older living in an assisted-living center) and was based upon the five domains of wellness in the Indivisible Self Model (Myers & Sweeney, 2005). Participants in the group were referred by the executive director and the activities director. The assisted-living home is located in a mid-sized Western city. Many of the residents are from the surrounding communities within a 50 mile radius. The size of the assisted-living center is approximately 70 residents. A regular schedule of activities exists; however, the executive director admitted that it was difficult to get the residents to participate and form relationships with one another. The executive director reported that many of the residents seemed to feel a significant amount of loneliness but did not interact with each other often; therefore, she was supportive of the group.

Table 1 provides an overview of the topics and framework for the 6-week LWLY group. The LWLY group began week one with an overview of the five domains of the Indivisible Self Model (Myers & Sweeney, 2005). Each additional week, the group curriculum focused on one of the five domains of the Indivisible Self Model. A variety of experiential activities were used to engage group participants in gaining self-awareness regarding their subjective experience of well-being.

While the initial plan for the LWLY group was to meet for 6-weeks, it became apparent that this time frame would not be long enough to establish rapport and safety in the group or to address all of the wellness information. This seemed particularly important as reminiscence in the form of stories is often normal with the aging population (Johnson, 1996). While the counselors made room for the participants’ stories, it was also important to intervene and help the group move to the topic of the day. Therefore, the counselors adapted the program to meet for 8-weeks. However, group members were so committed to the process that the majority of the group members have continued to attend the LWLY group, which has now been meeting for over 6 months. The group is being conducted by two new counseling students as the original group facilitators graduated from the counseling program. What follows is a more detailed description of the original 6-week group.

Table 1

Weekly Group Activities for Living Well in Later Years

Week 1

Counseling students began the group counseling process with participant introductions and an icebreaker activity. For the icebreaker activity, polka dot introductions were used. In this activity, group members picked from a variety of polka dots, which contained surface level, get to know you questions. The individuals introduced their name and then proceeded to answer the question on their chosen polka dot. After the icebreaker activity, counselors introduced the Indivisible Self Model and discussed how this model could apply to the participants’ lives. Counselors also ask participants to rate their 5-areas of wellness (from the five areas of wellness in the Indivisible Self Model) on a scale of 1–5, with 1 equal to low wellness and 5 equal to the highest possible wellness. For the relaxation technique, participants using balloon breathing to introduce the importance of breathing to wellness.

Week 2

Counseling students asked participants to reflect on their life by writing down what participants thought was their biggest accomplishment. Counselors encouraged participants to openly process their personal reflections and had open-ended questions to facilitate this process. Participants were lead through a relaxation technique known as CABIN (Shapiro, 2009). CABIN is a mnemonic for:

Close your eyes,

Adjust the way you are sitting,

Breathe in and out slowly,

Imagine your favorite place, and

Nurture yourself with kind words.

Week 3

Counseling students reintroduced the 5F Indivisible Self Model, giving specific attention to the creative self in later life. Using the Beach Ball Bounce activity, counselors asked participants to roll or toss the beach ball to each group member while answering specific questions about their personal life experience. Counselors processed each group member’s responses and used joining/linking techniques to draw similarities, patterns, and themes to allow group members to gain an understanding of adult perceptions of later life. Participants were given a 30-minute beginning session with a focus on Yoga poses.

Week 4

During this week, counseling students elaborated on the creative self in the 5F Invisible Self Model. As part of the group counseling process, participants were asked to complete a drawing or painting of what it meant to “be well.” This project was completed over the next three weeks of group meetings.

Week 5

Student counselors began group by providing play-dough for the participants to use for tactile enjoyment during the group check-in segment. This week’s focus of the group was physical wellness. Counselors and group members engaged in stretching activities and then had a dance off. In the dance off, participants shared with their group their favorite dance move, with the group then mirroring the dance move to the best of their ability; each group member had the opportunity to share their favorite dance move. After the dance off, the group members spent some time working on their wellness artifact. The group ended with a session on Tai Chi and group processing.

Week 6

The group activities for what was to be the final week focused on reiterating the components of the 5F Indivisible Self Model. Participants also completed and displayed their wellness artifact. Finally, the counselors led the group members in processing the group counseling experience using open-ended questions (Table 1).

The social domain of the Indivisible Self Model was addressed weekly utilizing the group counseling format. It was unusual for members of the assisted-living center to have an opportunity to meet weekly with the same group of individuals. Reports by participants spoke to the appreciation of getting to know other people better using the group counseling format. Research regarding group counseling formats with older adults reported the positive benefit of weekly physical contact with people (Johnson 1996; Hern & Weis, 1991).

The coping domain was addressed weekly through a relaxation or mindfulness exercise. The participants were hesitant at first to engage in different types of breathing and yoga moves; however, the notion of being kind to oneself and accepting one’s body’s capabilities was particularly relevant. Participants reflected on how they had never paid attention to their breathing before and found the relaxation exercises to be helpful.

The remaining three domains (physical, essential, and creative) were interspersed in weeks 2–5 consider how they view their own l. The final week was designated as a summary of the model and time was given to process what and how participants conceptualized their own wellness. Overall, informal feedback from the participants in the LWLY group seemed to suggest that the group helped them imitations, be less judgmental of their abilities, engage in meaningful relationships with others, and recognize that even in this stage of life, they can try new things.

Recommendations for Wellness Groups With the Aging Population

Johnson (1996) offered some general suggestions for using a group counseling format with the aging population to include keeping the group size small (4–8 members), increased diligence in keeping the members “on task,” keeping the session structured, and paying special attention to loss. In addition, the authors developed four main suggestions for duplicating the LWLY group centered on the following four areas: simplify information, address physical barriers, adjust group counseling skills, and be authentic.

Repetition of Information

The Indivisible Self Model is a fairly simple model; however, explaining the model in an understandable way to aging adults presented more of a challenge. Counselors found it helpful to repeat information often. Additionally, keep information about the model and each domain of the model simple. Consider using the same key words when describing the model and domain each week. For example, with essential self, the facilitators used the same key word from week to week: This is the meaning- making part of self.

Additionally, group leaders found that they were giving too much information each week and started focusing more on the experiential aspect of group counseling and focusing on making one or two statements that summarized the wellness domain that week. They found that this shortened delivery method of the psychoeducational material worked well. Also, counselors utilized a large visual diagram weekly for participants to see. It seemed to help when information was repeated in a variety of ways: experientially, verbally, and visually.

Address Physical Barriers

Leading LWLY, the facilitators found it was important to be aware of perceived and real physical barriers. Given the cognitive dissonance (Peck, 2008) that occurs for this population, what may be presented as real physical barriers, such as not being able to participate in certain activities, may actually be perceived barriers. For example, the facilitators found during the week that focused on creative self, the group was very resistant. They referenced not being able to see or hold pens/pencils/paintbrushes. The facilitators approached this with understanding regarding physical limitations; yet, they also recognized that they had not been resistant to other aspects of the wellness model. Eventually, the group members participated in the activities such as painting pictures or dancing. The members of the group discovered how much fun these activities were and while some physical limitations did limit participation, the group members were able to overcome perceived barriers. Additionally, these activities provided an opportunity for multiple members of the group to work together and encourage each other. They eventually embraced the idea that creative self is not about the end product, but about the process. This is an example of a perceived physical barrier, and group counselors need to engage members of a group in a respectful way to encourage them to try the activity.

In terms of real barriers when preparing materials, it is important to make the font dark and large on a light background, as many older individuals have difficulty seeing or reading materials. Some individuals of this age have limited mobility; when facilitating activities, it can be useful to create individual palettes or plates of paints or glue for each person as they may not be able to move around the table. Also, placing materials in the middle of the table may not be reachable for all, so create separate stations for each person, as this enables each member with easy access to all the material needed to participate in the activity.

Adjust Group Counseling Skills

The facilitators found it necessary to adjust the common group counseling skills such as cutting off, drawing out, and linking. When working with the aging population, the concept of reminiscence is particularly relevant given their developmental place in the lifespan (Johnson, 1996). It is not uncommon for group members to focus many of their stories on past events. Usually, group counseling is a modality that is facilitated in the present; therefore, it is necessary to adjust facilitation based upon this developmental consideration. However, it is also important to engage in cutting off at times to allow room for other participants. Group counselors may need to consider exploring their own feelings about working with elders, as feelings of disrespect may emerge for group leaders when using this critical group counseling skill. Moreover, if group leaders do not utilize the cutting off skill, then the group may not get to the active stage of group counseling where they are focused on the “here and now” (Johnson, 1996).

Additionally, it was necessary at times to draw members out. When using this skill, it is important to speak loud enough and look directly at the person. Many aging individuals read lips, so when speaking to someone it is particularly important to look directly at him or her. Additionally, linking seemed to be particularly important. The group leaders assumed because participants lived together that they knew each other; however, this was not the case. It is important to not make assumptions about a group member’s interactions outside of the group and to utilize linking skills. Additionally, Johnson (1996) stated that the initial stage of group counseling may be longer than working with younger adults as it may take aging individuals longer to feel comfortable. Linking is also relevant given that older adults often have a tendency to withdraw; therefore, by finding ways to link their experiences and stories, this creates additional external stimulation (Hern & Weis, 1991).

Be Genuine

Being genuine should be a skill that counselors naturally embody; however, LWLY group leaders found the group members taught them a lot about this skill. The aging population values authenticity and realness. It seems important to work through any personalization that counselors may hold regarding working with the aging population. Additionally, counselors are in an interesting position because they are working with a group of people in a life stage they themselves have not reached. There is no way to truly understand what the experience of old age is like; therefore, it is important to drop any facades and approach leading this group from a position of not knowing while incorporating a genuine willingness to learn and understand.

Implications for the Counseling Field

As noted earlier, in later life it is common to experience lower levels of subjective well-being (Maier & Smith, 1999; Peck, 2008). Counseling groups such as LWLY provide an opportunity for individuals in assisted-living centers to experience social support and understand how they can increase their own experience of well-being. Additionally, given that licensed professional counselors cannot bill Medicare, counselors do not often have opportunities to work with the aging population. This group used second-year counseling students in the first author’s counseling program to lead the groups. This provided a unique training opportunity for students to learn and understand how to work with older adults, a population they get little supervised experience with. However, with some advocacy efforts, perhaps, more community counselors could approach assisted-living centers to pay them to specifically run this counseling group, as assisted centers are often looking for additional funding. At the very least, running counseling groups such as these provides opportunities to do pro-bono work with a population that has great need.

Recommendation for Future Research

Recent research in the counseling field exploring group counseling as a preventative treatment modality with an older population is limited. The majority of the articles identified were from the 90s or earlier (Burlew, 1991; Hawkins, 1983; Hern & Weis, 1991; Johnson, 1996). Therefore, given that the aging population is increasing and loneliness is common (Johnson, 1996), it would seem plausible to explore the impact of group counseling both quantitatively and qualitatively. Additionally, incorporating a wellness-based perspective seems particularly relevant given that much of the developmental literature on aging paints a rather bleak picture. Counseling is a field founded on principles of wellness and well-being. To explore further research opportunities to increase the health and well-being of the aging population seems in line with the professional goals and visions of the counseling field.