Researching improving mental health support for older people

At the age of 75, I have just completed and written up four years of biographical psychotherapy research with fourteen unique and informative counselling service users aged 65 and upwards. My ‘critical narrative analysis’ of the findings from in-depth one-to-one interviews, exploring both growing older and talking therapy experiences in later life, was finally submitted in January 2024.

My resulting PhD thesis is intended to provide a significant contribution to future mental health care policy and practice with older people. My objective is to help meet the urgent need to develop more accessible, age-appropriate, and timely psychological support services, such as counselling, for people aged 65+ experiencing and surviving, sometimes traumatic, transition, change and loss.

Current NHS mental health ‘talking therapy’ provision tends to be only prescribed as a ‘one size fits all’ treatment for people who have already been diagnosed with illness or disorder, or are professionally assessed to be medically in need of mental health support.  

Current mental health concerns in the UK

According to a recent report by the Office for National Statistics (2022), the take-up of talking therapy services through ‘Improving Access to Psychological Therapies’ (IAPT) agencies by people aged 65+ has been much lower than the estimations of future need expected by the Department of Health and Social Care (DHSC) since 2011. The currently extremely low take up of mental health support services is despite the fact that the population of England and Wales aged 65+ has increased from 16.4% in 2011 to 18.6% in 2021 (Office for National Statistics, 2022). 

Research for the Royal College of Psychiatrists undertaken in August 2022 found that 43% of adults with mental illness reported the wait between the initial referral and the second appointment, the point where treatment usually starts, had caused their mental health to worsen (Royal College of Psychiatrists, 2022). A report by Age UK in July 2023, on the state of health and care of older people in England, concluded that Covid has cast a long shadow over older people's health and social care. The report findings indicate that many people still have poor mental or physical health which can be attributed to the Covid pandemic.

It is not surprising that hospitals and care services are under pressure because the need has unquestionably risen. There are particular groups of older people, such as those from some ethnic minorities, or living in deprived communities, whose experience is even worse than the rest of the population (Age UK, 2023). 

Health and social care policy ideas from Age UK

However, the Age UK report also argues that it doesn't have to be like this. There is an opportunity now to respond to the evidence presented in this report and change how we are supporting our growing older population, giving us a much greater chance of success.

The report recommends the establishment of a fundamental principle of ‘home first’ in our approach to care. Rather than older people always having to go to the hospital, it would often make more sense for the hospital to come to them. Hospital-at-home teams and virtual wards are proliferating as mechanisms for providing clinical oversight and care for older people in their own homes. Underpinning this should be sufficient numbers of people to staff our primary and community health and social care services.

As well as recommending paying carers fairly for their skills and commitment, the report argues that we also need to increase the overall attractiveness of their roles. There is also a need to support the health, well-being and finances of unpaid carers, many of whom are aged 65+. The Joseph Rowntree Foundation reports that poverty is now deepening in the UK and that informal carers are amongst the worst affected (Joseph Rowntree Foundation, 2024). According to Age UK’s research (Age UK, 2023), what would help these people the most is a good social care system they can rely on.

The report concludes that an infinitely more ambitious cross-government drive is required to narrow health inequalities between people of all ages, ethnicities and places, to address the social and economic determinants of ill health (Age UK, 2023). 

The broader social context of mental health services

My research identifies an urgent need to shift attention from individual pathology to our social, cultural and historical contexts. I have investigated this prospect by considering the structural issues such as inequality, poverty, discrimination, racism, ageism, marginalisation, and social exclusion, which are potential significant causal factors in the increase in diagnosed mental health problems in society today.

This conclusion is powerfully evidenced in the United Nations Special Rapporteur’s research on current political, economic, and social issues in the UK in terms of poverty, human rights and inequality (Alston, 2018). Alston’s challenging report critically observed the increasing deprivation and distress resulting from austerity policies in the UK, which have been the political choice of successive governments since at least 2010 (Alston, 2018, pp. 22-24).

One of the unintended consequences of austerity has been the gradual deterioration in the quality of life for many of the poorest older people in the UK, as clearly evidenced by recent social research (Centre for Ageing Better, 2019; 2023; Age UK, 2023; Joseph Rowntree Foundation, 2024). I contend that the individualistic ideology of recent governments has also contributed to a generalised reduction in the provision of ‘preventative’ health and social care services which promote psychological well-being for older people, including an increasing number of currently very poorly supported unpaid informal carers.  

Our ageing population

According to the Centre for Ageing Better (2019), there are more than 11.9 million people aged 65 and over in the UK, of which 3.2 million are over 80 and 1.6 million are 85 and over. We are living longer than ever, and the age profile of our society is changing rapidly. The number of people aged 65 and over is projected to increase by more than 40% within 20 years, and the number of households where the oldest person is 85 and over is increasing faster than any other age group. Findsen and Formosa (2015) estimate that one in nine people in the world are aged 60 years or over and that this is projected to increase to one in five by 2050 (Findsen and Formosa, 2015). ‘Ageing is inevitable, but how we age is not’ (Centre for Ageing Better, 2019, p. 4).

My thesis on positive ageing

In my PhD thesis, I contend that our current rates of chronic illness, mental health conditions, disability and frailty could be greatly reduced if we tackle the structural, economic, and social drivers of poor health earlier. I argue that we also need to learn how to enjoy and make the best of later life.

I view counselling as a helpful facility for opening up perspectives on later life, such as ‘lifelong learning’ opportunities, in the style of international institutions like the University of the Third Age. These movements have the potential to change public perceptions to include the possibility of experiencing continued lifelong learning and development, fulfilment and purpose in old age. My research argues that there is a need for government policies to promote continued learning opportunities which actively respond to the prospect of a ‘long life’ (Withnall, 2010).

Changing attitudes to ageing from negative to positive is particularly relevant to those who are not able to take advantage of the growing number of retirement life choices because of limited means, restricted environment, or lack of previous adult learning and education experiences (Withnall, 2010; Schmidt-Hertha et al., 2014; Findsen and Formosa, 2015). Low income, poor health and inadequate housing present considerable challenges for those of us striving to remain active, independent and purposeful in later life. Existing social inequalities are increasingly acute in this age group (Centre for Ageing Better, 2019; 2023; Age UK, 2023; Joseph Rowntree Foundation, 2024).

Who I am and why I decided to do this research

As a septuagenarian grandfather and a practising psychotherapist, I continue to be personally deeply engaged with this topic. I am striving to make a positive difference to the psychological well-being of adults over 65, who require practical, emotional and spiritual support, by improving their access to competent counselling services which address their needs and wishes.

I have been working professionally with older people in different situations for over 40 years. My previous professional training and qualifications are in social work and continuing education, and I have been developing my knowledge and competence in the education and training of health and social care practitioners and managers working with older people since 1985. I am currently a practising, BACP registered, psychotherapist and existential coach, and I have been providing voluntary counselling services for Age UK Warwickshire’s Psychological Support Service since 2010. I have written four feature articles for BACP’s ‘Private Practice’ journal since September 2017, in which I explored the qualities, power dynamics, potentials, and ethics of counselling relationships. 

The idea of undertaking a structured ‘narrative inquiry’ into people’s experiences of counselling in later life was initially envisaged whilst listening to Age UK Warwickshire’s Psychological Support counselling service users. Talking to these people, in various later-life stages, I frequently encountered an expressed sense of needing to stoically meet any adversity life threw at you, combined with attitudes of self-sufficiency, independent problem-solving, and emotional reticence. Many of the people I counselled were also concerned not to be a burden to their loved ones, and to continue to contribute to family and community well-being.

I also found that supporting these people to tell their stories and find meaning in past, present, and future existence, seemed to alleviate distress and enable my clients to maintain, or regain, their resilience, and adapt pro-actively to ongoing change and transition in their lives (Tovey, 2019; 2020). Also, as Viktor Frankl (1988) argues in his explanation of ‘logotherapy’, the process of seeking personal meaning for life experiences is unique for every talking therapy client (Frankl, 1988).

Frankl drew on both psycho-analytic theories and existentialist ideas, such as ‘being in the world’ (Heidegger, 1962), when he developed his revolutionary therapy model of ‘logotherapy’ in the 1930s as a form of existential psychiatry or ‘healing through meaning’ (Frankl, 1988). It is Frankl’s abiding concern about avoiding purely technological approaches, and also recognising the unequal power dynamics of medical diagnosis and dominant pathological explanations for distress, which I consider extremely relevant in our approaches to counselling and psychotherapy policy and practice today.

My inspirational personal encounters with experiences of post-traumatic growth

In my conversations with participants contributing to my research, I observed in some of their later life stories a gradual autonomous self-care process of personal adjustment and, ultimately transformative, recovery from traumatic distress, which I have identified in my analysis as ‘post-traumatic growth’. Researchers Calhoun and Tedeschi (2013), developing this valuable concept, in terms of generating ideas for supportive and facilitative counselling practice, refer to the role of the therapist as an ‘expert companion’ (Calhoun and Tedeschi, 2013). Stephen Joseph has written a valuable self-help guide to how people may recover from post-traumatic stress through posttraumatic growth (Joseph, 2013). He writes:

Most psychologists regard post-traumatic stress as symptomatic of disorder. But if we regard these cognitive processes from a perspective that encompasses their interaction with our assumptive world, we can understand them as steps in an adaptive process, rather than as symptoms of disorder. They are indicative of people’s struggle to rebuild their assumptions about themselves and their relation to the world (Joseph, 2013. p.110).

Joseph (2013) goes on to explain the importance of storytelling in the process of how people recover from trauma and distress. My reflexive approach to this narrative inquiry with counselling service users is strongly influenced by personal experience and my previous encounters with research and writing about the concept of post-traumatic growth (Calhoun and Tedeschi, 2013; Joseph, 2013). Joseph’s (2013) self-help book also gives useful perspectives on the importance and value of biographical qualitative research. I agree with Joseph’s arguments and the following quotation serves to underpin my own approach to both psychotherapy practice and counselling research:

Human beings are storytellers. It is human nature to make meaning of our lives by organising what happens to us into stories. We live our stories as if they were true.

"We tell stories to understand what happens to us and to provide us with a framework to shape new experiences. We are immersed in stories throughout our lives… through interaction with others, we confirm and disconfirm each other's stories. Our stories help us to construct self-understanding. They help us to bind together our thoughts, feelings and behaviours in a way that is continuous with our view of ourselves and our past history. The stories we tell reflect not only our personalities but also our cultural context. Different cultures have different ways of looking at the world: some place importance on a sense of community; Others value spiritual and religious views; Still others emphasise personal responsibility. Our meaning-making is inevitably influenced by this dominant discourse, regardless of what form it takes… Ultimately, we seek meaning in our experiences. Once we find it, meaning provides us with the strength to move forward." (Joseph, 2013, p. 143-144).

I find a case example from Viktor Frankl (1967; 1988), quoted by Joseph (2013), particularly helpful in illustrating the importance of personal meaning. Viktor Frankl discussed the story of one of his patients, an elderly doctor who, two years after the death of his wife, remained acutely distressed. Frankl asked the doctor what it would have been like had he died before his wife. "It would have been awful for her", the doctor replied, as she would have suffered terribly. Frankl pointed out that her suffering had been spared, and that the cost of this was that the doctor himself had to take on the burden of suffering. This was a brand new way of looking at what had happened. The doctor shook Frankl's hand and left the office with a new sense of meaning that allowed him to bear his own suffering (Joseph, 2013).

I share Joseph’s (2013) viewpoint that the stories we tell ourselves are the pathways through which we make sense of our lives, construct our identities and establish why we choose to live our lives one way and not another. Through storytelling we create understanding that increases our voluntary control over our memories and resolves the tension between pre-existing assumptions and new, sometimes distressing, experiences (Joseph, 2013).

Joseph goes on to explain that when ‘trauma creates a rupture in a person's life story’, assumptions about ourselves, our place in the world and our expectations about it are shaken, even shattered. He adds that trauma may have the effect of rendering our life stories obsolete, and because we base our sense of who we are through the stories we tell, we feel that we are losing our very identity. Thus it is only through telling new stories that we are able to rebuild our sense of self and to reconstruct an understanding of who we are, our place in the world, and what our expectations of the world are (Joseph, 2013, p. 145). 

My research has endeavoured to explore and respect the unique personal meanings individual people attribute to their distressing experiences and to fully recognise the potential significance of counselling service users’ social and economic circumstances.  I conclude that more qualitative biographical research is required to explore the personal meanings people attach to the serious social concerns and problems outlined in my investigation.

A broader societal perspective should acknowledge the need to shift attention urgently from the medical model of psychiatric forms of diagnosis, considering personal health pathology, to also considering our social, cultural and historical contexts as the potential root causes of our distress. Other forms of quantitative research, such as epidemiology (Bentall, 2023), would throw light on the extent of the disastrous health impact of long-term austerity policies resulting in rapidly diminishing welfare services (Age UK, 2023; Centre for Ageing Better, 2023; Joseph Rowntree Foundation, 2024). 

References:

• Age UK (2023) The State of Health and Care of Older People in England 2023.
• Alston, P. (2018) Statement on Visit to the United Kingdom by United Nations Special Rapporteur on extreme poverty. London: Equality and Human Right Commission.
• Bentall, R. P. (2023) ‘Challenging the medicalisation of psychological disorders’, in Sanders P. and Tolan J. (eds.) People not Pathology: Freeing therapy from the medical model. Monmouth: PCCS Books Ltd.
• Calhoun L. G. and Tedeschi R. G. (2013) Posttraumatic Growth in Clinical Practice. New York: Routledge
• Centre for Ageing Better (2019) The State of Ageing in 2019. London: Ageing Better Ltd.
• Centre for Ageing Better (2023) The State of Ageing in 2023. London: Ageing Better Ltd.
• Findsen, B. and Formosa, M. (eds.) (2015) International perspectives on older adult education: Research, policies and practice.  New York: Springer.
• Frankl, V. E. (1988) The Will to Meaning: Foundations and Application of Logotherapy. New York: Penguin.
• Heidegger, M. (1962) Being and Time. New York: Harper and Row.
• Joseph, S. (2013) What Doesn’t Kill Us: A Guide to Overcoming Adversity and Moving Forward. London: Piatkus.
• Joseph Rowntree Foundation (2024) UK Poverty 2024. York: Joseph Rowntree Foundation.
• Office for National Statistics (2022) Voices of our ageing population: Living longer lives. Calhoun L. G. and Royal College of Psychiatrists (2022) ‘Hidden waits force more than three quarters of mental health patients to seek help from emergency services’.
• Schmidt-Hertha, B. et al. (2014) Learning across Generations in Europe, 1-8. Rotterdam: Sense Publishers.
• Tovey, C. R. (2019) ‘The world and I are within one another’, BACP Private Practice Journal, March, pp. 10-14.
• Tovey, C. R. (2020) ‘Tales of transition’, BACP Private Practice Journal, June, pp. 8-12.
• Withnall, A. (2010) Improving Learning in Later Life. New York: Routledge.