Ha rold G Koenig
Postoral Counseling with the Aged 39
3. Pastoral Counseling
widely difre re nt areas o f the United States, fro m the South and Southeast
with the Aged
(Texas , Florida, and North Carolina) 10 th e Midwest (Iowa a.nd Minnesota)
In the decades a head. we wi ll see more and mo re o lde r adu lts who a re in
need of counseling. One reasun for this will be the sheer number of elde rly
people in the population . W hile in 1998 there were 35 million persom age
sixty.five or over in the United States (13 percent of the population), there
will be more than 70 millio n by the year 2035, maki ng up well over 20 per­
cent of the popu lation. Government fu nding of men tal health services for
the elderly is already coming under substantial strain. By the year Z007, the
Medicare budget wiU increase {ro m its curre nt $200 billion rer year to mo re
tllan $400 bi ll ion pe r year, as national heaJth expenditures inc rease from
$1 ItriWon to S2.J trillion (Smith et aI. 1998).
Rates of depression and oth.er emotional disorders requiring counsel­
ing are expected to d ramatically increase amo ng the e lde rly ( Koenig e t at
1994) Baby boomer.; (those bom ben-veen 1945 and 19(7) have high rates
or de pression eve n now, whe n the ir he alth and economic st<l tus are bette r
than those of an)' o the r gene ratio n in hislory. As p hYSical he alth proble ms
in crease and eronomic well-bei ng decreases , rates of d epression are
expected to soar even higher. \'\'hil e medical care is keeping people a live
lo nger, many people e):perie nce c hro nic physical disability as they move into
th eir late r years, The estimated num be r of severely disa bled people in the
United States age sixty-fwe or over is expected to increase from the cu rrent
numbe r o f 2-4 mUlion to upwa rd o f 12 million in the next 30-40 years
(Ku nke l & Applebaum 1992). Part o f the reason fo r this is t.he increase in the
number of persons with Alzheimer's disease, who currently make up on ly 4
million o f the population bu t who in the decades ahead will rise to nearly 14
miUio n. Physical and me ntal disa bility are onen accompanied by depreSSion
and substance abuse-as the disabled d esperately attempt to cope with
de pende ncy antl loss of meaning, p urpose. and value . In this c hapte r, I wiU
revie w the major p roblems that aging persons must d ea l with aud suggest
ways of he lping aging persons overcome them.
38
Common Problems in Laler Life
As people age, c hanges OCC\l J tha t for many c reate stless alld e mo­
tional turmo il. In 1995, I administe red a questiollllaire to forty p a~tors or
assistant pastors from Protestan t (Episcopalian , Pres byt erian, Luth eran,
Methodist, Baptis t) Rnd Cat holic traditions. These clt:rgy were located ill
to the West Coast (California and Hawaii). Their ages ranged from n-venty­
one to seventy-two years; both me n and '-"Ome n were included. The propor­
tion of th eir congregations that were over age ~ixly ranged from less than 5
percent to 99 percent (average 44 perrent). Over 95 pen;ent o f part.icipants
in the sample were full-time . active pastors leading congregations in small to
mid-sized towns (35,000 up to 285,(00). We administered th~ full question­
naire to twenty-seven clergy. For the remaining thirteen, we administered a
b rie fer versio n that foc used o n the types o fi nfo.rmation cle rgy wanted to
he lp the m bette r meet the health needs o f older adults and the ir families.
We also administered the briefer version of the questionnaire to fifty
religiOUS caregivers who atte nded u workshop 0 11 religion and he alth care of
the e lderly he ld in Tampa, FlOrida, in Septe mber J995. These re ligiOUScare­
givers were actively involved in their local churches , Betv,.·et::n one-third and
o ne-half of participants we re "Ste phe ns" ministe rs, a nd one -quarte r were
e lde rs or dea(."Oos. Their ages ranged from forty- six to eighty-fo ur (average
age Sixty-eigh t), more than one-ha lf we re women: and all were Protestant
Questions in both questionnaires focused o n identi fyi ng the most common
reasons that o lde r ad ults o r their families ca rne in fo r counse ling.
Th e tell areas abou t wh ich clergy most fr eq ue ntly me ntioned th ey
wanted infonnation were the foUO\ving:
1. Understanding and helping persons with Alzheimer's disease
2. Depression, grieving over loss, suicide
3. Nonnal physical and me ntal changes o f agi ng
4. Caring for tlle e lde rly and SUpportillg tbe ircaregivers
5. Coping with lonelines5 and isolation
6. Spiritual gl"O\vth and deve lnpme nt in later life
7. He lp e lders feel useful, netded, and able to cope with c hange
8. Information about nursing homes
9. E nd-of-life issues
LO. Identj fying needs o f e lde rs and community resources to meet
them.
40 Clinicol Handbook ofPastoral Counseling
The te n areas most frequ e ntly mentioned by r-eligious caregivers were th e
fo llowing:
J. Alzhe imer's disease and me mory changes with aging
2. Combating depression and maintaining hope
3. H ow to maintain and optimize mental and emotional growth
4. Overcoming loneliness afld isolation
5. Coping with disability and dependency
6. Quelitioos about nursing homes
7. He lping persons use their fai th to cope with chronic illness
8. How to help caregivers of persons wit.h Alzheim er's or chronic:
illness
9. How to maintain p hysical health in later life
10. Comforting persons who are te nninally ill o r dying.
Among the highest priority areas were understandi ng the no rma l
changes of aging. coping wi th chronic physical illness, dealing with issues
related to disability and dependency, depression and grieving, anxiety.
Alzheime r's disease. caregiver stress. and loss of me aning and purpose in
life. N though I review these topics brie ny, a more in·depth aJlalysis o f each
o f these areas can be found in Counseling Older Adults (1997) and Pasto,.al
Care a/ Olde,. Adults (1998 ).
Changes of NormaJ Aging
How does o ne dele nnine what is no nnaJ and what is abno rmal in olde r
persons? Man)' no rmal changes of aging are similar to and ble nd in with
symptom s of common diseases in later life . I will rocus hece primari ly on
changes experie nced in cognltive , psycholOgical, and social functioning with
in creasing age .
Chan ges in the brain \vith normal aging result in mild loss o f memory,
which has been given the name Aged-AssOCiated Me mory Impairme nt. ~ TILis
H
level of me mory loss is comple te ly nonnal and e;>..-pected, and does not pro­
gres~ive ly worsen into dementia . Persons may have difficulty remembering
names, go into the kitche n and forget why tJ,ey went there, or need to carry a
grocery list with the m whe n shopping. These people, however, don't beoome
{."o nfused or lose tbe ir orientation in familiar settings, get lost while driving
(except in clearly unfamiliar e nviro nments), or become unable to bala nce
the ir checkbook or pay the ir bills. UsuaUy, me mory changes associated with
normal aging become more noticeable after a penon reaches seventy-five or
eighty years of age. They do not worsen rapidly, however. and never inte rfe re
to any great degree with the persons normal overall level o f funct1oning.
Postoral ClIUnseling with the Aged 41
Because ofchanges in brain function with age, older adults need more
time to learn new tasks, but given adequate time to do S0 , they are able to
learn a nd relain info rmation just as well as yo unger pe rsons. O ld er adults
may also need more time to "retrieve" infonTlation from memo ry. They may
not rem embe r something imm e diately, but \vill remem ber il aft er a rew
minutes. Thus, the re is some slowing down in me ntal processes with age,
but again, thi s should not interfe re with the person's ge neral level of func­
tioning. It is also not uncommon for o lder adults to notice minor problems
with balance, coordination, and re action time ; these should 001 automati­
cally be interpreted as di sease. NevertJ,eless, an underlying disease may be
the cause of any persistent symptoms and milst be ruled out by careful med­
ical examinatio n. Normal changes of agillg may also be affecled by disease o r
medications (either prescription drugs o r over·the-counte r medications).
Psychologicol and Social Changes. Olde r persons do not o rdin ari ly
experience great changes in the ir personalities or inte rests as they age . Per­
so naJity characteristics te Jld to re main stable from middJe age on.ward . The
older person who was outgoing and extroverted in young adu lthood wi ll
likely t"Ontinue to be so as she grows olde r. Ukewise, the introverted and
socially phobiC younger person wiUlike ly have tJlese traits whe n he is o lde r.
If anything, personality trails become more accentuated w:ith age. O lde r
persons will continue to enjoy the same things they enjoyed whe n they were
younge r, whe the r vtlOrk. hobbies, social re lationships, o r sexual activity.
Sadness, lo~s of energy and interest, and withdrawal from a previously
enjoyed level of social activity do not occur with normal aging. More than
likely, these are sympto ms o f treatable illnesses. The sa me is tJUe ror sleep
disturbances . \Vhile olde r pe rso~s normally experie nce a red uction in the
deep type of sleep and conseque ntly have mo re rrequent awakenings during
the nighl , thei r need for sleep remai ns only slightly less than whe n they were
younger (about seven ho urs per night). If older adult s do not get adequate
sleep at night, they wiU feel tired and fatigued during the day; unfortun ately,
sleeping aids are not very helpful and may lead to me mory loss and cognitive
impairment. Some o ld er adults also e~ pe ri en ce an advancem e nt in their
sleep cycle , such that they \vill tend to go to bed earlier in the evening and
wake up earlie r in the mo rning.
Besides normal agi ng, several sleep d isorde rs (in somnia, hypersom­
nia, sleep apnea-ce.ssation of breathing evidenced b y loud snoring) are
common in late r life , and must be suspected whe n dayti me somnolence o r
nighttime insomni a is prese nt. Such symptoms may he rald e mo tional o r
ph~ical problems, including depreSSion, heart disease, endocrine disease,
or side e ffects from me dicatio n. If no disorders of a ny type are identified
o n complete medical and psychiatric evaJuatjon. the n changes may be due
42 Clin/ctJl Handbook of Pastoral Coullseling
10 normal aging o r to und iagnosed disease that has not sufficiently p ro­
greS5ed to be clinically evident.
Anycomplaillt that inle rfe res with the qualityof liIe o f an olde r penon
sho uld be taken seriously and that person monito red care fuUy. Neverthe less,
many older adults wi ll worry excessively aboul these problems because of a
relative or fri end who had similar symptoms and was diagnosed with an
underl)ring disease . Once disease has been carefully ruled out , education
about th e normal changes o f agin g and reassurance by the counselor can be
helpfu l in relieving patients' unnecessary anxiety.
Chronic Physical Illness
C hro nic heaJth proble ms, many of which are treatahle . are commo n in
olde r ad ults and can markedJy inten ere with daily life . Among persons age
sixty-five or over, approximate ly one-half have at least two ch roll..ic medical
conditions. T hese medical conditions, particularly whe n disabling and asso­
ciated with othe r uncomfo rtable sympto ms, ofte n create e mo tional stress in
the pe rson 's life . Sympto ms related to c h ronic illness often inte rfere with
sleep, appetite. and rec reatio nal activities. They also interfere with social
re lationships and can lead to isolation and a se nse of alienatio n fro m others.
Even the patie nfs family me mbers may not reaJly understand, partic ularly if
th ey must lake on extrA burdens to care for the chronic.-a11y ill per!'.On . Thus,
older adults with chronic h ealth proble ms often feel misunderstood, lone ly,
and at times. he lpless (along with angry and frustrated).
Many o ld e r persons with health problem s are struggling with loss­
loss of physical vigor, strength , and the ability to do the things that give their
lives meaning and p urpose . For that reason, o lde r adults tend to talk a lo t
about the ir health proble ms. This can be misilllerpre ted by the counselor as
siOlply complaining Or as a preoccupation with health (hy poclwndrio.sis),
Many times, howeve r, older ad ults sim ply need to talk about a nd work
through the ir health losses as a way o f mourning or grievi ng those losses. An
important phase in th e Oflrmal gri ef process is talking abo ut the loss with
someone else. T he pastoral counselor who ac tively li stens to the patient,
expresses empathy a nd unde rstanding, and validates the persun's loss wi ll
he lp facilitate the g rie f process and speed the patie nts recovery.
ReligiOUS belief and activity are powerful resources thai can he lp
chro nicaUy ill elders overcome negative feeLngs and ('.:q>erience a retum of
purpose and me aning to the ir liveS. Unfo rtunately, re ligious resources are
fre que ntly unde rutilized - even by pastoral co unselors, who may have
learned to prefer traditional psychotherapeutic techniques. In a recent study
o f eighty·seven elde rly pane nts at Duke Hospital who had multiple ch ro nic
Pastaral Counseling with the Aged 43
medical illnesse., a~d were in great psycho logical distress, we found tbat
patients who scored highest on intrinsic religiOSity (or personal faith in God)
recovered significantly faste r from de pression than did persons with less faith
( Koenig e t 31. 1998). Deg ree o f intrinsic religlo u sness h ad a p articul arly
strong e ffect on emotional healing in patients whose physical health prob­
lems were not responding to medical treatments (the chronically disabled).
Inte restingly, psycho therapy and evel\ drug treatme nts for de preSSion did not
speed recovery as qUickly as intrinsic faith did. Pas toral counselors should
take advantage of the person's religiOUS faith in helping her adapt to and (:ope
with chronic changes in he r health. How can this be done?
How RelIgion Helps Elden' to Cope. We asked olde r persons with
chronic health problems how they utilized their religiOUS faith to cope wi th
health problems. We re<:-eived a tre mendous variety of responses. The most
commo n response was p laCing trust and fai th in Cod. Many said that they
simply turned their situ ation over to Cod and let Cod deal with it. This
helped them to stop won )'lng and obses.singabout the problems and move on
to mo re important things in life, which proVided meaning am1 purpose. E mo­
lional disorder develops when people become p reoccupied with or ruminate
over a si tuation they cannot change . Releasing the problem to God can break
the vicious cycle of WOn)' and preoccupation. Unfortunately, many elders try
to ta ke the pro b le m back from Cod and struggle \vith it once again . The
counselor must gently remind the m o f what they are doing and help them
once again to give the problem to Cod. This involves a pnx:ess of mental dis­
cipline that must be learned and practiced . (I am assuming, of course. that
the person ha... done everytlting possible to relieve the ch ronic health prob­
le m by seeking medical cru-e and is complying with medical treatments.)
The second commo n way that elde rly subjects reported they coped
with health p roble ms was through personal prdyer--conversatiorwl prayer
with God . They indicated th at praying to God somehow brought them com­
fort , and in p articular, hope. Even thoug h they did not have control over
their situatio ns, the l>elie fth at Cod did have contro l and would respo nd to
prayer b rought great relie f. Prayi ng to Cod also relieved tJle ir loneliness and
ir
se nse of isolation; even their caregivers o r family members didn't under­
stand the m, Cod did, and would give the m stre ngth to make il through .
A third way th at re ligion bro ught com fort was thro ug h the Bihle o r
other inspirational Uterature. Interestingly, many could not deS<'ribe why read­
ing scriptures made them feel better; it just did. Some said they sang religiOUS
hymns to lift the ir spirit... O thers Ole ntioned that reUgious rituaJs such as tak·
ing communion or saying the rosary were very he lpful_Many chronically ill
persons remarked how visits and prayers from clergy and church members
gave the m stre ngth to cope \vith health proble ms. Knowing that their names
44 Clinical Handbook ofPastoral Counseling
had been mentioned during church services or had been pl aced on a prayer
list often brought com fort . Despite seriuus di~abili ty and health problems ,
going to church was very impo rtant for many elde rly patients , but they often
needed assistance and tIanspOrt-dtion .
\Vhy me ntion thes~ spontaneous responses of c hronically ill persons
abou t how religion he lp the m oope? These responses give clue!> about how
pastoral counselors <-'<In help persons use their faith to help them cope wit h
chronic health problems.
• Elde rs need a re lationship with God . know that they can communi­
cate wi th him as the ir closest personal frie nd, and know that Illey are
not alone in IheiT sln_ggle nor in the hands of aimless fate.
• EJders need to believe that God Ison their side, has the iI best interests
at stake, a nd has a plan fo r them- a good plan. If the re is some pur.
pose and greater des.ign for hUO'laruty, then our continued presence on
Earth--even when sick and disabled-can have meaning and puJ}'OSe.
We as counselors must help eldo::n find out what role they play in God's
plan given their-current health cirr.umfionces (see following).
• Elders need to realize that Cod is steadfastly present <lnu v.riDing to
he lp . Having done e\'erything they can to solve their proble ms. eld·
e rs mu st leam to sto p struggling with those proble ms and le t Cod
take Over. If e lde rs caM o t do this, they may need he lp working
through trust issues, which On e n relate to how they communicated
with the ir 0\\10 parents. Explo re in an open and accepting manne r
the ir doubts and difficulties be lievi ng in or trusting God. Many may
feel e mbarrassed a nd guilty about having such doubts, bllt verb.. ua­
iog the m to a concerne d 3Jld respected liste ne r can ofte n facilitalo=
proble m resolution and developme nt of trust
• Elders often need to be reminded ofthe power of prayer. Prayer is a
ready 100It.hat can be used at any time of the day or night, and is cer­
tainly more accessible than th e o ne or two h our~ per month spent
with the pastoral counselor. Whe n as ked how th ey prayed, our
chronically ill subjects said they talked with Cod as if the Crea to r
were right the rE' in the room with them. God really knew them and
unde rstood everything they were going through , a fact th at reduced
the ir lo ne~ness and sense of isolation.
• Pnl)"i ng with ~ti e nts and even "laying on of hands " in the traditional
bihlical sense can help re affirm be lief in Cod's heaJjng powe r. This
can be even more importa nt if do ne within the local churc h,
Pastoral Counseling with the Aged 45
because it oommunjcates to the chronically ill elder that he is part of
a caring religiOUS commuJlity.
• Elders may need to be e ncouraged to join prayer groups or p ra~'e r
c hai ns that commit to help those in need . By lellrning about and
prayi ng for the needs of o the rs, the elde r will be di strac ted fro m
he r own problems anu may o btain a g re ate r se nse of purpose and
usefu lness.
• Elde rs need to be encoun~ged to read the Bible and o the r inspi ra­
liona/ lite rature . Our c hro nically ill patie nts fre que nt ly me ntioned
that this brought them comfort. E lders may be given passages from
the Bible that are particu la rly applicable to the ir situations and
e ncouraged to meditate on these passages. Biblical figures provide
rote mode ls for virtually every life situation . Conside r Job, David,
Jeremiah , and Paul. The pastoral counselor shou ld discuss these
passages with the older patient. Ask what these passages meol n, and
actively listen as the older client ponders these hiblica.l truths. The
psalms are particularly helpful for people who are depressed or anx­
ious, since they convey comfort and security.
• Elders should be encour:lged to participate in th e rituals of th eir
faith tradition. Such rilua.1s include Holy Communion , confeSSion ,
or othe r ritualistic bleSSings pe rfo rmed by the pastor. Mo biJizing
family o r church me mbers to prOvide e lders with the opportunity to
atte nd church and participate in these rituals may g reatly faci litate
the ir coping with illness. Fo r e xample, receiving communio n may
re mind the m ofhO\v Christ surTe red and died for the m, reaffinni 'lg
Cod's deep love and commitme nt.
• Elders sho uld be e ncouraged 10 confess mistakes, ask fo r fo rgive­
ness, and give forgi veness to othe rs. Wh ether ronfesslon is ritual­
ized, as in th e Catholic trad itio n, o r more spontaneous. as in th e
Prutestan t, it is import aflt lhat ch ronically ill elde rs be give n an
opportunity to talk about past mistakes and <l.sk forgiveness. Real or
im agi ned guilt over sins may prevent th e elder from turning to Cod
in his present difficulti es.
These are but a few ways pasto ral counselors can he lp older adult5 lise
the ir re ligiOUS be lie fs to cope with c hro nic illness. In summary, e ncourage
e lde rs to re late with Cod in a personal way; pro\oide the m with re ligiOUS mate­
rials that may inspire, motivate. and give hope; and allow the m to talk about
and work through negative experie nces with religion or guilt over past sins.
46 Clinical Handbook of Pastoral Counseling
Disability and D ependency
Despite enormom improve men ts in health care that can extend the
length of lire, less progress has been made in reducing the pnysicaJ disability
associated with growing o lde r. As noted earlier, du ring the next 30-40 yem
the number or seve rel), disabled persons age shty-fi ve or over in the United
States is expected to rise dra maticaUy. One of the major reasons why chronic
physica.l illne ss causes d e pressio n and o ther e mo tiona l d isorders is that it
results in physical disabili ty. Indeed, o ne of the strongest predictors o f
de pressio n in late r tire is disability leve! (Koenig & George 1998).
Being disabled and depende nt on olbers strips a person oC rus identity
an d selr-esteem . Nobod y wan ts to be a burden on othe rs, particularly o n
beloved family members . Many elders, however, have no other choice but to
rely on others for their basic care needs. It is not surprising that a large pro­
portio n of o lder adults would rather die than live for the rest of their lives
under such conditions, no r is it unexpected that e ld e rs t ry to numb the ir
pain with drugs o r aJcoho l. Adjustme nt to disability is part icularly diffi cu lt
wbe n the disabili ty occ ur~ sudde nly in an e lde r who has pre viously been
independe nt and self-sufficie nt . Even whe n disability occurs mo re slowly, a);
seen in Parkinson·s disease, A.1zhei me r's d ementia , or arthritis, adjusting to
dependenC)' can be one o f life 's greatest chalJe nges .
\Vh at can the pastoral counselo r say to the e lder \...ho is struggling with
depe ndency? FollOwi ng is a list of practical suggestions for facilitating adap­
tation to chroni c disability and dependency:
• Provide t.he e lde r with adaptive devices to maximize th eir independ­
ence and se lf-~ uffici e n cy.
• Listen care fully. leam about his situatio n, and try to put you rself in
his shoes a nd e mpathize wit h him,
• En(;o urage e lders to verbalize the ir feelings, and give the m the time
to d o so witho ut inte rrupting. Validate the se feelings. You may be
the o nly o ne in this person·s life with whom she can share what h ~ r
disability means to he r, bow it has afTet.-ted he r hopes and dreams.
Perhaps most important, gently and sensitivel), help the disabled elde r
discover amI use the special gill that Cod has given him for his particular sit­
uation (see follO\ving).
Pastoral Coon.reling wUh the Aged 47
D epression, Grief, and Suicid e
DepreSSion is the most comm on and treatable of all psychiatriC ill­
nesses in later life. It affects up to 15 percent ofpersons age sixty-five or older
in the United States, increases to nearly 2S percent of e lde rs in nursing
homes, and explodes to nearly 50 pe rcent of olde r adults hospitalized with
ac ute medicaJ iUness (Natio nal Institutes o f He alth, 1991; Koenig et al.
1997), It is unfortunate- that primary care physicians ide ntify only about
10-20 percent o f e lders ,vith de pressio n, and even fewer receive adequate
treatment for the ir de pression . MallYo lde r ad ul ts, however, seek out clergy
and religiOUS prufessionals for he lp in d ealing with depression and related
emotional disorders.
It is important to remember that depression is a treatable emotional dis­
order, rwe a nonnal ccn.sequenu of aging. Depression is a persistent and
endUring mood disturbance that interferes with a person·s ability to carry out
normal activities at home or pursue relationships with others, Depression has
a lifetime mortality rate of 15 percent from suicide , and suicide among older
adults is increasing in the United States, The causes of depression in later life
are many. An olde r adult may be vulne rable to depression becllUse or he redi·
tary or gene tic inOue nces, because of poor nurtwing or tra umatic experie nces
in childboocl or bectluse of biological cha.nges in the brain brought on by ill·
ness or medication. Severe brie f stress or long.tenn moderate -to-severe stress
can predpilate depression in a susct:ptible person, and the greate r susceptibil­
ity to dep re.~on, the less stress is needed to precipitate depression. Everyone
has a stress threshold above which they will experience depression.
Treatm ent for Depression. T he th ree types of treatme nt for depres­
sion are psychoule rapy, antidepressant medication, and e lectroshock ther­
apy (ECT). Milde r forms of d epreSS io n respond well to brief connseling,
whereas more seve re depressions require medication and some times even
e lectroshoc k the rapy. Four types o f psycho the rapy a re used to treat
d epreSSion in oJde r aduJts: cognitive-be havioral the rapy (C ST), illterper­
sona l therap y (lPT ), re mini scen t the rapy (RT), and supportive t he rapy
(ST ). Tn C ST, the most com mo n psychotherapy used today to tre at de pres.
sion , the tbe rapi st atte mpts to c hange dys func tional be lie fs and attitudes
that are generating negative e mo tio ns, These nega ti ve cognitions are
transformed into more positive . rea li stic ways o f thinking that promote
men tal health , The behavio ral part ofeBT eocourages and rewards activi­
ties that produce pleasure and fulmlmeat . IPT is a form of b rief psychody­
namic therapy that helps the e lde r explore pre~e nt and past relationships
and rework conflicts in them. In HT, the e lder is e ncouraged to perform a
·'life review'· in o rde r to come to te rms with experiences in t..he past that are
contributing to prese nt diffic ulties.
48 Clinical Handbook ofPastQraJ Cou ru-eling
Supportive the rapy (ST ) is the most effective tre .. tment when an older
aduJ t has recently expe rienced severe trauma or loss. aJld needs support and
nurturance from otJlets to cope with the experience. Becau se most depres­
sion in late r life is a result of Joss, supportjve therapy can be ve r)" helpful,
especially in the short te rm. \\Then depression persists over many months,
however. then re-educative the rapies (CST, lIT. or othe rs) become neces­
sary. Persistent or severe depressions, especially those associated with suici­
dal thoughts, weight loss, sleep di sturban ce, and oth er "endogenous"
symptoms uf depress ion, may also have biological origins. In that case, treat­
ment ofdepreSslon requires the combined use orantidepressant medication
and psychotherapy, and possibly ECf.
Antidepressants are o rte n rapidly effective i.n the treatme nt or de pres­
sion . These drugs act by affecting brain levels o f serotonin and nore pineph.
rine , chemicals that become d epleted when depressio n strikes . Sign ificant
improve ment may occur in sleep and mood during the first week of treat·
me nt, al though many pe rsons do not notice imp roveme nts until afte r six to
e igh t """eeks o f treatme nt. There are many diffe rent types o f antide pressants,
and several may need to be tried befo re the "right ~ drug is ide ntified fo r the
person. The type o f antidepressant that is b est for a p articular individual
dep ends on drug side eITects, the type of de pressive ryrnptoms the pe rson is
haVing , a nd the pe rso n's phYS iological make up. Persons do no t become
'" addicted" to antidep ressants like they do to minor t raoquilizers , sleeping
pills. o r n;lrcotics for p ai n . However. if persons slop an antidepressant sud ­
denly, they may experience a withdrawal reaction that can be qu ite seve re in
some cases.
Pe rsons who do no t respond to a ntide pressants or who have lj fe ­
threatening symptom s of d epression (seriou s suicidal impu lses or weight
loss that threate ns survival) n eed immediate treatment. E lectroshock ther­
apy (ECT) is .rapid, effective, and safe in tre ating severe late life depressio n,
particularly when accompanied by panmoia o r delusions. ECf may actually
have fewer adverse co mplicatio ns than antidepressant med icatio n whe n
used in frail , medically ill older pati ents who cannot tole rate thl:: side effects
of drugs. New methods o f administering ECT have romple te ly revulutioJl '
iz.ed this fo rm or treatme nt compared to olde r methods dramatized in One
Flew over the Cuckoo's Nest .
The Pastoral Counselor. For o lder adu.lts with more seve.re or persiste nt
fOnTIS o f depreSSion , refe rra.l to a psychiatrnt is ofte n the best OOUJ"'S.e o f action .
Primary care physici ans seldo m know how to adequately treat s~'erely
d epressed olde r adults, particu larly elders with multiple , complex h ealth
proble ms. Many milde r forms of depression e.'Ilst that pastoral counseloe! cnn
and should treat. These de presSio ns are o ft en re lated to the process o f grie f.
Pastoral Counselin g with r~ Aged 49
Supportive the ropyand li.s1e ning. followed by re -educative the rapies afte r sev.
e ral weeks o r months, is o fte n sufficient to effectively treat depression in these
patie nts. Recall that successful grieving requires that a person talk about and
work through their loss . Working through grief always requires time, SO don't
be surprised jf it take s longer for olde r adults to work through their grief.
E lders are one n grievi og fo r many losses aU at ollce-Ioss o f he 31th, loss o f
independe nce, loss o f family me mbers and life long frie ndships, loss of fanner
lifestyle, and loss of posi tion in the family andlor society. A major loss may
require six months to a year to CQmplete grieving, and for some losses (death
of a spouse of fifty years), it may take many years. possibly even the rest of the
persons life. N¢\~ rtheless , if afte r the lirst six moolhs grief remains severe and
disabling, the n treatment must be sought.
Re[igiorl and Dq> resslon. Psychoth e rapy that utilizes the religiOUS
belie fs of the patient has bee n shown to be more rapidly efTective in reliev­
ing depresSio n thall secular psychothe rapy in re ligiOUS clients (Propst et aJ .
1992; Worthingto n et al. 1996; Koe nig & Pritc he tt 1998). Pastoral coun·
selors, the n, have a powe rful tool at the ir disposal to he lp treat dep ression
and hopelessness that secular the rap ists do no t have.
Depression itself can make it much harde r fo r religiOUS elde rs to
access spiritua l resources. The d e pressed p e rson may cry out for relie f to
God. who appears no t to be listening (as in the psal ms). The re ligiOUS e lde r
may feel de se rted by Cod and angry o ve r he r pain, even questioning he r
be lie fs. Depression makes it difficult for people to read the Bible, pra)'. or
make the e ffort to attend church services . 1 try to go slowly "",;th these
patients , realizing th at it is ve ry important fo r them to b e able to exp ress
these feelings a nd fru strations towa rd Cod in a supportive , unde rstanding
atmosphe re . These ree lings almost always p ass away, and if successfull y
worked through , will lead to a stre ngthening of religiOUS faith. not its dis·
missal. It is also important oot to arou~ e any further guilt in depressed
patients if they a re no t engaging ill religiOUS practices; self-condemnatio n is
usually already ove rwhelming at this stage .
Referrn{ to Psychologist or Psychiatrist ,"""he n grie f d ee pens to the
point that therapy doe.~ no t see m to be progressing, or if the elder appears
stuck in II p articular phase o f grie f (ange r, bargaining, denia.!), then re fe rral
to a mental health specialist with advanced trai ning sh ould be conside re d .
Be low are symptoms suggesting that re fe lTaI to a psychiatrist is necessary:
• Se ...·ere desponde ncy or ioabil..ity to experie nce pleasure that shows
no signs of improvement after 3-4 weeks of co\1nsel..ing
• 5lbs. or more or we ight loss. or 10 Ibs. o r more of weight gain
• Severe proble ms with sleep (insomnia o r hypersomnia)
• Severe fatigue o r psycho motor retardatio n
50 Clin;cal Handbook ofPoswral CoufiSeling
• Marked irritability. agitatio n, or restlessness
• Bizarre ideas o r paranoia (de lus io ru)
• Suicidal tho ughts o r desire fo r death
How to Prevent Suicide. Being alert for the signs and symptoms of sui·
c ide is the best way to prevent it. Nearly i5 pe rcent of suicides occ ur in
people who have seen th eir doctor within the p revious month. Inte restingly,
the o lde r adult is even more like ly to have l:Untact with the ir pastor o r pas­
to ral counselor prior tn atte mpting suicide (Weave r e l al . 1996). Unfo rtu ­
nate ly, cle rgy are among the leiist like ly professionals to recognize signs of
impe nding suicide ( dt about th e same level as educate d la)' person s)
(Domino 1985). Be alert for the following:
• An olde r white male who is divon:ed , separated, or bereaved
• Concurrent physica l illness or disabili ty. especially if accompanied
by ch ronic pain
• Cognitive impai rme nt, reducing threshold for impulsive actions
• Akoho l abuse
.. Extre me hopelessness, sense that the re is no way out . arid tiredness
• Prio r history of suidde atte mpts
• Restless, agitated, or an:<ious type of depression (with energy tll plan
or carry out suicide)
order (OeD). For patiellts with th ese diso rders, which are thought 10 be <It
.. Few supportive re lalio nships
least partly bio lOgical in origin, medical treatme nts are extreme ly effective in
• POSSf"..ssiOl\ of the means to (;o mmi! suicide
• f amily histol)'of suicide
The re is a cardinal rule that all counse lors must fo llow, al'ld th ere are
no exceptions. A lwalj .~ ask a de pressed person about suicidal thou ghts. no
matte r how mi ld sy mptom ~ may appear. I have been surprised by the fre­
quency or sui<;idallhoug)I!S among thoS{' with seemingly the mildest depres­
sio ns. While a bit e mbarrassed, mosl patients feel re lieved to talk ai.xlUt this.
Re me mber that you do Jlo t need to worry alxHlI "giving the person a n idea"'
by a.'i king abou t suicida l tho ug ht s. Neverthe less , it is best to approach the
topic st~1y and gcntJy, giving the p..1tie nt pe rmi ssio n to reveal their secret. I
often ask tht" pat ient if he or she wished the Lord would just take the m or
end their life. Ir the answer is Yes. the n I1 JlO'Ve slowly to determine whether
or not the person has a plan and the me,ms tu call')' o ut the plan. I rso. I sug­
gest the oounselor not tl)' to discourage or argue with the person. but rather
to Simply listen, try to unde rstand their (Min, oommunicate to Ihe fll that you
really care. and get infOnllation.
if the cide r has pe rsistent tho ug hts about harming himself or has
thought of a plan. this re quires that you take action to ensure the person's
Pastoral Counseling with the /\gal 51
safety. If the e lde r is unwilling te. (;oopefllte with your plan, and )'Our level of
concern is great enough, the n it is necessary to contact famiJy me mbers. You
may wish to urge family to fill out commi tme nt papers at the magistrate's
o ffic'C that will direct the sheriff to bring the person for psyc hi ~hic evaluation
agaimt thei r will. You the coun selo r may also flU out commitment papers if
there are no ram ily members available. If the dder de<.-ides to leave your offic."e
and you are lOSing c'Ontrol of the situation, call 9 11 or the she riffs office .
Anxie ty Rnd Fe ar
As people get older, the re are many thin gs to worry about- safety and
vulnerability to assault or robbery, health problems of oneself or loved ones,
increasing dependency, declining finances . need ttl sell one's homes. need to
move to a nursing home. lo ne liness. Among these many worries. fear o f
death is oft e n lower down Mlhe list.
Approximately 6 percent of o lde r adollS have diagnosable <lo>.;etydisor­
de rs thai reqoire psychiatric treatme nt , including panic disorde r (seve re a IL\:­
iety lasting a few minutes associated with rac ing heart and breathlessness) .
generalized anxiety disorder (C AD; often associated with :llifelong history of
feeling anxiuu5 or nervous much of the time), and obsessive-rompulsive dis­
relieving symptoms. Medications, particularly bem.odiazepines, can be habit
fa nning anJ have n umerous side e ffects in rrail e lde rs, including cogn itive
impairmen t, disturbance o f balance. oversedatio n, and interactions with
other medications. The best long-term biological treatm ent of anxiety disor­
ders in older adu lts is antidepressant ther<lpy. These drugs, particularly the
newer ones, are much safe r. are no t habit forming. and are equally e ffective.
The only problem is that antidepressants take iongerttlwork, and may take as
long as 4-6 weeks. and even 8-12 weeks for OCD. before benefits a rt" evi­
de nt. 1 usuaUycomLine treatme nt wi th both a benzodiazepine and an antide ­
pressant d uring the first couple weeks of the r.lpy. and o nce the
antidepressant begins to take e ffect , the bc::nzodi azepine <:an be gradually
withdrawn . ConCllrrent coun seling and psycho therapy is 001 o nly helpful ,
but often is neeessary to ensureClllnpliance with medical treatmen ts.
The majority of olde r adults with less severe anxiety do not require
drug thempy. Fur these mo~ mino r fears and worries, cognitive-behavioral
the rapy (CST) is ofte n very e ffective. C ST for am.iety ofte n involves teach­
ing the e lder proble m-solving strategies. correcting skill de ficits. modif}ing
ine ffective (.'ommunication patterns, and <:hallging the ph)'sical e n\o;ronment
in which proble ms arise . C ST i.s particularly e rreclivt" fo r anxiety because il
52 Clinical Handbook oj Postoral Counseling
di.~co urages "catastrophic thinking" and worr)' about the di sa ~ l e rs that
" might happen:' C BT is a fe-e ducative therapy that trains e lders to munitor
their thoughts and cha11enge~ negative thinking that arouses anxiety. Several
pupu lac books now describe how people can le.u" these techniques on their
own . Telling Yourself tile Truth ( Backus & C hapin 1980) uses a C hristi an
approach 10 e BT that c hal le nges pessimislic lind disaste r-type thinl..;ng aJld
promotes heahJly thought patte rns that red uce anxie ty and fear.
Religion oud An:riet y. Freud e mphaSized the neurosis-producing
e ITects of religion in mally of his writings. SurpriSingly, how~'er, the re is lil­
tle evidence from scientific research that devout religiousness is asSOCiated
with grealer neurosis or an.dety. In fact , our research studies in both older
and younger ad ults have doc ume n ted the opposite . Anxie ty symptoms and
disorde rs appear to be less commo n among persons actively involved in reli­
gious community a nd those with strong re ligious faith ( Koenig e t aJ . 1993;
Koenig & McConne U 19<J9). SCriphlles contain many re fe re nces to anxious
persons who roceived great comfort rrom God and were victorious over dif­
ficult Circumstances (Isa 2G:3, Cal 5: 22, 2 Tim 1:7, tu name just a few).
Pastoral Counseling Int e rventions. I have had success \vith having
o lde r patients memorize the se scriptures and repe al them during times of
an.'dety. Studies h ave shown that repeNting verses o f re ligious sCrip ture and
saying repetitive prayers can redllce anxie ty faste r than the use o f traditio nal
psychothe rapy a nd drug the rapy a lo ne ( Be nson 1984 ; Azhar e l al. 1994 ). 1
have a1so seen group praye r, especially with laying (.n of hands. be e ffective
for re lieving symptoms of panic attac k. Many a nxit:ty disorde rs require
multi-modal th e rapy that indudes prayer, repeating re ligiOUS scriptures,
mecLcation , and c:ogniUve-b eh av:ioral therapy, wh ich may work synergisti­
cally in the ht:al.ing p rocess.
Ah.he imer's Oisease
Alzheime r-s disease (AD) is one of the most fea red dist:ases of later
life. AD is a progressive brair) d l .~ea se that increases in fre 'lue n cy with
ioc reuing age. While only 5-10 pe rcent of persons over age Sixty-five have
tht' disease, some surveys re port a prcY-dlp-nce of almost SO percent among
perso ns age e ig hty- fi ve or o lde r. Ma ny people are surprised to le arn Ihat
Alzhe ime r"s disea..<;e is the fou rth le adi ng ca use o f d e at h in adults, a ft e r
heart diseltSe, cancer, and st roke . AD is cha racte rized by a g radual. insidi­
ous loss of memory and distorbance o f highe r cognitivE' func tioning that
has a COUTse lasting from two to fifteen years. More specific symptoms of
the disorde r incl ude the follOwing :
Postoral Counseling with.he Aged 53
• Me mory loss (misp lad ng objects, repeating stories, missing appoint­
ments, difficulty learning fleW infonnation)
• Language problems (diffi culty flnding th e right wo rd , naming
objects; may advance Uninte lligible spe«:h and muteness)
• Declining visuospatial skills (may report diffi cu lty cooking, setting
the table, l'lxing o r manipulating objects in the ho me )
• Impaired cognition (proble ms hand.Ling and manipulating informa­
tion, pe rfo rming calcu lations, making rationlll j udg me nts, or per­
fonning other higher cortical tasks)
• Personality changes (decreased motivation, indiffere nt, impulsive,
irrit able , Increasing self-centeredness. preoccupied, and socially
withdrawn)
Cognitive Impairment Not Related to Alzheimer's Disease. Diseases
o the r than Alzhe ime r's d isease cause confusio n a nd me mory loss. While
Alzhe imer's disease is the most com mo n cause o f "de me ntia" (about two­
thirds of dementias), o the r diseases have slmilar sigm and sym ptoms. About
15--20 p e rcen t of de mentias rtlsult from miTli-strokes (also called multi­
infarct dementia) and anoth er 5-10 percent are cau sed by chronic alcohol
ab use (called a1 cohouc dementia). It is important to distinguish among the
various types o f cognitive impairme nt , because the treatme nts are difTe ren t.
The pastoral counselo r may need to educate the patie nt and his family about
tbe need to seek medical atte ntion in o rde r to make the correct diagnoses .
For patients with Alzheime r's disease. tbe re is nQ\V medical treatme nt that
may help delay progreSSion of th e diso rde r. particularly if treatmeJ1t is begun
during the early stages. Far patients with mu lti-infarct dementia. treating
blood pressure and taking an aspirin once a day may he lp prevent furth e r
strokes and worsening of me mory loss . Studies have shown that cessation of
alcohol intake may nol only halt the progressioll o f alcoholic dementia, but
may actually reverse some changes.
It is particularly important to diffe re ntiate deme ntia (which is large ly
irreversible ) fro m delirium (wh ich is comple te ly reversible ). De lirium is
characterized by a relatively rapid onset. a decrease in level of alertness, and
fluctuating level of consciousness . Delirium h3..~ manyof the same symptoms
as deme ntia and is o rten (."()nfu sed with it . Because delirium is usually
reversibl e jf the cau se is id entified and treated (infectio n , side e ffects of
medication , metabolic diso rde r), it is essentialtQ make the correct di agnosis
to diffe re ntiate this tra nsie nt concLtio n from irreve rsible d e me ntia . There
are othe r conditions, called ~ reve rs i b le de me o.tia ," that a re caused by certain
vi tamin d efiCie ncies (B-12 d e fiC ie ncy o r pe rnicious a ne mia). hypothy­
roidism, norma) pressure hydrocephalus, o r neurosyphillis . Treatme n t of
these conditions will ofte n improve the dementia.
54 Clinical Handbook. of Pastoral Counselill.g
Once the diagnosis of Alzheimer's disease is made , there are many
things that can be done to improve the management and care of persons with
this condition. Pastoral counselors can direct family me mbers to community
resources, support groups, and reading mate rials th at make life for both
patient and caregiver much easier. Patients in the early stages of AD often
need counseOng because of the depression nod fear that memory loss arouses.
Supportive therapies and positive colmseling are best. Spiritual inte rve ntions
can often be very helpful at thi~ time:rnd at later stages in the disease as well.
Remember that Alzheimer's disease is a cortical dementia, often sparing those
areas of the brain responsible faT emotion and feeling. Even jn the late stnges
of the disease, singing familiar religious hym ns, saying famiJiar prayers, and
participation in religious rituals (worship servic..,'es, communion, and so on) are
often deeply meaningfo! to patien ts. I suggest that all counse lors read th e
book, My Joumey into Aizheirner-'s Disease (Davis 1989), which tells the pe r­
sonal SIOI)' of a promine nt Protestant cle rgyman from Flo rida who contmcted
the disease, and how it affected his relationship with God.
Family Caregivers
Car egivers of older adults with dementia, stroke , cancer, and o ther
chronic or disabling illnesses often expe rie nce severe emotional distress and
some times even physical illness fro m tryjJlg to sho ulde r the heavy responsi­
bilities involved in caring for the needs of a sic k loved o ne. For caregivers of
persons with AWleime r's disease, the borden ofcare is even greater be<-ause
of the prolonged course of the illness (2- 15 yean). In the early stages, per­
sons with Alzhe ime r's disease lose the ir ability 10 pe rform usual ho usehold
c ho res, transfe rring these additio nal respo nsibilities to the ca regiver. The
caregiver must now pay the bills, cook the meals, clean the house, do
nx
the laundry, take care of the yard, the car, all in addition to caring for the
patient. tn the late r stages of the disease, deme nted persons (flay need to be
dressed, bathed , and mo nitored day and night so thaI they do oot wander
out of the home, get los t, or perform dangeroos activities inside the ho me
(tum on the stove or gas) . In the later stages, de mented patie nts become
incontine nt of urine and stool, and may become belligere nt o r even physi­
cally viole nt toward the caregiver.
As the disease progresses, about one-half to three-quartel"'!; of patie nts
become delusional (have fixed false beliefs that they cannot be dissuaded
fro m- that someone is stealing from the m o r othe r paranoid ideas). Such
de lusio ns may cause agitation alld ca use patie nts to strike ou.t at a spouse
whom they no longer recognize . As th e di rease progresses furth er, pati enl s
require twenty-four hour a day supervision and cannot be left alone.
Pastoral Counseling with the Aged 55
Demented persons often become active at night and sleep throughout most
of the day. The caregiver may be bus)' aU night hying to contain the patient,
qUickly leading to sleep deprivation and fatigue during the day (whe n o the r
household responsibi:ities must be carried out). With little time 10 nurture
relationships with others outside the home, it is easy to see how caregivers
can ea..ily become exhausted and socially isolated. Unde r this burde n of
str~s. without relief or respite, the caregiver may easily become initable and
impatient with the uncooperative demented relative and may even physically
abuse rum or he r. DepreSSion, anxiety, insomnia marital conllict, alcohoUsm.
and physical health proble ms are aU higher among caregivers (Canto r 1983).
What can the pastoraJ counselo r do to help the caregiver? The primary
task of the counselor is to help the caregiver obtain respite from the caregiv­
ing role , which is strange ly ofte n res iste d by th e caregiver. Relieving the
stress associated with caregivi ng, the n , must be a high priOrity fOJ the pas­
toral counse lo r. If the caregiver can get Ollt of the house fo r several ho urs
two or three times per week to care for her or his own needs, this oflen pro­
vides the emotional outlet necessary to reduce stress. Other thhlgs the pas·
to ral counselor can do to he lp the caregiver include:
.. Encourage tIle caregiver to seek companionship and social activities
outside the home
• Educate the ca regiver o n community resources tha t \vi ll provide
him with practical he lp in the caregiving role
.. Provide supportive counseling and spiritual support
• Provide information about the disease, its course, and options for
home care and nursing home placement
.. At the appropriate ti me, p rOvide the caregiver with pe rmissio n to
place their loved one in a nursing home.
The pastoral counselor sho uld realize that the church may also play an
important role i.n assisting caregivers. Church me mber.; can provide respile
by taking tums spending afternoons with the patient, allOwing the caregiver
time offl o rejuvenate herself. Volunteers must be trained, and the necessary
papecwork fill ed o ut that waives Jiability (preventing the caregiver from
suing the volunteer o r Ihe volunteer fro m suing the caregiver). Seve ral
churches may get together to establish an adult d ay care that provides struc­
tured activities for demented persons for several hours per day. While pri­
vate adult day cares exist in the community, it can be very expenSive. The
churc h may he lp provide the finances 10 pay for adult day care once a week,
although it is likely 10 be less expensive to simply hire someone for an after­
noon per week to sit with the patient in rus home.
56 Clioictl/ Handbook ofPastoral Coun.seling
Depress ion o r olllxiety may o fte n impair the caregiver's ability to carry
out his responsibilities. III that case, counse ling and, in some cases, re fe rral
fo r medical trea tment become necessary. Verbalizing these stresses to a
knowledgeable and inte rested counselor can belp relieve the sense of alien­
ation and isolation so commonly seen in these circumstances. Rather than
use any paliicular psychotherape utic technique, I suggest the counselor
actiyely listen and try to undt:rstand the caregiver's situation . Because
research has shown that religiOUS be lie rs are important fOl he lping care­
give.rs adapt 10 stre$Ses of caregiving (Rabins e l aI . 1990). I encourage 00110 ­
5eloTs to stress the person 's reli giOUS faith and relationship with God as
pOwerful <.'o ping resources. Also, be sure that the caregiver bas a copy o f The
36-Hour Day (Mace & Rabins 1981), a 250-page book that addresses many
important questions that (:aregivers struggle with. Directing the caregiver to
a support group in his community is o lten extremely helpful; support groups
may be located by ca1ling the Natio naJ A1weime r·s Association at 1-800·272·
3900 or 1·80()'62L·0.379.
Beeause most family caregive rs are extraordinarily committed to car·
ing fo r the ir loved (mes at home, the y are sometimes reluc tan t to give up
this responsibility I':ven when it is clea rl y necessary (for their own health
and for the h e alth of th eir loved one ). M any famil y caregivers fee l
extre mely gUi lty about making the deciSion to put their loved o ne in a
nursi ng home. Pasto ral counselo rs, with guidance fto m the patie nt's per·
sonal physic ian , are in an ideal positio n to "give permission" to caregivers
to p lace the ir loved une. The counse lor wi ll o ften need to work wi th the
caregive r to he lp ove rcome and work through he r guilt before such guilt
inte rfe res with the c ~regiver's ability to spend time with the relative o nce
tran sferred to the nursing hom e . Th e level of care in thE' nursing h o me
that the deme nted relative receives is heavily dependent upun how much
time family spe nds visiting the patie nt.
The pastoral counselo r should also encourage the caregiver to e nsure
that he r demented Inved o ne has the hest of medical ca re, Nearly 50 percent
of persons with d eme ntia in the midcUe an d late r stages have delu sions and
o ther p sychotic symptoms that cause the m to be agitated and diffic ult to
care fo r, There are e ffective drugs available for controlling these symptoms
that are safe and e fT£'ctive.
Loss of Meaning and P urpose
Lik~ persons o f any age. olde r people need to feel useful and needed .
It is in later life, however, th at challenges to feelings o f meaning and purpose
Pastoral Counseling with Ole Aged 57
in life occur most regularly, The re is a wonde rful scripture that puts this
problem in perspective:
KFor I know the pl ans I have for you," declares the Lord, "plans
to prosper you and not to harm you, plans to give you hope and a
future," (J er 29:11, Nrv)
What can a pastoral counselo r do to he lp tlle older person feel use fu l
and needed? The re is ple nty fo r e lde rs to do in this day and age. regardless
orthei r phy'Sical health o r seeming incap acities. They may need, however, to
c hoose new roles and tasks thaI a:re different from their old ones . These n ew
roles may then provide the meaning and purpose that old ones did earlier in
life. This is possible for persons of faith who believe that God has a p urpose
for this world and that the elderly p lay a vital part in that purpose. As the eld ·
e rly population increases in the United States. many o lde r pe rsons' b asic
needs wi ll incre asingly be diffic ult to me e t by SOciety. This \vi.ll produce a
tremendo us o pportunity for e lde rly cong regants to e ogage in a powerful
ministry to each other.
For this reason it is essential that o ld e r adults discover their un ique
God· given gifls and talenu for the time , age , and situ ations they are cur·
rently in . Every situation , no matter how dismal or seemingly hopeless, con·
tains a pote ntia l for bringi ng ahout a greate r good (Rom 8:28). God has
equipped every elderly pe rson in every circumstance o f life with a truent o r
ability that the e lde r can use to serve God by se lVing othe rs. Some gifts o r
tale nts are more ohvious th an o the rs, whic h may re quire more effort to
identilY. Older ad uJts who have a relationship wiili GOO and who have com·
mitted the ir lives to selVing God with th eir gifts will find opportunities all
arou nd th em to be useful and n eeded . The pastural counseior 's job is to
inspire and motivate the olde r adu lt to ide ntify his special and unique talent
and utilize that true nt in se rvice to God.
E ven the chrOnically ill o r disabled e lde r who is comple te ly de pende nt
on others and perceives that ske has no abilities or talents left has a unique
gi ft and tal e nt that must be discovered . If that tal e nt is used as God
intended., this will create inside of the pe rson a feeling of being useful and
needed. I encourage pas toral counselors to obtain the book A Gospel for t1u
Mature Yea rs (Koenig et a1. 1997), in which we outline in great de tail how
o lde r adults can identify ilie ir gins, ulili7.e those gi fts. and avoid the pitfalls
that discourages many from living what can be the greatest and most mean­
ingful stage of life .
58 Clinical Handbook of Pastoral Counseling
Rererences
Azha r, M. Z., Varma , S. L., & Dharap. A. S. " Religious Psycho the rapy in
Anxiety Disord er Pati ents." Acta PSljchiatriC(J Sca ndi,woica 90
(1994), 1-3.
Backus, W. & Chap in, M. Tellin~ Yoursel/the Truth. Minneapolis: Be thany
House Publishers, 1980.
Be nson , H . Beyond the Relaxation Response. New York: lImes Books, 1984.
or
Cantor M . "Strain among Caregivers: A Study Experience in the United
States:- Gerontologist 23 (l9S3):597....(){J.4.
Davis, R. My Journey -i nto Alzheimer's Disease. Whea to n, IL: T)'ndaJe
H ouse Publishers, 1989.
Domino, C. "Clergy's Attitudes toward Suicide and Recognition of Suicide
Lethality," Death Studies 9 (1985):187-99.
Koenig. H. G. , George, L. K.. Blazer, D. G, Pritchett, J.. Meador, K. C. "'TIle
Relationship between Re ligion and Anxiety in a Sample o f Commu ·
n ily- Dwe lling O ld e r Ado lts." Journal of Geriatric Psychiatry 26: 1
(1993),65-93.
- - , Ceorge , L . K., Peterson, 8 . L _~ Re ligtos ity and Remissio n from
Depression in Medically III Older Patienls.ti American Journtli of PSIJ·
ch;n'''J 155 (1998)536-42.
- -, George, L. K., Pe te rson. 8 . L ., Pieper, C. F. "De p ression in Med.
ically III Hospila lized O ld er AJuits: Prevalence, Corre lates, and
Course of Symptoms Based on Six Diagnostic Schemes." American
Journol a/Psychiatry 154 (1997): 1376-83.
- - , George, L. K., Schneider, R. "Mental Health Care fo r Olde r Adults
in the Year 2020: A Dangerous and AVOided TopiC." Gerontologist 34
(199< ),674-79.
- - . LaOHl.r, T. , Lamar. B. A Gospel for the Mature Yeors: Finding Fulfil/·
ment by Kn owing and Using Your Gift. New York: Haworth Press,
1997
- - & McConnell , M . The Healing Powerof Faith. New York: Simon &
Schuste r, 1999.
- - & Weaver, A. J. Cour ~eli"g Older Adults and Their Families; A
Horllibock for PaJtot'S and Religious Caregiurs. Nashville, TN: Abing.
ton Press, 19fY/.
- - &: Weaver. A. J. pastoral Corea/Older Adults. Minneapolis: Furtress
Press, 1998.
- - & Pritchett, J. "Religion and Psychotherapy:' In Koenig, H . C ., ed.,
Handbook of RrJig;oll and Mentol Heolth. San Diego: Academic Press
(1998),32.>-36.
PMloral Counseling with the Aged 59
_ _ & George, L. K. " De pressio n and Phys ica l Health O utcomes in
De pressed Medically IU Hospitalized Older Adul ts . ~ Am.erican Jour­
nal ofCeriatric; Psychiatry 6, (1998):2J0.-..4 7.
Kunkel, S R. & Applebaum , R. A. "Estimat ing th e Prevalence of Long­
Term Disability for an Aging SOCiety." Journal o/ Gerontology (Social
Sciences) 47 (1992):5253-5260.
Mace N. L., Rabins P. V. The 36-Hour Day: A Family Guide to Caringfor
Persons with Alzhelmer's Disease, Rcloted Oementing Illnesses, and
MerrwnJ Loss in Later Life. Baltimore. M D: Johns Hopld ns Univenity
Press, 1981.
National Jnstitutes o f H ealth . Diagnosis and Treat ment of Depression in
Late Life (Consensus Develo pme nt Conference Stateme nt 9, 3),
Nov-ember 4-6, J991.
Propst , L. R. , Ostrom, R., Watkins , P., Dean, T. , Mashburn . D. "Compara­
tive Efficacy of ReligiOUS and NonreligiOUS Cognitive-Behavior Ther­
apy for the Treatment o f Clinical DepreSSion in Religious Individuals."
Journal ofConsultlllg and Clinical Psychology 60 (1992): 94-103.
Rabins, P. v., Fitting, M . D ., Easthanl, J., Zaoom, J. " Emotional Adaptation
Overli me in Care-Givers for C h ron.ically III Elderly People." Age and
~ng 19 (1900), 185-90.
Smith. S. , Freeland, M ., He m e r, 5. , McKusick. D ., & the H ealth Expendi­
tures Projectio n Tea m. "The Next Te n Years of Hea lth Spendi ng:
\-Vhat Does the Future Hold?' Health Affairs 17 (1998): 128-40.
Weaver A. J., Koenig H . C., Preston J. MElderly Suicide Prevention: W hat
Pastors Need to Know:' Quarterly Review (Summer 1996): 151---67.
Worthington , E. L., Kurusu, T. A., McCullough, M. E ., Sa.ndage, S. J.
"Empirical Research on Religion a nd Psychotherapeutic Processes
and Outcomes: A IO-Year Review and Research Prospect us." Psycho·
logical Bulletin 119 (1996):448-87.