Community,
Connection, and
Well-Being:
Promoting and
Sustaining our
Mental Health in
Older Adulthood
Daniel Parker PhD
Clinical Psychologist
email:danielparkerphd@aol.com
This presentation:
 Suicide prevention in context
of LGBTI older adult mental
health and services
 LGBTI older adults & ageing
services: Addressing
increased risks & decreased
service access
 Improving our community
responses to longevity &
ageing
 What can we do to minimise
MH risks and increase positive
ageing?
A few key points:
 Depression and suicidality are not normal parts
of ageing
 Higher levels of depression, anxiety and suicidal
ideation among LGBTI adults, but
 Unclear picture for LGBTI older adults
 Aged care services, including mental health,
may not be seen as welcoming of older LGBTI
people
 Need a focus on inclusive services, outreach,
and decreasing obstacles accessing mental
health supports
Standing Strong, Living Long: In a time
of significant change
 Ageing and longevity: 14% of LGBTI
Australians are 65 and older; by 2050, 23% of us
will be 65 and older.
 “REDESIGNING LONG LIFE”
 Mental health focus on severe illnesses of later
life is both necessary, and
 Mental health services for OA must be
integrated, expanded and broadened
 LGBTI communities currently lack an ethos of
ageing that is much better than the mainstream
(Australian Government, 2010; ABS, 2010)
(Stanford Center on Longevity)
Social debate on ageing: How will it impact
mental health?




Is longevity a gift or a burden?
How will care for those with dementia?
Can we afford to live longer?
How will our lives be structured as we
age?
 What are the responsibilities of older
adults?
 The Best Exotic Marigold Hotel, And What
If We All Lived Together?
We know there is a complex
relationship between:
 Occurrence and presentation of older adult
mental health disorders and
 Conditions of life for older adults, and
 Beliefs about ageing held generally & by older
adults themselves, and
 Whether and how older adults use mental health
services to address these
Common issues LGBTI seniors share
with all older adults:
 A focus on mental and physical health in
ageing.
 Issues of continued workplace and
community involvement,
 Making informed choices about
retirement, health and volunteering;
 Defining new longevity and increased
years in ways that feel rich and
meaningful;
Common issues LGBTI seniors share with
all older adults:
 The impact of chronic diseases and illnesses of
older adulthood, including dementia;
 Concerns about living situations and
environments;
 Needs for interpersonal care and support, as
well as institutional supports;
 Shared changes in the experience and structure
of social relationships, including with friends and
family;
 Needs to focus at times on issues of
bereavement and end of life preparations. (IOM,
2011)
Demographic Change 1:
What we know about normal ageing, and the
mental health of older adults
(Carstensen, 2009)
 “Paradox of ageing”: Many emotional
aspects of life improve as we get older
 Stress, worry, anger all decrease with age
 Fewer report psychological distress
 Even the very old report better emotional
well-being than younger people
Demographic Change 2:
Living Longer
with Chronic Health Conditions
 ABS 2007 data: Rates of MI decline for older
adults but physical health comorbidities are high
 Many more will live with dementia
 Prediction: Living well with chronic conditions
will increasingly be a focus in MH services
 LGBT older adults seem to have more chronic
health conditions & disabilities
 HIV has made this a focus in LGBTI mental
health for many years
Demographic Change 3: “Social Capital”
and Implications for Mental Health
(Laidlaw & Pachana 2008)
 Family structures, patterns of partnership,
marriage, childbearing and extended family
structures are changing
 “Social capital” is seen to change, generally
decrease for older adults
 Mental health in older adulthood heavily
impacted by “social capital” issues
 Central to debates over the impact of ageing
and caregiving
Demographic change 4:
“Retirement” and Work in Later Life
 Mark Freedman (2007): Current views of retirement are
a recent and probably temporary response to increased
longevity
 Is “retirement” socially and personally unsustainable?
 Rapidly changing beliefs about and plans for “retirement
years” will be a major focus in psychotherapy and be
intertwined with presentations for depression and
anxiety.
ABS 2007 National Survey of Mental
Health & Well-being
 In 2007 did ask about sexual orientation
 Looked at lifetime and 12-month prevalence of a
range of mental disorders and health conditions
 12 month prevalences for those 16-85:
Any MH Disorder
20.0%
Anxiety Disorders
14.4%
Affective Disorders
6.2%
Substance Disorders
5.1%
ABS 2007 National Survey of Mental
Health & Well-being
12 month prevalence rates decline with age:
 For those 16-54:
25% (approximate)
 For those 55-64:
13.6%
 For those 65-74:
8.6%
 For those 75-84:
5.9%
 For older adults: More anxiety than affective
disorders, and few substance issues
 Consistently more anxiety & affective disorders
for women, substance use for men
Suicide: LGBTI people and the broader
population
 ABS (2007): .3% of men, .5% of women attempt
suicide each year
 65,000 non-fatal suicide attempts each year
 11.9% of men, and 16.6% of women report
suicidal thoughts over their lifetime
 3 times as many men as women complete
suicides
 Private Lives & LGBTI: 16% had SI within 2
weeks
 SPA: LGBTI completed suicides may be 3.5 to
14 times higher than mainstream
And a variable picture for older adults
experiencing depression and suicidal
ideation…
 WA, 1986-2006: Decrease in rates of suicide among the
elderly, possibly due to increased diagnosis, treatment
 2009: Highest age-specific suicide death rate was
among men 85+
 Older adult mental health: Greater prevalence of
depression and comorbid physical illnesses
 Increased lethality in suicide attempts
 Less warning or explicit clues, and increased lethality
 Less likely to access help and can’t assume will tell GPs
LGBTI Older Adults: Likely risk
factors…
 Within “LGBTI” our differing experiences
 Lifetime histories of suicidal ideation, self-harm
behaviours and depression
 Possibly higher rates of substance use
 Impacts of stigma, exposure to violence
 Presumed increased social isolation due to
being single, living alone, lesser supports from
biological kin
 Possibly increased health issues, disability,
lesser incomes
 Fears about aged care services
LGBTI Older Adults:
Possible protective factors?
 Resilience, “crisis competence”
 Possibly fewer gender differences, and lessened
risks for G,B vs. heterosexual men
 Strong “family of choice” and community
supports
 More varied but strong caregiver supports
 More experience using MH services, and in
more varied ways
 “Prepared for ageing” by living as LGBTI
LGBTI ageing as an emerging focus
 The stage of
documenting and
developing strategies
to address significant
health/mental health
disparities
 GRAI
 National LGBTI
Health Alliance
Recent Developments in LGBTI ageing



Aged Care Act—”Special needs group” &
funding for cultural competency training
MindOUT: Focus on mental health &
suicide prevention
Commonwealth National LGBTI Ageing
and Aged Care Strategy
Why look at issues facing LGBTI
older adults?
 Legal and ethical responsibilities/duty of care
issues
 LGBTI older adults now a “special needs” group
under Aged Care Act
 Older adults a growing sector of LGBTI
community, as in the broader population
 Can learn from the issues and solutions of
LGBTI older adults
Before the Therapeutic Alliance: How
LGBTI elders approach older adult services
 Access to healthcare and providers with cultural
competence major issues for LGBTI older adults
 Actual homophobia, transphobia and fears of
encountering this
 Limited disclosure with health care providers
 Delay accessing services
 As the result of discrimination, possible
increased health, mental health, substance use
issues.
Older Adult Services, Service
Access and LGBTI Elders
 LGBT seniors report feeling lack of
support from, and unwelcome in
mainstream ageing programs. (SAGE, 2010)
 Few programs engage in outreach to
LGBT seniors.
 Most unprepared to address
discrimination by workers and other
clients. (SAGE, 2010)
The recent historical context for LGBTI
mental health…
 Religion, law and mental health: Three
structures defining life for LGBT people
 1973: End of homosexuality as mental
disorder in the DSM (later for ICD)
 Gender Identity Disorder and DSM-V
 Cohort differences: 1969 and Stonewall
 “The closet” to “don’t ask, don’t tell”.
 Impact of HIV/AIDS in the 80s and 90s.
The impact of policies of exclusion
on LGBTI mental health
 G. Rosenstreich: Discrimination, LGBTI
mental health and suicide (2011)
 Fear and shame, social bullying, invisibility
and “minority stress”
 Community responses of “Pride”,
community, coming out, and identity
 Mental health outcomes: Increased
stress, depression, suicidality, and anxiety
What do we understand about mental
health for LGBTI older adults?
 LGBTI people have
different and higher rates
of MH disorders across
the lifespan
 It is unclear whether
improvements in mental
health with age occur for
LGBTI older adults
 LGBTI people are active
MH consumers
 Data for LGBTI people
poorly integrated with
broader OA MH literature
Limitations to data about LGBTI elders
 Existing LGBTI health data fragmentary
 LGBTI studies include few older adults
 Differing ways of measuring sexual orientation: Sexual
attraction, behaviour, and identity
 And with depression: Emotional state/mood, symptom
cluster or clinical diagnosis?
 Considerable diversity among LGBTI people, and
between age cohorts
 No MH intervention studies for LGBT seniors, or of
services that exist.
 National Suicide Prevention Framework and Strategy are
the only national policies to address LGBTI people (Carman et al.
2012)
Recent Australian summaries of
research:
 GRAI (GLBTI Retirement Association Incorporated)
and Curtin Health Innovation Institute, Curtin
University. (2010). Retirement accommodation and
aged care issues for non-heterosexual populations:
Literature Review. Perth, WA.
 Australian Research Centre in Sex, Health and
Society (2008):
Feeling queer and blue: A review of the literature on
depression and related issues among gay, lesbian,
bisexual and other homosexually active people.
Melbourne, VIC.
LGBT Older Adults:
Recent US summaries
Institute for Multigenerational Health (2011).
The Aging and Health Report: Disparities and Resilience
among Lesbian, Gay, Bisexual, and Transgender Older
Adults. Seattle, Washington.
Institute of Medicine (2011): The health of lesbian, gay,
bisexual, and transgender people: Building a foundation for
better understanding.
MetLife (2010): Still out, still aging: the MetLife study of
lesbian and gay baby boomers.
SAGE and MAP (2010): Improving the lives
of LGBT older adults.
ABS 2007 National Survey of Mental Health &
Well-being: Higher 12 month prevalence rates for
LGB vs. Heterosexual respondents
45
40
35
30
25
Homosexual/Bisexual
Heterosexual
20
15
10
5
0
Anx
Affective
SU
Any MH
Lifetime prevalence of
mental health problems
(Fenway Guide to LGBT Health, 2008)
 Higher levels of mood disorders, anxiety and suicidal
ideation/behaviour (Ruble & Forstein, 2008)
 Higher rates of utilisation of mental health services by
both lesbians (over last 12 months, 66% vs. 35.8%, and
gay men (56.7% vs. 24.9%) Ruble & Forstein, 2008)
 Increased lifetime prevalence of suicidal ideation for G/L
people, but not completed suicides Ruble & Forstein, 2008)
 For bisexuals levels of distress and mental health
challenges at least as high as for lesbians and gay men:
Higher rates of depression, suicidal ideation, and eating
disorders
 When control for impacts of environmental and social
stressors, some of differences may disappear
Private Lives 2 (2012): Survey of 3835
LGBTI Australians 16-89


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Older adults only 2.3% of sample,
N=125
Those 65+ report good-to-excellent
health more than other Australians
While only suggestive, MH of LGBTI
older adults appears to improve
compared to those younger
Private Lives 2 (2012):
Factors Impacting
Mental Health & Treatment
 Until 55, distress rates 2-3 times those of mainstream peers
 In the last 3 years, 30.5% diagnosed/treated for depression, 22.3%
for anxiety
 Bisexual and trans men and women continue to have higher rates of
MH issues than G & L peers
 34.6% report occasionally or usually hiding their sexual orientation
from care providers
 31% said they had not told their GP their sexual orientation
 Significant numbers had experienced harassment or violence
related to being LGBT in the last year:




Verbal abuse
Written threats or abuse
Harassment (gestures, spitting)
Threats of or actual assault
25.5%
6.6%
15.5%
8.7%
US Institute of Medicine Summary:
LGBTI Mental Health in Later Life
(2011)
 “LGBT people in later adulthood typically are
well-adjusted and mentally healthy.”
 Depression levels and suicidality appear to be
elevated among older lesbians & gay men (less
research on bisexual and transgender elders).
 For those with mental health issues, existing
systems are often ignorant, neglectful or overtly
discriminatory.
 Some evidence of crisis competence (resilience
and perceived hardiness) within older LGBT
populations, but more research is needed.
The Aging and Health Report
(2011)
 US federally funded, community-based
study of 2500 LGBT older adults
 71% rate overall mental health as “good”
and 74% satisfied with lives
 Poor health, poverty and lower education
associated with poorer mental health
 30% reported clinical depression, 24% told
had anxiety disorder, & almost 50%
reported disability
The Aging and Health Report: Concerning
rates of health and mental health issues





53% reported loneliness
30% reported clinical depression
40% reported contemplating suicide at some point
24% had been told they have anxiety disorder
47% reported disability - 26% obese – 9% HIV+
Lesbians: 53% disabled – 34% obese
Gay men: 41% disabled - 19% obese – 14% HIV+
 Transgender older adults higher risk for disability,
depression, suicidal ideation, & loneliness than non-T
62% disabled
The Aging and Health Report:
Wellness and Social Supports
 91% engage regularly in wellness activities
 82% do moderate physical exercise
 38% attend spiritual or religious services or
activities
 90% feel good about belonging to their LGBT
community
 Average level of social support = 3.1 (on a 4 pt.
scale) (
 83% report someone w/whom to do something
enjoyable)
Assets and Liabilities: Looking at LGBT
Older Adults’ “Social Capital”
 Expect to see the impact
of unequal treatment
under laws, programs,
and in services
 We do know that LGBT
people have differing,
non-traditional patterns of
care and support
 Older adult services may
not evaluate this area
accurately
LGBT Care and Support Networks
 More likely to live alone, to be single or
never partnered.
 Up to 42%, vs. 27% of general population.
(MMI National Boomer sample).
 In some urban samples: Up to 65-75%
lived alone.
 More likely to be poor, and with higher
education earn less than peers.
Mitigating factors:
Social networks and supports
 LGBT elders generally not isolated and lonely.
Many have children and grandchildren.
 “Logical kin”, “families of choice” and the role of
friendships. 2/3 identify “chosen family”. (IOM, 2011)
 “Crisis competence” and doing for oneself.
 Community organising as a public health measure:
“prevention and early intervention”.
 Political, community organisations and agencies:
Significant majorities belong to at least one.
 Over 70% say “being LGBT helps prepare me for
ageing” (MMI National Boomer sample)
LGBTI caregiving:
Using latent social capital
 LGBT Baby Boomers are active as caregivers
(Met-
Life, 2010)
 Reversal of gender expectations: Gay men a bit
more so than lesbians
 “Halving it All”: Necessity dictates changes in
roles more than ideology
 HIV epidemic: The emerging of caregiving
groups out of friendship networks
(Deutsch, 1999)
Working with Older LGBTI Clients
There is no evidence that anxiety,
depression or suicidal ideation manifest
differently in LGBTI clients, and one can
work around these issues in standard
ways.
Summarising what we do know about LGBTI
older adults and suicide prevention:





Until proven otherwise, should assume higher risks
for LGBTI older adults, and
We should expect LGBTI older adults to be less likely
to come forward and access generic services than
age peers; and therefore
Outreach to LGBTI elders needs to be targeted,
clearly inclusive and repeated
Sex differences in willingness to access services may
be less pronounced
MH services need to prepare now to work effectively
with increased numbers of LGBTI older adults, and to
ensure their comfort and safety within services
(especially inpatient and residential services)
Replicable/sustainable LGBTI-specific services?
Looking at the GRC-SAGE program
 Specific focus on LGBTI older adults as “at risk”
population, and on prevention/early intervention.
 Easy access: Could self-refer, low or no costs,
in a non-clinical setting.
 Age-friendly: Center was both a venue for
services, and a project developed and run by
older adults
 Retirement, education, and work: Paid staff and
older volunteers equally. Use of “secondcareer” psychology registrars.
 Effective MH models: CBT models used in
LGBTI community settings with supervision
Characteristics of GRC program:
 “Prevention and early intervention” of late life
depression
 Clients were ambulatory, not housebound, with
less severe health issues, and few had major
cognitive impairments
 LGBT-specific services in community center with
900 members, and social, fitness, educational,
food programs
California Prevention and Early
Intervention Initiative:
Service Components:
 In-home MH services (PEARLS – Program to Encourage
Active & Rewarding Lives for Seniors).
 Caregiver support groups and services.
 Elder Suicide Prevention outreach and services.
 Outpatient psychotherapy: CBT for Late- Life Depression
ReStart Counselling Program: Use of
evidenced-based therapy models
PEARLS: Program to Encourage Active and Rewarding Lives for
Seniors.
 Designed for home-bound clients.
 Minor, major depression, dysthymia.
 Solving problems contributing to depression (PST).
 Increasing social, physical and pleasant activities.
CBT for Late-Life Depression
Funds for training mental health staff in work with LGBTI elders
using these models
Mental Health Services
offered in coordination with:
 Living a Healthy Life with Chronic
Conditions: Peer-led Chronic
Disease Self-Management
Program.
 And with additional GRC support
groups:
 Caregivers
 Bereavement
 Cancer Support
 Drug & Alcohol Recovery/
12 Step
 Alzheimer’s & Parkinson’s
Support
Exercise, health, social activities.
Building mental health and suicide
prevention services for LGBTI Older Adults
 Evidenced-based services can be provided in
non-traditional settings, and are tied to range of
other wellness services.
 Because suicidal ideation is common and risks
can be high, ties to LGBTI-inclusive higher level
MH services are needed.
 While separate services are not essential,
increasing LGBTI service access needs to be
planned and proactive.
Developing mental health services
for LGBTI older adults…
 Suicide prevention must be addressed explicitly, and
within a spectrum of MH services.
 A mental health focus on depression is far too narrow.
 Couples issues, issues around sexuality and relationship
enhancement need more attention.
 Group therapy may be under-utilized, is popular,
reinforces behavioural changes and allows for
collectively addressing issues of meaning and
community.
A comprehensive and holistic
mental health approach…
 Full inclusion in the benefits and responsibilities
of ageing & longevity
 Build protective factors for older adults, and
address those most isolated
 Counter the invisibility of older adults within our
communities and become models for change
 Suicide prevention within a broad mental health
fabric
National LGBTI Health Alliance:
Strategies for change
 Promote awareness, expertise and linkages in
older adult/aged care sector: Train OA mental
health services in LGBTI issues
 Build our own community supports and
organisational capacity
 Influence policy and research, and integrate
LGBTI data into existing MH and ageing data
 Having specific LGBTI mental health services
can be important as part of an array of services
What do we define as best practices for LGBTI
older adult mental health and suicide prevention?
 Community awareness and services for those most at
risk
 Levels of interventions, from prevention/early
intervention to crisis intervention
 Have mainstream inclusive services, as well as LGBTI
specific mental health services
 SP services visible and accessible to LGBTI older adults
 MH services in venues where older adults can and will
access them, including in the home
 Minimise stigma around MH services, and integrate
services with chronic disease management, wellness
and healthy ageing programs.
A few ways to address these issues
now in our work:
 Follow developments
in LGBTI aging
 DoHA National
Ageing & Aged Care
Strategy: Make
comments, and use it
as important guide
 Use GLHV’s or
GRAI’s guidelines to
make services
inclusive
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