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Apr 16, 2013

Counseling Younger Residents in a Skilled Nursing Setting

When I began my internship for my graduate program, almost two years ago, with a company working within assisted living and skilled nursing facilities, I was excited to immerse myself in counseling older adults. My experiences throughout my internship working with older adults afforded me invaluable opportunities to learn and cultivate my passion for older adults. A great deal of my focus in my own research and writing revolved around the older adult population, and this blog has been driven by my experiences with my older adult clients. As I transitioned to a professional counselor with the same company I interned for, my work as a counselor took many interesting twists and turns, which have further allowed me to take on more complicated presentations and diverse cultures. One sub-population of people I never fully thought I would encounter in a skilled nursing setting was that of younger residents. When I use the term “younger” resident, I am referring to individuals between the ages of 18 and 64, as this age range was never one I witnessed in skilled nursing homes both personally with family and professionally as a counselor. However, a few months into working as a professional counselor, I began receiving referrals for individuals who were in their 30’s and 40’s, even a couple residents as young as 20! There was a common thread for which these younger referrals were residing in one of the skilled nursing homes I worked in; that common thread was the residents’ injuries due to violence. Taking on the referrals of younger residents provided an interesting dynamic, not only because of their injuries due to violence, but because these individuals were living amongst older adults 65 years and up. In order to gain a better understanding of strategies for working with younger residents in skilled nursing care, I searched for literature that explored this unique combination of age and setting.

As I looked through the limited literature, I found that younger residents in skilled nursing homes is actually not as unique as I expected. More specifically, younger residents needing the skilled nursing due to an injury resulting from violence were also growing in numbers. According to an analysis of statistics from the Centers for Medicare and Medicaid Services (2012), over the past eight years the number of nursing home residents younger than 65 has risen approximately 22 percent. In addition to the increase in younger residents within skilled nursing homes, the Centers for Medicare and Medicaid services have also found that 37 percent of younger residents require skilled nursing as a result of vehicular accidents, while 28 percent of younger residents move to a skilled nursing setting due to injuries related to violence. Furthermore, injuries due to violence are increasing with younger residents, while injuries due to vehicular accidents are decreasing. The rise of injuries due to violence leaving younger individuals to be place in skilled nursing homes requires nursing home staff to place an increasingly important focus on trauma and the skills necessary for working with trauma related presentations.

My aim in briefly sharing my experiences in working with younger residents within a skilled nursing home is to raise awareness to the growing presence of younger residents in such a setting, and to share some of my own strategies for best working with the challenges of the individual’s trauma, culture of violence, presentation, and nuances of living in a facility that is predominantly occupied by older adults. I have grown to focus my work with any client, but especially younger residents, on managing the relationship. I have come to realize that there is little predictability in the presentation of younger residents dealing with the physical, mental, and emotional aftermath of trauma. I have experienced depressive symptoms, withdrawal, anxiety, anger, aggression, and non-compliance. This is where I found managing the relationship to be such a vital tool because it allowed me to use my role as the counselor to provide some realm of consistency and control for the younger resident. Simple tools and strategies such as helping the younger resident to develop and stick to a daily schedule, letting the younger resident know exactly what tasks and goals will be explored and worked on that day, and using empathy, validation, and redirection to stick to that schedule and task proved to provide a solid foundation for my work with younger residents.

One more point I would like to touch on in working with younger residents residing in a skilled nursing home involves the importance of a larger support system and community connection. Younger individuals may have trouble relating or connecting to the activities provided within the skilled nursing home as many of the activities are developed with older adults in mind. Therefore, as a counselor, I have found in my experiences that gaining a sense of the younger resident’s greater support system and helping to ensure their involvement in the younger resident’s care and rehabilitation can have a huge impact on his/her quality of life. For younger residents who may not have any outside supports, connecting that individual to outside community resources, support groups, or activities can also provide a sense of belonging and hope as they work to recover and live out their lives.

Thank you for reading and please feel free to email me with your own experiences or ideas at
Lee Kehoe is a counselor working with the older adult population. It is her passion to serve the older adult population through counseling, research, and advocacy efforts, with the hope of raising awareness to the growing needs of older adults and their families.

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