A commonly held view of older persons is that they are mentally incompetent. Although there is some cognitive decline associated with normal aging, the majority of older adults do not demonstrate significant mental decline. For LGBT elders, psychosocial issues arise from ongoing discrimination on the basis of their sexual orientation and gender identity, lack of acceptance from the heterosexual community and family members, and isolation and exclusion from LGBT communities because of ageism. The general lack of support in many political, educational, and religious institutions and the distinctively oppressive social climate for sexual minorities in which older LGBT generations live creates personal conflict that can manifest itself through internalized disorders (e.g., depression, homophobia) or externalized disorders (e.g., suicidal behavior) (Mabey 2007). Counseling or therapeutic intervention can help LGBT elders who experience multiple discrimination to come to terms with factors associated with ageism (Sue and Sue 2013) and how the historically negative climate of discrimination and oppression shapes their experiences with, and impressions of, their own sexual identity (Heaphy 2007; Porter et al. 2004). However, it is important for counselors not to view identity as necessarily problematic (Berger 1982; Mabey 2011). In fact, researchers have introduced the concept of “crisis competence” or “stigma competence” (Almvig 1982; Balsam and D’Augelli 2006; Vaughan and Waehler 2010), in which coming-out by LGBT persons allows them to develop a competency for dealing with other crises or stigma in the life span, including difficulties associated with aging (Heaphy 2007; Kimmel et al. 2006; Schope 2005). Stigma competence was first developed with regard to persons from racial and ethnic minority groups who have multiple minority statuses, including sexual minority identity. In a study testing the theory of stigma competence with lesbian, gay, and bisexual adults over age 60, Lawson-Ross (2013) found that older sexual minority adults who were more accepting of their sexual minority identities had lower levels of internalized ageism and had higher levels of life satisfaction and happiness than their peers who were less accepting of their sexual minority identities.

Counseling Approaches. In working with LGBT elders, the selection of the counseling approach should be based on the individual and his or her needs. Counselors tend to adapt their approaches to working with a client based on the person’s developmental changes in life, the particular cohort to which the person belongs, and the social context in which the person lives (Blando 2011). Older persons fit into a contextual, cohort-based, maturity-specific change model (Knight 1996) that suggests they face particular challenges that are unique in later life. Older LGBT persons belong to a particular cohort with a collection of experiences and norms that differ from those of the present and from heterosexual elders (Blando). In the remainder of this section, we will present select counseling approaches that may be effective with older LGBT populations. These counseling approaches are not intended to be either inclusive or suggestive; rather, they are a starting point or serve as guidelines.

One of the most common forms of therapy with the general population and with older adults is cognitive-behavioral therapy (CBT). CBT may be particularly efficacious with older adults because of its focus on the present, strict structure, emphasis on self-monitoring, psychoeducational orientation, and goal oriented. Adjustment may need to be made for older adults who have developmental changes such as speed of processing in intellectual configuration (e.g., later life of crystalized over fluid intelligence), emotional changes (i.e., emotions are more nuanced and complex and may include co-experience of discrepant emotions such as being both happy and sad), and the person’s worldview (Blando 2011). CBT examines the role thoughts play in maintaining a problem, stress, or concern. Emphasis is on changing dysfunctional thoughts that influence behavior. The application of CBT with LGBT elders may be effective in addressing behaviors stemming from past experiences of discrimination with institutions and service providers, fear of homophobia-based victimization, and also from fear or anticipation of discrimination. In addition, Satterfield and Crabb (2010) demonstrated the effectiveness of CBT for depression in an older gay man.

Guided autobiography is another approach that is effective with older adults. Guided autobiography is used to help people understand and make meaning from their past through reading and sharing brief, written essays about their lives, and sharing their thoughts about these stories. It promotes integration, fulfillment, and competence (Blando 2011). LGBT elders often have not had a safe venue in which to explore or express their feelings, self-concept, or self-identity. Guided autobiography offers them a private mechanism to do so.

Another approach applicable to working with LGBT elders is persons-centered therapy (PCT) by Rogers (1951). Rogers described people who are becoming increasingly actualized as having four characteristics: (a) an openness to experience, (b) a trust in themselves, (c) an internal source of evaluation, and (d) a willingness to continue growing. PCT has emphasized on how individuals can move forward in constructive directions and how they can successfully deal with obstacles both within themselves and outside of themselves that are blocking their growth. Through self-awareness, an individual learns to exercise choice. The therapeutic goal is for an individual to achieve a greater degree of independence and integration (Corey 2103).

A number of important theories and approaches germane to public health are salient for LGBT elders. It is important that at least two distinguishing approaches are borne in mind regarding public health constructs. First, public health primarily concerns population health versus the health of individuals, and so, allowing for within-group differences, public health efforts concern the population of LGBT elders rather than the actions of individuals. Second, public health stresses the importance of prevention efforts above and beyond any other efforts. Though this is not to say that public health does not involve intervention, public health experts seek to improve the health of LGBT elders far earlier than most other discipline’s current intervention efforts contemplate, for example, preventing poor health outcomes as a result of historic stressors and inequities, such as, until recently, the lack of health insurance coverage for same-sex partners. In this section, we explain four well-recognized approaches/theories to public health that have applicability to LGBT elders, in particular the socio-ecological model, the theory of reasoned action, the health belief model, and the transtheoretical model of change (DiClemente et al. 2013).

The first of these approaches is the socio-ecological model, most closely associated with Bronfenbrenner (1986). Applied to LGBT elders, the model places the elder at the center of four nested systems (depicted graphically as concentric circles), consistent with an “elder-centered” (Quandt et al. 1999) approach to prevention and intervention. The microsystem, which includes the older adult, includes biological and personal factors that converge to influence how individuals behave as well as risk factors for adverse health outcomes. Consideration of LGBT elders at the level of the mesosystem focuses on close relationships (e.g., family, friends, neighbors) in order to explore how such relationships either protect against or promote LGBT health and quality of life. The exosystem identifies community contexts in which social relationships occur (e.g., neighborhoods, service organizations). This system promotes how characteristics settings may affect LGBT elders’ health and well-being. Finally, the macrosystem includes broad ideological values, norms, and institutional patterns that may foster a climate in which LGBT elders are either encouraged or prohibited, including changes in power and control dynamics (e.g., dominance of spouse/partner; reversal of child/parent roles) as well as age-related changes in social positions and financial resources.

One of the most well-known value-expectancy theories in public health is the theory of reasoned action, which grew out of research Ajzen (2002) and Ajzen and Fishbein (1980) on behavior and attitude. Central to this theory is that people have control over their lives and can consequently make a decision made about a behavior to adopt or discontinue. The authors contend that an elder’s beliefs and attitudes shape his or her intent to take an action and that social influences or norms on LGBT elders also affect behavioral intent. For example, if an LGBT elder believes that stopping smoking is a goal but that society would offer little help for him or her to do so because of a pervasive attitude that the elder’s sexual orientation is causing the problem, then he or she is unlikely to attempt the change because the cost of doing so is too high or difficult.