Clinical Geropsychology: Implications for Practice in Medical Settings

Older adults are a rapidly growing segment of the population, who have high rates of chronic illness and who utilize health care resources heavily. Psychologists must become better prepared to work with older patients in geriatric settings, including geriatric assessment units, memory disorders clinics, and nursing homes. In addition, all psychologists will increasingly encounter older patients in environments such as primary care clinics, rehabilitation settings, and disease management programs focusing on problems that are prevalent in older patients (e.g., cancer, diabetes). Suggestions are offered for adaptation of usual clinical practice to address the special needs of older patients and their families, and recommendations made for advancing and expanding the practice of clinical geropsychology.     

The mental health system and older adults in the 1990s.

Trends in mental health services for older adults during the past decade were used to predict salient issues for the current decade. These include overreliance on inpatient treatment, increased use of general hospitals as treatment sites, inadequate integration with the nursing-home industry, and insufficient mental health referrals from general medical providers. In the decade ahead, the mental health needs of older adults are unlikely to be an identified focus; rather the issues will overlap with other priorities (e.g., biomedical research on brain functioning, alternative treatment programs for the chronically mentally ill, and containing health care costs). Advocates for the elderly will be successful to the extent that they cast aging services within the context of these other concerns.     

Counselling Older Adults Living in Residential Aged Care Settings: Four Illustrative Case Studies

The role of psychologists and other mental health professionals in long‐term care settings is undefined in Australia. Graduate psychology students receive little training in clinical geropsychology, and residential aged care providers do not routinely employ psychologists within such settings. Further, despite high rates of depression, neurocognitive problems, and other mental health problems, residents are rarely referred for evidence‐based psychological treatment. This article presents four case studies showing how psychology services may be employed in such settings within the context of a postgraduate psychology placement programme. These case studies emphasise the importance of engagement, the use of flexible and individualised treatment approaches, and the involvement of family and professional carers in the provision of psychological services. Psychology services in residential settings can have a positive impact on the care of older adults and their families.     

When Psychologists Work with Older Adults: A Survey of Ethical Beliefs and Practices

Despite the number of publications concerning legal and ethical issues faced by psychologists, and despite the increased interest in addressing specific concerns related to aging, little is known about the actual beliefs and practices of psychologists when they work with older adults. Given the changing demographics in the United States, many mental health professionals will have contact with older adult clients, and the focus of the present study was to examine the extent to which psychologists are prepared to work competently with older adult clients. Survey data were collected from 156 APA Division 12 (Clinical Psychology) and 17 (Counseling Psychology) members regarding the degree to which they engaged in each of 50 behaviors and the degree to which they considered each behavior ethical. Findings are presented in terms of percentages of responses to items on the questionnaire, and ANOVAs were performed on important demographic items to identify statistically significant differences among variables. Coursework in geropsychology or aging, specialization with older adults, and working with a high percentage of older adults were related to higher scores on the Overall Ethical Behavior scale. Females scored higher than males on the Overall Ethical Belief scale.     

Integrating Web-Based Applications into Aged Care: Two Case Studies and Discussion

In anticipation of the growing need for adequate mental health care for older adults in residential aged care facilities, psychologists are challenged to overcome several barriers that impede the uptake and delivery of their services in such settings. Information and communication technologies (ICT) have strong potential to overcome some of these barriers by supporting the delivery of evidence-based psychosocial treatments for common psychogeriatric issues. This paper presents two case studies that illustrate when and how psychologists can use various ICT applications (e.g., tablet devices, web-based applications) integrated with cognitive behavioural and reminiscence-based therapies. Both case studies demonstrate that ICT can effectively support the therapeutic alliance, enhance therapeutic engagement, and individualize treatment delivery to accommodate the needs of elderly patients. It is hoped that these case studies will encourage clinicians to consider using ICT to augment therapy with their elderly patients.     

Ageism in Mental Health and Health Care: A Critical Review

Discussions of aging and mental health widely assume that ageism among mental health providers is an important factor limiting access to mental health services for older adults. Given the widespread citation of ageism as a problem, we critically review the history of the ageism construct, and evidence for its existence in both mental health and medical professionals. There is surprisingly little empirical evidence for age bias among mental health providers. Considerable evidence does suggest differential medical treatment for older adults in such diverse areas as physician–patient interaction, use of screening procedures, and treatment of varied medical problems, although it is unclear whether age bias accounts for these differences. We suggest that innovations in delivery of psychological services, such as collaborative medical/psychological care in primary care settings, may ultimately prove more useful in improving access to mental health services than efforts to combat ageism.     

Mental Health Concerns of Older Adults Living in Long-Term Care Facilities: An Area of Expansion for MFTs

As baby boomers reach retirement age, the number of older adults living in long-term care will inevitably increase. Living in long-term care often brings psychological, relational, and emotional challenges for older adults, their families, and professional care-providers. Despite these trends and associated challenges, there appears to be an underrepresentation of attention addressing the mental health care of older adults and their families in marriage and family therapy (MFT) literature. Emphasis needs to be turned to assessing the quality and effectiveness of mental health resources for older adults in residential facilities, and to filling the gap where needed services are unavailable. The current review summarizes research addressing residential care for older adults, detailing a) mental health challenges faced by residents, families, and professional care-providers, b) effective mental health treatment options, and c) how MFTs are uniquely suited to working in long-term care settings.     

Application of the APA ethics code for psychologists working in integrated care settings: Potential conflicts and resolutions

ABSTRACT

Increasingly, there is evidence of the potential benefits of an integrated care model. In fact, the American Psychological Association (APA) supports the role of psychologists in integrated healthcare given the positive outcomes for patients in primary care settings such as increased access to mental health services, reduced mental illness stigma, and improved health associated with recognizing the impact of psychosocial factors on physical wellbeing. Less attention has been paid, however, to ethical dilemmas that may arise for psychologists working in integrated healthcare. This paper explores considerations for resolving potential ethical conflicts that may arise for psychologists working in integrated care settings.     

How changes in population demographics will impact health psychology: incorporating a broader notion of cultural competence into the field.

U.S. population demographics are undergoing striking changes that will impact health care and the research and practice of health psychology. An increase in the number of people who are older; belong to an ethnic minority group; have disabilities; identify as lesbian, gay, bisexual, or transgendered; or live in poverty will influence definitions of aging, health, and illness, and will challenge current psychological and medical treatment models. The authors argue that health psychologists need to become context competent for the field to be relevant and viable over the course of this new century. Health psychologists need to become aware of the multiple, overlapping contexts in which people live and apply this knowledge on a regular basis to research, practice, education and training, and policy in health psychology.     

Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations (e.g., older adults, people currently low in social status, immigrants, and racial/ethnic minorities) face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy.     

Improving Medicare coverage of psychological services for older Americans

Professional psychology's ability to meet older Americans' psychological needs and to simultaneously thrive as a profession will be closely tied to the federal Medicare program over the coming decades. Despite legislative changes in the 1980s providing professional autonomy to psychologists and expanding coverage for mental health services, Medicare coverage policies, reimbursement mechanisms, and organizational traditions continue to limit older Americans' access to psychological services. This article describes how psychologists can influence Medicare coverage policy. Specifically, the authors examine widely unrecognized policy processes and recent political developments and analyze the recent creation of a new Medicare counseling benefit, applying J. W. Kingdon's (1995) well-known model of policy change. These recent developments offer new opportunities for expanding Medicare coverage of psychological services, particularly in the areas of prevention, screening, and early intervention. The article provides an analysis to guide psychologists in engaging in strategic advocacy and incorporating psychological prevention and early intervention services into Medicare. As Medicare policy entrepreneurs, psychologists can improve the well-being of millions of Americans who rely on the national health insurance program and, in so doing, can help shape the future practice of psychology.     

Recognition and Treatment of Late-Life Addictions in Medical Settings

Addictive disorders among the elderly have emerged as a growing public health concern. As the proportion of the elderly population increases, more and more older adults will either develop addictions as a dysfunctional means of coping with the psychosocial consequences of aging, or will carry their long-standing addictive behaviors with them into later life. Among the most common of these addictions are smoking, excess consumption of alcohol, and gambling. This article briefly reviews these three addictive disorders and examines assessment and treatment options. The current cohort of older adults tends not to seek help for addiction problems in specialty mental health or substance abuse treatment. To improve rates of cessation and abstinence, assessment and intervention should be delivered in general medical settings such as primary care. With the addition of a behavioral health specialist, primary care has the potential to offer improved interventions in a cost-effective and time-efficient manner.     

The detection and management of mental health disorders in pediatric primary care

We reviewed the literature on the detection and management of mental health disorders within the context of pediatric primary care. Pediatricians have displayed a low sensitivity and high specificity in research investigating the detection of mental health impairment in children. Active management efforts characterize approaches to identified cases with more recently trained primary care pediatricians displaying a wider range of skills in managing mental health disorders. Few efforts have been made by pediatric psychologists to develop strategies for enhancing detection rates and management or to empirically evaluate the integration of pediatric psychology services into the primary care context. A conceptual model of factors influencing detection rates and ongoing management of mental health disorders within pediatric primary care is presented. Recommendations are made for more direct involvement of pediatric psychologists within the primary care context.     

General practitioners' perceptions of psychologists: A response to the Medicare changes in Australia

General practitioners (GPs) have historically been at the centre of primary health‐care delivery in Australia, including delivery of mental health‐care services. Recent changes, however, by the Australian Federal government have led to the creation of a number of mental health‐care items provided by psychologists that are now available on the Medicare Benefits Schedule. The aim of the present study was to examine GPs' perceptions of psychologists and the ways in which GPs have responded to these policy changes in making referrals for mental health patients. Nine GPs were interviewed regarding the provision of mental health‐care services. Analysis of the interviews indicated a number of themes including the benefits of the new Medicare policy in increasing accessibility of psychologists, GPs' frustrations with the bureaucracy surrounding the use of this policy, GPs' knowledge about the specific skills and training of psychologists, and the importance of GPs' matching patients and clinicians. Recommendations are made to facilitate the professional and clinical relationship between GPs and psychologists.     

Pragmatic Screening of Anxiety,Depression, Suicidal Ideation,and Substance Misuse in Older Adults

Older adults’ mental health needs are often unmet across care settings (e.g., primary or residential care) for a variety of reasons, such as mental health stigma and mental health care professionals’ lack of awareness of age-related changes in mental disorders. Screening, when coupled with access to evidence-based interventions, is effective at identifying and reducing anxiety, depression, suicidal ideation, and substance misuse in older adults across care settings. Unfortunately, due to lack of training many mental health care professionals may be unsure about what or how to screen, as well as which screening measures are available for use with older adults. Following professional guidelines recommended for older adults, we provide an overview of screening measures for anxiety, depression, suicidal ideation, and substance misuse that are evidence-based and meet pragmatic criteria identified by stakeholder research. Specific pragmatic criteria include screening measures developed with older adults (unless unavailable) as well as brief in length (items ≤30), time for administration (≤15 minutes), scoring (<5 minutes), and interpretation (<5 minutes). Other pragmatic criteria include screening measures readily available on the internet at no cost and usable across diverse settings (e.g., community, primary care, and/or residential care). For each measure, we also review relevant psychometric properties (e.g., reliability, cut-scores, sensitivity, specificity, and construct validity). Lastly, we discuss strategies to facilitate screening with older adults and direct mental health care providers to internet resources that can be used to learn more about assessment with older adults.     

Profession Differences in Family Focused Practice in the Adult Mental Health System

There is a large gulf between what psychiatric services should (or could) provide and what they do in practice. This article sought to determine practice differences between the differing professions working in adult mental health services in terms of their family focused work. Three hundred and seven adult mental health professionals completed a cross‐sectional survey of family focused practices in adult mental health services. Findings highlight that social workers engaged in more family focused practice compared to psychiatric nurses, who performed consistently the lowest on direct family care, compared to both social workers and psychologists. Clear skill, knowledge, and confidence differences are indicated between the professions. The article concludes by offering direction for future profession education and training in family focused practices.     

Counseling Older Adults with Dementia: A Survey of Therapists in Massachusetts

Although much has been written about therapeutic interventions with caregivers, little is known about the counseling services that are available for victims of dementia. The present study was designed to explore community mental health center (CMHC) services and therapists' experiences in providing psychotherapy to this population in Massachusetts. Only 27 of the 36 CMHCs in the state reported providing mental health services to older adults with a dementing illness. A survey of therapists who specialized in working with older adults found that the percentage of older adult clients estimated to have dementia averaged about half of their caseload. Older persons in the early phase of a dementing illness were most frequently referred for depression and anxiety, whereas those with moderate decline were most frequently referred for management of disruptive behavior. The most common services provided to clients with dementia consisted of assessment and individual counseling. The latter finding indicates a discrepancy between what is practiced and the professional literature. Most of the psychotherapy described in the literature concerns group interventions, which were rarely provided by the mental health centers in Massachusetts. The centers tended to offer individual counseling; however, little information on how to provide this form of treatment can be found.