Geropsychology is “the specialized field of psychology concerned with the psychological, behavioral, biological, and social aspects of aging,” with clinical geropsychology (which is what I do) as the applied version of this field. Geropsychology is a fairly new specialty, only recently recognized by the American Board of Professional Psychology (or ABPP) as a bona-fide discipline, requiring specialized training, education, and experience. In today’s article, I’d like to touch on the differences between geropsychologists and generalist adult psychologists. I’ll be focusing on psychotherapy, psychological testing (including capacity assessment), and long-term care psychology.
Geropsychologists do a number of things, many of which resemble what more generalist mental health providers do. Like other professionals, we’re trained to provide services such as: individual psychotherapy, couples therapy, and family therapy. In my case, however, I focus my energy on older adults.
The differences often come up when you consider the specific problems faced by my population of interest. Older adults tend to be a more diverse group. They may express psychiatric issues differently, as is the case with depression and anxiety disorders, and may respond differently to psychotherapy than their younger adult counterparts. Often, older adults require therapy to follow a slower pace, so that they have more time to process what psychotherapists discuss with them. Their lives are more oriented towards reflection, reminiscence, and the past as a way of understanding the present, whereas younger adults are almost entirely oriented towards the future.
Highly noted geropsychologists like Ken Laidlaw and Dolores Gallagher-Thompson have, to varying degrees, predicated their careers on the proposition that psychological intervention in its various forms needs to be specifically and carefully tailored for the needs of older adults — as opposed to just grafting what we do with younger adults and hoping it works. A great reference work of theirs, in fact, is on my shelf: Cognitive Behavior Therapy with Older People.
Psychological Testing — One of Our Specialties
Generalist psychologists who work with younger and middle aged adults may perform intelligence and educational testing to assess learning or developmental disabilities. They may be familiar with the administration of “omnibus” symptom questionnaires such as the MMPI-2 and PAI, which are useful tools to help manage treatment, identify psychiatric disorders, assess for disabilities, and assess personality function.
Most likely, they are familiar with a number of brief assessment tools that fit well into a busy psychotherapy practice that specializes in issues common to younger adults.
However, when you work with older adults (and particularly when you work with a population that’s almost exclusively residential/long-term care), you can’t escape working with issues relating to what is now called “major neurocognitive disorder” by the American Psychiatric Association — also known as dementia. One of the principal risk factors for developing dementia, such as Alzheimer’s Disease, is advanced age.
Dementia doesn’t automatically mean, of course, that one immediately has to retire from life and be taken care of by others. Plenty of people with dementia, albeit usually in the milder range, are quite able to make major life decisions on their own. In other words, dementia does not automatically mean one has lost the capacity to make sound decisions in one’s best interest.
Sometimes, it’s just important that dementia is diagnosed early. This is important because:
- There are now medications that can be given to older adults with dementia that can help slow the rate of decline in a person’s memory or cognitive functioning (or, in rare cases, temporarily improve their functioning) and;
- Geropsychological assessment can help identify whatever cognitive deficits are an issue, so that the older adult can get the specific support they need.
Capacity Assessment — A Geropsychologist at the Helm
When does dementia take away the capacity to make important decisions for oneself? When do family members need to step in and take over decision-making for a loved one?
In the state of California, where I live and practice, there’s a process called conservatorship, where family members, friends, or loved ones can petition the court to essentially declare a person incompetent to manage their own affairs. There’s a standard form used to apply for conservatorship as well, which I’ve filled out any number of times, the “GC-335.” To complete it, it needs to be filled out by a licensed physician or a psychologist with at least two years experience diagnosing dementia.
Although physicians may regularly fill out these capacity declaration forms, the fact is psychologists are the ones best suited to perform the proper assessment and complete the corresponding forms.
Why is this? The capacity to make medical and financial decisions, such as the decision to accept or refuse medical care, sign a will, purchase a car, etc., are all cognitively complex activities. Each of these activities places different demands on a person’s knowledge, memory, attention, intelligence, and so on — all of which can be affected by dementia or cognitive impairment.
In my opinion, because of our targeted specialized training, geropsychologists are the best-suited professionals to evaluate a patient’s mental capacity. This becomes even more crucial in the case of an older adult, who due to illness has lost the capacity to make sound decisions.
Yes, there are neuropsychologists who specialize in psychological assessments, but unless a neuropsychologist has specialized training and experience working with seniors, I would still say using a geropsychologist is a better approach. I speak from clinical experience, for over the years I have seen assessments made by otherwise competent neuropsychologists who missed important details.
Long-Term Care Psychology
Long-term care psychology is my area of specialization and has been for years, and is one of the areas where geropsychologists least resemble their generalist counterparts. In my day job, I work as the staff geropsychologist at the VA Palo Alto Healthcare System, at their “Community Living Center” (which is VA-speak for nursing home).
Unlike a general practice psychologist, who may spend 100% of her clinical time seeing patients for therapy, doing direct one-on-one care (or perhaps running some psychotherapy groups on the side), I spend a lot less time doing psychotherapy. I certainly know how to do it, and I’ve seen plenty of older adults for individual, family, and couples therapy, but for a long-term care psychologist, a very significant portion of my time is spent not on therapy, but primarily working with the Center’s staff.
One reason for this is simply because individual psychotherapy, depending on how it’s administered, imparts a fairly significant cognitive load on the patients. In other words, the patient needs to be able to remember reasonably well from one psychotherapy session to the next, follow instructions, and have a capacity for insight — and otherwise be alert and oriented.
According to various sources, between one-half to two-thirds of any nursing home patients suffer from dementia. This means that psychotherapy is not the most useful tool for my patients.
But the problem is that people with dementia can get depressed, anxious, stressed, etc., just like everyone else! So, what to do? I’ve talked about it elsewhere (at length on my own blog), but basically, it boils down to this: as a person’s level of cognitive impairment increases, the greater the degree clinical staff need to rely on environmental manipulation to create meaningful therapeutic change, and the less we can rely on direct methods of change (like cajoling, convincing, education, psychotherapy, etc).
Instead of getting a depressed patient to do thought records or engage in activity scheduling to help reduce their depression, we as a staff need to offer them a variety of recreational activities, social stimulation, and positive experiences. People with dementia don’t have the insight to see that what they are doing is problematic, or be reminded to behave better when they are in stressful or unpleasant situations. They instead will need to have their environments remade for them, to support them to be happier and more functional.
It’s a tough task, but fortunately, there are evidence-based approaches to foster such change in dementia patients (such as Linda Teri’s STAR program, or Medicare/CMS’s “Hand in Hand” training, which I discuss in my free eBook, “Working Through Behavior Management Problems: A Guide for Dementia Caregivers“) that work rather well. But again, it boils down to this — as a geropsychologist in long-term care, my average day is not filled with back-to-back psychotherapy sessions and “fifty minute hours,” group therapy, and family therapy. Instead, you’ll see me hanging out at nursing stations, at care plan meetings, and doing lots of assessments, testing, and chart reviews. The most “bang for my buck,” frequently, is not necessarily talking with patients themselves, but talking with staff — who really are the ones that know them best!
Geropsychology Will Be Increasingly Important in Years to Come
As I may have mentioned previously, the “demographic tsunami” of aging Baby Boomers will mean that professionals and providers who specialize in the needs of older adults will be increasingly important. As I’ve indicated, there are several areas where the specialized education, training, and experience of geropsychologists make them invaluable members of an older adult’s healthcare team. Hopefully, society will catch up and realize this!