Professional Psychology: Research and Practice In the public domain 2003, Vol. 34, No. 4, 435–443 DOI: 10.1037/0735-7028.34.4.435

Recommendations About the Knowledge and Skills Required of Psychologists Working With Older Adults

Victor Molinari Michele Karel Houston Veterans Affairs Medical Center, Houston, Texas Veterans Affairs Boston Healthcare System

Scott Jones Antonette Zeiss Perry Point Veterans Affairs Medical Center, Veterans Affairs Palo Alto Health Care System, Perry Point, Maryland Palo Alto, California

Susan G. Cooley Laura Wray Department of Veterans Affairs Veterans Affairs Western New York Healthcare System, Buffalo, New York broadly. publishers. Elizabeth Brown Dolores Gallagher-Thompson Veterans Affairs Boston Healthcare System Stanford University School of Medicine and Veterans Affairs allied Palo Alto Health Care System, Palo Alto, California disseminated its be of

to This article is an initial attempt to furnish recommendations for the skills and knowledge psychologists one

not need to work competently with older adults. We use two levels of competence across seven broad areas or is that are most relevant for professional practice. The first competence level is that required of general

and psychologists who provide some professional services to older adults; the second level is that needed by more specialized experts in the field for practice and training. This article is not fashioned as a “how to” user document and is not intended to disenfranchise anyone. Recommendations are proposed that delineate the Association types of competence needed for specific geropsychology activities that are relevant to a variety of settings providing mental health services to older adults. individual the Psychological of

use Adults 65 years of age or older make up approximately 13% of by the year 2020 (U.S. Bureau of the Census, 1996). With this our total population, and this percentage is expected to rise to 20% demographic surge there will be an increase in the number of older American personal the the by VICTOR MOLINARI received his PhD in from the University University of New York (SUNY) at Stony Brook. She is a clinical gero- for of Memphis. He is a professor in the Department of Aging and Mental Health psychologist for the VA Western New York Healthcare System and an of the Florida Mental Health Institute at the University of South Florida. His assistant professor of clinical medicine at the School of Medicine and solely areas of research interests are mental health interventions in long-term care Biomedical Sciences, Department of Medicine, Division of Geriatrics/ copyrighted settings, life review reminiscence, and personality disorders in older adults. is at SUNY Buffalo. Her areas of research include behavioral MICHELE KAREL received her PhD in clinical psychology from the Univer- management of , quality of life, burden of care, and intended sity of Southern California. She is a staff psychologist at the Veterans is health care utilization. Affairs (VA) Boston Healthcare System and assistant professor of psy- ELIZABETH BROWN received her PhD in clinical psychology from Florida document chology in the Department of Psychiatry at Harvard Medical School. Her

article State University. She is the acting chief of the domiciliary at the VA research interests include late-life , advance care planning for This Boston Healthcare System and an assistant clinical professor of psychology

This end-of-life care, and issues in geropsychology training. in the Department of Psychiatry at Harvard Medical School. Her research SCOTT JONES received his PhD in clinical psychology from Miami Univer- interests focus on issues of the seriously and persistently mentally ill, sity. He is the staff geropsychologist and neuropsychologist at the Perry program evaluation, and quality assurance. Point VA Medical Center, Perry Point, MD. His research interests include DOLORES GALLAGHER-THOMPSON received her PhD in clinical psychology interpersonal psychotherapy, neuropsychology of the , and phi- from the University of Southern California. She is a professor of research losophy of science issues. in the Department of Psychiatry and Behavioral Sciences at Stanford ANTONETTE ZEISS received her PhD in clinical psychology from the Uni- versity of Oregon. She is clinical coordinator and director of training in the University School of Medicine and is also affiliated with the VA Palo Alto Psychology Service at the VA Palo Alto Health Care System. Her research Health Care System. Her area of research is caregiver interventions with and scholarly interests include depression, sexual dysfunction, psychother- diverse populations. apy with older adults, and interprofessional teamwork. WE THANK George Niederehe and Mary Jansen for their astute comments SUSAN G. COOLEY received her PhD in clinical psychology from the on earlier versions of this article. University of Florida. She is affiliated with the Geriatrics and Extended CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Victor Care Strategic Healthcare Group at the Department of Veterans Affairs in Molinari, Department of Aging and Mental Health/MHC 1440, Louis de la Washington, DC, where she is chief of Geriatric Research and Evaluation Parte Florida Mental Health Institute, University of South Florida, 13301 and chief of Dementia Initiatives. Bruce B. Downs Boulevard, Tampa, Florida 33612-3899. E-mail: vmolinari@ LAURA WRAY received her PhD in clinical psychology from the State fmhi.usf.edu

435 436 MOLINARI ET AL.

adults requiring psychological services (Jeste et al., 1999), as well psychologists for a number of reasons: (a) It will help to serve the as a corresponding need for training in geriatric mental health profession of geropsychology; (b) it will act as a guide for training (American Psychological Association [APA], Interdivisional Task psychology students in geropsychology at the graduate, internship, Force, 2000). The need for specialized training in geropsychology and postdoctoral levels; (c) it will help psychologists to identify to address the common mental health problems of later life is their continuing education needs for serving older clients; and (d) based on the very extensive extant literature about how aging it will posit specific descriptive criteria for job positions that entail differs from other periods of the life cycle. Just as specialized varied amounts of expertise in addressing the mental health needs knowledge is required to treat children and adolescents effectively, of older adults. so too is such knowledge needed to treat the unique problems that The TAGG aims to provide recommendations for the skills and individuals confront in the latter half of life. Persons in their 60s, knowledge needed to work competently with older adults. A recent 70s, 80s, and beyond are likely to experience more negative life series of articles discussed geropsychology training within clinical events than younger or middle-aged adults. For the most part they psychology graduate (DeVries, 2001; Qualls & Ogland-Hand, also experience a variety of cognitive and physiological changes 2001), internship (Fruit, Gantz, & Hefner, 2001), and postdoctoral (e.g., decreased memory efficiency, decreased physical strength, (Hinrichsen, 2001) programs. That discussion was framed mainly etc.). Responding to these challenges, they draw upon their history with regard to the recommendations of the APA Interdivisional

broadly. of effective (or ineffective) coping, as well as on their personality Task Force on Qualifications for Practice in Clinical and Applied style, social support systems, and values and belief systems that Geropsychology (2000) in their draft document concerning prac- publishers. interact (with other factors—e.g., genetics) to determine whether tice in clinical geropsychology. We have extended these efforts mental health or mental illness occurs. Understanding the adjust- and outlined in detail the skills we believe are necessary for allied

disseminated ments of aging and the typical/atypical responses of older adults competent practice in postgraduate employment settings by mod- its be of requires a genuine interest in this stage of life, plus a broad ifying the framework of the 1992 National Conference on Clinical to spectrum of knowledge and skills (Bengston & Schaie, 1999). Training in Psychology (Teri, Storandt, Gatz, Smyer, & Stricker, one not or There is now an APA Committee on Aging (CONA), and 1992; reproduced in Knight, Teri, Wohlford, & Santos, 1995). By is clinical geropsychology has recently been awarded proficiency broad consensus, the 1992 report conceptualized three levels of and status by APA’s Commission for the Recognition of Specialties training in aging-related knowledge and skills: (a) general expo-

user and Proficiencies in Professional Psychology. Although the profi- sure to aging; (b) training in clinical geropsychology compatible Association ciency status acknowledges that a certain set of skills and knowl- with proficiency status; and (c) training in clinical geropsychology edge is necessary to work competently with older adults, there has compatible with specialty expertise. Although that framework was

individual been much debate about how to adequately credential those li- helpful conceptually in developing an understanding and definition

the censed psychologists whose clinical responsibilities involve some of clinical geropsychology, we propose a simpler model for the Psychological of work with an older population (Niederehe, Gatz, Taylor, & Teri, purposes of this project. Our model combines the first two levels

use 1995). A recent survey of professionally active APA members of the 1992 model as a single level but maintains the third level of indicates a fair amount of practitioner interest in seeking the the 1992 model as a separate category. We thereby use only two

American proficiency credential (Qualls, Segal, Norman, Niederehe, & levels of aging-related knowledge and skills: knowledge and skills personal the Gallagher-Thompson, 2002). Over half of the psychologists in this that all psychologists should have to work competently with older the by survey believed that they need some additional training in gero- adults in general practice (Level 1), and knowledge and skills

for psychology, and 27% were interested in obtaining such a creden- required for practice and training by more specialized experts in tial if it is developed. It is expected that such interest will heighten the field (Level 2). Level 2 defines the expected competencies

solely with the aging of the population and with the concomitant increase of a psychologist with an advanced clinical privilege in copyrighted in the number of older adults that most practicing psychologists geropsychology. is will have in their caseloads. This article is intended to be a broad schema to provide the intended

is Issues of aging and mental health are of great importance to the groundwork for what should be accomplished in a licensed psy- U.S. Department of Veterans Affairs (VA) as well. With the chologist’s training to prepare him or her for practice with older document

article increasing number of adults living longer, there has been a con- adults. The recommendations are not meant to be applied as rigid

This current increase in the number of older veterans (FY 1999 Annual standards. These ideas reflect the opinions of the individual mem- This Accountability Report, 2000) and an ever-increasing demand for bers of the TAGG and do not represent the official policy and quality mental health programs for older veterans (Kim, Jones, & position of the VA. The methodology for the development of these Goldstein, 2001). The VA administers the largest health care recommendations was straightforward. TAGG members were system in the United States and employs over 1,300 clinical and asked to provide examples of local recommendations for geropsy- counseling psychologists, making it the largest single employer of chologists within their medical center sites, including examples of psychologists in the nation. Background on geropsychology ser- objectives for geropsychology postdoctoral training at several vices and training in the VA system has been described elsewhere sites. These were collected, systematically examined, and inte- (Cooley, 1995). grated into a first draft. Because our recommendations are in- The VA Technical Advisory Group in Geropsychology (TAGG) formed by the draft document (“Training Guidelines for Practice in has been a vehicle of communication for geropsychologists within Clinical Geropsychology”; APA Interdivisional Task Force, the VA system. Pursuant to geropsychology’s designation as a 2000), we asked one of the authors of that document to review proficiency area and the fact that most VA psychologists are caring them for consistency with the original document’s intent. for older veterans, the TAGG undertook the daunting project of In summary, at a circumscribed level, this article attempts to defining what it is that psychologists need to know to provide furnish specific criteria that can be used in practice settings to competent care to older adults. This task is important to all translate educational theory into quality professional behavior. It PSYCHOLOGISTS WORKING WITH OLDER ADULTS 437

serves as an initial attempt to delineate the types of competence The psychologist is familiar with the strategies commonly used needed for specific geropsychology activities at general and more by older adults for coping with age-related changes (e.g., normal advanced levels of competence. On a broader level, the intended vs. pathological mourning, mnemonics, memory aides, par- audience is the entire community of mental health professionals ticipating in challenging and meaningful activities). who work with older adults or their families. Our expectation is that this delineation of requisite knowledge and skills in geropsy- chology will be helpful to a wide range of health care profession- Normal Aging: Level 2 als, including directors of training in professional psychology who The psychologist understands developmental and life span per- wish to incorporate age-related topics into their curricula, mental spectives regarding the continuities and discontinuities between health care line executives who need to make informed decisions younger and older adulthood. about hiring psychologists who will be spending at least some of The psychologist manifests a thorough understanding of the their time with older adults, or educators who must tailor their theories of and database regarding the difference between normal continuing education plans to reflect the demographics of the and abnormal aging and knows how to readily translate and apply aging population. We hope to stimulate discussion about the merits them in clinical situations. of this approach for improving quality assurance in the psycho-

broadly. logical care of older adults and to generalize these ideas across different clinical provision sites. ASSESSMENT publishers. In what follows, we list the specific skills and/or knowledge needed to function as a Level 1 or Level 2 psychologist within 7 Topic 1: Methods allied

disseminated broad competency areas that we believe are critical to geropsy- its be of chology practice. These 7 competency areas encompass the 13 Assessment: Level 1 to competency areas in the APA Interdivisional Task Force (2000) one

not The psychologist demonstrates appropriate levels of empathy, or draft report. We collapsed their first 7 knowledge areas into one is category called “normal aging” and emphasized the remaining 6 eliciting maximal cooperation of older adults with assessment and competency areas that are more relevant to professional practice. procedures (i.e., older adults may require more introduction to the assessment process than younger adults to fully engage them). user The 7 competency areas we address are (a) normal aging; (b) Association assessment, including methods, diagnostic issues, and communi- The psychologist conducts diagnostic interviews and basic psy- cation of results; (c) treatment, including skills and/or knowledge chological testing to accurately identify adjustment, mood, person- ality, and thought disorders in older adults. She or he administers,

individual relevant to therapeutic decision making, general mental health, scores, and interprets common tests of depression specific to older

the health-related issues, personality disorders, cognitive disorders, adults (e.g., the Geriatric Depression Scale; Yesavage et al., 1983). Psychological of working with , working with couples and families, and The psychologist identifies symptoms associated with the above

use treatment planning; (d) prevention and crisis intervention; (e) consultation, including access to services, advocacy, program de- disorders that may be caused by concurrent medical conditions and medications. The psychologist gathers information from a variety American velopment and evaluation, and supervision; (f) interfacing with

personal of supplemental sources, including other team members, family the other disciplines, including areas of communication, role in team

the members, medical records, and so forth. by education, team process, and team stress management; and (g)

for special ethical issues in providing services to the aged, including issues of communication, elder abuse reporting, incorporation of Assessment: Level 2 solely diversity factors, and informed consent, confidentiality, and copyrighted decision-making capacity. Throughout, it is assumed that those The psychologist uses standard guidelines, conducts brief men- is psychologists who meet Level 2 criteria de facto meet Level 1 tal status exams, or administers brief screening instruments, such intended

is criteria. as the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975), to determine general cognitive function. The document

article Recommendations for Psychologists Working With psychologist refers for formal neuropsychological evaluation as This appropriate. The psychologist uses the results to address specific

This Older Adults concerns of the team or caregivers regarding older adults’ ability to perform activities of daily living (ADLs; e.g., eating, bathing) or NORMAL AGING instrumental activities of daily living (IADLs; e.g., shopping, Normal Aging: Level 1 using the phone). The psychologist communicates the results of these assessments clearly and sensitively to the older adult, family, The psychologist has a basic understanding of theories of and other relevant care providers. healthy aging that includes familiarity with the research on cog- The psychologist is knowledgeable about normative data for nitive, social, psychological, biological, and sociocultural aspects testing instruments commonly used with older adults and interprets of aging at a level represented in an introductory graduate textbook test results accordingly. on normal aging. The psychologist administers, scores, and interprets tests used in The psychologist thinks in terms of interindividual variability dementia evaluations and differentiates among such conditions as and understands that “normalcy” encompasses a range of delirium, dementia, and depression. The psychologist makes ap- performance. propriate modifications of standard testing procedures to accom- The psychologist recognizes both historical (cohort) and devel- modate older adults with sensorimotor impairments and/or poor opmental influences on clinical presentation. stamina. 438 MOLINARI ET AL.

Topic 2: Diagnostic Issues and a conceptual framework to be used to make informed referral for treatment decisions of older adults. Assessment: Level 1 The psychologist is aware of empirically supported treatments The psychologist performs behavioral assessments and com- for older adults. bines the results with information obtained from cognitive assess- The psychologist makes informed decisions concerning how to ments and diagnostic interviews to identify factors associated with implement interventions commonly used with older adults (e.g., a variety of presenting concerns, such as nonadherence to medical grief and loss group) in typical practice settings (e.g., primary care, regimens, poor health-maintenance behaviors, mood or motiva- geropsychiatric unit, ). tional changes, or a range of potentially unsafe behaviors (e.g., wandering, erratic driving). Treatment: Level 2 When interpreting assessment results, the psychologist is able to interpret the significance of somatic complaints. The psychologist can apply theoretically sound and empirically The psychologist assesses lifestyle and behavioral factors asso- supported psychological treatments for older adults (e.g., ciated with problems such as smoking, poor diet, sleep disruption, cognitive–behavioral, psychodynamic, and interpersonal therapies and pain management in older adults. for depression, cognitive–behavioral therapies for insomnia, be- broadly. The psychologist assesses patients’ understanding of medical havioral and environmental approaches for behavior problems associated with dementia) and can appreciate the need for further publishers. consent and assists staff in presenting health-related information to patients for informed decision making. geropsychology intervention research.

allied The psychologist assesses the level of caregiver/family strain to The psychologist makes informed decisions concerning how to disseminated its identify the factors contributing to it. appropriately implement a broad array of general and specific be of interventions (e.g., environmental, care coordination, life review to one group) with older adults across a variety of institutional and not Assessment: Level 2 or

is noninstitutional settings, including home, day center, and nursing The psychologist is knowledgeable about the prevalence of homes. and psychological disorders in older adults and has a working under-

user standing of the comorbidity of mental and physical disorders. Association Areas of specific knowledge include (but are not limited to) the Topic 2: General Mental Health unique manifestations of mood disorders, disorders (and Treatment: Level 1 individual their frequent co-occurrence with depression), posttraumatic stress

the disorder, delirium, sleep disorders, substance disorders (e.g., alco- The psychologist provides appropriate interventions for older Psychological of hol, illegal drugs, prescription, and over-the-counter medications), adults with less complicated mental health problems in community use sexual dysfunction, and thought disorders in older adults. settings (e.g., simple breavement, adjustment to retirement). The psychologist assesses an older adult for capacity to perform The psychologist provides effective treatment to older adults for American ADL and IADL tasks, to manage medical needs, and to handle mental health problems commonly encountered in medical and personal the personal finances. The psychologist can assess how an individual’s psychiatric settings, including depression, anxiety, grief and loss, the by cognitive abilities may affect adjustment to his or her environment. adjustment reactions, and caregiver burden. for When interpreting assessment results, the psychologist takes account of the influence of various medication regimens on the solely testing performance of the older adult. Treatment: Level 2 copyrighted

is The psychologist conducts formal competency assessments for clinical and/or forensic purposes. The psychologist provides effective treatment to medically intended and/or cognitively frail older adults for a variety of mental health is problems, including sexual dysfunction, late-life depression, com- document Topic 3: Communication of Results plicated bereavement, and those with dual-diagnosis in a variety of article

This Assessment: Levels 1 and 2 home, community, and institutional settings. Practitioners at this This level of expertise treat older adults with either late onset or chronic The psychologist demonstrates the ability to communicate ge- serious mental illness (e.g., schizophrenia, psychotic mood disor- riatric assessment findings to a broad audience, writing prompt, ders) with the most up-to-date treatment protocols. clear reports that answer the referral question, providing relevant The psychologist provides effective treatment for frequently feedback, and relating test findings to practical recommendations occurring comorbid conditions among older adults (e.g., anxiety/ relevant to the unique aspects of daily care of older adults. depression; psychosis/dementia).

TREATMENT Topic 3: Behavioral Health-Related Issues Topic 1: Decision Making for Interventions Treatment: Level 1 Treatment: Level 1 The psychologist provides treatment for behavioral health- The psychologist understands the types of appropriate interven- related issues, which may include pain management, smoking tion modalities commonly used with older adults, the types of cessation, insomnia, dietary control, and/or poor adherence to locations in which these modalities are commonly implemented, medical regimens. PSYCHOLOGISTS WORKING WITH OLDER ADULTS 439

Treatment: Level 2 Topic 6: Working With Formal and Informal Caregivers

The psychologist functions as an expert consultant in the treat- Treatment: Level 1 ment of geriatric behavioral health-related issues by understanding the nuances of the relationship between physical and mental health For with relationship problems precipitated by and how best to change the unhealthy lifestyle habits of older aging-related cognitive problems, the psychologist conducts inter- adults. ventions (e.g., psychoeducation, support groups, individual psy- chotherapy) to reduce emotional distress, enhance understanding of the patient’s strengths and limitations, and communicate effec- Topic 4: Personality Disorders tively with other care providers. The psychologist conducts interventions with professional care- Treatment: Level 1 givers to reduce emotional stress and enhance understanding of the older adults’ strengths and limitations, and communicates effec- The psychologist formulates strategies to help the care providers tively with other care providers. or family members enhance the cooperation of older adults with behavior problems associated with personality disorders.

broadly. Treatment: Level 2

publishers. Treatment: Level 2 The psychologist is aware of the range of psychoeducational and cognitive–behavioral interventions developed to help family care- allied The psychologist has an in-depth understanding of how person- givers of frail and/or demented elders. disseminated its ality is affected by the aging process and cognitive impairment. The psychologist serves as a consultant to other health care be of

to The psychologist functions as an expert consultant in the for- professionals who intervene with overwhelmed and/or poorly ed- one mulation of strategies to help the care team manage and enhance

not ucated caregivers. or

is the cooperation of older adults with complex behavior problems

and associated with comorbid personality and/or cognitive disorders. Topic 7: Working With Couples and Families When indicated, the psychologist directly intervenes in the user

Association treatment of older persons with personality disorders (e.g., to assist Treatment: Level 1 a narcissistic husband cope with wife’s dementia or family alienation). The psychologist conducts effective interventions with older

individual couples and/or family members to relieve relationship difficulties

the and/or promote collaboration with the treatment team. Psychological of Topic 5: Cognitive Disorders use Treatment: Level 1 Treatment: Level 2

American Using an in-depth understanding of developmental changes in

personal The psychologist knows when and how to refer for additional the marital and parent–child relationships, the psychologist conducts

the assessment a client who is suspected of experiencing even mild by effective interventions with older couples and/or family members

for cognitive impairment, especially if there is suspected interference with the client’s usual functioning. to relieve long-standing relationship difficulties exacerbated by the aging process, and/or to promote collaboration with the treating solely team. copyrighted

is Treatment: Level 2

intended Topic 8: Treatment Planning

is The psychologist collaborates in the treatment/management of mild cognitive deficits due to age-related cognitive decline or early document Treatment: Level 1

article dementia.

This The psychologist implements treatment strategies to assist older Using a theoretically grounded case conceptualization based on This adults in coping with specific deficits from dementia and cognitive general psychological theory, the psychologist constructs and im- loss due to other medical illnesses (e.g., stroke), in collaboration plements an appropriate treatment plan for psychotherapy in cog- with rehabilitation staff (e.g., occupational therapist, physical ther- nitively intact older adults. The psychologist’s understanding of apist, speech pathologist) as needed. the older patient and the treatment plan is modified according to The psychologist implements clinical and/or computer-assisted new data as treatment progresses. cognitive rehabilitation strategies when appropriate and treats co- morbid psychological problems that interfere with the rehabilita- Treatment: Level 2 tion process. The psychologist devises and/or acts as an expert consultant to Using a theoretically grounded case conceptualization based on other staff on treatment/cognitive rehabilitation strategies for def- in-depth developmental considerations, the psychologist con- icits in attention, memory, awareness (agnosia), executive func- structs, implements, and revises treatment plans appropriate for tion, as well as the global deficits inherent in dementia. psychotherapy with cognitively impaired older patients (such as The psychologist serves as an expert consultant and/or treats those with dementia) as well as for older adults with complex psychiatric/behavioral complications of cognitive disorders such concerns such as safety or care coordination issues or comorbid as depression, delusions, agitation, wandering, and so forth. conditions. 440 MOLINARI ET AL.

PREVENTION AND CRISIS INTERVENTION Topic 3: Program Development and Evaluation Prevention and Crisis Intervention: Level 1 Consultation: Level 1 The psychologist provides basic mental health promotion and The psychologist assists with geriatric mental health program mental disorder prevention resources to community-dwelling older development and program evaluation activities in creating the care adults and/or family members of older adults. resources needed for optimal treatment of older adults.

Prevention and Crisis Intervention: Level 2 Consultation: Level 2 The psychologist provides community outreach for early detec- The psychologist takes primary responsibility for and oversees tion of mental health problems for older adults in crisis and makes geriatric mental health program development and program evalu- appropriate referrals. ation activities. The psychologist provides effective mental health services for The psychologist is a consultation resource on mental health and older adults in crisis and recognizes unique precipitating circum- aging for administrators who develop programs for older adults stances of older adults in crisis (e.g., death of spouse of many with mental health needs in community, medical, and psychiatric broadly. years, , stroke). settings. publishers. Topic 4: Supervision CONSULTATION allied

disseminated Consultation: Level 1 its be

of Topic 1: Access to Services

to The psychologist is familiar with the process of clinical super- one

not Consultation: Level 1 vision of geriatric mental health cases, including common emo- or is tional reactions of trainees in confronting illness, loss, and con- A psychologist is aware of points of entry for aging services for and cerns about patient autonomy or safety. such common problems as dementia (e.g., the Alzheimer Associ- The psychologist provides appropriate supervision and feedback user ation) or geropsychiatric symptoms (e.g., the local VA clinic or

Association to trainees at the externship and internship levels for mental health hospital). problems of older adults managed in the training setting. This The psychologist is familiar with procedures for older adults to supervision is limited to the areas of competence associated with individual access mental health services in his or her primary care setting. Level 1 expertise. the Psychological of Consultation: Level 2 Consultation: Level 2 use The psychologist is aware of geriatric mental health resources The psychologist provides appropriate supervision and feedback American available in community settings (e.g., geriatric day centers, care- to trainees at all levels, including postdoctoral fellows in geropsy- personal the giver support groups) and, given the constraints of resource limi- chology. In addition, the psychologist may supervise and train the by tation, how services can best be provided. other providers, including medical students, social work students, for The psychologist is aware of impediments to geriatric service psychiatry residents, and paraprofessionals in geriatric mental delivery and provides consultation to agencies serving older adults health issues. solely (e.g., Area Agency on Aging) on how efficacious mental health copyrighted is services can be provided in a cost-effective manner. INTERFACE WITH OTHER DISCIPLINES intended is Topic 2: Advocacy Topic 1: Communication document

article Consultation: Level 1 Interface: Levels 1 and 2 This

This The psychologist appropriately refers questions about effec- The psychologist communicates effectively with members of tive channels of advocacy for older adult mental health the treatment team in either a multidisciplinary or an interdiscipli- resources/programs. nary setting, both in team meetings and with individual staff members. In private and for-profit settings, the psychologist fosters com- Consultation: Level 2 munication with care providers in other agencies through proactive communication that seeks input and shares only information that is The psychologist knows and uses the most effective local chan- relevant to improving the quality of care provided by that agency. nels of advocacy for older adult mental health resources/programs (e.g., attends meetings of the local mental health association com- mittee on aging). Topic 2: Role in Team Education The psychologist is an expert consultant on the most effective Interface: Level 1 national channels of advocacy for older adult mental health re- sources/programs (e.g., serves on committees for the national The psychologist assists team members in understanding gen- Alzheimer Association, the American Society on Aging, or the eral geropsychological information (e.g., psychological needs of American Association of Retired Persons). community-dwelling older adults) and in helping them to use this PSYCHOLOGISTS WORKING WITH OLDER ADULTS 441

information to enhance the effectiveness of interventions with Special Ethical Issues: Level 2 older adults. The psychologist communicates effectively (orally and in writ- ing) with a wide variety of people, including family members, Interface: Level 2 government officials, and community care providers. The psychologist assists team members in understanding spe- Wherever possible, the psychologist writes reports tailored to cialized geropsychological information (e.g., psychological needs the most appropriate reader. These reports may be addressed to of frail older adults in long-term care settings) and helps them to concerned family members and/or civil officials. They may deal use the information to enhance the effectiveness of their with older adult competency issues related to comorbid psychiatric interventions. and cognitive impairment. The psychologist addresses specific questions regarding legal, ethical, and/or diversity issues (e.g., gender and long-term care, Topic 3: Team Process sexual orientation vis-a`-vis the “closeted” older gay individual, Interface: Level 1 physical disability and its effect on the body image of older adults) related to the assessment and treatment of older adults.

broadly. The psychologist functions as an effective member of the geri- atric team and is aware of team process issues. The psychologist is publishers. Topic 2: Elder Abuse Reporting familiar with different models of team functioning (e.g., consultation-liaison, multidisciplinary, or interdisciplinary). allied Special Ethical Issues: Level 1 disseminated its be of The psychologist knows relevant laws pertaining to elder abuse to Interface: Level 2 one and the procedures for making reports to appropriate authorities. not or

is The psychologist intervenes appropriately in geriatric team pro- The psychologist works with the team to identify situations with cess, given both the type of the problem and the team model of the potential for older adult abuse and/or neglect. and functioning.

user In an interdisciplinary setting, the psychologist helps with issues Association such as clarifying roles and responsibilities of team members, lead- Special Ethical Issues: Level 2 ership sharing, and team self-assessment and self-improvement. The psychologist prepares assessment reports on elder abuse individual appropriate for forensic use. the Topic 4: Team Stress Management Psychological of

use Interface: Level 1 Topic 3: Incorporation of Diversity Factors

American The psychologist assists team members, as needed, in managing Special Ethical Issues: Level 1 personal the their own emotional responses and stress with respect to issues the by such as older patients’ deaths, verbal abuse by older adults or The psychologist incorporates cultural, ethnic, and religious

for families, physical/sexual/emotional abuse of older adults by care- factors into his or her geriatric assessments, case conceptualiza- givers, and so forth. tions, and treatment plans. solely copyrighted is Interface: Level 2 Special Ethical Issues: Level 2 intended

is The psychologist has expertise in stress counseling to assist The psychologist serves as an expert consultant in considering

document team members who have been exposed to major traumatic events cultural, ethnic, and religious factors related to geriatric mental

article in the course of caring for older adults, such as violent death or health. For example, she or he consults with the local Alzheimer This serious abuse.

This Association on improving the participation of minority caregivers in family support group meetings. SPECIAL ETHICAL ISSUES

Topic 1: Communication Topic 4: Informed Consent, Confidentiality, and Decision-Making Capacity Special Ethical Issues: Level 1 Special Ethical Issues: Level 1 The psychologist communicates effectively (orally and in writ- ing) with older adults, families, clinical supervisors, team mem- The psychologist is familiar with informed consent and confi- bers, and staff. Wherever possible, reports are tailored to the most dentiality issues that occur when working with older adults and appropriate reader. helps others understand confidentiality/patient right issues. The psychologist knows when and to whom to refer specific The psychologist identifies the possibility that an older person questions regarding legal, ethical, and/or diversity issues (e.g., lacks decision-making capacity. In such instances, the psycholo- gender, sexual orientation, religious preference, physical disabil- gist makes a referral for determination of decision-making ity) related to the assessment and treatment of older adults. capacity. 442 MOLINARI ET AL.

Special Ethical Issues: Level 2 the APA Interdivisional Task Force (2000) for geropsychology training into “nuts and bolts” recommendations for clinical work. The psychologist determines whether an older person lacks Geropsychological knowledge has reached a critical mass as re- decision-making capacity, either globally or specifically related to flected in the proficiency status authorized by APA. Practitioners health, financial, or end-of-life issues. should now be measured against a reasonable standard relative to The psychologist is aware of the complex ethical issues in that corpus of knowledge and skill. Although originally geared to dealing with family members of those with dementia (e.g., when to VA settings, these recommendations should also be useful in a provide health-related information to family members despite non- variety of non-VA practice settings that serve older adults. We adjudication of guardianship). hope that they will stimulate dialogue between generalists and If an older person is found to lack capacity, the psychologist geropsychologists alike as a way of better defining the skills works with the next of kin to gain the person’s assent to assure that necessary to advance science and practice in the emerging field of the decisions made are consistent with the patient’s long-standing professional geropsychology. values, short- and long-term plans, and current needs.

References Implications broadly. American Psychological Association, Interdivisional Task Force on Qual- With the Senate Labor Health and Human Services Education ifications for Practice in Clinical and Applied Geropsychology. (2000, publishers. Subcommittee recently earmarking $3 million to support graduate September). Training guidelines for practice in clinical geropsychology training in geropsychology, there is a compelling need to deter- (Draft No. 8a). Washington, DC: Author. allied

disseminated American Psychological Association. (2001). Report of the Commission on

its mine the most effective use of these funds. The draft report of the be of APA Interdivisional Task Force (2000) noted that “greater speci- Education and Training Leading to Licensure in Psychology. Washing- to fication of suggested training and clinical experience can serve to ton, DC: Author. one

not Bengston, V. L., & Schaie, K. W. (Eds.). (1999). Handbook of theories of or inform those who offer training, consumers of geropsychological is services, managed care organizations, and others” (p. 2). This is aging. New York: Springer Publishing Company.

and Cooley, S. G. (1995). Geropsychology services and training in the U.S. consistent with a recent APA (2001) report on education that Department of Veterans Affairs. In B. G. Knight, L. Teri, P. Wohlford, user suggests defining those competencies expected of graduates of & J. Santos (Eds.), Mental health services for older adults: Implications Association psychology training programs, as well as with the recent practi- for training and practice in geropsychology (pp. 11–20). Washington, tioner survey (Qualls et al., 2002) recommending continuing ed- DC: American Psychological Association.

individual ucation in a wide variety of formats with both introductory and DeVries, H. (2001). Geropsychology courses in generalist clinical psychol-

the advanced levels of training. The TAGG has thereby outlined two ogy programs. Association of Psychology Postdoctoral and Internship Psychological of levels of competency across seven broad knowledge areas that we Centers (APPIC) Newsletter, 26(2), 15, 19, 37. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental use believe to be necessary for professional geropsychological practice in a variety of employment settings. State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. American Psychologists with limited training should err on the side of Fruit, M. A., Gantz, F. E., & Hefner, W. G. (2001). Integrating geropsy- personal the caution when deciding whether to provide services in particular chology into a psychology internship program. Association of Psychol- the by cases. Those older adults with comorbid Axis I and Axis II ogy Postdoctoral and Internship Centers (APPIC) Newsletter, 26(2), 17, for disorders, hospitalized patients with concomitant severe medical 42–43. and psychiatric complications, emergency room patients with FY 1999 Annual Accountability Report: Statistical appendix. (2000). solely acute changes in mental status, frail elders and/or the old-old in Washington, DC: Department of Veterans Affairs. Available from http:// copyrighted long-term care facilities, and those with atypical presentations www.va.gov/vetdata/census2000/index.htm is should probably be managed only via consultation with a psychol- Hinrichsen, G. (2001). Postdoctoral training in clinical geropsychology. intended Association of Psychology Postdoctoral and Internship Centers (APPIC)

is ogist who has Level 2 expertise. Higher levels of competence require advanced education in professional geropsychology. To Newsletter, 26(2), 18, 36. document Jeste, D. V., Alexopoulous, G. S., Bartels, S. J., Cummings, J. L., Gallo,

article meet this need, training offerings are increasingly being offered at J. J., Gottlieb, G. L., et al. (1999). Consensus statement on the upcoming This the graduate level (via coursework on aging and supervised practi-

This crisis in geriatric mental health. Archives of General Psychiatry, 56, cum experience in geriatric settings); at the internship level, where 848–853. greater numbers of major and minor rotations are being proffered; Kim, K. Y., Jones, E., & Goldstein, M. Z. (2001). Mental health services at the postdoctoral level, where fellowship programs in profes- for older veterans in the VA system. Practical Geriatrics, 52, 765–768. sional psychology with emphases in geropsychology are becoming Knight, B. G., Teri, L., Wohlford, P., & Santos, J. (Eds.). (1995). Mental more frequent; and at a variety of local, state, regional, and health services for older adults: Implications for training and practice in national continuing education venues. General textbooks on pro- geropsychology. Washington, DC: American Psychological Association. fessional geropsychology and more specialized readings are also Niederehe, G., Gatz, M., Taylor, G. P., & Teri, L. (1995). The case for available (see the Appendix). In addition, professional groups such certification in clinical geropsychology and a framework for implemen- as APA’s Division 12, Section 2 (Clinical Geropsychology), Psy- tation. In B. G. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults: Implications for training and practice in chologists in Long Term Care (PLTC), the American Society of geropsychology (pp. 143–151). Washington DC: American Psycholog- Aging (ASA), and the mental health special interest group of the ical Association. Gerontological Society of America (GSA) often sponsor educa- Qualls, S. H., & Ogland-Hand, S. (2001). Including geropsychology practi- tional initiatives. cum offerings in general clinical programs. Association of Psychology Again, it is important to emphasize that these recommendations Postdoctoral and Internship Centers (APPIC) Newsletter, 26(2), 16, are a first attempt at translating the general recommendations of 38–39. PSYCHOLOGISTS WORKING WITH OLDER ADULTS 443

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Appendix

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personal Websites the the by ϳ for Division 12, Section 2: http://bama.ua.edu/ appgero/apa12_2/ Gerontological Society of America: http://www.geron.org/ solely copyrighted American Society on Aging: http://www.asaging.org/ is Psychologists in Long Term Care: www.wvu.edu/ϳpltc/ intended is document article

This Received August 5, 2002

This Revision received January 3, 2003 Accepted March 19, 2003 Ⅲ