Clinical Geropsychology

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Clinical Geropsychology is broadly defined as the application of “the knowledge and methods of psychology to understanding and helping older persons and their families to maintain well-being, overcome problems and achieve maximum potential during later life" (Source: APA).

Background and Definition of Clinical Geropsychology

The population of the world is aging at a rapid rate. The Administration on Aging reports that people age 65 and older constituted about 13% of the US population in 2009, and these numbers are expected to grow exponentially. For the first time in human history, the world has more individuals age 65 and older than those age 5 years old and under. By 2030, there will be an estimated 72.1 million older adults in the US, constituting approximately 19% of the population. Given the expected growth of the older adult population, psychologists with specialty training in geropsychology are in demand.

Clinical geropsychologists are trained to address a variety of challenges common in later life. Older adults often experience a multitude of unique changes in later life, including declines in health, loss of loved ones, retirement, changes in residence, loss of independence, and others. Geropsychologists have specialized training to address problems such as depression, anxiety, neurocognitive disorders (e.g., dementia, mild cognitive impairment [MCI]) caused by problems such as Alzheimer's disease, caregiver stress, grief and bereavement, end-of-life care issues, and physical health problems (e.g., sleep disorders, diabetes, cardiovascular disease).

Clinical geropsychologists provide psychological assessment and intervention to older adults and their families, as well as consultation services to other health care professionals. These psychological services are provided in a variety of settings and contexts, including private practice, community mental health, integrated medical settings (e.g., primary care), rehabilitation care, inpatient psychiatric settings, residential care, long-term care, adult day health programs, and many other settings. Clinical geropsychologists are also trained to work in universities, academic hospitals and medical settings, research institutes, and public policy settings.

Early History of Clinical Geropsychology

In 1946, Sydney Pressey, PhD., and a coalition of supporters helped establish the Adult Development and Aging Division of the American Psychological Association (APA) devoted to the study of older adults and adult development (Birren & Morrow, 1996). The APA approved the Adult Development and Aging Division with a vote of 20 to 3, thus establishing it as the first aging-related expansion of the APA (Birren & Morrow, 1996).

In 1946, the first meeting of the Adult Development and Aging Division was held with 13 people in attendance. Despite its modest beginnings, by 1952, the annual meeting of the Adult Development and Aging Division was held jointly with the Gerontological Society in Washington, D.C. At this meeting, Harold Jones, a lifespan psychologist and director of the California-based Institute of Child Welfare, addressed the conference and argued for the establishment of “A national institute on the problems of aging.” Though it would be another 22 years before the National Institute of Aging (NIA) was established, in only six years, the Adult Development and Aging Division was able to establish its agenda as a national concern warranting increased government attention (Birren & Morrow, 1996).

In a 1953 meeting of The Adult Development and Aging Division, Nathan Shock, PhD., the founder of one of the first longitudinal studies on aging, the Baltimore Longitudinal Study, asked the psychologists present to consider “practical” issues of maturity and old age. This was the first known reference to a more applied and clinical approach to a psychology of aging outside of the medical field (Birren & Morrow, 1996).

In 1959, the National Institute of Mental Health (NIMH) established a section devoted to aging, and appointed James Emmett Birren, PhD, as chief of this division. Birren’s research focused on neurological, sensory, perceptual and cognitive functions in aging, and he is often considered the first modern experimental aging researcher (Birren & Morrow, 1996). As the chief of the section on aging at NIMH, he was instrumental as an organizer and promoter of the field. He developed and edited the Handbook of Psychology of Aging, became the editor-in-chief of the Journal Gerontology, and eventually went on to become the president of the Gerontological Society of America (Birren & Morrow, 1996).

In 1971, a White House Conference on Aging found that the education and training of health professionals in older adults was urgently warranted (Storandt, 1982). The conference recommended the creation of an aging institute, and in 1971 The Research on Aging Act was introduced. In 1974, The Research on Aging Act passed in Congress, and President Nixon signed the bill thus creating the National Institute on Aging (NIA) (Binstock, 2010). This was a pivotal moment in the emergence of clinical geropsychology as a distinct field of practice.

History of Medicare’s Reimbursement of Geropsychology Services

Providing psychology services to older adults was historically curtailed by Medicare’s limited coverage of mental health services. Barriers specific to psychological services were caused by Medicare’s provider restrictions, which did not allow reimbursement to psychologists until 1988. In addition, prior to 1988, Medicare capped reimbursement for all mental health outpatient services at $250 annually. The annual cap on outpatient mental health care was increased in 1988 and 1989, and then eliminated in 1990.

An additional discriminatory practice that resulted in barriers to mental health care for older adults was the Outpatient Mental Health Treatment Limitation, which established a 50% coinsurance for outpatient mental health treatment. This 50% coinsurance applied to outpatient treatment services, not to psychodiagnostic services, inpatient services, or psychological and neuropsychological assessment services. Passage of the Medicare Improvements for Patients and Providers Act of 2008 required a phased out elimination of the Outpatient Mental Health Treatment Limitation. Since January 1, 2014, Medicare’s coinsurance for outpatient mental health treatment is 20%, consistent with other outpatient services (Medicare Learning Network Matters®) (2013, January 18).

Current Medicare coverage policies for mental health care are available from several resources including Medicare Learning Network Matters® (2012, March) and Norris (in press).

While past reimbursement barriers for geropsychologists in the traditional Medicare plans have been largely amended, geropsychologists’ services are often disallowed by the limited in-network policies of Medicare Part C plans. An increasing number of Medicare beneficiaries are enrolling in Medicare Part C (also known as Medicare Advantage Plans), growing to over 13 million enrollees in 2013.

Unlike the fee-for-service Medicare Part A and B plans, Medicare Part C plans have restricted networks that limit access to providers.

Clinical Training and National Conferences

As the first president of the National Institute of Aging, Robert Butler, MD, made his first mission to enhance the education and training of health professionals in the field of aging. From 1975 to 1976, the Adult Development and Aging Division conducted a survey of graduate training programs in psychology that revealed only two psychology programs had a geriatrics track (M. Storandt, personal communication, April 4, 2010). Recognizing the dearth of training opportunities for geriatric clinicians and researchers, the Adult Development and Aging Division proposed to establish a task force on training in the psychology of aging. This recommendation was referred to the board of education and training, which fully endorsed the proposal. With support from the APA and funding from the NIA, the Adult Development and Aging Division assembled a task force in November 1977 to “assess the psychological needs of older adults and provide recommendations concerning the involvement of psychologists in mental health services to the older populations.” (Storandt, 1982) This set the stage for the first of three monumental conferences on clinical geropsychology: the 1981 conference on Training Psychologists for Work in Aging, known as the “Older Boulder” conference, held in Boulder, Colorado (in contrast to the “Boulder” conference of 1949 at which standards were made for the training of PhD clinical psychologists in general [i.e., the “Boulder model”]. At this conference, psychologists began discussing the knowledge base of geropsychology and how this information could be taught to new geropsychologists. The goal of Older Boulder was “to identify the resources we can use to develop and expand training in aging for psychologists… [and to] develop a set of policy recommendations.” Older Boulder’s organizers stressed the importance of a multidisciplinary approach to aging training, and thus, they encouraged general psychologists, geropsychologists, non-psychology gerontologists, consumers and students to attend the conference. In total, nearly 100 people participated in the conference (Storandt, 1982).

The results of the Older Boulder conference were the publication of Psychology and the Older Adult: Challenges for Training in the 1980s (Santos & Vandenbos, 1982), as well as a full report from the conference and many position papers on various topics. Most importantly, Older Boulder was a key first step to creating a training model for geriatric competencies for psychologists.

The second national conference, “Older Boulder II,” was held in Washington DC in 1992. At this conference, a greater focus was placed on skills training as well as the multiple levels of clinical training.

The third national conference was held in 2006 in Colorado Springs, Colorado. At this conference, a model of training was established for clinical geropsychologists: the Pikes Peak model (Knight et al., 2009). The Pikes Peak model coalesced the information already known about older adults and applied it to the establishment of competency areas for the training of clinical geropsychologists. For example, the model highlighted the need for training programs to educate students to differentiate between healthy and pathological aging, normative changes associated with later life, cohort effects, general knowledge about adult development, and various care settings for older adults, especially interdisciplinary care (Knight et al., 2009). Emphasis was also placed on the unique ethical and legal issues associated with working with older adults, as well as distinct age-related diversity and cultural issues. The Pikes Peak Geropsychology Knowledge and Skill Assessment tool provides a broad overview of competency areas needed for professional practice in geropsychology.

Society of Clinical Geropsychology (American Psychological Association Division 12, Section II)

In 1993, the American Psychological Association organized a subsection that would eventually be titled the Section on Clinical Geropsychology (sometimes referred to as APA Division 12, Section II). This was done at the initiative of a steering committee composed of several psychologists, including George Niederehe, Barry Edelstein, Dolores Gallagher-Thompson, Margaret Gatz, Alfred Kaszniak, Norm Abels, Michael A. Smyer, George Stricker, and Linda Teri (Routh, 1994). The steering committee pursued the establishment of the designated subsection of APA Division 12, Section II. This subsection is closely linked to APA’s Adult Development and Aging Division. The Society’s mission is fostering the mental health and wellness of older adults through science, practice, education and advocacy and by advancing the field of professional geropsychology. The name “Section of Clinical Geropsychology” was changed to “Society of Clinical Geropsychology” in 2008. The Society is active in promoting and supporting training in geropsychology at the doctoral, internship, and post-doctoral level, advocating for geropsychology in public policy, and promoting aging research that informs clinical practice. The Society publishes a newsletter three times per year. More information about the Society, including a listing of its current executive committee, can be found at the organization's website. The Society offers several awards to members annually: M. Powell Lawton Award for Distinguished Contributions to Clinical Geropsychology, Clinical Mentorship Award, and Student Research Award.

Recognition of Specialty Area

Professional geropsychology was acknowledged by the as a proficiency area by the American Psychological Association in 1997, and was recognized as a specialty area by APA in 2010. Additionally, in 2013, Geropsychology was established as an emerging specialty area by the American Board of Professional Psychology, allowing psychologists to attain board certification in geropsychology.

Related Professional Organizations

There are a number of national professional organizations related to clinical geropsychology.

References

http://apadiv20.phhp.ufl.edu/d20hist.pdf

  • Birren, J, & Schroots, J. (2001). History of Geropsychology. In J. Birren & K. Schaie (Eds.), Handbook of the Psychology of Aging (3-29). San Diego: Academic Press
  • Binstock, R (2010, March). 1974: GSA Plays Major Role in NIA’s Development. Gerontology News. Gerontological Society of America. Retrieved from http://www.geron.org/images/stories/newsletters/gerontology_news/March_2010.pdf
  • Busse, EW (1993). Duke Longitudinal Studies of Aging. Z Gerontol. 26(3). 123-128.
  • Blazer, D. (2004). Longitudinal Studies on Aging and the Development of Geriatrics in North America. Journal of Gerontology: Medical Sciences. 59(11): 1155-1156.
  • Hodes, R., Suzman, R (2011, September 15). Growing Older in America: The Health and Retirement Study. The National Institute on Aging.

Retrieved From http://www.nia.nih.gov/health/publication/growing-older-america-health-and-retirement-study/preface

  • Knight, B., Karel, M., Hinrichsen, G., Qualls, S., and Duffy, M. (2009). Pikes Peak Model for Training in Professional Geropsychology. American Psychological Association. 65(3). 205-214.
  • Medicare Improvements for Patients and Providers Act of 2008. Retrieved from http://www.gpo.gov/fdsys/pkg/PLAW-110publ275/pdf/PLAW-110publ275.pdf.
  • Medicare Learning Network Matters®. (2013, January 18). Outpatient mental health treatment limitation. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/downloads/MM6686.pdf.
  • Medicare Learning Network Matters®. (2012, March). Mental health services. Retrieved from

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Mental_Health_Services_ICN903195.pdf.

  • Morris, J (2012). The Aging Mind: Realities and Myths. Harvey A. Friedman Center for Aging, Institute for Public Health. St. Louis, MO: Washington University.
  • Norris, M. P. (in press). Evolutions and Revolutions in Medicare Policy and Reimbursement of Geropsychology Services. In P. Lichtenberg, B. Mast, B. Carpenter, and J. Wetherell (Eds.) APA Handbook of Clinical Geropsychology Washington DC: American Psychological Association.
  • National Institute on Aging, Baltimore Longitudinal Study on Aging Time Line (2009, January 9). Retrieved from

http://www.grc.nia.nih.gov/branches/blsa/timeline.html

  • Routh (1994). Clinical psychology since 1917: Science, practice and organization. New York, NY: Springer.
  • Storandt, M., Siegler, I., & Elias, M., (Eds). (1978). The Clinical Psychology of Aging. New York, NY: Plenum Press.
  • Storandt, M (1982). Where have we been? Where are we going? In J Santos, J
  • Vandenbos & R Gary (Eds.) Psychology and the Older Adult: Challenges for Training in the 1980s. Proceedings of the Conference on Training Psychologists for Work in Aging Boulder, Colorado. (11-17) Washington, DC,: American Psychological

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