Geropsychology, Specialization, and Boarding (hopefully not too boring)

I’d like to talk about the importance of Geropsychology as a bona-fide specialty area in clinical psychology. In my years of practice as a Geropsychologist, I have found that families and patients are in a lot of pain, turmoil, and confusion about where to turn when it comes to receiving competent services. An example comes to mind – recently, I had occasion to review the case of an older adult man who had received a diagnosis of “mild cognitive impairment” from a neuropsychologist (not a geriatrician) who had done what was otherwise a very detailed assessment of this gentleman’s cognitive functioning.

In reviewing this case, I noted that this gentleman (who was married and was the sole breadwinner, and also tended to be the primary financial decisionmaker) had a house that was now in foreclosure, and had several lawsuits against him for legal malpractice, and seemed to be making an increasing number of poor financial decisions over the last several years. He had recently gotten lost in his car in his hometown (greatly distressing his wife) and also had recently had an MVA with a parked vehicle. This and other issues led me to note a fairly clear pattern of occupational, financial, and physical dysfunction and risk of harm to this patient which had been escalating over the years. Subjective memory complaints were present and memory deficits were noted (along with other deficits) on neuropsychological testing.

After reviewing the testing report, I concluded that the “mild cognitive impairment” diagnosis had been improperly offered in this case. The report itself was carefully crafted, the data systematically reported, and the writing was clear. However, the conclusion, I believe, rested on what I consider to be somewhat of a basic mistake that I often see committed by non-geriatric specialists (and students in training) – basically, that it was concluded that a somewhat “softer” diagnosis to offer, less stigmatizing, possibly defensible, and therefore appropriate.

In my case, I felt the risk of harm to the patient by soft-pedaling the diagnosis (which clearly pointed to mild dementia, likely of the Alzheimer’s type, as far as I was concerned) was that treatment would  be unnecessarily delayed, as would be withdrawal from sensitive occupational responsibilities, and finally, measures that might need to be taken for the patients safety and health (and the health and safety of those around him) would also be needlessly put off – and the only upside of proffering the “softer” diagnosis of MCI in this case would be that the eventual difficulty of coming to terms with a dementia diagnosis would simply be pushed off until a later date, which, in this particular case, is exactly what happened.

So, how do you know how to choose a competent geriatric psychologist, or Geropsychologist? It’s a tough one. While most clinical psychologists (69%) report that they work with older adults in their practices, at least some of the time, less than a third of them report they have had any specialized graduate coursework in geriatrics. An even smaller percentage of that (20%) report they have any supervised experience providing services to older adult clientele, according to APA’s 2004 Guidelines for Psychological Practice with Older Adults.

So, let’s say you wish to hire a competent clinical psychologist in the area of, let’s say, late-life depression or dementia care. In other words, you want to hire a geriatric psychologist, or Geropsychologist. So, you’ll want to make sure they have three things – relevant education, training, and experience (and hopefully plenty of all three) in this particular area. Let’s start from first principles.

For clinical psychology per se, the very basic set of qualifications to assure a minimum level of competence is that they received training from a doctoral program in clinical psychology that was accredited by the American Psychological Association (APA) at the time of their graduation. While there are certainly a number of quality graduate programs in clinical psychology that do not have this nationally-recognized standard of accreditation for whatever reason, it should be pointed out that arguably, APA accreditation is not a particularly high bar for a program to attain, and as far as national standards are concerned, it’s really the only bar out there that’s universally recognized.

Moreover, even if a clinical psychologist has earned a doctoral degree from an otherwise quality, unaccredited program, the fact they have not achieved a degree from an APA-accredited program basically means that attaining quality internship and post-doctoral residency training programs are typically near to impossible, which further hampers their ability to attain quality training experiences. Basically, if your psychologist has not gotten their degree from an APA-accredited program, that would be a big red flag to me.

So, we’ve assured ourselves that our psychologist has graduated from a program that assures at least a basic standard of quality (APA accreditation) in the training it delivers to its graduates.  But we want to know – how can I find a good Geropsychologist?

We could ask ourselves whether a psychologist has received classwork that relates to Geropsychological practice, such as Adult Development and Aging (a course I took in graduate school), or Geri-Neuropsychological Assessment, or what have you. If a psychologist has received this kind of coursework in graduate school, I think this can be a potentially important. Again, a fairly small percentage of psychologists have had any formal classwork in gerontology-related topics at all.

However, one of the most important markers of specialty competence, that is, what makes a person a Geropsychologist, in my view, would be whether this person has received supervised experience delivering psychological services to substantial numbers of older adult clientele either as a predoctoral intern, a postdoctoral fellow, or ideally, both. Where a clinical psychologist receives their internship training is probably *the* single most important factor in terms of determining what area  a particular clinical psychologist will practice in after they become licensed (presuming they do not enter into a career as a researcher).

One reason why this is is that when employers first review résumés of freshly-licensed clinical psychologists, one of the first things they look at is where the person received their internship and postdoc training. In my case, both my internship and postdoc training programs were exclusively Geropsych-focused, which led me to a series of employment opportunities and most recently, to my last five years as staff Geropsychologist at the VA Palo Alto Healthcare System’s Livermore Division.

So, let’s talk about board certification. In the world of physicians, board-certification is basically de rigueur – it’s nearly mandatory. According to 2008 figures, approximately nine in ten US-licensed physicians possess board certification in a given specialty – for example, at my place of work, the physicians I work with (MDs) typically have board certification from organizations like the American Board of Medical Specialties or the American Board of Physician Specialists, in specialties such as geriatric medicine or hospice and palliative care.

What is board certification? It basically means that if a physician has attained this certification, you can be assured of a basic standard of competency in a given specialty area. A geriatric-boarded physician, in other words, you know has specialized knowledge in the care and treatment of older people and their particular issues.

What about psychologists? In contrast to medicine, where there are a small handful of nationally-recognized boarding agencies, for psychology there is only one, the American Board of Professional Psychology, or as most psychologists refer to it, “ABPP” (“ay-bepp”) which has, as of last year, 14 separate specialties that it recognizes as part of it’s boarding process. (It should be noted that there are other organizations that offer competing specialty certifications for psychologists, such as the International College of Professional Psychologists, or ICPP, but this organization and probably any of the others you might encounter, are not reputable). It should also be mentioned that there are definitely other ways that psychologists can attain formal, national recognition for their work as psychologists, such as being an APA or APS fellow, but ABPP is the only organization that recognizes clinical psychologists for reaching a standard of proficiency in specialty practice.

In contrast to physicians, where 90% or more of them are boarded, it’s worth noting that less than 4% of all eligible clinical psychologists are board certified. Personally, I find this a curious development, considering how clearly specialized (and competitive) the world of mental health practice has become. Might this be one of the reasons that reimbursement rates and salaries for psychologists have been dropping over the years?

One of the things that I have always found makes good career sense for professional psychologists (and something that I always advise my students) is to aim for specialization in your training as early as possible in your career, and to avoid where possible being tarred with the brush of being a “generalist” practitioner. Although there’s probably nothing wrong with aiming to be the “jack of all trades” in your practice (does that make you the master of none?), for a professional psychologist, not having carved out a career niche basically makes one, in my opinion, highly uncompetitive against all of the other (many of them quite newer) licensed mental health disciplines out there, such as MFTs, LPCs, etc…. that “generalist” psychologist will get their lunch promptly eaten.

So, obviously I’m making the case for psychologists achieving board certification status here. While it’s possible that a psychologist can distinguish themselves from the generalists by virtue of their education, training, and experience (as I talk about above), let’s be frank – I believe it’s a rarity that psychologists will post or make available their entire vita to prospective clients. Moreover, I would imagine that an even smaller percentage of clients will think to ask for a résumé from their prospective psychologist. Although I’m not exactly sure why, I think plenty of prospective clients feel it may be, well, unseemly to request a complete résumé or curriculum vita of a psychologist prior to hiring them. Moreover, even if a prospective client did acquire the work history of the psychologist they were considering working with – not many would know how to evaluate it. What do clients have to go on? Typically it’s a one-paragraph, pleasant-sounding blurb (e.g., “I work to help clients attain personal satisfaction in their lives, heal from trauma,” etc.), and sometimes information as to where they went to school, statements about what populations they work with (older adults, addictions, etc.), and that’s about it. If you’re lucky, someone might have rated them on Yelp.com.

As I have written about elsewhere, the “demographic tsunami” (e.g., the aging of the Baby Boom generation) is upon us. Demands for competent geriatric specialists are rising rapidly, and while there seems to be somewhat of a (growing) oversupply of clinical psychologists in the United States (thanks in part to the proliferation of large-scale professional psychology programs run by companies like the Apollo Group and University of Phoenix), there seems to be a rather distressing shortage of appropriately trained Geropsychologists in the United States that will only continue to grow.  It seems an extremely difficult situation for consumers who wish to find competent Geropsychological services – at the same time the supply of (in many cases, poorly trained) psychologists continues to grow, the supply of Geropsychologists relative to demand continues to shrink over time.

And this is where it gets exciting for Geropsychology. As of this year, ABPP has announced (after a multiple years of buildup) that they will begin the initial process of examining candidates to attain board-certification in the specialty area of Geropsychology! I consider this a critical step for consumers and organizations to begin to easily be able to sort the “wheat from the chaff” when it comes to the confusing world of clinical psychology. Specialty boarding in Geropsychology will be, without a doubt, a career goal for me. I consider it not only a smart career move (lets be honest), but it’s also a critical service to the community. As I showed in the example above (where I discussed the case of the older adult gentleman who was misdiagnosed with mild cognitive impairment as opposed to dementia), psychological, physical, and financial well-being can be at stake.