Greek Grandfamilies (Kinship Caregivers)

Although this blog is called “Aging in America,” indulge me just for today. Although I’ll talk a bit about Greece and Europe, this isn’t unrelated to issues here in these United States.

Anyways, I have a habit of getting up particularly early in the mornings, usually a shade before 5am. I kind of enjoy it – everyone’s asleep, and I get to bustle around the kitchen, make coffee, do the dishes, and make sure a hot breakfast is ready for my kids when they wake up in the morning. While I do it, I also play a feed of “Russia Today” (RT) on my laptop while I do my thing. This is where I get plugged into the currently rather dismal world of international politics and finance (maybe it’s always been dismal).

A few mornings ago, I heard a fascinating spin on something that we all know has been going on for awhile, the so-called Greek “austerity crisis,” which refers to the steep economic decline being suffered in this country supposedly due to what are widely seen in the media as “draconian” or “savage” spending cuts.

To digress for a moment – the true picture of what is causing Greece’s problems are likely a bit more complicated. It appears that spending growth (which is different than spending cuts) seems to have flattened in Greece. Taxes, particularly those that affect the middle and bottom rungs of the economic ladder, such as the highly regressive, infamous Value Added Tax, or VAT – have skyrocketed. Finally, pension and wage guarantees for middle and lower-class public sector workers have been slashed. Overall government spending doesn’t seem to have been significantly affected in Greece. Getting on my soapbox for a moment – my guess is that the well-connected banker types continue to find ways to line their pockets in the Eurozone, as always, while the net affect is that the middle and lower classes in Greece have seen their incomes slashed, services cut, and taxes hiked, with predictable results.

Politics aside, regardless as to what the ultimate cause of Greece’s troubles are, the end result is it’s a country mired in deep recession, if not outright economic depression.

So what does this have to do with older adults, or “aging in America”? One of the things that piqued my interest about this story on RT was that they talked about the increasingly-observed phenomenon in Greece of grandparents caring for grandchildren. This is being driven by the phenomenon of Greek adults who are increasingly being forced to seek work abroad due to the slumping Greek economy. In the story (which I only briefly overheard), the somber-voiced RT newscaster spoke about viewing a Greek square in a small Greek town where children played in a fountain and socialized while their adult caregivers watched. Yet when you actually looked at the adults that were minding these children, they were all clearly overwhelmingly aged grandparents, with no younger adult faces to be found. Economic security is gone from Greece, a stark contrast from a decade ago.

This phenomenon of “grandfamilies” or “kinship caregivers” is certainly one of which I am familiar, having worked with this population as a postdoc in Rochester, New York. In the United States, where this phenomenon has been well-studied at this point, it’s mostly a phenomenon found in the social underclass of poor, African-American families where the parents have been decimated by the War on Drugs and mass imprisonment, drug addiction, or HIV/AIDS. Grandparents typically step in and are the ones that provide custodial care in lieu of their grandchildren ending up in the foster care system, which is a laudable goal – it definitely fits with cultural values in this case, families in the African American community “taking care of their own” and being self-sufficient within their own community.

However, taking on this role comes with some costs; as research tends to suggest, kinship care can be a stressful business.  Older adults in this role find themselves at higher risk for depression, anxiety, and stress-related illness than others. Some think this is because kinship carers are mourning the loss of their imagined lifestyle at retirement (e.g., being able to travel, relax, not work, see family at their own leisure, etc.), but they may also be mourning the loss of their children, especially if the event that caused them to take on this role in the first place was something tragic, like death. Also, family strains are frequently found – in the kinship caregivers I worked with in Rochester, often there were ongoing issues with parents who were peripherally still involved in the childrens’ lives, but due to drug addiction were only able to contribute dysfunction to the family and not much else. These grandparents may also be “double caregivers,” they may be caring for a relative or spouse of their own (perhaps with dementia or another chronic illness) at the same time they are caring for their grandchildren.

Finally, the children themselves are obviously a source of stress. Not only must these older people re-acclimate themselves to the physically and mentally taxing nature of child caregiving, they must do it within the context of an aging body and with their own health issues to contend with. It becomes even more challenging when you consider the possibility that many of these children may have some serious behavioral and emotional issues of their own to contend with, which may make them even more of a challenge to care for.

As I mentioned earlier, the issue of kinship caregiving and “grandfamilies” is still a fairly wide-open area for study and intervention. While there is some activity out there suggesting that comprehensive intervention programs may be being developed to address issues found in kinship carers, as of yet this area has not developed to the degree seen in (for example) the REACH-II program for dementia caregivers.

I’m glumly noting that the economic troubles of Europe seem to be continuing and not resolving, as are much of the economic troubles of the world (some would say that the recession has never really ended in the United States). Does this mean more parents will be uprooted from their children in industrialized countries due to the desperation of needing to find paid work? If other nations “go Greece,” will the phenomenon of kinship caregiving spread to other industrialized nations? It’s possible kinship caregiving will cease being just seen as a niche issue only affecting the urban underclass of the US and the world, and may soon be something hitting near you. The upside of this is that these particular older adult caregivers may finally get the attention they deserve, and maybe they’ll start getting the help they need.

CBT and Geriatric Anxiety Disorder – It Doesn’t Work?

A few weeks ago I sat through a series of very nice presentations on geriatric mental health by a series of distinguished Geropsychologists and scholars at the VA Palo Alto Healthcare system and elsewhere. Wanted to highlight this, of course, because last week I groused about the dearth of quality CEs in and for Geropsychologists out there. Occasionally good CE experiences do happen to me!

Anyways, one particular presentation that stood out in my mind was one by psychologist Julie Wetherell, professor “in residence” at the Department of Psychiatry at UCSD. Dr. Wetherell has carved out a niche for herself doing research on chronic pain and germane to the current discussion, geriatric anxiety disorders and cognitive behavioral therapy, or CBT.

CBT, of course, is one of several schools of thought in psychotherapy (e.g., as contrasted with psychodynamic, humanistic, and family systems schools of thought). CBT has many features that distinguishes it from other schools of thought. It tends to be focused on the here-and-now, tends to be specific and problem-focused, and tends to emphasize hypothesis-testing and active experimentation and use of ‘homework assignments’ as part of the work. Therapeutic dialogue often takes the form of ‘Socratic questioning’ in CBT, often with the aim of helping patients to find more accurate ways of viewing and interacting with the world.

In the case of CBT, it’s been found to be an approach that works exceptionally well with older adults in the case of major depression, as has been found time and time again. It also works exceptionally well with middle aged and younger adults with depression and anxiety disorders.

Curiously, and this is where Dr. Wetherell’s presentation got interesting for me – CBT does not seem to work particularly well for older adults with anxiety disorders, particularly as regards the entity of generalized anxiety disorder.

Briefly on different anxiety disorders. Generally clinicians tend to split anxiety disorders into a few different categories. It’s worth mentioning that the introduction of the new edition of the Diagnostic and Statistical Manual of Mental Disorders has changed things up somewhat (e.g.,  the DSM-V), for example, post-traumatic stress disorder, or PTSD is not longer considered an anxiety disorder anymore and now is in a category of it’s own.  However, generally anxiety disorders are still broadly categorizable into three groups, at least as I see them. First, there’s panic attacks, or Panic Disorder. This particular disorder is not-uncommonly seen in emergency rooms, and is frequently misdiagnosed as heart attacks or other medical disorders. The sufferer complains of all sorts of bodily symptoms such as sweating, shaking, pressure in the chest, racing thoughts, dizziness, etc., and is fearful that the symptoms are harbingers of serious health consequences or death. Panic disorder is frequently treated with anxiolytics and/or antidepressants, and psychotherapy.

Another category of anxiety disorder is phobias – the most classic one of which is fear of snakes (e.g., Indiana Jones). These phobias can take many forms, fear of heights, fear of open spaces (agoraphobia), fear of public speaking, et cetera. In this case, the treatment of choice is a specific form of psychotherapy called exposure and response prevention, or ERP.

Finally,  there is Generalized Anxiety Disorder, or GAD. This is the classic “free floating anxiety,” where the patient reports being worried and anxious about, well, just about everything, and it seems disproportionate to anything being worried about. The treatment of choice for GAD, at least for younger adults, is CBT, as we mentioned, and as a second-line treatment, antidepressant treatment (typically with SSRIs).

The mystery is that according to published research out there, unlike with treatments for depression, CBT does not seem to work for older adults with GAD (which seems to be the most common anxiety disorder in older adults). So, if you’re working with an older adult with an anxiety disorder, and particularly if GAD is noted, the responsible advice to give them is to make use of an antidepressant like paroxetine or citalopram, and supplement with relaxation techniques (which, although isn’t psychotherapy per se, can be effective as a supportive therapy).

The older adult you’re working with may understandably protest – many are not keen on taking yet another pill. So what do you do? While I would certainly be sympathetic (given how so many older adults are probably tired of taking pills), given the state of current understanding as regards treatment for GAD and anxiety disorders in older adults, I would make sure the older adult in question is informed that there are significant risks to refusing what is in this case the first-line treatment for older adult GAD. I would then offer this older adult CBT and relaxation techniques, and do my very darndest.

The real question is, why does it seem like older adult GAD and anxiety disorders seem to be qualitatively different entities than in their younger adult and middle-aged counterparts? No one’s quite sure yet. I’ll let you know if anyone finds out.

Geropsychology Continuing Education – A Rant

So, it’s that time that every psychologist in California looks forward to every couple of years, that time when one enjoys the distinct pleasure of paying the California Board of Psychology its annual fee of several hundred dollars ($445 this year) to…. Well, I’m not sure what they do for me every two years. But I need to do it or they don’t let me keep my license.

As a sidenote, there are only a few states (a half dozen or so, if this list is accurate) that don’t require psychologists to attend a requisite number of Continuing Education (CE) courses every year, and these are apparently Colorado, Connecticutt, Hawaii, Illinois, Michigan, New Jersey, and New York. I can imagine the reaction of many mental health consumers out there – “I will stay away from those states, they just let psychologists sit around and collect their fees and not update their skills at all!”

I’m more than sympathetic to that sentiment – any psychologist who simply gets their doctorate and doesn’t make any effort to read relevant literature, stay current, learn new techniques, etc., will eventually find themselves selling a highly inferior and arguably even dangerous product to the public (whether this is a danger that requires government force to correct for is another matter).

In California, psychologists are required to earn 36 hours of CEs every two years (70 percent of which can be earned online).  These courses must be accredited by the American Psychological Association, or APA – like most other states, California’s psychologist licensing standards (in terms of ethical standards) are borrowed heavily from the APA’s Ethical Guidelines, and generally, California marches to the APAs tune, for good or ill.

So one of the positives of having a CE requirement like in California, of course, is that psychologists are then required to seek out learning experiences on a regular basis (for fear of losing their ability to practice). Hopefully, these learning experiences are relevant and useful for the psychologist in practice, and make them a better practitioner in the end.

Let’s take a look at what I’ve amassed over the past two years:

1)     “The Role of Clinical Supervision in Facilitating Compassion for Self and Others” (daylong live course)

2)     “Sleep in the Veteran Population” (daylong, live)

3)     “Risk Management: Medical eRisk Considerations for Online Communication” (online)

4)     “Ethical Principles of Psychologists and Code of Conduct” (online)

5)     “Legal and Ethical Issues Related to Clinical Decision Support Systems” (online)

6)     “Suicide Risk Management Training for Clinicians” (online)

7)     “Cognitive Processing Therapy (CPT) Enhancement Course” (online)

8)     “An Introduction to Telehealth in VA” (online)

9)     “Mental Health Assessment and Interventions With Older Veterans” (daylong, live)

10)  “14th Annual Updates on Dementia: Translating Research into Practice.” (daylong, live)

A few things to note about this list. Number one on the list is a required course I needed to take in order to retain my right to supervise students. Was it a particularly practical course? I honestly don’t remember much of it, but I do remember getting generally warm fuzzies at the end of it (it focused a lot on self-care and self-reflection as a tool for improving one’s supervisory capacity), but I’m not sure it necessarily made me a better supervisor. Frankly, I think getting personal therapy has made me a better supervisor more than anything (along with getting CEs specifically in geropsychology related coursework – more on that later).

The second item on the list was worthy of note – in this case, I don’t precisely recall learning anything earth-shattering from this course (it reviewed common issues related to sleep in veterans, such as optimizing adherence to C-PAP treatment in veteran populations, common sleep issues in polytrauma patients, etc.) but it was particularly useful for me given the preponderance of sleep-related issues that seem to impact my population. Although not directly related to Geropsychology, it was a valuable course for me to take, it definitely helped me to stay current in some things I need to stay current with on a day-to-day basis.

Now, let’s focus on the rest of the list. Aside from the last two items on the list (which were generally outstanding presentations on the state-of-the-art in assessment and interventions for dementia patients and older adults with psychiatric issues), let’s be honest: the rest of these CEs listed here were “filler” courses. Sure, all psychologists need to know basic risk management techniques for managing suicidality, and need to be familiar with the APA’s Ethical Guidelines (I would say I was familiar with both just fine before I took those courses). And sure, telehealth is interesting, certainly a fine subject -and I must say, I completely forgot about what “clinical decision support systems” was even about. Finally, I will not be using cognitive processing therapy in my work with veterans (this was a good online course in that it netted me 2.5 hours of CEs – most of these were 1 or 1.5 hours in length), mainly because I haven’t had supervised training in it – but I now have earned CEs in it. In short, what do most of these classes really have to do with my job? I’ll be bluntly honest – aside from the class on sleep and the two geropsychology courses, I took all of my other CEs to fulfill my 36 hour requirement with the government. I would have taken CEs on aging-related or geriatrics issues if I could. They just weren’t available.

I know what most of you are thinking. This is just where Dr. Lane is being a grumpy, cynical provider. It’s good that I keep abreast of these things, even if they don’t necessarily relate to my day-to-day duties as a Geropsychologist primarily working in long-term-care psychology. So, it’s all good, right?

Here’s where I protest. I didn’t get into this field in order to just become a psychotherapist and learn a few assessment tools and then stop right there. Clinical psychologists with a Doctor of Philosophy (PhD degree) are scientist-practitioners by trade. Whether or not they are primarily researchers, they identify with the idea that truly competent practitioners are ones who maintain a firm footing in current science, utilize the hypothetico-deductive method (hypothesis testing) in the way they frame clinical questions, and have a strong basis in current scientific thinking when they practice their craft (whether it be testing, consultation, or psychotherapy). I take that very seriously.

I also take my identify as a Geropsychologist very seriously. I typically find myself browsing Google Scholar at least once or twice a week to search out interesting basic research papers, clinical guidelines, or what have you. When I run into a difficult patient issue, I often find myself going back into the literature to make sure I remain firmly grounded in current understanding. My recent obsession was with fronto-temporal dementia (FTD), as I seemed to have a couple of patients recently with this issue that I wanted to make sure I understood properly (see this recent article for a discussion). Of course, none of this tends to reward me with any CEs.

One of my biggest grouses are that there just aren’t that many CE courses out there being offered for psychologists on geriatrics-related issues. A very brief, unscientific Google search for “geropsychology CE courses” yields a couple of interesting links: first, the APA’s own online listing of approved CE courses lists a number of topic areas and a total of just over three hundred (303) online CE courses one can take to fulfill the requirements of one’s respective state. All told, there are only 14 courses offered in “Geriatrics” (4.6% of the total). Topic areas with more courses in them include “Professional Resources for Practice,” “Psychotherapy,” “Health Psychology,” “Ethics in Psychology,” “Clinical Psychology,” and “Death, Grief, and Suicidology.”

Now, I have nothing against psychologists learning about any of these topic areas, and in fact (particularly as regards health psychology and the topic area of death and dying) many of these areas overlap with Geropsychology in terms of focus. However, let’s be frank – the population of older adults in the United States will continue to explode over the coming years, as I continually find myself saying. The “demographic tsunami” is right on top of us. And the well-documented shortage of Geropsychologists, or even general practitioners (in psychology or medicine) well trained in aging-related issues doesn’t look as if it will be getting better any time soon at this rate.

What does this matter to me? Well, perhaps not much. I consider myself much better trained in geriatrics than a sweeping majority of psychologists and mental health practitioners out there (although don’t look to me to do sandbox play therapy with your three year old – I have enough trouble raising my own children to worry about treating yours). So what if it’s harder to find quality CE courses in geropsychology for someone like me? Again, maybe it doesn’t matter much. On the other hand, I don’t think it bodes well for our (rapidly aging) future when aging-related issues don’t seem particularly well-valued. For my money, geropsychology should be the hottest topic area in CE provision out there, given the numbers.

There should be a “gold rush” on for providers to get trained in the latest and best methods for working with older adults – because by the numbers, every clinical practitioner will likely find themselves with older adult clients regularly at their doors in the near future – even those who ostensibly work with child populations (ever heard of kinship caregivers? I have).

If such a “gold rush” were ever to occur, there is at least one organization that stands to benefit. I’d like to introduce you to a relatively early-mover in the area of providing CEs for mental health providers in geriatrics: Concept Healthcare, Inc. Founded by Joe Casciani, Ph.D., the principal founder of the nursing home consulting firm, VeriCare, Concept Health bills itself as a company devoted to providing quality training to providers in mental health care services for older adults (although to be fair, I note they also manage a long-term-care psychology group practice as well). While this firm definitely looks promising and knowing Dr. Casciani, they likely offer quality products and services – I note that I do not have access to any of their products as a VA employee (although I could, theoretically, pay for some of their classes myself).

Soapbox rant over. Hopefully I’ll return to more interesting clinical issues in the next week or so.