Geropsychology as a Career? My unsolicited advice.

So I’m going to digress a bit here, and try and explain the long and winding path I took in my life to end up here – working in geriatric psychology. I wish I could tell you that I knew from a very young age that I wanted to work with older people, but I don’t have a neat story like that. Here’s what I can tell you – my parents (currently in their 70s, obviously at this point older adults themselves) told me they always thought from an early age I seemed more comfortable than most children speaking casually with adults, even as a toddler, at times I seemed to almost prefer the company of older people.

 

Aside from that, however, there wasn’t much about my life as a child that seemed to speak to a later career in geriatrics (defined as “of or relating to old people, esp. with regard to their health care”). I liked the company of adults, I felt comfortable with people a generation or two ahead of me, I was reasonably intelligent and curious about myself and others, and I was reasonably extraverted. That was about it – as a child, the idea of specific career aspirations was a confusing abstraction for the most part. I knew what I liked to do – reading nonfiction, writing stories, doing theatre camp, I remember at one point I did a summer camp where I worked in a local cable access TV production studio and made short films with other kids. I enjoyed myself, but through high school and into college, I was all over the map. Which I guess is typical.

When I got out of high school (which I was only too glad to do) and started undergraduate training I took some advice from adults and soft-pedaled my interests in television and entertainment. I was told that getting meaningfully employed in the entertainment world was something akin to winning the lottery – and the sacrifices in time and my personal life in order to be successful in such a field would be huge with a highly uncertain promise of reward. OK, fine. I wanted to be realistic, after all.

Fortunately, I found myself passionate about something else – psychology. While theatre and entertainment-related things scratched my itch for approval from others, one of my many hang-ups (applause after a good performance definitely scratches that itch), studying psychology scratched my own itch for self-reflection and self-knowledge. Or, at least, my yearning to “know thyself” at least provided some pretty strong motivation to move forward in it. While I don’t advise people to pursue psychology as a career because they’re curious about themselves, it’s undeniably a motivator for many, and potentially a powerful one.

I went to Reed College in the mid 90s. At the time, Reed was known in some circles as a place where students studied intensely hard, studied humanities, and where fraternities and sororities had no footprint, but at the time had a reputation that generally marked it as a school for the proverbial undergraduate “square pegs” who didn’t fit into the collegiate round holes of Stanford, Yale, etc. Since I left Reed, it’s reputation has only increased in prominence and respect, and now it’s considered one of the most academically challenging private colleges in the United States, at least by some metrics. I graduated in 1996 with a degree in psychology, with some emphasis on biology (I took biology courses at Reed, which I found incredibly daunting, and also did an honors thesis on neuropsychology).

After college, I did some traveling with my then-girlfriend and now-wife (Beth Trittipo, bio is here) worked as a research assistant for about year prior to attending graduate school at Pacific Graduate School of Psychology (now known as Palo Alto University, or PAU).

A brief, but I think important digression on graduate school in psychology. There may be any number of psychology students, or prospective graduate students in clinical psychology reading this blog who’ve considered the route of attending a professional doctoral program in clinical psychology, which overwhelming refers to unfunded doctoral programs. PAU is one of those programs. Granted, it tends to have a good reputation (arguably one of, if not the best) of unfunded professional programs. An overwhelming majority of its graduates (100% of its Psy.D. students as of last year) secure coveted internships accredited by the American Psychological Association, and tend to do well in terms of research productivity, licensure rates, and scoring high on the EPPP.

However, the biggest problem with professional programs in psychology, without a doubt, is the debt-to-income ratio that most students are left with. It’s a growing problem with all types of graduate and undergraduate degrees, but with students of professional (largely Psy.D.) programs, the problem has gotten out of control, with the average Psy.D. student leaving doctoral programs in psychology with 120K in student debt. At PAU, (which is in Palo Alto, after all) the average debt load is likely more than upwards of 250K at this point.

While 250K of student debt is manageable for a graduate of, say, a physician graduate of medical school who may begin earning six-figures or more immediately upon graduation, the median salary of a psychologist currently in the US is around 70,000 dollars per year according to the Bureau of Labor Statistics. That means if you have 200K-plus of debt as a graduate from a psychology professional program (very common these days), and you land a job paying around the median salary, even with the various repayment programs available to graduates these days (e.g., such as Income Contingent Repayment), the graduate could be sending out half a grand a month in loan repayments. If the graduate has private loans (which don’t qualify for these federal programs), this could drive up the costs further.

I graduated from PAU about a decade ago. While I have significant student loans from that adventure, they don’t approach the numbers I’m currently seeing with many clinical psychology graduate students, my interest rate is extremely low, and my payments, while annoying, are affordable with my VA salary. In short – I think I got lucky and I think I’m probably one of the last generation of professional student graduates from pricey schools like PGSP / PAU that can make the math even somewhat work. Even so, I pay several hundred dollars per month towards student loans, and that’s money that I definitely miss.

Anyways, off my soapbox.

So, I got into PGSP and began my studies. For me, getting into geropsychology was a matter of a bit of taking advantage of luck and propitious circumstance, and then capitalizing on the experiences gained even further, and then lather, rinse, and repeat. In graduate school, after languishing for a year or so doing generalist practicum experiences and toiling unproductively in a research group not related to geropsychology, I approached Larry Thompson and by extension, Dolores Gallagher-Thompson, both geropsychologists with stellar records of accomplishment and who were running a large-scale arm of the REACH-II (Resources for Enhancing Alzheimer Caregiver Health) research project on dementia caregiver interventions through the Older Adult and Family Center (OAFC) at the Menlo Park Department of Veterans Affairs.

Larry Thompson was very kind to me and offered to work with me on a dissertation project, and also found me a practicum training opportunity at the OAFC. This highly successful experience allowed me to attain an internship in geropsychology at the University of Medicine and Dentistry of New Jersey (UMDNJ), and then a fellowship in geropsychology at the University of Rochester Medical Center in Rochester, New York.

Since then, I’ve attained licensure as a psychologist, I’ve worked in community nursing homes, coordinated research projects, published articles, given talks, and have worked at the VA in Livermore as their staff Geropsychologist for approximately seven years now. I love my job, I enjoy what I do, and I think I’m very lucky.

So, what advice would I give to a student considering a career in geropsychology or geriatric mental health, in the future? I’ll break it down for you:

1) Don’t attend a doctoral program at a professional school in psychology, unless you’re independently wealthy or you receive some other form of funding. Just don’t. Make yourself competitive for funded programs. Get stellar grades in college. Get on publications, do research assisting for a year or two before you apply to graduate programs, and get a stellar GRE score, whatever you need to do. Moreover, short from a select number of professional programs like Rutgers, Baylor, perhaps PAU / PGSP, for the most part professional programs in psychology tend to struggle to match the reputations of funded programs, which is an extra cross to bear for professional school graduates. So, don’t do it.

2) Consider applying to nurse practitioner programs (medicine is OK too, but I see reimbursements declining, while tuition continues to rise). One side effect of Obamacare that I can see is that with all of the pressure being put on physicians due to what will supposedly be increased enrollment of the previously uninsured, demand for nurse practitioners will increase. And NPs command significantly greater salaries than psychologists. Consider masters-level programs in counseling or social work, with an emphasis in geriatric mental health as well (far less money and time for a degree that allows you to do many, if not most of the things professional clinical psychologists do).

3) If you’re bent on attending graduate programs in psychology, and you want to go into geropsychology, my advice is specialize, and specialize early. Make sure you get the specialty practicum, internship, and postdoctoral training opportunities where possible, and don’t forget to get elective coursework in geriatric mental health, geriatric neuropsychological assessment – as this will be critical in attaining later boarding as a Geropsychologist with the American Board of Professional Psychology (ABPP, something I talked about here). Geropsychology is a specialty, and in order to get specialized jobs, you’ll need specialized training.

4) Be prepared to not make a ton of money in geriatrics. This is not a glamorous field. Medicare continues to nickel-and-dime us to death. Don’t expect to get rich.

That’s it for now.

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.

 

“Robot & Frank” (2012): A Review

There’s a small collection of movies out there that offer a particularly notable and meaningful commentary on older adulthood. “Iris,” a bittersweet drama depicting the famous author and philosopher Iris Murdoch’s decline from Alzheimer’s, is a favorite of mine. The film’s depiction of the difficulties (and moments of joy) experienced by her devoted husband were extremely moving. There is also the hilarious fantasy tale in Pixar’s 2009 film “Up,” which so wonderfully and humorously depicts many of the prejudices and difficulties posed by older adults in our culture while at the same time spinning a delightful and eye-popping yarn.

“Robot and Frank” is a 2012 movie directed by the newcomer Jake Schreier in his feature-length debut. It stars Frank Langella who plays an aging, crotchety semi-retired cat burglar named Frank, who seems to be suffering from some early-stage dementia, and is cared for by his well-meaning but often-annoying two children.

The twist to this story (aside from Frank’s criminal tendencies) is that it takes place in the near future, and features a “healthcare robot” that Frank’s son has purchased to encourage Frank’s independence in his home, and to maintain Frank’s health. At first, Frank is hostile to the robot, but soon warms to his presence, particularly after he discovers that he can manipulate the robot into helping him resume his life of crime.  (Peter Sarsgaard plays the robot, FTW. — BT) On the one hand, you might think, “clearly this is a bug in this robot’s programming; why would the manufacturers allow this robot to participate in criminal behavior with their care recipients?” However, the movie explains that the robot does its best to create an individualized care plan for the care recipient, and the highest priority for the healthcare robot is to maintain high functioning in their charges.

Gerontologists will tell you: one of the best ways to slow or prevent cognitive decline in vulnerable elderly is for older adults to remain actively engaged in meaningful activities. The robot initially tries to encourage Frank to engage in activities like gardening and hiking, but this doesn’t quite do it for Frank. So, what we end up with in this movie is a series of hugely entertaining scenes where the robot is trained by Frank to pick locks, taken along with him to do “jobs,” and becomes Frank’s business partner in some of his exploits. As a result, Frank gets his second wind, begins to eat better, displays more excitement for life, and for a time, seems sharper than he has ever been – but as a downside he attracts the interest of the local police.

Throughout the movie, however, we’re reminded that Frank is never really quite well. He seems to be constantly disoriented (misremembering that his son is no longer in college; forgetting that his favorite restaurant has been gone for years), and at the end of the movie when the dramatic (obligatory for a buddy movie) chase scene ensues, he displays a massive lapse in his memory that really demonstrates that Frank’s memory may be beyond remediation.

The brilliance of this movie is that it does many things all at once, both cinematically and as a commentary on aging and dementia care. “Robot and Frank” manages to embed a humorous and fascinating commentary on dementia caregiving within a charming, heartwarming science fiction “buddy movie” storyline. Caregiving for an older adult with memory problems is challenging as any son or daughter with a demented older adult at home can tell you – this movie provides a whimsical way of exploring the challenges. This is quality and timely social commentary in a very fun package.