Geropsychology

              Geropsychology, 1990 M. Powell Lawton, Ph.D. Philadelphia Geriatric Center One of my most vivid training experiences was 2 years of psychological test seminars with David Wechsler. Wechsler was in his 60s then and he delighted in drawing and redrawing his age curve of raw scores on the Wechsler-Bellevuse. He liked that curve because it was one of the all-time great illustrations of a major effect: a steep rise until age 22, a fairly flat shape through most of adulthood, and an accelerating decline beginning around age 60-65. He was proud to have generated such compelling He was pretty evidence of the rise and fall of intelligence. forgetful himself, which he enjoyed pointing out and blaming not on himself but on the built-in biology of age-related intellectual deterioration. C The geropsychology of the time was characterized by a number of similar oversimplifications, many of them reinforcing an ageism that saw older people as inevitably confused and debilitated. Another psychologist of the time was Irving Lorge '^- f^^-f (of the Thorndike-Lorge word list) who was a--pioneer i t f ^ aging. to teach a course based on empirical knowledge about Courses at TC Columbia at the time were coded with 3 Although Lorge was one of the pioneers digits and 2 letters. against ageism he couldn't resist giving his course the number Address delivered to the Philadelphia Society of Clinical Psychologists, June 2 f 1990. 207AK, which those of you who know the term "alte kaker11 will no doubt recognize. We've come a long way since then, much of the motive power for new research having come from the changing demography of age about which so much has been written. I'll give myself a quota of just 5 tidbits of litany to illustrate why aging is no longer A the coming thing but the arrived thing: As of the end of WWII people 65+ constituted every twelfth person in the country. Before the end of our century they will represent every eighth person During the same time period, years have continued to be added to the lives of people even after they have reached age 6 5 : Over those 40 years men have been benefited by more than 2 additional years, women by almost 4. The very old as a group are growing. In 1950 the 85+ By 2000, they constituted 4.7% of the 65+ population. will constitute 13.3% of all older people. More than 80% have one or more chronic diseases, including 4 to 6 percent who suffer from Alzheimers disease. Despite this general level of morbidity only 5% are institutionalized and only 10% of those living in the community have self-care problems marked enough to require the help of another person. These snippets portray the magnitude of the societal issues revolving around the older population in terms of its relative m a s s , its center of gravity moving into the old-old region, and its health status -- the bad news is age-related morbidity and the good news is that morbidity does not necessarily equal disability and dependence. With this prologue completed, I'd like to take the rest of my time for a few thoughts on the relevance of aging for the practice of clinical psychology. The Relevance of Age and Cohort Membership to the Practice of Clinical Psychology Over the past years several studies have appeared of the age distribution of people in treatment for psychological conditions. Various estimates have appeared: In 1978 3% of psychiatrist office visits were by people 65+ and over, exactly the percentage estimated by Eisdoi^ter in 1987 for all private-practice mental health services. For CMHCs the estimate of percentage of all These percentages are A Is visits made by those 65+ was 6% (1984). grossly lower than the population proportion of older people. fact of life is thus thatause rates for MH services, a f * low. ji it ageism in professional practice, a matter of older people's lower income, of very limited reimbursement capacity, or of reluctance by older people to seek psychological services? It is worth lingering on this question in order to plan for the future. Mental health services now being planned and individual practitioners looking ahead may benefit from some interesting data relevant to changing demand for mental health services by the elderly. When considering change over time we have 3 inextricably related phenomena to consider. First is chronological aging. Second is life experiences that are specific to the periods of one's life, the sol-called cohort effects common to people born at a particular time. The third is historical time changes to which all people are exposed, such as world war^s and economic ^depression. Probably most of you are aware how recognition of these influences has enabled us to characterize many effects once presumed to have been due to aging (for exaMple, performance on some intellectual tasks) as being due to differential educational experience associated with birth cohort membership, rather than chronological aging. Similar considerations apply to attitudes, expectations, and behaviors associated with mental health and its treatment. I'll quote at length some relatively neglected findings from a study that allowed us to partially separate the contributions of age, cohort, and period diffeierrees to what we might call "readiness to seek mental health services." This study by Veroff, Gurin, and others was one of the landmark efforts that launched the Community Mental Health movement. The study was commissioned by the Presidential Task Force on Mental Health and Mental Illness to understand the position of mental health among the American public. The book that appeared in 1957, Americans View Their Mental Health, reported the state of people's mental health, their attitudes toward psychological concepts, their receipt of various mental health services, and their expectations about what they would do should they need help. was repeated 2 decades later. Essentially the same survey It has now been 16 years since that followup survey and one hopes that there will be a third coming along soon. Such a repeated study offers 3 possibilities for understanding any given issue. Responses to a particular question may change over 20 years for the entire population, in which case one would infer that social-historical change had influenced everyone's behavior or attitude. A second change might look at people in 1957 and see howA20 (A years of continued A :/ / f living might have affected responses -- the effect of age. Finallyf differences between people of one age in 1957 and different people the same age in 1977 would reflect birth cohort differences. You'll no doubt recognize that one can't separate there are always 2 of them each of the 3 effects one at a time -- that are confounded -- but I'll just implicitly take that into account as I note the findings. From 1957 to 1976 there was a substantial increase in the proportion of people of all ages who actually used some professional mental health services, an increase that could have been due to both increasing acceptance of such services as a function of time or to the movement through the at-risk period of birth cohorts who warer increasingly socialized to accept mental 4 health services. Of particular interest is the fact that the percentage of people 65+ fusincj such.services showed an increase of 63% over the 2 decades* from 7.7% to 12.6% of the 65+ age group. Looking longitudinally at those in the age 40-59 range in A J Ln 1 9 5 7 , their percentage use increased from 12.6% to 15.4% in 197 9^*^^ They apparently maintained their original propensity for helpseeking as well as sharing in the nationwide increase in helpseeking across those 20 years. At the very least there was no decrease with age in rate of receiving mental health services.