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2006 Polisher Research Institute Clinical Geropsychology: Problems & Prospects' M. Powell Lawton Philadelphia Geriatric Center For the past decade an occasional voice has been heard periodically decrying both the inattention of clinical psychologists to the aged and the inattention of gerontoiogists to the traditional areas of clinical psychology. Had one the proper sense of history and the patience of Job I suppose it should be possible to take heart from the sporadic, threshold-level, incremental growth^that has taken place during this time. So small has this growth been in aggregate, however, that I am motivated to retitle and scramble a couple of papers that I've written on this topic during this decade and proceed with full confidence that the same issues and facts apply today. My need for novel experience will, I hope, lead to some new material for 1978, but in the main, much of what could have been said about the "problem" side in 1968 could still be said today. I should like to begin with a recapitulation of some facts about the older person in the mental health system and in relation to the profn&ion of psychology. Then I shall consider r\fmjasonft**toti? gf the crucial question as to how desirable it is to foster the developlent of a discipline of geropsychology. Then I shall discuss in A relatively broad terms the current status of practice in some of the traditional areas of clinical psychology, and end with some suggestions regarding the use of the clinicianfs skills in nontraditional areas. It is clear that a single presentation cannot hope t o cover the sub, stance of practice nor should it attempt to review.the literature. A f\ Master Lecture, American Psychological Association, Toronto, August 3 0 , 1978 &? *it is hoped that the issues raised here will stimulate a wider group of nonspecialists in aging to investigate the existing literature and to proceed first-hand into practice and research that will lead u^ nmfhf issues and "-in t 's The older person in the mental health system Over a long period of time the characteristic mode of treatment for older people has bjsen the mental hospital. Recognizing that the elderly constitute a^eutr 10* percent of the population of the U.S.A., A by comparison they represented 28 percent of the mental hospital population in 1975 (National Institute of Mental Health, 1978^. The national move toward deinstitutionalization has, to be sure greatly reduced the number of older people in mental hospitals, from 140,000 in 1965 to 54,000 in 1975. However, the proportion of the total who are 65 and over decreased only two percent, from 30 percent in 1965 to 28 percent in 1975. And' as we all know "deinstitution- alization" may be an ideal, a state of mind, or a manner of speaking, but it certainly has not proved to be a reality in the case of the elderly. While exact: data are not available, a substantial proportion of the aged beneficiaries of the mental-hospital deinstitutionalization movement were dubiously benefited by transfer or directadmission to nursing homes. We do know that the number of older people in nursing homes has increased precipitously, from 462,000 in 1963 to 1.1 million in 1973-74. Between the Census years of 1960 and 1970, during which period a major part of the deinstitutionalization movement was effected, the overall percentage of older people in institutions of all types increased almost 25 percent, from 4.0 to 4.9 percent. most recent report from the 1973-74 Nursing Home Survey (National -2The Center for H e a l t h home S t a t i s t i c s , 1978-) i n d i c a t e s residents were to these considered that 58 p e r c e n t some or of of all nursing of the t i m e . confused proportion most Adding the s m a l l e r residents clear of the with that functional the n u r s i n g hospital. but not organic mental d i s t u r b a n c e s , it is a variant home has become at least p a r t l y mental On the community side, the best regarding age-specific treatA ment rates come from the network of federally-funded community mental health centers. In 1976, 3.9 percent of all clients treated in these 548 centers were 65 and over. This proportion has remained almost constant d since.1969, In 1975 the Community Mental Health i / L dg/jL '? ' 'yMvM'U fa A legislation added services to the elderly to the list of mandated services. percent *&& the first year following these amendments warn a 0.1 in the p r o p o r t i o n of e l d e r l y served; it r e m a i n s to decrease A be seen whether the two years that have followed have seen any, , :J'%? tendency to right the selective avoidance of the elderly by the CMHCs. The CMHC data give only aggregate age percentages and do not allow one to determine the type of treatment received by the elderly as compared^ to other age groups, ^owever, KiiHji (1975) has analyzed NIMH data. t8 concludie*that " 1 1 n r "rwftvPttf* access to treatment within ft) . h L, A than 139* o u t p a t i e n t services. elderly t h e CMHC^, w a s m u c h j^eti^r le i n p a t i e n t Among fared non-federally-funded mental health just c l i n i c s , the of even m o r e p o o r l y , r e p r e s e n t i n g in 1969 two p e r c e n t 1973). their clientele (Kramer, Taube, & Redick, thus a l l o w of c h o i c e from These data are been and the treatment away one to c o n c l u d e , f i r s t , that for the f ^ L d e r l y , second that health institutions there has a^trend finally, t r e a t m e n t .withitl the m e n t a l toward --3-- increasing system, mental that no trend use of o u t p a t i e n t health f a c i l i t i e s is discernible at t h i s point. w are not in e Moving specifically into our o n f i e l d , w p o s s e s s i o n of national data that would allow us to assess the extent to which psychologists provide services to the elderly either w i t h i n any of the mental health structures or on a private b a s i s . Some survey data -rnxsc^sf^ss^mmm^^SSS^ i l l u s t r a t e volvement of psychologists in private p r a c t i c e . the low level of in- Dorken & Whiting ( 1 9 7 4 ) , in a mail survey of the "service-providers" segment of an e a r l i e r A A sample (overall response rate of somewhat more than P determined that 26 percent "reported work with those over 64," However, less than two percent averaged more than one hour per week with older c l i e n t s ; clients C half) the aged accounted for only one percent of all seen. x.^-' A later survey by Dye (1978), done in 1975 was perhaps most eloquent in i t s demonstration of the level of 'interest in clinical work with the aged: A three- page survey of clinical and counseling psychologists on working with the aged elicited responses from only 19 percent. This low response rate precludes making parametric estimates of psychologists' experiences and attitudes toward older patients; however, of this nonrandom sample about one-third saw patients 60+ at least occasionally. Why a clinical psychology of later life? J i-t--is pTJ&blble-Tirsrt R e c e s s i y pr-^ 1 -- i il 1i fH -- neglect f^^.,hy to the mental h e a l t h yot system is +^- - U n ^ i y , part of I and m wy at-hogA ia ci LliaL acmytf generalized aLLBBi^jy-roty^uio tho yjmbltiW of '1t y m ny i of 1n f a r t | - * m only ? by s o c i e t y . symptomatic In t h i s the the e l d e r l y view, a i L m ooflo? n^ h t g the failure to develop clinical technologies suited to the unique needs of the elderly. ~ . . . . . ? ? ? ? ? . ? * ? It is thus felt that . ?. ? ? . . ' . ? . ' general knowledge regarding the clinical practice of psychology must be examined in light of its applicability to the older person and expended in light of the unique characteristics of this age group, Kastenbaum (1978) has, however, questioned the desirability of an age-specific clinical psychology, and in so doing, raised questions worthy of further consideration. He suggests that an "all- out effort to cultivate a special field of geriatric psychoth might end up as one more exercise emphasizing the separateness of the elderly from the rest of society and thereby cementing, rather than dissipating, the ageism of mental health practice, Kastenbaum proposes the alternative of looking toward knowledge already available in general mental health regarding approaches found to be useful in treating the physically ill, the^poor, the unemployed, or the bereaved. ^ 1 i Un 1 ^mmrnkm^ ^fhis r approach would stress the commonalities JK of the old and the young as they experience similar situations. Such advice should alert us to the possibility of jirsing literature and experience in these areas to augment the meager store of existing relevant technical knowledge. Whether it would constitute a superior alternative to an age-focused clincial psychology is another matter. -5-
Object Description
| Title | Clinical Geropsychology: Problems & Prospects |
| Abstract | This presentation criticizes the historical inattention of clinical psychologists to the elderly, as well as the inattention of gerontologists to areas of clinical psychology. Dr. Lawton first examines the older adult's place in the mental health system, including barriers to access to the mental health system and the debate surrounding age-categorical care. Aging adults constantly confront ageism in the mental health system, and many mental health providers hold on to their discriminatory beliefs despite the research refuting them. He follows this with a review of the traditional roles for clinical psychologists and suggests some nontraditional areas in which these practitioners' skills could be applied. Dr. Lawton concludes that clinical work with the aged does not appeal to enough people to stimulate the needed growth in the clinical geropsychology field, but believes financial incentives would. // This presentation is missing Figure 2 discussed on page 21, and there are no references. --AJL |
| Subject, Keyword | geropsychology, mental health |
| Subject, LCSH | gerontologists, clinical psychology, mental health, aging |
| Subject, MeSH | geriatrics, aged, clinical psychology, mental health |
| Subject | geropsychology; mental health; gerontologists; clinical psychology; mental health; aging; geriatrics; aged |
| Class. Number, LCC | RC467.C58613 |
| Class. Number, NLMC | WM 105 |
| Class. Number, DDC | 616.89084 |
| Creator | Lawton, M. Powell, 1923-2001 |
| Date Created | 1978 |
| Description | Master Lecture, American Psychological Association (August 30, 1978 : Toronto, ON) |
| Extent | 34 p. |
| Language | eng |
| Publisher | Polisher Research Institute |
| Rights | Copyright 2006 Polisher Research Institute |
| Access Rights | fair use rights |
| Contributors, Authors | M. Powell Lawton |
| Contributors, Principal Investigators | Rachel R. Resnick |
| Contributors, Research Assistants | Karen C. Kohn; Nicole Snyder; Amanda J. Lehning; Arthur Shum |
| Contributors, Reviewers | Philip D. Sloane; Maggie Calkins; Laura Gitlin; Jeanne Teresi; Patricia Parmelee |
| Related Documents | Lawton, M.P., & Gottesman, L.E. (1974). Psychological services to the elderly. American Psychologist, 29, 689-693. // Lawton, M.P. (1976). Geropsychological knowledge as a background for psychotherapy with older people. Journal of Geriatric Psychiatry, 9, 221-233. // Kaye, J.M., Lawton, M.P., & Kaye, D. (1990). Attitudes of elderly people about clinical research on aging. Ther Gerontologist, 30, 100-106. |
| Transcript | 2006 Polisher Research Institute Clinical Geropsychology: Problems & Prospects' M. Powell Lawton Philadelphia Geriatric Center For the past decade an occasional voice has been heard periodically decrying both the inattention of clinical psychologists to the aged and the inattention of gerontoiogists to the traditional areas of clinical psychology. Had one the proper sense of history and the patience of Job I suppose it should be possible to take heart from the sporadic, threshold-level, incremental growth^that has taken place during this time. So small has this growth been in aggregate, however, that I am motivated to retitle and scramble a couple of papers that I've written on this topic during this decade and proceed with full confidence that the same issues and facts apply today. My need for novel experience will, I hope, lead to some new material for 1978, but in the main, much of what could have been said about the "problem" side in 1968 could still be said today. I should like to begin with a recapitulation of some facts about the older person in the mental health system and in relation to the profn&ion of psychology. Then I shall consider r\fmjasonft**toti? gf the crucial question as to how desirable it is to foster the developlent of a discipline of geropsychology. Then I shall discuss in A relatively broad terms the current status of practice in some of the traditional areas of clinical psychology, and end with some suggestions regarding the use of the clinicianfs skills in nontraditional areas. It is clear that a single presentation cannot hope t o cover the sub, stance of practice nor should it attempt to review.the literature. A f\ Master Lecture, American Psychological Association, Toronto, August 3 0 , 1978 &? *it is hoped that the issues raised here will stimulate a wider group of nonspecialists in aging to investigate the existing literature and to proceed first-hand into practice and research that will lead u^ nmfhf issues and "-in t 's The older person in the mental health system Over a long period of time the characteristic mode of treatment for older people has bjsen the mental hospital. Recognizing that the elderly constitute a^eutr 10* percent of the population of the U.S.A., A by comparison they represented 28 percent of the mental hospital population in 1975 (National Institute of Mental Health, 1978^. The national move toward deinstitutionalization has, to be sure greatly reduced the number of older people in mental hospitals, from 140,000 in 1965 to 54,000 in 1975. However, the proportion of the total who are 65 and over decreased only two percent, from 30 percent in 1965 to 28 percent in 1975. And' as we all know "deinstitution- alization" may be an ideal, a state of mind, or a manner of speaking, but it certainly has not proved to be a reality in the case of the elderly. While exact: data are not available, a substantial proportion of the aged beneficiaries of the mental-hospital deinstitutionalization movement were dubiously benefited by transfer or directadmission to nursing homes. We do know that the number of older people in nursing homes has increased precipitously, from 462,000 in 1963 to 1.1 million in 1973-74. Between the Census years of 1960 and 1970, during which period a major part of the deinstitutionalization movement was effected, the overall percentage of older people in institutions of all types increased almost 25 percent, from 4.0 to 4.9 percent. most recent report from the 1973-74 Nursing Home Survey (National -2The Center for H e a l t h home S t a t i s t i c s , 1978-) i n d i c a t e s residents were to these considered that 58 p e r c e n t some or of of all nursing of the t i m e . confused proportion most Adding the s m a l l e r residents clear of the with that functional the n u r s i n g hospital. but not organic mental d i s t u r b a n c e s , it is a variant home has become at least p a r t l y mental On the community side, the best regarding age-specific treatA ment rates come from the network of federally-funded community mental health centers. In 1976, 3.9 percent of all clients treated in these 548 centers were 65 and over. This proportion has remained almost constant d since.1969, In 1975 the Community Mental Health i / L dg/jL '? ' 'yMvM'U fa A legislation added services to the elderly to the list of mandated services. percent *&& the first year following these amendments warn a 0.1 in the p r o p o r t i o n of e l d e r l y served; it r e m a i n s to decrease A be seen whether the two years that have followed have seen any, , :J'%? tendency to right the selective avoidance of the elderly by the CMHCs. The CMHC data give only aggregate age percentages and do not allow one to determine the type of treatment received by the elderly as compared^ to other age groups, ^owever, KiiHji (1975) has analyzed NIMH data. t8 concludie*that " 1 1 n r "rwftvPttf* access to treatment within ft) . h L, A than 139* o u t p a t i e n t services. elderly t h e CMHC^, w a s m u c h j^eti^r le i n p a t i e n t Among fared non-federally-funded mental health just c l i n i c s , the of even m o r e p o o r l y , r e p r e s e n t i n g in 1969 two p e r c e n t 1973). their clientele (Kramer, Taube, & Redick, thus a l l o w of c h o i c e from These data are been and the treatment away one to c o n c l u d e , f i r s t , that for the f ^ L d e r l y , second that health institutions there has a^trend finally, t r e a t m e n t .withitl the m e n t a l toward --3-- increasing system, mental that no trend use of o u t p a t i e n t health f a c i l i t i e s is discernible at t h i s point. w are not in e Moving specifically into our o n f i e l d , w p o s s e s s i o n of national data that would allow us to assess the extent to which psychologists provide services to the elderly either w i t h i n any of the mental health structures or on a private b a s i s . Some survey data -rnxsc^sf^ss^mmm^^SSS^ i l l u s t r a t e volvement of psychologists in private p r a c t i c e . the low level of in- Dorken & Whiting ( 1 9 7 4 ) , in a mail survey of the "service-providers" segment of an e a r l i e r A A sample (overall response rate of somewhat more than P determined that 26 percent "reported work with those over 64," However, less than two percent averaged more than one hour per week with older c l i e n t s ; clients C half) the aged accounted for only one percent of all seen. x.^-' A later survey by Dye (1978), done in 1975 was perhaps most eloquent in i t s demonstration of the level of 'interest in clinical work with the aged: A three- page survey of clinical and counseling psychologists on working with the aged elicited responses from only 19 percent. This low response rate precludes making parametric estimates of psychologists' experiences and attitudes toward older patients; however, of this nonrandom sample about one-third saw patients 60+ at least occasionally. Why a clinical psychology of later life? J i-t--is pTJ&blble-Tirsrt R e c e s s i y pr-^ 1 -- i il 1i fH -- neglect f^^.,hy to the mental h e a l t h yot system is +^- - U n ^ i y , part of I and m wy at-hogA ia ci LliaL acmytf generalized aLLBBi^jy-roty^uio tho yjmbltiW of '1t y m ny i of 1n f a r t | - * m only ? by s o c i e t y . symptomatic In t h i s the the e l d e r l y view, a i L m ooflo? n^ h t g the failure to develop clinical technologies suited to the unique needs of the elderly. ~ . . . . . ? ? ? ? ? . ? * ? It is thus felt that . ?. ? ? . . ' . ? . ' general knowledge regarding the clinical practice of psychology must be examined in light of its applicability to the older person and expended in light of the unique characteristics of this age group, Kastenbaum (1978) has, however, questioned the desirability of an age-specific clinical psychology, and in so doing, raised questions worthy of further consideration. He suggests that an "all- out effort to cultivate a special field of geriatric psychoth might end up as one more exercise emphasizing the separateness of the elderly from the rest of society and thereby cementing, rather than dissipating, the ageism of mental health practice, Kastenbaum proposes the alternative of looking toward knowledge already available in general mental health regarding approaches found to be useful in treating the physically ill, the^poor, the unemployed, or the bereaved. ^ 1 i Un 1 ^mmrnkm^ ^fhis r approach would stress the commonalities JK of the old and the young as they experience similar situations. Such advice should alert us to the possibility of jirsing literature and experience in these areas to augment the meager store of existing relevant technical knowledge. Whether it would constitute a superior alternative to an age-focused clincial psychology is another matter. -5- Within the larger arena of services in general, there has been a long-standing conflict between those who claim that services are delivered best when they are made available across the board to all ages and those who feel that equity will come to the aged only when they are singled out for special consideration. to the present, experience seems to have favored strongly agecategorical services^ if tihr ar i f ? j o n ? g Mmi r*A + r --fcho wollbeing ,f * ? n f fha ri.rirrly Let us take housing as an example. Older people Up lived in federally-assisted housing from the beginning of such programs. However, until the advent of age-categorical programs, (a) older people were served in disproportionately low numbers, (b) classes of aged such as single persons were excluded because of regulations framed to cover the younger majority, and (c) the housing environments were very likely to be planned and designed in ways that negativeily affected the wellbeing of older people. Other examples of instances where both access and quality of service have been enhanced by targeting to a particular age group are easy t o f i n d . rf r rr*" ^JLAJL^A^ jZtU.-*^t) J/ s^ju- *~ / n . ^ : ?,&*** +?* -? '4Uc~- ?*: -L-- Xccess to the mental health system In the case of mental health,access f? r older people under uncontrolled conditions is made more difficult by a variety of factors. First, mental health professionals typically prefer to they feel to be good therapeutic risks. work with patients whom Proverbially this assessment of risk results in the judgment that the young, attractive, intelligent, and middle class patient is the one most deserving of scarce therapeutic time. Part of the -6- explanation for these preferences lies in professional ageism. basis B u t it is also difficult to argue on an effort-optimizing a g a i n s t the idea that the longer life expectation of the younger p a t i e n t war ran toflee-ei'diflg-to' the yuniig correspondingly higher A p r i o r i t y for treatment. TJie only effective counteryargument^ 1 i c r -ic e right aJ^yij|dl'ttw?AAar pui?m& 11,^earned through past and present A contributions to societ}^, to whatever procedures may be of assistance in dealing with a psychological problem. While it has often been asserted (e.g., by Freud and many others) that the middle-aged . and aged cannot benefit from psychotherapy as easily as younger people, this sweeping generalization is impossible to substantiate. Indeed, it is of great interest to examine the intriguing "metaanalysis" of 375 research evaluations of psychotherapy reported by Smith & Glass (1977). In addition to demonstrating a significant positive effect over all studies, they examined a variety of predictors of size of favorable ?s?^rf Age of clients was unrelated to magnitude of outcome effect at either a zero-order or multivariate level. One must assume that the upper range of age was restricted, since so few studies of therapy with the aged have been reported. Nonetheless, within the range of client ages studied, the fact that a variety of other factors were consistently associated with outcome, while chronological age was not, is a most compelling argument against the glib equation of youth with therapeutic potential. A second barrier for the elderly is more broadly ba~sed "in people's psychological aversion to the elderly as a way of warding off anxiety over their own aging and ultimate death. While Kahn (1975) is correct in suggesting that this assertion has not been -7- tested 9Jfhere are a variety of^arf rat ional negative stero n o t i o n s about , fld age whose origins are .ve'ry likely to be psycholynamic. It is probably unrealistic to hope that the access barriers a t t r i b u t a b l e to professional ageism can be eased 9?sT through broads i d e education and sensitization of all mental health professionals. It is far more realistic to think in terms of "planting" an experta d v o c a t e in as many centers and other facilities as possible. Such ? *. pJw=Eie would presumably have MtfBMn0g either pre- or post-professionald e g r e e in gerontology and function as both the local source of exp e r t i s e and as a monitor to insure the equal access of the elderly"^# *iku \ e q u i t y * *? ^ 1 " ^r,T=I f iQ.^--P^"-^I I ty^trn nY n T-n r*, ^ and where necessary be the ? vi m p e t u s for the establishment of age-specific programs. The p s y c h o l o g i s t is suggested as the member of the mental-health team m o s t likely to be able to serve this function, primarily because of her dual roots in research and practice^ fas I shall suggest later, it seems essential for a clinical practitioner to be familiar with the large body of research in gerontology as a whole, and the psychol o g i s t is far more likely to have this^orientation? - third"ftoufod? f easier access f^irrTjmr yamigo-r^$aJLJ &&&Jlri?es A o *aei v lire--and'-of wa..yc &? g^LLing Lhe siill/lLft^ A (xhe younger person, more A tightly integrated into social modes of communication through work and other organizations is, other things being equal, more likely to know about mental^health services. He or she is alsp more likely to have the health and economic resouces to jvttiAhmQ * tfie serviced Medicare places s u b s t a n t i a l c o n s t r a i n t s upon mental health service payments. greater JHrtfT s?pe V e o i a l pressure integration. i?? also likely to 1 n w h r r , ^^^ r ? . ther m e n t a l 7 social on the y o u n g e r individual, t o ^ s e p rifrM^arH i ^?t3Mtfe' -d- 0 a v i d c H e a d on one ? s a family situation. are less To the extent that I ^mjH1 ties job 5 or in into.social reason institutions for older people, fewer people will have in distress difficult to seek psychological question to urge the older Finally, person treatment. relates^ the most access-relevant ^ While one evidence of a g e i s t i c professional the e n t i r e system practices extent is e a s y to m a r s h a l l , cannot honestly attribute of the age-related T h e fact is treatment that older gap to the m e n t a l - h e a l t h people properties. than a r e less ! i * s y c h o l o g i z e d l f n o w had c o m p l e t e d a fixture commonplace s OHpQriQ.11 Q Q are younger sohool cohorts. before"^U- T h o s e w h o are 65 or over school psychologist public long had b e c o m e were and b e f o r e psychodynamic As Kahn (1975) explanations has pointed of b e h a v i o r o u t , most iij, the m e d i a . W?th the people mental-health forbidding when system asylum. up u n t i l the p o s t - W o r l d War II per iod had bgcii the a psychiatrist only People were viewed as n e e d i n g severely ill, andfe-hcr-maiH or forms f f treatment were r A into account this great difference that unfamiliar. Taking pscyhological in s o c i a l i z a t i o n older people of to today thinking it is not s u r p r i s i n g as f r e q u e n t l y do n o t p r e s e n t patient ing mental themselves health rates as y o u n g e r people do for o u t data estimatthat or treatment. I am not a w a r e of good age-specific of s e l f - r e f e r r a l , but it seems be c o n s i d e r a b l y were it to be less-often offered. likely today's age c o h o r t would self-referred accepting of p s y c h o t h e r a p y -9- Similarly, estimates of perceived need for mental health services are difficult to locate. The best that we have are a great variety of "needs-assessment" surveys, which ask the respondent whether he or she . needs a particular service, would use it if it w e r e a v a i l a b l e * cwsrr-es&pvi? e?-&e s- o thex.-.s~?nii 1 a r hyp a tfeet i c a 1 a trt?trtrde?s c e ? # The disadvantages are obvious: People 1"' the same terminology in different ways, different are used by different investigators, people's hypothetical responses to suryey questions are notoriously poor predictors of behavior. &m JUZ reveal their real feelings, and so on. However, simply to illustrate the range of responses to this kind of inquiry, a convenience sample of six needs-assessment surveys were searched, which revealed that anywhere from 6 to 16 percent indicated a need for ? ? ? ? ? ? ? ? ? ? . ? ? ? . . . ? ' . . . . ?. # ? . ? ? counseling in the personal-social-family area. HXgher proportions felt that such services would be good for others ("attributed" need for service). t?--khx&^qn e iu.s t auc e. whara^lai-a-a-t e [?data from ISR if available]; iLt^^ erated^"Xe"ss ^ These estimates may be compared with the best national baseline l now available for people of.ages' " D^ttvan, Kulka, and Veroff (1978) A J in their repeat study of Americans View Their Mental Health found that 37 percent either "had used or could have used professional help fo a personal problem" ^ ^ j ^ &U'/pKjf T t Thus it seems/that older people are less likely to view themselves as candidates for counseling and psychotherapy and that this differential readiness to construe one's own problems in this way is one factor in their lower within-community treatment rate. -10What is Missing Page 11 their "true 1 1 rate Some of n e e d ? T h i s , of c o u r s e , is an u n a n s w e r a b l e that such need that surveys underindicators need (e.g., question. clues are given e s t i m a t e n e e d , a s in the f r e q u e n t o f need are often not accompanied that finding objective perceived by manifest C a n t o r , 1 9 7 6 , found New York groups). counseling by t h e high e l i g i b l e w h i t e aged less likely to a p p l y that in p o v e r t y areas o f ' other City w e r e m u c h Other f o r S S I than suggestive evidence low perceived need for is g i v e n may be camouflaging suicide rate a more extensive r e a l need of old^hg-A and the r e p o r t e d ^ ft e q u e n c y of depressed affect in the aged (?\jMxi -:Uw ; . information it s e e m s people1s safe to c o n - In t h e a b s e n c e clude that there of c o m p l e t e is no good r e a s o n w h y older limited need for be any recognize therapeutic different the cohort counseling that in i t s m o s t sense should from of y o u n g e r people. However, we must health difference in o r i e n t a t i o n to m e n t a l and a c c e p t a reduction in the " e l i g i b l e " p e r c e n t a g e of p s y c h o t h e r a p y as a r e s u l t x of t h e p e r s o n a l ? ., . unpalatability to some., In a b r o a d e r nf s e n s e , h o w e v e r , . t^4&^^'OTrr^3r^^'l|tid'- *?]&*?. e ' o g 'i'CT 1 e'wp'oif i i "l" of s t r e s s f u l -. g T n g flYpnpn.c i K^ --.i n. A* i IT - r ; | a, 1UJ, ,, t o - ^ widejP v a r i e t y a Ll . t\*WEBSS3ST l i k e l y to occur d u r i n g ex- periences lifespan: the io.aj^^rtry of t h e a d u l t - retirement - of self or p s o u s e members illness losses of f a m i l y of f a m i l y and f r i e n d s through death loss of i n c o m e changes in HWVIM U'lid 'jjp*jm9r&m^bQ\ ?12- - decline in environmental quality (crime, housing) - need to change residence I do not mean to suggest that older people experiencing these e v e n t s are necessarily candidates for psychotherapy oimply fraoanoe t u f f CJrr old: indeed, research has shown repeatedly that the impact jil of these events on healthy older people is far less than we may h a v e presumed. However, the fact is that they often happen to p e o p l e who are vulnerable on other c o u n t s ^ f k o s t obvious is pj "health / one (more than 80 p e r c e n t of all p e o p l e example). 65 and ovex suffer the from orxiore chronic d i s e a s e , for Compounding elderly. problem the & i s the firmest Haven, social"withdrawal replicated of s o c i e t y findings from m a n y O n e of research in g e r o n t o l o g y (Lowenthal ; Past^rello, a confidant events. I suggest that on older ) highlights people's the b u f f e r i n g to c o p e w i t h effect such of h a v i n g stressful Thus ability the r i s k of e x p e r i e n c i n g these potential and social e s s-in i;U-c-iiv^-even-fes-T~^c-oiiHb-irTre-ti--w4rt-h^-i;ireTM"gireater p h y s i c a l r 1 i P Vr\ ^ '*1 ? * y--o-i--ww?4w--^g4a,H *" } ^o^e^.tegtfwi fl nSed other for p e r s o n a l , s u p p o r t ;(,',':^ , . Mo-f t people tdian^iffiatr^exn&zdH*irc^*d*?*&*? ?' "" IN"" "' " ' age g r o u p s , A /. * s u p p o r t fv^ojn a s poiis^^a ? s hil dr^--e*s--a?. f ri p u J ^ b u t by various 4 e s t i m a t e s 20 to 35 percent of the elderly report having no confidant. -^i^e--inr-*fox^iLte ?Hfreretr''^^ One of the tasks for c l i n i c a l geropsychology is to identify which people are experiencing t h e s e events or transitions at greater psychic cost. Another is to d e t e r m i n e means by which formal assistance may be offered in a way c o n s i s t e n t with their earlier-life experiences. J.S the treatmen^^x.ocss_s;;i. The final -13- It seems probable that it is more congruent with the selfi m a g e s of today's cohort of older people to enter a counseling r e l a t i o n s h i p structured around these transition-related problems t h a n around a generalized mental health problem. Thus counseling o f f e r e d within the framework of a health center, multipurpose s e n i o r center, i i i H i T 1 I J i H i 1 IIJII [inTTT Ii I _ or p r e r e t i r e m e n t t education p r o g r a m m a y r e c r u i t n o t o n l y m ^ w ' - p cinmpAc w i t h transition-related problems but also those with more substantial problems for whom the prospect of entering the explicitly-designated mental health system may be tOo threatening. Age-specific treatment and quality of care Even if access might be enhanced by an approach tailored to the elderly, an even more important question is whether such an approach might improve the quality of treatment. The answer to this question depends almost wholly on indirect evidence at this point, since virtually no research exists that compares the differential effectiveness of any method of treatment according to any age group. ttBBsar&iK, Several years ago for an APA symposium I examined the gerontological literature for research whose results might, by analogy, have some implications for the manner in which therapy should be conducted with today's elderly cohort. Today I shall just sketch in a few illustrative examples of such conclusion^ and refer you to the published version in the Journal _ f Geriatric Psychiatry, o_ The re- search literature seems to support the idea that therapist sensitivity to a number of age differences may enhance the quality of therapy- -14- A search for increased awareness of the social norms and value systems that characterized the elderly client's period of early socialization Giving precedence to concrete rather than abstract ps,cyhodynamic approaches to verbal interchange Realization that ambiguity, open-endedness, and therapist inactivity may arouse anxiety in;a# counterproductive way Recognition that thefe4?i?e&l\uldbeyond which anxiety aroused during therapy serves a positive role may be - The pacing of: verbal interchange and complexity of ,concepts fl. ? ? ? ? ? ' A to the needs and abilities of th$ client - Cautiousness iii-do ullug IU'IC?! denial, positive thinking, 4 and other forms of defensive behaviorJT that may serve more positive functions for the elderly than for others. stance could easily T h o s e who disagree with the age-specific insist that sensitivity regardless to such issues - .H..^LJLLH h - i 1 \\\ nil; ? f the L a , -- Without the ability to work superior therapist of the type of client. to with look beyond one's own perspective it would be impossible a client of different ethnicity, education, or &ven Qaic ctft&^WS certarinly can-not dem^uad exact status-3tlarcJ^i.jig.. However, there is such a thing as specialization, wherethose with greatest interest, knowledge, and experience with a given client group become the most expert, and in turn become better able to transmit some of their expertise to the generalist. Thus I am arguing not for the limitation of clinical geropsychology to professionals who narrow their practices to this area, but, rather, a two-tiered approach whereby geropsycho-15- logical specialists generate more zf n nnn ?AIJI T n n expertise by sharing their own. Unfortunately that first tier does not now exist, Storandt (1978) has estimated that fewer than 100 clinicians with explicit university training in gerontology are now in practice. While the subject of training cannot be covered ip this presentation, I suggest that a " f a e e s f l - o l should include a required fitfaWc-ga course in gerontology for every clinical program and similiar continuing education requirements for any psychologist desiring reimbursement when and if psychologists become eligible as direct vendors in -16- any federal programs. It thus seems clear that a subspecialty of clinical geropsychology is desirable both in order to improve, access.to more*desirable forms of treatment and to raise the quality of treatment offered. At this point, A however, one must stand back and recognize that some of the arguments in favor of this position rest on cohort-specific phenomena that may not characterize the aged of the future. Some of the factors affecting choice of therapeutic technique may, for example, be related to educational background rather than being intrinsic to chronological aging. The next generation of elderly will have a median of 12 years of education; this fact might well make more abstract, ffinsightlf-oriented techniques more useful than they seem to be to todayfs elderly. They also will be far wiser to psychological thinking; while this may affect their ability to profit from psychotherapy very little, at least it should f improve their readiness to seek such treatment--if people are still doing, idp^by then! Nonetheless, n there will no doubt always be some cohort-related attitudinal or stylistic lags, sensitivity to which will be enhanced by. specialization. And in addition, the age-related transitional events and the hard core of true age-related changes will always require expertise beyond clinical generalism. Some traditional roles for the clinical geropsychologist 1. Clinical assessment Clinical assessment as practiced 30 years ago has been plunged into hard times recently by skepticism regarding the usefulness of psychological testing. This swing of a rather capricious pendulum has resulted in a -17- great lack of basic information on how older people perform on many psychological tests. Particularly in the area of personality testing there has been so little basic research and so little accumulation of qualitative clinical knowledge that one cannot honestly say whether their usefulness has even been tested. It certainly seems premature to sentence to death the traditional cognitive-plus-personality test battery prior to its having had the same chance to mature as it has in the case of children and younger adults. For the most part, iteJ&e&S&ee of usefulness^witlT the aged \re no For diagnosis of psychopathology, different from thu^a a? yoinger people: selection of treatment modality, definition of strengths, weakness and conflict areas preparatory to initiative therapy, assessing the impact of therapy and other interventions, and so on. This is not the appropriate context in which to review the psychometric characteristics of standard tests as used with the elderly. Some assistance may be found in Schaie and Schaie (1977), Savage et al. (j*!?1?), Costa and McCrae (1978), Eisdorfer and Cohen (1978), Kalen, Zarit and Miller (1978), Kahana (1978), and Lawton, Whelihan, and Belsky (in press). However it must be acknowledged that the first clinicianVs guide to assessing the elderly has yet to be written. These cited works all underline te&e problems associated with applying tests designed for uMflNBfch younger populations to the elderly. n.??nt^nnnl^rpYifaf p^-jAo^yMrnnnni -f f y ^nnf 1ifnrn,f-,,rn Mr the, apai'aciieffir"&f Mge norms for most of the standard tests. Our search netted exactly three instances where personality test reliabilities had been determined explicitly for this age group. -18- Even so fundamental a question as determining tlmi iinuiMiLiuyr base rates of successful completions of different tests has not been satisfactorily addressed. Although one study reported the MMPI testing of almost 14,000 people 60 and over (Swenson, Pearson, and Osborne, 1973), our culling of the test literature for indications of completion rate suggested that for some personality tests and some subject populations9 as many as half of all attempted protocols could not be completed satisfactorily. The geroclinician is thus faced with more formidable test^response problems than those usually encountered by the general clinician. While cognitive assessment is far \ better developed than personality assessment, many recept?? and response deficitjfe in older clinical populations make life difficult for the assessor. In sum, the challenge to clinicians remains, and must be answered by a proliferation of both research and reported clinical practice before we can know how strongly to recommend traditional assessment procedures for elderly clients. A word needs to be said at this point about a relatively encapsulated area of test development in the field of gerontology devoted to the measurement of what has been called "morale," "life satisfaction," "psychological wellbeing," "adjustment" and many other terms. Unlike the personality tests discussed previously, these measures have been developed and used by social scientists from a variety of disciplines rather than only by psychologists. The measures have used age-specific content, have frequently been devised for specific research undertakings and have been subjected to less-intensive psychometric analysis than the ideal "test" might. Because they are uniquely tailored for the elderly, such measures as the Kutner Morale Scale (Kutner, Fanshel, Togo, and Langner, lw* ) 9 the Life Satisfaction -19- Indices (Neugarten, Havighurst and Tobin, 1961), and the Philadelphia Geriatric Center Morale Scale (Lawton, rf7J5) are important for research and potentially for clinical use* A barrier to their use is the lack of conceptual clarity regarding the similarities and differences among the many meanings of these terms; psychometric respectability and high clinical utility cannot be attained until this clarification occurs. Discussion of these issues may be found in a monograph edited by Nydegger ('9?0 and excellent reviews of the characteristics of some of the scales in Larson (1978) and George and Maddox (1978). 2. Neuropsychological assessment The recent resurgence of psychological testing as an aid in the diagnosis of disorders of the nervous system and the localization of pathology warrants separate mention in a cataloguing of clinical geropsychological functions. The technology for such assessment has developed over a long * period of time, highlighted by the Halstead battery and its elaboration ,by. Reitan and associates (e.g., Reitan and Davison, 1974).^ *~ I ~ The results of neuropsychological test research with the aged h&e not always been confirmatory of these testsf discriminating power (Kahn and Miller, 1978). However, some hope is afforded that such tests may not only discriminate functional conditions, organic brain syndromes, and "normal11 aging but that localization and determination of etiology may be aided in a noninvasive fashion. Here again, howevex^, a review of this literature (Klisz, 1978) emphasizes the extent to*the case for neuropsychological testing with the elderly is made by analogy rather than^ a rich research base. Few function-specific studies over the complete age range have been -20- completed, despite the promise extended that these tests may be very helpful in understanding the behavioral effects of aging and neuropathology. 3. Functional behavioral assessment Like neuropsychological assessment, functional behavioral assessment is neither new nor essentially different in method from other types of assessment. Functional assessment, or "lifestyle competence assessment11 as I have referred to it elsewhere (Lawton, 1976),* may be defined as the assessment of the adaptive quality of behavior as it occurs in naturalistic situations. Unlike psychological test assessment, the data on which functional assessment is based may be either from the direct observation of the individual!s behavior, behavior as reported by the behaving individual, or behavior as reported by an informant. Each of thefee data ? M n ? offers its own sources of error and other measurement problems; an ideal functional assessment battery should use each data source for information relevant to each sector of behavior. The sectors of behavior that should be included in a complete behavioral assessment battery majr be seen as falling into a hierarchy of complexity, each behavioral class having a different range r*?~d^re&?m7r*~-*'*TM^ r;?Hy and maximum complexity (Figure 2). ?v*? The hierarchy of classes goes from life maintenance through functional health, sensationperception-cognition, physical self-maintenance, instrumental self-maintenance, and effectance to social behavior. Within any of these levels, the complexity of specific behaviors also varies--examples are indicated in Fig. 2. Note that the typical clinical psychological assessment procedures are subsumed mostly in the sensation-perc?ption-cognition category, while other relevant behavioral domains are ignoreid. -21- The Vineland Social Maturity Scale was perhaps the earliest of all functional assessment devices^ ixL-the-area-of developmental disability and mental -retardation the today form the cornerstone of those disciplines1 ability to assess the competence of individuals of that type- In gerontology there have always been assessment instruments used for some ranges of some sectors of the functioning of older people: The Rosow-Breslaii Guttman scale of functional health (Rosow and Breslatt,^^ ) , the ?&Xijt*dv ^ y ^ / a - : U \ i ^ # 2 ^ '1-n- ^f-y^'^'h-*^ (Jjt-UiHp (Jones^ the Philadelphia Geriatric Center Instrumental Activities of Daily Living Scale (Lawton and Brody,l9?9), the Ralen-Goldfarb Mental Status Questionnaire ( ^*-*l %\\OC\L i CoUfct-rhy HUf (M?I), ) , the Social Isolation scale and many others. of Granick and Nahemow Until recently, however9 these assessment devices were developed in a piecemeal, unintegrated fashion. The OARS Assessment Schedule (Pfeiffer, 1978) was the first approach to assessment that provided a single package to assess systematically most of the important sectors of functioning and to strive toward a metric that would provide a profile of functioning level in each sector. The OARS instrument contains a variety of questions answerable either by older subject or an informant in the areas of physical health and diseasejactivities of daily living, mental health, social functioning, and economic wellbeing. The responses to these specific questions are then used by the interviewer or a professional person to rate the individual on a six-point scale for each of these areas. An overall index of compteence is provided by summing the ratings in each of the five areas. -22- It should be noted that the OARS collapses cognitive functioning and psychological adjustment into the same area and rating scale. Further, economic wellbeing is not strictly speaking n individual behavior. * In fact, if we are to seek an overall assessment of the individual we cannot limit ourselves to the behavioral sectors shown in Fig. 2. In addition to the individual1^ economic status, his entire environmental situation, including housing, neighborhood, and community characteristics, transportation, access to goods and services, and so on, will affect the individuals wellbeing in a major way. On the other side, the psychological interior of the individual is not represented in the schema, of Fig. 2. "Psychological wellbeing"1 as discussed earlier is clearly a nonbehavioral component of a total assessment package; indicators of psychological wellbeing may be gained from the direct observation of behavior or from an informant, but perceived wellbeing, as reported by the older person, is seen as an essential component of an assessment battery that is not replaceable by observer or informant data. How does the geropsychologist fit into this function? In fact, one of the major features of functional assessment is that most such instruments are ma dm to be used by a variety of professional and subprofessional workers. The psychologist is seen as the one most capable of constructing the functional assessment device, training others to use it, and monitoring its use for service-delivery and research. The OARS, the Philadelphia Geriatric Center Multilevel Assessment Instrument, and other generalpurpose systems that might be developed in the future are seen to be of less than completely universal usefulness. J^W^i* Some of the behavioral tasks that define competence are seen as dependent upon the environmental context for definition. Perhaps the most obvious example might be the -23- institution, where the content of behavior that might indicate, competence in self-maintaining, effectance, and social behaviors would undoubtedly differ from the behavioral indicators of competence outside the institution. Similarly, behavior in planned housing for the elderly, 4 f * rural areaf lt small towns, and so on, might require supplemental measures in addition to the basic package such as the OARS. Another type of elaboration would be ( required by a service agency treating a wide variety of problems within a te+lnJi. vu*? ckJtdJL *^ Ux* iurvvetiVxtM R ^iCtMjUy limited area, for example, a rehabilitation hospital, The usve of a standard assessment package, plus A special-purpose more detailed assessment, o&CD desirable in such settings. , is Um A major role for the gero-^clinician is that of. advocate for the kind of approach under discussion; the taking of initiative in the construction of better instruments; the instruction of other service workers in its use; and the monitoring of the quality of completed assessment forms. If the clinician cannot overcome the reluctance of non-psychologists to perceive the advantages of such formal assessment, at the very least his own breadth of knowledge about an aged client would be greatly enlarged by adopting such a full-range package in addition to his preferred testing battery. Finally, it seems as if agencies giving broader types of services to the elderly, particularly those that have screening and referral functions, should have the benefit of consultation or direct services by the clinician in order to foster the systematic life-style competence assessment described here. -24- 4. Psychotherapy It is worthwhile at this point to review the manner in which therapy was treated by Storandt, Siegler, and Elias (1978) in the only currentlyavailable major work on clinical psychology and aging. A chapter by Kastenbaum (1978) recognizes the theoretical void underlying therapeutic approaches to the aged, and fills a much-needed purpose in relating concepts from some major personality theories to therapeutic issues. A chapter by Richards and Thorpe (1978) sketches out the rationale for behavioral-psychology approaches to behavior change in the elderly and reviews a fairly impressive body of research already done in this area. Another chapter by Kapnick (1978) provides a valuable resume for nonphysicians of pharmachological therapies for the aged. In a final chapter, Storandt (1978) discusses briefly some miscellaneous approaches, including group therapy, reality orientation, milieu therapy, and other specific approaches, all of which share the common characteristic of .being shopfe-on A age--specif ic i i n i h i i r T T ' 1 ' H i i n u f f ? " *?* ~* -* * *'?* ? ?-?* /? * ?t-^ ".?:?* ?--?. * ? ? * . ? ' : .,' - . s ^ w i . c ?? Each of these chapters provides extremely useful material not available elsewhere. The editors were clearly limited in what therapies could be discussed However, what is most by the dearth o f original material on which to draw. surprising is that no separate chapter on individual therapy and counseling was included. It is ironic that there was so much less to say about psychotherapy than about the other clinical functions, despite the fact that in general clinical psychology, therapy has assumed the dominant position. The explanation for the omission of such a chapter probably lies in the fact that most of what has appeared in the literature has been atheoretical, unfocussed, and remarkable for y i $ armchairt thinking. ?s -25- One looks in vain through the literature for empirical evaluations, with replication, of older people treated individually by differing approaches. Few also are the number of doctrinaire presentations of therapeutic methods based on schools of thought such as the different psychoanalytic approaches, ftdrgiaayi, Gestalt, and so on. While such polemic presentations are easy to attack, it is also a sign of vitality for a field to be able to generate conflicting b u t internally coherent views of how therapy should be done. At even the least scientific level, older people appear infrequently as the patient in published case histories. It is clear that some of the expertise that has been buried in a few presentations at meetings, and to some greater extent in the experience of the clinicians who now treat older people, needs to be mobilized into the production of a therapeutic state-of-the-art*plus-cookbook . Without any attempt to be comprehensive, or to select even the most important issues, a few examples of questions dealing with therapeutic techniques for older people may be sketched. a. Is individual therapy even appropriate for the older person to whom psychological thinking is alien or diminishing to self-esteem? It is conceivable that: cohort-specific attitudes toward mental disturbances and psychological explanations of behavior may be so negative as to contraindicate any attempt to apply traditional therapeutic techniques to older people who do not construe their problems in these terms. We need research directed toward the reasons why older people come to mental-health facilities, the terms in which they see their problems, and their perceptions of what transpires in different types of treatment situations. -26- One conclusion seems warranted, though based on qualitative observation only: Many older people are hungry for an occasion to share their problems with another person. Anyone who has fielded a research project is aware of the difficulty that interviewers have in extricating themselves when the interview is completed. Loneliness and the wish to talk are not, of course, the equivalent However, clinical geropsychology needs to explore of the need for counseling. in far greater depth whether there are outer conditions, such as the looafc-ien f3t treatment, the terms used to introduce the situation, or the professional m ? ? ? ? ? ? . . ? ? ? ? ? ? . . ? ? ? ? ' ? ? ? titles used, that may make it easier to apply professional expertise to older people who have such needs but see them in terms other than psychotherapy. b. Many external and internal concomitants of chronological aging conspire to heighten the dependence of older people on others. Should this dependence be treated as a given when mapping out therapeutic strategy? One of the few internally coherent statements of some principles of individual therapy for the aged was made by Goldfarb (|?4j), who argued that therapeutic benefit to the elderly could be increased by maximizing the extent to which the therapist encouraged and satisfied the dependency needs of the elderly client. In this view, the realistic deprivations of later life make more appropriate the therapist's willingness to assume some of the parental roles and to work with the patient so that this necessary personal dependence is accepted without guilt. In fact, this suggestion has some positive value if applied carefully, but to accept this principle requires one also to accept the idea that a good therapist is capable of determining when, or for which patient^ this dependency assumption is valid. It is clearly an inappropriate principle to the extent that the patient is healthy and has avoided the deprivations of aging in our society. It would seem that great vigilance by the therapist -27- is required against the automatic stereotypic assumption that "most older people are dependent", if the principle is to be used productively. c. Are "in-depth", psyche[fynamically-oriented explorations fruitful for working with older people? On-target data with which to answer this question are nonexistant. However, I should like to mention some tantalizingly relevant research findings that are over a decade old, have been virtually forgotten, but are illustrative of the kind of research that ought to have been going on all these years. Martin Lakin, one of the clinical psychologists with an early interest in aging, investigated processess that were similar to those that might occur during therapy, but the research was experimental and done with normals of differing ages. (Lakin, 19 In one study, ) , separate groups of middle-aged and retiring workers discussed A content analysis of 15 hours of discussion showed "problems of retirement." no age differences in verbal productivity or affective tone, but the older Ss produced more idiosyncratic and self-referent material, and were more apt to make statements of simple agreement or disagreement. In another study, (Kowal, Kemp, Lakin, and Wilson, 1*1^7), j s responded to thematic stimuli showing a person talking to an "expert" about a "personal problem." Older J3s told stories indicating less introspection, expression of inner feelings, and acceptance of personal responsibility for their problems. The author was careful to make no sweeping claims for the therapeutic relevance or generality of his findings. However, they illustrate the kind of research that has been done in great quantity with children and younger adults, and which is badly needed in both experimental and actual therapeutic settings with the elderly. -28- Because of lingering doubts about the relevance of insight-oriented, affectand relationship-based therapies for the aged, other approaches characterized as "training"1 rather than "psychotherapy11 have begun to be tried with the elderly. Some of these, such as Rosefs Interpersonal Skill Training (Berger & Rose, 1977) and Goldstein's *fgg2rial Learning Therapy7 (1973f*Lopez, ,|^979) are based on learning principles and deserve further exploration. Milieu therapy Early in the postwar years milieu therapy became an area of special interest to psychologists, partly because they were willing to work with poor-risk institutionalized patients and faced fewer turf problems with psychiatrists. Perusal of the literature on milieu therapy with the aged reinforces this idea strongly (Gottesman, Quarterman, and Cohn, 1973; Storandt, 1978). Early work in milieu therapy by Donahu^ ( \%0) and Gottesman (1965) indicated the positive value of instrumental, as opposed to recreational, roles for the elderly mental patient. This line of research continues to be reported (Ey^hjftgy??? ; Smyer, Siegler, and Gatz, 1976; Spence, Cohen, and Kowalski, 1975), with evidence mounting that the everyday functioning of relatively regressed mental patients is amenable to such intervention. In this day of childlike trust in the dream of solving the elderly mental patient's problems through "deinstitutionalization" into the stark environments of nursing homes and welfare hotels, continued effort to design better institution-based milieu programs seems highly desirable. One also continues to wish for definitive research to documentsthe balance of enrichments and deprivations in mental hosptials and the nursing-home environments into which deinstitutionalized patients are cast. Nontraditional Functions for the Geroclinician ----- Some nontraditional functions for the clinical geropsychologist have already been mentioned, such as^the resident expert in the community mental health center and the consultant on assessment for social service agencies. A variety -29- of other possibilities will be briefly mentioned. It must be emphasized that i w h i l e the need for psychological expertise in these areas is clear, a demand j(i?/t( xi S f" *t fViU-1 d ) & i ,iVVv r e m a i n s to b e created by psychologists who succeed in selling the idea o f t h e i r usefulness to organizations. 1. Alcoholism. Alcoholism rates are very high in the over-65 group, yet l i t t l e attention has been paid to the development of specific techniques to d e a l w i t h this problem in the elderly. A useful review of alcoholism among t h e aged has been provided b y Wood (1978) . 2. Suicide prevention. Male suicide rates rise as age increases. It m a y w e l l b e that specific techniques will b e selectively beneficial to the elderly, w h i c h would seem to b e best developed b y specialists in gerontology who a r e f a m i l i a r w i t h the many compounding problems of social isolation, poverty, and e n v i r o n m e n t a l barriers to support. 3. Drug addiction. Relatively little is known about the extent of drug It seems likely that the magnitude of the problem a d d i c t i o n in the elderly. w i l l increase among future cohorts o f the elderly and that there is enough p r e s e n t need for this age-specific expertise to warrant the entry of some g e r o p s y c h o l o g i s t s into this field. 4. Penal psychology. Presumably the substantial number of psychologists n o w employed in prisons a r e involved in some way with the minority o f incarcerated o l d e r people. However, little is known about the unique problems of this group. T h i s is undoubtedly a much more critical area now than it once was^f, considering t h e radical changes that have occurred over the past decades in the composition o f the prison population and the social milieux of prisons. Age-specific and a g e - s e g r e g a t e d rehabilitative activities seem essential, yet this author does n o t recall evertf seeinfany literature on this subject. -30- 5. Counseling elderly victims. A suddenly major social problem for the elderly is crime and the fear of crime, as shown in both the public media and in various national surveys that demonstrate a higher level of anxiety in this area among older people as compared to others. While some beginning is now evident in rape counseling, a far more general effort is needed to devise and practice counseling for the victims of all crimes, amimtmr (group methods that will deal with the,fears of t h much larger number who have not already been ^e victimized. Jtducation in counteractive f rrhnirpir^, fn ii in n rimimfn f r ml f r i i il i A 6. The mentally retarded elderly. There is a high probability that the number of such people will grow considerably in the next several decades. While advocate groups for the mentally retarded and some sectors of professionals in this work have given high priority to the growing problem of the mentally retarded, little expertise or interest in working with such groups now exists. 7. Sex therapy. The immense public interest (and sales of popular books) on sex in midlife and old age attests to the need for specialization in this area. The ever-present negative stereotypes about sex in later life show some danger of being counteracted by just as destructive unrealistic expectations about how things would be if it were not for the stereotypes. Not only is it necessary to develop general psychotherapeutic techniques, but the need is clear for practitioners who are more than minimally acquainted with the physiology of age changes in sexual capability and able to deal with both the good news and the bad news about sex in later life. 8. Death counseling. Like sex, death has undergone a recent renaissance of social concern. As in so many areas, however, there is far less intrinsic appeal to the practitioner in counseling older people than in the case of younger -31- people. Larger social issues such as the prolongation of life, the "living will" (i.e., the right of the individual to request that extraordinary life-supporting measures not be applied), and so on, make this area a critical one for the geropsychologist. 9. Longterm care. Few psychologists have direct associations with longterm care institutions except as a source of research subjects. The range of possibilities for service is especially wide in this sector, however, given the nation's at least verbal commitment to upgrade the quality of care. In addition to therapy and test evaluation (whether or not reimbursed by Medicare), psychologists have an almost open field in demonstrating their usefulness as program consultants and as in-service trainers for personnel. The usefulness of behavior modification with the institutionalized has been demonstrated in scattered reports and merits much more large-scale development: to help deal with the self-care and behavioral problems that are so frequent: in this target group. The clinician with some interest in environmental psychology will find increasing numbers of institutions open to suggestions regarding the human uses of spaces and objects. 10. Planned housing for the elderly. Counseling services for people in public and nonprofit housing for the elderly are available in very spotty fashion, if at all; they are especially needed in the||ncongregate housing" (i.e., housing with a high level of supportive services) model that will be implemented greatly in the next decade. Consultation^to staff and the conduct of both group and individual therapy are badly needed,' assd with the large numbers of older people living in one place, should be deliverable with relative efficiency. -32- 11. Senior centers. W h U e counseling regarding personal, social, and service-need problems is provided by many multipurpose senior centers, psychologists are rarely involved, and the level of ?xpertise for this counseling is quite variable. Demonstration of the effectiveness of input by trained geropsychologists for consultation, training, should lead to some expansion of opportunities supervision and direct services. Conclusion N o w , after this discursive set of random thoughts on this and that, what can be said in conclusion regarding the prospects for clinical geropsychology? Whether because of poverty of thought or lack of development in the field, I have little new to conclude since 1974 (Lawton and Gottesman, 1974). That is, one sees incremental growth of a just-noticeable-difference type, but nothing extraordinary. 1. I might call your attention to the following, however: (l The APA through its Committoa-ion Education and Training ( **j. ...l-t *Uv- './M '? : has established a Task Force on , ,C;A. ,; . ? ,, .x^ O n e of the first two major undertakings of this group will be devoted to furthering the development of university-based training in clinical geropsychology. 2. The Social and Behavioral Sciences Section of the Gerontological Society has established a Task Force on Clinical Psychology whose first purpose will be to serve as a focus for such interests within the Society. W h i l e the efforts of two professional organizations do not count for much within the social coantext of aging, concern on their part is at least a first condition of growth. Four years ago, Gottesman and I expressed some optimism about the chances ? " -- *?'* gp psychologists in the Medicare and Medicaid programs^. hopes are still of uncertain fulfillment. To this date, these Reimbursement for psychological -33- testing is currently possible only at the order of a physician, and for psychotherapy not to the psychologist at all, but only to a medical facility employing the psychologist. The Medicaid regulations do not even acknowledge Despite the lack of overt action the existence of psychology as a profession. over the past few years, the Association for the Advancement of Psychology feels very optimistic about the establishment of independent vendor status for L the psychologist within the next year or two. A ..... My feeling is that such recognition will be necessary if the status and supply of geroclinicians ? to grow to a pointfthat?aem begin to neot tbenQGcL Harsh a reality though it may be, I respectfully conclude that the intrinsic appeal of professional work with the aging is not great enough to stimulate an unusual degree of growth of this subprofession. The financial incentive of health-agency employers ofthe clinician in necessary component of growth. s rvice reimbursement for clinicians is a private practice and for the mentalIf and when this status is achieved, I should hope that by that time improved vehicles for the university training of clinical geropsychologists $ * ? ? ? ? ??? . . ?? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? 2 and for the continuing education of clinical generalists would be on hand. only way that our profession would be able to look the older client and the taxpayer in the eye as treatment is performed and the bills paid maximum professional competence among our practitioners. The is ba insuring -34- |
Description
| Title | Clinical Geropsychology: Problems & Prospects (pages 1-5) |
| Abstract | This presentation criticizes the historical inattention of clinical psychologists to the elderly, as well as the inattention of gerontologists to areas of clinical psychology. Dr. Lawton first examines the older adult's place in the mental health system, including barriers to access to the mental health system and the debate surrounding age-categorical care. Aging adults constantly confront ageism in the mental health system, and many mental health providers hold on to their discriminatory beliefs despite the research refuting them. He follows this with a review of the traditional roles for clinical psychologists and suggests some nontraditional areas in which these practitioners' skills could be applied. Dr. Lawton concludes that clinical work with the aged does not appeal to enough people to stimulate the needed growth in the clinical geropsychology field, but believes financial incentives would. // This presentation is missing Figure 2 discussed on page 21, and there are no references. --AJL |
| Subject, Keyword | geropsychology, mental health |
| Subject, LCSH | gerontologists, clinical psychology, mental health, aging |
| Subject, MeSH | geriatrics, aged, clinical psychology, mental health |
| Subject | geropsychology; mental health; gerontologists; clinical psychology; mental health; aging; geriatrics; aged |
| Class. Number, LCC | RC467.C58613 |
| Class. Number, NLMC | WM 105 |
| Class. Number, DDC | 616.89084 |
| Creator | Lawton, M. Powell, 1923-2001 |
| Date Created | 1978 |
| Description | Master Lecture, American Psychological Association (August 30, 1978 : Toronto, ON) |
| Extent | 5 p. |
| Language | eng |
| Publisher | Polisher Research Institute |
| Rights | Copyright 2006 Polisher Research Institute |
| Access Rights | fair use rights |
| Identifier | 1978ClinGer1.pdf |
| Contributors, Authors | M. Powell Lawton |
| Contributors, Principal Investigators | Rachel R. Resnick |
| Contributors, Research Assistants | Karen C. Kohn; Nicole Snyder; Amanda J. Lehning; Arthur Shum |
| Contributors, Reviewers | Philip D. Sloane; Maggie Calkins; Laura Gitlin; Jeanne Teresi; Patricia Parmelee |
| Related Documents | Lawton, M.P., & Gottesman, L.E. (1974). Psychological services to the elderly. American Psychologist, 29, 689-693. // Lawton, M.P. (1976). Geropsychological knowledge as a background for psychotherapy with older people. Journal of Geriatric Psychiatry, 9, 221-233. // Kaye, J.M., Lawton, M.P., & Kaye, D. (1990). Attitudes of elderly people about clinical research on aging. Ther Gerontologist, 30, 100-106. |
| Transcript | 2006 Polisher Research Institute Clinical Geropsychology: Problems & Prospects' M. Powell Lawton Philadelphia Geriatric Center For the past decade an occasional voice has been heard periodically decrying both the inattention of clinical psychologists to the aged and the inattention of gerontoiogists to the traditional areas of clinical psychology. Had one the proper sense of history and the patience of Job I suppose it should be possible to take heart from the sporadic, threshold-level, incremental growth^that has taken place during this time. So small has this growth been in aggregate, however, that I am motivated to retitle and scramble a couple of papers that I've written on this topic during this decade and proceed with full confidence that the same issues and facts apply today. My need for novel experience will, I hope, lead to some new material for 1978, but in the main, much of what could have been said about the "problem" side in 1968 could still be said today. I should like to begin with a recapitulation of some facts about the older person in the mental health system and in relation to the profn&ion of psychology. Then I shall consider r\fmjasonft**toti? gf the crucial question as to how desirable it is to foster the developlent of a discipline of geropsychology. Then I shall discuss in A relatively broad terms the current status of practice in some of the traditional areas of clinical psychology, and end with some suggestions regarding the use of the clinicianfs skills in nontraditional areas. It is clear that a single presentation cannot hope t o cover the sub, stance of practice nor should it attempt to review.the literature. A f\ Master Lecture, American Psychological Association, Toronto, August 3 0 , 1978 &? *it is hoped that the issues raised here will stimulate a wider group of nonspecialists in aging to investigate the existing literature and to proceed first-hand into practice and research that will lead u^ nmfhf issues and "-in t 's The older person in the mental health system Over a long period of time the characteristic mode of treatment for older people has bjsen the mental hospital. Recognizing that the elderly constitute a^eutr 10* percent of the population of the U.S.A., A by comparison they represented 28 percent of the mental hospital population in 1975 (National Institute of Mental Health, 1978^. The national move toward deinstitutionalization has, to be sure greatly reduced the number of older people in mental hospitals, from 140,000 in 1965 to 54,000 in 1975. However, the proportion of the total who are 65 and over decreased only two percent, from 30 percent in 1965 to 28 percent in 1975. And' as we all know "deinstitution- alization" may be an ideal, a state of mind, or a manner of speaking, but it certainly has not proved to be a reality in the case of the elderly. While exact: data are not available, a substantial proportion of the aged beneficiaries of the mental-hospital deinstitutionalization movement were dubiously benefited by transfer or directadmission to nursing homes. We do know that the number of older people in nursing homes has increased precipitously, from 462,000 in 1963 to 1.1 million in 1973-74. Between the Census years of 1960 and 1970, during which period a major part of the deinstitutionalization movement was effected, the overall percentage of older people in institutions of all types increased almost 25 percent, from 4.0 to 4.9 percent. most recent report from the 1973-74 Nursing Home Survey (National -2The Center for H e a l t h home S t a t i s t i c s , 1978-) i n d i c a t e s residents were to these considered that 58 p e r c e n t some or of of all nursing of the t i m e . confused proportion most Adding the s m a l l e r residents clear of the with that functional the n u r s i n g hospital. but not organic mental d i s t u r b a n c e s , it is a variant home has become at least p a r t l y mental On the community side, the best regarding age-specific treatA ment rates come from the network of federally-funded community mental health centers. In 1976, 3.9 percent of all clients treated in these 548 centers were 65 and over. This proportion has remained almost constant d since.1969, In 1975 the Community Mental Health i / L dg/jL '? ' 'yMvM'U fa A legislation added services to the elderly to the list of mandated services. percent *&& the first year following these amendments warn a 0.1 in the p r o p o r t i o n of e l d e r l y served; it r e m a i n s to decrease A be seen whether the two years that have followed have seen any, , :J'%? tendency to right the selective avoidance of the elderly by the CMHCs. The CMHC data give only aggregate age percentages and do not allow one to determine the type of treatment received by the elderly as compared^ to other age groups, ^owever, KiiHji (1975) has analyzed NIMH data. t8 concludie*that " 1 1 n r "rwftvPttf* access to treatment within ft) . h L, A than 139* o u t p a t i e n t services. elderly t h e CMHC^, w a s m u c h j^eti^r le i n p a t i e n t Among fared non-federally-funded mental health just c l i n i c s , the of even m o r e p o o r l y , r e p r e s e n t i n g in 1969 two p e r c e n t 1973). their clientele (Kramer, Taube, & Redick, thus a l l o w of c h o i c e from These data are been and the treatment away one to c o n c l u d e , f i r s t , that for the f ^ L d e r l y , second that health institutions there has a^trend finally, t r e a t m e n t .withitl the m e n t a l toward --3-- increasing system, mental that no trend use of o u t p a t i e n t health f a c i l i t i e s is discernible at t h i s point. w are not in e Moving specifically into our o n f i e l d , w p o s s e s s i o n of national data that would allow us to assess the extent to which psychologists provide services to the elderly either w i t h i n any of the mental health structures or on a private b a s i s . Some survey data -rnxsc^sf^ss^mmm^^SSS^ i l l u s t r a t e volvement of psychologists in private p r a c t i c e . the low level of in- Dorken & Whiting ( 1 9 7 4 ) , in a mail survey of the "service-providers" segment of an e a r l i e r A A sample (overall response rate of somewhat more than P determined that 26 percent "reported work with those over 64," However, less than two percent averaged more than one hour per week with older c l i e n t s ; clients C half) the aged accounted for only one percent of all seen. x.^-' A later survey by Dye (1978), done in 1975 was perhaps most eloquent in i t s demonstration of the level of 'interest in clinical work with the aged: A three- page survey of clinical and counseling psychologists on working with the aged elicited responses from only 19 percent. This low response rate precludes making parametric estimates of psychologists' experiences and attitudes toward older patients; however, of this nonrandom sample about one-third saw patients 60+ at least occasionally. Why a clinical psychology of later life? J i-t--is pTJ&blble-Tirsrt R e c e s s i y pr-^ 1 -- i il 1i fH -- neglect f^^.,hy to the mental h e a l t h yot system is +^- - U n ^ i y , part of I and m wy at-hogA ia ci LliaL acmytf generalized aLLBBi^jy-roty^uio tho yjmbltiW of '1t y m ny i of 1n f a r t | - * m only ? by s o c i e t y . symptomatic In t h i s the the e l d e r l y view, a i L m ooflo? n^ h t g the failure to develop clinical technologies suited to the unique needs of the elderly. ~ . . . . . ? ? ? ? ? . ? * ? It is thus felt that . ?. ? ? . . ' . ? . ' general knowledge regarding the clinical practice of psychology must be examined in light of its applicability to the older person and expended in light of the unique characteristics of this age group, Kastenbaum (1978) has, however, questioned the desirability of an age-specific clinical psychology, and in so doing, raised questions worthy of further consideration. He suggests that an "all- out effort to cultivate a special field of geriatric psychoth might end up as one more exercise emphasizing the separateness of the elderly from the rest of society and thereby cementing, rather than dissipating, the ageism of mental health practice, Kastenbaum proposes the alternative of looking toward knowledge already available in general mental health regarding approaches found to be useful in treating the physically ill, the^poor, the unemployed, or the bereaved. ^ 1 i Un 1 ^mmrnkm^ ^fhis r approach would stress the commonalities JK of the old and the young as they experience similar situations. Such advice should alert us to the possibility of jirsing literature and experience in these areas to augment the meager store of existing relevant technical knowledge. Whether it would constitute a superior alternative to an age-focused clincial psychology is another matter. -5- |
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