Geropsychology has made strides during last decade
(National Psychologist, January/February issue, Vol 9, No. 1., p.18-19)
By Paula E. Hartman-Stein, Ph.D.
Geropsychology, the branch of clinical psychology that relates directly to health care for older adults, has made its most significant professional strides over the past decade despite roots in the psychoanalytic literature of the early 20th century.
Karl Abraham wrote about successful psychoanalysis with older adults in 1919, and Bob Knight, Ph.D. from the University of Southern California recalled that Lillian Martin ran a counseling center for older adults in San Francisco in the 1920s. But despite auspicious beginnings, George Niederehe, Ph.D. of the National Institute of Mental Health, wrote as recently as 1984(An Introduction to gerontology and Geriatrics), that "gerontological interests have developed slowly within psychology." Although Sigmund Freud thought aging was depressing, Erik Erikson took psychoanalytic concepts and extended them through the lifecycle into old age.
Until the last decade, psychologists working in the field of aging tended to be researchers or academicians with very few practitioners involved. Although APAs Division 20, Adult Development and Aging, was founded in 1947, there were fewer than 90 psychologists with joint memberships in the clinical and aging divisions in 1970. In the early 1980s, an estimated 30% of psychologists had worked with older clients, and only about 15% of older adults who needed mental health services ever obtained them. Niederehe reported that during that time the older client represented only 2% of patients seen in outpatient settings.
Why the clinical disinterest in older adults? Negative attitudes toward the elderly are often cited as a culprit. The needs of soldiers returning from World War II thrust the field of clinical psychology into the forefront, but the focus was youth-oriented. The older adults perception of stigma toward mental health services and the reluctance of the family physician to refer patients to mental health practitioners were part of the mix contributing to the delayed development of geriatric behavioral healthcare.
The lack of a viable payment system for psychological services is another undeniably powerful force that adversely impacted the field. In 1965 when the Medicare system was about to go into effect, organized psychology missed a significant opportunity to be included for reimbursement for mental health services (see Nov./Dec. 1999 issue of The National Psychologist). As simple a requirement as APA signing a letter endorsing the Medicare bill then before Congress could have steered care for the elderly into an altogether different direction. But the missed opportunity cost psychology a 24 years delay in becoming participants in Medicare.
Under the Omnibus Reconciliation Act of 1989, a milestone for psychology, psychologists finally became independent providers serving the elderly population.
RBRVS payment system
Harvard economist, William Hsiao, developed the current Medicare payment system known as the Resource-Based Relative Value Scale (RBRVS). By the early 1990s Hsiaos group had studied areas of medicine recognized by the Medicare system to determine the economic value of medically necessary procedures. However, psychology was one of three areas that had been neglected in the research. The APA Practice Directorate convinced the HCFA to fund a study of psychological services separate from those of psychiatry. In 1993 Hsiao selected seven psychologists from a list of nominees from APA to give input to the Harvard research team. The result has been that, presently in many regions of the country, the allowed Medicare charge for psychotherapy is significantly greater than the discounted fee of many private sector managed care plans.
Parallel events in academia and politics
According to Martha Storandt, Ph.D. of Washington University, St. Louis, about half of American universities provided no formal course work in the study of adult development and aging, as recently as the mid-70s. Similarly, graduate programs in clinical psychology offered only limited training in the assessment and treatment of older adults. Two training milestones took place in the last 20 years: a 1981 conference known as Older Boulder I and a follow-up conference in 1992 (Older Boulder II).
In 2000 many more opportunities for training in geropsychology exist, but the competition is greater. Victor Molinari, Ph.D., of the Veterans Medical Center in Houston, TX, recently identified 15 formal postdoctoral fellowship programs in clinical geropsychology. Toni Zeiss, Ph.D., of the Palo Alto, CA Veterans Administration, said that in earlier times "we had to take pretty much whomever we could find who was interested, and persuade some others to use the training slots. Now there is hot competition." Molinari believes that the growing interest in geropsychology is directly tied in to financial incentives and increased job opportunities.
In 1973, Congress enacted the Older Americans Act (OAA) that created the network of Area Agencies on Aging, and later in that decade the Carter administration made older adults one of the targeted special populations for mental services. During the Clinton presidency, the White House sponsored a national conference on aging in 1995. In 2000, the OAA is slated to be reauthorized, with possible training funds for geriatric mental health practitioners.
Additional professional advancements
Psychologists in Long Term Care, a grassroots organization, began in 1983. A subcommittee from this organization published standards in 1998 for psychological practice in nursing homes. APAs Division 12, Section II, Clinical Geropsychology, was formed in 1993. The most recent milestone is the development of guidelines on Qualifications for Practice in Clinical Geropsychology, developed by a group of academics and practitioners. The APA Council of Representatives will discuss them in February 2000.
Although many professional advancements have occurred over the last 100 years, areas of conflict loom. At present, HCFA has assigned psychological testing the work value of zero. The reason: psychologists have used extenders or non-licensed technicians to administer testing. Work values can be assigned only when the licensed provider supplies the clinical service. Psychotherapy continues to be paid at 50% the allowed charge, unlike the 80% provided for medical services. In their zeal to weed out fraud and abuse, some Medicare carriers have targeted psychological practices in nursing homes to pay back large sums when the problem may not have been intentional fraud but rather ignorance about proper documentation.
The profession of geropsychology has clearly advanced from its infantile stage. In the future, the field needs to evolve into one that creatively broadens its roles, trains practitioners to perform therapy in a focused manner with emphasis on prevention, and is less dependent on an ever shrinking government resource base.
Paula Hartman-Stein, Ph.D. is a consultant and clinical psychologist specializing in treating geriatric clients and their families at the Center for Healthy Aging in Akron, Ohio. She served on the RVBS committee at Harvard in 1993 that impacted reimbursement for psychologists under Medicare. She can be reached via Internet at www.centerforhealthyaging.com