Evidence to Support the Pike’s Peak Model: The UA Geropsychology Education Program

Abstract

The University of Alabama’s Graduate Geropsychology Education program (GGE) was conceived and implemented in the years prior to the design of the Pike’s Peak Model (PPM) of geropsychology training. The GGE program provides a unique opportunity to evaluate the PPM, and this paper outlines the GGE program in the framework of the model. Three primary goals defined the GGE program: recruitment and retention of students in the geropsychology program, a doctoral level interdisciplinary class, and a set of clinical rotations in urban and rural sites. Outcomes were promising, indicating that geropsychology students were able to provide services with positive outcomes to underserved older adults in primary care settings and in a legal clinic, students from several disciplines rated the course very highly, and psychology students indicated that they were likely to continue in the field of geriatric care. Participating students have gone on to careers in geropsychology. Findings from this program support the design of the Pike’s Peak Model, and provide support for broader implementation of similar training programs.

There exists a severe shortage of qualified mental and behavioral health professionals to provide services to America's aging population. These shortages will only become more problematic as the population ages and the demand for specialized mental health services increases (Administration on Aging, 2007). Numerous authors have observed the growing need for trained geropsychologists and appropriate interdisciplinary training as the population of Americans over the age of 65 continues to swell (Drexler & Walker, 2003). In 2006, a conference was held to discuss training needs related to this specialized and rapidly growing field, and the Pike’s Peak Model (PPM) of geropsychology training was produced (Knight & Karel, 2006; Knight, Karel, Hinrichsen, Qualls, & Duffy, 2009). This model (See Table 1) provides guidance on the optimal training for geropsychologists in the United States. Subsequent to this training model development, geropsychology was recognized as a distinct specialty within the field of psychology (www.apa.org/ed/graduate/specialize/).

Table 1.

Pikes Peak Model components

Graduate level course in adult development and aging Didactic and clinical supervision by competent geropsychologists Experience including more than one setting in which older adults are served Clinical training with a wide variety of older adult clients Clinical experience with interdisciplinary teams Focus on ageism Cultural competence and awareness of cultural and individual diversity issues Clinical training that includes observation of trainee (directly or thru taping of sessions).

The Graduate Psychology Education grants, funded by the federal Health Resources and Services Administration, were intended to provide interdisciplinary training to psychology students. The University of Alabama (UA) was awarded one of these training grants from 2003–2006. The training program was advised by faculty from seven disciplines and involved three primary goals that align with the PPM: an interdisciplinary doctoral-level class, clinical placement in primary care settings, and student recruitment to the training program.

Partnerships were created across professions, and across agencies to create a training experience focusing on the nationally recognized goals found in Healthy People 2010 and the training recommendations of the National Training Conference on Professional Geropsychology (APA, 2003). This manuscript will consider the application of the PPM, by describing the specific objectives and framework of the UA Graduate Geropsychology Education (GGE) program as a model for those developing training programs in professional geropsychology. Specifically, this manuscript outlines how the GGE program addressed the eight main points of the Pike's Peak Model of training in geropsychology.

Objectives

The primary objective of the Graduate Geropsychology Education (GGE) program at UA was to expand and enhance the doctoral clinical geropsychology training program already present at the university, particularly with regard to promotion of interdisciplinary training. This was achieved by placing doctoral geropsychology students at interdisciplinary practicum sites, delivering an interdisciplinary course in Health and Aging for nursing, social work, medical and geropsychology students, sustaining a training committee composed of faculty from diverse disciplines who had interests in health and aging to oversee this training effort, and using student stipends to recruit and retain highly qualified students for our geropsychology program.

The Pike’s Peak Model of Training

The core elements of training, as delimited by the PPM (Knight et al., 2009), were eight points identified as important in the field of geropsychology. The UA GGE program, conceived several years earlier, met nearly all of these points directly and thus provided an opportunity to evaluate the PPM. Specific components of the program are detailed further in the remainder of this paper.

1. Graduate level course in adult development and aging

The PPM emphasized that students should gain an understanding of human development as it applies to aging to effectively intervene with clinical concerns. The Health and Aging graduate-level course developed for this program addresses the first component of this model.

Faculty from various disciplines team-taught the course with guidance from the instructor of record (FS) and a program coordinator (TW). Overall, a total of 12 faculty from eight disciplines (psychology, social work, nursing, medicine, public health, law, nutrition, and pharmacy) participated in the class and met monthly to discuss progress on the overall goals of the training grant. Over time, the course evolved from interdisciplinary faculty members offering lectures on discrete topics to a focus on the intersection of professions in the course of providing health care for elders through case-based round table discussions (See Table 2).

Table 2.

Selected didactic topics from the class

Sample Topics	Lecturer Disciplines
Interdisciplinary teams in VA primary care	VA-based clinical psychologist
Rural care	Nursing, Medicine and Psychology
Case management in nursing & social work	Nursing and Social Work
Similarities and differences in nursing & medicine practice in primary care	Nursing and Medicine
Psychology and law in end-of-life issues.	Clinical Psychology and Law
Special Topics in Caring for the Elderly (i.e. sexual orientation, race, gender, home remedies, etc.).	Public Health and Social Work

Graduate students from any discipline could enroll with approval, but the course was not cross-listed with any other department. Though it was a pass/fail course, workload for the class was normal for a three-credit course, involving weekly readings, class participation, in-class exercises, and a final oral presentation and paper. It was offered during the spring semester, and over a three-year period, a total of 17 advanced students enrolled in the course. Four additional students participated in multiple seminars but did not formally enroll. Of the 21 students, 11 students were from the doctoral clinical psychology program; two were from the doctoral social work program; two were from the master’s level social work program; three were from the doctoral pharmacy program; two were from the doctoral cognitive psychology program; and one was from the nursing program. Students were both male (n=3) and female (n=18), ranged in age from 23–35 years old, and self-identified as Caucasian, Hispanic and Asian, representing at least four self-identified religious perspectives.

Evaluation of the class

Two evaluation approaches were used to assess the class. The university evaluates all coursework using a standardized course evaluation form, provided at the end of each semester. In this evaluation, students were asked how they would “grade” the class, and responses indicated uniformly excellent evaluations (Mean= 4.0 out of 5.0 with 1=strongly disagree to 5=strongly agree to the statement “This course was excellent”). This student opinion mean score would be considered an average rating for a graduate level course. Although this form does provide some metrics, due to the didactic and experiential nature of the course, a qualitative investigation was initiated to explore the experience of participating in this novel teaching approach. The investigation used grounded theory methods as described by Glaser and Strauss (1967) to capture the personalized experiences of the faculty and students involved. Data were used to obtain information about the strengths and weaknesses of the course through exploration of emerging themes (See Table 3).

Table 3.

Themes and Clusters found in the course evaluation

Cluster 1: Format Themes	■Conceptualizing patients from multiple perspectives was a valuable learning experience ■Case-based v. topic based teaching (case-based conceptualization was an acceptable trade-off for the potential dropping of some basic science)
Cluster 2: Subject Themes	■Families and/or caregivers were raised by participants in every session ■The politics of the professions were made evident and discussed in a safe environment
Cluster 3: Context Themes	■Diversity of students was helpful to learning ■Faculty difficulty keeping up continuity of course ■Value of the course to student perspective

Interviews, focus group data, class observation, and narrative evaluations written by the students were used as the primary sources of information. Face-to-face, semi-structured interviews were done with the ten faculty members who were a part of both the class and the steering team; six students, representing all three years of enrollment, participated in a focus group, and anonymous narrative evaluations were requested of students from all three years to evaluate the course. With Institutional Review Board approval, interviews and focus group discussion were recorded and transcribed, and Atlas.ti software was used to assist in coding and managing the data. Member checking (Kuzel & Like, 1991) was used to ensure the trustworthiness of the data and participants had the opportunity to clarify information being reported.

When asked about the most important aspect of this class, students and faculty had similar responses related to the interdisciplinary conceptualization of care, for example:

“So much time is focused on how to be the best … whatever… Knowing your own discipline is not enough- you have to know where you fit. Older adults necessitate contact with other disciplines.”

“This class focuses more on the real world. There is more and more emphasis on interdisciplinary work in clinical and research arenas.”

All participants agreed that learning through case-based examples provided the best learning opportunities. Responses also indicated that pairing faculty across disciplines provided a more interprofessional focus to the topics. This was perceived as an acceptable trade-off given the inability to present basic scientific principles in each discipline due to time constraints. As families and caregivers were discussed in nearly every class session, by students or faculty, these became explicit content areas in year three.

All participants noted the unique value of this class in providing critical training in interprofessional work with older adults. They were unanimous in their assertion that the case round tables provided an opportunity to apply the knowledge gained during their training. At the end of each roundtable session, students were asked about the value of the interprofessional dialogue, and all emphatically supported the process and offered examples of novel information that would not have been accessed had they formulated case planning alone or strictly within their discipline. Students all agreed that this course offered their first exposure to explicitly interdisciplinary frameworks of care. In regards to the overall value of the course, all participants unanimously agreed that interprofessional education should have a high value for students planning to work with older adults. They further agreed that this course or a course similar to it would positively contribute to the education of students who plan to conduct research or practice with older adults.

2. Didactic and clinical supervision by competent geropsychologists

The second component of the PPM encourages clinical supervision by psychologists trained and experienced in working with older adults. Three licensed clinical psychologists with doctoral and postdoctoral training in geropsychology provided the weekly supervision of practicum students. All clinical supervisors regularly engaged in clinical work with older adults and supervision of practicum students.

3. Experience including more than one setting in which older adults are served

The PPM model encourages geropsychology training to include a number of settings such as: community, urban/rural, primary care, psychiatric care, hospital, hospice, long-term care, home-based care, legal, assisted living, etc. The GGE program placed eligible students at one of four clinical practicum placements. Doctoral students in clinical psychology were rotated to a different site after a minimum of one semester to allow students to interact with a wide variety of older adult clients, as well as a diverse set of professional team members and practice parameters.

A total of 13 students were supported in clinical placements. Students participating in practicum placements were beyond the 1^st year of training in the clinical psychology program at the University. The majority of these students were able to engage in a placement in more than one of these sites, for a minimum of one semester (14 weeks) and a maximum of 9 months (two semesters). Students were given a stipend and tuition reimbursement proportional to their hours worked, which ranged from 10 to 20 hours per week. All of the students who were supported for placements were female, ranging in age from 23 to 30 years of age. Eleven of these women identified as Caucasian, one identified as Hispanic, and one identified as Asian.

Practicum sites included one urban and two rural primary care clinics and the University of Alabama Elder Law Clinic. Grant-funded geropsychology services provided by the doctoral students were free of charge to the patients, removing a significant barrier to care. In addition to psychotherapeutic services, consultation and psychological testing were provided on an as-needed basis, also made possible by grant funding. The urban primary care site, a private non-profit, provides a full range of services including internal and family medicine, dental care, pharmacy services, laboratory services, nutritional consulting, HIV/AIDS case management, and adult and pediatric care. The two nurse practitioner administered rural primary care clinics were located in Walker County, Alabama, an under-served and economically-disadvantaged area. One of the rural clinics had multiple affiliations with UA, allowing exposure to other students in placement from a variety of disciplines, such as nursing, business, and pharmacy, in addition to psychology.

An additional training site was the Elder Law Clinic (ELC) of the University of Alabama’s School of Law. The ELC provides legal services to older adults across west Alabama on a sliding scale fee. Geropsychology students were able to provide extensive evaluation services related to civil capacity and cognitive functioning through placement at the ELC. Students provided consultative and educational services for law students involved with a rotation in this law clinic.

The utility and impact of geropsychology students in the placement sites was examined using a 5-item survey for professional site staff. No demographic information except for professional discipline was collected about them. Questions were rated on a scale from 1 (not important) to 7 (essential for best care) based on the perceived impact of geropsychology services on client outcomes. The site survey was hand-delivered to available staff at the sites by the students in placement and returned to the project coordinator in a sealed envelope at the end of the placement.

Student attitudes regarding interdisciplinary teams and care were examined using a pre-and post- practicum survey for students. The student survey, consisting of 40 items, measured the change in perception of various disciplines in a treatment team before and after the placement, and changes in the perception of interdisciplinary care. Items were measured on a Likert-type scale of 1(low value) to 10 (high value); intention to work in the field of geropsychology also was assessed. Findings from both of these surveys are presented under point 5, as part of the discussion of clinical experience with interdisciplinary teams.

4. Clinical training with a wide variety of older adult clients

The fourth component of the PPM identifies the value of exposure to a diverse client population of older adults. The GGE program provided opportunities to engage with a broader range of clients than had previously been possible. A total of 182 clients received clinical services through the GGE training grant. Of these, 98 completed opening paperwork for services lasting more than one session. The remaining participants were provided with mental health screening, psychological testing, consultation, or short-term crisis stabilization and/or referral services. The treatment participants (n=98) were primarily female (84.7%), and majority Caucasian (58.2%). A significant number were African-American (36.7%), and a smaller number (5%) were Native American. Eighty-two percent of the participants were aged 50–79 years old. The mean age of the clients was 57.5 (SD=10.9) and ranged from (40 to 90). Most of the clients (86%) had an income under $20,000, and a majority (59%) had income under $10,000, well below the poverty line.

Thirty-five percent of the participants reported that they were unable to work, and 42.9% reported that they were retired or unemployed. Of 96 participants who responded to the question, 33.7% were married and 42.8% reported that they were widowed or divorced. Self-reported physical health was reported in four categories (poor, satisfactory, good, or excellent); 31% of the participants reported poor health and 35% reported satisfactory health. Of the total new clients who presented at the clinics (n=182), 34% presented with depression, 11% with health management issues, 9% with memory difficulties, 9% with stress/PTSD, and the remainder presented with a variety of other complaints ranging from caregiving/family issues to other mental health concerns.

The population of patients seen at the two rural primary care sites was almost entirely Caucasian (mean age 55.35), while the urban primary care site population was almost entirely African-American and slightly older (mean age 58.74). Data indicated that urban elders tended to present with lower income than participants at the rural sites. Educational attainment was not statistically different between the two settings.

Data indicate that urban clients stayed in treatment longer (Mean number of sessions of treatment at urban site: 8.4; at rural site: 6.0). Overall, most patients attended 2–6 sessions. A total of 779 therapy sessions were conducted.

A total of 97 client consultations were done for the ELC, for the purpose of conducting civil capacity assessments. Clients were 63% female, and 67% Caucasian, with a mean age of 74 years old. Referral questions included whether clients were able to retain legal counsel (e.g., enter into a contract), execute legal documents, or live independently.

5. Clinical experience with interdisciplinary teams

The fifth component of the PPM encourages clinical work with explicitly interdisciplinary teams. This was addressed in our program in two ways: through clinical placements and in case-based teaching. The course used case-based round tables to teach interdisciplinary treatment planning. Faculty from multiple disciplines and students participated in discussions focused on the application of knowledge that they had gained during the course, specifically around the interdisciplinary nature of elder care. Cases were designed based on actual cases encountered by students in their placements and supplemented by case vignettes found in medical and nursing textbooks. The round table discussions produced a proposed interdisciplinary treatment plan, and a Venn diagram of how the groups envisioned disciplines working together on each case.

As noted earlier, this component of the PPM was also addressed in the clinical placements in which students provided care as part of interdisciplinary teams. This experience allowed students to compare the ideal care envisioned in the case-based round table discussions versus the vicissitudes of actual healthcare.

In response to our site survey, professionals at all sites seemed to perceive overall value in on-site psychology services for older adults, believing that it was essential for best care practices. Most also reported a change in attitudes about including psychological services in their treatment plans due to the presence of geropsychology students. Only one respondent answered that it did not change their attitude but noted an already positive attitude about inclusion of services and the presence of students had reinforced the feelings. All of the professionals (n=14) reported that they would be likely to seek psychological services as part of treatment planning as a result of their experience with geropsychology students. Further, they believe that psychological services improved treatment outcomes.

Eleven students in clinical placements completed a pre-post student survey. The survey was analyzed in two sections: the first related to perceptions of professional roles on interdisciplinary teams, and the second related to perceptions of interdisciplinary teams for elder care. Items were scored on a 1 (low value) to 10 (high value) scale. For the first section, relating to professional roles, scores were calculated by summing ratings of each profession in the role of an administrator, researcher, clinician, and teacher. T-tests were conducted on the scores to assess changes in perception from Time 1 to Time 2 by profession type. There were no significant differences found.

Overall, most students rated all disciplines favorably in all roles. In addition, most students (90%) were interested in pursuing geropsychology as a career, though their attitudes were quite positive at pre-test (M=8.27 vs. M2=8.18). One student who was previously uncertain became more interested and another student who was previously interested became less certain of pursuing geropsychology as a career.

In the second section, related to perceptions towards interdisciplinary teams, ratings for the 21 items were aggregated to produce a total scale score. The Cronbach’s alpha reliability for the scale was .87, indicating good reliability. A paired samples t-test was conducted to determine change in student perception of interdisciplinary health care teams before and after the clinical placement. Results indicate that student perceptions towards interdisciplinary teams improved significantly (p=0.02) following placements. Overall, students both initially and following placement seemed to indicate that interdisciplinary team care was beneficial for patient care (M1=7.19, SD1=1.02 vs M2=7.67, SD2= 1.05).

6. Focus on ageism

The PPM encourages an explicit focus on ageism. This was one of several social justice issues that were raised in the course and in supervision of clinical practice. Ageism, along with challenges and biases in rural care, racism, gender discrimination, and disability access and discrimination were addressed both explicitly in class, and as continuing themes throughout the course in all three years. The combination of coursework and clinical practice with minority and rural elders brought these issues into sharp focus for the students.

7. Cultural competence and awareness of cultural and individual diversity issues

The GGE program included specific foci on challenging issues in working with adults, including issues of ageism, cultural competence and diversity issues across gender, ethnicity and race, and sexual orientation, as well as rural and urban issues. As noted in the description of clients served, there was economic, geographic, and racial/ethnic diversity in the student’s service exposures.

8. Clinical training that includes observation of trainee (directly or thru taping of sessions)

Clinical placements were supervised by licensed psychologists, and weekly individual and group supervision included the review of audiotaped therapy sessions. These supervisory practices adhered to the larger UA training program based in the application of evidence-based treatments within the scientist-practitioner framework (Allen, Crowther, & Molinari, n.d.).

Student Recruitment

The availability of grant funding made it possible for students to have geropsychology specific experience and training that would not otherwise have been possible. This led to direct funding for fifteen students. A total of 13 students were supported by stipends and tuition reimbursement for participation in clinical placements at rural and urban primary care sites, and at the university Elder Law Clinic. Two students (both male, caucasian, aged 25–35) were supported for initial coursework, but due to their first-year status they were unable to participate in clinical placement activities. In addition to the 15 students supported directly by the grant, nine students who were not a part of the clinical geropsychology program attended the class. These male and female students were from the fields of experimental psychology, social work, nursing, and pharmacy, and ranged in age from 23 to 35 years old.

The impact of this training model can be seen in the career choices made by the students involved. All students who were supported by grant funding for either coursework or placements have graduated and currently pursue careers in geropsychology. They work with older adults in a range of capacities, including home-based care, palliative care, neuropsychological consultation, and psychological services for the VA system both in primary care clinics and long-term care facilities, as well as in faculty positions at research-oriented universities.

Discussion

The Graduate Geropsychology Education program at the University of Alabama sought to expand the existing geropsychology training program by implementing goals consistent with the Pike’s Peak Model. We believe that our program provides support for this model as a solid grounding for clinical geropsychology education. Effort was made to provide interdisciplinary experiences of education and clinical work with older clients to pre-doctoral geropsychology students. Additionally, provision of the graduate-level Health and Aging course supported relationships with the Schools of Medicine, Social Work, Nursing, and Law, the School of Pharmacy at Auburn University and the School of Public Health at the University of Alabama at Birmingham. Clinical practicum placements were facilitated by grant funding, allowing no-cost provision of mental health services to populations who had limited access, and relationships were built with urban and rural primary care sites serving older adults in their communities.

While the outcomes of all sections of the program were positive, there were some challenges that should be considered for future program implementation. As the Health and Aging course is out of the traditional realm of classes offered in clinical psychology programs, a significant amount of logistical support was necessary to facilitate the release and scheduling of faculty, the progression of topics covered, and the provision of materials for all seminars (along with summary notes for continuity) to both faculty and students. Such administrative support requires either a co-facilitator or a teaching assistant who can devote time each week to preparing materials and managing schedules of a group of busy faculty members. Additionally, while psychology and social work students had no difficulty registering for the course, students from other disciplines (such as nursing and medicine) had difficulty in this area. Questions were raised as to how the course could fit into the already tight schedules in those disciplines, as well as whether the level of education and training would be comparable enough to the other disciplines to allow for productive engagement in a didactic course of this nature. In an effort to facilitate participation, the instructor of record (FS) decided to allow students to attend individual seminars without registering for the entire semester. The additional participation contributed to the overall course environment, and while full registration of students in more diverse disciplines might have been optimal, the compromise that was made was an acceptable alternative.

Implications

Data demonstrate improvement in client-identified and objective measures of distress after relatively few sessions with clinical geropsychology students under licensed supervision. This is consistent with the overall literature on psychotherapy in which significant change is the norm for most clients. Students were given practical, real-life experience in busy urban and rural primary care sites where they partnered closely with professionals in other disciplines to provide best possible care to older adults. Students were also able to partner with the Elder Law Clinic to provide educational and evaluative services concerning older adults to the attorneys involved with that clinic. Staff at these clinical sites indicated that there is value in being able to provide geropsychological services to patients at their sites, and that the provision of these services assisted them to move towards improved outcomes for the patients.

Students responded well to the placement and class experiences provided by this grant project, evaluating the class favorably, and indicating through surveys that they continued to be positive in their feelings about interdisciplinary work with older adults. Students responded that it was highly likely that they would work in the field of geropsychology and that they would feel positively about working on an interdisciplinary team to provide the best possible care to older adults. Notably, all graduates who participated in this program have pursued careers in geropsychology.

Training directors and other faculty interested in implementing a program similar to that described here might consider the following issues. Because interdisciplinary training was the overarching goal of this project, the combination of a classroom experience and practical experience was crucial. We have found that health care facilities that serve older adults are quite receptive to the inclusion of psychology graduate students in an interdisciplinary mix but are usually unable to provide financial support for the student work. The grant described herein included the luxury of stipends that allowed students to devote time to unfunded positions; not all training programs will have this option and thus time that may be allocated to this practical experience may be limited. Implementation of the interdisciplinary Health and Aging course was also expedited by grant funds that might make inclusion in a graduate studies curriculum challenging. Faculty from other non-psychology disciplines donated their time to the course and efforts to make their involvement minimally time consuming was an important consideration. For example, we de-emphasized stand-up lecturing and instead involved other disciplines as consultants in mock health care planning exercises. Release time for the instructor of record was provided by the grant and it will be a challenge to many graduate training programs to include a course of this sort in an already crowded curriculum striving to meet the dictates of accrediting bodies. However, a course such as the Health and Aging offering described here could readily serve as an elective in an adult, health or geropsychology professional concentration.

An important topic for research with respect to this model would be whether introducing the interdisciplinary training experiences we have described significantly advance geropsychology competence as measured by the Pike’s Peak evaluation tool and, consequently, better prepare students for internship and postdoctoral training. We are confident that the results would support this curricular model.

The University of Alabama’s Graduate Geropsychology Education training program is consistent with the Pike’s Peak Model of geropsychology training. Based on the data from clinical outcomes, course evaluation, and student response, we believe that this model holds great promise for broader implementation in training programs across the country, even as assessment of geropsychology competencies continue to further evolve (Molinari, 2012).

Biographies

Tracy Wharton received her PhD in social work at the University of Alabama. She is currently an NIMH Research Fellow in Geriatric Psychiatry at the University of Michigan Medical School, focusing her research on long-term health and well-being of dementia caregivers.

Avani Shah received a PhD in Psychology from the University of Alabama. As an assistant professor in the School of Social Work at the University of Alabama, she develops and evaluates interventions for older adults with health conditions and depression.

Forrest R. Scogin received his PhD in psychology from Washington University in St. Louis. He is a professor of psychology at The University of Alabama, where his research focuses on geropsychology and depression. He is a fellow of APA Divisions 12 and 20 and the Gerontological Society of America.

Rebecca S. Allen received her PhD in psychology from Washington University in St. Louis. A professor of psychology at The University of Alabama, her research interests are: (1) interventions to reduce the stress of individuals, family and professional caregivers for older adults with advanced chronic illness; and (2) the cultural dynamics of healthcare decision making.