Teaching foundational attitudes and knowledge for psychological practice with older adults: Commentary on

In this issue, Hinrichsen, Emery-Tiburcio, Gooblar, and Molinari (2018) describe the geriatric mental health work-force crisis and the development of professional geropsychology as a specialty area of practice and remind us of the reality that geropsychology specialists alone will not be able to meet the behavioral and mental health needs of aging adults and their families. They delineate a continuing education (CE) curriculum for postlicensure psychologists to gain foundational attitudes and knowledge for psychological practice with older adults, per the American Psychological Association (APA) Council of Specialties (CoS) recommendations for 15 hrs of CE for “exposure” level training in a field. Based on a survey of geropsychologists completed in collaboration with the Council of Professional Geropsychology Training Programs (CoPGTP), they recommend how foundational geropsychology attitude and knowledge content could be allocated in 2-day CE workshop and/or readings and webinars.

We are delighted to comment on this important work, from our perspectives as professional geropsychology educators, supervisors, mentors, researchers, and administrators. For full transparency, we have both been working in this area for some time, and the first author consulted on earlier phases of this published project. The first author cochaired the 2006 Pikes Peak Conference on Training in Professional Geropsychology and led a group in developing the Pikes Peak Knowledge and Skill Assessment Tool (e.g., Karel et al., 2012). The second author is leading a team effort to characterize supply, demand, and practice patterns for geropsychological services, in collaboration with the American Psychological Association (APA) Center for Workforce Studies (CWS) (Moye et al., 2018, unpublished manuscript; www.apa.org/cws). Both authors collaborated in crafting a response with recommendations for psychology as a profession regarding the Institute of Medicine’s (IOM) 2012 report, The mental health and substance use workforce for older adults: In whose hands? (see Hoge, Karel, Zeiss, Alegria, & Moye, 2015).

By seeking input from psychologists who work regularly with older adults, Hinrichsen and colleagues have made a consensus-based and very useful contribution in response to calls for guidance on foundational geropsychology competencies for psychologists. For example, our first recommendation in response to the 2012 IOM report was, “Identify for all psychologists an essential set of core competencies and a minimum level of graduate training in the care of older adults” (p. 273). Hinrichsen and colleagues’ recommendations help to move us in this direction, particularly regarding continuing education planning for postlicen-sure psychologists. We would like to comment further on the challenges of training attitudes regarding aging and older adults; the balance of geropsychology assessment and intervention knowledge; the critical importance of foundational skills as well as knowledge; the role of graduate education; and the balance between foundational and specialist training in the field.

1 |. COMMENTARY

1.1 |. The realm of attitudes

Along with knowledge and skills, attitudes are an important part of professional competence. In the interdisciplinary field of gerontology, attitudes toward aging and older adults are an important focus of academic study given the cultural context of ageism and the impact of such attitudes (by older adults themselves, our communities, and health-care professionals) on health and mental health outcomes. Across professions, attitudes affect individuals’ initial level of interest in working with older adults, and how they function once in practice. In addition to foundational knowledge, Hinrichsen and colleagues (2018) included foundational attitudes about older adults and aging among the five domains that they asked their survey participants to rate in terms of hours to allocate of a total of 14 hrs of CE (i.e., a 2-day CE workshop). The domain of attitudes had the lowest average number of hours (1.42 hrs) allocated, compared to the four knowledge domains (i.e., knowledge of adult development and aging, and knowledge of foundations of: clinical practice, assessment, and intervention/consultation with older adults).

How then should attitudinal competencies be addressed at the foundational level? In the Hinrichsen et al. study, the relatively low allocation of CE hours to address these attitudes, apart from the very difficult task of allocating so many important topics to such limited time, may reflect recognition that attitudes are harder to “train” through traditional knowledge-based continuing education. However, in those 1.5 hrs of CE devoted to attitudes, it would be important to engage learners in dynamic exercises to encourage self-reflection on potential biases about working with older adults, and on illustrating the significant, rewarding, and meaningful contributions psychologists make in helping older adults and their families enjoy improved functioning and quality of life. Within the 2-day CE, an attitudinal exercise might be to reflect upon what has brought them to the room—as most psychologists do not choose geropsychology as a specialty, but many psychologists do find themselves working with older adults - and to use that self-reflection for the learners’ own attitudinal development.

1.2 |. The balance of assessment and intervention

In general, professional psychologists tend to focus moreso either on assessment (e.g., neuropsychological, vocational, forensic) or intervention/consultation (e.g., psychotherapy, training) activities in their practices. Geropsychology specialty competence requires knowledge and skills across assessment, intervention, and consultation domains. Hinrichsen and colleagues recommend equal allocation (3.5 CE hours each) to foundations of assessment of older adults and foundations of intervention, consultation, and other service provision, likely reflecting this breadth practice orientation within geropsychology. Yet, in the APA CWS study, psychologists who work at least occasionally with older adults report spending the overwhelming majority of their time (88%) in intervention activities. A challenge then will be to think about how to teach and emphasize the importance of foundational geropsychological assessment knowledge to psychologists, most of whom are likely primarily interventionists. Although true for all psychology practice, a critical challenge for psychological practice with older adults is correct diagnosis and case conceptualization to inform treatment. For example, underappreciated cognitive deficits, family systems influences, the impact of medical problems on everyday functioning, or suicide risk may lead to ineffective treatment or adverse outcomes. For geropsychology training beyond the “exposure” level, psychologists may choose to focus on knowledge and skill development within assessment versus intervention activities.

1.3 |. The importance of skill development

Hinrichsen and colleagues acknowledge that learning “about” something is different than learning “how to do” something. Foundational knowledge is a critical starting point. To develop skills for psychological practice with older adults, particularly those with complex health and/or psychosocial problems, psychologists need some supervision or consultation regarding actual clinical work. In our experiences providing geropsychology training and supervision over the past 20+ years, trainees in geropsychology tend to struggle more with “foundational” geropsychology skills (e.g., addressing ethical dilemmas, functioning on geriatric teams, communicating effectively across various systems of care) than in learning functional skills of geropsychological assessment, intervention, and consultation. It is difficult to learn how to address complex ethical and/or clinical dilemmas (e.g., regarding risk, decision-making capacity, end-of-life care, involvement of family, conflict on care teams) via knowledge-based continuing education.

Of course, “exposure” is the first step in training. Next, gaining the postlicensure “experience” level of preparation, per the CoS and summarized by Hinrichsen et al., requires 25 hrs of CE and 500 hrs of supervised service, at least 30% of which includes direct patient contact with older adults (e.g., equivalent of an internship rotation). Our recommendations in response to the 2012 IOM report included: “Establish an evidence-based continuing education pathway in geropsychology” (p. 274) to address knowledge and skill acquisition. Aspirationally, such CE would include “longitudinal and sequenced problem-oriented educational approaches that incorporate modeling of skills, observation of learner practice, coaching and feedback, and integration of learning into the flow of routine activities using work-based learning strategies” (p. 274). Practically, we need innovative models of distance-, virtual-, skill-based training to help motivated postlicensure psychologists get feedback on clinical work with older adults. At this level, training and feedback might focus more specifically on meeting the needs of older adults within one’s area of practice, whether that be in primary care, outpatient psychotherapy for particular mental disorders, hospital-based health psychology interventions, inpatient mental health risk assessment, or otherwise.

1.4 |. The role of graduate education

The Hinrichsen et al. work focuses on the development of a 2-day geropsychology CE workshop for postlicensure psychologists. It does not address whether these same attitude and knowledge competencies might or should be integrated into graduate-level training for all psychologists—a goal we identified in response to the IOM report as a need to “incorporate the minimum competency and educational standards into the APA Guidelines and Principles for Accreditation” (p. 273). APA requires that graduate programs address “cultural and individual” diversity which, despite including age as part of the definition, is often interpreted primarily as racial and ethnic diversity.

Including education from lifespan developmental and cohort/generational perspectives at the graduate and internship levels, perhaps aligning with the Hinrichsen et al. recommendations, would be a critical next step in preparing the psychology workforce. Such diversity-related training should also address intersectionality—that is, the interactions among diversity variables. For example, an expanding portion of the US population not only are older adults, but older adults from diverse racial and ethnic backgrounds, and individual differences related to gender, gender identity, sexual orientation, race, ethnicity, religion, and other aspects of diversity affect individuals differently across generations. Eventually, the examination for professional practice in psychology (EPPP) content should reflect the changing demography of our health-care recipients.

1.5 |. The role of specialists

If we achieve the lofty and necessary goal of preparing most psychologists to work with older adults through graduate-level training or postlicensure continuing education, what then is the role of specialists? In medicine, this dilemma has been referred to as “big G and little g”—recognizing the need for geriatric specialists (“big G”) to treat complex cases and to be educators, scientists, and leaders, and for all practitioners to have basic competencies (“little g”) (Tinetti, 2016). In the important push for foundational competencies for work with older adults, we would want to make sure that we sustain and grow the number of graduate programs and postdoctoral fellowships focused on producing specialists in geropsychology to fill these important (“big G”) roles.

2 |. CONCLUSION

In summary, we commend this important work to set forth a practical and needed CE curriculum for exposure to attitude and knowledge foundations of geropsychology practice. We hope it will inspire CE providers to develop and expand offerings in this area. We also hope it will set the stage for integrating these foundational attitude and knowledge domains into education at the graduate school level. In 2018, the big population bubble of the baby boomers range in age from 54 to 72, and all of us are living longer. All psychologists must be prepared for competent work with older adults and their families.