Why We Need an International Clinical Geropsychology
Abstract and Keywords
Clinical geropsychology benefits from a global perspective in a variety of ways. Gerontological theories and interventions may find new applications and expressions when tested in different cultural settings, and the sharing of datasets internationally expands their utility. Importantly, the training of health professionals, and particularly mental health professionals, to cope with increasing numbers of geriatric patients globally, is lagging. In this chapter, some of the ways in which clinical geropsychology has matured into an international field are explored, with reference to the chapters in this Oxford Handbook of Clinical Geropsychology where appropriate.
It is perhaps a truism that the world is getting smaller. So many advances in technology and communications have shrunk all sorts of putative distances—between people, between places, and even one might say, conceptual distances. The internet has increased the ease of access to information, and combined with increased ease of travel to even remote corners of the world, all parts of the globe are more interconnected than ever before. But in truth, networks between peoples through trade, migration, and exploration have existed for hundreds of years. Food, customs, ideas, and, at a basic level, the people themselves have been shared across cultures, with at times tensions but more often innovation and creativity resulting.
Sharing innovations and knowledge in a wide range of areas has benefit—for example, in the areas of technological advances and healthcare. Increasingly, coordinated responses on a global scale are required in the area of disease control—the recent coordinated global efforts on severe acute respiratory system (SARS) outbreaks are an example (Quammen 2012). But there are also worldwide efforts to improve and enhance quality of life. For example, the WHO age-friendly environments programme is aimed at positively impacting the health and well-being of older adults by ensuring the physical and social aspects of their living environments support their needs (WHO 2007). In order to foster and share information gained by participation in the programme, the WHO Global Network of Age-friendly Cities and Communities (GNAFCC) was established, allowing easy communication of innovations worldwide.
Global interconnectedness can have positive implications for the science and practice of clinical geropsychology. These consequences in our discipline are across the areas of the spread of ideas and approaches, sharing of datasets, the development and testing of tools and interventions, and the training of new clinical geropsychologists and enhancing the career paths of those already working. The implications of the global ageing of the population in the developed as well as the developing world flow through and in turn influence clinical geropsychology internationally.
(p. 1065) Clinical geropsychology as a discipline as well as clinical geropsychologists themselves benefit from a global outlook in a variety of ways. Advances and ideas are proposed in one quarter, and then tested, refined, and expanded by other individuals, who may also comment on the cross-cultural and societal implications of the ideas. Areas of the world where geropsychology is not so strong can access both the extant literature and collegial assistance in enhancing geropsychology in their local area. Clinical geropsychologists working in academia often require evidence of an international profile to apply for promotion; students can take advantage of international conferences to find expertise and mentorship in areas of scholarship unavailable in their own university.
In this chapter, some of the ways in which clinical geropsychology has matured into an international field are explored, with reference to the chapters in this Oxford Handbook of Clinical Geropsychology where appropriate.
Sharing Ideas and Approaches in Geropsychology
We have illustrated in this Handbook a variety of clinical ideas and concepts that have migrated internationally, and been enriched by that peregrination; there are also examples in the Handbook of constructs which may be less well known internationally, but should be better known. Two main illustrations of the benefits of cross-cultural exposure involve theories of ageing and clinical assessment and intervention techniques.
Theories of ageing
It is important to gauge how well theories of ageing apply cross-culturally and cross-nationally. For example, Carstensen’s Socioemotional Selectivity Theory (Charles and Carstensen 2010), and particularly the aspect of that theory known as the positivity effect (Carstensen and Mikels 2005), whereby older adults appear to avoid attention to and memory of negative information, are well known. This theory is discussed in Kessler and colleagues’ chapter on ‘Clinical Geropsychology: A Lifespan Perspective’, as well as elsewhere in this text. But how does the positivity effect play out internationally?
Fung and colleagues (2008) have looked at the positivity effect in an Asian population. In a series of studies this group has shown that older adults in Hong Kong do not demonstrate preferential cognitive processing of positively valenced stimuli relative to negatively valenced stimuli, in contrast to findings in Western samples. Fung and colleagues had hypothesized that persons operating in cultural contexts that attach less importance to positive emotions might not show the same effects. They posit that in cultures such as Japan and China, the desire to fit into social contexts motivates individuals to be attuned to negative emotions to avoid social faux pas (Kitayama and Karasawa 1995). Such international research efforts bring geropsychology theories a broader, more nuanced, and frankly more interesting view. This is demonstrated well in the chapter on ‘Social Capital and Gender’, with many cross-national studies on Antonucci’s Social Convoy Model (Antonucci 1985) cited.
(p. 1066) Kessler and colleagues’ chapter also introduces several theories which have had less exposure internationally than Carstensen’s theories. One is the Dual-Process Model of Assimilative and Accommodative Coping (Brandtstädter and Rothermund 2002), which helps make sense of two key means to achieving one’s objectives in the face of ageing: striving to pursue goals (assimilative strategies) and adjusting goals to suit constraints (accommodative strategies). This theory includes such concepts as rescaling personal expectations and letting go of self-images that do not fit the actual self anymore. Likewise, in the chapter in this Handbook on ‘Successful Development and Ageing’, the Self-Management of Well-being Theory (Steverink, Lindenberg, and Slaets 2005), an extension of the Social Production Functions (SPF)–Successful Aging theory (Steverink and Lindenberg 2006; Steverink, Lindenberg, and Ormel 1998), is discussed. The SPF theory encompasses a hierarchy of universal human needs, instrumental goals, and resources, such as maintaining friendships in later life; the better an individual’s needs are fulfilled, the higher their subjective well-being. Many of the theories presented in this Handbook, whether established or relatively new, would profit from greater exposure internationally. Steverink’s Self-Management of Well-being theory relies on hierarchies presented as universal, and so testing the theory across the widest possible cultural contexts would be useful.
Clinical assessment and intervention approaches
More efficacious and age-sensitive assessment of cognitive decline is of interest internationally. In the chapter on ‘Assessing Changes of Cognitive Trajectories over Time’, what can be expected of normal and abnormal cognitive changes with increasing age are outlined. The value of assessing such changes over multiple occasions is explored. Careful calculation of clinically relevant changes in scores (i.e. reliable change index methods) offer compelling data, as individual trajectories for decline are unique and informative, superior to a simple individual assessment with regard to both diagnosis and recommendations for care. The value of broadening out cognitive assessment to encompass emotional functioning, activities of daily living, social functioning, and the environment is discussed in the ‘Geropsychological Assessment’ chapter. These approaches are supplemented by careful attention to how the results of such tests are relayed back to referral sources and patients in the chapter on ‘Evaluation and Treatment of Geriatric Neurocognitive Disorders’. Involving older persons collaboratively in both the investigation of assessment goals and the feedback of assessment results has value, as they may be concerned about the consequences of such an evaluation. This is particularly true in parts of the world where educational attainment of older cohorts is low, and contact with psychologists infrequent.
Finally, recommendations for how rehabilitation strategies might move forward, given a holistic approach to assessment, are nicely captured by the Functional Integrative Approach to rehabilitation described in the chapter on ‘Cognitive Development in Ageing’. In this approach an individualized intervention that targets resources, environmental demands, and change expectations of the patient is stressed. This ensures an intervention approach which is effective as well as personally relevant for patients’ satisfaction with their cognitive health. What each of these chapters stresses is the value of trying to ascertain how an individual is functioning over time, in their unique context, and relaying assessment information back to the person while addressing their specific concerns and designing a tailored (p. 1067) strategy to address these. Such approaches benefit the practice of clinical geropsychology internationally by offering alternatives to a largely medical approach to assessment, particularly of dementia, and providing a detailed evidence base to support these more age-friendly and ageing-sensitive assessment approaches.
In a similar manner, many forms of psychotherapy and psychotherapeutic intervention strategies have been developed either for older persons specifically or applied to older persons, and these are being tested more frequently across cultural contexts. Perhaps the most widely practised and researched of these, cognitive-behavioural therapy (CBT; Beck et al. 1979), was developed in the US by Aaron Beck and proliferated widely. Research on the use of CBT with older adults quickly became a strong and vibrant topic within geropsychology. In this Handbook, the chapters on ‘Interpersonal Psychotherapy for the Treatment of Late-life Depression’, ‘Neuropsychiatric Approaches to Working with Depressed Older People’, and ‘The Use of CBT for Behaviours that Challenge in Dementia’ illustrate the breadth of current use of CBT in older populations. The practice of CBT with older persons has been explored by many writers but particularly Laidlaw and colleagues in the UK (Laidlaw and McAlpine 2008) and the US, who have discussed more precisely the ways in which the processes inherent within the practice of CBT both remain the same as practice with young and mid-aged adults, and how they might differ when treating older adults. The chapter on ‘Cognitive-Behaviour Therapy with Older People’ in this Handbook explores these ideas in more depth. Here is an illustration of a productive cross-national conversation that has increased our understanding of how CBT works with older people.
Interpersonal therapy (IPT) has proved to have great utility in treating depression in older persons (Hinrichsen 1997), and its efficacy is recognized by its support and dissemination within the US Department of Veterans Affairs, as described in the ‘Interpersonal Therapy for the Treatment of Late-life Depression’ chapter. Cognitive Analytic Therapy (CAT; Hepple and Sutton 2004) is also gaining in popularity as an approach with older adults, as described in the ‘Cognitive Analytic Therapy and Later Life’ chapter. Yet both the largely US-focused IPT and the largely British CAT have been slower to disseminate elsewhere. Future areas of research on these two therapeutic approaches might be to ascertain how they are impacting the health-service systems in which they are utilized, and how they might usefully be adapted for other settings and contexts.
Acceptance and commitment therapy (Luoma, Hayes, and Walser 2007) is also being increasingly used with older populations, as described in the chapters on ‘ACT and CBT in Older Age’ chapter and ‘Acceptance and Commitment Therapy with Dementia Care-givers’ chapter. For example, Wetherell and colleagues (2011) examined the utility of ACT versus CBT for generalized anxiety disorder in older adults; they found high levels of satisfaction with treatment in both approaches, and patients received benefits from both treatment approaches. The goal may be to ascertain better fits between patients and approaches so as to minimize dropout, as more CBT than ACT patients discontinued treatment in their trial.
Further work with each of these intervention methods is warranted across cultures and also with particular patient populations, such as those with comorbid medical illnesses (as described in the chapter on ‘Physical Comorbidity with Mood Disorders’). More work is also needed to look at these various interventions in combination with pharmacological treatments (as detailed in the chapter on ‘Combining Medication and Psychotherapy for Late Life Anxiety and Mood Disorders’). In light of DSM-5 changes as well as renewed (p. 1068) interest in the topic, the issues explored in the chapter on ‘Disorders of Personality in Late-life’ warrant further intervention research in older persons.
Innovations in therapeutic interventions also may involve the direct use of technology in therapy to forward treatment aims. The potential uses of ‘Virtual Reality Techniques in Older Adults’ and ‘Mobile Computing Technology in Rehabilitation Services’ are topics of chapters in this volume, as well as fertile areas for future research efforts, particularly given that the size and cost of such devices continues to decline, while potential uses continue to increase. For example, touch-screen technologies are helping older persons with dementia by enhancing communication with care-givers. The CIRCA system is an interactive, multimedia touch-screen system containing stimuli to prompt reminiscing; results suggest the device can assist communication and enhance engagement in persons with dementia (Astell et al. 2010). The development of assistive technologies for persons with dementia is a burgeoning field (Peterson and Prasad 2012).
In the chapter on ‘Positive Ageing: New Horizons for Older Adults’, how older persons meet their needs through social engagement is discussed. One new means of older adults engaging with friends, family, and the world is through social media; in the chapter in this Handbook on ‘Seniors’ Online Communities and Well-being in Later Life’, research on how older adults use the internet and social media, and the potential of such use to influence well-being and social connectedness in a positive manner, is explored. Social networks and their consequences, particularly at advanced ages (McLaughlin et al. 2010), are deserving of greater research attention. How social networks grow and change in later life with the use of social media is another fruitful area for attention.
Finally, the increasing importance of meta-analyses to inform the interventions used with older adults also impacts the importing of interventions across national boundaries. The chapter on ‘Meta-analyses in Clinical Geropsychology’ makes the point that varying levels of evidence exist for interventions, and such research also points to gaps in the literature in need of further research. This can both guide research efforts and prevent multiple inventions of the proverbial wheel, particularly a less than useful wheel, important in these times of constrained research and healthcare funding.
Sharing Large Datasets, Including Longitudinal Studies
Cross-national sharing of data, particularly large datasets, is another area of increasing activity in the geropsychology field. Research is expensive, and some of the most expensive research involves longitudinal research. As was discussed in the chapter in this Handbook on ‘Longitudinal Studies and Clinical Geropsychology’, many of the questions in the field of gerontology can be best answered via longitudinal research. Many longstanding longitudinal studies, such as the Seattle Longitudinal Study (Schaie 1993) or the Berlin Aging Studies (Baltes et al. 1993), have served as an important foundation for research worldwide.
(p. 1069) Issues with cross-national datasets
However, even with such large studies, not all questions can be answered. First, a nationally based large ageing study may have limited generalizability to other countries. Even within relatively contained geographical regions such as Europe, or where countries can appear much more similar than different (e.g. perhaps, the US and Canada), differences remain, and these can be significant for issues regarding ageing. For example, in the chapter on ‘Loneliness and Health in Later Life’ in this Handbook, differences between Northern and Southern Europe in terms of loneliness and social connectedness are mentioned. Similarly, the implications of the recognition of same-sex marriage in Canada (and the until recent and still uneven recognition of this social institution in the US) loom large with respect to claiming benefits and inheritance for older LGBT individuals, as discussed in the chapter on ‘Lesbian, Gay, Bisexual, and Transgender Ageing’.
Even within a country, individual longitudinal studies can offer more powerful data when combined. Anstey and colleagues have taken on the challenge of harmonizing the nine longitudinal studies on ageing in Australia (Anstey et al. 2010). Each of these longitudinal studies on its own offered unique contributions, whether it was the focus on gender and health (Brown et al. 1999; McLaughlin et al. 2011), or a particular health condition, typified by the Blue Mountain Eye Study (Hong et al. 2013), or whether it attempted to strike a core balance between data collection by post and face to face, allowing the maximization of subjective and objective observations (Graham, Ryan, and Luszcz 2011; Luszcz et al. 2007). However, combining these studies has led to key insights into ageing and older adults in Australia, particularly with respect to mental health and dementia (Anstey et al. 2010).
Now there is a growing interest in replicating versions of longitudinal studies cross-nationally to answer questions of a comparative nature. Interest in this for ageing studies and particularly centenarian studies has grown (Poon et al. 2007; see also the link for the International Centenarian Consortium at the end of this chapter). Using similar questions allows, of course, for direct comparisons of data, but more important is the thinking through of such questions in an international context. For example, even collecting demographic data can be challenging across countries. In the US, many studies ask for income or income brackets; this data is harder to access in cultures where disclosing this data is not part of the cultural norm (Brown et al. 1998). Similarly, if a particular demographic categorization predicts an outcome, but that categorization differs by country, then cross-national comparisons are made more difficult. For example, if marital status predicts health outcomes, but marital status is conceived differently in two countries (e.g. emphasis on married vs unmarried persons within the culture, or a lack of distinction between married and long-term partner in that society), then this fact has implications for collecting and interpreting data. Moreover, often these differences in categorization reflect the different sociopolitical structures in countries. For example, in a country where marriage is not required to collect benefits or claim inheritance, the population datasets (such as census data) may not contain the same data as countries where these variables have more legal and social implications.
The importance of social connections, or conceptions about the importance of mental health interventions and how these are best delivered, will differ even more widely cross-nationally perhaps than socio-demographic constructions. In the chapter on ‘Social (p. 1070) Capital and Gender’, the implications of how social connections play out in other cultures is cited as critical in influencing well-being in later life. Similarly, in the chapter on ‘Geropsychological Research and Practice in Mental Health in Mainland China’, the recent increase in interest in providing geropsychological services to older adults, and the changing role of the government in the provision of mental health services (now being augmented with NGO providers) is highlighted.
The impact of culture on cross-national research
Cultural influences on diagnosis, for example, are fairly well known (e.g. the ways in which culture can influence how people explain or define their symptoms, whom they approach for help, and how likely they are to access mental health services, as described in the chapter on ‘Psychosis in Older Adults). However, cross-national definitions of individual words themselves can differ widely, and can affect research into the issues around them.
The term dementia, like many illnesses, carries social and cultural weight, and is associated with stigma (e.g. Graham et al. 2003). For example, in China, dementia is often seen as the result of ‘worrying too much’, ‘wrongdoing’, or ‘fate’ and described as ‘craziness’ or ‘contagious’ (Hinton, Franz, and Friend 2004). Being affected by dementia, whether as one diagnosed with the illness or by being related to a person with dementia, thus has a negative connotation and suggests an attitude that the person with dementia or his/her family is at least partly responsible for developing the disease (Liu et al. 2008; Low et al. 2011).
The idea that dementia may be the result of a normal ageing process as well as a mental illness process which is stigmatizing are apparently contradictory and yet often co-exist in Chinese care-givers (Guo et al. 2000). Such opposing attitudes may contribute to care-giver stress by discouraging help-seeking and service engagement, and they may also affect care-givers’ willingness to participate in care-giving research studies (Hinton et al. 2000; Sun, Ong, and Burnette 2012; Yeo and Gallagher-Thompson 2006). The consequences of the meanings of dementia in the Chinese context have reverberated internationally, as highlighted in the chapter on ‘Caring for Care-givers of a Person with Dementia’, where the difficulties in engaging care-givers are expanded upon.
There are many gains to be had from pursuing cross-national research, both in terms of the data itself and how we think about instigating, collecting, and interpreting such data. The pursuit of cross-national collaborations goes beyond identical datasets; indeed, seeking to import or impose a set of questions onto another country can appear to be a form of imperialism. This is especially true in cultures and countries seeking to understand what might be termed ‘the other’. For example, seeking to set up a longitudinal study in an Asian country certainly goes beyond offering a set of questions or even offering money to pursue a research agenda; understanding how Asian countries pursue health and social research, particularly the close ties between research and the government, are key. In many Asian countries translational research is a given because there is a close (and possibly enviable alignment) of research agendas and the implementation of assessment and intervention strategies on a regional or national level. This situation affects everything from gaining ethical clearances to how fieldwork is implemented and, finally, to how and in what manner research findings are disseminated. This has resulted in exciting translational research opportunities (e.g. Coopmans, Graham, and Hamzah 2012). The importance of the nurturance of close, (p. 1071) collaborative, and long-term partnerships in this region, and perhaps more broadly with respect to cross-national research, cannot be overstated.
Development of Tools and Interventions
A moment of personal reflection: as a clinical geriatric neuropsychologist trained in the US, but now living in the Southern Hemisphere, I went through three distinct phases of professional acculturation as a geropsychologist living in a different country and a different culture. First, there was the realization that even in so-called ‘English-speaking’ countries, language varies. Holding up a pen and having to decide whether ‘Biro’ (a brand of pen) was the correct answer on the MMSE, while an amused group of trainee clinicians looked on, was an interesting moment. And so the first hurdle in cross-national assessment, language, was made salient to me. Language does matter, particularly in testing. Tests (and indeed clinical interviews) are standardized, and moving these across cultures can be no easy feat, even when all care has been taken with back translations. (For information about this see the excellent articles by Sousa and Rojjanasrrirat 2011 and Van de Vijver and Hambleton 1996).
The second phase of my acculturation involved the perils of test development. Although frustrated for many years at the uncanny resemblance of a beaver to a platypus when administering the Boston Naming Test in Australia, when designing the Geriatric Anxiety Inventory (Pachana et al. 2007; Byrne and Pachana 2011), my colleagues and I blithely put in many culturally specific idiomatic expressions (e.g. ‘I feel as though I have butterflies in my stomach’). This was justified (post hoc, of course) in that using the common vernacular is important in interviewing and testing older persons in the mental health context, a point well-made in the chapter on ‘Interviewing Older Adults’ in this Handbook. However, it still caused havoc with translations for countries where this expression was unknown. A flexible strategy was adopted; the phrase became ‘I feel as though I have ants in my stomach’ (Spain) and ‘I feel tight like the strings of a violin’ (Italian, and very poetic too). The need for specific translations for national populations (individualized Portuguese versions for both Portugal and Brazil, for example; Martiny et al. 2011) have led me to an increased awareness of what is required to make a test available internationally (Pachana and Byrne 2012).
The value of making tests, particularly tests designed specifically for older adult populations, and available to a wider audience, have great implications for both research and clinical practice in geropsychology. Several chapters in this Handbook have made the point about the utility of measures for various cultural and language groups (e.g. Caring for Care-givers chapter; ‘Barriers to Mental HealthCare Utilization’ chapter). The need for careful ‘translations’ of constructs, be they what is a standard drink (‘Substance Use, Misuse, and Abuse’ chapter) to how capacity is defined (‘International Perspectives on Capacity Assessment’ chapter) to what is valued at the end of life (‘Transitions in Later Life’ chapter), is apparent. Even the apparently ubiquitous notion of sleep (or at least, the significance of sleeping patterns, as described in the chapter on ‘Late-life Insomnia’) varies across nations, as anyone who has attempted to eat dinner in Madrid before 9pm can attest…
The third stage of my acculturation is the one I currently occupy. It involves being a practitioner who administers tests for a living in a multicultural society, and is struggling to do (p. 1072) so in a changing multicultural landscape. My clients in a large Australian city come from various nations, but have come to Australia at different points in their own history, and their family’s history. So issues of degree of acculturation crop up in terms of test administration and interpretation. Immigration laws are still relatively favourable in Australia for bringing ageing parents to live with relocated children; I see increasing numbers of persons with dementia only recently arrived from abroad. My last assessment client seen in an aged care facility arrived from Switzerland and was taken directly to a nursing home from the airport. The need for translators is dwarfed by the pressing need to understand the implications for such global migrations on care staff, families, and individuals themselves, in this case an individual with moderate dementia. Never mind what tool to choose; how can I make sense of the changing world I am seeing?
Tests used across populations
With respect to tests, one is guided by overarching assessment principles, including the excellent guidance given in the two chapters on ‘Geropsychological Assessment’ chapter as well as ‘Clinical Evaluation and Assessment Methods’ chapter offered in this Handbook. The need to be attuned keenly to culture in the clinical practice of geropsychology has been an important part of the CALTAP model of clinical interventions with older adults offered by Knight and Poon (2008).
Many tests mentioned in these chapters are deserving of further research, particularly cross-national validation. These include the useful Geriatric Suicide Ideation Scale (GSIS; Heisel and Flett 2006) mentioned in the chapter on ‘Suicidal Ideation in Late-life’, and the Everyday Problems Test (EPT; Diehl, Willis, and Schaie 1995; Willis and Marsiske 1993), an objective (i.e. performance-based) objective measure of a patient’s ability to solve IADL problems relevant to everyday life, as described in the chapter on ‘Functional Sequelae of Cognitive Decline in Later Life’.
Interventions tested across populations
Some intervention strategies have taken shape from particular healthcare niches (such as primary care; see the chapter on ‘Psychological Interventions in Non-mental Health Settings’). While the specifics of primary care, or care by a general practitioner (GP), vary between countries, the recent explosion of research into providing psychological interventions in the realm of general practice across a variety of countries speaks to the global interest in this area (Kroenke et al. 2007; Stanley, Diefenback, and Hopko 2003; Verhaak, Bensing, and Brink-Muinen 2007).
Other interventions spring from looming healthcare issues, such as the growing number of persons globally that suffer from cognitive decline and dementia, as described in the chapters on ‘Exercise and Health Promotion for Older Adults with Cognitive Impairment’ chapter and ‘Lifestyle Risks and Cognitive Health’ chapter. Prince et al. (2013) estimated that globally, 35.6 million people lived with dementia in 2010, with numbers expected to nearly double every twenty years, to 65.7 million in 2030 and 115.4 million in 2050. This growing population of patients with dementia increases the risk for elder abuse; just as dementia (p. 1073) is of growing concern internationally, ways to treat and in particular prevent elder abuse are being developed in many parts of the globe (see the chapter on ‘Elder Abuse’). It also increases the need for interventions at the family level, as described in the chapter on ‘Family Therapy with Ageing Families’.
Nearly every intervention chapter in this Handbook has mentioned important intervention approaches that could usefully be studied and adapted for use cross-culturally. For example, two types of reminiscence therapy—life review and life review therapy—have compelling support as efficacious treatments for improving well-being and for reducing depression in older persons, as detailed in the chapter on ‘Reminiscence Therapy’. The chapter on ‘Pain in Persons with Dementia and Communication Impairment’ describes a systematic hypothesis-testing method that integrates assessment and treatment of pain, which is required to identify, assess, and treat pain appropriately in older persons.
Training and Practice in Geropsychology Internationally
The world is becoming older, and the training of health professionals, and particularly mental health professionals, to cope with increasing numbers of geriatric patients, is lagging (Karel et al. 2010; Kneebone 1996). However, in thinking about expanding the workforce to cope with increasing numbers of older clients, the idea of ‘training’ must expand to encompass ‘re-skilling’ and the branching into geriatrics of health professionals who have mainly practised with adults (or even children). Finally, we must consider what is a minimum competency to practise as a clinical psychologist in an ageing world; increasingly, older clients will turn up everywhere (for example, as primary carers of grandchildren).
Training strategies and resources
Training in geropsychology varies internationally (Karel et al. 2010; Pinquart 2007). Cross-national comparative studies of geropsychology training (Pachana et al. 2010) and more recently competencies (Woodhead et al. 2013) have begun to appear in the literature. In the US, there has been a consolidation of training programmes in clinical geropsychology (Knight et al. 2009) and the development of an excellent resource in geropsychology (see link to GeroCentral website below); both of these initiatives have a nascent international component. (See also relevant sections of the chapter on ‘Interprofessional Geriatric Healthcare: Competencies and Resources for Teamwork’.) Peak psychology bodies internationally often have interest groups or divisions focusing on ageing. Most of these societies or organizations have practice, teaching, and research resources, tip sheets and other materials for clients, and information on mentoring and consultation outreach programmes. In many cases these resources are freely available online. (For interest, please see Appendix 1 for an undoubtedly incomplete list of such geropsychology organizations and peak bodies, internationally.) In general, Europe, North America, and Australia and New Zealand have well-developed networks of peak bodies and training programmes in geriatrics across health and mental health (p. 1074) disciplines. This is a growing area in Asia and South America, but due to demographic realities geriatric subspecialties and training are probably least developed in Africa.
In the US, a set of clinical geropsychology competencies has been developed, and these are beginning to be known outside the US context. The Pikes Peak Model for Training in Professional Geropsychology details competencies important for psychological practice with older adults (Karel et al 2010; Knight et al. 2009). These geropsychology competencies have now been transformed into an online tool which serves to assess competencies, as well as point a new or re-skilling practitioner to areas for which they may need to do either further reading or seek supervision and guidance (again, see the GeroCentral website link at the end of this chapter). Outside the US, there are often already existing national and/or regional guides for practice and, by extension, training for work with older adults (e.g. Pachana, Helmes, and Koder 2006; Fernández-Ballesteros 2007). Now the challenge will be in more coordinated, systematic training efforts in geropsychology, hopefully guided by empirical research.
Training in geropsychology for work with particular populations within geriatrics is also of concern. One such population is older persons living in nursing homes. There are not enough clinical psychologists with particular training and expertise in working in long-term care settings, as described in the chapter on ‘Older Adults and Long Term Care’.
Finally, introducing a more international perspective into training will equip geropsychology trainees with a bigger toolkit and a broader appreciation of cross-cultural and cross-national issues in ageing. A laudable internationalized training model in gerontology is the European Masters programme in Gerontology (EuMaG), which until recently was funded by the European Commission (Heijke 2004). Developed and delivered by a network of twenty European universities, EuMaG helped to train dozens of young European gerontologists. Its strong emphasis on cross-national comparisons of data, and its policy of various European universities hosting modules of content meant its graduates truly had an international view of ageing research, practice, and policy.
Potential hurdles and resources in geropsychology training
What might be some potential barriers or concerns with respect to increasing or improving our geriatric mental health workforce? Ageism among both mental health practitioners in general, and psychology trainee practitioners in particular (Gonçalves et al. 2011) may be one such barrier. Attempts to systematically address ageism in healthcare delivery systems and those who work in them are growing (Huang, Larente, and Morais 2011; Liu et al. 2012). Research efforts themselves are not free of ageism and age biases (Cherubini et al. 2010). Of course, psychology itself is not immune (e.g. Helmes and Gee 2003), and certainly addressing ageism and its consequences is deserving of more research in general clinical psychology as well as geropsychology training contexts. Again, contact with older persons is important if we are to stimulate students to work with older adults, and also potentially to stem negative attitudes towards older people (Gonçalves et al. 2011).
What resources are out there to help young clinicians gain the necessary skills and attitudes to work successfully with older adults? Careful explications of how to do therapy with older adults are important. Manualized approaches to therapy, such as those described in many (p. 1075) chapters in this Handbook, as well as explanations of how particular components of therapy work with older adults, such as homework (Kazantzis, Pachana, and Secker 2003), are important. Many authors in this text make a point about the need for increasing dissemination of strategies to work with older people in training programmes. Similarly, the need for improved training in interdisciplinary approaches is highlighted in the chapter ‘Interprofessional Geriatric Healthcare: Competencies and Resources for Teamwork’ in this Handbook.
Finally, there remain many areas of research that remain under-developed, such as ‘Late-life Anxiety’, which are discussed in this Handbook. If we are ever to close the research gap in such important areas, we need to train young clinical psychology investigators, and to do that, we must encourage more of them to choose later life as a specialty area. The demographics of the world are changing at an increasing rate (see chapter on ‘The Demography and Epidemiology of Population Ageing’); young researchers and clinicians both have to be across this data, and be armed with appropriate tools and knowledge with which to help older cohorts. This is especially true for practitioners, who may face a gap of many decades in age and several cohorts in lived experience when seeing their clients (Laidlaw and Pachana 2009).
We live in an ageing world. Older adults are a heterogeneous and growing population. Moreover, they migrate as well as stay rooted in their home (sometimes literally) of origin. They speak one or a dozen languages. They offer challenges to us with respect to ageing well and ageing with disorders of both a physical and psychological nature.
We currently have too few people trained to serve the needs of this diverse population of older persons. Our instruments and interventions proliferate, but would a more holistic view of their potential for cross-national application, as well as the limits to their application in particular regions or populations, help reduce inefficiencies and make stretched research and healthcare dollars go further?
I think the future of geropsychology lies in the international arena, and I think that future is a bright one.
Appendix 1 : Peak Geropsychology Groups and Organizations
Austrian Psychological Association, Geropsychology section. http://www.boep.or.at/Gerontopsychologie.241.0.html.
(p. 1076) Austrian Psychotherapeutic Association, Geropsychology section. http://www.psychotherapie.at/gerontopsychotherapie.
Psychology and Aging Interest Group (PAIG). http://www.groups.psychology.org.au/paig/.
Canadian Psychological Association: Adult Development and Aging. http://www.cpa.ca/aboutcpa/cpasections/adultdevelopmentandaging/.
Division of Aging Psychology, Gerontological Society of China (no webpage available).
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Swedish Psychological Association, Geropsychologists Association. http://www.psykologforbundet.se/Yrkesforeningar/Geropsykologer/.
British Psychological Society (BPS), Division of Clinical Psychology. http://dcp.bps.org.uk/.
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Australian Longitudinal Study on Aging. http://www.flinders.edu.au/sabs/fcas/alsa/.
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Gerontological Society of America: http://www.geron.org.
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International Centenarian Consortium. https://www.publichealth.uga.edu/geron/research/intl-centenarian-study.
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