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Working with Older Adults: Room to Improve

Working with Older Adults: Room to Improve

Seeking mental health care is often a struggle, and this struggle can be even more pronounced for older adults. Stigma, inaccurate beliefs about aging, as well as a variety of logistical barriers often hinder older adults from seeking and continuing care. Additionally, geropsychologists or other mental health providers who specialize in geriatrics are scarce. According to a survey of 4,109 doctoral psychologists conducted by APA’s Center for Workforce Studies (Moye et al., 2019), 1.2% of psychologists describe their primary specialty as geropsychology, while 15.4% specialize in child/adolescent psychology. There has been a similar shortage in gerontological social workers. Wang and Chonody (2013) reported that only 1,000 students were annually specializing in gerontological social work, while 5,000 additional gerontologically-trained social workers were needed to meet the needs of older adults. Why might that be? We have known for a long time that as baby boomers age in America, the number of older adults needing services is growing exponentially. We also know that older adults are less likely to seek mental health services. Again, why might that be? Might there be an interaction effect at play? 

In a study by Merz et al. (2017), semi-structured telephone interviews were conducted with 30 clinical geropsychologists about their training and current work. They found that personal experience with older adults and taking an aging course were the two most common pathways to working with older adults. “Direct exposure to older adults, whether in one’s own social network or in volunteer service positions, may demystify aging for some people, make ‘the other’ more familiar, expose interesting research questions, and generally highlight the real needs and potential joys of working with older adults'' (p. 9). Gregory Hinrichson, Ph.D. also addresses this in his book, Assessment and Treatment of Older Adults: A Guide for Mental Health Professionals: “Researchers have well documented that most people have complicated and often negative feelings about aging…for most of our lives, the ‘aged’ may seem like ‘them’…” (p. 12-13). 

If we are looking at older adults as “the other” or “them,” then we are also looking at misconceptions, stereotypes, and ageism. Common myths about aging include notions that most older people are depressed, sick, cognitively impaired, socially isolated, and inflexible (APA, 2014). The American Psychological Association requires accredited graduate, internship, and fellowship programs to address issues of cultural and individual diversity, but most programs focus on racial and ethnic diversity, not other aspects of diversity such as age (Yeo, Cornish, & Meyer, 2017). This leaves few psychologists entering the field of gerontology, and the rest having little exposure or education about older adults. 

What about the experience of older adults in the health care system?

Researchers consistently find that older adults receive poorer health care, and Hinrichson sums this up well: 

Old age becomes a sort of black box for explaining (or not explaining) medical concerns of older adults. Medical diagnoses are missed or overlooked, and care is less proactive than with younger adults. Medical providers spend less time with older than younger patients despite that many older adults have more complex medical conditions. Medical information and treatment recommendations often are not clearly communicated. There is little discussion about end-of-life preferences with older people. Long-standing concerns exist about the treatment of older adults in long-term care facilities, including misuse of antipsychotic medication to manage behavioral problems...[and] are more likely to be given psychotropic medication than psychotherapy services, despite their preference for psychotherapy (p. 20).

Is it any wonder older adults are not seeking treatment?

Older adults living in the community (versus long-term care facilities) generally have lower levels of mental disorders than younger adults, but the numbers of those with significant depression and anxiety are still significant. Many physical health problems common in older adults such as mobility, heart, lung, neurological problems, and pain can cause or exacerbate mental health concerns as can the medications used to treat them. 

According to a study by Wuthrich and Frei (2015), specific barriers to seeking therapy for older adults with comorbid anxiety and depression include difficulties with transportation, beliefs that it is normal to be anxious and depressed in old age, and beliefs by referrers that psychological therapy is less likely to be effective. In addition, older adults were less likely to continue therapy related to not finding therapy helpful, cost of treatment, and thinking that the therapist did not understand their issues. Both older adults and the providers treating them under-identified the need for help. Nelson (2005) noted older adults may be spoken to in a manner called “overaccommodating speech,” which can include being overly polite, speaking loudly and slowly, talking in simple sentences, and taking less seriously what is said by them compared with younger individuals. It is no wonder older adults would not return to treatment if spoken to in this manner. 

Most providers would agree that without training in specifically treating children, one should not provide services to children. Yet when it comes to older adults, these standards do not seem to apply. Of course, not everyone needs to specialize in gerontology, but there are many educational opportunities to increase our knowledge and skills in working with this population. CE-Credit features many article courses about older adults, including how to differentiate between depression and dementia, elder abuse, personality disorders in older adults, the effects of pharmacological treatment of major depression in older adults, and many more. Additionally, Dr. Hinrichson’s excellent, highly palatable, book about the assessment and treatment of older adults is available (and in my opinion, should be required reading for anyone working with older adults). 

When I transitioned from my position in geriatrics with the Veterans Health Administration to private practice, the first thing I did was become credentialed with Medicare. Over half my practice is over the age of 65, and I wouldn’t have it any other way. I receive incredible fulfillment from working with older adults and am routinely amazed at the wisdom and resilience of my clients. Of course, not everyone needs to have my level of excitement for working with older adults, yet some exposure to and education about older adults would be beneficial for everyone working in a mental health capacity. Even if you do not work directly with this population, you may encounter older adults in a variety of settings.

For more information about mental health and older adults, a comprehensive list of resources and organizations is available here: https://www.apa.org/pi/aging/resources/organizations

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References:

American Psychological Association. (2014). Guidelines for Psychological Practice with Older Adults. American Psychologist, 69(1), 34–65. https://doi.org/10.1037/a0035063

Hinrichson, G.A. (2020). Assessment and Treatment of Older Adults: A Guide for Mental Health Professionals, American Psychological Association. http://dx.doi.org/10.1037/0000146-000

Merz, C. C., Koh, D., Sakai, E. Y., Molinari, V., Karel, M. J., Moye, J., & Carpenter, B. D. (2017). The big shortage: Geropsychologists discuss facilitators and barriers to working in the field of aging. Translational Issues in Psychological Science, 3(4), 388–399. https://doi.org/10.1037/tps0000137

Moye, J., Karel, M. J., Stamm, K. E., Qualls, S. H., Segal, D. L., Tazeau, Y. N., DiGilio, D. A. (2019). Workforce analysis of psychological practice with older adults: Growing crisis requires urgent action. Training and Education in Professional Psychology, 13,(1): 46-55. DOI: 10.1037/tep0000206

Nelson, T. D. (2005). Ageism: Prejudice against our feared future self. Journal of Social Issues, 61(2), 207–221. https://doi.org/10.1111/j.1540-4560.2005.00402.x

Yeo, V., Erickson Cornish, J. A., & Meyer, L. (2017). An analysis of diversity content in doctoral health service psychology program websites. Training and Education in Professional Psychology, 11(2), 86–93. https://doi.org/10.1037/tep0000152

Wang, D., & Chonody, J. (2013). Social workers’ attitudes toward older adults: A review of the
literature. Journal of Social Work Education, 49(1), 150–172. https://doi.org/10.1080/
10437797.2013.755104

Wuthrich, V., Frei, J. (2015). Barriers to treatment for older adults seeking psychological therapy. International Psychogeriatrics, 27,(7): 1227-1236. DOI:10.1017/S1041610215000241

Elizabeth Mosco, Ph.D., PMH-C, CPLC

Elizabeth Mosco, Ph.D. is a licensed psychologist in Reno, NV. She opened a private practice after 10 years of conducting home-based assessment and therapy with the VA Sierra Nevada Health Care System. Dr. Mosco’s clinical interests include maternal mental health, older adults, and third wave cognitive behavioral therapies.

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Opinions and viewpoints expressed in this article are the author's, and do not necessarily reflect those of CE Learning Systems.

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