Geropsychology Workforce Crisis: An International Perspective
I am pleased to have this opportunity to write about the shortage of psychologists trained to work with older adults in Australia, where I live and work, as well as including a perspective on a number of additional countries from around the globe. This snapshot reflects twin issues of an ageing population in both the developed and the developing world, and barriers which limit the number of psychologists who choose to either train particularly to work with geriatric populations, or who choose to refocus and work with this group, in either research or clinical settings.
Although it is well known that the population in most countries is ageing, and that this phenomenon is accelerated in those in advanced old age, what does this mean for practice? For psychology it means that the nature of service provision will change to reflect older adults who are older and frailer, with multiple medical co-morbidities. It means that empirical methods of intervention must be tested on older populations; studies with a mean age of 62 are going to become increasingly irrelevant for our ageing population in search of mental health treatments. And it means that psychological researchers will have to try to advance our theoretical paradigms in clinical psychology to incorporate the latest findings in gerontology with respect to the old and the oldest old (Laidlaw & Pachana, 2009).
Barriers limiting training in either research and/or clinical skills include the failure of training programs to provide adequate geropsychology didactic content and placement opportunities. For example, in a cross-national study of geropsychology content across three countries (USA, Australia, Canada), a minority of programs provided strong leadership in the ageing area (Pachana et al., 2010). Others (notably Susan Krauss Whitbourne; e.g. Whitbourne & Cavanaugh, 2003) have written eloquently about the perils of not including ageing into the undergraduate curriculum (and this would apply to all disciplines, not just psychology). Many of the countries discussed in this piece find their undergraduate curriculums do not include a true lifespan approach, with ageing invisible within the curriculum. How are young adults meant to see study and applied work with older adults as a career option if it is never mentioned?
Then there are, of course, ageist attitudes among the general public, policy makers, and health care providers, mentioned in Jeff Lyness’ geriatric psychiatrist workforce article. A recent cross-disciplinary study (Goncalves et al, 2011) found that nursing and social work students displayed more positive attitudes, knowledge, and interest in working with older adults compared to psychology students. A regression analysis on the data indicated that attitudes, knowledge, and previous formal contact with older adults were significant predictors of interest in working in geriatric settings.
One way to combat ageist attitudes is via exposure. In the USA many psychologists-in-training have the opportunity to begin specialized preparation for practice with older adults during the internship year, in the final year of their doctoral training (the PhD is the base required degree for practice in the US). These one-year nationally accredited internships can offer intensive, supervised rotations in older adult settings including Veteran’s Affairs Medical Centers, outpatient clinics, psychiatric hospitals, and rehabilitation hospitals. The 2011 US Association of Psychology Postdoctoral and Internship Centers (APPIC) directory listed 86 accredited internship programs in the U.S. that provide a major rotation in geropsychology, and 223 programs offering a minor rotation in geropsychology, out of a total of 670 such programs currently offered.
In the USA 4.2% of licensed health service providers who are members of the American Psychological Association identified geropsychology as an area of current focus (APA, 2008), and 39% reported that they provided at least some service to adults over the age of 65 during the most recent typical week of practice. An average of 8.5% of all US psychologist health service provider time is being spent with adults over the age of 65. In a similar survey conducted in 1999, 3.0% of licensed health service providers viewed geriatric patients as their primary professional target (Qualls, et al., 2002). Psychologists who identified as geropsychologists in the 2008 APA Survey of Psychology Health Service Providers reported working across a range of settings; the most common primary employment settings were individual private practice (35.1%), nursing home (16.3%), group private practice (11.7%), and VA medical center (7.9%). Very few geropsychologists reported working in “primary care office/community health center.” It is anticipated that the number of geropsychologists working in these settings will increase as support and funding for integrated models of care for the geriatric population expands.
In a recent large survey of psychologists practicing in Australia, average ratings of confidence in working with older adults were modest, and only 6% of psychologists surveyed specialized in working with older adults (Koder & Helmes, 2008). In this survey 40% of psychologists reported no contact at all with older adults. This has profound implications for the future workforce in Australia. This is unfortunate, for in the current environment of shrinking health care dollars, advocacy for geriatric services becomes very important. In Australia, with increasing health care efficiency and outcome accountability under the current National Health reform agenda, and a genuine opportunity for widespread adoption of innovative models of care, a ‘critical mass’ of engaged psychology workforce is absent at the outset – and therefore unlike some other professions, psychology is not in a strategic position in Australia to easily demonstrate clinical research and health quality and cost outcomes for older adults. As the proportion of healthcare delivered to older adults increases dramatically in the future, lack of this data for psychologists at the outset becomes a self-perpetuating barrier to the inclusion of designated geropsychology roles in benchmarking for new or expanded services.
In Brazil, the workforce situation for psychologists interested in working with older people is similar to the scenario described in Australia. The rapid ageing of the population is posing many challenges in health and social areas, yet at the same time new work opportunities are emerging. Many psychologists are being called upon to assist older adults and their family members and caregivers, who may be facing dementia, depression and end-of-life issues. Nonetheless, at this time, in Brazil there are only a limited number of psychologists trained to work with older adults. A recent search in the site of the Brazilian Society of Geriatrics and Gerontology indicated that the number of Psychologists certified in Gerontology is quite low (120 psychologists), especially when one considers the size of the Brazilian territory and the number of older adults who will be alive in the next three decades. Future psychologists should be encouraged to seek training in aging as an unlimited number of work opportunities will abound and it will certainly represent one of the most relevant societal concerns in Latin America.
Long-term care situations are another area where workforce issues for psychologists are important internationally. In the US a group of psychologists champion this particular work setting (www.pltcweb.org), and this group works to encourage colleagues and students to specialize in such work. In Japan such work is not as prominent, and specialized training opportunities are rare. A 2007 survey revealed only fifty clinical psychologists working with older adults in old age care facilities, representing 0.5% of all clinical psychologists in that country. In order to work in long term care settings and provide appropriate care, providers must have knowledge about the special needs of such patients. Psychologists without formal geropsychology training may find that that they are providing clinical services in such settings. In a recent Norwegian study by Nordhus and colleagues (in press), members of the Norwegian Psychological Association working in clinical practice were invited to participate in a web-based survey measuring knowledge about Alzheimer’s Disease and related disorders. The average mean knowledge score was below dementia care specialists, a not unreasonable finding. An important finding was that being indirectly exposed to dementia (for example in older family members) did contribute to higher knowledge levels about dementia. This underscores the important role of contact with older adults in training settings.
A final workforce setting of note is universities, where both future clinicians and researchers are trained (at least in many countries). Although available numbers are scarce, Portugal, for example, follows the trend observed in geropsychology in Europe where, in general, research on aging is more developed than the field of clinical or teaching geropsychology (Pinquart, 2007). The differences between European countries are large but there is an overall lack of investment in this area, ignoring the ‘graying of society’. According to Pinquart the average number of full professors was 2.3 per country and the mean of geropsychologists was 146, which motivates the European Federation of Psychologists Association to launch a Task Force on Geropsychology. In Portugal, the workforce situation for psychologists interested in working with older people is restrained by the lack of education and training in the core curriculum of Psychology in most of the universities, and the lack of opportunities to become specialized in geropsychology (Ribeiro et al, 2010). Services for older people are mainly providing work for social workers and nurses ignoring the potential of geropsychologists in improving positive outcomes of the aging process and on the other hand psychologists seemed not to be aware of the needs and opportunities of working with old people, namely beyond neuropsychological assessment.
From this global snapshot one can see that a lack of geropsychology roles within all settings then severely limits positive formal contact opportunities for psychologists in training, which as noted above, presents a barrier to the development of positive attitudes towards choosing a career involving working with older adults (Goncalves et al, 2011). A limited geropsychology presence also impacts negatively on the supervision opportunities and therefore competency acquisition and capability of the non-specialised psychology workforce who will find themselves ever increasingly in contact with older adults.
I would like to thank my colleagues Dr. Annette Broome (Australia), Deborah DiGilio (USA), Prof. Inger Hilde Nordhus (Norway), Prof. Constança Paul (Portugal), Prof. Mônica Yassuda (Brazil), and Dr. Kiyoko Iiboshi (Japan) who assisted me with country-specific perspectives.
APA Center for Workforce Studies. (2008). APA Survey of Psychology Health Service Providers, www.apa.org/workforce/publications/08-hsp
Gonçalves, D.C., Guedes, J., Foneca, A.M., Cabral Pinto, F., Martin, I., Byrne, G.J.A., & Pachana, N.A. (2011). Attitudes, knowledge and interest: Preparing university students to work in an ageing world. International Psychogeriatrics, 23(2), 315-321.
Koder, D.A. & Helmes, E. (2008). The current status of clinical geropsychology in Australia: A survey of practising psychologists. Australian Psychologist, 43(1), 22-26.
Laidlaw, K. & Pachana, N.A. (2009) Aging, mental health, and demographic change. Professional Psychology: Research and Practice, 40(6), 601-608.
Nordhus, I.H., Sivertsen, B. & Pallesen, S. Knowledge about Alzheimer’s disease among Norwegian psychologists: The Alzheimer’s disease knowledge scale. Aging & Mental Health. 2011 Nov 30. [Epub ahead of print] DOI:10.1080/13607863.2011.628973
Pachana, N.A., Emery, E., Konnert, C.A., Woodhead, E., & Edelstein, B. (2010). Geropsychology content in clinical training programs: A comparison of Australian, Canadian and U.S. Data. International Psychogeriatrics, 22(6), 909-918.
Pinquart, M. (2007). Main trends in Geropsychology in Europe research, training and practice. In R. Fernandes-Balesteros (Ed.) (pp. 15-30). GeroPsychology, European Perspectives for an Aging World, Hogrefe & Huber Publishers.
Qualls, S. H., Segal, D., Norman, S., Niederehe, G., & Gallagher-Thompson, D. (2002). Psychologists in practice with older adults: Current patterns, sources of training, and need for continuing education. Professional Psychology: Research and Practice, 33, 435-442.
Ribeiro, O., Fernandes, L., Firmino, H., Simões, M.R., & Paul, C. (2010). Geropsychology and psychogeriatrics in Portugal: research, education and clinical training. International Psychogeriatrics, 22(6), 854-863.
Whitbourne, S.K., & Cavanaugh, J.C. (2003). Integrating aging topics into psychology: A practical guide for teaching undergraduates. Washington, DC: American Psychological Association
Nancy A Pachana, PhD, is Professor of Clinical Psychology at the University of Queensland, Brisbane, Australia. Dr. Pachana is a co-chair of the IPA Psychologists Professional Discipline Forum, member of the IPA Expert Advisory Council and former member of the IPA Board of Directors as well as former deputy editor of International Psychogeriatrics. She is the National Convener of the Australian Psychological Society’s Psychology & Ageing Interest Group.