Clinical Psychology with Clinical Psychology with Older People: Older People:

a perspective from the UKa perspective from the UKBob WoodsBob Woods

University of Wales BangorUniversity of Wales Bangorb.woods@b.woods@bangorbangor.ac..ac.ukuk

OutlineOutline

PSIGE PSIGE –– a brief history and exploration of a brief history and exploration of the PSIGE mentalitythe PSIGE mentalityTraining in clinical psychology Training in clinical psychology –– the UK the UK positionpositionAgeism and being ‘specialist’Ageism and being ‘specialist’Building the evidence baseBuilding the evidence base

“You don’t have to be crazy to “You don’t have to be crazy to work here, but it helps…”work here, but it helps…”

PSIGE was formed by people PSIGE was formed by people whose colleagues thought they whose colleagues thought they were crazy to work with older were crazy to work with older

peoplepeople

Crazy Crazy –– Oxford DictionaryOxford Dictionary

Insane or mad; foolishInsane or mad; foolishExtremely enthusiastic (about)Extremely enthusiastic (about)(Slang) exciting, unrestrained(Slang) exciting, unrestrained(Slang) excellent(Slang) excellentMade of irregular pieces fitted together Made of irregular pieces fitted together

What led to the formation of What led to the formation of PSIGE?PSIGE?

Government commissioned Government commissioned TrethowanTrethowanReport on the organisation of clinical Report on the organisation of clinical psychology services: identified work with psychology services: identified work with older people as a distinct speciality within older people as a distinct speciality within an Area Clinical Psychology Service an Area Clinical Psychology Service (1977)(1977)In some places, ‘Head of Specialist In some places, ‘Head of Specialist Grouping’ posts were set up Grouping’ posts were set up –– typically typically group of 1group of 1

1979: Raising the profile1979: Raising the profileScottish group (PACE) meeting regularly Scottish group (PACE) meeting regularly –– first first newsletter (combined with PSIGE1982)newsletter (combined with PSIGE1982)BPS Bulletin carried a number of flag waving BPS Bulletin carried a number of flag waving pieces:pieces:

Article by Article by MumfordMumford & Carpenter on ‘Psychological & Carpenter on ‘Psychological services and the elderly’services and the elderly’Letter from Jeff Garland asking for interested people Letter from Jeff Garland asking for interested people to contact him re forming a group as in Scotlandto contact him re forming a group as in ScotlandLetter from John Hodge outlining aims and functions Letter from John Hodge outlining aims and functions of PACEof PACE

1979 1979 -- continuedcontinuedAge Concern England initiated meeting with Age Concern England initiated meeting with BPS Division of Clinical Psychology BPS Division of Clinical Psychology -- November November 2424th:th:

Attended by Sally Attended by Sally GreengrossGreengross and several colleaguesand several colleaguesJeff Garland & Bob Woods, together with DCP Jeff Garland & Bob Woods, together with DCP Secretary David Secretary David MulhallMulhall attended for DCPattended for DCPAmong planned actions was to call a meeting for all Among planned actions was to call a meeting for all psychologists interested in spring of 1980psychologists interested in spring of 1980

Article in DCP Newsletter ‘Sans psychologists, Article in DCP Newsletter ‘Sans psychologists, sans everything’ appeared early in 1980 to sans everything’ appeared early in 1980 to introduce this development (Woods, 1980)introduce this development (Woods, 1980)

When did PSIGE begin?When did PSIGE begin?

May 23May 23rdrd 1980: ‘Inaugural meeting of 1980: ‘Inaugural meeting of special interest group for psychologists special interest group for psychologists working with the elderly’ working with the elderly’

Held at Corbett Hospital, Stourbridge, West Held at Corbett Hospital, Stourbridge, West Midlands (courtesy of Anne Midlands (courtesy of Anne BroadhurstBroadhurst))Agenda included newsletter, regional subAgenda included newsletter, regional sub--groups, links with other organisations & groups, links with other organisations & appointment of officersappointment of officers

The first conference proper The first conference proper ––Leicester University, 1981Leicester University, 1981

Around 35 people attendedAround 35 people attendedCost £20 members (nonCost £20 members (non--residential)residential)106 on membership list106 on membership listAgreed constitution and nameAgreed constitution and name

The nameThe name

SIGPE? Leicester conference flyer 1981SIGPE? Leicester conference flyer 1981SIGE? Newsletter No. 2 SIGE? Newsletter No. 2 –– January 1981January 1981

Competition for best name announcedCompetition for best name announcedPrize of a year’s free membershipPrize of a year’s free membership

PSIGE? Newsletter No. 3 PSIGE? Newsletter No. 3 –– postpost--AGM AGM 19811981

What’s in a name?What’s in a name?

When PSIGE formally became part of DCP in When PSIGE formally became part of DCP in 1983 it was: ‘Psychologists’ Special Interest 1983 it was: ‘Psychologists’ Special Interest Group in the Elderly of the Division of Clinical Group in the Elderly of the Division of Clinical Psychology of the British Psychological Society’ Psychology of the British Psychological Society’ -- a change of name was considered and a change of name was considered and rejected!rejected!2003: ‘Psychology Specialists working with 2003: ‘Psychology Specialists working with Older People: a Faculty of the Division of Clinical Older People: a Faculty of the Division of Clinical Psychology of the British Psychological Society’Psychology of the British Psychological Society’

A lot of interest from the outsetA lot of interest from the outset

But relatively few members worked fullBut relatively few members worked full--time with older peopletime with older peopleVariable geographic coverageVariable geographic coverage

The perceived mythology The perceived mythology (Woods, 1980 DCP newsletter)(Woods, 1980 DCP newsletter)

Few are interested in the speciality and even Few are interested in the speciality and even fewer work in itfewer work in itTrainee psychologists will resist having to carry Trainee psychologists will resist having to carry out placements with older peopleout placements with older peopleThere will be a dearth of applicants for new There will be a dearth of applicants for new postspostsTraining courses provide little training in work Training courses provide little training in work with older peoplewith older peopleThere is little point anyway There is little point anyway –– older people are older people are dementingdementing or are too rigid to change or have or are too rigid to change or have only a short time to liveonly a short time to live

The PSIGE mentality 1: passionate The PSIGE mentality 1: passionate about older peopleabout older people

Psychologists working with older people Psychologists working with older people often have a real enthusiasm and passion often have a real enthusiasm and passion for the work and for the client group, which for the work and for the client group, which colleagues may find difficult to understandcolleagues may find difficult to understandSometimes comes from experience Sometimes comes from experience working on a ward or care home, or from working on a ward or care home, or from personal contact in a family context or…personal contact in a family context or…For me it was Denbigh Ward, For me it was Denbigh Ward, FulbournFulbournHospital, 1973, and the chance to make a Hospital, 1973, and the chance to make a differencedifference

The PSIGE mentality 2: on the The PSIGE mentality 2: on the outside, excludedoutside, excluded

PSIGE has had to battle for work with older PSIGE has had to battle for work with older people to be seen as mainstream, core to the people to be seen as mainstream, core to the NHS and Social ServicesNHS and Social ServicesWhy do we still have to remind the powers that Why do we still have to remind the powers that be that services for older people are not an be that services for older people are not an optional addoptional add--on?on?Why have research studies so often excluded Why have research studies so often excluded older people? older people? Why are less resources available for a care Why are less resources available for a care package for an older person with a disability package for an older person with a disability than for a younger person with a disability?than for a younger person with a disability?Why are older people still seen as ‘bed blockers’ Why are older people still seen as ‘bed blockers’ and a care home seen as a solution?and a care home seen as a solution?

Fear of older patientsFear of older patients

CautelaCautela, 1966 described ‘, 1966 described ‘gerontophobiagerontophobia’ ’ and suggested that behaviour therapy and suggested that behaviour therapy could be used to could be used to desensitise staff, so they desensitise staff, so they feel at ease with ugly or messy patientsfeel at ease with ugly or messy patientsIs ageism still an issue??Is ageism still an issue??

The PSIGE mentality 3: the need The PSIGE mentality 3: the need for like minded soulsfor like minded souls

The PSIGE Conference has been the The PSIGE Conference has been the annual ‘fix’ for many a lone workerannual ‘fix’ for many a lone workerWe are not alone…We are not alone…

The PSIGE mentality 4: the pioneer The PSIGE mentality 4: the pioneer instinctinstinct

So little had gone beforeSo little had gone beforeSo much could be done So much could be done –– so many so many opportunities for innovation, for new opportunities for innovation, for new projects and approachesprojects and approachesSo many different types of work So many different types of work –– such such variety of roles and styles of workingvariety of roles and styles of working

The PSIGE mentality 5: welcoming The PSIGE mentality 5: welcoming allall--comerscomers

The desire was to be inclusive and for all The desire was to be inclusive and for all interested in the application of psychology with interested in the application of psychology with older people to find a home in PSIGEolder people to find a home in PSIGEBig concern about becoming a BPS subBig concern about becoming a BPS sub--system system in 1983 was danger of excluding nonin 1983 was danger of excluding non--psychologists (and nonpsychologists (and non--BPS members) who BPS members) who were denied voting rightswere denied voting rightsPotential for committee coPotential for committee co--options to reflect options to reflect other interestsother interestsShould perhaps have looked for a place within Should perhaps have looked for a place within the BPS outside the confines of the DCP e.g. the BPS outside the confines of the DCP e.g. Section on Ageing?Section on Ageing?

The PSIGE mentality 6: it’s not a The PSIGE mentality 6: it’s not a competitioncompetition

PSIGE has been characterised by PSIGE has been characterised by openness and generosity of spiritopenness and generosity of spiritIt has welcomed inputs from Assistant, It has welcomed inputs from Assistant, Trainee and newly qualified membersTrainee and newly qualified membersPointPoint--scoring has been rarescoring has been rareA wide range of members have shared A wide range of members have shared leadership responsibility over the yearsleadership responsibility over the years

The PSIGE mentality 7: therapeutic The PSIGE mentality 7: therapeutic optimismoptimism

‘Therapeutic nihilism’ was the order of the ‘Therapeutic nihilism’ was the order of the dayday‘It’s organic, there’s nothing a psychologist ‘It’s organic, there’s nothing a psychologist can do’can do’‘People with dementia can’t learn’‘People with dementia can’t learn’‘Older people won’t benefit from CBT / ‘Older people won’t benefit from CBT / psychodynamic therapy / fill in the gap…’psychodynamic therapy / fill in the gap…’But that didn’t deter us…But that didn’t deter us…

The PSIGE mentality 8: committed The PSIGE mentality 8: committed to trainingto training

The input to training courses increased The input to training courses increased dramatically in the first ten years of PSIGE (In dramatically in the first ten years of PSIGE (In 1983 survey showed average of 15 hours 1983 survey showed average of 15 hours teaching)teaching)The Newsletter in the early years was offering The Newsletter in the early years was offering reading lists compiled by membersreading lists compiled by membersThere were few books available (maybe There were few books available (maybe BirrenBirren & & Schaie’sSchaie’s Handbook of the Psychology of Ageing, Handbook of the Psychology of Ageing, the odd chapter in edited books)the odd chapter in edited books)

The PSIGE mentality 8: committed The PSIGE mentality 8: committed to training (continued)to training (continued)

PSIGE members outstanding commitment PSIGE members outstanding commitment to offering trainee placements, made the to offering trainee placements, made the unthinkable possible in the 1990’s:unthinkable possible in the 1990’s:MANDATORY PLACEMENT MANDATORY PLACEMENT EXPERIENCE WITH OLDER ADULTS!!!!EXPERIENCE WITH OLDER ADULTS!!!!But then came ‘Core competencies’ But then came ‘Core competencies’ And a real siege mentality was needed to And a real siege mentality was needed to hold out against the forces massed hold out against the forces massed against usagainst us

Clinical psychology training Clinical psychology training –– UK UK stylestyle

3 year doctoral programmes 3 year doctoral programmes –– DClinPsyDClinPsyMost candidates have 2 years or more Most candidates have 2 years or more experience as assistant psychologists / or experience as assistant psychologists / or research assistantsresearch assistantsHighly competitive to enter programmes Highly competitive to enter programmes (although big expansion in training places)(although big expansion in training places)6 x six6 x six--month clinical placements (average month clinical placements (average 3 days per week)3 days per week)

Training UK style Training UK style -- 22

As training places expanded in late As training places expanded in late 1990’s, it became increasingly difficult to 1990’s, it became increasingly difficult to maintain number of older adult maintain number of older adult placements, whilst retaining qualityplacements, whilst retaining qualityThis was seen as a bottleThis was seen as a bottle--neck to neck to expansion, and so BPS criteria for expansion, and so BPS criteria for accreditation of programmes were revised accreditation of programmes were revised in 2002in 2002

Training UK style Training UK style -- 33All trainees must gain clinical experience with All trainees must gain clinical experience with people ‘across the lifepeople ‘across the life--span’span’Trainee logTrainee log--books of clinical experience monitor books of clinical experience monitor thisthisSpecial Interest Groups in each region monitor Special Interest Groups in each region monitor use of placements, to ensure Older Adult use of placements, to ensure Older Adult placements are used effectivelyplacements are used effectivelyIn Bangor 8/9 trainees have older adult In Bangor 8/9 trainees have older adult placement placement –– others see older people in Health others see older people in Health Psychology or Psychology or NeuropsychologyNeuropsychology placement placement

Teaching input on Older Adults Teaching input on Older Adults ––BPS Accreditation Criteria BPS Accreditation Criteria -- 20022002‘While it is appropriate that Programmes ‘While it is appropriate that Programmes should differ in their emphases and should differ in their emphases and orientations, they must all provide academic orientations, they must all provide academic teaching relevant to the full range of client teaching relevant to the full range of client groups and a wide range of clinical methods groups and a wide range of clinical methods and approaches. This will include teaching and approaches. This will include teaching on children, adults and older adults and on children, adults and older adults and cover mild, moderate and severe mental cover mild, moderate and severe mental health problems, learning disabilities, health problems, learning disabilities, sensory and physical handicaps, brain sensory and physical handicaps, brain injury, alcohol and other drug problems and injury, alcohol and other drug problems and range of physical health problems.’range of physical health problems.’

Teaching input on Older AdultsTeaching input on Older Adults

Bangor has 66 hours teaching specifically Bangor has 66 hours teaching specifically on Older Adultson Older AdultsAdult Mental Health Adult Mental Health –– 105105NeuropsychologyNeuropsychology –– 5757Learning Disability Learning Disability –– 114114Child & Adolescence Child & Adolescence -- 120120

Is Ageism still an issue?Is Ageism still an issue?

National Service Framework (2001) for National Service Framework (2001) for Older People Older People –– age discrimination in age discrimination in health care to be rooted outhealth care to be rooted outArbitrary age distinctions not a basis for Arbitrary age distinctions not a basis for service provisionservice provisionOlder people need champions Older people need champions –– in in psychology (as elsewhere) psychology (as elsewhere) –– underunder--represented in clinical practicerepresented in clinical practice

New cases seen by clinical New cases seen by clinical psychologists in NHS, England, psychologists in NHS, England,

2002/32002/3rate per 1,000 population

all male female

All ages 3.8 3.5 4.1

0-4 2.2 2.8 1.75-15 3.4 4.0 2.716-54 4.5 3.7 5.255-64 3.3 3.0 3.665-74 2.6 2.4 2.775-84 2.7 2.7 2.885 and over 2.5 2.8 2.3

Rooting out ageism in clinical Rooting out ageism in clinical psychologypsychology

Exposure worksExposure worksAll clinical psychologists need exposure or All clinical psychologists need exposure or will continue to follow the negative will continue to follow the negative stereotypesstereotypesOlder people already majority of users of Older people already majority of users of NHS in the UKNHS in the UKAs older people reach 20% and then 25% As older people reach 20% and then 25% of the population will mainstreaming be of the population will mainstreaming be required?required?

Specialist v. ageistSpecialist v. ageist

How can we manage the generalist / specialist How can we manage the generalist / specialist divide? Don’t we all work with adults? Can we divide? Don’t we all work with adults? Can we trust adult services to work with older people?trust adult services to work with older people?If we can no longer define our If we can no longer define our specialismspecialism in in terms of age, how do we view it? What are we terms of age, how do we view it? What are we really about?really about?When is our specialist input needed?When is our specialist input needed?How do we maintain and develop our distinct How do we maintain and develop our distinct identity?identity?

The growing evidence baseThe growing evidence base

There are many systematic reviews and There are many systematic reviews and metameta--analyses availableanalyses availableWoods & Roth (2005) in the second Woods & Roth (2005) in the second edition of Roth & edition of Roth & Fonagy’sFonagy’s ‘What works for ‘What works for whom?’ is a convenient launchwhom?’ is a convenient launch--pad!pad!BUT, could we do more to add to the BUT, could we do more to add to the evidenceevidence--base (whilst recognising the base (whilst recognising the limitations of relying too much on the ‘gold limitations of relying too much on the ‘gold standard’ RCT approach)standard’ RCT approach)

NICE Depression Guidelines NICE Depression Guidelines (2004)(2004)

‘The full range of psychological ‘The full range of psychological interventions should be made available to interventions should be made available to older adults with depression, because they older adults with depression, because they may have the same response to may have the same response to psychological interventions as younger psychological interventions as younger people’ people’

Recommendation based on expert committee Recommendation based on expert committee reports or opinions and/or clinical experiences reports or opinions and/or clinical experiences of respected authoritiesof respected authorities

Psychological interventions in Psychological interventions in dementiadementia

A number of Cochrane reviews are availableA number of Cochrane reviews are availableMainly indicate there is not enough rigorous research Mainly indicate there is not enough rigorous research (e.g. Reminiscence)(e.g. Reminiscence)Can we provide the empirical underpinning for our Can we provide the empirical underpinning for our pioneers’ initiatives? NICE guidelines on management of pioneers’ initiatives? NICE guidelines on management of dementia due out in 2007.dementia due out in 2007.Can we work with UK Dementia Research Network to Can we work with UK Dementia Research Network to achieve good quality research on psychological achieve good quality research on psychological interventions?interventions?There is now a largeThere is now a large--scale, rigorous evaluation of scale, rigorous evaluation of Cognitive Stimulation groups (taken the mantle of RO), Cognitive Stimulation groups (taken the mantle of RO), showing significant impact on cognitive function and showing significant impact on cognitive function and Quality of Life Quality of Life ((SpectorSpector et al., British J Psychiatry, 2003)et al., British J Psychiatry, 2003)

RCT of Cognitive Stimulation RCT of Cognitive Stimulation Therapy (2003)Therapy (2003)

Treatment and Control Groups - differences between baseline and

follow up: Cognition (n=201)

MMSEp=0.04

ADASp=0.01

-1

0

1

2

3

chan

ge treatment control

RCT of Cognitive Stimulation RCT of Cognitive Stimulation Therapy Therapy –– QOLQOL--ADAD

Treatment and Control Groups - differences between baseline and follow up: Quality of Life (n=201)

p=0.03-1

-0.50

0.51

1.5

1

QOL

chan

ge treatment control

SelfSelf--reported Quality of Life and reported Quality of Life and dementiadementia

QOLQOL--AD (Logsdon et al, 1999)AD (Logsdon et al, 1999)Simple selfSimple self--report measure of report measure of QoLQoL

13 items, 4 point scale13 items, 4 point scaleE.g. Energy; Fun; Money; Physical health; E.g. Energy; Fun; Money; Physical health; Friends; Family etc.Friends; Family etc.Completed in interview with person Completed in interview with person Domains validated from focus groups Domains validated from focus groups (people with dementia & carers) & (people with dementia & carers) & questionnaires (professionals)questionnaires (professionals)

Can you rely on what people with Can you rely on what people with dementia tell you about their dementia tell you about their QoLQoL? ?

((ThorgrimsenThorgrimsen et al. (2003) Whose quality of life is it anyway? The validity et al. (2003) Whose quality of life is it anyway? The validity and reliability of the Quality and reliability of the Quality of Life of Life -- Alzheimer's Disease (Alzheimer's Disease (QoLQoL--AD) Scale. AD) Scale. Alzheimer Disease and Associated Disorders, 17Alzheimer Disease and Associated Disorders, 17(4), (4),

201201--208)208)

Internal consistency Internal consistency (N=201)(N=201) : alpha = 0.82: alpha = 0.82ReRe--test reliability test reliability –– 1 week 1 week (N=38) (N=38) : :

Total score 0.87 (Total score 0.87 (intraclassintraclass correlation)correlation)SubSub--scales Kappa’s 4/13 ‘good’ agreement; 8/13 ‘fair’ scales Kappa’s 4/13 ‘good’ agreement; 8/13 ‘fair’ agreementagreement

InterInter--raterrater reliability reliability (N=38)(N=38) ::Total score 0.96 (Total score 0.96 (intraclassintraclass coefficient)coefficient)SubSub--scales Kappa’s 12/13 ‘excellent’ agreementscales Kappa’s 12/13 ‘excellent’ agreement

Associated with observed wellAssociated with observed well--being (Dementia being (Dementia Care Mapping) r=0.39 p=0.05Care Mapping) r=0.39 p=0.05

QoLQoL and cognitive functionand cognitive functionSample of 201 people with dementia in Sample of 201 people with dementia in residential homes / day centres (MMSE 14.4 residential homes / day centres (MMSE 14.4 sdsd3.8)3.8)QOLQOL--AD not correlated with memory and AD not correlated with memory and cognition measures such as ADAScognition measures such as ADAS--Cog or Cog or MMSEMMSEHigherHigher in those with moderate dementia than in in those with moderate dementia than in those with mild dementia on clinical dementia those with mild dementia on clinical dementia ratingratingSelfSelf--rating relates to depression, not cognitionrating relates to depression, not cognitionProxyProxy--ratings relate to challenging behaviour ratings relate to challenging behaviour (Hoe et al., in press)(Hoe et al., in press)

QOLQOL--AD in severe dementiaAD in severe dementia

Hoe et al. (2005) Age & Ageing, 34, 130Hoe et al. (2005) Age & Ageing, 34, 130--135135Evidence for validity and reliability for Evidence for validity and reliability for people with MMSE scores of 3people with MMSE scores of 3--1111QOL does not decrease as cognition QOL does not decrease as cognition worsensworsens

Recognising the person with dementia Recognising the person with dementia –– the major change since 1980the major change since 1980

Opens the way for psychological Opens the way for psychological interventions with the person with interventions with the person with dementiadementiaEncouraging work on CBT for depression Encouraging work on CBT for depression and anxietyand anxietyPsychologists have a key role in ensuring Psychologists have a key role in ensuring the perspective of the person with the perspective of the person with dementia remains centre stagedementia remains centre stage