Posts tagged: psychological

FAQ Regarding Psychological Practice in Geriatric Facilities

Over the last ten years, I have received multiple questions regarding psychological services in nursing homes and assisted living facilities.  Many of the questions are difficult to answer, due to the actual naming of a practice or individual.  What follows is a general fAQ for administrators and social workers to identify suspicious professional practice::

1)  They are marketed as appropriately trained psychologists when in fact most have no formal training in geriatrics, let alone dementia assessment and treatment. This is defined as “unethical” practice by the American Psychological Association.  Psychologists must have formal training in any population served or intervention offered.  My suggestion is to examine the psychologist’s vita for appropriate training.  Do not trust what marketing people have to say regarding qualifications.  See for yourself.

2)  The psychologist is working three to five days a week in your 120 bed facility. This is a recipe for ethical disaster, if not overt malpractice.  A 400 bed nursing home is not likely to offer more than 2 full days of work for most psychologists.  If the psychologist is not trained in neuropsychological assessment, one day should be plenty!  As the kids say-do the math.  Are there more than five or ten high functioning (mentally ill) residents that could profit from insight-oriented psychotherapy in your building?  Probably not.  Psychologists trained in outpatient work will fill their clinical time by treating demented residents.  It is imperative that they generate the numbers that please their respective corporations.  Medical necessity is reduced to a vague consideration.

3)  The psychologist treats dozens of residents, yet does not obtain written permission to treat any resident. A psychology corporation executive told me that an attending physician’s medical release covers psychologist’s liability as well.  This is not the historical position taken by the Florida Dept. of Health, Medicare, or the American Psychological Association.  Psychology is an independent profession that requires written permission to treat, and offers informed consent regarding the nature of the treatment.  As explained to the executive, I worked many years ago as a neuropsychologist for a company called Apogee.  A Medicare audit discovered that Apogee did not obtain written permission to treat their nursing home patients.  Medicare demanded a full refund for each patient that had not signed a release.  The company folded like a tent in a hurricane.

4)  The psychologist assigned to your facility changes every year or two. This reflects the fact that most psychologists hired by psychological corporations are young graduates.  Most have no experience in long-term care, have no formal training in dementia care, and have little desire to make a career in this area.  On the other hand, some older psychologists gravitate to geriatrics after failing in their primary area of interest.  This actually describes two owners of a local geriatric psychology corporation.  Both the young and old clinicians are similar in the sense of being inadequately trained.  They differ in that the young clinicians will move on to their chosen area of interest, and the older will cling to nursing homes as their last resort.  I do not believe either group adequately serves the interests of the residents.

5)  The psychologist/marketer offers to wave Medicare copays and treat managed care residents for free. An offer to wave Medicare copays is definitely not kosher.  Medicare rules for participating providers are clear that we must bill for our copays a total of three times!  I must admit that if I receive a letter refusing to pay, I let the matter drop at that point.  Technically, I may be in the wrong.  To tell others that I will not collect copays whatsoever is another matter.  As for free treatment of Medicaid and managed care residents, I’ll believe that when I see it.  I suspect that unpaid Medicaid patients are cured in two sessions, while all the paid residents require years of follow-up.

In summary, it is not difficult to identify unethical behavior or actual malpractice in your facility, but first you must be educated regarding the behavioral markers.  It is important to always keep in mind that psychological corporations are in your building to make money-period.  If your goal is to have all the Medicare residents billed as frequently as is allowable, I believe that you will not be disappointed with most psychology corporations.  If your goal is effective and ethical treatment of your residents, I fear you will have to look for individual experts and small dedicated group practices.  Lastly, I offer Holzmacher’s general rule of nursing home marketing as a helpful guide:

The potential for fraud and abuse increases in direct proportion to the slickness of the marketing, the frequency of the marketing efforts, and the reticence to supply the names and skills of those who actually perform the work.

Good luck!

Zimmerjection

Business Logo for Psychological and Neuropsychological IssuesThe theatrics surrounding the George Zimmerman trial call to mind an oft used psychological term.  The term is called “projection.”  The Freudian notion of projection is that a person rids themselves of unwanted thoughts and emotions by attributing them to another person.  Their ego is unable to cope with the unwanted thoughts, and blames them on others, in an effort to maintain a consistent self-concept.  As with most aspects of Freudian theory, his concept of projection does not readily lend itself to experimental validation.  It has remained an interesting concept that awaits proof.  It should be noted that projection is often used by graduate students of clinical psychology, or rather it is hurled between said students of psychology.  Upon initial exposure to this concept, it becomes addictive to label fellow students as projecting; especially if one does not agree with their viewpoint.

Thankfully, there are scientific underpinnings to the psychological concept of projection.  The famous Rorschach Inkblot Test is based upon the concept of projection.  Perhaps difficult to believe, it is the only test on Earth that can differentiate a psychotic from a normal person.  People will project their inner experience more readily when the stimulus field is ambiguous.  This is a fancy way to state that when unsure, people tend to reveal what is actually on their mind.  People that are confident in their environment may lean on old thoughts to guide their lives.  When faced with situations that are ambiguous or completely novel, one cannot lean on old thoughts to explain the new situation.  A person must generate novel thoughts to explain the new or ambiguous situation.  This generation of novel thoughts to ambiguous stimuli is the  kernel of psychological projection.  These thoughts need not be unwanted or forced upon another, as Freud theorized.  It is a morally neutral cognitive process that helps any person organize their thoughts and master unusual situations.

In a related manner, the recent George Zimmerman trial has draped the public under a pervasive cloak of ambiguity.  The legal details do not, however, appear very ambiguous.  The conservative author of the law readily admitted it was not intended to defend provocation.  The “Stand Your Ground” law was intended to assist in the defense of random victimization.  It is precisely Mr. Zimmerman’s motivation in confronting Mr. Martin that is highly ambiguous.  His stoic appearance during the trial accentuated the ambiguity.  The lack of evidence supporting a personal racist history heightened the confusion over his possible motives.  Furthermore, consider the very day Mr. Martin was killed.  Mr. Zimmerman’s thoughts during his first glance at Mr. Martin are completely unknown, and will remain so.  His thoughts at the moment of killing Mr. Martin will also remain clouded in mystery.  There does not appear to be any evidence for or against a racist agenda in the targeting of Mr. Martin.  The racist motivations of Mr. Zimmerman are, hence, perfectly ambiguous.

Due to this ambiguity, Mr. Zimmerman may be considered a projective test of the populace.  Given the lack of evidence as to his racist motivations, people are free to project their thoughts and emotions onto Mr. Zimmerman.  People are free to project hatred as well as sympathy.  They are free to project anger and sorrow.  They are free to describe their inner experience through the ambiguity of George Zimmerman.  So do not be deceived by experts and pundits who claim to know the racial motivations of Mr. Zimmerman.  What they know is their own beliefs regarding racism, and that is exactly what they are espousing when talking about George Zimmerman.  Perhaps in addressing the law that created this nightmare, some good may be extracted from the bad.  Addressing the competence and motivation of zealous prosecutors may assist in separating the ripe from the rotten.  To address the racial motivations of Mr. Zimmerman is to reveal the racial beliefs of those who address him.  It is Zimmerjection.

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