Category: Depression

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!

Emotional Support

Buildings are supported, bridges are supported, governments are supported, and even people are supported.  It is relatively easy to spot sufficient support of the first three.  If the physical structure of the first two bear your weight and resist the urge to fall down, then the building or bridge is considered well supported.  Governments that receive sufficient financial support shoulder the desires of the populace and stand tall in adversity.  Similarly, people who receive adequate emotional support bear the weight of their world and remain standing throughout.  Perhaps physical support is not far removed from its emotional cousin.  Perhaps that is why the word “support” lends itself to both interpretations.

It may be less than flattering to compare oneself with a government, much less a building or bridge.  Americans do not readily accept support, and view the need for support as a sign of weakness.  Americans are great at providing support, especially physical support; perceiving the lending of support as virtuous and powerful.  Americans are much happier giving support than receiving the same.  Perhaps it is the vestiges of the pioneer spirit.  Perhaps it is a fear of appearing needy and weak.  It can’t be denied that the receiving of support automatically assumes a one down position.  How one chooses to perceive this one down position is the critical factor in the equation.

No matter the degree of intelligence and self-sufficiency, all people require support at some time in their lives.  Some people may never require further physical support after childhood, but they will require emotional support to thrive.  We are social animals, and the fact that ninety percent of us live in cities is sufficient proof of this allegation.  A particular subset of people called schizoid do not appear to need contact with other people; at least not much.  For the rest of us, depression ensues when there is a lack of emotional support in our social environment.  The experience of grief is largely the result of a sudden break in social support.  The recent surge in mass shootings almost always comes from those who, for one reason or another, lack emotional support.
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The schizoid person, mentioned above, does not perceive a problem with little emotional support.  This is their preference, and they may be quite successful in other areas of their life.  Such people are rather rare, accounting for far less than one percent of the population.  People that experience grief over a sudden loss are typically bathed in attention from other people, as this is the standard response of most cultures.  A progressive loss of support from illness or job loss does not curry the sympathy engendered by the death of an intimate attachment.  It may be difficult for this subset of people to develop supportive relationships, at least until they feel better or obtain a new job.  Those who take up a gun are exacting revenge upon a society that they perceive as purposefully withholding support.  They experience the lack of emotional support as a personal affront.

Perhaps the alienation many Americans experience is really a loss of emotional support.  We Americans are loath to ask for physical or emotional support, such that the subsequent alienation may be more prevalent in this country than others.  Furthermore, the recent economic downtown has disrupted work relationships and created greater familial stress over finances.    It is a general rule that increased stress engenders decreased emotional availability.  It is difficult to think of others when preoccupied with ourselves.  Many are injured and yet they do not ask for help.  Perhaps it is time for the pioneer philosophy to end.  It would be great to retain its spirit of optimism and enterprise, but this philosophy appears to come at the cost of our emotional well-being.  Increasingly, it is placing our physical well-being at risk from an alienated few.  If only Adam Lanza had decided to pick up the telephone, before deciding to pick up the gun.