Clinical experiences needed for geriatric neuropsychology residency?

[neurofreakout]

PhD I student in Clinical Psychology here. I'm wondering if anyone can offer advice on the types of practica experiences I should be pursuing ahead of applying to residency in a couple years. For my long-term goals, I would like to be a geriatric neuropsychologist (ideally) specializing in assessing neurodegenerative disorders and performing differential diagnosis in the context of multicomorbidities. My first practica was in a hospital neurorehabilitation setting doing assessments with adults and some older adults. My understanding is that I need to demonstrate "breadth and depth" of experiences, but it's not totally clear to me what this means and how best to do this in neuropsychology specifically. Yes, I have spoken with my DCT/clinic director about how to get the types of experiences I need, however neither of them are neuropsychologists. Their advice was helpful but I also got the impression that they were not 100% knowledgeable about specifics for neuro. Here are some questions I have about preparing for a geriatric neuro-specific residency:

1. What does "breadth and depth" look like for neuropsychology residency applications?
2. Apart from neuropsych assessment practica, what types of experiences are helpful?
3. What proportion of my direct hours should be neuro-specific vs. non-neuro?
4. Are there any other experiences, outside of practica, that will boost the quality of my application for geriatric neuro?

Any other helpful tips are welcome. TIA!

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[szymk1sm]

PhD I student in Clinical Psychology here. I'm wondering if anyone can offer advice on the types of practica experiences I should be pursuing ahead of applying to residency in a couple years. For my long-term goals, I would like to be a geriatric neuropsychologist (ideally) specializing in assessing neurodegenerative disorders and performing differential diagnosis in the context of multicomorbidities. My first practica was in a hospital neurorehabilitation setting doing assessments with adults and some older adults. My understanding is that I need to demonstrate "breadth and depth" of experiences, but it's not totally clear to me what this means and how best to do this in neuropsychology specifically. Yes, I have spoken with my DCT/clinic director about how to get the types of experiences I need, however neither of them are neuropsychologists. Their advice was helpful but I also got the impression that they were not 100% knowledgeable about specifics for neuro. Here are some questions I have about preparing for a geriatric neuro-specific residency:

1. What does "breadth and depth" look like for neuropsychology residency applications?
2. Apart from neuropsych assessment practica, what types of experiences are helpful?
3. What proportion of my direct hours should be neuro-specific vs. non-neuro?
4. Are there any other experiences, outside of practica, that will boost the quality of my application for geriatric neuro?

Any other helpful tips are welcome. TIA!

Early career faculty here not involved in internship / postdoc training, so these are just my opinions. I identify as a medical / geriatric neuropsychologist:

1. What does "breadth and depth" look like for neuropsychology residency applications?

As a clinical psychology student: Breadth = having practica outside of neuropsych that allows you to develop non-neuro intervention and assessment skills; Depth = doing a neuropsych practicum (so getting experience with your specialty area)

As someone interested in neuropsychology: Breadth = getting experience with a variety of populations who present for neuropsychological assessment; Depth = doing one or more practica focused in geriatrics given your interests (so a memory disorders clinic, movement disorders clinic, ADRC, etc).

2. Apart from neuropsych assessment practica, what types of experiences are helpful?

Research in neuropsychology, intervention (doesn't necessarily need to be in neuro populations), health psychology practica (I use the skills and knowledge I learned on these soooo much in my current practice)

3. What proportion of my direct hours should be neuro-specific vs. non-neuro?

I'll leave this to those involved in training..

4. Are there any other experiences, outside of practica, that will boost the quality of my application for geriatric neuro?

A dissertation focused in aging (healthy or pathological), publications focused in aging, doing aging-related coursework (or a minor / certificate in gerontology if your institute offers this), attending didactics (in Neurology, Geriatric Psychology, Geriatric Medicine, etc, if available), attending virtual didactics in aging (to give yourself exposure to information -- ANST Aging Focus Group, KnowNeuropsychology, etc.), reading geriatric neuropsych textbooks (I'm currently reading "A Handbook of Geriatric Neuropsychology: Practice Essentials, 2nd edition" -- pretty good so far)

 

[PsyPsy]

Hello,

Current intern at a VA in their neuropsych track who obtained a geriatric neuropsych fellowship at an AMC. Breadth and depth, to me, is getting as much exposure to geriatric patients at various practica settings, engaging in research/publishing/presenting at conferences with a focus on this population (and their caregivers), and of course, obtaining foundational knowledge in neuropsychology through np curricula. For breadth, you also want to make sure you’re well-rounded and have training in other areas bedsides geriatrics alone.

If you’re able to get a np practica in a VA, that’s probably where you might get most bang for your buck. I would say about 50-75% of the patients are older adults, and the referral questions are often related to dementia. VA patients are complex because they have many comorbid medical, substance, and psychiatric conditions, too. Most VA’s also offer cog rehab, which might be another way to make yourself competitive for fellowship because many of the treatments focus on older adults, along with their caregivers.

 

[AcronymAllergy]

I would second/third everything above. For neuropsych, breadth is going to mean a couple things: working with adults/older adults across different settings, but also working with different populations (e.g., getting some experience with younger adults and kiddos) in neuropsych as well as getting solid clinical psych training (e.g., psychotherapy, non-neuro assessment). Depth, as has been said, will be working with adults/older adults with various different clinical presentations.

You may not be able to get all of that in grad school, so just do what you can. For example, if you've already completed a couple adult/older adult neuropsych rotations and have the option of doing another one of those or a more psych-focused practicum at, say, a community mental health clinic working with SMI and/or substance use, I might opt for the latter for the variety of experiences.

As far as what types of non-neuro practica might be helpful, I would say just do what seems interesting and/or what gets you outside your comfort zone. Some amount of med/health psych experience will be very helpful, whether you get it in grad school, internship, or fellowship. But plenty of things outside of that can also round out your skills as a neuropsychologist. Providing psychotherapy to individuals with SMI, PTSD-focused psychotherapy, running caregiver support groups, substance use treatment (particularly MI), working with adults with severe neurodevelopmental disorders; it can all build various skills that you can draw from in your neuropsych work.

Other types of things that can be helpful: again as was said, research productivity. Ideally in your area(s) of interest, but publications outside your interest area are much better than no publications at all. A dissertation focused on your interest area (not a necessity, but can definitely be helpful; at the very least, it would ideally have a neuropsych/assessment focus). Neuropsych coursework and other didactics.

I don't know if there's an ideal proportion of hours. You'll probably want the majority of your hours to be in neuropsych, but beyond that, focus more on the quality of your training and what you're getting out of it than the hours themselves. If you're doing some kind of clinical practicum every year or almost every year, you'll likely be fine in terms of number of hours.

 

[Therapist4Chnge]

AA just crushed it w their post.

This advice is more practical in nature, but I think worthwhile to know as you go through your training.

1. Before you can be a good neuropsychologist, you need to have a solid foundation as a clinical psychologist. Trainees often want to jump right to the niche work, but from a 'real world' perspective, your skills as a clinical psychologist are going to allow you to leverage your speciality training, not the other way around. Strong interviewing skills (e.g. efficiently collecting info, being thorough, etc) and the ability to build rapport quickly are both key. Whether you are in-pt and need to do a quick cog eval post-CVA or you are in an out-pt dementia clinic and need to do the interview, testing, etc all in one shot; interviewing skills will make or break that experience.

2. I'd add to not underestimate the importance of being able to provide effective feedback to patients and families. Providing feedback is a really important aspect of doing assessment work, but especially for a neuropsychologist. This is an area that needs a lot of practice, which should start in practica and continue through fellowship. Often trainees get hyperfocused on report writing, differential diagnosis, etc...but the real value to the patient and their family is in understanding the diagnosis and what it means within the context of their lives. There are some good books, like "Feedback that sticks" by Postal & Armstrong, and also some articles that I'm sure your mentors will share as you go through your training.

3. Gaining exposure to health and/or primary care training experiences. There are a ton of comorbidities that come with evaluating a gero population. Understanding the prevalence rates of various conditions, typical treatments, and common side effects of those treatments will all impact interpreting the data collected during your assessment.

4. Regardless of what area(s) of assessment you ultimately decide to practice, you need to be very comfortable reviewing research literature. You need to consistently consume new articles and studies because they will inform your practice. It's helpful when providing therapy or psychoeducation, but it's essential when primarily conducting assessment work. Some of the low hanging fruit for gero work would be reviewing the literature on neurodegenerative disorders, staying up on the various (*cough* placebo *cough*) medications for ALZ, and having a strong foundation in comorbid medical conditions most likely to impact the 65+ crowd.

5. Substance abuse/addiction experience can also be helpful. Substance abuse can be a very impactful consideration when evaluating a gero population. Whether it is alcohol, benzos ("grandma's little helper"), and/or pain meds for chronic pain. As someone who has done quite a bit of work with polytrauma cases, substance abuse is a bigger issue because of duration (for abuse) and potential impact (increased vulnerability to effects).

 

[jdawg2017]

Current adult/geriatric neuropsych intern here at an AMC who will be doing a 60/40 clinical/research post-doc at another AMC. What everyone has said is spot-on, so I won't beat a dead horse. Anecdotally, my neuro/therapy hour split was roughly 2.5 to 1, which makes sense given that I did two advanced neuro pracs, and prac in-house that was about 50/50 therapy and neuropsych assessment. There's no magic ratio for hours, but you definitely want to do several advanced practica across different populations.

I HIGHLY recommend you do a practicum at a VA and one an at AMC if you can. This will make you competitive for both VA and AMC internships given that both types of sites typically like to see that you've trained in a similar environment.

I also echo to not hyper-specialize clinically too early. You want the breadth so you can understand as much as the lifespan as you can. The most complex cases I have seen have been people with long-standing cognitive issues due to learning or developmental disorders who now are having MCI symptoms and your job, to a degree, is to figure out if the symptoms are "normal" given the history (+ healthy aging) or truly something else on top of the history. It's fine to see a lot of dementia cases if you really want that to be your bread and butter, but you also never know what other things you might like until you get out there and try different experiences.

Student leadership experiences in your local ANST chapter or national/international neuropsych organizations can definitely be viewed as a bonus, beyond what others have stated r.e. a neuropsych-focused dissertation.

 

[neurofreakout]

Early career faculty here not involved in internship / postdoc training, so these are just my opinions. I identify as a medical / geriatric neuropsychologist:

1. What does "breadth and depth" look like for neuropsychology residency applications?

As a clinical psychology student: Breadth = having practica outside of neuropsych that allows you to develop non-neuro intervention and assessment skills; Depth = doing a neuropsych practicum (so getting experience with your specialty area)

As someone interested in neuropsychology: Breadth = getting experience with a variety of populations who present for neuropsychological assessment; Depth = doing one or more practica focused in geriatrics given your interests (so a memory disorders clinic, movement disorders clinic, ADRC, etc).

2. Apart from neuropsych assessment practica, what types of experiences are helpful?

Research in neuropsychology, intervention (doesn't necessarily need to be in neuro populations), health psychology practica (I use the skills and knowledge I learned on these soooo much in my current practice)

3. What proportion of my direct hours should be neuro-specific vs. non-neuro?

I'll leave this to those involved in training..

4. Are there any other experiences, outside of practica, that will boost the quality of my application for geriatric neuro?

A dissertation focused in aging (healthy or pathological), publications focused in aging, doing aging-related coursework (or a minor / certificate in gerontology if your institute offers this), attending didactics (in Neurology, Geriatric Psychology, Geriatric Medicine, etc, if available), attending virtual didactics in aging (to give yourself exposure to information -- ANST Aging Focus Group, KnowNeuropsychology, etc.), reading geriatric neuropsych textbooks (I'm currently reading "A Handbook of Geriatric Neuropsychology: Practice Essentials, 2nd edition" -- pretty good so far)

Thanks for the helpful breakdown comparing clinical psych vs. np expectations for breadth and depth. I've been weighing whether to pursue more general psych or health psych focused opportunities so its great to know that the health psych skills are particularly useful in geriatric np. I hadn't come across the Bush & Yochim text before so thanks for the plug!

 

[neurofreakout]

Hello,

Current intern at a VA in their neuropsych track who obtained a geriatric neuropsych fellowship at an AMC. Breadth and depth, to me, is getting as much exposure to geriatric patients at various practica settings, engaging in research/publishing/presenting at conferences with a focus on this population (and their caregivers), and of course, obtaining foundational knowledge in neuropsychology through np curricula. For breadth, you also want to make sure you’re well-rounded and have training in other areas bedsides geriatrics alone.

If you’re able to get a np practica in a VA, that’s probably where you might get most bang for your buck. I would say about 50-75% of the patients are older adults, and the referral questions are often related to dementia. VA patients are complex because they have many comorbid medical, substance, and psychiatric conditions, too. Most VA’s also offer cog rehab, which might be another way to make yourself competitive for fellowship because many of the treatments focus on older adults, along with their caregivers.

Good to know re: academic/research activities in the neuropsych field. My dissertation is geriatric np focused so it's reassuring to know that this may be handy for internship later on. Now I just need to work on the publications

 

[neurofreakout]

I would second/third everything above. For neuropsych, breadth is going to mean a couple things: working with adults/older adults across different settings, but also working with different populations (e.g., getting some experience with younger adults and kiddos) in neuropsych as well as getting solid clinical psych training (e.g., psychotherapy, non-neuro assessment). Depth, as has been said, will be working with adults/older adults with various different clinical presentations.

You may not be able to get all of that in grad school, so just do what you can. For example, if you've already completed a couple adult/older adult neuropsych rotations and have the option of doing another one of those or a more psych-focused practicum at, say, a community mental health clinic working with SMI and/or substance use, I might opt for the latter for the variety of experiences.

As far as what types of non-neuro practica might be helpful, I would say just do what seems interesting and/or what gets you outside your comfort zone. Some amount of med/health psych experience will be very helpful, whether you get it in grad school, internship, or fellowship. But plenty of things outside of that can also round out your skills as a neuropsychologist. Providing psychotherapy to individuals with SMI, PTSD-focused psychotherapy, running caregiver support groups, substance use treatment (particularly MI), working with adults with severe neurodevelopmental disorders; it can all build various skills that you can draw from in your neuropsych work.

Other types of things that can be helpful: again as was said, research productivity. Ideally in your area(s) of interest, but publications outside your interest area are much better than no publications at all. A dissertation focused on your interest area (not a necessity, but can definitely be helpful; at the very least, it would ideally have a neuropsych/assessment focus). Neuropsych coursework and other didactics.

I don't know if there's an ideal proportion of hours. You'll probably want the majority of your hours to be in neuropsych, but beyond that, focus more on the quality of your training and what you're getting out of it than the hours themselves. If you're doing some kind of clinical practicum every year or almost every year, you'll likely be fine in terms of number of hours.

Thank you for this detailed response! This is incredibly helpful for me to understand the bigger picture to contextualize my training goals. What I'm taking away is that whether I get gen psych/health psych/substance use experience, it can all be applied to my future np work to help round out my training and skills. To touch on one of your last points, being in an intense program with frequent milestone requirements (courses/dissertation/candidacy/gaining hours/publishing) can sometimes make it difficult to orient to the more qualitative aspects of my work as a trainee. Perhaps focusing on what I'm getting out of these experiences and my long term goals will make the other parts less stressful.

 

[AcronymAllergy]

Thank you for this detailed response! This is incredibly helpful for me to understand the bigger picture to contextualize my training goals. What I'm taking away is that whether I get gen psych/health psych/substance use experience, it can all be applied to my future np work to help round out my training and skills. To touch on one of your last points, being in an intense program with frequent milestone requirements (courses/dissertation/candidacy/gaining hours/publishing) can sometimes make it difficult to orient to the more qualitative aspects of my work as a trainee. Perhaps focusing on what I'm getting out of these experiences and my long term goals will make the other parts less stressful.

Very possibly. Particularly while working toward internship, many trainees can get so caught up in jumping through hoops and the numbers game (e.g., numbers of hours, numbers of publications and posters) that they lose sight of the ultimate goal--getting good training from which you hopefully also get some enjoyment.

But yes, I would say there are probably few if any clinical practicum experiences in grad school that wouldn't improve your eventual work as a neuropsychologist. I've used some of the same principles in adjusting testing strategies that I learned while working with adults with severe or profound ID when later working with folks with substantial physical disabilities or older adults with dementia, for example. On the flip side, seeing a fair amount of "worried well" patients can help you get a feel for their test performance characteristics so as to not overpathologize. This obviously isn't to say that the populations are all the same, but that there are general principles that can be applied across multiple populations and settings.

 

[neurofreakout]

AA just crushed it w their post.

This advice is more practical in nature, but I think worthwhile to know as you go through your training.

1. Before you can be a good neuropsychologist, you need to have a solid foundation as a clinical psychologist. Trainees often want to jump right to the niche work, but from a 'real world' perspective, your skills as a clinical psychologist are going to allow you to leverage your speciality training, not the other way around. Strong interviewing skills (e.g. efficiently collecting info, being thorough, etc) and the ability to build rapport quickly are both key. Whether you are in-pt and need to do a quick cog eval post-CVA or you are in an out-pt dementia clinic and need to do the interview, testing, etc all in one shot; interviewing skills will make or break that experience.

2. I'd add to not underestimate the importance of being able to provide effective feedback to patients and families. Providing feedback is a really important aspect of doing assessment work, but especially for a neuropsychologist. This is an area that needs a lot of practice, which should start in practica and continue through fellowship. Often trainees get hyperfocused on report writing, differential diagnosis, etc...but the real value to the patient and their family is in understanding the diagnosis and what it means within the context of their lives. There are some good books, like "Feedback that sticks" by Postal & Armstrong, and also some articles that I'm sure your mentors will share as you go through your training.

3. Gaining exposure to health and/or primary care training experiences. There are a ton of comorbidities that come with evaluating a gero population. Understanding the prevalence rates of various conditions, typical treatments, and common side effects of those treatments will all impact interpreting the data collected during your assessment.

4. Regardless of what area(s) of assessment you ultimately decide to practice, you need to be very comfortable reviewing research literature. You need to consistently consume new articles and studies because they will inform your practice. It's helpful when providing therapy or psychoeducation, but it's essential when primarily conducting assessment work. Some of the low hanging fruit for gero work would be reviewing the literature on neurodegenerative disorders, staying up on the various (*cough* placebo *cough*) medications for ALZ, and having a strong foundation in comorbid medical conditions most likely to impact the 65+ crowd.

5. Substance abuse/addiction experience can also be helpful. Substance abuse can be a very impactful consideration when evaluating a gero population. Whether it is alcohol, benzos ("grandma's little helper"), and/or pain meds for chronic pain. As someone who has done quite a bit of work with polytrauma cases, substance abuse is a bigger issue because of duration (for abuse) and potential impact (increased vulnerability to effects).

I appreciate that you highlighted some of the (softer?) np skills like interviewing, rapport, and feedback. These are actually some of the components that I enjoy most about assessment work, particularly optimizing rapport building. While I'm still early in my training, I've found that DBT tenets (validation, change through acceptance) and my very basic MI skills have been helpful for me when building rapport/interviewing/delivering feedback. I'm very interested in sharpening these further. As a follow up question, any experiences/modalities/skills that you have found particularly useful for the developing the "soft" np skills?

Also, I'm a big Karen Postal fan! I've only read a couple chapters of Feedback that Sticks but really enjoyed her talk here for others that are interested.

 

[neurofreakout]

Current adult/geriatric neuropsych intern here at an AMC who will be doing a 60/40 clinical/research post-doc at another AMC. What everyone has said is spot-on, so I won't beat a dead horse. Anecdotally, my neuro/therapy hour split was roughly 2.5 to 1, which makes sense given that I did two advanced neuro pracs, and prac in-house that was about 50/50 therapy and neuropsych assessment. There's no magic ratio for hours, but you definitely want to do several advanced practica across different populations.

I HIGHLY recommend you do a practicum at a VA and one an at AMC if you can. This will make you competitive for both VA and AMC internships given that both types of sites typically like to see that you've trained in a similar environment.

I also echo to not hyper-specialize clinically too early. You want the breadth so you can understand as much as the lifespan as you can. The most complex cases I have seen have been people with long-standing cognitive issues due to learning or developmental disorders who now are having MCI symptoms and your job, to a degree, is to figure out if the symptoms are "normal" given the history (+ healthy aging) or truly something else on top of the history. It's fine to see a lot of dementia cases if you really want that to be your bread and butter, but you also never know what other things you might like until you get out there and try different experiences.

Student leadership experiences in your local ANST chapter or national/international neuropsych organizations can definitely be viewed as a bonus, beyond what others have stated r.e. a neuropsych-focused dissertation.

Ahh thanks so much for the rough hours split. I know it's just an estimate but this will help me have an idea of what to aim for. It sounds like my practica are structured similarly to yours as well! Good to know that I am not expected to specialize too much at this level of training. It's always hard to tell given how specialized some of the internships appear to be.