Clinical Psychology in the Mental Health Inpatient Setting

International Perspectives

Meidan Turel, Michael Siglag, Alexander Grinshpoon, Meidan Turel, Michael Siglag, Alexander Grinshpoon

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429876066
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This ground-breaking volume provides an encompassing and detailed account of clinical psychologists' highly varied work on the psychiatric ward in mental health inpatient settings. An international collection of clinical psychologists describe challenges and achievements inherent to their work, illustrating application of established, state-of-the-art, and cutting-edge methods and modes of intervention, assessment, therapeutic work, training, and leadership roles currently practiced in these settings.

Chapters present numerous examples of psychologists' ability to contribute in multiple ways, benefiting patients, staff, and the overall functioning of the ward. Each of the book's four sections is dedicated to a specific domain of the clinical psychologist's work within the psychiatric inpatient setting. These include systemic modes of intervention; psychotherapeutic interventions; assessment and psychodiagnosis; and internship and supervision.

From novice to experienced practitioners, psychologists will gain insight from the innovative and creative ideas this book brings to the practice of clinical psychology, as well as the practical suggestions that will enhance the varied interventions and therapeutic work they do in such settings.

Part 1

Systemic Multiple Modes and Levels of Intervention

Introduction to Part 1

Meidan Turel and Michael Siglag

All of the work described in this book is carried out by clinical psychologists in systemically complex and challenging mental health inpatient settings. For clinical psychologists working in these settings, systemic work through multiple modes and levels of interventions forms a crucial and integral part of their practice. This dimension of their work provides psychologists with some of the most unique and challenging aspects of their practice there. Thus, this first and opening part of the book focuses on the systemic level of clinical psychologists’ involvement and interventions in mental health inpatient settings.

The nine chapters in this part each describe interventions and perspectives informed by their author’s understanding and attention to systemic aspects of the units and facilities in which they work. Settings include open units, community-oriented units, closed and acute care units, and forensic closed units in a variety of mental health facilities in various countries.

The term ‘multiple modes and levels of interventions’ refers to the wide and flexible range of possible systemic interventions uniquely available to the clinical psychologist in mental health inpatient units, beyond the foundational clinical interventions of psychotherapy and assessment, the backbone of the profession.

Such systemic multiple modes and levels of interventions include, among others:

• Leading unit group activities such as community meetings.
• Structured interventions involving multidisciplinary staff. These include consultations with team members individually and in group settings that concern patient treatment planning as well as unit management issues; leading staff in implementing systems-level interventions with patients (e.g., behavioral intervention programs with patients); training staff in acquiring therapeutic tools and programs; etc.
• Provisory interventions with both staff members and patients, spontaneously improvised or planned, in response to various situations and conditions as they arise on the unit. For example, leading debriefings following sentinel or other adverse events on the ward (such as patient suicide or an injurious act of violence); creating an informal ad hoc consultation in the nurses’ station on specifics of a patient’s situation; etc.

A major challenge inherent to such systems-level interventions is the clinical psychologist’s ongoing task of successfully translating psychological understanding of the issues at hand into language that can be heard on the unit and put to constructive use. Through the process of articulating issues so that they can be addressed in a shared language with all those involved and impacted, the clinical psychologist enhances the quality of the unit’s therapeutic efforts, contributing to the evolution of a therapeutic approach more tailored and responsive to the specific needs and communications of the unit’s patients.

The ability to achieve this mission is contingent on a myriad of factors active in the setting, not least of which is the person of the psychologist: his/her professional disposition, abilities, as well as previous experience in such work.

The systems-level dimension of the clinical psychologist’s work is, therefore, to some extent, an open-ended venture. Beyond specific systems oriented interventions that might be structured into a given unit’s program (e.g., scheduled staff debriefing group meetings), it is up to the clinical psychologist to flexibly and creatively find ways and means to fulfill this dimension of the work within the particulars and circumstances operating in the setting.

This aspect of the clinical psychologist’s systems-level work is well represented in the nine chapters comprising this part of the book, in which authors describe their interventions in response to specific issues and challenges in their particular settings. The nine chapters fall into three thematic clusters and are grouped accordingly. Following is a brief description of these three clusters and the included chapters:

In the first thematic cluster (Chapters 1, 2, 3, and 4), authors present a broad perspective and overview of their roles and functions within their respective inpatient settings:

In the first of these (Chapter 1), Mark McFetridge describes his work of many years as a clinical psychologist within an open unit in an independent inpatient psychiatric facility in the United Kingdom. McFetridge highlights a variety of the psychologist’s roles and functions, which extend beyond the confines of the consultation room and involve systemic and group work with patients and staff, all of which valuably contribute to an integrated and psychologically minded approach to the therapeutic work on the ward. McFetridge encouragingly concludes that although the work is challenging and at times daunting,

clinical psychologist(s) … are perfectly placed and ideally trained to fulfill the range of roles outlined here, and through these have a significant influence on the good work of the ward that extends well beyond the walls of the clinical room.

In the next chapter (Chapter 2), Marilyn Charles describes her psychoanalytically oriented systems-level work within a renowned psychoanalytically and psychotherapeutically oriented private psychiatric inpatient facility in the United States. Through her examples, the author describes the clinical psychologist’s pivotal role in providing understanding and recognition of underlying dynamics at play around various treatment issues. Her description of the systemic model used in her facility highlights how multiple levels of dynamics play out in the hospital, allowing for more efficient and transformative therapeutic work to unfold between the staff and patients.

In Chapter 3, authors Peter Walker and Sophie Li describe the clinical psychologist’s placement and position within the Australian mental health inpatient system. Relying on their own experience as well as on input they collected through a survey conducted with fellow colleagues, the authors paint a rather grim picture of the limited degree of clinical psychologists’ involvement and latitude in providing quality clinical psychology services on closed wards in the public mental health inpatient system. They convey a perspective suggesting that overemphasis on a biologically-based medical treatment model, together with limited resources available for patient care and rehabilitation within the broader public mental health inpatient system, creates conditions in which infringements of patients’ human rights may occur. Stemming from this perspective, they endorse and summarize a human rights advocacy stance that clinical psychologists can take to safeguard patients’ rights. The authors describe the implementation of cognitive behavioral therapy-based interventions and techniques on both systemic and individual levels and argue that by their very nature such interventions can remediate some of the more harmful aspects of inpatient mental health care.

In this cluster’s closing chapter (Chapter 4), Heidi Camerlengo discusses the ethical issues and challenges involved in clinical psychologists’ work in mental health inpatient settings. The author describes a variety of ethical dilemmas and issues faced by psychologists; some derived from her own experiences and some from experiences recounted by colleagues in both public and private psychiatric hospitals in the United States. In her chapter, Camerlengo demonstrates how ethical dilemmas abound in clinical psychologists’ work in these settings, and how their impact crosses over into several aspects of the psychologist’s clinical and administrative work, and sometimes into personal aspects of their work and lives as well. While the ethical dilemmas discussed in the chapter are not exhaustive, they represent some of the more common situations that psychologists encounter when providing inpatient mental health treatment. The author shows how addressing ethical dilemmas and conflicts is an ever-challenging part of the inpatient psychologist’s responsibilities.

The second thematic cluster of chapters in this part includes three chapters (Chapters 5, 6, and 7) that delineate specific, original, and innovative systems-level interventions, created and led by the clinical psychologists in response to situations and needs they identified within their units.

In the first of these, Jimmy Kim and Peter D’Amico (Chapter 5) describe their implementation of a positive behavioral support model within an acute care inpatient unit in a public psychiatric facility in New York. The authors describe how through the use of this model they develop patient-specific behavior plans that help the ward maximize clinical care, patient stabilization and reduction of aggressive behavior. The authors discuss how, as clinical psychologists cast in the role of behavioral consultants on the ward, they assist the multidisciplinary team, the patient, and family members to understand patient’s disturbing behaviors as a form of communication. This, in turn, opens the way to address underlying needs generating such behaviors and facilitates change.

In the next chapter (Chapter 6), Amit Fachler describes three of the more implicit roles that may be undertaken by a clinical psychologist in an acute closed inpatient unit. Using composite case examples taken from such work in a public psychiatric hospital in Israel, the author describes a psychodynamically minded clinical psychologist functioning as (a) an interpreter of patients’ and family members’ communications, (b) an informal organizational consultant, and (c) as ‘regulator’ of the unit’s social climate. The author shows how functioning in these roles provides the psychologist opportunities to enhance the team’s benign and thoughtful stance when confronted with difficult and challenging situations in their work on the acute closed ward.

In Chapter 7, Enav Or-Gordon describes her work with a recovery-oriented behavioral tool, developed and implemented in a closed psychiatric forensic ward in a state hospital in Prague, Czech Republic. The author demonstrates how work with this tool (a personalized notebook allocated to participating patients), promotes integration of the varied interventions on the ward into a unified structure and contributes to a cohesive course of therapy, enhancing patient’s self-agency and constructive involvement in shared hospitalization goals.

The last cluster of chapters in this part contains two chapters (Chapters 8 and 9) in which their authors address, through a more personal narrative, their first-hand experience of work within the mental health inpatient setting:

In Chapter 8, author Jim Geekie presents his personal, lived experience of work in a public mental health inpatient unit in the United Kingdom. The author explores some of the challenges encountered in attempting to reconcile personal and professional values while working in an institution dominated by medicalized approaches to understanding and relating to mental distress. Geekie considers from a personal perspective, if and how it may – or may not – be possible to work within such a system while remaining true to his values.

In this part’s closing chapter, Michael Siglag (Chapter 9) describes his many years of work within public and forensic state psychiatric hospitals in New Jersey, USA. Michael describes many influences and challenges encountered through his career path, starting as a unit based psychologist and moving ahead to management positions such as director of the APA-accredited internship in the hospital, followed by chairing the hospital’s psychology department. The author presents this personal narrative of his long-term experience within the public psychiatric inpatient facilities, seeing it as representing experiences and challenges faced by many clinical psychologists working in similar public settings.

This collection of nine chapters, each describing psychologists’ systemic-level perspectives and interventions, demonstrates the unique and valuable contribution such work holds for the mental health inpatient service, its units, patients, and staff. For the clinical psychologist committed to this level of work, experiencing his or her contribution to the unit’s ability to fulfill its patients’ therapeutic needs is rewarding and satisfying. Continuously holding in mind the potential influence of systems-level interventions on the unit, the clinical psychologist can turn every excursion from the privacy of the consulting room to the unit’s public arena, into an opportunity to promote the system’s psychological mindedness for the better care of its patients.

1 Therapy Beyond Walls

The Clinical Psychologist’s Multi-Level Work in the Psychiatric Ward

Mark Andrew McFetridge

Twenty-five years earlier, Michael’s key nurse Dawn met me at the entrance of the Acute Psychiatric unit known as ‘Derwent ward’. The river Derwent in the north of England is unusual in that it flows upstream (rather than Nature’s design of downstream) into the tidal river Ouse; a Roman shortcut to York.

I noticed that Dawn seemed reluctant to facilitate my use of the ward’s consulting room to meet with Michael for our seventh therapy session. ‘How has Michael been since our therapy appointment last week?’ I asked. ‘He’s cut his face again; it was the day after your session’. I thought privately that my nursing colleague just did not understand the importance of this crucial therapeutic work on Michael’s experiences of childhood sexual abuse. Dawn privately thought this young clinical psychologist was misguided, causing Michael to become more disturbed and unnecessarily extending his admission to Derwent ward.

Having had a quarter of a century to consider this view (it is important to take a little time to reflect) I now consider Dawn to have been correct. There were key things I had yet to learn, including that any individual therapy on inpatient units needs to be fully integrated with the service and not undertaken by clinicians having little communication and shared formulation with the core inpatient team. I had yet to learn that clients who have histories of childhood abuse who self-harm must develop alternative ways of safely managing distress before addressing their traumatic memories in therapy. If not, the flow of the intrinsic emotional distress is inevitably against the self in a direction congruent with the invasion of their childhood.

Later in my career, I had the opportunity to work with, and learn from, a number of group analyst colleagues. I already had experience facilitating therapeutic groups for clients and training groups for staff; however, I was not aware of the therapeutic potential of the group within the inpatient setting for developing the sense of community, belonging, involvement and agency (Kennard & Haigh, 2009; Pearce & Haigh, 2017).

Over the next two decades, I had the privilege of being a staff member of the Acorn program, a DBT-informed Therapeutic Community at the Retreat York, UK. Opening in 1796, the Retreat ‘mental health project’ and its founders rejected the inhumane treatments of the day (purging, burning, bleeding) and applied their Quaker values and practice to a new institution for the treatment of the insane that was to prove remarkably effective (Tuke, 1813). Samuel Tuke wrote of the importance of ‘exciting the capability of the patient’, implicitly acknowledging that the ward environment could have a powerfully enabling effect. The relevance of the Quakers original approach to contemporary mental healthcare is still apparent (Borthwick et al., 2001).

Too often, we presume that the problem is solely located within the patient, and the correct therapy will remedy this pathology. Comprehensive formulation of our patients’ clinical presentations might still usefully take account of social, environmental, occupational, and spiritual factors, as did the Quakers. There was a reason this pioneering institution was built on an eminence, with beautiful grounds of sufficient size for animal husbandry (Tuke, 1813).

The importance (if not primacy) of attachment experiences and learning has been acknowledged as important for us all (Bowlby, 2005). Perhaps the nature of the anticipated interaction and the actual relationships between the patient and others might exceed the effect of any simple intervention. Wampold (2013) found 87% of outcome variance was due to client-related factors and other factors outside therapy. Only 13% could be attributed to the treatment itself, and of this the therapeutic alliance had by far the greatest contribution to the outcome, far greater than the therapeutic model (Green & Latchford, 2012). If this is correct, our therapeutic interventions need to extend beyond the walls of our therapy office in order to maximize effectiveness.

While the complexity of client presentation may be particularly challenging, the clinical psychologist is perfectly placed to make a valuable contribution to the care and treatment received during their psychiatric admission. The integration of theory, research, and practice is what differentiates the clinical psychologist from other professions. Skillful, collaborative formulation of the individual’s mental health difficulties and strengths, in the context of their past/present relationships and life experiences, will effectively inform the inpatient team’s considered interventions and care plans.

Lucy was a 50-year-old teacher. She was admitted to the ward following a life-...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Acknowledgments
• List of contributors
• About the editors
• Introduction: The Practice of Clinical Psychology in the Mental Health Inpatient Setting
• PART 1: Systemic Multiple Modes and Levels of Intervention
• PART 2: Psychotherapeutic Interventions in the Mental Health Inpatient Setting
• PART 3: Assessment and Psychodiagnosis in Mental Health Inpatient Settings
• PART 4: Clinical Psychology Internship and Supervision in the Mental Health Inpatient Setting
• Editors’ Perspectives and Closing Remarks
• Index