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A RI';l'ORT OF ANEDUCATI ONAL PSYCHOLOGYINTERNSHIPAT '['HE PSYCHOLOGY DEPARTMEN'f, WATE RFORD HOS P I TAL ,

INCLUDING AREVI EW OF CASESTUDY RESEARCH ON THEEFFECTIVENESSOFTREATMENT MATCHING FOR

DEPRESSED PATIENTS

by John R.O'Connell

Pr esentedto The FacultyofGraduate Studies Memorial University of Newfou ndland

St. John's,Newfoundland

In PartialFul f illme nt ofthe Requi rementsfor the De g r e e

Ma s t e r of Educat ion

Faculty of Educatio n April, 1992

11+.

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distribu er ou vendredescopies de 51l these deQuelquc menlere at SOLIS ouctquoforme Quecesoil pourmettredesexornptasosde cettethese a tadispositi ondesocrscno o s fnteress eos.

L'auteurconservetopropricl~dudroitd'auteur quiprotegesathese.Nilathescnidcsoxnntts substantialsde ceue-crnedotve ntetro imprlmesauautrcmcntrcorooctts sam;son eotortsatron.

ISBN 0-31 5-73 3 13 - 6

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for Barbara

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ABSTRACT

This report pr ovi de s anaccountof a full timethirteen week internshipserve dwiththe Psycholog yDepartmentat the Wa te r f o r d Hospital in St.John's,Newfoundland. The inte r ns hi p periodwas from Ma y 6, 1991 toAugus t 2, 19$11-

Chapter 1 discussesthe rationalefor the placement, describes the settingandthe departmentto whichthe int e r n was attached,and sets out the internshipccjectIves .

Chapter2de s c ri be s the intern'sactivit iesduring th e int e r nsh ip indetail, rev iewsthe accompli shmentof objectives, and makes recommendationsfor future inte r ns h i ps at the site.

ChapterJ out! ines the backgroundand rationale for the inter n^I5 research proj ect conductedduringthe int e r ns h i p.

Literatureis presented to supp ort the choice of resea r ch designandtreatment methodology.

Chap ter4 details the intern's res e a r c hpro j e c t. The int ern cond ucteda series of case studies wit hdepressed patie nts , in an attempt to show that treatment matched to ind i v i d ua l patient'sproblem areasis effective in alleviatingdepression. Results indicatedtha t matched treatment effect ively re duc e s depre ss ion.

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ACKNOWLEDGEM ENTS

The conclus ionof thisinternshiprepresentsoneof tho serareopportuni tiesinlifewhen you'realmost forced tolook back and reflect. Itis a milestone, sort of.m int ers ectioninli f e whereyouI!1!!.llpause andth ink; look ba ck , lookah e a d, and lo ok at the here and now.

This intern hasbeen extr eme l y fortunate tohavehild so many pos iti ve infl uences inhis life, wh o have shapedhis char a ct er , giv enhi minsight , and shared th e i r humanitv.

Tr ul '{, their infl ue ncecons ti tu t e s much ofWhatthe in tern is be ing andbec omi ng.

At thi s writ ing , I wishto sh arewit hthe read e r s my feeling s to wa r d s ma ny of th e s e influentia l pe o p l e inmy lif e,who have played a majorpart in who I amtod a y,.m ll who hav e contributed tothesu c c e s s fu l eccc e p lIe he cnt.of th i s intern s h i p experience.

No wordscan evencomeclose to expres singthe con t ri b utio n toIlly life, and to thi s work, made bymywife, Barbara. She ismy soulmat e, mylover, my confid ante, my partner, my teacher, andmybes t fr i e nd , I can't imaqine my li fewith ou t he r . She ha s stuc k wit hme onsunny da ys , i1nd calmda y s, andstormy days. I amthe bene f i ciar y of her lov e,andhe r tenderness and understandi ng neve alway s gottenme thr ou gh , Shehas pu t up withconside r a b le dis ru ptioninher dailylife,and inher lif e style , ro r me

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to pursuethisquest. Barb brings out th e bestin me , and ovorLockn the rest.. I lov e her morethan I cantellyou, andsh e deservesmuchcredit for her suppor t ive rol e in this project.

Mylute parents, Lee and DodieO'Connel l,werethe kind of pare ntsI wish for every child. They werewar m, compassi onate, loving, and goodteachers. Duri ng those impo rta ntfo r ma t i v e years, when manychildren seem to learn fear, mistrus t, and hurt, I experiencedal l the goodth in g s . My fathertaught me responsi bility , integrity,andto vcrx hardanddo the job right. He was alsoa warmman, who ex t e n de d himself for others, and sough t no credit. Mom taught me tore a ch for the stars . She wa s ins pirational, and thoughinpo o r healthformuc h of her life, was always help i ng others. To Mom, allthings were po s sible. Sheha d tr emendous faith, and was alway smyconfid ante. My childhoodwasa wo nde r fu l experien ce . My paren t s wer e alwaystherefor me. The ylived th e ir conv iction s , and I learned from theirexamp l e .

Lee Klas, professor, friend, and ally,has served in the role ofuni v e r s i t y sup e r viso r for th i s intern s h ip ,and has beenmy advi sor thr ou gh outmygr a d ua t e prog ram. lowe Lee an eno r mou s de bt of gr a ti t ud e . Hewas the r e forme 15 years ago, and has stead fastly be lieved inme. Without Lee'shelp, i t isun li k e l y thatI would ha ve be e nin this

program, and it was his suggestion that1 consider the Waterford Hospital as a placement. Lee has been ste«dy support in the sometimes unsteady waters of my life, and 1 am deep l y gra.teful for hisfriendship, his quIdance, end his understanding, I admire Lee andhav e truly benefited tr-oe coen my professional and non-professional relationship with h Lm over thesemany years.

Assen Alladin , SeniorPsychologist at the wat.orrorcr Hospital, was my field supervisor for 2 terms, Assan W,l~';my mentor. He took me underhis wing,and unselfis hlysu.u-ocr his knowledge. He ta ugh t me how to judge, nov tot.hiuk, nnd howto practically applype yc h o Lcq.i ca I techniques. In short, he taught me the rudimentsof being an effective therapist in a healthsetting. He also becamemyfrie nd. Thou gh we cone from qutt.e different backq r-ounds , we shcrc manyof the same professional interestsand beliefs, and thisha s made workingwithAs s e n very rewarding. nu rinq my timeatthe Ha t er f o r d , he ha s pr o v i d e d both p rcfeasionnl anu personalguidance, and hisoff ertohel p in any way is ever present. He is a master teacher,and I am indeedfortunate to have had the opportun ityto work with him.

HassanKha l i l !,Director of pnycholoqy at thewa t.e rro r u Hospital, is one of the kindest and gentlest peopleJhave known. He is aman of limitlesspatience and great compassion. He is also a man of action, and ror rcvsup his

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ideasvrt ohurd workand commitmen t. Asboth an abl e edeinfsc rat.cr andanef f e c t i v e clinic ian,he leads hi s staff withvieicn, understand.ing,and professionalism. He offered me his full support durin g the internShip, and it hasbe e n lIy extraordinarygood fortune to have beenassocia t e dwith him .

Bil lKane. Seni o r Psychologis t. ha s shar edwithmehi s dedi c ationto hissezvicearea s in the ho s p dtiaL, and hi.s commitme ntto providingmore psycho l o g i c al servi ces and prog r ammin gtothi s portion of th epat i ent pcpuj etIcn.

Tom Hona n,Staff Psy chol ogis t, befrie nd ed meupo nmy arrival at th e Waterford, ma demydays more fun , andoffered to assist mein any way. He hasadeep commitmen t to the welfareof every patient, and itismy pleasureto havebeen associatedwi t hhim.

Halcol fllSimpson, Staff Psychologist, imp r e ssedme with his patience ,dedication. andconfidence. He has always made time for me.and I haveap pre cia t e d his level - headednessand perspect ive.

Hea th e r Dalz i el,Staffps y c h ol og ist,has treatedme lik e abro t he r. She ha s gr ac i o u sly sh aredher knowledge withme, andhashel ped me in a multi tu d e ofways. Ial wa ys felt li ke it was OR to"askHeather ," andsh e neverlet me dcwn.

Kar en svtntcn, Staff Psyc h o l og i st, went;outof her way vii

toinc l u d e me. Shehel pe d me to feel pa rt ofth e to.un, <lnd respond ed imme d i a t e l y wheneverI askedtier foraomet.h Lnq ,

Nen a Sandoval , Ps y c h ol o g i c al Assistant, ha s a voortn01 knowledgein the ar e a s of assessment, sexua lity, an d m'lllt"1 re t a r da tio n. She to o wa s al wa y s verywilling to sha reth is knowledgewithme, andto discuss cases andass essmen tu .

During myintern ship , I was warm lytreatedby st<lrl from many other depar t ments in the hospital . The i r nmn c u ar e too numerousto mentionhere, for therearedozo ns 01 them. Theirho s p i t al ityan d professior:alism, ho we v er , helpe d tomake everydaya pleasure.

Withintheho s pi t al comm unity, t.ncre isno doubt tl1<lt my deep estgratitudeis extendedtothe pat i en tsof the Wa t erfo r d Hospital. The se indiv idua l s allowed me to int r ude inthe i r lives, and to wanderth ro ugh theirho me onad,;,ily basis . Ma n y of them allowed me to see thematve r y low pointsin their lives, and sharedwithmetheLrsurr e rtnn , their de s p e ra t ion , and theirhumiliation. They trustedme to help them , and I was fundame ntallychangedby my encoun terswith th em.

l o wemuch to my pro fe s s o r s inthe H.Ed. programin Edu c a ti o nal Psychology at Me mo r i a l universityof New f o und l a nd . I app r ec i atedthei r In divid u al atte nt ionilnd concern , and found eachand everyoneof themto be

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supportive of my efforts. I enjoyed working with them, an d benefitted both from thei rexpertise,and fr o m thele a rn i n g opportunJ t.iestheypresen te d. Inad di t i o n to Lee Klas, I wishto especiallythan)(, GlennSheppard, Normcar rIe , Bil l Spain, cr u-y Jef fery, Ron Lehr, Bruce Gilbert, Dave Watts, and Terry aoa k foral l thatthey sharedwi t h me. My th anks also goout toMi k e Dcy Le for bothhispr o f e s s i on a l and personal input, and toae v Kendall for so cheerfully answer ing my questionsan d lookingafter administrative detai ls.

Additi ona lly, I wouldlike to acknowl edgethe co ns i d e r a bl e impact upon my l i fe ofth esta f fat Botwood Senior HighSChool in Botwood, Newf o u nd l a n d, duringthe eight yearsI taught there fr o m 1977 to 1985. There too,I felt ve ry muchli k e partof a team,and I haveveryfond memoriesof my c oLjee quess and of myst ude nt s . Huber t Smi t h was my princ ipalduring those eight years. He is a man for whom I ha v e great respect and affection. I havecome to app r e c ia t e his leadersh ip ,wisdom, an d compassion ever more overthe years. Hegave me his tru s t and supportedmy ef f o rt s athi s school,whichmademy ti me th ere rewardi ng and fulfillinq. Frank Dominie, dedicatedE:,glish te a c h e r an d wonderf u l humanbeing,went out ofhis way to welcomeme at the sc h o o l ,to Offer hi s assistance, andto be myfr i en d.

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As he isnow re t i red, current and future studentsin the community will missan en rich ingencounter . wes Robbins, science teacher, consumma togardoncr ,confida nte, and friend, sharedpr ob a b l y15 0 0 lunch hours withme over those eight yea r s. As the onlytwo teac h ersi:1theschoolduri ng lunc h t i me, we had manyconversationseuourmany t.hLnqe. can' t do that for eight yearsandno t be affe cte d .

Theaforementione d, my other fell ow teachers at th e school, and the teach ersin theother schools in the community all welcomedme in whatwas my firstsnrbsstantLa I ja b in Newfoundland, and supported me during mysta y thoro.

Fina lly, I wish tore c o gni z e the influence of my mother-in- l aw, May Byrne,of Grand Falls, Newfoundl and.

Mr s. By r ne hasno t onlyac c e pted me as part ofher ramily for over15 years , but sheha s co:.ntinuallyencoura gedmy effortsand boosted my spirits. She has raised a fine family, whoalso ha v e continuallysuppo rted me in every WilY, and he r perso nalphi losophyis refreshing . She is truly yo u n g at heart, and I wish her many, ma nyyearsof 900<1 he alth andhappiness.

TABLE OF CONTENTS

DEDI CATION••••••• •••• .•. .. •...•..••• ••••.• • . ••••• •. •.•ii ABSTRACT•.••••••• .••.••..• ••.•. •.• ••• • •••••••• ••••... ii i ACKNOWLEDGEM ENTS•••• • •.. . ..• .... . .. .•.•.••••.••••••.••iv LISTOF TABLES •••••• ••• •.•.•. ••...•.•••• •..•• • ••••• ••xi v FOREwORD.• ••..•....• ...•...•. . .•..• ••••••• •••..••. •xv CHAPTER 1

In tr odu ction•• • • •.. .•.•• ..• . •• .• ..• ••• . •.••• •.••.• 1 Th e Setting•.•.••• .•. . •...•.•.•..••• . •.••.•. . •••. •2 Waterfor,JHospitalMission Goals••• •.••••.• ...•. . •5 PsychologyDe p a rtme nt••.• •.••• • •••••.•. •• ••• •..•••7 supe rvi si cn•• •• • •••• • • ••..••.• • ••.•• •••...•• •••••11 Internshi p Object ive s••••• •••••••••• •••. ..• • ..••• 13 CHAPT ER2

De scrip tionof Acti vi t ies••.••. •••••••••••••• •• ••19 Reviewof Objectives ••••••••.•..•••••• •••••••• •••46 Summary and~ecoJfIJDend a tio n s•. •••••••... •.. . .. .53 CHAPT ER 3

t.tt eraeu r-e Review and Rationaletor the Study Research Deslq"•••••• •.••.•••••••.• . . •.•••••58 Treatme ntMatchin g•• ••.••.••••.••••.• •... •.• 79 Depression••• • ••. .• •. .•.• ..•• ..• •••• .••. ••.. 88 cognitive Therapy : Ba sicconcepts•• ••• •••• •• 96 Tre a tm en t Efficacyof cognitiveThera py•.••• 99

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Durability of Treatment•.•••• • •. •••. ••• •.. .1112 MatchedTr e a t .e nt of Depression 104 CHAPTER4

Cas e Study Research on the Effective ne ssof Tre a tme nt Hatching for Depressed Pa t i e nts

Depres s ion...••...•.... . ••• • ...•.•... .•.116 Current Tr e .!lt ments....•. ••.. . .• . .. . ...• .. ..118 Hyp otheses.• • •.. . . .... ..•. •. • • •... ... .•17.1 Me thod.. ..•. . . .... .. . .... ... . .• ... ...]7.1 Proc edu r e .•.•. .•..•.. ....•.•.... •. •... . ....1~ 7.

Th e Ins t r u ml'm t s : Natureand Application to theStudy ...•.• .•. • • • •... ... .. . ..124 Tre a t me nt Techniqu e s: Natureand

Application to the Study... ... .•. . • • 110 Individual Case Discussion s •••••..•.•...lJ7 Di s cuss i o n •••.•.•••... . .. ....• ... . . . .. .1"'7 Limitationsof the Study •• • • • ••...• .. ... . ..171 Strengthsof the Study ..•..• •..• • •.• •• •••••174 Co nc lu s i o n s •.. • .•• •.• •••• •••.•••. • •. . ... .]77 Summaryand Recommenda t ions••.. • • • •.•• • • . •.1"18 REFERENCES •••• • ••••.•• •••.. • •••.••• . • ••.•..•.. ..•. .••18 1 APPENDICE S

AppendixA CAB Form.. .. . • . .. • ••. •. ... • .•... .. 1<> 7- Appendix B comp l e t e d RETWo r k-Sh~e t••..•..•.•193 AppendixC RETWork-Sheet•. .• ••.••• . .• •. ...1'J4

xii

Appendi x 0 BOIResults - LineGraph••.•••••• •195 Appendix E BOI Res u l t s - Bar Graph••••••••• ••196 Appendix F Readin g sonSu icide•••• •..•...••• •197 App e ndixG Readings inNeuro ps y c h o l og y•• • •.•• 19 9

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Title

Ta ble 4.1 Table 4.2 Ta ble4.3 Table 4.4 Table 4.5 Table 4.6 Table4.7 Table 4.8

LIST OFTABLES

Page

BOI ScoreInte r p retation•..•...• • ••.••..•.125 BHSScore Inte rp r e t a ti on ••.•.••...•.• . ....t26 Pr e- Post Res ults Patie ntR•••• • • ••• • ••••143 Pr e- Post ResultsPatien t lJ •••• ••••••••••14'/

Pre- Post Result sPat ientI ••••,•••• • •• •_JS3 Pre- Pos t ResultsPatientT•••• ••••••• •••160 Pr e- Pos t Resul t s Pat i e n t w•• • ••• • • • • ••••166 BeckDepression InventoryResult s ••.••• .•.16 8

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FOREWORD

On a bronze plaque mounted in the front entrance of the Waterford Hospital, and posted throughout the complex, will see the following words:

TheWaterfordHosp itaL•• .• .Be li ev i nq inPeople.

The WaterfordHospital believes that every individual... HaG the right to humandignity ...

Has the right to seek education and explore life's goals... Has the right to individual thought,

freedom of speechand self- expression..•Has the right to be

loved and cared for in times of need ...Has the right to the best of healthservices ...Has the right

to try again.

These inspirational words embody the spirit of many of the care-givers at the WaterfordHospital. They live this philosophy in their daily work. This is what makes the

\'/aterford Hospitalwhat it is, and this is why itha s been such apl e a s u r e and a privilege for me to work there.

Chapter I

INTRODUCTI ON

wit h nineyears experience asaspecial education te a cher in Newfoundland, the intern brought tohi s qr-a.Iuat.e pro g rama substantial ba c kg r ou ndin the wo r k ings of tihn educationa l system. Realizi ngthat the in ter ns hipop tion for his degreecou ld affordhi m the opportunity for both skil limprovement and a broadening of his experience, the intern and his advisor sought1'\placementwhe r e he could obtain additional clinicalexperience in a non-educational setting .

Initialplac e men t at the internship site bega nwi til a pre-practicumexperie nceof one-halfday pe r weekduring th e Fall semester, 1990. Thiswas followedby a two day per week placement during Winter semester, 1991, and finallyby the inter ns hip pl a c e me nt itself. Thein ternshipper iod enc o mpa s s ed thethirteen week periodfrom May 6, 1991 to Augus t 2, 19 91. Additio nally,the intern visited thesite on a part-timebasis duringthe remainderof themon thof August, 1991, to conti n u etherapysessions withclientsand topa r t i c i p a te inother ac t i v i t i e s of professio nalinterest.

This repo r t will discussth e activities of the intern

duri ng tho int e r nsh i p pe riodonly. The priorplacements at th e setrt.Lnq, which fa c i l i tated a much riche r internsh i p placeme nt, ha v e been documented in earlierrep o r ts.

THE SETTIN G

The internshipsite, a continua tionof thepr e - practicumand practicum placeme n t chosen by the internand hi s edv Luor-, was th e Psychology De pa r tmen t ofthe Waterfo rd Hospital, St. Joh n 's, New f o un d l and .

TheWate r fo rd Ho s p i t al is theonlymajor psychiatric treatme n t lind referral centre for theProvince. Asof June, 1991 (Ca n t we l l ,1(91), thehospital of f ered the foll owing cl inienl ee e-vices:

a) Acute Se rvice: thre eadmissionsunits comprising atotal of 70 be d s.

b) Forensicse rvic e: one 17 be dunit provid i ng inpa t i e n t assessme ntand/or treatment for persons refe r red byth e JusticeSystemor the Correctional Sy s tem.

c) LongTerm Ps ych i at r i c services: -rnroe units, wit h a totalof 80 beds, de l i ve r i n g a range of rehabilitative services.

d) MedicalServices: Oneunit of30beds p rov Ldinq diagnosis and care for patients wi t h acuteor chronicmedical conditions.

e) Psychogeriatricservice s: Twounitsto t a ll i n q 70 beds, one un itdesigned for thosewith advanceddementias/high level of care, and anotherho us i ng more independent patien t s.

f) Men talRetardation Services: Po u r un i t s co mp r i s ing 106 beds , providinga range of care and reha b i l i t at i o n programs.

g) AmbUlatoryCa r e serv ices: Crisis intervention, consultation, fo l l ow-u p,after care,outreach, and daytr eat me nt prog rams.

h) communityCare Services: 280 beds. Lo ng term supported and supervisedboarding care for the chronica l lymentally illin 20 Iic e nsed homes in conceptionBay South/Holyroodandon the Southern

Shore.

Clinicaldepartmen tsrepr esente d at th e hospital in clu de :

ill Department of Nursing b) Department of Psychology c) Depar tmentof Social Wo r k d) Depa rtment of occupat ional The r ap y e) Rehab il i t a t i on Se rvices f) Depar tmen t of Pa stora 1 Care

Di agnos t i c sup porti veservices include laboratory me di c ine,radiolog y ,electrocardiography,

electroence p halog ra phy, phys i other ap y, and pha rmacy.

Thehos pital has itsown De pa rtment of Den t istry anda Departme nt of Diet e tics . AnAdult Educat i o nalAcademic Programsponsored by the Department of Car eer Devel op me nt of the Province is available,as ar ebo t h st.a r r andpat i e nt li br a r i e s . In addition to it s cust omary functi o ns , the PersonnalDepartme nthas responsibi l i ties in both Staff He alth and StaffEd uca tion.

Inaddi tion to theMed i ca l Dire ctorandtheClinical Di r ect o r,bo thof whom areps ychia t ris ts, theWater fo r d

Hos pital cur r e ntl y employs eight staff ps ych ia t ri s t s and ten phys i cia n s. Add it i on all y , thehospi ta l util izesst arr con s u l t ants in psychiatry, Intern"lMed i cine, Neu rol ogy , Rad iolog y, Anesthesio logy, Oral Surgery ,and ophthalmology.

Not to be forgott en in an overvie woftheset t i ngare the substantial cont r i bution smade by volunteersan d supp ortiveser vicesstaff, both in patientca re an d in providinga pleasant and clean environment for patiLentu and staff.

WATERFORDHOSPITALMISSION GOALS The Board ofTru stee s of the Waterford Hospi t al hae enactedthefollowing goals in pur s u it of its Mission of providing hi gh qua lity men t alhea lthse rvicesto the popu la t ionof thePro vince:

1. To prov idecompre h e nsiveprog ra msof care to pe r s on s wit h menta l heal t h pro blems , and to pr ovi d e for suchperson s an atmos ph ere conduc iveto carrying out th e ra pe ut ic pr ograms.

'roprovideMe nt al Health Servicesand facilitiestome e t id ent if ied communityand pro vincial needs, through an integratedplan which re c og ni ze s the servicespr o vid e dby otherhealth care and social agencies .

3. To participatein all aspects of thecon tinuum of care related to the fi eldof mentalhe a lth , th rouqhpromotion, prevention,inter vention , diagnos is, treatment , andrehabilitation.

4. To provide an organizat ion, withcompetentand dedicatedprofessional, medical and support st a f f, which is conduciveto the provisionof qualityhe a l t h c.are.

5. To participate inte a chin qpr og r a msf designed to assist in th e provisionof manpower for the Mental Health field.

G. To supportcont i n ui ng education, andencourage all staff to takean active part in programs of ed ucati o n, both internal and external to the hospi tal .

7. Topa rt i c i pate in, an dencourage Menta l Hea l th Re s earc h in cooperat ionwi th other hea lth , soc ial, and educationa l fac ilitie s and age ncie s .

8. To co-operatewi thother health, social , and ed ucatio na l facili ti e s and or gani z a t i on s in thera t i ona li za t i on , coordination , and plan nin gof men ta l heal thse r vi c es.

9. To partici p ate in the development, upqra d ing anduphold ingof standa rds rel a t e d to mantaI health se rvices.

(Wat erford Ho sp i t a l Board of Trustees, 1988.)

PSYCHOLOGYDEPARTM ENT

~:

Th e ph ilosophyofthePsy cho l og y Depart mentatthe Wat e rford Hospital is stated ina preface toth e Dep artme nt 'spo l i c y and Proc edureMan u a l (1991):

TheWaterfo r d Hospita l is themajorps yc hiatr i c ho sp ital inth e province of Newf o un dla nd and

Labrado r. The PsychologyDepartmentis committed to the hosp ital'smiss ion statement topr ov i d e qua l ity patient -or iented ca r e with in the multid iscipli naryteam appro ach . Eachmember of the depart mentalso adheres to the St a nda r d s for Prov iders of Psychological Servi cesand the caned Le nCode of Ethics for Psychologists. (p.i) .

In ad d itiontoadhering to the CanadianCode of Ethics for Psycho l ogists (Ca n ad i an Psychologica lAssoc iation, 1986) ee c n psychologi s tin the departmentmust be regi stered in Newfo u nd l a n dund e r The PsychologistsAct 19 8 6.

The Ps ychology Department functionsas an autonomous unit with in the hospital, reportingdirect lytothe AssociateExecu ti ve Director,Who is responsibleonlyto the Executive Director. Neitherof these individualsis a medi calpractitioner .

~~:

Membersof the Department exercise substantia l professiona ljUdgementin th ecarrying out ofthe i r duties, and as members of an int e rdisci pli na r y team, contribute theirexpert iseprimarily inthe areas of assessment, cons u ltation, andtreat ment. In addi t ion , staff are

expectedto beengaged in teac h i ng , research, pro reeetonat dev elopmentand programdevelopment, related to both their pe rsonal inte rests an d de partmental as s i gn ment s.

All new admissions to the hos pi t a l are screenedby Psych ol o gy staff, andade c i s i o n is made astowhethe r the pa tie nt is likely to benefitfrom the Department of Psychology's involvement. some times these decisionsar e straightforward, but often cases are discussed withother psycho logists on the team to determi nethe appropriate courseto follow. Generally, all first admissions to the ho s p i t a l are interviewedby a psychologist, and a special effort is made to giveful lattention to young patientswi t h no or few prior admissions. Patients under sixteenyears of age are admittedto the WaterfordHospital onlyin extraordinary circumstances.

Pat i e nt s are assignedto a psychologistfor follow-up at weeklyallocationmeeti ngs, and a oa t e nc e is attempted between psychologis t interest, ar ea of expertise, workload, ra p port withpatient, and otherfactors. Oftentimes ,th e psyc ho l ogistassign e dto screenadmissions ona certain unit accepts the assignedcases onth at unit .

Assessmen tsareconduc t edupon requestof the

10 respec t iveint erdiscipli naryteam ona give nun i t, but gene rallyonly i fthey can be showntobe of potential value tc; thepatient. Assess men t sarenever'admini s trative l y ordere d ,andtheps ych omet r i c i an bec omesinvol ve donly if theDepartm entof Psych ol ogy is convi nc ed the re is good reaso n to cc duct anassessme nt. If an assessment wil l help to clarify a diagnosis, su pportanopi nio n, or assist a patLe nt;in obtainingproper services/treatment, then the Department of Psychology pro v i d e s te sting serv ices.

Psycholog istsare availab leas consu ltantsto all de pa r't.nerrt s in thehos p ital,andoftenassist in developi ng behavior modificatio nand re ha b i lita t i veprograms on the units. Consultation wi thnur s i ng staff, socia l wor ke rs, medica l professiona lsandotherson a pat i e nt'streatme nt team is a routine. ongoi ngoccu r renc e, both in weekly ward round s mcetLnqs, andin everyday interchange .

The snru c t ur e of the Ps ych ol og yDepartment at the waee r roro Hospitalhas unde rg one considera b lechanqeduring theLrrt. erna hi.p . The curr e nt orga ni zation divi des thestaff into two sepa ra te te ams , each headed bya Senior ps yc hol og i s t . Thesetwo Sen iorpsyc hologistsre po r t tothe Oirectorof Psyc ho l ogy. The Psychol ogy staf frembe rs atthe

11 Waterford Hospitalar e organizedas follows:

Director of Psychology

Acute , Foren s ic ,Outpa tie n t Team: 1Senior Psycho logist . J Staff Psychologists

Habil i tat i on/Rehab i l itat ion Te am:

1Sen ior Ps y chologi st 1 Staf t Psyc holog i st 1 PsychologicalAss istant

*The in t e r n '5 supe rvisorduring thi s J.nt e rnship was the SeniorI?SYChClIogiston the Acute, Forens ic, outpatient Team.

SUPERVISION

The inter n's work withthe psycho logyDepartme nt^titthe Water f o r dHosp italwa s supe r v isedby both a universi t y supervisor and a fieldsupe r viso r. Dr. Lero yKIas, Professor , Facultyof Education, served asuni v e rsi t y supe rv i sor duringall of the intern' s placements at the

12 Waterford. His support and advice have been deeply appreciated by the intern.

Dr. Hassan Khalili, Director of Psychology,directly supervised the intern during Ills Fall semester pre-practicum placement, and he has generously offered his assistance to the intern duringhisent i r e stay at the Waterford.

Dr. Ass en AHad!n, senior Psychologist, supervisedthe intern during the~linterpracticum and during this full -time internship. During the internship, Dr. Alladin and the internmet formally for at least one hour weekly to discuss the Inber-nt s activities, and his therapy with patients. Dr.

Allad!n provided superbguidance to the intern, graciously sharing his considerable knOWledge, and providingendless learning opportuni ties. The intern consulted with Dr.

Alladin extensively outside of the formal supervision period, and he invariably responded with kindness and professionalism.

While other members of the Psychology Department not listed as official fieldsupervisors,the internwould be remiss not to mentiontheir substantial contributionsto his1earnin~. The intern alwaysfeltwarmlyacceptedby everyone in the department, and had the opportunityto work

13 alongside many of the department st a f f. Ea c h individual was receptive to taking the intern"unde r his/he rwing,"or letting him "tag along"when feasible. Theydrew his attent ionto situations they felt might beor i.n t e r e st to him, answeredhis many questions, andtr e a tedhi m more asa colleague, than as a student.

INTERNSHIP OB.:.ECT I VES

since the internha d spent the two pricr semeste r s in part-timeplacementswiththe PsychologyDep a rtmentat the Waterford Ho s p i t a l, he was familiarwith the set ting,and had alreadyaccomplisheda broad range of specific goals prior to thecommencement ofth e in te rns h i p.

Acc ordingly, theintern proposedto fu nctio n asa

"j un i o r member"of the PsychologyDepar tmentduri nghis internship, withhis maj o r thrus t being the further developmentofhis therapeuticskill s. Addit ional ly , assessments, consu ltation, and ot he r ectLvLt ies wouldbe carriedout asne e d ed ,and as appropriate opportunitiesto do so occ urred.

14 I. MAJOR OBJECTIVE

3. Indiyjdualcounseling andth e ra p y The internproposed to learn andpractice cognitive-behavioral therapyskills, and utilize them in the treatment of a minimum of five patientsinth e Psychology Clinics in thehaspi tal.

Activitieswould inclu de:

Patient therapy Co-therapy

Observation oftr e a t me nt study of the treatment methodology Consultatloo regarding treatme nt SchedUled supervision andfeedback

Itwassuggestedthat skills learned/applied might include:

RelaxationTraining Cognitive Restructuring Assert ivenessTraini ng systematic Desensitization Hy p no s i s

II. MINOROBJECTIVES

a. ~

The internpropose dto conduct clinica l interv iewingan d fo r mal testing asrequ ired by the depar tm en t. Staf f psychologists wcuLdbeencourage dto consider the availabilityof theint e r nwhe n assessments wereindicated.

The internhad conductedassessmentswith the following ten different instrume n tsin his placement with the Psychology Departmentduri ngtheprior semester:

Assertio nQuestionnaire BeckDepressionInventory Bec kHo p el e s s ne s s Scale Dysf unctionalAttitudeSurvey Mi ll o n ClinicalMul t i ph a s i c Inventory Mi nn e s ot a MUltiphasicPerso nalityInventory Psychopa t hology Inventory for Mentally

Retarded Adults seL-90symptom Scal e

Self Ev aluationQues tionnaire (State/Tra it Anxie ty Ind e x) Wechsl er Ad ul t Inte ll i ge nce Scale-Revised

There fore, furtherassessmentswere not consid ereda priorit y duri ng th e internship.

15

16 b. Consul tatioo

The int e rnproposed to func tionas both a consultant and a consultee regarding pa tie nt s andtheir treatment, as feasible.

Itwassu g g e sted that those consultedwith during the internshipmightinc l ud e :

Ps y c h ol o g i s t s Psychiatrists

Medicaldoctorsand interns Nurs ingstaff

So cial Workers Occupational Therapists Phys i o t he r a p i s t s community Care Personnel clergy

Family members community agencies Patient Activitystaff

c. Group co u ns el ing

si nc e the PsychologyDepartmentdidno t ha v e any active groups imme d i a t e l y priorto, or during, the internship, the Day CareDepartment (Nursing) conse n ted tha t the intern could continuehisinvolvement withone of their

groups. The internhadbeen inv o lved inco -l e a d i ng their Adv a nc e d Soci alskillsgroupdur ingthe previ o us se me st e r . It was pr op o s e d that the writer would either cont i nue wit h th e Advanc ed Social skillsgr ou p or , prefe rab ly , be involve d in theUnd e r s t and i ngscaiac p h r eme group. 'rh oUnd e r stand i ng Schizophren ia gr ou p was du e to startsoon afterthe commencementof theinte r ns h i p . The intern's ac t i vi tywo u 1d include plann.i.ng, co-therapy , and pre andpost - g roup discussionswith the Day Ca renu r ses.

d. Exposuretoot h e r ment al healthsettings Itwas proposedby the supervisorsthatthe intern briefly vi sitsome other men talhealthsetting s in the St.

Joh n ' s area. It wasfelt that it wouldbe beneficial for the intern toha v e some exposureand or i entat i on tcot her mental healthse t t ing s, eventhough the off icia l internshi p site was the Wat erford Ho sp it a l.

It waspr op o s e dtha t these visitsbe made as pr act i c able, and as availableas po s s ib l e . They wouldbe arrangedby the Departmentof Psychologystaffat the Waterford.

e.Other activities

1. It wasproposed by the intern th a t hevi s i t the CummunityCare Centre at LongPond, inclUdinga tourof

18 one ortwo of the associate d boa rdinghome s.

2. Th e in t e r n proposed att e nd ing one GrandRou n d s or Water ford Round s duringtheinternship.

Chapter II

DESCRIPTION OF ACTIVITIES

Duri ngthe in t e rnsh ip , theLn t ern was jo i ne d by two Memorialun ive r s i t y Clinical Ps yc h o l ogy graduate stude nts serving two-day-per-weekplaceme nts. Th e internbenef I te d from and enjoyed workingwiththese two brightand capnb Le ind i v idua ls. Their concurrent pr e s e n c e, howeve r, le d to decreasedpart i cipat ionby the inte r n in so me acti vitins.

These students hadno t had previ ousexpo s ure tothe Waterfo r d Ho s pi t a l. Adecreas ed le ve l ofadmiss i ons qe ri e r-aLl .y, a smalle r numbe r ofadmis si ons forwhich psych ol og i cal int ervent i on wasdee med approp r iate, andthe necessi tyof provid ingassessmentand screeni ng opportuni ties for these students, which theinte r n had enjoyedtheprevious semester, decreased the frequency of both as sessmentandsc r e e ni ngop portu ni t iesfor th e intern.

1. Lia is on psycholog ist

For fi ve weeks duri ng th e Lrrt.erneh Lp , the r nt.e rn , assisted and supervised by Dr. Alladi n , substituted for staffpsycholog istswho wereill or vacationing. The in t e rn did not assume responsibili tyfor ongoing patient therapy with patientsof these absent psychologis ts, but assumed their role as lia isonon a particular acute/admis si onuni t .

20 Pr ill,a r i l y , this involved the screening of all new admissions on the respective units during theirabsence, and attendance at the weekly mUltidisciplinaryroundsmeetings whereall patients on theunit are discussed. The intern filledin for two psychologistson unitN28, and for one on unitN38.

Inaddition, the internattended rounds onthe Forensic unit, !'I4B, for Dr. Alladin, during one occasion when he was un a b l e to at t e nd .

2. Screeninginterviews

Not allnew admissionsto the hospitalare interviewed by members of the Psychology Departme nt . While ath or o u gh chart rev iew iscomp l e t e d, many patients' conditions on admission are not conduciveto interviewing. Some refuse an interview. Ma ny have mUlt ipleprevio us ad mi s s i o ns and are well knowntothe mUltidiscipli naryunitte a m.

During theinternship,the internparticipa tedin seventee nscreening interviews, asrorrcvss

InterYiewed by inte rn alone Interviewed as co-interv iewer

withDr.Khalil i with Dr . Alladin wit hMr.Simpson withMs. Dalziel

17

' 1

I

ar

Priorto each interview, th e in tern read theadmitting physician 'sreport, the notes of nursi ng uni t staff ,andthe writte ncomments of anyother team memberswh o may have recorded their observationsor interactio ns withthe patient. Ifthepa tie nt ha d beenadmitted to the Wa t e r fo rd Hospital on previous occasions, the past recordswer e aLao reviewed. Onsomeoccasions i twas possibletobr i efly conversewith other team members regarding e patientto be in t e r vie we d , i f they happenedto be presen t dur-Lnq tntspre - interviewreview period. Ofte ntimes, artctttIonaI vnLua bje informationcouldbe gleaned quicklyin this way, or confusion cl e are d up. Th e internfound that this pre- in terview review gave him a flavorfo r the patient, as well as he lpinghim to informa llyst ruct ure his ecreen Lnq inte rv i e w. Inf o r ma t i o nrec o r d ed by other teammembe rs co u ld be checked by asking similar questions and discer ni ng whet herthe ans wers wereconsiste ntwithearlier replies.

Wh ile thein ter n used no set list of questi ons, queries included:

a) How did you come to be here?

b) What doyou thin kthepr ob l e mis ?

c) Has anything like thi s happenedto you befo r e?

d) Wh a t hav eyoutr i e d to do aboutit?

e) A ch eckof orientation to timeand pl ac e.

22 f) Questions of demographics.

g) Personal history ofprevious difficulties . h) F~m ilyhistory ofmental difficult ies . i) An attempt to determinestressors. j) Hallucinations/delusions and content.

k) What didyou do?

1) Howdidyou feel?

m) What we re you thinking?

nJ Present affectandappropriateness . 0) Pre sence/absence of ins i g ht into pr o b lem.

p) Willingness towork wi t h psychologist. q) Agreeabletopsychological testing?

r) Attitude towards medi cat ions.

5) Availabilityfor outpatienttherapy.

t) Motivation/psychologicalminded ness.

u) support system outsidehospital.

v) Nutrition/lifestyle

w) Do you have eny questionsfor me?

x] Isthere anything I ca n do for yell now?

During the screening inte rview, the internwould initiallyat t e mpt toestablis hrapportquicklywith the patient, byint r odu c i ng himself and explainingthat his purpose was to see if the PsychologyDepartment could be of help to the patient. The intern attempted to vary his style

to suitthepati en t ,but alwa ys to actpr o f ess ional ly ,and to be support iveand reassuring. In additi onto the administrati ve functionof:screeningpatientstojudg e their ap p r o pr i ate n ess forpsrycho LoqLceI in te r ven t io n, theintern alsorealizedthatth e s eint e rv i ewscould be pot.entially th erapeut i c fo r the patients. wi t h thatgo alin mind, he always at temptedto in s ti l lhope and reduc e anx i e t yfor the interviewe e , regardless of whetherhe felt it likelythat the pati entwould have further inv olvementwi thPsyc h ol o g y staff .

At the conclu sionof th e inte rv iew,a jud g e me ntmustbe made regarding whetherthe patien t islike l yto bene f i t fr om psycholog i cal inv olv e men t at th i s time. Some ofthese de c isionsare ratherst r aig h t f o r wa r d . If a patientis psychoti c ,has had mul tiplepreviousadmiss io n s, has aclear diagnosis, and stoppedta k i ng his/hermedicationspr i or to admissi on , thenpsychological int e rv e ntio n is pro b ab lynot warranted. On theot h e r hand , if a pati en t is motivated, has insight intotds/he r dif f i culty, is notpsych ot i c , is a resident of the St.John 'sarea ,availableasanout p a t i e nt , and eager forpsychologicalhelp, a Psycho logystaff membe r willlik e l y be assigned to work with the pat i ent. Inma ny cases, however, whetheror notto allocate the patientfor psychologi cal interventionin vo l v e s diffi cult jud g e me nts.

The internsometimes discussed thesequesti on swithct.hcr-

24 membe rsof the Psychologystaff, or delayedjUdgement, pendingthe future progressof the pa tien t.

Dur i n g the internship, theint er n ,throu gh both experience andob s e r va t ion , gained a better graspof what questions to ask patients, wh a t clues to follow up, and the important factorstolook for when reviewingrecords prior tothe inte r v i ew. Inthe interviews he conducted jointly with otherstaffme mbe r s , he was exposed toth e ir different styles of interviewing, not e d areas he shouldbe sure not to overlook wheninterviewingalone,and received immediate po<:;t-Ine e r vle w feedback regarding his performance. The Lnt.e rnfeels that thr ou g h this on-the-jobtraininghe has sharpened his inte rviewingskills. Not only doeshe feel more competent as an in forma t i o ngat h ereranddecision maker, but his exp osureto a wide range ofpa t i e n ts and a varietyof interviewing styleshas re s ul t e d in a more matu re and aencl t Lva personal in t e r v i e wi ng stylefor th e int ern . The interncanno w confidentlyconduct these screening inte r v i ews , whichhehad never previouslyoo n d u c tied, and about Whi ch, initially, hekn e w very l i t t le.

J. PCltient C9ntact/th~

The Lrrt.ern had contact of at Lee st; three sessions with ten pa ti en t s:

Onepa tie nt was a lIaleinpa tie n t the internhad bee n counselingsince hisadmission in February. 19 91. The interncontinued to counseland provide su pport for this patient during thein t e r n s h i p,untilhewas transfe rredfrom th e Wat e rfordto anurs ingho me facility. Until hi s tran sfe r . th e intern saw thispatientseveraltimesa week . Hi scase was challengingand involvedcon s i d e r ab le co ns u l t ationwith uni t staff.

A femal e outpatient in he r mid-fiftieswasseenby the int e rn on several oc c a s i o ns duringthein t e r nsh i p , both joint lywith Dr. Alladin, andas a so la therapist. Th e inte rnhad been presentduring each of the week Ly sessions with this patient duringhis placementthe previo us semest er. Thi s wOllanha d sut tered frolllsevereanxietyand panicattacks,andwas trea t edwithretaxa t Icn training , cog n itiv e therapy,and systemati cdes e nsit iz at ion. Duri ng the internship , she wasprimarilygiven su p port ive counseling rel a t edto her continuingprogr e s s, andto prescript ion drugwithdrawal.

Two other inpa tien ts were interviewedon sev e ra l occa s ions , but the in t e r nwasuna bleto establish aprogram of therapy fo r the m. On e was a middl e-a g ed mal e with multiple previousadmissions and a longhis t o r y of ps y ch ol og i c al involveme n t. Anoth e r was a female in he r earl y twe n tie s who both Dr. Alladinand anotherstaff

2'

psy ch ol og i s t felt wa s too muchof acha llengefor theintern at th ispoint inhis career . Both co n ti nu e as inpatie nt s at the time of thi swri ti ng.

Ano therpat i e nt treat e dwas ami dd l e-a g e d maleon the Forensicun!t who was extremelyanxious . The int e r n in it iallyintervie....ed hi m with Dr.Alladin, and then followedupwi t h additionalcounseling, andrelaxa tio n in vivopri or tohi s court case.

Five additiona l patientswere seen onmUl t i p l e occasions for treatment, and wil l be discussed in de p th in Chap terIII, as theirtreatment constitutes the research componentof the internship.

Prior to comingtotheWate r f o r d Hosp ital ,therapy fo r patientsin a me nt a l he alth facil ity wa s something the inte r n had on lyreadabout. He had read in his textsabo ut many di s ord ers, but most of them he had never actua l lysee n. While the inte rnhad developedsometh e rapeut i c skills through his previousgraduate training and workexper ienc e s , he hadne ve r treate d pat i e nts as a therapistin a mental he a l th sett i ng. Themajor thrustof his internship was ar r an ge d soas to pr ovide th eopport unity fo r the intern to enha nce hi s the r a pe ut i c skills, and toac t ua lly work as a therap ist at his internshipsite. Thi s was aocompkLahed, The internwa s trained inthe basicsk ills of cogn i t i ve ther apybyhi s fiel dsup ervisor, Dr.Alladi n, andduringth e

27 internship, the intern served as a therapist to hosspLt.a I patients . The internhad regularmeetingswithhis field supervisor ,during which previouspatient treatmentsessions were reviewed,and suggestions were made ror upcoe Lnq thera pysessions. As well, pre and postse aeut-eewere carried out fo r thosepatien tsseen inthe Cognitive'l'herllp¥

for DepressionClinic.

The inter n ha d his mostmea n ing ful andpro f o und le a r n i ng expe ri ence swhen he serv edas sole ther a p i s t, and act.u a l l y appl i e d thosetechni q ues heha d learned. Pr i or to the inter n s h ip , the internhad ne v ertr e a t ed anyo newith cognitivetherapy. He hasnow doneit . He has Lear-nedand appli ed the skills, and whilebyno meansis he a seasoned thera pist, he is confident inhisabili tyto work effective lywith patients utilizing thesenewly-learned skills. The intern ha s received feedback rreehis field supervisoras well, that he is satisfiedthat the intern ha s success fullylearnedand applied coqnitive therapy techniq ues.

4. Mse s sm e n t s

As previous lyno t e d,assignmentof assessments to the int e r n dur ingthe inte r ns hip was limi t ed by ava i la b ilityof asse s s me n ts, andby the need to pr o v i d e assessmen t experi e nce for the two other gradua te studentsthere

28 concurrently.... ith the int e r n.

a) Minnesota MUltiphasic PersonalityInvent ory (MMPI) - Th e int ern acor-ed , interpreted, ran through a comput e r interpretati onprog r a m, and discussedthere s ults ofthetestwith Dr.All.ad in.

b) MillonClin icalMultiphasic Inventory (HeM!) - The inter nscored , interpreted,and dis cussedthe results of the ins t ru mentwith Dr .All adi n .

0) Minnesota MUl ti pha sic PersonalityInventory II (MMPI II) - The intern sco r ed , interpreted ,anddiscusse d the resul ts of the test with Dr.Khalili.

d) Th e followingfi ve in s t r u me nts were administe red , sco r e d,and interpretedten timesby the int ern dur inghis inte rns hip :

As s e r ti o n Questionnaire Beck Depression Inventory Beck HopelessnessScale Dysfun ctionalAttitude Scale State -T r a it AnxietyInventory

Theseinstruments constitutedthe pretes t and posttest measures fortheca s e studies discussed in ChapterIII.

Four individ ualscompletedthe instrumentsas bot h pre and post tests, wh ile two other individua ls completedthe measuresasprete s t s only. One of these individualsdropped out of the program. The other was not include d in the

"

treatment program, due to complicating psychopathology, th e adv iceof theint e r n's fie l d supervisor, Dr.T\lladln.

While the int e r n had previous asses s mentexpe rience, the majority of the instruments he us e d at theWaterford werene w tohim. Dur i ngtheinte r ns hi p , he became mo re comfortabl ewith thesenew instruments he was using,and in becoming mor e familiarwith them, his assessment ak.iLls improved in seve ra lareas:

a. He wasbetter ab leto understand the ration al e behind theus e of these parti cu l artests, and holda be t te r feel for what wa sbeingme a sured .

b. He wa smore comfo r t a ble in expla i ning the purposes of theseins t r ument s to patients, and in d r avlnq their attentiontoi.mpo rt a n t asp ectsofthe direction s.

c. He gainedapeed and con f i d e nc e in the scor.i ng and interpretationof these ins t r umen t s.

d. He gained furthe rinsight int o patient diff iculties through the analys i s of resultsof these in s t r ume nt s . He alsoexperienced the satisfa ct ionwhich occurredwhen writtentests confirmed hiscl i nica l observations, and the quandarywhich resultedwhen testing disconfirmedhi s observations.

e. He came to appreciate th e valueof testingas aneffi cient "s h o r t c u t"in info r ma t ion gathe r ing , which affordsthe patientmore directedtreatment, and ho p e fu lly ,

30

quickerrelie f.

f. He cameto more full y apprec iate thediffi cult jUdgements inherentin assessmen t in acli n ica l setting.

The r e is ali mi t to theamoun t of assessmentth a t canbe done, andass es s me nt per se does notmake a patientbetter.

g. He no ti ce d weaknesses in some of the Inct.r-uecnt;che us e d, such as ambi guous items , excess Ive lengt h,and poor layou t s. His pat i e nt s somet i me s drew these facts tohis at t e nt ion, eitherdirectlyorth ro u gh omissi on.

h. He experienced the wil li ng n e s s of most pat.Lerr t sto coope ra tewit h testing inthe i r qu e s t to feel better, andtheir hopes tha t the writerwould be able to helpthem as ares ul t of theireffort s on the tests.

i. Hefeels that, as a result of theint e r ns hi p experience, he is nowmore competentto choose, administer, score, and interp retpsychologic al testsproperlythanhe waspri or to the internsh i p .

5. Consulta tio n

Theinternhad extensi ve oppor t uni t y to COnsultwith other st aff regard ing patient car e andprogramming . In addition toongo i ng consultationwith the fieldsupervisor and other members ofth e Psychology Department, the intern had regular contact with nursi ngstaff,social work staff, psy chi at r ists ,medi caldoctors, and med i c al residentsand

31 interns. Thiscontact wa s bothth rough theweekly mult idiscip linary round s , as well as informallyonthe units.

Wh il e the intern ha d substantia l consultation expe r i e nc e during hi spr e vi ou s placementat the Wate r ford, he was ableto becomemorede e ply involved du r i ngthi s full timeint e r n sh i p. Aswel l,sincehe had be e n at the ho s p l ta l sinceSeptember, 1990, staffwere marefamilia r and comfortablewithhimdur i ng thein t e r ns h i pthan might otherwisehave beenthe case.

In particUlar ,the inter nconsultedwith ana psychiatriston an ongoing basis regarding a parti cular patient,and with two social workers regarding twopa t ient s . On occasion, the intern was asked forhis opinionby s tnff other than Psychology staff, and he found this gratifying . The inte r n was al s oableto consult closelywitha medicalinte rnonone case . The two had becomencqu.a Lnt.ed du rin g the fall at the hospi t a l , and this was a particUlar ly rewarding experience.

Three additional consultati on opportunit ieswere afr"rdedto the intern , whichhad beenunavailableto him

"ou sLyr The int ern consultedwith theheadnurse on one

e hospital units, aswe l l as with thehea d nur s e on a unit in another facility,reg arding the potentialtransfer of apa t i en t tothe otherfacility. The inter n had occa s i on

32 to consultwithth eWaterfordunithe adnur s e concerning severalissues per t a in i ng to this patient. As well, after the pa t i e ntIs subsequenttransfer, the unit he a d nursefrom the ot her facilityphonedthe intern to consul t wi th him regarding the patient . The intern also had contact with the patient afterhis tr an sfe r , assisting him with minor matters.

The secondnewarea of consultatioo for the intern duringthisplacementwas in working wit h volunteer agenc ies to assist anoutpatient in finding meaningful activity.

This entailed some phone callsand a visit by the internand the patient to the community Services Council, as well as somephone calls and a personal visit to Volunteer Services at the WaterfordHospita L

Additionally, the intern met wi t h theDirecto r of Socia l Work, Ms . FrankieO'Flaherty ,onJul y 5. Th is meeting wa s arranged at the request of theinte rn.

Ms.0' Flilherty an dthe intern discussed herde p a r t me nt , th e operation of thehospi tal , andpot ential opportunitiesfor Social Work and Psychologyto work toget her . Ms. O'Flaherty has anextensive background at the Waterford Ho s pi t a l , and the intern gainedfromher histori caloverview ,and from her Social Work perspective.

The intern le a r ne d that the Water fordHospital, thoug h filled ....ith many carin g ind ividual s, is an institutionWhe re

33 internal politics isveryimpo rtant. In orderto best serv e in the rol e of patie nt ad v oca te , the internhadto fully abs or b andapp r ec ia t e th ehierarchicalstructureofthe ins t i tu tion . Hehad to be come aware ofthe differe nces in per spect i ve of va rio us discip l i nes, theterdtor ia lityof di ffere n t de partments, and theindi vidua ldiffe r e ncesan d pers onal i t i es of ma nyof theind i v id u a l swith wh o mhe cto ert.

In the int ere s t of the patients, he le a r ne dto adopt the poj ItIce of pragmat ics,andto work as earnestlyfor the pa t i en t s as he cou ld,wi thout jeopardizing professio nul rela t i on s h i p s. He learnedto choose his al lies, and his batt l e s , carefully , and to wit hdra w wheni t seemedprude nt to doso. Sometimeshe wasdi s a ppo int edwi t h his results , buthe rea l i z e d that buil di ng pr of e s s i ona l cred LbLLitywit h a vast ar r a y of new acq u a i nt a n c e s, pa rtIc u La r Iy asa student, is a slowproce ss .

Th e internhadtwo prime foc i in hi s consultation enco unters:

a. He en deavoredalways to present himselfin sucha way soastobrin gcreditto thePsycholog y Depar tm e ntat the Waterford. He was,after all, their repre senta tive,and he strove to ma k e the experi encesof thos eot her profess ion a ls with whomhe consulted fr ui tfUl, pos iti v e,an d prof essio n al.

b. Heknewt~h athi s pur posewas tohelp tho

34 pat ients, but thatmanythingsthe patie ntsne ededhe could not do for them direct ly. Therefore,withthe goal of helpingthepatientsinmind, the int e rnattemp t edto apply his psyche logical and behavior change skillswith staff members, as well as wi thpatients. Throughpractically applyinghi ssk i.ll s of li stening, empathy, reinforceme nt, selectiveattention ,and nego t i at i o n, the internat t empted to build relationships with otherhos p i tal staffme mb e r s thatwould fa c il itat e thewel f a r e of the patients.

6. Weekly AllocationMeetings

The int e r n attended Psyc holog yDe partmentpatient allocationmeetingsweekly. At thesemeetings, staff discussnewjy-udm Lt.bed patients whom they have scre ened and foun d likelyto benefit from ps ychol og i c al services. The staff member Whoha s scree ne d thepa t i en t pres e nts de ta il s of the patient and the presenting pr ob l e m tothe group,who the n discussthecase. The pa tie ntis then al locatedto a staff memberfor follow-up .

Dur i ng the majorit yof thein t e rnshi p , on e meetingwas heldweekly, whi c hthe entire staff att e nded. Commencing in July, the PsychologyDe partmen t reorg ani z edin totwoteams as outlinedpreviousl y in th e departme ntstruc ture. After the re or gan i zat i on ,the int e r nattende d theAcute , outpatient,Forensic team al l ocati onmeeting we e kly.

35 At the allocation meetings,the internpresented informationon patients to be allocated, and discussed cases. Th e s e meetings serve animportant educational purpose,as well as an admin istrativeone, inth a t staff of fer theirpersona lexpertiseand perspect iveto each cosc. The int ernfou n dth e s e meetingsto be bothhi g h l y interestingand an exc e l l e nt le a rni ng vehicle.

Since staf fmeetingsare held only once a mon t h illthe Ps y c holog y Department, the timeperi od immediatelyfo ll owing pati en t allocation of t e nse r v ed as a further op p o r t u nity fo r grou p exchangereg a r d ingtherap y ,or brief administr-etiive matters. The inte rn wasal wa ys included in the s ema t t c r ~ , and this inclusio nenhanced hisexperience etqnLr icant rv. Aside fromits necessary administrativefunction, the allocationmeetingserves as a forumfor dis cussionof new patients and their problems. Here the internwa s exp osedto the varying perspectivesand orientatio ns ofdepartment members. Hereis where psy chol ogist s of t e n formall Lan c es to work togetheron acase, even if one se rv e s onlyas(I

consultanttoanother. Here the internlear ne d the strengths of indi v id ualpsy ch ol og ists, as they offeredthe benefits of theirexperience to each other,and asked for adv ice on how to proceed. Her-eis where Psycholoyy Departmentstaffmemberswonderedaloud aboutthe origin sof patient pr o bl ems , and asked the scree ningpsychologist

as focusedquestionsto try to shed furt herlighton whe r e to pro ce ed witha pati e nt. He r e too,psychologistswould sometimesbring up difficu lties theywere havingwith a staffme mber inanot herdiscipline,andask forad vice.

To the intern, the allocationmeetingwas aweekly ex perience wh e r e he learnedalot. He le a rn e dwh a t ki n d of patientswerecurrentlybeingadmittedthat the

psychologists felt the y could he l p. He heard anoverviewof these pa tient sIbackgroundsand circumstances. He learned whathe shouldbe sureto know abouthi s patients by li s t ening toth e presentations madeand questions eexeeby other psychologists. Hepi c ke d up manyclin ic al "t i db its"

thatwereexc h a nge d betweendepartmentmembers . Pe r ha p s mostof all, it was inthe allocationmeetingstha t the in ternobservedthehumani t y andcommitmen t to helping that ma debeing a part of the Ps ych o l ogy Departmentso rewarding.

7. Monthly StaffMeet ing s

The inte r nattended themonth ly Psycho logyDepartment s taff meetingsforMa y , June, an d July ,1991. Th ese meetingswere pa rt i cUl arly int erestingdue to the reorganizationofthe dep artme nt,whichwasinth e final planningand ea rly impl ement at i o n stages duringthe inte rns h ip. T....a of the se meeti ngswere fol l owed by pr e s enta t i on s ontime manageme nt ,which the inte r n also

37 at t ende d .

The intern wasoften asked forhi s contribution du r i ng thes e mee t i ng s , whichwerevery cooperative and productive innatur e . Pri or to the July meeting, the intern had expressedconcern to his field superviso r thatmany pot ent i a l patients were no t being seen due to th e endu ring stigma of th ewaterfordHo s pi t al ,andthe 8:3 0AMto4:30 PM,Mo nda y throughFriday,hours. This ite m WO$ incl udedon the Julyme e t i ng agenda. Th e internpresentedi talong with some euqqes tiLcns forcha n g e at the meeting, and staff membe r s showed greatin t e r es t and support for addr-es s Lnq this is sue. Thissituationis currentlybeing pursue d by theDepartment.

While the internis generallynot fond of meeti ngs,he foundthe Ps ychol og y Departmentstaff mee tingsto be focused andproduc t i ve . Under the leadershipof theDir e c to r of Psycho logy, Or. Kha l i l i , sweeping changes areund e r wa y in the department,whichappear to be very posit ive . In the intern'sopinion, these are exciting times at th e Waterford, andhe was fortunate to havebee nwitne s s totheirplan n ing andimplement a t i o n.

Eac h ofthe meetingswas held in a confere n ceroom, aroun d a largeta ble,an d coffee was provided. Items for theagenda were ac c umulat e dov erthe prior month, and could becontributedby any Psycholog yDe partmentmember. Minutes

38 were t.exen by staff members on a rotating basis, which was the ultimate in fairness. All items of business were recorded, along with the column notation, "Fo r Action By" , which served as a convenient reminder of who would follow up on that item. The intern found thissystem to be very efficient. Tasks were assigned, and in this way everyone knew who had the responsibility for a project, and who to check with for progress reports. Each staff member was provided with a copyof the minutes, and the prior month's minutes were briefly reviewed at the start of each monthly meeting.

The intern found these monthly meetings to be an avenue through which seniorstaff members shared planning ideas and hospital news with the entire staff, and through which the entiredepartment was able to come togetheraround an issue and form aco h e s i v e position.

The in t e r n found the meetings well run and organized, and a goodmo d e l for efficient informationsharing and planning.

8. Suicide Prevention and Treatment On June 13th and 14th, the intern, his field supervisor, and the two Clinical Psychology graduate students attended the 16 hour Suicide InterventionWorkshop

39 coordinat e dby Mr. GerryDool eyofthe Staff Educati on Departme n t oftheWate r ford Has p i tal. Mr. Doole yhas con duc te dthispr o gram forseveralyears, and dea lsdi rectly with suic ida l indivi duals on anongoingbasis. We ware the first representa tivesof the Ps yc ho l og y Departme nttoat t end the course.

The programwas educ a tional, highlyexpe r ienti al, and se rvedas a spri ngboardfor the intern , hi s fi eld supervisor andthe two Cl inicalPsychologygraduatest u de n t s topu r su e thetop i c furt he r. Based on ourin terest insu icide, and ourdes i r e tomake a cont r i butionto prevention and treatment, those ofuswho atte nde d th ewo.i-kshcp formeda sui c i d e study gr ou p . sev era l me etingswere he l d , and a Su i cid eManagement Wo rkshop is pla n ne d for Octo ber24t hnnd 25th, de s i gnedasa fo ll o w-u pto th esuici de r ntarvcnt.Lcn Wo rkshop . The inte rn'sfield sup e rv i s o r , Dr.All ad i n,will bethe primary pres e n t e r at the initial offeri ng of the cours e. It is intende d tha t thisworks hopbe a perma ne ntly av ailablefollow-uptoth e interven tionwor kshop.

At the la s t meeti ng regarding th i s project, Mr. Dooley expresse d hisstro ng supp o r t , and hi s depa rtm e n t is as s i st i ng with prepa rat i on of ma t er i a l s, promotion, re g istration, and so on. The work sho p isde sig ned to pi c k upwhere his works hop leav esoff, and,accordingtoMr. Dooley, is greatl ynee ded.

40 The int ern conducteda literaturesearch for journal contribut ionson the topic ofsuicideby a recommended aut ho r, and dist ributedcopies togr o up members. As well, he contributed to dis c us s i o ns regarding the workshopforma t, and to discuss i on spertaining to me d i a treatmentof sui c i de being activel ypursued byMs.RhondaHa c k e tt, one of the ClinicalPsychologygraduate st u de n t s .

The gr ouphas alsodiscussedthe possibilityof a fu r t he r wo rk sh opdealing withthe aftermath of suicide, wellas the establ ishmentof a Provincial su i c i d eCe nt e r whichwou ldserve asan in format ion andeducation source.

Whil e the internwas well aware, priorto the internsh ip, of the very serious issue of suici de,his experiencesduringtheint e rns h i p have bothheightened his awarenessof this proble m and moti vatedhimto becomemore ski lled as a therapist/intervenerin these cas e s.

Many inpatients and outpatientsat the Water ford Hos p i t al express suic i da l ideation. Theyst a t e that they seeno reasontolive, and often feel that they will make things bet ter fo r others if they killthemselves. Their feelings ofhelplessnessand hopelessnesscan be profo und.

To be awareof thisaspectof life onlyinthe abstract se ns e is disturbing. To be the s e patien ts ' therapistis the ultimateinre s po ns i bi li t y.

The intern has learned the importance of asking

41 straightforwardly , "Are you thinkingof killing yourself?", and has asked this questionof patients. lieha s been exposed to the frustration and dilemma oftr e a t me n t for those patients who frequentlyself-mutilate; the y see mingly do not want to kill themselves, but sometime s su c c e e d.

He has beenco n f r o n t e d with peoplewhosa ythey do no t wi sh tolive, an d withhavingto knowhow to respond most therape utically. Not on l y doesthe int ern havetobe skilled at preven t ingthesu i c i d e, he hasto kno wwh a t todo next. Amistakehereco u l d mean thede ath of th e pa ciont . Even ifhe does everythingright,the patientcoul d sti11 kill him s elf/herself .

Yet the internhas learnedthatth e thre at;of su ic i de is a r-equ Lar-pa r t of clin ical wo rk, and he now re eiIaec that hene e d sto becomeY..lil:Ycompete nt in thisar-e a, During the int e r n s h ip , he has begun tolearn someof thesesk ills , and expects to add tohis abilities and understanding throuqh whatever means are availableto hi m. Whi l e he never expects to be ccnr ort.ecaewith the issue of suicide, the internha s now dealt..,ith patients with suic idalideation, and he accepts the responsibilityof provid ing the se individu al s with sensitive and competentcare.

42 9. Visitto CommunityCare

On.July 22, the inte r npaid avis ittotheCommuni t y Ca r e Depa rtme ntin Lon g Pond. Hetouredthe ma in fa c i l i ty , andspoke with thedirector,Ms. Kare n McGrath . Ms . McGrath gave the intern a thorough overview of the operat ion and its histo r y , and an swe red allof his questio ns . Heapp r e cia t e d he r fr ankn e s s, and found he r to be a ve ry competen t prof essional .

Ms. McGrath arrangedato ur of threeof theaffilia teLi boarding homes forthe intern, so that he would be able to samp lethe rangeof facilitiesusedto hou sepatien tsinthe Commu nity Care program. Ther e wa s ind eed a vastdiff erence inthefa c il i ti e s viewed, and the intern felt histi me in explo ri ng this dep a rt me nt of thehosp ita l was well-spent.

10 . Prozac Present atio n

On aune 20, the intern and his fi el dsupe rv i s or attended a presentat ionatth ewa t e r f ord onPr ozacbyits manufacturer, Eli Lilly. Thispresentationwas al s o attended by the majorityof thestaffpsychiat rists, doctors, andme d i c al interns, whose questions and comments the internfound inte rest i ng.

Prozac, a controvers ialantidepr essa nt wh ich ha s rece ivedmuch neg ativepublicity inthepopula r pr e s s, pres entedfavorablyby the manu fa c t ure r. Thecompa ny's

representative refuted much of the evidence against the drug, and offered suggestions concerningthe source of the storiescondemning it.

The intern'sfield supervisor, Dr. Al ladin, had also had exposure to Prozac in England, wherethe drugha s been inus e for many years, and hi s comments were also quite interesting to the intern.

II. un i v e r s i t y Rounds

On June 7, the intern and his fieldsupervisorattended a presentationat the Waterford by staff from Memorial University Medical School on Alzheimer'sDisease. The focus ofth e talk was the review of experiments on rats which looked at the int r odu c t i onof virusesthroug h the nasal cavityas a potential source ofAl zh eime r ' s Disease.

Tentativeconclusionswere that this seemed possible.

The presentationwas heavily attended, and the intern againbenefitedfrom the que at.Lonand answer session at the end of the presentation. While he found some of the material presentedquite technical, i t became clearerdur-Lnq his evening course inneuropsychology which commenced severa l weeks later.

44

12. NeuropsychologyCourse

During SummerSession, June27 toAug us t 6, the intern was enrol ed in Educatio nG6855 at Memorial Un iversity . This graduate course met on Tuesday and Thursday eveni ngs,and didnotdisrupt the intern 'sday schedule at the Waterford Hospital. Du r i ng this course, theinternobtain eda broad overview of neuropsychology, and didextensive readingin the area. In addition to assignedreadings, the intern intensively studied Wernicke-Ko rsakoff'sDisease, the sUbject of his paperand presen tation for the course. He chose this topic due to an interestin the brain and alcohol, generatedby involvementwithalcoholicpa tients during the internshi p.

Whilenotfo r ma ll y considered part of the inter nship, the intern feltthecourse deserved me ntion in his report, since it absorbedmost of his even ingand weekend time duringthe latterportionof the inte rnship. Formerly, much ofthe intern 'sevening andweekend time had beenspent in reading related to the internIs vork atth e waeerrcre, Duringthe neuropsychology course, this was no longer possible.