I. The Inpatient Experience
There are two acute 24 hour, 70 bed inpatient units, one of which was granted a New York State Office of Mental Health Program and System Award for Inpatient as the most outstanding inpatient unit in the State. Housed within the Center building, its availability to the community prevents disruption of the patient’s social roots and enables sustained family involvement. Treatment occurs through the therapeutic community that encompasses all disciplines. The primary goal of the inpatient unit is to reintegrate patients into the community as rapidly as possible, while maintaining standards consistent with good patient care. A necessary consequence of the attempts to avoid long-term hospitalizations, which has recently been exacerbated by the restrictions of managed care, is a high rate of recidivism. Thus, there is an increasingly significant caseload of patients with severe and chronic pathology, but who are nevertheless able to return to community ties and family.
On this unit, the intern will work with patients in the most acute stages of their disturbances and will gain experience with patients whose problems encompass a wide spectrum of severe pathology. The intern’s confidence as a clinician should blossom rapidly, as he or she takes on management responsibilities for as few as four to as many as six patients. The intern will become directly involved in the establishment and integration of appropriate treatment goals. The intern will maintain continual contact with the assigned patients evaluating their clinical status vis-a-vis treatment goals, as well as arranging for the patient’s after care following discharge. In negotiating patients' discharges and transfers to other units of service, the intern will be expected to engage in on-going communication with the clinical staff of the units. He or she will thereby develop the skills necessary for effective professional collaboration.
Acquisition of group therapy skills with the severely and chronically disturbed will occur in a number of contexts. The intern will act as co-therapist in group therapy with the senior psychologist as well as a leader or participant in other kinds of patient groups. The intern is also the staff member responsible for conducting community meetings within the therapeutic community.
Brief psychodiagnostic assessment techniques are utilized. The intern will learn to compose reports, which directly address the referral problem. Recent changes due to managed care and reduced patient stays have placed an emphasis on quick, pointed and succinct assessment.
The daily interaction of the intern with the intense affective states of deeply disturbed patients facilitates the diminishment of anxieties in the intern regarding exposure to severe mental illness. Care and treatment of hospitalized patients also requires techniques of family intervention. The intern will learn to identify particular family crises or dynamics that may have contributed to patients’ hospitalizations and will assist in preparing families for the return of the hospitalized patient.
II. Wellness Recovery (Formerly CDTS)
With a highly skilled interdisciplinary staff and an array of clinical services and group programs, this newly developed program addresses the needs of the severely and persistently mentally ill. The director of the service is a psychologist providing the intern with role models of psychologists in leadership positions.
The Wellness Recovery Program focuses on supporting patients in their wellness and recovery goals (ADLs, joining national support networks, making greater use of community resources) and daily maintenance. The clinic serves an adult population 18 years and older with a chronic history of inpatient hospitalization. Patients are often diagnosed with Schizophrenia, Schizoaffective Disorders or Bipolar Disorders.
The Wellness Recovery clinic adopts a model similar to an Adult Outpatient service and emphasizes patients’ more robust wellness recovery goals such as gainful employment, formal education and volunteering. This is also an adult population with a less extensive history of inpatient hospitalization. Appropriate patients span the full spectrum of adult diagnostic categories and co-morbidities with a more stable symptom profile. Attendance is not greater than 2-3 times a week with attendance in:
- Specialized Group therapy (i.e. OCD, anger expression)
- Individual Psychotherapy
- Creative Arts Therapy
Clinic patients are welcome to utilize our psychosocial activities on days that they do not have a formal prescribed appointment as referenced above.
During the four-month rotation, the intern will acquire supervised experience in case management, intake interviewing, psychodiagnostic assessments, and family involvement. The intern will be expected to participate in groups with a cognitive-behavioral orientation. The program uses computers with software specifically designed for a variety of clinical reports, which the intern is expected to master. Treatment planning conferences will offer the intern an active role in professional discussions. Patient-staff discussions within an interdisciplinary team approach, make available a variety of clinical role models and theoretical approaches from the purely dynamic to the psychoeducational. Conducting intakes will bring decision-making encounters with other disciplines and services. Collaborating and negotiating differences of opinion is a powerful growth experience.
Psychological assessment will be heavily emphasized in this service, using objective tests that can be rapidly scored on the computer and by more traditional intelligence and projective exams. This will fortify skills needed in the currently changing field and provide the expertise required to navigate today’s marketplace. Relative to other CMHC units, assignment to the Wellness and Recovery Unit will bring the intern into a much more informal ambiance of patient-staff interactions.
III. Outpatient Services
For four months, each intern will rotate through a variety of outpatient services. Our goal for the intern in the outpatient rotation is to offer a broad and varied experience, allowing exposure to the many roles of a psychologist in a medical center
Adult Outpatient Services (AOS)
Its interdisciplinary setting includes a senior psychologist who serves as the intern’s unit supervisor. The team to which the intern is assigned provides immediate intake and crisis intervention and emergency services.
The Screening and Intake Clinic (Rapid Access) is the front door to the CMHC. Applicants for treatment and active patients provide the intern with a variety of clinical problems needing immediate decisions. These include acceptance into long term treatment for the chronically ill, crisis intervention and referral for the more functional patient, and inpatient, and partial hospitalization for the severely disturbed. The intern will actively participate in this process. Evaluation for outpatient treatment will entail an extended and in-depth interview by the intern and other staff members who will then prepare the clinical material. Immersion in this screening and intake process, which requires on the spot clinical evaluation and decisions will help develop the intern’s capacity to make immediate clinical judgments with confidence and sensitivity.
Patients who are applying for treatment and are deemed sufficiently functional can be assigned to the intern for up to several sessions of crisis intervention. Here, the intern will learn to work actively in unearthing and addressing the immediate issues in a patient’s anxieties or symptoms. The interweaving of neurotic or character pathology and stressful events in the patient’s life will emerge as the intern explores the patient’s current crisis. Family involvement and home visits may, at times, be clinically indicated.
Assignment of a diverse caseload of long term psychotherapy and crisis intervention cases enables development of clinical flexibility that is invaluable within the public mental health sector. Treating the severely ill along with the more neurotic patient will strengthen skills in an area where society is increasingly focusing mental health resources.
As on the inpatient unit, many of the adult patients are medicated. The intern will learn about the varieties of medication, will begin to understand its use and evolve a collaborative relationship with the
Child and Adolescent Outpatient Services (CAOS)
Another component of the outpatient training is in this service. The priority Psychology and the CMHC gives to the treatment of our young are underscored by the fact that a majority of CMHC psychologists work in this unit.
Orthodox/Hassidic and Puerto Rican cultures support large families. Thus, a proportionately large number of children from these minority groups are in need of this service. Intense efforts have been made to recruit psychologists who can understand and relate to these specific ethnic needs.
Interns will explore the full range of professional skills utilized for the treatment of the child and adolescent; play therapy, individual psychotherapy, and family therapy. In addition to standard intelligence and projective tests, the intern will learn to administer various achievements and other specialized tests. Intake interviews in this service will more frequently utilize family members. The intern will learn how to organize and formulate clinical findings with respect to many participants including schools and social agencies frequently involved with our children. Testing and intake work-ups are presented by the intern at multidisciplinary clinical staff conferences.
Interns will spend a day in, both, the adult and pediatric Emergency Rooms performing rapid daignostic work, as well as addressing hospitalization and treatment issues with acutely mentally ill and substance abusing patients. They have an opportunity to work as a member of an interdisciplinary team, while assisting patients in their inital exposure to the hospital setting.
The interns have the opportunity to complete one neuropsychological test battery on a child ranging in age from 4-18 years old. The children seen are typically experiencing medical issues with cognitive sequelae in addition to psychological difficulties and academic problems. The neuropsychological battery is utilized to inform medical and mental health care as well to determine appropriate school accommodations. The interns meet with the service supervisor weekly for supervision.
While rotating through the different units of service, interns will concurrently be working with up to 8 long-term psychotherapy patients. These patients are maintained for the entire clinical year, with new patients added when initially assigned patients leave treatment. An attempt is made to offer the intern therapeutic experiences in areas that he or she would like to gain additional expertise. Interns are expected to work with both adults and children or adolescents although the number of patients in either group can be skewed to the intern’s particular interests. Individual, couple and family therapy are the most frequent modalities of treatment for long-term patients, although interns can join an on-going long-term therapy group for the year as a co-therapist. Long-term therapy offers interns an opportunity to work in depth with patients and to utilize the therapeutic techniques (under close supervision) that they have been studying in their respective schools. Along with all of the other experiences it is an opportunity for the intern to have experience in areas, which heretofore had only been theoretical.