Current Interns - Western State Hospital Internship Program

August 08 2015

Friday Factoids: Abandonment

Research has shown that therapists view termination as a complex stage of psychotherapy (Gelso & Woodhouse, 2002, as cited in Hardy & Woodhouse, 2006), though client responses are variable.

As cited by Hardy and Woodhouse (2006) clients often report positive feelings regarding termination, to include: pride, health, a sense of accomplishment, independence, cooperative, calmness, alive, agreeable, friendly, good, healthy, thoughtful, and satisfied. Interestingly, Hunsely, Aubry, Verstervelt, and Vito (1999) reported that 38.6% of clients attributed termination as a successful achievement of goals. Thus, Hardy and Woodhouse (2006) note that therapists may underestimate client perception of growth.

It is important that therapists become aware of these positive reactions, as psychotherapists may attribute more negative emotional reactions to termination. Additionally, understanding the difference between termination and abandonment is essential to ethical practice. Termination is a clinical decision based on competent practice. Per the ethics code, termination becomes clear when the client no longer needs services, is not likely to benefit, or is being harmed by continued service (American Psychological Association [APA], 2010). The latter may occur when a psychologist is not working within his or her boundaries of competence. Abandonment is an inappropriate termination (Behnke, 2009). Again, sound clinical thinking and consultation/supervision may help guide the decision process to ensure ethical termination. Yet, unfortunately termination can be more abrupt, such as in forced termination for interns (end of rotation)?

Often with forced termination, the goals of therapy have not been met and the provider may not handle the termination in an appropriate manner. Such may be due to lack of training. For instance, Zuckerman and Mitchell (2004) found that pre-doctoral interns reported they felt less than adequately prepared for forced termination. Thus, Hardy and Woodhouse (2006) highlight the need for focused training, specific to forced termination. According to the ethics code, pre-termination counseling is recommended (APA, 2010). With forced termination, often the end of services is known, therefore one should be proactive and notify the client in an appropriate manner. In other words, with termination, preparation of the client is necessary. When it is appropriate and after sound clinical decision-making and supervision, all efforts should be made to ensure an ethical termination and transfer to another provider occurs. Taking such care will help minimize harm and promote ethical practice.

References
American Psychological Association. (2010). Ethical Principles of Psychologists and Code of Conduct. Retrieved from http://www.apa.org/ethics/code/

Behnke, S. (2009). Termination and abandonment: A key ethical decision. Retrieved from http://www.apa.org/monitor/2009/09/ethics.aspx

Hardy, J. A. & Woodhouse, S. S. (2008, April). How We Say Goodbye: Research on Psychotherapy Termination. Retrieved from http://societyforpsychotherapy.org/say-goodbye-research-psychotherapy-termination

Hunsley, J., Aubry, T. D., Verstervelt, C. M., & Vito, D. (1999). Comparing therapist and client perspectives on reasons for psychotherapy termination. Psychotherapy, 36, 380-388.

Zuckerman, A., & Mitchell, C. L. (2004). Psychology interns’ perspectives on the forced termination of psychotherapy. The Clinical Supervisor, 23, 55-70.

Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee

August 08 2015

Friday Factoids Catch-Up: Is Stress Contagious?

Research is demonstrating that stress can be contagious across various populations. In a study completed by Waters, West, and Mendes (2014) results indicate that babies quickly pick up their mother’s stress and show corresponding physiological (cardiac) changes. West et al. (2014) findings demonstrate that emotions may be communicated through a variety of channels, such as odor, vocal tension, facial expression, or touch. This leads to questions of whether these findings are applicable to adults or among strangers? Can stress still be contagious beyond the intimate bond of mother and child?

Findings from Engert, Plessow, Miller, Kirschbaum, and Singer (2014) show that observing others in a stressful situation can make your body release the stress hormone cortisol. The results show that being around a loved one or a stranger that is stressed results in quantifiable stress reactions. This study involved having subjects paired with loved ones and strangers of the opposite sex, and then divided participants into two groups. One group underwent challenging math questions and an interview to emulate a stressful situation, whereas the other group of 211 participants observed the test. Only 5% of the participants that were involved in the stressful situation remained calm, while the other 95% showed signs of stress. Interestingly, 26% of observers had increased cortisol indicating empathetic stress. When directly observed, empathetic stressed increased significantly when the observer watched a loved-one experience stress. Additionally, empathetic stress increased when observers watched a stranger in a stressful situation via video transmission.

Overall, stress is a major health threat in today’s society; even still, the likelihood of coming into contact with stressed individuals is also prominent (Max-Planck-Gesellschaft, 2014). Thus understanding the impact of stress and empathetic stress is important for developing prevention and/or intervention strategies. As Engert et al. (2014) suggest, we should be cautious of watching or observing stressful shows or other stimuli, as this may transmit stress to the viewers (Max-Planck-Gesellschaft, 2014). Also, the results of the study show that emotional closeness is a facilitator but not necessary to the experience of empathetic stress. Respective of these studies, the authors conclude “stress has enormous contagion potential” (Max-Planck-Gesellschaft, 2014).

References
Engert, V., Plessow, F., Miller, R., Kirschbaum, C., & Singer, T. (2014). Cortisol Increase in empathic stress is modulated by social closeness and observation modality. Psychoneuroendocrinology, 45, 192-201. DOI: 10.1016/j.psyneuen.2014.04.005

Waters, S. F., West, T. V., & Mendes, W. B. (2014). Stress contagion: Physiological covariation between mothers and infants. Psychological Science, 25(4), 934-942. doi: 10.1177/0956797613518352

Max-Planck-Gesellschaft. (2014). Your stress is my stress. Retrieved from http://www.mpg.de/research/stress-empathy

Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee

August 08 2015

Article Summary: The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards (Nijman, Simpson, & Jones, 2011)

Purpose
Bowers, Nijman, Simpson, and Jones (2011) examined the relationship between leadership, teamworking, structure, burnout and attitude towards patients on acute psychiatric wards. They looked at how these factors and the dynamics between these factors influence rates of conflict (which they specified included self-directed violence, irritability and aggression, inappropriate behavior, and nonadherence with treatment) and containment (which they specified included sedating medications, special levels of observation, manual restraints, and seclusion). They concluded by creating a model illustrating these factors and their influence on each other.

Background
Bowers, Nijman, Simpson, and Jones (2011) highlighted that difficult behaviors of patients on an acute psychiatric unit create challenges for the staff who work on those units. Staff on these units strive to keep the patients, visitors, themselves, and other employees safe while conducting assessments and providing treatment to the patients. The article acknowledged that there are different conflict and containment rates between hospitals. The researchers conducted a number of studies in the UK and have previously found that many staff factors seemed to influence the conflict and containment rates. They listed examples including the staff’s psychological understanding of the patient’s behaviors, the staff’s moral commitments, how well the staff work together as a team, and the staff’s ability to provide structure on the unit (e.g. effective rules and routines). The findings suggested that the structure of the units was most closely related to the rates of conflicts and containments.

Methodology
The researchers examined 136 acute psychiatric wards in the UK over a six month period during 2004-2005. They distributed five questionnaires including the attitude to personality disorder questionnaire (APDQ), ward atmosphere scale (WAS), team climate inventory (TCI), multifactor leadership questionnaire (MLQ), and Maslach burnout inventory (MBI). The study involved 6,661 completed questionnaires and the analysis was conducted by ward. Three analyses were completed. The first was a principal component analysis (PCA) where they looked for covariance to see if the number of factors could be reduced. The second involved the factors from the PCA being put into a structural equations modelling (SEM) specification search to find a model that best incorporated all of the factors. The third analysis was a cluster analysis, which was conducted to place the wards into categorical groups. Finally, the researchers examined the relationship between each of the wards and their relationship to conflict and containment rates.

Conclusion
During the first analysis, they concluded that the number of factors could not be reduced and they continued to include all factors. The second analysis produced a model involving all of the factors. They represented the model in a diagram form. A summary of the model is as follows: leadership impacts teamwork, teamwork impacts structure, structure impacts burnout rates, and burnout influences attitudes towards difficult patients. They concluded that the teamwork among the staff members and the organization of the unit can be used to impact and prevent staff burnout and exhaustion. One of the discussion points noted that if reducing staff burnout is a goal, interventions may be beneficial if they focus on improving the structure on the unit. The researchers even suggested that increasing the structure on the unit may be more helpful for reducing burnout rates than improving the effectiveness of the team leader.

Reference
Bowers, L., Nijman, H., Simpson, A., & Jones, J. (2011). The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards. Social Psychiatry and Psychiatric Epidemiology, 46 143-148. doi:10.1007/s00127-010-0180-8

Brittany Best, MA
WKPIC Doctoral Intern

August 08 2015

Friday Factoids: Relationship between Tobacco Use and Psychosis

Though an association between tobacco smoking and psychotic illness is well known, reasons for the association are more ambiguous. Recent research has associated smoking tobacco with an increased risk for developing psychosis (Gurillo, Jauhar, Murray, & MacCabe, 2015). The authors reviewed studies that reported rates of smoking in people with psychotic disorders compared with controls. They hypothesized that tobacco use is associated with increased risk of psychotic illness, that smoking is associated with an earlier age of onset of psychotic illness, and an earlier age of smoking is associated with increased risk of psychosis. Overall, though the association between tobacco use has been established, little attention has addressed if tobacco may actually increase the risk of psychosis.

Gurillo, Jauhar, Murray, and MacCabe’s (2015) analyzed 61 studies composed of 15,000 tobacco users and 273,000 controls. The results indicate that people who suffer from psychosis are three times more likely to smoke. Also, 57% of individuals with first episode psychosis were smokers. The risk of psychotic disorder increased modestly by daily smoking. In short, daily tobacco use was associated with increased risk of psychosis and with an earlier age of onset of psychosis.

Again, it is difficult to determine the direction of causality; rather an association between tobacco use and psychosis was supported. Also, the authors noted the possibility of publication bias might be present. Even still, the authors caution that smoking should be considered a possible risk factor for developing psychosis, and should not be construed as merely a consequence of the illness. Furthermore, consistent with the dopamine hypothesis, they suggest that nicotine exposure may increase the release of dopamine and cause psychosis to develop. Limitations include, a small number of longitudinal prospective studies and determining the exact consumption of other substances in some of the included studies. Of course the authors suggest more research is needed. Overall, they note that tobacco use may be a modifiable risk factor for psychosis, and every effort should be made to modify smoking habits in this population.

Gurillo, P., Jauhar, S., Murray, R. M., & MacCabe, J. H. (2015). Does tobacco cause psychosis? Systematic review and meta-analysis. Lancet Psychiatry, 2(8), 718-725.

Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee

August 08 2015

Friday Factoids: Sleep and Brain Functioning

A Monday catch-up factoid!

We all recognize the importance of sleep, but there is emerging evidence that describes a causal relationship between sleep and emotional brain function (Goldstein & Walker, 2014). The literature indicates that sleep abnormalities are involved in nearly all mood and anxiety disorders. For example, as in Posttraumatic Stress Disorder (PTSD), Rapid Eye Movement (REM) sleep is diminished and disrupted. Goldstein and Walker (2014) propose that after a traumatic experience, REM sleep helps to decouple emotion from memory, and if this is not achieved, the process will be repeated in subsequent nights. What is experienced is a hallmark symptom of PTSD, nightmares.

Further, Major Depression is associated with exaggerated REM sleep, which includes faster entrance into REM sleep, increased intensity of REM, and longer duration of REM sleep (Goldstein & Walker, 2014). With this underlying disruption of REM sleep, individuals with Major Depression are noted to experience next-day blunting due to excess amounts of REM sleep, which alters PFC-amygdala sensitivity and specificity to emotional stimuli (Goldstein & Walker, 2014).

Overall, without sleep, the regulation and expression of emotions is compromised (Goldstein & Walker, 2014). Goldstein and Walker (2014) argue that REM sleep provides a restoration of “appropriate next-day emotional reactivity and salience discrimination” (p. 702). Consequently, emotional responsiveness, sleep, and consistent REM sleep promote the processing of emotional memories. REM sleep provides not only a therapeutic depotentiation of emotion from affective experiences, but also provides a re-calibration that restores emotional sensitivity and specificity. Thus, rather than being a symptom of a psychiatric disorders, the relationship between sleep and psychiatric disorders is now considered to be more causal and bidirectional (Krystal, 2012). In short, given this intimate and causal relationship highlights the importance of assessing for sleep disturbance, as well as informing intervention.

Goldstein, A. N., & Walker, M. P. (2014). The role of sleep in emotional brain function. Annual Review of Clinical Psychology, 10, 679-708.

Krystal, A. D. (2012). Psychiatric disorders and sleep. Neurologic Clinics, 30(4), 1389-1413.

Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
Psychology Practicum Student

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Category Archives: Current Interns

Friday Factoids: Abandonment

Article Summary: The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards (Nijman, Simpson, & Jones, 2011)

Friday Factoids: Relationship between Tobacco Use and Psychosis

Friday Factoids: Sleep and Brain Functioning

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