Behavioural analysis of ward rounds within a general hospital psychiatric unit.

A naturalistic observational procedure was used to examine the content of staff verbal interaction during the ward rounds of two inpatient teams in a general hospital psychiatric unit. Observers reliably rated staff discussion of 10 neurotic and 10 psychotic inpatients, using a nine category behavioural scale. The major focus of this scale was the extent to which three broad orientations, viz the medical, psychotherapeutic and sociotherapeutic models, were utilized by the staff. It was found that an eclectic approach was used by staff in their discussion of patients' aetiology, treatment and prognosis. However, the medical model was primarily utilized to formulate patient care, with the sociotherapeutic approach being employed for approximately one-third of the time. The psychotherapeutic orientation was only used 2.9% of the total time that patients were discussed. This pattern of use of the three orientations was consistent across the psychotic and neurotic patient groups. The behavioural data were found to be at variance with the degree to which staff believed the models should be applied. Analysis of the amount of time during which each professional group spoke in the ward rounds, and the rate at which they were found to make denned ‘authority statements’, indicated that a hierarchical model of management operated in the unit. These findings are related to the concept of shared power and responsibility within the therapeutic team.     

Changing caring behaviours in rehabilitation after a hip fracture – A tool for empowerment?

Different rehabilitation programs after surgery have been presented to improve the outcome for patients with a hip fracture. Empowerment has been suggested as useful, but requires a change in the caring behaviours of health professionals. The aim with this study was to evaluate if training and supervision of the nursing staff could alter caring behaviours. A case-control study of nursing staff treating hip fracture patients was performed at a hospital with two sites. Training and supervision was given to the nursing staff at the intervention site. The intervention focused on creating positive care interaction by using eight guidelines. The evaluation was performed with recordings of a constructed caring situation before training, and observations of care situations at the ward before and after intervention. The results showed no differences at baseline between the two sites in the caring behaviours. After intervention, significant effects of caring behaviours were seen in seven out of eight guidelines, the effect sizes ranged from medium to large. The findings indicate that the nursing staff can change caring behaviours and facilitate the empowerment of patients with a hip fracture.     

The effects of interactive staff training on staff programing and patient aggression in a psychiatric inpatient ward

Interactive staff training (IST) uses principles of organizational psychology to help line-level staff members design and implement social learning programs for severely mentally ill inpatients. IST is a training package that includes assessment of staff perceptions regarding programatic needs, selection of appropriate social learning strategies to meet these needs, appointment of a program committee from within the ward to champion development of the social learning strategy, and participative decision making about aspects of the social learning strategy. Staff on an extended care ward at a state hospital participated in IST for 15 months as part of a pilot study of its effects. Ongoing examination of ward programing showed that IST significantly increased staff and patient participation in rehabilitation programing and decreased the rate of physical restraints and aggression-related. Changes in staff attitudes about rehabilitation programing were noted on a subsample of IST participants. Implications for more controlled research into IST are discussed.     

Spiritual advisors and old age psychiatry in the United Kingdom

This survey investigates the role and views of NHS spiritual advisors across the United Kingdom on the provision of pastoral care for elderly people with mental health needs. The College of Health Care Chaplains provided a database, and questionnaires were sent to 405 registered NHS chaplains/spiritual advisors. The response rate was 59%. Quantitative and qualitative analyses were carried out. Spiritual advisors describe their working patterns and understanding of their roles within the modern NHS, and their observations of the level of NHS staff awareness of the importance of spiritual issues in the mental health care of older adults. They provide insights into possible negative and positive perceptions of their roles at a service level, and contribute suggestions of topics relevant to shared education between pastoral care and clinical services. This survey further highlights ethical and operational dimensions at the point of integration of the work of spiritual advisors and multidisciplinary teams.     

Towards emotional containment for staff and patients: developing a Work Discussion group for play specialists in a paediatric ward

This paper describes the evolution of a staff Work Discussion group run by a child psychotherapist in a teaching hospital for more than 15 years. It offers insight into the emotional experience of both NHS staff and patients as seen through the lens of the discussion of the staff’s work. The author identifies three main stages in the evolution of this group, as trust and the feeling of a safe space gradually developed. The first stage was identifying and understanding the emotional experience of patients, through the use of observational skills and psychoanalytic concepts; the second emerged as staff began to include their own emotional experience in the narrative; the last stage saw a qualitative shift in the staff’s capacity to share the pain generated by the work, knowing about it through holding it in the group’s mind and being able to reflect on it, allowing them to process experience in a way that made the work more bearable – akin to Bion’s concept of ‘containment’. This evolution is illustrated with relevant vignettes in the light of some theoretical and historical considerations. The paper demonstrates the value of Work Discussion groups in terms of indirectly supporting hospitalised patients, as well as promoting staff’s resilience and professional capacities in difficult contexts.     

Some thoughts and responses to The Francis Report

This response to the report by lawyer Robert Francis into the failure of National Health Service (NHS) care in Mid-Staffordshire is fairly positive about its conclusions but points out that without consideration of personal, psychosocial factors in care, on the ward, in the institution things are unlikely to improve, the report leaves much unconsidered. Francis emphasises that patient care is at the very centre of the NHS, this is obvious but so often forgotten. He comments that the unhelpful blame culture still exists. Missing from Francis’ analysis is a psychological perspective – the systemic factors he mentions are administrative not relational. This response is an attempt to redress the balance in thinking about the improvement of care for patients and of the working lives of staff.     

BEING DRIVEN MAD: TOWARDS UNDERSTANDING BORDERLINE AND OTHER DISTURBED STATES OF MIND THROUGH THE USE OF THE COUNTER‐TRANSFERENCE

In this paper material is presented from supervision groups run for nurses and other mental health professionals. The patients presented to the group came from different mental health settings with a diagnosis that included borderline features and/or other disturbed states of mind. All of the patients described caused strong counter‐transference feelings of sympathy, confusion, anger, hopelessness and guilt. Although these views were not expressed in formal ward rounds or recorded in clinical notes, evidence of their influence could be seen in the staff's attitude toward these patients. In supervision groups staff would either say that the patients were victims of mistreatment or they adopted a rather moralistic tone saying, ‘the patient is attention‐seeking’, ‘manipulative’ or ‘not mentally ill’. Psychoanalytic supervision which puts the transference and counter‐transference relationship at the centre of practice can help staff to think about their feelings and digest them in a way that makes use of them as evidence rather than discarding them as purely subjective. It also helps to reduce the toxic effects of the patient's projections upon the clinician's mind and this in turn helps to reduce retaliatory or manic clinical decisions. In this paper I argue that staff teams need time to reflect on their practice in handovers and clinical meetings and that psychoanalytic supervision can offer a particularly valuable clinical perspective on patients with Borderline features. This sort of support should be seen as an essential part of the work of nurses and other mental health professionals rather than an unaffordable luxury.     

Physical and observational practice afford unique learning opportunities

In 2 experiments, the authors studied the effectiveness of physical and observational practice on learning and the effect on learning of combining physical practice and observation, as compared with providing physical practice alone. In Experiment 1, retention and transfer performance of 30 university students after physical, observational, or no practice were contrasted. Consistent with findings from other studies, the retention results indicated that observational practice is inferior to physical practice. The transfer data indicated no differences between observation and physical practice groups. In Experiment 2, retention and transfer performance of 30 participants in physical and combined (alternating physical and observational) practice groups were contrasted. The retention results showed no differences between the combined and physical practice groups, but the combined group performed significantly better than the physical practice group on the transfer test. Those findings suggest that a combination of observation and physical practice permits unique opportunities for learning beyond those available via either practice regimen alone.     

Demonstrator skill modulates observational aversive learning

Learning to avoid danger by observing others can be relatively safe, because it does not incur the potential costs of individual trial and error. However, information gained through social observation might be less reliable than information gained through individual experiences, underscoring the need to apply observational learning critically. In order for observational learning to be adaptive it should be modulated by the skill of the observed person, the demonstrator. To address this issue, we used a probabilistic two-choice task where participants learned to minimize the number of electric shocks through individual learning and by observing a demonstrator performing the same task. By manipulating the demonstrator’s skill we varied how useful the observable information was; the demonstrator either learned the task quickly or did not learn it at all (random choices). To investigate the modulatory effect in detail, the task was performed under three conditions of available observable information; no observable information, observation of choices only, and observation of both the choices and their consequences. As predicted, our results showed that observable information can improve performance compared to individual learning, both when the demonstrator is skilled and unskilled; observation of consequences improved performance for both groups while observation of choices only improved performance for the group observing the skilled demonstrator. Reinforcement learning modeling showed that demonstrator skill modulated observational learning from the demonstrator’s choices, but not their consequences, by increasing the degree of imitation over time for the group that observed a fast learner. Our results show that humans can adaptively modulate observational learning in response to the usefulness of observable information.     

Mental health consultation in infant day care: A new frontier of prevention

This paper deals with the mental health aspects of infant day care emphasizing that mental health input into the design, implementation and ongoing supervision/evaluation of the majority of day care programs is minimal at the present time. The author proposes the following three criteria by which the adequacy of mental health input in a day care program could be judged: 1) ongoing mental health consultation to the caregiver staff on a weekly basis and by the same clinician(s), 2) assignment of primary caregivers to the infants, 3) periodic naturalistic observations of the infants to be recorded and discussed by the caregivers. The author postulates that consultation to the caregiver staff of infant day care programs represents the opportunity to establish a new frontier of prevention. Therefore, the mental health profession should consider it a goal that every infant day care setting would have a mental health clinician as a consultant. The methods, preventive functions and manpower aspects of such consultation work is discussed.     

MMPI correlates of performance on a behavior therapy ward.

In a behavioral treatment program for acute psychiatric patients, points were earned for adaptive behavior (e.g. self-care, attending ward activities) and lost for maladaptive behavior (e.g. assaults, verbal abuse). Points earned could be spent for a variety of goods and services (e.g. passes, extra staff time). Statistically significant correlations were found between MMPI scale scores and point-earning behavior. High scores on the F, 5, 6 and 8 scales were associated with low point gain for adaptive behavior, high point loss for maladaptive behavior, a high proportion of points spent to points earned, and a low overall net point earnings. Low score on F scale in combination with high score on 2 scale best predicted point-gain behavior, whereas high score on 8 scale in combination with low score on 1 scale best predicted point-loss behavior. Overall net points were best predicted by low score on F scale in combination with high scores on 0 and 9 scales. When subjects were grouped into common psychiatric profile types, differences were found in point-gain behaviors for items related to personal care and attending ward activities. At least some of these differences could be attributed to two factors: high scores on the 2, 3 and 7 scales were associated with higher than average point earnings, while high scores on the 8 scale were associated with lower than average point earnings.     

The team meeting on a rapid turnover psychiatric ward: clinical illustration of a model for stages of group development.

This article illustrates stages of group development in a semi-structured team meeting of staff and patients in an inpatient psychiatric unit. Clinical material drawn from such a group at the Massachusetts Mental Health Center is presented in support of the view that, even in a rapid-turnover ward, group process in a mixed-level, mixed-diagnosis "ward meeting" follows some predictable lines and responds to the articulation of certain predictable concerns. Garland's (1981) model of group development is adapted to show the cyclical nature of group process in a teaching hospital, where doctors as well as patients may make only brief stays. Effective leadership strategies are suggested.     

Risk–need–responsivity and its application in behavioral health settings: A feasibility study of a treatment planning support tool

The risk–need–responsivity (RNR) model suggests several key practices for justice‐involved populations under correctional supervision. Behavioral health treatment planning aligned with RNR principles for offender populations with co‐occurring mental health and substance use disorders (CODs) could be one method for integrating RNR into clinical care. To explore a unique approach to working with behavioral health and RNR principles, the authors implemented a mixed‐methods feasibility study of the acceptability, usability, and utility of a newly developed RNR treatment planning support tool (RNR TST). The tool was implemented in a re‐entry program serving adults with co‐occurring mental health and opioid use disorders. Chart reviews of RNR TSTs (N = 55) and a focus group (N = 14 re‐entry clinical staff) were conducted. Ninety‐six percent of the RNR TSTs incorporated the use of a validated risk–need assessment and 70% of the RNR TSTs were semi‐complete to complete. Focus group interviews highlighted behavioral health staff perspectives on the acceptability, usability, and utility of the RNR TST. This novel RNR TST has the potential to assist behavioral health providers in integrating RNR principles into treatment planning. Further development and testing are needed to determine its impact on client care and outcomes.     

Dependence in the elderly from an interactional point of view: verbal and observational data

Dependence in the elderly was investigated from an interactional point of view. Observations as well as verbal data of the elderly and professional caregivers were considered. Samples consisted of 14 elderly people receiving regular home health care (M = 78.9, SD = 6.3 years) and 16 elderly people receiving regular nursing home care (M = 81.4, SD = 7.5 years). Results showed a strong tendency toward independence in the elderly. Sense of control in the self-care interactions observed was higher in the home health care group than in the group receiving nursing home care. Division of the elderly into subgroups with high, medium, and low perceived self-efficacy showed that the elderly high in self-efficacy were more independent in terms of observed self-care. Causal explanations of the elderly's competence and their nonuse of competence were significantly different between the elderly and staff.     

Operant conditioning of activities of daily living on a psychogeriatric ward: a simple method.

On a psychogeriatric ward a simple token economy was established by handing out coffee and cigarette tickets for demands of concrete Activities of Daily Living from 14 men and 16 women. During the treatment period the number of target behaviors increased dramatically and many positive spin-off effects were observed. It was concluded that simple token economies of even 18 weeks can easily be introduced and administered and produce decisive positive changes with respect to psychogeriatric patients' activities of daily living, staff attitudes, and ward atmosphere.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

The management of sexual issues in adolescent treatment programs

Disturbed adolescents confined to inpatient treatment settings present special problems for the management of sexual behaviors. Ego impaired, delinquent, and autonomy-seeking adolescents provoke unique conflicts among their peers and staff. Staff's sexual anxiety caused by societal stereotypes of adolescents, inexperience with the techniques of unbiased observation and limit-setting, ignorance of normal adolescent development, and countertransference may lead to inadequate or inappropriate interventions. The authors describe the goals of a training program to reduce staff sexual anxiety: to develop a body of knowledge about the interaction between normal sexual development and psychopathology; to promote awareness about the staff's own feelings and the ways they influence observation and interaction; to lessen anxiety about self-exposure in the group setting; and to gain mutual support. Specific guidelines regarding effective staff interventions at an individual and group level are described. Alertness to the broad implications of sexuality in staff and patients and the necessity for careful monitoring of ward anxiety is emphasized.     

A safety mechanism for observational learning

This empirical article presents the first evidence of a “safety mechanism” based on an observational-learning paradigm. It is accepted that during observational learning, a person can use different strategies to learn a motor skill, but it is unknown whether the learner is able to circumvent the encoding of an uncompleted observed skill. In this study, participants were tested in a dyadic protocol in which an observer watched a participant practicing two different motor sequences during a learning phase. During this phase, one of the two motor sequences was interrupted by a stop signal that precluded motor learning. The results of the subsequent retention test revealed that both groups learned the two motor sequences, but only the physical practice group showed worse performance for the interrupted sequence. The observers were consequently able to use a safety strategy to learn both sequences equally. Our findings are discussed in light of the implications of the action observation network for sequence learning and the cognitive mechanisms of error-based observation.     

Action-effect binding by observational learning

The acquisition of bidirectional action–effect associations plays a central role in the ability to intentionally control actions. Humans learn about actions not only through active experience, but also through observing the actions of others. In Experiment 1, we examined whether action–effect associations can be acquired by observational learning. To this end, participants observed how a model repeatedly pressed two buttons during an observation phase. Each of the buttonpresses led to a specific tone (action effect). In a subsequent test phase, the tones served as target stimuli to which the participants had to respond with buttonpresses. Reaction times were shorter if the stimulus–response mapping in the test phase was compatible with the action–effect association in the observation phase. Experiment 2 excluded the possibility that the impact of perceived action effects on own actions was driven merely by an association of spatial features with the particular tones. Furthermore, we demonstrated that the presence of an agent is necessary to acquire novel action–effect associations through observation. Altogether, the study provides evidence for the claim that bidirectional action–effect associations can be acquired by observational learning. Our findings are discussed in the context of the idea that the acquisition of action–effect associations through observation is an important cognitive mechanism subserving the human ability for social learning.     

An analysis of observational learning in autistic and normal children

The present investigation studied observational learning in autistic children. Fifteen autistic and 15 normal children watched an adult model engage in a set of behaviors under specific verbal instructions. After observing this situation, the children were tested to determine what they had acquired through observation. The results showed that (1) the majority of the autistic and the youngest normal children acquired only some limited features of the observational situation and (2) chronological age was related to the amount of learning through observation in the normal children but not in the autistics. The deficit that the autistic children showed in observational learning may be related to a failure to discriminate or attend to the total stimulus input presented. Their failure in observational learning can be seen to contribute in a major way to the severely impoverished behavioral repertoires of these children.